Ex-Vivo Repair of Complex Hilar Renal Artery Aneurysms and Auto-Transplantation of Solitary Kidney.

Renal artery aneurysms (RAA) are rare and challenging to repair. We present a case of a 48-year-old female with solitary right kidney who had complex aneurysms near the renal hilum. CT angiogram showed fibromuscular dysplasia (FMD) features of the renal artery and 2 saccular aneurysms measuring 2.3 cm and 1 cm. An additional small lower pole renal artery added to the complexity of the case. Ex-vivo aneurysm repair was performed after the kidney was removed and flushed with preservation solution. This was followed by auto-transplantation to the right external iliac vessels. The patient did well postoperatively without need for dialysis with serum creatinine returning to normal 5 weeks after.

Effects of stereotactic radiofrequency thermocoagulation in the globus pallidus internus on refractory tic disorders.

OBJECTIVE: To investigate the effect of stereotactic radiofrequency thermocoagulation in the globus pallidus internus on refractory tic disorders. MATERIALS AND METHODS: Forty patients with refractory tic disorders were enrolled between January 2015 and July 2017 to experience stereotactic radiofrequency thermocoagulation in the globus pallidus internus. All clinical data, Yale Global Tic Severity Scale (YGTSS) scores, serum dopamine (SDA), and 5-hydroxytryptamine (5-HT) were analyzed. RESULTS: Radiofrequency thermocoagulation was successfully performed in all patients. Periprocedural complications occurred in two patients (5.0%), one with fever (2.5%) and one with a urination disorder (2.5%); both returned to normal after treatment. After 12 months of follow-ups, excellent improvement was exhibited in 18 patients (45.0%), marked improvement in 10 (25.0%), good improvement in 9 (22.5%), and invalid in 3 (7.5%), with a total efficacy rate of 92.5% (37/40). Twenty-eight patients (70%) showed excellent or marked improvement without additional treatment after surgery. YGTSS scores were significantly (p < 0.05) decreased after compared with before thermocoagulation. SDA was significantly (p < 0.05) decreased 6 months (80.78 ± 18.82 ng/ml) and 12 months (75.65 ± 15.23 ng/ml) after compared with before (125.63 ± 35.26 ng/ml) surgery, whereas 5-HT was significantly (p < 0.05) increased 6 months (58.93 ± 16.88 ng/ml) and 12 months (62.63 ± 15.21 ng/ml) after compared with before (35.62 ± 3.41 ng/ml) surgery. CONCLUSION: Stereotactic radiofrequency thermocoagulation can be safely applied in the globus pallidus internus to treat refractory tic disorders, resulting in significant tic symptom relief and a decrease in SDA but increase in 5-HT.

Neutrophil-to-lymphocyte ratio associated with renal function in type 2 diabetic patients.

BACKGROUND: Type 2 diabetes mellitus (T2DM) is a leading risk factor for the development and progression of chronic kidney disease (CKD). However, an accurate and convenient marker for early detection and appropriate management of CKD in individuals with T2DM is limited. Recent studies have demonstrated a strong correlation between the neutrophil-to-lymphocyte ratio (NLR) and CKD. Nonetheless, the predictive value of NLR for renal damage in type 2 diabetic patients remains understudied. AIM: To investigate the relationship between NLR and renal function in T2DM patients. METHODS: This study included 1040 adults aged 65 or older with T2DM from Shanghai's Community Health Service Center. The total number of neutrophils and lymphocytes was detected, and NLR levels were calculated. CKD was defined as an estimated glomerular filtration rate ≤ 60 mL/min/1.73 m². Participants were divided into four groups based on NLR levels. The clinical data and biochemical characteristics were compared among groups. A multivariate logistic regression model was used to analyze the association between NLR levels and CKD. RESULTS: Significant differences were found in terms of sex, serum creatinine, blood urea nitrogen, total cholesterol, and low-density lipoprotein cholesterol among patients with T2DM in different NLR groups (P < 0.0007). T2DM patients in the highest NLR quartile had a higher prevalence of CKD (P for trend = 0.0011). Multivariate logistic regression analysis indicated that a high NLR was an independent risk factor for CKD in T2DM patients even after adjustment for important clinical and pathological parameters (P = 0.0001, odds ratio = 1.41, 95% confidence intervals: 1.18-1.68). CONCLUSION: An elevated NLR in patients with T2DM is associated with higher prevalence of CKD, suggesting that it could be a marker for the detection and evaluation of diabetic kidney disease.

Enhancement of struvite generation and anti-fouling in an electro-AnMBR with Mg anode-MF membrane module.

Severe membrane fouling and the inability to remove/recover nitrogen and phosphorus are bottlenecks of anaerobic membrane bioreactors (AnMBRs) for large-scale application in wastewater treatment. Herein, an electrochemical AnMBR with a Mg anode-membrane module (electro-AnMBR) was built and showed good performance in terms of membrane fouling mitigation and nutrient recovery during sewage treatment. Compared with the traditional AnMBR, membrane fouling in the electro-AnMBR was reduced by up to 30%. The application of an electric field decreased the zeta potential, viscosity, and EPS concentration of the sludge-water liquor in the electro-AnMBR, which could improve the cake layer structure and thus enhance water permeability. Meanwhile, 26% of NH4+ and 48% of PO43- co-precipitated with Mg2+ generating from the sacrificial Mg anode and were recovered as struvite deposited onto cathode in the electro-AnMBR. Hydrogen evolution provided a relatively alkaline pH environment, resulting in struvite electrodeposition on the graphic cathode, which partly separated the formed struvite from the sludge with a purity of 77%. In the electro-AnMBR, the electrochemical reactions provided alkalinity and effectively inhibited anaerobic acidification. The applied voltage of 0.6 V reduced the relative abundance of methanosaeta, but increased that of methanosarcina, which is also beneficial for the membrane anti-fouling.

Endoscope-Assisted Keyhole Surgery for Traumatic Subacute Subdural Hematoma Evacuation in Emergencies.

OBJECTIVE: This study aimed to investigate whether a simple endoscopic method was effective for the evacuation of traumatic subacute subdural hematomas. METHODS: A total of 51 patients with subacute subdural hematomas requiring surgery were enrolled in this study. An endoscopic hematoma evacuation was performed through a small bone window for 22 patients. Hematoma evacuation by open surgery was performed for 29 patients. The postoperative Glasgow Coma Scale scores improvement, surgery times, displacement of midline measurements, and intraoperative blood loss were recorded and analyzed for each patient. RESULTS: The average time from the initial incision to suture completion was 38.41 ± 6.97 minutes for the endoscopic surgery group and 74.66 ± 9.54 minutes for the open-surgery group (P < 0.01). The average total blood loss was 41.36 ± 10.82 ml for the endoscopic group and 250.00 ± 58.25 ml for the open-surgery group (P < 0.01). No postoperative bleeding occurred in either group. The midline displacement measurement showed significant improvement on the day after surgery, with 5.21 ± 1.98 mm in the study group versus 6.75 ± 1.37 mm in the control group (P < 0.01). At the 1-month follow-up appointment, the midline measurement was normal in both groups. Computed tomography scans revealed almost no residual hematomas, representing an average evacuation rate of 100% in both groups. The average Glasgow Coma Scale scores improvement on the day after surgery were 1.77 ± 1.93 in the endoscopic surgery group and 1.66 ± 0.77 in the open-surgery group (P = 0.766). CONCLUSION: Endoscopic subacute subdural hematoma removal through a small bone window achieved satisfactory hematoma removal using a minimally invasive method when compared with an open-surgery method.

Developing a quality improvement project to tackle the desflurane problem.

Anaesthesia is associated with the routine use of volatile anaesthetic agents, all of which are potent greenhouse gases in varying degrees. Desflurane, in particular, has a high global warming potential and in recent years, there has been a global movement to reduce or remove its usage entirely from operating theatres. We work in a large tertiary teaching hospital in Singapore with deeply entrenched practices of using desflurane to facilitate high turnover of operating theatre cases. We launched a quality improvement project to (1) reduce the median usage of desflurane by 50% (by volume), and (2) reduce the number of theatre cases administering desflurane by 50% over a period of 6 months.We collected baseline data to determine departmental monthly median usage of desflurane. We then deployed sequential quality improvement methods to educate staff and to eliminate misconceptions, as well as to promote a gradual cultural change.We successfully reduced monthly median desflurane usage from 31.5 L to 12.2 L per month (61.3% reduction) within our targeted time frame. We also achieved a reduction in the number of theatre cases using desflurane by approximately 80%. This translated to significant cost savings of US$195 000 per year and over 840 tonnes of carbon dioxide equivalents saved.Healthcare is a resource intensive industry. Anaesthetists are well placed to play an important role in reducing healthcare-related carbon emissions by choosing anaesthetic techniques and resources responsibly. Through multiple Plan-Do-Study-Act cycles and a persistent, multifaceted campaign, we achieved a sustained change in our institution.

Laparoscopic radical cystectomy with pelvic lymph node dissection and ileal orthotopic neobladder by a total extraperitoneal approach: Our initial technique and short-term outcomes.

PURPOSE: With the increasing application of laparoscopic or robot-assisted radical cystectomy, a reliable and promising method is needed for reducing postoperative complications. We describe the short-term outcomes of totally extraperitoneal laparoscopic radical cystectomy (TELRC) with extraperitoneal pelvic lymph node dissection (EPLND) and extraperitoneal ileal orthotopic neobladder (EION) techniques. MATERIALS AND METHODS: From January 2020 to December 2021, we performed TELRC and EPLND with EION in 72 patients in our center. The accompanying video highlights our novel techniques. The patients' demographic data, intraoperative data, and perioperative complications were collected, and short-term oncological and functional results are reported. RESULTS: All procedures were technically successful without conversion to open surgery. The patients' mean body mass index was 26.22±5.71. Median age was 57.51±12.34 years. Average hospital stay was 13.78±4.62 days. Median intraoperative blood loss was 112.92±88.56 mL. No blood transfusion was needed during the operations and only one blood transfusion was performed during the perioperative period. Mean operating time was 259.44±49.84 minutes. Average cost was US$9,875.71±1,873.08. Postoperative short-term complications included short-term ileus (n=3), infection (n=13), leakage of urine (n=11), and lymph fistula (n=7). One late complication of unilateral vesicoureteral anastomotic stenosis occurred. The mean follow-up was 13.42±8.77 months, and no patient developed local or systemic recurrence. The short-term follow-up and small cohort of patients limited our evaluation of outcomes. CONCLUSIONS: TELRC with PLND and EION was technically feasible and clinically promising, with a reduced potential harm of postoperative complications. Long-term follow-up and a larger cohort of patients are needed for further study.

Antiplatelet therapy and outcomes following endovascular therapy for acute ischemic stroke: A systemic review and meta-analysis.

OBJECTIVE: The outcomes of antiplatelet therapy (APT) in patients with acute ischemic stroke (AIS) receiving endovascular therapy (EVT) remains controversial. Thus, we sought to make a systematic review and meta-analysis of recent clinical trials to confirm the safety and efficacy of APT. METHODS: All of clinical trails were systematically retrieved from PubMed, Embase and Cochrane. The endpoints or main outcome measures included symptomatic intracranial hemorrhage (sICH), 3-month mortality, successful recanalisation (SR) and 3-month functional independence (FI). Odd ratios (ORs) with their 95% confidence intervals (CIs) were calculated to synthesize effect size by using random-effects models. Sensitivity analysis was performed via calculation of rest data owiting one by one. RESULTS: 23 articles were included after screening. APT as an adjunct to EVT was associated with a higher likelihood of pooled successful recanalisation (OR 1.46, 95% CI 1.07-2.00) and 3-month FI (OR 1.24, 95% CI 1.01-1.51), no associated with sICH and 3-month mortality. However, Sensitivity analysis indicated that the association between APT and SR and 3-month FI were unstable. For patients with prior use of APT or receiving intravenous thrombolysis before EVT, no associated were found between APT and all of endpoints above. CONCLUSION: Although adjuvant APT appears to increase the number of SR and 3-month FI, the results were unstable. Randomised controlled trials are needed to confirm the efficacy.

[Effectiveness of double metatarsal osteotomy for severe hallux valgus with increased distal metatarsal articular angle].

OBJECTIVE: To summarize the technique and effectiveness of double metatarsal osteotomy for treating severe hallux valgus with increased distal metatarsal articular angle (DMAA). METHODS: Between June 2014 and December 2017, 64 patients (94 feet) of severe hallux valgus with an increased DMAA were treated with the double metatarsal osteotomy (distal metatarsal Reverdin osteotomy+proximal metatarsal open wedge osteotomy) combined with Akin osteotomy and soft tissue surgery to correct the deformity. There were 10 males (15 feet) and 54 females (79 feet) with an average age of 44.5 years (range, 26-66 years), including 34 of unilateral foot and 30 of bilateral feet. The Maryland metatarsophalangeal joint score of the American Orthopaedic Foot and Ankle Society (AOFAS) was 54.3±7.4 and the visual analogue scale (VAS) score was 6.0±2.0. The pre- and post-operative AOFAS score, VAS score, DMAA, hallux valgus angle (HVA), first-second intermetatarsal angle (1-2IMA), and the first metatarsal length (FML) were recorded and compared. RESULTS: All incisions healed by first intention. All patients were followed up 12-15 months, with an average of 13.2 months. The complications occurred in 4 feet, including 1 foot of hallux stiffness, 1 foot of numbness at the edge of the wound, 1 foot of metastatic metatarsalgia, and 1 foot of metatarsal bone necrosis. At 1 year after operation, the Maryland metatarsal joint score of AOFAS was 89.2±7.4, showing significant difference compared with preoperative score ( t=18.427, P=0.000); and the effectiveness was rated as excellent in 78 feet, good in 12 feet, poor in 3 feet, and bad in 1 foot, with an excellent and good rate of 95.7%. The VAS score was 1.5±2.0, showing significant difference compared with the preoperative score ( t=10.238, P=0.000). The X-ray films showed that the osteotomies achieved bony healing at 3 months after operation. There were significant differences ( P<0.05) in HVA, 1-2IMA, and DMAA between preoperation and 6 months and 1 year after operation; but no significant difference was found in FML between preoperation and 1 year after operation ( t=0.136, P=0.863). CONCLUSION: For the patients with severe hallux valgus with increased DMAA, the double metatarsal osteotomy can significantly relieve the clinical symptoms and improve the imaging parameters with less postoperative complications.