A generic scope actuation system for flexible endoscopes.

BACKGROUND: A scope actuation system assists a surgeon in steering a scope for navigating an operative field during an interventional or diagnostic procedure. Each system is tailored for a specific surgical procedure. The development of a generic scope actuation system could assist various laparoscopic and endoscopic procedures. This has the potential to reduce the deployment and maintenance costs for a hospital, making it more accessible for clinical usage. METHODS: A modular actuation system (for maneuvering rigid laparoscopes) was adapted to enable incorporation of flexible endoscopes. The design simplifies the installation and disassembly processes. User studies were conducted to assess the ability of the system to focus onto a diagnostic area, and to navigate during a simulated esophagogastroduodenoscopy procedure. During the studies, the endoscope was maneuvered with (robotic mode) and without (manual mode) the actuation system to navigate the endoscope's focus on a predefined track. RESULTS: Results show that the robotic mode performed better than the manual mode on all the measured performance parameters including (a) the total duration to traverse a track, (b) the percentage of time spent outside a track while traversing, and (c) the number of times the scope focus shifts outside the track. Additionally, robotic mode also reduced the perceived workload based on the NASA-TLX scale. CONCLUSIONS: The proposed scope actuation system enhances the maneuverability of flexible endoscopes. It also lays the groundwork for future development of modular and generic scope assistant systems that can be used in both laparoscopic and endoscopic procedures.

Pathophysiology of bone disease in chronic kidney disease: from basics to renal osteodystrophy and osteoporosis.

Chronic kidney disease (CKD) is a highly prevalent disease that has become a public health problem. Progression of CKD is associated with serious complications, including the systemic CKD-mineral and bone disorder (CKD-MBD). Laboratory, bone and vascular abnormalities define this condition, and all have been independently related to cardiovascular disease and high mortality rates. The "old" cross-talk between kidney and bone (classically known as "renal osteodystrophies") has been recently expanded to the cardiovascular system, emphasizing the importance of the bone component of CKD-MBD. Moreover, a recently recognized higher susceptibility of patients with CKD to falls and bone fractures led to important paradigm changes in the new CKD-MBD guidelines. Evaluation of bone mineral density and the diagnosis of "osteoporosis" emerges in nephrology as a new possibility "if results will impact clinical decisions". Obviously, it is still reasonable to perform a bone biopsy if knowledge of the type of renal osteodystrophy will be clinically useful (low versus high turnover-bone disease). However, it is now considered that the inability to perform a bone biopsy may not justify withholding antiresorptive therapies to patients with high risk of fracture. This view adds to the effects of parathyroid hormone in CKD patients and the classical treatment of secondary hyperparathyroidism. The availability of new antiosteoporotic treatments bring the opportunity to come back to the basics, and the knowledge of new pathophysiological pathways [OPG/RANKL (LGR4); Wnt-ß-catenin pathway], also affected in CKD, offers great opportunities to further unravel the complex physiopathology of CKD-MBD and to improve outcomes.

Vitamin D and Chronic Kidney Disease Association with Mineral and Bone Disorder: An Appraisal of Tangled Guidelines.

Chronic kidney disease (CKD) is a highly prevalent condition worldwide in which the kidneys lose many abilities, such as the regulation of vitamin D (VD) metabolism. Moreover, people with CKD are at a higher risk of multifactorial VD deficiency, which has been extensively associated with poor outcomes, including bone disease, cardiovascular disease, and higher mortality. Evidence is abundant in terms of the association of negative outcomes with low levels of VD, but recent studies have lowered previous high expectations regarding the beneficial effects of VD supplementation in the general population. Although controversies still exist, the diagnosis and treatment of VD have not been excluded from nephrology guidelines, and much data still supports VD supplementation in CKD patients. In this narrative review, we briefly summarize evolving controversies and useful clinical approaches, underscoring that the adverse effects of VD derivatives must be balanced against the need for effective prevention of progressive and severe secondary hyperparathyroidism. Guidelines vary, but there seems to be general agreement that VD deficiency should be avoided in CKD patients, and it is likely that one should not wait until severe SHPT is present before cautiously starting VD derivatives. Furthermore, it is emphasized that the goal should not be the complete normalization of parathyroid hormone (PTH) levels. New developments may help us to better define optimal VD and PTH at different CKD stages, but large trials are still needed to confirm that VD and precise control of these and other CKD-MBD biomarkers are unequivocally related to improved hard outcomes in this population.

User interfaces for actuated scope maneuvering in surgical systems: a scoping review.

BACKGROUND: A variety of human computer interfaces are used by robotic surgical systems to control and actuate camera scopes during minimally invasive surgery. The purpose of this review is to examine the different user interfaces used in both commercial systems and research prototypes. METHODS: A comprehensive scoping review of scientific literature was conducted using PubMed and IEEE Xplore databases to identify user interfaces used in commercial products and research prototypes of robotic surgical systems and robotic scope holders. Papers related to actuated scopes with human-computer interfaces were included. Several aspects of user interfaces for scope manipulation in commercial and research systems were reviewed. RESULTS: Scope assistance was classified into robotic surgical systems (for multiple port, single port, and natural orifice) and robotic scope holders (for rigid, articulated, and flexible endoscopes). Benefits and drawbacks of control by different user interfaces such as foot, hand, voice, head, eye, and tool tracking were outlined. In the review, it was observed that hand control, with its familiarity and intuitiveness, is the most used interface in commercially available systems. Control by foot, head tracking, and tool tracking are increasingly used to address limitations, such as interruptions to surgical workflow, caused by using a hand interface. CONCLUSION: Integrating a combination of different user interfaces for scope manipulation may provide maximum benefit for the surgeons. However, smooth transition between interfaces might pose a challenge while combining controls.

Scope actuation system for articulated laparoscopes.

BACKGROUND: An articulated laparoscope comprises a rigid shaft with an articulated distal end to change the viewing direction. The articulation provides improved navigation of the operating field in confined spaces. Furthermore, incorporation of an actuation system tends to enhance the control of an articulated laparoscope. METHODS: A preliminary prototype of a scope actuation system to maneuver an off-the-shelf articulated laparoscope (EndoCAMaleon by Karl Storz, Germany) was developed. A user study was conducted to evaluate this prototype for the surgical paradigm of video-assisted thoracic surgery. In the study, the subjects maneuvered an articulated scope under two modes of operation: (a) actuated mode where an operating surgeon maneuvers the scope using the developed prototype and (b) manual mode where a surgical assistant directly maneuvers the scope. The actuated mode was further assessed for multiple configurations based on the orientation of the articulated scope at the incision. RESULTS: The data show the actuated mode scored better than the manual mode on all the measured performance parameters including (a) total duration to visualize a marked region, (a) duration for which scope focus shifts outside a predefined visualization region, and (c) number of times for which scope focus shifts outside a predefined visualization region. Among the different configurations tested using the actuated mode, no significant difference was observed. CONCLUSIONS: The proposed articulated scope actuation system facilitates better navigation of an operative field as compared to a human assistant. Secondly, irrespective of the orientation in which an articulated scope's shaft is inserted through an incision, the proposed actuation system can navigate and visualize the operative field.

Overcoming limits: First ABO incompatible living donor paired kidney transplant in an hypersensitized pediatric recipient in Spain.

INTRODUCTION: HLA sensitization is a growing problem in children awaiting kidney transplantation. In some cases, finding an immunologically compatible donor entails contemplating the option of an ABO incompatible transplant or paired transplant. METHODS: Patient with genetic nephrotic syndrome and progressive chronic kidney disease, with a previous thrombosis of a first kidney transplant, resulting hypersensitized and remaining for a long-time on hemodialysis. Despite a desensitization strategy, family members were incompatible and deceased donation options must be ruled out due to the presentation of donor-specific antibodies (DSA). After 4 years, the possibility arises to perform a kidney paired transplant with a 62-year-old woman with an incompatible blood group. Although the current cytotoxicity- and cell-based crossmatches were negative, history of DSA were recorded. RESULTS: An intensive ABO and HLA desensitization protocol was performed in order to combat the isohemagglutinin antibodies and on the memory-HLA, based on rituximab, apheresis sessions, and immunoglobulins. Despite the donor being older in terms of pediatric transplantation, the donor-recipient weight difference, and immunological risk, the transplant was completed successfully. Maintenance of titration of up to 1/2 was confirmed after 3 weeks post-transplant (IgM and IgG). Kidney biopsy at 2 weeks and 6 months without signs of rejection. The patient is currently 12 months post-transplant and has not presented any signs of transplant rejection and has proper renal function. CONCLUSIONS: Kidney paired transplantation is an excellent solution for hypersensitized children, and ABO incompatibility can be considered to increase their options to find a good donor, without thereby obtaining worse results.

Covid-19 en prisión. Una aproximación a la tendencia epidemiológica en Colombia / Covid-19 in prison. An approximation to the epidemiological trend in Colombia

RESUMEN Objetivo Realizar una aproximación a la tendencia epidemiológica de la COVID-19 en las prisiones colombianas. Materiales y Métodos Se emplearon datos demográficos de morbilidad y mortalidad registrados entre abril y octubre de 2020 correspondientes a la población detenida en las prisiones nacionales. Para analizar la situación de la COVID-19 se consultaron los reportes de la Organización Panamericana de la Salud (OPS). Mediante el uso de MS-Excel y R, se realizó un análisis descriptivo y se calcularon indicadores epidemiológicos. Resultados Los datos revelan una progresión de la pandemia con un incremento de casos positivos, reclusos hospitalizados en unidades de cuidado intensivo (UCI) y muertes relacionadas. Entre abril y octubre de 2020 se reportaron 16 804 casos positivos de COVID-19, con 80 reclusos en UCI y 136 muertes relacionadas. De estas muertes, el 94,9% se reportaron en hombres y el 5,1%, en mujeres. Respecto a su distribución por edad, el 63,2% de las muertes se presentaron en población entre 60 y más años. Conclusiones La tendencia de la COVID-19 en prisión presenta un comportamiento similar a la registrada en Colombia. Es decir, una fase interpandémica con un aumento progresivo de casos, hospitalizados en UCI y muertes, un pico significativo en agosto y un decrecimiento en septiembre. Sin embargo, en octubre la tendencia se revierte y se presenta un aumento en la confirmación de casos. Los indicadores epidemiológicos muestran una situación desfavorable respecto a la población general. En agosto, la Incidencia de casos fue 3,9 veces mayor. Mientras que, en octubre, la incidencia fue 1,5 veces mayor.

ABSTRACT Objective To approximate the epidemiological trend of COVID-19 in Colombian prisons. Materials and Methods Demographic, morbidity and mortality data recorded between April and October, 2020, corresponding to the population detained in national prisons were used. To analyze the situation of COVID-19, the reports of the Pan American Health Organization (PAHO) were consulted. Using MS-Excel and R, a descriptive analysis was performed, and epidemiological indicators were calculated. Results The data reveal a progression of the pandemic with an increase in positive cases, inmates hospitalized in intensive care units (ICU) and related deaths. Between April and October, 2020, 16,804 positive COVID-19 cases were reported with 80 inmates in ICU and 136 related deaths. Of these deaths, 94.9% were reported in males and 5.1% in females. Regarding their age distribution, 63.2% of deaths occurred in the population aged 60 years and older. Conclusions The trend in prison shows a behavior similar to that recorded in Colombia. That is, an interpandemic phase with a progressive increase in the number of cases, hospitalized in ICU and deaths, a significant peak in August and a decrease in September. However, in October the trend reversed and there was an increase in the confirmation of cases. Epidemiological indicators show an unfavorable situation with respect to the general population. In August, the incidence of cases was 3.9 times higher. In October, the incidence was 1.5 times higher.

Covid-19 en prisión. Una aproximación a la tendencia epidemiológica en Colombia / Covid-19 in prison. An approximation to the epidemiological trend in Colombia

RESUMEN Objetivo Realizar una aproximación a la tendencia epidemiológica de la COVID-19 en las prisiones colombianas. Materiales y Métodos Se emplearon datos demográficos de morbilidad y mortalidad registrados entre abril y octubre de 2020 correspondientes a la población detenida en las prisiones nacionales. Para analizar la situación de la COVID-19 se consultaron los reportes de la Organización Panamericana de la Salud (OPS). Mediante el uso de MS-Excel y R, se realizó un análisis descriptivo y se calcularon indicadores epidemiológicos. Resultados Los datos revelan una progresión de la pandemia con un incremento de casos positivos, reclusos hospitalizados en unidades de cuidado intensivo (UCI) y muertes relacionadas. Entre abril y octubre de 2020 se reportaron 16 804 casos positivos de COVID-19, con 80 reclusos en UCI y 136 muertes relacionadas. De estas muertes, el 94,9% se reportaron en hombres y el 5,1%, en mujeres. Respecto a su distribución por edad, el 63,2% de las muertes se presentaron en población entre 60 y más años. Conclusiones La tendencia de la COVID-19 en prisión presenta un comportamiento similar a la registrada en Colombia. Es decir, una fase interpandémica con un aumento progresivo de casos, hospitalizados en UCI y muertes, un pico significativo en agosto y un decrecimiento en septiembre. Sin embargo, en octubre la tendencia se revierte y se presenta un aumento en la confirmación de casos. Los indicadores epidemiológicos muestran una situación desfavorable respecto a la población general. En agosto, la Incidencia de casos fue 3,9 veces mayor. Mientras que, en octubre, la incidencia fue 1,5 veces mayor.

ABSTRACT Objective To approximate the epidemiological trend of COVID-19 in Colombian prisons. Materials and Methods Demographic, morbidity and mortality data recorded between April and October, 2020, corresponding to the population detained in national prisons were used. To analyze the situation of COVID-19, the reports of the Pan American Health Organization (PAHO) were consulted. Using MS-Excel and R, a descriptive analysis was performed, and epidemiological indicators were calculated. Results The data reveal a progression of the pandemic with an increase in positive cases, inmates hospitalized in intensive care units (ICU) and related deaths. Between April and October, 2020, 16,804 positive COVID-19 cases were reported with 80 inmates in ICU and 136 related deaths. Of these deaths, 94.9% were reported in males and 5.1% in females. Regarding their age distribution, 63.2% of deaths occurred in the population aged 60 years and older. Conclusions The trend in prison shows a behavior similar to that recorded in Colombia. That is, an interpandemic phase with a progressive increase in the number of cases, hospitalized in ICU and deaths, a significant peak in August and a decrease in September. However, in October the trend reversed and there was an increase in the confirmation of cases. Epidemiological indicators show an unfavorable situation with respect to the general population. In August, the incidence of cases was 3.9 times higher. In October, the incidence was 1.5 times higher.

Urinary CD80 Discriminates Among Glomerular Disease Types and Reflects Disease Activity.

INTRODUCTION: Heterogeneity of nephrotic diseases and a lack of validated biomarkers limits interventions and reduces the ability to examine outcomes. Urinary CD80 is a potential biomarker for minimal change disease (MCD) steroid-sensitive nephrotic syndrome (NS). We investigated and validated a CD80 enzyme-linked immunosorbent assay (ELISA) in urine in a large cohort with a variety of nephrotic diseases. METHODS: A commercial CD80 ELISA was enhanced and analytically validated for urine. Patients were from Mayo Clinic (307) and Nephrotic Syndrome Study Network Consortium (NEPTUNE; 104) as follows: minimal change disease (MCD, 56), focal segmental glomerulosclerosis (FSGS, 92), lupus nephritis (LN, 25), IgA nephropathy (IgAN, 20), membranous nephropathy (MN, 49), autosomal dominant polycystic kidney disease (ADPKD, 10), diabetic nephropathy (DN; 106), pyuria (19), and controls (34). Analysis was by Kruskal-Wallis test, generalized estimating equation (GEE) models, and receiver operating characteristic (AUC) curve. RESULTS: Urinary CD80/creatinine values were highest in MCD compared to other glomerular diseases and were increased in DN with proteinuria >2 compared to controls (control = 36 ng/g; MCD = 139 ng/g, P < 0.01; LN = 90 ng/g, P < 0.12; FSGS = 66 ng/g, P = 0.18; DN = 63, P = 0.03; MN = 69 ng/g, P = 0.33; ng/g, P = 0.07; IgA = 19 ng/g, P = 0.09; ADPKD = 42, P = 0.36; and pyuria 31, P = 0.20; GEE, median, P vs. control). In proteinuric patients, CD80 concentration appears to be independent of proteinuria levels, suggesting that it is unrelated to nonspecific passage across the glomeruli. CD80/creatinine values were higher in paired relapse versus remission cases of MCD and FSGS (P < 0.0001, GEE). CONCLUSION: Using a validated ELISA, urinary CD80 levels discriminate MCD from other forms of NS (FSGS, DN, IgA, MN) and primary from secondary FSGS.

Respuestas de salud pública para manejo de la COVID-19 en centros reclusión: revisión de literatura / Public health responses for the management of COVID-19 in detention centers: literature review

RESUMEN Objetivo Identificar en la literatura las recomendaciones para la prevención y control de la COVID-19 en prisiones y centros de detención preventiva, con el fin de caracterizar las líneas de respuesta. Materiales y Métodos Se identificaron 88 publicaciones en bases datos y repositorios digitales usando términos clave. Luego de aplicar la metodología PRISMA, se seleccionaron 18 publicaciones para realizar el análisis cualitativo. Las publicaciones elegidas refieren a recomendaciones de académicos, investigadores y expertos. Para ilustrar el enfoque de la respuesta gubernamental, se analizan seis publicaciones emitidas por autoridades gubernamentales de Canadá, Bélgica, Francia y Estados Unidos. Se excluyeron publicaciones relacionadas con centros de detención para menores o pacientes psiquiátricos. Resultados Si bien hay poca literatura, se logró caracterizar las recomendaciones disponibles, agrupándolas en seis líneas de respuesta. En su caracterización resulta primordial el establecimiento de medidas físicas, administrativas, jurídicas, higiénicas y de salubridad. Asimismo, se plantea la necesidad de garantizar el manejo epidemiológico y la adecuación de los servicios de salud en concordancia con la carga de enfermedad y las vulnerabilidades de los detenidos. Conclusiones La respuesta a la COVID-19 en centros de reclusión es compleja y desafiante. Por ende, las medidas convencionales del orden higiénico, sanitario, médico y epidemiológico no son suficientes. Estas deben ir acompañadas por un ajuste de las políticas criminal y penitenciaria, con el fin de reducir y controlar la densidad poblacional, además de la adaptación permanente de la administración de justicia en función de las medidas de contención, mitigación o supresión de la pandemia.(AU)

ABSTRACT Objective To identify in the literature the recommendations for the prevention and control of COVID-19 in prisons and other preventive detention centers, in order to characterize the response lines. Materials and Methods 88 publications were identified in databases and digital repositories using key terms. After applying the PRISMA methodology, 18 publications were selected to carry out the qualitative analysis. The chosen publications refer to recommendations from academics, researchers and experts. 6 publications issued by the Governments of Canada, Belgium, France and United States of America were analyzed to make clear the government perspectives. Publications related to underage and psychiatric patients were not considered. Results Although there isn't enough literature, it was possible to characterize the available recommendations, grouping them into 6 lines of action. Within these lines, the establishment of physical, administrative, legal, hygienic and health measures is considered essential. In addition, it is necessary to ensure the epidemiological management and adaptation of health services based on the burden of disease and susceptibility of the persons under arrest. Conclusions The response to COVID-19 in detention centers is complex and challenging. Therefore, the conventional steps like hygienic, sanitary, medical and epidemiological care aren't enough. In fact, the adjustment of criminal and penitentiary policies and the transformation of the justice system are considered essential to reduce and control the residential density.(AU)

[Public health responses for the management of COVID-19 in detention centers. Literature review]. / Respuestas de salud pública para manejo de la COVID-19 en centros reclusión. Revisión de literatura.

OBJECTIVE: To identify in the literature the recommendations for the prevention and control of COVID-19 in prisons and other preventive detention centers, in order to characterize the response lines. MATERIALS AND METHODS: 88 publications were identified in databases and digital repositories using key terms. After applying the PRISMA methodology, 18 publications were selected to carry out the qualitative analysis. The chosen publications refer to recommendations from academics, researchers and experts. 6 publications issued by the Governments of Canada, Belgium, France and United States of America were analyzed to make clear the government perspectives. Publications related to underage and psychiatric patients were not considered. RESULTS: Although there isn't enough literature, it was possible to characterize the available recommendations, grouping them into 6 lines of action. Within these lines, the establishment of physical, administrative, legal, hygienic and health measures is considered essential. In addition, it is necessary to ensure the epidemiological management and adaptation of health services based on the burden of disease and susceptibility of the persons under arrest. CONCLUSIONS: The response to COVID-19 in detention centers is complex and challenging. Therefore, the conventional steps like hygienic, sanitary, medical and epidemiological care aren't enough. In fact, the adjustment of criminal and penitentiary policies and the transformation of the justice system are considered essential to reduce and control the residential density.

Osteoporosis, bone mineral density and CKD-MBD (II): Therapeutic implications. / Osteoporosis, densidad mineral ósea y complejo CKD-MBD (II): implicaciones terapéuticas.

Osteoporosis (OP) and chronic kidney disease (CKD) both independently affect bone health. A significant number of patients with CKD have decreased bone mineral density (BMD), are at high risk of fragility fractures and have an increased morbidity and mortality risk. With an ageing population, these observations are not only dependent on "renal osteodystrophy" but also on the associated OP. As BMD predicts incident fractures in CKD patients (partI), we now aim to analyse the potential therapeutic consequences. Post-hoc analyses of randomised studies have shown that the efficacy of drugs such as alendronate, risedronate, raloxifene, teriparatide and denosumab is similar to that of the general population in patients with a mild/moderate decline in their glomerular filtration rate (especially CKD-3). These studies have some flaws however, as they included mostly "healthy" women with no known diagnosis of CKD and generally with normal lab test results. Nevertheless, there are also some positive preliminary data in more advanced stages (CKD-4), even though in CKD-5D they are more limited. Therefore, at least in the absence of significant mineral metabolism disorders (i.e. severe hyperparathyroidism), the potential benefit of these drugs should be considered in patients with a high or very high fracture risk. It is an important change that the new guidelines do not make it a requirement to first perform a bone biopsy and that the risk/benefit ratio of these drugs may be justified. However, we must also be aware that most studies are not consistent and the level of evidence is low. Consequently, any pharmacological intervention (risk/benefit) should be prudent and individualised.

Osteoporosis, bone mineral density and CKD-MBD complex (I): Diagnostic considerations. / Osteoporosis, densidad mineral ósea y complejo CKD-MBD (I): consideraciones diagnósticas.

Osteoporosis (OP) and chronic kidney disease (CKD) independently influence bone and cardiovascular health. A considerable number of patients with CKD, especially those with stages 3a to 5D, have a significantly reduced bone mineral density leading to a high risk of fracture and a significant increase in associated morbidity and mortality. Independently of classic OP related to age and/or gender, the mechanical properties of bone are also affected by inherent risk factors for CKD ("uraemic OP"). In the first part of this review, we will analyse the general concepts regarding bone mineral density, OP and fractures, which have been largely undervalued until now by nephrologists due to the lack of evidence and diagnostic difficulties in the context of CKD. It has now been proven that a reduced bone mineral density is highly predictive of fracture risk in CKD patients, although it does not allow a distinction to be made between the causes which generate it (hyperparathyroidism, adynamic bone disease and/or senile osteoporosis, etc.). Therefore, in the second part, we will analyse the therapeutic indications in different CKD stages. In any case, the individual assessment of factors which represent a higher or lower risk of fracture, the quantification of this risk (i.e. using tools such as FRAX®) and the potential indications for densitometry in patients with CKD could represent an important first step pending new clinical guidelines based on randomised studies which do not exclude CKD patients, all the while avoiding therapeutic nihilism in an area of growing importance.

Alkaline Phosphatases in the Complex Chronic Kidney Disease-Mineral and Bone Disorders.

Alkaline phosphatases (APs) remove the phosphate (dephosphorylation) needed in multiple metabolic processes (from many molecules such as proteins, nucleotides, or pyrophosphate). Therefore, APs are important for bone mineralization but paradoxically they can also be deleterious for other processes, such as vascular calcification and the increasingly known cross-talk between bone and vessels. A proper balance between beneficial and harmful activities is further complicated in the context of chronic kidney disease (CKD). In this narrative review, we will briefly update the complexity of the enzyme, including its different isoforms such as the bone-specific alkaline phosphatase or the most recently discovered B1x. We will also analyze the correlations and potential discrepancies with parathyroid hormone and bone turnover and, most importantly, the valuable recent associations of AP's with cardiovascular disease and/or vascular calcification, and survival. Finally, a basic knowledge of the synthetic and degradation pathways of APs promises to open new therapeutic strategies for the treatment of the CKD-Mineral and Bone Disorder (CKD-MBD) in the near future, as well as for other processes such as sepsis, acute kidney injury, inflammation, endothelial dysfunction, metabolic syndrome or, in diabetes, cardiovascular complications. However, no studies have been done using APs as a primary therapeutic target for clinical outcomes, and therefore, AP's levels cannot yet be used alone as an isolated primary target in the treatment of CKD-MBD. Nonetheless, its diagnostic and prognostic potential should be underlined.

Elemental composition in rainbow trout tissues from a fish farm from Patagonia, Argentina.

Rainbow trout is a salmonid specie of commercial importance raised in hatcheries in many countries. Studies over mineral requirements have being perform to guarantee the fulfillment of the nutritional needs and therefore improving the fish farm productions. The aim of this work was to investigate the performance of the elements like Ag, As, Br, Ca, Cr, Cs, Fe, Hg, K, Na, Rb, Se, and Zn, in rainbow trout from a Patagonian fish farming. Body burden of each element in relation to weight were analyzed for identifying potential bioaccumulation or dilution processes. Our results indicated that water and food were the sources for most of the elements, except Se and Ag. Selenium showed the highest value in unfertilized eggs, and Ag was detected in larvae newly after feeding. Toxic elements as Ag, Cr, and Hg were below the regulation standards for human consumption but tend to bioconcentrate in the juvenile state, and the As was during all the growth studied. The macro and micro nutrients assemble the daily requirements for the humans consume, excepting the K.

Osteoporosis, bone mineral density and CKD-MBD: treatment considerations.

Osteoporosis and chronic kidney disease (CKD) have both independently important potential impact on bone health. A significant number of patients with CKD stages 3a-5D have been shown to have low bone mineral density (BMD), leading to a strikingly elevated risk of fractures (mainly hip fractures) and higher associated morbidity and mortality. Mechanical properties of bone beyond age and menopausal status are additionally affected by intrinsic uremic factors. Therefore, we review in this article not only general concepts of osteoporosis and related consequences, but also the diagnostic and therapeutic implications of low BMD and bone fractures in CKD, beyond increased vascular calcification. Antiresorptive agents (mainly bisphosphonates) were not previously recommended when the estimated glomerular filtration rate (GFR) was lower than 30 ml/min/1.73 m2. However, post-hoc analysis of large randomized clinical trials found that these drugs (i.e. alendronate, ribandronate, denosumab) had comparable efficacy in improving BMD and reducing fracture risk in individuals (mainly women) with moderate reductions of GFR (mostly CKD stages 3-4). Therefore, at least in the absence of clear abnormalities of CKD-related mineral metabolism disturbances, bone antiresorptive agents (and maybe anabolic agents) that are or will be approved for general osteoporosis may be appropriate for CKD. Nephrologists should probably not ignore any longer fracture risk assessment, especially in patients with additional risk factors for osteoporosis if results will impact treatment decisions. However, although different therapeutic agents have been shown to reduce the risk of fracture in CKD patients with low BMD, specific prospective studies, with or without bone biopsies, in CKD are urgently needed.

Adult choledochal cysts: current update on classification, pathogenesis, and cross-sectional imaging findings.

Approximately 20% of choledochal cysts (CC) present in adult patients and they are commonly associated with a high risk of complications, including malignancy. Additionally, children who underwent internal drainage procedures for CCs can develop complications during adulthood despite treatment. Concepts regarding classification and pathogenesis of the CCs have been evolving. While new subtypes are being added to the widely accepted Todani classification system, simplified classification schemes have also been proposed to guide appropriate management. The exact etiology of CCs is currently unknown. The two leading theories involve either the presence of an anomalous pancreatico-biliary junction with associated reflux of pancreatic juice into the biliary system or, more recently, some form of antenatal biliary obstruction with resulting proximal bile duct dilation. Imaging studies play an important role in the initial diagnosis, surgical planning, and long-term surveillance of CCs.

Intraluminal air within an obstructed appendix: a CT sign of perforated or necrotic appendicitis.

RATIONALE AND OBJECTIVES: The aim of this study was to evaluate the predictive value of intraluminal air for appendiceal necrosis and/or perforation when not apparent on imaging. Additional factors of intraluminal appendicoliths, age, and gender were also assessed. MATERIALS AND METHODS: Patients with pathologically proven appendicitis who underwent multidetector computed tomographic imaging over a 3-year period (n = 487) were retrospectively reviewed. Those with imaging evidence for perforation were excluded to create a study population of apparent uncomplicated acute appendicitis (n = 374). Each scan was assessed for intraluminal appendiceal air and appendicoliths on multidetector computed tomography and compared against surgical and pathologic results for appendiceal necrosis and/or perforation. RESULTS: Image-occult necrosis or perforation was present in 17.4% (65 or 374) of the study cohort. Intraluminal air and appendicoliths were predictive variables by univariate logistic regression (P = .001 and P ≤ .001, respectively), with odds ratios of 2.64 (95% confidence interval, 1.48-4.73) for intraluminal air and 2.67 (95% confidence interval, 1.55-4.61) for appendicoliths. Both remained independent variables on multivariate modeling despite multicollinearity. Increasing age was also predictive (odds ratio, 1.25; 95% confidence interval, 1.09-1.44; P = .002), whereas gender was not (P = .472). CONCLUSIONS: Intraluminal appendiceal air in the setting of acute appendicitis is a marker of perforated or necrotic appendicitis. Recognition of this finding in otherwise uncomplicated appendicitis at imaging should raise suspicion for image-occult perforation or necrosis.

Coexisting MS and Lhermitte-Duclos Disease.

We report the case of a patient with pre-existing multiple sclerosis, who presented with horizontal diplopia, and a prior episode of progressive ataxia and dizziness lasting one week. While initially attributed to multiple sclerosis, subsequent imaging demonstrated a concurrent left cerebellar gangliocytoma, also known as Lhermitte-Duclos disease.