Prevention and management of cytomegalovirus infection and disease in kidney transplant: A consensus statement of the Transplantation Society of Taiwan.

Kidney transplant recipients have an increased risk of cytomegalovirus (CMV) infection and disease. A strategy for mitigating the risk of CMV infection in kidney transplant recipients has not yet been established in Taiwan. The Transplantation Society of Taiwan aimed to develop a consensus by expert opinion on the prevention and management of CMV infection. Based on the results of Consensus Conference, we suggested low-dose valganciclovir prophylaxis (450 mg once daily) for kidney transplant recipients. The prophylaxis duration was ≥6 months for high-risk (D+/R-) patients and 3 months for moderate-risk (R+) patients. Even for low-risk (D-/R-) patients, prophylaxis for at least 3 months is recommended because of the high seroprevalence of CMV in Taiwan. CMV prophylaxis was suggested after anti-thymocyte globulin treatment but not after methylprednisolone pulse therapy. Routine surveillance after prophylaxis, secondary prophylaxis after CMV disease treatment, and mTOR inhibitors for primary CMV prophylaxis were not recommended. Letermovir and marabavir are emerging CMV agents used for prophylaxis and refractory CMV disease. CMV immunoglobulins have been used to treat refractory CMV disease in Taiwan. We hope this consensus will help professionals manage patients with CMV in Taiwan to improve the quality of care.

In vivo biodistribution and pharmacokinetics of sotrovimab, a SARS-CoV-2 monoclonal antibody, in healthy cynomolgus monkeys.

PURPOSE: Sotrovimab (VIR-7831), a human IgG1κ monoclonal antibody (mAb), binds to a conserved epitope on the SARS-CoV-2 spike protein receptor binding domain (RBD). The Fc region of VIR-7831 contains an LS modification to promote neonatal Fc receptor (FcRn)-mediated recycling and extend its serum half-life. Here, we aimed to evaluate the impact of the LS modification on tissue biodistribution, by comparing VIR-7831 to its non-LS-modified equivalent, VIR-7831-WT, in cynomolgus monkeys. METHODS: 89Zr-based PET/CT imaging of VIR-7831 and VIR-7831-WT was performed up to 14 days post injection. All major organs were analyzed for absolute concentration as well as tissue:blood ratios, with the focus on the respiratory tract, and a physiologically based pharmacokinetics (PBPK) model was used to evaluate the tissue biodistribution kinetics. Radiomics features were also extracted from the PET images and SUV values. RESULTS: SUVmean uptake in the pulmonary bronchi for 89Zr-VIR-7831 was statistically higher than for 89Zr-VIR-7831-WT at days 6 (3.43 ± 0.55 and 2.59 ± 0.38, respectively) and 10 (2.66 ± 0.32 and 2.15 ± 0.18, respectively), while the reverse was observed in the liver at days 6 (5.14 ± 0.80 and 8.63 ± 0.89, respectively), 10 (4.52 ± 0.59 and 7.73 ± 0.66, respectively), and 14 (4.95 ± 0.65 and 7.94 ± 0.54, respectively). Though the calculated terminal half-life was 21.3 ± 3.0 days for VIR-7831 and 16.5 ± 1.1 days for VIR-7831-WT, no consistent differences were observed in the tissue:blood ratios between the antibodies except in the liver. While the lung:blood SUVmean uptake ratio for both mAbs was 0.25 on day 3, the PBPK model predicted the total lung tissue and the interstitial space to serum ratio to be 0.31 and 0.55, respectively. Radiomics analysis showed VIR-7831 had mean-centralized PET SUV distribution in the lung and liver, indicating more uniform uptake than VIR-7831-WT. CONCLUSION: The half-life extended VIR-7831 remained in circulation longer than VIR-7831-WT, consistent with enhanced FcRn binding, while the tissue:blood concentration ratios in most tissues for both drugs remained statistically indistinguishable throughout the course of the experiment. In the bronchiolar region, a higher concentration of 89Zr-VIR-7831 was detected. The data also allow unparalleled insight into tissue distribution and elimination kinetics of mAbs that can guide future biologic drug discovery efforts, while the residualizing nature of the 89Zr label sheds light on the sites of antibody catabolism.

A new missense mutation of calcium sensing receptor with isoleucine replaced by serine at codon 857 leading to type V Bartter syndrome.

Several genetic defects on thick ascending limb (TAL) of Henle loop were reported to cause Bartter syndrome (BS) characterized by metabolic alkalosis, hypokalemia, and normal or low blood pressure. Among them, defective basolateral calcium sensing receptors (CaSR) on TAL could result in type V BS that not only presents typical characteristics of BS but also hypocalcemia. Herein we report a 54 years old female patient with a novel mutation of CaSR that leads to type V BS. A sequencing of CaSR gene in peripheral blood mononuclear cells and urine stem cells both disclosed a heterozygous substitution of thymine for guanine (NM_001178065.1:c.2570T > G) in exon 7 at codon 857 resulting in substitution of isoleucine for serine (p.I857S). We performed functional tests of the mutant CaSR gene in vitro using urine stem cells to determine whether this mutation is responsible for the clinical presentations. Urine stem cells expressing abundant CaSR on flow cytometry of this patient and a normal subject were obtained for in vitro functional studies, including intracellular calcium and inositol 1,4,5-trisphosphate concentrations in response to increasing concentrations of extracellular calcium. The results show all of their responses to extracellular calcium are extremely sensitive in urine stem cells of the case as compared to those of the normal subject, indicating a prominent gain-of-function mutation. A novel mutation I857S in transmembrane domain 7 of CaSR in our patient would be added to the list of mutations leading to type V BS.

Infectious complications in adult patients with idiopathic minimal change nephrotic syndrome undergoing immunosuppressive therapy.

BACKGROUND: Patients with idiopathic minimal change nephrotic syndrome (MCNS) undergoing immunosuppressive therapy are susceptible to infectious complications. Study specifically focusing on adult population's infectious complications is lacking. METHODS: We retrospectively collected 101 adult patients with biopsy-proven idiopathic MCNS and analysed for the infectious complications. Published literatures were also reviewed aiming to evaluate the feasibility of prophylactic antibiotic treatment. RESULTS: Infectious complications developed in 17 of 101 (16.8%) patients, with pneumonia (n = 4), cellulitis/fasciitis (n = 4) and urinary tract infection (UTI) (n = 4) being the dominant diseases, and Gram-negative bacilli the main cause. AKI stage ≥2 (Hazard ratio = 6.1; 95% CI: 1.2-31.9, p = 0.031) and non-remission by treatment (Hazard ratio = 4.4; 95% CI: 1.2-15.6, p = .023) were the two independent risk factors relevant to developing infectious complications. Review of 16 published literatures and our data showed that even no prophylactic antibiotic therapy, only one case of Pneumocystis jirovecii pneumonia developed among the 1787 accumulative cases of MCNS. In contrast, 16 (44%) of acute flare cases were reported among the 36 patients with positive hepatitis B surface antigen that did not receive antiviral prophylactic therapy. CONCLUSIONS: Advanced acute kidney injury and non-remission by treatment are the risk factors toward developing infectious complications in adult MCNS undergoing immunosuppressive therapy. It appears unnecessary to use prophylactic antibiotic for Pneumocystis jirovecii pneumonia or other bacterial infections, while screening and prophylactic therapy for hepatitis B and latent tuberculosis are critical for patients in prevalent area.

Prophylactic hemodialysis following coronary angiography and one-year outcomes in non-dialysis patients with chronic kidney disease: A propensity-matched study.

BACKGROUND/PURPOSE: Prophylactic hemodialysis after coronary angiography in patients with chronic kidney disease (CKD) prevents contrast nephropathy; however, the one-year outcomes are unclear. This study aimed to investigate the one-year outcomes of prophylactic hemodialysis against standard treatment in patients with CKD who underwent coronary angiography. METHODS: A cohort study of 359 patients with CKD, coronary artery disease (CAD), and serum creatinine levels of 176.8-530.4 µmol/L, who were referred for elective coronary angiography was conducted. Propensity score matching identified 118 patient pairs for outcome comparisons. The hemodialysis group underwent prophylactic hemodialysis after coronary angiography, whereas the control group received standard treatment. The study's primary outcome was free from dialysis was considered the primary outcome, whereas the secondary outcome was overall survival. Unadjusted estimates of the probability of free from dialysis and overall survival were computed using Kaplan-Meier survival curves and log-rank tests. Cox proportional-hazards regression models were used in determining the risk factors associated with ESRD and mortality. RESULTS: During a mean 9.3 months follow-up duration, the hemodialysis group had significantly better free from dialysis (85.6% vs. 64.4%; P = 0.002) and overall survival (85.4% vs. 78.5%; P = 0.008) rates than the control group. Cox proportional-hazards regression analyses of the propensity score-matched patients showed that the hemodialysis group had reduced risks for ESRD and mortality (hazard ratios, 0.32 and 0.48, respectively). CONCLUSION: Prophylactic Hemodialysis following coronary angiography was associated with reduced ESRD and mortality risks in CKD patients with CAD, who did not routinely undergo dialysis.

The effect of mechanical traction on low back pain in patients with herniated intervertebral disks: a systemic review and meta-analysis.

OBJECTIVE: To evaluate the effectiveness of traction in improving low back pain, functional outcome, and disk morphology in patients with herniated intervertebral disks. DATA SOURCE: PubMed, Scopus, Embase, and the Cochrane Library were searched from the earliest record to July 2019. REVIEW METHODS: We included randomized control trials which (1) involved adult patients with low back pain associated with herniated disk confirmed by magnetic resonance imaging or computed tomography, (2) compared lumbar traction to sham or no traction, and (3) provided quantitative measurements of pain and function before and after intervention. Methodological quality was assessed using the physiotherapy evidence database (PEDro) scale and Cochrane risk of bias assessment. RESULTS: Initial searches for literature yielded 3015 non-duplicated records. After exclusion based on the title, abstract, and full-text review, 7 articles involving 403 participants were included for quantitative analysis. Compared with the control group, the participants in the traction group showed significantly greater improvements in pain and function in the short term, with standard mean differences of 0.44 (95% confidence interval (CI): 0.11-0.77) and 0.42 (95% CI: 0.08-0.76), respectively. The standard mean differences were not significant to support the long-term effects on pain and function, nor the effects on herniated disk size. CONCLUSION: Compared with sham or no traction, lumbar traction exhibited significantly more pain reduction and functional improvements in the short term, but not in the long term. There is insufficient evidence to support the effect of lumbar traction on herniated disk size reduction.

Clinical risk factors and outcomes of massive ascites accumulation after discontinuation of peritoneal dialysis.

Background: Encapsulating peritoneal sclerosis (EPS) is a serious complication of peritoneal dialysis (PD), with high morbidity and mortality that requires an early diagnosis for effective treatment. PD withdrawal and bacterial peritonitis are important triggers for the onset of EPS. However, few studies have focused on cases of PD withdrawal without a clinical diagnosis of peritonitis, cirrhosis, or carcinomatosis. We aimed to compare the clinical characteristics and computed tomography (CT) images of patients with or without ascites in such situations and assess clinical outcomes in terms of mortality.Methods: Our retrospective review included 78 patients who withdraw PD between January 2000 and December 2017.Results: Ten patients had ascites, and 68 did not have a significant intra-abdominal collection. The ascites group had a significantly longer PD duration (months; 134.41 [range, 35.43-181.80] vs. 32.42 [733-183.47], p < 0.001) and higher peritoneal membrane transport status based on the dialysate-to-plasma ratios of creatinine (0.78 ± 0.08 vs. 0.68 ± 0.11, p = 0.009) and glucose (0.27 ± 0.07 vs. 0.636 ± 0.08, p = 0.001) than the control group. CT parameters, including peritoneal calcification, thickness, bowel tethering, or bowel dilatation, were not all present in each patient with ascites and EPS. During the 12-month study period, the ascites group had a higher risk for developing EPS (70% vs. 0%, p < 0.001) and a higher 12-month all-cause mortality (30% vs. 0%, p = 0.002).Conclusions: Ascites accumulation was not rare after PD discontinuation. A longer PD duration and high peritoneal membrane transport status could predict subsequent ascites accumulation. Furthermore, patients with ascites were at a higher risk of EPS.

Secretome of Hypoxic Endothelial Cells Stimulates Bone Marrow-Derived Mesenchymal Stem Cells to Enhance Alternative Activation of Macrophages.

We intended to explore the cellular interaction between mesenchymal stem cells (MSCs) and injured endothelial cells leading to macrophage alternative polarization in healing kidney ischemic reperfusion injury. In vivo, the amounts of recruited macrophages were significantly mitigated by MSCs in the injured tissues, especially in the group using hematopoietic cell E- and L-selectin ligand (HCELL)-positive MSCs. Compared to controls, MSCs also enhanced expression of CD206 and CD163, which was further enhanced by HCELL expression. In vitro, analysis of cytokines involving macrophage polarization showed IL-13 rather than IL-4 from MSCs agreed with expression of macrophage CD206 in the presence of hypoxic endothelial cells. Among them, HCELL-positive MSCs in contact with hypoxic endothelial cells produced the greatest response, which were reduced without HCELL or using a transwell to prevent cell contact. With blockade of the respective cytokine, downregulated MSCs secretion of IL-13 and CD206 expression were observed using inhibitors of IFN-γ and TNF-α, but not using those of TGF-ß and NO. With IFN-γ and TNF-α, MSCs IL-13 secretion and CD206 expression were upregulated. In conclusion, hypoxia induces endothelial cells producing multiple cytokines. Among them, IFN-γ and TNF-α that stimulate MSCs to secrete IL-13 but not IL-4, leading to alternative polarization.

Automatic image processing pipeline for tracking longitudinal vessel changes in magnetic resonance angiography.

BACKGROUND: Cerebral vessel diameter changes objectively and automatically derived from longitudinal magnetic resonance angiography (MRA) facilitate quantification of vessel changes and further modeling. PURPOSE: To characterize longitudinal changes in intracranial vessel diameter using time-of-flight (TOF) MRA. STUDY TYPE: Retrospective longitudinal study. SUBJECT POPULATION: IN all, 112 pediatric patients, aged 9.96 ± 4.59 years, with craniopharyngioma from 2006-2011 scanned annually. FIELD STRENGTH/SEQUENCE: 1.5T and 3T TOF MRA. STATISTICAL TESTS: Chi-square and Wilcoxon-Mann-Whitney tests. ASSESSMENT: Manual measurements using interventional angiography was established as a reference standard for diameter measurements. Constant and linear quantile regression with absolute difference, percentage difference, and relative difference was used for outlier detection. RESULTS: Major vessels surrounding the circle of Willis were successfully segmented except for posterior communicating arteries, mostly due to disease-related hypoplasia. Diameter measurements were calculated at 1-mm segments with a median computed vessel diameter of 1.25 mm. Diameter distortion due to registration was within 0.04 mm for 99% of vessel segments. Outlier detection using quantile regression detected less than 4.34% as being outliers. Outliers were more frequent in smaller vessels and proximity to bifurcations (P < 0.001). DATA CONCLUSION: Using the proposed method, objective changes in vessel diameter can be acquired noninvasively from routine longitudinal imaging. High-throughput analyses of imaging-derived vascular trees combined with clinical and treatment parameters will allow rigorous modeling of vessel diameter changes. LEVEL OF EVIDENCE: 2 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;50:1063-1074.

Meta-analyzability Concerns in Meta-analyses.

Many studies to date have conducted a meta-analysis on a mix of effectiveness and superiority studies. This methodological flaw will lead to difficulties in interpreting the results. We addressed this issue in this article, illustrated our point with a simulated experiment, and re-analyzed a recent meta-analysis study based on the effectiveness-superiority dichotomy to provide a real-world correlate of our point of view.

Effectiveness and Superiority of Rehabilitative Treatments in Enhancing Motor Recovery Within 6 Months Poststroke: A Systemic Review.

OBJECTIVE: To investigate the effects of various rehabilitative interventions aimed at enhancing poststroke motor recovery by assessing their effectiveness when compared with no treatment or placebo and their superiority when compared with conventional training program (CTP). DATA SOURCE: A literature search was based on 19 Cochrane reviews and 26 other reviews. We also updated the searches in PubMed up to September 30, 2017. STUDY SELECTION: Randomized controlled trials associated with 18 experimented training programs (ETP) were included if they evaluated the effects of the programs on either upper extremity (UE) or lower extremity (LE) motor recovery among adults within 6 months poststroke; included ≥10 participants in each arm; and had an intervention duration of ≥10 consecutive weekdays. DATA EXTRACTION: Four reviewers evaluated the eligibility and quality of literature. Methodological quality was assessed using the PEDro scale. DATA SYNTHESIS: Among the 178 included studies, 129 including 7450 participants were analyzed in this meta-analysis. Six ETPs were significantly effective in enhancing UE motor recovery, with the standard mean differences (SMDs) and 95% confidence intervals outlined as follow: constraint-induced movement therapy (0.82, 0.45-1.19), electrostimulation (ES)-motor (0.42, 0.22-0.63), mirror therapy (0.71, 0.22-1.20), mixed approach (0.21, 0.01-0.41), robot-assisted training (0.51, 0.22-0.80), and task-oriented training (0.57, 0.16-0.99). Six ETPs were significantly effective in enhancing LE motor recovery: body-weight-supported treadmill training (0.27, 0.01-0.52), caregiver-mediated training (0.64, 0.20-1.08), ES-motor (0.55, 0.27-0.83), mixed approach (0.35, 0.15-0.54), mirror therapy (0.56, 0.13-1.00), and virtual reality (0.60, 0.15-1.05). However, compared with CTPs, almost none of the ETPs exhibited significant SMDs for superiority. CONCLUSIONS: Certain experimented interventions were effective in enhancing poststroke motor recovery, but little evidence supported the superiority of experimented interventions over conventional rehabilitation.

Evaluation of the association of Wnt signaling with coronary artery calcification in patients on dialysis with severe secondary hyperparathyroidism.

BACKGROUND: Patients with end-stage renal disease have a higher risk of death from cardiovascular events, which can be mainly attributed to coronary artery calcification (CAC). Wnt signaling is involved in vascular development and may play a role in vascular calcification. This study aimed to evaluate CAC prevalence in patients on dialysis with severe secondary hyperparathyroidism (SHPT) and identify CAC risk factors. METHODS: The study is a retrospective analysis of the severe hyperparathyroidism registration study that prospectively recruited patients on dialysis with severe SHPT who were candidates for parathyroidectomy, from October 2013 to May 2015. CAC and bone mineral density (BMD) were measured. Demographic and clinical data including calcium, phosphorus, alkaline phosphatase, intact parathyroid hormone, Dickkopf-related protein 1 (DKK1), and sclerostin levels were analyzed. CAC scores were reported in Agatston units (AU). RESULTS: A total of 61 patients were included in this study. No CAC, mild CAC (<100 AU), moderate CAC (>100 AU), and severe CAC (>400 AU) were observed in 4.9%, 11.4%, 14.8%, and 68.9% of patients, respectively. DKK1 and sclerostin were not associated with CAC. In univariate analysis, CAC was significantly correlated with age, sex (male), total cholesterol, and intravenous pulse calcitriol (p<0.05). CAC was not inversely correlated with the BMD, T scores, or Z scores of the femoral neck (p>0.05). In multivariate analysis, the stepwise forward multiple linear regression revealed that CAC was associated with age, male sex and intravenous pulse calcitriol (p<0.05). Furthermore, serum sclerostin was positively correlated with the BMD of the femoral neck but negatively associated with intact parathyroid hormone (p<0.05). Serum sclerostin was significantly associated with severely low bone mass with Z-scores<-2.5 of the femoral neck, even when adjusted for serum intact parathyroid hormone, vitamin D status, dialysis pattern, sex, and DKK-1 (p<0.05). CONCLUSIONS: The patients on dialysis with severe SHPT have a high prevalence of vascular calcification. Although the Wnt signaling pathway could play a role in hyperparathyroid bone disease, CAC may be mainly due to the treatment modality rather than the Wnt signaling pathway associated bone metabolism in patients on dialysis with severe SHPT.

CD44 fucosylation on mesenchymal stem cell enhances homing and macrophage polarization in ischemic kidney injury.

The lack of homing ability possibly reduces the healing potential of bone-marrow-derived mesenchymal stem cells (MSCs). Therefore, transforming native CD44 on MSCs into a hematopoietic cell E-/L-selectin ligand (HCELL) that possesses potent E-selectin affinity might enhance the homing and regenerative abilities of MSCs. Through fucosyltransferase VI (FTVI) transfection, MSCs were fucosylated on N-glycans of CD44 to become HCELL positive, thus interacting with E-selectin on injured endothelial cells. HCELL expression facilitated MSC homing in kidneys within 24h after injury and reduced lung stasis. An in vitro adhesion assay revealed that transfection enhanced the association between MSCs and hypoxic endothelial cells. In mice treated with HCELL-positive MSCs, the injured kidneys exhibited clusters of homing MSCs, whereas MSCs were rarely observed in mouse kidneys treated with HCELL-negative MSCs. Most MSCs were initially localized at the renal capsule, and some MSCs later migrated inward between tubules. Most homing MSCs were in close contact with inflammatory cells without tubular transdifferentiation. Furthermore, HCELL-positive MSCs substantially alleviated renal injury, partly by enhancing the polarization of infiltrating macrophages. In conclusion, engineering the glycan of CD44 on MSCs through FTVI transfection might enhance renotropism and the regenerating ability of MSCs in ischemic kidney injury.

Automatic recognition of subject-specific cerebrovascular trees.

PURPOSE: An image filter designed for reconstructing cerebrovascular trees from MR images is described. Current imaging techniques capture major cerebral vessels reliably, but often fail to detect small vessels, whose contrast is suppressed due to limited resolution, slow blood flow rate, and distortions around bifurcations or nonvascular structures. An incomplete view of angioarchitecture limits the information available to physicians. METHODS: A novel Hessian-based filter for contrast-enhancement in MR angiography and venography for blood vessel reconstruction without introducing dangling segments is presented. We quantify filter performance with receiver-operating-characteristic and dice-similarity-coefficient analysis. Total extracted vascular length, number-of-segments, volume, surface-to-distance, and positional error are calculated for validation. RESULTS: Reconstruction of cerebrovascular trees from MR images of six volunteers show that the new filter renders more complete representations of subject-specific cerebrovascular networks. Validation with phantom models shows the filter correctly detects blood vessels across all length scales without failing at bifurcations or distorting diameters. CONCLUSION: The novel filter can potentially improve the diagnosis of cerebrovascular diseases by delivering metrics and anatomy of the vasculature. It also facilitates the automated analysis of large datasets by computing biometrics free of operator subjectivity. The high quality reconstruction enables computational mesh generation for subject-specific hemodynamic simulations. Magn Reson Med 77:398-410, 2017. © 2016 Wiley Periodicals, Inc.

Pelvic drainage during removal of dialysis catheter decreases the risk of subsequent intra-abdominal complications in refractory peritoneal dialysis-related peritonitis.

AIM: Some patients with refractory peritoneal dialysis-related peritonitis continue to develop intra-abdominal complications despite removal of the peritoneal catheter. Repeated percutaneous drainage or open laparotomy is often required, and mortality is not uncommon. The benefits of pelvic drainage placement during catheter removal in decreasing these complications and interventions remain unproven. METHODS: Forty-six patients with refractory peritonitis who underwent removal of a Tenckhoff catheter between 1991 and 2013 were reviewed retrospectively. Twelve patients had pelvic drainage using closed active suction devices during catheter removal (drainage group). The remaining 34 patients underwent catheter removal without drainage (non-drainage group). The outcomes measured were the development of intra-abdominal complications and the requirement for repeated percutaneous drainage or open laparotomy within 90 days after the catheter removal. RESULTS: Baseline characteristics were similar with the exception of a higher median number of previous peritonitis episodes in the drainage group compared with the non-drainage group (2 vs 0, P = 0.02). During the follow-up period, intra-abdominal complications occurred in 15 (44%) of 34 patients in the non-drainage group, compared with one (8%) of 12 patients in the drainage group (P = 0.03). Twelve (35%) patients in the non-drainage group required repeated percutaneous drainage or open laparotomy for management, compared with zero (0%) patients in the drainage group (P = 0.02). Drain tubes were removed at a median of 6 days (inter-quartile range: 5-10) without complications. CONCLUSIONS: In the management of refractory peritonitis, pelvic drainage during removal of dialysis catheter decreases the risk of subsequent intra-abdominal complications and invasive interventions.

Parathyroidectomy improves cardiovascular outcome in nondiabetic dialysis patients with secondary hyperparathyroidism.

OBJECTIVE: Secondary hyperparathyroidism and its associated abnormalities in mineral metabolism and haemodynamic changes increase the cardiovascular risk in patients with end-stage renal disease (ESRD). Our objective was to determine the association of parathyroidectomy (PTX) with major cardiovascular events in nondiabetic dialysis patients with severe secondary hyperparathyroidism (SHPTH). DESIGN AND PATIENTS: We performed a cohort study with fifty-three nondiabetic ESRD patients who were treated with maintenance haemodialysis and who had intact parathyroid hormone (PTH) levels > 800 pg/ml. Participants received either only medical therapy or medical therapy and total PTX with autotransplantation for SHPTH. MEASUREMENTS: We evaluated the associations between PTX and major cardiovascular events including death, cerebrovascular accident and myocardial infarction. The biochemical and haemodynamic changes associated with PTX were measured. RESULTS: During the mean follow-up of 72 months, twenty-three patients received only medical treatment (medical group) while thirty patients underwent PTX in addition to medical treatment (PTX group). The two groups were comparable in respect of baseline characteristics. PTX group was found to be associated with a reduced incidence of major cardiovascular events (P = 0·021). A multiple Cox regression analysis showed that the variable significantly associated with major cardiovascular events was treatment modality (medical therapy vs medical therapy and parathyroidectomy, hazard ratio = 26·12, 95% CI = 1·30-526·27, P = 0·033). Blood pressure, haemoglobin, alkaline phosphatase, calcium, phosphate and calcium × phosphate product significantly improved after PTX. CONCLUSIONS: PTX was associated with better cardiovascular outcome in nondiabetic dialysis patients with severe SHPTH.

Retrospective evaluation of standard diagnostic procedures in identification of the causes of new-onset syndrome of inappropriate antidiuresis.

BACKGROUND: Many diagnostic procedures are conducted in patients with syndrome of inappropriate antidiuresis (SIAD). However, the contribution in identification of the cause of SIAD remains unknown. METHODS: The study was conducted at Kaohsiung Veterans General Hospital in southern Taiwan. From January 2000 to December 2009, medical records of 439 adult patients hospitalized for new-onset SIAD at a single center were retrospectively collected. All diagnostic procedures during hospitalization were divided into four groups: chest/lung, central nervous system, abdomen, and bone marrow to evaluate their positive rate leading to the cause of SIAD. Factors associated with "procedures leading to the cause" were also analyzed to improve efficacy of survey. RESULTS: Cause of SIAD was identified in 267 (60.8%). Of them, 150 were pulmonary disorders, 44 were drugs, 37 were central nervous system disorders, 32 were malignancy and 4 were post-surgery. Survey for chest/lung, central nervous system, abdomen, and bone marrow were performed in 96.6%, 29.2%, 38.0% and 3.6% of patients, respectively; positive findings leading to the cause of SIAD were 39.6%, 12.5%, 5.3% and 6.3%, respectively. Among the diagnostic procedures, chest x-ray (424/439, 96.6%) was most frequently performed with the highest identification rate of 34.7% (147 cases). Major significant independent factors that associated with "procedure leading to a cause" were: absence of SIAD-associated drug history, presence of fever/chills, and presence of respiratory symptoms. Cause of SIAD became evident later during the follow-up period in 10 of 172 (5.8%) patients who were initially thought to be cause-unknown. Malignancy was the cause for 5 cases and pulmonary tuberculosis was for the other five. Eight of these causes became evident within one year after the diagnosis of SIAD. CONCLUSIONS: SIAD with unidentified causes were prevalent. Current diagnostic procedures remain not satisfying in determining the cause of SIAD, but chest radiograph did demonstrate higher diagnostic rate, especially in patients presented with fever, chills, respiratory symptoms, and without SIAD-associated drug history. Patients with unidentified cause should be followed for at least one year when most hidden causes (e.g. malignancy and tuberculosis) become obvious.

The Additional Effect of Interfascial Hydrodissection with Dextrose on Shoulder and Neck Function in Patients with Myofascial Pain Syndrome: A Randomized Control Trial.

OBJECTIVES: To evaluate whether the application of an interfascial injection with dextrose water could result in reduced pain, improved shoulder function and range of motion. DESIGN: This is a double-blind randomized controlled trial. Thirty-five patients with chronic shoulder pain were randomly assigned to receive either an interfascial injection of 10 mL of 10% dextrose water guided by ultrasound, or a sham injection of 0.5 mL of 10% dextrose water into the subcutaneous layer. All patients received education on a home program of self-massage and self-stretching. Shoulder pain, shoulder range of motion (ROM), and neck and shoulder function were measured before injection, and at 4 and 12 weeks after injection. RESULTS: Both groups showed significant improvements in visual analog scale (VAS) scores at 12 weeks follow-up. The interfascial injection group exhibited a significant pain reduction compared with the sham group at the 12 weeks follow up. No between group differences were observed in shoulder ROM, pain threshold and neck and shoulder function. CONCLUSION: Interfascial injection is effective in decreasing pain in patients with myofascial pain syndrome.

Effect of wearable exoskeleton on post-stroke gait: A systematic review and meta-analysis.

BACKGROUND: Wearable exoskeletons are a recently developed technology. OBJECTIVES: The present systematic review aimed to investigate the effect of a wearable exoskeleton on post-stroke walking by considering its use in a gait training system and simply as an orthosis assisting walking. METHODS: We systematically searched for randomised and quasi-randomised controlled trials in PubMed, Scopus, CINAHL and Embase databases from their earliest publication record to July 2021. We chose reports of trials investigating the effects of exoskeleton-assisted training or the effects of wearing an exoskeleton to assist walking. A meta-analysis was conducted to explore the benefits of the wearable exoskeleton on mobility capacity, walking speed, motor function, balance, endurance and activities of daily living. RESULTS: We included 13 studies (492 participants) comparing exoskeleton-assisted training with dose-matched conventional gait training. Studies addressing the effect of wearing a wearable exoskeleton were unavailable. As compared with conventional gait training at the end of the intervention, exoskeleton-assisted training was superior for walking speed (mean difference [MD] 0.13 m/s, 95% CI 0.05; 0.21) and balance (standardized MD [SMD] 0.3, 95% CI 0.07; 0.54). The subgroup with chronic stroke (i.e., > 6 months) presented the outcome favouring exoskeleton-assisted training regarding overall mobility capacity (SMD 0.37, 95% CI 0.04; 0.69). At the end of follow-up, exoskeleton-assisted training was superior to conventional gait training in overall mobility (SMD 0.45, 95% CI 0.07; 0.84) and endurance (MD 46.23 m, 95% CI 9.90; 82.56). CONCLUSIONS: Exoskeleton-assisted training was superior to dose-matched conventional gait training in several gait-related outcomes at the end of the intervention and follow-up in this systematic review and meta-analysis, which may support the use of exoskeleton-assisted training in the rehabilitation setting. Whether wearing versus not wearing a wearable exoskeleton is beneficial during walking remains unknown.

Comparison of primary total hip arthroplasty with limited open reduction and internal fixation vs open reduction and internal fixation for geriatric acetabular fractures: a systematic review and meta-analysis.

Purpose: Comminuted fractures with poor bone quality in the elderly are associated with poor outcomes. An alternative to open reduction and internal fixation (ORIF) alone, primary or acute total hip arthroplasty (aTHA), allows early mobilization with full weight bearing. In this study, we aim to analyze whether treatment of aTHA with/withtout ORIF (limited ORIF) vs ORIF alone yields better intra-operative results, functional outcomes, and less complications. Methods: PubMed, Cochrane, Embase, and Scopus databases were searched in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. Random-effects model and 95% confidence intervals were used. The outcomes of interest were surgery time, blood loss, length of hospital stay, Harris hip score (HHS), 36-Item Short Form Survey (SF-36), complication rate, surgical site infection rate, heterotopic ossification rate, reoperation rate, and mortality rate. Results: Ten observational studies with a total of 642 patients (415 ORIF alone and 227 aTHA with/without ORIF) were included in the systematic review. Compared to ORIF alone, aTHA with limited ORIF provided higher HHS (P = 0.029), better physical function (P = 0.008), better physical component summary (P = 0.001), better mental component summary (P = 0.043) in postoperative 1-year SF-36, lesser complication rate (P = 0.001), and lesser reoperation rate (P = 0.000), but however greater bodily pain (P = 0.001) in acetabular fractured elderlies. Conclusions: Acute THA with limited ORIF is favorable alternative to ORIF technique alone. It provided better HHS, physical, and mental component summary in SF-36 and yielded lower complication and reoperation rate compare to ORIF alone.