Predicting new-baseline glomerular filtration rate (NBGFR) after donor nephrectomy: validation of a split renal function (SRF)-based formula.

BACKGROUND: Accurate prediction of post-donor nephrectomy (DN) glomerular filtration rate is potentially useful for evaluating and counselling living kidney donors. Currently, there are limited tools to evaluate post-operative new-baseline glomerular filtration rate (NBGFR) in kidney donors. We aim to validate a conceptually simple formula based on split renal function (SRF) previously developed for radical nephrectomy patients. METHODS: Eighty-three consecutive patients who underwent DN from 2010 to 2016 were included. Pre-operative CT imaging and functional data including pre-DN baseline Global GFR (108.2 ± 13.2 mL/min/1.73m2) were included. Observed NBGFR was defined as the latest eGFR 3-12 months post-DN. SRF, defined as volume of the contralateral non-resected kidney normalised by total volume of kidneys, was determined from pre-operative cross-sectional imaging (49.2 ± 2.36%). The equation derived from Rathi et al. is as detailed: Predicted NBGFR = 1.24 × (Global GFR Pre-DN) x (SRF). RESULTS: The relationship between predicted NBGFR (66.0 ± 8.29 mL/min/1.73m2) and observed NBGFR (74.9 ± 16.4 mL/min/1.73m2) was assessed by evaluating correlation coefficients, bias, precision, accuracy, and concordance. The new SRF-based formula for NBGFR prediction correlated strongly with observed post-operative NBGFR (Pearson's r = 0.729) demonstrating minimal bias (median difference = 7.190 mL/min/1.73m2) with good accuracy (96.4% within ± 30%, 62.7% within ± 15%) and precision (IQR of bias = - 0.094 to 16.227). CONCLUSION: The SRF-based formula was also able to accurately discriminate all but one patient to an NBGFR of > 45 mL/min/1.73m2. We utilised the newly developed SRF-based formula for predicting NBGFR in a living kidney donor population. Counselling of donor post-operative renal outcomes may then be optimised pre-operatively.

Multi-photon microscopy for the evaluation of interstitial fibrosis in extended criteria donor kidneys: A proof-of-concept study.

INTRODUCTION: To evaluate the initial use of label-free second harmonic generation (SHG) imaging with two-photon excitation (2PE) auto-fluorescence in multiphoton microscopy (MPM) for the quantification of collagen/fibrosis on preimplantation biopsies of extended criteria donors (ECD). MATERIALS AND METHODS: Twenty preimplantation core biopsies were extracted from 10 donor kidney samples, of which originated from seven donors. Kidney Donor Profile Index (KDPI) and Remuzzi scores of biopsies were calculated. Collagen parameters measured included quantification by the Collagen Area Ratio in Total Tissue (CART) and qualitative measurements by Collagen Reticulation Index (CRI). RESULTS: Biopsies classified with > 85% KDPI scores had significantly higher CART (p = .011) and lower CRI values (p = .025) than biopsies with ≤ 85% KDPI scores. Increase in CRI values correlated significantly with rise in recipient creatinine levels 1-year post-transplant (p = .027; 95% CI: 4.635-66.797). CONCLUSION: MPM is an evolving technology that enables the quantification of the amount (CART) and quality (CRI) of collagen deposition in unstained preimplantation biopsies of donor kidneys stratified by KDPI scores. This initial evaluation found significant differences in both parameters between donor kidneys with more or less than 85% KDPI.

Tryptophan-kynurenine ratio as a biomarker of bladder cancer.

OBJECTIVES: To investigate plasma and urinary kynurenine (KYN)-tryptophan (TRP) ratios in bladder cancer, expression of indoleamine 2,3-dioxygenase 1 (IDO1) in relation to tryptophan 2,3-dioxygenase (TDO2) in bladder tumour, and the correlation of KYN-TRP ratio with bladder tumour burden. METHODS: Metabotyping of the TRP-KYN metabolic axis was performed via a clinical case-control study. Expression of IDO1 and TDO2 was measured in human biopsied tissues. Correlational experiments between KYN-TRP ratio and bladder tumour were performed using a murine orthotopic prostate-specific antigen (PSA)-secreting MB49 bladder cancer model. RESULTS: We established for the first time that plasma TRP level was significantly decreased, while both plasma and urinary KYN-TRP ratios were significantly higher in bladder cancer patients, and expression level of IDO1 but not TDO2 was increased in human bladder tumour. We reported the positive correlation between IDO1 expression, KYN-TRP ratio, normalized PSA to creatinine, and bladder tumour burden in the murine model. CONCLUSION: Kynurenine-tryptophan ratio is a promising surveillance biomarker for bladder cancer, but would require further validation before clinical translation.

Combination therapy of oxidised regenerated cellulose/collagen/silver dressings with negative pressure wound therapy for coverage of exposed critical structures in complex lower-extremity wounds.

Complex wounds with exposed critical structures such as tendon and bone are a conundrum in wound management, especially in the setting where the patient is not a suitable candidate for flap surgery. While the individual use of negative pressure wound therapy (NPWT) and oxidised regenerated cellulose (ORC)/collagen/silver (PROMOGRAN PRISMA) dressing has been described in the literature, there are little data on the efficacy of their combined use. In this study, we describe a novel technique of combining the use of NPWT and ORC/collagen/silver dressings to manage complex wound beds as an alternative management option for patients not suitable for reconstructive flap surgery. This technique was performed in a series of 37 patients with complex lower-extremity wounds that were not healing with conventional NPWT alone. All patients had open wounds with exposed critical structures that were difficult to manage, such as exposed tendon, bone, deep crevices, and joint. Successful coverage of exposed critical structures was achieved in 89% of patients, and coverage was achieved within 28 days of combination therapy in 82% of these patients, without any complications. The novel technique of combining ORC/collagen/silver dressing and NPWT provides a useful option in the armamentarium of a reconstructive surgeon dealing with difficult complex lower-extremity wounds.

Visceral obesity in Asian living kidney donors significantly impacts early renal function after donor nephrectomy.

INTRODUCTION: Obesity may be a risk factor for kidney donors to develop reduced renal function. The Framingham heart study suggested that visceral adipose tissue (VAT) confers a more adverse metabolic profile compared with subcutaneous adipose tissue (SAT). Asians tend to have a higher VAT composition and it is unclear if their kidney function is affected differently. We hypothesized that Asian living kidney donors who have visceral obesity are at a higher risk of renal function deterioration 1 year after donation. METHODS: Between 2011 and 2014, we retrospectively evaluated data from 73 consecutive patients (52% male; mean age 44.9 ± 11.7 years) before they underwent donor nephrectomy and at their 1 year routine follow-up. VAT and SAT were measured at the level of the umbilicus on pre-operative computerized tomography (CT). Visceral obesity (VO) was defined as a VAT > 100 cm [2] and patients were then further divided and compared in two subgroups: VAT > 100 and < 100 cm [2]. Estimated glomerular filtration rate (eGFR, mL/min per 1.73 m [2]) was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation pre-operatively and 1 year post-operatively. RESULTS: Both subgroups had similar baseline kidney function (P = NS) pre-operatively. At the 1 year follow-up, patients with VO experienced a more significant decline of renal function (109 ± 9 to 89 ± 8 mL/min per 1.73 m2), compared to those without VO (111 ± 12 to 96 ± 11 mL/min per 1.73 m2, P = 0.013). VO was associated with a body mass index (BMI) > 25 kg/m2 (P < 0.001), male gender (P < 0.001) and older age at the time of donor nephrectomy (48.0 vs 39.5 years, P = 0.01). The presence of hypertension or hyperlipidaemia pre-operatively, choice of surgical approach, and post-operative complication rates, did not differ significantly between the subgroups. CONCLUSIONS: Visceral obesity as defined by VAT > 100 cm2 at the level of the umbilicus on cross-sectional imaging, may have a significant impact on early renal function after donor nephrectomy. Adiposity markers, as measured by cross-sectional CT imaging, may be incorporated into routine pre-operative kidney donor workup.

The Use of Acellular Dermal Matrix in Combination With Pedicled Buccal Fat Pad in Wide Cleft Palate Repair: A Case Report and Literature Review.

We describe a case of the combined use of acellular dermal matrix and pedicled buccal fat pad (BFP) in a wide U-shaped cleft palate repair. Acellular dermal matrix was used as a "patch" repair for the nasal mucosa defect as opposed to the conventional inlay graft. The advantages include reduced cost and a smaller avascular graft load. Lateral relaxing incisions were made to ensure tension-free closure of oromucosa at midline. Lateral oromucosa defect closure with well-vascularized pedicled BFP ensures enhanced healing, less palatal contracture and shortening, and reduced infection. The palate healed with mucosalization at 2 weeks, and no complications were noted at 6 months follow-up.

Choosing the larger kidney on CT volumetry: a study on the early post-donation kidney function of living donors.

BACKGROUND: Selecting the smaller kidney for donation has been advocated if there is a size difference of > 10% between the 2 kidneys but has never been prospectively evaluated. With increase in donor nephrectomies, it is important to evaluate this to minimize loss of renal function to donors. METHODS: 75 consecutive donor nephrectomy patients were included in our longitudinal study. The Split Renal Volume (SRV) of bilateral kidneys were measured using contrasted computer tomography scans and patients segregated into 2 groups depending on donated kidney having more (Group 1) or less than (Group 2) 52.5% of SRV. RESULTS: Patients in Group 1 (n = 19) and 2 (n = 56) were of similar age (43.8 vs. 48.3), BMI (22.4 vs. 25.2), sex (57.9 vs. 55.4% women), respectively. Although total kidney volumes were similar in both groups, Group 1 had significantly smaller right kidney volumes (120.4 ± 24.9 vs. 142.7 ± 28.4 mls, p = 0.003). EGFR pre-operatively (116.3 ± 20.8 vs. 106.3 ± 23.8 mL/min/1.73 m2) and at 6-months (65.7 ± 13.3 vs. 66.9 ± 15.5 mL/min/1.73 m2) were not different between groups. However, patients in Group 1 had significantly greater absolute (50.6 ± 14.9 vs. 39.5 ± 14.7 mL/min/1.73 m2) and relative decline (43.0 ± 8.6 vs. 36.3 ± 10.6%) in eGFR at 6 months (p = 0.06, 0.009). CONCLUSION: With a SRV difference of 5% between the 2 sides, removal of the larger kidney for living kidney donation resulted in greater early decline of renal function than kidney donors whose larger or equivalent kidney is preserved.

Use of metallic ureteric stents for chronic ureteric obstruction and its association with value-based care.

Introduction: We aimed to compare the real-world data and our clinical experience with metallic stents (MSs) and conventional polymeric stents (PSs) in the management of both malignant and benign chronic ureteric obstruction (CUO), in terms of clinical outcomes and costs. Methods: Clinical data from our institution, including outcomes for all ureteric stents inserted for long-term management of CUO from all causes from 2014 to 2017, were retrospectively reviewed and compared between the MS and PS episodes. Results: A total of 247 stents were placed in 63 patients with CUO over the 4-year study period. Of these, 45 stents were MSs. There was no significant difference in all baseline characteristics between the MS and PS groups, except for the aetiology of obstructive cause. Mean indwelling stent duration was significantly greater for MS than for PS (228.6 ± 147.0 vs. 146.1 ± 66.0 days, P < 0.001), thereby leading to lower average number of stent changes per year in the MS group compared to the PS group (1.4 vs. 6.3 times, respectively). Despite the higher unit cost of MS compared to PS, there was no significant mean cost difference overall (cost per dwelling day SGD 7.82 ± SGD 10.44 vs. SGD 8.23 ± SGD 20.50, P = 0.888). Conclusion: Resonance MS is a better option than PS to manage CUO from malignant and benign causes because its significantly longer indwelling time mitigates the higher unit cost of the stent. It potentially reduces the number of procedures and operations in patients. Thus, it should be considered for all patients with CUO requiring long-term ureteric drainage.

A systematic review and meta-analysis on the effect of goal-directed fluid therapy on postoperative outcomes in renal transplantation surgeries.

Introduction: This systematic review and meta-analysis investigated the impact of intraoperative goal-directed therapy (GDT) compared with conventional fluid therapy on postoperative outcomes in renal transplantation recipients, addressing this gap in current literature. Method: A systematic search of patients aged ≥18 years who have undergone single-organ primary renal transplantations up to June 2022 in PubMed, Embase, Scopus and CINAHL Plus was performed. Primary outcome examined was postoperative renal function. Secondary outcomes assessed were mean arterial pressure at graft reperfusion, intraoperative fluid volume and other postoperative complications. Heterogeneity was tested using I² test. The study protocol was registered on PROSPERO. Results: A total of 2459 studies were identified. Seven eligible studies on 607 patients were included. Subgroup assessments revealed potential renal protective benefits of GDT, with patients receiving cadaveric grafts showing lower serum creatinine on postoperative days 1 and 3, and patients monitored with arterial waveform analysis devices experiencing lower incidences of postoperative haemodialysis. Overall analysis found GDT resulted in lower incidence of tissue oedema (risk ratio [RR] 0.34, 95% CI 0.15-0.78, P=0.01) and respiratory complications (RR 0.39, 95% CI 0.17-0.90, P=0.03). However, quality of data was deemed low given inclusion of non-randomised studies, presence of heterogeneities and inconsistencies in defining outcomes measures. Conclusion: While no definitive conclusions can be ascertained given current limitations, this review highlights potential benefits of using GDT in renal transplantation recipients. It prompts the need for further standardised studies to address limitations discussed in this review.

Findings from a Malaysian multicentre study on oropharyngeal squamous cell carcinoma.

BACKGROUND: In addition to the conventional aetiologic agents of oropharyngeal squamous cell carcinoma (OPSCC) such as tobacco usage, alcohol consumption and betel quid usage, it has been established that a proportion of OPSCC are driven by persistent oncogenic human papillomavirus (HPV) infections. Currently, there is a lack of data on the burden of HPV- associated OPSCC in Asian countries including Malaysia. METHODS: A cross-sectional multicentre study with tissue analysis of Malaysian patients diagnosed with primary OPSCC within a five-year period, from 2015 to 2019 between 01/01/2015 to 31/12/2019 was undertaken. Determination of HPV status was carried out using p16INK4a immunohistochemistry on tissue microarrays constructed from archived formalin-fixed paraffin-embedded tissue. RESULTS: From the cases identified, 184 cases had sufficient tissue material for analysis. Overall, median age at diagnosis was 63.0 years (IQR = 15) and 76.1% of patients were males. In our cohort, 35.3% of patients were Indian, 34.2% were Chinese, 21.2% were Malay and 9.2% were from other ethnicities. The estimated prevalence of HPV-associated OPSCC in our cohort was 31.0% (CI 24.4-38.2%). The median age for the HPV-associated OPSCC sub-group of patients was not significantly lower than the median age of patients with HPV-independent OPSCC. More than half of HPV-associated OPSCC was seen in patients of Chinese ethnicity (54.4%). Patients with HPV-associated OPSCC had a much better overall survival than patients with HPV-independent OPSCC (Log rank test; p < 0.001). Patients with HPV-associated OPSCC with no habit-related risk factors such as smoking, were found to have much better overall survival when compared to all other sub-groups. CONCLUSIONS: The findings from our study suggests that prevalence of HPV-associated OPSCC in Malaysia, though not as high as some developed countries, is however on an upward trend. HPV-associated OPSCC appears to be more frequently encountered in patients of Chinese ethnicity. Conventional risk-factors associated with OPSCC such as smoking, alcohol consumption and betel quid chewing should still be considered when estimating prognosis of patients with HPV-associated OPSCC.

Domestication and growth hormone transgenesis cause similar changes in gene expression in coho salmon (Oncorhynchus kisutch).

Domestication has been extensively used in agricultural animals to modify phenotypes such as growth rate. More recently, transgenesis of growth factor genes [primarily growth hormone (GH)] has also been explored as a rapid approach to accelerating performance of agricultural species. Growth rates of many fishes respond dramatically to GH gene transgenesis, whereas genetic engineering of domestic mammalian livestock has resulted in relatively modest gains. The most dramatic effects of GH transgenesis in fish have been seen in relatively wild strains that have undergone little or no selection for enhanced growth, whereas genetic modification of livestock necessarily has been performed in highly domesticated strains that already possess very rapid growth. Such fast-growing domesticates may be refractory to further stimulation if the same regulatory pathways are being exploited by both genetic approaches. By directly comparing gene expression in wild-type, domestic, and GH transgenic strains of coho salmon, we have found that domestication and GH transgenesis are modifying similar genetic pathways. Genes in many different physiological pathways show modified expression in domestic and GH transgenic strains relative to wild-type, but effects are strongly correlated. Genes specifically involved in growth regulation (IGF1, GHR, IGF-II, THR) are also concordantly regulated in domestic and transgenic fish, and both strains show elevated levels of circulating IGF1. Muscle expression of GH in nontransgenic strains was found to be elevated in domesticated fish relative to wild type, providing a possible mechanism for growth enhancement. These data have implications for genetic improvement of existing domesticated species and risk assessment and regulation of emerging transgenic strains.

The roles of gaze and head orientation in face categorization during rapid serial visual presentation.

Little is known about how perceived gaze direction and head orientation may influence human categorization of visual stimuli as faces. To address this question, a sequence of unsegmented natural images, each containing a random face or a non-face object, was presented in rapid succession (stimulus duration: 91.7 ms per image) during which human observers were instructed to respond immediately to every face presentation. Faces differed in gaze and head orientation in 7 combinations - full-front views with perceived gaze (1) directed to the observer, (2) averted to the left, or (3) averted to the right, left ¾ side views with (4) direct gaze or (5) averted gaze, and right ¾ side views with (6) direct gaze or (7) averted gaze - were presented randomly throughout the sequence. We found highly accurate and rapid behavioural responses to all kinds of faces. Crucially, both perceived gaze direction and head orientation had comparable, non-interactive effects on response times, where direct gaze was responded faster than averted gaze by 48 ms and full-front view faster than ¾ side view also by 48 ms on average. Presentations of full-front faces with direct gaze led to an additive speed advantage of 96 ms to ¾ faces with averted gaze. The results reveal that the effects of perceived gaze direction and head orientation on the speed of face categorization probably depend on the degree of social relevance of the face to the viewer.

The use of negative-pressure wound therapy over a cultured epithelial autograft for full-thickness wounds secondary to purpura fulminans in an infant.

Purpura fulminans is a serious condition that can result in severe morbidity in the pediatric population. Although autologous skin grafts remain the gold standard for the coverage of partial- to full-thickness wounds, they have several limitations in pediatric patients, including the lack of planar donor sites, the risk of hemodynamic instability, and the limited graft thickness. In Singapore, an in-house skin culture laboratory has been available since 2005 for the use of cultured epithelial autografts (CEAs), especially in burn wounds. However, due to the fragility of CEAs, negative-pressure wound therapy (NPWT) dressings have been rarely used with CEAs. With several modifications, we report a successful case of NPWT applied over a CEA in an infant who sustained 30% total body surface area full-thickness wounds over the anterior abdomen, flank, and upper thigh secondary to purpura fulminans. We also describe the advantages of using NPWT dressing over a CEA, particularly in pediatric patients.

Rhythmic timing in aging adults: On the role of cognitive functioning and structural brain integrity.

Here we asked whether impaired timing in older adults results from an aging clock or a more general brain and cognitive decline. Healthy aging adults (N = 70, aged 62-83 years) tapped to the beat of a periodic and a syncopated rhythm. Analyses focused on performance differences between rhythms (periodic-syncopated), which reduced the impact of timing unrelated processes. Apart from tapping, participants completed a cognitive assessment and neuroimaging of gray matter volume (GMV) and fractional anisotropy (FA) globally as well as regionally (cortical: auditory, premotor, paracentral; subcortical: putamen, caudate, cerebellum). The rhythm difference showed no significant age effects for tapping asynchrony and an age-related decrease for tapping consistency. Additionally, age reduced cognitive functioning, global GMV/FA, and, beyond this, auditory GMV. Irrespective of age, the rhythm difference in tapping asynchrony was linked, not to GMV, but to caudal, premotor, and paracentral FA after controlling for global FA. Tapping consistency was associated with global rather than regional brain integrity. Additionally, age differences in tapping consistency were mediated by a decline in global brain integrity as well as cognitive functioning. Together these results agree with previous proposals differentiating between timing accuracy and reliability and suggest that aging largely preserves the former but not the latter. Whereas timing accuracy may depend on an internal clock supported by robust striatocortical circuitry, timing reliability may depend on global brain and cognitive functioning, which show a pronounced age-related decline. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Effects of choral singing versus health education on cognitive decline and aging: a randomized controlled trial.

We conducted a randomized controlled trial to examine choral singing's effect on cognitive decline in aging. Older Singaporeans who were at high risk of future dementia were recruited: 47 were assigned to choral singing intervention (CSI) and 46 were assigned to health education program (HEP). Participants attended weekly one-hour choral singing or weekly one-hour health education for two years. Change in cognitive function was measured by a composite cognitive test score (CCTS) derived from raw scores of neuropsychological tests; biomarkers included brain magnetic resonance imaging, oxidative damage and immunosenescence. The average age of the participants were 70 years and 73/93 (78.5%) were female. The change of CCTS from baseline to 24 months was 0.05 among participants in the CSI group and -0.1 among participants in the HEP group. The between-group difference (0.15, p=0.042) became smaller (0.12, p=0.09) after adjusting for baseline CCTS. No between-group differences on biomarkers were observed. Our data support the role of choral singing in improving cognitive health in aging. The beneficial effect is at least comparable than that of health education in preventing cognitive decline in a community of elderly people. Biological mechanisms underlying the observed efficacy should be further studied.

Detection of Clinical Mesenchymal Cancer Cells from Bladder Wash Urine for Real-Time Detection and Prognosis.

Bladder cancer (BC) is a disease that requires lifelong surveillance due to its high recurrence rate. An efficient method for the non-invasive rapid monitoring of patient prognosis and downstream phenotype characterization is warranted. Here, we develop an integrated procedure to detect aggressive mesenchymal exfoliated bladder cancer cells (EBCCs) from patients in a label-free manner. Using a combination of filtration and inertial focusing principles, the procedure allowed the focusing of EBCCs in a single stream-line for high-throughput separation from other urine components such as large squamous cells and blood cells using a microfluidic sorting device. Characterization of enriched cells can be completed within hours, suggesting a potential utility for real-time detection. We also demonstrate high efficiency of cancer cell recovery (93.3 ± 4.8%) and specific retrieval of various epithelial to mesenchymal transition (EMT) phenotype cell fractions from respective outlets of the microfluidic device. EMT is closely associated with metastasis, drug resistance and tumor-initiating potential. This procedure is validated with clinical samples, and further demonstrate the efficacy of bladder wash procedure to reduce EBCCs counts over time. Overall, the uniqueness of a rapid and non-invasive method permitting the separation of different EMT phenotypes shows high potential for clinical utility. We expect this approach will better facilitate the routine screening procedure in BC and greatly enhance personalized treatment.

Isolation, characterization and comparison of Atlantic and Chinook salmon growth hormone 1 and 2.

BACKGROUND: Growth hormone (GH) is an important regulator of skeletal growth, as well as other adapted processes in salmonids. The GH gene (gh) in salmonids is represented by duplicated, non-allelic isoforms designated as gh1 and gh2. We have isolated and characterized gh-containing bacterial artificial chromosomes (BACs) of both Atlantic and Chinook salmon (Salmo salar and Oncorhynchus tshawytscha) in order to further elucidate our understanding of the conservation and regulation of these loci. RESULTS: BACs containing gh1 and gh2 from both Atlantic and Chinook salmon were assembled, annotated, and compared to each other in their coding, intronic, regulatory, and flanking regions. These BACs also contain the genes for skeletal muscle sodium channel oriented in the same direction. The sequences of the genes for interferon alpha-1, myosin alkali light chain and microtubule associated protein Tau were also identified, and found in opposite orientations relative to gh1 and gh2. Viability of each of these genes was examined by PCR. We show that transposon insertions have occurred differently in the promoters of gh, within and between each species. Other differences within the promoters and intronic and 3'-flanking regions of the four gh genes provide evidence that they have distinct regulatory modes and possibly act to function differently and/or during different times of salmonid development. CONCLUSION: A core proximal promoter for transcription of both gh1 and gh2 is conserved between the two species of salmon. Nevertheless, transposon integration and regulatory element differences do exist between the promoters of gh1 and gh2. Additionally, organization of transposon families into the BACs containing gh1 and for the BACs containing gh2, are very similar within orthologous regions, but much less clear conservation is apparent in comparisons between the gh1- and gh2-containing paralogous BACs for the two fish species. This is consistent with the hypothesis that a burst of transposition activity occurred during the speciation events which led to Atlantic and Pacific salmon. The Chinook and other Oncorhynchus GH1s are strikingly different in comparison to the other GHs and this change is not apparent in the surrounding non-coding sequences.

An Overview of the Use of Bromelain-Based Enzymatic Debridement (Nexobrid®) in Deep Partial and Full Thickness Burns: Appraising the Evidence.

Recent introduction of rapid bromelain-based enzymatic debridement has been increasingly popular in its use in nonsurgical debridement in deep partial and full thickness burns. We designed this study to evaluate the evidence suggested by current studies on the perceived benefits of using Nexobrid® compared with traditional surgical standard of care in burns wound debridement. A comprehensive search on electronic databases Pubmed, Embase, and Web of Science was done to identify studies published between 1986 and 2017 involving the use of Nexobrid® in deep partial and full thickness burns. Studies were evaluated for proposed benefits and categorized under supporting evidence, contradicting evidence, and anecdotal opinions. Seven well-designed prospective studies met the inclusion comprising four randomized controlled trials. Six proposed benefits associated with the use of Nexobrid® were extracted including reduced time to complete debridement, need for surgery, area of burns excised, need for autograft, time to wound closure, and improved scar quality. Most proposed benefits have strong supporting evidences with minimal anecdotal opinions from controlled trials except the proposed improvement in scar quality and reduced time to wound healing that had at least three refuting evidence and one anecdotal evidence. Incidence of pain was also evaluated and was mainly anecdotal lacking formal objective assessment or cohort study. Despite the lack of literatures available, the benefits of Nexobrid® are evident in published randomized and single arm studies. Large number of studies is needed to aid further evaluating the proposed benefits of Nexobrid®.

Robotic kidney autotransplantation in a porcine model: a procedure-specific training platform for the simulation of robotic intracorporeal vascular anastomosis.

Robotic-assisted kidney transplantation (RKT) with the Da Vinci (Intuitive, USA) platform has been recently developed to improve outcomes by decreasing surgical site complications and morbidity, especially in obese patients. This potential paradigm shift in the surgical technique of kidney transplantation is performed in only a few centers. For wider adoption of this high stake complex operation, we aimed to develop a procedure-specific simulation platform in a porcine model for the training of robotic intracorporeal vascular anastomosis and evaluating vascular anastomoses patency. This paper describes the requirements and steps developed for the above training purpose. Over a series of four animal ethics' approved experiments, the technique of robotic-assisted laparoscopic autotransplantation of the kidney was developed in Amsterdam live pigs (60-70 kg). The surgery was based around the vascular anastomosis technique described by Menon et al. This non-survival porcine training model is targeted at transplant surgeons with robotic surgery experience. Under general anesthesia, each pig was placed in lateral decubitus position with the placement of one robotic camera port, two robotic 8 mm ports and one assistant port. Robotic docking over the pig posteriorly was performed. The training platform involved the following procedural steps. First, ipsilateral iliac vessel dissection was performed. Second, robotic-assisted laparoscopic donor nephrectomy was performed with in situ perfusion of the kidney with cold Hartmann's solution prior to complete division of the hilar vessels, ureter and kidney mobilization. Thirdly, the kidney was either kept in situ for orthotopic autotransplantation or mobilized to the pelvis and orientated for the vascular anastomosis, which was performed end to end or end to side after vessel loop clamping of the iliac vessels, respectively, using 6/0 Gore-Tex sutures. Following autotransplantation and release of vessel loops, perfusion of the graft was assessed using intraoperative indocyanine green imaging and monitoring urine output after unclamping. This training platform demonstrates adequate face and content validity. With practice, arterial anastomotic time could be improved, showing its construct validity. This porcine training model can be useful in providing training for robotic intracorporeal vascular anastomosis and may facilitate confident translation into a transplant human recipient.