Does pure robotic partial nephrectomy provide similar perioperative outcomes when compared to the combined laparoscopic-robotic approach?

Laparoscopic and robotic partial nephrectomy have become the preferred option for surgical management of incidentally discovered small renal tumors. Currently there is no consensus on which aspects of the procedure should be performed laparoscopically versus robotically. We believe that combining a laparoscopic exposure and hilar dissection followed by tumor extirpation and renorrhaphy with robotic assistance provides improved perioperative outcomes compared to a pure robotic approach alone. We performed a comparison of perioperative outcomes between combined laparoscopic-robotic partial nephrectomy-or hybrid procedure-and pure robotic partial nephrectomy (RPN). A multi-center retrospective analysis of patients undergoing RPN and hybrid PN using the da Vinci S system(®) was performed. Patient data were reviewed for demographic and perioperative variables. Statistical analysis was performed using the Welch t test and linear regression, and nonparametric tests with similar significance results. Thirty-one patients underwent RPN while 77 patients underwent hybrid PN between 2007 and 2011. Preoperative variables were comparable in both groups with the exception of lesion size and nephrometry score which were significantly higher in patients undergoing hybrid PN. Length of surgery, estimated blood loss and morphine used were significantly less in the hybrid group, while warm ischemia time was significantly longer. The difference in WIT was accounted for in this data by adjusting for nephrometry score. In our multi-center series, the hybrid approach was associated with a shorter operative time, reduced blood loss and lower narcotic usage. We believe this approach is a valid alternative to RPN.

Drugs and blood transfusions: dogma- or evidence-based practice?

There is a lack of consensus on the safety of the coadministration of drugs and red blood cells (RBCs). A systematic review was undertaken to establish the evidence base for this question and assess how the evidence may be translated into present clinical day practice. Comprehensive searches of MEDLINE, EMBASE, CINAHL, the Cochrane Library and hand searching of transfusion journals, guidelines and websites identified 12 relevant papers: 11 in-vitro experiments and 1 case report. Data on incidences of haemolysis and agglutination following coadministration were extracted and analysed. Overall findings suggest that iron chelators (two papers), antimicrobials (three papers) and lower doses of opioids (three papers) are safe to coadminister with RBCs. Haemolysis was observed with higher doses of opioids (three papers). Transposition of these findings to clinical practice is limited because of the lack of clinical applicability of in-vitro experiments and diversity in how, and what, clinical outcome measures were used. Further evidence from true clinical settings would be required to inform clinical practice on the efficacy and safety of the coadministration of drugs and RBCs.

How often should a red blood cell administration set be changed while a patient is being transfused? A commentary and review of the literature.

Current recommendations vary with regard to the frequency of change of a red blood cell (RBC) administration set. A full review was undertaken to evaluate the recommendations for how often a RBC administration set should be changed while a patient is being transfused. Comprehensive searches of Medline, Embase, Cinahl, the Cochrane Library, handsearching of transfusion journals, guidelines and websites and contact with administration set manufacturers identified 32 relevant papers: 11 clinical updates; 11 guidelines; 5 manufacturer data sheets; 3 standards; 1 Department of Health report and 1 expert opinion. Recommendations varied widely across papers. There was no pattern in recommendation by paper type, date or country of origin. Recommendations were based on change of RBC administration set either after a given number of hours or number of RBC units. The recommendations varied widely and ranged from 4 to 48 h and from 'every unit' to 'several units'. The most frequent recommendations were change of RBC administration set after 12 h or 4 units. Methodological quality of the included papers is poor. There is no formal evidence base on which to support current recommendations or challenge the current British Committee for Standards in Haematology guideline. Targeted research aimed at establishing an evidence base may be warranted and would need to document other variables that can impact frequency of change, including type of filter, age of blood and duration of RBC transfusion.

Standardized bench method for evaluating the efficacy of phototherapy devices.

AIM: As phototherapy (PT) devices employ a variety of broadband light sources, we developed and tested a standardized bench method for evaluating the efficacy of some devices. METHODS: To evaluate efficacy, we quantified the in vitro photodegradation rate (expressed as t1/2) of unconjugated bilirubin in solution at 37 degrees C during exposure to a given light source at its mean delivered irradiance to the 2D body surface area (BSA) of newborn models. Reproducibility (between-day variation) of the method was determined at irradiance levels from 10 to 70 microW/cm2/nm on three different days. RESULTS: Between-day t1/2 measurements had coefficients of variation from 3% to 10%. When t1/2 values were normalized to the exposable 2D horizontal BSA, halogen lamp devices, without and with fiberoptics, were least effective (t1/2=60-108 min and 100-126 min for preterm and term models, respectively). Fluorescent tube devices had t1/2=19-78 min and 25-78 min, for preterm and term models, respectively. Light-emitting diode (LED)-based devices yielded the shortest t1/2 values (16-24 min) for preterm and term newborn models. CONCLUSIONS: We demonstrated the applicability of the method through the determination of the efficacy of several commercially available PT devices. This standardized method is reproducible and effectively evaluates the relative in vitro efficacy of various devices and may guide further in vitro and in vivo evaluations of devices.

A rapid interview protocol supporting patient-centered quality improvement: hearing the parent's voice in a pediatric cancer unit.

BACKGROUND: The Institute of Medicine's 2001 report on quality delimits six dimensions of optimal care: safety, effectiveness, efficiency, timeliness, patient centeredness, and equity. In fall 2001 parents of pediatric cancer patients were interviewed to determine how well they thought these dimensions were addressed with respect to medication administration. Immediate goals were to identify system weaknesses and devise strategies to prevent future errors. A higher-order goal was to develop and demonstrate a model protocol for rapid-cycle interview assessments. METHODS: Hematology/oncology directors worked with a research expert to develop a semistructured interview protocol. After training, which included directed reading, oral instruction, and role-playing, a convenience sample of 20 English- and Spanish-speaking parents of inpatients was recruited. Parents were asked to characterize current medication administration practices and to describe problems that they had experienced or witnessed. Rapid content analysis techniques were used to identify issues of importance to the parents. FINDINGS: Parents' medication concerns centered on their children's comfort. Parents called for communication improvements, standardization of all nursing procedures and techniques, and a guide or an outline providing a clear understanding of what to expect when and from whom. Viewing these concerns in relation to the Institute of Medicine's quality domains allowed the department to frame an improvement action plan aligned with organizational and national priorities. IMPLICATIONS: With good supervision and limited focused training, inexperienced staff can successfully administer semistructured qualitative interviews and help analyze findings for rapid cycle improvement purposes. The protocol can be adapted for use in organizations interested in rapid qualitative assessments of patient and parent preferences.

Red cell aplasia due to erythrovirus parvovirus B19 infection in a Jehovah's witness with post-transplant EBV-induced aggressive lymphoma: management considerations.

The refusal of Jehovah's Witnesses to accept blood and blood products often poses a clinical dilemma to present day medicine. We present a case of a Jehovah's Witness who had undergone renal transplantation, only to develop an Epstein-Barr virus associated aggressive lymphoma post-transplant. His condition was further complicated by erythrovirus (parvovirus) B 19 infection resulting in red cell aplasia and severe anemia. The management of this difficult clinical situation is discussed together with a review of recommendations for chemotherapy treatment in Jehovah's Witnesses.

African-American and white head and neck carcinoma patients in a university medical center setting. Are treatments provided and are outcomes similar or disparate?

Racial and ethnic disparities occur in many areas of the health care management system in the United States. These disparities include disease incidence, access to health and medical services, treatments provided, and disease outcomes. Health care delivery organizations have limited resources. Encounters between patients and providers in health care delivery organizations typically are cross-cultural. Access to care, quality of care, and equity may be affected by limited resources and cross-cultural encounters. This impacts the diagnosis, treatments provided, and outcomes, with African-American patients faring poorly compared with white patients. African Americans are 15% more likely to develop cancer than whites and are about 34% more likely to die of cancer than whites in the United States. The purpose of this study was to determine and compare the characteristics of African-American patients and white patients with carcinoma of the head and neck at the University of Cincinnati Medical Center, an equal-access facility, reporting similarities and disparities in disease stage at the time of diagnosis, treatment received, and patient outcomes.

Preliminary Investigations into the use of a Human Bronchial Cell Line (16HBE14o-) to Screen for Respiratory Toxins In Vitro.

A transformed epithelial cell line derived from normal human bronchial epithelium (16HBE14o- cells) was used to assess the in vitro toxicity of six compounds. The compounds were sodium chloride and titanium dioxide (reference compounds) and sodium carbonate and silica (respiratory toxins). In addition, two compounds (compounds A and B) were tested which have been shown to induce respiratory toxicity in the rat during preclinical safety assessment. Confluent monolayers of 16HBE14o- cells were treated for 24hr with the test compounds and toxicity was assessed using two conventional cytotoxicity assays (neutral red uptake and MTT reduction). Transepithelial resistance (TER) was also measured throughout the treatment period as a possible alternative endpoint for toxicity measurement. Neither sodium chloride nor titanium dioxide caused toxicity in 16HBE14o- cells using any of the toxicity endpoints. With the exception of silica, all irritant compounds caused concentration-related cytotoxicity in 16HBE14o- cells. For each compound, when the three toxicity endpoints were compared, similar IC(50) values were obtained irrespective of the endpoint used. These initial results indicate that 16HBE14o- cells may be a suitable cell line for future use in development of in vitro assays for respiratory toxicity.

Comparison of hepatocyte cultures and liver slices in in vitro toxicity testing.

The aim of this study was to compare the in vitro toxicities of two hepatotoxins in hepatocyte cultures and in liver slices from both rats and dogs. Hepatocytes and liver slices were pre-incubated for 2 hours and then exposed to galactosamine or paracetamol, both of which mainly induce liver necrosis in vivo. Following exposure to the compounds for 20 hours, neutral red uptake (NRU [hepatocyte cultures only]), MTT reduction, and reduced glutathione (GSH), adenosine triphosphate (ATP) and protein content, were used to measure the toxicity induced. In general, galactosamine and paracetamol exposure caused comparable levels of toxicity in hepatocyte cultures and in liver slices. For galactosamine, no consistent differences were seen between hepatocyte cultures and liver slices. With paracetamol, the toxic effects were generally slightly more pronounced in hepatocyte cultures than in liver slices, and the preparations from dog liver were more sensitive than those from rat liver to paracetamol exposure. These results are in agreement with previously described species differences in vitro. NRU and GSH content were more sensitive and more consistent endpoints than MTT reduction, ATP content or protein content. Liver slices appeared to lose viability over the 20 hours in culture. Therefore, it can be concluded that liver slices should only be used in relatively short-term investigations.

Ethionine toxicity in vitro: the correlation of data from rat hepatocyte suspensions and monolayers with in vivo observations.

The hepato-steatogenic compound ethionine has been used to investigate the correlations between in vivo and in vitro toxicity data. The aim was to find a suitable model of toxicity in hepatocyte suspensions or monolayers in vitro, which could predict the known toxicity of ethionine in vivo and which could be implemented in screening compounds of unknown toxicity. Thus a variety of markers of cytotoxicity, metabolic competence and liver-specific functions were investigated in rat hepatocyte suspensions and monolayers and compared with in vivo data in the rat. The following markers were measured in the appropriate system: (1) Neutral red uptake; 3-(4,5 dimethyl)thiazol-2-yl,-2,5-diphenyl tetrazolium bromide (MTT) reduction; lactate dehydrogenase (LDH), aspartate aminotransferase (AST) and alanine aminotransferase (ALT) leakage (cytotoxicity). (2) ATP levels, protein synthesis and glutathione (GSH) levels (metabolic competence). (3) Urea and triglyceride synthesis and beta-oxidation (liver specific functions). Ethionine (0-30 mM) did not affect the markers of direct cytotoxicity, except neutral red uptake, which was reduced by 18 and 30 mM ethionine after 20 h in culture. ATP and GSH depletion occurred in hepatocyte suspensions at the highest concentrations of ethionine (20 and 30 mM) after 1 h. In monolayers, GSH levels were reduced after 4 h, but not 20 h. Urea synthesis was increased in hepatocyte suspensions from 1 to 3 h by 10-30 mM ethionine and reduced after 20 h in cultured hepatocytes (18-30 mM). Protein synthesis was reduced and beta-oxidation was increased in ethionine-treated hepatocyte suspensions. Unfortunately, there was no measurable effect on triglyceride accumulation within cells (the major biochemical change in vivo) in either system. Ethionine treated hepatocytes in suspension showed the same rate of triglyceride synthesis and transportation out of cells as control cells. Thus, hepatocyte suspensions were able to mimic the early biochemical effects of ethionine in vivo (ATP and GSH depletion, inhibition of protein synthesis) and some effects on urea synthesis, but monolayer cultures appeared to be less sensitive to the toxicity of ethionine. However, neither in vitro system was able to model the effects of ethionine on the accumulation of triglycerides in vivo.

Self-efficacy measurements: an approach for predicting practice outcomes in continuing education?

This study assessed the usefulness of measurements of self-efficacy in evaluating practice outcomes following a continuing education course in advanced practice pharmacology. Self-efficacy, a central construct in social-cognitive theory, refers to an individual's confidence in being able to perform a specific task to successful completion. The study demonstrated that a valid and reliable measure of self-efficacy could be developed from program objectives and used in conjunction with pre- and post-knowledge measures to gain a broader perspective of learning outcomes. Measurements of self-efficacy was a useful adjunct in post-instruction evaluation and may be a cost-effective alternative to longitudinal impact evaluation.

Impact of hospital thrombolysis policy on out-of-hospital response to suspected myocardial infarction.

The treatment of acute myocardial infarction changed when several trials reported that thrombolytic agents given within a few hours of infarction improved outcome. We present data from the Nottingham Heart Attack Register comparing 1982-84, when thrombolysis was not available, and 1989-90, when it was hospital policy to give thrombolysis to all patients who arrived within 6 hours of the onset of symptoms, in the absence of a specific contraindication. The number of patients referred with symptoms suggestive of acute myocardial infarction increased by 75% from 1982 to 1990; a diagnosis of "possible infarction" was made in about half of all patients in 1982-84 and 23% in 1989-90. Our current thrombolytic policy has had little impact on patient and general practitioner (GP) behaviour. The GP was contacted by most patients. The median time between the onset of a patient's symptoms and admission to hospital when the GP was involved was 229 min in 1982-84 and 210 min in 1989-90; when he was not involved in arranging the admission median times to admission were 89 min and 75 min, respectively. By 6 hours from symptom onset, 60% of patients had been admitted; by 12 hours, about 70% were in hospital and by 24 hours, 80%. Of 7855 patients admitted with suspected acute myocardial infarction in 1989-90, 4465 were admitted within 6 hours of symptom onset. Of these, 736 (16%) patients received a thrombolytic drug. 389 (9%) patients had a specific, documented contraindication to thrombolysis. Although we estimate that the policy has saved about 8 lives per year, it is not surprising that there has been no improvement in overall case fatality after myocardial infarction.

The use of programmed electrical stimulation to assess the fibrillatory propensity of ionic and nonionic contrast media.

Coronary angiography occasionally results in ventricular fibrillation. To compare the fibrillatory propensity of conventional ionic and nonionic contrast media, we measured QT intervals and performed programmed electrical stimulation during intracoronary injection of Renografin 76 (R76), Hypaque 76 (H76), and iopamidol (IOP) in 16 open chest dogs. In ten dogs the incidence of ventricular fibrillation following induction of a single premature ventricular beat after every fourth atrial paced beat was 19/20 with R76, 8/20 with H76, and 0/20 with IOP (P less than .001). When two premature beats were induced, the incidence of ventricular fibrillation was 20/20 with R76, 19/20 with H76, and 1/20 with IOP (P less than .001). In six additional dogs, the mean prolongation of the QT interval was 170 +/- 20 msec with R76, 105 +/- 14 msec with H76, and 63 +/- 9 msec with IOP (P less than .001). Thus, programmed electrical stimulation readily induces ventricular fibrillation during intracoronary injection of conventional ionic contrast media. The incidence of ventricular fibrillation parallels the amount of QT interval prolongation produced. H76, which lacks EDTA and sodium citrate, is less fibrillatory than R76. However, the nonionic medium IOP appears far less fibrillatory than either R76 or H76.