Randomized clinical trial of non-antibiotic prophylaxis with d-Mannose plus Proanthocyanidins vs. Proanthocyanidins alone for urinary tract infections and asymptomatic bacteriuria in de novo kidney transplant recipients: The Manotras study.

BACKGROUND: Studies analyzing non-antibiotic alternatives in kidney transplant UTI's are lacking. d-Mannose, a simple sugar, inhibits bacterial attachment to the urothelium, as does Proanthocyanidins; both could act as a synergic strategy preventing UTI; nonetheless their efficacy and safety have not been evaluated in kidney transplant population yet. METHODS: This is a pilot prospective, double-blind randomized trial. Sixty de novo kidney transplant recipients were randomized (1:1) to receive a prophylactic strategy based on a 24-h prolonged release formulation of d-Mannose plus Proanthocyanidins vs. Proanthocyanidins (PAC) alone. The supplements were taken for the first 3 months after kidney transplant and then followed up for 3 months as well. The main objective of the study was to search if the addition of Mannose to PAC alone reduced the incidence of UTI and/or asymptomatic bacteriuria in the first 6 months post-transplantation. RESULTS: 27% of patients experienced one UTI episode (cystitis or pyelonephritis) while asymptomatic bacteriuria was very common (57%). Incidences according UTI type or AB were: 7% vs. 4% for cystitis episode (p 0.3), 4% vs. 5% for pyelonephritis (p 0.5) and 17% vs. 14% for asymptomatic bacteriuria (p 0.4) for patients in the Mannose+PAC group vs. PAC group respectively. The most frequent bacteria isolated in both groups was Escherichia coli (28% of all episodes), UTI or AB due to E. coli was not different according to study group (30% vs. 23% for Mannose+PAC vs. PAC alone p 0.37). CONCLUSIONS: Non-antibiotic therapy is an unmet need to prevent UTI after kidney transplantation; however, the use of d-Mannose plus PAC does not seem capable to prevent it.

Pulmonary Embolism after Core Decompression of the Femoral Head Using Injectable Bone Graft Substitute: A Case Report.

The authors report a rare complication regarding the case of an 18-year-old female with bilateral osteonecrosis of the femoral head (ONFH) secondary to the treatment and hematopoietic stem cell transplant (HSCT) of an acute lymphoblastic leukemia (ALL). The patient underwent a bilateral necrotic bone debridement and core decompression (CD) surgery with injectable synthetic bone graft, which unfortunately caused a pulmonary injectable bone graft substitute embolism.

Congenital lung abnormality quantification by computed tomography: The CLAQ method.

INTRODUCTION: To date, no consensus has been reached on the optimal management of congenital lung abnormalities, and factors predicting postnatal outcome have not been identified. We developed an objective quantitative computed tomography (CT) scoring method, and assessed its value for clinical decision-making. METHODS: Volumetric CT-scans of all patients born with a congenital lung abnormality between January 1999 and 2018 were assessed. Lung disease was quantified using the newly-developed congenital lung abnormality quantification (CLAQ) scoring method. In 20 equidistant axial slices, cells of a square grid were scored according to the abnormality within. The scored CT parameters were used to predict development of symptoms, and SD scores for spirometry and exercise tolerance (Bruce treadmill test) at 8 years of age. RESULTS: CT-scans of 124 patients with a median age of 5 months were scored. Clinical diagnoses included congenital pulmonary airway malformation (49%), bronchopulmonary sequestration (27%), congenital lobar overinflation (22%), and bronchogenic cyst (1%). Forty-four patients (35%) developed symptoms requiring surgery of whom 28 (22%) patients became symptomatic before a CT-scan was scheduled. Lesional hyperdensity was found as an important predictor of symptom development and decreased exercise tolerance. Using receiver operating characteristic analysis, an optimal cut-off value for developing symptoms was found at 18% total disease. CONCLUSION: CT-quantification of congenital lung abnormalities using the CLAQ method is an objective and reproducible system to describe congenital lung abnormalities on chest CT. The risk for developing symptoms may increase when more than a single lung lobe is affected.

Akin osteotomy: Is the type of staple fixation relevant?

BACKGROUND: Although different fixation techniques for the Akin osteotomy have been described in the literature, there are no many studies trying to analyze the differences between the types of fixation available. The aim of this study is to analyze if there are any differences between three types of staple fixation available in the market. METHOD: We present a retrospective study of 145 cases in which an Akin osteotomy was performed and fixed with three different kinds of implants staple A (28%), staple B (45%), and staple C (27%). Staple A is made out of stainless steel, and the surgeon mechanically controls the compression applied. Staple B increases the compression when heat is applied to it. Staple C has an intrinsic elastic memory that closes the osteotomy. In all cases, distal articular set angle, interphalangeal joint obliquity angle, and metatarsophalangeal angle were measured pre-operatively and 1.5 months post-operatively on dorsoplantar weight-bearing radiographs. Other details such as post-operative complications, implant migration, osteolysis, or fracture of the lateral cortex during surgery were also recorded. RESULTS: Clinical and radiological results show no relevant differences between the three types of fixation. The mean angular corrections of DASA, interphalangeal joint obliquity angle, and metatarsophalangeal angle were 5, 12, and 21, respectively, for staple A; 4, 10, and 19, respectively, for staple B; and 7, 10, and 23, respectively, for staple C. The rates of intra-operative and post-operative complications were similar for all groups. There was one case of infection per group. We had five cases of delayed union two with staple A and three with staple C. In four cases, there was a loss of correction, two of them fixed with staple A and two with staple C. Seven cases developed a Südeck's syndrome, four of them fixed with staple A and three with staple C. Fifteen patients suffered an uncontrolled fracture of the lateral cortex of the phalanx when performing the osteotomy (3, 8, and 4 cases fixed with staples A, B, and C, respectively), and 87.5% of the patients that developed a plantar displacement of the osteotomy had an uncontrolled fracture of the lateral cortex (p < 0.05). All three staples achieved a rigid internal fixation and minimal periosteum damage and provided a good bone-bone contact. CONCLUSIONS: According to our results, the radiological differences are minimal, and although the thermal compression staple had less complication, clinical differences were also not statistically significant. This means the choice of implant could be left to the surgeon's preferences or made according to cost.

Use of the Kishigami Atlantoaxial Tension Band in eight toy breed dogs with atlantoaxial subluxation.

OBJECTIVE: To determine the applicability, complications, and long-term functional outcome of the Kishigami Atlantoaxial Tension Band (Kishigami AATB) for management of congenital and traumatic atlantoaxial (AA) instability in toy breed dogs. STUDY DESIGN; Case series. ANIMALS: Toy breed dogs (n=8) with congenital or traumatic AA instability. METHODS: The AA joint of each dog was surgically stabilized through a dorsal approach using the original or a modified version of the Kishigami AATB. Pre- and postoperative neurologic status, radiographs, and complications were reviewed. Follow-up examination was performed at 1 and 12 months. RESULTS: Functional improvement occurred in 5 dogs; 1 dog did not improve or worsen and 2 dogs were euthanatized at owner request. Adequate reduction and stabilization was achieved in 7 dogs based on immediate postoperative radiographs; failure of reduction was evident in 1 dog. No relevant complications occurred. CONCLUSIONS: Kishigami AATB may be acceptable as an alternative method for dorsal stabilization of AA subluxation in toy breed dogs in which use of ventral screws or pins is challenging. Experience with this technique in a larger population is necessary to compare our results to those reported by ventral approach. CLINICAL RELEVANCE; The surgical technique described is effective, safe, and simple in the surgical treatment of AA subluxation in toy breed dogs.

Positive margins after nephron-sparing surgery for renal cell carcinoma: long-term follow-up of patients on active surveillance.

OBJECTIVE: To analyse our long-term oncological outcomes with active surveillance in patients with positive surgical margins (PSMs) after nephron-sparing surgery (NSS) for renal cell carcinoma (RCC), as this situation is a difficult therapeutic dilemma. PATIENTS AND METHODS: We performed open NSS for renal masses with frozen-section analysis of any suspicious zone of the surgical bed, followed by extensive argon-beam coagulation. In patients where the final histopathological examination of the renal mass revealed PSMs, follow-up consisted of computed tomography (CT) every 6 months in the first 2 years and then annually up to 5 years, and thereafter we alternated ultrasonography with CT. RESULTS: From 1995 to 2003 we had 11 cases of microscopic definitive PSMs after NSS for RCC. Two patients required nephrectomy (one for postoperative bleeding and another as an elective procedure), so nine were followed. These patients were either operated under elective (seven) or imperative (two) conditions. The histological subtype was clear cell carcinoma in three, papillary in two, chromophobe in two and hybrid oncocytic RCC in two, with a Furhman grade of 2 in six and 3 in three. The mean size was 31.4 mm, and the stage was pT1a in six, pT1b in one and pT3a in two. After a median follow-up of 80.5 months, there was no local recurrence or distant progression. CONCLUSIONS: In our experience, microscopic PSMs in NSS specimens can be managed conservatively with active surveillance, achieving excellent results and avoiding extensive reoperation without compromising long-term oncological outcomes.

Voiding urosonography: the study of the urethra is no longer a limitation of the technique.

BACKGROUND: Voiding urosonography (VUS) has proved to be a reliable method for the study of vesicoureteric reflux (VUR). Early reports considered it inadequate for imaging the male urethra. OBJECTIVE: To determine the usefulness of contrast-enhanced VUS for the study of the urethra. MATERIAL AND METHODS: A total of 208 children aged 2 days to 10 years underwent VUS to confirm or exclude VUR for different reasons (n = 150) or for follow-up (n = 58). Patients with unconfirmed suspicion of VUR (99 boys and 51 girls) also underwent VUS for the study of the urethra. Examinations were performed using a harmonic imaging mode specific for contrast (Levovist) enhancement. We used a 6-4-MHz convex probe and a transperineal and/or a transpelvic approach. RESULTS: The neck of the bladder and the entire urethra were visualized in all patients (n = 150). The male urethra was considered normal in 95 boys (95.95%). We diagnosed posterior urethral valves in two patients, diverticulum of the prostatic utricle in one, and diverticulum of the anterior urethra in one. All abnormal cases were confirmed using conventional voiding cystourethrography. CONCLUSION: VUS can replace voiding cystourethrography as the method of choice for the initial study of suspected VUR in children.

Endovascular stent-graft treatment of thoracic aortic disease.

Aneurysmal diseases of the thoracic aorta are life-threatening conditions. In such cases, stent-graft treatment has been proposed as an alternative to surgery. The morbidity and mortality associated with endovascular repair are significantly lower than those associated with open surgery. In the largest surgical series, the mortality ranged from 5% to 20%. In studies of endovascular repair, the 30-day mortality was 0%-20% and the periprocedural stroke rate was 0%-7%. Often, open surgery is prohibited in patients with these high-risk lesions; thus, in many cases endovascular treatment is the only alternative. Thoracic aortic diseases that can be treated with endovascular stent-graft placement include aneurysms, dissection, traumatic rupture, traumatic pseudoaneurysms, intramural hematoma, penetrating atherosclerotic ulcers, and aortic rupture. Thorough preprocedure imaging is essential for selecting patients, choosing the stent-graft devices, and planning the intervention. Prerequisites for endovascular stent-graft placement are an adequate neck for graft attachment and adequate vascular access. When the ascending aorta or aortic arch is involved, surgical and endovascular procedures can be combined and performed simultaneously, allowing treatment of a wider range of cases. An experienced interdisciplinary team is needed to manage such cases.

Evaluation of pre-implantation kidney biopsies: comparison of Banff criteria to a morphometric approach.

BACKGROUND: Donor glomerulosclerosis, interstitial fibrosis, and fibrous intimal thickening correlate with graft outcome. We evaluate chronic lesions in donor biopsies according to Banff criteria and with a morphometric technique to ascertain their predictive value on graft outcome. METHODS: We evaluated 77 cadaveric donor biopsies according to Banff criteria. Glomerulosclerosis was expressed as the percentage of global sclerotic glomeruli. The following morphometric parameters were obtained: cortical interstitial volume fraction (Vvint/c), cortical glomerular volume fraction (Vvglom/c), mean glomerular volume (Vg), mean and maximal intimal arterial volume fraction (Vvintima/art), and Vvintima/art of the largest artery. We evaluated the correlation of histologic lesions with delayed graft function, 3 months' glomerular filtration rate (GFR), and death-censored graft survival. RESULTS: Multivariate logistic regression showed that delayed graft function was associated with cv score [relative risk (RR) 4.2 and 95% CI 1.1 to 16.0) and glomerulosclerosis (RR 1.06 and 95% CI 1.01 to 1.13). Stepwise regression showed that Vvint/c and glomerulosclerosis were independent predictors of 3 months' GFR (R= 0.62, P= 0.0001). Repeated analysis not considering morphometric parameters showed that glomerulosclerosis, cv score and ci score were independent predictors of 3 months' GFR (R= 0.64, P= 0.0001). A donor chronic damage score was generated considering glomerulosclerosis, cv score and ci score. This score after adjusting for clinical variables was associated with 3 months' GFR (R= 0.71, P < 0.0001) and death-censored graft survival (RR 2.2 and 95% CI 1.3 to 3.7). CONCLUSION: Combined evaluation of donor glomerulosclerosis, chronic vascular and interstitial damage according to Banff criteria allows a precise prediction of graft outcome. Morphometric evaluation of donor biopsies does not improve the predictive value of semiquantitative grading.

Angiotensin converting enzyme genotype and chronic allograft nephropathy in protocol biopsies.

Genotype DD of the angiotensin-converting enzyme (ACE) is not associated with an increased incidence of native renal diseases, although it could modulate progression to renal failure in patients who already display chronic lesions. Because its role in renal allograft degeneration is not well characterized, whether ACE genotype was associated with the prevalence of chronic allograft nephropathy (CAN) was studied, in a group of protocol biopsies from 180 patients, or with the incidence of CAN in 152 patients with at least two sequential biopsies. As a control group, ACE genotype was also studied in 41 donors and 72 healthy subjects. For analyzing the influence of ACE genotype in graft survival, patients were grouped into six categories (II-normal biopsy, ID-normal, DD-normal, II-CAN, ID-CAN and DD-CAN). Finally, relative renal ACE mRNA levels were measured in 67 cases by real-time PCR using the delta threshold cycle method. ACE-DD genotype was more frequent in patients who received a transplant than in control subjects (43.3% versus 30.1%, P = 0.026), but prevalence (DD = 42.7% versus non-DD = 42.2%) or incidence (DD = 24.6% versus non-DD = 29.9%) of CAN was not different regarding recipient ACE genotype. Furthermore, patients with the ACE-DD genotype and CAN had the poorest graft survival (II-normal = 100%, ID-normal = 91%, DD-normal = 84%, II-CAN = 100%, ID-CAN = 66%, and DD-CAN = 36%; P = 0.034) and higher ACE mRNA levels than non-DD and CAN (DD = -3.36 +/- 2.35 versus non-DD = -5.65 +/- 1.72-fold in ACE copies; P = 0.012). It is concluded that ACE-DD genotype is not associated with an increased prevalence or incidence of CAN but is actually associated with higher ACE mRNA levels and poorer graft survival in patients who already display CAN.