Multi-institutional feasibility and safety outcomes of retroperitoneal robot-assisted partial nephrectomy in morbidly obese patients.

Background: Robotic-assisted partial nephrectomy (RAPN) is an established treatment modality for small renal masses. While retroperitoneal RAPN (rRAPN) has the benefit of avoiding the peritoneal cavity and provides more direct access to the renal hilum and posterior kidney, there is concern about the feasibility of rRAPN particularly in morbidly obese [body mass index (BMI) ≥40 kg/m2] patients. We present a large scale multi-institutional study on the outcomes of rRAPN in morbidly obese patients. Methods: A retrospective review of a cohort of morbidly obese patients who underwent rRAPN at two academic institutions was performed. Patient characteristics, operative data, and postoperative complication rates were assessed. Results: A total of 22 morbidly obese patients were included for analysis, with a median follow-up duration of 52 months. Median patient age was 61 years and median BMI was 44.9 kg/m2. Based on nephrometry score, 55% of the masses had low complexity and 32% had intermediate complexity. Median operative time was 186.0 minutes and median warm ischemia time was 23.5 minutes. Median postoperative length of stay was 2 days, and only one patient experienced a high-grade complication within 30 days of surgery. Conclusions: rRAPN in select morbidly obese patients appears to have acceptable operative and postoperative outcomes. Further studies and follow-up are needed to better generalization and understand long-term impacts.

Xylaria feejeensis, SRNE2BP a Fungal Endophyte with Biocontrol Properties to Control Early Blight and Fusarium Wilt Disease in Tomato and Plant Growth Promotion Activity.

Over the past decade endophytic fungi have been known as a source of secondary metabolites with the ability to act as a biocontrol agents. Xylaria feejeensis, SRNE2BP a fungal endophyte isolated from a mangrove tree exhibited antagonistic activity against two fungal pathogens of tomato. Crude extract of X. feejeensis SRNE2BP significantly inhibited Fusarium oxysporum MFLUCC 19-0157 growth as shown approximately 60-75% in in vitro and in situ assays. Both assays showed that the endophyte also inhibited mycelium formation of Alternaria solani MFLUCC 19-0093 by 56% and 87%, respectively. The half maximal inhibitory concentration of X. feejeensis SRNE2BP crude extract against A. solani and F. oxysporum was approximately 7 mg/l. Crude extract and mycelium of X. feejeensis SRNE2BP showed potential in controlling early blight and fusarium wilt disease in tomato, respectively. Seedlings from seeds coated with crude extract of X. feejeensis SRNE2BP had lower disease severity (31.71%) of early blight disease compared to un-treated seeds (57.13%). Soil treated with 10% endophytic mycelium not only reduced fusarium wilt in tomato plant (55.55% severity compared with 91.66% in un-treated soil) but also promoted seed emergence and growth of tomato. Structure analysis revealed that 12 secondary metabolites, especially mellein derivatives, are major components of the crude extract of X. feejeensis SRNE2BP. These compounds could be responsible for antifungal activities; however, further study is required. Our findings strongly suggest that colonization with this fungal endophyte can be beneficial to the host plant especially with regards to plant growth promotion and broad antagonistic activity.

Agile Development of a Smartphone App for Perinatal Monitoring in a Resource-Constrained Setting.

Technology provides the potential to empower frontline healthcare workers with low levels of training and literacy, particularly in low- and middle-income countries. An obvious platform for achieving this aim is the smartphone, a low cost, almost ubiquitous device with good supply chain infrastructure and a general cultural acceptance for its use. In particular, the smartphone offers the opportunity to provide augmented or procedural information through active audiovisual aids to illiterate or untrained users, as described in this article. In this article, the process of refinement and iterative design of a smartphone application prototype to support perinatal surveillance in rural Guatemala for indigenous Maya lay midwives with low levels of literacy and technology exposure is described. Following on from a pilot to investigate the feasibility of this system, a two-year project to develop a robust in-field system was initiated, culminating in a randomized controlled trial of the system, which is ongoing. The development required an agile approach, with the development team working both remotely and in country to identify and solve key technical and cultural issues in close collaboration with the midwife end-users. This article describes this process and intermediate results. The application prototype was refined in two phases, with expanding numbers of end-users. Some of the key weaknesses identified in the system during the development cycles were user error when inserting and assembling cables and interacting with the 1-D ultrasound-recording interface, as well as unexpectedly poor bandwidth for data uploads in the central healthcare facility. Safety nets for these issues were developed and the resultant system was well accepted and highly utilized by the end-users. To evaluate the effectiveness of the system after full field deployment, data quality, and corruption over time, as well as general usage of the system and the volume of application support for end-users required by the in-country team was analyzed. Through iterative review of data quality and consistent use of user feedback, the volume and percentage of high quality recordings was increased monthly. Final analysis of the impact of the system on obstetrical referral volume and maternal and neonatal clinical outcomes is pending conclusion of the ongoing clinical trial.

Physiological and neurobehavioral effects of cholinesterase inhibition in healthy adults.

INTRODUCTION: Based on common pharmacodynamic mechanisms, recent efforts to develop second generation alternatives for organophosphate (OP) prophylaxis have expanded to include cholinesterase (ChE) inhibiting compounds traditionally approved for use in the treatment of Alzheimer's disease (AD). The primary purpose of this study was to determine the extent to which low-dose huperzine A, galantamine, or donepezil selectively inhibited acetylcholinesterase (AChE) versus butyrylcholinesterase (BChE) activity in healthy adults and whether such inhibition impacted neurobehavioral performance. METHODS: In addition to hourly red blood cell cholinesterase sampling, neurobehavioral function was assessed before and after a single oral dose of huperzine A (100 or 200 µg), galantamine (4 or 8 mg), donepezil (2.5 or 5mg), or placebo (n=12 subjects per drug/dose). RESULTS: Compared to placebo, both dosages of huperzine A and galantamine inhibited circulating AChE but not BChE. With the exception of huperzine A (200 µg), which maintained declarative recall performance across sessions, compounds did not improve neurobehavioral performance. Some aspects of neurobehavioral performance correlated with AChE activity, although associations may have reflected time of day effects. DISCUSSION: Although huperzine A and galantamine significantly inhibited AChE (and likely increased central acetylcholine levels), neither compound improved neurobehavioral performance. The latter was likely due to ceiling effects in this young, healthy test population. Under conditions of reduced cholinergic activity (e.g., Alzheimer's disease), AChE inhibition (and corresponding maintenance of cholinergic tone) could potentially maintain/augment some aspects of neurobehavioral function.

Development and implementation of a cohort review for latent tuberculosis infection.

The Centers for Disease Control and Prevention (CDC) recommends that, in low-incidence settings for tuberculosis (TB), health departments periodically review their cases of latent TB infection (LTBI). The objective of this study was to evaluate the design and implementation of an LTBI cohort review that can be used to assess program performance. The methods used for the LTBI cohort review were developed and modified from those described previously by the CDC for TB disease. A stratified random sample of LTBI cases was selected from three U.S. Army installations to compare program outcomes. A total of 295 TB tests were performed on 215 patients. Sixty-one (76%) of the 80 repeat tests performed were positive. Of the 194 patients who were recommended therapy, 146 (75%) initiated therapy and 114 (59%) completed therapy. The U.S. Army's TB control program can be improved by reducing unnecessary testing of low-risk groups, increasing completion of LTBI treatment, reducing treatment delays, and ensuring data accuracy. The LTBI cohort review should be performed at least annually at the installation level to improve the quality of TB control programs.

Tuberculosis trends in the U.S. Armed Forces, active component, 1998-2012.

Members of the Armed Forces represent a segment of the U.S. population that may be at increased risk for tuberculosis (TB) infection, disease, and transmission due to overseas service in endemic areas and residence in congregate settings. The purpose of this study was to examine recent surveillance trends and risk factors associated with TB disease in the active component U.S. military. The rate of TB in the U.S. military -0.6 per 100,000 population (n=128) over the interval from 1998 to 2012 - was lower than the age-adjusted rate among the U.S. population (adjusted rate ratio=0.20) over the same time interval. During the last five years of the surveillance period, the most common factor associated with the diagnosis of TB disease during military service was latent infection at time of accession; also, as many as nine (24%) cases of TB were associated with deployment to Iraq or other military exposures. TB control activities should continue to mitigate unique military exposures such as crowding during recruit training and deployments to TB endemic areas.

Using the tuberculosis cohort review to evaluate and improve the U.S. Army's tuberculosis control program.

The challenges of tuberculosis (TB) control in the U.S. military are similar to those in other low-incidence populations; in addition, the U.S. Military Health System must account for geographic separation, frequent staff turnover, deployments to TB-endemic areas, and residence in congregate settings. The objective of this evaluation was to use a TB cohort review process to assess indicators of the quality and effectiveness of the TB control program in the U.S. Army. Ten cases of TB disease occurred at U.S. Army installations in 2011; all were pulmonary. Two cases occurred among the active component U.S. Army, a rate of 0.4 per 100,000 population; no case was attributable to infection acquired during deployment. Eight (80%) were foreign born. Seven (70%) were smear positive and one (10%) had multi-drug resistant TB. One (10%) case died. All (100%) of the nine remaining cases completed therapy. The median time from onset of symptoms to diagnosis was 98 days, but there was substantial variability (range 21-444). This is the first report of the cohort review methodology being applied to a military population. Most performance indicators in the U.S. Army met or approached national standards.

Tuberculosis among nonimmigrant visitors to US Military installations.

BACKGROUND: Nonimmigrant visitors are not required to be evaluated for tuberculosis (TB) before entering the country. Little literature exists describing the challenges of TB control among this demographic. This report reviews the challenges in managing TB in this population on U.S. military installations. METHODS: Six cases were identified from reportable medical event reports. Information was obtained from public health personnel via phone interviews. Verified cases from 2004 to 2011 were included. RESULTS: Challenges were congruent among locations including: lack of procedures to screen for infection and disease among individuals at time of entry allowing one case to be admitted with acquired immunodeficiency syndrome and another concurrently on treatment for active TB; delays in the diagnosis of active TB as median time from entry to diagnosis was 62 days; and the need to conduct an effective contact investigation as the mean contact index was 77 including 1 secondary case of active TB. CONCLUSIONS: These cases emphasize the need for screening for TB in visitors from high-risk countries at time of entry, prompt diagnosis and treatment if found, procedures for evaluation of contacts, and interjurisdictional cooperation in large contact investigations. These challenges are common to nonimmigrants in both military and civilian settings.

Screening for sickle trait among potential live kidney donors: policies and practices in US transplant centers.

Sickle cell trait is common in the United States (US) and associated with abnormalities of renal function. Little is known, however, about the potential risk of sickle cell trait to live kidney donors. Using an original questionnaire, we assessed the policies and practices of US renal transplant centers with regard to screening for sickle trait among potential live kidney donors. Fifty-four percent (137/252) of centers responded. Eighty-three percent (113/137) of transplant centers had no policy to screen donors for sickle trait. Thirty-four percent (46/135) of centers reported actually screening donors for sickle trait in practice. Thirty-seven percent (39/105) of centers reported excluding donors with sickle trait always or most of the time. High volume centers (>100 live donor transplants/year) were more likely to screen for sickle trait (Fisher's exact, P = 0.03), but not more likely to exclude potential donors with sickle trait from donating. Most US renal transplant centers do not screen donors for sickle trait. Wide variation is evident in center practice regarding exclusion of donors on the basis of sickle trait. Research into the potential impact of sickle trait on renal function after donation is needed to guide transplant clinicians.