Clinical Considerations and Outcomes of Robotic Urologic Surgery in Obese Patients.

Obesity is associated with many significant physiological changes. These considerations are important to surgery, especially in urological procedures. Obese patients often undergo surgical procedures and are at higher risk of complications. This investigation reviews physiological and anaesthesia considerations for obese and morbidly obese patients. In addition, urological surgeries and procedures should be considered for these higher risk patients. Clinical anaesthesiologists must use detailed assessment and, when appropriate, consultation in developing safe anaesthesia plans for these patients. Newer technologies have improved safety related to airway management, advanced airway devices, and regional anaesthesia with ultrasound-guided nerve blocks, which can reduce the need for opioids postoperatively. Recent developments in drug and monitoring technologies have also been developed and can be effective for obese and morbidly obese patients undergoing urological procedures and perioperative surgery, thus improving the likelihood of safety in this higher risk population.

ANCA-Associated Vasculitis: Practical Issues in Management.

ANCA associated vasculitides are multi-system autoimmune diseases which are increasing in prevalence. In this review we will discuss the clinical manifestations and review the management options. We highlight the various trials of induction and maintenance therapy and discuss the areas of unmet need. These include understanding which patients are at highest risk of relapse, clinical adaptation of improved biomarkers of disease activity and tools to discuss long term prognosis.

Genetic divergence accessed with microsatellite markers reflects the time of Crassostrea gigas genetic breeding in Brazil.

The Pacific Oyster was introduced on Santa Catarina Island in 1987, experiencing processes of selection and genetic breeding since then. Such procedures may have led to the establishment of specific strains, given the saltier and warmer conditions of the Atlantic Ocean. This study employed microsatellite markers to compare allelic patterns of oysters cultivated in Santa Catarina, the USA, and Asia. Specific allelic patterns were revealed in the Santa Catarina samples, reflecting the time of selection/breeding of the oyster in this region. This result supports the effectiveness of the selection/breeding procedures and the demand for protection of this commercially important genetic resource.

Periodic Addition of Glucose Suppressed Cyanobacterial Abundance in Additive Lake Water Samples during the Entire Bloom Season.

Previously, we showed that prophylactic addition of glucose to Harsha Lake water samples could inhibit cyanobacteria growth, at least for a short period of time. The current study tested cyanobacterial control with glucose for the entire Harsha Lake bloom season. Water samples (1000 ml) were collected weekly from Harsha Lake during the algal-bloom season starting June 9 and lasting until August 24, 2022. To each of two 7-liter polypropylene containers, 500 ml of Harsha Lake water was added, and the containers were placed in a controlled environment chamber. To one container labeled "Treated," 0.15 g of glucose was added, and nothing was added to the container labeled "Control." After that, three 25 ml samples from each container were collected and used for 16S rRNA gene sequencing each week. Then 1000 ml of Harsha Lake water was newly collected each week, with 500 ml added to each container, along with the addition of 0.15 g glucose to the "Treated" container. Sequencing data were used to examine differences in the composition of bacterial communities between Treated and Control containers. Treatment with glucose altered the microbial communities by 1) reducing taxonomic diversity, 2) largely eliminating cyanobacterial taxa, and 3) increasing the relative abundance of subsets of non-cyanobacterial taxa (such as Proteobacteria and Actinobacteriota). These effects were observed across time despite weekly inputs derived directly from Lake water. The addition of glucose to a container receiving weekly additions of Lake water suppressed the cyanobacterial populations during the entire summer bloom season. The glucose appears to stimulate the diversity of certain bacterial taxa at the expense of the cyanobacteria.

Ketamine: Pro or antiepileptic agent? A systematic review.

Purpose: of Review: This evidence-based systematic review evaluated the safety of ketamine as regard the potential to provoke epilepsy to help better guide anesthesiologists in their practice. Recent findings: Ketamine, originally developed as a dissociative anesthetic, has gained attention for its potential therapeutic applications in various medical conditions, including epilepsy. Ketamine is generally well-tolerated and widely used in anesthesia, however, conflicting data are confusing the anesthesiologists regarding the potential risk of seizures associated with its use. The literature that claimed the proepileeptic property are inconsistent and the mechanism of action is unclear. Moreover, the case reports had been in same certain contexts, such as procedural sedation where ketamine was used as a single agent. On the other hand, the retrospective data analysis confirmed the positive role ketamine plays as antiepileptic agent. Summary: Many studies have shown promising results for the use of ketamine as antiepileptic agent. In case of epileptic patients, there is no contraindication for using ketamine, however, combining with benzodiazepine or propofol may enhance the safety.

CD36 regulates macrophage and endothelial cell activation and multinucleate giant cell formation in anti neutrophil cytoplasm antibody vasculitis.

OBJECTIVE: To investigate CD36 in ANCA-associated vasculitis (AAV), a condition characterized by monocyte/macrophage activation and vascular damage. METHODS: CD36 expression was assessed in AAV patients and healthy controls (HC). The impact of palmitic acid (PA) stimulation on multinucleate giant cell (MNGC) formation, macrophage, and endothelial cell activation, with or without CD36 knockdown, was examined. RESULTS: CD36 was overexpressed on AAV patients' monocytes compared to HC, regardless of disease activity. AAV patients exhibited elevated soluble CD36 levels in serum and plasma and PR3-ANCA patients' monocytes demonstrated increased MNGC formation following PA stimulation compared to HC. PA stimulation of macrophages or endothelial cells resulted in heightened CD36 expression, cell activation, increased macrophage migration inhibitory factor (MIF) production, and c-Myc expression, with attenuation upon CD36 knockdown. CONCLUSION: CD36 participates in macrophage and endothelial cell activation and MNGC formation, features of AAV pathogenesis. AAV treatment may involve targeting CD36 or MIF.

Sex non-specific growth charts and potential clinical implications in the care of transgender youth.

Introduction: The Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) created separate growth charts for girls and boys because growth patterns and rates differ between sexes. However, scenarios exist in which this dichotomizing "girls versus boys" approach may not be ideal, including the care of non-binary youth or transgender youth undergoing transitions consistent with their gender identity. There is therefore a need for growth charts that age smooth differences in pubertal timing between sexes to determine how youth are growing as "children" versus "girls or boys" (e.g., age- and sex-neutral, compared to age- and sex-specific, growth charts). Methods: Employing similar statistical techniques and datasets used to create the CDC 2000 growth charts, we developed age-adjusted, sex non-specific growth charts for height, weight, and body mass index (BMI), and z-score calculators for these parameters. Specifically, these were created using anthropometric data from five US cross-sectional studies including National Health Examination Surveys II-III and National Health and Nutrition Examination Surveys I-III. To illustrate contemporary clinical practice, we overlaid our charts on CDC 2000 girls and boys growth charts. Results: 39,119 youth 2-20 years old (49.5% female; 66.7% non-Hispanic White; 21.7% non-Hispanic Black) were included in the development of our growth charts, reference ranges, and z-score calculators. Respective curves were largely superimposable through around 10 years of age after which, coinciding with pubertal onset timing, differences became more apparent. Discussion: We conclude that age-adjusted, sex non-specific growth charts may be used in clinical situations such as transgender youth in which standard "girls versus boys" growth charts are not ideal. Until longitudinal auxological data are available in these populations, our growth charts may help to assess a transgender youth's growth trajectory and weight classification, and expectations surrounding these.

Review: Discogenic Back Pain: Update on Treatment.

Purpose of Review: Lower back pain (LBP) has a lifetime prevalence of 80% in the United States population. Discogenic back pain (DBP), a subcategory of LBP, occurs as a result of the interverbal disc degeneration without disc herniation. Diagnosis relies on history, physical exam, and imaging such as MRI, provocative discography, or CT discography. Recent Findings: Treatment of DBP involves a multifaceted approach with an emphasis on conservative measures including behavioral modification, pharmacologic management, and other non-pharmacologic interventions with invasive therapy reserved for select patients. Due to the paucity of data on the treatment of DBP, treatment also relies on data derived from treatment of chronic LBP (CLBP). Summary: Despite the scarcity of data for the treatment of DBP, treatments do exist with varying efficacy for DBP. Novel techniques such as the use of biologics may provide another avenue for treatment though further studies are needed to better evaluate the most efficacious regimen for both novel and existing treatments.

ERAS Protocol Options for Perioperative Pain Management of Substance Use Disorder in the Ambulatory Surgical Setting.

Even prior to the COVID-19 pandemic, rates of ambulatory surgeries and ambulatory patients presenting with substance use disorder were increasing, and the end of lockdown has further catalyzed the increasing rates of ambulatory patients presenting for surgery with substance use disorder (SUD). Certain subspecialty groups of ambulatory procedures have already established protocols to optimize early recovery after surgery (ERAS), and these groups have subsequently enjoyed improved efficiency and reduced adverse outcomes as a result. In this present investigation, we review the literature as it relates to substance use disorder patients, with a particular focus on pharmacokinetic and pharmacodynamic profiles, and their resulting impact on the acute- or chronic user ambulatory patient. The systematic literature review findings are organized and summarized. We conclude by identifying areas of opportunity for further study, specifically with the aim of developing a dedicated ERAS protocol for substance use disorder patients in the ambulatory surgery setting. - Healthcare in the USA has seen an increase in rates of both substance use disorder patients and separately in ambulatory surgery cases. - Specific perioperative protocols to optimize outcomes for patients who suffer from substance use disorder have been described in recent years. - Agents of interest like opioids, cannabis, and amphetamines are the top three most abused substances in North America. - A protocol and recommend further work should be done to integrate with concrete clinical data, in which strategies should be employed to confer benefits to patient outcomes and hospital quality metrics like those enjoyed by ERAS protocol in other settings.

Non-steroidal Anti-inflammatory Drugs: Clinical Implications, Renal Impairment Risks, and AKI.

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most common class of drugs utilized for a variety of disorders, including headaches, pain states, fever, and other common conditions. In recent years, a link between NSAIDs and adverse effects has been identified, including renal, heart, and liver disease, bleeding, and increased mortality. NSAID-mediated renal disease is associated with interference with the cyclooxygenase enzyme. Literature evaluating NSAID renal effects has indicated that a number of factors are associated with acute and chronic kidney injury (AKI). Early diagnosis can identify changes in renal function and allow for cessation of NSAID use, limiting the risk for long-term chronic renal disease and in some cases reversal of renal injury. Alternative medications should be considered in those patients identified with morbidity linked to NSAID use. Nephrotoxicity is increased in the elderly population and in hypovolemia, high dose exposure, use of vasoconstrictors such as calcineurin inhibitors, and use of renin-angiotensin-aldosterone system (RAAS) inhibitors or diuretics. Careful risk/benefit considerations from healthcare professionals can limit the incidence and degree of morbidity and mortality, including in NSAID-mediated renal disease. Selective NSAID cyclooxygenase-2 inhibitors also possess risks and therefore clinicians should always recommend short-term courses of this class of drugs versus long-term dosing because of the risk of morbidity and mortality. Given that these drugs are available over the counter as well by prescribing, clinicians must communicate the risks and benefits of NSAIDs and provide sound recommendations to their patients regarding use short and long term.

Quality indicators in burn care: An international burn care professionals survey to define them.

INTRODUCTION: Quality indicators (QIs) are tools for improving and maintaining the standard of care. Although burn injuries are a major global health threat, requiring standardized management, there is a lack of worldwide accepted quality indicators for burn care. This study aims to identify the best burn care-specific QIs as perceived by worldwide burn practitioners. METHODS: The ISBI Burn Care Committee developed a survey to analyze which burn care- specific QIs were relevant to international burn care professionals. The questionnaire was based on the three dimensions of the Donabedian model (i.e., Structure, Process, and Outcome) to evaluate the quality of care. The study was conducted from April to September 2021 and analyzed and reported following the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). RESULTS: According to the 124 worldwide respondents, the most relevant QIs were: access to intensive care, burn surgeons, and dedicated burn care nurses (Structure category), 24-hours access to burn services, local protocols based on documented guidelines (Process category), and in-hospital mortality and incidence of severe infections (Outcome category). CONCLUSIONS: Specific QIs related to structures, clinical processes, and outcomes are needed to monitor the treatment of burn patients globally, assess the efficiency of the provided treatment, and harmonize the worldwide standard of burn care.

Proteinase 3 promotes formation of multinucleated giant cells and granuloma-like structures in patients with granulomatosis with polyangiitis.

OBJECTIVES: Granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA) are autoimmune vasculitides associated with antineutrophil cytoplasm antibodies that target proteinase 3 (PR3) or myeloperoxidase (MPO) found within neutrophils and monocytes. Granulomas are exclusively found in GPA and form around multinucleated giant cells (MGCs), at sites of microabscesses, containing apoptotic and necrotic neutrophils. Since patients with GPA have augmented neutrophil PR3 expression, and PR3-expressing apoptotic cells frustrate macrophage phagocytosis and cellular clearance, we investigated the role of PR3 in stimulating giant cell and granuloma formation. METHODS: We stimulated purified monocytes and whole peripheral blood mononuclear cells (PBMCs) from patients with GPA, patients with MPA or healthy controls with PR3 or MPO and visualised MGC and granuloma-like structure formation using light, confocal and electron microscopy, as well as measuring the cell cytokine production. We investigated the expression of PR3 binding partners on monocytes and tested the impact of their inhibition. Finally, we injected zebrafish with PR3 and characterised granuloma formation in a novel animal model. RESULTS: In vitro, PR3 promoted monocyte-derived MGC formation using cells from patients with GPA but not from patients with MPA, and this was dependent on soluble interleukin 6 (IL-6), as well as monocyte MAC-1 and protease-activated receptor-2, found to be overexpressed in the cells of patients with GPA. PBMCs stimulated by PR3 formed granuloma-like structures with central MGC surrounded by T cells. This effect of PR3 was confirmed in vivo using zebrafish and was inhibited by niclosamide, a IL-6-STAT3 pathway inhibitor. CONCLUSIONS: These data provide a mechanistic basis for granuloma formation in GPA and a rationale for novel therapeutic approaches.

Homological landscape of human brain functional sub-circuits.

Human whole-brain functional connectivity networks have been shown to exhibit both local/quasilocal (e.g., set of functional sub-circuits induced by node or edge attributes) and non-local (e.g., higher-order functional coordination patterns) properties. Nonetheless, the non-local properties of topological strata induced by local/quasilocal functional sub-circuits have yet to be addressed. To that end, we proposed a homological formalism that enables the quantification of higher-order characteristics of human brain functional sub-circuits. Our results indicated that each homological order uniquely unravels diverse, complementary properties of human brain functional sub-circuits. Noticeably, the H1 homological distance between rest and motor task were observed at both whole-brain and sub-circuit consolidated level which suggested the self-similarity property of human brain functional connectivity unraveled by homological kernel. Furthermore, at the whole-brain level, the rest-task differentiation was found to be most prominent between rest and different tasks at different homological orders: i) Emotion task H0, ii) Motor task H1, and iii) Working memory task H2. At the functional sub-circuit level, the rest-task functional dichotomy of default mode network is found to be mostly prominent at the first and second homological scaffolds. Also at such scale, we found that the limbic network plays a significant role in homological reconfiguration across both task- and subject- domain which sheds light to subsequent Investigations on the complex neuro-physiological role of such network. From a wider perspective, our formalism can be applied, beyond brain connectomics, to study non-localized coordination patterns of localized structures stretching across complex network fibers.

The Anticancer Effect of Metformin Combined with Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitors in Non-small Cell Lung Cancer Patients with or Without Type 2 Diabetes Mellitus: A Systematic Review and Meta-analysis.

INTRODUCTION: Despite the growing evidence for the anticancer effect of metformin or its combination with epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs), the efficacies and side effects of such strategies in non-small cell lung cancer (NSCLC) patients with or without type 2 diabetes mellitus (T2DM) are not well understood. This meta-analysis was performed to determine the efficacy and side effects of metformin combined with EGFR-TKIs (MET-EGFR-TKIs) for the treatment of NSCLC with or without T2DM. METHODS: PubMed and Cochrane Library databases were used to retrieve relevant studies through August 2020 using the keywords "metformin", "EGFR-TKIs" ("gefitinib" or "erlotinib" or "afatinib" or "icotinib" or "dacomitinib") and "lung cancer". The patients in the experimental group received MET-EGFR-TKIs, while those in the control group received only EGFR-TKIs. The outcome analysis reported overall survival (OS), progression-free survival (PFS), objective response rate (ORR), and disease control rate (DCR). Random-effect models and fixed-effect models were used to estimate the combined hazard ratio (HR) and odds ratio (OR) depending on the data heterogeneity. Three studies (including 1996 patients) were included in the current meta-analysis. RESULTS: There were significant differences in PFS (HR 0.84; 95% confidence interval (CI) 0.75-0.95; P = 0.004) and OS (HR 0.77; 95% CI, 0.50-1.04; P < 0.001) between the MET-EGFR-TKI and EGFR-TKI groups. Although the ORR (OR 1.38; 95% CI 0.66-2.88; P = 0.105) and DCR (OR 2.61, 95% CI 0.68-9.95, P = 0.160) were improved, there was no statistical significance. OS subgroup analysis showed that the combination was more effective in NSCLC with T2DM than in NSCLC without T2DM (HR 0.84; 95% CI 0.74-0.95; P < 0.005). CONCLUSIONS: MET-EGFR-TKIs provided benefits for PFS and OS, and OS subgroup analysis showed that patients with NSCLC with T2DM received greater benefit than NSCLC patients without T2DM. However, further large-scale, well-designed randomized controlled trials (RCTs) are warranted to confirm the findings in the present investigation.

Pharmacological management of cancer pain: Novel therapeutics.

Patients diagnosed with cancer often experience pain during their treatment course, making it difficult to care for themselves and continue with their activities of daily living. When cancer is found at later stages, the pain can become severe and constant; reducing their quality of life and significantly affecting mental and physical well-being. Despite opioids being known to provide adequate analgesia for higher pain levels, they are often the reason for under-dosing because of their adverse effects and concern for addiction. There are also patients who do not respond well to opioids because of genetic anomalies or personal preference. Therefore, there is a need for novel non-opioid cancer pain treatments. There are many new cancer pain treatments that are emerging. This manuscript discusses cancer pain, risk factors, epidemiology, guidelines for the treatment of cancer pain, personalization of cancer pain therapy, breakthrough pain, cancer-induced peripheral neuropathy, established cancer pain treatment options, and novel emerging cancer pain treatment options.

Neuromodulation for Management of Chronic Pelvic Pain: A Comprehensive Review.

INTRODUCTION: Chronic pelvic pain (CPP) is a symptom that derives from a complex group of heterogeneous pathologies of the pelvic organs. The aim of this study was to review the available evidence on efficacy of neuromodulatory modalities including sacral neuromodulation, dorsal root ganglion stimulation, dorsal column neuromodulation, and pudendal nerve stimulation. METHODS: This narrative review focuses on updated information on neuromodulation for management of chronic pelvic pain. In 2022, we searched English-language studies on neuromodulation, pelvic pain, and chronic pain in a comprehensive search. We searched the following databases: PubMed, Medline, SciHub, Cochrane Database of Systematic Reviews, and Google Scholar. We used the following combinations of keywords: neuromodulation, pelvic pain, chronic pain, chronic pelvic pain, pelvic pain treatment. We tried to include as many recent manuscripts as possible (within the last 3 years) but also included papers older than 3 years if they were particularly relevant to our topic. We also attempted to search for, use, and cite primary manuscripts whenever possible. RESULTS: CPP is a challenging entity to treat because of diagnostic inconsistencies and limited evidence for therapeutic modalities. Our review found evidence suggestive of benefit for all modalities reviewed but the data was of overall low quality with numerous limitations. The literature highlights a lack of randomized controlled trials for neuromodulatory therapies but suggests a growing role for such techniques in treating refractory chronic pelvic pain syndrome (CPPS). CONCLUSIONS: This review explores the available evidence on efficacy of neuromodulatory modalities for CPPS and contextualizes the results with information about the type of neuromodulation, lead location and waveform, pain outcomes and assessment timepoints, and reported adverse effects.

Clinical outcomes in patients who need acute renal replacement therapy in the intensive care unit / Desenlaces clínicos de pacientes con requerimiento de terapia de reemplazo renal aguda en unidad de cuidado intensivo

Abstract Objective: to establish the renal outcomes of patients needing dialysis due to acute kidney injury who were admitted to the intensive care unit at Hospital Departamental Universitario Santa Sofía de Caldas from 2006 to 2018, and determine the factors associated with these outcomes. Methods: a retrospective cohort study carried out at Hospital Departamental Universitario Santa Sofía de Caldas on 122 patients over the age of 18 who required dialysis in the intensive care unit due to acute kidney injury, from 2006 to 2018. The major adverse kidney events (MAKE) composite outcome was evaluated, composed of partial recovery of kidney function, dialysis dependence and death, with 90-day and one-year follow up. Results: there is a relationship between diabetes, the APACHE II score, metabolic acidosis, anuria and the dialysis start time and MAKE at 90 days and one year. In the logistic regression, patients who developed MAKE at 90 days had a greater probability of having had anuria (OR=6.71; 95%CI: 1,497-30,076), acidosis (OR=4,349; 95%CI: 1,616-11.7) and a late treatment start (OR=3,013; 95%CI: 1,241-7,316). The one-year MAKE showed similar results, with the addition of the continu ous therapy modality (OR=2,841; 95%CI: 1,193-6,763). Conclusions: diabetes, a high APACHE II, anuria, metabolic acidosis and late dialysis treat ment are more frequent in patients who develop MAKE. (Acta Med Colomb 2022; 47. DOI:https://doi.org/10.36104/amc.2022.2229).

Resumen Objetivo: determinar los desenlaces renales de los pacientes con requerimiento de diálisis por lesión renal aguda, que ingresaron a la unidad de cuidado intensivo del Hospital Departamental Universitario Santa Sofía de Caldas desde el año 2006 a 2018 y determinar los factores asociados a estos desenlaces. Métodos: estudio retrospectivo de cohortes llevado a cabo en el Hospital Departamental Universitario Santa Sofía de Caldas en 122 pacientes mayores de 18 años, que requirieron diálisis por lesión renal aguda en la unidad de cuidado intensivo entre los años 2006 y 2018. Se evaluó el desenlace compuesto del MAKE (Major Adverse Kidney Events) conformado por recuperación parcial de la función renal, dependencia de la diálisis y muerte con seguimiento a los 90 días y un año. Resultados: existe asociación entre diabetes, puntaje APACHE II, acidosis metabólica, anuria y tiempo de inicio de la diálisis con el MAKE a 90 días y al año. En la regresión logística aquellos pacientes que desarrollaron MAKE a los 90 días tenían mayor probabilidad de haber presentado anuria (OR=6.71; IC95%: 1497-30 076), acidosis (OR=4349; IC95%: 1616-11.7) e inicio tardío de la terapia (OR=3013; IC95%: 1241-7316). En el MAKE a un año hubo resultados similares, adicionando modalidad de terapia continua (OR=2841; IC95%: 1193-6763). Conclusiones: diabetes, APACHE II alto, anuria, acidosis metabólica y terapia dialítica tardía son más frecuentes en pacientes que desarrollan MAKE. (Acta Med Colomb 2022; 47. DOI:https://doi.org/10.36104/amc.2022.2229).