A prospective case series to evaluate subcostal nerve injury with high-resolution ultrasound in posterior retroperitoneoscopic adrenalectomy.

BACKGROUND: Posterior retroperitoneoscopic adrenalectomy has several advantages over transabdominal laparoscopic adrenalectomy regarding operating time, blood loss, postoperative pain, and recovery. However, postoperatively several patients report chronic pain or hypoesthesia. We hypothesized that these symptoms may be the result of damage to the subcostal nerve, because it passes the surgical area. METHODS: A prospective single-center case series was performed in adult patients without preoperative pain or numbness of the abdominal wall who underwent unilateral posterior retroperitoneoscopic adrenalectomy. Patients received pre- and postoperative questionnaires and a high-resolution ultrasound scan of the subcostal nerve and abdominal wall muscles was performed before and directly after surgery. Clinical evaluation at 6 weeks was performed with repeat questionnaires, physical examination, and high-resolution ultrasound. Long-term recovery was evaluated with questionnaires, and photographs from the patients were examined for abdominal wall asymmetry. RESULTS: A total of 25 patients were included in the study. There were no surgical complications. Preoperative visualization of the subcostal nerve was possible in all patients. At 6 weeks, ultrasound showed nerve damage in 15 patients, with no significant association between nerve damage and postsurgical pain. However, there was a significant association between nerve damage and hypoesthesia (p = 0.01), sensory (p < 0.001), and motor (p < 0.001) dysfunction on physical examination. After a median follow-up of 18 months, 5 patients still experienced either numbness or muscle weakness, and one patient experienced chronic postsurgical pain. CONCLUSION: In this exporatory case series the incidence of postoperative damage to the subcostal nerve, both clinically and radiologically, was 60% after posterior retroperitoneoscopic adrenalectomy. There was no association with pain, and the spontaneous recovery rate was high.

Adrenal fast-track and enhanced recovery in retroperitoneoscopic surgery for primary aldosteronism improving patient outcome and efficiency.

PURPOSE: No data exist on perioperative strategies for enhancing recovery after posterior retroperitoneoscopic adrenalectomy (PRA). Our objective was to determine whether a multimodality adrenal fast-track and enhanced recovery (AFTER) protocol for PRA can reduce recovery time, improve patient satisfaction and maintain safety. METHODS: Thirty primary aldosteronism patients were included. Fifteen patients were treated with 'standard-of-care' PRA and compared with 15 in the AFTER protocol. The AFTER protocol contains: a preoperative information video, postoperative oral analgesics, early postoperative mobilisation and enteral feeding, and blood pressure monitoring at home. The primary outcome was recovery time. Secondary outcomes were length of hospital stay, postoperative pain and analgesics requirements, patient satisfaction, perioperative complications and quality of life (QoL). RESULTS: Recovery time was much shorter in both groups than anticipated and was not significantly different (median 28 days). Postoperative length of hospital stay was significantly reduced in AFTER patients (mean 32 vs 42 h, CI 95%, p = 0.004). No significant differences were seen in pain, but less analgesics were used in the AFTER group. Satisfaction improved amongst AFTER patients for time of admission and postoperative visit to the outpatient clinic. There were no significant differences in complication rates or QoL. CONCLUSION: Despite no difference in recovery time between the two groups, probably due to small sample size, the AFTER protocol led to shorter hospital stays and less analgesic use after surgery, whilst maintaining and even enhancing patient satisfaction for several aspects of perioperative care. Complication rates and QoL are comparable to standard-of-care.

Association of frequent intradialytic hypotension with the clinical outcomes of patients on hemodialysis: a prospective cohort study.

Intradialytic hypotension (IDH) is a common complication of hemodialysis (HD), but there is no consensus on its definition. In 2015, Flythe proposed a definition of IDH (Definition 1 in this study): nadir systolic blood pressure (SBP) <90 mmHg during hemodialysis for patients with pre-dialysis SBP <159 mmHg, and nadir SBP <100 mmHg during hemodialysis for patients with pre-dialysis SBP ≥160 mmHg. This prospective observational cohort study investigated the association of frequent IDH based on Definition 1 with clinical outcomes and compared Definition 1 with a commonly used definition (nadir SBP <90 mmHg during hemodialysis, Definition 2). The incidence of IDH was observed over a 3-month exposure assessment period. Patients with IDH events ≥30% were classified as 'frequent IDH'; the others were 'infrequent IDH'. All-cause mortality, cardiovascular mortality, and all-cause hospitalization events were followed up for 36 months. This study enrolled 163 HD patients. The incidence of IDH was 11.1% according to Definition 1 and 10.5% according to Definition 2. The Kaplan-Meier curves showed that frequent IDH patients had higher risks of all-cause mortality (p = 0.009, Definition 1; p = 0.002, Definition 2) and cardiovascular mortality (p = 0.021, Definition 1). Multivariable Cox regression analysis indicated that frequent IDH was independently associated with a higher risk of all-cause mortality (Model 1: HR = 2.553, 95%CI 1.334-4.886, p = 0.005; Model 2: HR = 2.406, 95%CI 1.253-4.621, p = 0.008). In conclusion, HD patients classified as frequent IDH are at a greater risk of all-cause mortality. This highlights the significance of acknowledging and proactively managing frequent IDH within the HD patients.

Construction of an evaluation index system of core competencies for critical care blood purification nurses in China: A Delphi study.

AIM: The purpose of this study was to construct a core competencies evaluation index system for critical care blood purification nurses in China. BACKGROUND: While nursing is an integral part of critical care blood purification treatment, there are no established indicators to evaluate the core competencies of critical care blood purification nurses. DESIGN: A Delphi study. METHODS: An initial draft of the competencies evaluation index system for critical care blood purification nurses was developed through a literature review and semi-structured interviews. From February 2023 to March 2023, a two-round Delphi survey was conducted to consult with 18 experts in the field of critical care blood purification from eight provinces in China to rate the importance of each item and propose modifications to the evaluation index system. RESULTS: The effective questionnaire recovery rates in two rounds of expert consultation were 94.4 % and 94.1 % and the average expert authority coefficients were 0.88 in both rounds. The core competencies evaluation index system of critical care blood purification nurses consisted of 39 items in five domains, namely theoretical knowledge, practical skills, professional development capability, critical thinking ability and personal qualities and attributes. The Kendall's W coefficients for the first- and second-level indicators were.21 and.20 in the first round and.23 and.25, respectively, in the second round of consultations (p < .01). CONCLUSION: The core competencies evaluation index system of critical care blood purification nurses is scientific and reliable and can provide references for the recruitment, training and management of critical care blood purification nurses.

Impact of frequent intradialytic hypotension on quality of life in patients undergoing hemodialysis.

BACKGROUND: Intradialytic hypotension (IDH) is frequently accompanied by symptoms of nausea, dizziness, fatigue, muscle spasm, and arrhythmia, which can adversely impact the daily lives of patients who undergo hemodialysis and may lead to decreased quality of life (QoL). This study employed the KDQOL™-36 scale to evaluate the impact of frequent IDH, based on the definition determined by predialysis blood pressure (BP) and nadir systolic blood pressure (SBP) thresholds, on the QoL of patients. METHODS: This is a single center retrospective cohort study involving 160 hemodialysis patients. We enrolled adult patients with uremia who received routine hemodialysis (4 h/time, 3 times/week) from October 1, 2019, to September 30, 2021. Frequent IDH was defined as an absolute nadir SBP < 90 mmHg occurring in no less than 30% of hemodialysis sessions when predialysis SBP < 159 mmHg (or < 100 mmHg when predialysis BP ≥ 160 mmHg).The differences between patients with and without frequent IDH were compared using the independent t test, Kruskal‒Wallis test, or chi-square test. The primary visit was at month 36, and the remaining visits were exploratory outcomes. RESULTS: Compared to patients with infrequent IDH at baseline, those with frequent IDH had significantly lower scores on the symptoms and discomfort of kidney disease dimension at all follow-up points (P < 0.05). The symptoms and discomfort of kidney disease dimension were worse in patients with frequent IDH. Those with frequent IDH had a significantly poorer QoL regarding the dimensions of symptoms and discomfort of kidney disease and the impact of kidney disease on life. CONCLUSIONS: The findings of the study suggest an association between frequent IDH and QoL dimensions of symptoms and discomfort of kidney disease and the impact of kidney disease on life dimension under the definition of frequent IDH.

Potential drug-drug interactions in males living with HIV who use drugs to treat lower urinary tract symptoms.

OBJECTIVE: Lower urinary tract symptoms (LUTS) are becoming more prevalent in the ageing population of males living with HIV. Drugs to treat LUTS are known for both their potential role as victims in drug-drug interactions (DDIs) and their side effects. We aimed to evaluate the current use of drugs to treat LUTS and to assess potential DDIs in our cohort of adult males living with HIV. DESIGN: This was a retrospective review of pharmacy records. METHODS: We recorded the combination antiretroviral therapy (cART) regimen and any use of drugs to treat LUTS (anatomical therapeutic chemical codes G04CA/CB/CX and G04BD). Potential DDIs were assessed using the interaction checker developed by the University of Liverpool (https://www.hiv-druginteractions.org/checker). RESULTS: A total of 411 adult males living with HIV were included in this analysis. The median (interquartile range [IQR]) age was 53 (41-62) years. Nineteen (4.6%) patients used one or more drugs to treat LUTS. As expected, older patients were more likely to be receiving treatment for LUTS: Q1 (20-40 years) = 0%; Q2 (41-52 years) = 2%; Q3 (53-61 years) = 7%; Q4 (62-79 years) = 10%. Seven potential DDIs between cART and LUTS treatment were noted in six of the 19 (32%) patients. Following medication reviews of these six patients, the following interventions were proposed: evaluate safe use of alpha-blocker (n = 4), change in cART (n = 2), and dose reduction of the anticholinergic agent (n = 1). CONCLUSION: Treatment for LUTS coincided with cART in 7%-10% of patients aged above the median age of 53 years in our cohort. Improvements in DDI management appeared to be possible in this growing cohort of males living with HIV and with LUTS.

Finasteride Alleviates High Fat Associated Protein-Overload Nephropathy by Inhibiting Trimethylamine N-Oxide Synthesis and Regulating Gut Microbiota.

Unhealthy diet especially high-fat diet (HFD) is the major cause of hyperlipidemia leading to deterioration of chronic kidney diseases (CKD) in patients. Trimethylamine N-oxide (TMAO) is a gut-derived uremic toxin. Our previous clinical study demonstrated that the elevation of TMAO was positively correlated with CKD progression. Finasteride, a competitive and specific inhibitor of type II 5a-reductase, has been reported recently to be able to downregulate plasma TMAO level thus preventing the onset of atherosclerosis by our research group. In this study, we established a protein-overload nephropathy CKD mouse model by bovine serum albumin (BSA) injection to investigate whether hyperlipidemia could accelerate CKD progression and the underlying mechanisms. Finasteride was administrated to explore its potential therapeutic effects. The results of biochemical analyses and pathological examination showed that HFD-induced hyperlipidemia led to aggravated protein-overload nephropathy in mice along with an elevated level of circulating TMAO, which can be alleviated by finasteride treatment possibly through inhibition of Fmo3 in liver. The 16 S rRNA sequencing results indicated that HFD feeding altered the composition and distribution of gut microbiota in CKD mice contributing to the enhanced level of TMAO precursor TMA, while finasteride could exert beneficial effects via promoting the abundance of Alistipes_senegalensis and Akkermansia_muciniphila. Immunofluorescence staining (IF) and qRT-PCR results demonstrated the disruption of intestinal barrier by decreased expression of tight junction proteins including Claudin-1 and Zo-1 in HFD-fed CKD mice, which can be rescued by finasteride treatment. Cytokine arrays and redox status analyses revealed an upregulated inflammatory level and oxidative stress after HFD feeding in CKO mice, and finasteride-treatment could alleviate these lesions. To summarize, our study suggested that finasteride could alleviate HFD-associated deterioration of protein-overload nephropathy in mice by inhibition of TMAO synthesis and regulation of gut microbiota.

Stabilization of hypoxia-inducible factor ameliorates glomerular injury sensitization after tubulointerstitial injury.

Previously, we found that mild tubulointerstitial injury sensitizes glomeruli to subsequent injury. Here, we evaluated whether stabilization of hypoxia-inducible factor-α (HIF-α), a key regulator of tissue response to hypoxia, ameliorates tubulointerstitial injury and impact on subsequent glomerular injury. Nep25 mice, which express the human CD25 receptor on podocytes under control of the nephrin promotor and develop glomerulosclerosis when a specific toxin is administered were used. Tubulointerstitial injury, evident by week two, was induced by folic acid, and mice were treated with an HIF stabilizer, dimethyloxalylglycine or vehicle from week three to six. Uninephrectomy at week six assessed tubulointerstitial fibrosis. Glomerular injury was induced by podocyte toxin at week seven, and mice were sacrificed ten days later. At week six tubular injury markers normalized but with patchy collagen I and interstitial fibrosis. Pimonidazole staining, a hypoxia marker, was increased by folic acid treatment compared to vehicle while dimethyloxalylglycine stimulated HIF-2α expression and attenuated tubulointerstitial hypoxia. The hematocrit was increased by dimethyloxalylglycine along with downstream effectors of HIF. Tubular epithelial cell injury, inflammation and interstitial fibrosis were improved after dimethyloxalylglycine, with further reduced mortality, interstitial fibrosis, and glomerulosclerosis induced by specific podocyte injury. Thus, our findings indicate that hypoxia contributes to tubular injury and consequent sensitization of glomeruli to injury. Hence, restoring HIFs may blunt this adverse crosstalk of tubules to glomeruli.

Percutaneous Nephrolithotomy with Intraoperative Computed Tomography Scanning Improves Stone-Free Rates.

Introduction: The use of fluoroscopy during percutaneous nephrolithotomy (PCNL) may lead to an overestimation of stone-free rates. The objective of this study is to demonstrate the feasibility of intraoperative CT-guided PCNL compared with standard of care (SoC) PCNL. Patients and Methods: A prospective feasibility study (20 patients undergoing PCNL with an intraoperative CT scan between June 2017 and February 2020) and a retrospective study of a historical cohort (20 consecutive patients undergoing SoC PCNL between September 2015 and September 2016) were conducted. All procedures were performed by an expert endourologist in a tertiary referral hospital. Follow-up was performed at 6 weeks postoperatively. The primary goal is to investigate the practicality and potential benefits and harms of intraoperative CT scanning during PCNL. Secondary outcomes are a stone-free rate after the 6-week follow-up, perioperative radiation exposure, the need for postoperative imaging, and peri- and postoperative complications. Statistical significance was considered at p < 0.05. Results: The initial stone-free rate in the CT scan group was 65% (n = 13). In 25% (n = 5) of patients, residual stone fragments were removed after the perioperative CT scan. In the SoC group, 85% (n = 17) of patients were thought to be stone free perioperatively. At the 6-week follow-up, 80% (n = 16) in the CT scan group vs 50% in the SoC group (n = 10) were found to be stone free. Radiation exposure, perioperatively, was higher in the CT scan group. Complications were comparable between groups. Limitations of the study are the nonrandomized design of the study and nonstandardized follow-up imaging. Conclusions: Intraoperative CT scanning during PCNL is feasible and gives a better estimate of any remaining stone fragments compared with fluoroscopy only.

Complete remission of nephrotic syndrome in a young woman with anti-LRP2 nephropathy after immunosuppressive therapy.

BACKGROUND: Anti-low density lipoprotein receptor-related protein 2 (LRP2) nephropathy/anti-brush border antibody (ABBA) disease is a disorder characterized by acute tubulointerstitial injury associated with circulating antibodies to kidney proximal tubular brush border protein LRP2/megalin. Patients are typically elderly and present with acute kidney injury and subnephrotic proteinuria. They progress to end-stage renal disease with poor response to immunosuppressive therapies. CASE PRESENTATION: We report a case of a 29-year-old Chinese woman, who presented with nephrotic syndrome with normal kidney function. Kidney biopsy showed no obvious tubular injury or interstitial inflammation. Positive immunoglobulin G (IgG) staining was revealed along the brush border of proximal tubular cells. Anti-LRP2 antibody was identified in serum, consistent with a diagnosis of anti-LRP2 nephropathy. The patient achieved complete remission after receiving prednisone and cyclophosphamide. CONCLUSIONS: Anti-LRP2 nephropathy can also present as nephrotic syndrome in young patients and complete remission from nephrotic syndrome may be achieved after immunosuppressive therapy.

The Utility of Rise in Red Cell Distribution Width in Determining the Risk of Renal Relapse in Lupus Nephritis.

BACKGROUND: We hypothesized that the levels of red cell distribution width (RDW) would correlate with lupus nephritis (LN) disease activity, therapeutic response after induction therapy, and its rise would be associated with future renal relapse in patients who had achieved clinical remission. METHODS: The associations of RDW and Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), renal response, and renal relapse after induction therapy were examined in 172 biopsy-proven LN patients at the Division of Nephrology, Huashan Hospital Fudan University between 2007 and 2017. RESULTS: The median RDW of LN patients was significantly higher than that of healthy individuals (p < 0.001). Baseline RDW demonstrated positive correlation with baseline SLEDAI (r = 0.239, p = 0.004). Overall RDW after induction treatment was significantly decreased (p = 0.005), especially in the complete remission (CR) group (p = 0.02), and the partial remission (PR) group had a decreasing trend (p = 0.09), while the change of RDW in the no response (NR) group was not statistically significant (p = 0.70). Among the 153 patients who achieved remission after induction therapies, 37 (24.2%) patients developed 42 episodes of subsequent renal flare during a median follow-up of 36.0 (IQR, 20 - 66) months. The median time from remission to renal flare was 18.0 (IQR, 7.0 - 45.0) months. The overall renal flare rate was 0.065 relapse per patient-year. During follow up, 54 RDW rises (defined as more than 0.5% increase in RDW) were identified. There were 33 episodes (61.1%) of renal flares in patients with RDW rises, while there were only 9 renal flares (8.65%) in 104 patients without RDW rise (p < 0.001). Survival analysis showed that RDW rise was associated with a significantly higher risk of future renal relapse (adjusted HR, 14.03; 95% CI, 5.29 to 37.20; p < 0.001). CONCLUSIONS: In addition to correlating with disease activity and therapeutic response to induction therapy in patients with LN, RDW rise is a significant predictor of future renal relapse in patients who achieve remission.

Ranitidine and finasteride inhibit the synthesis and release of trimethylamine N-oxide and mitigates its cardiovascular and renal damage through modulating gut microbiota.

Trimethylamine N-oxide (TMAO) leads to the development of cardiovascular and chronic kidney diseases, but there are currently no potent drugs that inhibit the production or toxicity of TMAO. In this study, high-fat diet-fed ApoE-/- mice were treated with finasteride, ranitidine, and andrioe. Subsequently, the distribution and quantity of gut microbiota in the faeces of the mice in each group were analysed using 16S rRNA sequencing of the V3+V4 regions. Pathological examination confirmed that both ranitidine and finasteride reduced atherosclerosis and renal damage in mice. HPLC analysis also indicated that ranitidine and finasteride significantly reduced the synthesis of TMAO and the TMAO precursor delta-Valerobetaine in their livers. The 16S rRNA sequencing showed that all 3 drugs significantly increased the richness and diversity of gut microbiota in the model mice. Bioinformatic analysis revealed that the faeces of mice treated with ranitidine and finasteride, had significant increases in the number of microbes in the families g_Helicobacter, f_Desulfovibrionaceae, Mucispirillum_schaedleri_ASF457, and g_Blautia, whereas the relative abundances of microbes in the families Enterobacter_sp._IPC1-8 and g_Bacteroides were significantly reduced. The microbiota metabolic pathways, such as nucleotide and cofactor and vitamin metabolism were also significantly increased, whereas the activities of metabolic signalling pathways related to glycan biosynthesis and metabolism and cardiovascular diseases were significantly reduced. Therefore, our study indicates that in addition to their known pharmacological effects, ranitidine and finasteride also exhibit potential cardiovascular and renal protective effects. They inhibit the synthesis and metabolism of TMAO and delay the deposition of lipids and endotoxins through improving the composition of the gut microbiota.

Urological, Sexual, and Quality of Life Evaluation of Adult Patients With Exstrophy-Epispadias Complex: Long-term Results From a Dutch Cohort.

OBJECTIVE: To assess urological function, sexual function, and quality of life in patients with exstrophy or epispadias. Little is known regarding these outcomes in adult patients; our aim is to determine where improvements are needed for long-term management. METHODS: The study population comprised adult (>18 years) patients. Demographic data were gathered and patients were asked to fill out 4 validated questionnaires: (1) International Consultation on Incontinence Questionnaire urinary incontinence form (ICIQ-UI) regarding continence; (2) International Prostate Symptom Score (IPSS) for men and International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms (ICIQ-FLUTS) for women regarding lower urinary tract symptoms; (3) 12-Item Short Form Health Survey regarding quality of life; (4) International Index of Erectile Function for men and Female Sexual Function Index for women regarding sexual function. RESULTS: Seventeen patients were included (9 men and 8 women) with a median age of 36 years (range 19-73). Median score on ICIQ-UI was 5/21. Median IPSS score was 7/35 and median quality of life score was 1 (=pleased). Median scores per domain within ICIQ-FLUTS were 7 for storage, 0 for voiding, and 6 for urinary incontinence with bother scores of 4, 0, and 2.8, respectively. Scores for 12-Item Short Form Health Survey in the study population were comparable with those of the Dutch population, except for Physical Component Summary in women. For sexual function, no difference was found between those in the general population and our participants except for the domain "pain" in Female Sexual Function Index. CONCLUSION: Adult patients with exstrophy or epispadias have a high rate of incontinence and lower urinary tract symptoms with relatively low to some degree of bother. When compared with the general population, quality of life, and sexual function of our patients were more or less similar.

An Update on Early Urological Complications in Kidney Transplantation: A National Cohort Study.

BACKGROUND This study aimed to provide an update on the occurrence of early urological complications in living-donor and deceased-donor kidney transplantation (KTX). MATERIAL AND METHODS Data on all kidney transplant recipients in the Netherlands between January 2005 and December 2015 were retrieved from the prospectively collected Dutch National Organ Transplant Registry Database (NOTR). We assessed the incidence of major urological complications (MUCs) within 3 months after KTX, defined as urinary leakage and ureteral obstruction. Outcomes of living donor and deceased donor kidney transplants were compared. We performed regression analysis to identify predictive factors of urological complications and studied the influence of early urological complications on graft and patient survival. We performed an additional sub-study to explore the influence of preservation of the peri-ureteric connective tissue in living-donor KTX on the occurrence of urological complications. RESULTS Among 3329 kidney transplant recipients, urological complications occurred in 208 patients (6.2%) within 3 months after surgery. There were no significant differences in complication rates between recipients from living donors and deceased donors. Multiple regression analysis showed that older donor age and previous cardiac events of the recipient were predictors for the development of urological complications. Graft and patient survival were not affected by early MUCs. The additional sub-study showed that preservation of peri-ureteric tissue within living-donor KTX was not independently associated with urological complications. CONCLUSIONS Many living- and deceased-donor KTX recipients have early urological complications. MUCs did not affect long-term graft or patient survival.

Role of Modified Atmosphere in Pest Control and Mechanism of Its Effect on Insects.

Pests not only attack field crops during the growing season, but also damage grains and other food products stored in granaries. Modified or controlled atmospheres (MAs or CAs) with higher or lower concentrations of atmospheric gases, mainly oxygen (O2), carbon dioxide (CO2), ozone (O3), and nitric oxide (NO), provide a cost-effective method to kill target pests and protect stored products. In this review, the most recent discoveries in the field of MAs are discussed, with a focus on pest control as well as current MA technologies. Although MAs have been used for more than 30 years in pest control and play a role in storage pest management, the specific mechanisms by which insects are affected by and adapt to low O2 (hypoxia) and high carbon CO2 (hypercapnia) are not completely understood. Insect tolerance to hypoxia/anoxia and hypercapnia involves a decrease in aerobic metabolism, including decreased NADPH enzyme activity, and subsequently, decreases in glutathione production and catalase, superoxide dismutase, glutathione-S-transferase, and glutathione peroxidase activities, as well as increases in carboxyl esterase and phosphatase activities. In addition, hypoxia induces energy and nutrient production, and in adapted insects, glycolysis and pyruvate carboxylase fluxes are downregulated, accompanied with O2 consumption and acetate production. Consequently, genes encoding various signal transduction pathway components, including epidermal growth factor, insulin, Notch, and Toll/Imd signaling, are downregulated. We review the changes in insect energy and nutrient sources, metabolic enzymes, and molecular pathways in response to modified O2, CO2, NO, and O3 concentrations, as well as the role of MAs in pest control. This knowledge will be useful for applying MAs in combination with temperature control for pest control in stored food products.

α-Blockers for uncomplicated ureteric stones: a clinical practice guideline.

OBJECTIVE: To develop an evidence-based recommendation concerning the use of α-blockers for uncomplicated ureteric stones based on an up-to-date Cochrane review, as the role of medical expulsive therapy for uncomplicated ureteric stones remains controversial in the light of new contradictory trial evidence. METHODS: We applied the Rapid Recommendations approach to guideline development, which represents an innovative approach by an international collaborative network of clinicians, researchers, methodologists and patient representatives seeking to rapidly respond to new, potentially practice-changing evidence with recommendations developed according to standards for trustworthy guidelines. RESULTS: The panel suggests the use of α-blockers in addition to standard care over standard care alone in patients with uncomplicated ureteric stones (weak recommendation based on low-quality evidence). The panel judged that the net benefit of α-blockers was small and that there was considerable uncertainty about patients' values and preferences. This means that the panel expects that most patients would choose treatment with α-blockers but that a substantial proportion would not. This recommendation applies to both patients in whom the presence of ureteric stones is confirmed by imaging, as well as patients in whom the diagnosis is made based on clinical grounds only. CONCLUSION: The Rapid Recommendations panel suggests the use of α-blockers for patients with ureteric stones. Shared decision-making is emphasised in making the final choice between the treatment options.

α-blockers as medical expulsive therapy for ureteric stones: a Cochrane systematic review.

OBJECTIVE: To assess the effects of α-blockers compared to standard therapy or placebo for ureteric stones of ≤10 mm confirmed by imaging in adult patients presenting with symptoms of ureteric stone disease. PATIENTS AND METHODS: We performed a systematic search in multiple databases and grey literature with no restrictions on the language of publication or publication status, up until November 2017. We included randomised controlled trials evaluating ureteric stone passage in adult patients that compared α-blockers with standard therapy or placebo. Two review authors were independently responsible for study selection, data extraction, and risk-of-bias assessment. We performed a meta-analysis using a random-effect model. The quality of evidence was assessed on outcome basis according to Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach. RESULTS: We included 67 studies, with 10 509 participants overall. Of these, 15 studies with 5 787 participants used a placebo. Stone clearance: treatment with an α-blocker may result in a large increase in stone clearance (risk ratio [RR] 1.45, 95% confidence interval [CI] 1.36-1.55; low-quality evidence), corresponding to 278 more (95% CI: 223-340 more) stone clearances per 1 000 participants. For major adverse events, treatment with an α-blocker may have little effect (RR 1.25, 95% CI: 0.80-1.96; low-quality evidence), which corresponds to five more (95% CI four fewer to 19 more) major adverse events per 1 000 participants. Patients treated with α-blockers may also experience shorter stone expulsion times (mean difference [MD] -3.40 days, 95% CI: -4.17 to -2.63; low-quality evidence), use less diclofenac (MD -82.41 mg, 95% CI: -122.51 to -42.31; low-quality evidence) and likely require fewer hospitalisations (RR 0.51, 95% CI: 0.34-0.77; moderate-quality evidence). Meanwhile, the need for surgical intervention appears similar (RR 0.74, 95% CI: 0.53-1.02; low-quality evidence). Based on a pre-defined subgroup analysis (test for subgroup difference, P = 0.002), there may be a different effect of α-blockers based on stone size with RRs of 1.06 (95% CI: 0.98-1.15; P = 0.16; I² = 62%) for stones of ≤5 mm vs 1.45 (95% CI: 1.22-1.72; P < 0.0001; I² = 59%) for stones of >5 mm. We did not find evidence for possible subgroup effects based on stone location or α-blocker type. CONCLUSIONS: In patients with ureteric stones, α-blockers likely increase stone clearance but probably also slightly increase the risk of major adverse events. Subgroup analyses suggest that α-blockers may be less effective in smaller (≤5 mm) than larger stones (>5 mm).