Robotic assisted partial nephrectomy reduces warm ischemia time and improves renal function acutely compared to the traditional laparoscopic approach; A single surgeon twin centre study.

Herein, we compared peri-operative and post-operative outcomes between robotic-assisted and laparoscopic partial nephrectomy. Various reviews of the current literature have detailed the lack of single-surgeon studies in this domain. Our study featured a single surgeon experienced in both approaches to reduce this bias seen in other multi-centre studies. We retrospectively analysed data from two hospitals to compare patient demographics, tumour characteristics, peri-operative and post-operative outcomes of all partial nephrectomies undertaken by a single surgeon with extensive experience in both approaches. Statistical analysis was carried out using GraphPad prism software. Warm ischaemia time was significantly reduced in the robotic arm compared to the laparoscopic group. This translated into an improvement in acute renal function. Length of stay was also significantly reduced. This study highlights some benefits of robotic-assisted in comparison to laparoscopic partial nephrectomy. Further large-scale prospective studies would be valuable in confirming these findings and justifying their usage against their financial cost.

Primary Ewing sarcoma of the kidney presenting as haematuria in a pregnant woman - A case report highlighting the diagnostic and therapeutic dilemmas of the condition in pregnancy.

Primary Ewing sarcoma of the kidney is an extremely rare yet aggressive tumour. We present a 31-year-old pregnant female who presented to the emergency department with macroscopic haematuria and an ultrasound scan demonstrating a right renal mass. On magnetic resonance imaging, the lesion had features concerning for malignancy. She underwent a radical nephrectomy and was commenced on a personally tailored chemotherapy regime designed to permit healthy delivery of her baby while adequately treating her disease. This highlights an extremely rare differential for a renal mass which should be considered in rapidly growing renal tumours of a young patient.

Benefits of Robotic Assisted vs. Traditional Laparoscopic Partial Nephrectomy: A Single Surgeon Comparative Study.

PURPOSE: The current study aims to compare peri-operative and post-operative outcomes between robotic assisted vs. laparoscopic partial nephrectomy. Multiple reviews of the current literature have detailed the lack of single surgeon studies in this domain. To limit inter-operator bias, we utilise a single surgeon experienced in both approaches to reduce this bias seen in other multi-centre studies. METHODS AND MATERIALS: We retrospectively compared patient demographics, tumour characteristics, peri-operative and post-operative outcomes of all partial nephrectomies undertaken by a single surgeon between 2014 and 2021 with experience in both laparoscopic and robotic surgery. The Da Vinci surgical system was utilized. Statistical analysis was carried out using GraphPad prism software version 7.03, San Diego, CA, USA. RESULTS: Warm ischemia time was reduced by 2.6 min, length of stay reduced by 1.3 days and acute renal function deterioration was reduced by 55% with all these results being significant with robotic assisted partial nephrectomy compared to laparoscopic partial nephrectomy. CONCLUSION: This study highlights the benefits of robotic assisted in comparison to laparoscopic partial nephrectomy. Further large-scale prospective studies and cost-benefit analysis of robotic assisted partial nephrectomy would be valuable in confirming these findings and justifying the usage against their financial cost.

Research Participation Influences Willingness to Reduce Zoonotic Exposure in Uganda.

The majority of emerging and re-emerging infectious diseases in people are zoonotic. Despite substantial research in communities adjacent to protected areas with high levels of biodiversity, limited data exist on people's knowledge, attitudes, and practices to avoid exposure to infections from domestic and wild animals. We used a modified grounded-theory framework in QS NVivo to develop a Knowledge, Attitude, and Practices (KAP) survey administered at two time points, KAPT1 (April-July 2016) and KAPT2 (February-May 2018) to participants living at the edge of Kibale National Park, Uganda. We measured the difference in willingness to engage in protective behaviors around zoonotic exposure between an Intervention group (n = 61) and a Comparison group (n = 125). Prior to KAPT1, the Intervention group engaged in a human-centered design (HCD) activity identifying behaviors that reduce zoonotic exposure (March-May 2016). Using a difference-in-difference approach, we compared the Intervention and Comparison groups to assess sustained willingness and use of protective behaviors against domestic and wild animal exposures. At KAPT1, Comparison group participants had a significantly lower (p < 0.05) level of willingness to engage in behaviors that increase exposure to zoonoses from domestic animals; Intervention group participants had a significantly higher (p < 0.01) level of willingness to engage in behaviors that increase exposure to zoonoses from wild animals. At KAPT2, the treatment effect was significant (p < 0.01) for sustained willingness to engage in protective behaviors for domestic animal exposure in the Intervention group. There were no significant differences in practices to avoid domestic and wild animal zoonotic exposure between the Intervention and Comparison groups.

Increasing taxonomic diversity and spatial resolution clarifies opportunities for protecting US imperiled species.

Continental- and regional-scale assessments of gaps in protected area networks typically use relatively coarse range maps for well documented species groups, creating uncertainty about the fate of unexamined biodiversity and providing insufficient guidance for land managers. By building habitat suitability models for a taxonomically diverse group of 2216 imperiled plants and animals, we revealed comprehensive and detailed protection opportunities in the conterminous United States. Summing protection-weighted range-size rarity (PWRSR, the product of the percent of modeled habitat outside of protected areas and the inverse of modeled habitat extent) uncovered novel patterns of biodiversity importance. Concentrations of unprotected imperiled species in places such as the northern Sierra Nevada, central and northern Arizona, the Rocky Mountains of Utah and Colorado, southeastern Texas, southwestern Arkansas, and Florida's Lake Wales Ridge have rarely if ever been featured in continental- and regional-scale analyses. Inclusion of diverse taxa (vertebrates, freshwater mussels, crayfishes, bumble bees, butterflies, skippers, and vascular plants) partially drove these new patterns. When analyses were restricted to groups typically included in previous studies (birds, mammals, and amphibians), up to 53% of imperiled species in other groups were left out. The finer resolution of modeled inputs (990 m) also resulted in a more geographically dispersed pattern. For example, 90% of the human population of the conterminous United States lives within 50 km of modeled habitat for one or more species with high PWRSR scores. Over one-half of the habitat for 818 species occurs within federally lands managed for biodiversity protection; an additional 360 species have over one-half of their modeled habitat on federal multiple use land. Freshwater animals occur in places with poorer landscape condition but with less exposure to climate change than other groups, suggesting that habitat restoration is an important conservation strategy for these species. The results provide fine-scale, taxonomically diverse inputs for local and regional priority-setting and show that although protection efforts are still widely needed on private lands, notable gains can be achieved by increasing protection status on selected federal lands.

Improving species status assessments under the U.S. Endangered Species Act and implications for multispecies conservation challenges worldwide.

Despite its successes, the U.S. Endangered Species Act (ESA) has proven challenging to implement due to funding limitations, workload backlog, and other problems. As threats to species survival intensify and as more species come under threat, the need for the ESA and similar conservation laws and policies in other countries to function efficiently has grown. Attempts by the U.S. Fish and Wildlife Service (USFWS) to streamline ESA decisions include multispecies recovery plans and habitat conservation plans. We address species status assessment (SSA), a USFWS process to inform ESA decisions from listing to recovery, within the context of multispecies and ecosystem planning. Although existing SSAs have a single-species focus, ecosystem-based research can efficiently inform multiple SSAs within a region and provide a foundation for transition to multispecies SSAs in the future. We considered at-risk grassland species and ecosystems within the southeastern United States, where a disproportionate number of rare and endemic species are associated with grasslands. To initiate our ecosystem-based approach, we used a combined literature-based and structured World Café workshop format to identify science needs for SSAs. Discussions concentrated on 5 categories of threats to grassland species and ecosystems, consistent with recommendations to make shared threats a focus of planning under the ESA: (1) habitat loss, fragmentation, and disruption of functional connectivity; (2) climate change; (3) altered disturbance regimes; (4) invasive species; and (5) localized impacts. For each threat, workshop participants identified science and information needs, including database availability, research priorities, and modeling and mapping needs. Grouping species by habitat and shared threats can make the SSA process and other planning processes for conservation of at-risk species worldwide more efficient and useful. We found a combination of literature review and structured discussion effective for identifying the scientific information and analysis needed to support the development of multiple SSAs. Article impact statement: Species status assessments can be improved by an ecosystem-based approach that groups imperiled species by shared habitats and threats.

Mejoramiento de la Evaluación del Estado de una Especie bajo el Acta de Especies en Peligro de los Estados Unidos y Sus Consecuencias para los Retos de la Conservación Multiespecie a Nivel Mundial Resumen A pesar de su éxito, el Acta de Especies en Peligro de los E.U.A. (AEP) ha sido un reto de implementación por las limitaciones en su financiamiento, el retraso en la carga de trabajo y otros problemas. Conforme se intensifican las amenazas a la supervivencia de las especies y más especies resultan amenazadas, aumenta la necesidad de que la AEP y las políticas similares de otros países funcionen efectivamente. Los intentos por parte del Servicio Estadounidense de Pesca y Fauna (SEPF) para optimizar las decisiones de la AEP incluyen planes multiespecie de recuperación y planes de conservación de hábitat (PRH). Abordamos la evaluación del estado de las especies (EEE), un proceso del SEPF para orientar las decisiones del AEP desde el listado hasta la recuperación, dentro del contexto de la planeación multiespecie y de ecosistemas. Aunque las EEE existentes tienen un enfoque sobre una única especie, la investigación basada en el ecosistema puede orientar eficientemente a múltiples EEE dentro de una región y proporcionar una base para la transición a las EEE multiespecie en el futuro. Consideramos a las especies y los ecosistemas en riesgo de los pastizales del sureste de los Estados Unidos, en donde un número desproporcionado de especies raras y endémicas está asociado con los pastizales. Para iniciar nuestra estrategia basada en el ecosistema, usamos un formato de taller de World Café estructurado y basado en la literatura para identificar la necesidad de tener EEE. Las discusiones se centraron en cinco categorías de amenazas para las especies y ecosistemas de los pastizales, consistentes con las recomendaciones para volver a las amenazas compartidas un foco de la planeación bajo la AEP: (1) pérdida del hábitat, fragmentación y disrupción de la conectividad funcional; (2) cambio climático; (3) regímenes alterados de perturbación; (4) especies invasoras; y (5) impactos localizados. Para cada amenaza, los participantes del taller identificaron las necesidades científicas y de información, incluyendo la disponibilidad de bases de datos, prioridades de la investigación y necesidades de modelado y mapeado. La agrupación de las especies por hábitat y amenaza compartida puede hacer más eficientes y útiles el proceso de EEE y otros procesos de planeación de la conservación de especies en riesgo a nivel mundial. Encontramos una combinación de revisiones bibliográficas y discusiones estructuradas para identificar la información y el análisis necesarios para respaldar el desarrollo de múltiples EEE.

Can decision support combat incompleteness and bias in routine primary care data?

OBJECTIVE: Routine primary care data may be used for the derivation of clinical prediction rules and risk scores. We sought to measure the impact of a decision support system (DSS) on data completeness and freedom from bias. MATERIALS AND METHODS: We used the clinical documentation of 34 UK general practitioners who took part in a previous study evaluating the DSS. They consulted with 12 standardized patients. In addition to suggesting diagnoses, the DSS facilitates data coding. We compared the documentation from consultations with the electronic health record (EHR) (baseline consultations) vs consultations with the EHR-integrated DSS (supported consultations). We measured the proportion of EHR data items related to the physician's final diagnosis. We expected that in baseline consultations, physicians would document only or predominantly observations related to their diagnosis, while in supported consultations, they would also document other observations as a result of exploring more diagnoses and/or ease of coding. RESULTS: Supported documentation contained significantly more codes (incidence rate ratio [IRR] = 5.76 [4.31, 7.70] P < .001) and less free text (IRR = 0.32 [0.27, 0.40] P < .001) than baseline documentation. As expected, the proportion of diagnosis-related data was significantly lower (b = -0.08 [-0.11, -0.05] P < .001) in the supported consultations, and this was the case for both codes and free text. CONCLUSIONS: We provide evidence that data entry in the EHR is incomplete and reflects physicians' cognitive biases. This has serious implications for epidemiological research that uses routine data. A DSS that facilitates and motivates data entry during the consultation can improve routine documentation.

Management of hydroureteronephrosis secondary to an aberrant middle rectal artery in a patient with congenital unilateral renal agenesis.

Presented here is the case of a 21-year-old man, with a family history of unilateral renal agenesis, who presented with obstruction of his solitary functioning right kidney. Initially thought to be secondary to an obturator fossa hernia on endoscopic and retrograde pyelography assessment, diagnosis of obstruction secondary to an aberrant middle rectal artery was determined at laparotomy and division of this vessel relieved the patient's obstruction without any short-term or long-term complications. To the best of the authors' knowledge, this is the first reported case in the literature of hydroureteronephrosis secondary to an aberrant middle rectal artery.

A phase I clinical trial of CD1c (BDCA-1)+ dendritic cells pulsed with HLA-A*0201 peptides for immunotherapy of metastatic hormone refractory prostate cancer.

Preclinical studies have suggested that purified populations of CD1c (BDCA-1) blood-derived dendritic cells (BDC) loaded with tumor-specific peptides may be a feasible option for prostate cancer immunotherapy. We performed an open-label dose-finding Phase I study to evaluate the safe use of CD1c BDC in patients with advanced metastatic hormone refractory prostate cancer. HLA-A*0201-positive patients with advanced metastatic prostate cancer were recruited and consented. The vaccine was manufactured by pulsing autologous CD1c BDC, prepared by magnetic bead immunoselection from apheresed peripheral blood mononuclear cells, with a cocktail of HLA-A*0201-restricted peptides (prostate-specific antigen, prostate acid phosphatase, prostate specific membrane antigen, and control influenza peptide) and keyhole limpet hemocyanin. The vaccine was administered intradermally or intravenously and peripheral blood was taken at predetermined intervals for clinical and immunologic monitoring. The vaccine was manufactured with a median purity of 82% CD1c BDC and administered successfully to 12 patients. Each patient received between 1 and 5 × 10 fresh CD1c BDC on day 0, followed by cryopreserved product in the same dose on days 28 and 56. The vaccine was well tolerated in all patients, with the most frequent adverse events being grade 1-2 fever, pain, or injection-site reactions. Vaccination with CD1c BDC is therefore feasible, safe, and well tolerated in patients with advanced-stage metastatic prostate cancer.

Probiotics, dendritic cells and bladder cancer.

What's known on the subject? and What does the study add? The suppressor effect of probiotics on superficial bladder cancer is an observed phenomenon but the specific mechanism is poorly understood. The evidence strongly suggests natural killer (NK) cells are the anti-tumour effector cells involved and NK cell activity correlates with the observed anti-tumour effect in mice. It is also known that dendritic cells (DC) cells are responsible for the recruitment and mobilization of NK cells so therefore it may be inferred that DC cells are most likely to be the interphase point at which probiotics act. In support of this, purification of NK cells was associated with a decrease in NK cells activity. The current use of intravesical bacille Calmette-Guérin in the management of superficial bladder cancer is based on the effect of a localised immune response. In the same way, understanding the mechanism of action of probiotics and the role of DC may potentially offer another avenue via which the immune system may be manipulated to resist bladder cancer. Probiotic foods have been available in the UK since 1996 with the arrival of the fermented milk drink (Yakult) from Japan. The presence of live bacterial ingredients (usually lactobacilli species) may confer health benefits when present in sufficient numbers. The role of probiotics in colo-rectal cancer may be related in part to the suppression of harmful colonic bacteria but other immune mechanisms are involved. Anti-cancer effects outside the colon were suggested by a Japanese report of altered rates of bladder tumour recurrence after ingestion of a particular probiotic. Dendritic cells play a central role to the general regulation of the immune response that may be modified by probiotics. The addition of probiotics to the diet may confer benefit by altering rates of bladder tumour recurrence and also alter the response to immune mechanisms involved with the application of intravesical treatments (bacille Calmette-Guérin).

Generalized, pruritic, ulcerating maculopapular rash necessitating cessation of sirolimus in a liver transplantation patient.

The use of sirolimus as an alternative to calcineurin antagonists has enabled the continuation of immunosuppression in patients with renal impairment with preservation of kidney function. Sirolimus is generally well tolerated, with the main causes of cessation of therapy related to its effect on blood lipid profile as well as leukopenia and thrombocytopenia. We report a case of a debilitating ulcerating maculopapular rash necessitating cessation of the drug in a liver transplantation patient. A 56-year-old Caucasian liver transplantation patient presented with a diffuse, debilitating rash attributed to sirolimus use. This ultimately necessitated cessation of the immunosuppressant with subsequent resolution of her symptoms. From a review of the current literature, this is a highly unusual adverse reaction to sirolimus.