Aplicaciones clínicas, experimentales y resultados del uso de diferentes dispositivos de aspiración en la cirugía intrarrenal retrógrada. Revisión sistemática / Experimental and clinical applications and outcomes of using different forms of suction in retrograde intrarenal surgery. Results from a systematic review

Objetivo Identificar los últimos avances en los dispositivos de aspiración para la cirugía retrógrada intrarrenal (CRIR) y la ureteroscopia en el tratamiento de la litiasis, y evaluar los resultados de su aplicación. Procedimiento El 4 de enero de 2023 se realizó una búsqueda bibliográfica sistemática en Scopus, PubMed y EMBASE. Solo se incluyeron artículos en inglés; se aceptaron estudios en la población pediátrica y estudios en adultos. Se excluyeron los estudios duplicados, los informes de casos, las cartas al editor y los resúmenes de congresos. Hallazgos principales Se seleccionaron 21 trabajos. Se han propuesto varios sistemas de aspiración para la CRIR: a través de la vaina de acceso ureteral o directamente por el endoscopio. La inteligencia artificial también puede desempeñar un papel, monitorizando los valores de la presión y del flujo de irrigación. Todas las técnicas propuestas mostraron resultados perioperatorios satisfactorios en cuanto a tiempo quirúrgico, tasa libre de cálculos (TLC) y fragmentos residuales. Además, la reducción de la presión intrarrenal (mediante la aspiración) también se asoció a una tasa de infección menor. Incluso los estudios que incluyen cálculos renales con un diámetro de 20mm o superior informan de una mayor TLC y una reducción de las complicaciones postoperatorias. Sin embargo, la falta de parámetros bien establecidos para la presión de la aspiración y el flujo de líquido impide la estandarización del procedimiento. Conclusión Como ha sido demostrado en los estudios incluidos, el uso de dispositivos de aspiración en el tratamiento quirúrgico de los cálculos urinarios favorece la obtención de una TLC mayor y reduce las complicaciones infecciosas. La CRIR con sistema de aspiración podría sustituir a la técnica tradicional, gracias a sus ventajas asociadas al control de la presión intrarrenal y aspiración del polvo fino. (AU)

Objective To identify the latest advances in suction devices and evaluate their effect in Retrograde intrarenal surgery (RIRS) and ureteroscopy for stones. Basic procedures A systematic literature search was performed on 4th January 2023 using Scopus, PubMed, and EMBASE. Only English papers were included; both pediatric and adult studies were accepted. Duplicate studies, case reports, letters to the editor, and meeting abstracts were excluded. Main findings Twenty-one papers were selected. Several methods have been proposed for suction use in RIRS, such as through the ureteral access sheath or directly to the scope. Artificial intelligence can also regulate this system, monitoring pressure and perfusion flow values. All the proposed techniques showed satisfactory perioperative results for operative time, stone-free rate (SFR), and residual fragments. Moreover, the reduction of intrarenal pressure (induced by aspiration) was also associated with a lower infection rate. Even the studies that considered kidney stones with a diameter of 20mm or higher reported higher SFR and reduced postoperative complications. However, the lack of well-defined settings for suction pressure and fluid flow prevents the standardization of the procedure. Conclusion Aspiration device in the surgical treatment of urinary stones favours a higher SFR, reducing infectious complications, as supported by the included studies. RIRS with a suction system provided to be a natural successor to the traditional technique, regulating intrarenal pressure and aspirating fine dust. (AU)

Experimental and clinical applications and outcomes of using different forms of suction in retrograde intrarenal surgery. Results from a systematic review.

OBJECTIVE: To identify the latest advances in suction devices and evaluate their effect in Retrograde intrarenal surgery (RIRS) and ureteroscopy for stones. BASIC PROCEDURES: A systematic literature search was performed on 4th January 2023 using Scopus, PubMed, and EMBASE. Only English papers were included; both pediatric and adult studies were accepted. Duplicate studies, case reports, letters to the editor, and meeting abstracts were excluded. MAIN FINDINGS: Twenty-one papers were selected. Several methods have been proposed for suction use in RIRS, such as through the ureteral access sheath or directly to the scope. Artificial intelligence can also regulate this system, monitoring pressure and perfusion flow values. All the proposed techniques showed satisfactory perioperative results for operative time, stone-free rate (SFR), and residual fragments. Moreover, the reduction of intrarenal pressure (induced by aspiration) was also associated with a lower infection rate. Even the studies that considered kidney stones with a diameter of 20 mm or higher reported higher SFR and reduced postoperative complications. However, the lack of well-defined settings for suction pressure and fluid flow prevents the standardization of the procedure. CONCLUSION: Aspiration device in the surgical treatment of urinary stones favours a higher SFR, reducing infectious complications, as supported by the included studies. RIRS with a suction system provided to be a natural successor to the traditional technique, regulating intrarenal pressure and aspirating fine dust.

Evolution of hepatic encephalopathy over time: ecological data from a tertiary referral centre for hepatology.

OBJECTIVES: Few data on hepatic encephalopathy (HE) over time are available, thus our aim was to study its evolution in patients with varying degree of HE on first assessment. METHODS: Eighty-six patients with cirrhosis (age = 58 ± 11 years; males = 72) were evaluated 2-10 times for liver transplantation selection purposes, differential diagnosis or treatment optimization. The presence/severity of HE was assessed by clinical and neuropsychiatric indices [ Psychometric Hepatic Encephalopathy Score (PHES) and electroencephalography (EEG)] and the severity of liver disease by the Model for End-Stage Liver Disease (MELD) score. Treatment was instituted/modified after each evaluation. RESULTS: Amongst 23 unimpaired patients, 56/6% remained unimpaired, 35/3% developed covert HE, 9/0% developed overt HE on second/third evaluation. Amongst 32 patients with covert HE, 25/10% became unimpaired, 44/19% remained covert, 31/13% developed overt HE. Finally, amongst 32 patients with overt HE, 19/16% became unimpaired, 25/13 % became covert and 56/25% remained overt. PHES results improved in patients with overt HE and EEG worsened over time (despite remaining normal) in unimpaired patients. In patients with multiple evaluations, HE evolution was manifold and difficult to predict. CONCLUSIONS: HE evolution over time is variable and largely dependent on HE history/management. These data support the concept that HE is an essentially reversible condition.

Fitoterapia para los síntomas del tracto urinario inferior en el varón: ¿qué ocurre después? Diez años de investigación / Phytotherapy for male luts: What happens then? 10-year research

Introducción y objetivos Nuestro objetivo es evaluar los resultados de la fitoterapia a largo plazo, centrándonos en el intervalo entre la fitoterapia y los tratamientos farmacológicos y los factores de riesgo que predisponen a dicho cambio en un seguimiento de 10 años. Material y métodos Se revisaron retrospectivamente los datos de los pacientes varones que tomaban fitoterapia para los síntomas del tracto urinario inferior (STUI) de leves a moderados entre enero y diciembre de 2010, a partir de una base de datos mantenida prospectivamente. Se realizó un seguimiento de los pacientes durante 10 años mediante consultas médicas presenciales y telefónicas. Resultados Ciento dos pacientes se sometieron al menos a un ciclo de fitoterapia para los STUI. Veinte (19,6%) pacientes resolvieron sus síntomas tras un ciclo fitoterápico y abandonaron el tratamiento, 27 (26,4%) continuaron con la fitoterapia y 52 (51%) cambiaron a bloqueadores alfa y/o inhibidores de la 5a-reductasa tras un intervalo medio de 24 meses. El motivo del cambio de tratamiento fue la sintomatología (n=45) o la progresión clínica (aumento del volumen residual n=15; retención urinaria, n=5). Los pacientes que cambiaron a fármacos sintéticos tenían una mediana de edad más alta (60 frente a 49), mayor volumen prostático (40 frente a 26cc) y antígeno prostático específico (1,9 frente a 0,9ng/ml), volumen residual más elevado (40 frente a 0cc) y una tasa de flujo máximo (Qmáx) más baja (12 frente a 15ml/s) en el momento de la presentación. Conclusiones El 46% de los pacientes con STUI leves o moderados sometidos a fitoterapia estarán libres de tratamiento o seguirán con la fitoterapia a los 10 años de la presentación de la enfermedad. Los pacientes de mayor edad, con próstatas más grandes, con volumen residual y antígeno protático específico más alto, deben ser informados sobre un mayor riesgo de progresión sintomática o clínica (AU)

Introduction and objectives Our objective is to assess the long-term results of phytotherapy, focusing on the interval between phytotherapy and pharmacological treatment and the predisposing risk factors to such switch on a 10-year follow-up. Material and methods The data of patients taking phytotherapy for mild to moderate male lower urinary tract symptoms (LUTS) from January to December 2010 were retrospectively reviewed from a prospectively maintained database. Patients were followed for 10 years through medical visits and telephone consultations. Results 102 patients underwent at least one cycle of phytotherapy for LUTS. Twenty (19.6%) patients resolved their symptoms after one phytotherapy cycle and stopped any treatment, 27 (26.4%) continued phytotherapy, and 52 (51%) switched to alpha-blockers and/or 5a-reductase inhibitors after a median interval of 24 months. The reasons for treatment switch were symptoms (n=45) or clinical progression (increased residual volume n=15; urinary retention, n=5). Patients switching to synthetic drugs had median higher age (60 vs 49), prostate volume (40 vs 26cc), prostate specific antigen (PSA) (1.9 vs 0.9ng/ml), residual volume (40 vs 0cc), and a lower maximum flow rate (Qmax) (12 vs 15ml/sec) at presentation. Conclusions 46% patients with mild to moderate LUTS undergoing phytotherapy will be either free of treatment or still on phytotherapy at 10 years from disease presentation. Older patients with larger prostates, increased residual volume and PSA, should be informed regarding their higher risk of symptomatic or clinical progression: the risk of a treatment switch to alpha-blockers or 5a-reductase inhibitors becomes an actual fact after an average span of 2 years (AU)

Phytotherapy for male luts: What happens then? 10-year research.

INTRODUCTION AND OBJECTIVES: Our objective is to assess the long-term results of phytotherapy, focusing on the interval between phytotherapy and pharmacological treatment and the predisposing risk factors to such switch on a 10-year follow-up. MATERIAL AND METHODS: The data of patients taking phytotherapy for mild to moderate male lower urinary tract symptoms (LUTS) from January to December 2010 were retrospectively reviewed from a prospectively maintained database. Patients were followed for 10 years through medical visits and telephone consultations. RESULTS: 102 patients underwent at least one cycle of phytotherapy for LUTS. Twenty (19.6%) patients resolved their symptoms after one phytotherapy cycle and stopped any treatment, 27 (26.4%) continued phytotherapy, and 52 (51%) switched to alpha-blockers and/or 5a-reductase inhibitors after a median interval of 24 months. The reasons for treatment switch were symptoms (n = 45) or clinical progression (increased residual volume n = 15; urinary retention, n = 5). Patients switching to synthetic drugs had median higher age (60 vs 49), prostate volume (40 vs 26 cc), prostate specific antigen (PSA) (1.9 vs 0.9 ng/ml), residual volume (40 vs 0 cc), and a lower maximum flow rate (Qmax) (12 vs 15 ml/s) at presentation. CONCLUSIONS: 46% patients with mild to moderate LUTS undergoing phytotherapy will be either free of treatment or still on phytotherapy at 10 years from disease presentation. Older patients with larger prostates, increased residual volume and PSA, should be informed regarding their higher risk of symptomatic or clinical progression: the risk of a treatment switch to alpha-blockers or 5a-reductase inhibitors becomes an actual fact after an average span of 2 years.

Prototyping a memristive-based device to analyze neuronal excitability.

Many efforts have been spent in the last decade for the development of nanoscale synaptic devices integrated into neuromorphic circuits, trying to emulate the behavior of natural synapses. The study of brain properties with the standard approaches based on biocompatible electrodes coupled to conventional electronics, however, presents strong limitations, which in turn could be overcame by the in-situ growth of neuronal networks coupled to memristive devices. To meet this challenging task, here two different chips were designed and fabricated for culturing neuronal cells and sensing their electrophysiological activity. The first chip was designed to be connected to an external memristor, while the second chip was coated with TiO2 films owning memristive properties. The biocompatibility of chips was preliminary analyzed by culturing the hybrid motor-neuron cell line NSC-34 and by measuring the electrical activity of cells interfacing the chip with a standard patch-clamp setup. Next, neurons were seeded on chips and their activity measured with the same setup. For both cell types total current and voltage responses were evoked and recorded with optimal results with no breakdowns. In addition, an external stimulation was applied to cells through chip electrodes, being effective and causing no damage or pitfalls to the cells. Finally, the whole bio-hybrid system, i.e. the chip interconnected with a commercial memristor, was tested with promising results. Spontaneous electrical activity of neurons grown on the chip was indeed present and this signal was collected and sent to the memristor, changing its state. Taken together, we demonstrated the ability of memristor to work with a synaptic/plastic response together with natural systems, opening the way for the further implementation of basic computing elements able to perform both storage and processing of data, as in natural neurons.

RIRS in the elderly: Is it feasible and safe?

BACKGROUND: The aim of this study was to compare the safety and efficacy of RIRS in men ≥65 years to those <65 years. MATERIALS AND METHODS: Patients who underwent RIRS were prospectively collected from March 2013 to March 2014 in 5 European centers. Perioperative outcomes and complications in elderly men were compared with men <65 years. Univariable and multivariable analyses were performed for factors predicting overall complications. The groups were compared using Mann-Whitney U test. Categorical variables were compared using chi-squared test and the Yates correction or the Fisher's exact test. RESULTS: A total of 399 patients with renal stones were included, 308 (77.19%) were aged <65 years, 91 (22.8%) were aged ≥65 years. Elderly patients were more likely to have higher ASA scores (35.7% vs 92.3%; p < 001), Charlson Comorbidity Index (1.8 vs. 5.2, p < 0.001), hyperlipidemia (10.06% vs. 30.76%; p = 0,0005) and coronary heart disease (5.51% vs. 17.58; p = 0.005) compared to younger cohort. Perioperative outcomes (stone free rate, operative time and re-intervention rate) did not show differences between the two groups (p > 0.05). Surgical and medical complication rates were similar between the cohorts (14.28% vs 9.89%; p = 0.38). Multivariate analysis did not identify any predictive factors of complications among the two groups (p > 0.05). CONCLUSIONS: In this study, elderly RIRS patients had comparable short term efficacy and perioperative complications to younger patients, despite a higher prevalence of comorbidity. Age itself should not be considered as a risk factor for the development of complications in patients undergoing RIRS for renal stone.

The surgical experience influences the safety of retrograde intrarenal surgery for kidney stones: a propensity score analysis.

The aim of this study is to evaluate if surgical experience could influence the outcomes of retrograde intrarenal surgery (RIRS) in terms of stone clearance and complication rate. Patients from five institutions were included in this study. Patients were divided into two groups. Group 1: patients treated by three surgeons in the early phase of learning curve (surgical experience <100 procedures); Group 2: cases operated by two surgeons with great endourological experience (>400 procedures). Patients and stone characteristics, outcome and complications were analyzed. Multivariable regression model was used. Differences between groups were estimated using propensity scores to adjust for the bias inherent to the different characteristics. 381 RIRS were analyzed (Group 1: 150 RIRS; Group 2: 231 RIRS). Clinical data and stone parameters were comparable. The SFR was 70 % in Group 1 and 77.9 % in Group 2 (p = 0.082). Operative time was significantly shorter in the Group 2 (76.3 vs. 53.1 min, p = 0.001). The overall complication rate was significantly lower in Group 2 (20.7 vs. 8.7, p = 0.001). At unadjusted analysis, a non-significant difference was found between centers on SFR (OR 1.51 95 % CI 0.95-2.41). Conversely, a significant difference was found on overall complications (OR 0.36 95 %CI 0.20-0.67) with lower overall complication in Group 2. This study shows that surgeon experience influences the outcomes of RIRS mainly in terms of safety. Further studies will be needed to assess the exact number of procedures necessary to obtain a plateau in the rate of complications and success.

Complications associated with ureterorenoscopy (URS) related to treatment of urolithiasis: the Clinical Research Office of Endourological Society URS Global study.

INTRODUCTION: Ureterorenoscopy (URS) is a popular and growing option for management of ureteric and renal stones. The CROES URS Global Study was set up to assess the outcomes of URS in a large worldwide cohort of patients involving multiple centres. In this paper, we analysed the database for intra-operative and post-operative complications associated with ureterorenoscopy. METHODS: The CROES database was established via collaboration between 114 centres in 32 countries worldwide, and information on both intra-operative and post-operative complications was collected electronically between January 2010 and October 2012. RESULT: On analysis of a total of 11,885 patients, the overall complication and stone-free rates were found to be 7.4 and 85.6 %, respectively. The intra-operative and post-operative complication rates were 4.2 and 2.6 %, respectively, and in total 5 deaths were reported in the study period. Taking into account different world economies, there were no differences in the complication rates between the developing and developed nations or between different centres from different continents. CONCLUSION: Ureterorenoscopy is a safe and effective procedure for treatment of stones, the outcomes of which are broadly comparable in different parts of the world for similar patient and stone demographics.

Contemporary ureteroscopic management of renal stones.

The advancements in the endourological armamentarium and the evolution of ureteroscopes with the advent of fiberoptic first and then digital technology, the introduction of holmium laser lithotripters, together with the increasing number of requests for minimally invasive procedures has ameliorated outcomes, patients' safety and comfort, making the use of flexible ureteroscopy for urinary calculi increasingly attractive and widespread among urological community. Due to its high stone-free rates and low morbidity, flexible ureteroscopy has become a viable option for the treatment of renal stones. This review describes the contemporary ureteroscopic management of kidney stones.

Resonance(®) metallic stent in patients with ureterocutaneostomies.

PURPOSE: To evaluate the effectiveness and the safety of Resonance(®) stents in patients with ureterocutaneostomies (UCS). MATERIALS AND METHODS: We retrospectively enrolled all patients with UCS who presented with impaired ureteral drainage with traditional polymeric ureteral prosthesis. Preoperative and follow-up (1, 3, 6, 12 months) workup, after Resonance(®) placement, included: medical history, physical examination, serum laboratory tests, urinalysis, urine culture and urinary tract imaging by ultrasound, administration of the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire C30 (QLQ-C30) and an evaluation of patients' satisfaction rate. In addition, the number of emergency department patient admissions and hospitalizations occurred 1 year before and after the stent Resonance(®) placement was noted. RESULTS: Twenty-five renal units in 14 patients with UCS were included. Statistically significant improvements in creatinine serum levels, patients' satisfaction rate, hydronephrosis and number of urinary tract infections (UTI) were found at 1-, 3-, 6-, and 12-month follow-up compared to baseline. Statistically significant differences in EORTC QLQ-C30 were detected only in Emotional, Social and Global QoL domains before and after Resonance(®) placement (p < 0.0001). At inclusion, a total of 39 referrals to ED were recorded; at 1-year follow-up, only five cases of ED presentations have been recorded (p < 0.01). At the same endpoints, the number of hospitalizations was 18 and 2, respectively (p < 0.05). Failure rate was 8.3%. CONCLUSION: At 1-year follow-up, Resonance(®) stents are effective and safe in patients with UCS refractory to polymeric ureteral prosthesis, reporting evidence for significant improvements in hydronephrosis rate, renal function, UTI, and patients' satisfaction rate and QoL.

Optimization of silver nanowire-based transparent electrodes: effects of density, size and thermal annealing.

Silver nanowire (AgNW) networks are efficient as flexible transparent electrodes, and are cheaper to fabricate than ITO (Indium Tin Oxide). Hence they are a serious competitor as an alternative to ITO in many applications such as solar cells, OLEDs, transparent heaters. Electrical and optical properties of AgNW networks deposited on glass are investigated in this study and an efficient method to optimize them is proposed. This paper relates network density, nanowire dimensions and thermal annealing directly to the physical properties of the nanowire networksusing original physical models. A fair agreement is found between experimental data and the proposed models. Moreover thermal stability of the nanowires is a key issue in thermal optimization of such networks and needs to be studied. In this work the impact of these four parameters on the networks physical properties are thoroughly investigated via in situ measurements and modelling, such a method being also applicable to other metallic nanowire networks. We demonstrate that this approach enables the optimization of both optical and electrical properties through modification of the junction resistance by thermal annealing, and a suitable choice of nanowire dimensions and network density. This work reports excellent optical and electrical properties of electrodes fabricated from AgNW networks with a transmittance T = 89.2% (at 550 nm) and a sheet resistance of Rs = 2.9 Ω â–¡(-1), leading to the highest reported figure of merit.

Is retrograde intrarenal surgery a viable treatment option for renal stones in patients with solitary kidney?

PURPOSE: To evaluate the effectiveness and safety of retrograde intrarenal surgery (RIRS) for stones up to 2 cm in diameter in patients with solitary kidney. METHODS: From January 2008 to January 2013, we prospectively enrolled all consecutive patients with solitary kidney and renal stones. Plain abdominal computed tomography scan was performed preoperatively and 1 month after the procedure to assess the stone-free rates (SFR). Serum creatinine levels were detected preoperatively, at day 1 postoperatively, at 1 month postoperatively, and then every 6 months postoperatively. RESULTS: During the study period, we prospectively enrolled a total of 29 patients. The mean age was 55.7 ± 12.3 years; the mean stone size was 1.3 ± 0.4 cm. The primary SFR was 72.4 %; the secondary SFR was 93.1 %. The mean number of procedures per patient was 1.24. The mean serum creatinine levels were 1.5 ± 0.6, 1.6 ± 0.7, 1.6 ± 0.6, and 1.7 ± 0.7 mg/dl preoperatively, at 1 day after RIRS, at 1 month after RIRS, and at 1 year after RIRS, respectively, without detection of any statistical difference (p = 0.76). Median follow-up time was 35.7 ± 19.3 (12-72) months, but that was available for only 18 patients. The mean serum creatinine level at the last follow-up was 1.7 ± 0.9 mg/dl. No major complications were recorded. Grade I complications occurred in eight patients (27.4 %). CONCLUSIONS: RIRS is safe and effective in the treatment of renal stones in patients with solitary kidney, without worsening renal function.

Metallic nanowire networks: effects of thermal annealing on electrical resistance.

Metallic nanowire networks have huge potential in devices requiring transparent electrodes. This article describes how the electrical resistance of metal nanowire networks evolve under thermal annealing. Understanding the behavior of such films is crucial for the optimization of transparent electrodes which find many applications. An in-depth investigation of silver nanowire networks under different annealing conditions provides a case study demonstrating that several mechanisms, namely local sintering and desorption of organic residues, are responsible for the reduction of the systems electrical resistance. Optimization of the annealing led to specimens with transmittance of 90% (at 550 nm) and sheet resistance of 9.5 Ω sq(-1). Quantized steps in resistance were observed and a model is proposed which provides good agreement with the experimental results. In terms of thermal behavior, we demonstrate that there is a maximum thermal budget that these electrodes can tolerate due to spheroidization of the nanowires. This budget is determined by two main factors: the thermal loading and the wire diameter. This result enables the fabrication and optimization of transparent metal nanowire electrodes for solar cells, organic electronics and flexible displays.

Cystoman® and calculi: a good alternative to standard therapies in preventing stone recurrence.

To assess the efficacy and tolerability of D-mannose-containing product (Cystoman(®)) in preventing recurrence in patients who underwent surgical treatment for infection related urinary stones. From January 2011 to February 2013 we have enrolled all consecutive patients affected by staghorn calculi and recurrent urinary tract infections (UTIs). All patients recommended for surgery were scheduled for percutaneous nephrolithotomy. The study agent was administered daily for 5 months after surgical procedure. At baseline and 5-month follow-up all patients underwent abdominal Computed Tomography (CT) scan and they also completed Medical Outcomes Study short-form, 36-item questionnaire (SF-36). They performed urine and urine culture monthly. The primary endpoints were the assessment of the efficacy with regard to infection-related urinary stone recurrence and the tolerability of Cystoman(®). The secondary endpoint was the evaluation of quality-of-life symptoms. During the study period, a total of 27 patients were included in the study. The data from 25 patients were analyzable. Seventeen patients (68%) did not report UTIs during follow-up. Eight patients (32%) remained infected and the average number of UTIs was 2.6 ± 1.6 in 5 months. At 5-month follow-up 17 (68%) patients were free from stones recurrence; in 8 (32%) cases CT scan revealed stone recurrence with an average stone diameter of 1.1 ± 0.4 cm. In nonrecurring patients, 2 (11.7%) reported an average of 1.5 ± 0.7 UTIs episodes; in recurring patients, 6 (75%) showed 3 ± 1.67 of UTIs episodes. Statistically significant differences were seen in the occurrence of UTIs episodes were detected between nonrecurring stone patients and recurring patients (p < 0.05). Moreover, statistically significant changes were detected in SF-36 scores from baseline to month 5 in the categories of physical functioning and energy/fatigue (p < 0.05). Cystoman(®) is effective in preventing infection-related urinary stones.

Pathophysiology of cardiorenal syndrome in decompensated heart failure: role of lung-right heart-kidney interaction.

Cardiorenal syndrome (CRS) is defined as an interaction of cardiac disease with renal dysfunction that leads to diuretic resistance and renal function worsening, mainly with heart failure (HF) exacerbation. Hemodynamic variables linking heart and kidney are renal blood flow (cardiac output) and perfusion pressure, i.e., the aortic - renal venous pressure gradient. CRS has traditionally been interpreted as related to defective renal perfusion and arterial underfilling and, more recently, to elevation in central venous pressure transmitted back to renal veins. Our suggestion is that in a setting where aortic pressure is generally low, due to heart dysfunction and to vasodrepressive therapy, the elevated central venous pressure (CVP) contributes to lower the renal perfusion pressure below the threshold of kidney autoregulation (≤80mm Hg) and causes renal perfusion to become directly pressure dependent. This condition is associated with high neurohumoral activation and preglomerular vasoconstriction that may preserve pressure, but may decrease filtration fraction and glomerular filtration rate and enhance proximal tubular sodium absorption. Thus, congestion worsens and drives the vicious cycle of further sodium retention and HF exacerbation. Lowering CVP by targeting the lung-right heart interaction that sustains elevated CVP seems to be a more rational approach rather than reducing intravascular volume. This interaction is crucial and consists of a cascade with stepwise development of pulmonary post-capillary hypertension, precapillary arteriolar hypertone, right ventricular overload and enlargement with tricuspid incompetence and interference with left ventricular filling (interdependence). The resultant CVP rise is transmitted to the renal veins, eventually drives CRS and leads to a positive feedback loop evolving towards HF refractoriness.

Macrophage activation syndrome in a child affected by malaria: the choice of steroid.

Macrophage activation syndrome is a potentially fatal clinical syndrome caused by an excessive activation and proliferation of macrophages and T cells, leading to an exaggerated inflammatory reaction. It is well known that it can complicate the course of different conditions, especially autoimmune, lympho-proliferative, infectious diseases and drugs. Many infective pathogens can trigger the syndrome but the association with malaria has rarely been described, especially in children. We report a child with severe malaria complicated by MAS, in whom the clinical appearance of this syndrome could be considered as worsening of malaria itself. Furthermore, the use of steroids as first choice drugs in this complication, but arguable in malaria, has been highlighted. Clinicians should be aware of this syndrome when malaria does not respond to conventional therapy, since early diagnosis and prompt treatment may dramatically reduce the mortality associated with this condition.