Cost-effectiveness of emergency versus delayed laparoscopic cholecystectomy for acute gallbladder pathology.

BACKGROUND: The optimal timing of cholecystectomy for patients admitted with acute gallbladder pathology is unclear. Some studies have shown that emergency cholecystectomy during the index admission can reduce length of hospital stay with similar rates of conversion to open surgery, complications and mortality compared with a 'delayed' operation following discharge. Others have reported that cholecystectomy during the index acute admission results in higher morbidity, extended length of stay and increased costs. This study examined the cost-effectiveness of emergency versus delayed cholecystectomy for acute benign gallbladder disease. METHODS: Using data from a prospective population-based cohort study examining the outcomes of cholecystectomy in the UK and Ireland, a model-based cost-utility analysis was conducted from the perspective of the UK National Health Service, with a 1-year time horizon for costs and outcomes. Probabilistic sensitivity analysis was used to investigate the impact of parameter uncertainty on the results obtained from the model. RESULTS: Emergency cholecystectomy was found to be less costly (£4570 versus £4720; €5484 versus €5664) and more effective (0·8868 versus 0·8662 QALYs) than delayed cholecystectomy. Probabilistic sensitivity analysis showed that the emergency strategy is more than 60 per cent likely to be cost-effective across willingness-to-pay values for the QALY from £0 to £100 000 (€0-120 000). CONCLUSION: Emergency cholecystectomy is less costly and more effective than delayed cholecystectomy. This approach is likely to be beneficial to patients in terms of improved health outcomes and to the healthcare provider owing to the reduced costs.

A Bayesian estimation approach for the mortality in a stage-structured demographic model.

Control interventions in sustainable pest management schemes are set according to the phenology and the population abundance of the pests. This information can be obtained using suitable mathematical models that describe the population dynamics based on individual life history responses to environmental conditions and resource availability. These responses are described by development, fecundity and survival rate functions, which can be estimated from laboratory experiments. If experimental data are not available, data on field population dynamics can be used for their estimation. This is the case of the extrinsic mortality term that appears in the mortality rate function due to biotic factors. We propose a Bayesian approach to estimate the probability density functions of the parameters in the extrinsic mortality rate function, starting from data on population abundance. The method investigates the time variability in the mortality parameters by comparing simulated and observed trajectories. The grape berry moth, a pest of great importance in European vineyards, has been considered as a case study. Simulated data have been considered to evaluate the convergence of the algorithm, while field data have been used to obtain estimates of the mortality for the grape berry moth.

Pregnancy and melanoma: a European-wide survey to assess current management and a critical literature overview.

BACKGROUND: Management of melanoma during pregnancy can be extremely challenging. The reported incidence of melanoma in pregnancy ranges from 2.8 to 5.0 per 100 000 pregnancies. There are no guidelines for the management of melanoma during pregnancy. METHODS: The survey was designed to investigate the opinions of melanoma physicians on decision making in relation to pregnancy and melanoma. A clinical scenario-based survey on management of pregnancy in melanoma was distributed all over Europe via the membership of the EORTC and other European melanoma societies. RESULTS: A total of 290 questionnaires were returned with a larger participation from southern Europe. A large heterogeneity was found for the answers given in the different clinical scenarios with 50% of the answers showing discordance, especially regarding sentinel lymph node biopsy during pregnancy. Discordant answers were also found for the counselling of women about a potential delay in getting pregnant after a high-risk melanoma (35% for a 2 year wait minimum vs. 57% no waiting needed), while for thin melanomas, as expected, there was more concordance with 70% of the physicians recommending no delay. Fifteen per cent of physicians recommended an abortion in stage II melanoma during the third month of pregnancy. Twenty per cent of the responders advised against hormonal replacement therapy in melanoma patients. CONCLUSIONS: The management of melanoma during pregnancy varies widely in Europe. At present, there is a lack of consensus in Europe, which may lead to very important decisions in women with melanoma, and guidelines are needed.

Meta-analysis of perioperative antibiotics in patients undergoing laparoscopic cholecystectomy.

BACKGROUND: The effectiveness of perioperative antibiotics in reducing surgical-site infection (SSI) and overall nosocomial infections in patients undergoing laparoscopic cholecystectomy for biliary colic and low- and moderate-risk cholecystitis (Tokyo classification) is unclear. A systematic review and meta-analysis was performed to assess this. METHODS: Searches were conducted of the MEDLINE, Embase and Cochrane databases. Only randomized clinical trials (RCTs) were included. The analysis was performed using the random-effects method, and the risk ratio (RR) with 95 per cent c.i. was employed. RESULTS: Nineteen RCTs, published between 1997 and 2015, with a total of 5259 participants, of whom 2709 (51·5 per cent) were treated with antibiotics, were included. SSI and overall nosocomial infections were detected in 2·4 and 4·2 per cent respectively of patients given perioperative antibiotics, and in 3·2 and 7·2 per cent of those who received no antibiotics. Antibiotics did not significantly reduce the risk of SSI (RR 0·81, 95 per cent c.i. 0·58 to 1·13; P = 0·21) or overall nosocomial infections (RR 0·64, 0·36 to 1·14; P = 0·13). There was no significant between-study heterogeneity for SSI, but significant between-study heterogeneity in the eight studies that reported nosocomial infections. Analysis of studies considered to be high quality, grouped according to the timing of antibiotics (preoperative only or perioperative) and reporting intention-to-treat analyses, again failed to show a significant reduction in SSI. CONCLUSION: Antibiotics should not be administered before laparoscopic cholecystectomy in patients with biliary colic and/or low- and moderate-risk cholecystitis.

Videoscopic ilioinguinal lymphadenectomy for groin lymph node metastases from melanoma.

BACKGROUND: Groin lymph node dissection for melanoma is burdened by high postoperative morbidity. Videoscopic lymphadenectomy may lower the incidence of complications, including infection, dehiscence and lymphoedema. This pilot study aimed to investigate the feasibility and postoperative outcomes of videoscopic ilioinguinal lymphadenectomy in patients with inguinal nodal melanoma metastases. METHODS: Patients with inguinal nodal metastases, with either a positive sentinel lymph node biopsy or clinically positive nodes from melanoma, were enrolled. Inguinal dissection was performed via three ports. Iliac dissection was obtained through a preperitoneal access. Intraoperative and postoperative data were collected. RESULTS: Of 23 patients selected for 24 procedures, four needed conversion to an open procedure. Median duration of surgery was 270 (i.q.r. 245-300) min. Wound-related postoperative complications occurred in four patients, although only one needed further intervention. The median number of excised lymph nodes was 21 (i.q.r. 15-25). After a median follow-up of 18 months, regional lymph node recurrence was observed in two patients. CONCLUSION: Videoscopic ilioinguinal lymphadenectomy for melanoma groin lymph node metastases is technically feasible, safe, and associated with acceptable morbidity and oncological outcome.

The number of excised lymph nodes is associated with survival of melanoma patients with lymph node metastasis.

BACKGROUND: Although the number of excised LNs has been associated with patient prognosis in many solid tumors, this association has not been widely investigated in cutaneous melanoma. This study aims to evaluate the association between the number of excised regional lymph nodes (LNs) and melanoma-specific survival. PATIENT AND METHODS: Clinico-pathological data from 2507 patients with LN metastasis treated at nine Italian centers were retrospectively collected. RESULTS: The number of excised LNs correlated with younger age (P < 0.001), male sex (P < 0.001), neck LN field (P < 0.001), LN micrometastasis (P < 0.001) and number of positive LNs (P < 0.001). The number of excised LNs was an independent prognostic factor (HR = 0.85; P = 0.002) after adjustment for other staging features. Upon subgroup analysis, the number of excised LNs had a significant prognostic value in patients bearing 1.01-2.00 mm (HR = 0.79; P = 0.032) and 2.01-4.00 mm (HR = 0.71; P < 0.001) thick melanomas, primary tumors showing ulceration (HR = 0.86; P = 0.033) and Clark level V of invasion (HR = 0.86; P = 0.010), LN micrometastasis (HR = 0.83; P = 0.014) and two to three positive LNs (HR = 0.71; P = 0.001). Finally, this study investigated the influence of the number of excised LNs on patient staging: only when ≥11 nodes were excised the AJCC N stage could stratify prognosis (P < 0.001). Considering the number of excised LNs for each lymphatic field, at least 14, 11, 10 and 12 LNs were needed to stage patients according to the AJCC N stage after a lymphadenectomy of the neck, axilla, inguinal and ilioinguinal LN fields, respectively. CONCLUSIONS: The number of excised LNs can be considered for risk stratification of patients with regional LN metastasis from cutaneous melanoma. We demonstrated that a minimum number of LNs is required for the correct staging of patients. Further research is needed to evaluate the effectiveness of the minimum number of LNs to be dissected.

Histopathological characteristics of subsequent melanomas in patients with multiple primary melanomas.

BACKGROUND: Multiple primary melanomas (MPM) occur in up to 20% of melanoma patients, and subsequent tumours seem to have a favourable histopathological pattern. OBJECTIVE: A prospectively collected cohort of 194 patients with MPM was retrospectively reviewed to investigate clinical and histopathological features of first and subsequent melanomas. METHODS: Patients with MPM who were diagnosed at our Department (1985-2011) and who attended at least a follow-up control yearly were identified. RESULTS: The number of nevi was <10, 10-50 and >50 in 8.7%, 41% and 50.3% of patients respectively. Histopathological dysplastic nevi have been diagnosed in 105 patients. During a median follow-up of 58 months, 159 (81.9%), 24 (12.3%), 7 (3.6%) and 4 (2%) patients developed 2, 3, 4 and ≥ 5 melanomas, respectively. The median time to second primary melanoma was 45 months. The second primary melanoma was diagnosed within 1-year and after 5-year from the first melanoma in 36.6% and 17.3% of patients respectively. First and second primary melanomas were in situ in 41 (21%) and 104 (54%) patients respectively (P < 0.001). Among patients with ≥ 2 invasive melanomas (N = 80), median tumour thickness and ulceration of first and second primaries were 0.91 and 0.44 mm (P <0.001), and 32% and 7.7% (P = 0.001) respectively. CONCLUSIONS: Subsequent melanomas occurred within 1-year from the appearance of the first melanoma in 36% of patients with MPM, while a late melanoma diagnosis was detected in 17% of cases. Second primary melanoma had favourable histopathological features. Our findings support long-term skin surveillance to detect subsequent melanomas at an early stage.

Immediate prepectoral breast reconstruction in nipple-sparing mastectomy with Wise-pattern incision in large and ptotic breasts: Our experience and short-term results.

INTRODUCTION: Current breast cancer treatment trends advocate nipple-sparing mastectomy (NSM) as the preferred technique for selected patients. A considerable and ptotic breast is often considered a relative contraindication for NSM due to the increased risk of skin and nipple necrosis. METHODS: A retrospective review was performed for patients who underwent immediate prepectoral breast reconstruction (PPBR) after NSM with Wise-pattern incision between February 2020 and February 2023 at our institution. This procedure was offered to patients with grade II or III ptosis or large breasts eligible for NSM for therapeutic or prophylactic purpose. Exclusion criteria comprised a preoperative nipple-sternal notch distance greater than 30 cm, previous radiotherapy, pinch test <1 cm, body mass index (BMI) greater than 34 and active smoke. We present our short-term results with this technique. RESULTS: During the study period, 62 patients (76 breasts) had NSM with Wise-pattern incision. Patients had immediate PPBR with implant or tissue expander, both entirely wrapped with ADM. The median age of the patients was 57.0 years [The Interquartile Range (IQR 50.0-68.6)] with a median BMI of 25.5 (IQR 23.3-28.4). The median mastectomy specimen weight was 472 g (341-578). Median implant volume was 465 g (IQR 370-515). Major complications occurred in 8 patients (10.5%). Three patients experienced total nipple-areolar complex (NAC) necrosis (3.9%), and partial NAC necrosis occurred in 2 patients (2.6%). Two patients developed implant infection (2.6%). Univariate analysis showed a statistically significant correlation between major complications and the mastectomy specimen weight (p = 0.003). CONCLUSION: If oncologically indicated, NSM with Wise-pattern incision and immediate PPBR can safely be performed in selected patients with large and ptotic breasts.

Adherence to treatment guidelines for primary sarcomas affects patient survival: a side study of the European CONnective TIssue CAncer NETwork (CONTICANET).

BACKGROUND: The impact of adherence to clinical practice guidelines (CPGs) for loco-regional treatment (i.e. surgery and radiotherapy) and chemotherapy on local disease control and survival in sarcoma patients was investigated in a European study conducted in an Italian region (Veneto). PATIENTS AND METHODS: The completeness of the adherence to the Italian CPGs for sarcomas treatment was assessed by comparing the patient's charts and the CPGs. Propensity score-adjusted multivariate survival analysis was used to assess the impact of CPGs adherence on patient clinical outcomes. RESULTS: A total of 151 patients were included. Adherence to CPGs for loco-regional therapy and chemotherapy was observed in 106 out of 147 (70.2%) and 129 out of 139 (85.4%) patients, respectively. Non-adherence to CPGs for loco-regional treatment was independently associated with AJCC stage III disease [odds ratio (OR) 1.77, P = 0.011] and tumor-positive excision margin (OR 3.55, P = 0.003). Patients not treated according to the CPGs were at a higher risk of local recurrence [hazard ratio (HR) 5.4, P < 0.001] and had a shorter sarcoma-specific survival (HR 4.05, P < 0.001), independently of tumor stage. CONCLUSIONS: Incomplete adherence to CPGs for loco-regional treatment of sarcomas was associated with worse prognosis in patients with non-metastatic tumors.

Hypnosis as sole anaesthesia for skin tumour removal in a patient with multiple chemical sensitivity.

A female patient with multiple chemical sensitivity and previous anaphylactoid reactions to local anaesthetics was admitted for removal of a thigh skin tumour under hypnosis as sole anaesthesia. The hypnotic protocol included hypnotic focused analgesia and a pre-operative pain threshold test. After inducing hypnosis, a wide excision was performed, preserving the deep fascia, and the tumour was removed; the patient's heart rate and blood pressure did not increase during the procedure. When the patient was de-hypnotised, she reported no pain and was discharged immediately. Our case confirms the efficacy of hypnosis and demonstrates that it may be valuable as a sole anaesthetic method in selected cases. Hypnosis can prevent pain perception and surgical stress as a whole, comparing well with anaesthetic drugs.

Anastomotic techniques for oesophagectomy for malignancy: systematic review and network meta-analysis.

BACKGROUND: Current evidence on the benefits of different anastomotic techniques (hand-sewn (HS), circular stapled (CS), triangulating stapled (TS) or linear stapled/semimechanical (LSSM) techniques) after oesophagectomy is conflicting. The aim of this study was to evaluate the evidence for the techniques for oesophagogastric anastomosis and their impact on perioperative outcomes. METHODS: This was a systematic review and network meta-analysis. PubMed, EMBASE and Cochrane Library databases were searched systematically for randomized and non-randomized studies reporting techniques for the oesophagogastric anastomosis. Network meta-analysis of postoperative anastomotic leaks and strictures was performed. RESULTS: Of 4192 articles screened, 15 randomized and 22 non-randomized studies comprising 8618 patients were included. LSSM (odds ratio (OR) 0·50, 95 per cent c.i. 0·33 to 0·74; P = 0·001) and CS (OR 0·68, 0·48 to 0·95; P = 0·027) anastomoses were associated with lower anastomotic leak rates than HS anastomoses. LSSM anastomoses were associated with lower stricture rates than HS anastomoses (OR 0·32, 0·19 to 0·54; P < 0·001). CONCLUSION: LSSM anastomoses after oesophagectomy are superior with regard to anastomotic leak and stricture rates.

ANTECEDENTES: La evidencia actual sobre los beneficios de diferentes técnicas de anastomosis, incluyen la técnica manual (hand-sewn, HS), la sutura mecánica circular (circular stapled, CS), la sutura mecánica triangular (triangular stapler, TS) o la sutura mecánica lineal/semi-mecánica (linear stapler/semi-mechanical., LSSM) tras una esofaguectomía es contradictoria. El objetivo de este estudio fue evaluar la evidencia referente a las técnicas de anastomosis esofagogástrica (oesophagogastric, OG) y su impacto sobre los resultados perioperatorios. MÉTODOS: Se efectuó una revisión sistemática y metaanálisis en red, basados en una búsqueda sistemática en las bases de datos PubMed, EMBASE y Cochrane Library de estudios aleatorizados y no aleatorizados que describiese técnicas para la anastomosis OG. Se llevó a cabo un metaanálisis en red para los resultados de fugas anastomóticas y estenosis postoperatorias. RESULTADOS: De los 4.192 artículos revisados, se incluyeron 15 estudios aleatorizados y 22 no aleatorizados con un total de 8.618 pacientes. Las anastomosis con LSSM (razón de oportunidades, odds ratio, OR 0,49, i.c. del 95%: 0,33-0,74, P = 0,001) y las anastomosis con CS (OR 0,68, i.c. del 95%: 0.48-0,95, P = 0,027) se asociaron con tasas de fugas anastomóticas más bajas que las anastomosis con HS. Las anastomosis con LSSM se asociaron con unas tasas más bajas de estenosis (OR 0,15, i.c. del 95%: 0,08-0,28, P < 0,001), frente a las anastomosis con TS y HS. CONCLUSIONES: Las anastomosis con LSSM después de esofaguectomía son superiores en relación a las tasas de fugas anastomóticas y estenosis.

Development and calibration of a model for the potential establishment and impact of Aedes albopictus in Europe.

The Asian tiger mosquito (Aedes albopictus) is one of the most invasive disease vectors worldwide. The species is a competent vector of dengue, chikungunya, Zika viruses and other severe parasites and pathogens threatening human health. The capacity of this mosquito to colonize and establish in new areas (including temperate regions) is enhanced by its ability of producing diapausing eggs that survive relatively cold winters. The main drivers of population dynamics for this mosquito are water and air temperature and photoperiod. In this paper, we present a mechanistic model that predicts the potential distribution, abundance and activity of Asian tiger mosquito in Europe. The model includes a comprehensive description of: i) the individual life-history strategies, including diapause, ii) the influence of weather-driven individual physiological responses on population dynamics and iii) the density-dependent regulation of larval mortality rate. The model is calibrated using field data from several locations along an altitudinal gradient in the Italian Alps, which enabled accurate prediction of cold temperature effects on population abundance, including identification of conditions that prevent overwintering of the species. Model predictions are consistent with the most updated information on species' presence and absence. Predicted population abundance shows a clear south-north decreasing gradient. A similar yet less evident pattern in the activity of the species is also predicted. The model represents a valuable tool for the development of strategies aimed at the management of Ae. albopictus and for the implementation of effective control measures against vector-borne diseases in Europe.

Molecular modelling as the spark for active learning approaches for interdisciplinary biology teaching.

We present here an interdisciplinary workshop on the subject of biomolecules offered to undergraduate and high school students with the aim of boosting their interest toward all areas of science contributing to the study of life. The workshop involves mathematics, physics, chemistry, computer science and biology. Based on our own areas of research, molecular modelling is chosen as the central axis as it involves all disciplines. To provide a strong biological motivation for the study of the dynamics of biomolecules, the theme of the workshop is the origin of life. All sessions are built around active pedagogy, including games, and a final poster presentation.

Coarse-grained dynamic RNA titration simulations.

Electrostatic interactions play a pivotal role in many biomolecular processes. The molecular organization and function in biological systems are largely determined by these interactions. Owing to the highly negative charge of RNA, the effect is expected to be more pronounced in this system. Moreover, RNA base pairing is dependent on the charge of the base, giving rise to alternative secondary and tertiary structures. The equilibrium between uncharged and charged bases is regulated by the solution pH, which is therefore a key environmental condition influencing the molecule's structure and behaviour. By means of constant-pH Monte Carlo simulations based on a fast proton titration scheme, coupled with the coarse-grained model HiRE-RNA, molecular dynamic simulations of RNA molecules at constant pH enable us to explore the RNA conformational plasticity at different pH values as well as to compute electrostatic properties as local pK a values for each nucleotide.

Fluctuation-induced interactions between dielectrics in general geometries.

We study thermal Casimir and quantum nonretarded Lifshitz interactions between dielectrics in general geometries. We map the calculation of the classical partition function onto a determinant, which we discretize and evaluate with the help of Cholesky factorization. The quantum partition function is treated by path integral quantization of a set of interacting dipoles and reduces to a product of determinants. We compare the approximations of pairwise additivity and proximity force with our numerical methods. We propose a "factorization approximation" that gives rather good numerical results in the geometries that we study.

Numerical methods for fluctuation-driven interactions between dielectrics.

We develop a discretized theory of thermal Casimir interactions to numerically calculate the interactions between fluctuating dielectrics. From a constrained partition function we derive a surface free energy, while handling divergences that depend on system size and discretization. We derive analytic results for parallel plate geometry in order to check the convergence of the numerical methods. We use the method to calculate vertical and lateral Casimir forces for a set of grooves.

[Diagnostic strategies in kidney disease with chronic renal failure]. / Il percorso diagnostico delle nefropatie con insufficianza renale cronica.

Chronic kidney disease affects large numbers of individuals in countries across the world. Recent reports from the United States indicate that 30% of the adult population has a mild or moderate degree of chronic renal failure and more than 600,000 patients are projected to have end-stage renal disease by the year 2010. Similar elevated rates have been reported in Europe, Asia and Australia. Optimal management of chronic renal failure is mandatory. It requires a correct diagnosis of the underlying nephropathy and specific strategies to slow the progression of renal damage and to prevent cardiovascular events. The differential diagnostic approach to chronic renal failure consists of serologic studies, renal biopsy, and urinary tract imaging, which, however, may exacerbate the pre-existing nephropathy or have severe adverse effects. The challenge for the nephrologist is to balance the need to correctly identify chronic nephropathy against the risks related to aggressive diagnostic procedures. In order to optimize the diagnostic strategies in patients with chronic renal disease, consensus guidelines will be needed.

Measuring the quality of melanoma surgery - Highlighting issues with standardization and quality assurance of care in surgical oncology.

In an attempt to ensure high standards of cancer care, there is increasing interest in determining and monitoring the quality of interventions in surgical oncology. In recent years, this has been particularly the case for melanoma surgery. The vast majority of patients with melanoma undergo surgery. Usually, this is with combinations of wide excision, sentinel lymph node biopsy and lymphadenectomy. The indications for these procedures evolved during a time when no effective systemic adjuvant therapy was available, and whilst the rationale has been sound, the justification for differences in extent and thoroughness has generally been supported by inadequate or low-level evidence. This has led to a substantial variation among melanoma centres or even among surgeons within a centre in how these procedures are done. With recent rapid progress in the efficacy of systemic treatments that are impacting on overall survival, the prospect of long-term survival in these previously high risk patients means that more than ever long-term locoregional control of melanoma is imperative. Furthermore, the understanding of effects of systemic therapy on locoregional disease will only be interpretable if surgeons use standardized, high quality techniques. This article focuses on standardization and evolution of quality indicators for melanoma surgery and how these might have a positive impact on patient care.

IgM nephropathy: is it closer to minimal change disease or to focal segmental glomerulosclerosis?

Immunoglobulin (Ig)M nephropathy (IgMN), known since 1978, is a very controversial clinicopathological entity characterized by IgM diffuse deposits in the mesangium at immunofluorescence whereas light microscop identifies minimal glomerular lesion, hypercellularity and expansion of the mesangium or sclerotic focal, segmental lesion. Clinically, it is a nephrotic syndrome, especially in pediatric patients, or asymptomatic proteinuria and/or isolated hematuria. These characteristics narrowly define IgMN between minimal change disease and focal segmental glomerulosclerosis, so it is not often recognized as a separate pathology. Homogeneous epidemiologic, pathogenetic, clinical or histological data are not available. Recent research on the pathogenetic role of mesangial IgM has, however, renewed interest in IgMN and naturally the controversies.

Light chains removal by extracorporeal techniques in acute kidney injury due to multiple myeloma: a position statement of the Onconephrology Work Group of the Italian Society of Nephrology.

Acute kidney injury (AKI) is a frequent complication of multiple myeloma and is associated with increased short-term mortality. Additionally, even a single episode of AKI can eventually lead to end-stage renal disease (ESRD), significantly reducing quality of life and long-term survival. In the setting of multiple myeloma, severe AKI (requiring dialysis) is typically secondary to cast nephropathy (CN). Renal injury in CN is due to intratubular obstruction from precipitation of monoclonal serum free light chains (sFLC) as well as direct tubular toxicity of sFLC via stimulation of nuclear factor (NF)κB inflammatory pathways. Current mainstays of CN treatment are early removal of precipitating factors such as nephrotoxic drugs, acidosis and dehydration, together with rapid reduction of sFLC levels. Introduction of the proteasome inhibitor bortezomib has significantly improved the response rates in multiple myeloma due to its ability to rapidly reduce sFLC levels and has been referred to as "renoprotective" therapy. As an adjunct to chemotherapy, several new extracorporeal techniques have raised interest as a further means to reduce sFLC concentrations in the treatment of CN. Whether addition of extracorporeal therapies to renoprotective therapy can result in better renal recovery is still a matter of debate and there are currently no guidelines in this field. In this positon paper, we offer an overview of the available data and the authors' perspectives on extracorporeal treatments in CN.