Transgluteal CT-Guided Percutaneous Renal Access for Percutaneous Nephrolithotomy in a Pelvic Horseshoe Kidney

CT-guided percutaneous renal access has been described as a safe and effective access technique in patients with complex anatomy, including ectopic kidney, retrorenal colon, spinal dysraphism, hepatomegaly, and splenomegaly. In comparison to conventional intraoperative fluoroscopic-guided access, CT imaging allows for delineation of surrounding structures that are at risk for injury during percutaneous access. However, previous reports indicate that pelvic kidneys might be inaccessible percutaneously without laparoscopic assistance. Herein, we present a novel transgluteal route to renal access for percutaneous nephrolithotomy (PCNL) in a patient with a pelvic horseshoe kidney and severe spinal deformity

Contemporary Practice Patterns of Flexible Ureteroscopy for Treating Renal Stones: Results of a Worldwide Survey

Introduction: Flexible ureteroscopy (fURS) is increasingly used in the treatment of renal stones. However, wide variations exist in technique, use, and indications. To better inform our knowledge about the contemporary state of fURS for treating renal stones, we conducted a survey of endourologists worldwide. Methods: An anonymous online questionnaire assessing fURS treatment of renal stones, consisting of 36 items, was sent to members of the Endourology Society in October 2014. Responses were collected through the SurveyMonkey system over a 3-month period. Results: Questionnaires were answered by 414 surgeons from 44 countries (response rate 20.7%). U.S. surgeons accounted for 34.4% of all respondents. fURS was routinely performed in 80.0% of institutions, with 40.0% of surgeons performing >100 cases/year. Respondents considered fURS to be first-line therapy for patients with renal stones 2?cm. Basket displacement for lower pole stones was routinely performed by 55.8%. Ureteral access sheaths (UAS) were preferred for every case by 58.3%. Respondents frequently utilized high-power lasers and dusting techniques. Criteria for determining stone-free rate were defined as zero fragments or residual fragment (RF) <1, <2, <3, and <4?mm by 30.9%, 8.9%, 31.5%, 15.8%, and 11.2% of respondents, respectively. Conclusion: The overwhelming majority of endourologists surveyed consider fURS as a first-line treatment modality for renal stones, especially those <2?cm. Use of UAS, high-power holmium lasers, and dusting technique has become popular among practitioners. When defining stone free after fURS, the majority of endourologists used a zero fragment or RF <2?mm definition.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140082/1/end.2015.0260.pd

Endoscopic Evidence That Randall's Plaque is Associated with Surface Erosion of the Renal Papilla

OBJECTIVE: This study was conducted to assess the reliability and precision of an endoscopic grading scale to identify renal papillary abnormalities across a spectrum of equipment, locations, graders, and patients. MATERIALS AND METHODS: Intra- and interobserver reliability of the papillary grading system was assessed using weighted kappa scoring among 4 graders reviewing a single renal papilla from 50 separate patients on 2 occasions. Grading was then applied to a cohort of patients undergoing endoscopic stone removal procedures at two centers. Patient factors were compared with papillary scores on the level of the papilla, kidney, and patient. RESULTS: Graders achieved substantial (kappa >0.6) intra- and inter-rater reliability in scored domains of ductal plugging, surface pitting, and loss of contour. Agreement for Randall's Plaque (RP) was moderate. Papillary scoring was then performed for 76 patients (89 kidneys, 533 papillae). A significant association was discovered between pitting and RP that held both within and across institutions. A general linear model was then created to further assess this association and it was found that RP score was a highly significant independent correlate of pitting score (F = 7.1; p < 0.001). Mean pitting scores increased smoothly and progressively with increasing RP scores. Sums of the scored domains were then calculated as a reflection of gross papillary abnormality. When analyzed in this way, a history of stone recurrence and shockwave lithotripsy were strongly predictive of higher sums. CONCLUSIONS: Renal papillary pathology can be reliably assessed between different providers using a newly described endoscopic grading scale. Application of this scale to stone-forming patients suggests that the degree of RP appreciated in the papilla is strongly associated with the presence of pitting. It also suggests that patients with a history of recurrent stones and lithotripsy have greater burdens of gross papillary disease

Use of mechanical circulatory support in patients with non-ischaemic cardiogenic shock

Aims Despite its high incidence and mortality risk, there is no evidence-based treatment for non-ischaemic cardiogenic shock (CS). The aim of this study was to evaluate the use of mechanical circulatory support (MCS) for non-ischaemic CS treatment.Methods and results In this multicentre, international, retrospective study, data from 890 patients with non-ischaemic CS, defined as CS due to severe de-novo or acute-on-chronic heart failure with no need for urgent revascularization, treated with or without active MCS, were collected. The association between active MCS use and the primary endpoint of 30-day mortality was assessed in a 1:1 propensity-matched cohort. MCS was used in 386 (43%) patients. Patients treated with MCS presented with more severe CS (37% vs. 23% deteriorating CS, 30% vs. 25% in extremis CS) and had a lower left ventricular ejection fraction at baseline (21% vs. 25%). After matching, 267 patients treated with MCS were compared with 267 patients treated without MCS. In the matched cohort, MCS use was associated with a lower 30-day mortality (hazard ratio 0.76, 95% confidence interval 0.59-0.97). This finding was consistent through all tested subgroups except when CS severity was considered, indicating risk reduction especially in patients with deteriorating CS. However, complications occurred more frequently in patients with MCS; e.g. severe bleeding (16.5% vs. 6.4%) and access-site related ischaemia (6.7% vs. 0%).Conclusion In patients with non-ischaemic CS, MCS use was associated with lower 30-day mortality as compared to medical therapy only, but also with more complications. Randomized trials are needed to validate these findings.[GRAPHICS

Heart failure in COVID-19: the multicentre, multinational PCHF-COVICAV registry.

AIMS: We assessed the outcome of hospitalized coronavirus disease 2019 (COVID-19) patients with heart failure (HF) compared with patients with other cardiovascular disease and/or risk factors (arterial hypertension, diabetes, or dyslipidaemia). We further wanted to determine the incidence of HF events and its consequences in these patient populations. METHODS AND RESULTS: International retrospective Postgraduate Course in Heart Failure registry for patients hospitalized with COVID-19 and CArdioVascular disease and/or risk factors (arterial hypertension, diabetes, or dyslipidaemia) was performed in 28 centres from 15 countries (PCHF-COVICAV). The primary endpoint was in-hospital mortality. Of 1974 patients hospitalized with COVID-19, 1282 had cardiovascular disease and/or risk factors (median age: 72 [interquartile range: 62-81] years, 58% male), with HF being present in 256 [20%] patients. Overall in-hospital mortality was 25% (n = 323/1282 deaths). In-hospital mortality was higher in patients with a history of HF (36%, n = 92) compared with non-HF patients (23%, n = 231, odds ratio [OR] 1.93 [95% confidence interval: 1.44-2.59], P < 0.001). After adjusting, HF remained associated with in-hospital mortality (OR 1.45 [95% confidence interval: 1.01-2.06], P = 0.041). Importantly, 186 of 1282 [15%] patients had an acute HF event during hospitalization (76 [40%] with de novo HF), which was associated with higher in-hospital mortality (89 [48%] vs. 220 [23%]) than in patients without HF event (OR 3.10 [2.24-4.29], P < 0.001). CONCLUSIONS: Hospitalized COVID-19 patients with HF are at increased risk for in-hospital death. In-hospital worsening of HF or acute HF de novo are common and associated with a further increase in in-hospital mortality

New persistent opioid use after ureteroscopy for stone treatment

Introduction & Objectives: Over 100 Americans die every day from opioid overdose. Emerging data suggest that many opioid addictions surface after surgery. To examine this issue, we measured the incidence of persistent opioid use following ureteroscopy (URS) for stone treatment. Materials & Methods: Utilizing the Clinformatics DataMart™ Database, we identified adults who underwent outpatient URS for stone treatment between January 1, 2008 and December 31, 2016 and filled an opioid prescription attributed to surgery. Our primary outcome was new persistent opioid use—defined as previously opioid-naïve patients (i.e., those with no opioid prescriptions between 12 months and 31 days before surgery), who filled an opioid prescription attributed to surgery and then filled at least one additional opioid prescription between 90 and 180 days after surgery. We then fit a multivariable logistic regression model to determine patient factors associated with new persistent opioid use. Results: Over the study period, 48,576 patients underwent outpatient URS for stone treatment. Of these, 53% were opioid-naïve, 33% were intermittent opioid users, and 14% were chronic opioid users. Among opioid-naïve patients, 1,671 (7%) developed new persistent opioid use after URS. The figure shows the trajectory of mean daily opioid dose with patients stratified by perioperative opioid use. Three months after surgery, patients with new persistent opioid use continued to fill opioid prescriptions, corresponding to less than 1 tablet per day of 5-mg hydrocodone (3.3 oral morphine equivalents). Patient factors associated with increased odds of new persistent opioid use included filling an opioid prescription within the 30 days before surgery [odds ratio (OR), 1.26; 95% confidence interval (CI), 1.12 to 1.41) and female gender (OR, 1.17; 95% CI, 1.06 to 1.30). [Figure presented] Conclusions: Nearly 1 in 14 opioid-naïve patients go on to persistent opioid use after URS for stone treatment. In light of these findings, urologists should consider alternatives to opioids for postoperative pain management

Propylene polymerization and deactivation processes with isoselective {cp/flu} zirconocene catalysts

International audienceIndustrially relevant single‐site precatalysts used to produce isotactic polypropylene (iPP) include C2‐symmetric {SBI} and C1‐symmetric {Cp/Flu} complexes of group 4 metals. While the latter can produce iPPs with a higher degree of isotacticity, they also suffer from poor productivity com-pared to their {SBI} counterparts. Several causes for this trend have been suggested—2,1‐Regioinser-tions are frequently pointed out, as they are suspected to drive the catalyst into a dormant state. While this event does not seem to significantly impact the productivity of {SBI} systems, the influence of these regioerror is poorly documented for isoselective {Cp/Flu} precatalysts. To address this issue, new Ph2X(Cp)(Flu) (Ph2X = Ph2C, FluC, Ph2Si) proligands (2a–k) and some of the correspond-ing dichlorozirconocenes (3a–h,k) were synthesized. These new compounds were characterized and tested in homogeneous propylene polymerization at 60 °C and the amounts of regioerrors in the resulting polymers were examined by13C NMR spectroscopy. A possible correlation between poor productivity and a high number of regioerrors was investigated and is discussed. Further-more, a C‐H activation process in the bulky nBu3C substituent upon activation of 4c (the dimethyl-ated analog of 3c) by B(C6F5)3 has been evidenced by NMR; DFT calculations support this C‐H activation as a deactivation mechanism. © 2021 by the authors. Licensee MDPI, Basel, Switzerland