The impact of laparoscopic adrenalectomy on renal function. Results of a prospective randomised clinical trial

Introduction: Laparoscopic adrenalectomy is the gold standard management of benign adrenal masses and isolated metastases to adrenal glands. Two techniques of endoscopic adrenalectomy: lateral transperitoneal approach (LTA) and posterior retroperitoneal approach (PRA) seem to be equally safe and effective. Recent studies suggest advantages of PRA over LTA in terms of lower intensity of postoperative pain, shorter hospital stay, faster recovery, and lower early morbidity. However, PRA involves high insufflation pressure of CO2 within a limited retroperitoneal space. The aim of our study was to prospectively assess the effect of LTA versus PRA laparoscopic adrenalectomies on renal function. Material and methods: We randomly assigned patients referred for unilateral adrenalectomy to either LTA (n = 33) or PRA (n = 44). The inclusion criteria were: hormonal activity and/or tumour diameter > 4 cm and/or suspicion of metastasis to adrenal gland. The exclusion criteria comprised: tumours > 8 cm, results of imaging studies suggesting primary invasive malignancy, and refusal to undergo randomisation. The patients were prospectively followed for a minimum of six months. Serum creatinine, cystatin C, and urinary neutrophil gelatinase-associated lipocalin (NGAL) were measured preoperatively and at postoperative days: 1, 7, and 30. Results: We found increased concentrations of urinary NGAL at day 1 following laparoscopic adrenalectomy using PRA, as compared to LTA. Patients undergoing right-sided PRA had increased creatinine concentrations, as compared to left-sided PRA. Patients with aldosterone-producing adenoma had decreased preoperative eGFR as compared to subjects with non-functioning incidentaloma. NGAL increased significantly in this group postoperatively. All the disturbances normalised within one month postoperatively. Conclusions: Renal function impairment after PRA may result from compression of inferior vena cava by high retroperitoneal pressure during right-sided adrenalectomy. Despite the transient character of the observed abnormalities, we suggest that patients with high risk of acute kidney injury may benefit from an alternative technique of adrenalectomy using LTA

Wrodzony hiperinsulinizm — próba optymalizacji diagnostyki i leczenia u polskich pacjentów

  Introduction: Congenital hyperinsulinism of Infancy (CHI) comprises heterogenic defects of insulin secretion with diverse molecular aetiology, histological features, severity of symptoms, and response to pharmacotherapy. The study aimed to establish the first clinical characteristics of Polish patients with CHI and to propose a novel clinical algorithm allowing the prioritisation of genetic and radiology studies, based on patient’s characteristics and response to pharmacotherapy. Material and methods: Thirty-one patients with CHI were recruited from five reference centres in Poland. Clinical and biochemical parameters were statistically evaluated and compared to those of a control group (n = 30). Results: CHI predisposes to increased birth weight (p = 0.004), lower Apgar score (p = 0.004), perinatal complications (74%), and neurological implications (48%). Diagnostic process and therapy were inconsistent. A trial of pharmacotherapy was applied in 21 patients (68%), and diagnostic imaging with 18F-L-DOPA PET was performed in only 3. Eighteen patients (58%) were surgically treated, including 8 infants (44%) aged less than 2 months. Depending on the type of resection, further hypoglycaemia was observed postoperatively in 50% (n = 9) and hyperglycaemia in 39% (n = 7) of cases. Based on foregoing results, a clinical algorithm was proposed. Conclusions: Standardisation of clinical management with the use of pharmacotherapy, genetic screening, and diagnostic imaging will allow the optimisation of therapy and minimisation of treatment complications. (Endokrynol Pol 2015; 66 (4): 322–328)    Wstęp: Wrodzony hiperinsulinizm (CHI) obejmuje heterogenną grupę zaburzeń sekrecji insuliny przez komórki β trzustki i charakteryzuje się zróżnicowaną etiologią molekularną, obrazem histopatologicznym, nasileniem objawów oraz odpowiedzią na leczenie farmakologiczne. Celem pracy było stworzenie charakterystyki klinicznej polskich pacjentów z wrodzonym hiperinsulinizmem oraz podjęcie próby stworzenia algorytmu diagnostyczno-terapeutycznego, umożliwiającego priorytetyzację badań genetycznych i obrazowych w zależności od obrazu klinicznego, wyników badań laboratoryjnych oraz odpowiedzi na leczenie farmakologiczne. Materiał i metody: Do badania włączono 31 pacjentów z rozpoznaną hipoglikemią w przebiegu hiperinsulinizmu z 5 ośrodków w Polsce. Analizę danych klinicznych oraz parametrów biochemicznych pacjentów hipoglikemią odniesiono do 30-osobowej grupy kontrolnej. Wyniki: Pacjenci z CHI charakteryzowali się znacznie wyższą masą urodzeniową (p = 0,004), niższą oceną uzyskaną w okołoporodowej skali Apgar (p = 0,004), częstszymi komplikacjami okołoporodowymi (74%) oraz powikłaniami neurologicznymi (48%). Przeprowadzona w badanej grupie diagnostyka była niespójna. U 21 pacjentów (68%) włączono leczenie za pomocą Diazoksydu, a u 3 pacjentów (9,7%) wykonano diagnostykę obrazową przy użyciu 18F-L-DOPA PET. Wśród 18 (58%) pacjentów leczonych chirurgicznie u 8 (44%) resekcję wykonano w wieku poniżej 2. miesiąca życia. Pooperacyjnie w zależności od typu wykonanej operacji obserwowano hipoglikemię u 50% (n = 9), a hiperglikemię u 39% (n = 7). Na podstawie uzyskanych wyników zaproponowano pierwszy w Polsce algorytm diagnostyczno- terapeutyczny. Wnioski: Ujednolicenie schematu postępowania diagnostycznego-terapeutycznego z wykorzystaniem wszystkich dostępnych metod umożliwi zapobieganie kolejnym epizodom choroby, oraz zminimalizuje komplikacje wynikające z leczenia. (Endokrynol Pol 2015; 66 (4): 322–328)

Preparation of the donor to the removal of organs — the most common clinical problems

Przeszczepienie narządu to najskuteczniejsza metoda leczenia, gdy dochodzi do jego niewydolności. W procesie transplantacji ważne jest przygotowanie dawcy tak, aby możliwe było pobranie wielonarządowe. Na przeszkodzie temu stoi wiele procesów patofizjologicznych rozwijających się po śmierci mózgu. W części przypadków mają one bezpośredni związek z powstającą „burzą cytokinową”, a część problemów wynika z samego pobytu dawcy na oddziale intensywnej terapii — zwiększa się ryzyko rozwoju zakażeń szpitalnych. W pracy zaprezentowano najczęstsze problemy stojące na przeszkodzie pobrania jak największej liczby narządów w celu ocalenia życia innym pacjentom.An organ transplantation is the most effective method of treatment when the organ is becoming insuficient. In the process of the transplant arrangements it’s important to prepare donor for multiorgan donation. Many pathophysiological processes after the brain death making it imposible. In some cases those disorders are caused by cytokines and in the others higher risk of nosocomial infection during the treatment in ICU. In this article were presented the most common problems of multiorgan donation, which make donation impossible or less effective

Real-time back surface landmark determination using a Time-of-Flight camera

Postural disorders, their prevention, and therapies are still growing modern problems. The currently used diagnostic methods are questionable due to the exposure to side effects (radiological methods) as well as being time-consuming and subjective (manual methods). Although the computer-aided diagnosis of posture disorders is well developed, there is still the need to improve existing solutions, search for new measurement methods, and create new algorithms for data processing. Based on point clouds from a Time-of-Flight camera, the presented method allows a non-contact, real-time detection of anatomical landmarks on the subject’s back and, thus, an objective determination of trunk surface metrics. Based on a comparison of the obtained results with the evaluation of three independent experts, the accuracy of the obtained results was confirmed. The average distance between the expert indications and method results for all landmarks was 27.73 mm. A direct comparison showed that the compared differences were statically significantly different; however, the effect was negligible. Compared with other automatic anatomical landmark detection methods, ours has a similar accuracy with the possibility of real-time analysis. The advantages of the presented method are non-invasiveness, non-contact, and the possibility of continuous observation, also during exercise. The proposed solution is another step in the general trend of objectivization in physiotherapeutic diagnostics

Hybrid system of emotion evaluation in physiotherapeutic procedures

Nowadays, the dynamic development of technology allows for the design of systems based on various information sources and their integration into hybrid expert systems. One of the areas of research where such systems are especially helpful is emotion analysis. The sympathetic nervous system controls emotions, while its function is directly reflected by the electrodermal activity (EDA) signal. The presented study aimed to develop a tool and propose a physiological data set to complement the psychological data. The study group consisted of 41 students aged from 19 to 26 years. The presented research protocol was based on the acquisition of the electrodermal activity signal using the Empatica E4 device during three exercises performed in a prototype Disc4Spine system and using the psychological research methods. Different methods (hierarchical and non-hierarchical) of subsequent data clustering and optimisation in the context of emotions experienced were analysed. The best results were obtained for the k-means classifier during Exercise 3 (80.49%) and for the combination of the EDA signal with negative emotions (80.48%). A comparison of accuracy of the k-means classification with the independent division made by a psychologist revealed again the best results for negative emotions (78.05%)

Ozonation of Whole Blood Results in an Increased Release of Microparticles from Blood Cells.

Autohemotherapy with ozonated blood is used in the treatment of a broad spectrum of clinical disorders. Ozone demonstrates strong oxidizing properties and causes damage to cell membranes. The impact of whole-blood ozonation on the release of microparticles from blood and endothelial cells and the concentration of selected markers in the hemostatic system (APTT, PT, D-dimer, fibrinogen) were investigated. Venous blood, obtained from 19 healthy men, was split into four equal parts and treated with air, 15 µg/mL ozone, or 30 µg/mL ozone, or left untreated. The number and types of microparticles released were determined using flow cytometry on the basis of surface antigen expression: erythrocyte-derived microparticles (CD235+), platelet-derived microparticles (CD42+), leukocyte-derived microparticles (CD45+), and endothelial-derived microparticles (CD144+). The study is the first to demonstrate that ozone induces a statistically significant increase in the number of microparticles derived from blood and endothelial cells. Although statistically significant, the changes in some coagulation factors were somewhat mild and did not exceed normal values

Familial hypercholesterolaemia in children and adolescents from 48 countries: a cross-sectional study

Background: Approximately 450 000 children are born with familial hypercholesterolaemia worldwide every year, yet only 2·1% of adults with familial hypercholesterolaemia were diagnosed before age 18 years via current diagnostic approaches, which are derived from observations in adults. We aimed to characterise children and adolescents with heterozygous familial hypercholesterolaemia (HeFH) and understand current approaches to the identification and management of familial hypercholesterolaemia to inform future public health strategies. Methods: For this cross-sectional study, we assessed children and adolescents younger than 18 years with a clinical or genetic diagnosis of HeFH at the time of entry into the Familial Hypercholesterolaemia Studies Collaboration (FHSC) registry between Oct 1, 2015, and Jan 31, 2021. Data in the registry were collected from 55 regional or national registries in 48 countries. Diagnoses relying on self-reported history of familial hypercholesterolaemia and suspected secondary hypercholesterolaemia were excluded from the registry; people with untreated LDL cholesterol (LDL-C) of at least 13·0 mmol/L were excluded from this study. Data were assessed overall and by WHO region, World Bank country income status, age, diagnostic criteria, and index-case status. The main outcome of this study was to assess current identification and management of children and adolescents with familial hypercholesterolaemia. Findings: Of 63 093 individuals in the FHSC registry, 11 848 (18·8%) were children or adolescents younger than 18 years with HeFH and were included in this study; 5756 (50·2%) of 11 476 included individuals were female and 5720 (49·8%) were male. Sex data were missing for 372 (3·1%) of 11 848 individuals. Median age at registry entry was 9·6 years (IQR 5·8-13·2). 10 099 (89·9%) of 11 235 included individuals had a final genetically confirmed diagnosis of familial hypercholesterolaemia and 1136 (10·1%) had a clinical diagnosis. Genetically confirmed diagnosis data or clinical diagnosis data were missing for 613 (5·2%) of 11 848 individuals. Genetic diagnosis was more common in children and adolescents from high-income countries (9427 [92·4%] of 10 202) than in children and adolescents from non-high-income countries (199 [48·0%] of 415). 3414 (31·6%) of 10 804 children or adolescents were index cases. Familial-hypercholesterolaemia-related physical signs, cardiovascular risk factors, and cardiovascular disease were uncommon, but were more common in non-high-income countries. 7557 (72·4%) of 10 428 included children or adolescents were not taking lipid-lowering medication (LLM) and had a median LDL-C of 5·00 mmol/L (IQR 4·05-6·08). Compared with genetic diagnosis, the use of unadapted clinical criteria intended for use in adults and reliant on more extreme phenotypes could result in 50-75% of children and adolescents with familial hypercholesterolaemia not being identified. Interpretation: Clinical characteristics observed in adults with familial hypercholesterolaemia are uncommon in children and adolescents with familial hypercholesterolaemia, hence detection in this age group relies on measurement of LDL-C and genetic confirmation. Where genetic testing is unavailable, increased availability and use of LDL-C measurements in the first few years of life could help reduce the current gap between prevalence and detection, enabling increased use of combination LLM to reach recommended LDL-C targets early in life

Nadciśnienie tętnicze u dzieci z cukrzycą typu 1

Arterial hypertension is a main risk factor of cardiovascular, renal and microvascular complications in diabetes. It is estimated that arterial hypertension is more prevalent among type 1 diabetic children than in general pediatric population. Arterial wall injury caused by hyperglycemia and subclinical diabetic kidney disease play a role in pathogenesis of arterial hypertension in diabetic children. Overweight and secondary insulin resistance are other factors playing role in pathogenesis of arterial hypertension. Recent guidelines recommend to perform regular blood pressure measurements and to start early antihypertensive treatment. Antihypertensive treatment in diabetic children should be based on inhibitors of converting enzyme or, in case of intolerance, blockers of angiotensin II receptor.Nadciśnienie tętnicze (NT) ma istotne znaczenie kliniczne u dzieci i młodzieży chorej na cukrzycę typu 1. Badania wskazują na większą częstość występowania nadciśnienia tętniczego w tej grupie chorych, niż w populacji ogolnej. W patogenezie uwzględnia się bezpośrednie i pośrednie działanie hiperglikemii na funkcję naczyń. Istotne znaczenie ma wspołwystępująca cukrzycowa choroba nerek. Należy również podkreślić wpływ coraz częściej występującej nadwagi i otyłości oraz związanej z nimi insulinooporności. Nadciśnienie tętnicze odgrywa ważną rolę w patogenezie powikłań sercowo-naczyniowych oraz rozwoju i progresji mikroangiopatii. Regularne pomiary ciśnienia tętniczego są uwzględniane we wszystkich zaleceniach dotyczących opieki nad dziećmi z cukrzycą typu 1. Istnieją natomiast rozbieżności dotyczące docelowych wartości ciśnienia tętniczego i progu, od ktorego należy zaczynać terapię hipotensyjną. Lekami z wyboru w leczeniu NT są inhibitory konwertazy angiotensyny, a w przypadku ich nietolerancji antagoniści receptora angiotensyny. W artykule przedstawiono przegląd aktualnych zaleceń dotyczących leczenia hipotensyjnego u dzieci i młodzieży z cukrzycą typu 1

Zalecenia Sekcji Pediatrycznej Polskiego Towarzystwa Nadciśnienia Tętniczego dotyczące postępowania diagnostycznego i terapeutycznego w nadciśnieniu tętniczym u dzieci i młodzieży

Prezentowane zalecenia są rozszerzoną i uaktualnioną wersją zaleceń pediatrycznych Polskiego Towarzystwa Nadciśnienia Tętniczego (PTNT) opublikowanych w 2015 roku. Od tego czasu ukazały się nowe opracowania wprowadzające między innymi nową klasyfikację nadciśnienia tętniczego, nowe zasady postępowania w grupach ryzyka oraz metody oceny uszkodzenia narządowego. W prezentowanych, zaktualizowanych zaleceniach pediatrycznych PTNT uwzględniono zmiany wprowadzone w zaleceniach pediatrycznych Europejskiego Towarzystwa Nadciśnienia Tętniczego (ESH, European Society of Hypertension) z 2016 roku i wcześniej opublikowane jako rekomendacje Instytutu „Pomnik — Centrum Zdrowia Dziecka” (IPCZD) w Warszawie. Omówiono również zmiany wprowadzone w opublikowanych w 2017 roku zaleceniach American Academy of Pediatrics. W obecnej wersji dodano informacje epidemiologiczne dotyczące występowania i zapadalności na nadciśnienie tętnicze w wieku rozwojowym, uaktualniono definicje poszczególnych stadiów nadciśnienia tętniczego, przedyskutowano problemy interpretacyjne wartości ciśnienia tętniczego, zmodyfikowano podrozdziały dotyczące diagnostyki i oceny uszkodzenia narządowego, zasady diagnostyki i leczenia nadciśnienia tętniczego u dzieci z cukrzycą, z przewlekłą chorobą nerek oraz podrozdział omawiający trudności diagnostyczne i terapeutyczne z ustaleniem docelowych wartości ciśnienia tętniczego. Uwzględniono zasady wczesnej diagnostyki nadciśnienia tętniczego w opiece powypisowej u dzieci urodzonych do 33. tygodnia ciąży