Towards a standardised informed consent procedure for live donor nephrectomy: The PRINCE (Process of Informed Consent Evaluation) project-study protocol for a nationwide prospective cohort study

Introduction: Informed consent is mandatory for all (surgical) procedures, but it is even more important when it comes to living kidney donors undergoing surgery for the benefit of others. Donor education, leading to informed consent, needs to be carried out according to certain standards. Informed consent procedures for live donor nephrectomy vary per centre, and even per individual healthcare professional. The basis for a standardised, uniform surgical informed consent procedure for live donor nephrectomy can be created by assessing what information donors need to hear to prepare them for the operation and convalescence. Methods and analysis: The PRINCE (Process of In formed Consent Evaluation) project is a prospective, multicentre cohort study, to be carried out in all eight Dutch kidney transplant centres. Donor knowledge of the procedure and postoperative course will be evaluated by means of pop quizzes. A baseline cohort (prior to receiving any information from a member of the transplant team in one of the transplant centres) will be compared with a control group, the members of which receive the pop quiz on the day of admission for donor nephrectomy. Donor satisfaction will be evaluated for all donors who completed the admission pop-quiz. The primary end point is donor knowledge. In addition, those elements that have to be included in the standardized format informed consent procedure will be identified. Secondary end points are donor satisfaction, current informed consent practices in the different centres (eg, how many visits, which personnel, what kind of information is di

Patients with encapsulating peritoneal sclerosis have increased peritoneal expression of connective tissue growth factor (CCN2), transforming growth factor- β1, and vascular endothelial growth factor

Introduction: Encapsulating peritoneal sclerosis (EPS) is a devastating complication of peritoneal dialysis (PD). The pathogenesis is not exactly known and no preventive strategy or targeted medical therapy is available. CCN2 has both profibrotic and pro-angiogenic actions and appears an attractive target. Therefore, we studied peritoneal expression of CCN2, as well as TGFb1 and VEGF, in different stages of peritoneal fibrosis.Materials and methods: Sixteen PD patients were investigated and compared to 12 hemodialysis patients and four preemptively transplanted patients. Furthermore, expression was investigated in 12 EPS patients in comparison with 13 PD and 12 non-PD patients without EPS. Peritoneal tissue was taken during kidney transplantation procedure or during EPS surgery. In a subset of patients, CCN2 protein levels in peritoneal effluent and plasma were determined. Samples were examined by qPCR, histology, immunohistochemistry, and ELISA.Results: Peritoneal CCN2 expression was 5-fold higher in PD patients compared to pre-emptively transplanted patients (P< 0.05), but did not differ from hemodialysis patients. Peritoneal expression of TGFβ1 and VEGF were not different between the three groups; neither was peritoneal thickness. Peritoneum of EPS patients exhibited increased expression of CCN2 (35- fold, P<0.001), TGFβ1 (24-fold, P< 0.05), and VEGF (77-fold, P<0.001) compared to PD patients without EPS. In EPS patients, CCN2 protein was mainly localized in peritoneal endothelial cells and fibroblasts. CCN2 protein levels were significantly higher in peritoneal effluent of EPS patients compared to levels in dialysate of PD patients (12.0±4.5 vs. 0.91±0.92 ng/ml, P<0.01), while plasma CCN2 levels were not increased.Conclusions: Peritoneal expression of CCN2, TGFβ1, and VEGF are significantly increased in EPS patients. In early stages of peritoneal fibrosis, only CCN2 expression is slightly increased. Peritoneal CCN2 overexpression in EPS patients is a locally driven response. The potential of CCN2 as biomarker and target for CCN2-inhibiting agents to prevent or treat EPS warrants further study

Surgical interventions and studies of the carotid sinus

Background: The carotid baroreflex buffers acute changes in blood pressure and is triggered by baroreceptors in the carotid sinus. Baroreceptor firing results in an increased parasympathetic tone and a decreased sympathetic tone leading to reduced heart rate and blood pressure. Under normal conditions, sympathetic and parasympathetic action at the level of the carotid sinus is balanced. In contrast, patients suffering from a carotid sinus syndrome (CSS) may demonstrate an exaggerated carotid baroreflex response. Symptoms of dizziness and syncope may occur because of episodes of a brief asystole or a profound drop in blood pressure. In a mostly elderly patient group these syncopes may be associated with frequent falls leading to serious sequelae.Pacemaker implantation is nowadays considered ‘gold standard’ for treating CSS patients with repetitive syncope, but may not always be effective. The sympathetic nervous system also plays a crucial role in the pathofysiology of hypertension. An association was found between systemic hypertension and the presence of an abnormal baroreflex. Large clinical trials indicate that up to 30% of hypertensive patients do not reach normotension despite life style changes in combination with the use of pharmacological agents these measures. This therapy resistant hypertension is a major risk factor for the development of cardiovascular events. Aims Aims of this thesis are: first to study the effects of carotid sinus denervation by means of adventitial stripping in patients suffering from carotid sinus syndrome (CSS) and second, to explore the concept of mechanical carotid sinus stimulation in the treatment of hypertension. Methods A literature study was performed on technique, efficacy and safety of a surgical technique termed adventitial stripping of the carotid sinus as a treatment of CSS. Second, the anatomy of nerve structures surrounding the carotid bifurcation with special emphasis on the carotid sinus nerve (CSN) and its branches was studied, followed by a microscopic study of baroreceptor distribution in the carotid bifurcation. Next, short and long term efficacy and safety of adventitial carotid stripping was studied in a cohort of 27 CSS patients. Finally, a first-in-man study of mechanical carotid sinus stimulation was performed. Conclusions -Substantial or complete relief of CSS associated symptoms was achieved by adventitial carotid stripping in 85% of the patients reported in the literature. -Carotid sinus nerve (CSN) anatomy is characterized by a great variability. Therefore, CSN transection as a single treatment for patients with CSS may be insufficient. -Baroreceptor density is highest in the first cm portion of the medial internal carotid artery (ICA). Therefore, adventitial stripping of the proximal ICA is sufficient for CSS. -Adventitial stripping of the proximal 3 cm of the ICA appears effective in 93% of our CSS patient cohort (n=27),whereas CSS recurrence was absent on the long term. -Carotid denervation by adventitial stripping is safe. -Mechanical carotid stimulation lowers blood pressure in an acute human model

Abberant Sex Habits Leading to Acute Limb Ischemia and Hematuria

We report a case of a 42 year-old man suffering from an acute limb ischemia. Upon urokinase treatment he developed gross hematuria. Finally, CT scanning revealed a self-inserted foreign body not only causing thrombosis of the external iliac artery, but also forming an arteriovesical fistula.This case emphasises the importance of detailed history taking and thorough further investigation in recurrent macroscopic hematuria in a patient. Massive bleeding from the bladder should alert the doctor for a rare, but life-threatening arteriovesical fistula

AMOS: Using the cloud for on-demand execution of e-Science applications

The amount of computing resources currently available on Clouds is large and easily available with pay per use cost model. E-Science applications that need on-demand execution benefit from Clouds, because no permanent computing resources to support peak demand has to be acquired. In this paper, we present AMOS, a system that automates creation and management of temporary Grids on a Cloud to execute (parts of) application workflows. We performed experiments with AMOS and a representative e-Science application on a research Grid and on the Amazon EC2 Cloud. The results show that AMOS is a viable approach to manage and execute e-Science applications in a flexible Grid environment and to explore novel mechanisms that allow optimal utilization of Cloud resources. Furthermore, we consider AMOS as a step towards an operating system for (virtual) infrastructures that enables Grid applications to control their computational resources at run-time. © 2010 IEEE

Abdominal stent-graft collapse due to progression of a Stanford type B dissection.

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