Background
Robot-assisted partial nephrectomy (RAPN) has become widely accepted, but its different underlying types of learning curves have not been comparatively analyzed to date. This study aimed ...to determine and compare the impact that the learning curve of the department, the console surgeon, and the bedside assistant as well as patient-related factors has on the perioperative outcomes of RAPN.
Methods
The study retrospectively analyzed 500 consecutive transperitoneal RAPNs (2007–2018) performed in a tertiary referral center by 7 surgeons and 37 bedside assistants. Patient characteristics and surgical data were obtained. Experience (EXP) was defined as the current number of RAPNs performed by the department, the surgeon, and the assistant. As the primary outcome, the impact of EXP and patient-related factors on perioperative outcomes were analyzed and compared. As the secondary outcome, a cutoff between “experienced” and “inexperienced” was defined. Correlation and regression analysis, receiver operating characteristic curve analysis, Fisher’s exact test, and the Mann–Whitney
U
test were performed, with
p
values lower than 0.05 denoting significance.
Results
The EXP of the department, the surgeon, and the assistant each has a major influence on perioperative outcome in RAPN irrespective of patient-related factors. Perioperative outcomes improve significantly with EXP greater than 100 for the department, EXP greater than 35 for the surgeon, and EXP greater than 15 for the assistant.
Conclusions
The perioperative results of RAPN are influenced by three different types of learning curves including those for the surgical department, the console surgeon, and the assistant. The influence of the bedside assistant clearly has been underestimated to date because it has a significant impact on the perioperative outcomes of RAPN.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Borg’s rating of perceived exertion (RPE) is a widely used psycho-physical tool to assess subjective perception of effort during exercise. We evaluated the association between Borg’s RPE and ...physiological exercise parameters in a very large population. In this cohort study, 2,560 Caucasian men and women median age 28 (IQR 17–44) years completed incremental exercise tests on treadmills or cycle ergometers. Heart rate, blood lactate concentration, and RPE (Borg scale 6–20) were simultaneously measured at the end of each work load. Rating of perceived exertion was strongly correlated with heart rate (
r
= 0.74,
p
< 0.001) and blood lactate (
r
= 0.83,
p
< 0.001). The mean values for lactate threshold (LT) and individual anaerobic threshold corresponded to an RPE of 10.8 ± 1.8 and 13.6 ± 1.8, respectively. Fixed lactate thresholds of 3 and 4 mmol/L corresponded to RPEs of 12.8 ± 2.1 and 14.1 ± 2.0. Gender, age, coronary artery disease (CAD), physical activity status and exercise testing modality did not influence this association significantly (all
p
> 0.05). Borg’s RPE seems to be an affordable, practical and valid tool for monitoring and prescribing exercise intensity, independent of gender, age, exercise modality, physical activity level and CAD status. Exercising at an RPE of 11–13 (“low”) is recommended for less trained individuals, and an RPE of 13–15 may be recommended when more intense but still aerobic training is desired.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background Mineralocorticoid receptor antagonists (MRA) improve survival in heart failure with reduced ejection fraction but are often underused, mostly due to concerns of hyperkalemia. Because ...hyperkalemia occurs also on placebo, we aimed to determine the truly MRA-related rate of hyperkalemia. Methods We performed a meta-analysis including randomized, placebo-controlled trials reporting hyperkalemia on MRAs in patients after myocardial infarction or with chronic heart failure. We evaluated the truly MRA-related rate of hyperkalemia that represents hyperkalemia on MRA, corrected for hyperkalemia on placebo (Pla), according to the equation: True MRA (%) = (MRA (%) − Pla (%))/MRA (%). Results A total number of 16,065 patients from 7 trials were analyzed. Hyperkalemia was more frequently observed on MRA (9.3%) vs placebo (4.3%) (risk ratio 2.17, 95% CI 1.92-2.45, P < .0001). Truly MRA-related hyperkalemia was 54%, whereas 46% were non–MRA related. In trials using eplerenone, hyperkalemia was documented in 5.0% on eplerenone and in 2.6% on placebo ( P < .0001). In spironolactone trials, hyperkalemia was documented in 17.5% and in 7.5% of patients on placebo ( P = .0001). Hypokalemia occurred less frequently in patients on MRA (9.3%) compared with placebo (14.8%) (risk ratio 0.58, CI 0.47-0.72, P < .0001). Conclusion This meta-analysis shows that in clinical trials, 54% of hyperkalemia cases were specifically related to the MRA treatment and 46% to other reasons. Therefore, non–MRA-related rises in potassium levels might be underestimated and should be rigorously explored before cessation of the evidence-based therapy with MRAs.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Cardiac surgery is associated with a high risk of postoperative acute kidney injury (AKI) and subsequent loss of kidney function. We explored the clinical utility of urinary dickkopf-3 (DKK3), a ...renal tubular stress marker, for preoperative identification of patients at risk for AKI and subsequent kidney function loss.
This observational cohort study included patients who had cardiac surgery in a derivation cohort and those who had cardiac surgery in a validation cohort (RenalRIP trial). The study comprised consecutive patients who had elective cardiac surgery at the Saarland University Medical Centre (Homburg, Germany; derivation cohort) and those undergoing elective cardiac surgery (selected on the basis of a Cleveland Clinical Foundation score of 6 or higher) who were enrolled in the prospective RenalRIP multicentre trial (validation cohort) and who were randomly assigned to remote ischaemic preconditioning or a sham procedure. The association between the ratio of preoperative urinary concentrations of DKK3 to creatinine (DKK3:creatinine) and postoperative AKI, defined according to the Kidney Disease Improving Global Outcomes criteria, and subsequent kidney function loss, as determined by estimated glomerular filtration rate, was assessed.
In the 733 patient in the derivation cohort, urinary concentrations of DKK3 to creatinine that were higher than 471 pg/mg were associated with significantly increased risk for AKI (odds ratio OR 1·65, 95% CI 1·10–2·47, p=0·015), independent of baseline kidney function. Compared with clinical and other laboratory measurements, urinary concentrations of DKK3:creatinine significantly improved AKI prediction (net reclassification improvement 0·32, 95% CI 0·23–0·42, p<0·0001). High urinary DKK3:creatinine concentrations were independently associated with significantly lower kidney function at hospital discharge and after a median follow-up of 820 days (IQR 733–910). In the RenalRIP trial, preoperative urinary DKK3:creatinine concentrations higher than 471 pg/mg were associated with a significantly higher risk for AKI (OR 1·94, 95% CI 1·08–3·47, p=0·026), persistent renal dysfunction (OR 6·67, 1·67–26·61, p=0·0072), and dialysis dependency (OR 13·57, 1·50–122·77, p=0·020) after 90 days compared with DKK3:creatinine concentrations of 471 pg/mg or less. Urinary DKK3:creatinine concentrations higher than 471 pg/mg were associated with significantly higher risk for AKI (OR 2·79, 95% CI 1·45–5·37) and persistent renal dysfunction (OR 3·82, 1·32–11·05) only in patients having a sham procedure, but not remote ischaemic preconditioning (AKI OR 1·35, 0·76–2·39 and persistent renal dysfunction OR 1·05, 0·12–9·45).
Preoperative urinary DKK3 is an independent predictor for postoperative AKI and for subsequent loss of kidney function. Urinary DKK3 might aid in the identification of patients in whom preventive treatment strategies are effective.
No study funding.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background The discovery of filaggrin (FLG) null mutations as a major risk factor for eczema represents a milestone toward the understanding of an important mechanism in this complex disease. ...However, published studies demonstrate differences concerning design and effect size, and conflicting results for asthma have been reported. Objectives We sought to provide a more accurate estimate of FLG effect sizes and to better refine FLG risk profiles within the broad and inclusive eczema diagnosis. We also sought to provide a more detailed and conclusive estimate of the risk for asthma associated with FLG null alleles. Methods We performed a meta-analysis of 24 studies on FLG mutations and eczema involving 5,791 cases, 26,454 control subjects, and 1,951 families as well as 17 studies on asthma involving 3,138 cases, 17,164 control subjects, and 1,511 offspring. Results Both case-control and family studies showed strong associations with eczema. Case-control studies were heterogeneous, whereas family studies yielded more homogeneous results. Combined analysis showed that FLG haploinsufficiency strongly increases the eczema risk (odds ratio OR, 3.12; 95% CI, 2.57-3.79) and is associated with more severe and dermatologist-diagnosed disease. FLG mutations are also significantly associated with asthma (OR, 1.48; 95% CI, 1.32-1.66). However, although strong effects for the compound phenotype asthma plus eczema (OR, 3.29; 95% CI, 2.84-3.82) were observed, there appears to be no association with asthma in the absence of eczema. Conclusions This meta-analysis summarizes the strong evidence for a high eczema risk conferred by FLG mutations and refines their risk profiles, suggesting an association with more severe and secondary care disease. FLG mutations are also a robust risk factor for asthma and might help define the asthma endophenotype linked with eczema.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Objective Bicuspid aortic valve (BAV) anatomy is associated with ascending aortic aneurysm in approximately 50% of individuals; it may also lead to severe aortic regurgitation (AR) with ...aortic dilatation. Both entities may be treated by valve repair and root remodeling. The objective was to review the cumulative experience of 20 years. Methods Between 11/95 and 12/15, 357 patients (324 male, age 10 to 80 years, mean 49±13 years) underwent combined BAV repair and root remodeling. AR was relevant in 265 cases; the main indications for surgery were AR (n=241), aortic aneurysm (n=102), and acute dissection (n=9). In 225 instances a suture annuloplasty was added. In 52 cases cusp calcification was present beyond the raphe, in 39 instances an autologous pericardial patch was implanted for partial cusp replacement. All patients were followed, follow up was 97.8% complete with a mean of 57±51 months (median 39 months). Results Two patients died (hospital mortality 0.6%), survival at 15 years was 81%. Reoperation became necessary for recurrent AR in 24, 6 were reoperated for stenosis. Cumulative incidence of reoperation at 15 years was 21.7%. Cusp calcification and the use of a pericardial patch for cusp reconstruction were associated with time to reoperation (p=0.002). Conclusions Repair of the bicuspid aortic valve combined with root remodeling leads to excellent 10 and 15 year results. Cusp calcification and the need for partial cusp replacement are associated with valve failure.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Purpose To derive limits of metric keratoconus indices for classification into keratoconus stages. Design Validity and reliability analysis of diagnostic tools. Methods A total of 126 patients from ...the keratoconus center of Homburg/Saar were evaluated with respect to Amsler criteria, using Pentacam (Keratoconus Index KI, Topographic Keratoconus Classification TKC), Topographic Modeling System (Smolek/Klyce, Klyce/Maeda), and Ocular Response Analyzer (Keratoconus Match Probability KMP, Keratoconus Match Index KMI). Mean value, standard deviation, 90% confidence interval, and the Youden J index for definition of the thresholds were evaluated. Results For separation of keratoconus stages 0/1/2/3/4 we derived the following optimum thresholds: for KI 1.05/1.15/1.31/1.49 and for KMI 0.77/0.32/-0.08/-0.3. For Smolek/Klyce and Klyce/Maeda high standard deviations and overlapping confidence intervals were found; therefore no discrete thresholds could be defined. Nevertheless, for them we still found a good sensitivity and specificity in discriminating between healthy (stage 0) and keratoconus (stages 2–4) eyes in comparison with the other indices. Conclusions We derived thresholds for the metric keratoconus indices KI and KMI, which allow classification of keratoconus stages. These now need to be validated in clinical use. Smolek/Klyce and Klyce/Maeda were not sufficiently sensitive to allow classification into individual stages, but these indices did show a good specificity and sensitivity in discriminating between keratoconus and healthy eyes.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Although the clinical course of Alzheimer disease (AD) is gradual, it is useful for a number of reasons to distinguish between different levels of severity. The Clinical Dementia Rating (CDR) has ...demonstrated high validity and reliability for this purpose, but it requires a considerable amount of data to be collected both from the patient and from an informant. In the present study, the authors mapped Mini-Mental State Examination (MMSE) scores onto CDR categories to determine how well the MMSE performs as a surrogate of the CDR as a timesaving method of staging dementia.
Eight hundred sixty-three probands, including 524 patients with probable AD, 92 patients with questionable dementia, and 247 with memory complaints but no objective cognitive impairment, were included. Cutoff scores were identified on one-half of the sample using a receiver operating characteristic analysis. The cutoff values were then applied to the other half of the sample, and the agreement between MMSE score ranges and CDR stages was determined by calculating Cohen's kappa.
The MMSE discriminated well between CDR stages 0.5, 1, 2, and 3 but performed poorly in the separation between CDR stages zero and 0.5. The MMSE ranges were 30 for no, 26–29 for questionable, 21–25 for mild, 11–20 for moderate, and 0–10 for severe dementia. Substantial agreement between the two instruments was obtained for the categories mild (κ = 0.62, p <0.001, N = 115), moderate (κ = 0.69, p <0.001, N = 114), and severe dementia (κ = 0.76, p <0.001, N = 39), whereas the agreement was moderate for no (κ = 0.44, p <0.001, N = 120) and only fair for questionable dementia (κ = 0.28, p <0.001, N = 42).
The MMSE can be used as a surrogate measure for the CDR for the staging of dementia in AD.
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NUK, ODKLJ, OILJ, UL, UM, UPUK
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