Robotic-assisted kidney transplantation (RKT) with the Da Vinci (Intuitive, USA) platform has been recently developed to improve outcomes by decreasing surgical site complications and morbidity, ...especially in obese patients. This potential paradigm shift in the surgical technique of kidney transplantation is performed in only a few centers. For wider adoption of this high stake complex operation, we aimed to develop a procedure-specific simulation platform in a porcine model for the training of robotic intracorporeal vascular anastomosis and evaluating vascular anastomoses patency. This paper describes the requirements and steps developed for the above training purpose. Over a series of four animal ethics’ approved experiments, the technique of robotic-assisted laparoscopic autotransplantation of the kidney was developed in Amsterdam live pigs (60–70 kg). The surgery was based around the vascular anastomosis technique described by Menon et al. This non-survival porcine training model is targeted at transplant surgeons with robotic surgery experience. Under general anesthesia, each pig was placed in lateral decubitus position with the placement of one robotic camera port, two robotic 8 mm ports and one assistant port. Robotic docking over the pig posteriorly was performed. The training platform involved the following procedural steps. First, ipsilateral iliac vessel dissection was performed. Second, robotic-assisted laparoscopic donor nephrectomy was performed with in situ perfusion of the kidney with cold Hartmann’s solution prior to complete division of the hilar vessels, ureter and kidney mobilization. Thirdly, the kidney was either kept in situ for orthotopic autotransplantation or mobilized to the pelvis and orientated for the vascular anastomosis, which was performed end to end or end to side after vessel loop clamping of the iliac vessels, respectively, using 6/0 Gore-Tex sutures. Following autotransplantation and release of vessel loops, perfusion of the graft was assessed using intraoperative indocyanine green imaging and monitoring urine output after unclamping. This training platform demonstrates adequate face and content validity. With practice, arterial anastomotic time could be improved, showing its construct validity. This porcine training model can be useful in providing training for robotic intracorporeal vascular anastomosis and may facilitate confident translation into a transplant human recipient.
Chest radiographs (CXRs) are widely used for the screening and management of COVID-19. This article describes the radiographic features of COVID-19 based on an initial national cohort of patients.
...This is a retrospective review of swab-positive patients with COVID-19 who were admitted to four different hospitals in Singapore between 22 January and 9 March 2020. Initial and follow-up CXRs were reviewed by three experienced radiologists to identify the predominant pattern and distribution of lung parenchymal abnormalities.
In total, 347 CXRs of 96 patients were reviewed. Initial CXRs were abnormal in 41 (42.7%) out of 96 patients. The mean time from onset of symptoms to CXR abnormality was 5.3 ± 4.7 days. The predominant pattern of lung abnormality was ground-glass opacity on initial CXRs (51.2%) and consolidation on follow-up CXRs (51.0%). Multifocal bilateral abnormalities in mixed central and peripheral distribution were observed in 63.4% and 59.2% of abnormal initial and follow-up CXRs, respectively. The lower zones were involved in 90.2% of initial CXRs and 93.9% of follow-up CXRs.
In a cohort of swab-positive patients, including those identified from contact tracing, we found a lower incidence of CXR abnormalities than was previously reported. The most common pattern was ground-glass opacity or consolidation, but mixed central and peripheral involvement was more common than peripheral involvement alone.
Surgically induced chronic kidney disease (CKD) has been found to have less impact on survival as well as function when compared to medical causes for CKD. The aim of this study is to evaluate ...whether preoperative remaining kidney volume correlates with renal function after nephrectomy, which represents an individual's renal reserve before surgically induced CKD.
A retrospective review of 75 consecutive patients (29.3% females) who underwent radical nephrectomy (RN) (2000-2010) was performed. Normal side kidney parenchyma, excluding renal vessels and central sinus fat, was manually outlined in each transverse slice of CT image and multiplied by slice thickness to calculate volume. Estimated glomerular filtration rate (eGFR) was determined using the Modification of Diet in Renal Disease equation. CKD is defined as eGFR < 60 mL/min/1.73 m(2).
Mean preoperative normal kidney parenchymal volume (mean age 55 SD 13 years) is 150.7 (SD 36.4) mL. Over median follow-up of 36 months postsurgery, progression to CKD occurred in 42.6% (n = 32) of patients. On multivariable analysis, preoperative eGFR and preoperative renal volume <144 mL are independent predictors for postoperative CKD. On Kaplan-Meier analysis, median time to reach CKD postnephrectomy is 12.7 (range 0.03-43.66) months for renal volume <144 mL but not achieved if renal volume is >144 mL.
Normal kidney parenchymal volume and preoperative eGFR are independent predictive factors for postoperative CKD after RN and may represent renal reserve for both surgically and medically induced CKD, respectively. Preoperative remaining kidney volume may be an adjunct representation of renal reserve postsurgery and predict later renal function decline due to perioperative loss of nephrons.
In end-stage heart failure (HF) that is not eligible for mechanical assist device or heart transplant, palliative care serves to maximise symptom control and quality of life. We sought to evaluate ...the impact of home-based advance care programme (ACP) on healthcare utilisation in end-stage HF patients.
Prospectively collected registry data on all end-stage HF recruited into ACP between July 2008 and July 2010 were analysed. Chart reviews were conducted on HF database and hospital electronic records. Phone interview and home visit details by ACP team were extracted to complete data entry. HF and all-cause hospitalisations 1 year before, and any time after ACP inception were defined as events. For the latter analysis, follow-up duration adjustment to event episodes was performed to account for death less than a year.
Forty-four patients (mean age 79 years, 39% men) were followed up for 15±8 months. Fifty-seven percent had diabetes, 80% ischaemic heart disease, and 60% chronic kidney disease. All reported functional class III/IV at enrolment. Mean serum sodium was 136±6 mmol/L, and creatinine 186±126 mmol/L. Thirty (68%) died within the programme. Mean time to death was 5.5 months. Mean all-cause and HF hospitalisations were 3.6 and 2.0 per patient before enrolment, but improved to 1.0 and 0.6 respectively after ACP. Thirty-six (71%) patients had fewer HF hospitalisations. When only those who survived more than a year were considered (n = 14), 10 (71%) and 9 (64%) experienced reduced HF (mean: 1.4 episodes per patient) and all-cause hospitalisations (mean: 2.2 episodes per patient) respectively.
Home-based advance care programme is potentially effective in reducing healthcare utilisation of end-stage HF patients, primarily by reducing HF rehospitalisations, and in probably saving costs as well.
Abstract
Background
Numerous reports have emerged about the neurotoxic effects of ertapenem. A recent study supports carbapenem use for the treatment of extended spectrum β-lactamase (ESBL)- ...producing Gram-negative bacteremia. This will likely bolster the use of ertapenem as it is a convenient choice to complete antibiotic treatment in an outpatient setting. This study aims to review the incidence of neurotoxicity with ertapenem and the risk factors associated with it.
Methods
A retrospective nested cohort study was conducted in Changi General Hospital in Singapore from January 2015 to Decemeber 2016. All patients who received at least 24 hours of ertapenem were identified. Those who exhibited ertapenem-associated neurotoxic effects were selected as cases while those who did not were included in the pool of controls and randomly selected at a 1:3 ratio.
Results
A total of 544 patients were treated with ertapenem in our hospital during this 2-year period. Twenty-five patients (incidence 4.6%) developed neurotoxic manifestations and 75 patients were included as controls. Acute confusion was the commonest reaction (n = 19, 76%) followed by hallucinations (n = 8, 32%) and seizures (n = 5, 20%). Baseline characteristics were similar in both groups; the median age of the cases was 79 years (IQR 71–83 years) and 14 (56%) were males. The median duration of ertapenem use before neurotoxicity occurred was 7 days (IQR 5–11days). The median Naranjo ADR probability score for cases was 7 (range 5 to 7) which suggests a probable relationship. Univariate analysis showed that renal impairment (with CrCl< 60 mL/minute) (OR 3.31, 95% CI 1.03–10.64), a history of a vulnerable brain (including stroke and epilepsy etc)(OR 2.61 95% CI 1.03–6.61) increased the risk of neurotoxicity. Neurotoxicity was also significantly associated with longer hospitalization (median 21 days, p = 0.03).
Conclusion
Our study suggests that renal impairment or a history of vulnerable brain may increase the risk for ertapenem-associated neurotoxicity. Hence, caution should be exercised when ertapenem is used to treat these individuals. Future prospective studies to further evaluate risk and to derive a prediction scoring system may help to reduce the incidence of neurotoxic adverse events with ertapenem use.
Disclosures
All authors: No reported disclosures.
RATIONALEBoth tuberculosis and melioidosis are commonly encountered infectious diseases in South East Asia. However, these conditions occur commonly in isolation, cases of coinfection of ...Mycobacterium tuberculosis and Burkholderia pseudomallei are rare. These cases report of the isolation of both organisms concomitantly in a single disease site. We report the first case of concomitant infection at distinct noncontiguous sites. PATIENT CONCERNSA 64-year-old man, with chronic alcohol consumption, presented with a month long history of left-sided abdominal pain, as well as significant weight loss and fever prior to the onset of abdominal pain. DIAGNOSISDisseminated tuberculosis with pulmonary and gastrointestinal involvement and a splenic abscess due to melioidosis. INTERVENTIONSThe patient was treated concomitantly for pulmonary and gastrointestinal tuberculosis, as well as a splenic abscess due to melioidosis. OUTCOMESThe patient is reported to be well, with resolution of symptoms, as well as radiological resolution of the splenic abscess. LESSONSBoth melioidosis and tuberculosis can present with a similar clinical picture, and coinfections are rare. Hence, increased awareness among clinicians and microbiologists can help in diagnosing both diseases even when it is not clinically apparent.
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