Key articles from international medical journals
RM (inter-patient variability) was closely related to adverse allograft outcomes, and hence, more attention must be given to pre-transplant PRA-positive patients. Source: Combined impact of the inter and intra-patient variability of tacrolimus blood level on allograft outcomes in kidney transplantation. Yohan Park, Hanbi Lee, Sang Hun Eum, Eun Jeong Ko, Ji Won Min, Se-Hee Yoon, Won-Min Hwang, Sung-Ro Yun, Chul Woo Yang, Jieun Shin, Byung Ha Chung. Front Immunol 2022 Nov 16;13:1037566. doi: 10.3389/fimmu.2022.1037566. eCollection 2022. No opioid strategy is feasible after major urologic surgery Opioid analgesics have been correlated with an increased rate of death in the US. Such prescriptions after surgery remain a major contributor to the opioid misuse crisis, potentially leading to inadequate chronic use or overdose-related deaths. In this prospective study, the authors have designed an intervention protocol aiming at avoiding any opioid prescriptions at discharge after major urologic surgery (nephrectomy, cystectomy, radical prostatectomy). The primary outcome was the number of patients receiving any opioid prescription and the opioid dose prescribed per patient. Secondary outcome measures included the need for additional opioid prescriptions, patient-reported outcomes, unplanned health care utilisation (telephone calls, clinic or emergency department visit, re-admissions), and complication rates. The control (preintervention) group included 202 patients, from May 2017 to December 2018, who were given opioid prescriptions (dose, duration) at the discretion of discharging health care professional. In the initial feasibility, patients were given a 1-page informational handout that explained the rationale for avoiding opioids and using nonopioid medications for post-operative pain control. The opioid prescriptions were at the discretion of the prescribers who were given instructions to try to limit opioid prescriptions to four days or fewer. For the intervention (ie, NOPIOIDS group with 384 patients), a standardised workflow included preferential use of nonopioid analgesics during hospital stay using electronic order sets, with instructions to prescribers (via email). Instructions were repeated when staff rotations changed. In addition, an instruction sheet with visual guidance for use at home was provided at discharge. "An improved peri-operative protocol may virtually eliminate opioid prescriptions after major abdominopelvic surgery." Of 686 patients, 202 (29.4%) were in the control group, 100 (14.6%) were in the lead-in group, and 384 (56%) were in the NOPIOIDS group. Thirty-nine patients (5.7%) were using opioids prior to surgery. No difference in baseline patient characteristics was noted including the use of robotic approach among the groups. Among 647 opioid-naive patients, the proportion of patients receiving any opioid prescription at discharge decreased significantly from 80.9% in the control group, to 57.9% in the lead-in group, and 2.2% in the NOPIOIDS group, mainly for kidney surgery (p<.001). None of the 229 patients undergoing radical cystectomy or prostatectomy required any opioid prescriptions at discharge in the NOPIOIDS group. The number of calls related to
calculated sample size consisted of 45 patients per arm with a statistical power set to 80% to detect a difference of 6 minutes or more of operative time. Whether or not this primary endpoint reflects a meaningful clinical issue is out the aims of the present report. Secondary endpoints included laser firing time, total laser energy, ablation efficiency (defined as total laser energy/stone volume), stone-free rates (defined as either no visible at all or <3mm stone fragments on KUB X-ray at four to eight weeks after JJ stent removal), complication rate and quality of life scores at WISQOL (Wisconsin Stone Quality of Life) questionnaire. Inclusion criteria involved ureteric and renal stones of maximum 20 mm per stone without restriction of overall number of stones. In both patient groups, a 200 µm core laser-fibre was used with an initial default setting of 0.8 J and 8 Hz for fragmentation and 0.3 J and 80 Hz for dusting. However, surgeons were free to customise the settings during the surgeries according the circumstances. Overall, no differences for baseline characteristics regarding patients (age, gender, ASA [American Society of Anesthesiology] score, etc) and stones (number, size, sites, overall volume burden, etc) details were recorded. The null hypothesis was accepted, as no difference in terms of ureteroscope length of time was detected between groups (21.4 vs 19.9 minutes for Moses and TFL groups, respectively). Furthermore, no differences were reported for most of the secondary endpoints, including stone-free rate, complication rate, and QoL scores. Nevertheless, lower total energy and higher ablation efficiency was observed in favour of the Moses group. According to the authors impressions, less ablation efficiency for the TFL laser was observed anecdotally in cases of harder/denser calcium stones; however, the increased need of energy for the TFL not necessarily translates to a higher risk for harms to patients. Furthermore, the TFL potentiality is still to be fully explored, so that at the end of the study there is no “winner” but rather the confirmation that both laser are excellent options for stones lasertripsy. Source: Pulse-modulated Holmium:YAG laser vs the thulium fiber laser for renal and ureteral stones: A single- centre prospective randomised clinical trial. Christopher R Haas, Margaret A Knoedler, Shuang Li, Daniel R Gralnek, Sara L Best, Kristina L Penniston, Stephen Y Nakada J Urol . 2023 Feb;209(2):374-383. doi: 10.1097/JU.0000000000003050. Epub 2023 Jan 9. QPM assay: A promising rapid, first-stage tool for infection and AMR diagnosis Effective antibiotics should be administered within one hour after diagnosis of severe urinary tract infections and sepsis. However, current state-of-the-art infection and antimicrobial resistance (AMR) diagnostics are based on culture-based methods with a detection time of 48–96hrs. Therefore, it is essential to develop novel methods that can provide real-time diagnoses. In this paper investigators demonstrate that the complimentary use of label-free optical assay with whole-genome sequencing (WGS) can enable rapid diagnosis of infection and AMR.
inadequate pain control were similar between the controls. No patients in any group required an unplanned visit to the clinic or emergency department due to pain. The overall 30-day complication rates were similar between groups, ranging from 16% to 21 (P = .69). This study shows that an improved peri- operative protocol may virtually eliminate opioid prescriptions after major abdominopelvic surgery. Preoperative patient engagement to set appropriate expectations and post-discharge analgesic instructional handout made this intervention readily acceptable by the prescribers and the patients. Some limitations may be highlighted such as the lack of patient-reported outcomes data for the control group and only from a small number in the lead-in group. However, this prospective, interventional study clearly demonstrates that a perioperative program involving both patients and caregivers, focusing on education and team engagement may drastically change the prescription of opioids after major abdominopelvic cancer surgery without adversely affecting pain control, complications, or recovery. Source: Implementation and assessment of no opioid prescription strategy at discharge after major urologic cancer surgery. Mian BM, Singh Z, Carnes K, Lorenz L, Feustel P, Kaufman RP Jr, Avulova S, Bernstein A, Cangero T, Fisher HAG. JAMA Surg. 2023 Feb 8:e227652. doi: 10.1001/jamasurg.2022.7652. Epub ahead of print. PMID: 36753170; PMCID: PMC9909575. Which laser is better for the endoscopic treatment of stone disease? Technology in urological endoscopy continually evolves. Advances involve the use of new lasers for the fragmentation, dusting, and vaporisation of urinary stones. Thulium Fibre Laser (TFL) has been recently introduced in the market as an effective alternative to the Holmium-YAG lasertripsy due to its high-absorption coefficient (four times higher than holmium), substantial versatility in terms of range of settings, and physical characteristics allowing for thinner fibres as small as 50 µm. TFL has been proposed as the ideal solution not only for the lasertripsy of urinary stones but also for other applications on soft tissue (e.g. prostate enucleation, ablation of upper tract urothelial tumours, etc). A number of in-vitro and in-vivo publications have shown a superiority of TFL over standard Ho:YAG laser for lasertripsy of urinary stones, even though several biases have been identified. None of them included the latest generation of Ho:YAG embedded with the so-called Moses technology, consisting in high-powered pulse-modulated Ho:YAG laser. Recently, a randomised trial of a single institution has been conducted to test the efficacy of the latest generation of the two lasers (i.e. the TFL and the advanced pulse-modulated Ho:YAG [Moses]) at the same range of settings and conditions. "A lower ablation efficiency for the TFL laser was observed anecdotally in cases of harder/denser calcium stone." The primary endpoint was the ureteroscope time, calculated from the insertion of the scope (either semi-rigid or flexible ones) in the ureteric orifice. Accordingly, the
Dr. Guillaume Ploussard Section editor Toulouse (FR)
g.ploussard@ gmail.com
Dr. Peter Østergren Section editor Copenhagen (DK)
peter.busch. oestergren@ regionh.dk
Prof. Francesco Sanguedolce Section editor Barcelona (ES)
fsangue@ hotmail.com
High variability of tacrolimus trough levels
impacts allograft outcomes Tacrolimus (TAC) has been widely used as an immunosuppressant after kidney transplantation (KT). However, the combined effects of intra-patient variability (IPV) and inter-patient variability of TAC-trough level (C0) in blood remains controversial. This study aimed to determine the combined impact of TAC-IPV and TAC inter-patient variability on allograft outcomes of KT. “Considerable tacrolimus serum level variations contribute to adverse allograft outcomes.” In total, 1,080 immunologically low-risk patients who were not sensitised to donor human leukocyte antigen (HLA) were enrolled. TAC-IPV was calculated using the time-weighted co-efficient variation (TWCV) of TAC-C0, and values > 30% were classified as high IPV. Concentration-to-dose ratio (CDR) was used for calculating TAC inter- patient variability, and CDR < 1.05 ng•mg/mL was classified as rapid metabolisers (RM). TWCV was calculated based on TAC-C0 up to 1 year after KT, and CDR was calculated based on TAC-C0 up to 3 months after KT. Patients were classified into four groups according to TWCV and CDR: low IPV/ non-rapid metaboliser (NRM), high IPV/NRM, low IPV/RM, and high IPV/RM. Subgroup analysis was performed for pre-transplant panel reactive antibody (PRA)-positive and negative patients (presence or absence of non-donor-specific HLA-antibodies). Allograft outcomes, including death-censored graft loss and biopsy-proven allograft rejection were compared. The incidences of death-censored graft loss, allograft rejection and overall graft loss were the highest in the high-IPV/RM group. In addition, a high IPV/RM was identified as an independent risk factor for death-censored graft loss. The hazard ratio of high IPV/RM for death-censored graft loss and the incidence of active antibody-mediated rejection were considerably increased in the PRA-positive subgroup.
The presented assay is based on microscopy methods exploiting label-free, highly sensitive
The authors conclude from their results that high intra-patient variability combined with
quantitative phase microscopy (QPM) followed by deep convolutional neural
Key articles
EAU EU-ACME Office
European Urology Today
10
April/May 2023
Powered by FlippingBook