Optimizing the lithotripsy timing after drainage of the upper urinary tract in patients with urolithiasis and obstructive uropathy

Introduction. Timely unresolved upper urinary tract (UUT) obstruction in patients with infection can cause severe complications, such as sepsis, pyonephrosis and even death. There are no clear recommendations regarding the methods and timing of drainage. At the same time, this issue is still the subject of discussion in publications of recent years.Purpose of the study. To optimize the timing of lithotripsy after drainage of the UUT in patients with urolithiasis and obstructive uropathy (OU).Materials and methods. At the first stage, 90 patients with OU caused by the stone of the ureteropelvic junction underwent drainage of the UUT using a percutaneous nephrostomy. Subsequently, percutaneous nephrolithotripsy (PNLT) was performed at various times after drainage. The level of inflammatory markers (IL-8) and profibrotic factor (MCP-1) in the urine was determined. The calculated concentrations of urinary biomarkers were normalized by the level of urinary creatinine. Urine sampling for the analysis was carried out during and after the PCN placement (nephrostomy urine) 7 days later, and then once weekly before surgery. The coefficient K was calculated using a patented formula to evaluate the process of kidney remodeling. Urine sampling was performed for culture to determine the bacterial spectrum and antibiotic sensitivity.Results. The values of K ≤ 1.85 were observed in 11 patients of the group with OU (12.2%), K > 1.85 in 79 (87.8%) by day 21. The values of K ≤ 1.85 were achieved in 70 patients (88.6%) by day 28 and 4 patients (80.0%) by day 35. PNLT was performed on 21 days in patients with K ≤ 1.85 (11 patients), no complications were noted in the postoperative period., PNLT was performed in patients with K ≤ 1.85 (70 patients) by day 28, exacerbation of pyelonephritis and the development of chronic kidney disease were not noted. Six patients with values of K ˃ 1.85 underwent PNLT by day 28. In the postoperative period, all patients had an exacerbation of calculous pyelonephritis, 50% had a decrease in glomerular filtration rate within 3 months after surgery. The bacteria in urine were detected in 55 (61.0%) patients. Escherichia coli (63.0%), Proteus mirabilis (18.0%), Enterococcus faecalis (14.5%), Streptococcus haemolyticus (2.5%) were identified most often.Conclusion. The use of the developed remodeling index allows optimizing the surgery timing and minimizing the development of complications during the postoperative period. The presence of bacteria is associated with a long process of renal parenchymal remodeling.

Effect of COVID-19 on Ulnar Collateral Ligament Reconstruction in Major League Baseball Pitchers

Background: The coronavirus disease of 2019 (COVID-19) pandemic led to the suspension and shortening of the 2020 Major League Baseball (MLB) season from 162 to 60 regular season games. The effect of this disruption on injury rates, specifically injury to the ulnar collateral ligament (UCL), has not been quantified. Purpose/Hypothesis: The purpose of this study was to compare the rate of UCL reconstruction (UCLR), surgery timing, and pitching workload in MLB pitchers from before and after the COVID-19 pandemic lockdown. We hypothesized that UCLR rates relative to games played would be increased and pitching workload would be decreased in 2020 compared with previous seasons. Study Design: Cohort study; Level of evidence, 3. Methods: An extensive online search using publicly available data was conducted to identify all MLB pitchers who underwent UCLR between January 1, 2017, and December 31, 2020. Only pitchers who were competing at the MLB level when undergoing reconstruction were included. Player characteristics and surgery date, as well as career and season of surgery pitching workload, were collected for all included pitchers. All data were compared as a pooled sample (2017-2019 vs 2020). Results: A similar number of pitchers underwent UCLR during or after the 2020 regular season (n = 18) compared with the 2017-2019 seasons (n = 16, 20, and 16, respectively). However, after accounting for the decrease in games played during the 2020 regular season, an MLB pitcher was 2.9 times more likely to undergo surgery per game after the COVID-19 lockdown compared with the previous years ( P < .001). MLB pitchers who underwent surgery in 2020 threw fewer preseason innings than did pitchers who underwent surgery between 2017 and 2019 (5.98 vs 9.39; P = .001). Conclusion: MLB pitchers were almost 3 times more likely to undergo UCLR per game after the COVID-19 lockdown. A decreased preseason pitching workload because of the COVID-19 lockdown may have had an effect on per game UCLR rates.

Implementation of Multigene Germline and Parallel Somatic Genetic Testing in Epithelial Ovarian Cancer: SIGNPOST Study

We present findings of a cancer multidisciplinary-team (MDT) coordinated mainstreaming pathway of unselected 5-panel germline BRCA1/BRCA2/RAD51C/RAD51D/BRIP1 and parallel somatic BRCA1/BRCA2 testing in all women with epithelial-OC and highlight the discordance between germline and somatic testing strategies across two cancer centres. Patients were counselled and consented by a cancer MDT member. The uptake of parallel multi-gene germline and somatic testing was 97.7%. Counselling by clinical-nurse-specialist more frequently needed >1 consultation (53.6% (30/56)) compared to a medical (15.0% (21/137)) or surgical oncologist (15.3% (17/110)) (p < 0.001). The median age was 54 (IQR = 51–62) years in germline pathogenic-variant (PV) versus 61 (IQR = 51–71) in BRCA wild-type (p = 0.001). There was no significant difference in distribution of PVs by ethnicity, stage, surgery timing or resection status. A total of 15.5% germline and 7.8% somatic BRCA1/BRCA2 PVs were identified. A total of 2.3% patients had RAD51C/RAD51D/BRIP1 PVs. A total of 11% germline PVs were large-genomic-rearrangements and missed by somatic testing. A total of 20% germline PVs are missed by somatic first BRCA-testing approach and 55.6% germline PVs missed by family history ascertainment. The somatic testing failure rate is higher (23%) for patients undergoing diagnostic biopsies. Our findings favour a prospective parallel somatic and germline panel testing approach as a clinically efficient strategy to maximise variant identification. UK Genomics test-directory criteria should be expanded to include a panel of OC genes.

A Case-Control Study of Hip Fracture Surgery Timing and Mortality at an Academic Hospital: Day Surgery May Be Safer than Night Surgery

Time from hospital admission to operative intervention has been consistently demonstrated to have a significant impact on mortality. Nonetheless, the relationship between operative start time (day versus night) and associated mortality has not been thoroughly investigated. Methods: All patients who underwent hip fracture surgery at a single academic institution were retrospectively analyzed. Operative start times were dichotomized: (1) day operation—7 a.m. to 4 p.m.; (2) night operation—4 p.m. to 7 a.m. Outcomes between the two groups were evaluated. Results: Overall, 170 patients were included in this study. The average admission to operating room (OR) time was 26.0 ± 18.0 h, and 71.2% of cases were performed as a day operation. The overall 90-day mortality rate was 7.1% and was significantly higher for night operations (18.4% vs. 2.5%; p = 0.001). Following multivariable logistic regression analysis, only night operations were independently associated with 90-day mortality (aOR 8.91, 95% confidence interval 2.19–33.22; p = 0.002). Moreover, these patients were significantly more likely to return to the hospital within 50 days (34.7% vs. 19.0%; p = 0.029) and experience mortality prior to discharge (8.2% vs. 0.8%; p = 0.025). Notably, admission to OR time was not associated with in-hospital mortality (29.22 vs. 25.90 h; p = 0.685). Hip fracture surgery during daytime operative hours may minimize mortalities.

Cervical Steroid Injections Are Not Effective for Prevention of Surgical Treatment of Degenerative Cervical Myelopathy

Study Design: Retrospective cohort study. Objective: The objective of this study is to determine how often patients with degenerative cervical myelopathy (DCM) and initially treated with cervical steroid injections (CSI) and to determine whether these injections provide any benefit in delaying ultimate surgical treatment. Methods: All patients with a new diagnosis of DCM, without previous cervical spine surgery or steroid injections, were identified in PearlDiver, a large insurance database. Steroid injection and surgery timing was identified using Current Procedural Terminology (CPT) codes. Multivariate logistic regression identified associations with surgical treatment. Results: A total of 686 patients with DCM were identified. Pre-surgical cervical spine steroid injections were utilized in 244 patients (35.6%). All patients underwent eventual surgical treatment. Median time from initial DCM diagnosis to surgery was 75.5 days (mean 351.6 days; standard deviation 544.9 days). Cervical steroid injections were associated with higher odds of surgery within 1 year (compared to patients without injections, OR = 1.44, P < .001) and at each examined time point through 5 years (OR = 2.01, P < .001). In multivariate analysis comparing injection types, none of the 3 injection types were associated with decreased odds of surgery within 1 month of diagnosis. Conclusions: While cervical steroid injections continue to be commonly performed in patients with DCM, there is an overall increased odds of surgery after any type of cervical injection. Therefore injections should not be used to prevent surgical management of DCM.

Comparison of the Unilateral and the Bilateral Pedicle Screw Fixation without Using an Interbody Cage: Randomized Clinical Trial

BACKGROUND: Lumbar spine instability is one of the main causes of low back pain and has become more prevalent in recent years. Bilateral pedicle screw fixation is used to perform posterior lumbar stabilization, which is complemented by the installation of an interbody cage. AIM: The aim of the study was evaluating of the results of unilateral and bilateral pedicle screw fixation without using of an interbody cage. METHODS: A prospective randomized study of 96 patients was carried out. Forty-seven patients were assigned to the group of the unilateral pedicle screw fixation versus 49 patients were moved to the group of the bilateral pedicle screw fixation of the lumbar spine. Of the 96 patients, 80 patients eventually were included in the study. However, seven patients in the first group and nine patients were lost to follow-up. Surgery timing, blood loss volume, clinical outcomes (scores on the Oswestry disability index [ODI], EQ-5D and visual analogue scale [VAS]) were evaluated in 6–12 months after surgical treatment. All the patients included in this study underwent functional and control computed tomography in 12 months after surgery. RESULTS: Both groups showed a significant improvement in VAS, EQ-5D, and ODI in 1 year after surgical treatment. The two groups significantly differed in the surgery timing (unilateral – 90.2 min; and bilateral – 129.4 min) and blood loss volume (unilateral – 152.7 ml; and bilateral – 230.1 ml), p < 0.05. CONCLUSIONS: Unilateral and bilateral pedicle screw fixation showed similar clinical results, while results in both types of fixation differed in slight manner. However, the duration of surgical treatment and intraoperative blood loss volume proved to be lower for the unilateral fixation group, which indicates that the use of the unilateral fixation can be the choice of performing posterior stabilization at a single-level instability of the spine without using an interbody cage.

Preoperative stroke before cardiac surgery does not increase risk of postoperative stroke

The optimal time when surgery can be safely performed after stroke is unknown. The purpose of this study was to investigate how cardiac surgery timing after stroke impacts postoperative outcomes between 2011–2017 were reviewed. Variables were extracted from the institutional Society of Thoracic Surgeons database, statewide patient registry, and medical records. Subjects were classified based upon presence of endocarditis and further grouped by timing of preoperative stroke relative to cardiac surgery: Recent (stroke within two weeks before surgery), Intermediate (between two and six weeks before), and Remote (greater than six weeks before). Postoperative outcomes were compared amongst groups. 157 patients were included: 54 in endocarditis and 103 in non-endocarditis, with 47 in Recent, 26 in Intermediate, and 84 in Remote. 30-day mortality and postoperative stroke rate were similar across the three subgroups for both endocarditis and non-endocarditis. Of patients with postoperative stroke, mortality was 30% (95% CI 4.6–66). Timing of cardiac surgery after stroke occurrence does not seem to affect postoperative stroke or mortality. If postoperative stroke does occur, subsequent stroke-related mortality is high.