Saturday, October 18, 2014

US Centers for Disease Control and Prevention (CDC) Ebola outbreak

The risk of an Ebola outbreak in the United States is very low. Currently, the US Centers for Disease Control and Prevention (CDC) recommends avoiding travel to the affected countries in West Africa. Travel to other countries in Africa has not been restricted. In general, the risk among travelers of getting Ebola virus disease is very low unless they are spending time inside a hospital having direct contact with infected patients.
The CDC has been working closely with US Customs and Border Protection, airlines, and cargo ships to help ensure that the chance of Ebola virus being brought into the United States is very low. According to the CDC, the current outbreak does not pose a major risk to the United States. For the latest updates on the current Ebola virus disease outbreak, visit the CDC website below.
http://jama.jamanetwork.com/article.aspx?articleid=1915432

Saturday, October 11, 2014

Obesity and Long-Term Survival After Radical Prostatectomy



ABSTRACT


The Journal of Urology
Obesity and Long-Term Survival After Radical Prostatectomy
J Urol 2014 Oct 01;192(4)1100-1104, HJ Chalfin, SB Lee, BC Jeong, SJ Freedland, H Alai, Z Feng, BJ Trock, AW Partin, E Humphreys, PC Walsh, M Han

Who Really Benefits From Nephron-Sparing Surgery?

In the last 15 years, new information has fundamentally changed our approach to the management of renal masses. Previously, all renal masses, regardless of size, in the presence of a normal contralateral kidney were managed by radical nephrectomy (RN). The fundamental belief then was that this was akin to kidney donation for transplantation. Now we know that young, healthy, and carefully selected kidney donors sit in contradistinction to most sporadic renal tumor patients, who are 25 years older, and many of whom suffer from common medical comorbidities that affect renal function, including hypertension, diabetes, obesity, and cigarette smoking–induced vascular disease.1
The recent understanding that chronic kidney disease (CKD)—renal function below an estimated glomerular filtration rate (eGFR) of 60 mL/min/1.73 m2 but above that of end-stage renal disease (<15 mL/min/1.73 m2)—is associated with cardiovascular morbidity and mortality2 has led to many studies evaluating whether nephrectomy for renal masses induces similar adverse renal functional and cardiovascular events. Although most studies, such as this one, are retrospective reviews of institutional or multi-institutional databases and are subject to all of the usual weaknesses of such studies, key observations have been consistently made. First, up to 30% of patients with renal tumors have preexisting CKD (stage 3 or worse), even if their serum creatinine is within normal limits. Second, partial nephrectomy (PN) effectively prevents or delays the onset of CKD and is associated with less cardiovascular morbidity and better overall survival.3-7
As demonstrated by Woldu and colleagues, within their pool of patients undergoing renal tumor surgery from 1992 to 2012, there is a range of presurgical renal function, yet the majority (80%) had eGFR >60 mL/min/1.73 m2 (CKD stage 1 and 2, considered "normal" by most nephrologists), and 20.1% had an eGFR <60 mL/min/1.73 m2 (CKD stage 3).The authors report that PN was associated with a significantly lower rate of annual eGFR decline in patients with a starting eGFR >60 mL/min/1.73 m2, but not in patients with a starting eGFR <60 mL/min/1.73 m2. The group at the greatest risk for developing "significant" renal impairment (defined as eGFR <45 mL/min/1.73 m2 or 30 mL/min/1.73 m2) was restricted to those with CKD stage 2 (eGFR between 60 and 89 mL/min/1.73 m2).
Certain factors in this dataset could influence these results. The study covers a 20-year period. Initially PN was used sparingly (18.8%); however, PN became the predominant procedure (53.6%) in the latter part of the study as the surgeons became more comfortable executing this complex operation. Many unaccounted for technical factors, including estimated blood loss, intraoperative hypotension, ischemia type (ie, warm, cold, or none), percentage of kidney preserved, and degree of surgical difficulty (nephrometry) could also influence these results. Notably, higher-stage tumors were treated with RN across the board. Assuming that these higher-stage tumors were larger, the possibility of contralateral renal compensation leading to a greater renal reserve and lesser impact of RN exists.
Despite the limitations implicit in this kind of surgical research, this study and others like it clearly indicate that kidney preservation for the management of renal masses is now front and center in contemporary urology. For healthy patients with excellent preexisting kidney function, the impact of PN on overall renal function may not be as great as in patients with moderate to severe preexisting renal impairment. All groups benefit from the equivalent local tumor control of PN to RN, with the added benefit of facing the low but real possibility of a contralateral tumor in their lifetime with much more than a solitary kidney. For elderly, comorbidly ill, and otherwise vulnerable patients with small renal masses, the other rational approach to kidney preservation is active surveillance, with only rare patients outliving their medical problems to experience significant renal cancer progression.8
References
  1. Russo P. The role of surgery in the management of early-stage renal cancer. Hematol Oncol Clin North Am2011;25(4):737-752.http://www.hemonc.theclinics.com/article/S0889-8588%2811%2900051-7/abstract
  2. Go AS, Chertow GM, Fan D, et al. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Eng J Med. 2004;351(13):1296-1305. http://www.nejm.org/doi/full/10.1056/NEJMoa041031
  3. Huang WC, Levey AS, Serio AM, et al. Chronic kidney disease after nephrectomy in patients with renal cortical tumors: a retrospective cohort study. Lancet Oncol. 2006;7(9):735-740.http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045%2806%2970803-8/abstract
  4. Thompson HR, Boorjian SA, Lohse CM, et al. Radical nephrectomy for pT1a renal masses may be associated with decreased overall survival compared to partial nephrectomy. J Urol. 2008;179(2):468-473.http://www.urosa.co.za/images/RadicalNephrectomyT1aRenalmassesOverall.pdf
  5. Huang WC, Elkin EB, Levey AS, et al. Partial nephrectomy versus radical nephrectomy in patients with small renal tumors–is there a difference in mortality and cardiovascular outcomes. J Urol. 2009;181(1):55-62.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2748741/
  6. Tan HJ, Norton EC, Ye Z, et al. Long-term survival following partial vs. radical nephrectomy among older patients with early-stage kidney cancer. JAMA. 2012;307(15):1629-1635. http://jama.jamanetwork.com/article.aspx?articleid=1148150
  7. Kim SP, Thompson H, Boorjian SA, et al. Comparative effectiveness for survival and renal function of partial and radical nephrectomy for localized renal tumors: A systematic review and meta-analysis. J Urol. 2012;188(1):51-57.http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0049517/
  8. Jewett MAS, Zuniga A. Renal tumor natural history: The rationale and role for active surveillance. Urol Clin North Am. 2008;35(4):627-634.http://www.urologic.theclinics.com/article/S0094-0143%2808%2900059-1/abstract


Urology
Who Really Benefits From Nephron-Sparing Surgery?
Urology 2014 Oct 01;84(4)860-868, SL Woldu, AC Weinberg, R Korets, R Ghandour, MR Danzig, A RoyChoudhury, SD Kalloo, MC Benson, GJ DeCastro, JM McKiernan

Kidney Preservation in the Management of Renal Masses

In the last 15 years, new information has fundamentally changed our approach to the management of renal masses. Previously, all renal masses, regardless of size, in the presence of a normal contralateral kidney were managed by radical nephrectomy (RN). The fundamental belief then was that this was akin to kidney donation for transplantation. Now we know that young, healthy, and carefully selected kidney donors sit in contradistinction to most sporadic renal tumor patients, who are 25 years older, and many of whom suffer from common medical comorbidities that affect renal function, including hypertension, diabetes, obesity, and cigarette smoking–induced vascular disease.1
The recent understanding that chronic kidney disease (CKD)—renal function below an estimated glomerular filtration rate (eGFR) of 60 mL/min/1.73 m2 but above that of end-stage renal disease (<15 mL/min/1.73 m2)—is associated with cardiovascular morbidity and mortality2 has led to many studies evaluating whether nephrectomy for renal masses induces similar adverse renal functional and cardiovascular events. Although most studies, such as this one, are retrospective reviews of institutional or multi-institutional databases and are subject to all of the usual weaknesses of such studies, key observations have been consistently made. First, up to 30% of patients with renal tumors have preexisting CKD (stage 3 or worse), even if their serum creatinine is within normal limits. Second, partial nephrectomy (PN) effectively prevents or delays the onset of CKD and is associated with less cardiovascular morbidity and better overall survival.3-7
As demonstrated by Woldu and colleagues in an article recently published in Urology,8within their pool of patients undergoing renal tumor surgery from 1992 to 2012, there is a range of presurgical renal function, yet the majority (80%) had eGFR >60 mL/min/1.73 m2 (CKD stage 1 and 2, considered "normal" by most nephrologists), and 20.1% had an eGFR <60 mL/min/1.73 m2 (CKD stage 3).The authors report that PN was associated with a significantly lower rate of annual eGFR decline in patients with a starting eGFR >60 mL/min/1.73 m2, but not in patients with a starting eGFR <60 mL/min/1.73 m2. The group at the greatest risk for developing "significant" renal impairment (defined as eGFR <45 mL/min/1.73 m2 or 30 mL/min/1.73 m2) was restricted to those with CKD stage 2 (eGFR between 60 and 89 mL/min/1.73 m2).
Certain factors in this dataset could influence these results. The study covers a 20-year period. Initially PN was used sparingly (18.8%); however, PN became the predominant procedure (53.6%) in the latter part of the study as the surgeons became more comfortable executing this complex operation. Many unaccounted for technical factors, including estimated blood loss, intraoperative hypotension, ischemia type (ie, warm, cold, or none), percentage of kidney preserved, and degree of surgical difficulty (nephrometry) could also influence these results. Notably, higher-stage tumors were treated with RN across the board. Assuming that these higher-stage tumors were larger, the possibility of contralateral renal compensation leading to a greater renal reserve and lesser impact of RN exists.
Despite the limitations implicit in this kind of surgical research, this study and others like it clearly indicate that kidney preservation in the management of renal masses is now front and center in contemporary urology. For healthy patients with excellent preexisting kidney function, the impact of PN on overall renal function may not be as great as in patients with moderate to severe preexisting renal impairment. All groups benefit from the equivalent local tumor control of PN to RN, with the added benefit of facing the low but real possibility of a contralateral tumor in their lifetime with much more than a solitary kidney. For elderly, comorbidly ill, and otherwise vulnerable patients with small renal masses, the other rational approach to kidney preservation is active surveillance, with only rare patients outliving their medical problems to experience significant renal cancer progression.9

Clinical Relevance of AR-V7 in Castrate-Resistant Prostate Cancer

Androgen receptor splice variants (AR-Vs) have been described for a number of years, but their clinical relevance has been unclear until now. In an article recently published inThe New England Journal of Medicine,1 Antonarakis and colleagues demonstrated that patients with metastatic castrate-resistant prostate cancer (mCRPC) expressing AR-V7 in circulating tumor cells (CTCs) have a 0% response rate to newer androgen axis-targeting agents such as enzalutamide and abiraterone. This is an important observation that indicates that AR-V7 is a predictive biomarker for an important class of drugs.
AR-V7 lacks the C-terminal androgen receptor ligand–binding domain and functions as a constitutively active ligand-independent transcription factor. Simply stated, that means that AR-V7 is fully functional in terms of DNA binding and transcriptional activity despite a complete lack of testosterone and dihydrotestosterone binding. Enzalutamide and abiraterone can only block the androgen-signaling axis when the androgens initiate the signaling cascade. They are ineffective therapies in the presence of ligand-independent androgen receptor variants.
The assays were performed on CTCs derived from blood of men with advanced cancers. If there were no circulating CTCs, there was no assay to perform. Patients examined by these assays all had advanced cancer; all had mCRPC, and most had undergone multiple therapies when the assays were performed. Men with earlier-stage prostate cancer are less likely to have CTCs.
The number of patients treated was small, but the clinical relevance is clear. Abiraterone and enzalutamide are important new agents in the clinician’s armamentarium. Men with CTCs positive for AR-V7 do not respond to these agents; further, they progress rapidly and die quickly. There is much more to learn, but the implications of AR-V7 detection in CTCs are important in the management of advanced prostate cancer patients.

Venous Thromboembolism After Major Urologic Oncology Surgery: High Rate for Radical Cystectomy

http://www.practiceupdate.com/journalscan/13058

Article of the Week: Assessing prostate cancer brachytherapy using patient-reported outcomes

http://www.bjuinternational.com/article-of-the-week/using-patient-reported-outcomes-to-assess-and-improve-prostate-cancer-brachytherapy/

Patient-reported outcomes in prostate cancer brachytherapy

http://www.youtube.com/watch?v=UAjCiQqIxHg&list=UUInXkfY9yLXsBtYnJDQblTg

BJUI - BJU International

http://www.bjuinternational.com/

The 'Big Data' challenge

https://www.youtube.com/watch?v=5FbX1S2bZcU


Published on Jun 6, 2014
Amplify your content using video and maximise your impact.
For more information, read the June 2014 editorial at http://www.bjuinternational.com/?p=14248


Guideline of guidelines: prostate cancer screening

You have free access to this content

BJU InternationalVolume 114, Issue 3, Article first published online: 25 AUG 2014






http://onlinelibrary.wiley.com/doi/10.1111/bju.12854/pdf

Bracco gets FDA nod for ultrasound contrast agent

October 10, 2014 -- A third contestant has joined the U.S. market for ultrasound contrast agents: Bracco Diagnostics today received U.S. Food and Drug Administration (FDA) approval for its Lumason ultrasound contrast agent.
Known previously as SonoVue, Lumason (sulfur hexafluoride lipid microbubbles) is indicated for patients whose echocardiography images are hard to see with ultrasound, according to the FDA. The agency noted that three clinical trials involving 191 patients with suspected cardiac disease were used to establish Lumason's safety and efficacy

http://www.auntminnie.com/index.aspx?sec=sup&sub=ult&pag=dis&itemid=108760&wf=6196

Superb Micro-Vascular Imaging (SMI)

Toshiba's innovative Superb Micro-Vascular Imaging (SMI) technology expands the range of visible blood flow and provides visualization of low velocity microvascular flow never before seen with ultrasound.
SMI's level of vascular visualization, combined with high frame rates, advances diagnostic confidence when evaluating lesions, cysts and tumors, improving patient outcomes and experience.

http://medical.toshiba.com/products/ul/general/aplio-500/clinical-applications/advanced-applications.php?utm_source=Aunt+Minnie+UL+Community&utm_medium=Banner&utm_term=0814&utm_content=Banner&utm_campaign=SMI

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