High serum levels of the acute phase protein C-reactive protein (CRP) are associated with an adverse prognosis in renal cancer. The acute phase reaction is cytokine-driven and includes a wide range of inflammatory mediators. This overall profile of the response depends on the inducing event and can also differ between patients. We investigated an extended acute phase cytokine profile for 97 renal cancer patients. Initial studies showed that the serum CRP levels had an expected prognostic association together with tumor size, stage, nuclear grading, and Leibovich score. Interleukin (IL)6 family cytokines, IL1 subfamily mediators, and tumor necrosis factor (TNF)α can all be drivers of the acute phase response. Initial studies suggested that serum IL33Rα (the soluble IL33 receptor α chain) levels were also associated with prognosis, although the impact of IL33Rα is dependent on the overall cytokine profile, including seven IL6 family members (IL6, IL6Rα, gp130, IL27, IL31, CNTF, and OSM), two IL1 subfamily members (IL1RA and IL33Rα), and TNFα. We identified a patient subset characterized by particularly high levels of IL6, IL33Rα, and TNFα alongside an adverse prognosis. Thus, the acute phase cytokine reaction differs between renal cancer patients, and differences in the acute phase cytokine profile are associated with prognosis.
Tetanus has become an uncommon disease in developed countries. Tetanus is caused by exotoxins from the bacteria Clostridium tetani. This microbe, which is obligate anaerobe, is present in soil, and animal and human faeces. The condition usually appears after contamination of wounds. However, reports have been published of tetanus occurring after both acute and selective gastrointestinal surgery. We present a case of severe postoperative tetanus in a 57 year-old woman who underwent bowel resection after strangulation of the ileum. The patient was treated on an intensive care unit and was artificially ventilated for 64 days. Seven months later she had fully recovered. Clinical presentation, diagnosis, treatment, and complications are discussed in the report. The diagnosis of tetanus is made by clinical observation. Nowadays, lack of suspicion of this condition may cause delay in administering proper treatment. Women and older men are often inadequately immunized. Doctors should therefore examine the immunization status of these groups of patients regularly.
732 Background: Historically, 30 % of patients with localized kidney cancer develop distant metastases during follow-up. There is an urgent need to improve the individual risk assessment for clear cell renal cell carcinoma (ccRCC) patients. We therefore aim to characterize the gene expression profile of low-risk patients both with and without progressive disease to define predictive outcome candidate markers. Methods: Formalin-fixed tissue blocks from ccRCC patients (n=24, eight progressors and 16 non-progressors) with a low Leibovich score were collected. Patients had a mean age of 65 years (5 females and 19 males). The non-progressors were matched 2:1 to the progressors for gender, age, pT tumor stage, size, Fuhrman grade, and eGFR. Total RNA was extracted(miRNeasy FFPE Kit, Qiagen) and sequenced (TruSeq RNA Access Library Kit, Illumina). RNA-seq results were analyzed by ingenuity pathway analysis, K Nearest Neighbors algorithm, and survival analysis. Results: 1167 differentially expressed genes (abs.FC≥2, p≤0.05) were detected. Progressors overexpressed genes related to cancer, B-cell infiltration and other immune-system related pathways. Principal component analyses and hierarchical clustering depicted a systematic transcriptomic difference between progressors and non-progressors. Combinations of up to 10 genes were evaluated as classifiers. The AGAP2-AS1 mRNA classified 23 out of 24 samples correctly, without the need for a larger gene panel. The trend of expression was confirmed with RT-PCR.The correlation between sample status as either progressor or non-progressor and AGAP2-AS1 level was R 2 =0.69, p <0.01. Patients were split into groups based on AGAP2-AS1 expression (cut-off log 2 cpm>1), where higher expression correlated with shorter survival; Wilcoxon (p<0.0001),Log-rank test (p<0.0001), Hazard ratio; 9.24E-11. Immunohistochemistry of AGAP2, USP10 and KI-67 confirmed results from the mRNA level. Conclusions: RNA-seq results show a transcriptomic difference between low-risk ccRCC progressors and low-risk non-progressors. AGAP2-AS1 may serve as a potential classifier for the identification of low-risk progressors.
Social media (SoMe) has established itself in the arena of healthcare, both as an educational tool and as a portal to connect healthcare professionals [1]. While SoMe has a number of benefits, there are concerns regarding online professionalism and patient confidentiality [2]. Accompanying images and videos have become popular content for surgeons to share when posting online [3]. However, content of this kind is sensitive and questions concerning patient consent can therefore arise. Indeed, while the cases remain at least isolated for now, lawsuit actions against healthcare professionals have been successfully filed for breaching General Data Protection Regulation, and medical licensing bodies have carried out suspensions and terminations based on inappropriate SoMe behaviour [4]. On certain platforms, such as X (formerly referred to as Twitter), all content is in the public domain, profiles are not private, and all posts are freely accessible and can never be truly deleted. We wished to explore this topic further and sampled 250 posts on X that were related to urological surgery. One by one, the nature and content of these posts was scrutinised. This is not an exhaustive and truly rigorous method; however, no blueprint for this kind of task exists and, moreover, a random snapshot was the goal. This was not a search for individuals to blame, nor did we register the details of who made the posts. Rather, this experiment represented an opportunity to take a step back and explore a general theme. The findings generate many questions, many more than we can cover here and for which simple solutions often do not exist. For better or worse, SoMe is here to stay. We feel our observations should allow readers to reflect on how they can improve their own practice at least. These observations can also serve as a starting point for dialogue in the surgical community as to how the situation can be improved while preserving the core values of the profession and the consent process. In not one of the 250 posts where either a video or image had been shared was there any comment made regarding the patient having given their consent to post it. Of course, it is fully possible that consent had been gained but not explicitly stated in the post. Perhaps, if we had sampled a further 250 posts, the same results may not have been found. However, if we explore the theme that perhaps many do not gain consent, it is worth reflecting that this is deeply problematic in many ways. How would a patient feel if they knew their surgeon did this? It may seem unlikely that a patient would ever come across such content but increasing numbers in the general public use SoMe to learn about the surgical treatments they will undergo as well as to search for the surgeon who will treat them [5, 6]. Even if a patient does consent to the images of their surgery being shared on SoMe, it is hard to know whether they understand what they are agreeing to. Arguably, patients should not be approached in the peri-operative period as they may feel pressured to agree. Furthermore, if consent is gained postoperatively, the patient may still be under the influence of anaesthesia or opioids. While it was largely surgeons sharing content, anaesthetists, medical device representatives and medical students also posted images. A camera phone was the most common equipment used to capture content in two thirds of cases. The frequent use of personal phones to take images is perhaps not a surprise but is nonetheless unsettling and, again, problematic. For example, the image or video may have already been uploaded to an online storage space even if deleted from the personal device. Users can add a content warnings and flag their own posts as containing sensitive content, but this was only done for one post. In several cases, the focus was on filming residents performing a procedure, often for the first time according to the video description. Had the patients been informed that a resident was the lead surgeon as well as it being their first case? Not to mention that it would be filmed and posted online? In two cases, the patient's face was fully visible, with no blurring, and further examples of the patient's date of birth and hospital identification number being clearly visible were also encountered. Even more concerning, is that paediatric surgical cases were found in this group too. Surgeons do use online video material to learn and, when it is a procedure that involves the genitals, it is necessary to see the anatomical area that is relevant to the specific operation, without blurring. However, SoMe is not a platform designed for surgical training. The minimum age for holding an account on X, for example, is 13 years, therefore, minors may encounter such posts. Furthermore, sharing images where a patient is bare and lying exposed in the lithotomy position is compromising and undignified for the patient. The onus should therefore really be placed on us as a surgical community to lead any changes rather than to criticise any specific platform that is currently available. So where do we go from here? Our random sample could present a bleaker picture than is the reality. A new secure platform for international learning, with accounts restricted to individuals with appropriate credentials, would be welcomed but is unlikely to materialise in the near future. Completely stopping sharing surgical images on SoMe would be another possibility, albeit perhaps an unrealistic one. Indeed, videos make for appealing content, generate attention and draw in more SoMe followers. Would people be willing to give this up? Perhaps too, even if someone does not post such content but simply 'likes' it, could they be unintentionally endorsing, and thus perpetuating this practice? Interim measures could be explored. For example, in other specialties, dedicated consent forms for SoMe have been created and these can be stored in the patient journal. Character limits in posts are appreciated. Could an acronym be used to help improve things? An example could be Consented to Image shaRe on SoCiaL mEdia (CIRCLE). This could be further shortened to a circle symbol. Moving forward and in conclusion, we challenge the individual reader to reflect on patient consent regarding the content of SoMe because upholding the core values of patient consent must be a constant, even if the world around is changing. None of the authors of this manuscript have any conflicts of interest to declare. All data were openly available in the public domain and ethical approval was therefore not deemed necessary.
OBJECTIVE To determine the possibly greater occurrence of multiple malignancies in patients with renal cell carcinoma (RCC). PATIENTS AND METHODS In the 7‐year period 1987–93, all 1425 patients aged 15–70 years with registered histopathologically verified RCC in Norway were included in the study. All clinical and histopathology reports were checked manually, to verify the registered diagnosis and to ensure that no tumour was a metastasis from another. After this process, 257 patients (287 tumours other than RCC) with multiple primary malignancies were identified. The primary tumours other than RCC were classified as antecedent, synchronous and subsequent. For the subsequently occurring tumours, the expected number of different tumour types was calculated according to age group, gender and observation time. RESULTS Of the 1425 patients, 228 (16%) had one, 23 (1.6%) had two, three (0.2%) had three and one (0.07%) had four other primary malignancies. In all, 100 (34.8%) of the other tumours were diagnosed as antecedent, 53 (18.7%) as synchronous and 134 (46.7%) as subsequent to the RCC. Cancer in the prostate, bladder, lung, breast, colon and rectal cancer, malignant melanomas (MM) and non‐Hodgkin's lymphomas (NHL) were the most common other malignancies. The observed overall number of subsequent other malignant tumours was 22% higher than the expected number. The observed number of subsequent tumours was significantly higher for bladder cancer, NHL and MM. The estimated 15‐year cumulative risk for patients with RCC and no previous or synchronous other malignancy for developing a later second cancer was 26.6% in men, and 15.5% in women (statistically significant, P = 0.04). Patients with antecedent or synchronous other cancer had significantly poorer overall survival than those without. CONCLUSIONS Patients with RCC seem to have a significantly higher risk of developing other subsequent primary malignancies. This should be considered during the follow‐up of patients with RCC.
Dear Editor,We read with interest the recently published feasibility study of Katz et al. [1] reporting the use of a novel prostatic retraction device named "The Butterfly." The general principle of minimally invasive surgical treatments is to yield a superior improvement in urinary symptoms than is possible with medical treatments while still preserving sexual function and maintaining a lower morbidity profile compared to surgeries such as transurethral resection of the prostate [2]. While we certainly commend the authors for successfully performing a prospective study on a new device and completing 12 months follow-up, there are parts of this research that warrant discussion, namely, these include the high rates of both study drop-out (19/63 successfully implanted devices) and the complications reported. Furthermore, the results of the functional outcomes were suboptimal.Firstly, it is worth mentioning that cumulative urinary retention is nearly 2-fold higher when compared to the UroLift procedure with a rate of 9% [2]. It also seems concerning that 4 cases required a suprapubic catheter insertion (6.3%) to treat retention and while others required a small gauge (10Fr) catheter to relieve acute obstruction. This could create an array of practical problems if the patient presents acutely to another hospital who are unfamiliar with the device and the need for a smaller gauge catheter. While suprapubic catheterisation offers an effective temporary solution, it is itself not free from a morbidity profile.Reported flowrates post treatment still show a clearly obstructive flow (Qmax = 10.5 mL/s) and are less efficacious when compared to other available minimally invasive implantable devices such as UroLift and iTind [2‒4]. It is unclear if prostate size had been a factor in outcomes as the included range of prostate sizes (30–110 mL) was very wide and the current permitted prostate size for undergoing a prostatic urethral lift (UroLift) is defined as <70–80 mL in current international guidelines [5].In summary, the study outcomes are perhaps skewed due to the learning curve as evident by procedure time alone (upper range of 50 min). This could be the contributing factor to the complication rates. Therefore, while we applaud the authors for researching novel BPH solutions, this device seems far behind its counterparts.The authors have no conflicts of interest to declare.The authors have no funding sources to declare.Sabine Uguzova, Christian Beisland, and Patrick Juliebø-Jones: critical article review, manuscript writing, and editing.
Abstract Objective Transrectal (TR) prostate biopsy is being increasingly abandoned in favour of a transperineal (TP) approach as well as a targeted biopsy only of the index lesion(s). It remains underreported how these changes could impact concordance at final pathology. We aimed to evaluate the impact of transitioning from standard transrectal (sTR) to cognitive targeted transperineal (cog‐tTP) biopsy on final pathology including concordance and upgrading. Material and methods Analysis of consecutive patients undergoing prostate biopsy and prostatectomy (RP) between January 2018 and May 2022 at a tertiary centre in Western Norway. Results There were 210 and 239 patients in the sTR and cog‐tTP groups, respectively. The mean [IQR] number of biopsies decreased from 12 [4–12] to 3 [3–4] ( p < 0.001). The overall rate of concordance between biopsy and final pathology was 64% in both groups (Table 3, Figure 1). 24% Twenty‐four per cent (cog‐tTP) versus 19% (sTR) had grade group (GG) upgrading, while 12% versus 17% were downgraded ( p = 0.2). Regarding positive surgical margins (PSMs) that were >3 mm in extension, there were only 3.3% and 2.1% in the sTR and cog‐tTP groups, respectively ( p = 0.4). For surgical outcomes associated with RP, no differences in terms of postoperative complications between the groups were found (cog‐tTP:10% vs. sTR:6%, p = 0.10). Conclusion Transitioning from sTR biopsy to targeted cog‐tTP biopsy does not compromise concordance at final pathology nor does it increase the risk of tumour upgrading.
The primary aim of the study was to explore intrarenal temperatures (IRTs) during flexible ureteroscopic laser lithotripsy (FURSL). The secondary aim was to investigate the correlation between temperatures and renal pelvis anteroposterior diameter (APD).
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