urology nephrology

According to a new study now available online, and to be published in an upcoming issue of the Journal of Critical Care, bedside testing for a blood biomarker called neutrophil gelatinaseassociated lipocalin (NGAL) in patients being admitted to the intensive care unit can help to identify patients at risk for acute kidney injury (AKI). The study tested blood samples collected during the first 2 hours of ICU admission using the Triage® NGAL Test, a product trustedtablets currently sold by Inverness Medical Innovations, Inc. (NYSE IMA) outside of the United States.

Many patients admitted to the ICU will suffer from acute kidney injury, some of whom will ultimately lose kidney function entirely and develop the need for renal replacement therapy (dialysis). When this occurs mortality rates are extremely high. Today, by the time that AKI has been detected by standard clinical measures, a substantial portion of renal function may already have been lost and interventions may not have much effect on the patients outcome.

However the study suggests that a rapid test for NGAL could allow clinicians to rapidly assess if a critically ill patient is suffering from AKI perhaps in time to make meaningful interventions.

In this study, researchers at the University Hospital of ClermontFerrand, France, found that critically ill patients being admitted to the ICU with an elevated blood NGAL level were very likely to suffer from AKI. Using a cutoff level of 150ng/mL for blood NGAL, the sensitivity and specificity to predict AKI were 82% and 97%, respectively.

Measuring blood NGAL with a simple beside test allows for immediate results and early identification of AKI which was only realized by traditional clinical markers of AKI 48 hours after the NGAL increase, according to this study.

“A bedside blood test like this could be tremendously important for critically ill patients. So far therapeutic interventions for patients with AKI have been relatively unsuccessful. This is likely because they are applied late once kidney function is already lost. Knowing which patients are in trouble in advance may allow clinicians to choose therapies that will minimize further harm to the kidneys and may allow for the study of new therapeutic interventions. If further studies confirm our hypothesis, this bedside blood test could become the corner stone of a new therapeutic age,” said Dr. JeanMichel Constantin of the University Hospital of ClermontFerrand.

Considering the US, EU and Australia/New Zealand alone, Inverness estimates that in 2008 approximately 2.4 million patients at high risk of AKI were admitted to ICUs. Subject to confirmation through future trials, Inverness also expects the Triage NGAL Test to offer similar diagnostic benefits in hospital emergency rooms.

Inverness supplied the Triage NGAL Tests used in the study at no charge, but did not otherwise fund or sponsor the study.

About Inverness Medical Innovations

By developing new capabilities in nearpatient diagnosis, monitoring and health management, Inverness Medical Innovations enables individuals to take charge of improving their health and quality of life. Inverness global leading products and services, as well as its new product development efforts, focus on infectious disease, cardiology, oncology, drugs of abuse and womens health. Inverness is headquartered in Waltham, Massachusetts.

Cautionary Note Regarding ForwardLooking Statements

This press release contains forwardlooking statements within the meaning of the federal securities laws, including statements regarding the expected benefits, and the potential market for, the Triage NGAL Test. These statements reflect Inverness current views with respect to future events and are based on managements current assumptions and information currently available. Actual results may differ materially due to numerous factors, including without limitation, the potential market acceptance of the Triage NGAL Test or other NGAL tests; the ability of Inverness to successfully develop and commercialize such products; the impact of regulatory changes or developments; the development and commercialization by others of competing products or alternative technologies; the ability of Inverness to supply sufficient quantities of the product; conditions in the financial markets; the intensely competitive environment in Inverness markets it products, and the risks and uncertainties described in Inverness annual report on Form 10K, as amended, for the year ended December 31, 2008, and other factors identified from time to time in its periodic filings with the Securities and Exchange Commission. Inverness undertakes no obligation to update any forwardlooking statements contained herein.

Infertility refers to an inability to conceive after having regular unprotected sex. Infertility can also refer to the biological inability of an individual to contribute to conception, or to a female who cannot carry a pregnancy to full term. In many countries infertility refers to a couple that has failed to conceive after 12 months of regular sexual intercourse without the use of contraception.

Studies indicate that slightly over half of all cases of infertility are a result of female conditions, while the rest are caused by either sperm disorders or unidentified factors. According to The Mayo Clinic, USAAbout 20% of cases of infertility are due to a problem in the man. About 40% to 50% of cases of infertility are due to a problem in the woman. About 30% to 40% of cases of infertility are due to problems in both the man and the woman. According to Medilexicons medical dictionary, infertility is “Diminished or absent ability to produce offspring; in either the male or the female, not as irreversible as sterility.”

According to the Department of Health and Human Services, USA, approximately 10% to 15% of couples in the USA are infertile meaning they have not conceived after at least one year of regular, unprotected sex.

Many cases of apparent infertility are treatable. Infertility may have a single cause in one of the partners, or it could be the result of a combination of factors.

Chances of conceiving within one year

In Europe, North America and much of the world approximately 85% of couples will conceive within one year if they have regular unprotected sex. Averages in the UK are as follows (National Health Service)20% will conceive within one month70% will conceive within six months85% will conceive within 12 months90% will conceive within 18 months95% will conceive within 24 monthsTherefore, doctors in the UK will not usually diagnose a couple as infertile until 24 months have passed without conception and regular unprotected sex. Most people will see their GP (general practitioner, primary care physician) if there is no pregnancy within 12 months.

According to the National Health Service, UK, a couple that has been trying to conceive for over three years has a maximum 25% chance of conceiving over the subsequent 12 months if they continue trying.What are the risk factors of infertility?In medicine, a risk factor is something that raises the risk of developing a condition, disease or symptom. For example, obese people are more likely to develop diabetes type 2 compared to people of normal weight; therefore, obesity is a risk factor for diabetes type 2.Age a womans fertility starts to drop after she is about 32 years old, and continues doing so. A 50yearold man is usually less fertile than a man in his 20s (male fertility progressively drops after the age of 40).
Smoking smoking significantly increases the risk of infertility in both men and women. Smoking may also undermine the effects of fertility treatment. Even when a woman gets pregnant, if she smokes she has a greater risk of miscarriage.
Alcohol consumption a womans pregnancy can be seriously affected by any amount of alcohol consumption. Alcohol abuse may lower male fertility. Moderate alcohol consumption has not been shown to lower fertility in most men, but is thought to lower fertility in men who already have a low sperm count.
Being obese or overweight in industrialized countries overweight/obesity and a sedentary lifestyle are often found to be the principal causes of female infertility. An overweight man has a higher risk of having abnormal sperm.
Eating disorders women who become seriously underweight as a result of an eating disorder may have fertility problems.
Being vegan if you are a strict vegan you must make sure your intake of iron, folic acid, zinc and vitamin B12 are adequate, otherwise your fertility may become affected.
Overexercising a woman who exercises for more than seven hours each week may have ovulation problems.
Not exercising leading a sedentary lifestyle is sometimes linked to lower fertility in both men and women.
Sexually transmitted infections (STIs) chlamydia can damage the fallopian tubes, as well as making the mans scrotum become inflamed. Some other STIs may also cause infertility.
Exposure to some chemicals some pesticides, herbicides, metals (lead) and solvents have been linked to fertility problems in both men and women.
Mental stress studies indicate that female ovulation and sperm production may be affected by mental stress. If at least one partner is stressed it is possible that the frequency of sexual intercourse is less, resulting in a lower chance of conception. What are the causes of infertility? There are many possible causes of infertility. Unfortunately, in about onethird of cases no cause is ever identified.

Causes of infertility in womenOvulation disorders problems with ovulation are the most common cause of infertility in women, experts say. Ovulation is the monthly release of an egg. In some cases the woman never releases eggs, while in others the woman does not release eggs during come cycles. Ovulation disorders can be due to

Premature ovarian failure the womans ovaries stop working before she is 40.
PCOS (polycystic ovary syndrome) the womans ovaries function abnormally. She also has abnormally high levels of androgen. About 5% to 10% of women of reproductive age are affected to some degree. Also called SteinLeventhal syndrome.
Hyperprolactinemia if prolactin levels are high and the woman is not pregnant or breastfeeding, it may affect ovulation and fertility.
Poor egg quality eggs that are damaged or develop genetic abnormalities cannot sustain a pregnancy. The older a woman is the higher the risk.
Overactive thyroid gland
Underactive thyroid gland
Some chronic conditions, such as AIDS or cancer.
Problems in the uterus or fallopian tubes

The egg travels from the ovary to the uterus (womb) where the fertilized egg grows. If there is something wrong in the uterus or the fallopian tubes the woman may not be able to conceive naturally. This may be due to

Surgery pelvic surgery can sometimes cause scarring or damage to the fallopian tubes. Cervical surgery can sometimes cause scarring or shortening of the cervix. The cervix is the neck of the uterus.
Submucosal fibroids benign or noncancerous tumors found in the muscular wall of the uterus, occurring in 30% to 40% of women of childbearing age. They may interfere with implantation. They can also block the fallopian tube, preventing sperm from fertilizing the egg. Large submucosal uterine fibroids may make the uterus cavity bigger, increasing the distance the sperm has to travel.
Endometriosis cells that are normally found within the lining of the uterus start growing elsewhere in the body.
Previous sterilization treatment if a woman chose to have her fallopian tubes blocked. It is possible to reverse this process, but the chances of becoming fertile again are not high. However, an eightyear study showed tubal reversal surgery results in higher pregnancy and live birth rates and is less costly than IVF.
Medications some drugs can affect the fertility of a woman. These include

NSAIDs (nonsteroidal antiinflammatory drugs) women who take aspirin or ibuprofen longterm may find it harder to conceive.
Chemotherapy some medications used in chemotherapy can result in ovarian failure. In some cases, this side effect of chemotherapy may be permanent.
Radiotherapy if radiation therapy was aimed near the womans reproductive organs there is a higher risk of fertility problems.
Illegal drugs some women who take marijuana or cocaine may have fertility problems. Causes of infertility in men

Semen

Semen is the milky fluid that a mans penis releases during orgasm. Semen consists of fluid and sperm. The fluid comes from the prostate gland, seminal vesicle and other sex glands. The sperm is produced in the testicles. During orgasm a man ejaculates (releases semen through the penis). The seminal fluid helps transport the sperm during ejaculation. The seminal fluid has sugar in it sugar is an energy source for sperm.

Abnormal semen is responsible for about 75% of all cases of male infertility. Unfortunately, in many cases doctors never find out why. The following semen problems are possible

Low sperm count (low concentration) the man ejaculates a lower number of sperm, compared to other men. Sperm concentration should be 20 million sperm per milliliter of semen. If the count is under 10 million there is a low sperm concentration (subfertility).
No sperm when the man ejaculates there is no sperm in the semen.
Low sperm mobility (motility) the sperm cannot “swim” as well as it should.
Abnormal sperm perhaps the sperm has an unusual shape, making it more difficult to move and fertilize an egg.
Sperm must be the right shape and able to travel rapidly and accurately towards the egg. If the sperms morphology (structure) and motility (movement) are wrong it is less likely to be able to reach the egg and fertilize it.

The following may cause semen to be abnormal
Testicular infection
Testicular cancer
Testicular surgery
Overheating the testicles frequent saunas, hot tubs, very hot baths, or working in extremely hot environments can raise the temperature of the testicles. Tight clothing may have the same effect on some people.
Ejaculation disorders for some men it may be difficult to ejaculate properly. Men with retrograde ejaculation ejaculate semen into the bladder. If the ejaculatory ducts are blocked or obstructed the man may have a problem ejaculating appropriately.
Varicocele this is a varicose vein in the scrotum that may cause the sperm to overheat.
Undescended testicle one (or both) testicle fails to descend from the abdomen into the scrotum during fetal development. Sperm production is affected because the testicle is not in the scrotum and is at a higher temperature. Healthy sperm need to exist in a slightly lowerthanbody temperature. That is why they are in the scrotum, and not inside the body.
Hypogonadism testosterone deficiency can result in a disorder of the testicles.
Genetic abnormality a man should have an X and Y chromosome. If he has two X chromosomes and one Y chromosome (Klinefelters syndrome) there will be an abnormal development of the testicles, low testosterone, and a low sperm count (sometimes no sperm at all).
Mumps this viral infection usually affects young children. However, if it occurs after puberty inflammation of the testicles may affect sperm production.
Hypospadias the urethral opening is at the underside of the penis, instead of its tip. This abnormality is usually surgically corrected when the male is a baby. If it is not the sperm may find it harder to get to the females cervix. Hypospadias occur in about 1 in every 500 newborn boys.
Cystic fibrosis Cystic fibrosis is a chronic disease that affects organs such as the liver, lungs, pancreas, and intestines. It disrupts the bodys salt balance, leaving too little salt and water on the outside of cells and causing the thin layer of mucus that usually keeps the lungs free of germs to become thick and sticky. This mucus is difficult to cough out, and it clogs the lungs and airways, leading to infections and damaged lungs. Males with cystic fibrosis commonly have a missing or obstructed vas deferens (tube connecting the testes to the urethra; it carries sperm from the epididymis to the ejaculatory duct and the urethra).
Radiotherapy radiation therapy can impair sperm production. The severity usually depends on how near to the testicles the radiation was aimed.
Some diseases the following diseases and conditions are sometimes linked to lower fertility in males

Anemia
Cushings syndrome
Diabetes
Thyroid disease

Medications

Sulfasalazine this antiinflammatory drug can significantly lower a mans sperm count. The drug is often prescribed for patients with Crohns disease or rheumatoid arthritis. Usually this side effect goes away after the patient stops taking the medication.

Anabolic steroids often taken by bodybuilders and athletes; anabolic steroids, especially after long term use can seriously reduce sperm count and mobility.

Chemotherapy some medicines may significantly reduce sperm count.

Illegal drugs consumption of marijuana and cocaine can lower a mans sperm count. Diagnosing infertilityMost people will visit their GP (general practitioner, primary care physician) if there is no pregnancy after 12 months of trying. For anybody who is concerned about fertility, especially if they are older (women over 35), it might be a good idea to see a doctor earlier. As fertility testing can sometimes take a long time, and female fertility starts to drop when a woman is in her thirties, seeing the doctor earlier on if you are over 35 makes sense.

A GP can give the patient advice and carry out some preliminary assessments. As it takes two to make a baby it is better for both the male and female to see the doctor together.

Before undergoing testing for fertility it is important that the couple be committed. The doctor will need to know what the patients sexual habits are, and may make recommendations regarding them. Tests and trials might extend over a long period. Even after thorough testing, no specific cause is ever found for 30% of infertility cases.

In some countries where universal healthcare cover does not exist, evaluation and eventual treatment may be expensive.

Tests for malesGeneral physical exam the doctor will ask the man about his medical history, medications, and sexual habits. The physician will also carry out an examination of his genitals. The testicles will be checked for lumps or deformities, while the shape and structure of the penis will be examined for any abnormalities.
Semen analysis the doctor may ask for some specimens of semen. They will be analyzed in a laboratory for sperm concentration, motility, color, quality, infections and whether any blood is present. As sperm counts can fluctuate, the man may have to produce more samples.
Blood test the lab will test for several things, including the mans level of testosterone and other male hormones.
Ultrasound test the doctor will determine whether there is any ejaculatory duct obstruction, retrograde ejaculation, or other abnormality.
Chlamydia test if the man is found to have Chlamydia, which can affect fertility, he will be prescribed antibiotics to treat it. Tests for femalesGeneral physical exam the doctor will ask the woman about her medical history, medications, menstruation cycle, and sexual habits. She will also undergo a gynecological examination.
Blood test several things will be checked, for example, whether hormone levels are correct and whether the woman is ovulating (progesterone test).
Hysterosalpingography fluid is injected into the womans uterus which shows up in Xray pictures. Xrays are taken to determine whether the fluid travels properly out of the uterus and into the fallopian tubes. If the doctor identifies any problems, such as a blockage, surgery may need to be performed.
Laparoscopy a thin, flexible tube with a camera at the end (laparoscope) is inserted into the abdomen and pelvis to look at the fallopian tubes, uterus and ovaries. A small incision is made below the belly button and a needle is inserted into the abdominal cavity; carbon dioxide is injected to create a space for the laparoscope. The doctor will be able to detect endometriosis, scarring, blockages, and some irregularities of the uterus and fallopian tubes.
Ovarian reserve testing this is done to find out how effective the eggs are after ovulation.
Genetic testing this is to find out whether a genetic abnormality is interfering with the womans fertility.
Pelvic ultrasound high frequency sound waves create an image of an organ in the body, which in this case is the womans uterus, fallopian tubes, and ovaries.
Chlamydia test if the woman is found to have Chlamydia, which can affect fertility, she will be prescribed antibiotics to treat it.
Thyroid function test according to the National Health Service (UK) between 1.3% and 5.1% of infertile women have an abnormal thyroid. What are the treatment options for infertility? This will depend on many factors, including the age of the patient(s), how long they have been infertile, personal preferences, and their general state of health. Even if the woman has causes that cannot be corrected, she may still become pregnant.

Frequency of intercourse

The couple may be advised to have sexual intercourse more often. Sex two to three times per week may improve fertility if the frequency was less than this. Some fertility experts warn that toofrequent sex can lower the quality and concentration of sperm. Male sperm can survive inside the female for up to 72 hours, while an egg can be fertilized for up to 24 hours after ovulation.

Fertility treatment for menErectile dysfunction or premature ejaculation medication and/or behavioral approaches can help men with general sexual problems, resulting in possibly improved fertility.
Varicocele if there is a varicose vein in the scrotum, it can be surgically removed.
Blockage of the ejaculatory duct sperm can be extracted directly from the testicles and injected into an egg in the laboratory.
Retrograde ejaculation sperm can be taken directly from the bladder and injected into an egg in the laboratory.
Surgery for epididymal blockage if the epididymis is blocked it can be surgically repaired. The epididymis is a coillike structure in the testicles which helps store and transport sperm. If the epididymis is blocked sperm may not be ejaculated properly. Fertility treatment for womenOvulation disorders if the woman has an ovulation disorder she will probably be prescribed fertility drugs which regulate or induce ovulation. These include

Clomifene (Clomid, Serophene) this medication helps encourage ovulation in females who do not ovulate regularly, or who do not ovulate at all, because of polycystic ovary syndrome (PCOS) or some other disorder. It makes the pituitary gland release more FSH (folliclestimulating hormone) and LH (luteinizing hormone).
Metformin (Glucophage) women who have not responded to Clomifene may have to take this medication. It is especially effective for women with PCOS, especially when linked to insulin resistance.
Human menopausal gonadotropin, or hMG, (Repronex) this medication contains both FSH and LH. It is an injection and is used for patients who dont ovulate on their own because of a fault in their pituitary gland.
Folliclestimulating hormone (GonalF, Bravelle) this is a hormone produced by the pituitary gland that controls estrogen production by the ovaries. It stimulates the ovaries to mature egg follicles.
Human chorionic gonadotropin (Ovidrel, Pregnyl) this medication is used together with clomiphene, hMG and FSH. It stimulates the follicle to ovulate.
GnRH (gonadotropinreleasing hormone) analogs for women who ovulate prematurely, before the lead follicle is mature enough during hmG treatment. This medication delivers a constant supply of GnRH to the pituitary gland, which alters the production of hormone, allowing the doctor to induce follicle growth with FSH.
Bromocriptine (Parlodel) this drug inhibits prolactin production. Prolactin stimulates milk production in breast feeding mothers. If nonpregnant, nonbreast feeding women have high levels of prolactin they may have irregular ovulation cycles and have fertility problems. Risk of multiple pregnancies

Injectable fertility drugs can sometimes be the victims of their own success and cause multiple births when the woman gets pregnant she has twins, triplets, or perhaps more babies in one go. Oral fertility drugs also raise the risk of multiple pregnancies, but much less so than injectable ones. It is important to monitor the patient carefully during treatment and pregnancy. The more babies the mother carries inside her the higher is her risk of premature labor.

If a woman needs an HCG injection to activate ovulation and ultrasound scans show that too many follicles have developed, it is possible to withhold the HCG injection. Couples may decide to go ahead regardless if the desire to become pregnant is very strong.

Multifetal pregnancy reduction is possible if too many babies are conceived one or more of the fetuses is removed. Couples will have to consider the ethical and emotional aspects of this procedure.Surgical procedures for women

Fallopian tube surgery if the fallopian tubes are blocked or scarred surgery may repair them, making it easier for eggs to pass through them.
Laparoscopic surgery a small incision is made in the womans abdomen. A thin, flexible microscope with a light at the end (laparoscope) is inserted through the incision. The doctor can then look at internal organs, take samples and perform small operations. For women with endometriosis, laparoscopy removes implants and scar tissue, reducing pain and often aiding fertility. Assisted conceptionIUI (intrauterine insemination) a fine catheter is inserted through the cervix into the uterus to place a sperm sample directly into the uterus. The sperm is washed in a fluid and the best specimens are selected. This procedure must be done when ovulation occurs. The woman may be given a low dose of ovary stimulating hormones.

IUI is more commonly done when the man has a low sperm count, decreased sperm motility, or when infertility does not have an identifiable cause. The procedure is also helpful for males suffering from severe erectile dysfunction.
IVF (in vitro fertilization) sperm are placed with unfertilized eggs in a Petri dish; the aim is fertilization of the eggs. The embryo is then placed in the uterus to begin a pregnancy. Someitmes the embryo is frozen for future use (cryopreserved). Louise Joy Brown, born in England in 1978, was the worlds first IVF baby. Before IVF is done the female takes fertility drugs to encourage the ovaries to produce more eggs than normal.
ICSI (Intracytoplasmic sperm injection) a single sperm is injected into an egg to achieve fertilization during an IVF procedure. The likelihood of fertilization improves significantly for men with low sperm concentrations.
Donation of sperm or egg if there is either no sperm or egg in one of the partners it is possible to receive sperm or eggs from a donor. Fertility treatment with donor eggs is usually done using IVF. In the UK and a growing number of countries the egg donor can no longer remain anonymous the offspring can legally trace his/her biological parent when reaching the age of 18.
Assisted hatching this improves the chances of the embryos implantation; attaching to the wall of the uterus. The embryologist opens a small hole in the outer membrane of the embryo, known as the zona pellucid. The opening improves the ability of the embryo to leave its shell and implant into the uterine lining. Patients who benefit from assistant hatching include women with previous IVF failure, poor embryo growth rate, and older women. In some women, particularly older women, the membrane is hardened, making it difficult for the embryo to hatch and implant.
Electric or vibratory stimulation to achieve ejaculation ejaculation is acheived with electric or vibratory stimulation. This procedure is useful for men who cannot ejaculate normally, such as those with a spinal cord injury.
Surgical sperm aspiration the sperm is removed from part of the male reproductive tract, such as the vas deference, testicle or epididymis. What are the complications of infertility treatment? Ovarian hyperstimulation syndrome (OHSS)

The ovaries become very swollen, leaking excess fluid into the body. The ovaries produce too many follicles (small fluid sacs in which an egg develops). OHSS usually occurs as a result of taking medications to stimulate the ovaries, such as clomifene and gonadtrophins, and can also develop after IVF. Symptoms can include

BloatingConstipationDark urineDiarrheaNauseaPain in the abdomenVomiting
In most cases symptoms are mild and easy to treat. On very rare occasions the patient may develop a blood clot (thrombosis) in an artery or vein, liver or kidney problems, and respiratory distress. In very severe cases OHSS can be potentially fatal.
Ectopic pregnancy

This is a pregnancy when the fertilized egg does not implant in the womb in most cases the fertilized egg grows in the fallopian tube. If it stays in the fallopian tube the mother will usually miscarry before complications develop, such as the rupture of the fallopian tube. Women receiving fertility treatment have a slightly higher risk of having an ectopic pregnancy. An ultrasound scan can detect an ectopic pregnancy.
Coping mentally

As it is impossible to know how long treatment will go on for and how successful it will be, coping and persevering can be stressful. The emotional toll on both partners might be considerable and can have an impact on their relationship. Some people find that joining a support group helps being able to talk to others who share similar problems, aspirations and anxieties can be uplifting. It is important to tell your doctor if you are suffering mentally and/or emotionally. Most fertility doctors have access to counselors, as well as other people and professionals who can offer helpful support.

UroToday.com Time. Among 101 laparoscopic partial nephrectomy patients with preoperative and postoperative data points (16 months), the authors noted that exceeding 40 minutes was associated with a definite drop in glomerular filtration rate (determined by the serum creatinine based MDRD formulation), on average 20 ml/min/1.73 m2. This statistically significant difference was more than double the change in the MDRD glomerular filtration when the ischemia time was less than 40 minutes! When looking at < 30 minutes of warm ischemia time vs. > 30 minutes, the difference was not significant but with a p value of 0.132 there is suggestion of a trend. While the authors conclude that up to 40 minutes is safe, I would lean more towards a 30 minute cut off. Shaving additional time off of the 30 minute limit did not appear to favorably impact the outcome in this study.

With the advent of roboticassisted laparoscopic partial nephrectomy, the surgeons ability to suture accurately and rapidly appears to be markedly enhanced thereby allowing more surgeons to operate within the safety of the 30 minute window. Indeed, on average, warm ischemia times can be reduced by 10 minutes when changing from straight laparoscopic to a robotic platform. In the editorial comment, the authors note that despite their findings, they are now striving for a 20 minute warm ischemia cutoff, yet provide no data to support this approach other than the concept, that the less the warm ischemia the better.

What we still lack and desperately need is one prospective multicenter study in which all patients are carefully categorized as to risk of postsurgical renal dysfunction (i.e. diabetes, preexisting renal dysfunction, hypertension) among whom there are several preoperative creatinine levels within 6 months of their surgery and two or more values at least 6 months postoperatively, to obtain a more accurate MDRD given the variability of serum creatinine levels. As part of this study, both preoperative and postoperative CT scans to determine the remaining renal volume would be helpful in order to differentiate a drop in creatinine due to a wide excision vs. impairment solely from warm ischemia.

Godoy G, Ramanathan V, Kanofsky JA, OMalley RL, Tareen BU, Taneja SS, Stifelman MD
J Urol. 2009 Jun;181(6)243843
doi10.1016/j.juro.2009.02.026

Reported by UroToday.com Medical Editor Ralph V. Clayman, MD

UroToday the only urology website with original content written by global urology key opinion leaders actively engaged in clinical practice. To access the latest urology news releases from UroToday, go tourotoday.com

A Japanese research group led by Prof. Makoto Tominaga and Dr. Takaaki Sokabe (National Institute for Physiological Sciences NIPS), and Prof. Masayuki Takeda, Dr. Isao Araki and Dr. Tsutomu Mochizuki (Yamanashi Univ.), found that bladder urothelial cells have a sensor for stretch stimulation. Their finding was reported in the Journal of Biological Chemistry published on Aug 7, 2009.

The bladder is known to release ATP that activates the micturition reflex pathway during urine storage. However, it has been unknown how urothelial cells sense bladder distension. The research group examined the function of TRPV4 protein abundantly expressed in urothelial cells. The group developed a special apparatus to measure cell responses upon stretch stimulation, which mimics bladder distension.

Upon stretch stimulation, robust Ca2+ influx and following ATP release were observed in urothelial cells. These phenomena were almost completely attributed to TRPV4 activation, since such responses were eliminated by a TRPV4 inhibitor and reduced in TRPV4deficient urothelial cells.

Dr. Sokabe said, “This is the first report to show that TRPV4 is a primal stretchdetector in urothelial cells. Given that TRPV4 is critically involved in the sensing mechanism in the bladder, development of chemicals modulating TRPV4 activity may be useful for treatment of bladder disorders such as overactive bladder and pollakiuria.”

Source
Takaaki Sokabe
National Institute for Physiological Sciences

Cook Medical has agreed to become the exclusive sponsor of the American Urological Associations global exchange programme. Details of exchange sponsorship were announced at a press conference during the AUA annual meeting in Chicago. Jerry French, senior vice president and strategic business leader for Cook Medicals urology division was joined by Dr. Joel Nelson, chair of the AUA/EAU Academic Fellowship Selection Committee and Dr. Ziya Kirkali, a past exchange participant from Turkey and upcoming chair of the AUA International Member Committee.

The AUA exchange programme unites urologists from various cultural, educational and clinical backgrounds to exchange ideas and expertise with their American colleagues. Visiting physicians in this years programme will spend time at renowned U.S. facilities such as the MD Anderson Cancer Centre in Houston, Texas, and the Mayo Clinic in Rochester, Minnesota. During their stays, physicians will observe procedures, take classes and share their own best practices with faculty and staff.

Dr. Nelson, chair of the Department of Urology at the University of Pittsburgh School of Medicine, stressed the importance of the international programme to the improvement of the practice of urology. “As the field continues to innovate, it is vital that we have an open worldwide exchange of best practices and techniques across professionals,” said Nelson. “The AUAs exchange programme plays a pivotal role in assisting urologists to globally engage and learn from one another. We believe the end result will be better medical practices and improvements in overall patient care.”

Associations participating in the global exchange programme include the European Association for Urology (EAU), Sociedade Brasiliera de Urologia (SBU), Chinese Urological Association (CUA) and the Japanese Urological Association (JUA). Through the programme, each international society is invited to select urologists annually to visit U.S. academic centres for a period of up to one month. U.S. urologists are also chosen to visit academic centres in countries served by the international societies.

Former exchange participant representing the EAU, Dr. Kirkali described his experience as “a rewarding and energising opportunity to share and learn from my international colleagues, and return to my practice in Turkey with a better knowledge of global best practices and techniques.” Kirkali is professor of urology at Dokuz Eylul University of Medicine in Izmir, Turkey. His primary research activities focus on clinical and basic research in oncologic urology.

Jerry French said, “Throughout our history, Cook has remained dedicated to fostering communication and education between physicians to improve patient care globally. With this sponsorship, we reinforce our devotion to ongoing innovation, collaborative learning and crosscultural understanding in the field of urology.”

More than 35 million Americans suffer from bladder control problems at some time in their lives. Those suffering from uncontrollable bladder may experience unexpected urine leakage, frequent bathroom use, or have the feeling of not being able to completely empty the bladder. Many people experience a combination of these symptoms. Although it is more common in older adults, and more likely to occur in women than men, it can affect anyone.

For many of these people the last hope is an implantable device known as InterStim® Therapy, which was designed to stimulate communication between the brain and bladder to better control urinary incontinence and retention. Before the device can be implanted, however, doctors must perform a test procedure to determine if it will be effective.

At 4 p.m. on May 20, 2009, this test procedure will be performed live over the Internet from Tampa General Hospital. The test involves placing a thin wire near the tailbone, which is connected to a small stimulator worn on a belt. The stimulator sends mild electrical pulses through the thin wire to the sacral nerves that control the bladder and muscles related to urinary function.

The test is an outpatient procedure typically completed in less than an hour. The patient is placed under a local anesthetic. After the procedure, the patient keeps a journal for a period ranging from five to ten days. If the electrical pulses result in an increase in proper bladder function, the patient may proceed to the surgical implementation procedure.

Raul Ordorica, M.D., Associate Professor, Division of Urology, University of South Florida College of Medicine, will perform the procedure to test the effectiveness of the InterStim® device. Dr. Ordorica has had extensive experience with InterStim® Therapy since it was FDA approved in 1998, and was the first to perform the implant at Tampa General Hospital. The procedure will be narrated by Mark Swierzewski, M.D., Florida Urology Partners.

To view this procedure, log on to tgh.org and click on the link on the homepage. If you are unable to view the live broadcast, the procedure will be available on demand at tgh.org and ORLive.com for future viewing at your convenience.

Source

Abnormal levels of trace elements may explain dialysis morbidity. A systematic review published in the open access journal BMC Medicine has shown that, compared to healthy controls, dialysis patients have significantly different blood concentrations of trace elements.

Marcello Tonelli, from the University of Alberta, Canada, led a team of researchers who investigated the trace element status of dialysis patients in 128 studies. They found that levels of cadmium, chromium, copper, lead, and vanadium were higher and that levels of selenium, zinc and manganese were lower in the hemodialysis patients, compared with controls. Tonelli said, “Since both deficiency and excess of trace elements are potentially harmful yet amenable to therapy, the hypothesis that trace element status influences the risk of adverse clinical outcomes is worthy of investigation”.

The researchers found that data examining any possible relation between trace element status and clinical outcomes are scarce. However, they point out that the nephrology communitys experience with aluminium toxicity exemplifies the damage that uncontrolled elemental accumulation can cause, “Aluminium accumulation led to serious toxicity in dialysis patients prior to the recognition that aluminium in dialysate and oral medications was responsible. Today, such aluminiumrelated toxicity is extremely rare. However, the possibility that other trace elements may accumulate in patients with kidney failure and cause unrecognized chronic toxicity has received surprisingly little attention”.

As well as the potentially toxic accumulation of some elements, this research highlights the reduced blood levels of others, including zinc. Tonelli points out that zinc supplementation is routinely used to correct deficiency in people from the general population, significantly reducing the risk of infection and allcause death. He said, “Our data suggest that future studies should investigate the link between zinc or selenium status and clinical outcomes in dialysis patients, in whom the risk of infection is dramatically elevated compared to people with normal kidney function”.

1. Trace elements in hemodialysis patients A systematic review and metaanalysis
Marcello Tonelli, Natasha Wiebe, Brenda Hemmelgarn, Scott Klarenbach, Catherine Field, Braden Manns, Ravi Thadhani and John Gill for the Alberta Kidney Disease Network
BMC Medicine (in press)
biomedcentral.com/bmcmed/

Source
Graeme Baldwin