ObjectivesAlthough the National Early Warning Score (NEWS) and its latest version NEWS2 are recommended for monitoring deterioration in patients admitted to hospital, little is known about their performance in COVID-19 patients. We aimed to compare the performance of the NEWS and NEWS2 in patients with COVID-19 versus those without during the first phase of the pandemic.DesignA retrospective cross-sectional study.SettingTwo acute hospitals (Scarborough and York) are combined into a single dataset and analysed collectively.ParticipantsAdult (≥18 years) non-elective admissions discharged between 11 March 2020 and 13 June 2020 with an index or on-admission NEWS2 electronically recorded within ±24 hours of admission to predict mortality at four time points (in-hospital, 24 hours, 48 hours and 72 hours) in COVID-19 versus non-COVID-19 admissions.ResultsOut of 6480 non-elective admissions, 620 (9.6%) had a diagnosis of COVID-19. They were older (73.3 vs 67.7 years), more often male (54.7% vs 50.1%), had higher index NEWS (4 vs 2.5) and NEWS2 (4.6 vs 2.8) scores and higher in-hospital mortality (32.1% vs 5.8%). The c-statistics for predicting in-hospital mortality in COVID-19 admissions was significantly lower using NEWS (0.64 vs 0.74) or NEWS2 (0.64 vs 0.74), however, these differences reduced at 72hours (NEWS: 0.75 vs 0.81; NEWS2: 0.71 vs 0.81), 48 hours (NEWS: 0.78 vs 0.81; NEWS2: 0.76 vs 0.82) and 24hours (NEWS: 0.84 vs 0.84; NEWS2: 0.86 vs 0.84). Increasing NEWS2 values reflected increased mortality, but for any given value the absolute risk was on average 24% higher (eg, NEWS2=5: 36% vs 9%).ConclusionsThe index or on-admission NEWS and NEWS2 offers lower discrimination for COVID-19 admissions versus non-COVID-19 admissions. The index NEWS2 was not proven to be better than the index NEWS. For each value of the index NEWS/NEWS2, COVID-19 admissions had a substantially higher risk of mortality than non-COVID-19 admissions which reflects the increased baseline mortality risk of COVID-19.
Intravesical gemcitabine (Gem) has shown promising activity against transitional cell carcinomas (TCC) of the bladder, with moderate urinary toxicity and low systemic absorption. The present phase II study evaluated the activity of biweekly intravesical treatment with Gem using a scheme directly derived from in vitro preclinical studies. Patients with Bacille Calmette-Guérin (BCG) -refractory Ta G3, T1 G1-3 TCC underwent transurethral bladder resection and then intravesical instillation with 2000 mg Gem diluted in 50 ml saline solution on days 1 and 3 for 6 consecutive weeks. Thirty-eight (95%) of the 40 patients showed persistent negative post-treatment cystoscopy and cytology 6 months after Gem treatment, while the remaining 2 patients relapsed at 5 and 6 months. At a median follow-up of 28 months, recurrences had occurred in 14 patients. Among these, four had downstaged (T) disease, three had a lower grade (G) lesion and three had a reduction in both T and G. Urinary and systemic toxicity was very low, with no alterations in biochemical profiles. In conclusion, biweekly instillation of Gem proved active in BCG-refractory Ta G3, T1 G1-3 TCC. Our results highlight the importance of preclinical studies using in vitro systems that adequately reproduce the conditions of intravesical clinical treatment to define the best therapeutic schedule.
Alterations in the expression of signal activation molecules, such as the T-cell receptor (TCR) zeta and epsilon chains and p56lck tyrosine kinase, are described in tumor-infiltrating lymphocytes (TIL). The aim of this study was to ascertain if such molecules were present in near-tumor-tissue lymphocytes (NTTL) and peripheral blood lymphocytes (PBL), as well as TIL, of renal cell carcinoma patients, to verify whether this tumor induces immunosuppression only locally or affects distant lymphocytes as well. Tissue from the tumor and from healthy nearby sites, as well as blood samples, were obtained from 27 consecutive patients who had undergone radical nephrectomy for renal cell carcinoma. Phenotype analysis and immunohistochemical staining of the TCR zeta and epsilon chains and p56lck were performed with standard techniques on TIL, NTTL, and PBL, and values were compared for each patient. Low expression of the TCR zeta chain and an almost complete absence of TCR epsilon chain and p56lck expression was observed in TIL (median values: 10% for zeta chain and 0% for epsilon and p56lck). In NTTL, these signal transduction molecules were expressed by a higher percentage of cells (60%, 50%, and 60%, respectively; p=0.000 vs. TIL), whereas PBL showed an almost normal expression of zeta and epsilon chains (80% and 90%, respectively; p=0.000 vs. TIL). Conversely, p56lck was detected in a greater proportion of NTTL than PBL (50% vs. 10%; p=0.001). The absence or the very low expression of signaling activation molecules in TIL compared with NTTL and PBL in renal cancer patients suggest that tumor-induced immunosuppression generally occurs or starts locally.
Introduction: As a result of the growing evidence on tumor radical resection in literature, simple enucleation has become one of the best techniques associated to robotic surgery in the treatment of renal neoplasia, as it guarantees minimal invasiveness and the maximum sparing of renal tissue, facilitating the use of reduced or zero ischemia techniques during resection. The use of a robotic ultrasound probe represents a useful tool to detect and define tumor location, especially in poorly exophytic small renal mass. Materials and methods: A total of 22 robotic enucleations were performed on < 3 cm renal neoplasias (PADUA score 18 Pz 6/7 e 4 Pz 8) using a 12-5 MHz robotic ultrasound probe (BK Drop-In 8826). Results: Once kidney had been isolated from the adipose capsule at the site of the neoplasia (2), the exact position of the lesion could be easily identified in all cases (22/22), even for mostly endophytic lesions, thanks to the insertion of the ultrasound probe through the assistant port. Images were produced and visualized by the surgeon using the TilePro feature of the DaVinci surgical system for producing a picture-in-picture image on the console screen. The margins of resection were then marked with cautery, thus allowing for speedy anatomical dissection. This reduced the time of ischemia to 8 min (6-13) and facilitated the enucleation technique when performed without clamping the renal peduncle (6/22). No complications due to the use of the ultrasound probe were observed. Conclusions: The use of an intraoperative robotic ultrasound probe has allowed for easier identification of small, mostly endophytic neoplasias, better anatomical approach, shorter ischemic time, reduced risk of pseudocapsule rupture during dissection, and easier enucleation in cases performed without clamping. It is noteworthy that the use of intraoperative ultrasound probe allows mental reconstruction of the tumor through an accurate 3D vision of the hidden field during surgical dissection.KEY WORDS: Robotic ultrasound probe; Renal tumor; Simple enucleation; Psychomotor skills. SummaryNo conflict of interest declared.
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