To explore the influencing factors of perioperative renal function change and their relationship with prognosis on renal cell carcinoma (RCC) patients with tumor thrombus after nephrectomy and thrombectomy.The clinical and pathological data of 135 patients with RCC and tumor thrombus, who underwent nephrectomy and thrombectomy at Peking University Third Hospital from May 2015 to July 2018, was retrospectively analyzed. Absolute change in estimated glomerular filtration rate (eGFR) (ACE) and percent change in eGFR (PCE) were calculated by preoperative and postoperative renal function. Linear regression analysis was used to explore the influencing factors of ACE and PCE, and logistic regression analysis was used to explore the influencing factors of worse postoperative renal function [eGFR≤60 mL/(min × 1.73 m^2)]. Cancer-specific survival (CSS) was estimated by Kaplan-Meier method and multivariate Cox regression, which were used to explore the effect of ACE and PCE on prognosis.P < 0.001) and pathological type (P = 0.038) were significant predictive factors of ACE. In aspect of PCE, preoperative eGFR (P < 0.001) and pathological type (P = 0.002) were significant predictors. In multivariate logistic regression analysis, preoperative eGFR (P = 0.016) was the only risk factor of predicting worse postoperative renal function. During follow-up, 22 patients (16.3%) were dead due to RCC. According to ROC analysis, the cut off value of ACE and PCE was 13.9 and 0.16, respectively. ACE> 13.9 and PCE > 0.16 indicated worse CSS . However, in multivariate Cox regression analysis of several related factors, perinephric tissues invasion (P = 0.001), sarcomatoid differentiation (P = 0.001) and ACE> 13.9 (P = 0.002) were significant prognostic factors for CSS. PCE > 0.16 seemed to be not (P = 0.055).Of all the 135 patients, 101 patients (74.8%) were male and 34 patients (25.2%) were female. The mean preoperative eGFR was 73.9 ± 21.8 mL/(min × 1.73 m^2) and postoperative eGFR was 69.5 ± 25.2 mL/(min × 1.73 m^2). In multivariate linear regression analysis, preoperative eGFR (We explored several clinicopathological risk factors of predicting renal function change and their relationship with prognosis of RCC patients with tumor thrombus after nephrectomy and thrombectomy. The renal function change, which was associated with preoperative eGFR and pathological type, was prognostic risk factor for CSS and ACE> 13.9 indicated the worse prognosis. P < 0.001) . We made multivariate analysis for factors which had statistical significance in univariate analysis. The significant factors of univariate analysis were CSS was estimated by the Kaplan-Meier method and compared by log-rank test in different level of ACE and PCE, which was calculated by Receiver Operating Characteristic (ROC) curve. A two-sided P value < 0.05 was considered to be statistically significant. All data were collected and analyzed by SPSS 22.0 software .Continuous variables were presented as the mean value ± SD and were analyzed using Mann-Whitney U test. Categorical variables were compared by using the Pearson xDemographic and clinicopathological characteristics of 135 patients with RCC with TT, including 101 (74.8%) males and 34 (25.2%) females, are summarized in Table All the patients underwent RN or CN with thrombectomy successfully. There are four patients with thoracotomy and extracorporeal circulation; two patients with thoracotomy without extracorporeal circulation; others without thoracotomy. During operation, It is common to clam the contralateral renal vein. Only one patients underwent venal graft placement. During the operation, the distal end of inferior vena cava was found to be free of tumor invasion. A part of the uninjured wall of inferior vena cava was resected and reconstructed as the distal end of renal vein in the healthy side to ensure renal blood flow in the healthy side.For operation-related data, the mean operation time was 337.0 ± 122.7 min and the mean intraoperative blood loss 1387.7 ± 1640.6 ml. Fifty six patients had postoperative complications according to Clavien classification, while only 18 patients had serious complications. In all patients, 115 patients had clear cell carcinoma and 20 patients were other histological types. The median follow-up was 11.4 months (range: 0–37). During follow-up, 22 patients (16.3%) were dead due to the disease. The 1-year CSS of patients with low preoperative renal function is 87.5% and 2-year CSS of these is 58.3%. The 1-year CSS of patients with low postoperative renal function is 84.9% and 2-year CSS of these is 79.2%. The 3-year CSS of all the patients is 91.5% and 5-year CSS of these is 86.0%.P < 0.001) and pathological type (P = 0.038) were significant predictive factors of ACE (Table P = 0.002) were significant predictors (Table P = 0.016), was the only risk factor of predicting worse postoperative renal function defined as eGFR≤60 mL/(min × 1.73 m^2)  in Kaplan-Meier analysis , sarcomatoid differentiation (P = 0.001) and ACE> 13.9 (P = 0.002) were significant prognostic factors for CSS. PCE > 0.16 seemed to be not (P = 0.055)  Table . Accordit P = 0.05 ]. In addition, the ACE and PCE were also vital important variables in evaluating renal function [In our study, we validated the serum creatinine increased and the eGFR decreased postoperatively, revealing that RN with thrombectomy might also have an effect on patients’ renal function which was associated with OSfunction . The greAfter following RN, the renal function of RCC patients significantly declined . YokoyamAfter that, we also explore influencing factors of postoperative renal function, as well as its change rate. Preoperative eGFR seemed to be an important variable in assessing postoperative renal function, which was similar to previous studies. Lane et al.  reviewedSeveral researches have been established to explore the prognostic outcomes after RN with thrombectomy. Tang et al.  carried In our single institution experience, the reason of renal insufficiency after RN with thrombectomy consists of at least two aspects. One is renal ischemia caused by uninjured renal vein occlusion during operation. The other might be caused by insufficient circulation volume due to a large amount of bleeding during operation. In addition, the urine color and volume should be closely observed after operation. Several serum markers, such as serum creatinine, urea and electrolyte, should also be monitored. For patients with oliguria, increased serum creatinine or urea, it is recommended to supply blood volume and perform diuretic therapy in time, even making blood dialysis therapy if necessary.Limitations of the study include that this is a retrospective and single institution study. In addition, lymph node was independent prognostic factor in univariate analysis, but not in multivariate analysis, as well as metastasis. These results might be attributed to the small sample size of the patients in our group patients, for the reason that this is a disease with a relatively low incidence and the number of patients who can be operated on is much less. In addition, the renal function is truly influenced by many factors. Our article only lists some of them, which is not comprehensive enough. However, there seems to be less studies about renal function changes in TT patients in our knowledge and our study has obtained some conclusions for foundation of further research. Therefore, next research needs lager cohort, more multi-center and prospective studies and we expect a new more complex index including all prognostic predictors in assessing the change of perioperative renal function of patients following RN with thrombectomy in the future.We explored several clinicopathological risk factors of predicting renal function change and their relationship with prognosis of RCC patients with tumor thrombus after nephrectomy and thrombectomy. The renal function change, which was associated with preoperative eGFR and pathological type, was prognostic risk factor for CSS and ACE> 13.9 indicated the worse prognosis.Additional file 1: Table S1. Patient demographic and postoperative data according to different histology


Promoting patient and occupational safety are two key challenges for hospitals. When aiming to improve these two outcomes synergistically, psychosocial working conditions, leadership by hospital management and supervisors, and perceptions of patient and occupational safety climate have to be considered. Recent studies have shown that these key topics are interrelated and form a critical foundation for promoting patient and occupational safety in hospitals. So far, these topics have mainly been studied independently from each other. The present study investigated hospital staffs’ perceptions of four different topics: (1) psychosocial working conditions, (2) leadership, (3) patient safety climate, and (4) occupational safety climate. We present results from a survey in two German university hospitals aiming to detect differences between nurses and physicians.We performed a cross-sectional study using a standardized paper-based questionnaire. The survey was conducted with nurses and physicians to assess the four topics. The instruments mainly consisted of scales of the German version of the COPSOQ , one scale of the Copenhagen Burnout Inventory (CBI), scales to assess leadership and transformational leadership, scales to assess patient safety climate using the Hospital Survey on Patient Safety Culture (HSPSC), and analogous items to assess occupational safety climate.A total of 995 completed questionnaires out of 2512 distributed questionnaires were returned anonymously. The overall response rate was 39.6%. The sample consisted of 381 physicians and 567 nurses. We found various differences with regard to the four topics. In most of the COPSOQ and the HSPSC-scales, physicians rated psychosocial working conditions and patient safety climate more positively than nurses. With regard to occupational safety, nurses indicated higher occupational risks than physicians.The WorkSafeMed study combined the assessment of the four topics psychosocial working conditions, leadership, patient safety climate, and occupational safety climate in hospitals. Looking at the four topics provides an overview of where improvements in hospitals may be needed for nurses and physicians. Based on these results, improvements in working conditions, patient safety climate, and occupational safety climate are required for health care professionals in German university hospitals – especially for nurses.The online version of this article (10.1186/s12913-018-3862-7) contains supplementary material, which is available to authorized users. Promoting patient and occupational safety are two key challenges for hospitals. To effectively manage these challenges, healthcare organizations are recommended to develop a culture of safety . An orgaGiven the dynamic nature of modern hospitals, healthcare professionals are confronted with major changes in psychosocial working conditions characterized by skills shortage or imbalance, increasing workload and task complexity –10. In aIn recent years, several studies on working conditions , 25–32, Previous studies showed that physicians and nurses perceptions on psychosocial working conditions and safety culture vary, although they work in the same setting , 47. RecMoreover, when aiming to improve both patient and occupational safety in hospitals, psychosocial working conditions, leadership by hospital management and supervisors, and perceptions of occupational and patient safety climate have to be considered. Consequently, studies aiming to assess and potentially improve occupational as well as patient safety climate should take into account the views of nurses and physicians. Likewise, it is important to assess and evaluate perceptions and attitudes of the closely cooperating frontline healthcare workers to these four topics in order to develop comprehensive improvement measures for patient and occupational safety culture in hospitals.The present study investigated hospital staffs’ perception of these four topics for the first time from the perspectives of both nurses and physicians. We present descriptive findings on the current state in two German university hospitals and investigate perceptions and attitudes of nurses and physicians related to these four topics aiming to detect possible differences.Working conditions, safety culture and patient safety in hospitals – what predicts the safety of the medication process (WorkSafeMed). Part of the WorkSafeMed project was a staff survey using a standardized paper-based questionnaire. An overview of all scales and items used in this paper is provided in Table Between 2014 and 2017 we conducted a cross-sectional, multicenter, mixed-methods project Psychosocial working conditions: To measure staffs’ perceptions of psychosocial working conditions and the according strain (job satisfaction and burnout), we used 16 scales, each with a number of items ranging between three to seven, from the German version of the Copenhagen Psychosocial Questionnaire (COPSOQ) [(COPSOQ) –52. The (COPSOQ)  with the(COPSOQ) . Before Leadership: To measure leadership, and especially transformational leadership, we focused on the leadership quality scale from the COPSOQ-questionnaire [ionnaire , 51 and ionnaire . The lationnaire , 56. Eacionnaire . The itePatient safety climate: The multi-dimensional construct of safety culture is usually quantitatively measured by safety climate, which can be defined as the shared perceptions of employees about safety-relevant aspects of their work environment [Hospital Survey on Patient Safety Culture (HSPSC-D) [patient safety grade, and one single-item outcome on the overall safety grade in the medication process. Scale-items were rated on a 5-point Likert scale, either of agreement (from “1 = strongly disagree” to “5 = strongly agree”) or frequency . Scale scores were calculated after reverse coding of negatively worded items. High values on scales imply a high perception on patient safety climate. The two single-item outcomes were answered on a 5-point Likert frequency scale ranging from “1 = excellent” to “5 = failing”, where high values imply a rather low perception of these two outcomes. Based on findings from a former study [Individual influence on patient safety at the workplace), where high values imply a rather low perception of one’s own influence.ironment , 58. To HSPSC-D) . The inser study , self-deOccupational safety climate: As described above for the patient safety climate, we employed an identic item set to capture aspects of supervisor and management support regarding occupational safety as important aspect of the occupational safety climate . Each item here was rated on a 5-point Likert scale of agreement (from “1 = strongly disagree” to “5 = strongly agree”) or frequency . Maximum values are positive except for one item , where high values imply a rather low perception of one’s own influence. To assess occupational safety climate outcomes, we used three self-constructed indices , which measure perceived occupational safety: (1) subjective assessment of specific protective measures (behaviour & regulations) related to work-related infectious diseases (e.g. protective gloves), (2) subjective assessment of occupational safety measures initiated by the employer, related to own safety (e.g. regulations on how to act in the case of fire or other emergency) and (3) personal perception of the frequency of occupational risks (e.g. do you feel exposed to risks of infection?). Items were answered on a 5-point Likert scale of agreement (from “1 = strongly agree” to “5 = strongly disagree”) or frequency . Low values on scales and single items imply a high perception of occupational safety climate.The questionnaire used common and validated instruments to measure four study topics:Prior to data collection, the final survey underwent a pre-test with 4 physicians and 8 nurses using cognitive think aloud interviews.We conducted the staff survey with healthcare professionals at two German university hospitals. Hospital selection was based on a convenient sample to have an appropriate sample size large enough to perform multivariate analyses and keep organizational characteristics as comparable as possible. We included all inpatient units, which treat at least 500 patients per year and excluded intensive care and psychiatric units.Prior to data collection, the consent of the executive board of directors, the workers council, and the medical directors of the clinics/departments participating in the study was obtained in both university clinics. After a hospital-wide information by the executive medical directors of the two participating university clinics, the study was presented in department meetings of physicians or during regular team meetings of nurses in the units. The questionnaire then was distributed to a total of 2512 physicians and nurses . In total, we collected data from 37 departments including 73 units. The data collection took place between April 2015 and July 2015. After approximately two to four weeks, at least one written and, if necessary, oral reminder was carried out on the level of departments (physicians) or units (nurses).n = 4 , imputation group 2 (leadership): n = 42 , imputation group 3 (patient safety climate): n = 21 , imputation group 4 : n = 22 ). Then data for each group were imputed with NORM 2.03 software using the Expectation-Maximization-algorithm [P-values ≤.05 were considered statistically significant. As this is an explorative study, significance testing was conducted to discover tendencies and not for confirmatory purposes, thus no adjustment for multiple testing was applied. We calculated and categorized the effect size according to Cohen’s suggestions: mean/SD < .30 = small effect/difference, <.50 = medium effect/difference and ≥ .50 = large effect/difference [Prior to data analyses, we imputed missing values in the survey data (excluding sociodemographic items). For this, scale items from the four different topics  were grouped into four separate imputation groups. Within each imputation group, respondents with missing values of > 30% for scale items were excluded because of the limited data quality : lgorithm , 62. Aftfference . Data weEthics approval was obtained from the ethical committees at the two participating university hospitals. Informed consent was sought from participants, who were informed that the study was voluntary and that they could withdraw at any time. The data were analysed anonymously.A total of 995 out of 2512 distributed questionnaires were completed and returned. Thus, the overall response rate was 39.6%. The sample consisted of 381 physicians and 567 nurses . The response rates were 39.4% for nurses and 35.5% for physicians. In addition, 47 persons participated who either belonged to another professional group (19 persons) or gave no information on their professional status (28 persons). The characteristics of the sample are summarized in Table Descriptive results including differences for nurses and physicians in scale scores and items are presented on Table Quantitative demands were rated higher than emotional demands. The mean score of the work-privacy-conflict scale was also high in both professional groups. When comparing the two professional groups, we found that physicians experienced significantly greater quantitative demands (71.9 ± 13.9) than nurses (66.5 ± 13.5). However, there were no significant differences in emotional demands. Furthermore, although high in both professional groups, physicians reported a significantly greater work-privacy-conflict (68.7 ± 25.1) than nurses (61.3 ± 24.4). Both differences represented medium effects .When analysing demands, we found high values for both professional groups. influence at work, degree of freedom at work, and workplace commitment, while high (positive) value ranges were reported for possibilities for development and meaning of work. All in all, physicians made more positive indications in this domain than the nurses (see Table degree of freedom at work (d = .58), possibilities for development (d = .53), and workplace commitment (d = .68) presented a large effect, while the other two scales (influence at work: d = .13 and meaning of work: d = .32) represented small to medium effects.There were medium value ranges given for predictability, role clarity, feedback, and sense of community. We identified significant differences with small or medium effects in three scales . Nurses experienced more role conflicts (50.6 ± 17.2) than did the physicians (45.1 ± 18.4) in our sample. Concurrently, the results also indicate that nurses experienced more social support (66.7 ± 17.0) compared to physicians (64.2 ± 17.0). Physicians rated items on the scale social relations more positively (51.5 ± 15.1) than the nurses (45.0 ± 17.0).The results for interpersonal relations showed medium or high value ranges. Overall, we found fewer differences between physicians and nurses. There were no statistically significant differences between the two professional groups in the four scales job satisfaction was high in both professional groups, while the results of the scale patient-related burnout were low. However, physicians had significantly higher values for job satisfaction (73.4 ± 12.0) than the nurses (67.5 ± 10.2). Similarly, physicians reported significantly fewer symptoms for patient-related burnout (28.0 ± 16.5) compared to nurses (36.5 ± 17.6). The differences between the professional groups with regard to job satisfaction and patient-related burnout represented a large effect size (job satisfaction: d = .54 and patient-related burnout: d = −.50).The average mean on the scale Values for employees’ views on transformational leadership were relatively high for both physicians (3.2 ± 0.8) and nurses (3.1 ± 0.8). There was no significant difference in rating transformational leadership. Nurses rated the quality of leadership more positively (53.8 ± 22.7) than physicians (49.2 ± 22.9). This difference was significant but represented a small effect size (d = −.20).staffing (2.8 ± 0.8), nonpunitive response to error (3.5 ± 0.8) management support for patient safety (3.0 ± 0.8), and teamwork across units (3.1 ± 0.7) than nurses . By contrast, nurses gave significantly higher ratings for the two scales communication openness (3.7 ± 0.6) and handoffs and transitions (3.2 ± 0.6) than the physicians . All of these differences represented a medium to rather large effect size, with exception of the scales teamwork across units and nonpunitive response to error. We observed no significant differences between the two professional groups in the remaining four scales .We observed statistically significant differences between nurses and physicians in six out of ten patient safety culture scales. Physicians gave significantly higher ratings for the four scales We also identified significant differences for the twin items regarding patient safety climate. Physicians rated the three scales focusing on management and the scale addressing individual influence on patient safety at the workplace more positively than nurses. These differences represented a small to medium effect size. We found no significant differences between the two professional groups in the other four scales.patient safety grade and safety grade in the medication process were rated significantly less safe by the nurses  than by physicians . In addition, physicians rated the overall perceptions of patient safety as significantly safer (3.3 ± 0.8) than the nurses (2.9 ± 0.7). These differences represented a medium to large effect. We found no significant difference in frequency of reported events.The single items individual influence on occupational safety less positively than individual influence on patient safety.We identified significant differences for the twin items covering occupational safety climate. Physicians rated two of the three scales focusing on management more positively than the nurses . They also indicated higher occupational risks (3.2 ± 0.8) than physicians (3.5 ± 0.7). This difference was significant and it also represents a medium effect (d = .39). Both professionals groups also stated that specific protective measures related to infectious diseases were important.Two significant differences between the two professional groups were found in the outcome scales. Nurses rated This paper analysed data from a staff survey conducted at two German university hospitals. The applied standardized questionnaire was used to assess psychosocial working conditions, job satisfaction, patient safety climate, and occupational safety climate. We report results of descriptive and inferential statistics aiming to detect differences between the two professional groups.Overall, there are few studies which use the COPSOQ instrument to jointly question physicians and nursing staff on their psychosocial working conditions and to compare the results. Ilic et al. questioned nurses and physicians on their working conditions and found some differences between the two professional groups . The phyinfluence at work, degree of freedom at work, possibilities for development, meaning of work, workplace commitment, role conflicts, social relations, job satisfaction, and the additional scale patient-related burnout) were significantly more positively assessed by physicians than the nursing staff. This may be due to the fact that some of the differences also lie in the work characteristics of the two occupational groups. A physician usually has more influence at work than a nurse. Nursing staff assessed a total of three scales addressing the concept of psychosocial working conditions  significantly more positively than physicians. The results imply that, on the whole, the surveyed physicians in our study evaluated their psychosocial working conditions more positively than nursing staff. That nurses critically assess their working conditions was also demonstrated in other studies. For example in the RN4Cast study, in nine out of 12 European countries more than half of the surveyed nurses reported that the work environment at their hospital was poor or fair, as opposed to good or excellent [Our study found significant differences between the two professional groups in 12 out of 17 scales. Nine scales  were rated more positively by physicians than nurses. In contrast, nursing staff rated the scales communication openness and handoffs and transitions more positively than physicians. Our results correspond to other studies which questioned both physicians and nursing staff about patient safety and reported apparent differences between occupational groups [We found significant differences between the occupational groups for patient safety climate in nine out of 14 scales. Similar to the assessment of the psychosocial working conditions, patient safety climate was also assessed more positively by physicians than by nursing staff. Seven scales


Febrile seizures are the most common type of seizure in the first 5 years of life, and many factors that increase seizure risk have been identified. This study was performed to examine the association between iron status and febrile seizures in children in South Korea.A prospective unmatched case control study was performed in 63 cases of febrile seizures and 65 controls with febrile illness but no seizures.P = 0.012) and ferritin < 30 ng/mL  were associated with increased risk of developing febrile seizures in multivariate logistic regression analysis.Serum iron, plasma ferritin, and transferrin saturation were significantly lower in children with febrile seizures compared to the controls. Iron deficiency, defined as ferritin < 30 ng/mL, was more prevalent in the febrile seizure group (49.2%) than in the control group (16.9%). Serum iron < 22 ng/dL (odds ratio 3.42, 95% confidence interval [CI] 1.31–8.9, These observations suggest that iron deficiency prior to development of anemia may increase risk of febrile seizures. Febrile seizures are defined as seizures accompanied by fever without central nervous systemic infection or metabolic disorder. It is the most common type of seizure in the first 5 years of life, which affect 2–5% of all children . ChildreIron is an important nutrient that acts as a cofactor for several enzymes in the body, as well as playing roles in the production and function of neurotransmitters, hormones, and DNA (deoxyribonucleic acid) duplication. Iron is also essential for enzymes involved in neurochemical reactions, such as myelin formation, metabolism of some neurotransmitters, and brain energy metabolism . Iron deReports regarding the association between febrile seizures and iron status have been inconsistent; some studies indicated that iron deficiency with or without anemia was more prevalent in children with febrile seizures –18, wherHere, we compared the iron status of children with febrile seizures and controls to investigate the association between iron status and febrile seizures in children in South Korea.This prospective case control study was performed between August 2015 and July 2017. The study population consisted of 128 patients aged 6 to 60 months admitted to the Department of Pediatrics of Kyung Hee University Hospital . Sixty-three children with febrile seizures and 65 controls with febrile illness only were included in the study. The parents of all patients provided written informed consent for inclusion in the study, which was approved by the Medical Sciences Ethics Committee of Kyung Hee University Hospital.n = 63) included patients with seizure accompanied by fever ≥38 °C without central nervous system infection or metabolic disorders. The control group (n = 65) was selected randomly from among children admitted for febrile illnesses, such as gastroenteritis, otitis media, or respiratory tract infections, without seizure around the same time with the cases. Patients with chronic cardiovascular, renal, rheumatological or malignant diseases, and hemoglobinopathies, or other blood disorders were excluded from the study as they were more likely to have anemia. Patients with central nervous system diseases such as developmental delay, motor disabilities, and mental or cognitive defects were also excluded as they could have nutritional deficiency that may affect the results of the study. All of the febrile seizure patients and controls received appropriate diets for their ages without feeding problems. The febrile seizure and control groups were comparable in age, gender distribution, and clinical characteristics of febrile illness. Routine hematologic investigation were performed at the emergency department or 1st day of admission. The laboratory results regarding blood indices and iron status were analyzed using complete blood count (CBC), serum iron, plasma ferritin, total iron binding capacity (TIBC), and transferrin saturation, which were compared between the two groups. Patients were diagnosed with complex febrile seizures if they had experienced prolonged (> 15 min in duration), focal, or repetitive (more than one seizure within 24 h) seizures [The febrile seizure group (seizures . The labAnemia was defined as a hemoglobin (Hb) level of 2 standard deviations below the normal values for age, i.e., Hb < 10.5 g/dL for ages 6–24 months and < 11.5 g/dL for ages 2–5 years. Iron deficiency was defined as serum iron < 22 μg/dL, plasma ferritin < 30 ng/mL, or transferrin saturation < 16% .Children with a history of afebrile seizures, any antiepileptic drug medication, central nervous system infection, neurological deficit, or developmental delay were excluded from the study.A pilot study on 60 patients (24 cases and 34 controls) was performed for sample size estimation. Using G*power 3.1, based on α = 0.05 and study power (1–β) = 0.8, mean ferritin level 38.4 ± 20.5 ng/mL (cases) and 60.9 ± 53.1 ng/mL (control), the sample size of each group was estimated 52.t-tests. After checking normality of the data by Shapiro-Wild test, we applied Mann-Whitney U tests for non-normal data and independent t tests for normally distributed data. The q-q- plots of hematocrit and serum iron level are presented in Figs. P < 0.10. Multiple logistic regression analysis was performed to examine the relationship between iron deficiency and development of febrile seizures. P < 0.05 was taken to indicate statistical significance.The collected data were analyzed using SPSS 21.0 statistical software. The Chi-square test was used for analysis of qualitative variables, while continuous variables were compared between case and control groups using independent-samples P = 0.07). The mean hemoglobin levels were 12.27 ± 0.75 g/dL in the febrile seizure group and 12.16 ± 1.01 g/dL in the control group; the difference was not significant. Comparison of the demographic and clinical characteristics between the two groups showed that body temperature was slightly higher in the febrile seizure group than the control group (Table The study population consisted of 63 children in the febrile seizure group and 65 children in the control group.). The mean age was 27.1 ± 13.5 months in febrile seizure group and 22.8 ± 13.3 months in control group (P > 0.05). Table P = 0.03), plasma ferritin , and transferrin saturation  were significantly lower in the febrile seizure group compared to the controls.Among children aged 6 to 24 months, two of 65 children in the control group and none of 63 children in the febrile seizure group had anemia. Two older children aged 24 to 60 months in each group had anemia; the difference was not statistically significant  and serum iron < 22 ng/dL  were more prevalent in the febrile seizure group compared with the control group. Comparing the hematological variables between simple (n = 47) and complex (n = 16) febrile seizures, there were no differences in hemoglobin, serum iron, TIBC, ferritin, or transferrin saturation (Table P = 0.01)  and low plasma ferritin < 30 ng/mL  were shown to increase the risk of developing febrile seizures  in Greece. In a study performed in Jordan, mean ferritin level was significantly lower in cases with first febrile seizures than in controls [P < 0.001) or MCV , was associated with febrile seizures. Karimi et al. [In a case–control study performed in 1996, Pisacane et al.  reportedcontrols . In contcontrols  and Bidacontrols  reportedcontrols –28. In tcontrols , iron dei et al.  performei et al.  also repi et al. . In the Notably, the overall prevalence of iron deficiency anemia in the present study was 4.7% (6/128), which was much lower than in previous studies performed in the Middle East. The low prevalence of iron deficiency anemia may reflect improved nutritional status in children in South Korea. Most of the patients were from the capital, Seoul, which is a megacity with a high quality of life. The small number of patients with anemia may have led to a lack of association between iron deficiency anemia and febrile seizures. However, iron deficiency itself was found to increase the risk of febrile seizures in the present study.Iron is an essential nutrient for proper growth and development in children. Iron deficiency interferes with the function of many organs, leading to anemia, abnormal growth and behavior, cognitive deficits, altered thermoregulation, impaired physical performance, and immune dysfunction , 36. TheIron status may also reflect general health, including nutrition, growth, and immunity in children. Poorer general health status may be associated with febrile seizures via low seizure threshold or frequent infection , 42.The main limitation of the present study was the potential confounding effect of ferritin as an acute-phase reactant agent, which can interfere with identifying the influence of iron status on febrile seizures. However, patients in both the febrile seizure group and the control group were enrolled at the time of febrile illness, so it is supposed that the difference in ferritin level between the two groups would be significant.The results of this study were noteworthy based on its prospective design and its location in East Asia, in contrast to most previous studies regarding this issue. It is suggested that iron deficiency is a significant issue for children worldwide, that clinicians should pay attention to.Iron deficiency, defined by low ferritin level or low serum iron, was associated with increased risk of febrile seizures. Therefore, in children with febrile seizures, we suggest that clinicians should be concerned for iron status even at normal hemoglobin levels. Further studies are required to determine the detailed pathomechanism underlying the association between iron deficiency and a lower seizure threshold. In addition, further prospective studies are needed to determine whether iron supplementation can prevent the occurrence of febrile seizures.


To evaluate corneal biomechanical properties by the Ocular Response Analyzer (ORA) in non keratoconic patients underwent penetrating keratoplasty (PK).Corneal hysteresis (CH), corneal resistance factor (CRF), Goldmann- correlated intraocular pressure (IOPg), cornea-compensated IOP (IOPcc) using the ORA, and central graft thickness (CGT) were measured in 30 eyes at least two years after penetrating keratoplasty for non keratoconic indications. IOP using the Goldmann applanation tonometer (GAT) was also obtained after compensation for graft thickness and astigmatism.P < 0.001). No significant association was found between CGT and IOP readings obtained using either the ORA or GAT. There were significant negative association between CH with both IOP GAT and IOPcc, while CRF had significant positive association with IOPg.The mean age of patients was 33.1 ± 10.13 years; indications for PK were herpetic corneal scar (53.3%), corneal stromal dystrophy (23.3%), traumatic corneal opacity (10%), chemical corneal opacity (6.7%), and Fuchs endothelial dystrophy (6.7%). Mean CH and CRF were 8.52 ± 1.81 mmHg, and 8.56 ± 1.59 mmHg, respectively. Mean CGT was 532.43 ± 30 μm. Mean IOP GAT, IOPg, and IOPcc were 11.88 ± 3.66, 14.64 ± 4.08, and 17.27 ± 4.60 mmHg, respectively (After penetrating keratoplasty for non keratoconic patients, graft biomechanics does not return to average values even 2 years after the operation; moreover, intraocular pressure measurement with ORA gives higher values than thickness compensated GAT. Corneal transplantation, regardless the technique, aims at restoration of anatomical as well as optical properties of the eye. Nonetheless, the exact changes in biomechanical properties of the graft are not fully explored. Moreover, intraocular pressure (IOP) follow up after corneal transplantation is of a particular importance, as high IOP (more than 21 mmHg) is reported in transplanted eyes at a high incidence, ranging from 10 to 42% [P value that is less affected by corneal properties, such as CCT. Corneal Resistance Factor (CRF) is calculated using a proprietary algorithm and is an indicator of the overall cornea resistance [Using the bidirectional applanation measurements, the ocular response analyzer  is able to present the four main measurements. Corneal hysteresis (CH) is the difference between the two pressure values, which represents the corneal viscoelastic damping. The mean of these two pressures is the Goldmann-correlated IOP (IOPg). The Corneal-compensated IOP (IOPcc) is a pressure measurement that uses the CH to determine an IOsistance .In many reports, CH and CRF were found to be significantly lower in keratoconic eyes than in normal eyes , 5. AnteThis study aims to evaluate the impact of penetrating keratoplasty on corneal biomechanics for non keratoconic patients.This was a cross sectional study on non keratoconic patients who underwent penetrating keratoplasty at “Ophthalmology department of Menoufia University Hospitals & Memorial institute of ophthalmology in Giza” from January 2014 to February 2016. After receiving the approval of Ethical Committee of the Menoufia University Hospital, all patients received a thorough explanation of the study design and aims followed by a signed informed consent; the study was conducted in compliance with the tenets of the Declaration of Helsinki.Included eyes showed clear graft after successful penetrating keratoplasty for non keratoconic indications, with all sutures removed; and at least 2 years passed after the operation. The technique for penetrating keratoplasty, carried out by the same surgeon (MSA), was almost identical in all patients with trephine- punch disparity of 0.25 mm (recipient trephine size of 7.5 mm and donor punch size 7.75 mm), postoperative treatment in the early period included topical moxifloxacin hydrochloride 0.5% and prednisolone acetate 1% eyes drops with gradual tapering over the first year; if corneal opacification originated from herpes simplex virus (HSV), additional oral acyclovir was added with a dose of 400 mg twice daily for at least one year.Sutures removal started, on average, 6 months after the procedure for correction of residual astigmatism, all included eyes had their sutures entirely removed with average of 6 months before measurements.Exclusion criteria were as follows: keratoconic patients, history of glaucoma, previous intraocular ocular surgery, post keratoplasty corneal scars or opacities, use of contact lenses after PK, and systemic collagen diseases e.g.: Marfan, Ehler Danlos syndromes.Each subject had a comprehensive ophthalmologic examination, including a review of their medical history, uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA) measured by decimal notation, manifest and cycloplegic refraction, slit lamp biomicroscopy, fundus examination, manifest refraction, and keratometry.To obtain corneal hysteresis (CH), corneal resistance factor (CRF), Goldmann-related IOP (IOPg) and cornea-compensated IOP (IOPcc); we used the ocular response analyzer , 3 readings were recorded consecutively at the same session and the average was calculated, all low quality recordings were excluded.Applanation tonometry measurements (IOP GAT) were done the same day after the ORA readings are obtained, using Goldmann applanation tonometry AT 900 . Two separate observers took the measurements at 10 min interval, and then the average is recorded. To compensate for corneal thickness; central graft thickness (CGT) was measured separate using an ultrasonic contact pachymeter  under topical anesthesia The probe was held perpendicular to the center of the graft and 5 measurements were obtained with the average calculated automatically. Meanwhile the average GAT measurement is manually introduced into the ultrasonic machine to get (thickness corrected IOP) automatically. With corneal astigmatism more than 4 diopters, the prism was rotated so the red mark on the prism holder is set at the least curved meridian of the cornea .P-value < 0.05 was considered statistically significant. P < 0.05 was considered statistically significant.Data were presented in terms of mean ± standard deviation (± SD), median and range, or frequencies and percentages when appropriate. Paired t-test was used to compare mean IOP readings by the ORA and GAT. Repeated measurement comparison analysis adjusted for multiple comparisons by the Bonferroni method was used to compare mean IOP readings by the ORA and GAT. The agreement between the two tonometers was evaluated with Bland-Altman plots. The correlation of CGT, refractive status , and graft biomechanical properties (CH and CRF) with the IOP readings by both tonometers was investigated using multivariate regression analysis. Multiple linear regression analysis models with the ENTER method were conducted with IOPcc and IOPg as the outcomes while age, corneal pathology, CCT, corneal astigmatism, mean K reading, CH and CRF as potential predictors. All statistical calculations were done using computer program SPSS  version 21 for Microsoft Windows.In this cross-sectional study, a total of 30 eyes underwent PK for non keratoconic reasons, were recruited. Of these eyes, 16 eyes suffered from post herpetic corneal scar, 7 eyes had corneal stromal dystrophy, corneal scars from blunt trauma encountered in 3 eyes, and chemical injuries in 2 eyes. Two eyes suffered end stage Fuchs endothelial dystrophy. The demographic data of this study is summarized in Table Postoperative spherical equivalent refractive error (SRE), mean keratometry, and keratometric astigmatism were − 4.325 ± 2.16 D, 44.71 ± 2.03 D, and − 6.97 ± 3.21D, respectively. As well, mean CH and CRF were 8.52 ± 1.81 mmHg, and 8.56 ± 1.59 mmHg, respectively. Mean central graft thickness (CGT), measured by ultrasonic pachymetry, was 532.43 ± 30 μm.p < .001*).As demonstrated in Table The Bland-Altman plots show the agreement between pressure measurements obtained with ORA and GAT as dots lie within limits of confidence interval (CI) of agreement Figs.  and 2 asP < .001)}.Correlations of biometric characteristics  with IOP measurements obtained with the ORA and GAT are summarized in Table Results of the multiple regression analysis models are presented in Table The human cornea is a viscoelastic tissue with various biomechanical properties which significantly impact its functional abilities, and ultimately the vision. As well, CBMs can be used as indicators for its structural integrity & IOP measurements. It is now well-established that different physiological factors and corneal disorders alter these properties, which may solve the mystery for many features of these disorders. Age, gender and pregnancy as well as diabetes mellitus, keratoconus, iatrogenic ectasia, Fuch’s dystrophy and keratitis are known to profoundly affect the CBMs , 8–13. KIn this study, it is hypothesized that the altered corneal structure in post-PK eyes may result in changes of corneal biomechanics; which in part may be also affected by the recipient remaining corneal tissue. Different corneal layers contribute with different proportions to the biomechanical properties, however, the collagen bundles in the stroma play the master role. Given that, pathological changes affecting the stromal bundles possess the most striking changes in biomechanics , 17. ThiTherefore, we excluded KC patients to get over the primary pathology and highlight the effect of PK on corneal biomechanics as well as IOP assessment. As well, in our series, all sutures were removed at least 6 months before the assessment of individual cases. However, it is worth mentioning that the impact of sutures on CBMs is negligible as reported in different studies , 21, 22.Murugesan and his colleagues reported CH and CRF values of 8.4- and 8.8-mmHg respectively with significant correlation detected with IOPg and IOPcc. This report was derived from 100 healthy eyes and 54 post-PK ones with a mean follow-up period of 19 months. Nonetheless, masking the indication (the preoperative pathology) in the PK group brake driving further implications [The corneal hysteresis ranges normally between 9.3 ± 1.4 and 11.4 ± 1.5 mmHg, while CRF ranges between 9.2 ± 1.4 and 11.9 ± 1.5 mmHg. In this study, the mean CH and CRF was 8.52 ± 1.81 mmHg and 8.56 ± 1.59 mmHg respectively after two years of successful penetrating keratoplasty. While these values are below the normal range, lack of a self-controlled comparison with the contralateral eyes due to existence of similar corneal pathologies. Comparable to our results, ications .Shin et al. followed 26 eyes for an average of 19 months that underwent PK for various pathologies not including KC. What distinguishes the latter study is the contralateral healthy eye that was assigned as a control. CH and CRF were 8.9- and 10.2 mmHg respectively which are close to our results. However, both of them showed no significant difference between PK and control groups [l groups .Glaucoma is among the most common causes of graft failure due to endothelial dysfunction and loss. In addition, the risk of glaucoma after keratoplasty is very high, ranging from 14 to 30%, owing to different mechanisms, including the peripheral anterior synechia which is the most common one for late-onset glaucoma. Given all the previous facts, accurate assessment of IOP after keratoplasty is vital for to maintain functional graft. Goldman applanation tonometer (GAT) is the gold standard tool for IOP Nonetheless, after keratoplasty, surface irregularity and graft thickness as well as the astigmatism pose challenges for this apparently simple measure in practice, with no well-approved tool for this measure , 24–26.In this study, we compared the intraocular pressure measurements obtained from GAT and ORA (IOPg and IOPcc) after PK for non keratoconic patients. GAT showed the least IOP reading while IOPcc gives the highest measurement with a statistically significant difference between the 3 measurements. Outcomes for IOP measurements obtained from different studies after penetrating keratoplasty are summarized in Table p < 0.01) and the positive one between CRF and IOPg , both of them are consistent with our study with a higher negative correlation for IOPcc and CH. This may be explained by the exclusion of KC cases in our study that we believe it profoundly alter the CBMs compared to all other disorders [In addition, we highlight the results of Fabian due to similarities in IOP assessment protocol, including different pathologies and the long mean follow-up period (65 months). Similar to our results, Fabian et al. reported significantly different GAT, ORA and Tonopen IOP measurements with IOPcc was the highest. As well, no correlation was detected for IOP with astigmatism, corneal curvature or graft thickness. However, Fabian reported no correlation between IOP and CBMs except for the inverse correlation between CH and IOPcc  and CCT or astigmatism. As well, IOPcc was the highest reading obtained with an average of 18.6 mmHg similar to our results. However, what is really stunning in Murugesan study is the IOP measurements in normal and post-PK eyes when plotted against graft thickness. According to the Goldman principle, IOP is inversely correlated to the corneal thickness, so in a thicker cornea, IOP is over-estimated and vice versa. Trying to apply this, it is a bit odd to get significantly lower IOP with thicker corneas in the latter study. Normal and post-PK corneas had an average CCT of 530.5 μm and 516.2 μm respectively. The corresponding IOPg and IOPcc were 14.1- and 15.2-mmHg in normal corneas, while in post-PK ones IOPg and IOPcc were 15.9- and 18.6-mmHg respectively [Shin’s study where IOPg and IOPcc was 19.2- and 20.8-mmHg respectively in the PK group compared to 15.07- and 16.2-mmHg respectively in the healthy control eyes. The corresponding CCT was 489.1- and 556-μm in the PK and normal groups respectively [The concept of no correlation between IOP & CBMs on one side and graft thickness on the other side isn’t odd with many studies reinforce it. ectively . It can’Clemmensen investigated the IOP & CBMs changes in Fuch’s dystrophy and after DSEAK. IOPcc was significantly higher than GAT in Clemmensen’s study [Vajaranant explored the IOP after DSEAK with non-contact tonometer, showing that it was independent from the graft thickness [In penetrating keratoplasty, different elements interact and are supposed to alter the IOP measurement. Astigmatism and corneal curvature are among these factors. Anterior lamellar keratoplasty induces less changes in biomechanics when compared to PK. Building on this, IOP changes are expected to differ from those after PK , 29. Sca’s study . Similarhickness . This caAiming to unveil the key predictors and effectors after PK, the multivariate regression analysis was planned with IOPcc and IOPg as the outcomes while age, corneal pathology, CCT, corneal astigmatism, mean K reading, CH and CRF as potential predictors. The adjusted R  for IOPcYenerel et al. showed that mean CH and CRF values were significantly lower in all groups  when compared to normal eyes. However; they reported mean CH and CRF values after PK of 10.16 ± 1.93- and 9.94 ± 2.34- mmHg respectively [Feizi et al. reported a CH and a CRF of 10.1- and 10- mmHg respectively in KC eyes after PK, which is quite different from our results and other studies on non-keratoconic eyes [While we excluded KC from our study for the previously explained rationale, it is still of value to contrast our outcomes with those obtained from KC studies. ectively . The disnic eyes . This exLimitations of this study is the relatively small sample size considering the underlying multiple subgroups. While this may be explained by excluding KC eyes, the relatively small sample limits the value of the regression analysis model. As well, comparing different corneal pathologies as subgroups couldn’t be conducted. In addition, lack of data for the corneal biomechanics of donors which definitely may have some impact on final postoperative outcomes.After PK, the corneal tissue becomes weaker after surgical intervention. Moreover; the cornea doesn’t not achieve the same tensile strength even two years after surgical intervention, with all of its biomechanical measures are compromised. As well, after PK, ORA is valuable for IOP assessment which largely depend on CBMs rather than graft thickness.


With the achievement of longevity in hemodialysis patients, the risk of comorbid cancer has begun to draw attention. In the present study, we examined dialysis‐related practice patterns and compared those patterns by cancer status.Using data from the Japan Dialysis Outcomes and Practice Patterns Study phase 4, we evaluated 2153 hemodialysis patients. Baseline cancer status for patients was separated into 3 categories: no cancer, cancer with recent treatment, and cancer without recent treatment. We then assessed variations among hemodialysis patients in dialysis‐related practice patterns, including anemia management, management of mineral and bone metabolism disorder, nutritional management, and dialysis treatment, by cancer status.3 IU/L/month) than in those without cancer. Phosphorus and calcium levels were also similar. Nutrition statuses were similar among cancer statuses, as were dialysis therapies. These results suggested that physicians do not modulate their dialysis‐related practices based on whether or not a hemodialysis patient has cancer.We observed both similarities and differences in dialysis‐related practice patterns among hemodialysis patients, by cancer status. Hemoglobin levels were largely similar for all cancer statuses, although erythropoiesis stimulating agents dose tended to be higher in hemodialysis patients with recent cancer treatment  than in those without cancer. Phosphorus and calcium levels were also similar. Nutrition statuses were similar among cancer statuses, as were dialysis therapies. These results suggested that physicians do not modulate their dialysis‐related practices based on whether or not a hemodialysis patient has cancer.Conclusion: Among long‐term facility‐based hemodialysis patients with cancer, we detected no statistically significant differences to suggest that cancer status affects hemodialysis practice regarding mineral and bone disorder management, nutritional management, and dialysis treatment. Facility‐based hemodialysis patients with recent cancer treatment, however, receive a higher dose of erythropoietin‐stimulating agent than those without cancer. For example, while erythropoiesis‐stimulating agent (ESA) is widely used for anemia management in HD patients, the clinical guidelines for general patients with cancer recommend against the use of ESA in such situations, as ESA might adversely affect cancer progression.Once we determine if and how physicians presently alter their dialysis‐related practices for HD patients with cancer, we can begin to discuss how to improve the quality of care and clinical outcomes of this particular patient population. In the present study, to clarify the real‐world situation of these patients, we examined and compared the dialysis‐related practice pattern in patients with cancer with or without recent treatment, to those without cancer.22.1We conducted a cross‐sectional analysis using baseline data from the Japan Dialysis Outcomes and Practice Patterns Study (J‐DOPPS) phases 4 (2009‐2011). Details regarding the study design of J‐DOPPS were reported in a previous study.2.2J‐DOPPS complied with the Declaration of Helsinki, and all participants gave informed consent before enrollment. This study's conduct was approved by the Ethics Committee of Tokyo Women's Medical University .2.3We included HD patients aged 18 or more who participated in J‐DOPPS. Patients without data on their cancer status were excluded.2.4Information on the presence or absence of malignant tumors was collected at baseline in J‐DOPPS. Cancer status was divided into 3 categories: no cancer, cancer with recent treatment, and cancer without recent treatment. Presence or absence of cancer was measured at enrollment in J‐DOPPS. Recent treatment was defined as treatment for cancer within 1 year prior to the baseline evaluation. Cancer type was defined as solid tumor with metastasis, solid tumor without metastasis, myeloma, or leukemia.2.5Dialysis‐related practice included anemia management, management of mineral and bone metabolism disorder (MBD), nutritional management, and dialysis treatment. These data were measured at baseline. For anemia management, we measured serum levels of hemoglobin (Hb) and ferritin; administration of ESA, including rHuEPO‐α (or β), darbepoetin‐α, and epoetin β pegol; ESA dose; erythropoietin resistance index (ERI); administration of intravenous iron; and blood transfusion. In accordance with the method of an earlier study, dose conversion from darbopoetin‐α or epoetin β pegol to rHuEPO‐α (or β) was performed using 1:200 ratios per week.2.6P values for differences in practices by cancer status were calculated using analysis of variance (ANOVA) or χ2 test. To account for the facility‐level clustering effect, we used a generalized estimating equation with robust variance.We described patient characteristics by cancer status . Continuous data with a normal distribution were summarized as mean values (standard deviation), while continuous data with skewing were presented as medians (interquartile range) and categorical data as proportions. We also described dialysis‐related practice by cancer status. 33.1Among 2153 HD patients, 84 (3.9%) had cancer without recent treatment and 68 (3.2%) had cancer with recent treatment  and >10 g/dL in all groups. The mean ferritin level was different among the groups . The fully adjusted mean difference in ferritin level was 122.4 ng/mL in those with recent cancer treatment, compared with the reference group of “no cancer.” The mean ESA dose was higher in those with cancer than in the “no cancer” group. Among those with recent cancer treatment, the fully adjusted mean difference in ESA dose was 5.4 × 103 IU/L/month compared with the “no cancer” group. The mean ESA resistance index was higher in patients with recent cancer treatment than in those without cancer . No significant differences were noted between groups in intravenous iron use or incidents of blood transfusion.Table 3.3Table 3.4Table 3.5Table 4We found both similar and different characteristics of dialysis‐related practice patterns among HD patients depending on their cancer status. Hb level was similar among all statuses, with ESA dose greater in HD patients with recent cancer treatment than in those without. Phosphorus levels and calcium levels were also similar across all statuses. Normalized protein catabolic rates were similar among all cancer statuses, as were dialysis therapies. These findings suggest that physicians did not modulate their dialysis‐related practices based on cancer status according to the patient's condition, among HD patients in Japan.3 IU/L/month in ESA dose among HD patients who had recently received cancer treatment compared with those without cancer, after adjusting. The proportion of ESA use among patients with cancer exceeded 85% in the present study, which was higher than that noted in a previous study (37% in the CANDY study).Controversy persists regarding ESA use for anemia management in patients with cancer. A previous systematic review revealed increased rates of death and thrombosis among ESA users with cancer.Physicians might be administering a greater dose of ESA for HD patients with cancer in an effort to avoid unnecessary blood transfusions or iron replacement therapy.In the present study, serum ferritin levels were different among cancer statuses. Some studies have reported that elevated serum ferritin was associated with malignancy.In terms of MBD management, the proportions of phosphate binder use, intravenous vitamin D receptor activator use, and cinacalcet use did not markedly differ by cancer status. Phosphorus levels and calcium levels were also similar among cancer statuses. The mean values of phosphate, calcium, and intact‐parathyroid hormone were controlled to within the target ranges of the clinical guidelines, regardless of cancer status. Incidentally, hypercalcemia was found in approximately 1.5% to 5% of patients in each group.Our results show no marked difference in the control of calcium levels between the patients with cancer and those without cancer. Because serum calcium levels tend to be higher because of hypercalcemia in patients with malignancy, calcium level control in patients with cancer is generally difficult.Neither nutritional management nor dialysis treatment differed markedly among cancer statuses. Although both HD and cancer patients have been reported to be at risk for having low nutritional status,In terms of dialysis treatment, Japanese HD patients receive moderate dialysis therapy at a low blood flow rate, with a long dialysis time and low intradialytic weight in comparison with other countries.Among baseline characteristics, a number of differences were seen between patients with and without cancer; among these, patients with cancer tended to be older and more commonly female than those without cancer. In general, older patients tend to have a higher risk of cancer. Similar trends were found in end‐stage renal disease (ESRD) patients: one study reported a higher standardized incident rate of cancer in ESRD patients aged over 40 years than in those under 40 years of age,Several strengths to the present study warrant mention. First, 2‐stage stratified random sampling was used in the J‐DOPPS cohort. Therefore, this study involves a representative cohort of Japanese HD patients. Second, we had access to detailed data from this cohort on multidisciplinary dialysis‐related practice patterns, including anemia management, MBD management, nutritional management, and dialysis treatment. Third, to our knowledge, this is the first study to examine variations in dialysis‐related practice patterns based on cancer status.However, several limitations should also be mentioned. First, we only included patients who received long‐term HD therapy at a facility. Therefore, our results may not be applicable to other ESRD populations, such as predialysis patients, peritoneal dialysis patients, and home dialysis patients. In addition, we only included Japanese HD patients. Second, other factors might have affected the dialysis‐related treatment. For example, mean age differed among the cancer status groups Table , and diaAmong patients with cancer who receive facility‐based HD treatment in Japan, we detected no statistically significant differences to suggest that cancer status affected HD practice regarding MBD management, nutritional management, and dialysis treatment. Facility‐based HD patients with cancer receive a higher ESA dose than those without cancer.This study was supported by Kyowa Hakko Kirin. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.Nishiwaki H. received grants from Kyowa Hakko Kirin. Fukuma S. has acted as a scientific advisor to Kyowa Hakko Kirin. Fukuhara S. has acted as a scientific advisor to and received grants from Kyowa Hakko Kirin. Akizawa T. has consultancy agreements with Astellas Pharma, AbbVie, Kyowa Hakko Kirin, Bayer HealthCare Pharmaceuticals, GlaxoSmithKline, JT Pharmaceuticals Corporate, Kissei Pharmaceutical, Nipro Medical Corporation, Ono Pharmaceutical, and is a member of the Astellas' advisory panel. Akizawa T. is also a scientific advisor of Bayer HealthCare Pharmaceuticals and a member of the speaker's bureau of Bayer HealthCare Pharmaceuticals, Kyowa Hakko Kirin, Chugai Pharmaceutical, Torii Pharmaceutical, Fuso Pharmaceutical Industries, and Teijin Pharma. Hasegawa T has consultancy agreements with Kyowa Hakko Kirin. These conflicts did not affect the design, results, or conclusions of the study.Conceptualization: Hiroki Nishiwaki, Takeshi HasegawaFormal analysis: Shingo Fukuma, Miho KimachiMethodology: Hiroki Nishiwaki, Takeshi HasegawaSupervision: Tadao Akizawa, Shunichi FukuharaWriting—original draft preparation: Hiroki Nishiwaki, Shingo Fukuma, Miho KimachiWriting—review and editing: Takeshi Hasegawa, Tadao Akizawa


The purpose of this study was to report the outcomes of patients who underwent penile implantation with AMS 700 LGX inflatable penile prosthesis (IPP) in a single center by a single surgeon.A total of 342 patients with erectile dysfunction who underwent AMS 700 LGX IPP implantation between October 2014 and April 2016 were included in this study. All patients were evaluated using the International Index of Erectile Function questionnaire preoperatively and at 3, 6, and 12 months postoperatively. We also investigated the mean stretched flaccid penile length before and after surgery as well as the complications related to and the mechanical reliability of the IPP.P < 0.001), 6 , and 12  postoperatively. There were no intraoperative or perioperative complications. However, one patient had infection and 10 patients developed mechanical failure during the follow-up duration.The questionnaire scores at 12 months were statistically significantly higher than the baseline scores. The mean stretched flaccid penile length was 11.1 ± 0.8 cm at baseline and was longer at 3 (11.9 ± 0.9 cm, The results of our study suggest that the AMS 700 LGX IPP could be used to prevent penile shortening in patients undergoing IPP implantation. Furthermore, erectile function and patient satisfaction were improved excellently. Although oral phosphodiesterase type 5 inhibitors, vacuum erection devices, and intracavernosal vasoactive agent injection are the preferred therapies for erectile dysfunction (ED), penile prosthetic implants are regarded as effective, safe, and durable for patients who are refractory to medical treatment and/or prefer a more effective and permanent therapy. Since Scott et al.  first reThe American Medical Service (AMS) 700 Ultrex  was developed in the 1990s to promote penile lengthening. However, mechanical failure and complications occurred frequently; therefore, the use of this device was discontinued , 4. AMS This study was aimed at evaluating and reporting the results of the use of AMS 700 LGX for IPP implantation, including preservation of penile length, complications , and patient satisfaction after surgery.IPP implantation is performed in patients to treat ED if they do not respond to conventional ED therapy, including failure of oral phosphodiesterase type 5 inhibitors with maximal-dose or intracavernosal injection therapy. Patients who underwent implantation with the AMS 700 LGX IPP at a single andrology center between October 2014 and April 2016 were included. We excluded patients who were undergoing repeat implantation operation or prosthesis implantation because of Peyronie’s disease. Because ED treatment expenses, including IPP implantation procedures, are not covered by the Korean National Health Insurance program, the patient paid the related costs (operation and prosthesis fee and postoperative follow-up), and the type of penile prosthesis was selected by the patients and urologist together. Approximately 50% of the patients received AMS 700 LGX, 30% received AMS 700 CX, and 20% received AMS 700 CXR at the time of surgery .One andrologist (MYL) met all patients, gathered information on their medical history, and performed clinical and physical examinations. Data were obtained from the patients’ medical records and interviews. The data included early and late postoperative morbidities, such as infection, mechanical malfunction, and other surgical complications. Patients answered the International Index of Erectile Function (IIEF) questionnaire before undergoing surgery. When patients visited the outpatient department, they completed the questionnaire in private before meeting with an andrologist. The IIEF is a self-administered instrument comprising domains related to sexual function such as erectile function, orgasmic function, sexual desire, satisfaction with intercourse, and overall satisfaction . The sevWe obtained approval from our institutional ethical review board to perform this study, which was conducted in accordance with the principles of the Declaration of Helsinki. Informed consent was obtained from patients before the IPP procedure.P < 0.05.All statistical analyses were conducted using the SPSS statistical software . Since this is a retrospective study, sample size calculation was not needed. The preoperative and postoperative IIEF scores and stretched flaccid penile length were compared using Student’s t test. All data are presented as the mean ± standard deviation, and statistical significance was defined as A total of 342 patients underwent implantation with the AMS 700 LGX IPP between October 2014 and April 2016. The mean age of the patients and ED period were 58.3 ± 9.2 and 4.3 ± 2.5 years, respectively. None of the patients had previously undergone IPP implantation. The indications for IPP implantation were vascular ED for 134 patients, diabetes mellitus for 130, and pelvic surgery such as radical prostatectomy or cystectomy for 48 , 6 months  and 12 months  postoperatively. There was no significant difference in the stretched flaccid penile length between 6 and 12 months (P = 0.31). The mean and penile length with the IPP fully inflated was 11.8 ± 1.2 at baseline, 12.6 ± 1.0 at 3 months, 12.6 ± 1.1 at 6 months, and 12.7 ± 1.2 at 12 months. There was a statistically significant difference in penile length with the IPP fully inflated from baseline to 3, 6, and 12 months (P < 0.001). No statistical difference in penile length with the IPP fully inflated was noted between 6 and 12 months (P = 0.14) , all postoperative IIEF erectile domain scores (P < 0.05), and all postoperative IIEF satisfaction domain scores (P < 0.05), compared with the preoperative scores (Table The total mean preoperative IIEF scores, IIEF erectile function domain scores, and IIEF satisfaction domain scores were 23.2 ± 2.9, 6.5 ± 2.5, and 6.4 ± 2.4, respectively. Postoperatively, the total IIEF scores were 41.8 ± 4.5, 55.3 ± 6.2, and 61.9 ± 9.5 at 3, 6, and 12 months, respectively (Fig. IPP implantation is a well-known, established, and considerably satisfactory treatment option for ED. Although an IPP is regarded to have good mechanical reliability in the long term, patient satisfaction with penile length after surgery has not been achieved because of the patient’s expectation in relation to the preimplantation erect penis length. The causes of dissatisfaction with the penile length are long ED duration, obesity, in which there are added tissues in the prepubic area, and acquired penile disorder such as Peyronie’s disease . Deveci Although the exact mechanism of penile length shortening after IPP implantation has not been fully elucidated, incorrectly measuring the corporeal length during surgery and lack of glans tumescence after implantation might decrease the penile length . IntraurIn the 1990s, the AMS 700 Ultrex penile prosthesis was developed to prevent penile shortening and increase penile girth and length. Montague et al.  reportedIn the present study, at 6 and 12 months postoperatively, the stretched penile length was longer than the preoperative length. We confirmed that all postoperative total IIEF scores, postoperative IIEF erectile function domain scores, and postoperative satisfaction domain scores significantly improved, compared with the preoperative scores. Furthermore, complications such as infection, skin necrosis, and erosion occurred rarely. The mechanical malfunction rate was also very low, and no mechanical complications such as a cylinder aneurysm or S-shaped deformity occurred. Therefore, the AMS 700 LGX is an excellent IPP to preserve penile length in patients who are concerned about decreases in their original penile length and has a low rate of complications and mechanical malfunction.The present study has several limitations. First, this is a retrospective study. Second, the IPP implantation procedures were performed by an andrologist who performs a high volume of these procedures; therefore, it is difficult to generalize our results to surgeons who are less experienced. Third, this study excluded patients with Peyronie’s disease and corporal fibrosis as well as those who underwent a reoperation. A further study about the usefulness of AMS 700 LGX in patients with these conditions should be performed. Fourth, there are no validated questionnaires for evaluating erection and patient satisfaction with the IPP; hence, we used the IIEF to evaluate patients’ satisfaction. Thus, an IPP-specific validated questionnaire should be developed in the future. Finally, we did not record the patients’ weight, which could have resulted in some differences in the stretched flaccid penile lengths. Despite these limitations, our present study provides data on the outcomes of the use of and patient satisfaction with the AMS 700 LGX penile prosthesis in Korea for the first time.We believe that the AMS 700 LGX is a safe and reliable prosthesis for patients with ED and is effective in preventing penile shortening in patients undergoing IPP implantation, with high patient satisfaction. A longer follow-up of these patients and a prospective study are mandatory to confirm these results.