Trends in Presentation and Management of Pediatric Renal Trauma

OBJECTIVE

We queried the Pediatric Health Information System (PHIS) to evaluate the presentation, management, and outcomes of renal trauma in children from birth to 18 years from 2007-2018.

METHODS

Patients were categorized as infants (0-1 year), toddlers (2-4 years), children (5-9 years), preteen (10-14 years), and teens (15-18 years), and patient demographics, grade of injury, and mechanism of injury including sports-related trauma (SRT) were collected. Each group was then evaluated for the level of management and patient outcome.

RESULTS

We identified 3720 patients with renal trauma. Our cohort was predominantly White (68.5%), male (68.6%), and required public insurance (38.5%). Most injuries were low grade (86.7%) and managed non-operatively (94.7%). The overall mortality was 51 (1.4%). Younger patients (infants, toddlers, children) were more likely to present with complex injuries and they were more likely to have been involved in a motor vehicle accident. They had higher blood transfusion rates, longer inpatient courses, higher levels of admission acuity, and higher mortality. Patients in the older age groups presented most after SRT. Across all age groups, the most common source of SRT was limited contact sports; however, when considering only teens, full contact sports were the primary offending activity. This review of the PHIS database provides insight to the rates and patterns of pediatric renal trauma in the United States.

CONCLUSION

Our data suggest an age-related differences in the presentation, management, and outcomes of pediatric renal trauma patients.

Fully automated kidney image biomarker prediction in ultrasound scans using Fast-Unet+

Any kidney dimension and volume variation can be a remarkable indicator of kidney disorders. Precise kidney segmentation in standard planes plays an undeniable role in predicting kidney size and volume. On the other hand, ultrasound is the modality of choice in diagnostic procedures. This paper proposes a convolutional neural network with nested layers, namely Fast-Unet++, promoting the Fast and accurate Unet model. First, the model was trained and evaluated for segmenting sagittal and axial images of the kidney. Then, the predicted masks were used to estimate the kidney image biomarkers, including its volume and dimensions (length, width, thickness, and parenchymal thickness). Finally, the proposed model was tested on a publicly available dataset with various shapes and compared with the related networks. Moreover, the network was evaluated using a set of patients who had undergone ultrasound and computed tomography. The dice metric, Jaccard coefficient, and mean absolute distance were used to evaluate the segmentation step. 0.97, 0.94, and 3.23 mm for the sagittal frame, and 0.95, 0.9, and 3.87 mm for the axial frame were achieved. The kidney dimensions and volume were evaluated using accuracy, the area under the curve, sensitivity, specificity, precision, and F1.

Cost comparison of intra-detrusor injection of botulinum toxin versus augmentation cystoplasty for refractory neurogenic detrusor overactivity in children

INTRODUCTION

Treatment options for refractory neurogenic detrusor overactivity (NDO) in children include botulinum toxin type A (BTX-A) and augmentation cystoplasty (AC). Although BTX-A is accepted in contemporary pediatric urologic practice, cost and long-term outcomes data for BTX-A are limited relative to the gold standard, AC. The purpose of this study was to compare the projected 10-year costs of AC versus BTX-A.

METHODS

We performed a cost analysis from the payer perspective by computationally modeling treatment sequences by a Markov model. In the model, we used probabilities derived from published sources, and costs obtained at a tertiary medical center. The base case was a pediatric patient with refractory NDO. In the model, we assumed biannual BTX-A treatments. Treatment costs over 10 years were compared between immediate AC versus bridging therapy with BTX-A. Using the computational model, we simulated 100,000 instances of 10-year treatment cost for each of the two treatment modalities. The costs for the two treatment approaches were then compared using t-test and Wilcoxon test.

RESULTS

The projected median and mean 10-year cost of immediately AC were $51,798.72 (95% CI [$51,798.72, $327,483.80]) and $123,473.4 (SD: $98,085.23) respectfully, while the projected median and mean 10-year cost of bridging therapy with BTX-A prior to proceeding to AC as needed were $74,552.46 (95% CI [$53,188.56, $309,913.07]) and $124,858.80 (SD: $84,495.35) (p < 0.001).

CONCLUSIONS

For a typical index pediatric patient with NDO, bridging therapy with intravesical BTX-A is associated with an increased cost compared to immediate AC over a ten-year period.

Clinical target segmentation using a novel deep neural network: double attention Res-U-Net

We introduced Double Attention Res-U-Net architecture to address medical image segmentation problem in different medical imaging system. Accurate medical image segmentation suffers from some challenges including, difficulty of different interest object modeling, presence of noise, and signal dropout throughout the measurement. The base line image segmentation approaches are not sufficient for complex target segmentation throughout the various medical image types. To overcome the issues, a novel U-Net-based model proposed that consists of two consecutive networks with five and four encoding and decoding levels respectively. In each of networks, there are four residual blocks between the encoder-decoder path and skip connections that help the networks to tackle the vanishing gradient problem, followed by the multi-scale attention gates to generate richer contextual information. To evaluate our architecture, we investigated three distinct data-sets, (i.e., CVC-ClinicDB dataset, Multi-site MRI dataset, and a collected ultrasound dataset). The proposed algorithm achieved Dice and Jaccard coefficients of 95.79%, 91.62%, respectively for CRL, and 93.84% and 89.08% for fetal foot segmentation. Moreover, the proposed model outperformed the state-of-the-art U-Net based model on the external CVC-ClinicDB, and multi-site MRI datasets with Dice and Jaccard coefficients of 83%, 75.31% for CVC-ClinicDB, and 92.07% and 87.14% for multi-site MRI dataset, respectively.

Fast and Accurate U-Net Model for Fetal Ultrasound Image Segmentation

U-Net based algorithms, due to their complex computations, include limitations when they are used in clinical devices. In this paper, we addressed this problem through a novel U-Net based architecture that called fast and accurate U-Net for medical image segmentation task. The proposed fast and accurate U-Net model contains four tuned 2D-convolutional, 2D-transposed convolutional, and batch normalization layers as its main layers. There are four blocks in the encoder-decoder path. The results of our proposed architecture were evaluated using a prepared dataset for head circumference and abdominal circumference segmentation tasks, and a public dataset (HC18-Grand challenge dataset) for fetal head circumference measurement. The proposed fast network significantly improved the processing time in comparison with U-Net, dilated U-Net, R2U-Net, attention U-Net, and MFP U-Net. It took 0.47 seconds for segmenting a fetal abdominal image. In addition, over the prepared dataset using the proposed accurate model, Dice and Jaccard coefficients were 97.62% and 95.43% for fetal head segmentation, 95.07%, and 91.99% for fetal abdominal segmentation. Moreover, we have obtained the Dice and Jaccard coefficients of 97.45% and 95.00% using the public HC18-Grand challenge dataset. Based on the obtained results, we have concluded that a fine-tuned and a simple well-structured model used in clinical devices can outperform complex models.

Analysis of Fractures and Disability Defects Accidents in Lian Oil Company by Tripod Beta Technique

Introduction: Undoubtedly, the first step in controlling accidents is to analyze them to identify the root causes. In this study, the root causes of accidents leading to severe consequences have been analyzed using the beta tripod technique in Lian Oil Company. Materials and Methods: The research method is descriptive-analytical. In this research, the events of 2020 in two barrel-making and barrel filling units of Lian Oil Refining and Trade Company have been investigated. The tripod-beta method is one of the methods of tracing the roots of accidents, which is widely used in the oil industry because of its special attitude towards the element of human error. Using investigator software, a tripod beta diagram related to three fracture and disability accidents was drawn and after recording and identifying the relevant causes and obstacles, corrective measures were taken to prevent similar accidents. The basis of accident control is the creation of appropriate control and defense systems in such a way as to prevent the interconnection and interaction of the risk factor and the target factor. Results: The results of this study show that non-compliance with safety principles due to reduced staff awareness and lack of long-term and short-term training are the root causes of accidents studied and had the highest impact on these events. 45% of cases were related to the cause of the accident. Other cases after training have had almost the same effect on the occurrence of events. Each of the cases accounted for 11% of the causes of the accidents.  Conclusion: Beta tripod technique is currently one of the best methods for tracing the roots of accidents. The results also indicate that effective measures in the normal time phase, i.e. employing more talented people, conducting training at the beginning of employment, and upstream perspective, i.e. operator coordination with hardware and methods of implementation in the phase of ideas and thinking and design will greatly prevent accidents.

Comparison of error tree analysis and TRIPOD BETA in accident analysis of a power plant industry using hierarchical analysis

Introduction: Due to the importance and necessity of accident analysis, it is necessary to use the proper technique for precise accident analysis and provide corrective and preventive measures to prevent an accident's recurrence. Materials and Methods: In this descriptive-analytical paper, the most important criteria for investigating and selecting accident investigation and analysis techniques and selecting the best accident analysis method were identified in critical industrial accidents in the construction phase, were identified and analyzed. In this study, the most important criteria for selecting an accident analysis method were identified using previous research and gathering expert opinions. Then, two critical power plant accidents were analyzed using TRIPOD BETA and FTA accident analysis methods. Then the pairwise comparisons matrix was formed based on the strengths and weaknesses of the models. Finally, the prioritization of these two methods was done using the hierarchical analysis decision-making method.  Results: In this paper, seven key factors, model realism, model descriptive, systematic modeling, run time, required training courses, ability to quantify, and visibility of events, were identified as the most important criteria for selecting an incident analysis method. Conclusion: The TRIPOD BETA method has been introduced as an optimal method for investigating specific events due to its capabilities.

Comparison of efficiency of engineering and administrative interventions on risk level of occupational hazards in task of emergency nurses in yazd Shahid Rahnamoon hospital

Introduction: Emergency ward nurses are exposed to occupational hazards. Job Safety Analysis (JSA) is a way to identify and assess job-related risks and provide control strategies to reduce risks. The purpose of this study was to evaluate Job Safety Analysis and compare the efficacy of control (engineering and administrative) interventions in emergency nursing. Materials and Methods: This was an interventional study performed to assess the risk by Job Safety Analysis (JSA) in three groups of nurses working in emergrncy ward of Shahid Rahnemoon hospital in 2019. First, the initial risk assessment code (pre-intervention) estimated, then the engineering and administrative controls were implemented and the secondary risk assessment code (after intervention) was calculated after three months. Results: According to the results of the study، risk of musculoskeletal disorders with risk score of 20, was identified as the highest risk in all three emergency nursing groups, also mean risk assessment code for the occupational hazards in nurses was calculated which was in the unacceptable risk range and reached an acceptable level after performing administrative and engineering interventions. Conclusion: Results of this study showed that the implementation of engineering and administrative interventions had a positive effect on reducing the mean risk assessment code, also risk assessment code for occupational hazards reduced to almost the same amount with the implementation of each engineering and administrative intervention. This indicates similar role for these interventions in reducing the risk level.

Determining optimal risk assessment model in construction projects (Case study: steel plant construction project

Introduction: Identifying occupational hazards and managing occupational safety and health risks has been the most important mission and responsibility of the health and safety management system in organizations and adopting coded plans to achieve this is the key to continuously improving this system and promoting it. The aim of the present study was to determine the optimal risk assessment methodology in development projects. Materials and Methods: This was a descriptive-analytic research In this research, using previous research studies and collecting expert opinions, the most important criteria for selecting a specific risk assessment methodology, and then using one of the three most-used techniques is an important activity in the steel making industry and risk assessment. Then, the decision matrix is based on the strengths and weaknesses of the models. The prioritization of these three methods is done using the hierarchical analysis decision method. Results: In this paper, five key factors, the degree of application in identifying hazards, usability in different stages of risk assessment, reliability, ease of use, and training needs and costs, are identified as the most important criteria for choosing a risk assessment technique and the FMEA method was considered as the best  Risk Assessment Method. Conclusion: FMEA methodhas been introduced with regard to its capabilities as an optimal risk assessment method for contruction projects.

The effect of prior endoscopic correction of vesicoureteral reflux on open ureteral reimplantation: Surgical outcomes and costs

INTRODUCTION

Endoscopic injection of a bulking agent is a common first-line approach to the treatment of vesicoureteral reflux (VUR). While early outcomes are comparable to open ureteroneocystotomy, 5-25% of children will eventually develop recurrent reflux necessitating repeat injections or open ureteral reimplantation.

OBJECTIVE

To determine whether prior endoscopic injection of a bulking agent impacts outcomes of subsequent open ureteral reimplantation.

STUDY DESIGN

Using a retrospective cohort design, radiographic and clinical outcomes of open ureteral reimplantation were compared between patients with and without prior endoscopic correction of reflux. Surgical and hospitalization data were also compared between groups and a cost comparison was performed to assess differences in healthcare costs between the two cohorts. Units of analysis included total ureters or total patients. For certain variables, subanalysis of unilateral versus bilateral reimplantation was included.

RESULTS

A total of 258 patients underwent open reimplantation for VUR between 2007 and 2016 by five pediatric urologists. Final analysis (see Summary Table) included 192 patients with pre-operative and postoperative voiding cystourethrogram (VCUG) and follow-up data at a median 4.95 months. Among 317 reimplanted refluxing ureters, radiographic resolution was reached in 26/27 (96.3%) patients with and 279/290 (96.2%) without prior endoscopic treatment (P = 0.981). Clinical success was achieved in 17/17 (100%) patients with and 174/175 (99.4%) without prior endoscopic treatment (P = 0.755). There were no statistically significant differences between duration of surgery or length of hospital stay. There were no statistically significant differences between total charges, total costs, and operating room (OR) costs between groups.

DISCUSSION

This study indicated that prior endoscopic injection of a bulking agent did not impact the outcomes or costs of subsequent open ureteroneocystotomy. While prior studies have demonstrated tissue changes associated with injection of a bulking agent, these did not seem to significantly impact the difficulty of later open surgery or the success rates compared to patients who proceeded directly to open correction of reflux.

CONCLUSION

Open ureteral reimplantation for recurrent VUR after failed endoscopic injection of a bulking agent was safe and effective, with comparable outcomes and costs to open surgery in patients without prior endoscopic correction.

Comparison and Evaluation of Different Treatment Plans with IFRT Field and 6 and 18 MV Energies in Hodgkin's Lymphoma Involvement Neck and Mediastinum

BACKGROUND

Radiotherapy with large mantle field is an effective technique in increasing the risk of secondary cancers among HL (Hodgkin Lymphoma) patients; therefore, it is essential to choose an effective treatment field including the least medical conditions in radiotherapy.

OBJECTIVE

The present study aimed to plan separate fields for neck and mediastinum using various energies, to compare dose distribution with MLC and to block field formation.

MATERIALS AND METHODS

In this study, 3D conformal treatments, Siemens Oncor accelerator equipped with multi-leaf collimator (MLC) were performed to create anterior-posterior fields. CT-scan data of 18 female patients with neck and mediastinal involvement was imported in TIGRT treatment planning system, and then treatment plans were introduced.

RESULTS AND CONCLUSION

Using treatment plan 1, photon 6 MV in neck weighting 1 from interior, 0.5 from posterior, photon 18MV in mediastinum weighting 1 from interior and 0.5 from posterior, it was shown that regarding the common treatment plan used with photon 6 MV, mean dose delivered to breast, lung, esophagus and larynx reduced 6, 7, 41 and 10 percent, respectively and uniformity index improved by 10 percent. Using block compared to MLC in all treatment plans offered improved average dose in all organs under study. To protect breast and lung while using MLC and block in the first treatment plan seemed to be more appropriate; however, using blocks in comparison to MLC increased delivered mean dose in all organs under study. Using separate fields with Pb blocks, though, showed smaller increase.

Robotic-Assisted Urologic Surgery in Infants: Positioning, Trocar Placement, and Physiological Considerations

Pediatric robotic-assisted laparoscopic procedures are becoming increasingly common. They have been shown to be safe in younger patients, including infants. Successful adoption of robotic-assisted surgery in infants requires an understanding of the technical factors unique to this patient population. This review will delineate the specific considerations to safely perform robotic-assisted laparoscopic procedures in infants, including physiological changes associated with pneumoperitoneum in infants, positioning, trocar placement, and docking.

A multi-institutional study of perioperative and functional outcomes for pediatric robotic-assisted laparoscopic Mitrofanoff appendicovesicostomy

BACKGROUND

Robotic techniques are increasingly being used for reconstructive procedures in the pediatric population.

OBJECTIVE

The present study reported the functional and perioperative outcomes of a multi-institutional cohort of pediatric patients who underwent robotic-assisted laparoscopic Mitrofanoff appendicovesicostomy (RALMA).

STUDY DESIGN

Pediatric patients who underwent RALMA at five different centers were included. Positioning is shown (Summary Figure). Demographics were gathered, and intraoperative parameters included concomitant procedures, detrusor tunnel length, estimated blood loss (EBL) and operative time. Perioperative outcomes included length of hospital stay (LOS), morphine use and 30-day complications. Outcomes were reported in terms of stomal continence and surgical revisions.

RESULTS

Eighty-eight patients with a mean age of 10.4 ± 4.0 years were included in the analysis. Median follow-up was 29.5 months (IQR 11.8-45.0). Bladder augmentation was performed concomitantly in 15 (17%) patients, and bladder neck procedures in 34 (39%). Mean detrusor tunnel length was 3.9 ± 1.0 cm, EBL was 54 ± 70 ml, and operative time was 424 ± 120 min. Postoperatively, mean LOS was 5.2 ± 2.8 days. Patients who underwent concomitant augmentation had higher EBL and operative times (both P < 0.05). At 90 days, complications occurred in 26 patients (29.5%) with six Clavien grade ≥3 (6.8%). During follow-up, 11 (12.5%) patients required appendicovesicostomy revision. Regarding functional outcomes, 75 (85.2%) patients were initially continent. After additional procedures, 81 (92.0%) patients were continent at last follow-up.

DISCUSSION

Compared to previous open series, initial stomal continence rates with RALMA were acceptable, with a minority of patients requiring subsequent procedures to manage complications and achieve continence.

CONCLUSION

RALMA is safe and effective in a pediatric population with regard to perioperative complications and stomal continence.

Results of combination chemotherapy and radiation therapy in non-metastatic gastric cancer in Yazd--Iran

BACKGROUND

Gastric cancer is the first cause of cancer death in Iran. Most of the patients are diagnosed in advanced stages and survival rate is low. The aim of this study was to evaluate the survival rate of patients with gastric and gastroesophageal junction adenocarcinoma receiving combination chemotherapy and radiation therapy in Iran.

MATERIALS AND METHODS

This study was conducted on 53 patients with gastric or gastroesophageal junction adenocarcinoma referring to Shahid Ramezanzadeh Radiation Oncology Center between 2004 and 2010. All patients underwent surgical operation, chemotherapy, and radiotherapy. Data contained in patients' records were extracted and follow-up was conducted through telephone contacts. To analyze the data, Kaplan Meier curves, and SPSS software were employed.

RESULTS

Seventeen (32.1%) patients were female and 36 (67.9%) were male. Mean age was 58.32 years. In 14 patients (26.9%) no lymph node was resected or reported by the pathologist. In 29 patients (54.7%) one to six lymph nodes were found, and in10 patients (18.9%) seven lymph nodes or more were detected. In two patients, (3.77%) more than 15 lymph nodes were resected. Surgical staging was impossible for 16 patients (30.2%). Mean survival was 50.9 months and median survival was 51 months. 3,5 and 7 year survival rates were 73%, 36%, and 18% respectively. None of the variables had a significant relation to survival.

CONCLUSIONS

Despite inadequate surgery, the survival rate in our study is one of the best one reported in our country. We think this advantage may be due to poly drug chemotherapy and sequential radiation therapy.

Prophylactic Bilateral Gonadectomy for Ovotesticular Disorder of Sex Development in a Patient With Mosaic 45,X/46,X,idic(Y)q11.222 Karyotype

Ovotesticular disorder of sex development is historically thought to confer a relatively low risk of germ cell malignancy relative to other disorders of sex development. This is likely due in part to the high prevalence of a normal 46,XX karyotype in these patients. However, disorders of sex development represent a broad phenotypic spectrum, and often patients cannot be neatly categorized with a single diagnosis. We report an atypical case of ovotesticular disorder of sex development in a child with ambiguous genitalia and 45,X/46,XY mosaic karyotype. Prophylactic bilateral gonadectomy was performed at age 14 months.

Renal cell carcinoma in children, adolescents and young adults: a National Cancer Database study

PURPOSE

We compared the presentation and outcomes of patients younger than 21 years with renal cell carcinoma and determined risk factors associated with mortality.

MATERIALS AND METHODS

We searched the National Cancer Database for patients diagnosed with renal cell carcinoma between 1998 and 2011. We evaluated patients younger than 30 years with renal cell carcinoma, including clear cell, chromophobe, papillary and not otherwise specified subcategories. We used logistic regression to compare presenting cancer, demographics and treatment variables in patients 0 to 15 years, 15 to 21 years and 21 to 30 years old. Cox regression analysis was used to determine risk factors for mortality in patients younger than 21.

RESULTS

Of 3,658 patients younger than 30 years included in the study 161 were younger than 15 and 337 were 15 to 21 years old. A higher proportion of younger patients had renal cell carcinoma not otherwise specified and papillary histology compared to those 21 to 30 years (p < 0.001). Younger patients presented with higher stage (p < 0.0001), higher grade (p < 0.0001) and larger tumors (p < 0.0001) than those 21 to 30 years. A higher percentage of younger patients underwent lymph node dissection (p < 0.0001) or chemotherapy as first-line treatment (p < 0.0001) compared to those 21 to 30 years. Cox regression analysis demonstrated that stage 4 presentation, government insurance status, nonchromophobic pathology results and not undergoing surgery as first-line treatment were independently associated with increased mortality in patients younger than 21 years.

CONCLUSIONS

Children and adolescents with renal cell carcinoma present with more advanced disease than those 21 to 30 years old. In patients younger than 21 years mortality was associated with the nonchromophobe histological subtype, stage 4 disease, government insurance and not undergoing surgery as first-line therapy.

Robot-assisted extravesical ureteral reimplantation: outcomes and conclusions from 78 ureters

OBJECTIVE

Extravesical robot-assisted laparoscopic ureteral reimplantation (RALUR) is a popular alternative to open surgery. We report our experience with RALUR and evaluate clinical variables as predictors for failure.

METHODS

We retrospectively evaluated the records of patients who underwent RALUR by a single surgeon for treatment of primary vesicoureteral reflux. Clinical and demographic variables were determined. Clinical variables were compared with surgical outcomes using the Student two-tailed type 2 t test.

RESULTS

Fifty patients underwent a combined 78 extravesical RALURs. Median (range) age was 6.2 (1.9-18.0) years; median (range) preoperative reflux grade was 3 (0-5). Dysfunctional elimination syndrome (DES) was present in 32 (64%). Ten (20%) patients had prior deflux, and two (4%) had prior ureteroneocystostomy on the ipsilateral side. Postoperative cystogram was performed in 100% at a median (range) of 55 (27-133) days. Median (range) follow-up was 286 (27-2238) days. Febrile urinary tract infection occurred in five (10%), none of whom had reflux on initial follow-up postoperative cystogram. All five had a history of DES and were female. Six complications occurred in five (10%) patients, including ileus (2), ureteral obstruction (2), ureteral injury (1), and perinephric fluid collection (1). Transient urinary retention occurred in one. Five of 22 (22.7%) patients undergoing unilateral surgery had contralateral de novo reflux. Six of 78 ureters (7.7%) had persistent reflux postoperatively. Neither persistent nor de novo reflux was associated with any of the clinical variables assessed.

CONCLUSIONS

RALUR is an effective and safe option for patients with primary vesicoureteral reflux requiring surgery.

Pediatrician noncompliance with the American Academy of Pediatrics guidelines for the workup of UTI in infants

BACKGROUND

The American Academy of Pediatrics (AAP) guidelines on the workup for urinary tract infections (UTIs) in infants discourages the use of bagged urine specimens for urine culture. We report the results of a survey to assess urine collection preferences and adherence to AAP guidelines in clinical practice.

METHODS

A 29-question survey was e-mailed to pediatrician AAP members to determine their preferred method of urine collection in hypothetical infant patients.

RESULTS

Data from 155 respondents were analyzed. In febrile, circumcised boys, up to 18% preferred bagged specimens for urine culture, against AAP recommendations. In febrile girls, 13% of respondents preferred bagged specimens. There was no significant relationship between adherence to AAP guidelines and respondent's age, gender, years in practice, fellowship training, academic affiliation, or other demographic factors.

CONCLUSIONS

Up to 18% of practitioners prefer bagged specimens over more sterile ones in the workup of febrile UTIs in infants, against AAP guidelines.

Clinicopathologic characteristics and outcome of childhood and adolescent Ewing's sarcoma in center of Iran

BACKGROUND

Ewing's sarcoma family is a group of small round cells tumors. The aim of this study is to evaluate clinicopathologic characteristics and outcome of Ewing's sarcoma in children and adolescents in Yazd, Iran.

MATERIALS AND METHODS

All patients under 19 years with documented pathology of Ewing's sarcoma family tumor who referred to Shahid Ramazanzadeh Radiotherapy center between 2002 to 2010 were enrolled in this retrospective study. Overall survival and disease free survival and prognostic factors were evaluated.

RESULTS

Among approximately 80,000 patients who referred to Shahid Sadoughi pathology department, over an 8-year period, the total number of patients with Ewing sarcoma was 32, of which, 18 cases were under the age 19 . The mean age was 13.72 years. Five patients (27.8%) had metastatic disease at the time of diagnosis. Complete response had been achieved in 8 (44.4%) of the patients. Local recurrence occurred in 4 (22.2%) of the patients. During the follow up 13 (72.2%) of the patients showed metastases. The mean overall survival was 34.79 months (95% CI: 22.27-47.32) .One, two, four and five year survival was 72%, 39%, 25% and 17% respectively. Complete remission occurred in 10 patients (63.6%). A trend of better overall survival was found in these patients (p=0. 55). When the brain and bone metastases occurred, the overall survival decreased significantly (p=0. 003 ).

CONCLUSIONS

The overall survival rate of Ewing's sarcoma is very low in comparison with other parts of the world.

Negative pressure pulmonary edema after laparoscopic donor nephrectomy

Although usually a self-limiting phenomenon, negative pressure pulmonary edema requires immediate re-establishment of the airway, adequate oxygenation, and application of a positive airway.

Introduction:

Laparoscopic donor nephrectomy is associated with a 10% chance of morbidity and a 0.03% mortality rate. We present a case of negative pressure pulmonary edema (NPPE) in a healthy subject immediately following a laparoscopic donor nephrectomy. In this report, we will use the case to review the complications of NPPE and to illustrate its management.

Case Description:

A healthy 19-y-old male presented at our institution as a living-related donor for left laparoscopic donor nephrectomy. Following the surgery, the patient was reintubated and kept in the intensive care unit secondary to NPPE. The patient experienced an uneventful postoperative course and was subsequently discharged.

Discussion:

Although a self-limiting phenomenon, mainstay NPPE therapy requires immediate re-establishment of the airway, adequate oxygenation, and application of positive airway pressure.

Triterpenes from Euphorbia spinidens with immunomodulatory activity

Dried aceton-chloroform extract of aerial parts of Euphorbia spinidens Bornm. ex Prokh. endemic to Iran, yielded two new triterpenoids, lup-20(29)-ene-33, 28 diol commonly known as betulin and (3β,23E)-Cycloarta-23-ene-3,25-diol. The structures of the isolated compounds were elucidated by 13C- and 1H-NMR as well as 2D-NMR, IR and by the aid of mass fragmentation pattern. In phagocyte chemiluminescence assay, different concentrations of compounds were incubated with the human whole blood in triplicate and the chemiluminescence activity of phagocytic cells were measured by using serum opsonized zymosan and luminol. For lymphocyte proliferation assay, peripheral human blood lymphocytes were incubated with different concentrations of the test compound in supplemented Roswell Park Memorial Institute (RPMI) 1640 medium along with 5.0 μg/ml phytohemagglutinin (PHA) at 37°C in CO2 environment for 72 h and proliferation level was determined by Beta-scintillation counter. In phagocyte chemiluminescence assay, betulin showed moderate inhibitory effect on the oxidative burst in the neutrophils, while addition of betulin triterpene was able to stimulate the proliferation of the phytohemagglutinin (PHA) treated human peripheral blood lymphocytes (hPBLs).

Clomiphene citrate is safe and effective for long-term management of hypogonadism

OBJECTIVE

To assess the efficacy and safety of long-term clomiphene citrate (CC) therapy in symptomatic patients with hypogonadism (HG).

PATIENTS AND METHODS

Serum T, oestradiol and luteinizing hormone (LH) were measured in patients who were treated with CC for over 12 months. Additionally, bone densitometry (BD) results were collected for all patients. Demographic, comorbidity, treatment and Androgen Deficiency in Aging Men (ADAM) score data were also recorded. Comparison was made between baseline and post-treatment variables, and multivariable analysis was conducted to define predictors of successful response to CC. The main outcome measures were predictors of response and long-term results with long-term CC therapy in hypogonadal patients.

RESULTS

The 46 patients (mean age 44 years) had baseline serum testosterone (T) levels of 228 ng/dL. Follow-up T levels were 612 ng/dL at 1 year, 562 ng/dL at 2 years, and 582 ng/dL at 3 years (P < 0.001). Mean femoral neck and lumbar spine BD scores improved significantly. ADAM scores (and responses) fell from a baseline of 7 to a nadir of 3 after 1 year. No adverse events were reported by any patients.

CONCLUSIONS

Clomiphene citrate is an effective long-term therapy for HG in appropriate patients. The drug raises T levels substantially in addition to improving other manifestations of HG such as osteopenia/osteoporosis and ADAM symptoms.

Müllerian remnant malignancy

Mixed gonadal dysgenesis is a disorder of sexual differentiation, characterized by mosaicism, ambiguous external genitalia, and both Wolffian and Müllerian internal genitalia. These patients are at a known increased risk of germ cell cancer, specifically gonadoblastoma; however, in this report we describe a case of adenocarcinoma of a remnant Müllerian structure.

Does size matter? The significance of prostate size on pathologic and functional outcomes in patients undergoing robotic prostatectomy

Background

We examined the effect of prostate weight on perioperative data, and the pathological and functional outcomes of robotic-assisted laparoscopic prostatectomy (RALP).

Patients and methods

Data were available from 716 consecutive patients before, during and after undergoing RALP at one institution. Prostate size was arbitrarily stratified by recorded prostate weight into <50, 50–80 and >80 g, corresponding to small, moderate and large glands, respectively. Perioperative data and the histopathological and functional outcomes were compared across these groups by both univariable and multivariable-adjusted analyses.

Results

Increased prostate size was associated with increased age, preoperative prostate-specific antigen levels, body mass index, operative duration, blood loss, lower biopsy and pathological Gleason scores, and lower pathological staging (P < 0.05). The incidence of extensive positive surgical margins was 14.8%, 9.7%, and 5.3% in small, moderate and large prostates, respectively (P < 0.001). However, after multivariable adjustment, only Gleason score and pathological stage were significantly associated with the incidence of positive margins (P < 0.05); prostate weight was not significantly associated. Overall, 78% and 92% of patients were potent and continent at 12 months, respectively, which was not affected by prostate size.

Conclusion

Patients with larger prostates had favourable pathological outcomes after RALP. When controlling for pathological stage, prostate size was not associated with margin positivity. Functionally, neither continence nor potency at 12 months was affected by prostate size.

Emerging biomarkers for prostate cancer diagnosis, staging, and prognosis

The introduction and widespread adoption of PSA has revolutionized the way prostate cancer is diagnosed and treated. However, the use of PSA has also led to over-diagnosis and overtreatment of prostate cancer resulting in controversy about its use for screening. PSA also has limited predictive accuracy for predicting outcomes after treatment and for making clinical decisions about adjuvant and salvage therapies. Hence, there is an urgent need for novel biomarkers to supplement PSA for detection and management of prostate cancer. Despite the progress in developing new biomarkers, several obstacles remain before such biomarkers can be clinically used. These challenges include analytical and regulatory barriers, issues with study design and data analysis that lead to lack of reproducibility of promising results, and the lack of large scale trials to adequately assess the utility of promising biomarkers. In this article we discuss the challenges in biomarker research and the statistical considerations for biomarker evaluation. There is a plethora of promising blood and urine based biomarkers. For the purpose of this review, we focus on PSA derived forms, human kallikrein 2, Early Prostate Cancer Antigen, Transforming Growth Factor-Beta 1 and Interleukin-6, Endoglin, PCA3, AMACR and ETS Gene Fusions. These biomarkers have shown promise in early studies and are at various stages of development. However, in the future it is very likely that a panel of biomarkers will be used to achieve sufficient degree of certainty in order to guide clinical decisions. To be able to be used commercially such a panel will have to answer clinically relevant questions in a simple and cost-effective way.

Low voltage cycling of programmable metallization cell memory devices

Future nanoscale memory technologies must ultimately be able to operate at power supply voltages in the order of 0.6 V or less. We have demonstrated in this work that it is possible to utilize symmetric program-erase (P-E) cycling for Ag/Ag-Ge-S/W programmable metallization cell devices at voltages below 0.6 V and still maintain an OFF/ON resistance ratio well in excess or 10 over a wide range of program and erase currents (0.27, 1.6, 55 and 220 µA) as set by a series resistance. The distributions of resistance values for 10(4) P-E cycles indicate that the margins between the highest on- and lowest off-state resistances are sufficient for unambiguous differentiation in all but the lowest current case in which there is some overlap. In addition, there is no substantial change in switching speed for up to 1.5 × 10(6) P-E operations, the maximum number of cycles attempted in this study.

Simple, age-based formula for predicting renal length in children

OBJECTIVE

To determine a simple, age based formula for predicting ideal renal length in children. Renal size is a valuable marker in the evaluation of children with urological disorders. Although many authors have described complex nomograms and multivariate formulas for determining renal size, we propose a simple and accurate formula.

MATERIAL AND METHODS

All renal ultrasound (US) studies performed over a 9-year period in patients <18 years of age were retrospectively evaluated, excluding patients with a history of urinary tract disease or with abnormal renal US findings.

RESULTS

Ultrasounds were performed in 778 children <18 years who met inclusion criteria. Sixty-one percent of the patient population was ≥1 year of age at the time of the US. Forty-four percent of the children were male. In children 1 year of age or older, the formula was length (cm) = age (years) × 0.3 + 6, R(2) = .81. In infants younger than 1 year, renal length was poorly estimated by a simple age-based formula.

CONCLUSION

Our proposed formula can be used to predict renal length in children older than 1 year.

Ossifying fibromyxoid tumour: a rare soft tissue tumour of intermediate malignancy

Ossifying fibromyxoid tumours (OFTs) are uncommon soft tissue tumours. A 73-year-old male presented with a painless exophytic mass located in the left scapular area which was identified 1 year earlier. An incisional biopsy was performed and microscopic features were compatible with OFT. Radiologic evaluation revealed multiple pulmonary metastasis. Although many cases persue an indolent biologic behaviour, local recurrence and metastasis have been reported and long-term follow-up should be considered.

Urologic aspects of HIV infection

Although lifespan has dramatically improved in the human immunodeficiency virus-positive (HIV+) population, HIV and its treatment continue to be a source of substantial morbidity in many organ systems, including the genitourinary tract. As the number of long-term survivors increases with advances in antiretroviral therapy, age-associated urologic symptoms are also becoming increasingly relevant considerations for people living with HIV. Primary care physicians have a major role to play in maintaining the genitourinary health of their HIV+ patients. This role is of great importance not just for the well-being of the individual patient but for the public health, as the genitourinary tract is a common vector for HIV transmission. In this article the authors review the management of the genitourinary system in patients with HIV infection. Particular consideration is given to urinary tract infections, lower urinary tract symptoms, renal insufficiency, sexual and fertility problems, and cancers of the genitourinary tract. Management algorithms are outlined and indications for referral to a urologist are emphasized.

Long-term follow-up and late complications following treatment of pediatric urologic disorders

Many pediatric urologic disorders have sequelae that may affect patients well into adulthood. Despite adequate treatment, many patients are at risk for progressive urologic deterioration years after surgical reconstruction. While many pediatric urologists follow their patients years after surgery, screening for late complications is a shared responsibility with primary care providers. This article discusses potential late complications and appropriate follow-up for patients who have a history of ureteral reimplantation, pyeloplasty, hypospadias repair, posterior urethral valve ablation, and intestinal interposition.

Nevoid malignant melanoma in an albino woman

Albinism is a disorder of hypopigmentation affecting the skin, hair and eyes. Ultraviolet light induced cutaneous tumours are common in patients with albinism due to reduced or absent protection from melanin, with squamous cell carcinoma being the most common. Although non-melanomatous skin cancers are more frequent in patients with albinism, dysplastic nevi and melanoma present a greater diagnostic challenge in this group because of their hypopigmented appearance. Here the authors report a case of nevoid malignant melanoma in a patient who had type 1A oculocutaneous albinism.