Testicular pain as an atypical presentation of sarcoidosis

Sarcoidosis is a systemic granulomatous disease, with genitourinary tract involvement being very rare (0.2% of all sarcoidosis cases). Genitourinary sarcoidosis may present with a scrotal mass with or without testicular pain, often mimicking epididymo-orchitis or malignancy. Only 8 cases of genitourinary sarcoidosis have been reported in the literature in the last 14 years. We describe the case of a 25-year-old man who was referred with testicular pain. Scrotal ultrasonography demonstrated multiple bilateral hypoechoic testicular lesions that were of similar size and distributed unusually throughout the testicular parenchyma. Computed tomography detected a nodule in the middle lobe of the right lung, multiple small volume nodes in the retrocaval and left para-aortic regions, and enlarged bilateral external iliac and inguinal nodes, similar to those found in metastatic testicular cancer. Following ultrasound guided excision of one of the lesions, histopathological examination confirmed granulomatous inflammation consistent with sarcoidosis.

Is it necessary to perform week three dosimetric analysis in low-dose-rate brachytherapy for prostate cancer when day 0 dosimetry is done? A quality assurance assessment

PURPOSE

To determine whether computed tomography/magnetic resonance imaging-based day 0 (d0) dosimetry is a meaningful predictor of day 21 (d21) dosimetry in low-dose-rate brachytherapy for localized prostate cancer.

METHODS AND MATERIALS

The study population consisted of 277 men with localized (T1-2 N0 M0), low-/intermediate-risk prostate cancer treated with low-dose-rate brachytherapy. Computed tomography/magnetic resonance imaging fusion was used for postimplant dosimetry at d0 and d21. Logistic regression was used to construct receiver operating characteristic curves for achieving each constraint at d21, based on d0 D90 and V100, and Youden's index was used to evaluate cutpoints. Freedom from biochemical failure (FBCF) was estimated with the Kaplan-Meier method.

RESULTS

The median d0 D90 increased from 133 to 150 Gy at d21, and median d0 V100 increased from 87% to 91%. For achieving the D90 constraint at d21, the optimal cut-point for d0 D90 was 135 Gy, with 84% of these patients maintaining a d21 D90 > 145 Gy. For achieving the D90 constraint at d21, the optimal cut-point for d0 V100 was 87%, with 83% of these patients maintained a d21 V100 > 90%. There was no improvement in FBCF in patients with a d0 D90 > 135 Gy or D90 > 145 Gy. Similarly, there was no improvement in FBCF in patients with a d0 V100 > 87% or V100 > 90%.

CONCLUSIONS

Meeting dosimetric constraints on d0 does not obviate d21 dosimetric analysis. Constraints used for dose prescriptions on d0 are not the ideal predictors of d21 dosimetry.

Use of a virtual reality simulator to improve percutaneous renal access skills: a prospective study in urology trainees

OBJECTIVES

This study aims to assess the impact of a virtual reality trainer in improving percutaneous renal access skills of urological trainees.

METHODS

A total of 36 urology trainees participated in this prospective study. Initially, they were taken through the exercise of gaining access to the lower pole calyceal system and introducing a guidewire down the ureter. Trainees' performance was then assessed by virtual reality-derived parameters of the simulator at baseline and after 2 h of training.

RESULTS

Participants who underwent training with the simulator demonstrated significant improvement in several parameters compared to their baseline performance. There was a statistically significant correlation between total time to perform the procedure and time of radiation exposure, radiation dose and correct calyx puncture (p < 0.01). Trainees needed a mean of 15.8 min from skin puncture to correct guidewire placement into the pelvicalyceal system before and 6.49 min following training.

CONCLUSIONS

We found percutaneous renal access skills of trainees improve significantly on a number of parameters as a result of training on the PERC Mentor TM VR simulator. Such simulated training has the potential to decrease the risks and complications associated with the early stages of the learning curve when training for percutaneous renal access in patients.

Laparoscopic sleeve gastrectomy in partial situs inversus

Laparoscopic surgery in a patient with Partial Situs Inversus may pose interesting challenges to the surgeon. Here we report a case of a morbidly obese young female with partial situs inversus who underwent Laparoscopic Vertical Sleeve Gastrectomy (LSG). The peri-operative challenges very many and these have been enumerated. The mirror image approach is recommended in such cases for a successful surgery which was not employed in this case. Postoperative barium swallow was normal and the patient has been on regular follow up.

Detailed analysis of 22q11.2 with a high density MLPA probe set

The presence of chromosome-specific low-copy repeats (LCRs) predisposes chromosome 22 to deletions and duplications. The current diagnostic procedure for detecting aberrations at 22q11.2 is chromosomal analysis coupled with fluorescence in situ hybridization (FISH) or PCR-based multiplex ligation dependent probe amplification (MLPA). However, there are copy number variations (CNVs) in 22q11.2 that are only detected by high-resolution platforms such as array comparative genomic hybridization (aCGH). We report on development of a high-definition MLPA (MLPA-HD) 22q11 kit that detects copy number changes at 37 loci on the long arm of chromosome 22. These include the 3-Mb region commonly deleted in DiGeorge/velocardiofacial syndrome (DGS/VCFS), the cat eye syndrome (CES) region, and more distal regions in 22q11 that have recently been shown to be deleted. We have used this MLPA-HD probe set to analyze 363 previously well-characterized samples with a variety of different rearrangements at 22q11 and demonstrate that it can detect copy number alterations with high sensitivity and specificity. In addition to detection of the common recurrent deletions associated with DGS/VCFS, variant and novel chromosome 22 aberrations have been detected. These include duplications within as well as deletions distal to this region. Further, the MLPA-HD detects deletion endpoint differences between patients with the common 3-Mb deletion. The MLPA-HD kit is proposed as a cost effective alternative to the currently available detection methods for individuals with features of the 22q11 aberrations. In patients with the relevant phenotypic characteristics, this MLPA-HD probe set could replace FISH for the clinical diagnosis of 22q11.2 deletions and duplications.

Antithrombin and anti-Xa agents in the control of thrombogenesis

Recent developments as well as future trends in the area of thrombin inhibitors and anti-Xa agents are reviewed.

Construction of a 780-kb PAC, BAC, and cosmid contig encompassing the minimal critical deletion involved in B cell chronic lymphocytic leukemia at 13q14.3

A putative tumor suppressor gene involved in B cell chronic lymphocytic leukemia (B-CLL) was mapped to human chromosome 13q14.3 close to the genetic markers D13S25 and D13S319. We constructed a 780-kb-long contig composed of cosmids, bacterial artificial chromosomes, and bacteriophage P1-derived artificial chromosomes that provides essential information and tools for the positional cloning of this gene. The conting contains both flanking markers as well as several additional genetic markers, three ESTs, and one potential CpG island. In addition, using one B-CLL patient, we characterized a small internal deleted region of 550 kb. Comparing this deletion with other recently published deletions narrows the minimally deleted area to less than 100 kb in our physical map. This deletion core region should contain all or part of the disrupted in B cell malignancies tumor suppressor gene.

Interaction of Ca2(+)-activated K+ channels with refolded charybdotoxins mutated at a central interaction residue

Charybdotoxin is a small peptide blocker of K+ channels, rigidly held in active conformation by three disulfide bonds. The toxin blocks K+ channels by binding to a receptor site located at the external "vestibule", and thus physically occluding the outer opening of the K+ conduction pore. In the blocked complex, K27, a residue on the toxin's molecular surface, projects its epsilon-amino group into the K(+)-selective pore. The results here show that CTX, produced by heterologous expression in E. coli, may be manipulated to place unnatural positively charged residues at position 27. The toxin folds faithfully to its native conformation when the crucial lysine at position 27 is replaced by a cysteine residue, a maneuver that allows specific chemical modification of this side-chain. Replacements of K27 by side-chains slightly shorter or slightly longer than lysine yield active toxins. The toxin variant with ornithine at this position interacts much less strongly with K+ ions in the pore of slowpoke-type Ca2(+)-activated K+ channels than does wild-type toxin. This result argues that the epsilon-amino group of K27 in bound toxin lies only a few ångstroms away from a K+ ion occupying the blocked pore. The peptide folds with high efficiency to form the correct disulfides even in the presence of strong denaturants.

Surveillance for fetal alcohol syndrome in Colorado

The authors performed surveillance for fetal alcohol syndrome with an existing birth defects registry. Fetal alcohol syndrome cases were identified from multiple sources using passive surveillance and from two selected medical sites using enhanced surveillance. Between May 1992 and March 1994, a total of 173 cases were identified, and the medical records of the cases were reviewed to determine whether the cases met a surveillance case definition for fetal alcohol syndrome. Of these cases, 37 (21 percent) met either definite (28) or probable (9) criteria for fetal alcohol syndrome, 76 met possible criteria (44 percent), and 60 (35 percent) were defined as not fetal alcohol syndrome. Enhanced surveillance had the highest sensitivity for definite or probable cases, 31 of 37 (84 percent), followed by hospital discharge data, 14 of 37 (38 percent). The authors also compared birth certificate information for 22 definite or probable cases in children born between 1989 and 1992 to birth certificate information for all Colorado births for that period. The proportion of mothers of children with fetal alcohol syndrome was statistically significantly greater (as determined by exact binomial 95 percent confidence limits) than the proportion of all mothers for the following characteristics: black race (0.23 versus 0.05), unmarried (0.55 versus 0.22), not employed during pregnancy (0.86 versus 0.43), and started prenatal care in the third trimester (0.18 versus 0.04). Surveillance for fetal alcohol syndrome can be accomplished with an existing registry system in combination with additional case finding and verification activities. Through followup investigation of reported cases, data can be gathered on the mothers of children with fetal alcohol syndrome. These data could be used to target fetal alcohol syndrome prevention programs.