Laparoscopic onlay-flap ureteroplasty using cecal appendix.

INTRODUCTION: The management of ureteral strictures longer than 1-2 cm must be treated by major surgery (1, 2). The strictures located at the distal part of the ureter can be managed by a ureteral reimplantation using a psoas hitch or a Boari flap depending on its proximity to the bladder (3). Those located at the proximal ureter can be treated by a pyeloplasty (4). The ureteric strictures in the mid-ureter are the ones that pose a greater challenge for the urologist because a ureteral substitution is needed, either using a segment of the intestine or a buccal mucosa graft (5, 6). Our main objective is to present the management and results at 36 months of a patient with a right mid-ureter stricture. MATERIAL AND METHODS: A 63-year-old male with chronic kidney disease (CKD) and a right single functioning kidney was referred to our department with the diagnosis of a 3 cm stricture in the right mid-ureter. He had a long-term JJ-stent in place but in the last year we had to replace it three times precociously and he even needed the placement of a nephrostomy tube due to the obstruction of the JJ-stent. Accordingly, a permanent resolution was sought and a laparoscopic onlay-flap ureteroplasty using cecal appendix was performed. RESULTS: The first step was to identify the cecal appendix. Then we identified and dissected the ureter. With the ureter dissected, we performed a ureteroscopy to pinpoint the stricture. Once we knew where the stricture was, we proceeded with the ureterotomy and preparation of the cecal appendix. The final step was to perform the ureteroplasty between the ureter and the cecal appendix placing a JJ-stent before the last stitches were done. Total operative time was 190 minutes without any intraoperative complication. The JJ-stent was removed 7 weeks later. The follow-up of the patient was done with regular blood test and ultrasound to rule out deterioration of the CKD and worsening of the residual hydronephrosis. With a follow-up of 36 months, the patient is stent free, he hasn't had any further intervention and neither the CKD nor the hydronephrosis haven't worsened. CONCLUSIONS: Laparoscopic onlay-flap ureteroplasty using cecal appendix is a feasible and well tolerated procedure for patients with right mid-ureter stricture. However, we must bear in mind the difficulty of these cases and they should be performed in expert centers.

Static Respiratory System Compliance as a Predictor of Extubation Failure in Patients with Acute Respiratory Failure.

PURPOSE: Ventilator weaning protocols rely in part on objective indices to best predict extubation failure in the critically ill. We investigated static respiratory system compliance (RC) as a predictor of extubation failure, in comparison to extubation readiness using rapid shallow breathing index (RSBI). MATERIAL AND METHODS: This was a cross-sectional, multi-institutional study of mechanically ventilated patients admitted between 12/01/2017 and 12/01/2019. All patients older than 18 years with a documented spontaneous breathing trial and extubation trial were included. RC and RSBI were calculated prior to the extubation trial. The primary outcome was extubation failure-defined as need for reintubation within 72 h from time of extubation. RESULTS: Of the 2263 patients, 55.8% were males with a mean age of 68 years. The population consisted mostly of Caucasians (73%) and African Americans (20.4%). 274 (12.1%) patients required reintubation within 72 h. On multivariate logistic regression after adjusting for age, sex, body mass index (BMI), admission Sequential Organ Failure Assessment (SOFA) score, number of ventilator days, and the P/F ratio on the day of extubation, RC remained the strongest predictor for extubation failure at 24 h (aOR 1.45; 95% CI 1.00-2.10) and 72 h (aOR 1.58; 95% CI 1.15-2.17). There was no significant association between RSBI and extubation failure at 24 (aOR 1.00; 95% CI 0.99-1.01) or at 72 h (aOR 1.00; 95% CI 0.99-1.01). CONCLUSION: RC measured on the day of extubation is a promising physiological discriminant to potentially risk stratify patients with acute respiratory failure for extubation readiness. We recommend further validation studies in prospective cohorts.

Morphological characterization and first molecular identification of the eleven Eimeria species that infect sheep from Mexico.

Within livestock production, enteric diseases play an important role, since they cause severe economic losses due to mortality, growth depression, and reduction in the conversion rate. Coccidiosis caused by Eimeria spp. is a parasitic disease of high morbidity that affects various animal species, including sheep. In sheep, eleven species of Eimeria have been identified mainly through microscopical identification of the oocysts; however, this technique has certain limitations that make it difficult to identify the different Eimeria species. The objective of the present study was to morphologically identify the eleven species of Eimeria that infect sheep in the southeastern region of the State of Mexico, as well as obtain the partial sequence of the ITS-1 rRNA region of each species and analyze it phylogenetically. A total of 412 samples were collected from the 13 municipalities that comprise the region I of the State of Mexico, out of which, 40 had approximately 80% of a single Eimeria species. Among these, the eleven Eimeria species reported in sheep were identified. The phylogenetic analysis showed that the species reported in this study are associated with those reported in rabbits, bovines, and birds. It is suggested that the phylogenetic division of sheep in two clades may be associated with the presence or absence of the residual body. It is proposed that the present methodology can be used effectively for diagnosis and to obtain information about the epidemiology of ovine coccidial infection. The results obtained in this study constitute the first report of the ITS-1 region of the eleven Eimeria species that infect sheep worldwide.

Kommerell's Diverticulum in an Aberrant Right Subclavian Artery: First Case Reported in a Male of Puerto Rican Descent.

A Kommerell's diverticulum is a rare embryologic defect of the aortic arch. The majority of the patients having this defect present with dysphagia, dyspnea, and syncope, or a combination of any 2 or all 3. For symptomatic cases, surgical correction is always the standard of care. However, it is somewhat controversial what to do about asymptomatic cases. While surgery is almost always recommended, should asymptomatic patients undergo this procedure or not? Is it worth performing thoracic surgery for an anomaly whose nature is not really understood? In this case report, we describe a Kommerell diverticulum discovered incidentally in a 70-year old asymptomatic male. Surgery was not advisable for this patient; therefore, it was decided to manage him with surveillance. This is the first report in the Englishlanguage medical literature of a Kommerell diverticulum in a man of Puerto Rican descent. A thorough discussion of this rare anomaly follows; multimodality images of it are included at the end of this manuscript.

Prediction models of COVID-19 fatality in nine Peruvian provinces: A secondary analysis of the national epidemiological surveillance system.

There are initiatives to promote the creation of predictive COVID-19 fatality models to assist decision-makers. The study aimed to develop prediction models for COVID-19 fatality using population data recorded in the national epidemiological surveillance system of Peru. A retrospective cohort study was conducted (March to September of 2020). The study population consisted of confirmed COVID-19 cases reported in the surveillance system of nine provinces of Lima, Peru. A random sample of 80% of the study population was selected, and four prediction models were constructed using four different strategies to select variables: 1) previously analyzed variables in machine learning models; 2) based on the LASSO method; 3) based on significance; and 4) based on a post-hoc approach with variables consistently included in the three previous strategies. The internal validation was performed with the remaining 20% of the population. Four prediction models were successfully created and validate using data from 22,098 cases. All models performed adequately and similarly; however, we selected models derived from strategy 1 (AUC 0.89, CI95% 0.87-0.91) and strategy 4 (AUC 0.88, CI95% 0.86-0.90). The performance of both models was robust in validation and sensitivity analyses. This study offers insights into estimating COVID-19 fatality within the Peruvian population. Our findings contribute to the advancement of prediction models for COVID-19 fatality and may aid in identifying individuals at increased risk, enabling targeted interventions to mitigate the disease. Future studies should confirm the performance and validate the usefulness of the models described here under real-world conditions and settings.

Granulomatosis with poliangiitis mimicking testicular torsion.

Granulomatosis with polyangiitis (GPA) is an autoimmune vasculitis which rarely affects the lower genitourinary tract. We share the case of a 53-year-old man who presented with a retroperitoneal mass and thereafter developed a left multiseptated hydrocele that conditioned a testicular infarction. The pathology report of the orchidectomy was consistent with GPA.

Recurring renal lithiasis due to Dent's disease.

Dent's disease is a rare cause of hypercalciuria and recurring urolithiasis. Patients with this disease have elevated bone resorption due to the presence of parathormone (PTH) in the urine. We describe the case of a 21-year-old male with hypercalciuria, elevated bone resorption and recurring bilateral urolithiasis that achieves radiological and clinical stability with percutaneous nephrolithotomy (PNL) and medical treatment with hydrochlorothiazide, potassium-citrate and phytate.

New pathologic entities in penile carcinomas: an update of the 2004 world health organization classification.

Most primary malignant tumors of the penis are squamous cell carcinomas (SCC) of the usual type. In recent years several variants, each with distinctive clinicopathologic features, have been described. Pseudohyperplastic carcinoma and carcinoma cuniculatum are both low-grade, extremely well-differentiated SCC variants characterized by an indolent clinical course and good prognosis. The former, which may be confused with pseudoepitheliomatous hyperplasia, preferentially affects the inner foreskin mucosa of elderly men and the latter is a verruciform tumor with an endophytic, burrow-like pattern of growth. Pseudoglandular carcinoma (featuring solid tumor nests with extensive central acantholysis simulating glandular lumina) and clear cell carcinoma (human papillomavirus [HPV]-related tumors composed of periodic acid-Schiff positive clear cells) are aggressive tumors with a high incidence of inguinal nodal metastases. Papillary carcinomas are HPV-unrelated verruciform tumors composed of complex papillae with acanthosis, hyper- and parakeratosis, absence of koilocytes, irregular fibrovascular cores, and jagged tumor base. Finally, in warty-basaloid carcinomas areas of warty (condylomatous) and basaloid carcinomas coexist in the same tumor, either separated or intermingled, giving the tumor a variegated appearance. In this review special emphasis is given to the differential diagnosis of these special variants with a discussion of the possible implications for clinical management.

Epidemiological study of granulomatous prostatitis in a tertiary hospital: Associated risk factors and relationship with prostate cancer.

OBJECTIVE: The primary objective was to estimate the incidence of granulomatous prostatitis (GP) in Son Espases University Hospital, a tertiary care hospital, in Palma de Mallorca (Spain). As secondary objectives, presence of concomitant PCa in the biopsy was analyzed, as well as the history of previous BCG instillations, biopsy origin, urinary symptoms, and cardiovascular risk (CV) factors. METHODS: A descriptive retrospective study of GP and the aforedescribed variables were carried out from 2010 to 2017. RESULTS: A total of 3651 histopathological prostate specimens were analyzed, 39 of which were diagnosed with GP (incidence of 1.06%). Lower urinary tract symptoms (LUTS) were present in a 48.7% and previous history of bladder tumor resection (TURBT) was present in 35.9% of the cases. Also, urinary tract infections were equally present. All cases with prior TURBT had intravesical instillations with BCG, although 5 (12.8%) and 4 (10.3%) cases had abnormal rectal examination and elevated PSA levels after instillations, respectively. Finally, in 14 cases (35.9%) there was also a diagnosis of concomitant PCa. The most common CV risk factor in these patients was smoking (79.5%) followed by hypertension (64.8%). CONCLUSIONS: The estimated incidence of GP in our center (1.06%)g is close to that described by other authors. About 14 cases were diagnosed with PCa (35.9%), a higher value than previously described in the literature, and most of these were found incidentally, especially in cystoprostatectomies. This high percentage of concomitant GP and PCa could be due to a rise in Transrectal Prostate biopsies (TRPB), as in recent years there has been a tendency to increase the use of PSA in routine clinical practice.

Differentiated precursor lesions and low-grade variants of squamous cell carcinomas are frequent findings in foreskins of patients from a region of high penile cancer incidence.

AIMS: About 10-20% of all penile squamous cell carcinomas (SCCs) originate in the foreskin, but knowledge about preputial precursor and associated lesions is scant. The aims of the present study were to determine the prevalence of various precancerous and cancerous lesions exclusively affecting the foreskin, and to describe their pathological features. METHODS AND RESULTS: One hundred consecutive circumcision specimens from symptomatic patients living in a region of high penile cancer incidence were analysed. Clinical diagnoses included mostly phimosis and chronic balanoposthitis (40 and 35 cases, respectively), but also a tumour mass (11 cases). Histopathological lesions found included: squamous hyperplasia in 61 cases; lichen sclerosus in 53 cases; penile intraepithelial neoplasia (PeIN) in 30 cases (all differentiated PeIN, with two cases showing multicentric foci of basaloid and warty-basaloid PeIN); and invasive SCC in 11 cases (three usual, three pseudohyperplastic, two verrucous-pseudohyperplastic, and one case each of basaloid, papillary and mixed usual-basaloid carcinomas). Lichen sclerosus was present in all low-grade SCC cases. Patients with no lesions were younger (mean age 44 years) than those with precursor lesions (mean age 54 years) or with invasive SCC (mean age 68 years). Immunohistochemistry for p16(INK4a) was performed in 19 precancerous lesions. All differentiated PeINs (18 lesions) were negative, and one basaloid PeIN was positive. CONCLUSIONS: The frequent coexistence of lichen sclerosus, squamous hyperplasia, differentiated PeIN and low-grade SCC suggests a common non-human papillomavirus related pathogenic pathway for preputial lesions, and highlights the importance of circumcision in symptomatic patients for the prevention of penile cancer.

Performance of Automated Telemetry in Diagnosing QT Prolongation in Critically Ill Patients.

BACKGROUND: QT prolongation increases the risk of ventricular arrhythmia and is common among critically ill patients. The gold standard for QT measurement is electrocardiography. Automated measurement of corrected QT (QTc) by cardiac telemetry has been developed, but this method has not been compared with electrocardiography in critically ill patients. OBJECTIVE: To compare the diagnostic performance of QTc values obtained with cardiac telemetry versus electrocardiography. METHODS: This prospective observational study included patients admitted to intensive care who had an electrocardiogram ordered simultaneously with cardiac telemetry. Demographic data and QTc determined by electrocardiography and telemetry were recorded. Bland-Altman analysis was done, and correlation coefficient and receiver operating characteristic (ROC) coefficient were calculated. RESULTS: Fifty-one data points were obtained from 43 patients (65% men). Bland-Altman analysis revealed poor agreement between telemetry and electrocardiography and evidence of fixed and proportional bias. Area under the ROC curve for QTc determined by telemetry was 0.9 (P < .001) for a definition of prolonged QT as QTc ≥ 450 milliseconds in electrocardiography (sensitivity, 88.89%; specificity, 83.33%; cutoff of 464 milliseconds used). Correlation between the 2 methods was only moderate (r = 0.6, P < .001). CONCLUSIONS: QTc determination by telemetry has poor agreement and moderate correlation with electrocardiography. However, telemetry has an acceptable area under the curve in ROC analysis with tolerable sensitivity and specificity depending on the cutoff used to define prolonged QT. Cardiac telemetry should be used with caution in critically ill patients.

[Renal tubular distal acidosis: nephrocalcinosis as initial diagnosis.] / Nefrocalcinosis como manifestación de la acidosis tubular renal distal.

We present a case of a woman affected by Systemic Lupus Erythematosus (SLE) and distal renal tubular acidosis (DRTA) that during pregnancy presented an exacerbation of SLE together with a renal colic with spontaneous stone passage. Radiological exam revealed diffuse calcifications in both kidneys which suggests, in a context of DRTA, a nephrocalcinosis. With the stabilization of SLE and medical treatment directed to correct metabolic alterations we achieved radiological and clinical stability of lithiasic disease.

Se presenta el caso de una mujer afecta de Lupus Eritematoso Sistémico (LES) y acidosis tubular renal distal (ATRD) que en el embarazo presenta una exacerbacióndel LES junto con un cuadro de cólico nefrítico con expulsión espontánea de cálculos. Las pruebas radiológicas muestran calcificaciones difusas en ambos parénquimas renales lo cual sugiere, en el contexto de una ATRD, una nefrocalcinosis. Junto con la estabilización del LES y un tratamiento médico dirigido a corregir las alteraciones metabólicas se alcanza una estabilidad radiológica y clínica de la enfermedad litiásica.

Prevalence of BK Virus in Renal Transplant at a Single Center: Experience With Our Ureteral Reimplantation Surgical Technique.

OBJECTIVES: BK polyomavirus is one of the main causes of chronic renal failure and ureteral stenosis in kidney transplant recipients, affecting approximately 15% of kidney transplant patients during the first year after transplant. The immunosuppressive treatment used in these recipients allows a reactivation of the virus by allowing infection, which can manifest from viruria, viremia, or nephropathy. The use of ureteral stents in renal transplant to prevent postoperative complications has been associated with an increase in BK polyomavirus nephropathy. Our objective was to describe associations between viruria and viremia and our reimplantation surgical technique and ureteral stenting. MATERIALS AND METHODS: We conducted a retrospective review of 184 transplant recipients who were seen at our center between January 2013 and December 2016. To define possible risk factors from analysis of different variables, we categorized patients into 3 groups: patients who did not present with either viremia or viruria caused by BK virus, patients who presented with viremia, and patients who presented with viruria. RESULTS: We found that 127 transplant recipients (69%) presented with neither BK viruria nor BK viremia, 11 recipients (6%) presented with BK viremia, and 46 recipients (25%) presented with BK viruria. No patient in the study had BK polyomavirus nephropathy. CONCLUSIONS: Our type of ureteral stenting has a low rate of BK viruria and BK viremia compared with other studies. In addition, with our technique, the ureteral stent removal procedure does not require an invasive endoscopic procedure, thereby avoiding the consequent economic and assistance inconvenience typically associated with an endoscopic procedure.

Influence of a Polyherbal Mixture in Dairy Calves: Growth Performance and Gene Expression.

A polyherbal feed mixture containing (Achyrantes aspera, Trachyspermum ammi, Citrullus colocynthis, Andrographis paniculata, and Azadirachta indica) was evaluated in growing calves through blood chemistry, blood biometry, and gene expression during the pre-ruminant to weaning period. Forty Holstein calves (initial BW 45.6 ± 3.2 kg; 22.8 ± 0.9 days post birth) from a dairy farm were randomly assigned to the following treatments: 0, 3, 4, and 5 g/d of a polyherbal mixture, dosed in colloid gels with gelatin. Calves were housed in individual outdoor boxes with ad libitum access to a 21.5% CP calf starter and water and fed individually with a mixture of milk and a non-medicated milk replacer (22% CP). Blood samples were collected on day 59 for blood chemistry, blood biometry, and gene expression analysis in leukocyte through microarray assays. Immunoglobulins were quantified by enzyme-linked immunosorbent assay. The animals treated with the polyherbal mixture showed a quadratic effect on final body weight, daily weight gain, final hip height, and final thoracic girth. The best performance results were obtained with a treatment dose of 4 g/d. The serum IgG increased linearly with the treatment doses. Gene set enrichment analysis of upregulated genes revealed that the three biological processes with higher fold change were tight junction, mucin type O-Glycan biosynthesis, and intestinal immune network for IgA production. Also, these upregulated genes influenced arachidonic acid metabolism, and pantothenate and CoA biosynthesis. Gene ontology enrichment analysis indicated that the pathways enriched were PELP1 estrogen receptor interacting protein pathways, nuclear receptors in lipid metabolism and toxicity, tight junction, ECM-receptor interaction, thyroid hormone signaling pathways, vascular smooth muscle contraction, ribosome function, glutamatergic synapse pathway, focal adhesion, Hippo, calcium, and MAPK signaling pathways.

Iliac-Ileal Conduit Fistula.

One of the possible complications of chronic ureteral stenting is an artery-urinary tract fistula, although it is very rare. If it occurs, it is an emergency that needs surgery because of hemorrhage. We describe a case of an iliac-ileal conduit fistula, which is extremely rare, that was successfully treated by endovascular stent grafting.

Carcinoma cuniculatum: a distinctive variant of penile squamous cell carcinoma: report of 7 cases.

We are reporting a peculiar variant of penile squamous cell carcinoma (SCC) characterized by its peculiar deeply penetrating and burrowing pattern of growth. This low grade, verruciform penile neoplasm is similar to the plantar epithelioma cuniculatum originally described by Ayrd in 1954. Clinical and pathologic features of 7 patients are presented. There were 7 partial penectomies and 4 bilateral inguinal node dissections. The mean patient's age was 77 years. Grossly, the tumors were white to gray, exo-endophytic, and papillomatous with a cobblestone or spiky appearance. All cases affected the glans and extended to coronal sulcus and foreskin (average size was 6.3 cm). The hallmark of the lesion was noted on cut surface where there were deep tumoral invaginations forming irregular, narrow, and elongated neoplastic sinus tracts connecting the surface of the neoplasm to deep anatomic structures. The neoplasm invaded through lamina propria and corpus spongiosum and grew along the loose connective tissue of Buck fascia to involve the tunica albuginea and corpora cavernosa (average depth was 32 mm). Deeply invasive keratin filled cysts or crypts, on serial sections, showed to be connected to the surface tumor. Fistulization to the skin was also noted. Microscopically, the lesions corresponded to well-differentiated carcinomas with bulbous front of invasion. There were focal areas of higher histologic grade and more infiltrative and jagged borders in 4 cases. Inguinal nodes were negative in 4 patients in which groin dissection was performed. Carcinoma cuniculatum is a variant of penile SCC with distinctive growth pattern and should be distinguished from other verruciform tumors such as the verrucous, papillary, and warty carcinomas. Unlike most subtypes of penile SCCs and despite the deep invasion, none of the tumors showed groin or systemic dissemination at time of diagnosis.

Delirium management in critically ill patients.

Delirium among critically ill patients is common. Presence of delirium imparts a poorer prognosis to patients, including longer ICU and hospital length of stay, increased risk of institutionalization, higher health related costs, and elevated mortality. Even with such grave consequences, the rates of delirium diagnosis are dire. The importance of early recognition through validated tools and appropriate management of this life-threatening condition cannot be over emphasized. This article provides an overview of delirium pathophysiology, diagnosis, and management with a focus on critically ill patients.

Granulomatosis con poliangeítis simulando una torsión testicular / Granulomatosis with poliangiitis mimicking testicular torsion

La granulomatosis con poliangeítis (GPA) es una vasculitis autoinmune que raramente afecta al tracto genitourinario inferior. Presentamos el caso de un varón de 53 años que debutó con una masa retroperitoneal y posteriormente desarrolló un hidrocele multiseptado izquierdo que condicionó un infarto testicular. El informe anatomopatológico de la orquiectomía reveló hallazgos sugestivos de GPA.(AU)

Granulomatosis with polyangiitis (GPA) is an autoimmune vasculitis which rarely affects the lower genitourinary tract. We share the case of a 53-year-old man who presented with a retroperitoneal mass and thereafter developed a left multiseptated hydrocele that conditioned a testicular infarction. The pathology report of the orchidectomy was consistent with GPA.(AU)