Long-term follow-up and outcomes of percutaneous nephron-sparing surgery for upper tract urothelial carcinoma.

INTRODUCTION: Upper tract urothelial carcinoma (UTUC) is uncommon, accounting for 5%-10% of all urothelial carcinomas. Current standard of care for localized disease consists of radical nephroureterectomy (RNU) which leads to loss of half the patient's functioning nephrons. Percutaneous nephron-sparing surgery (PCNSS) is an alternative minimally-invasive approach in selected cases where nephron preservation is desired. The long-term outcomes of this procedure at a single center are described. METHODS: All patients undergoing PCNSS, with the operation carried out by a single surgeon, were included. Equipment used was a standard 26Ch resectoscope through a 30Ch Amplatz sheath, with all patients receiving postoperative intrapelvic Mitomycin. Data for each patient were collected on patient age; tumor size at diagnosis; grade; stage; oncological recurrence; requirement for subsequent RNU; and overall survival. Primary outcomes were disease recurrence and overall mortality, and secondary outcome was rate of subsequent RNU. RESULTS: Fifteen patients in total underwent PCNSS, 14 were diagnosed with UTUC; benign leiomyoma was proven in one patient and excluded from final analysis. Overall survival at 5 and 10 years was 92.9% and 78.6%, respectively, with disease-specific mortality at 10 years of 7.1% (one patient who developed metastatic carcinoma); 21.4% of patients had recurrent ipsilateral UTUC and all required subsequent RNU for this indication. No patients had seeding of the percutaneous tract. CONCLUSION: PCNSS for UTUC is a feasible approach to consider in carefully selected patients who agree to intensive follow-up, even for higher grade tumors. Where recurrent UTUC occurs, further management options still exist for disease treatment.

Retrograde Ureteral Stents Versus Percutaneous Nephrostomy in the Management of Malignant Ureteral Obstruction: A Systematic Review and Meta-analysis.

OBJECTIVE: To evaluate outcomes in cancer patients with ureteral obstruction by comparison of retrograde stenting and percutaneous nephrostomy techniques. METHODS: Systematic review of all studies up to October 2023. Studies were identified from all major databases including MEDLINE, Cochrane, and EMBASE. All comparative studies between retrograde stenting and percutaneous nephrostomy were searched; studies with paediatric populations were excluded. Primary outcomes were procedure and intervention failure rates; secondary outcomes were infection, blockage, displacement, and unplanned exchange rates along with procedure time and length of stay. RESULTS: Eighteen studies with 1228 patients contributed to the summative outcome. Percutaneous nephrostomy was statistically superior to retrograde stenting for procedure failure rate (P <.00001) and intervention failure rate (P =.0004). Retrograde stenting was statistically superior to percutaneous nephrostomy for displacement rates (P = .003), procedure time (P <.00001), and length of stay (P <.00001). Retrograde stenting showed no difference to percutaneous nephrostomy for infection rates (P = .94), blockage rates (P = .93), unplanned exchange rates (P = .48), CONCLUSION: There is no absolute superiority for retrograde stenting or percutaneous nephrostomy for malignant ureteral obstruction. Both techniques have their advantages and disadvantages, with some comparable outcomes; patients are key when selecting the best technique. Larger studies are required to assess the outcomes of both techniques.

Role of energy consumption and sustainability-oriented eco-innovation on economic growth: evidence from Middle Eastern economy.

Economic growth is a global requirement that requires extensive energy consumption, and this phenomenon needs researchers' attention and regulators' focus. Thereby, the paper scrutinizes the determinants of energy consumption such as fossil fuel energy consumption (FFEC), energy use, nuclear energy consumption (NEC), energy import, and renewable energy consumption (REC) and sustainability-oriented eco-innovation and their effectiveness on the economic growth of Saudi Arabia. The study extracted data from the World Bank from 1989 to 2020. Stationarity was examined using augmented Dickey-Fuller (ADF) tests, and the associations among constructs were analyzed through QARDL model. The findings revealed that FFEC, EU, NEC, EI, REC, and sustainability-oriented eco-innovation are significantly correlated with the EG of Saudi Arabia. The study also provides insights to new researchers who will investigate this area in the future and guides regulators in developing regulations related to economic growth using an appropriate level of energy and adoption of sustainability-oriented eco-innovation.

Synchronous AML and pancreatic neuroendocrine neoplasm, both successfully treated with somatostatin analogs and decitabine.

Summary: Downregulation of tumor suppression genes by DNA hypermethylation has been proposed as a potential cause of neuroendocrine neoplasm (NEN) formation. In this report, we present a patient simultaneously diagnosed with acute myeloid leukemia (AML) and a metastatic nonfunctioning pancreatic NEN. Because of the two competing diagnoses, he was treated with lanreotide, venetoclax and a long course of the hypomethylating agent decitabine. The AML responded to venetoclax and decitabine treatment while the PanNEN stabilized on lanreotide. Over multiple months of treatment, the PanNEN showed gradual tumor response, consistent with decitabine treatment effect, and the patient remained without disease progression for both malignancies. We believe that some PanNENs can benefit from treatment with hypomethylating agents such as decitabine. To support this, we review the relevant literature and suggest a mechanism for the efficacy of decitabine in our case. Learning points: Neuroendocrine neoplasms are associated with an increased risk of second primary cancers.Epigenetic changes such as hypermethylation and inhibition of tumor suppressor genes might explain the development and behavior of certain NENs.The use of hypomethylating agents such as decitabine might have a role in the treatment of PanNENs. Future studies are needed to confirm that.

Immunotherapy-Induced Auto-Splenectomy in a Patient of Malignant Melanoma.

Immune checkpoint inhibitors like programmed cell death 1 (PD-1) and cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) are biological agents that help in boosting the immune system of the body to fight against cancer cells. These checkpoint inhibitors are now being approved by the Food and Drug Administration (FDA) to treat various malignancies due to remarkable response. Here, we present a rare immune-related adverse event in a 77-year-old female with metastatic melanoma treated with ipilimumab and nivolumab, later presented with auto-splenectomy.

A Rare Case of Synovial Sarcoma of the Prostate Causing Urinary Retention.

Synovial sarcomas of the prostate are exceedingly rare malignant tumors. Only a few cases have been reported so far. We discuss a case of a 52-year-old male who presented with signs and symptoms of benign prostate hyperplasia (BPH) and was diagnosed with synovial sarcoma of the prostate. Since this sarcoma is rare, it can easily be misdiagnosed with BPH or adenocarcinoma of the prostate.

Neurotoxicity: A Rare Side Effect of Programmed Cell Death 1 (PD-1) Inhibitors.

Immunotherapy is a biological therapy that helps the body's immune system to fight against cancer cells. The Food and Drug Administration (FDA) approved the first immune checkpoint inhibitor in 2011. Since 2011, many immune checkpoint inhibitors have been approved. Programmed cell death 1 (PD-1) inhibitors are now commonly used in multiple malignancies due to their remarkable response. Thus, immune-related adverse events are now coming into the limelight due to the increasing use of PD-1 inhibitors. Here, we present a case of a 54-year-old female with non-small cell lung cancers (NSCLC) treated with pembrolizumab and later presented with severe neurotoxicity.

How COVID-19 induced panic on stock price and green finance markets: global economic recovery nexus from volatility dynamics.

This paper investigates the effect of different categories of essential COVID-19 data from 2020 to 2021 towards stock price dynamics and options markets. It applied the hypothetical method in which investors develop depression based on the understanding suggested by various green finance divisions. Furthermore, additional elements like panic, sentiment, and social networking sites may impact the attitude, size, and direction of green finance, subsequently impacting the security prices. We created new emotion proxies based on five groups of information, namely COVID-19, marketplace, lockdown, banking sector, and government relief using Google search data. The results show that (1) if the proportional number of traders' conduct exceeds the stock market, the effect of sentimentality indexes on jump volatility is expected to change; (2) the volatility index component jump radically increases with the COVID-19 index, city and market lockdown index, and banking index; and (3) expanding the COVID-19 index gives rise to the stock market index. Moreover, all indexes decreased in jump volatility but only after 5 days. These findings comply with the hypotheses proposed by our model.

Assessing Financial Risk Spillover and Panic Impact of Covid-19 on European and Vietnam Stock market.

This study examined the influence of tail risks on global financial markets, which aids in better understanding of the emergence of COVID-19. This study looks at the global and Vietnamese stock markets impacted by the COVID-19 pandemic to identify systemic emergencies. Risk dependent value (CoVaR) and Delta link VaR are two important tail-related risk indicators used in Conditional Bivariate Dynamic Correlation (DCC) (CoVaR). The empirical findings demonstrate that when COVID-19's worldwide spread widens, the volatility transmission of systemic risks across the global stock market and multiple exchanges shifts and becomes more relevant over time. At the time of COVID-19, the world industrial market was larger than the Vietnamese stock market, and the Vietnamese stock market posed a lesser danger to the global market. A closer examination of the link between the Vietnam value-at-risk (VaR) range index sample and the world stock index indicates a significant degree of downside risk integration in key monetary systems, particularly during the COVID-19 era. Our study findings may help regulators, politicians, and portfolio risk managers in Vietnam and worldwide during the unique moment of uncertainty created by the COVID-19 epidemic.

Stent diameter and stent-related symptoms, does size matter? A systematic review and meta-analysis.

The ureteral insertion of a silicone tube was first performed in 1967. A validated ureteral stent symptom questionnaire (USSQ) is used for an objective assessment of patient-reported stent-related symptoms. As the impact of stent diameter on the incidence of stent-related symptoms is unclear, we aimed to perform a systematic review and meta-analysis comparing USSQ reported outcomes when using a 6 Fr diameter ureteric stent, versus smaller diameter stents (4.7-5 Fr) when inserted for ureteric stones. All randomized control trials and comparative studies of 6 Fr versus 4.7-5 Fr ureteric stents were reviewed. The USSQ outcomes were considered as the primary outcome measures while stent migration was considered as a secondary outcome measure. A total of 61 articles were identified of which four studies met the eligibility criteria. There was a statistically significant association between the use of wider (6 Fr) diameter stents and the incidence of urinary symptoms as measured by the urinary index score. Larger stent diameters were associated with a statistically significant increase in the pain index score. There was no statistically significant difference in the scores between the compared stent diameters with regard to work performance score, general health index score, additional problems index score, and stent migration. There were insufficient reported outcomes to perform a meta-analysis of sexual matters index score. Our meta-analysis shows that using smaller diameter ureteric stents is associated with reduced urinary symptoms and patient-reported pain. Other USSQ parameter outcomes are statistically similar in the 6 Fr ureteric stent cohort versus the 4.7-5 Fr ureteric stent cohort. Our meta-analysis was limited due to the limited number of studies and gross heterogeneity of reporting parameters in various studies. We hope a large-scale homogeneous randomized control trial will further shed more insight into the stent symptoms response to stent diameter.

Open Partial Nephrectomy with Zero Ischaemia Using a Supra 12th Rib Miniflank Incision: A Minimally Invasive Open Approach for Small Renal Masses.

INTRODUCTION: To assess a minimally invasive open technique for partial nephrectomy with zero ischaemia time. METHODS: A review was performed in a prospectively maintained database of a single surgeon series of all patients undergoing partial nephrectomy using a supra 12th rib miniflank incision with zero ischaemia. Data of seventy one patients who underwent a partial nephrectomy over an 82-month period were analyzed. Data analyzed included operative time, estimated blood loss, pre and postoperative renal function, complications, final pathological characteristics, and tumour size. RESULTS: Seventy one partial nephrectomies were performed from February 2009 to October 2015. None were converted to radical nephrectomy. Mean operative time was 72 minutes (range 30-250), and mean estimated blood loss was 608 mls (range 100-2500) with one patient receiving blood transfusion. The mean pre and postoperative haemoglobin levels were 144 and 112 g/l. The mean pre and postoperative creatinine levels were 82 and 103 Umol/L. There were 8 Clavian-Dindo Grade 2 complications and 1 major complication (Clavian IIIa). Histology confirmed 24 benign lesions and 47 malignant lesions, 46 cT1a lesions, 24 cT1b lesions, and 1 cT2 lesion. Median follow-up was 38 months with no local recurrence or progression of disease with 5 patients having a positive margin (7%). CONCLUSION: Our results demonstrate that a supra 12th miniflank incision open partial nephrectomy with zero ischaemic time for SRMs has satisfactory outcomes with preservation of renal function. A minimally invasive open partial nephrectomy remains an important option for units that cannot offer patients a laparoscopic or a robotic procedure.

Metastatic Castrate-Resistant Prostate Cancer: A Rare Cause of Bowel Obstruction.

Prostate cancer most commonly metastasizes to bone, lymph nodes, lungs, or liver, but rarely spreads to the large intestine. This case highlights a rare case of castrate-resistant prostate cancer (CRPC) that spread locally to the large intestine and rectum, significant enough to cause bowel obstruction. Metastatic prostate carcinomas are considered an infrequent cause of bowel obstruction.

Safety and Efficacy of Transurethral Resection of Bladder Tumor Comparing Spinal Anesthesia with Spinal Anesthesia with an Obturator Nerve Block: A Systematic Review and Meta-analysis.

Aims: To investigate whether spinal anesthesia with an obturator nerve block (SA+ONB) can be effectively used for transurethral resection of bladder tumor (TURBT) during the coronavirus disease 2019 (COVID-19) pandemic to improve patient outcomes while also avoiding aerosol-generating procedures (AGPs). We aimed to compare outcomes of TURBTs using spinal anesthesia (SA) alone vs SA+ONB in terms of rates of obturator reflex, bladder perforation, incomplete tumor resection, tumor recurrence, and local anesthetic toxicity. Methods: We conducted a comprehensive search of electronic databases (MEDLINE, PUBMED, EMBASE, CINAHL, CENTRAL, SCOPUS, Google Scholar, and Web of Science), identifying studies comparing the outcomes of TURBT using SA vs spinal with an ONB. The Cochrane risk-of-bias tool for randomized-controlled trials (RCTs) and the Newcastle-Ottawa scale for observational studies were used to assess the included studies. Random effects modeling was used to calculate pooled outcome data. Results: Four RCTs and three cohort studies were identified, enrolling a total of 448 patients. The use of SA+ONB was associated with a significantly reduced risk of obturator reflex (p < 0.00001), bladder perforation (p = 0.02), incomplete resection (p < 0.0001), and 12-month tumor recurrence (p = 0.005). ONB was not associated with an increased risk of local anesthetic toxicity (0/159). Conclusion: Our meta-analysis suggests that TURBT using SA+ONB is superior to the use of SA alone. During the COVID-19 pandemic, where avoidance of AGPs such as a general anesthesia is paramount, the use of an ONB with SA is essential for the safety of both patients and staff without compromising care. Further high-quality RCTs with adequate sample sizes are required to compare the different techniques of ONB as well as comparing this method with general anesthesia with complete neuromuscular blockade.

Safety and Efficacy of Bipolar Transurethral Resection of the Prostate vs Monopolar Transurethral Resection of Prostate in the Treatment of Moderate-Large Volume Prostatic Hyperplasia: A Systematic Review and Meta-Analysis.

Aims: To compare outcomes of monopolar vs bipolar transurethral resection of the prostate (TURP) in the management of exclusively moderate-large volume prostatic hyperplasia in terms of maximum flow rate as a surrogate for clinical efficacy, duration of catheterization, hospital stay, operative time, resection weight, transurethral resection (TUR) syndrome, acute urinary retention (AUR), clot retention, and blood transfusion. Methods: We conducted a search of electronic databases (PubMed, MEDLINE, EMBASE, CINAHL, and CENTRAL), identifying studies comparing the outcomes of monopolar and bipolar TURP in the management of large-volume prostatic hyperplasia. The Cochrane risk-of-bias tool for randomized controlled trials (RCTs) and the Newcastle-Ottawa scale for observational studies were used to assess included studies. Random effects modeling was used to calculate pooled outcome data. Results: Three RCTs and four observational studies were identified, enrolling 496 patients. No difference was observed in the clinical efficacy between each procedure at 3 months postoperatively (p = 0.99), 6 months (p = 0.46), and 12 months (p = 0.29). The use of bipolar TURP was associated with significantly shorter inpatient stay (p = 0.01) and a shorter duration of catheterization (p = 0.05). Monopolar TURP was associated with an increased risk of TUR syndrome (p = 0.03). Operative time (p = 0.58), resection weight (p = 0.16), AUR (p = 0.96), clot retention (p = 0.79), and blood transfusion (p = 0.39) were similar in both groups. Conclusion: Our meta-analysis demonstrated that bipolar TURP in the treatment of moderate-large volume prostatic disease may be associated with a significantly lower rate of TUR syndrome and shortened length of hospital stay, with similar efficacy when compared with monopolar TURP. Further high-quality RCTs with adequate sample sizes are required to compare both monopolar and bipolar TURP to open prostatectomy or laser enucleation in the treatment of exclusively large-volume prostates with stricter definition of size.

How energy insecurity leads to energy poverty? Do environmental consideration and climate change concerns matters.

The aim of the study is to estimate the nexus between energy insecurity and energy poverty with the role of climate change and other environmental concerns. We used DEA like WP methods and properties of MCDA, a most common form of data envelopment analysis (DEA) to estimate the nexus between constructs. This paper presents a measurement and analysis of G7 countries' energy, economic, social, and environmental performance associated with energy poverty indexes. The study used the multiple, comprehensive, and relevant set of indicators, including energy economics and environmental consideration of energy poverty. The net energy consumption of al G7 economies is equal to 34 percent of the entire world along with the net estimate GDP score of around 50 percent. Using DEA modelling and estimation technique, our research presented valuable insights for readers, theorists and policy makers on energy, environment, energy poverty and climate change mitigation. For this reasons, all these indicators combined in a mathematical composite indicator to measure energy, economic, social, and environmental performance index (EPI). Results show that Canada has the highest EPII score, which shows that Canada's capacity to deal with energy self-sufficiency, economic development, and environmental performance is greater than the other G7 countries. France and Italy rank second and third. Japan comes next with 0.50 EPI scores, while the USA has the lowest average EPI score environment vulnerable even though have higher economic development among the G7 group countries. We suggest a policy framework to strengthen the subject matter of the study.

Trilemma association of energy consumption, carbon emission, and economic growth of BRICS and OECD regions: quantile regression estimation.

Recent research has shown a huge impact of non-renewable energy (NRE) production on environmental health. In this context, this work analyzes the effects of GDP growth and long- and short-term consumption of renewable and non-renewable energy (RE and NRE, respectively) on carbon emission in BRICS and OECD economies. The quantile autoregressive distributed lag (QARDL) model was employed on the panel data from 1980 to 2016. Findings suggest a negative GDP-carbon emission correlation and a positive NRE-carbon emission correlation in the considered economies. Furthermore, carbon emission decreases with increase in gross capital formation, whereas trade openness does not have any significant effect on carbon emission. It has been determined that the application of the error correction method (ECM) has less effect on energy consumption as compared to the past levels and changes in energy consumption. In the long-term, a positive correlation of carbon emission and energy consumption is observed, whereas limited short-term effects of energy consumption on carbon emission are observed. Therefore, an RE-based energy production approach is recommended in the selected region for the future projects.

Cholecystitis Masquerading as Cardiac Chest Pain: A Case Report.

BACKGROUND Cope's sign is the association of bradycardia with symptoms of acute cholecystitis, which can occur due to a vagal cardiobiliary reflex. The clinical and electrocardiographic changes of bradycardia or complete heart block can mimic the presentation of acute coronary syndrome. This report highlights the unique possibility that bradycardia in patients with abdominal pain and gallstones can be due to this reflex. CASE REPORT A 46-year-old obese man with hyperlipidemia and gallstones presented with chest pain suggestive of cardiac ischemia. The initial electrocardiography (EKG) was normal, although the patient subsequently developed bradycardia and a 2nd-degree atrioventricular (AV) block. The results of further cardiothoracic investigations (including echocardiography and pharmacologic stress testing) were normal. An ultrasound of the abdomen revealed acute cholecystitis. After he underwent a laparoscopic cholecystectomy, the chest pain resolved completely, and the EKG reverted to its normal sinus rhythm. CONCLUSIONS Acute cholecystitis rarely presents with cardiac chest pain and EKG changes due to triggering of the vagal cardiobiliary reflex. Given this atypical presentation, patients often undergo invasive cardiac procedures in search of a nonexistent cardiac etiology coupled with the possibility of a missed diagnosis of cholecystitis. When clinicians consider a diagnosis of acute coronary syndrome in patients with bradycardia, T-wave inversion, and ST-segment elevation (especially in the inferior leads), they should add the possibility of intra-abdominal pathologies (including cholecystitis) in the differential diagnosis.

Comparison of the Efficacy of Male Sexual Activity Versus Alpha-Blockers in the Expulsion of Distal Ureteric Stones: A Systematic Review and Meta-Analysis.

Globally, the prevalence of urolithiasis is increasing, with limited effective treatment options. Though debate exists within the literature, the use of medical expulsive therapy (MET) for distal ureteric stones in the form of alpha-blockers is commonplace. Alpha-blockers work via the inhibition of norepinephrine, resulting in a small degree of distal ureteric relaxation. Nitric oxide (NO), the main neurotransmitter involved in penile erection, causes smooth muscle relaxation of the distal ureter. It is hypothesised that these alternative pathways may achieve the same desire clinical effect. To our knowledge, this is the first meta-analysis comparing the efficacy of male sexual activity, in the form of intercourse or masturbation, to alpha-blockers in the expulsion of ureteric stones. We conducted a comprehensive search of electronic databases (PubMed, MEDLINE, EMBASE, SCOPUS, CENTRAL and Google Scholar), identifying studies comparing male sexual activity versus alpha-blockers, in male patients with distal ureteric stones. The Cochrane risk-of-bias tool was used to assess the included studies. For data analysis, a random effects model was used in the event of significant heterogeneity (>75%), with fixed-effects modelling in the event of low-moderate heterogeneity. A search of electronic databases found three randomised control trials (RCTs), enrolling a total of 262 patients. There was no statistically significant difference observed when patients engaged in sexual activity rather than alpha-blocker, when looking at stone expulsion rate at two weeks (P=0.36), expulsion rate at four weeks (P=0.57), or the mean stone expulsion time (P=0.21). Furthermore, there was no significant difference observed when looking at analgesic requirements (P=0.43), or the requirement for additional procedures (P=0.57). Our meta-analysis demonstrated that male sexual activity as an alternative therapy for distal ureteric stones had comparable outcomes to the use of alpha-blocker, proving a viable alternative therapy in those patients wishing to avoid pharmacological management.