A comparison of operative and margin outcomes from surgeon learning curves in robot assisted radical prostatectomy in a changing referral practice.

Introduction The aim of this study was to explore the impact of increasing proportions of high risk referrals on surgical margin outcomes of a surgeon's learning curve in robotic prostatectomy. Methods All patients in this study underwent robot assisted radical prostatectomy (RARP) performed by three different consultant urological surgeons. Data collected included preoperative clinical stage, Gleason score and prostate specific antigen levels, which were used to risk stratify patients according to National Institute for Health and Care Excellence criteria. Oncological clearance was assessed by overall and stage specific positive margin status. Comparisons were made between each surgeon for the first and second 50 consecutive cases. Results For the three surgeons, there was a progressive increase in the proportion of high risk cases referred accompanied by a corresponding decline in low risk disease (p<0.001). Postoperative pathology also showed an upward trend in pT3 cases across the three eras. There was no statistical difference in overall positive margin rates between the surgeons. The overall rates were 12%, 20% and 23% for the first 50 cases, and 32%, 36% and 21% for the second 50 cases for the three surgeons respectively. Conclusions Our series demonstrates an upward trend in the risk profile of men referred for robotic prostatectomy over a nine-year period. Despite this, there was minimal impact on pathological and surgical outcomes among our surgeons, who were at the initial stages of their RARP learning curve. Our results suggest that there is no requirement for an active case selection bias against patients with high risk disease for surgeons newly embarking on their RARP learning experience.

Integration of copy number and transcriptomics provides risk stratification in prostate cancer: A discovery and validation cohort study.

BACKGROUND: Understanding the heterogeneous genotypes and phenotypes of prostate cancer is fundamental to improving the way we treat this disease. As yet, there are no validated descriptions of prostate cancer subgroups derived from integrated genomics linked with clinical outcome. METHODS: In a study of 482 tumour, benign and germline samples from 259 men with primary prostate cancer, we used integrative analysis of copy number alterations (CNA) and array transcriptomics to identify genomic loci that affect expression levels of mRNA in an expression quantitative trait loci (eQTL) approach, to stratify patients into subgroups that we then associated with future clinical behaviour, and compared with either CNA or transcriptomics alone. FINDINGS: We identified five separate patient subgroups with distinct genomic alterations and expression profiles based on 100 discriminating genes in our separate discovery and validation sets of 125 and 103 men. These subgroups were able to consistently predict biochemical relapse (p = 0.0017 and p = 0.016 respectively) and were further validated in a third cohort with long-term follow-up (p = 0.027). We show the relative contributions of gene expression and copy number data on phenotype, and demonstrate the improved power gained from integrative analyses. We confirm alterations in six genes previously associated with prostate cancer (MAP3K7, MELK, RCBTB2, ELAC2, TPD52, ZBTB4), and also identify 94 genes not previously linked to prostate cancer progression that would not have been detected using either transcript or copy number data alone. We confirm a number of previously published molecular changes associated with high risk disease, including MYC amplification, and NKX3-1, RB1 and PTEN deletions, as well as over-expression of PCA3 and AMACR, and loss of MSMB in tumour tissue. A subset of the 100 genes outperforms established clinical predictors of poor prognosis (PSA, Gleason score), as well as previously published gene signatures (p = 0.0001). We further show how our molecular profiles can be used for the early detection of aggressive cases in a clinical setting, and inform treatment decisions. INTERPRETATION: For the first time in prostate cancer this study demonstrates the importance of integrated genomic analyses incorporating both benign and tumour tissue data in identifying molecular alterations leading to the generation of robust gene sets that are predictive of clinical outcome in independent patient cohorts.

Identification of pathologically insignificant prostate cancer is not accurate in unscreened men.

BACKGROUND: Identification of men harbouring insignificant prostate cancer (PC) is important in selecting patients for active surveillance. Tools have been developed in PSA-screened populations to identify such men based on clinical and biopsy parameters. METHODS: Prospectively collected case series of 848 patients was treated with radical prostatectomy between July 2007 and October 2011 at an English tertiary care centre. Tumour volume was assessed by pathological examination. For each tool, receiver operator characteristics were calculated for predicting insignificant disease by three different criteria and the area under each curve compared. Comparison of accuracy in screened and unscreened populations was performed. RESULTS: Of 848 patients, 415 had Gleason 3+3 disease on biopsy. Of these, 32.0% had extra-prostatic extension and 50.2% were upgraded. One had positive lymph nodes. Two hundred and six (24% of cohort) were D'Amico low risk. Of these, 143 had more than two biopsy cores involved. None of the tools evaluated has adequate discriminative power in predicting insignificant tumour burden. Accuracy is low in PSA-screened and -unscreened populations. CONCLUSIONS: In our unscreened population, tools designed to identify insignificant PC are inaccurate. Detection of a wider size range of prostate tumours in the unscreened may contribute to relative inaccuracy.

Comparative evaluation of microleakage of silorane-based composite and nanohybrid composite with or without polyethylene fiber inserts in class II restorations: an in vitro study.

AIM: To evaluate microleakage between nanocomposite and silorane composite in class II restorations with or without a polyethylene fiber insert. METHODOLOGY: Standardized class II cavities were prepared on extracted molars and randomly divided into 4 groups (n=20 each): group 1, Ceram X mono; group 2, Ceram X mono + Ribbond; group 3, Filtek P90; and Group 4, Filtek P90 + Ribbond. All specimens were subjected to a thermocycling regime, immersed in 2% methylene blue dye for 24 hours, sectioned longitudinally, and examined under a stereomicroscope to assess dye penetration on a six-point scale. The score data were subjected to statistical analysis whereby Kruskal-Wallis analysis of variance was used for multiple group comparisons and the Mann-Whitney test for groupwise comparisons at a significance level of p≤0.05. RESULTS: A statistically significant decrease in microleakage was found when Ribbond fiber was used with nanoceramic and silorane composite. A highly significant decrease in microleakage scores was found in silorane composite when compared to nanoceramic composite. CONCLUSION: Use of polyethylene fiber and silorane composite reduces microleakage in class II composite restorations with gingival margins below the cemento-enamel junction.

A rare congenital heart disease in an elderly long-distance runner: a case report.

Introduction. Cor triatriatum is a rare congenital heart disease found incidentally in children. Although cor triatriatum can be an incidental finding in asymptomatic adults; it is extremely rare to find elderly patients without symptoms and is unique in a long distance runner. Case Presentation. We present the case of an 83-year-old long-distance runner with cor triatriatum sinistrum and atrial fibrillation who continues to be asymptomatic and has continued to run long distances, retaining his excellent functional capacity. Conclusion. Cor triatriatum sinistrum is a rare congenital disease, which is often found incidentally in children. Although it is also seen in adults without symptoms at normal exertion, it is rare to have this condition in long-distance runners especially in elderly people with other structural heart disease, that is, atrial fibrillation and mitral regurgitation.

PONI and its association with oxidative stress in type I and type II diabetes mellitus.

OBJECTIVE: Paraoxonase (PON) is an antioxidant enzyme linked with cardiovascular disease (CVD), diabetes as it prevents LDL oxidation. The relation of PON with the other established risk factor of diabetic complications has not been looked into. RESEARCH DESIGN AND METHODS: 370 subjects were included in the study. Dividing into four group, i.e. group I included type II DM (n=220), group II was age matched control (n=100), group III were type I DM (n=25) and group IV (n=25) were age matched control group. The protocol of the study was approved by the ethical committee of the institute. SOD, GSH, PON (paraoxonase and arylesterase activity), GHb, and MDA were estimated. RESULTS: A highly significant decrease in paraoxonase and arylesterase activity was seen in the type II DM (p<0.0001) while in type I DM both the activity was not significant (p>0.05). Paraoxonase and arylesterase activity of PONI showed a negative significant correlated with MDA (r=-0.51, p<0.0001 and r=-0.23, p<0.001) in type II DM but was not correlated in type I DM. The GHb and MDA levels were significantly increased (p<0.0001) while the levels of SOD and GSH have been decreased in type I and type II DM. CONCLUSION: PONI is definitely associated with development of the complications of diabetes. This may be due to the role of it as an antioxidant. As it also show a negative correlation with MDA like the other antioxidants studied.

Robotic-assisted laparoscopic prostatectomy.

Prostate cancer remains a significant health problem worldwide and is the second highest cause of cancer-related death in men. While there is uncertainty over which men will benefit from radical treatment, considerable efforts are being made to reduce treatment related side-effects and in optimising outcomes. This article reviews the development and introduction of robotic-assisted laparoscopic radical prostatectomy (RALP), the results to date, and the possible future directions of RALP.

Impacts of a participatory approach to assess sustainable sewage treatment technologies for urban fringe of Surat city in India.

This paper describes the assessment of the sustainability of a number of different sewage treatment technologies by means of a multi-criteria, participatory method for a scattered settlement of urban fringe of Surat. The special efforts have been made for the broad participation to achieve stronger democracy, better quality of the end product, and a more effective process. The mere participation of technocrats and bureaucrats certainly lead to the greater efficiency in working methods. However, the ultimate goal of sustainable developments of such technologies could not be reached in absence of democratic participation and social learning. Keeping this important aspect in view for assessment of sustainability, the detailed study was conducted in the presence of policy makers and stakeholders, academicians, technical experts, finance managers and NGO, to find out sustainability criteria and indicators for three different sewage treatment technologies: (A) Conventional Activated Sludge Process (B) Extended Aeration System, and (C) Upflow Anaerobic Sludge Blanket (UASB) Reactor followed by Aerated Lagoon and Polishing Pond. Technologies were compared according to four criteria subdivided into twenty operational indicators. Criteria and indicators were evaluated as in a weighted-scale matrix. In India, sustainability criteria used in this type of comparisons are often restricted to a limited set of environmental impacts and financial costs but in this study additional criteria were evaluated including economic, social, and technical aspects. Based on the values assigned by the panel, the Sustainability Index (SI) was calculated for each technology. According to the SI and a predefined scale, sustainability was medium for options A and B, whereas high for option C. The purpose of this study is to provide a basis for the selection of a particular technology based on a rational and democratic assessment of its contribution to sustainability in the local and global context.

Critical configuration analysis of four methods for measuring polymerization shrinkage strain of composites.

OBJECTIVES: To compare four methods for measuring polymerization shrinkage strain of composites and to develop a rational basis for comparing data from different methods and laboratories. METHODS: Dilatometry, modified bonded disk, strain gage, and a new linear transducer method were used to measure polymerization shrinkage strain of a model composite under similar irradiation conditions. The resin consisted of an untinted resin (50:50 BISGMA/TEGDMA, 0.7% CQ, 0.35% DMAEM, 0.05% BHT) filled with 5% fumed silica and 67 wt% untreated hybrid filler. Specimens (n = 10) were exposed for 60 s at 600 mW/cm2 and then monitored for 300 s. Specimen volumes were 8 mm3 for the strain gage method, 25 mm3 for the linear transducer and dilatometer methods and 43 mm3 for the bonded disk method. The degree of constraint applied to the specimens by each method was calculated and compared. Shrinkage strain values at 60 and 300 s were tested for significance at p = 0.05 using one-way ANOVA and Tukey's test. RESULTS: Shrinkage strain magnitudes at 60 and 300 s for the four methods were significantly different (p < 0.01) The modified bonded disk method measured the highest shrinkage value and exhibited the highest degree of specimen constraint. There was a 5 s delay after light activation before strain was detected by the strain gage. SIGNIFICANCE: Specimen constraint differed in all four methods and was linearly correlated with shrinkage strain magnitude when the degree of constraint was less than 42%.

Research capacity building in general practice. The new Australian scene.

BACKGROUND: Primary care research needs strengthening. The Commonwealth Government Department of Health and Aged Care has recently funded the university departments of general practice and rural health to build research capacity in primary care. OBJECTIVE: To explore issues surrounding building primary care research capacity, as well as looking at barriers to research capacity building and ways of overcoming them. DISCUSSION: New funding provides many opportunities for increasing research capacity in primary health care areas. Different institutions will select those methods that are best suited to their skills and the requirements of their area.

The acute effects of continuous and conditional neuromodulation on the bladder in spinal cord injury.

STUDY DESIGN: Laboratory investigation using serial slow-fill cystometrograms. OBJECTIVES: To examine the acute effects of different modes of dorsal penile nerve stimulation on detrusor hyperreflexia, bladder capacity and bladder compliance in spinal cord injury (SCI). SETTING: Spinal Injuries Unit, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK. METHODS: Fourteen SCI patients were examined. Microtip transducer catheters enabled continuous measurement of anal sphincter, urethral sphincter and intravesical pressures. Control cystometrograms were followed by stimulation of the dorsal penile nerve at 15 Hz, 200 micros pulse width and amplitude equal to twice that which produced a pudendo-anal reflex. Stimulation was either continuous or in bursts of one minute triggered by a rise in detrusor pressure of 10 cm water (conditional). Further control cystometrograms were then performed to examine the residual effects of stimulation. RESULTS: Bladder capacity increased significantly during three initial control fills. Continuous stimulation (n=6) significantly increased bladder capacity by a mean of 110% (+/-Standard Deviation 85%) or 173 ml (+/-146 ml), and bladder compliance by a mean of 53% (+/-31%). Conditional stimulation in a different group of patients (n=6) significantly increased bladder capacity, by 144% (+/-127%) or 230 ml (+/-143 ml). In the conditional neuromodulation experiments, the gap between suppressed contractions fell reliably as bladder volume increased, and the time from start of stimulation to peak of intravesical pressure and 50% decline in intravesical pressure rise was 2.8 s (+/-0.9 s) and 7.6 s (+/-1.0s) respectively. The two methods of stimulation were compared in six patients; in four out of six conditional neuromodulation resulted in a higher mean bladder capacity than continuous, but the difference was not significant. CONCLUSIONS: Both conditional and continuous stimulation significantly increase bladder capacity. The conditional mode is probably at least as effective as the continuous, suggesting that it could be used in an implanted device for bladder suppression.

Rosai-Dorman disease causing cervical myelopathy.

STUDY DESIGN: A case report of a rare disease entity and review of the literature. OBJECTIVES: To illustrate the occurrence of an unusual disease affecting the spine and spinal canal. SUMMARY OF BACKGROUND DATA: Rosai-Dorman disease is considered an idiopathic benign lymphoproliferative disease that typically occurs in the earlier decades of life. The usual manifestation is painless massive cervical lymphadenopathy, although involvement of many extra nodal sites is common. This case illustrates Rosai-Dorman disease occurring in an elderly man with myelopathy and mass lesions of the cervical, thoracic, and lumbar spinal canal without typical lymphadenopathy.- METHODS: Case report illustrating clinical presentation as well as radiographic and pathologic findings, including comparisons to cases previously reported. RESULTS: Surgical decompression with incomplete resection of the lesion was performed, providing diagnosis and treatment guidance. The patient experienced significant neurologic improvement of myelopathy. CONCLUSIONS: Recognizing clinical and laboratory features of this disease may permit earlier diagnosis and limit or avoid surgical intervention in some cases.

Magnetic resonance imaging (MRI) of Saccharum officinarum L. (sugarcane) during its growth for sucrose content.

Magnetic Resonance Imaging (MRI) was employed to monitor changes in image intensities in stems of sugarcane which reflect on the increase in sucrose concentration. Contrast in images originates in the increase of sucrose concentration in the aqueous phase of the predominant parenchyma cells and physiological changes. In matured stems mixed MR intensity patterns were observed in transverse planes. We associate this due to the reflection of vascular bundles in ground parenchyma cells which constitute 80% sucrose storage.

Use of Memokath temporary urethral stent in treatment of detrusor-sphincter dyssynergia.

In spinal-injured patients, detrusor-sphincter dyssynergia (DSD) can lead to high intravesical pressures, upper tract dilation, and recurrent infections. The standard treatment for DSD is sphincterotomy and, more recently, permanent sphincter stenting. Many spinal-injury patients would prefer a reversible treatment because of concern about fertility or because they are awaiting a "miracle cure." There is also concern over the theoretical long-term risk of squamous carcinoma after permanent stenting. In view of this, the Memokath, a thermosensitive temporary stent, has been undergoing trials at our center to determine which patients could benefit. Fourteen Memokath stents have been inserted in spinal-injured patients with DSD at our center, and they have been followed up for as long as 2 years. Stents were placed under cystoscopic guidance as a day case procedure. The stents were inserted either through the sphincter alone (short [4-cm] stents; 3 patients) or through the sphincter and bladder neck (long [5-7-cm] stents; 11 patients). There were no complications during surgery in either placement or removal of these stents. There was a significant (p < 0.001) reduction in the residual urine volume after stenting. Preoperative hydronephrosis and attacks of autonomic dysreflexia noted in some patients also resolved after stenting. Short stents that bridge the external urethral sphincter were ineffective in emptying the neuropathic bladder. Therefore, we advise that only long stents that lie across both the bladder neck and the external sphincter be used. Because of its easily reversible nature, the Memokath should be adopted for use in patients who are unsure about their preferred option of bladder management and those involved in a fertility program.

Hitherto unreported medicinal uss of plants of lucknow district.

The medicinal uses of thirteen plants from Lucknow District are reported in this paper.

In vitro Propagation of Valeriana wallichii.

A tissue culture procedure has been developed for the rapid multiplication of VALERIANA WALLICHII D C. through shoot tip and axillary bud explants. MS medium containing Kn or BAP (5.0 mg/l (-1)) in combination with IAA (1.0 mg/l (-1)) induced an optimal growth of shoots within 6-8 days from both apical and axillary bud explants. The roots developed on the same medium within 2-3 weeks. Hardening of IN VITRO grown plantlets in pots under glass-house conditions was dependent upon the temperature and humidity. A cold-temperate climate favoured early establishment. Following the given procedure, a large number of plants have been established under field conditions at two locations. The method has implications in the early introduction of an elite population as well as its improvement.