Abdominal CT Segmentation for Body Composition Assessment Using Network Consistency Learning.

Estimating skeletal muscle (SM) and adipose tissues is an invaluable prognostic indicator in cancer treatment, major surgeries, and general health screening. Body composition is usually measured with abdominal computed tomography (CT) scans acquired in clinical settings. The whole-body SM volume is correlated with the estimated SM based on the measurement of a single two-dimensional vertebral slice. It is necessary to label a CT image at the pixel level to estimate SM, known as semantic segmentation. In this work, we trained a segmentation model using the labeled abdominal CT slices and the additional unlabeled slices. In particular, we trained two identical segmentation networks with differently initialized weights. Network Consistency Learning (NCL) allowed learning from unlabeled images by forcing the predictions from both networks to be the same. We segmented abdominal CT images from a newly created in-house dataset. The proposed approach gained 10% better performance in terms of Dice similarity score (DSC) than that obtained by a standard supervised network demonstrating the effectiveness of NCL in exploiting unlabeled images.Clinical relevance- An efficient and cost-effective method is proposed for assessing body composition from limited labeled and abundant unlabeled CT images to facilitate fast diagnosis, prognosis, and interventions.

Intensification of Biodiesel Processing from Waste Cooking Oil, Exploiting Cooperative Microbubble and Bifunctional Metallic Heterogeneous Catalysis.

Waste resources are an attractive option for economical the production of biodiesel; however, oil derived from waste resource contains free fatty acids (FFA). The concentration of FFAs must be reduced to below 1 wt.% before it can be converted to biodiesel using transesterification. FFAs are converted to fatty acid methyl esters (FAMEs) using acid catalysis, which is the rate-limiting reaction (~4000 times slower than transesterification), with a low conversion as well, in the over biodiesel production process. The study is focused on synthesizing and using a bifunctional catalyst (7% Sr/ZrO2) to carry out esterification and transesterification simultaneously to convert waste cooking oil (WCO) into biodiesel using microbubble-mediated mass transfer technology. The results reveal that a higher conversion of 85% is achieved in 20 min using 7% Sr/ZrO2 for biodiesel production. A comprehensive kinetic model is developed for the conversion of WCO in the presence of a 7% Sr/ZrO2 catalyst. The model indicates that the current reaction is pseudo-first-order, controlled by the vapor-liquid interface, which also indicates the complex role of microbubble interfaces due to the presence of the bifunctional catalyst. The catalyst could be recycled seven times, indicating its high stability during biodiesel production. The heterogeneous bifunctional catalyst is integrated with microbubble-mediated mass transfer technology for the first time. The results are unprecedented; furthermore, this study might be the first to use microbubble interfaces to "host" bifunctional metallic catalysts. The resulting one-step process of esterification and transesterification makes the process less energy-intensive and more cost-efficient, while also reducing process complexity.

The Dynamics of Aerotaxis in a Simple Eukaryotic Model.

In aerobic organisms, oxygen is essential for efficient energy production, and it acts as the last acceptor of the mitochondrial electron transport chain and as regulator of gene expression. However, excessive oxygen can lead to production of deleterious reactive oxygen species. Therefore, the directed migration of single cells or cell clumps from hypoxic areas toward a region of optimal oxygen concentration, named aerotaxis, can be considered an adaptive mechanism that plays a major role in biological and pathological processes. One relevant example is the development of O2 gradients when tumors grow beyond their vascular supply, leading frequently to metastasis. In higher eukaryotic organisms, aerotaxis has only recently begun to be explored, but genetically amenable model organisms suitable to dissect this process remain an unmet need. In this regard, we sought to assess whether Dictyostelium cells, which are an established model for chemotaxis and other motility processes, could sense oxygen gradients and move directionally in their response. By assessing different physical parameters, our findings indicate that both growing and starving Dictyostelium cells under hypoxic conditions migrate directionally toward regions of higher O2 concentration. This migration is characterized by a specific pattern of cell arrangement. A thickened circular front of high cell density (corona) forms in the cell cluster and persistently moves following the oxygen gradient. Cells in the colony center, where hypoxia is more severe, are less motile and display a rounded shape. Aggregation-competent cells forming streams by chemotaxis, when confined under hypoxic conditions, undergo stream or aggregate fragmentation, giving rise to multiple small loose aggregates that coordinately move toward regions of higher O2 concentration. By testing a panel of mutants defective in chemotactic signaling, and a catalase-deficient strain, we found that the latter and the pkbR1 null exhibited altered migration patterns. Our results suggest that in Dictyostelium, like in mammalian cells, an intracellular accumulation of hydrogen peroxide favors the migration toward optimal oxygen concentration. Furthermore, differently from chemotaxis, this oxygen-driven migration is a G protein-independent process.

Community Based Assessment of Behavior and Awareness of Risk Factors of Cystic Echinococcosis in Major Cities of Pakistan: A One Health Perspective.

Background: The parasitic disease, cystic echinococcosis (CE), is a serious health problem in Pakistan. Risk of disease transmission is increased by economic and political instability, poor living conditions, and limited awareness of hygienic practices. The current study aimed to investigate the community perception and awareness regarding the risk factors of CE in Pakistan, from a One Health perspective. Methods: We conducted a community-based survey involving 454 participants in the major cities of Pakistan. Quantitative data based on knowledge, attitude, and practices (KAP), the One Health concept, risk factors, and community perception of CE among the general population of the major cities of Pakistan were collected. The questions included those related to knowledge, attitude, practices, One Health concept, risk factors, and community perception. The Chi-squared test was applied to determine the associations regarding KAPs across socio-demographic parameters. Results: KAPs had no significant associations with sociodemographic aspects such as age, sex, religion, ethnicity, education, marital status, occupation, or financial status of the participants. The findings indicated a lack of awareness about CE among the participants. Respondents were unaware of the risk factors and the One Health concept of CE. However, the community attitude and perception were positive toward the control of CE. Conclusion: Illiteracy, deficient sanitation systems and lack of awareness are the contributing factors to CE in Pakistan. It is necessary to make the community aware regarding CE and its importance. Increasing this awareness represents an important step toward the eradication and control of CE.

Farming practices and deficit irrigation management improve winter wheat crop water productivity and biomass through mitigated greenhouse gas intensity under semi-arid regions.

Understanding the greenhouse gas emissions mechanism from the agricultural soils is essential to reach an agricultural system with a lower impact on the environment. The cultivation practices in combination with deficit irrigation have been used in a dry-land farming system to modify the soil water status. However, few research works have been focused on plastic film with deficit irrigation regimes on global warming potential (GWP), greenhouse gas intensity (GHGI), and biomass productivity under simulated rainfall conditions. In the current study, a 2-year study was carried out in a rainproof mobile shelter to study the potential role of two cultivation practices (i.e., furrow with plastic mulching on ridges, RF; and conventional flat cultivation, TF) in combination with two deficit irrigation regimes (i.e., 150 and 75 mm) and three simulated rainfall (i.e., 1, 275 mm; 2, 200 mm; and 3, 125 mm). . We found that RF2150 treatment was more effective in improving the soil water content, soil respiration rate, and winter wheat production and significantly reduced (39.2%) the GHGI and GWP than TF2150 treatment. The RF2150 treatment improved soil moisture and significantly increased (18.9%) grain yield, (11.1%) biomass, (75.8%) WUEg, and (64.1%) WUEb of winter wheat and largely mitigated GWP and GHGI. The RF system with 150-mm deficit irrigation regime plays a significant role in increasing the biomass productivity and soil respiration rate and minimizing the seasonal greenhouse gas fluxes, GHGI, and field ET rates under 200-mm precipitation condition. Compared with TF practice, the plastic film mulching on ridges and furrow on the planting zone could significantly improve biomass and WUE and reduce N2O, CO2, and CH4 emissions. The RF2150 treatment should be very good water-saving approach and a powerful tool to decrease GHGI and GWP via increased biomass, WUE, soil respiration rate, and wheat yields under a dry-land farming system.

Comparative transcriptome and metabolomic profiling reveal the complex mechanisms underlying the developmental dynamics of tobacco leaves.

Although the leaf is the most important photosynthetic organ in most plants, many of the molecular mechanisms underlying leaf developmental dynamics remain to be explored. To better understand the transcriptional regulatory mechanisms involved in leaf development, we conducted comparative transcriptomic and metabolomic analysis of leaves from seven positions on tobacco (Nicotiana tabacum) plants. A total of 35,622 unique differentially expressed genes and 79 metabolites were identified. A time-series expression analysis detected two interesting transcriptional profiles, one comprising 10,197 genes that displayed continual up-regulation during leaf development and another comprising 4696 genes that displayed continual down-regulation. Combining these data with co-expression network results identified four important regulatory networks involved in photorespiration and the tricarboxylic acid cycle; these networks may regulate carbon/nitrogen balance during leaf development. We also found that the transcription factor NtGATA5 acts as a hub associated with C and N metabolism and chloroplast development during leaf development through regulation of phytohormones. Furthermore, we investigated the transcriptional dynamics of genes involved in the auxin, cytokinin, and jasmonic acid biosynthesis and signaling pathways during tobacco leaf development. Overall, our study greatly expands the understanding of the regulatory network controlling developmental dynamics in plant leaves.

Isolated Female Epispadias with Urinary Incontinence.

Isolated female epispadias without bladder extrophy is a rare variant of female urethral anomaly reported rarely in the literature. For optimal and early management, early clinical diagnosis is important. Female with isolated epispadias usually presents with primary urinary incontinence with abnormal looking external genitalia on examination. We present a case of a 23-year female with urinary incontinence with bifid clitoris and widely separated labia minora on genital examination. Reconstructive surgery of urethra, labia minora and bifid clitoris was performed in one stage. The goals of management in this case were to achieve urinary continence with reasonable time between voids and cosmetically acceptable female genitalia. Key Words:  Epispadias, Bifid clitoris, Urinary incontinence.

Long-Term Oncologic Outcomes of Minimally Invasive Proctectomy for Rectal Adenocarcinoma.

BACKGROUND: Long-term oncologic outcomes after minimally invasive surgery (MIS) for rectal adenocarcinoma compared to open surgery continue to be debated. We aimed to review our high-volume single-institution outcomes in MIS rectal cancer surgery. METHODS: A retrospective review of a prospectively collected database was completed of all consecutive adult patients with rectal adenocarcinoma treated from January 2005 through December 2011. Stage IV or recurrent disease was excluded. Demographics and operative and pathologic details were reviewed and reported. Primary endpoints include survival and recurrence. RESULTS: A total of 324 patients were included and median follow-up was 54 months (IQR = 37.0, 78.8). The mean age was 58.2 ± 14.1 years. Tumors were in the upper rectum in 111 patients, mid-rectum in 113 patients, and lower rectum in 100 patients. Stage III disease was most common (49.4%). Overall conversion to open procedure rate was 13.9%. The circumferential radial margin was positive in only 1 patient (0.3%) and the mean lymph node yield was 24.7 ± 17.2. Cancer recurred in 42 patients (13%), 10 (2.5%) patients developed local recurrence, 32 (9.8%) developed distant metastasis, and 2 (0.6%) patients had both. The 5-year overall survival for stage 0, 1, 2, and 3 disease is 96, 91, 80, and 77%, respectively (p = 0.015). CONCLUSION: In carefully selected rectal cancer patients treated with MIS, long-term outcomes of survival and recurrence appear to compare favorably to previously published series.

Timing of Surgical Resection for Curative Colorectal Cancer with Liver Metastasis.

PURPOSE AND DESIGN: Optimal surgical strategy for resectable synchronous colorectal cancer with liver metastasis (SCRLM) remains a therapeutic dilemma. Multiple retrospective studies including several meta-analyses have been published since 2001 to help facilitate the decision making process and identify the optimal surgical approach. Controversy limits the generalization of available data to draw conclusions. A review of available literature on appropriate surgical timing may alleviate confusion among physicians and promote a more evidence based approach. RESULTS AND CONCLUSION: Current evidence supports the feasibility, safety, and equivalent oncological outcomes of simultaneous curative resection of stage IV colorectal cancer with liver metastasis in appropriately selected patients.

Radiation efficiency and nitrogen fertilizer impacts on sunflower crop in contrasting environments of Punjab, Pakistan.

Sunflower (Helianthus annuus L.) is the leading non-conventional oilseed crop in Pakistan. Nitrogen fertilizer can affect plant growth and productivity by changing canopy size which has an effect on the radiation use efficiency (RUE) of the crop. The response of sunflower hybrids in terms of phenology, fraction of intercepted radiation (F i), and RUE to nitrogenous rates (0, 60, 120, 180, and 240 kg ha-1) was studied in three field experiments conducted in three various environments: Multan (arid), Faisalabad (semi-arid), and Gujranwala (sub-humid) during spring seasons 2008 and 2009. The treatments were laid out according to a randomized complete block design with split plot arrangements, keeping the sunflower hybrids in main plots and nitrogen rates in sub-plots, and replicated three times. The results showed Hysun-38 took a maximum number of days to anthesis (101) as compared to Pioneer-64A93 (100) and Hysun-33 (99). The mean values of F i were 0.850, 0.903, and 0.978, and the estimated values of RUE for total aboveground dry matter were 2.14, 2.47, and 2.65 g MJ-1 at experimental locations of Multan, Faisalabad, and Gujranwala, respectively. The values of RUE for grain yield (RUEGY) were 0.78, 0.98, and 1.26 g MJ-1 at experimental locations of Multan, Faisalabad, and Gujranwala, respectively. The average RUEGY values over three locations were 2.61, 2.60, 2.43, and 2.36 g MJ-2 in N4 (180 kg ha-1), N5 (240 kg ha-1), N3 (120 kg ha-1), and N2 (60 kg ha-1) treatments, respectively. Increasing rates of N increased RUEGY over the standard treatment N3 (120 kg N ha-1); however, the averaged values over three locations were 1.22, 1.08, 0.99, and 0.92 g MJ-2 in N4, N5, N3, and N2 treatments, respectively. Therefore, optimum water and N doses are important for attaining higher RUE, which may enhance sunflower growth and yield.

Why more research needs to be done on echinococcosis in Pakistan.

BACKGROUND: Echinococcosis has a worldwide geographical distribution with endemic foci on every inhabited continent. Due to the frequent outbreaks in different parts of Pakistan in the recent past, echinococcosis is being described as a neglected tropical disease and is considered one of the most neglected parasitic diseases in the country. In endemic regions, predominantly settings with limited resources, there are high numbers of echinococcosis patients, as these communities do not have access to appropriate treatment. In Pakistan, there are limited reports on echinococcosis. The disease is prevalent in human and livestock, but this has not been sufficiently explored yet. Pakistan is an agricultural country and due to the disease's zoonotic mode of transmission, there is a dire need of future research on it. The present paper is an effort to highlight the importance of echinococcosis in Pakistan. DISCUSSION: There is a dire need for future research on echinococcosis in Pakistan as very few investigations had been carried out on this topic thus far. The prevalence of the disease in neighbouring countries highlights that Pakistan might be at severe risk of this zoonotic infection and further supports the need for more research. In Pakistan, the majority of the population lives in rural areas with limited acess to proper hygienic/sanitary facilities. These conditions favour the outbreak of diseases such as echinococcosis. The limited available data could result in higher outbreaks in the future, and thus cause the already weak healthcare system to overburden. The country has a meagre annual budget for health, which is being spent on known infections such as polio, dengue fever and hepatic viral infections. A proper surveillance system for echinococcosis is required across the country as treatment is usually expensive, complicated and may require extensive surgery and/or prolonged drug therapy. Development of new/novel drugs and other treatment modalities receives very little, if any, attention. Prognostic awareness programmes against this infection involve deworming of the infected animals, improved food inspection and slaughterhouse hygiene, and public education campaigns. CONCLUSION: Future research on echinococcosis is anticipated to demonstrate whether the epidemiology, diagnosis and recombinant vaccines/antibodies relating to echinococcosis can meet the quality standards (purity, potency, safety and efficacy) defined by the World Health Organization. Research work should be carried out on the epidemiology and serodiagnosis of echinocossis in the different areas of Pakistan, which will be useful for the proper eradication of echinococcosis in this region. The health department should implement awareness-raising campaigns for the general public in order to reduce the burden of disease.

Safety of an Enhanced Recovery Pathway for Patients Undergoing Open Hepatic Resection.

BACKGROUND: Enhanced recovery pathways (ERP) have not been widely implemented for hepatic surgery. The aim of this study was to evaluate the safety of an ERP for patients undergoing open hepatic resection. METHODS: A single-surgeon, retrospective observational cohort study was performed comparing the clinical outcomes of patients undergoing open hepatic resection treated before and after implementation of an ERP. Morbidity, mortality, and length of hospital stay (LOS) were compared between pre-ERP and ERP groups. RESULTS: 126 patients (pre-ERP n = 73, ERP n = 53) were identified for the study. Patient characteristics and operative details were similar between groups. Overall complication rate was similar between pre-ERP and ERP groups (37% vs. 28%, p = 0.343). Before and after pathway implementation, the median LOS was similar, 5 (IQR 4-7) vs. 5 (IQR 4-6) days, p = 0.708. After adjusting for age, type of liver resection, and ASA, the ERP group had no increased risk of major complication (OR 0.38, 95% CI 0.14-1.02, p = 0.055) or LOS greater than 5 days (OR 1.21, 95% CI 0.56-2.62, p = 0.627). CONCLUSIONS: Routine use of a multimodal ERP is safe and is not associated with increased postoperative morbidity after open hepatic resection.

Annual Surgeon Volume and Patient Outcomes Following Laparoscopic Totally Extraperitoneal Inguinal Hernia Repairs.

PURPOSE: Data on laparoscopic totally extraperitoneal inguinal hernia repairs (TEP-IHRs) suggest that approximately 250 operations are needed to gain mastery, but the annual volume required to maintain high-quality outcomes is unknown. MATERIALS AND METHODS: A retrospective review was performed of every patient undergoing a TEP-IHR at the Mayo Clinic (Rochester, MN) from 1995 to 2011. Analysis focused on the annual volume of 21 staff surgeons and their specific patient outcomes broken up into three groups: Group 1 (G1) (n = 1 surgeon) performed >30 repairs per year; Group 2 (G2) (n = 3 surgeons), 15-30 repairs; and Group 3 (G3) (n = 17), <15 repairs. RESULTS: In total, 1601 patients underwent 2410 TEP-IHRs, with no significant patient demographic differences among groups. Greater annual surgeon volume (G1 > G2 > G3) was associated with improved outcomes as shown by the respective rates for intra- (1%, 2.6%, and 5.6%) and postoperative (13%, 27%, and 36%) complications, need for overnight stay (17%, 23%, and 29%), and hernia recurrence (1%, 4%, and 4.3%) (all P < .05). Surgeons with greater annual operative volumes were more likely to operate on patients with bilateral and recurrent hernias. Surgeons performing at least 15 repairs per year (G1 and G2) showed improvements in quality metrics over time. CONCLUSIONS: Annual operative volumes of >30 repairs per year are associated with the highest quality outcomes for TEP-IHR. Operative volumes of at least 15 repairs per year are associated with improvements in quality metrics over time. Mentorship and operative assistance of low-volume TEP-IHR surgeons may be useful in improving patient outcomes.

Optimizing training cost-effectiveness of simulation-based laparoscopic inguinal hernia repairs.

BACKGROUND: Motor learning theory suggests that highly complex tasks are probably best trained under conditions of part task (PT), as opposed to whole-task (WT) training. Within PT, random practice of tasks has been shown to lead to improved skill retention and transfer. METHODS: General surgery residents were equally randomized to PT vs WT, mastery learning type, and simulation-based training of laparoscopic inguinal hernia repair. Training time and resources used to reach mastery (skill acquisition), performance at 1-month testing (skill retention), and intraoperative time and performance scores (skill transfer) were compared. RESULTS: Forty-four general surgery trainees were randomized. All residents achieved mastery benchmarks. Trainees in the PT group achieved mastery on average 17 minutes faster (60.2 ± 23.8 vs 77.1 ± 24.8 minutes, P = .02, saving 6.2 instructor hours), used fewer material resources (curricular cost savings of $2,380 or $121 per learner), and were more likely to retain mastery level performance at 1-month retention testing (59% vs 22.7% P = .03). No differences in intraoperative performance were encountered. CONCLUSIONS: For laparoscopic inguinal hernia repair, random PT simulation-based training seems to be more cost-effective, compared with WT training.

Morphological Variants of Renal Carcinoma in Radical Nephrectomy Specimens.

OBJECTIVE: To determine the morphological variants of Renal Cell Carcinoma (RCC) to detect the commonest histopathological type with special focus to the newly introduced entity Clear Cell Papillary Renal Cell Carcinoma (CCPRCC). STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Department of Pathology, Basic Medical Sciences Institute, JPMC, Karachi, from January 2007 to December 2012. METHODOLOGY: Paraffin embedded blocks of 32 cases of radical nephrectomy specimens for renal mass were selected from records of Pathology Department, BMSI. Cases were excluded due to inadequate biopsies. Remaining 30 cases of renal cell carcinoma were included in study. H & E staining was done for all cases and PAS stain was employed for a few cases. All cases were reviewed under light microscope. RESULTS: The 30 cases of renal cell carcinoma included 21 (70%) clear cell renal cell carcinoma, 03 (10%) clear cell papillary renal cell carcinoma, 02 (6.6%) papillary renal cell carcinoma and 04 (13.33%) hybrid tumors. Majority of cases (53.3%) found in age range between 40 - 60 years while 23.33% cases were found in 7th and 6.6% in 8th decade of life. While 16.66% cases were in younger age group that is between 31 - 40 years of age. Sixty percent cases of right radical nephrectomies and 40% cases of left radical nephrectomies. CONCLUSION: CCRCC was most common histopathologic type followed by CCPRCC, hybrid tumors and PRCC.

Delayed Single Stage Perineal Posterior Urethroplasty.

OBJECTIVE: To determine the delayed single stage perineal posterior urethroplasty for treatment of posterior urethral stricture/distraction defect. STUDY DESIGN: Descriptive case series. PLACE AND DURATION OF STUDY: Department of Urology, Jinnah Postgraduate Medical Centre, Karachi, from January 2009 to December 2011. METHODOLOGY: Patients were selected for delayed single stage perineal posterior urethroplasty for treatment of posterior urethral stricture / distraction defect. All were initially suprapubically catheterized followed by definitive surgery after at least 3 months. RESULTS: Thirty male patients were analyzed with a mean follow-up of 10 months, 2 patients were excluded as they developed failure in first 3 months postoperatively. Mean patient's age was 26.25 ± 7.9 years. On follow-up, 7 patients (23.3%) experienced recurrent stricture during first 10 months. Five (16.6%) patients were treated successfully with single direct visual internal urethrotomy. Two patients (6.6%) had more than one direct visual internal urethrotomy and considered failed. Re-do perineal urethroplasty was eventually performed. The overall success rate was 93.3% with permissive criteria allowing single direct visual internal urethrotomy and 76.6% with strict criteria allowing no more procedures postoperatively. CONCLUSION: Posterior anastomotic urethroplasty offers excellent long-term results to patients with posterior urethral trauma and distraction defect even after multiple prior procedures.

Model to predict survival after surgical resection of intrahepatic cholangiocarcinoma: the Mayo Clinic experience.

BACKGROUND: The 7th edition of the American Joint Committee on Cancer (AJCC) staging system has recently been validated and shown to predict survival in patients with intrahepatic cholangiocarcinoma (ICC). The present study attempted to investigate the validity of these findings. METHODS: A single-centre, retrospective cohort study was conducted. Histopathological restaging of disease subsequent to primary surgical resection was carried out in all consecutive ICC patients. Overall survival was compared using Kaplan-Meier estimates and log-rank tests. RESULTS: A total of 150 patients underwent surgery, 126 (84%) of whom met the present study's inclusion criteria. Of these 126 patients, 68 (54%) were female. The median length of follow-up was 4.5 years. The median patient age was 58 years (range: 24-79 years). Median body mass index was 27 kg/m(2) (range: 17-46 kg/m(2) ). Staging according to the AJCC 7th edition categorized 33 (26%) patients with stage I disease, 27 (21%) with stage II disease, five (4%) with stage III disease, and 61 (48%) with stage IVa disease. The AJCC 7th edition failed to accurately stratify survival in the current cohort; analysis revealed significantly worse survival in those with microvascular invasion, tumour size of >5 cm, grade 4 disease, multiple tumours and positive lymph nodes (P < 0.001). A negative resection margin was associated with improved survival (P < 0.001). CONCLUSIONS: The AJCC 7th edition did not accurately predict survival in patients with ICC. A multivariable model including tumour size and differentiation in addition to the criteria used in the AJCC 7th edition may offer a more accurate method of predicting survival in patients with ICC.

Expression of Von Hippel - Lindau (VHL) gene mutation in diagnosed cases of renal cell carcinoma.

OBJECTIVE: To evaluate the expression of Von Hippel Lindau (VHL) gene in diagnosed cases of renal cell carcinoma. METHODS: This cross sectional study was conducted in department of Pathology, Basic Medical Sciences Institute, JPMC, Karachi, from January 2007 to December 2012. Paraffin embedded blocks of 30 cases of radical nephrectomy specimens diagnosed as renal cell carcinoma including CCRCC 21 (70%) CCPRCC, 3 (10%), PRCC 2 (6.79%), hybrid tumor 4 (13.3%), chromophobe tumor (0%) processed for VHL gene expression on Polymerase Chain Reaction. RESULTS: All the 30 cases previously diagnosed as renal cell carcinoma were processed on PCR, VHL gene mutations were seen in 20 (95.23%) of CCRCC while a single case was negative for VHL mutations. All CCPRCC were negative for VHL mutation. Among the hybrid tumor 03 cases with foci of clear cells show VHL mutation while a single case showing combination of clear cells and chromophobe cells was negative for mutation. Both the cases of PRCC were positive for mutation. Exon 3 mutation at base pair 194 seen in 8 (32%) cases and Exon 2 mutation at base pair 150-159 seen in 17 (68%) cases. None of the cases showed Exon 1 mutation. CONCLUSION: The present study shows that majority of CCRCC showed VHL mutation including the hybrid tumor with clear cell component in our population.

The rationale for combining an online audiovisual curriculum with simulation to better educate general surgery trainees.

BACKGROUND: Surgery interns' training has historically been weighted toward patient care, operative observation, and sleeping when possible. With more protected free time and less clinical time, real educational hours for trainees in 2013 are precious. METHODS: We created a 20-session (3 hours each) simulation curriculum (with pre- and post-tests) and a 24/7 online audiovisual (AV) curriculum for surgery interns. Friday morning simulation sessions emphasize operative skills and judgment. AV clips (using operating room, whiteboard, and simulation center videos) take learners through 20 different general surgery operations with follow-up quizzes. We report our early experience with this novel setup. RESULTS: Thirty-two surgical interns (2012-2013) attended simulation sessions on 20 separate subjects (hernia, breast, hepatobiliary, endocrine, etc). Post-test scores improved (P < .05) and trainees enjoyed using surgical skills for 3 hours each Friday morning (mean, >4.5; Likert scale, 1-5). The AV curriculum feedback is similar (mean, >4.3) and usage is available 24/7 preparing learners for both operating room and simulation sessions. Most simulation sessions utilize low-fidelity models to keep costs <$50 per session. Scores on our semiannual Surgical Olympics (mean score of 49.6 in July vs 82.9 in January; P < .05) improved significantly, suggesting that interns are improving their surgical skills and knowledge. CONCLUSION: Residents enjoy and learn from the step-by-step, in-house, AV curriculum and both appreciate and thrive on the 'hands-on' simulation sessions mimicking operations they see in real operating rooms. The cost of these programs is not prohibitive and the programs offer simulated repetitions for duty-hour-regulated trainees.

Outcome of percutaneous nephrolithotomy.

OBJECTIVE: To assess the implementation of Percutaneous Nephrolithotomy (PCNL) in renal stone management and evaluate the factors for efficacy and safety of PCNL. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Department of Urology at Jinnah Postgraduate Medical Centre, Karachi, from January 2008 to December 2011. METHODOLOGY: Patients aged above 12 years of age, irrespective of gender with normal renal function, mean stone size > 2 cm, lower pole stones > 1 cm, and ESWL failure were selected. After the procedure, on the first postoperative day, a plain abdominal radiograph was obtained to verify stone clearance. A nephrostomy tube was clamped overnight and subsequently removed when no residual stone which needs second sitting was seen. RESULTS: In 175 patients, 62.86% (n=110) were male and the mean age was 35 ± 9.56 years. One hundred and seventeen (66.85%) patients were primarily stone free and 13.71% (n=24) patients needed a second look procedure, thus, a total of 80.57% (n=141) patients were stone free in the same admission. Complications included failure in 4.0% (n=7) patients, bleeding in 8.57% (n=15) patients, a small residual stone in 15.43% (n=27) patients; and puncture site pain almost in every patient. Transient fever occurred in 55.43% (n=97) patients, urinary leakage in 8.57% (n=15) patients, urinary tract infections in 5.14% (n=9) patients, ureteric colic in 3.43% (n=6) patients, colonic injury in 0.57% (n=1) patient; and nephrectomy was required in 0.57% (n=1) patient due to severe bleeding. One patient (0.57%) expired due to anaesthesia complications. CONCLUSION: Percutaneous nephrolithotomy (PCNL) has a good success rate. There is minimal blood loss, and few major complications.