Special emphasis on bone health management in prostate cancer patients: a prospective longitudinal study.

INTRODUCTION: Use of androgen deprivation therapy (ADT) in carcinoma prostate (CaP) has deleterious effect on bone mineral density (BMD) leading to increase incidence of osteoporosis and skeletal-related events. We evaluated bone health status and impact of bone-directed therapy (BDT) and ADT on BMD in these patients from Jan 2015-Dec 2018. MATERIALS AND METHOD: Baseline bone health was assessed using Tc-99 MDP Bone scan/DEXA scan for patients on ADT. Monthly zoledronic acid (ZA) was given to high-risk candidates (T-score ≤2.5 or previous hip/vertebral fracture) or Skel et al. metastatic patients who were receiving ADT. Baseline and follow-up (at 12-months) BMD using DEXA scan at various sites (spine, femur total, femur neck and radius) and subjective improvement in bony pain using Numeric Pain Rating Score after administration of ZA were compared. RESULTS: A total of 96-patients of locally advanced and metastatic prostate cancer receiving ADT with or without BDT were included in the study cohort. Mean age of presentation was 68.4±15.61 years. Median serum PSA was 32.2±13.1ng/mL. There was significant improvement in mean BMD (T-score) in 64-patients post ZA therapy at 12-months (at femoral total, femoral neck and spine; 0.95, 0.79 and 0.68, respectively) (p < 0.05) while there was significant deterioration in mean BMD at 12-months (at spine, femoral neck and femoral total; -0.77, -0.55 and -0.66, respectively) in 32 patients who did not receive ZA and were on ADT (p < 0.05). Pain scores significantly decreased in patients after 12-months of ZA use (-2.92±2.16, p < 0.01). CONCLUSION: Bone-directed therapy (Zoledronic acid) leads to both subjective and objective improvement in bone health of prostate cancer patients on ADT.

Transvaginal Repair of Vesico Vaginal Fistula: A 10-Year Experience with Analysis of Factors Affecting Outcomes.

OBJECTIVES: To highlight the transvaginal route as an excellent approach for repair of a simple trigonal, supra-trigonal vesico-vaginal and urethrovaginal fistulae without compromising on the successful patient outcomes. We also determine factors affecting outcomes in such patients. MATERIALS AND METHODS: A retrospective analysis was carried out on 58 patients with simple trigonal, supra trigonal and urethrovaginal fistula who underwent transvaginal repair in the last 10 years. Simple fistulas were defined as fistula less than 3 cm in size or recurrent fistulae less than 1.5-2 cm in size and located either supra-trigonally (above the bar of mercier) or sub-trigonally (below the bar of mercier) as determined by cystoscopy. RESULTS: Obstetric cause, due to obstructed labour, was the most common cause of fistula formation (68.96%), while remaining (29.31%) were attributed to hysterectomy. Primary fistulae were found in 68.9% of patients and recurrent fiistulae in 31.1% patients. The mean age of patients was 33.4 years. Average fistula size was 1.5 cm. The success rate of primary operation was 84.12% (50/58). On using a multivariate regression model, the underlying aetiology (OR 2.2), fistula location (OR 2.5) and history of previous repair (OR 2.4) were found to be significant factors affecting outcome. CONCLUSION: The transvaginal approach is less invasive and achieves comparable success rates as compared to other methods of vesico-vaginal fistula repair. This surgery with Foley catheter has a high success rate with reduced morbidity. We postulate that vaginal approach should be preferred over abdominal approach for repair of all vaginally accessible vesico vaginal fistulae, both of obstetrical and gynaecological origin.

Assessment of long term outcomes after buccal mucosal graft urethroplasty: the impact of chronic kidney disease.

OBJECTIVES: To compare and assess various outcomes and success of buccal mucosal graft urethroplasty (BMGU) in patients with CKD versus patients having normal renal function. MATERIAL AND METHODS: This was a retrospective, single centre study, during period 2013 to 2017. Patients were grouped into two groups. Group 1 had patients with estimated Glomerular Filtration Rate (eGFR)>60mL/min/1.73m2 while group 2 had patients with eGFR <60mL/min/1.73m2. eGFR was calculated according to the MDRD equation. The two groups were compared with regard to various outcomes like length, location of stricture, technique of graft placement, intra-operative blood loss (haemoglobin drop), duration of hospital stay, post-operative complications and recurrence. RESULTS: A total of 223 patients were included in study with group 1 had 130 patients and group 2 had 93 patients. Mean age of patients with CKD were higher (47.49 years versus 29.13 years). The mean follow-up period was comparable between both groups (23.29 months and 22.54 months respectively). Patients with CKD had more post-operative Clavien Grade 2 or higher complications (p=0.01) and a greater recurrence rates (p<0.001) than in non-CKD patients. On multivariate analysis, age and CKD status was significant predictor of urethroplasty success (p=0.004) (OR= 14.98 (1.952-114.94, 95% CI). CONCLUSIONS: CKD patients are more prone to post-operative complications in terms of wound infection, graft uptake and graft failure and higher recurrence rates following BMGU.

A prospective study assessing feasibility of performing percutaneous nephrolithotomy in chronic kidney disease patients - What factors affect the outcome?

OBJECTIVES: To primarily evaluate the functional outcomes of PCNL for bilateral renal calculi/calculi in solitary functioning kidney with Chronic Kidney Disease(CKD). To identify factors affecting the renal replacement therapy following PCNL. MATERIALS AND METHODS: Patients with bilateral renal calculi/calculi in solitary kidney and CKD (eGFR<60/s.creatinine>2) and Good Performance Status [Eastern Cooperative Oncology Group (ECOG): 0-2] were included in the study. RESULTS: A total of 60 patients with CKD who had bilateral renal calculi/calculi in solitary functioning kidney underwent PCNL. At 6 months, eGFR improved or stabilized in 45 (75%) patients, while in 15 (25%) patients eGFR deteriorated. A total of 5 (14.28%) and 2 (25%) patients of CKD stage 4 and 5 respectively had improvement in eGFR as well as CKD stage. Fourteen (82.35%), 21 (60%), 3 (37.5%) patients of CKD stage 3, 4, 5 had improvement in eGFR but not signifi cant enough to cause stage migration. Again 3 (17.65%), 9 ( 40%) and 3 (37.5%) patients of CKD stage 3, 4, 5 had reduction in eGFR but not signifi cant enough to cause stage migration. None of the patients had worsening of CKD stage. Preoperative CKD stage and eGFR were compared with measurements made at the fi nal follow up visit (6 months). CONCLUSION: Our results indicate that most patients of renal calculi with CKD show improvement or stabilization of renal function with aggressive stone removal. Improvement is more in patients who have mild to moderate CKD. Aggressive management of comorbidities, peri-operative UTI and complications may delay or avoid progression of CKD status in such patients.

Transfer learning based generalized framework for state of health estimation of Li-ion cells.

Estimating the state of health (SOH) of batteries powering electronic devices in real-time while in use is a necessity. The applicability of most of the existing methods is limited to the datasets that are used to train the models. In this work, we propose a generic method for SOH estimation with much wider applicability. The key problem is the identification of the right feature set which is derived from measurable voltage signals. In this work, relative rise in voltage drop across cell resistance with aging has been used as the feature. A base artificial neural network (ANN) model has been used to map the generic relation between voltage and SOH. The base ANN model has been trained using limited battery data. Blind testing has been done on long cycle in-house data and publicly available datasets. In-house data included both laboratory and on-device data generated using various charge profiles. Transfer learning has been used for public datasets as those batteries have different physical dimensions and cell chemistry. The mean absolute error in SOH estimation is well within 2% for all test cases. The model is robust across scenarios such as cell variability, charge profile difference, and limited variation in temperature.

Improving Retinopathy of Prematurity Care: A Medico-Legal Perspective.

ABSTRACT: Retinopathy of prematurity (ROP) is the leading cause of preventable infant blindness in the world. India leads all nations with the highest number of premature infants born each year. Asia has the highest estimated incidence, where visual loss from ROP is over twice as high per million live births compared to established market economies. The problems of ROP management in these countries are compounded by a large cohort of babies who require screening, relatively few ROP specialists, and more recently medico-legal challenges. The authors share the Indian jurisprudence literature from the past decade relating to ROP, summarizing key clinical lessons learned from these legal judgments. The authors endeavor to enlist good clinical practices for various key steps involved in ROP care to help mitigate future litigations as well as protect the clinical interest of the infants who require ROP screening and treatment.

CanDIG: Federated network across Canada for multi-omic and health data discovery and analysis.

We present the Canadian Distributed Infrastructure for Genomics (CanDIG) platform, which enables federated querying and analysis of human genomics and linked biomedical data. CanDIG leverages the standards and frameworks of the Global Alliance for Genomics and Health (GA4GH) and currently hosts data for five pan-Canadian projects. We describe CanDIG's key design decisions and features as a guide for other federated data systems.

Prosthodontic rehabilitation of a patient with true partial anodontia - A case report.

Congenital absence of teeth is a hereditary phenomenon passed through generations by an autosomal dominant pattern. Such a patient often presents with poor esthetics, mastication and disturbed social behavior. Here is a case of partial anodontia with agenesis of 15 teeth, which has been treated by providing maxillary complete overlay denture and mandibular overlay removable partial denture.

An Incremental Voltage Difference Based Technique for Online State of Health Estimation of Li-ion Batteries.

Accurate state of health (SOH) estimation of rechargeable batteries is important for the safe and reliable operation of electric vehicles (EVs), smart phones, and other battery operated systems. We propose a novel method for accurate SOH estimation which does not necessarily need full charging data. Using only partial charging data during normal usage, 10 derived voltage values ([Formula: see text]) are collected. The initial [Formula: see text] point is fixed and then for every 1.5% increase in the Coulomb counting, other points are selected. The difference between the [Formula: see text] values ([Formula: see text]) and the average temperature during the charging form the feature vector at different SOH levels. The training data set is prepared by extrapolating the charging voltage curves for the complete SOH range using initial 400 cycles of data. The trained artificial neural network (ANN) based on the feature vector and SOH values can be used in any battery management system (BMS) with a time complexity of only [Formula: see text]. Less than 1% mean absolute error (MAE) for the test cases has been achieved. The proposed method has a moderate training data requirement and does not need any knowledge of previous SOH, state of charge (SOC) vs. OCV relationship, and absolute SOC value.

Internal short circuit detection in Li-ion batteries using supervised machine learning.

With the proliferation of Li-ion batteries in smart phones, safety is the main concern and an on-line detection of battery faults is much wanting. Internal short circuit is a very critical issue that is often ascribed to be a cause of many accidents involving Li-ion batteries. A novel method that can detect the Internal short circuit in real time based on an advanced machine leaning approach, is proposed. Based on an equivalent electric circuit model, a set of features encompassing the physics of Li-ion cell with short circuit fault are identified and extracted from each charge-discharge cycle. The training feature set is generated with and without an external short-circuit resistance across the battery terminals. To emulate a real user scenario, internal short is induced by mechanical abuse. The testing feature set is generated from the battery charge-discharge data before and after the abuse. A random forest classifier is trained with the training feature set. The fault detection accuracy for the testing dataset is found to be more than 97%. The proposed algorithm does not interfere with the normal usage of the device, and the trained model can be implemented in any device for online fault detection.

Rectal duplication cyst causing acute urinary retention with bladder outlet obstruction: an unusual presentation.

Anterior rectal duplication cyst is rare entity with <50 reported cases to date. It has myriad presentations like bleeding per rectum, constipation, rectal prolapsed and intestinal obstruction due to extrinsic compression of rectum. However, the association of enlarged duplication cyst compressing the bladder neck or ureter, and leading to bladder outlet obstruction or hydroureteronephrosis is extremely rare with only a handful of reported cases. We report a rare case of large anterior rectal duplication cyst in a young girl leading to acute urinary retention with bladder outlet obstruction which was eventually managed by laparoscopic-assisted transabdominal surgical excision of the cyst. The authors believe that such an association has not been previously reported in this age group.

Air in the urine: a mystified patient and a concerned surgeon.

Appendicovesical fistula is a rare type of enterovesical and a very rare complication of acute appendicitis. Herein, we report a case of a 22-year-old man who presented with cloudy urine and pneumaturia with a prior history of acute appendicitis. Imaging techniques including ultrasonography, CT and cystoscopy were performed to diagnose the abnormality. Diagnosis of this fistula is challenging and relies on detailed history and radiological imaging.

Squamous cell carcinoma of skin due to prolonged indwelling percutaneous nephrostomy catheter.

Percutaneous nephrostomy (PCN) catheter placement is a commonly performed procedure in the urological practice for various indications like percutaneous nephrolithotomy, pyonephrosis, infected hydronephrosis and after failed attempt of ureteric stenting. The nephrostomy catheter is usually associated with low complication and morbidity rate, but prolonged indwelling nephrostomy tube may be hazardous in some cases. We hereby report a case of squamous cell carcinoma of skin around the PCN, which was attributed to chronic inflammation and persistent irritation from a long-term neglected indwelling nephrostomy catheter for last 3 years. The patient was managed with wide local excision of skin carcinoma and ureterocalicostomy for pelviureteric junction stricture. The authors report the first documented case with aforementioned presentation.

Varicella gangrenosum in adult: a fatal chickenpox complication.

Varicella gangrenosum is a gangrenous ulceration of varicella lesions involving the skin and soft tissues of the body. The term was coined more than 100 years ago. This occurs due to superimposed bacterial infection. The presentation of primary varicella in adults is more severe with catastrophic systemic complications as compared with children. These complications include necrotising fasciitis, disseminated intravascular coagulation, wet/dry gangrene and death, as was seen in our case. Survival is dependent on early diagnosis and treatment. Adequate antibiotic treatment and particularly early radical surgical debridement should be the cornerstone of management. Less than 10 such cases are reported in the literature.

Laparoscopic transperitoneal heminephrectomy for treatment of the nonfunctioning moiety of duplex kidney in adults: A case series.

Purpose: We report the results and experience of a tertiary care center in laparoscopic transperitoneal heminephrectomy for the treatment of a non-functioning upper pole moiety of duplex kidney in adults. Materials and Methods: The key point of the technique included the placement of a 6-Fr ureteric catheter in the healthy ureter at the beginning of the procedure under fluoroscopic guidance cystoscopically. A standard laparoscopic 3- to 4-port placement was done after placing the patient in a 45 to 90 degrees lateral decubitus position. The upper pole was mobilized transperitoneally and transected using a harmonic scalpel. Results: A total of 17 patients aged 19 to 44 years underwent laparoscopic upper pole heminephrectomy. All patients had a complete duplicated renal collecting system on the ipsilateral side. Three patients were found to have ureterocele. The average blood loss was minimal (50-150 mL) with a mean of 95 ml. None of the patients required any blood transfusions. The mean operative time was 220 minutes (range, 160-315 minutes). The average length of hospital stay was 3 days (range, 2-4 days). Only 2 patients had Clavien-Dindo grade 3a complications, which were managed by double J stenting and percutaneous aspiration, respectively. Conclusions: Laparoscopic heminephrectomy is playing a cornerstone role in the treatment of the non-functioning moiety of duplex kidneys. The procedure is safe, efficient and offers the typical preoperative and postoperative benefits of laparoscopic surgery. The rate of complications in adults is acceptable and is similar to that reported in pediatric patients.

Implications of the Fracture Risk Assessment Algorithm for the assessment and improvement of bone health in patients with prostate cancer: A comprehensive review.

OBJECTIVE: Maintaining the optimum bone health is one of the important concerns in patients with prostate cancer, but it usually remains neglected. Failure to screen these patients is detrimental to both the length and the quality of life. The estimation of bone mineral density (BMD) and more recently the World Health Organization's fracture risk assessment (FRAX) algorithm in appropriate patients is recommended by several specialty organizations/associations at the time of instituting androgen deprivation therapy (ADT) for metastatic and high-risk individuals. It provides a 10-year risk evaluation of hip and major osteoporotic fractures (MOF). Using this web-based new investigating tool, candidates at high risk of fractures can be predicted more accurately according to clinical risk factors (CRF) alone or in combination with the femoral neck BMD. The FRAX application for senile osteoporosis has been studied and reviewed extensively, but no systematic review has ever been conducted for assessing the implication of FRAX in prostate cancer. This review article will give insight about the validity, role, and utility of this investigating tool in clinical practice for fracture risk assessment in these individuals. MATERIAL AND METHODS: This systematic review was carried out as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and Cochrane review principles. We searched the PubMed, Cochrane database of systematic reviews, and the EMBASE electronic database until December 2018 using the medical subject heading terms prostate cancer and FRAX. RESULTS: A total of nine studies meet the inclusion criteria and were included in the review. These studies enrolled a total of 3704 patients (sample size range, 78-1220) of localized, metastatic, castration resistant prostate cancer with or without ADT and/or on photon or radiotherapy. The factors that influenced FRAX included age, ethnicity, baseline BMD, duration of ADT, presence of CRF, and measurement methods (CRF, with/without BMD, computed tomography based). An advanced age and duration of ADT were the most robust risk factors. A 10-year MOF and hip fracture risk estimation was higher when the femoral neck BMD was not incorporated in the FRAX measurement. Despite several well-known strengths of using FRAX in the fracture risk assessment of suitable candidates with prostate cancer, several risk factors such as the mode/duration of ADT, mode of radiotherapy, Vitamin D levels, bone remodeling markers, and recent/recurrent fractures need to be incorporated in the FRAX calculator for improving the predictive ability. In contrast to senile osteoporosis with a longer life expectancy, the fracture risk in patients with prostate cancer need to be measured more frequently and for a shorter time. Therefore, models like Garvan calculator with both 5- and 10-year risk estimates have to be developed for these patients. Additionally, its utilization is of limited value in the presence of recurrent fractures or falls. CONCLUSION: The FRAX algorithm is beneficial in identifying patients who require early intervention or bone-directed therapy as an early step to decrease skeletal-related events and other morbidity. Several risk factors need to be added for improving the FRAX predictive value. This model is still underutilized in the clinical practice and increasing the awareness among treating physicians will help in optimizing the bone health and the quality of life of this important population subgroup.

Quick Sequential (Sepsis Related) Organ Failure Assessment: A high performance rapid prognostication tool in patients having acute pyelonephritis with upper urinary tract calculi.

Purpose: To analyze the utility of quick Sequential Organ Failure Assessment (qSOFA) in patients with uro-sepsis due to acute pyelonephritis (APN) with upper urinary tract calculi, we conducted this study. The role of qSOFA as a tool for rapid prognostication in patients with sepsis is emerging. But there has been a great debate on its utility. Literature regarding utility of qSOFA in uro-sepsis is scarce. Materials and Methods: Ours was a retrospective study including 162 consecutive patients who were admitted for APN with upper urinary tract calculi over a 3 and half years (total 42 months) period. We evaluated the accuracy of qSOFA in predicting inhospital mortality and intensive care unit (ICU) admissions and compared this with the predictive accuracy of systemic inflammatory response syndrome (SIRS). We used the Area Under Curve (AUC) of the Receiver Operator Characteristic curve to calculate it and also calculated the optimum cut off for qSOFA score. Results: The overall mortality and ICU admission rates were 7.4% and 12.9%, respectively. qSOFA had a higher predictive accuracy for in-hospital mortality (AUC, 0.981; 95% confidence interval [CI], 0.962-1.000) and ICU admissions (AUC, 0.977; 95% CI, 0.955-0.999) than SIRS. A qSOFA score of ≥2 was an optimum cut off for predicting prognosis. In a multivariate model qSOFA ≥2 was a highly significant predictor of in-hospital mortality and ICU admissions (p<0.001). Conclusions: qSOFA is a reliable and rapid bedside tool in patients with sepsis with accuracy more than SIRS in predicting inhospital mortality and ICU admissions.

The effects of preoperative blood pressure on early failure rate of distal arteriovenous fistulas for hemodialysis access.

INTRODUCTION: The first choice of vascular access for hemodialysis in patients with end-stage renal disease is a distal radiocephalic arteriovenous fistula (AVF). Early failure rates for these AVFs vary from 10% to 53%. The effects of predialysis hypotension on failure of AVFs have been described in the literature. Weather lower blood pressures affect early AVF failure has not been extensively studied. We conducted this study to evaluate the effects of preoperative blood pressures on early AVF failure. METHODS: Ours was a prospective observational study over a period of 2 years that included 224 patients who underwent distal radiocephalic AVF creation. Only those patients were included whose fistulas were made by surgeons with an experience of greater than five cases. The systolic, diastolic, and mean arterial pressures (MAPs) were recorded preoperatively. Early failure was defined as failure to achieve vascular access from the fistula within first 4 months of its creation. FINDINGS: The overall early failure rate was 27.7%. Early failure was more common in females and diabetic patients. The systolic, diastolic, and MAPs were significantly lower in patients with early failure (P < 0.05). In a multivariable adjusted analysis, lower preoperative diastolic and MAPs were predictors for early failure of distal radiocephalic AVF. DISCUSSION: Our study shows that patients with early failure of AVFs have lower preoperative blood pressure. A larger study is required to substantiate our findings and define target preoperative blood pressure for AVF creation.

A prospective study evaluating impact on renal function following percutaneous nephrolithotomy using Tc99m ethylenedicysteine renal scan: Does multiplicity of access tracts play a role?

PURPOSE: A prospective study evaluating impact of percutaneous nephrolithotomy (PCNL) on renal function following PCNL using ethylenedicysteine (EC) renal scan. Does multiplicity of access tracts play a role? MATERIALS AND METHODS: A prospective observational study was done and patients undergoing PCNL for renal calculi at our urology department were selected. Renal Tc99m EC scan was done pre-surgery and at 3 months follow-up. An assessment was done on decline in glomerular filtration rate (GFR) in postoperative period based on number of access tracts required. RESULTS: A total of 110 patients were enrolled in the study. The total number of punctures was 170 with 141 being supra-costal puncture and 29 infra-costal. The total number of single punctures were 60 and classified as Group I whereas patients with double puncture and triple puncture (40 and 10 patients, respectively) were classified as Group II. Mean postoperative split renal function (in Tc99m EC scans) of patients of Group I (40.93±19.62%) was found to be higher than that of Group II (32.82±16.98%). Mean change (decline) in GFR for single, double and triple tracts were 2.68 mL/min, 3.80 mL/min, and 4.2 mL/min, respectively. CONCLUSIONS: PCNL used for stone removal can improve renal function by eradicating obstruction; however, this procedure may itself negatively impact the functions of the targeted kidney. Our study showed post PCNL decrease in GFR which worsens with an increasing number of accesses.

Acute mechanical duodenal obstruction due to giant hydronephrosis: an unusual cause of acute abdomen.

Giant hydronephrosis (GH) is a rare clinical entity with about 600 cases and defined as the adult renal pelvis containing greater than 1 L of fluid, or at least 1.6% of the body weight or kidney occupying the hemiabdomen. The pelvic-ureteric junction (PUJ) obstruction is the most frequent cause of GH. We thus report a case of massive abdominal distension due to GH secondary to PUJ obstruction who presented with acute duodenal obstruction due to extrinsic compression and was managed with percutaneous nephrostomy followed by open nephrectomy.