Artificial neural network discovery of a switchable metasurface reflector.

Optical materials engineered to dynamically and selectively manipulate electromagnetic waves are essential to the future of modern optical systems. In this paper, we simulate various metasurface configurations consisting of periodic 1D bars or 2D pillars made of the ternary phase change material Ge2Sb2Te5 (GST). Dynamic switching behavior in reflectance is exploited due to a drastic refractive index change between the crystalline and amorphous states of GST. Selectivity in the reflection and transmission spectra is manipulated by tailoring the geometrical parameters of the metasurface. Due to the immense number of possible metasurface configurations, we train deep neural networks capable of exploring all possible designs within the working parameter space. The data requirements, predictive accuracy, and robustness of these neural networks are benchmarked against a ground truth by varying quality and quantity of training data. After ensuring trustworthy neural network advisory, we identify and validate optimal GST metasurface configurations best suited as dynamic switchable mirrors depending on selected light and manufacturing constraints.

Micafungin and a case of polymorphic ventricular tachycardia.

WHAT IS KNOWN AND OBJECTIVE: Although echinocandins are relatively safe antifungal drugs, cardiovascular toxicity is an emerging adverse event. This report reviews those side effects and describes a case of polymorphic ventricular tachycardia suggestive of torsades de pointes with micafungin. CASE DESCRIPTION: The patient was on micafungin for oesophageal candidiasis due to drug-drug interactions with fluconazole and amiodarone. WHAT IS NEW AND CONCLUSION: This is the first known case of polymorphic ventricular tachycardia with micafungin as the possible cause. Clinicians should be aware of this potential adverse event and monitor patients receiving concomitant drugs that can prolong QT interval.

Long-term outcome of transobturator tape (TOT) for treatment of stress urinary incontinence in females with neuropathic bladders.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVES: Stress urinary incontinence (SUI) is a cause of significant distress in women with neurogenic bladder dysfunction (NBD) due to spinal cord injury (SCI). Transobturator tape (TOT) has not previously been studied in this select group for cure of SUI. We aim to determine the long-term safety and efficacy of TOT in SCI patients with NBD and SUI. SETTING: London, the United Kingdom. METHODS: All patients undergoing TOT between 2005 and 2013 were identified (27 patients). All patients had pre-operative videocystometrogram (VCMG) and all had VCMG-proven SUI. Mean follow-up was 5.2 years. Patient-reported leakage, satisfaction, change in bladder management, complications and de novo overactive bladder (OAB) were recorded. RESULTS: Mean age was 56 years (range 30-82) with complete follow-up. Twenty-two patients (81.5%) reported complete dryness from SUI post surgery. One patient (3.7%) reported SUI only when her bladder was very full but was satisfied. Twenty-three patients (85.2%) were happy. Four patients (14.8%) remained wet. Twenty-five patients (92.6%) had no change in bladder management. Two out of five patients (40%) who voided by straining prior to surgery required clean intermittent self-catheterisation (CISC) post-operatively. Two patients (7.4%) developed de novo OAB. No bladder or vaginal injuries, tape erosions or urethral obstruction were seen. Three patients (11.1%) had transient thigh pain. CONCLUSION: In women with NBD and SUI, TOT should be considered safe and effective with very good medium/long-term outcomes. There may be an increased risk of CISC in women who void by straining pre-operatively.

Long-term urological management in spinal injury units in the U.K. and Eire: a follow-up study.

AIMS: The majority of patients with spinal cord injury (SCI) will develop neurogenic lower urinary tract dysfunction (NLUTD). These patients require a long-term urological follow-up. The follow-up protocol has varied across SCI units in the United Kingdom and Eire. We reviewed the long-term management in the SCI units to identify changes in practice over a decade and compared them to current guidelines. METHODS: We present results of a review of all SCI centres in the United Kingdom and Eire on their long-term urological management before and after the current guidelines and compared the results with European Association of Urology (EAU) Guidelines on NLUTD and the proposed British guidelines for the urological management of patients with SCI. Data were collected through questionnaires posted to SCI units. RESULTS: SCI patients are followed up in outpatients annually in the SCI centres and the frequency of follow-up remains largely unchanged. More SCI units perform renal tract imaging annually as a part of SCI follow-up. Most units follow the proposed British guideline indications for urodynamics and do not perform 'routine urodynamics'. CONCLUSIONS: We conclude that the long-term management of SCI patients in SCI units in the United Kingdom and Eire has changed overtime to follow the proposed British guidelines. EAU guidelines offer a more extensive follow-up regime. Last, there is a continued lack of high-quality evidence to support an optimal long-term follow-up protocol. Importantly, there is a lack of evidence on clinical outcomes when these guidelines have been followed.

Correlation of estimated and measured glomerular filtration rate in patients with interposed bowel in the urinary tract.

OBJECTIVE: Isotope glomerular filtration rate (GFR) measurement is invasive, time-consuming and expensive. Estimated glomerular filtration rate (eGFR) is used as a surrogate, but has not been validated in patients whose lower urinary tract (LUT) is replaced with bowel. This study aimed to evaluate the correlation between the Modification of Diet of Renal Disease (MDRD) eGFR andchromium-51 ethylenediamine tetra-acetic acid (Cr-EDTA) GFR in patients with LUT reconstruction/diversion. MATERIAL AND METHODS: A retrospective chart review was undertaken of 75 consecutive patients with LUT reconstruction/diversion attending scheduled follow-up in a single institutional setting. Cr-EDTA GFR, serum creatinine and eGFR were compared. Routine patient demographics, type of bowel reconstruction/diversionand time since surgery were noted. RESULTS: The correlation between Cr-EDTA GFR and creatinine was poor (r (2) = 0.411) and the limits of agreement between variables were wide (-118 to +102, p = 0.053). The correlation between Cr-EDTA GFR and eGFR was slightly better (r (2) = 0.536), and the limits of agreement narrowed to -39 to +37 (p = 0.0003). The correlation was improved (r (2) = 0.623) when separating patients with renal failure (eGFR ≤ 60 ml/min per 1.73 m(2), n = 21), but the agreement between variables was poor (-20 to +16 ml/min per 1.73 m(2), p = 0.424).Study limitations include the heterogeneous/complex patient population and types of bowel interposition, and asynchronous eGFR and Cr-EDTA GFR measurement (although no clinical events were recorded between measures). These reflect the reality in which eGFR is often used. CONCLUSIONS: There is poor correlation between eGFR and Cr-EDTA GFR in patients with LUT reconstruction/diversion with bowel. eGFR should be used with caution as a surrogate marker for isotope GFR in these patients. Larger prospective studies controlling for the study limitations identified are indicated.

A tertiary experience of ileal-ureter substitution: Contemporary indications and outcomes.

OBJECTIVE: Complex ureteric stricture disease in contemporary practice is typically related to prior pelvic surgery, radiotherapy, or complicated, repeated retrograde stone surgery, although outcomes in this group have not been well studied. The aim of this study was to report medium-term outcomes with ileal-ureter substitution for complex ureteric stricture disease. MATERIALS AND METHODS: All patients who had undergone ureteric reconstructive surgery using small bowel over a 5 year period between 2010 and 2015 were identified from the theatre database and their case notes reviewed. Data were collected on aetiology of ureteric stricture, prior surgery or radiotherapy, baseline renal function and comorbidity. Postoperative complications were recorded using the Clavien-Dindo classification, and overall outcome and need for further intervention were documented. RESULTS: Nine patients underwent ileal-ureter substitution for complex ureteric stricture disease over this period, with four having bilateral ileal interpositions. Median age was 48 years (38-62 years) with a median follow-up of 17 months (1-40 months). Simple untailored ileal segments and refluxing anastomoses were used in all cases. One case of anastomotic leak and restricture required reintervention, but all others had favourable outcomes with no stricture and no requirement for further intervention. Two patients reported recurrent cystitis following surgery but there was no deterioration in renal function in any patient, with no metabolic complications reported. CONCLUSION: Ileal-ureter substitution surgery is a valuable option for selected patients with complex, difficult-to-treat ureteric defects that cannot be bridged by other methods. Simple onlay techniques do not seem to affect renal or metabolic function. Avoiding the extra complexity of tailored and tunnelled anastomoses may reduce the potential morbidity and reintervention rate in patients with challenging surgical fields.

Stress urinary incontinence: current understanding.

Many new concepts were introduced in epidemiology, a etiopathology and treatment of stress urinary incontinence. This review gives a short account of these concepts and compares the results of commonly used treatment options with new ones recently introduced.

Voiding disorders in young male adult.

Two hundred four male patients (aged twenty to forty-five years) with symptoms of lower urinary tract dysfunction have been investigated by urodynamic studies. Patients with symptoms of bladder overactivity (53 per cent) had a low incidence of bladder outflow obstruction but a high incidence of bladder hypersensitivity and bladder instability. Their symptomatic complaints accurately reflected their cystometric findings and, therefore, a urine flow rate estimation was the only necessary urodynamic investigation in most cases. Urine flow studies are an essential first investigation in all patients with possible bladder outflow obstruction (26 per cent), and full studies were necessary in many patients to discriminate the low flow rates produced both by outflow obstruction and by bladder underactivity which were diagnosed in a high proportion of patients. Similarly, in the neurologically abnormal patients (12 per cent), full urodynamic studies were necessary with the studies described in this article the minimum required.

ThioTEPA pharmacokinetics during intravesical chemotherapy and the influence of Tween 80.

A pharmacokinetic study of randomised crossover design was carried out in which eight patients with recurrent stage pTa or pT1 transitional cell carcinoma of the bladder were given thioTEPA (30 mg) in distilled water or in 10% (v/v) Tween 80 (30 ml) intravesically for 2 h, followed 3 months later by the alternative treatment. ThioTEPA and its primary metabolite, TEPA, were measured in plasma and urine using a sensitive and specific chromatographic assay. Large differences between patients were observed in the proportion of thioTEPA absorbed, ranging from 20%-78%. Peak plasma levels of thioTEPA were observed within 1 h of intravesical administration. By 2 h after administration the plasma levels of TEPA were similar to those of thioTEPA and, in contrast to those of the parent compound, remained at a similar level over the next 4 h. The rate of absorption of thioTEPA was not influenced by Tween 80, but it did cause statistically significant increases in mean peak plasma levels (from 101 to 154 ng/ml) and mean AUC values (from 0.376 to 0.496 micrograms h per ml) and a decrease in the mean half-life (from 1.83 to 1.25 h). To obtain plasma levels similar to those achieved after instillation with thioTEPA alone, the dose should be reduced with Tween 80.

The value of the MACE (Malone antegrade colonic enema) procedure in adult patients.

BACKGROUND: We report our experience with the Malone antegrade colonic enema (MACE) procedure in adult patients suffering from urinary incontinence and intractable constipation with or without fecal soiling. STUDY DESIGN: Since June 1990, the MACE procedure was initiated in 4 female and 12 male patients 14-54 years old (mean age, 29.9 years) with different pathologic conditions (myelodysplasia, n = 7; anorectal anomaly, n = 3; spinal cord lesion, n = 4; neuropathic disease of unclear cause, n = 2). Three surgical techniques were used: reversed and in situ appendix and tapered ileum). Complex simultaneous urologic continence procedures were performed in nine patients. Two patients had undergone previous operations in the lower urinary tract. RESULTS: After 6.6 years of followup (average, 41.7 months), eight patients (50%) were still using the MACE successfully. They were completely clean day and night and were relieved of symptoms of constipation. Eleven complications related to the MACE procedure occurred in seven patients (44%). Eight patients abandoned the procedure for various reasons. The failure rate was higher in chronically constipated patients without fecal soiling. CONCLUSIONS: The MACE procedure is associated with a high failure rate when used in adults, but it may be possible to identify a subgroup of patients in whom the procedure could be beneficial. Success would depend on overcoming technical problems and difficulties with patient compliance.

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.

Tuberculosis of the craniocervical junction.

Tuberculosis of the craniocervical junction is rare even where the condition is endemic. It poses problems in both diagnosis and management. We describe 25 cases followed over a period of 12 years, and relate the presentation, diagnosis and management. Of our 25 patients 16 were managed conservatively and nine by surgery. In order to diagnose this condition a high index of suspicion and advanced imaging techniques are necessary. Early diagnosis and adequate treatment led to good results without fatal complications.

Design, analysis, and implementation of a telemedicine remote consultation and diagnosis session playback using discrete event system specification.

Telemedicine remote consultation and diagnosis (RCD) software is a complex and distributed system. RCD allows physicians to collaborate on radiology or pathology cases from distributed geographic locations. It is very important to simplify design, construction, and maintenance of such a system. Currently, object-oriented design methodology is used to design and develop a software system in a modular fashion. Object-oriented software is made of various objects that work together. From the design of the software system, we get information about object methods and inheritance. We also get information about which objects are contained in a particular object and which objects are used by another object. One important element that the traditional object-oriented design misses is time. We propose the use of discrete event system specification (DEVS) in the design and analysis of a software system, such as RCD. With DEVS, coupling between objects can be specified explicitly and an object behavior can be shown in time. We introduce DEVS, show the time-line analysis of Remote Consultation and Diagnosis session playback using DEVS, and then describe its implementation.

Uptake of Ga-67 in the cardiac region in hypersensitivity angiitis.

Although Ga-67 can be used to recognize various inflammations of the heart and pericardium, it is seldom used to evaluate the inflammatory process of a myocardial infarction because of lack of specificity, lack of early uptake, and other factors. However, inadvertent recognition on routine Ga-67 scans is always a possibility and has been reported once before. Here described is another case of silent, multiple myocardial infarction seen by Ga-67 scan as a consequence of multiple organ involvement with hypersensitivity angiitis. This incidental finding was the only indication of direct cardiac involvement at the time of the patient's death by cardiac arrest on the same day as the Da-67 scan.

How does bladder function change in the early period after surgical alteration in outflow resistance? Preliminary communication.

A decrease in voiding pressures because of decreased outflow resistance has been demonstrated in 8 males, and conversely an increase in voiding pressures because of increased outflow resistance has been demonstrated in 7 females undergoing surgery. These changes occur in the early postoperative period.

Role of suprapubic catheterization in retention of urine.

One hundred and nine male patients took part in a randomized trial of elective suprapubic or urethral catheterization in retention of urine. The self-retaining trocar suprapubic catheter proved safe and reliable in trained hands and its use was associated with a low incidence of side effects. The suprapubic catheter when used to allow continuous flow resection appeared to lead to decreased blood loss and reduced resection time. No decrease in urinary infection rate over the period of hospital stay was noted in the suprapubic group. The suprapubic catheter was more comfortable than the urethral and also allowed a trial of voiding prior to removal. Use of the suprapubic catheter was not associated with an increased hospital stay.

The interrelationships between facial areas and other body dimensions.

The data from 35 premenarchial Gujarati, Hindu girls, selected at random, in the age range of 120 months to 144 months were collected to find out statistically the nature and the values of correlation coefficients among various facial areas and other body dimensions such as body weight, stature, chronological and skeletal ages. The correlation coefficients between skeletal, chronological, height and weight ages ranged from 0.413 to 0.8105 showing moderately high association. Height and weight ages turned out to be the most reliable indicators of growth and development of facial areas in this age group and the chronological age as in ineffectual indicator of the same. Maxillary and mandibular areas showed a high value of correlation coefficients (0.67) while the orbitoethmoidal area did not show any correlation with any age variables or with other facial areas. The mandibular areas showed the highest correlation with weight age (0.63) and lowest with chronological age (0.431). The maxillary area showed highest correlation with chronological age (0.62) and lowest with skeletal age (0.42). Fifteen empirical formulae have been developed by which average value of facial areas could be predicted from the other variables.

Productivity and quality improvements in health care through airboss mobile messaging services.

The US health care industry is in the midst of revolutionary changes. Under tremendous pressures from third-party payers and managed care programs to control costs while providing high quality medical services, health care entities are now looking at information technologies to help them achieve their goals. These goals typically include improved productivity, efficiency and decision-making capabilities among staff members. Moreover, hospitals and other health care facilities that provide a broad and integrated range of inpatient and outpatient care, wellness and home care services are in the best position to offer comprehensive packages to managed care and private insurers. Many health care providers and administrators are considered mobile employees. This mobility can range from intra-building and intra-campus to multi-site and metropolitan areas. This group often relies on a variety of information technologies such as personal computers, communicating laptops, pagers, cellular phones, wireline phones, cordless phones and fax machines to stay in touch and handle information needs. These health care professionals require mobile information access and messaging tools to improve communications, control accessibility and enhance decision-making capabilities. AirBoss mobile messaging services could address the health care industry's need for improved messaging capabilities for its mobile employees. The AirBoss family of services supports integrated voice services, data messaging, mobile facsimile and customized information delivery. This paper describes overview of the current mobile data networking capability, the AirBoss architecture, the health care-related applications it addresses and long-term benefits. In addition, a prototype application for mobile home health care workers is illustrated. This prototype application provides integrated e-mail, information services, web access, real-time access and update of patient records from wireline or wireless networks, and cross media delivery and notification. It provides seamless wide area access to patient data in a secure environment, thus providing a continuity of care from the hospital to home.

Bladder and renal stones: management and treatment.

The prevalence of renal tract calculi in the population is such that patients may present acutely not only to urologists, but in the setting of any medical specialty. This article aims to enable all practitioners to be able to recognize the condition and instigate early investigation and management before referring to the urologist for definitive treatment.

A case report of Evans Syndrome.

Evans Syndrome (ES) is the rare simultaneous or subsequent development of immune thrombocytopenia purpura (ITP) and autoimmune hemolytic anemia (AIHA). It portends a poorer prognosis and a more aggressive line of management than either condition presenting alone. Here we report a case of a young female who presented with both bleeding and acute decompensated anemia. Although she was successfully treated, mystery still shrouds the etiology, pathophysiology, as well as line of management of this rare and enigmatic disease.