Outpatient healthcare utilization among incident cases of systemic sclerosis: results from a population-based US cohort (1988-2016).

OBJECTIVE: Systemic sclerosis (SSc) is a complex, heterogeneous connective tissue disease with multiorgan dysfunction. This study aimed to compare healthcare utilization among incident cases of SSc versus age- and gender-matched comparators. METHOD: A population-based cohort of physician-diagnosed patients with SSc in Olmsted County, MN, USA, from 1 January 1988 to 31 December 2016 was assembled. A 2:1 cohort of age- and gender-matched non-SSc subjects was randomly selected for comparison. Patients were followed until death, migration from Olmsted County, or 31 December 2017. Outpatient utilization data were obtained beginning 12 months before the SSc incidence/index date and compared using negative binomial and multinomial models. Services were summarized as visit-days to avoid overestimation of services provided. RESULTS: The study included 69 incident SSc cases and 138 non-SSc comparators (mean ± sd age 57 ± 16 years at diagnosis/index, 90% female). Patients with SSc had higher utilization of outpatient physician, laboratory, and combined radiology visit-days annually for the year before and for each of the first 5 years after diagnosis than comparators. Among patients with SSc, healthcare utilization was highest during the year of SSc diagnosis. Rate ratios comparing utilization in patients with and without SSc ranged from 1.8 to 3.0 for all comparisons. CONCLUSION: Higher utilization of outpatient physician, laboratory, and radiology visit-days was observed among patients with SSc compared to non-SSc subjects throughout 5 years of disease duration, indicating high and continued care needs in this patient population. The highest utilization of services among SSc patients occurred during the year of SSc diagnosis.

Pseudohyperplastic variant of adenocarcinoma as a component of α-methyl-CoA-racemase (AMACR negative) carcinosarcoma of the prostate.

Carcinosarcoma (CS) or Sarcomatoid carcinoma (SC) of the prostate is a very rare malignant tumor of the prostate having an aggressive clinical course and dismal prognosis. The adenocarcinomatous element is usually of the acinar type and closely admixed with a sarcomatous component. We report a case of α-methyl-CoA-racemase (AMACR)-negative pseudohyperplastic variant of adenocarcinoma in CS. To the best of our knowledge, there have been no published case reports of this variant in CS till date. An accurate diagnosis is essential as this uncommon, aggressive cancer has limited therapeutic options.

Bilateral hybrid oncocytoma and renal cell carcinoma.

A 26-year-old female presented with abdominal pain and distension in 2003. Clinical evaluation and imaging were suggestive of bilateral benign renal solid masses. Fine needle aspiration showed tubular cells only. Patient was kept under periodic follow up. She reported 4 years later with increase in pain and size of masses, and underwent bilateral staged nephron sparing surgery. The histopathology was reported as bilateral oncocytoma. Two years after surgery, she developed epidural spinal cord compression and liver metastasis. A decompression laminectomy and biopsy revealed conventional renal cell carcinoma (RCC). To our knowledge this is the first case report of sporadic bilateral synchronous hybrid RCC and oncocytoma in a young woman, with spinal epidural metastasis.

Neurofibromatosis 1 with pheochromocytoma.

Von Hippel-Lindau (VHL) disease includes a wide spectrum of highly vascular tumors like pheochromocytoma, cysts and adenomas of the pancreas and kidney, endolymphatic sac and renal cell carcinoma. Molecular analysis of the VHL gene is vital in these patients and their kindred. Neuroendocrine pancreatic tumors are rare and are known for their malignant and metastatic potential. We discuss an interesting case of a young lady who had a strong family history of central nervous system and spinal tumors. Our patient presented with recently detected severe hypertension. She was found to have elevated urinary normetanephrine levels; radiological imaging revealed bilateral pheochromocytomas with a pancreatic lesion. On genetic analysis, a variation, c.IVS 2 + 3 A > G, was found in the intronic region following exon 2 of the VHL gene. This variant appears novel. This patient underwent bilateral adrenalectomy (right total and left cortical sparing), distal pancreatectomy and splenectomy. Histology was diagnostic for pheochromocytoma with a neuroendocrine tumor of the pancreas. The postoperative period was uneventful. She was advised genetic screening of all her first-degree relatives.

Urodynamic Management of Neurogenic Bladder in Spinal Cord Injury.

BACKGROUND: A spinal cord injury is devastating and produces profound changes in the life style of the individual and his family. It is difficult to predict bladder and sphincter behaviour on the basis of clinical somatic neurological deficits. METHODS: A prospective study of 100 spinal cord injury patients was conducted to establish a bladder management protocol. The urodynamic variables were assessed frequently. Clean Intermittent Catheterization (CIC) along with antimuscarinic drugs was instituted and response monitored. Nonresponders were offered Intradetrusor Botulinum toxin. RESULT: Spinal shock lasted for upto six months and only 8% could be converted to CIC during the acute phase. A total of 82% patients underwent three to four urodynamic studies which revealed an increase in cystometric capacity and a decrease in the maximum detrusor pressures. This lowered the incidence of incontinence episodes and prevented upper urinary tract damage. Botulinum toxin provided only temporary relief. CONCLUSION: Aggressive management of neurogenic bladder (NB) dysfunction is a crucial component of the rehabilitation programme for spinal cord injury patients. Repeated urodynamic studies are an essential aid in managing the evolving nature of the bladder dysfunction. Meticulous bladder management protocol can prevent upper urinary tract complications.

Male Andropause : A Myth or Reality.

Male andropause, male climacteric or viropause is a condition in which men suffer from complex symptomatology due to low androgen level with aging. After the age of 40 years testosterone level starts declining and andropause corresponds to the age at which a pathogenic threshold is reached. This review summarizes the etiology, consequences, screening, diagnosis, monitoring of androgen deficiency in aging male (ADAM). The pros and cons of testosterone replacement therapy (TRT) in elderly male have been discussed. Currently oral, transdermal, transbuccal, intramuscular, and subcutaneous implants are available for clinical use. The choice is made by physicians based on therapeutic indication and patient preferences.

Successful medical treatment of emphysematous pyelonephritis in a renal allograft recipient.

Emphysematous pyelonephritis in renal allograft recipients is a rare but serious complication. The management of this entity is a subject of controversy in live related donor programs where the absence of a second donor is a key factor influencing surgical removal of the graft. We present a case of emphysematous pyelonephritis in a renal allograft recipient managed successfully with medical therapy alone.

Urological complications of live related donor renal transplantation: 13 years' experience at a single center.

BACKGROUND: This study is a retrospective analysis of urological complications and their treatment in our series of live-donor renal transplantation. MATERIAL AND METHODS: The series comprised of 500 patients. All underwent extravesical ureteroneocystostomy and all except a few initial patients were stented. RESULTS: There were 92 complications in 82 patients (18.4%). Urinary leakage occurred in 1.2%. There were no intrinsic ureteric obstructions. Extrinsic ureteric obstruction occurred in 0.8% of cases. The incidence of UTI was 15.4% and of urethral strictures 1%. CONCLUSION: The technique of stented extravesical ureteroneocystomy has led to an extremely low rate of urological complications in our series, over a long time and in a substantial number of patients.

Intravesical Explosion during Transurethral Resection of Prostate - a reminder.

Intravesical explosion during transurethral resection of the prostate (TURP) is an extremely rare but dreaded complication and results in rupture of the bladder. It is believed that intravesical explosion occurs due to formation of explosive gases in the bladder during TURP and its admixture with air. A case of intravesical explosion during TURP resulting in bladder rupture at our institution is described. Though the management of this catastrophe is relatively straightforward, it has the potential for dire consequences. We emphasize that, despite its rare occurrence, it is preventable and suggest measures to avoid it.

Real-time study of fast-electron transport inside dense hot plasmas.

We offer a method to study transport of fast electrons in dense hot media. The technique relies on temporal profiling of the laser induced magnetic fields and offers a unique capability to map the hot electron currents and their neutralization (or lack of it) by the return currents in the plasma. We report direct quantitative measurements of strong electric inhibition in insulators and turbulence induced anomalous stopping of hot electrons in conductors. The present technique can prove extremely important from the point of view of fast ignition scheme, which relies on the penetration of fast electrons into the fusion core.

Dispelling inhibition for laparoscopic surgery in younger children with Cushing's syndrome. Case report and literature review.

Laparoscopic adrenalectomy (LA) is now the gold standard for the treatment of small, benign adrenal tumors in adults. In Cushing's syndrome (CS), LA is difficult and seldom done, especially in younger children. A 6-year-old girl was diagnosed with CS due to a juxtaadrenal tumor. She underwent LA and made an uneventful recovery. The histopathology was reported as paraganglioma which is a very rare cause of CS. LA is seldom done in younger children with CS owing to extreme obesity, abundant perinephric fat and a high incidence of pre- and postoperative complications.

Assessing the efficiency of extracorporeal shockwave lithotripsy for stones in renal units with impaired function: a prospective controlled study.

The objective was to determine the efficiency of extracorporeal shockwave lithotripsy (ESWL) in clearing stones from renal units with impaired function. Thirty-five patients with poorly functioning kidneys determined by intravenous urogram and 99mtechnetium diethylene triamine pentacetic acid renal dynamic scan underwent ESWL. Stone clearance was assessed at 3 months and compared with that in normally functioning kidneys. The study group was divided into two subgroups. Those with split glomerular filtration rate (GFR) of the concerned kidney between 10 and 20 ml/min were in group 1. Group 2 consisted of patients with split GFR between 20 and 30 ml/min. A control group (group 3) was formed from patients with urolithiasis and normally functioning kidneys. The overall retreatment rate was 84.4%. The overall stone clearance rate in the study group was 34.2% while it was 57.7% in the control group. The stone clearance rate in group 2 was 40%. The difference in stone clearance rate between the study and control groups was statistically significant (P=0.023) but that between group 2 and the control group was not (P=0.159). The incidence of steinstrasse between the study group 2 and control group was not statistically significant (P=0.408). The clearance rate for ureteral stones was comparable in all the three groups. The stone-free rate and rate of steinstrasse for renal stones in kidneys with moderately impaired function were comparable to normally functioning kidneys. However, kidneys with severely impaired function had poor results. The clearance rate for ureteral stones was not influenced by the impairment of renal function.

A Comparative Study of Laparoscopic with Conventional Open Donor Nephrectomy in Renal Transplantation.

BACKGROUND: Laparoscopic donor nephrectomy (LDN) has been gaining popularity among kidney donors. There have been concerns about the safety and efficacy of the procedure as compared to open donor nephrectomy (ODN). We compare our results on LDN with ODN. METHODS: We retrospectively analysed our data of LDN and ODN. Duration of surgery, blood loss, period of hospitalisation, per oral intake and analgesic requirements. RESULT: 22 LDNs were done, the operation time ranged from 220-300 minutes, and blood loss from 100-150ml. In the first 10 laparoscopic operations four cases required conversion to open surgical dissection. Only one case was converted to open surgery in the subsequent 12 laparoscopic cases. Oral intake was started on the first postoperative day. Analgesic requirement in laparoscopy cases was less. Patients were mobilised on the first day after surgery. Patients were discharged by seventh day. There was no significant difference in the functioning of the graft after revascularisation in the recipient. CONCLUSION: Laparoscopic donor nephrectomy is a safe and effective technique of donor nephrectomy.

Experience with marginal living related kidney donors: are they becoming routine or are there still any doubts?

OBJECTIVES: To analyze donor and recipient outcome of grafts from marginal kidney donors (ie, elderly or suffering from some anomaly). METHODS: We had 81 marginal donors from July 1996 to July 2004; 46 were older than 60 years, and 39 had renal or nonrenal anomaly. The donors and recipients were evaluated for morbidity, graft and recipient survival, and the number of rejection episodes. RESULTS: The mean (+/- standard deviation) age of elderly donors was 62.2 +/- 3.1 years. Follow-up ranged from 6 months to 50 months (mean 21.15 +/- 0.9 months). Actuarial 1-year and 3-year graft survival rates were 95% and 81%, respectively. Twenty-six percent of recipients maintained serum creatinine levels less than 1.4 mg/dL. The mean age of hypertensive donors was 46.2 years, and blood pressure was controlled with one drug. Serum creatinine levels in the recipients were less than 1.4 mg/dL in 10 and less than 2.5 mg/dL in the rest. Eleven percent of hypertensive donors required an increase in their antihypertensive medication. All donors showed a 15% to 20% increase in their glomerular filtration rate. Donors underwent simultaneous surgery when indicated. CONCLUSIONS: Criteria to reject donors need to be reviewed periodically. The elderly and donors with other anomalies are consistently showing acceptable results. Hypertensive donors require assessment with awake ambulatory blood pressure monitoring.

Laser-pulse-induced second-harmonic and hard x-ray emission: role of plasma-wave breaking.

We report time resolved measurements of second-harmonic and hard x rays emitted during the interaction of an intense laser pulse (10(16) W cm(-2), 100 fs) with a preplasma generated on a solid target. We observe that for a particular length scale the second harmonic goes through a minimum, while hard x-ray emission on the contrary maximizes. Theoretical or numerical modeling of this anticorrelation in terms of wave breaking of strongly driven electron plasma waves clearly brings out hitherto unexplored links between the physical mechanisms of second-harmonic generation and hard x-ray emission.

Partial laser turbinectomy: two year outcomes in patients with allergic and non-allergic rhinitis.

OBJECTIVE: The aim was to compare two year outcomes of partial laser turbinectomy in patients with allergic and non-allergic rhinitis with respect to nasal obstruction symptom scores and nasal peak inspiratory flow rates (nPIFR). This has not been reported previously. METHOD: Fifty-four patients underwent partial laser turbinectomy (28 with allergic rhinitis, 26 with non-allergic rhinitis). NPIFR was measured preoperatively, at 3 months and two years postoperatively. A symptom score questionnaire was also completed. RESULTS: Both allergic and non-allergic patients showed a significant improvement in symptom scores and nPIER at three months (n = 54). The improvement in allergic patients was greater. In the 31 patients seen at two years, there was still a significant improvement in median symptom scores but no such improvement in median nPIFR. In allergic patients (n = 18) at two years, there was no significant improvement in symptom and nPIFR scores. Non-allergic patients (n = 13), however, did show sustained significant improvement in these scores (p < 0.05). Eighty-seven percent (26/31) considered the operation successful and would recommend it to others. CONCLUSIONS: Non-allergic patients derive a more sustained improvement in the medium term compared to allergic individuals when undergoing partial laser turbinectomy. The improvement in symptom scores in the group as a whole was still significant.

Metal nanoplasmas as bright sources of hard X-ray pulses.

We report significant enhancements in light coupling to intense-laser-created solid plasmas via surface plasmon and "lightning rod" effects. We demonstrate this in metal nanoparticle-coated solid targets irradiated with 100 fs, 806 nm laser pulses, focused to intensities approximately 10(14)-10(15) W cm(-2). Our experiments show a 13-fold enhancement in hard x-ray yield (10-200 keV) emitted by copper nanoparticle plasmas formed at the focal volume. A simple model explains the observed enhancement quantitatively and provides pointers to the design of structured surfaces for maximizing such emissions.

Endopyelotomy - a Minimally Invasive Surgical Option for Pelvi-ureteric Junction Obstruction: a Study Of 34 Cases.

We performed antegrade endopyelotomy in 34 cases in the last 2½ years. In all cases standardized antegrade percutaneous method was used. A single guide wire and a cold knife were used to perform the endopyelotomy. Nephrostomy tube was retained for 48 hours and the repair stented for 6 weeks. Patients were followed up at 3 months, 6 months and 1 year post-operatively for subjective improvement and objectively by DTPA scans/IVU and ultrasound. The population included 2 bilateral cases, one horseshoe kidney and 3 children. The patient's age ranged from 9-59 years, average 32 years. There were 21 males and 13 females. 28 renal units were primary and 8 were secondary pelviureteric junction (PUJ) obstruction. Follow up period was 3-28 months. Most cases had significant symptomatic and functional recovery postoperatively. Five cases presented with urinary tract infection, which regressed after treatment. At 3(rd) month postoperatively the DTPA/IVU scan was equivocal in 7 cases. In these, a RGP was done which in every case showed a patent PUJ. In 5 cases that were still symptomatic, 6-8 weeks of further stenting produced symptom regression. Two cases failed and needed revision, one by open pyeloplasty and the other by endopyelotomy. Our success rate overall in these cases followed upto 1 year post operatively is 91.6%. We conclude that endopyelotomy is successful across a wide spectrum of cases.