Treatment Response following Radioactive Iodine Therapy in Miliary versus Macronodular Pulmonary Metastases in Papillary Thyroid Carcinoma.

Background Pulmonary metastases in papillary thyroid carcinoma have two common presentations-micro/miliary (MM) and macronodular metastases (MN). The mainstay of treatment, posttotal thyroidectomy, is multiple radioactive iodine ablations (RAIA) every 6 to 12 months. Response assessment is determined by decline in stimulated serum thyroglobulin levels (sTg), disease regression on chest x-ray (CXR), computed tomography thorax, or whole body iodine scintigraphy (TWBS). Aim This study aims to assess the difference in response to RAIA based on the pattern of presentation. Methodology Retrospective analysis of patients from January 2008 to July 2017 was done. Patients with pulmonary metastases treated with RAIA (3700MBq per therapy as opposed to theAmerican Thyroid Association recommendation of 7400MBq per therapy) and a minimum follow-up of 8 months were included. The initial and the final sTg, TWBS, and CXR were analyzed for both groups. Final outcome in terms of complete response, disease regression, static disease, and disease progression was determined. Results Of the total of 1,793 patients, 71 were included. There were 43 females and 28 males. The median age was 39 years and the range was 14 to 79 years. Forty-five (63.3%) patients had MM and 26 (36.6%) patients had MN disease. The average number of therapies was three and maximum follow-up period was 15 years. Of the 45 MM patients, 1 had progression, 7 were static, 23 had regression, and 14 had complete response. Of the 26 MN patients, 22 had progression, 2 were static, 1 had regression, and 1 had complete response. Conclusion MM metastases, when compared with MN disease, respond to RAIA with a better outcome. In addition to achieving comparable response with a lower dose per therapy, there were no radiation-related long-term complications reported.

Pathological response and clinical outcomes in operable triple-negative breast cancer with cisplatin added to standard neoadjuvant chemotherapy.

BACKGROUND: Response to neoadjuvant chemotherapy is associated with improved outcomes for patients with triple negative breast cancer (TNBC). Patients with residual disease are at increased risk of relapse and death from breast cancer. In this retrospective study, we aimed to evaluate the efficacy and safety of cisplatin added to standard neoadjuvant chemotherapy for locally advanced TNBC. MATERIALS AND METHODS: All TNBC treated with neoadjuvant cisplatin 60mg/m2 once in 3 weeks with weekly paclitaxel for 12 weeks, following 8 weeks of dose-dense epirubicin 90mg/m2 or doxorubicin 60mg/m2 with cyclophosphamide 600mg/m2 were analyzed retrospectively. The data related to pathological complete response, adherence to planned therapy, disease-free survival and overall survival were collected. RESULTS: Eighty-three patients were included, of whom 80% had stage III disease. Pathological complete response in both breast (T0/Tis) and axilla (N0) was observed in 48.1% of patients. Miller Payne grade 5 pathological response in the breast was seen in 61% of patients. Good partial responses (Miller Payne grades 3,4) were observed in 32.5% of patients. The remaining 6.5% were poor responders. Seventy-seven patients underwent surgery. The disease-free survival at 1 and 3 years for those who had a pathological complete response was 96.7% and 77.6%, respectively, and 92.3% and 62.7% for those who did not, respectively. The predominant adverse events were hematological, with anemia being the most common one. CONCLUSION: The addition of cisplatin to neoadjuvant chemotherapy with anthracycline and taxane in TNBC was tolerable and produced a high rate of pathological complete response. Cisplatin added to standard chemotherapy in patients with locally advanced TNBC could improve clinical outcomes.

Pimavanserin Treatment for Parkinson's Disease Psychosis in Clinical Practice.

BACKGROUND: Parkinson's disease psychosis (PDP) is a common, nonmotor symptom of Parkinson's disease (PD), which may affect up to 60% of patients and is associated with impaired quality of life, increased healthcare costs, and nursing home placement, among other adverse outcomes. Characteristic symptoms of PDP include illusions; visual, auditory, tactile, and olfactory hallucinations; and delusions. PDP symptoms typically progress over its course from being mild, infrequent, and often untroubling to complex, sometimes constant, and potentially highly disturbing. PDP has traditionally been treated with atypical antipsychotics (e.g., clozapine and quetiapine) although these are not approved for this indication and clozapine requires frequent white blood cell count monitoring due to the risk of agranulocytosis. Pimavanserin is a newer atypical antipsychotic with highly selective binding to serotonergic receptors, no evidence for worsening motor symptoms in PD, and no need for white blood cell count monitoring. It is currently the only approved medication indicated for PDP treatment. However, because it was approved relatively recently (2016), clinical experience with pimavanserin is limited. Case Presentations. A wide variety of representative clinical scenarios are presented, each with distinct variables and complications. Issues addressed include distinguishing PDP from similar symptoms caused by other disorders such as dementia, coordinating pimavanserin with other PD medications and with deep brain stimulation, adapting pimavanserin dosing for optimal benefit and tolerability, and recognizing variability of PDP symptoms due to patients' changing life circumstances. CONCLUSIONS: These scenarios provide multiple insights regarding PDP management and the role of pimavanserin. Effective treatment of PDP may reduce disturbing symptoms of psychosis, thus improving patient function and quality of life. In addition, effective pharmacotherapy for PDP may also facilitate the use of other medications needed to treat neurological symptoms of PD (e.g., tremor, bradykinesia, and dyskinesia), although they may also have adverse effects that contribute to symptoms of PDP.

Laparoscopy-assisted ureterostomy- technique.

INTRODUCTION: Urinary tract anomalies in children at times pose challenges in which immediate urinary diversion is required before definitive reconstruction. Open cutaneous ureterostomy technique is a well-established approach for this scenario. We describe the laparoscopy-assisted alternative. MATERIAL AND METHODS: Transperitoneal laparoscopy is performed with three ports. One trans-umbilical 5mm port for vision and two 3mm working instruments, one of which is through the proposed ureterostomy site minimising scarring. The position of the third port is carefully checked both externally and internally. Laparoscopic identification of the dilated ureter is quick and easy. The redundant ureter is mobilised and excess excised if needed. The ureteric loop is then exteriorised and the ureterostomy fashioned externally. Proximal and distal patency is checked both externally and laparoscopically. RESULTS: Nineteen patients underwent the procedure for primary VUR (n=6), neuropathic bladder 7, posterior urethral valve 4, and vesico-ureteric obstruction 2. The mean operative time was 40 minutes. the patients received three doses of perioperative antibiotics and were discharged in 72 hours (mean). At three months, clinical and ultrasound review have shown satisfactory and stable upper tracts and no episodes of UTI. DISCUSSION: The laparoscopic view gives the benefit of direct visualisation and identification with adequate dissection in order to bring the ureter to the surface in a tensionless manner. A redundant ureter can be easily addressed to correct tortuosity or redundancy appropriately. Bladder drainage can be ensured with careful dissection of the distal ureter and inspection at the end of the procedure. CONCLUSION: Laparoscopy-Assisted ureterostomy formation is easy and quick to perform. It is feasible even in the smallest of babies, assures the shortest segment of ureter to the bladder providing prompt drainage in a refluxing ureterostomy setting. Our early experience is promising with potential benefits.

Laparoscopic posterior appendix Mitrofanoff using the modified Shanfield anastomosis.

Laparoscopic transperitoneal technique for appendicovesicostomy was performed in a 5-year-old boy with a non-neurogenic neuropathic bladder using a transumbilical 5-mm port, two 3-mm working ports and a modified Shanfield anastomosis. Posterior extramucosal detrusorotomy and submucosal dissection was performed. The proximal appendix was spatulated and advanced into the bladder through a mucosal window using a U-stitch and fixed. The detrusor was then approximated creating an antirefluxing extramucosal tunnel. VQ plasty was fashioned for stoma formation. The procedure and postoperative period were uneventful. Clean intermittent catheterisation (CIC) was established subsequently and continued for the last 6 months. Our experience shows that appendix Mitrofanoff can be performed with minimal number and size of ports, resulting in a good cosmetic outcome. A simplified anastomosis makes it less cumbersome, and catheterisation is reliable as there is no mucosa-mucosa junction to negotiate.

Mid- to long-term outcomes of the 'anatomical approach' to congenital megaprepuce repair.

INTRODUCTION: The understanding of the aetiopathogenesis and the long-term outcomes of correctional repair of congenital megaprepuce (CMP) remains unestablished. Different techniques have been described; however, optimum results have been difficult to achieve. OBJECTIVE: The aim of our study was to review our experience of the 'anatomical approach' to the correction of CMP. MATERIAL AND METHODS: This is a retrospective review of boys who underwent CMP repair between 2003 and 2014. All of them had the anatomical approach: A curved incision is made between the scrotal and penile skin. Circumferential dissection superficial to Buck's fascia frees the penis and allows the scrotum to assume a more caudal position. The dissection distally lifts the preputial sac that is opened ventrally. The redundant inner preputial skin is excised. After full degloving, the dorsal flap of skin is thinned. The base of the flap is anchored, and the rectangle of skin is wrapped around the shaft. The remaining diamond-shaped incision is closed in a vertical line. Postoperatively, foam dressings and urethral catheter are left in place. Symptomatology, hospital stay, postoperative complications, redosurgery, voiding and cosmesis were evaluated. RESULTS: Sixty-one patients had surgery at 5-151 months (median 17 months). Median hospital stay was 24 h (12-168 h). Foam dressings and urethral catheter were used in 47 boys and removed in outpatient clinic after 3-7 days. There were two immediate postoperative complications requiring surgery. One due to severe oedema and constriction ring, and the other had wound infection with wound breakdown, both in patients with no dressings (P < 0.05). Follow-up was available for 58 patients, with a median of 22 months (3-79 months). Two required redosurgery (3.5%), one with poor cosmetic result and one recurrence. In all patients, a normal circumcised appearance had been achieved and in 47, cosmetic result was excellent (81%). Five patients have residual suprapubic fat, and four, excess ventral skin. One with residual suprapubic fat has reached puberty and it has resolved. All declared good stream. The same technique was used for six patients with poor cosmetic result after surgery elsewhere. The outcome is excellent for all, with median follow-up of 20.5 months (5-31 months). CONCLUSION: The 'anatomical' repair provides the ability to create the appearance of a standard circumcision, which is generally accepted as normality. Apart from the penis itself, this technique facilitates correction of the penoscrotal transposition, giving the external genitalia the best appearance. It seems to provide good functional and cosmetic outcomes, and it holds true at mid- to long-term follow-up. Dressings and catheter can potentially prevent postoperative complications. However, a prospective study with standardised parameters is required to confirm these findings.

Ultrasound-guided Fine-needle Aspiration Cytology along with Clinical and Radiological Features in Predicting Thyroid Malignancy in Nodules ≥1 cm.

AIMS AND OBJECTIVES: The aim of the study is to examine the adequacy and accuracy of ultrasound-guided fine-needle aspiration cytology (US-FNAC) in thyroid nodules ≥1 cm and to analyze the clinical, sonological, and cytological features in predicting thyroid malignancy. MATERIALS AND METHODS: US-FNAC was done on 290 patients from December 2013 to December 2014 by the radiologist. The Thyroid Imaging Reporting and Data System (TIRADS) was used to record the sonological features. FNAC samples were reported by a dedicated cytopathologist. Accuracy was calculated by comparing US-FNAC, clinical features and ultrasound (US) features for those who had final histopathology till April 2017. RESULTS: The adequacy of US-FNAC in this study was 80.2%. Thyroidectomy was performed in 128/290 (44.1%). The sensitivity and specificity of US-FNAC in this study is 83.9 and 76.3%, respectively, with a positive predictive value of 85.2%, negative predictive value of 74.4%, and an accuracy of 81% in predicting malignancy in thyroid nodules ≥1 cm. The malignancy rate in benign FNAC sample was 25% (10/40), and was 69% (8/13) in those with a follicular lesion of undetermined significance (FLUS). Around 80% of benign and 89% of FLUS had follicular variant of papillary carcinoma of thyroid (FVPTC). US-FNAC, a high TIRADS score, and US features such as marked hypoechogenicity, taller than wide, irregular margins, microcalcification, and clinical features, such as hard in consistency and significant cervical lymph nodes, were important in predicting malignancy (P < 0.001). CONCLUSIONS: The accuracy of US-FNAC in this study is 81%. The US-FNAC, a high TIRADS score, a hard thyroid nodule, and significant cervical lymph nodes are important in predicting malignancy. The accuracy rate in benign and atypia undetermined significance categories needs to improve in this study. Further research to help in decreasing false negative rates of FVPTC will help in increasing the accuracy of US-FNAC in the present study.

External stent in laparoscopic pyeloplasty: The K-wire technique.

The majority of surgeons leave internal stents following laparoscopic pyeloplasty, which necessitates a second anaesthetic for removal. A novel technique of placing external nephro-ureteric stents, thus obviating a second procedure for retrieval, is shown in this video bank. As demonstrated in the video, a Kirschner wire (K-wire) is used to thread the stent in place. Although, there are few reports of using externalised stents in laparoscopic pyeloplasty, it is believed that this technique has not been previously described. So far this technique has been used in 22 patients without any stent-related complications. The technique is feasible, safe and reproducible. It obviates the need for a further anaesthetic and avoids potential risks of another procedure. Secondary benefits include avoiding another hospital admission.

Hydronephrotic kidney with multiple extra-renal calyces.

Extra-renal calyces are a rare anomaly of the renal collecting system, characterised by the presence of calyces and pelvis outside the renal parenchyma. It may also be associated with other anomalies, such as renal ectopia, fusion and malrotation. We describe an unusual case of extra-renal calyces with six long calyces arising from a suspected multicystic dysplastic kidney that was successfully managed laparoscopically.

Hypomagnesemia in the ICU - Does Correction Matter?

BACKGROUND: Magnesium is a cation that is constantly being rediscovered. A number of studies have linked low magnesium levels to poor outcome of critically ill patients. Despite this hypomagnesemia continues to be under-recognized and uncorrected. There are no studies, in our knowledge, that have assessed the impact of correction of hypomagnesaemia on the outcome of the ICU patient. AIMS AND OBJECTIVE: To determine the standard Mg levels in a healthy population sample and to correlate it with western data. To estimate the admission Mg levels in critically ill patients admitted to the ICU and to determine if routine correction of hypomagnesaemia altered their outcomes as compared with the retrospectively collected data of a similar group of patients admitted to the same ICU prior to the routine testing of Mg levels. This was an observational study carried out in the intensive care unit of a tertiary hospital in south India. RESULTS: The mean serum magnesium in a sample of healthy Indian population was noted to be 2.112 mg/dl, which is consistent with that of the western data. Among the critically ill admitted to the medical ICU, the incidence of Hypomagnesemia (defined as serum Mg+2 of ≤1.7mg/dl on admission), was 23.96%. The study group in whom serum Magnesium was routinely corrected, showed a decrease in the mean total duration of icu stay (94.265 vs. 99.443 hours with p=0.78); the need for mechanical ventilation (52.08% vs. 65.625%) and the duration of Mechanical Ventilation (36.64 vs. 58.75 hours with p=0.04). Mortality was significantly higher in the comparison group (p=0.01) (39.6% vs. 22.9%). CONCLUSIONS: The range of Magnesium levels in a healthy Indian population matches that of the west despite variations in diet and lifestyle. Routine screening and replacement of magnesium in critically ill patients with hypomagnesaemia resulted in reduction of morbidity and statistically significant reduction in overall ICU mortality.

Global minimally invasive pyeloplasty study in children: Results from the Pediatric Urology Expert Group of the European Association of Urology Young Academic Urologists working party.

INTRODUCTION: Minimally invasive pyeloplasty (MIP) for ureteropelvic junction (UPJ) obstruction in children has gained popularity over the past decade as an alternative to open surgery. The present study aimed to identify the factors affecting complication rates of MIP in children, and to compare the outcomes of laparoscopic (LP) and robotic-assisted laparoscopic pyeloplasty (RALP). MATERIALS AND METHODS: The perioperative data of 783 pediatric patients (<18 years old) from 15 academic centers who underwent either LP or RALP with an Anderson Hynes dismembered pyeloplasty technique were retrospectively evaluated. Redo cases and patients with anatomic renal abnormalities were excluded. Demographics and operative data, including procedural factors, were collected. Complications were classified according to the Satava and modified Clavien systems. Failure was defined as any of the following: obstructive parameters on diuretic renal scintigraphy, decline in renal function, progressive hydronephrosis, or symptom relapse. Univariate and multivariate analysis were applied to identify factors affecting the complication rates. All parameters were compared between LP and RALP. RESULTS: A total of 575 children met the inclusion criteria. Laparoscopy, increased operative time, prolonged hospital stay, ureteral stenting technique, and time required for stenting were factors influencing complication rates on univariate analysis. None of those factors remained significant on multivariate analysis. Mean follow-up was 12.8 ± 9.8 months for RALP and 45.2 ± 33.8 months for LP (P = 0.001). Hospital stay and time for stenting were shorter for robotic pyeloplasty (P < 0.05 for both). Success rates were similar between RALP and LP (99.5% vs 97.3%, P = 0.11). The intraoperative complication rate was comparable between RALP and LP (3.8% vs 7.4%, P = 0.06). However, the postoperative complication rate was significantly higher in the LP group (3.2% for RALP and 7.7% for LP, P = 0.02). All complications were of no greater severity than Satava Grade IIa and Clavien Grade IIIb. DISCUSSION: This was the largest multicenter series of LP and RALP in the pediatric population. Limitations of the study included the retrospective design and lack of surgical experience as a confounder. CONCLUSIONS: Both minimally invasive approaches that were studied were safe and highly effective in treating UPJ obstruction in children in many centers globally. However, shorter hospitalization time and lower postoperative complication rates with RALP were noted. The aims of the study were met.

Single incision retro-peritoneoscopic paediatric nephrectomy: early experience.

Single incision, single port, or single site surgery for retro-peritoneoscopic nephrectomy and nephro-ureterectomy in paediatric practice using an advanced access platform (GelPOINT Mini) is described in two patients. One patient had bilateral synchronous nephrectomy. The technique, advantages, and challenges are reported. Beyond the initial hurdles and learning curve, this technique is promising and has the potential to be extended to other procedures in paediatric urology.

Primary bladder exstrophy closure in neonates: challenging the traditions.

PURPOSE: We describe a novel approach to neonatal bladder exstrophy closure that challenges the role of postoperative immobilization and pelvic osteotomy. MATERIALS AND METHODS: We reviewed the primary management of bladder exstrophy at our institutions between 2007 and 2011. In particular we compared postoperative management in the surgical ward using epidural analgesia to muscle paralysis and ventilation in the intensive care unit. Clinical outcome measures were time to full feed, length of stay, postoperative complications and redo closure. Cost-effectiveness was also evaluated using hospital financial data. Data are expressed as median (range). Significance was explored by Fisher exact test and unpaired t-test. RESULTS: A total of 74 patients underwent primary closure without osteotomy. Successful closure was achieved in 70 patients (95%). A total of 48 cases (65%) were managed on the ward (group A) and 26 (35%) were transferred to the intensive care unit (group B). The 2 groups were homogeneous for gestational age (median 39 weeks, range 27 to 41) and age at closure (3 days, 1 to 152). Complications requiring surgical treatment were noted in 4 patients (8.3%) in group A and 3 (11.5%) in group B (p = 0.609). Length of stay was significantly shorter for the group managed on the ward (11 vs 18 days, p <0.0001). Median costs were $42,732 for patients admitted to the intensive care unit and $16,214 for those admitted directly to the surgical ward (p <0.0001). CONCLUSIONS: Primary closure of bladder exstrophy without lower limb immobilization and osteotomy is feasible. Postoperative care on the surgical ward using epidural analgesia results in shorter hospitalization.

A massive occult pericardial effusion in an athletic young male.

We present a case of a 27-year-old Royal Marine with a massive pericardial effusion, presenting with minimal clinical findings, suggesting that high levels of physical fitness may effectively mask the normal symptoms of this potentially life-threatening condition.

Randomised controlled trial for efficacy of unfractionated heparin (UFH) versus low molecular weight heparin (LMWH) in thrombo-prophylaxis.

OBJECTIVE: To study if low dose Unfractionated heparin (UFH) is as effective and safe as Low-molecular weight heparin (LMWH) and also economical as a prophylactic agent for venous thromboembolism in medically ill patients. METHODOLOGY: A prospective double blind randomised controlled trial consisting of 92 patients fulfilling the inclusion criteria who were admitted to Bangalore Baptist Hospital, Bengaluru, between March 2008 and July 2009 were randomised to receive Unfractionated heparin (UFH) or Low-molecular weight heparin (LMWH). RESULTS: The result based on intention to treat (ITT)analysis with best outcome scenario: in the UFH arm there were 47 (97.9%) patients who had not developed DVT/PE as compared to 42 (95.5%) in the LMWH arm. The difference in proportion of patients who had not developed DVT/PE between UFH and LMWH was 2.4% (-5.0, 9.8). The results based on per protocol analysis: In the UFH arm there were 44 (97.8%) patients who had not developed DVT/PE as compared to 39 (95.1%) in the LMWH arm. The difference in proportion of patients who had not developed DVT/PE between the UFH and LMWH arm was 2.7% (-5.2, 10.5). Patients on UFH had higher major bleeding complications 4 (8.9%) as compared to 0 in LMWH arm. But with respect to other complications like thrombocytopenia (HIT) and mild or minimal bleeding both arms were comparable. CONCLUSION: This study has demonstrated that low dose UFH is as effective as LMWH as a prophylactic agent for venous thromboembolism in medically ill patients and economical also.

High or low- a trial of low dose anti snake venom in the treatment of poisonous snakebites.

OBJECTIVE: To demonstrate that use of lower doses of anti-snake venom is as effective as high doses and is associated with less complications and lower mortality especially in the wake of rising cost of medical treatment, the people most affected by snakebites being the poor farmers. METHODOLOGY: A prospective descriptive study consisting of 54 snakebite patients fulfilling the inclusion criteria who were admitted to Bangalore Baptist Hospital, Bengaluru, between November 2006 and November 2008 and were treated with a low dose ASV regime. The patients were initially given 2 vials of ASV followed later with 1 vial at a time according to clotting time. Any other supportive measures were undertaken as necessary. RESULTS: In this study the average dose of ASV required was only 6.70 +/- 3.24 vials. The complications--12.9% patients had ARF, and another 12.9% patients had neuropraralysis severe enough to require ventilatory support. There were 2 deaths (mortality of 3.7%) in the study. CONCLUSION: Low dose ASV regime in poisonous snakebites along with supportive treatment as necessary is as good as high dose regime, and has lesser adverse effects while reducing the cost of treatment too. Hence low dose regime can be used with beneficial results in poisonous snakebites.

Combined laparoscopic and cystoscopic injection sclerotherapy for bladder venous malformation: a novel technique.

Treatment of vascular malformations of the urinary bladder can be challenging. We report a case of bladder venous malformation treated with sodium tetradecyl sulphate (STS 3%) sclerotherapy, using a combined cystoscopic and percutaneous transperitoneal laparoscopy guided approach. When cystoscopic views are poor, the laparoscopic approach is a useful adjunct to aid sclerotherapy of bladder venous malformation. This technique has not been previously described.