Diagnostic accuracy of MRI for detection of occult instability of type I anterior to posterior pelvic injuries.

Type I Young and Burgess anterior posterior compression (APC) pelvic injuries have been classically managed non operatively due to theoretical integrity of sacroiliac joint ligaments (SIJL), though examination under anesthesia (EUA) has been proven occult mechanical instability in up to 50% of these injuries.  We sought to determine the diagnostic accuracy of magnetic resonance (MRI) for detection of occult instability on APC-I injuries when compared to EUA. METHODS: Diagnostic test study of prospectively recruited patients admitted with APC-I pelvic injuries between 2015 and 2022. All patients consented to participate in this study were subjected to MRI and EUA. The evaluators of each of these tests were blinded.  On MRI evaluation, SIJL were considered compromised when unilateral injury to anterior SIJL was visualized in three or more consecutive images or in bilateral injuries, when injury to the anterior SIJL in two or more consecutive images on each side was observed. Positive EUA was considered a symphyseal diastasis over 25 mm on stress fluoroscopy. Demographic data was collected as recruited and sensitivity, specificity, accuracy, and positive and negative predictive values were calculated. Confidence interval was set at 95%. EUA was considered the gold standard in statistical analysis. RESULTS: A total of 32 patients mean aged 36 (24-61) years were included. Mean symphyseal diastasis at admission was 17.58 (11 - 25) mm. The median time from injury to EUA was 5 (0-21) days. Positive EUA was observed on 20 patients and 25 patients  presented compromised SIJL. MRI presented a sensitivity of 95% (75.13% - 99.87%), specificity of 50% (21.09% - 78.91%), positive-predictive value of 73% (60.61% to 82.93%), negative-predictive value of 87% (48.66% - 98.08%). CONCLUSION: Injury to SIJL on MRI presented an accuracy of 77% (58.29% - 89.64%) for the detection of occult pelvic instability on EUA.

Examination under anesthesia: Preferred Practice.

Pediatric ocular examinations are often a challenge in the outpatient setting due to limited cooperation of the child. Hence an evaluation under anesthesia (EUA) or sedation is important for a holistic ophthalmic examination. It can be combined with short procedures, such as suture removal and corneal scrappings, both for diagnosis and for the management of several ophthalmic disorders. It can also be performed before planning a surgical intervention to record the baseline characters and formulate or refine a surgical plan. Every EUA must be used as a chance to perform a complete ophthalmic examination rather than perform a single task such as recording the intraocular pressure. This article aims to provide a protocol that can be followed for a complete EUA.

Crohn's disease-related anal fistula cancer diagnosed by examination under anesthesia: a case report.

BACKGROUND: As the number of patients with inflammatory bowel disease (IBD) increases, the incidence of IBD-related colorectal cancer (CRC) is also on the rise. Crohn's disease (CD)-related CRC has been reported to have a poorer prognosis than sporadic CRC, and the early detection of CD-related CRC is difficult. Japanese patients with CD are reported to have a higher frequency of anorectal cancer than the Western population; however, methods for early diagnosis have not yet been established because of perianal pain during the examination. CASE PRESENTATION: We report a case of CD-related anal fistula cancer that was detected early by surveillance examination under anesthesia (EUA). The patient was a 37-year-old man, diagnosed with CD at the age of 15 years and started medical treatment. However, due to poor disease control, the intestinal tract remained highly inflamed and the patient continued to have over 10 bowel movements per day. He was referred to our hospital for surgical treatment after a colonoscopy (CS), which revealed multiple active ulcers and stenoses. Since three perianal seton drainage tubes had been placed around his anus since the age of 33 years, we decided to perform an EUA to rule out cancer coexistence in the anorectal region. After a random biopsy of the rectum by CS under general anesthesia, we resected and curetted multiple perianal fistulas as much as possible and reinserted the seton drainage tubes. Pathological examination of the fistula tract revealed adenocarcinoma in one tract, indicating the coexistence of anal fistula cancer. Based on the diagnosis of multiple intestinal stenoses and anal fistula cancer due to CD, we performed hand-assisted laparoscopic total colectomy, rectal amputation, extensive perineal resection, and reconstruction using a left rectus abdominis flap. CONCLUSION: In a long-term CD patient with anorectal lesions, we performed an EUA to diagnose the coexistence of anal fistula cancer at an early stage, and surgical resection was achieved. EUA is effective for the early detection and treatment of CD-related CRC and may contribute to an improved prognosis.

Intraoperative OCT Angiography in Pediatric Patients with Persistent Fetal Vasculature.

PURPOSE: To describe abnormalities of the optic nerve microvasculature in patients with persistent fetal vasculature (PFV) and their fellow eyes using OCT angiography (OCTA). DESIGN: Cross-sectional study. SUBJECTS: Fifty eyes of 25 patients with PFV who underwent prospective imaging using supine OCTA during examination under anesthesia at Bascom Palmer Eye Institute from March 1, 2019, to December 31, 2022. METHODS: OCT angiography images of the optic nerve of the included patients were analyzed with a primary focus on blood flow. Demographic, clinical, and treatment factors were compared with morphologic changes in the optic disc microvasculature. MAIN OUTCOME MEASURES: Prevalence of optic nerve microvascular abnormalities on OCTA in the affected and fellow eyes of patients with PFV. RESULTS: A total of 50 eyes from 25 patients were reviewed, and 28% (7/25) met image quality criteria for OCTA analysis. Optic nerve OCTA showed a persistent hyaloid artery (PHA) in all (7/7) PFV eyes analyzed. Of these, flow on OCTA was detectable in 57% (4/7). A Bergmeister papilla was evident in 100% (25/25) fellow eyes, of which flow was detected in 68% (17/25). Fluorescein angiography (FA) demonstrated blood flow within the stalk in 40% (10/25) of PFV eyes and within the Bergmeister papilla in 25% (6/25) of fellow eyes. Similar findings of abnormal blood flow and presence of fibrovascular stalk were seen in both treatment-naïve and treated groups. CONCLUSIONS: OCT angiography allows for high-resolution visualization of subtle vascular abnormalities that are not readily apparent using RetCam FA and may serve as a useful noninvasive test to confirm the patency of the PHA and Bergmeister papilla in children. The results of the present study suggest that PFV may be a bilateral and asymmetric process. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

The EMS stress view: occult pelvic instability revealed by pre-hospital pelvic binder placement.

PURPOSE: To describe and evaluate the serendipitous pelvic binder stress radiographs of lateral compression type (LC) pelvic ring injuries. METHODS: This was a retrospective case series performed at a single, level I academic trauma center from 2016 to 2018. All patients presenting with a minimally displaced LC pelvic ring injury were reviewed (< 10 cm displacement on static pelvic radiographs). Patients with X-rays (XR) in a pelvic binder (EMS stress) and with the pelvic binder removed were included. Pelvic ring stability was determined by attending surgeon evaluation of EMS stress radiographs versus static XR of the pelvis. Patients were treated non-operatively and allowed to weight bear or taken to the operating room for exam under anesthesia (EUA) and potential operative fixation. Clinical success of treatment was determined by evaluation of further displacement at the completion of their most recent follow-up. RESULTS: Thirty-seven patients of the initial 398 reviewed met inclusion criteria. Fourteen of 37 patients (38%) were categorized as stable with no significant pelvis displacement seen on EMS stress and were treated non-operatively without further sequelae (4.6 months mean follow-up). The remaining 23/37 (62%) were treated operatively. Occult instability was identified on EMS stress in 14 (61%) of those 23 patients and the remainder were determined to be unstable based upon fracture pattern or EUA. All patients went on to successful treatment without significant pelvic deformity (7.8 months mean follow-up). CONCLUSION: The EMS stress XR is a valuable, opportunistic evaluation in LC pelvic ring injuries. This evaluation is a useful diagnostic adjunct to alert the provider that additional stress imaging may be indicated to evaluate for occult pelvic ring instability.

[Glaucoma in infancy and childhood]. / Glaukom im Säuglings- und Kindesalter.

Glaucoma in infancy and childhood is a rare disease. An immediate diagnosis and treatment are absolutely necessary to prevent blindness of affected children. Childhood glaucoma is characterized by a heterogeneous phenotype: besides primary congenital glaucoma, secondary types often exist and the individualized treatment requires an experienced interdisciplinary team. The pathogenesis is not always discernible and genetic alterations sometimes cause the disease. A surgical procedure is usually necessary to lower the intraocular pressure. Refractive and orthoptic care are equally important to avoid amblyopia. This article gives an overview of childhood glaucoma and outlines the most important diagnostic and therapeutic aspects.

Can MRI Be Used as a Sole Diagnostic Modality in Determining Clinical Stage in Cervical Cancer?

OBJECTIVE: The objective of this study was to compare staging by MRI to clinical staging in patients with cervical cancer and to determine the histological accuracy of staging by MRI and examination under anesthesia (EUA) in early stage disease. METHODS: This was a retrospective cohort study of patients diagnosed with cervical cancer between 2010 and 2020 at the Radboud University Medical Centre, the Netherlands. Pretreatment stage (FIGO 2009) by MRI was compared with staging by EUA. Diagnostic accuracy in terms of sensitivity, specificity, positive, and negative predictive value was calculated for MRI and EUA in patients undergoing surgery (early stage disease) with histological results as a reference standard. RESULTS: A total of 358 patients were included in the study and MRI-based stage differed from EUA stage in 30.7%. In 12.3% this meant a discrepancy in treatment assignment between MRI and EUA. Diagnostic accuracy of MRI in terms of sensitivity and specificity for detecting early stage disease was comparable to EUA in surgical patients. Further analyses showed that premenopausal status, early stage disease and a tumor diameter of <2 cm were associated with improved comparability of MRI and EUA (98%). CONCLUSION: There is still a large discrepancy between MRI and EUA. In patients with suspected early stage disease, diagnostic accuracy of MRI is similar to EUA, especially for premenopausal women with early stage disease and a tumor diameter of <2 cm.

Contemporary Staging for Muscle-Invasive Bladder Cancer: Accuracy and Limitations.

CONTEXT: Bladder cancer prognosis and treatment are heavily dependent on accurate staging. Traditional imaging and pathologic evaluation of transurethral resection (TUR) specimens have been associated with high rates of clinical understaging at the time of radical cystectomy (RC). OBJECTIVE: We describe current components and limitations of bladder cancer staging for muscle-invasive bladder cancer (MIBC), and discuss the rationale for inclusion of novel biomarkers and imaging modalities to improve diagnostic accuracy. EVIDENCE ACQUISITION: We summarize the data informing MIBC staging accuracy using a nonsystematic review of published literature and provide expert opinion on current and emerging standards in MIBC staging. EVIDENCE SYNTHESIS: Nearly 50% of patients undergoing RC are clinically understaged preoperatively. Components of clinical staging include TUR specimen evaluation, bimanual examination under anesthesia (EUA), and cross-sectional imaging of the chest, abdomen, and pelvis. Complete endoscopic resection of visible disease with sampling of muscularis propria is indicated. While histologic features such as tumor size, focality, variant histologic differentiation, and lymphovascular invasion have prognostic utility, insufficient evidence exists to incorporate them into current staging paradigms. For primary tumor staging, conventional computed tomography (CT) has limited accuracy in differentiating non-MIBC from MIBC. Magnetic resonance imaging (MRI) has exhibited superior pT staging accuracy with the validated Vesical Imaging Reporting and Data System. Positron emission tomography (PET)/CT does not increase clinical nodal staging accuracy beyond CT or MRI, and there exists no consensus role for the use of PET in routine clinical staging. CONCLUSIONS: In the absence of reliable biomarkers to serve as staging adjuncts, we continue to rely heavily on basic clinical staging components-TUR with accurate pathologic evaluation, EUA, and standard cross-sectional imaging modalities. MRI shows promising accuracy and interobserver reliability for primary tumor staging. PATIENT SUMMARY: Effective clinical staging for muscle-invasive bladder cancer estimates local and systemic disease burden and can dictate eligibility for systemic therapy and/or radical cystectomy. Herein, we review the accuracy and limitations of current and emerging staging modalities.

The Management of Perineal Trauma in Children.

Aims: This study aimed to evaluate the outcome of perineal trauma in children and to a define protocol for their management. Methods: It is a retrospective study of children who presented with perineal injury between August 2012 and December 2020. The patients were classified into three groups: Group-1 included children with perineal and genitourinary injuries; Group-2 included patients with perineal and anorectal injuries; and Group-3 included patients with perineal, genitourinary, and anorectal injuries. All patients underwent primary repair. Those with full-thickness anorectal injury underwent an additional covering colostomy, while urethral disruption was initially managed by a diverting suprapubic cystostomy (SPC). Results: A total of 41 patients were studied. Impalement injury (n = 11; 27%) and sexual abuse (n = 11; 27%) were the most common mechanisms of injury. Twenty (49%) patients had anorectal injuries with 10 (24%) each of partial-thickness and full-thickness injury. There were 24 (59%) genital injuries and five (12%) urethral injuries. One patient each developed anal and vaginal stenosis, both were managed with dilatation. One patient developed a rectovaginal fistula repaired surgically at a later date. Conclusion: Perineal injuries with resultant anorectal or genital damage require a careful primary survey. Following stabilization, an examination under anesthesia as a set protocol will help determine the treatment strategy. A colostomy is essential in the acute management of severe anorectal injuries to reduce local complications and preserve continence. Urethral injuries may warrant an initial diverting SPC in selected cases.

A Multi-Disciplinary Approach to Perianal Fistulizing Crohn's Disease.

Perianal fistulizing Crohn's disease represents a severe phenotype associated with significant morbidity. Patients with perianal fistulizing disease are more likely to have a severe disease course and have significant reductions in quality of life. Moreover, these patients are at risk for the development of distal rectal and anal cancers. Given the complexity and severity of this patient group, the management of perianal Crohn's disease must be undertaken by a multidisciplinary team. The gastroenterologist and colorectal surgeon play a critical role in the diagnosis and management of perianal fistulizing disease. An examination under anesthesia provides critical information and is an essential part of the work-up of complex perianal fistulas. The radiologist also plays a central role in characterizing anatomy and assessing response to treatment. Several imaging modalities are available for these patients with magnetic resonance imaging as the imaging modality of choice. Perianal disease developing after ileal pouch-anal anastomosis represents a particularly challenging form of fistulizing disease and requires a multidisciplinary clinical and radiologic approach to differentiate surgical complications from recurrent Crohn's disease.

The Importance of Clinical Examination under General Anesthesia: Improving Parametrial Assessment in Cervical Cancer Patients.

BACKGROUND: Parametrial tumor involvement is an important prognostic factor in cervical cancer and is used to guide management. Here, we investigate the diagnostic value of clinical examination under general anesthesia (EUA) and magnetic resonance imaging (MRI) in determining parametrial tumor spread. METHODS: Post-operative pathological findings of 400 patients with primary cervical cancer were compared to the respective MRI data and the results from EUA. The gynecological oncologist had access to the MR images during clinical assessment (augmented EUA, aEUA). RESULTS: Pathologically proven parametrial tumor invasion was present in 165 (41%) patients. aEUA exhibited a higher accuracy than MRI alone (83% vs. 76%; McNemar's odds ratio [OR] = 2.0, 95%CI 1.25-3.27, p = 0.003). Although accuracy was not affected by tumor size in aEUA, MRI was associated with a lower accuracy in tumors ≥2.5 cm (OR for a correct diagnosis compared to smaller tumors 0.22, p < 0.001). There was also a decrease in specificity when evaluating parametrial invasion by MRI in tumors ≥2.5 cm in diameter (p < 0.0001) compared to smaller tumors (< 2.5 cm). Body mass index had no influence on performance of either method. CONCLUSIONS: aEUA has the potential to increase the diagnostic accuracy of MRI in determining parametrial tumor involvement in cervical cancer patients.

Clinical Presentation, Treatment, and Challenges in the Management of Child Sexual Assault at a Tertiary Care Referral Center in India.

BACKGROUND: Child Sexual Assault (CSA) is not an uncommon but an under-reported crime. Along with social and psychological critical issues, there are multiple challenges faced by the surgical team for the treatment of complex perineal injuries associated with CSA. This study was conducted to find clinical presentation and management of CSA along with its problems and challenges encountered by the pediatric surgical team. MATERIALS AND METHODS: This was a retrospective study from 2010 to 2019, conducted in the department of pediatric surgery at a tertiary referral center. All-female patients with a definitive history of sexual assault were included in the study. RESULTS: Seven patients fulfilled the inclusion criteria and the mean age was 5.3 years. After a primary survey, all patients were taken up for examination under anesthesia (EUA). Three patients were managed by the primary repair of the wound and did well during follow-up. Four patients had grade 4 perineal injury and required stage reconstruction. As a first stage, repair of rectal tear, vaginal tear, and the perineal body reconstruction was done along with diversion colostomy. One patient required redo repair of the perineal body and one had developed a rectovaginal fistula. Three patients completed all stages and they are fully continent. CONCLUSION: The spectrum of injuries varies widely in CSA and more chances of high-grade perineal injuries in children due to distinctive local anatomy. EUA is crucial to assess the extent of the injury and to decide the course of management. Meticulous anatomical repair and diversion stoma is the key for successful complex repair and excellent long-term outcomes in terms of continence for the severe grade of perineal injuries.

Number, frequency and time interval of examinations under anesthesia in bilateral retinoblastoma.

PURPOSE: Current practice in retinoblastoma (Rb) has transformed this malignancy into a curable disease. More attention should therefore be given to quality of life considerations, including measures related to examinations under anesthesia (EUAs). We aimed to investigate EUA measures in bilateral Rb patients and compare the findings to EUAs in unilateral Rb. METHODS: A retrospective analysis of bilateral Rb patients that presented to the London Rb service from 2006 to 2013, were treated and had long-term follow-up. RESULTS: A total of 62 Rb patients, 15 (24.2%) of which had International Intraocular Retinoblastoma Classification (IIRC) group A/B/no Rb at presentation, 26 (41.9%) C/D, and 21 (33.9%) were E in at least one eye. The mean number of EUAs was 35.8 ± 21.5, mean time from first to last EUA was 50.6 ± 19.9 months, and mean EUA frequency was 0.715 ± 0.293 EUAs/month. IIRC group was found not to correlate with any of the EUA measures. Age at presentation inversely correlated with time interval from first to last EUA and to EUA frequency (p ≤ 0.029). Rb family history correlated with the latter measure (p = 0.005) and intraophthalmic artery chemotherapy and brachytherapy correlated with all EUA measures (p ≤ 0.029). Mean follow-up time was 80.1 ± 24.3 months. When compared with a previously reported cohort of unilateral Rb, the present group underwent 3× more EUAs (p < 0.001) over nearly double the time (p < 0.001). CONCLUSIONS: Families should be counselled on anticipated EUA burden associated with bilateral Rb. In this respect, age at presentation and family history were found to have a predictive role, whereas IIRC group did not.

Pediatric intraocular pressure measurements: Tonometers, central corneal thickness, and anesthesia.

Measuring intraocular pressure (IOP) is the cornerstone of a comprehensive glaucoma examination. In babies or small children, however, IOP measurements are problematic, cannot often be performed at the slit lamp, and sometimes require general anesthesia. Therefore, it is essential for an ophthalmologist who examines a pediatric patient to be aware of the different tonometers used in children, as well as the effects of central corneal thickness and anesthesia on IOP measurements. Goldmann applanation tonometry is the gold standard for IOP assessment. Most alternative tonometers tend to give higher IOP readings than the Goldmann applanation tonometer, and readings between different tonometers are often not interchangeable. Similar to Goldmann tonometry, many of these alternative tonometers are affected by central corneal thickness, with thicker corneas having artifactually high IOP readings and thinner corneas having artifactually lower IOP readings. Although various machines can be used to compensate for corneal factors (e.g., the dynamic contour tonometer and ocular response analyzer), it is important to be aware that certain ocular diseases can be associated with abnormal central corneal thickness values and that their IOP readings need to be interpreted accordingly. Because induction and anesthetics can affect IOP, office IOPs taken in awake patients are always the most accurate.

Upper extremity conversion disorder in children.

BACKGROUND: Conversion disorder in children presents a challenge to orthopedic surgeons. The condition is frequently associated with unnecessary diagnostic tests, treatments, and cost. The purpose of this study was to report a series of children with upper extremity conversion disorder to raise awareness for this uncommon condition and to assist with its diagnosis and management. METHODS: A retrospective review was conducted of 4 pediatric patients with upper extremity conversion disorder at a tertiary pediatric hospital from 2015 to 2017. Medical records were reviewed for patient demographics, including psychiatric history, clinical findings, diagnostic studies, treatment, and cost of care. RESULTS: Patients presented with upper extremity muscle stiffness, unremitting dysmorphic muscle spasms, weakness, pain, very limited shoulder range of motion, and complaints of recurrent shoulder dislocations. All patients had been evaluated by multiple specialists and had an extensive prior diagnostic workup that was inconclusive. Two patients had a history of prior psychiatric illness and suicidal ideation, and all patients expressed despair and depression. All patients had normal physical examination findings under anesthesia. Two patients with muscle stiffness were treated with botulism injections and improved their shoulder range of motion. The average total charge for care since presentation was $42,729. CONCLUSIONS: Conversion disorder should be considered in patients with an extensive prior diagnostic workup, deficits inconsistent with anatomic patterns or imaging findings, and a history of prior psychiatric illness. Examination under anesthesia is a successful diagnostic approach in children with suspected conversion disorder.

Effect of anesthesia on intraocular pressure measurement in children.

Measurement of the intraocular pressure (IOP) is central to the diagnosis and management of pediatric glaucoma. An examination under anesthesia is often necessary in pediatric patients. Different agents used for sedation or general anesthesia have varied effects on IOP. Hemodynamic factors, methods of airway management, tonometry technique, and body positioning can all affect IOP measurements. The most accurate technique is one that reflects the awake IOP. We review factors affecting IOP measurements in the pediatric population and provide recommendations on the most accurate means to measure IOP under anesthesia based on the present literature.

Risks of concomitant trauma to the knee in lower limb long bone shaft fractures: A retrospective analysis from a prospective study population.

BACKGROUND: Numerous associated injuries (bony and/or soft tissue lesions) occur commonly in conjunction with fractures of the femoral shaft in young patients after high-energy injuries. Knee ligamentous injuries, historically called as the internal derangements of the knee or IDK, are mostly not visible in plain radiographs taken in the emergency and these injuries are likely to be overlooked by clinicians because first attention always goes to open wounds and radiologically visible injuries of the limb whenever a patient is received in a trauma unit. MATERIALS AND METHODS: A total of 93 cases of lower limb long bone fractures were retrospectively analyzed from materials of a prospective study conducted on consecutive patients having high-velocity injuries to lower limb long bones with a view to confirm or rule out concomitant ipsilateral IDK in cases of femoral and tibial shaft fractures, that already employed a policy of focused clinical examination followed by arthroscopy of the ipsilateral knee, immediately after operative fracture fixation under the same anesthesia. The goal was to determine the incidence of concomitant internal derangement of the ipsilateral knee and to understand any value of adding arthroscopy to detect concomitant IDK in lower limb long bone fractures besides careful intraoperative examination to propose a recommendation thereof. RESULTS: Concomitant knee injury was found in 14 femoral fractures and 1 tibial fracture. Fifteen out of 93 (16%) such cases had concomitant knee ligamentous or meniscal injures. A total of 13 anterior cruciate and 4 posterior cruciate tears, 11 collateral ligament tears, and 10 meniscal injuries were confirmed in these 15 knees. Femoral shaft fractures were associated with a high incidence of serious ligamentous, meniscal, and chondral injury. Twelve out of 41 femoral fractures had chondral injuries (contusion), especially of the patello-femoral articulation, identifiable during arthroscopy. CONCLUSION: One should have high index of suspicion about internal knee injuries and capsule-ligamentous injuries while dealing with femoral shaft fractures in particular. Arthroscopy of knee may safely enhance the diagnosis of simultaneous IDK. We propose that when MR imaging is not possible and when contraindication for arthroscopy does not exist, a careful clinical examination followed by arthroscopy of the knee may be considered a useful adjunct in femoral shaft fractures as it can readily confirm IDK by its ability to objectively look, probe, and distinguish fragile tissue from a normal one. Further study in larger number of subjects is needed to validate our findings.

Refining patient selection for neoadjuvant chemotherapy before radical cystectomy.

PURPOSE: We evaluated the survival of patients with muscle invasive bladder cancer undergoing radical cystectomy without neoadjuvant chemotherapy to confirm the utility of existing clinical tools to identify low risk patients who could be treated with radical cystectomy alone and a high risk group most likely to benefit from neoadjuvant chemotherapy. MATERIALS AND METHODS: We identified patients with muscle invasive bladder cancer who underwent radical cystectomy without neoadjuvant chemotherapy at our institution between 2000 and 2010. Patients were considered high risk based on the clinical presence of hydroureteronephrosis, cT3b-T4a disease, and/or histological evidence of lymphovascular invasion, micropapillary or neuroendocrine features on transurethral resection. We evaluated survival (disease specific, progression-free and overall) and rate of pathological up staging. An independent cohort of patients from another institution was used to confirm our findings. RESULTS: We identified 98 high risk and 199 low risk patients eligible for analysis. High risk patients exhibited decreased 5-year overall survival (47.0% vs 64.8%) and decreased disease specific (64.3% vs 83.5%) and progression-free (62.0% vs 84.1%) survival probabilities compared to low risk patients (p <0.001). Survival outcomes were confirmed in the validation subset. On final pathology 49.2% of low risk patients had disease up staged. CONCLUSIONS: The 5-year disease specific survival of low risk patients was greater than 80%, supporting the distinction of high risk and low risk muscle invasive bladder cancer. The presence of high risk features identifies patients with a poor prognosis who are most likely to benefit from neoadjuvant chemotherapy, while many of those with low risk disease can undergo surgery up front with good expectations and avoid chemotherapy associated toxicity.

Pharmaco-economics: Minute-based cost of sevoflurane in pediatric short procedures and its relation to demographic variables.

BACKGROUND: Inhalation agents account for significant cost of short daycare procedures. The estimation of this cost to pre-calculate expected expenditure is not available in literature. As for intravenous agents, their relations to weight and other demographic parameters are also not well established. The present study aims to evaluate the above concern. MATERIALS AND METHODS: A total of 100 pediatric (ASA I, II) patients scheduled for ophthalmological examination under anesthesia (EUA) were included in the study. Following premedication, anesthesia in all children was induced using incremental concentrations of sevoflurane at a flow of 6 l with 1:1 oxygen:nitrous oxide ratio. Upon induction, the flows were reduced to 2 l, keeping sevoflurane at 1 to 2 minimum alveolar concentration (MAC). Using Dion's equation, the costs for induction and maintenance with sevoflurane were calculated for each patient. RESULTS: The cost per minute of sevoflurane was found to be Rs. 13.23. Unlike intravenous agents, no significant correlation was found to exist between sevoflurane consumption with age or weight. The sevoflurane consumption was also not influenced by the gender. The total cost of EUA correlated most strongly with duration of maintenance phase, followed by induction duration.