The difficulties of diagnosing food-dependent exercise-induced anaphylaxis in childhood -- a case study and review

We describe a case report of peanut and hens egg-dependent exercise-induced anaphylaxis in a 13-yr-old child, and assess the fundamental importance of careful investigations to differentiate food-dependent exercise-induced anaphylaxis from other forms of allergic reactions.

The technique of apical dissection of the prostate and urethrovesical anastomosis in robotic radical prostatectomy

OBJECTIVE

To describe the technique of dissecting the apex of the prostate and a modified single running-suture urethrovesical anastomosis in patients undergoing robot-assisted radical prostatectomy for organ-confined prostate cancer.

PATIENTS AND METHODS

Over 550 robot-assisted radical prostatectomies have been undertaken using Vattikuti Institute Prostatectomy (VIP) technique in patients with localized carcinoma of the prostate. We present a critical analysis of the first 120 procedures by one surgeon (M.M.) at our institution using this newly developed technique of urethrovesical anastomosis preceded by dissecting the apex of the prostate.

RESULTS

The mean time for the urethrovesical anastomosis was 13 min. All but 24 patients had their catheter removed 4 days after surgery, as indicated by a cystogram. The catheter was removed successfully at 7 days in the remaining 24 patients who had a mild leak on cystography. Two patients had urinary retention within a week of removing the catheter and had to be re-catheterized. Continence was evaluated using standardized criteria before and after the procedure. The patients also replied to a mailed validated questionnaire survey; 96% were continent at 3 months and the remaining 4% used a thin pad for security.

CONCLUSIONS

We report a technique of dissecting the apex of the prostate and prostatovesical junction for dividing the bladder neck, and a modified single running-suture urethrovesical anastomosis, in patients undergoing robot-assisted radical prostatectomy for organ-confined cancer of the prostate. The same principles can also be applied for the anastomosis during pure laparoscopic procedures and for urethro-neovesical anastomosis in patients undergoing robotic radical cystoprostatectomy for carcinoma of the bladder.

Nerve-sparing robot-assisted radical cystoprostatectomy and urinary diversion

OBJECTIVE

To develop a technique of nerve-sparing robot-assisted radical cystoprostatectomy (RRCP) for patients with bladder cancer.

PATIENTS AND METHODS

Robotic assistance should enhance the ability to preserve the neurovascular bundles during laparoscopic radical cystectomy. Thus we undertook RRCP and urinary diversion using a three-step technique. First, using a six-port approach and the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA), one surgeon carried out a complete pelvic lymphadenectomy and cystoprostatectomy using a technique developed specifically for robotic surgery. The neurovascular bundles were easily identified and dissected away, the specimen entrapped in a bag and removed through a 5-6 cm suprapubic incision. Second, a different surgical team exteriorized the bowel through this incision and created a neobladder extracorporeally. Third, the neobladder was internalized, the incision closed and the primary surgeon completed the urethro-neovesical anastomosis with robotic assistance.

RESULTS

RRCP was carried out in 14 men and three women by the primary surgeon (M.M.). The form of urinary reconstruction was ileal conduit in three, a W-pouch with a serosal-lined tunnel in 10, a double-chimney or a T-pouch with a serosal-lined tunnel in two each. The mean operative duration for robotic radical cystectomy, ileal conduit and orthotopic neobladder were 140, 120 and 168 min, respectively. The mean blood loss was < 150 mL. The number of lymph nodes removed was 4-27, with one patient having N1 disease. The margins of resection were free of tumour in all patients.

CONCLUSIONS

We developed a technique for nerve-sparing RRCP using the da Vinci system which allows precise and rapid removal of the bladder with minimal blood loss. The bowel segment can be exteriorized and the most complex form of orthotopic bladder can be created through the incision used to deliver the cystectomy specimen. Performing this part of the operation extracorporeally reduced the operative duration.

A prospective comparison of radical retropubic and robot-assisted prostatectomy: experience in one institution

The authors from the Vattikuti Institute in the USA report a prospective comparison of radical prostatectomy and robot-assisted prostatectomy. They found that the robot-assisted procedure was safer, and yielded favourable oncological and functional results. They also present work in association with the Department of Urology in Mansoura into robot-assisted radical cystoprostatectomy and urinary diversion, and point out the advantages and disadvantages associated with performing the most complex types of urinary diversion. There is also an interesting paper relating to the association between sexual factors and prostate cancer, from authors in institutions in Australia, New Zealand and Italy. They found that in a case-control study of men aged <70 years, ejaculatory frequency was negatively associated with the risk of prostate cancer. Technology has made many contributions to the management of urological patients. The classic example is that of urinary stone management. Authors from the USA evaluated cyroablation of renal carcinoma in patients with solitary kidneys. They are encouraged by their results and suggest that there is merit in this treatment, but indicate the need for a longer follow-up.

OBJECTIVE

To prospectively compare standard radical retropubic prostatectomy (RRP) and the robotically assisted Vattikuti Institute prostatectomy (VIP) in the management of localized prostate cancer.

PATIENTS AND METHODS

The study was a single-institution, prospective, unrandomized comparison of histopathological, and functional outcomes, at baseline and during and after surgery, in 100 patients undergoing RRP and 200 undergoing VIP.

RESULTS

While the variables before surgery, the operative duration (163 vs 160 min) and pathological stages were comparable, there were significant differences in the measured outcomes. The blood loss was 910 and 150 mL for RRP and VIP, respectively, and transfusion was greater after RRP (67% vs none; both P < 0.001). There were four times as many complications after RRP (20% vs 5%, P < 0.05), the haemoglobin level at discharge was lower (100 vs 130 g/L, P < 0.005) and the hospital stay longer (3.5 vs 1.2 days; P < 0.05). Most (93%) of VIP and none of the RRP patients were discharged within 24 h (P < 0.001); the duration of catheterization was twice as long after RRP (15.8 vs 7 days; P < 0.05). Positive margin was more frequent after RRP (23% vs 9%, P < 0.05). After VIP, patients achieved continence and return of erections more quickly than after RRP (160 vs 44, and 180 vs 440 days, both P < 0.5). The median return to intercourse was 340 days after VIP but after RRP half the patients have as yet not resumed intercourse at 700 days (P < 0.05).

CONCLUSIONS

The VIP procedure appears to be safer, less bloody and requires shorter hospitalization and catheterization. The oncological and functional results were favourable in patients undergoing VIP.

Use of artificial neural networks in prostate cancer

Artificial neural networks (ANNs) are a type of artificial intelligence software inspired by biological neuronal systems that can be used for nonlinear statistical modeling. In recent years, these applications have played an increasing role in predictive and classification modeling in medical research. We review the basic concepts behind ANNs and examine the role of this technology in selected applications in prostate cancer research.

Predictive modeling techniques in prostate cancer

A number of new predictive modeling techniques have emerged in the past several years. These methods can be used independently or in combination with traditional modeling techniques to produce useful tools for the management of prostate cancer. Investigators should be aware of these techniques and avail themselves of their potentially useful properties. This review outlines selected predictive methods that can be used to develop models that may be useful to patients and clinicians for prostate cancer management.

Artificial neural network model to predict biochemical failure after radical prostatectomy

BACKGROUND

Biochemical failure, defined here as a rise in the serum prostate specific antigen (PSA) concentration to >0.3 ng/mL or the initiation of adjuvant therapy, is thought to be an adverse prognostic factor for men who undergo radical prostatectomy (RP) as definitive treatment for clinically localized cancer of the prostate (CAP). We have developed an artificial neural network (ANN) to predict biochemical failure that may benefit clinicians and patients choosing among the definitive treatment options for CAP.

MATERIALS AND METHODS

Clinical and pathologic data from 196 patients who had undergone RP at one institution between 1988 and 1999 were utilized. Twenty-one records were deleted because of missing outcome, Gleason sum, PSA, or clinical stage data. The variables from the 175 remaining records were analyzed for input variable selection using principal component analysis, decision tree analysis, and stepped logistic regression. The selected variables were age, PSA, primary and secondary Gleason grade, and Gleason sum. The records were randomized and split into three bootstrap training and validation sets of 140 records (80%) and 35 records (20%), respectively.

RESULTS

Forty-four percent of the patients suffered biochemical failure. The average duration of follow up was 2.5 years (range 0-11.5 years). Forty-two percent of the patients had pathologic evidence of non-organ-confined disease. The average area under the receiver operator characteristic (ROC) curve for the validation sets was 0.75 +/- 0.07. The ANN with the highest area under the ROC curve (0.80) was used for prediction and had a sensitivity of 0.74, a specificity of 0.78, a positive predictive value of 0.71, and a negative predictive value of 0.81.

CONCLUSION

These results suggest that ANN models can predict PSA failure using readily available preoperative variables. Such predictive models may offer assistance to patients and physicians deciding on definitive therapy for CaP.

Genetic adaptive neural network to predict biochemical failure after radical prostatectomy: a multi-institutional study

BACKGROUND AND PURPOSE

Despite many new procedures, radical prostatectomy remains one of the commonest methods of treating clinically localized prostate cancer. Both from the physician's and the patient's point of view, it is important to have objective estimation of the likelihood of recurrence, which forms the foundation for treatment selection for an individual patient. Currently, it is difficult to predict the probability of biochemical recurrence (rising serum prostate specific antigen [PSA] concentration) in an individual patient, and approximately 30% of the patients do experience recurrence. Tools predicting the recurrence will be of immense practical utility in the treatment selection and planning follow up. We have utilized preoperative parameters through a computer based genetic adaptive neural network model to predict recurrence in such patients, which can help primary care physicians and urologists in making management recommendations.

PATIENTS AND METHODS

Fourteen hundred patients who underwent radical prostatectomy at participating institutions form the subjects of this study. Demographic data such as age, race, preoperative PSA, systemic biopsy based staging and Gleason scores were used to construct a neural network model. This model simulated the functioning of a trained human mind and learned from the database. Once trained, it was used to predict the outcomes in new patients.

RESULTS

The patients in this comprehensive database were representative of the average prostate cancer patients as seen in USA. Their mean age was 68.4 years, the mean PSA concentration before surgery was 11.6 ng/mL, and 67% patients had a Gleason sum of 5 to 7. The mean length of follow-up was 41.5 months. Eighty percent of the cancers were clinical stage T2 and 5% T3. In our series, 64% of patients had pathologically organ-confined cancer, 33% positive margins, and 14% had seminal vesicle invasion. Lymph node positive patients were not included in this series. Progression as judged by serum PSA was noted in 30.6%. With entry of a few routinely used parameters, the model could correctly predict recurrence in 76% of the patients in the validation set. The area under the curve was 0.831. The sensitivity was 85%, the specificity 74%, the positive predictive value 77%, and the negative predictive value of 83%.

CONCLUSION

It was possible to predict PSA recurrence with a high accuracy (76%). Physicians desiring objective treatment counseling can use this model, and significant cost savings are anticipated because of appropriate treatment selection and patient-specific follow-up protocols. This technology can be extended to other treatments such as watchful waiting, external-beam radiation, and brachytherapy.

Silver amalgam versus resin modified GIC class-II restorations in primary molars: twelve month clinical evaluation

The purpose of this study was to compare the clinical efficacy of resin modified GIC with amalgam as a restorative material, in Class-II cavities of primary molars. Restorations were evaluated at four, eight, and twelve months for their marginal integrity, anatomic form and development of recurrent caries. When each parameter was considered separately, there was no difference in the success rate between the two groups, except development of recurrent caries significantly less (p<0.05) in RMGIC group(4.7%) compared to amalgam group (12.5%) at twelve month follow up. However, the cumulative success rate at 12 month was found to be significantly higher (p<0.05) in RMGIC (Fuji II LC) group(83.1%) compared to amalgam(72%).

Robot assisted laparoscopic nephrectomy

PURPOSE

The feasibility and safety of remote laparoscopic surgery using a surgical telemanipulator have been demonstrated in laboratory experience and recently in clinical practice. To our knowledge we report the first robot assisted, laparoscopic nephrectomy in a human.

MATERIALS AND METHODS

A 77-year-old woman was diagnosed with a nonfunctioning hydronephrotic right kidney due to ureteropelvic junction obstruction. Robot assisted, transperitoneal right laparoscopic nephrectomy was performed.

RESULTS

Complete dissection was successfully performed with the robot. The renal pedicle was dissected without any problem, and the artery and vein were individually ligated. Operative time was 200 minutes, anesthesia time was 245 minutes and blood loss was less than 100 ml. Convalescence was uneventful. Histological examination confirmed the preoperative diagnosis.

CONCLUSIONS

We report the technical feasibility of robot assisted laparoscopic nephrectomy in humans. Current technology needs further improvement and its actual usefulness for patient treatment must be established by large clinical trials. Technological improvements and future telecommunication networks should open new avenues in surgery, namely remote telesurgery.

The effect of ship scrapping industry and its associated wastes on the biomass production and biodiversity of biota in in situ condition at Alang

The main pollutants for the ship scrapping industry and its associated wastes at Alang are heavy metals, petroleum hydrocarbon and bacterial contaminations. The concentration of iron, manganese, cobalt, copper, zinc, lead, cadmium, nickel and mercury were 25 to 15,500% more at nearshore station of Alang as compared to control site at Piram. The concentration of heavy metals in the nearshore station of Alang was always higher than its concentration at 10 km away. The concentration of petroleum hydrocarbon was 16,973 and 53,900% more at the nearshore and 10 km away respectively at Alang as compared to controls. The concentration of chlorophyll-a and phaeophytin were in non-detectable range (< 0.2 and < 0.1 mg m3) or much lower concentration at both the stations of Alang as compared to controls. The total viable count, total coliform, Escherichia coli, Vibrio cholerae, Vibrio parahaemolyticus and other Vibrio, Streptococcus faecalis, Shigella, Salmonella, Proteus, and Klebsiella were always higher (17%-605%) at the nearshore station of Alang as compared to control. Similar trend was observed at 10 km away from Alang. Bacteria in sediment also showed the same pattern of variation. Phytoplankton counts at the nearshore station and 10 km away from Alang were only slightly raised. In contrast to phytoplankton, the zooplankton showed considerable reduction of growth (-10 to -66%) at Alang.

Effects of variation in the timing of palatal repair on sagittal craniofacial morphology in complete cleft lip and palate children

The complete cleft lip and palate children, ranging from 6-14 years of age were studied to evaluate the effect of variation in the timing of palatal repair on craniofacial morphology and compared to the noncleft children. It was observed that all the groups early (8 to < or = 24 months), medium (> 24 to < or = 36 months) and late repair (> 36 to < or = 78 months) had significantly larger cranial base, retruded maxillomandibular relations, skeletodental and incisal relationships compared to the noncleft children. However, intercomparison among the cleft groups showed insignificant difference amongst them suggesting that the timing of palatal repairs does not effect the anterioposterior (sagittal) relationship.

Efficient estimation of number density in opaque material microstructures: the large-area disector

Unbiased and efficient estimation of number density of features in opaque material microstructures has been quite difficult. In this contribution a montage-based efficient serial sectioning technique is presented as a practical solution for efficient estimation of number density in such microstructures. The new technique utilizes a combination of digital image analysis and unbiased disector sampling procedures.

Frequency- and time-dependent effects of fendiline on action potentials of guinea pig papillary muscle

The action of fendiline on cardiac electrical activity was investigated in guinea pig papillary muscle by monitoring frequency- and time-dependent changes in membrane potential, action potential (AP) configuration and conduction velocity. Isolated guinea pig papillary muscles driven at 0.1 to 3 Hz showed a concentration-dependent reduction of +Vmax, overshoot, and AP duration at -20mV (APD20) in the presence of fendiline (1-320 microM), reflecting inhibition of Na+ and L-type Ca2+ channels, respectively. No significant change in resting potential and AP duration at 90% repolarization (APD90) were observed. Inhibition of +Vmax and APD20 was more prominent at higher frequency of stimulation (2 Hz) than at lower ones (0.2 Hz), demonstrating frequency-dependent block of Na+ and Ca2+ channels including an open channel block. A good relationship between changes in +Vmax and APD20 suggested some commonality in the mechanism of inhibition of Na+ and Ca2+ channels by fendiline. Time-dependence of effects of fendiline, observed in presence of bolus dose (200 microM), showed an earlier onset of inhibition of +Vmax and APD20, particularly at higher frequencies. Missed beats and conduction block also appeared earlier in preparations driven at higher frequency. These findings suggest a frequency-dependent (and open channel) block of Na+ and Ca2+ channels by fendiline, leading to inhibition of fast and slow conduction in addition to its reported inactivated Ca2+ channel block.

Effects of variation of the timing of palatal repair on nasality of speech in complete cleft lip and palate children

Nasality is related to factors like velopharyngeal closure and acoustic factors pertaining to cavities. The present investigation is a retrospective study aimed at evaluating the effects of variation in the timing of palatal repair on nasality during speech development in complete cleft lip and palate cases. It has been observed that the delay in palatal repair is associated with increase in nasality. Also, from the operated complete cleft lip and palate cases, it has been observed that the early and medium repair groups had almost similar effects on nasality of speech. (if they were operated before 36 months of age).