What Is New with Rezūm Water Vapor Thermal Therapy for LUTS/BPH?

PURPOSE OF REVIEW

Rezum® is a novel convection-based thermal therapy for benign prostatic hyperplasia (BPH) induced lower urinary tract symptoms (LUTS). This review provides an overview of its safety, efficacy, cost, and potential role in the paradigm of BPH/LUTS therapies.

RECENT FINDINGS

Data regarding Rezum® stems primarily from one large randomized controlled trial of 197 patients with 4 years of follow-up. The efficacy and safety of Rezum® is further supported by 4 additional studies including 1 prospective pilot study, 1 crossover study, and 2 retrospective studies. Durable improvements in IPSS (47-60%), QoL (38-52%), Qmax (45-72%), and PVR (11-38%) were seen without causing deterioration of sexual function. Rezum® offers a cost-effective and safe approach to treating BPH/LUTS and should be considered as a possible first-line therapy for patients with moderate to severe symptoms.

Giant Malignant Phyllodes Tumour of Breast- A Clinical Dilemma and Surgical Challenge

Phyllodes tumour is an uncommon tumour of the breast. It is fibroepithelial in origin and mostly benign. Giant phyllodes tumours are described as tumours with size more than 10 cm and are extremely rare. Differentiating malignant and benign tumours pathologically is difficult and needs clinical judgement and high index of suspicion. A 50-year-old female presented with complaint of swelling in the left breast. On further evaluation, it was diagnosed as phyllodes tumour on biopsy. She underwent left mastectomy and excision of pectoralis major muscle due to clinical and radiological suspicion of malignancy. Postoperative histopathology report revealed malignant phyllodes tumour. Cases of giant phyllodes tumour should undergo adequate imaging and image guided biopsy with high index for suspicion for malignancy. They should be operated as per the principles of oncosurgery as there is a high probability of such huge tumours harboring malignancy.

Predictors of Mortality in Patients of COVID-19 Pneumonia in Intensive Care Unit: An Observational Study in a Tertiary Care Hospital, Lucknow, India

Introduction: Coronavirus Disease-2019 (COVID-19) is caused by the Severe Acute Respiratory Coronavirus-2 (SARS-CoV-2) which is an enveloped positive-sense single-stranded RNA virus. Initial steps of the infection involve binding of the spike protein (S) of the virus to Angiotensin Converting Enzyme-2 (ACE-2) receptor on the mucosal surfaces of various organs like lungs, kidney, heart, intestine. Pathogenesis of complications are still poorly understood. Aim: This study was designed to find out the baseline biochemical parameters at the time of admission which may predict outcome in COVID-19 patients. Materials and Methods: This observational study was conducted in a dedicated COVID-19 hospital, Dr. Ram Manohar Lohia Institute of Medical Sciences (Dr. RMLIMS), Lucknow, Uttar Pradesh, India, from 1st July, 2020 to 30th November, 2020. A total of 109 moderate to severe COVID-19 pneumonia patients who required Intensive Care Unit (ICU) admission, were enrolled. Based on their outcome, patients were divided into two groups: “Survived” and “Expired”. Biochemical characteristics of patients were compared among the two groups using univariate and multivariate analysis. Results: On Univariate analysis Coagulation profile, Prothrombin Time (PT), International Normalised Ratio (INR), Activated Partial Thromboplastin Time (APTT) and D-Dimer values were raised significantly in the expired group. Among other acute phase reactants Lactate Dehydrogenase (LDH), C-Reactive Protein (CRP), Interleukin-6 (IL-6), and Creatinine Phosphokinase-MB (CPKMB) were raised in expired group and this difference was significant statistically too. On Multivariate analysis among all acute phase reactant only IL-6 was increased significantly. All other variables were found to be non significantly associated with mortality, statistically (p-value <0.05). Conclusion: Baseline biochemical parameters have prognostic values in COVID-19 patients. Raised IL-6 levels can be viewed as an independent predictor of mortality among COVID-19 patients at the time of admission in ICU.

Impact of Co-morbidities on Outcome of COVID-19 Patients: An Observational Study among Patients Admitted to Intensive Care Unit

Introduction: Coronavirus Disease-2019 (COVID-19) has been a major cause of apprehension, morbidity, and mortality in 2020. It had been postulated that associated co-morbid conditions in COVID-19 patients increase the severity of COVID-19 which leads to six times more chances of hospitalisation than patients without co-morbid condition. Mortality is also 12 times higher in such patients. Aim: To find out the association between co-morbidities and mortalities due to COVID-19 pneumonia. Materials and Methods: A prospective, observational study was conducted in a tertiary teaching institute of North India which was designated Level 3 (L-3) facility for treatment of COVID- 19 patients. All 109 COVID-19 patients confirmed by Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR), admitted in Intensive Care Unit (ICU) from 1st July 2020 to 30th November 2020 formed the sample of the study. Data was taken regarding past history, clinical histories and examinations and ICU care and treatments. Based on their final outcome at the end of ICU care, patients were divided into two groups-group 1 (Non-survivor or Expired) and group 2 (Survived) and intergroup differences were studied. Results: COVID-19 infection was about three times more common in males. Severe category of COVID-19 patients had higher mortality (59.2% of severe category expired during hospital course, 1.7% patients expired in moderate category group). Most common co- morbidities were hypertension (n=51, 46.8%) and diabetes (n=48, 44%). Multivariate analysis showed that co-morbidities in the form of chronic liver disease (OR -0.127 (0.024-0.681, p-value 0.016)) and post tubercular sequel (OR 0.036 (0.003-0.442, p-value 0.009)) were less likely to occur in COVID-19 patients who survived, thus making these co-morbidities significant contributor to the adverse outcomes in COVID-19 patients. More number of co-morbidities in a patient were associated with higher chance of mortality and this trend was significant statistically (p-value <0.001). Conclusion: Patients with multiple co-morbidities, chronic liver disease and post tubercular sequel were associated with higher mortality in COVID-19 patients.

Comparing pattern of musculoskeletal injuries prior to and during COVID-19 lockdown: A time-trend case study from a tertiary level Trauma Center of Northern India

BACKGROUND AND AIMS

In the COVID-19 times, Indian sub-continent is struggling to contain the epidemic and trying to strengthen the existing health infrastructure, the national level lockdown has raised concerns about the pattern of injuries whether it has remained the same or has changed over this period. This is the first study to compare injury pattern during the two months lockdown period with the data of corresponding months from years 2016-2020. Also we compared the age- and sex-wise distribution patterns of these injuries for the above mentioned period.

METHODS

This retrospective cross sectional study was conducted by the Department of Orthopaedics in Guru Gobind Singh Medical College and Hospital (GGSMCH) in Faridkot, Punjab. Secondary data for patient's age and sex, mode of injury, and site of injury was collected through record review for the period of two months (24th March to 24th May) for five consecutive years of 2016-2020. Descriptive analysis and Chi-square test was used to see the association between age and sex with mode and type of injury.

RESULTS

The five year injury trends reflected that the proportion of injuries in 2016 was 16.5% (n = 48) of the total musculoskeletal injuries (n = 291) which rose to 23.4% (n = 68) in 2020. Majority of the patients were males (80%), and belonged to adult age group (69.4%) followed by elderly (17.2%), adolescents (8.6%) and children (4.8%). The proportion of road traffic accidents out of all injuries significantly reduced during the lock down period of two months in 2020 (p = 0.001). On the contrary, the proportion of injuries due to falls as well as unspecified assault increased significantly in 2020 as compared to previous years.

CONCLUSIONS

The proportion of musculoskeletal injuries have increased from 2016-2020. Unspecified assault and all types of falls pushed the road traffic accidents to third position during the lockdown period in 2020 as compared to previous four years. Injury surveillance needs to be integrated in routine hospital system for precise information and for more efficient functioning.

Evaluation of Risk Factors for Septic Complications after Laparotomy for Abdominal Trauma: A Longitudinal Cohort Study

Introduction: Septic complications are the most common cause of death in trauma patients who survive beyond 48 hours. Early diagnosis and treatment of infectious complications is essential to prevent life-threatening complications like Systemic Inflammatory Response Syndrome (SIRS) and Multi-Organ Dysfunction Syndrome (MODS). Aim: To study the various risk factors for septic abdominal complications following laparotomy for trauma. Materials and Methods: A prospective longitudinal cohort single-center study was conducted from November 2016 to March 2018. Sixty patients above the age of 12 years, who underwent laparotomy for abdominal trauma in the Surgical Department of our hospital, were included in the study. Various patient variables were compared with postoperative septic abdominal complications like wound infection, wound dehiscence, anastomotic leak and intra-abdominal abscess. Data was analysed using Statistical Package for Social Sciences (SPSS) version 21.0. Results: In the total 60 patients (35.60±16.54), significant association was seen between wound infection and dehiscence with the time interval between trauma and surgery (p<0.001), lesser Revised Trauma Score (RTS) (p<0.001) and greater Injur Severity Score (ISS) (p<0.001). A significant association of all septic complications was seen with the need for Intensive Care Unit (ICU) stay (p<0.001) and the presence of associated injuries (p<0.001). Variables such as age, gender, co morbidities, Body Mass Index (BMI), pre-hospital care received, intraoperative findings and duration of ICU stay had no association with outcomes (p>0.05). Conclusion: In trauma patients, factors like low RTS score, high ISS score, need for ICU stay and the presence of associated injuries may help the surgeons to decide in which patients to go for techniques like delayed closure of the wound, stoma instead of bowel anastomosis, etc., which may help to reduce postoperative septic complications.

Serum Metabolic Disturbances Associated with Acute-on-chronic Liver Failure in Patients with Underlying Alcoholic Liver Diseases: An Elaborative NMR-based Metabolomics Study

Objectives:

Acute-on-chronic liver failure (ACLF), which develops in patients with underlying alcoholic liver disease (ALD), is characterized by acute deterioration of liver function and organ failures are secondary to that. The clear understanding of metabolic pathways perturbed in ALD-ACLF patients can greatly decrease the mortality and morbidity of patients through predicting outcome, guiding treatment, and monitoring response to treatment. The purpose of this study was to investigate the metabolic disturbances associated with ACLF using nuclear magnetic resonance (NMR)-based serum metabolomics approach and further to assess if the serum metabolic alterations are affected by the severity of hepatic impairment.

Materials and Methods:

The serum-metabolic profiles of 40 ALD-ACLF patients were compared to those of 49 age and sex-matched normal-control (NC) subjects making composite use of both multivariate and univariate statistical tests.

Results:

Compared to NC, the sera of ACLF patients were characterized by significantly decreased serum levels of several amino acids (except methionine and tyrosine), lipid, and membrane metabolites suggesting a kind of nutritional deficiency and disturbed metabolic homeostasis in ACLF. Twelve serum metabolic entities (including BCAA, histidine, alanine, threonine, and glutamine) were found with AUROC (i.e., area under ROC curve) value >0.9 suggesting their potential in clinical diagnosis and surveillance.

Conclusion:

Overall, the study revealed important metabolic changes underlying the pathophysiology of ACLF and those related to disease progression would add value to standard clinical scores of severity to predict outcome and may serve as surrogate endpoints for evaluating treatment response.

Resonant filters with concurrently tuned central wavelengths and sidebands

Tunable infrared filters are important for various optical and optoelectronic systems. Ideally, such filters should span wide spectral ranges while retaining constant performance. Here, as a fundamental approach, we theoretically treat tunable resonant filters and realize favorable spectral profiles. Implementing a chirped zero-contrast grating on wedged sublayers, we optimize the resonant tunable filter for operation in the ∼5-14µm band. To clarify the root causes of the physical processes enabling the observed performance, attendant resonance modal processes and background reflection behavior are analyzed in detail by equivalent models as well as by rigorous electromagnetic models. The key innovative contribution of this research is that it enables efficient filters with simultaneously tuned operational wavelengths and sidebands.

Partial Nephrectomy For a Presumed Single Renal Mass Revealing Multiple Tumor Histologies: A Series of 4 Patients

Introduction/Objective

Renal mass biopsy is known to have a low but unavoidable diagnostic error rate. However, the occurrence of multiple adjacent masses mimicking one mass clinically has been minimally studied.

Methods

We report a series of four patients who were radiologically presumed to have a single renal mass and treated with partial nephrectomy, yet who were found to have multiple demarcated renal cell carcinoma histologies at pathologic evaluation.

Results

All were men aged 63–70 years. Grossly, tumors were red brown with scant, bright yellow foci in one of them. Dominant tumors followed by smaller tumors were: patient 1 - clear cell renal cell carcinoma (5.0 cm), clear cell papillary renal cell carcinoma (0.5 cm), and papillary adenoma (0.6 cm); patient 2 - clear cell renal cell carcinoma (1.5 cm) and clear cell papillary renal cell carcinoma (0.5 cm); patient 3 - papillary renal cell carcinoma (5.0 cm) and eosinophilic variant of chromophobe renal cell carcinoma (1.0 cm); patient 4 - chromophobe renal cell carcinoma (4.0 cm) and clear cell papillary renal cell carcinoma (0.6 cm). Immunohistochemical studies for cytokeratin 7, carbonic anhydrase IX, high molecular weight cytokeratin, CD10, and alpha-methyl acyl-CoA racemase (AMACR) confirmed the separate components in all.

Conclusion

This series adds to the spectrum of causes that may contribute to discordant results of renal mass biopsy and resection specimens. Secondary smaller tumors appear to be predominantly nonaggressive histologies, enriched for clear cell papillary renal cell carcinoma. Pathologists and urologists should be aware of this occurrence when considering the role of renal mass biopsy and interpreting the results.

Microenvironmental Hypoxia Induces Dynamic Changes in Lung Cancer Synthesis and Secretion of Extracellular Vesicles

Extracellular vesicles (EVs) mediate critical intercellular communication within healthy tissues, but are also exploited by tumour cells to promote angiogenesis, metastasis, and host immunosuppression under hypoxic stress. We hypothesize that hypoxic tumours synthesize hypoxia-sensitive proteins for packing into EVs to modulate their microenvironment for cancer progression. In the current report, we employed a heavy isotope pulse/trace quantitative proteomic approach to study hypoxia sensitive proteins in tumour-derived EVs protein. The results revealed that hypoxia stimulated cells to synthesize EVs proteins involved in enhancing tumour cell proliferation (NRSN2, WISP2, SPRX1, LCK), metastasis (GOLM1, STC1, MGAT5B), stemness (STC1, TMEM59), angiogenesis (ANGPTL4), and suppressing host immunity (CD70). In addition, functional clustering analyses revealed that tumour hypoxia was strongly associated with rapid synthesis and EV loading of lysosome-related hydrolases and membrane-trafficking proteins to enhance EVs secretion. Moreover, lung cancer-derived EVs were also enriched in signalling molecules capable of inducing epithelial-mesenchymal transition in recipient cancer cells to promote their migration and invasion. Together, these data indicate that lung-cancer-derived EVs can act as paracrine/autocrine mediators of tumorigenesis and metastasis in hypoxic microenvironments. Tumour EVs may, therefore, offer novel opportunities for useful biomarkers discovery and therapeutic targeting of different cancer types and at different stages according to microenvironmental conditions.

Cardiorenal Syndrome in Type 2 Diabetes Mellitus - Rational Use of Sodium-glucose Cotransporter-2 Inhibitors

Cardiorenal syndrome (CRS) in people with type 2 diabetes mellitus (T2DM) illustrates the bidirectional link between the heart and the kidneys, with acute or chronic dysfunction of one organ adversely impacting the function of the other. Of the five subtypes identified, type 1 and 2 CRS occur because of the adverse impact of cardiac conditions on the kidneys. Type 3 and 4 occur when renal conditions affect the heart, and in type 5, systemic conditions impact the heart and kidneys concurrently. The cardiovascular and renoprotective benefits evidenced with sodium-glucose cotransporter-2 (SGLT2) inhibitors make them a potential choice in the management of CRS. Cardiovascular protection is mediated by a reduction in cardiac workload, blood pressure, and body weight; with improvement in lipid profile, uric acid levels, and adaptive ketogenesis process. Renoprotection is facilitated by reduction in albuminuria and hypoxic stress, and restoration of tubuloglomerular feedback. The favourable effect on cardiovascular complications and death, as well as renal complications and progression to end-stage kidney disease, has been confirmed in clinical trials. Guidelines endorse first-line use of SGLT2 inhibitors after metformin in patients with T2DM with high cardiovascular risk, chronic kidney disease or both. Since most trials with SGLT2 inhibitors excluded subjects with acute illness, patients with CRS subtypes 1 and 3 have not been studied adequately, making SGLT2 initiation in clinical practice challenging. Ongoing trials may provide evidence for SGLT2 inhibitor use in CRS. This review aims to enhance understanding of CRS and provide guidance for judicious use of SGLT2 inhibitors in T2DM.

Embedded product authentication codes in additive manufactured parts: Imaging and image processing for improved scan ability

The layer-by-layer printing process of additive manufacturing methods provides new opportunities to embed identification codes inside parts during manufacture. These embedded codes can be used for product authentication and identification of counterfeits. The availability of reverse engineering tools has increased the risk of counterfeit part production and new authentication technologies such as the one proposed in this paper are required for many applications including aerospace components and medical implants and devices. The embedded codes are read by imaging techniques such as micro-Computed Tomography (micro-CT) scanners or radiography. The work presented in this paper is focused on developing methods that can improve the quality of the recovered micro-CT scanned code images such that they can be interpreted by standard code reader technology. Inherent low contrast and the presence of imaging artifacts are the main challenges that need to be addressed. Image processing methods are developed to address these challenges using titanium and aluminum alloy specimens containing embedded quick response (QR) codes. The proposed techniques for recovering the embedded codes are based on a combination of Mathematical Morphology and an innovative de-noising algorithm based on optimal image filtering techniques. The results show that the proposed methods are successful in making the codes scannable using readily available smartphone apps.