621 Robot-Assisted Radical Cystectomy: A Complete Audit Cycle of Our First 118 Cases

Aim

There are 10,200 cases of bladder cancer diagnosed every year in the UK, accounting for 3% of all new cancer diagnoses. Robot-assisted radical cystectomy (RARC) is a minimally invasive treatment option for muscle invasive and high-risk bladder cancer with a rising uptake. Between 2017 and 2019, RARC accounted for 40.6% of all cystectomies performed in the UK, increasing to 52% in 2018 to 2019. We compared our outcomes with the best practice of RARC set by the Pasadena consensus panel in 2015.

Method

A review of the prospective database of all RARC performed by two surgeons at Royal Wolverhampton Hospital between May 2013 and October 2020 was conducted. Operative and oncological outcome data were collected from Clinical Web Portal and Somerset Cancer Register and analysed using Microsoft Excel.

Results

A total of 118 RARC were performed in the study period, 50 cases were analysed in the first audit loop and 68 cases in the second. The mean age was 69 years (44 – 82), 84% were men and 70% were ASA grade II or less. Median operating time was 376 minutes (210 – 555) and the median blood loss was 250mls. 79% of urinary diversion was intra-corporeal and 84% was ileal conduit diversion. Median length of stay was 8 days; complication rate with Clavien Dindo score of III or higher was 12.7%. 86% of our patients are still alive.

Conclusions

RARC is a safe option for the radical management of bladder cancer. Our outcomes are consistent with the Pasadena consensus recommendations.

Psoas muscle atrophy following unilateral hip arthroplasty

BACKGROUND

Studies have demonstrated the presence of muscle atrophy around the hip in patients with hip osteoarthritis. Few studies have examined the psoas muscle or assessed it at a paraspinal level in patients post-total hip arthroplasty. The aim of this study was to determine if there is significant psoas muscle atrophy as indicated by muscle cross-sectional area and high degree of fat infiltration post-unilateral hip arthroplasty.

METHODS

Retrospective analysis of 341 patients with unilateral hip implant and subsequent lumbar spine MRI over a 8-year period was performed. Fat infiltration and cross-sectional area of the psoas muscle at L3/4 level were measured by two musculoskeletal fellows (1 year experience in musculoskeletal radiology), and comparison made between the implant and non-operative sides was made. Fat infiltration was measured using the modified Goutallier grading. The degree of hip osteoarthritis in the non-operative side was measured using the Kellgren-Lawrence grading. The data was analysed using paired t test, ANOVA, unpaired t test, Pearson correlation and Jonckheere-Terpstra test.

RESULTS

The cross-sectional area of the psoas muscle on the implant side was significantly less than the non-operative side. There was significance between the cross-sectional area difference and the fat grade of the implant side.

CONCLUSION

Our results demonstrate psoas atrophy on the implant side compared to the non-operative side in post-unilateral implant patients. Post-operative hip implant rehabilitation may benefit from more focused psoas strengthening exercises to improve functional outcome.

Pulmonary ischaemia without pulmonary arterial thrombus in COVID-19 patients receiving extracorporeal membrane oxygenation: a cohort study

AIM

To evaluate the incidence of pulmonary ischaemia in COVID-19 patients on extracorporeal membrane oxygenation (ECMO), and its correlation with pulmonary artery thrombosis.

MATERIALS AND METHODS

Computed tomography (CT) thorax of all patients receiving ECMO with proven COVID-19 pneumonitis between March and May 2020 were analysed for the presence and extension of pulmonary thromboembolic disease.

RESULTS

Fifty-one patients were reviewed. The mean (range) age of 45 (26–66) years; 38/51 (74.5%) were men. All patients had severe COVID-19 pneumonitis, and 18/51 (35.3%) had macroscopic thrombosis (15 with associated ischaemia); however, 13/51 (25.5%) patients had ischaemia without associated thrombus.

CONCLUSION

The majority of patients with COVID-19 who received ECMO had areas of ischaemia within consolidated lungs, almost half of these without subtending pulmonary artery thrombosis. Although the prognostic significance of these findings is unclear, they are highly suggestive of lung ischaemia due to isolated microvascular immune thrombosis.

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High incidence of pulmonary artery thrombosis in COVID-19 ECMO patients.

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Lung ischaemia seen in patients with and without visible pulmonary artery thrombus.

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Ischaemia with no visible thrombus suggest microvascular thrombosis.

Ex vivo interaction between blood components and hormone-dependent breast cancer cells induces alterations associated with epithelial-mesenchymal transition and thrombosis

The prevalence of breast cancer is steadily increasing with metastasis and thromboembolic complications identified as the most common causes of death. The acquisition of an aggressive phenotype by hormone-dependent breast cancers is mediated by Transforming Growth Factor Beta 1 (TGF-β₁) expression and is associated with epithelial-mesenchymal transition (EMT) and, potentially, increased propensity for thrombosis. We investigated this phenomenon by assessing the effect of platelet-rich plasma (PRP) and whole blood (WB) on parameters of EMT and hypercoagulation in vitro. MCF-7 breast cancer cells were cultured under standard conditions, followed by co-culture with PRP or WB. Cells were processed for real-time PCR (TGF-β₁ and vimentin), electron microscopy or immunocytochemistry (TGF-β₁). Micrographs were qualitatively assessed, and real-time PCR data analyzed with PAST Statistical Software. The addition of blood components heightened TGF-β₁ immunolocalization and significantly increased corresponding gene expression. Both PRP and WB significantly increased vimentin expression and induced a shape change from a typical epithelial phenotype to a spindle-shape morphology, indicative of EMT. Fibrin fiber, network and plaque formation indicated a hypercoagulatory environment. The results thus show that in preparation for hematogenous metastasis, hormone-dependent breast cancer cells assume an aggressive phenotype associated with EMT, simultaneously increasing the propensity for the formation of thrombo-emboli.

Is percentage theatre utilisation data an accurate predictor of cost-effectiveness and performance in urology?

Objective:

The current economic and political climate demands a focus on efficiency and productivity, whilst delivering quality, across all aspects of the National Health Service (NHS). Operative theatres act as a critical, yet costly resource. The Audit Commission employs the use of percentage theatre utilisation as a principal measure of NHS operating theatre service and efficiency performance. We analysed theatre utilisation data in a five-consultant, high turnover, urology department within a NHS University Teaching Hospital. Our aim was to examine the relationship between theatre utilisation data, cost effectiveness and income generated.

Patients and methods:

Data on the usage of a dedicated urology theatre was collected over 251 hours for a full calendar month. A total of 176 consecutive procedures were performed. Linear regression analysis was performed to assess the correlation between number of operating hours, cases per hour, utilisation percentages and income generated.

Results:

There was no correlation between percentage theatre utilisation and income ( R2=0.0191, p=0.82). No relationship was identified between percentage theatre utilisation and total number of cases performed ( R2=0.0001, p=0.99). Although there appeared to be a positive correlation between the number of cases performed and income generated, this was not statistically significant ( R2=0.725, p=0.067). Furthermore, there was no association between the number of cases performed per hour and income generated ( R2=0.3184, p=0.32).

Conclusion:

Our data identifies no correlation between percentage theatre utilisation, income generated and number of cases performed. Utilisation percentages are not a reliable performance indicator when used in isolation, and therefore should be used as part of a more global picture when assessing cost effectiveness and efficiency performance.

Role of FDG-PET/CT in staging and follow-up of head and neck squamous cell carcinoma

The established and emerging roles of FDG positron-emission tomography/computed tomography (PET/CT) in the evaluation of squamous cell carcinoma of head and neck region is reviewed with a strong clinical focus on recommended applications and methodologies. In the staging of newly diagnosed disease, detection of cervical nodal involvement is the major indication but exclusion of distant metastases and of synchronous primary malignancy is also a valuable adjunct. Use in radiotherapy planning is advantageous for locally-advanced disease. Although there are few data yet to assess the use of FDG PET/CT to assess response during therapy, there is good evidence that this technique can accurately assess the post-treatment neck to identify those who might benefit from salvage therapy and those in whom observation or palliative treatment might be more appropriate. Although more expensive than other imaging modalities used for assessing this disease, the superior diagnostic accuracy and impact of incremental information provided by this technology has been shown to be cost-effective in several clinical scenarios.

Silent But Giant: Giant ureteric calculus in a 7-year-old boy

Giant ureteric calculi are extremely rare in children. We present a case of a child who was originally admitted for observation following non-accidental injury and had an episode of painless haematuria as an inpatient. Ultrasonography demonstrated left hydronephrosis and a 2cm echogenic area in the proximal ureter. A plain abdominal radiograph surprisingly revealed two left ureteric calculi, one 7cm and the other 4cm in length. Stone extraction was achieved using an open left ureterolithotomy and pyelolithotomy.

Outcomes of myringoplasty in Australian Aboriginal children and factors associated with success: a prospective case series

The objective of this study was to assess the outcomes of myringoplasties in Aboriginal children and to identify factors associated with a successful outcome with the use of prospective case series from primary health care clinics and hospitals in four rural and remote regions of Western Australia. All 58 Aboriginal children, aged 5-15 years, who underwent 78 myringoplasties between 1 January 2000 and 30 June 2001 were included in the study. Complete postoperative (post-op) follow-up was achieved following 78% of myringoplasties. The main outcome measures were (a) success, i.e. an intact tympanic membrane and normal hearing six or more months post-op in the operated ear, (b) closure of the perforation, (c) Post-op hearing improvement. Forty-nine per cent of myringoplasties were successful, 72% resulted in closure or reduction in the size of the perforation and 51% resulted in hearing improvement. After controlling for age, sex, clustering and number of previous myringoplasties, no association was observed between success or hearing improvement and perforation size, or the presence of serous aural discharge at the time of surgery. Myringoplasty resulted in hearing improvement and/or perforation closure in a significant proportion of children. Thus, primary school-aged Aboriginal children in whom conservative management of chronic suppurative otitis media has been unsuccessful should have access to myringoplasty because of the positive impact on their socialization, language and learning that results from improved hearing.

John Flynn Scholarship students: case studies of useful contributions to remote health care

In 1997, the John Flynn Scholarship (JFS) program was launched as an initiative to increase recruitment of doctors to rural areas. These scholarships enable undergraduate medical students to spend 2 weeks each year for 4 years at the same rural location. Given the magnitude of Australia's unmet rural health needs, we asked whether the experience could be enhanced by ensuring the students undertook meaningful work that was useful for the community. This paper describes, using case studies, some of the activities in which four JFS students have been involved and the positive contributions that they have made to rural health. The case studies indicate that pre-clinical students can be valuable members of the rural health workforce. We hope that if JFS students are given the opportunity to work as responsible health professionals they will have a better learning experience and will be more likely to return to the bush as doctors.

Middle-ear disease in remote Aboriginal Australia: a field assessment of surgical outcomes

Chronic middle-ear disease is highly prevalent among Australian Aboriginal people, and many undergo surgical treatment. However, the outcomes of surgery in this group have not been fully evaluated. This is a descriptive study of operations for middle-ear disease (excluding grommets) on Aboriginal patients in Kimberley hospitals between 1 October 1986 and 31 December 1995. Logistic regression was used to model predictors of surgical outcome. Success was defined by an intact tympanic membrane and air-bone gap of < or = 25 dB at review at, or later than, six months post-operation. A success rate of 53 per cent was observed; increasing age was the only variable predictive of success. Successful outcomes were more likely in adults and children aged > 10 years, however, this does not take into account the necessity of hearing for language acquisition and learning. Dedicated resources must be allocated for post-operative follow-up of Aboriginal patients so that much-needed, rigorous evaluations of ENT surgery can be conducted.

Cystic fibrosis transmembrane conductance regulator-associated ATP release is controlled by a chloride sensor

The cystic fibrosis transmembrane conductance regulator (CFTR) is a chloride channel that is defective in cystic fibrosis, and has also been closely associated with ATP permeability in cells. Using a Xenopus oocyte cRNA expression system, we have evaluated the molecular mechanisms that control CFTR-modulated ATP release. CFTR-modulated ATP release was dependent on both cAMP activation and a gradient change in the extracellular chloride concentration. Activation of ATP release occurred within a narrow concentration range of external Cl- that was similar to that reported in airway surface fluid. Mutagenesis of CFTR demonstrated that Cl- conductance and ATP release regulatory properties could be dissociated to different regions of the CFTR protein. Despite the lack of a need for Cl- conductance through CFTR to modulate ATP release, alterations in channel pore residues R347 and R334 caused changes in the relative ability of different halides to activate ATP efflux (wtCFTR, Cl >> Br; R347P, Cl >> Br; R347E, Br >> Cl; R334W, Cl = Br). We hypothesize that residues R347 and R334 may contribute a Cl- binding site within the CFTR channel pore that is necessary for activation of ATP efflux in response to increases of extracellular Cl-. In summary, these findings suggest a novel chloride sensor mechanism by which CFTR is capable of responding to changes in the extracellular chloride concentration by modulating the activity of an unidentified ATP efflux pathway. This pathway may play an important role in maintaining fluid and electrolyte balance in the airway through purinergic regulation of epithelial cells. Insight into these molecular mechanisms enhances our understanding of pathogenesis in the cystic fibrosis lung.

An outbreak of non-sexually transmitted gonococcal conjunctivitis in Central Australia and the Kimberley region

From 13 February to 27 June 1997, 447 cases of gonococcal conjunctivitis were identified by Communicable Disease and Public Health Centres and Community Clinics in the Northern Territory, Western Australia and South Australia. The outbreak involved Aboriginal communities predominantly in Central Australia and the Kimberley region in Western Australia. This was the first outbreak recorded in the Kimberley region. It is not yet known whether the Kimberley cases were part of the larger Central Australian outbreak or whether they represented a separate and unrelated outbreak. Environmental factors associated with this outbreak were similar to those seen in previous outbreaks. Control measures were based on early recognition and treatment of index cases and identifying and treating contacts. Until sexually transmitted Neisseria gonorrhoeae is controlled in communities gonococcal conjunctivitis is likely to appear again. The role of oropharyngeal carriage of N. gonorrhoeae needs to be evaluated further.

Effects and sustainability of a cervical screening program in remote Aboriginal Australia

We assessed the effects of an organised cervical screening program, using a population-based cervical cytology register, for Aboriginal women in the Fitzroy Valley, a remote part of the Kimberley region of Western Australia. Comparison of age-specific screening rates in the area during 1987-88, 1990-92 and 1993-94 showed that establishing the program in late 1989 was accompanied by dramatic increases in cervical screening rates, ranging from two- to over fourfold, with the largest increases in women aged 50 years and over. Following the departure of the coordinator in early 1993, screening rates decreased to between 76 per cent and 29 per cent of their 1990-92 levels, with the largest decreases occurring in the 40-49 and 60-69 years age groups. Rates were still above 1987-88 levels for most age groups. Of 545 women screened during 1991-92, 65 per cent had undergone a second Pap smear within the follow-up period of two to four years. Among women recommended for a repeat smear in two years, the probability of having a second smear was negatively associated with age (log-rank statistic = 35.58, 4 df, P < 0.0001). Follow-up of smears recommended for repeat in 12 months or earlier was less adequate in 1993-94 (46 per cent) than in 1991-92 (75 per cent). The program was successful in recruiting a large proportion of eligible women within a relatively short time, but coverage, especially of older women, was not sustained after a decline in the functioning of the recall system owing to staffing and organisational changes.

Phase II trial of procarbazine, vincristine and lomustine (POC) chemotherapy in metastatic cutaneous malignant melanoma

40 patients with symptomatic metastatic melanoma were treated with procarbazine, vincristine and lomustine (POC). 4 patients had received chemotherapy previously. Responses were seen in 8 patients (20%), 4 of whom had a complete remission. All responding patients had some tumour shrinkage after one cycle. The median duration of response was 27 weeks, with 2 patients remaining in complete remission at 6 and 6.5 years. The median survival for the whole group was 22 weeks, whilst that of the responding patients was 35 weeks. Using conventional anti-emetics, the principal toxicities were nausea and vomiting, severe in 15% of cycles. Other nonhaematological toxicity was uncommon. Neutropenia (WHO grade 3 or 4) occurred in 11% of cycles and thrombocytopenia in 8%. The response rate of metastatic melanoma to POC chemotherapy was similar to other cytotoxic regimens though toxicity, other than nausea and vomiting, was minimal. The rapid response allows patients with unresponsive disease to be identified early, avoiding continuing toxicity.

Patient assessment of a combined medical and nursing preparation to cytotoxic chemotherapy

At Auckland hospital there is a combined medical and nursing preparation for patients receiving cytotoxic chemotherapy. The aim of the current study was to assess whether patients felt that this combined approach had prepared them adequately for chemotherapy. Patients were asked to complete three questionnaires anonymously at different times in their treatment programme: immediately prior to chemotherapy, after three cycles of chemotherapy and 2 months after completion of chemotherapy. A high level of satisfaction with the programme was demonstrated: 68% of patients thought the orientation programme had prepared them "very well", 32% "adequately" and none "poorly" for their chemotherapy. Separate interviews with medical and nursing staff were thought a "good idea" by 86% of patients and only 1 of 100 medical and 100 nursing interviews was assessed as "not worthwhile". This study suggests that a combined medical and nursing preparation is a worthwhile practice in preparing patients for cytotoxic chemotherapy.

Ondansetron reduces chemotherapy induced nausea and vomiting refractory to standard antiemetics

Ondansetron, a selective 5HT3 (serotonin) antagonist, was used in patients refractory to standard antiemetics. Seventy-five patients receiving chemotherapy without cisplatin were given ondansetron 4 mg IV and 4 mg orally immediately prior to chemotherapy, then 8 mg orally after six and 12 hours, followed by 8 mg orally eight hourly during days 2-5. Complete control of vomiting occurred in 52 patients (69%) on the first day and 45 patients (60%) on days 2-5. Sixty patients (80%) preferred ondansetron to their previous antiemetics. The efficacy of ondansetron was maintained over multiple chemotherapy cycles. Ondansetron was also given to 16 patients receiving cisplatin chemotherapy. They received 8 mg IV immediately prior to chemotherapy followed by an infusion of 1 mg/hr for 8 hr, with 8 mg orally at the end of the infusion and then 8 mg orally eight hourly during days 2-6. Some control of vomiting (less than = 5 vomits) was achieved in eight patients (50%) on the first day and in 14 patients (87%) on subsequent days. Eight patients (50%) preferred ondansetron to their previous antiemetics. Adverse events with ondansetron were frequent but mild, with constipation and headache being most common. Ondansetron is highly effective in patients refractory to standard antiemetics, especially after noncisplatin chemotherapy.

Reduction of carboplatin induced emesis by ondansetron

Ondansetron is a selective 5-HT3 antagonist with significant antiemetic properties in patients receiving cytotoxic chemotherapy. Patients who had suffered severe vomiting on carboplatin alone (23 patients with ovarian carcinoma) or in combination (two patients with testicular cancer) despite intensive antiemetic regimens were treated with ondansetron, given as 8 mg immediately prior to carboplatin followed by 8 mg orally, 8 hourly for 5 days. Twenty-five patients received 58 courses of ondansetron. In the first 24 h after the first course of chemotherapy with ondansetron, 17 patients (68%) experienced no vomiting, five patients (20%) had almost complete control and the other three patients had partial control. During the subsequent 4 days slightly lesser control was achieved. Nausea was similarly controlled in most patients. Twenty-two patients stated a preference for ondansetron with future chemotherapy. Fourteen patients received additional chemotherapy with ondansetron and in only three patients did the efficacy of therapy lessen. Toxicity was mild and transient with headache and constipation predominant. No extrapyramidal reaction was seen. Sedation was absent. Ondansetron is highly effective in refractory vomiting associated with carboplatin chemotherapy. It may be particularly beneficial when an extrapyramidal reaction has occurred on previous antiemetics and when sedation is unacceptable.

The binding of polyribosomes to smooth and rough endoplasmic-reticulum membranes

In vitro the binding of polyribosomes to smooth endoplasmic-reticulum membranes is more sensitive to ionic strength than is the binding to rough endoplasmic-reticulum membranes. Polyribosomes from the free and membrane-bound fractions bind with equal efficiency to endoplasmic-reticulum membranes.

3H-2-glucose in turnover studies

In rats the reported difference between the slopes of the specific activities of plasma glucose following i.v. injection of either 3H-2-glucose or 14C-1-glucose is abolished by evisceration and nephrectomy. This proves that the difference observed in normal rats is due to the reincorporation of 14C atoms into newly released glucose and not to a non-metabolic tritium–proton exchange in plasma glucose.

THE PHOTOIONIZATION OF NITROGEN DIOXIDE

The ionization of nitrogen dioxide by photons has been studied using a photoionization mass spectrometric technique and also by the ordinary electron impact method. The photoionization results show a large variation in the relative ionization efficiency within the energy range 9–14 ev, and help to explain the differences between previously reported values for the first ionization potential of this compound. The photoionization efficiency curve indicates the first ionization potential to lie at 9.8 ev and inner ionization potentials to lie at about 11.1 and 12.7 ev.The electron impact ionization efficiency curve for the NO2+ ion exhibits a low ion intensity near the threshold. This confirms the viewpoint that previous determinations of the first ionization potential have employed threshold energy measuring techniques not properly suited for the type of molecule such as nitrogen dioxide which radically changes symmetry on ionization.