Extracorporeal shock wave lithotripsy: Prematurely falling out of favour? A 7 year retrospective study from an Australian high-volume centre.

Objectives: The aim of this study is to audit 7 years of data with a 3 year follow up from a high-volume stone centre performing extracorporeal shock wave lithotripsy (ESWL) to evaluate efficacy in stone clearance compared to existing knowledge and understand reasons for this performance. Methods: Patients who received ESWL treatment for renal or proximal ureteric stones at a single centre between January 2012 and January 2019 (to allow minimum 3 year follow up) were retrieved. A retrospective analysis was performed cross referencing for stone size, location, treatment and need for further procedures. Ethical approval was granted through Metro North HHS HREC, Queensland, Australia. Results: A total of 1930 patients met inclusion criteria. Fifty-seven percent (n = 1100) underwent left-sided ESWL, compared to 43% (n = 830) on the right. Stone size and location were both statistically significant to treatment outcome. Small stones (<1 cm) had an overall clearance rate of 81.9%, medium stones (1-2 cm) had a clearance rate of 60.6% and stones (>2 cm) had a clearance rate of 31.3%. Small stones in an upper calyx had the highest clearance rate (87.5%, n = 120). Allowing for two procedures, 89% of stones were treated successfully. Conclusion: ESWL remains a legitimate option for the treatment of small and medium sized renal calculi. ESWL stone clearance rates at our centre are higher than published elsewhere and serve as proof to its efficacy. X-ray imaging on the day of the procedure, heavy consultant input and frequent intra-operative imaging are cited as key reasons for success. Further research is warranted to elucidate factors affecting stone clearance rate and to enable more standardised outcomes. Further investment may be required into ESWL provisions in most Australian states and especially in Queensland to enable its continued use in contrast to developing endourological techniques.

SLAP Trial: Shock Wave Lithotripsy and Mechanical Percussion Therapy Post ESWL for Renal Calculi.

Methods: We conducted a prospective randomised control trial. Included patients were males and females greater than 18 years of age with single or multiple ipsilateral renal calculi of total ≤10 mm on plain X-ray and noncontrast CT KUB. ESWL was performed at a single centre, at supine position under general anaesthesia with maximum 3000 shocks at a rate of 100 shocks per minute. Patients were discharged and randomised to either the control arm or MPI therapy. MPI therapy was self-directed in a home setting for 10 minutes a day, three times per week. Both arms had standard follow-up at 12 weeks with a plain X-ray KUB. Patients in the control group were offered cross over to the MPI arm after 12 weeks if residual stone fragments were detected. Statistical analysis was performed using SPSS software via Chi squared and Fisher's exact tests. Ethical approval was obtained via the Prince Charles Hospital HREC Committee, HREC/2022/QPCH/84961. Results: 70 patients met inclusion criteria and underwent ESWL, and 5 were withdrawn. 33 patients were randomised to the MPI group and 32 to the control group. MPI significantly increased the stone clearance rate anywhere in the kidney (87.9% in the MPI group versus 59.4% in the control group, p=0.089), as well as the clearance rate in the lower pole (91.7% in the MPI group versus 63.2% in the control group, p=0.022). Delayed percussion did not improve the clearance rate over primary percussion (p=0.835). Conclusion: This study has shown that MPI can be effectively performed in a home setting without the need for medical supervision and results in improved stone clearance rates post ESWL. The main limitations to the study were the use of X-ray over CT during the follow-up and variability in MPI compliance and administration. Further research is warranted into standardising home MPI protocols. This trial is registered with ANZCTR387061.

Pretreatment of choriocarcinoma syndrome: a rare complication of metastatic germ cell tumours.

A 27-year-old man newly diagnosed with metastatic testicular choriocarcinoma developed a large right perinephric haematoma secondary to a metastatic deposit in his right kidney. His presentation was also complicated by bilateral iliac venous thrombosis and pulmonary embolism identified prior to initiation of chemotherapy. He underwent multiple attempts at angioembolisation of the bleeding vessels and ultimately angioembolisation of the main renal artery had to be performed to control the bleeding. Following resolution and commencement of chemotherapy, the patient also developed spontaneous intracranial haemorrhage requiring craniotomy.

Development of a field artificial intelligence triage tool: Confidence in the prediction of shock, transfusion, and definitive surgical therapy in patients with truncal gunshot wounds.

BACKGROUND: In-field triage tools for trauma patients are limited by availability of information, linear risk classification, and a lack of confidence reporting. We therefore set out to develop and test a machine learning algorithm that can overcome these limitations by accurately and confidently making predictions to support in-field triage in the first hours after traumatic injury. METHODS: Using an American College of Surgeons Trauma Quality Improvement Program-derived database of truncal and junctional gunshot wound (GSW) patients (aged 16-60 years), we trained an information-aware Dirichlet deep neural network (field artificial intelligence triage). Using supervised training, field artificial intelligence triage was trained to predict shock and the need for major hemorrhage control procedures or early massive transfusion (MT) using GSW anatomical locations, vital signs, and patient information available in the field. In parallel, a confidence model was developed to predict the true-class probability (scale of 0-1), indicating the likelihood that the prediction made was correct, based on the values and interconnectivity of input variables. RESULTS: A total of 29,816 patients met all the inclusion criteria. Shock, major surgery, and early MT were identified in 13.0%, 22.4%, and 6.3% of the included patients, respectively. Field artificial intelligence triage achieved mean areas under the receiver operating characteristic curve of 0.89, 0.86, and 0.82 for prediction of shock, early MT, and major surgery, respectively, for 80/20 train-test splits over 1,000 epochs. Mean predicted true-class probability for errors/correct predictions was 0.25/0.87 for shock, 0.30/0.81 for MT, and 0.24/0.69 for major surgery. CONCLUSION: Field artificial intelligence triage accurately identifies potential shock in truncal GSW patients and predicts their need for MT and major surgery, with a high degree of certainty. The presented model is an important proof of concept. Future iterations will use an expansion of databases to refine and validate the model, further adding to its potential to improve triage in the field, both in civilian and military settings. LEVEL OF EVIDENCE: Prognostic, Level III.

Endoscopic Stents in the Management of Bariatric Complications: Our Algorithm and Outcomes.

BACKGROUND: Endoscopic techniques can provide an alternative to surgery in the management of post-bariatric surgery complications such as leaks, strictures, fistulas, and erosion of transgastric and adjustable gastric bands. Endoscopically placed stents can also be used to manage gastric perforations secondary to NSAIDS or perforated marginal ulcers following gastric bypass surgery. Additionally, stents can be used in conjunction with operative intervention to decrease the risk of more deleterious complications that could require additional operations. OBJECTIVES: The objective of this report is to describe our private practice experience in managing bariatric procedure complications with fully covered endoscopic stents. We present the algorithm we use in the application of endoscopic stents in the management of complications following bariatric surgery. SETTING: Private practice, Single provider, Tertiary Referral Center, USA METHODS: Data for all patients who underwent endoscopic stent placement for complications after various bariatric surgeries (Roux-en-Y gastric bypass, gastric sleeve, lap band, and vertical banded gastroplasty) performed by several different surgeons between July 2015 and December 2018 at a single private practice were retrospectively reviewed. Patient's medical history, perioperative information, stent placement details, outcomes, and subsequent interventions were reviewed and analyzed. RESULTS: Thirty-five patients who were treated with endoscopic stents after bariatric surgery were identified. Complications after bariatric surgery treated with stenting included staple line leaks, anastomotic leaks, strictures, marginal ulcer perforations, gastrogastric fistula, and lap band erosion repairs. Mean duration of each stent round also varied. Resolution occurred in 33 patients (94.3%). Stent migration occurred in seven patients (20%) and in eight of 51 stents placed (15.7%). Two patients ultimately required revision surgery, though only one was related to stent (2.9%). CONCLUSIONS: Our findings suggest that foregut stents deployed according to our algorithm can facilitate healing of anastomotic leaks, staple line leaks, and marginal ulcer perforations. Furthermore, stent placement can also bolster tenuous repairs of band erosion sites, repairs staple line failure, and manages leaks at band erosion repair sites. Endoscopic stents can also be utilized to augment both balloon and savory dilation of gastric anastomoses and gastric sleeve strictures. Stents should be clipped proximally and distally to minimize the risk of migration.

Prostatic Abscess due to Burkholderia pseudomallei: Facilitating Diagnosis to Optimize Management.

Prostatic involvement is common in men with melioidosis. Indeed, some clinicians recommend radiological screening of all male patients as an undrained prostatic abscess may result in relapse of this potentially fatal disease. However, sophisticated medical imaging is frequently unavailable in the remote and resource-poor locations where patients are managed. In this retrospective study from Queensland, Australia, 22/144 (15%) men with melioidosis had a radiologically confirmed prostatic abscess. The absence of urinary symptoms had a negative predictive value (NPV) (95% confidence interval [CI]) for prostatic abscess of 96% (90-99%), whereas a urinary leukocyte count of < 50 × 106/L had an NPV (95% CI) of 100% (94-100%). A simple clinical history and basic laboratory investigations appear to exclude significant prostatic involvement relatively reliably and might be used to identify patients in whom radiological evaluation of the prostate is unnecessary. This may be particularly helpful in locations where radiological support is limited.

Buerger's disease presenting as a testicular mass: A rare presentation of an uncommon disease.

Thromboangiitis obliterans is an uncommon nonatherosclerotic segmental inflammatory disease that predominantly affects the small and medium-sized arteries and veins of the distal extremities. It was first described in 1879 and is also known as Buerger's disease. Buerger's usually begins with ischemia of small vessels producing digital infarcts and may progress to more proximal arteries and veins, producing claudication of the feet, legs, hands, or arms. Tobacco smoking is essential to the initiation and the progression of disease and it typically occurs in males under the age of 45 years. Although Buerger's most commonly affects the arms, hands, legs, and feet, it has also been reported in other vascular beds including cerebral, coronary, renal, mesenteric, and pulmonary arteries. There are also a small number of cases involving the male genitalia. To our knowledge, there has only been one English case of Buerger's involving the testis, published in 1940. Here, we present a new case of Buerger's presenting as a testicular mass in a 17-year-old cannabis smoker.

Laparoscopic nephron sparing surgery: an Australian experience.

BACKGROUND: The objective of this study was to evaluate clinical outcomes from our initial experience with laparoscopic nephron sparing surgery (LNSS) for small renal masses in Australian practice. METHODS: A retrospective review was performed on an initial 50 patients undergoing LNSS. All procedures performed between April 2006 and September 2012 were included with median follow-up of 30 months. Outcomes measured were: positive surgical margin, warm ischaemic time, total operative time, blood transfusion and complications in the first 30 days after surgery. RESULTS: The mean age of patients was 57 years. The mean pre-operative creatinine was 85 µmol/L and the mean post-operative creatinine was 89 µmol/L. Sixty-four per cent of the tumours were malignant tumours. The mean size of tumours was 2.5 cm. There were two malignant positive surgical margins on histology. The mean total operative time was 224 min and the mean warm ischaemic time was 24 min. Nine patients had complications with Clavien-Dindo grade III or lower. There was no grade IV or V complication. No patients were lost to follow-up and there have been no tumour recurrences to date. CONCLUSIONS: LNSS is emerging as a viable alternative to open NSS for small renal tumours with lower morbidity and equivalent oncological and functional outcomes. There is, however, a steep learning curve associated with the procedure.

Using technology to deliver healthcare education to rural patients.

INTRODUCTION: The prevalence of chronic disease in the US population is increasing. Projections indicate that half the US population will live with at least one chronic disease by the year 2030. Statistics indicate that chronic illnesses account for 70% of all deaths. Developing healthy self-management behaviors can lower the risk of developing chronic disease and also minimize the magnitude of subsequent morbidity and disability. Individuals need access to reliable information in order to learn successful self-management skills. Delivering healthcare information in rural areas is difficult. Geography, distance, inclement weather and/or the lack of financial resources are barriers that can prevent individuals from accessing health care and health education. Likewise, rural health clinics often lack the financial resources to provide the most current patient education materials. However, the internet allows remote and immediate access to this type of information if individuals know how and where to search for it. An internet portal, My Health Education & Resources Online (MyHERO) was created to facilitate locating current, non-commercial, reliable, evidence-based health information. The authors sought to assess the impact of a publically accessible internet information portal on diabetes knowledge, quality of life (QOL) measures, and self-management behaviors in a US rural area. METHODS: Participants (n=48) with type 2 diabetes in one clinic received regularly scheduled, one-on-one individualized diabetes-related health education and hands-on instructions on how to use an internet portal from a nurse educator. Each health clinic was supplied with a laptop computer for participants to use if they lacked internet access. Control participants (n=50) in a second clinic received a pamphlet describing how to access the portal. All participants completed baseline and end-of-study surveys. Disease knowledge was measured with the BASICS test developed by the International Diabetes Center. Problem Areas In Diabetes (PAID), developed by the Joslin Diabetes Center, was utilized to measure diabetes QOL. All participants completed a behavior modification survey at the conclusion of the study. Intervention participants were asked to complete a satisfaction survey at the conclusion of the study. Demographic and relevant laboratory values (eg serum glucose, HbA1c, lipids) were collected via chart review at baseline, 3, and 6 months. RESULTS: Demographic and baseline scores were similar between groups. At 6 months, the intervention group showed significant increases in disease knowledge and self-blood glucose monitoring behavior. There were no differences in QOL between the groups at 6 months. Participants in the intervention group were highly satisfied with the nurse educator, but not with the internet as a resource. CONCLUSION: Disease knowledge and self-blood glucose monitoring improved with one-on-one education. High attrition and a short study period were limitations of this study. The researchers speculate that the age of the participants and low internet penetration affected satisfaction scores. Future recommendations include a longer data collection period, more widespread publically accessible internet kiosks (grocery stores, malls, churches etc), other chronic disease states, and younger participants.

Enhancing the quality of life and preserving independence for target needs populations through integration of assistive technology devices.

Telehealth Test Bed-Quality of Life Studies is a research study investigating, testing, evaluating, and demonstrating technologies that have the potential to improve the quality of life for target populations, such as warriors in transition, veterans, individuals with physical and mental disabilities, and adults age 65 and older, who may require assistive technology devices to aid in maintaining or improving their quality of life. Thousands of soldiers who fought in Operation Iraqi Freedom and Operation Enduring Freedom have been wounded in action or have sustained injuries from noncombat accidents. Many of these injuries affecting military populations, as well as the general public, have resulted in amputations, traumatic brain injuries, and other physical or mental impairments. Depending on the severity of the injury, assistive technologies may be temporarily needed, or as a long-term solution, to regain and maintain normal daily functions. Saint Francis University's Center of Excellence for Remote and Medically Under-Served Areas developed an evaluation matrix comparing assistive technologies to identify devices that will improve or maintain the quality of life for these target populations. The integration of telehealth and telerehabilitation applications into patients' daily lives was examined to help improve home rehabilitation via access to healthcare specialties in rural and medically underserved settings. Researchers identified and tested assistive technology devices to be included in a self-sufficient living environment. The continuation of this research involves recruiting individuals to test and evaluate the functions of these commercially available technologies and to complete data collection surveys and questionnaires. The results are useful in selecting devices that will enhance or extend the quality of life of the target populations.

Spatial distribution maps for atom probe tomography.

A real-space technique for finding structural information in atom probe tomographs, spatial distribution maps (SDM), is described. The mechanics of the technique are explained, and it is then applied to some test cases. Many applications of SDM in atom probe tomography are illustrated with examples including finding crystal lattices, correcting lattice strains in reconstructed images, quantifying trajectory aberrations, quantifying spatial resolution, quantifying chemical ordering, dark-field imaging, determining orientation relationships, extracting radial distribution functions, and measuring ion detection efficiency.

In-home wound care management utilizing information technology.

Chronic wounds are a major healthcare crisis, presenting challenges for home health agencies lacking specially trained staff to properly monitor and manage these wounds. Consequently, the home health industry needs to improve wound management methods and technologies to properly care for patients with chronic wounds. Saint Francis University's Center of Excellence for Remote and Medically Under-Served Areas partnered with a home health agency (University of Pittsburgh Medical Center Lee Regional Community Nursing Service) to identify a solution to this problem.

Metastatic seminoma with cervical lymphadenopathy as the initial manifestation.

Advanced testicular germ cell tumors commonly involve cervical lymph nodes. In most circumstances, the diagnosis of germ cell tumor is established before the neck disease is noted. In rare cases, these tumors have been found along with cervical lymphadenopathy in patients with a previously undiagnosed primary tumor. In this article, we report the unusual case of a 71-year-old man whose metastatic seminoma initially manifested as an asymptomatic neck mass. This finding reinforces the need to include metastatic disease in the differential diagnosis of neck masses. Our discussion of this case focuses on the appropriate management of cervical metastases of germ cell tumors.

Dirofilarial infection presenting as a facial mass: case report of an emerging zoonosis.

Dirofilariasis is a parasitic infection caused by nematodes. Human infection remains rare but is increasing in scope, particularly in endemic areas. Dirofilariasis typically presents as a subcutaneous mass or with pulmonary nodules. Here, we present the case of a 73-year-old woman whose asymptomatic facial mass was caused by dirofilarial infection. The pathophysiology, diagnosis, and treatment of dirofilariasis of the head and neck will be discussed. In endemic areas, dirofilariasis must be considered in the differential diagnosis of facial masses.

Cardiac norepinephrine release: modulation by ovariectomy and estrogen.

Previously, we have demonstrated that in contrast to male rats, female rats do not show an age-related reduction of depolarization-elicited norepinephrine (NE) release from cardiac synaptosomes (resealed nerve terminals). These results suggest that sex hormones such as estrogen may modulate NE release from cardiac synaptosomes prepared from female rats. The present study was designed to test the hypotheses that long-term estrogen depletion, resulting from ovariectomy, and estrogen replacement alters depolarization-elicited NE release from cardiac synaptosomes. Female F344 rats were divided into two groups, one of which underwent bilateral ovariectomy, whereas the other underwent a sham operation. Three ovariectomized subgroups received daily injections of conjugated equine estrogens, delta8,9-dehydroestrone or 17 alpha-dihydroequilenin. Another ovariectomized control subgroup and the sham-operated animals received daily injections of vehicle. After 90 or 270 days of treatment, the animals were sacrificed. Cardiac synaptosomes were prepared from each heart, incubated with [(3)H]-NE, and used to evaluate NE release capacity by exposure to 50 mM K(+). The effectiveness of the ovariectomy and the estrogenic actions of the test compounds was confirmed by evaluating vaginal smears, determining uterine weights, and measuring serum luteinizing hormone (LH) concentrations. Ovariectomy (after both 90 and 270 days) significantly increased depolarization-induced NE release compared with sham-operated rats. Treatment with all three estrogenic preparations reduced NE release in ovariectomized rats to values similar to those observed in sham-operated animals. Interestingly, NE release rates from rats treated with conjugated estrogens for 270 but not 90 days were significantly below that observed in age-matched sham animals. These results demonstrate that estrogen modulates depolarization-elicited NE release from cardiac nerve terminals. Such modulation may represent a protective action by estrogen at the cardiac synapse.