Management of extramammary Paget's disease with a staged, modified Mohs technique.

Extramammary Paget's disease (EMPD) is a rare intraepithelial adenocarcinoma arising from apocrine glands. We describe an innovative surgical technique to manage extensive cutaneous malignancies in a notoriously challenging location. The patient is a 78-year-old male who presented with 'jock itch' on his left groin refractory to topical treatment. A shave biopsy of the lesion demonstrated non-invasive EMPD which yielded a urology consult. Rather than the standard wide local excision (WLE), which can lead to positive margins, progression, and recurrence, we used a modified the Mohs technique and staged the procedure, providing excellent oncologic and cosmetic outcomes. The described technique has particular merit with uncertain margin status and when geography of lesions preclude a standard Mohs surgery.

How Does TeamSTEPPS Affect Operating Room Efficiency?

OBJECTIVE: To evaluate the effect of TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) on operating room efficiency for the otolaryngology service at a tertiary care medical center. STUDY DESIGN: Retrospective database review. SETTING: Otolaryngology department at tertiary care medical center. SUBJECTS AND METHODS: To assess the impact of implementing an evidence-based patient safety initiative, TeamSTEPPS, on operating room efficiency in the otolaryngology department, the operative times, time lost to delayed starts, and turnover times during the year following the implementation of TeamSTEPPS were compared with the values from the prior year. RESULTS: The study compared 1322 cases and 644 turnovers in the year prior to TeamSTEPPS implementation with 1609 cases and 769 turnovers in the following year. There were no statistically significant decreases in operating room efficiency in the year after the TeamSTEPPS rollout. CONCLUSION: Operating room efficiency was preserved after the rollout of a rigorous evidence-based patient safety initiative that requires active participation from all operating room team members.

TeamSTEPPS Improves Operating Room Efficiency and Patient Safety.

The objective was to evaluate the effect of TeamSTEPPS on operating room efficiency and patient safety. TeamSTEPPS consisted of briefings attended by all health care personnel assigned to the specific operating room to discuss issues unique to each case scheduled for that day. The operative times, on-time start rates, and turnover times of all cases performed by the urology service during the initial year with TeamSTEPPS were compared to the prior year. Patient safety issues identified during postoperative briefings were analyzed. The mean case time was 12.7 minutes less with TeamSTEPPS (P < .001). The on-time first-start rate improved by 21% with TeamSTEPPS (P < .001). The mean room turnover time did not change. Patient safety issues declined from an initial rate of 16% to 6% at midyear and remained stable (P < 0.001). TeamSTEPPS was associated with improved operating room efficiency and diminished patient safety issues in the operating room.

Fluoroscopy time during uncomplicated unilateral ureteroscopy for urolithiasis decreases with urology resident experience.

PURPOSE: To determine predictors of fluoroscopy time during uncomplicated, unilateral ureteroscopy for urolithiasis performed by urology residents during the first 2 years of residency. METHODS: The patient charts and computed tomography scans of consecutive, unilateral, uncomplicated ureteroscopy cases for urolithiasis were retrospectively reviewed. The cases were performed by beginning urology residents over the course of their first 2 years of urology residency training. RESULTS: A total of 200 ureteroscopy cases were reviewed. The mean stone diameter was 7.1 (±3.2) mm. Forty-three percent of cases were performed for renal stones and 58 % for ureteral stones. The mean operative time was 80.2 (±36.9) min. The mean fluoroscopy time was 69.1 (±38.2) s. No significant differences existed between cases performed by each of the two residents, and no statistical differences in case difficulty were observed throughout the study period. Linear regression analysis revealed the strongest association with lower fluoroscopy time to be increasing resident experience (p < 0.001). By the end of the 2-year review, fluoroscopy time decreased by 79 % from 135 to 29 s per case. Other significant factors associated with increasing fluoroscopy time were placement of a postoperative stent under fluoroscopic guidance (p < 0.001), utilization of a flexible ureteroscope as opposed to a semirigid ureteroscope (p < 0.001), and balloon dilation of the ureteral orifice (p < 0.001). CONCLUSIONS: Fluoroscopy time during uncomplicated, unilateral ureteroscopy for urolithiasis decreases with increasing urology resident operative experience. Other technical options during ureteroscopy were also found to influence fluoroscopy time.

CT evaluation of the upper urinary tract in adults younger than 50 years with asymptomatic microscopic hematuria: is IV contrast enhancement needed?

OBJECTIVE: The purpose of this study is to compare CT urography (CTU) with unenhanced CT in the evaluation of upper urinary tracts in adults younger than 50 years with asymptomatic microscopic hematuria. MATERIALS AND METHODS: In this study, 1516 CTU examinations were reviewed in adults younger than 50 years. Inclusion criteria were no significant prior urologic disease and asymptomatic microscopic hematuria with at least one urinalysis with greater than or equal to 3 RBCs/high-power field and less than or equal to 50 RBCs/high-power field. Upper urinary tract findings on CTU were classified as malignancy-related or non-malignancy-related hematuria and incidental non-hematuria-related findings. A blinded radiologist reviewed the unenhanced images, recording upper urinary tract findings and recommendations for further contrast-enhanced imaging. The modified Wald equation at a 95% CI, the "Rule of Threes" equation, and binomial distribution were used for malignancy-related findings. RESULTS: Four hundred forty-five examinations in 442 patients met inclusion criteria. CTU reports showed zero malignancy-related hematuria findings, 64 non-malignancy-related hematuria findings (62 renal calculi and two others), and 138 incidental non-hematuria-related findings. Unenhanced CT interpretation had a sensitivity of 100% (64/64) and a specificity of 89.2% (337/378). The theoretic risk of an upper urinary tract malignancy is 0-1.1%. CONCLUSION: CTU added no additional diagnostic benefit versus unenhanced CT in evaluating the upper urinary tracts of adults younger than 50 years with asymptomatic microscopic hematuria. Using only unenhanced CT can reduce radiation and minimize contrast agent-associated risk, with a less than 1.0% risk of missing upper urinary tract hematuria-related malignancy.

Safety, minimization, and awareness radiation training reduces fluoroscopy time during unilateral ureteroscopy.

OBJECTIVE: To determine the impact of Safety, Minimization and Awareness Radiation Training (SMART) on fluoroscopy time during unilateral uncomplicated ureteroscopy for urolithiasis performed by urology residents. MATERIALS AND METHODS: All consecutive ureteroscopy cases for urolithiasis meeting inclusion criteria and performed by first-year urology residents over a 2-year period were reviewed. Fluoroscopy times during SMART and without SMART were compared. RESULTS: A total of 202 ureteroscopy cases were reviewed. The mean patient age was 48.7 years. The mean stone diameter was 7.6 ± 3.3 mm. The mean operating time was 79.8 ± 34.3 minutes. The mean cumulative fluoroscopy time was 85.6 ± 36.9 seconds per case. A Spearman rank correlation identified 8 variables significantly correlated with fluoroscopy time, with the most significant correlation between shorter fluoroscopy time and SMART exposure (rho = 0.532; P <.001). Multivariate regression analysis (r = 0.701) revealed that fluoroscopy time was significantly shorter with SMART (P <.001). Post hoc comparisons revealed the fluoroscopy time of the cases performed during SMART (mean, 45 seconds) to be significantly shorter than the fluoroscopy time of cases performed by the same residents before SMART (mean, 102 seconds; P = .005), and the fluoroscopy time of cases performed by residents the previous year with similar ureteroscopic experience but without SMART (mean, 78 seconds; P <.001). CONCLUSION: SMART reduces fluoroscopy time during unilateral uncomplicated ureteroscopy for urolithiasis performed by urology residents by 56%.

Hospice care for 86 year old male with recurrent breast cancer: a case report.

Terminal illness poses a tremendous challenge to patients, their families and their health care providers. It is often difficult to determine when hospice is appropriate. Timely referrals are beneficial to both patient and caregivers as a way to offer improved care and support at end of life; when multiple, complicated, co-morbid states affect care. This is especially true when a patient's psychosocial background would otherwise make it difficult to ensure proper comfort and quality of life. In this report, we present an 86 year old man with a history of right-sided breast cancer, bipolar disorder and dementia. Patient is 20 years status-post a total mastectomy. He declined adjuvant radiation, chemotherapy, and hormone therapy, and did not pursue any further medical follow-up. Patient now presented with a rapidly enlarging, ulcerating right anterior chest wall tumor. Surgical biopsy revealed recurrent infiltrating ductal carcinoma of the breast. Patient was started on tamoxifen and palliative radiation. An oncology evaluation determined that he is not a candidate for curative treatment. Patient's primary caregiver (wife) concurrently suffers from dementia, one son is Bipolar, and the second son is out of state. A full geriatric assessment concluded that based on the patient's medical and socioeconomic history, he is an ideal candidate for hospice. With the family's consent, he was enrolled in one of our local hospice organizations. Currently, he is in a skilled nursing facility with hospice.

Histomorphometric evidence of growth plate recovery potential after fractionated radiotherapy: an in vivo model.

This study evaluated the hypothesis that early growth plate radiorecovery is evident by growth rate, histomorphometric and immunohistochemical end points after exposure to clinically relevant fractionated radiation in vivo. Twenty-four weanling 5-week-old male Sprague-Dawley rats were randomized into eight groups. In each animal, the right distal femur and proximal tibia were exposed to five daily fractions of 3.5 Gy (17.5 Gy) with the left leg serving as a control. Rats were killed humanely at 7, 8, 9, 10, 11, 14, 15 and 16 days after the first day of radiation exposure. Quantitative end points calculated included individual zonal and overall growth plate heights, area matrix fraction, OTC-labeled growth rate, chondrocyte clone volume and numeric density, and BrdU immunohistochemical labeling for proliferative index. Transient postirradiation reductions occurred early and improved during observation for growth rate, proliferative indices, transitional/hypertrophic zone matrix area fraction, proliferative height, and clonal volume. Reserve and hypertrophic zone height remained increased during the period of observation. The current model, using a more clinically relevant fractionation scheme than used previously, shows early evidence of growth plate recovery and provides a model that can be used to correlate temporal changes in RNA and protein expression during the early period of growth plate recovery.