Active Surveillance in Metastatic Renal Cell Carcinoma.

Metastatic renal cell carcinoma (mRCC) is a heterogenous disease with a variable clinical course. While therapies for treatment of this condition have progressed, they are not without toxicity. In some patients, active surveillance (AS) of this disease is increasingly considered to delay its toxicity. This article seeks to review the literature and discuss management of metastatic renal cell carcinoma, specifically regarding upfront AS, the role of radiation therapy in delaying systemic therapy, and surveillance after initial treatment with systemic therapy. Median time on AS prior to initiation of systemic therapy ranged from 14 to 60 months across studies. AS is appropriate to offer in favorable or intermediate risk, asymptomatic, and systemic treatment naïve patients with mRCC.

Fournier's Gangrene in Females: Presentation and Management at a Tertiary Center.

OBJECTIVE: To report and compare presentation and management of Fournier's Gangrene (FG) in female vs male patients at a single tertiary care center. METHODS: Patient demographics, clinical characteristics, treatments and outcomes were summarized and compared between males and females who were treated for FG from 2011 to 2018 at a single institution. RESULTS: Of the 143 patients treated for FG at our institution, 33 (23%) were female. Female patients were predominantly white (82%), with a median (IQR) age of 55 (46, 59). Median female boby mass index (BMI) was 42.1 (32, 50.4). Female patients' wound cultures were polymicrobial mix of gram positive and gram negative organisms. Median number of debridements for females was 2 (1,3). The most common anatomic region of gangrene involvement in females was labia (76%) followed by perineum (55%) and gluteus/buttocks (42%). Mortality rate during initial admission was 6% for females. Female patients had a higher median BMI than males (42.1 vs 33.7 respectively; P = .003). FG severity index, length of hospital stay, number of debridements, and wound cultures were comparable to males. The surgical team managing initial debridements differed with females managed primarily by general surgery and males primarily by urology. Mortality rate was comparable to men (6% vs 7%, P >.05). CONCLUSION: Female patients with FG have greater BMI but similar clinical presentation, microbiologic characteristics and mortality rate compared to men. Urologists have little involvement during initial management for females at our institution.

Does Timing of Diagnosis and Management of Iatrogenic Ureter Injuries Affect Outcomes? Experience From a Tertiary Center.

OBJECTIVE: To report urologic outcomes from a series of IUIs, sustained during nonurologic procedures, with regards to timing of diagnosis and management of the injury. Iatrogenic ureteral injury (IUI) is the most common mechanism of ureteral trauma. Injuries can be intraoperatively diagnosed (IOD) or postoperatively diagnosed (POD). METHODS: This was a retrospective chart review of adult patients at a single institution who sustained an IUI from a non-urologic procedure between 2008 and 2019. Primary outcome was tube-dependence (ureter stent or nephrostomy tube) and nephrectomy rates at last follow-up. Secondary outcome was the number of additional urologic procedures required to manage subsequent complications of IUI. RESULTS: There were 30 patients with IOD and 57 patients with POD. In the IOD group, at mean follow up of 6.3 months, 4 patients (14.3%) were tube dependent. In the POD group, at mean follow up of 13.1 months, 5 patients (10%) were tube dependent (P = .570). Rate of nephrectomy was higher in POD group compared to IOD, but the difference was not statistically significant (12.3% vs 6% respectively, P = .414). Additionally, in the POD group, 56% and 19.3% required a secondary and tertiary procedure to manage IUI complications, respectively. These rates were 16.7% (P < .001) and 3.3% (P = .002) in the IOD group. CONCLUSION: Delayed diagnosis of IUI was significantly associated with increased number of procedures needed to manage the injury. The rate of nephrectomy and tube dependence in this group was higher but not statistically significant. Delayed diagnosis of IUI is associated with higher treatment burden.

Microorganisms and Antibiogram Patterns in Fournier's Gangrene: Contemporary Experience from a Single Tertiary Care Center.

PURPOSE: We evaluate the prevalent microorganisms, antibiotic sensitivity patterns and associated outcomes in patients with Fournier's gangrene. MATERIALS AND METHODS: A retrospective chart review of patients with Fournier's gangrene was conducted between October 2011 and April 2018 at our institution. Univariate analysis was performed using the independent t-test or Kruskal-Wallis H test for continuous variables and exact test for categorical variables. RESULTS: Of the 143 patients included in this study, wound culture was available in 131 (92%) patients with a median number of 3 microorganisms per wound. The most commonly grown pathogens were Staphylococcus species (66, 46%), Streptococcus species (53, 37%), Bacteroides species (34, 24%), Candida species (31, 22%), Escherichia coli (28, 20%) and Prevotella species (26, 18%). Most bacteria were sensitive to ampicillin-sulbactam, ceftriaxone, piperacillin-tazobactam, amikacin and cefepime, and resistant to ampicillin, trimethoprim-sulfamethoxazole, levofloxacin and clindamycin. Enterococcus faecalis and Streptococcus anginosus were resistant to vancomycin. The overall Fournier's gangrene mortality count was 14 (10%) patients. No association was noted between the type of infection and Fournier's gangrene severity index, length of hospital stay or mortality. CONCLUSIONS: At our institution Candida is a prevalent pathogen in the wound culture of patients with Fournier's gangrene. The resistance patterns for clindamycin and vancomycin are concerning. Addition of an antifungal agent to the empiric treatment should be considered based on clinical presentation.

Nursing Handovers in Critical Care: A Retrospective Analysis of Information Content and Function.

Translating validated handover protocols from physicians in non-critical care settings to nursing report in critical care is challenging. Our objectives are to identify information content in verbal reports, where information is documented, and the function of non-documented communication. This is a descriptive study of 20 reports describing 27 patients from two medical intensive care units. Analysis involved unique coding of phrases and emergent themes analysis. Information categories included: Identify patient (51.9%); Narrative history (96.3%); Unusual symptoms (88.9%); Response to care (37%); Status of tasks (100%); Expectations of patients and families (55.6%). Information is documented in progress notes, the medication administration record, nursing flowsheets, lab results, orders, and past medical history. Information not typically documented supports providing patient-centered care, sharing clinical judgments, coordinating work, and mentorship. These objectives may guide nursing administrators in tailoring policies and procedures for nursing report to the needs of registered nurses in a critical care setting.

Intraoperative Onabotulinumtoxin-A Reduces Postoperative Narcotic and Anticholinergic Requirements After Continent Bladder Reconstruction.

OBJECTIVE: To determine if intradetrusor injection of onabotulinumtoxin-A (BTX-A) would reduce postoperative narcotic and anticholinergic requirements in children undergoing open continent bladder reconstruction. MATERIALS AND METHODS: After institutional review board approval, we retrospectively reviewed all bladder reconstructions performed. Bladder reconstruction was defined as the following procedures in any combination: bladder neck reconstruction and sling, bladder neck closure, Mitrofanoff, Monti, or bladder augmentation. We identified 15 children who underwent reconstruction with BTX-A injection and compared these with 15 children who did not receive BTX-A. Postoperative narcotic and anticholinergic requirements were recorded as well as length of stay, time to diet, time to return of bowel function, and complications. All medications were converted to morphine mEq/kg per day or mg/kg per day to standardize for patient size and length of stay. RESULTS: Thirty patients who underwent open bladder reconstruction were included. Fifteen received BTX-A injection and 15 did not. The BTX-A group required significantly less narcotic medication postoperatively compared with the no-BTX-A group (0.32 vs 0.85 morphine mEq/kg per day; P = .0002). The BTX-A group also required significantly less anticholinergic medication compared with the no-BTX-A group (0.22 vs 0.88 mg/kg per day; P = .024). There was no significant difference between the groups with respect to length of stay (98.27 vs 9.287 days; P = .34) or return of bowel function (5.53 vs 4.93 days; P = .994). Complication rate between the groups was similar (P >.99). CONCLUSION: Intraoperative injection of BTX-A significantly reduced postoperative narcotic and anticholinergic requirements in patients who underwent open continent bladder reconstruction. This is an encouraging alternative treatment to manage postoperative pain with no associated risk of significant complications.

Is Delayed Phase Computed Tomography Imaging Necessary After Blunt Renal Trauma in Children?

OBJECTIVE: To characterize the utilization of delayed phase computed tomography (CT) imaging in blunt renal trauma and determine if the omission of delayed phase CT imaging affected clinical outcomes in children. MATERIALS AND METHODS: A prospectively collected trauma database was reviewed between 2006 and 2016 to identify patients aged ≤21 years with a diagnosis of renal injury from blunt trauma. Demographic characteristics, injury grade, Injury Severity Score, non-kidney organ injuries, radiologic studies, and clinical course were reviewed. Patients were categorized into 2 groups: those who received CT with delayed images in the emergency room and those who did not. RESULTS: In total, 121 patients met the inclusion criteria. Delayed scans were obtained in 50 patients (41%) but omitted in 71 (59%). Age, weight, non-kidney organ injuries, and imaging location did not differ between groups. Injury Severity Score was higher in the no-delay group than in the delay group (median 16 vs 10, respectively, P = .40). Median length of stay was 3 days without significant differences by cohort (P = .24). The proportion of patients who received abdominal CT scans after admission, underwent a urologic procedure, or were readmitted did not differ significantly between groups. CONCLUSION: This study was unable to demonstrate a difference in outcomes between patients who had a CT with delayed imaging and patients who did not. This questions the universal necessity for delayed images after blunt renal trauma. Future prospective studies are necessary to develop pediatric trauma guidelines that balance imaging needs and radiation exposure.

The Association Between BXO and Obesity in Boys Undergoing Circumcision.

This study investigated whether boys with balanitis xerotica obliterans (BXO) have increased rates of obesity compared with boys with no concern for BXO (NCB). Boys ≤18 years old with circumcision pathology-confirmed BXO were compared with an age-matched group who had NCB during circumcision. Boys with BXO were found to have a mean body mass index of 70.64 percentile for age compared with 52.43 percentile in age-matched controls (P = .0005). The rate of obesity was significantly higher in boys with BXO (42%) compared with 12.4% in boys with NCB (odds ratio = 5.12; 95% CI = 2.6 to 10.06). Given the increasing rates of childhood obesity and the long-term health consequences of both BXO and obesity, special attention should be paid to this population. Further research is needed to determine if BXO in obese children may represent an early indicator of a systemic disease process where intervention may be warranted.

Winning the war on terror: psychology as a strategic framework.

International relations is fundamentally about people. Psychology provides a wide range of tools to understand the rise of Islamic fundamentalist terrorism and offers part of the framework for its resolution. Western societies need to avoid being consumed with fear, revenge or anger which might lead to polarisation and perpetuate the cycle of violence. Understanding the enemy and the virulence of their ideas is essential to winning the hearts and minds of their potential supporters through dialogue, public diplomacy and foreign policy. The West needs to build trust, relationships, reputation and address double standards in its behaviour in order to build a global coalition of people with shared values. The concept of 'war on terror' has been damaging, not least by inhibiting western societies from the self-reflection required to overcome the challenge of terrorism.