Renal autotransplantation in the management of a ureteroarterial fistula: a case report and review of the literature.

A 57-year-old woman who had been treated with an indwelling ureteral stent for over a year was admitted with massive gross hematuria caused by a fistula between the left ureter and hypogastric artery. Despite intensive radiographic evaluation, the definitive diagnosis was made only at the time of surgical exploration. Because of radiation-induced retroperitoneal fibrosis, midureteral obstruction, and prior pelvic and abdominal surgery, primary ureteral repair was not possible, and renal autotransplantation was performed. This case illustrates the need to consider the diagnosis of ureteroarterial fistula in patients with massive hematuria who have chronic indwelling stents, and the feasibility of autotransplantation when primary ureteral repair is not feasible.     

Bacteriuria in pregnancy

The urinary tract undergoes profound physiologic and anatomic changes during pregnancy that facilitate the development of symptomatic urinary tract infections in women with bacteriuria. While the adverse effects of asymptomatic bacteriuria on maternal and fetal health continue to be debated, it is clear that asymptomatic bacteriuria is the major risk factor for developing symptomatic urinary tract infection and that symptomatic infections are associated with significant maternal and fetal risks. Because the majority of symptomatic urinary tract infections develop in women with bacteriuria earlier in pregnancy, treatment of bacteriuria is undertaken to prevent symptomatic infections. All women should be screened at the first antenatal visit, which is reliably and inexpensively done with a dipstick culture. Short-course therapy is as effective as prolonged therapy and should be followed with a repeat culture to document clearing of the bacteriuria. Failure to eliminate bacteriuria with repeated therapy or recurrence with the same organism is indicative of renal parenchymal infection or a structural abnormality. All women with persistent bacteriuria or recurrent infection should have follow-up cultures and a complete urologic evaluation after delivery.     

Testicular tumors: findings with color Doppler US.

A study of 28 patients with surgically proved testicular tumors was performed to determine the appearance at color Doppler ultrasound (US) scanning. There was a general correlation of tumor size and vascularity. Twenty of 21 (95%) tumors larger than 1.6 cm were hypervascular. Six of seven (86%) tumors smaller than 1.6 cm were hypovascular. One small, 1.1-cm-diameter seminoma was hypervascular, and one 2.8-cm-diameter seminoma was hypovascular. The histologic findings of the tumor did not correlate with the vascularity of the lesion as seen at color Doppler US. Resistive indexes ranged from .476 to 1.0 (mean, 0.70). Peak systolic velocities ranged from 8.4 cm/sec to 64.9 cm/sec (mean, 9.8 cm/sec). Venous flow was detected in eight tumors. The gray-scale findings, as well as history and physical examination findings, correctly suggested a neoplasm in all cases. The findings at color Doppler US were prospectively interpreted as indicative of neoplasm in 27 cases and as indicative of inflammation in one case. The authors conclude that color Doppler US scanning has only a limited role in the evaluation of testicular tumors.     

Community-acquired respiratory infection: keeping patients at home

This overview focuses on two types of lower respiratory infections: acute bacterial exacerbations of chronic bronchitis and community-acquired pneumonia. Each of these types of respiratory infection is responsible for considerable morbidity, and in some instances mortality, in adults every year. Not all adult cases, however, require hospitilization. Specifically, prompt initiation of appropriate antimicrobial therapy is of primary importance in minimizing the deleterious effects of acute bacterial exacerbations of chronic bronchitis. The majority of patients can be treated effectively as out-patients. Similarly, most patients with community-acquired pneumonia can be cared for at home. The need for hospitalization must be determined individually and is based upon the severity of the patient's illness as well as the presence of associated underlying disease.     

Prostate Specific Antigen Density Versus Prostate Specific Antigen Slope as Predictors of Prostate Cancer in Men with Initially Negative Prostatic Biopsies

Purpose

We determined if prostate specific antigen (PSA) density and PSA slope alone or in combination could be used to predict which men with persistently elevated serum PSA and prior negative prostate biopsies will have prostate cancer on repeat evaluation.

Materials and Methods

In our PSA-1 data base we identified 327 men 50 years old or older with an initially negative prostate biopsy who had persistent PSA elevation, and compared those who did and did not have prostate cancer on subsequent serial prostatic biopsy.

Results

Of 70 men with a PSA density of 0.15 or more and PSA slope of 0.75 ng./ml. or more annually compared to 83 with a PSA density of less than 0.15 and PSA slope of less than 0.75 ng./ml. annually 32 (46 percent) and only 11 (13 percent), respectively, had prostate cancer on subsequent prostate biopsies (p less than 0.0001). In a hierarchical logistic regression analysis PSA density and PSA slope were predictive of prostate cancer on subsequent biopsy (p = 0.001 and 0.03, respectively). PSA density of 0.15 or more alone or PSA slope of 0.75 ng./ml. or more annually alone as the indicator for repeat biopsy would have missed 35 and 40 percent of cancers, respectively.

Conclusions

In men with persistently elevated serum PSA after an initially negative prostate biopsy, PSA density and PSA slope alone or in combination provide useful predictive information about the results of repeat prostate biopsies. However, these parameters are not sufficiently sensitive to identify all patients with detectable prostate cancer.     

Combined finasteride and flutamide therapy in men with advanced prostate cancer

Objectives

To evaluate the efficacy of combined finasteride and flutamide therapy in men with advanced prostate cancer by determining (1 ) the short-term tolerability of finasteride monotherapy and its effect on serum prostate-specific antigen (PSA) and hormone (testosterone, dihydrotestosterone) levels, and (2) the effects of the addition of flutamide on tolerability and on serum PSA and hormone levels.

Methods

Thirteen hormone-naive men with advanced prostate cancer (4 with Stage D2, 1 with Stage D1, 1 with Stage DO, 7 with rising PSA levels after radical prostatectomy [n = 2]or definitive radiation therapy [n = 5]) were initially treated with 5 mg finasteride daily. Flutamide (250 mg three times a day) was added after serum PSA levels stabilized.

Results

Finasteride alone (median 5 weeks) had no significant effect on serum PSA levels (P>0.05). Combined finasteride and flutamide resulted in a mean 91% reduction in serum PSA levels, with 85% of men achieving a nadir serum PSA level of less than 4.0 ng/mL and 46% achieving undetectable levels (0.2 ng/mL or less). Finasteride alone had no significant effect on serum testosterone levels (P>0.05) but did result in a mean 74% reduction in serum dihydrotestosterone levels. Combined finasteride and flutamide resulted in a mean 56% increase in serum testosterone levels but had no additional effect on serum dihydrotestosterone levels (P>0.05). Side effects occurred in 85% (gynecomastia or breast tenderness in 62% [8 of 13]and diarrhea in 23% [3 of 13]) of men on combined therapy. Potency was preserved in 66%. Combined finasteride and flutamide therapy was withdrawn from 15% (2 of 13) because of flutamide-induced diarrhea and from 23% (3 of 13) because of disease progression. All remaining patients (8 of 13) have serum PSA levels below 4.0 ng/mL and 4 of these 8 have undetectable levels. These men have received combined finasteride and flutamide for a median 11 months (range 6 to 19).

Conclusions

Finasteride monotherapy is inadequate therapy for advanced prostate cancer, but combined finasteride and flutamide may be a reasonable alternative for men with advanced prostate cancer who refuse conventional hormone therapy.     

Enterococcal meningitis: Combined vancomycin and rifampin therapy

Intrathecal vancomycin and oral rifampin have been used together to successfully treat a patient with enterococcal meningitis who was allergic to penicillin and who had failed a course of treatment with chloramphenicol. This therapy was tolerated very well and represents an alternate mode of therapy which should be considered in penicillin allergic patients with enterococcal meningitis.     

An Effective Method for Segmentation of MR Brain Images Using the Ant Colony Optimization Algorithm

Since segmentation of magnetic resonance images is one of the most important initial steps in brain magnetic resonance image processing, success in this part has a great influence on the quality of outcomes of subsequent steps. In the past few decades, numerous methods have been introduced for classification of such images, but typically they perform well only on a specific subset of images, do not generalize well to other image sets, and have poor computational performance. In this study, we provided a method for segmentation of magnetic resonance images of the brain that despite its simplicity has a high accuracy. We compare the performance of our proposed algorithm with similar evolutionary algorithms on a pixel-by-pixel basis. Our algorithm is tested across varying sets of magnetic resonance images and demonstrates high speed and accuracy. It should be noted that in initial steps, the algorithm is computationally intensive requiring a large number of calculations; however, in subsequent steps of the search process, the number is reduced with the segmentation focused only in the target area.     

The Composite Severity Score for Lumbar Spine MRI: a Metric of Cumulative Degenerative Disease Predicts Time Spent on Interpretation and Reporting

Conventional measures of radiologist efficiency, such as the relative value unit, fail to account for variations in the complexity and difficulty of a given study. For lumbar spine MRI (LMRI), an ideal performance metric should account for the global severity of lumbar degenerative disease (LSDD) which may influence reporting time (RT), thereby affecting clinical productivity. This study aims to derive a global LSDD metric and estimate its effect on RT. A 10-year archive of LMRI reports comprising 13,388 exams was reviewed. Objective reporting timestamps were used to calculate RT. A natural language processing (NLP) tool was used to extract radiologist-assigned stenosis severity using a 6-point scale (0?=?“normal” to 5?=?“severe”) at each lumbar level. The composite severity score (CSS) was calculated as the sum of each of 18 stenosis grades. The predictive values of CSS, sex, age, radiologist identity, and referring service on RT were examined with multiple regression models. The NLP tool accurately classified LSDD in 94.8% of cases in a validation set. The CSS increased with patient age and differed between men and women. In a univariable model, CSS was a significant predictor of mean RT (R²?=?0.38, p?<?0.001) and independent predictor of mean RT (p?<?0.001) controlling for patient sex, patient age, service location, and interpreting radiologist. The predictive strength of CSS was stronger for the low CSS range (CSS?=?0–25, R²?=?0.83, p?<?0.001) compared to higher CSS values (CSS?>?25, R²?=?0.15, p?=?0.05). Individual radiologist study volume was negatively correlated with mean RT (Pearson’s R?=????0.35, p?<?0.001). The composite severity score predicts radiologist reporting efficiency in LMRI, providing a quantitative measure of case complexity which may be useful for workflow planning and performance evaluation.