Multiple arterial emboli secondary to left ventricular thrombus in a 35-year-old obese male

The very unusual case of a 35-year-old obese male patient with a left ventricular (LV) thrombus secondary to a silent myocardial infarction and resultant shower emboli to multiple arterial sites is described. His presentation with acute limb ischemia led to arterial imaging and the identification of the underlying cardiac pathology in addition to splenic and bilateral renal infarcts. He was also found to suffer from previously undiagnosed hypertension. He underwent femoral embolectomy and multiple arterial revascularization attempts but required bilateral above knee amputations and a prolonged intensive care unit stay. This rare and extreme example of a LV thrombus in a young male emphasizes the potential sequellae of the condition. Furthermore, with the increasing incidence of obesity this case demonstrates the importance of considering undiagnosed cardiovascular risk factors when assessing obese patients

‘A reservoir within a reservoir’ – An unusual complication associated with a defunctioned inflatable penile prosthesis reservoir

INTRODUCTION: Inflatable penile prostheses (IPP) have been a successful method of treating men with erectile dysfunction since the early 1970s. IPP are comprised of two intracorporal cylinders, a scrotal pump and a fluid reservoir. PRESENTATION OF CASE: We present a case of a retained reservoir in a sixty eight year old gentlemen presenting with a cystic abdominal mass and bothersome LUTS, 15 years after the removal of the penile components of a three-piece penile prosthesis. Percutaneous drainage of the cyst was performed, with four litres of purulent fluid evacuated. A midline laparotomy was required to remove the reservoir and drain the collection completely. DISCUSSION: Inflammatory reaction and subsequent erosion of an IPP reservoir is an infrequent but severe complication of IPP insertion, replacement or infection. Infection remains the primary indication for penile prosthesis removal and in this setting removal of the reservoir is routine. A thorough literature search has identified that in the non-infective setting, the routine removal of the original reservoir is not standard practice during three-component IPP replacement. In patients with a history of IPP presenting with new LUTS, reservoir erosion should be considered in the differential diagnosis and investigation with cystoscopy and computed tomography included early in the investigatory armament of the urologist. CONCLUSION: It is our belief that a defunctionalized reservoir serves no purpose; rather it can only cause trouble in the future. Consequently, at our institution we do not leave defunctionalized reservoirs in situ

Complicated Urinary Tract Infections: Highlights On Diagnosis And Minimally Invasive Treatment

Complicated urinary tract infection (UTI) has always been a challenging subject to diagnose and treat. New, less invasive, techniques have been introduced in the last decade with the development of the new generations of high definition endoscopes and the robotic platforms to treat the surgically correctable pathologies underlying UTIs. This review will discuss the different underlying pathological conditions for complicated UTI and their management

Collaborative eye tracking: A potential training tool in laparoscopic surgery

Background: Eye-tracking technology has been shown to improve trainee performance in the aircraft industry, radiology, and surgery. The ability to track the point-of-regard of a supervisor and reflect this onto a subjects' laparoscopic screen to aid instruction of a simulated task is attractive, in particular when considering the multilingual make up of modern surgical teams and the development of collaborative surgical techniques. We tried to develop a bespoke interface to project a supervisors' point-of-regard onto a subjects' laparoscopic screen and to investigate whether using the supervisor's eye-gaze could be used as a tool to aid the identification of a target during a surgical-simulated task. Methods: We developed software to project a supervisors' point-of-regard onto a subjects' screen whilst undertaking surgically related laparoscopic tasks. Twenty-eight subjects with varying levels of operative experience and proficiency in English undertook a series of surgically minded laparoscopic tasks. Subjects were instructed with verbal queues (V), a cursor reflecting supervisor's eye-gaze (E), or both (VE). Performance metrics included time to complete tasks, eye-gaze latency, and number of errors. Results: Completion times and number of errors were significantly reduced when eye-gaze instruction was employed (VE, E). In addition, the time taken for the subject to correctly focus on the target (latency) was significantly reduced. Conclusions: We have successfully demonstrated the effectiveness of a novel framework to enable a supervisor eye-gaze to be projected onto a trainee's laparoscopic screen. Furthermore, we have shown that utilizing eyetracking technology to provide visual instruction improves completion times and reduces errors in a simulated environment. Although this technology requires significant development, the potential applications are wide-ranging. © Springer Science+Business Media, LLC 2012.link_to_subscribed_fulltex

Discovery and validation of urinary metabotypes for the diagnosis of hepatocellular carcinoma in West Africans

There is no clinically applicable biomarker for surveillance of hepatocellular carcinoma (HCC), because the sensitivity of serum alpha-fetoprotein (AFP) is too low for this purpose. Here, we determined the diagnostic performance of a panel of urinary metabolites of HCC patients from West Africa. Urine samples were collected from Nigerian and Gambian patients recruited on the case-control platform of the Prevention of Liver Fibrosis and Cancer in Africa (PROLIFICA) program. Urinary proton nuclear magnetic resonance (1H-NMR) spectroscopy was used to metabolically phenotype 290 subjects: 63 with HCC; 32 with cirrhosis (Cir); 107 with noncirrhotic liver disease (DC); and 88 normal control (NC) healthy volunteers. Urine samples from a further cohort of 463 subjects (141 HCC, 56 Cir, 178 DC, and 88 NC) were analyzed, the results of which validated the initial cohort. The urinary metabotype of patients with HCC was distinct from those with Cir, DC, and NC with areas under the receiver operating characteristic (AUROC) curves of 0.86 (0.78-0.94), 0.93 (0.89-0.97), and 0.89 (0.80-0.98) in the training set and 0.81 (0.73-0.89), 0.96 (0.94-0.99), and 0.90 (0.85-0.96), respectively, in the validation cohort. A urinary metabolite panel, comprising inosine, indole-3-acetate, galactose, and an N-acetylated amino acid (NAA), showed a high sensitivity (86.9% [75.8-94.2]) and specificity (90.3% [74.2-98.0]) in the discrimination of HCC from cirrhosis, a finding that was corroborated in a validation cohort (AUROC: urinary panel = 0.72; AFP = 0.58). Metabolites that were significantly increased in urine of HCC patients, and which correlated with clinical stage of HCC, were NAA, dimethylglycine, 1-methylnicotinamide, methionine, acetylcarnitine, 2-oxoglutarate, choline, and creatine. Conclusion: The urinary metabotyping of this West African cohort identified and validated a metabolite panel that diagnostically outperforms serum AFP