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Objectives To determine the safety of urological admissions and procedures during the height of the COVID‐19 pandemic using “hot” and “cold” sites. The secondary objective is to determine risk factors of contracting COVID‐19 within our cohort. Patients and methods A retrospective cohort study of all consecutive patients admitted from March 1 to May 31, 2020 at a high‐volume tertiary urology department in London, United Kingdom. Elective surgery was carried out at a “cold” site requiring a negative COVID‐19 swab 72‐hours prior to admission and patients were required to self‐isolate for 14‐days preoperatively, while all acute admissions were admitted to the “hot” site. Complications related to COVID‐19 were presented as percentages. Risk factors for developing COVID‐19 infection were determined using multivariate logistic regression analysis. Results A total of 611 patients, 451 (73.8%) male and 160 (26.2%) female, with a median age of 57 (interquartile range 44‐70) were admitted under the urology team; 101 (16.5%) on the “cold” site and 510 (83.5%) on the “hot” site. Procedures were performed in 495 patients of which eight (1.6%) contracted COVID‐19 postoperatively with one (0.2%) postoperative mortality due to COVID‐19. Overall, COVID‐19 was detected in 20 (3.3%) patients with two (0.3%) deaths. Length of stay was associated with contracting COVID‐19 in our cohort (OR 1.25, 95% CI 1.13‐1.39). Conclusions Continuation of urological procedures using “hot” and “cold” sites throughout the COVID‐19 pandemic was safe practice, although the risk of COVID‐19 remained and is underlined by a postoperative mortality.

Infections continue to be a significant cause of morbidity and mortality after solid organ transplantation. Early identification of the pathogenic organism is extremely important as the disease process might progress rapidly resulting in fatality. In this case series, we describe varying presentations of pulmonary nocardiosis, an uncommon opportunistic bacterial infection that often complicates the diagnosis of pneumonia, especially in immunocompromised patients. Although cough, fever, expectoration and breathlessness are the most common symptoms of pulmonary nocardiosis, they can also manifest as night sweats, weight loss and malaise. Some are incidentally diagnosed while being evaluated for other causes. Radiological features are also non-specific, usual findings being irregular nodules, cavitation, reticulo nodular diffuse pneumonia and pleural effusions. Bronchoalveolar lavage has the best diagnostic yield, but may have to be repeated several times to confirm a diagnosis, if the index of suspicion is high. Initial therapy with high dose trimethoprim- sulfamethoxazole is found to be effective in most of the cases. Duration of treatment should be a minimum of 6 months, and at least 12 months if central nervous system is affected. Other agents used for treatment include imipenem, minocycline, third generation cephalosporins, linezolid and amikacin. A high index of suspicion, with aggressive evaluation in an immunosuppressed individual will enable an early diagnosis, leading to prompt treatment and limit dissemination of disease thus preventing fatality.

Background: Studies on posttransplantation anemia (PTA) are scarce. There is a large variability in its prevalence (20%–70%). Research focuses on anemia in early (3–6 months) or late (>6 months) posttransplant period. Little is known about PTA within first 3 months. Aim: The aim of the study was to determine the prevalence and possible associated factors of immediate PTA in patients undergoing renal transplant. Materials and Methods: This was a prospective, observational, single-center study of 30 consecutive patients who underwent live renal allograft transplant. Follow-up period was 3-month posttransplant. Hemoglobin (Hb) was done at 1-week and 1, 2, and 3-month posttransplant. Erythropoietin (EPO) levels were recorded pre and posttransplant. Peripheral smear, lactate dehydrogenase, iron and ferritin levels, serum creatinine, days of hospital stay, rejections, infections, and immunosuppressive regime were recorded. Results: All patients were anemic within 1 week of transplantation and 40% had severe anemia. The prevalence of PTA at 3 months was 76.7%. PTA correlated with higher donor age, lower ferritin, Hb, and EPO levels in pretransplant period. However, even though EPO levels posttransplant were lower in patients with anemia, this correlation was not statistically significant. The lowest Hb correlated with Hb levels and dose of EPO-stimulating agents pretransplant. Conclusions: The prevalence of anemia is high in the immediate posttransplant period. High donor age, graft dysfunction, and iron stores before transplantation correlate with Hb levels at 3 months. It is prudent to maintain a better Hb in the pretransplant period to avoid PTA. Lower EPO levels before transplant may indicate immediate PTA. Correlation of EPO levels posttransplant with Hb needs further study.

Study the changing clinical and therapeutic profiles of type 2 diabetes (T2D) patients during a 10-year period in a diabetes care centre in Southern India.Retrospective, cross-sectional data of newly registered and review patients at four periods between 2009 and 2018 were analysed (n = 50,322). Clinical findings, anthropometry, blood pressure (BP), glycaemia, lipids, treatment, and co-morbid conditions were analysed. We studied the trends in age and gender distributions, body mass index (BMI), glycaemia, (Glycosylated haemoglobin A1c (HbA1c) levels), BP, cholesterol, triglycerides and therapeutic regimen during this period. Trend analyses were done.Approximately 60% of patients were men. Percentages in 30-40 years increased, ∼60% were aged 50-69 years and proportion of older patients decreased (p 0.0001). In 10 years, 85.9% was overweight, obesity increased from 22.1% to 25.0% (p 0.0001) and13% maintained normal BMI. HbA1c7.0% remained approximately at 22%, percentage with moderate glycaemic control (HbA1c 7.0-7.9%) increased significantly, HbA1c of ≥9.0% decreased from 35.1% to 29.1% (p 0.0001). Use of monotherapy decreased. Prevalence of hypertension increased from 16.2% to 21.6% (p 0.0001); use of Angiotensin Receptor Blockers (ARB) and calcium channel blockers increased, Angiotensin Converting Enzyme Inhibitors and thiazides decreased (p 0.0001). Increased use of statins paralleled with reduction in total cholesterol and LDLc.Increasing percentages of younger patients and obesity, use of multiple drugs and reduction in HbA1c were the important observations. Rising prevalence of hypertension, increased use of ARB and statins with better control of dyslipidaemia was observed. Achievement of ideal HbA1c and BP were suboptimal.

Background Adult primary intraventricular hemorrhage (PIVH) is a rare type of hemorrhagic stroke that is poorly understood. The study attempts to define the clinical profile, yield of diagnostic cerebral angiography, and prognosis of patients with PIVH. Patients and Methods Retrospective data analysis of all patients with PIVH admitted between February 2015 and February 2019 at a tertiary care center. Outcome was assessed using the modified Rankin scale (mRS) at 6 months. Results and Discussion Our study group of 30 patients constituted 3.3% (30/905) of our spontaneous intracerebral hemorrhage (SICH) patients in the study period. The mean Glasgow Coma Score on admission was 11 ± 3.33 and the mean IVH Graeb score was 5.2±2.4. All patients underwent angiography. Angiography detected moyamoya disease in four patients (13.3%) and aneurysms in two patients (6.6%) and these patients were managed surgically. Extraventricular drainage with intraventricular instillation of Streptokinase was performed in five patients. The rest of the patients was managed conservatively. At 6-month follow-up, 25 patients (83.33%) achieved favorable outcome (mRS score of 0.1 or 2), whereas five (16.66%) patients had a poor outcome (mRS score of 3 or more. Three patients succumbed to the illness. IVH Graeb score and presence of hydrocephalus have significant correlation with poor outcome. Conclusion PIVH is an uncommon entity but carries a better long-term prognosis than SICH angiography helps in diagnosing surgically remediable underlying vascular anomalies and is indicated in all cases of PIVH.

We compared retrograde extraperitoneal open radical cystoprostatectomy (REORC) and robot-assisted radical cystoprostatectomy with intracorporeal diversion (iRARC) and have reported the early perioperative outcomes.REORC and iRARC were each performed at a different tertiary high-volume center in 2 countries. Men aged ≥ 18 years with precystectomy clinical stage T1-T3 disease were included. Patients with previous major pelvic and/or intra-abdominal surgery, those who had undergone previous pelvic and/or abdominal irradiation, women, and patients with clinical stage T4 disease were excluded. All cases were managed according to a standardized enhanced recovery after surgery protocol, and all the patients had undergone ileal conduit urinary diversion. Bowel recovery was one of the main endpoints; thus, the intervals to passing flatus, tolerating oral feeding, and bowel opening were determined. The operative time, estimated blood loss, intraoperative complications, length of hospital stay, postcystectomy tumor type, stage, margin status, lymph node yield, and 30- and 90-day complications were analyzed.We performed a retrospective analysis of prospectively collected data from October 2016 to December 2018 of 99 patients, 50 of whom had undergone REORC and 49 iRARC. The demographic data and preoperative parameters were comparable between the 2 groups. REORC resulted in a significantly shorter mean operative time (P .001), significantly greater mean estimated blood loss (P .001), and greater percentage of patients requiring blood transfusion (98% vs. 12.24%). No significant differences in the length of stay were observed (P = .412). The rate of prolonged postoperative ileus was 16% and 18.4% in the REORC and iRARC groups, respectively (P = .3). Differences in the interval to passing flatus, tolerating solid oral intake, and bowel opening were not statistically significant between the 2 groups (P = .423, P = .770, and P = .700, respectively). No statistically significant difference was observed in the postcystectomy pathologic outcomes and overall and major complications rates at 30 and 90 days.REORC resulted in quicker bowel recovery and a shorter length of stay compared with conventional open procedures, with advantages comparable to those realized with iRARC. Thus, REORC can be adopted as the preferred open approach at institutions without surgical robots available.

Left ventricular hypertrophy (LVH), the most common structural cardiac complication, is the single most important cause for sudden cardiac death. There are no published data from India looking at the changes in left ventricular mass and cardiac dysfunction after kidney transplantation. We aimed to determine the changes in the left ventricular mass and other cardiovascular risk factors in kidney transplant recipients. This was a prospective observational study. All patients who underwent kidney transplantation at Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, during the study period were included in the study. Measurement of clinical and biochemical parameters and echocardiography were done before, six months, and one year after transplantation. There was significant reduction in LV mass index (124.8 ± 39 vs. 102.2 ± 24.4 g/m2, P

Thalassemia presenting with compressive myelopathy secondary to extramedullary hematopoiesis (EMH) is rare. We report the rare case of spinal EMH with dorsal cord compression and myelopathy in a 28-year-old male with inadequately transfused beta thalassemia major who presented with paraparesis and acute sphincter disturbance.

The aim of the Scot BC Quality OPS clinical project is to create a reliable prospective data set for evaluating real-world effectiveness and efficiency consequent to standardisation and monitoring of bladder cancer treatment (through the national Quality Performance Indicator programme) and streamlined surveillance in Scotland. Several work packages have been created, reflecting wide clinical and research collaboration.

Background: Adenine phosphoribosyltransferase (APRT) enzyme deficiency is a rare autosomal recessive disorder of purine metabolism affecting mainly the kidneys. It can present at any age with varying degrees of acute and chronic renal damage. Though xanthine dehydrogenase inhibitors offer effective control over the disease process, delay in diagnosis and treatment often lead to compromised function of native and even graft kidneys. Methods: We have done a retrospective search of records of renal biopsies reported at our center during the 5-year period from 2014 to 2018 to identify biopsies with 2,8-dihydroxyadenine crystal deposits. The demographic, clinical, and histopathological findings in these cases were studied and reviewed in the light of available literature. Results: Of 9059 renal biopsies received during the study period, 3 cases had the rare 2,8- dihydroxyadenine (DHA) crystals. All of them were diagnosed for the first time on allograft biopsies. Conclusion: A high index of clinical suspicion together with the characteristic microscopic appearance of crystals on renal biopsy and urine microscopy can clinch the diagnosis of this rare disease. Hence, improving awareness about this entity among clinicians and pathologists is extremely important.

A question that routinely arises in medical device clinical studies is the homogeneity across demographic subgroups, geographical regions, or investigational sites of the enrolled patients in terms of treatment effects or outcome variables. The main objective of this paper is to discuss statistical concepts and methods for the assessment of such homogeneity and to provide the practitioner a statistical framework and points to consider in conducting homogeneity assessment. Demographic subgroups, geographical regions, and investigational sites are discussed separately as each has its unique issues. Specific considerations are also given to randomized controlled trials, non-randomized comparative studies, and single-arm studies. We point out that judicious use of statistical methods, in conjunction with sound clinical judgment, is essential in handling the issue of homogeneity of treatment effect in medical device clinical studies.

BackgroundPatients and their families often have an inadequate understanding of the risks and benefits of their advance care planning (ACP) options. Improving patients’ knowledge of therapeutic interventions allows them to better select treatments they believe are most appropriate for their condition.ObjectivesTo determine if a video aimed at educating and engaging hospitalised patients on a standardised ACP order set can improve (1) inpatient understanding of key ACP concepts, (2) ACP documentation within 48 hours of hospital admission, (3) concordance between a patient’s expressed and chart-documented care preferences, (4) patient satisfaction with decision-making, and (5) patient’s decisional confidence.MethodsA prospective, non-randomised, pre-post intervention study of 252 inpatients in a 215-bed community-based hospital in Comox, British Columbia, Canada.ResultsOur video decision support tool was associated with significant improvements in (1) patient understanding of key ACP concepts (70%–100%; pConclusionA 13 min video aimed at educating and engaging inpatients on ACP concepts improved patient understanding of key ACP concepts, rates of ACP documentation and patient satisfaction with decision-making.

Objective: Thoracic myelopathy has gradually risen to be a prominent diagnosis in patients with persistent upper back pain, bladder symptoms and spastic paraparesis. Often encountered, these conditions pose a serious dilemma to neurosurgeons with respect to surgical planning, timing of surgery, prognosis and possible complications and outcome assessment. In view of these queries and to clarify the indications of when to intervene the following study has been undertaken.To analyze the clinical presentation, radiological features, clinical implications and surgical nuances and outcomes in patients with single and multiple level dorsal canal ossified ligamentum flavum (D-OLF) and associated dural ossification (DO). Patients and methods: Nineteen patients with the diagnosis of thoracic myelopathy (TM) were identified between January 2012 and March 2017. All patients were treated surgically, with decompressive laminectomies, in a single tertiary care center in Southern India. mJOA was calculated preoperatively and assessed postoperatively and a mean mJOA was calculated to assess the significance in neurological improvement. The data was collected from the medical records department and various factors were analyzed, using SPSS software, for correlation. Results: Mean age of our group was 50.84 years with a range of 29 to 71 years. It comprised of 11 males and 8 females. All patients had features of myelopathy. Surgery did have a positive effect on neurological improvement (p = 0.001) in all patients except one. Dural ossification had correlation with pre op and post op urinary disturbances with p value of 0.02. (Mann Whitney Test for 2 independent variables used). A total of ten patients had urinary symptoms pre operatively, out of which six patients showed postoperative improvement at the end of one year. Four of these patients continued to have symptoms, two patients were on Clean Intermittent Catheterisation (CIC), and one patient had features of hesitancy and frequency. Preoperative bladder dysfunction was a strong predictor for continued bladder dysfunction at the end of 1 year (p

Background Bladder cancer (BC) is the 9th most common cancer worldwide, but little progress has been made in improving patient outcomes over the last 25 years. The King’s Health Partners (KHP) BC biobank was established to study unanswered, clinically relevant BC research questions. Donors are recruited from the Urology or Oncology departments of Guy’s Hospital (UK) and can be approached for consent at any point during their treatment pathway. At present, patients with bladder cancer are approached to provide their consent to provide blood, urine and bladder tissue. They also give access to medical records and linkage of relevant clinical and pathological data across the course of their disease. Between June 2017 and June 2019, 531 out of 997 BC patients (53.3%) gave consent to donate samples and data to the Biobank. During this period, the Biobank collected fresh frozen tumour samples from 90/178 surgical procedures (of which 73 were biopsies) and had access to fixed, paraffin embedded samples from all patients who gave consent. Blood and urine samples have been collected from 38 patients, all of which were processed into component derivatives within 1 to 2 h of collection. This equates to 193 peripheral blood mononuclear cell vials; 238 plasma vials, 224 serum vials, 414 urine supernatant vials and 104 urine cell pellets. This biobank population is demographically and clinically representative of the KHP catchment area. Conclusion The King’s Health Partners BC Biobank has assembled a rich data and tissue repository which is clinically and demographically representative of the local South East London BC population, making it a valuable resource for future BC research.

BackgroundContracting COVID-19 peri-operatively has been associated with a mortality rate as high as 23%, making prevention vital.ObjectivesThe primary objective is to determine safety of surgical admissions and procedures during the height of the COVID-19 pandemic using ‘hot’ and ‘cold’ sites. The secondary objective is to determine risk factors of contracting COVID-19.Design, Setting and ParticipantsA retrospective cohort study of all consecutive patients admitted from 1st March – 31st May 2020 at a high-volume tertiary urology department in London, United Kingdom. Elective surgery was carried out at a ‘cold’ site requiring a negative COVID-19 swab 72 hours prior to admission and to self-isolate for 14 days pre-operatively, whilst all acute admissions were admitted to the ‘hot’ site.Outcome Measurements and Statistical AnalysisComplications related to COVID-19 were presented as percentages. Risk factors for developing COVID-19 infection were determined using multivariate logistic regression analysis.Results and LimitationsA total of 611 patients, 451 (73.8%) male and 160 (26.2%) female, with a median age of 57 (interquartile range 44-70) were admitted under the urology team; 101 (16.5%) on the ‘cold’ site and 510 (83.5%) on the ‘hot’ site. Procedures were performed in 495 patients of which 8 (1.6%) contracted COVID-19 post-operatively with 1 (0.2%) post-operative mortality due to COVID-19. Overall, COVID-19 was detected in 20 (3.3%) patients with 2 (0.3%) deaths. Length of stay was associated with contracting COVID-19 in our cohort (OR 1.25, 95% CI 1.13-1.39). Limitations include possible under reporting due to post-operative patients presenting elsewhere.ConclusionsContinuation of surgical procedures using ‘hot’ and ‘cold’ sites throughout the COVID-19 pandemic was safe practice, although the risk of COVID-19 remained and is underlined by a post-operative mortality.Patient SummaryUsing ‘hot’ and ‘cold’ sites has allowed the safe continuation of urological practice throughout the height of the COVID-19 pandemic.

Background. This article attempts to evaluate the clinical profile and outcome determinants following hypertensive SICH in a South Indian population. The study represents the largest series of SICH reported from a single centre in India. Materials and Methods. Prospective data collection and analysis of patients with SICH admitted to our centre between 1st January 2015 and 31st December 2018. The variables analysed include: age, sex, comorbidities, Glasgow coma score (GCS) on admission, radiological features, treatment modality, and outcome at three months. Modified Rankin score (mRS) was used to assess the outcome at discharge and three months. Results. Our study group of 905 patients included 638 males and 267 females and the mean age at presentation was 58.10 ± 12.76 years. The study group included 523 patients (57.8%) previously diagnosed hypertensive, of whom 36.3% (n=190) were on irregular medication. The most frequent locations of hematoma were basal ganglia (478), thalamus (202), lobar (106), cerebellar (61), brainstem (31), and primary intraventricular haemorrhage (27). Secondary intraventricular extension was seen in 425 (47%) patients on admission. The mean volume of the clot on admission was 23.45 ± 19.79 ml, and clot progression was seen in only 46 (5.08%) cases. Surgical evacuation through craniotomy was done in 147 (16.8%) patients, and external ventricular drainage (EVD) was placed in 56 (6.2%) patients. Overall 3−month mortality was 30.1% (266 patients). On the last follow up a favorable outcome (mRS 0−3) was observed in 412 (45.53%) patients and a poor outcome (mRS 4−5) in 207 patients (22.87%). Independent predictors of mortality are Age >70 (p=<0.001, OR 4.806, 95% CI 3.064–7.54), admission GCS p=<0.001, OR7.684, 95% CI 5.055#x2013;11.68), and Hematoma volume >30 ml (p=<0.001, OR 2.45, 95% CI 1.626–3.691). Intraventricular haemorrhage was an additional poor outcome predictor (p<0.015, CI 1.105–2.585). Surgical evacuation reduced mortality in the group, but morbidity rates remained the same. Conclusions. SICH predominantly affects a younger population in India in comparison to the Western society. Elderly age, poor GCS on admission, clot volume above 30 ml and intraventricular extension remain the most consistent predictors of death and poor outcome. Further studies are needed to assess the risk of SICH among hypertensive patients and to prognosticate the outcome after SICH using novel predictors, including biomarkers.

Objective: To investigate whether a totally intracorporeally radical cystectomy (RC) can be considered the new ‘gold standard’ in bladder cancer, as open RC (ORC) is the current ‘gold standard’ for surgical treatment of muscle-invasive and high-grade non-muscle-invasive bladder cancer. However, robot-assisted radical cystectomy (RARC) is becoming the preferred surgical approach in many centres as it seems to maintain the oncological control of open surgery whilst offering improved perioperative benefits. Materials and methods: A review of the literature was conducted using the Pubmed/MEDLINE, ISI Web of Knowledge and Cochrane Databases to identify studies that included both ORC and RARC with intracorporeal and extracorporeal urinary diversion (UD) published up to July 2017. Results: Evidence from four single-centre randomised controlled trials and now the multicentre Randomized Trial of Open versus Robotic Cystectomy (RAZOR) trial demonstrate the oncological equivalence of RARC to ORC. The only convincing evidence for the superiority of RARC is in the area of blood loss and transfusion rates. However, the UD procedure in these trials was performed extracorporeally and, to realise the full benefits of RARC, a totally intracorporeal approach is needed. Intracorporeal UDs (ICUDs) have been shown to be technically feasible by a few expert centres and have demonstrated some improved short-term perioperative outcomes compared to extracorporeal UDs. Conclusions: Although initial outcomes appear promising, RARC with ICUD is far from gaining ‘gold standard’ status. Further studies are needed to confirm that outcomes are reproducible widely. Furthermore, the benefits of a totally intracorporeal approach must be confirmed in randomised controlled trials. Keywords: Radical cystectomy, Intracorporeal urinary diversion, Extracorporeal urinary diversion, Robotics, Bladder cancer

Concomitant cerebral infarction developing soon after a parenchymal intracerebral hemorrhage is a rare occurrence. Usually, these remote site changes follow tumor decompression and are associated with hemorrhagic changes rather than infarcts. We report a case of a fatal malignant internal carotid territory infarct in a hospitalized patient being conservatively managed for a vermian hematoma and discuss the probable pathophysiology. Stroke physicians need to be aware that spontaneous intracerebral hematoma patients have a potential threat of developing large vessel occlusion with malignant cerebral infarcts, especially after surgical decompression. Although the exact pathogenesis is unknown, size of the clot, intraventricular hemorrhage, hydrocephalus, and aggressive reduction of blood pressure appear to be predictive factors.

Androgen deprivation therapy (ADT), which involves the maximal suppression of circulating testosterone, underpins the treatment approach to metastatic hormone sensitive prostate cancer. Although initial responses are generally favourable, approximately half of cases progress to metastatic castrate resistant prostate cancer (mCRPC), rendering traditional hormonal therapies ineffective. mCRPC is defined by disease progression despite established ADT. New research has improved our understanding of the the molecular mechanisms behind metastatic castration-resistant prostate cancer (mCRPC). This has led to a renewed interest in the androgen receptor as a target for therapy, paving the way for the introduction of novel androgen therapies such as abiraterone acetate and enzalutamide. Recent trials on these treatments have demonstrated their benefit to improving overall survival in the setting of mCRPC. The resultant effect is a new, constantly changing, and complex treatment paradigm for treating clinicians, who are now required to know the mechanism of actions of new medications, side effect profiles, modes of administration, and preferred sequencing of various treatment options. Furthermore, treatments involving new androgen biosynthesis are currently being developed and tested. Therefore, in the context of a highly heterogenous disease with a continuously changing treatment landscape, management of mCRPC can be particularly challenging. The purpose of this review is to provide an overview of the literature on new androgen receptor targeted therapies, and discuss the changing treatment landscape specific to metastatic CRPC.

The role of local treatment in oligometastatic prostate cancer remains contentious. Treatment of the prostate in metastatic disease may confer benefit, but prospective data are lacking. With improvements in treatments, aggressive strategies directed at metastases have increasingly become of clinical interest. Current evidence suggests good local control can be achieved; however, further data are required to determine overall cancer outcomes. This article evaluates the evidence available and consider whether local treatment of oligometastatic disease is a feasible, safe, and a positive strategy in this disease cohort. Cure should not be expected, although prolonged disease and treatment-free survival may be observed.

[This corrects the article DOI: 10.1016/j.ekir.2017.10.017.].

SummaryHyperprolactinaemia is a common endocrine disorder that can be associated with significant morbidity. Antipsychotic medications are frequently linked to hyperprolactinaemia. This disorder usually presents as menstrual problems in women and sexual problems in men, which affect the patients' quality of life and adherence to antipsychotic treatment. In the past, treatment for hyperprolactinaemia was recommended only for symptomatic patients. However, it has become clear that persistent asymptomatic hyperprolactinaemia can be associated with long-term physical morbidities such as osteoporosis and possibly breast cancer. Hence, it is imperative that hyperprolactinaemia is managed even if asymptomatic when initially detected. This article discusses the various management options, such as reducing the dose of antipsychotic medication, switching to a prolactin-sparing antipsychotic and adding aripiprazole to the treatment regimen.Learning Objectives• Understand the physiology of the prolactin hormone• Be able to judge when to intervene if a patient on an antipsychotic medication presents with hyperprolactinaemia• Learn about the different treatment options

Summary Background The use of electroconvulsive therapy (ECT) is limited by concerns about its cognitive adverse effects. Preliminary evidence suggests that administering the glutamate antagonist ketamine with ECT might alleviate cognitive adverse effects and accelerate symptomatic improvement; we tested this in a randomised trial of low-dose ketamine. Methods In this multicentre, randomised, parallel-group study in 11 ECT suites serving inpatient and outpatient care settings in seven National Health Service trusts in the North of England, we recruited severely depressed patients, who were diagnosed as having unipolar or bipolar depressive episodes defined as moderate or severe by DSM-IV criteria, aged at least 18 years, and were able and willing to provide written consent to participate in the study. Patients were randomly assigned (1:1) to ketamine (0·5 mg/kg intravenous bolus) or saline adjunctive to the anaesthetic for the duration of their ECT course. Patients and assessment and ECT treatment teams were masked to treatment allocation, although anaesthetists administering the study medication were not. We analysed the primary outcome, Hopkins Verbal Learning Test-Revised delayed verbal recall (HVLT-R-DR) after four ECT treatments, using a Gaussian repeated measures model in all patients receiving the first ECT treatment. In the same population, safety was assessed by adverse effect monitoring. This trial was registered with International Standard Randomised Controlled Trial Number, number ISRCTN14689382. Findings Between early December, 2012, and mid-June, 2015, 628 patients were screened for eligibility, of whom 79 were randomly assigned to treatment (40 in the ketamine group vs 39 in the saline group). Ketamine (mean 5·17, SD 2·92), when compared with saline (5·54, 3·42), had no benefit on the primary outcome (HVLT-R-DR; difference in means −0·43 [95% CI −1·73 to 0·87]). 15 (45%) of 33 ketamine-treated patients compared with 10 (27%) of 37 patients receiving saline experienced at least one adverse event which included two (6%) of 33 patients who had ketamine-attributable transient psychological effects. Psychiatric adverse events were the most common in both groups (six [27%] of 22 adverse events in the ketamine group vs seven [54%] of 13 in the saline group). Interpretation No evidence of benefit for ketamine was found although the sample size used was small; however, the results excluded greater than a small to moderate benefit with 95% confidence. The results do not support the use of adjunctive low-dose ketamine in routine ECT treatment. Funding National Institute for Health Research (NIHR) Efficacy and Mechanism Evaluation (EME) programme, an MRC and NIHR partnership.

Introduction: Being able to counter immune-mediated rejection has for decades been the single largest obstacle for the progress of vascular composite allotransplantation (VCA). The human immune system performs the key role of differentiating the ‘self’ from the ‘non-self’. This, although is quintessential to eliminate or resist infections, also resists the acceptance of an allograft which it promptly recognises as ‘non-self’. Materials and Methods: Pre-operative evaluation of the recipient evaluation included immunological assessment in the form of panel reactive antibodies (PRA), human leucocyte antigen (HLA) typing, donor-specific antibody detection assays (DSA) and complement-dependent cytotoxicity assays (CDC). Induction immunosuppression was by thymoglobulin and the maintenance by the standard triple-drug therapy. Results: Both the recipients were managed by the standard triple drug therapy and have had only minor episodes of rejections thus far which have been managed appropriately. Discussion: Induction immunosuppression was by thymoglobulin and the maintenance by the standard triple-drug therapy. Various groups have tried various other formulations and regimes as well. Conclusion: A comprehensive plan has to be drawn up for immunological screening, selection and the post-operative immunosuppressant usage. The ultimate goal of these immunosuppression modalities is to achieve a state of donor-specific tolerance.

Traumatic head injuries are often encountered in the emergency triage, and usually these patients have open head injuries or traumatic pneumocephalus secondary to base of skull fractures. The first line of management involves conservative approaches that include the use of carbonic anhydrase inhibitors, loop diuretics, and, occasionally, lumbar CSF diversion techniques. Surgical intervention is considered once conservative management fails after 2 weeks of institution of conservative management. Here, we discuss the various clinical scenarios, clinical presentation, treatment dilemmas, and possible complications in patients with traumatic pneumocephalus.

Fourth ventricular dilatation is usually seen along with tri-ventriculomegaly in patients with communicating hydrocephalus. Isolated fourth ventricular dilatation is uncommon, especially as a sequelae following infective or post hemorrhagic communicating hydrocephalus. Communicating hydrocephalus is reported in vestibular schwannoma with an incidence of 3.7 to 23.5%, but 4th ventricular dilatation following its treatment has not been reported in the literature. We report a novel case of isolated fourth ventricular obstruction following surgery for recurrent vestibular schwannoma and ventriculoperitoneal shunt placement for communicating hydrocephalus. Management strategies range from endoscopic procedures to ventricular shunt placement. We describe the surgical technique for the placement of a fourth ventricular shunt with the use of a Y connector.

INTRODUCTION AND OBJECTIVES:There remains a perception that cystectomy following prior pelvic irradiation (PPI) confers worse outcomes. With the increasing experience in robot assisted cystectomy (...

INTRODUCTION AND OBJECTIVES:With increasing experience in robot assisted cystectomy (RAC), it remains unclear whether it should be adopted as the preferential technique in patients with prior pelvi...

Inflammation plays a role in secondary brain injury after intracerebral haemorrhage (ICH). Peripheral biomarkers of inflammation especially the neutrophil-to-lymphocyte ratio (NLR) have been shown to influence outcome following ischemic stroke and traumatic brain injury. Role of NLR in outcome prognostication following haemorrhagic stroke has not yet been conclusively established. This study analyses the prognostic significance of admission neutrophil to lymphocyte ratio on mortality and 90-day outcome in patients admitted with acute SICH.A total of 851 patients with spontaneous ICH were retrospectively investigated. Admission haematological parameters were retrieved from our hospital laboratory systems and NLR was then calculated using the formula ANC/ALC. (Absolute neutrophil count/Absolute lymphocyte count) Clinical outcome was assessed by modified Rankin Scale at 90 days. Logistic regression was performed to identify independent risk factors of mortality and 90-day outcome. Receiver operator curve (ROC) test was used to determine the predictive value of NLR for 30-day death.A total of 851 patients enrolled in the study. Our 30 day and 90 day mortality were 125 (17.7 %) and 244 (28.7 %) respectively. The mean NLR in the entire cohort was 9.03 ± 7.6. NLR was significantly higher in the mortality group compared to the survivors (11.98 ± 9.91 vs 8.52 ± 7.05) P 0.001. NLR in patients with a good outcome at 90 days (7.21 ± 6.06) was a lower in comparison to patients with poor outcome(10.66 ± 8.48).(p=0.001). NLR was dichotomised at 8.2 which was computed based on ROC curve. Mortality and poor outcome were higher in the NLR 8.2 group at 140 (40.1 %) and 23 (67.8 %) respectively (p 0.001). Age, GCS 8, Volume of Hematoma, Intra ventricular extension of hematoma and NLR 8.2 were found to be independent predictors of outcome. GCS 8 had a greater predictive value (5.236) compared to NLR.8.2 (1.78).Elevated levels of admission NLR were independently related to poor mortality and 90-day outcome after ICH. NLR is a novel, easily available and cost effective prognostic biomarker following ICH.

Sylvian arachnoid cysts pose considerable management dilemmas. Surgical options include cyst fenestration, either endoscopically or microsurgically, and cysto-peritoneal shunt. One of the rare complications after rapid decompression of the arachnoid cysts is haemorrhage in the surrounding brain as well as in remote areas. We describe a case of multiple remote-site intra-parenchymal haemorrhage as a rare complication after surgical decompression of a sylvian fissure arachnoid cyst.

Robot assisted radical cystectomy (RARC) and totally intracorporeal neobladder (ICNB) reconstruction remains a challenge. Despite the potential advantages of RARC, which include decreased blood loss, quicker return to bowel function, reduced analgesic requirements and decreased wound complications (1); ICNB reconstruction is not without its shortcomings.

Epilepsy surgery has been rapidly progressing over the last decade or so, with many previously untreatable conditions now satisfactorily managed to allow improved quality of life and seizure control without excessive medication and debilitating neurological deficits. We present a brief recap on accepted axioms of epilepsy surgery with a look at the future with a short summary of seizure disorder itself and the various management options. The article is directed at general physicians and Internalists who deal with epilepsy on a daily basis. Many have been exasperated by drug recalcitrant epilepsy and have tried with limited success to manage the condition medically. Many are not aware of the speciality of epilepsy surgery, which as mentioned above has made great strides in seizure control over the last decade. The piece also adds emphasis on diagnosis, seizure semiology and detection along with post procedure analysis and evaluation of efficacy. This has been added to assist the general physician in assessing the disease appropriately and referring the disease correctly to ensure proper diagnosis and treatment early. The authors hope that this piece helps sensitise the physicians to the existence of epilepsy surgery, so that they will refer their patient more and more to neurosurgeons for better care and results to their patients.