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Background With the ongoing coronavirus disease (COVID-19) pandemic, along with the development of new mutations of the virus and an increase in the number of cases among pediatrics, physicians should be aware and alerted on the atypical presentations of the disease, especially in less expected individuals. Case presentation Here we present a 12-year-old obese boy (BMI = 37.5 kg/m2) who presented with empyema, which was following SARS-CoV-2 infection. The patient had no history of fever. Due to the onset of dyspnea, a chest tube was inserted for him which was later altered to a pleural drainage needle catheter. Conclusion Our case is the first report of COVID-19 presenting as empyema among pediatrics. Pleural empyema should be considered as a rare complication of COVID-19. Since there is still no guideline in the management of empyema in the context of COVID-19, delay in diagnosis and intervention may cause morbidity and mortality in children.

Although nearly a year has passed since the emerge of the SARS-CoV-2 virus, with it, a serious and novel pediatric condition called children's multisystem inflammatory syndrome (MIS-C) has subsequently emerged. In order to achieve a better understanding and management of the disease, documentation and reporting of atypical cases is justified, particularly with the growing number of children with inflammatory syndrome with clinical features simulating MIS during the ongoing COVID-19 pandemic. Based on similar reports from numerous countries with temporal relation to COVID-19 infection in the community, it is essential for general pediatricians to be on alert for such atypical presentations and early referral to tertiary care should be considered as appropriate. Here we four cases of Multisystem Inflammatory Syndrome (MIS) during the COVID-19 pandemic. Early diagnosis and treatment of patients meeting full or partial criteria for MIS are critical to preventing end-organ damage and other long-term complications, especially during times of public crisis and global health emergencies, such as the novel coronavirus pandemic.

Traditional ureteral access sheaths rely on tapered dilators and the Dotter principle of axial force to gain access into the ureter. We compared the performance of a novel balloon expandable ureteral access sheath using radial dilatation with that of a conventional ureteral access sheath.Ten farm pigs underwent randomized placement of the novel sheath in 1 ureter and a conventional ureteral access sheath in the contralateral ureter followed by videotaped ureteroscopy. Acute study end points included maximum and mean force of sheath insertion and removal, saline flow rate and subjective urothelial damage following sheath insertion/inflation. Additionally, blinded reviewers rated urothelial damage on digitally recorded video following sheath removal. Chronic data included gross and histological ureteral analysis at 30 days.The novel ureteral access sheath inserted with less maximum force (0.36 vs 1.48 pounds, p0.001) and less average force (0.11 vs 0.49 pounds, p = 0.001). The flow rate during 5 minutes was higher in the new sheath (90.0 vs 80.6 cc per minute, p0.05). Withdrawal forces were not statistically different between the sheaths. The novel sheath also had a lower subjective trauma scale rating (4.2 vs 6.1, p0.05). Eight blinded reviewers determined that the novel ureteral access sheath resulted in less total urothelial tear length (1.3 vs 2.7 cm, p = 0.03) and less visible ureteral damage in all animals except 1 (p = 0.04).The novel balloon expandable ureteral access sheath had easier insertion and a better flow rate, and caused less urothelial trauma in this porcine model. This ureteral access sheath offers a promising new option for ureteral access. A randomized clinical trial is in progress to assess the benefits of this new ureteral access sheath.

Prior research has demonstrated that counterintuitive laparoscopic surgical skills are enhanced by experience with video games. A similar relation with robotic surgical skills has not been tested. The purpose of this study was to determine whether prior video-game experience enhances the acquisition of robotic surgical skills.A series of 242 preclinical medical students completed a self-reported video-game questionnaire detailing the frequency, duration, and peak playing time. The 10 students with the highest and lowest video-game exposure completed a follow-up questionnaire further quantifying video game, sports, musical instrument, and craft and hobby exposure. Each subject viewed a training video demonstrating the use of the da Vinci surgical robot in tying knots, followed by 3 minutes of proctored practice time. Subjects then tied knots for 5 minutes while an independent blinded observer recorded the number of knots tied, missed knots, frayed sutures, broken sutures, and mechanical errors.The mean playing time for the 10 game players was 15,136 total hours (range 5,840-30,000 hours). Video-game players tied fewer knots than nonplayers (5.8 v 9.0; P = 0.04). Subjects who had played sports for at least 4 years had fewer mechanical errors (P = 0.04), broke fewer sutures (P = 0.01), and committed fewer total errors (P = 0.01). Similarly, those playing musical instruments longer than 5 years missed fewer knots (P = 0.05).In the extremes of video-game experience tested in this study, game playing was inversely correlated with the ability to learn robotic suturing. This study suggests that advanced surgical skills such as robotic suturing may be learned more quickly by athletes and musicians. Prior extensive video-game exposure had a negative impact on robotic performance.

OBJECTIVE To determine whether men previously diagnosed with prostatitis also have pathology originating in the bladder. PATIENTS, SUBJECTS AND METHODS We administered the pelvic pain and urgency/frequency (PUF) questionnaire and the potassium-sensitivity test (PST) to 50 patients with prostatitis presenting in urological and primary care, and to 14 controls. In a separate control group of 22 men, the urethra was irrigated with KCl or NaCl (11 each) before and after experimental injury of the urethral mucosa. RESULTS All 50 patients with prostatitis had PUF scores of ≥ 7; 77% were positive for the PST. All 14 controls had PUF scores of 1 or 0 and a negative PST. In the urethral irrigation study in controls, KCl but not NaCl provoked urethral pain after mucosal injury. Before injury, neither KCl nor NaCl caused symptoms. CONCLUSION The high rate of positive PST in patients with ‘classic’ prostatitis indicates that pathology originating in the bladder may be an important source of symptoms in most. In patients with prostatitis and female patients with interstitial cystitis, symptoms may arise not from separate disease entities but from a continuum of epithelial dysfunction and potassium cycling that may be present throughout the lower urinary tract.

Background Cardiac allograft vasculopathy (CAV) remains the leading cause of late mortality in heart transplant recipients. Activated T lymphocytes and macrophages infiltrate the donor heart before vascular intimal thickening develops, but the specific mediators of mononuclear cell recruitment leading to CAV are unknown. Therefore, we sought to define the relationship between chemokine gene expression and production, T lymphocyte and macrophage recruitment, and intimal thickening in a murine model of CAV. Methods B10.A or B10.BR strain hearts were transplanted heterotopically into B10.BR mice. Recipients were killed at 1, 4, 7, 14, and 30 days. Donor hearts were assayed for chemokine gene expression with ribonuclease protection and for protein with ELISA. Intragraft cellular infiltration was defined immunohistochemically. Intimal thickening was quantitated morphometrically. Results Early and late patterns of intragraft chemokine expression associated with distinct cellular infiltration were identified. First, transient MIP-2 and MCP-1/JE production in isografts and allografts correlated with neutrophil and macrophage infiltration. MCP-1/JE production and macrophage infiltration was greater in allografts than isografts. Second, allografts demonstrated sustained lymphotactin, RANTES, and IP-10 expression, beginning at day 4, correlating with persistent macrophage and T lymphocyte infiltration. Intimal thickening became evident at 14 days. Isografts did not display the late pattern of sustained chemokine gene expression, cellular infiltration, or intimal thickening. Conclusions Transient, early MIP-2, and MCP-1/JE production in isografts and allografts correlated with neutrophil and macrophage recruitment, and is likely related to ischemia-reperfusion. In allografts, the delayed induction of chemokines specific for macrophages and T lymphocytes correlated with mononuclear cell infiltration and preceded intimal thickening. This study thus demonstrates a dual pattern of chemokine induction correlating with intragraft mononuclear cell recruitment, associated with ischemia-reperfusion and CAV development. Chemokine-directed interventions may interfere with leukocyte trafficking and inhibit CAV development.

We compared laparoscopic and robotic pyeloplasty to identify factors associated with procedural efficacy.We conducted a retrospective multicenter trial incorporating 865 cases from 15 centers. We collected perioperative data including anatomical and procedural factors. Failure was defined subjectively as pain that was unchanged or worse per medical records after surgery. Radiographic failure was defined as unchanged or worsening drainage on renal scans or worsening hydronephrosis on computerized tomography. Bivariate analyses were performed on all outcomes and multivariate analysis was used to assess factors associated with decreased freedom from secondary procedures.Of the cases 759 (274 laparoscopic pyeloplasties with a mean followup of 15 months and 465 robotic pyeloplasties with a mean followup of 11 months, p0.001) had sufficient data. Laparoscopic pyeloplasty, previous endopyelotomy and intraoperative crossing vessels were associated with decreased freedom from secondary procedures on bivariate analysis, with a 2-year freedom from secondary procedures of 87% for laparoscopic pyeloplasty vs 95% for robotic pyeloplasty, 81% vs 93% for patients with vs without previous endopyelotomy and 88% vs 95% for patients with vs without intraoperative crossing vessels, respectively. However, on multivariate analysis only previous endopyelotomy (HR 4.35) and intraoperative crossing vessels (HR 2.73) significantly impacted freedom from secondary procedures.Laparoscopic and robotic pyeloplasty are highly effective in treating ureteropelvic junction obstruction. There was no difference in their abilities to render the patient free from secondary procedures on multivariate analysis. Previous endopyelotomy and intraoperative crossing vessels reduced freedom from secondary procedures.

Aim: Natural orifice approaches for nephrectomy have included access via the stomach, vagina, bladder, and rectum. The use of the ureter as a natural orifice for natural orifice translumenal endoscopic surgery (NOTES) nephrectomy has not previously been reported. The aim of this study was to test the feasibility of transureteral laparoscopic NOTES nephrectomy. Materials and Methods: Three female farm pigs (29.2–30.8 kg) were placed into the lithotomy position. A cystoscopically placed extra-stiff guide wire was used to place a prototype dilating sheath into the left ureter. After dilation of the ureter and urethra, the sheath was exchanged for a 12-mm bariatric laparoscopic trocar. A 10.5-inch-long, 10-mm offset operating laparoscope with an internal 5-mm working port was utilized for the nephrectomy. One 2-mm and one 2/3-mm port were placed transabdominally to facilitate in situ morcellation. The kidney was cut into slices using the bipolar device and extracted via the ureteral port using the ho...

Objectives: To address the significant shortage of kidneys available for transplant, laparoendoscopic single-site surgery (LESS) has been employed to further decrease the morbidity of kidney donation. To circumvent the complexity of LESS, we have developed a bridging hand-assisted LESS (BLESS) technique that allows the surgeon to gain experience with single-incision surgical techniques in the setting of traditional hand-assisted laparoscopy. Methods: A retrospective study of three patients undergoing BLESS donor nephrectomy was performed. Similar to LESS, this bridging technique employs a single periumbilical incision, but enlargement of the incision by a few centimeters facilitates immediate transition to hand-assisted laparoscopy if needed. Statistics on preoperative, perioperative, and postoperative variables was collected for the patients undergoing this procedure. Results: BLESS patients had a mean age of 31. Average postoperative hospital stay was short at 1.34 days, with two of the three p...

Natural orifice approaches for nephrectomy have included access via the stomach, vagina, bladder, and rectum. The use of the ureter as a natural orifice for natural orifice translumenal endoscopic surgery (NOTES) nephrectomy has not been previously reported. The purpose of this study is to test the feasibility of transureteral laparoscopic NOTES nephrectomy.Three female farm pigs (29.2-30.8 kg) were placed into the lithotomy position. A cystoscopically placed extra-stiff guidewire was used to place a prototype dilating sheath into the left ureter. After dilation of the ureter and urethra, the sheath was exchanged for a 12-mm bariatric laparoscopic trocar. A 10.5-inch long 10-mm offset operating laparoscope with an internal 5-mm working port was used for the nephrectomy. One 2-mm and one 2/3-mm port were placed transabdominally to facilitate in situ morcellation. The kidney was cut into slices using the bipolar device and extracted via the ureteral port using the housing of a 12-mm bariatric stapling device.All three transureteral nephrectomies were successfully completed. The total mean operative time was 220 minutes (range 113-346 min). Component portions of the procedure were: Ureteral access (mean 21 min), nephrectomy (mean 70 min), and kidney morcellation (mean 103 min). Mean estimated blood loss was 20 mL (range 5-50 mL). There were no intraoperative complications.This nonsurvival porcine feasibility study demonstrates the successful performance of transureteral nephrectomy. This approach shows promise as a way to decrease the invasiveness of NOTES nephrectomy by using the ureteral orifice as an access site.

Significant bleeding necessitating use of a tamponade balloon, embolization, or renal exploration is a rare but catastrophic complication after percutaneous nephrolithotomy (PCNL). The purpose of this study is to review the success of a novel, minimally invasive technique for controlling percutaneous tract bleeding that is refractory to conventional measures.A retrospective review was performed on four patients with refractory tract hemorrhage that was managed with a novel gelatin matrix hemostatic sandwich technique. In this technique, a 5F angiographic reentry catheter was placed through the kidney into the bladder and a 22F Councill-tip catheter balloon was passed over this catheter and positioned so that the inflated balloon would occlude the inner surface of the nephrostomy tract. Next, a 16F Councill-tip catheter was placed over a second wire so that the uninflated balloon was just underneath the skin surface. Gelatin matrix hemostatic sealant was then injected to fill the tract. Inflation of the outer balloon completely sealed the tract, completing the hemostatic sandwich.This technique was successfully applied to four patients with tract bleeding that would not stop with pressure or a conventional nephrostomy tube alone. The average estimated blood loss was 562 mL, and three of four patients avoided transfusion. All postoperative hemoglobin values stabilized within 2 days of surgery. There were no major or minor complications after use of this technique. No patients needed angioembolization or renal exploration.This novel hemostatic sandwich technique should be considered as an option for the control of refractory tract hemorrhage after PCNL.

Although radiation exposure from CT and plain film imaging has been characterized, the radiation received by patients during modern-era fluoroscopy has not been well described. The purposes of this study were to measure absolute organ and tissue-specific radiation doses during ureteroscopy and to determine the influence of body mass index (BMI) and sex on these doses.Eight cadavers underwent a simulated left ureteroscopy. Using a modern C-arm with automatic exposure control settings, thermoluminescent dosimeters were exposed for a fluoroscopy time of 145 seconds (mean time of clinical ureteroscopies from 2006 to 2008). Total tissue exposures were compared by BMI and between sexes using the Wilcoxon signed ranks test and the Mann-Whitney test with p0.05 considered significant.Among all cadavers, radiation doses were significantly lower in all contralateral organs excluding the gonad (p0.012). Doses were similar bilaterally in the gonad in cadavers with BMI30, and in all organs in cadavers with BMI30 (p0.05). There were significantly higher mean bilateral gonadal doses in female cadavers (3.4 mGy left and 1.9 mGy right) compared with male cadavers (0.36 mGy left and 0.39 mGy right). The highest cancer risk increase was seen at the posterior skin equivalent to 104 additional cancers per 100,000 patients.Contralateral doses were lower for all organs except the gonad when the BMI was30. In contrast, when the BMI was30, there was no difference in radiation dose delivered to the ipsilateral and contralateral organs. Gonadal doses were significantly higher in female cadavers. Modern-era fluoroscopy remains a significant source of radiation exposure and steps should be taken to minimize exposure during ureteroscopy.

During laparoscopic surgery, scissors are used to cut a variety of tissue, including fibrotic or calcified tissue, sutures, and occasionally tissue containing staples. Disposable scissors may become dull and ineffective. The purpose of this study is to compare the durability and ergonomics of three different brands of laparoscopic scissors.Three different laparoscopic scissors (Applied Medical Direct Drive, Ethicon Endosurgery Endopath, U.S. Surgical Auto Suture Endo Shear) were used in this study. Six of each type were compared in a variety of objective and subjective tests. Subjective testing included two surgeons' ratings of the scissors' ability to cut fresh tissue and tissue with staples. Twenty blinded volunteers also rated the cutting ability and ergonomics of the scissors. Objective data included high-resolution digital photography and scanning electron microscopy of the scissor blades to quantify the number of imperfections after use.All three new scissors easily cut fresh tissue. The Direct Drive performed significantly better when cutting staples, when cutting tissues after cutting staples, and in the combined overall comparison. Volunteers rated the cutting ability and ergonomics of the Direct Drive more desirable than the other brands. Further, high-resolution digital photography and scanning electron microscopy demonstrated significantly less damage to the Direct Drive. Finally, a reusable handle on the Direct Drive scissor resulted in a 53% and 59% cost savings compared with the Endopath and Endo Shear, respectively.All three types of scissors cut fresh tissue easily. The Direct Drive was significantly more durable, had better ergonomics, and was less expensive compared with the other two brands.