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The number of protein structures is increasing due to the individual initiatives and rapid development of structure determination techniques. Structure-based sequence alignments of distantly related proteins enable the investigation of structural, evolutionary and functional relationships between proteins and their domains leading to their common evolutionary origin. Protein Alignments organized as Structural Superfamilies (PASS2) is a database that provides such alignments of members of protein domain superfamilies of known structure and with less than 40% sequence identity. PASS2 has been continuously updated in accordance to Structural Classification of Proteins (SCOP), and now Structural Classification of Proteins - extended (SCOPe). The current update directly corresponds to SCOPe 2.06, dealing with 2006 domain superfamilies of known structure and about 14 000 domains. Alignments have been augmented by features such as hidden Markov models, highly conserved residues, structural motifs and gene ontology terms, which are available for download. In this update, we introduce the concepts of ‘extreme structural outliers’ and ‘split superfamilies’ as well.

The elimination of noise from images becomes a trending field in image processing. Imagesmay got corrupted by random change in pixel intensity, illumination, or due to poor contrast and can't be used directly. Therefore, it is necessary to get rid of impulse noise presented inan image. In order to remove such impulse noise, Median based filters are commonly used. However, we use various types of median filters such as recursive median filter, iterative median filter, directional median filter, weighted median filter, adaptive median filter progressive switching median filter and threshold median filter. This paper will survey various median filtering techniques for excluding noisy pixel from a digital image.

Background: Rhabdomyolysis, which can be defined as a CPK level greater than five times the upper limit of normal, is related to muscle breakdown and hypovolemia in heat stroke patients.1 CPK levels will likely be higher because of increased muscle breakdown in exertional heat stroke when compared with classic heat stroke. Methods: We reviewed 50 patients who came into the Emergency Department of Hamad General Hospital during the months of July to September 2015, and who were diagnosed with exertional heat stroke. Results: In 44 out of 50 heat stroke patients, the level of serum CPK was markedly elevated (mean 20,300 ± 25,500 U/l) compared with the elevated levels of other lab values (serum myoglobin 2500 ± 3000 ng/ml, creatinine 1.8 ± 2.4 mg/dL, BUN 90 ± 104 mg/dL, potassium 2.6 ± 3.6 mEq/L, sodium 135 ± 155 mEq/L) on admission. The repeated lab values after the 12th hour showed that the CPK rose further (28,500 ± 32,500 U/L) while the others (serum myoglobin 800 ± 1,200 ng/ml, creatinine 1.1 ± 1.4 mg/dl, BUN 35 ± 60 mg/dL, potassium 2.2 ± 3.4 mEq/L, sodium 110 ± 130 mEq/L) recorded a decrease. Conclusion: In our cohort of patients, CPK levels were significantly high in the setting of exertional heat stroke. A possible relation to renal failure need to be explored in a prospective research design. Keywords: exertional heat stroke, rhabdomyolysis, creatinine phosphokinase REFERENCE: [1] Santelli J, Sullivan J. An evidence based approach on emergency medicine. Emerg Med Prac. 2014;16:6–15.

Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE To determine the feasibility, instrumentation, and learning curve for single-port laparoscopic partial nephrectomy (SPLPN) in a pig model. MATERIALS AND METHODS Ten transumbilical SPLPN were performed using the R-Port (Advanced Surgical Concepts, Wicklow, Ireland) multi-instrument port, a 5-mm flexible laparoscope (Olympus Surgical, Orangeburg, NY, USA), and custom-engineered articulating needle drivers, graspers, and scissors (Cambridge Endo, Framingham, MA, USA). After general anaesthesia, the pig was placed in the flank position. After umbilical placement of the R-Port, Gerota’s fascia was incised and hilar dissection performed with the newly engineered articulating instruments. Either the upper or lower pole of the kidney was scored and excised after placing a bulldog clamp on the renal pedicle. The bolsters were prepared with absorbable haemostat, placed at the site of excision, and secured with polyglactin sutures. RESULTS A fascial incision of ≥2.5 cm should be made to allow adequate room for passing the instruments. Also, use of the 5 mm flexible laparoscope minimizes instrument crowding and allows for optimal visualization. The mean (sd, range) time for hilum dissection was 12.2 (4.3, 7–20) min, while that for total excision was 9.8 (1.7, 8–12) min. Modified suturing techniques were developed to achieve reconstruction in a small working space. Specialized instrumentation is essential for a successful SPLPN with no need for an additional port for triangulation. The mean duration of intracorporeal suturing was 27.7 min (declining from 40 to 15 min). The total ischaemia time decreased from 50 min in the first case to 27 min in the last (mean 37.4 min). The mean estimated blood loss was 81.1 (31.7, 50–150) mL. CONCLUSIONS SPLPN is technically feasible but further refinement of instrumentation and techniques is needed to decrease the ischaemia time and optimize the procedure.

We evaluated the feasibility and outcomes of performing a novel laparoscopic adhesiolysis technique before robot-assisted laparoscopic radical prostatectomy (RALRP) in patients with previous abdominal surgery.A total of 18 men with incision scars from previous abdominal surgeries underwent RALRP. A 12-mm trocar was placed at the lateral lower quadrant away from the incision site, and a teaching laparoscope was introduced into the peritoneal cavity. Meticulous adhesiolysis was performed through a single trocar to subsequently allow safe placement of additional robotic trocars. Age, type of previous surgery, total operative time, console time, anastomosis time, estimated blood loss, transfusion rate, complications, and conversion rate were recorded.All patients had multiple abdominal surgeries. Mean operative time was 297 minutes, mean console time was 194 minutes, and mean estimated blood loss was 241 mL. No access-related complication and no conversion to open surgery occurred.This novel laparoscopic technique of adhesiolysis with a teaching laparoscope through a single trocar facilitates safe placement of trocars and accomplishment of RALRP in patients with previous abdominal surgery.

We compared and evaluated the objective characteristics (deflection characteristics, field of view and flow rate) of a disposable flexible ureteroscope and 6 established, commercially available flexible ureteroscopes.Six commonly used ureteroscopes, including Olympus URF-P3, Storz(R) 11278AU and 11274AAU, ACMI DUR-8 Elite and DUR-8, and Wolf 7331.001 (Richard Wolf Medical Instruments, Vernon Hills, Illinois), were compared with the recently introduced SemiFlex Scope disposable flexible ureteroscope. Specifications and purchase costs were acquired from each manufacturer. The disposable ureteroscope consisted of a reusable eyepiece and a semiflexible shaft with a 3.3Fr working channel. Active tip deflection was measured with and without the 3Fr basket, the 365 mum laser fiber and the 3Fr forceps. The flow rate and field of view of each scope were evaluated.Active tip deflection (down/up) was highest in the disposable ureteroscope at 300/265 degrees. Although deflection was decreased by inserting the different endoscopic tools in all ureteroscopes, the disposable ureteroscope had the highest loss in flexion characteristics (35.7% down and 39.3% up). The flow rate, measured at 25 ml per minute in the disposable ureteroscope, was significantly lower than that of other ureteroscopes. The disposable ureteroscope had a 72-degree field of view, comparable to the optical characteristics of the other scopes. Compared to the other 6 flexible ureteroscopes the purchase price of the disposable scope was significantly lower and no further maintenance/repair expenses were required.The disposable flexible ureteroscope has acceptable active tip deflection, field of view and flow rate compared to those of other flexible ureteroscopes on the market. Further evaluation of surgical outcomes will help delineate the definitive usefulness of the disposable flexible ureteroscope.

To determine the role of laparoscopy for large adrenal tumors in terms of outcomes, pathology, operative time, and morbidity.A retrospective review of 24 patients who underwent laparoscopic adrenalectomy was performed to record the size of the lesions, surgical techniques used, operative times, estimated blood loss, duration of hospital stay, need for blood transfusion, conversion to open surgery, and complications. The laparoscopic adrenalectomy patients were divided into two groups based on tumor size:8 cm (n = 16, group 1) andor=8 cm (n = 8, group 2).Mean tumor size was 5.6 cm for group 1 and 12.1 cm for group 2. Mean operative times were 143.12 and 188.75 minutes for groups 1 and 2, respectively. Mean estimated blood loss was 89.69 mL for group 1 and 334.38 mL for group 2. Operative time and blood loss were significantly higher in group 2. Pathologic examination revealed eight adrenal cortical adenomas, five myolipomas, four pheochromocytomas, four cysts/pseudocysts, and three adrenocortical hyperplasias. No significant difference was found between groups concerning transfusion rates, duration of hospital stay, and conversion to open surgery.Laparoscopic adrenalectomy is a feasible procedure for large masses but results in longer operative times and higher total blood loss when compared with results for masses smaller than 8 cm. Our findings suggest, however, that laparoscopic adrenalectomy for masses larger than 8 cm can produce comparable results concerning hospital stay, conversion to open surgery rate, and pathologic outcome in comparison with results for adrenal masses smaller than 8 cm.

We compared the surgical outcomes of robot assisted laparoscopic dismembered pyeloplasty in patients presenting with anterior crossing vessels with and without transposition of the crossing vessel.A total of 107 patients with ureteropelvic junction obstruction underwent robot assisted laparoscopic dismembered pyeloplasty. Evaluation of surgical success was based on validated pain scores, diuretic renography and imaging results, including excretory urography, computerized tomography or ultrasound.Anterior crossing vessels were identified in 48 patients (44.9%) and vessels were transposed in 18 (37.5%) (group 1). No transposition was performed in 30 patients (62.5%) (group 2). Mean radiological followup was 52.9 weeks in group 1 and 65.3 weeks in group 2 (p = 0.181). Mean pain score on a scale of 10 was 0.82 in group 1 and 0.74 in group 2 (p = 0.917). A Whitaker test performed in 3 patients with persistent pain was negative. Preoperatively mean differential function on the affected side was 35.1% in group 1 and 36.9% in group 2 (p = 0.133). Half-time was calculated as a mean of 46.3 minutes in group 1 and 49.4 minutes in group 2 (p = 0.541). In groups 1 and 2 mean postoperative differential function improved to 41.1% and 40.9%, and mean half-time improved to 7.43 and 8.03 minutes, respectively (p = 0.491). A comparison of preoperative and postoperative differential function, and half-time in each group showed a statistically significant difference. The radiographic and symptomatic success rate was 100% with no open conversion and recurrence.Comparison of robot assisted laparoscopic dismembered pyeloplasty outcomes revealed similar success rates in terms of the change in symptoms and renal function in patients with or without anterior crossing vessel transposition. Transposition of crossing vessel should only be performed when the anatomical relation dictates and it should be an intraoperative decision.

As more and more patients are living longer, they bring with them a host of chronic conditions. Often times, these comorbidities may prevent patients from being optimal candidates for the standard treatment for invasive or high-grade bladder cancer. This chapter briefly looks at some therapeutic surgical options for patients who are not ideal candidates for a prolonged radical cystectomy with concomitant reconstruction of the urinary tract.