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Purpose: We sought to automate R.E.N.A.L. (for radius, exophytic/endophytic, nearness of tumor to collecting system, anterior/posterior, location relative to polar line) nephrometry scoring of preoperative computerized tomography scans and create an artificial intelligence-generated score (AI-score). Subsequently, we aimed to evaluate its ability to predict meaningful oncologic and perioperative outcomes as compared to expert human-generated nephrometry scores (H-scores). Materials and Methods: A total of 300 patients with preoperative computerized tomography were identified from a cohort of 544 consecutive patients undergoing surgical extirpation for suspected renal cancer at a single institution. A deep neural network approach was used to automatically segment kidneys and tumors, and geometric algorithms were developed to estimate components of R.E.N.A.L. nephrometry score. Tumors were independently scored by medical personnel blinded to AI-scores. AI- and H-score agreement was assessed using Lin's concordance correlation and their predictive abilities for both oncologic and perioperative outcomes were assessed using areas under the curve. Results: Median age was 60 years (IQE 51e68), and 40% were female. Median tumor size was 4.2 cm and 91.3% had malignant tumors, including 27%, 37% and 24% with high stage, grade and necrosis, respectively. There was significant agreement between H-scores and AI-scores (Lin's -0.59). Both AI- and Hscores similarly predicted meaningful oncologic outcomes (p <0.001) including presence of malignancy, necrosis, and high-grade and -stage disease (p <0.003). They also predicted surgical approach (p <0.004) and specific perioperative outcomes (p <0.05). Conclusions: Fully automated AI-generated R.E.N.A.L. scores are comparable to human-generated R.E.N.A.L. scores and predict a wide variety of meaningful patient-centered outcomes. This unambiguous artificial intelligence-based scoring is intended to facilitate wider adoption of the R.E.N.A.L. score. [ABSTRACT FROM AUTHOR]

Objective: Cure after adrenalectomy for primary aldosteronism has been reported in only 15% to 40% of patients, with no disease severity score available to measure response objectively. Furthermore, the criteria used to define cure are outdated. This study aims to determine the rate of cure based on the current definition of normal blood pressure and develop a disease severity score to measure clinical improvement after adrenalectomy for primary aldosteronism., Methods: This was a retrospective single-center study that included patients who underwent adrenalectomy for primary aldosteronism between 2000 and 2023. Blood pressure, a defined daily dose of antihypertensives, and potassium supplementation were incorporated into a new Primary Aldosteronism Disease Severity Score (PADSS), which was calculated with preoperative and 6-month postoperative parameters., Results: The study included 201 patients. Adrenalectomy was guided by adrenal venous sampling in 86.1% of patients. The cure rate per the new definition of normal blood pressure was 7.5% (n = 15). The median PADSS was 16.3 (13.6-19.9) preoperatively and decreased to 10 (4.5-13.3) postoperatively. An improvement of the PADSS was observed in 90% (n = 180) of patients at 6 months of adrenalectomy. The median rate of improvement in PADSS was 33.3% (13.8% to 56.6%)., Conclusions: Although complete cure rates are low after adrenalectomy in primary aldosteronism, especially based on the new definition of normal blood pressure, a clinical improvement is seen in the vast majority of patients postoperatively. The newly introduced PADSS can be used to assess the clinical benefit achieved with adrenalectomy., Competing Interests: Disclosureds The authors declare the following financial interests/personal relationships which may be considered as potential competing interests. Dr Eren Berber has consulting agreements with Ethicon, Medtronic, and Fluoptics. He has received honoraria for unrelated consulting work. Dr Dingfeng Li is an employee of BridgeBio, which is unrelated to the conduct of this study. The other authors do not have any disclosures., (Copyright © 2024 AACE. Published by Elsevier Inc. All rights reserved.)

Objective: To automate the generation of three validated nephrometry scoring systems on preoperative computerised tomography (CT) scans by developing artificial intelligence (AI)-based image processing methods. Subsequently, we aimed to evaluate the ability of these scores to predict meaningful pathological and perioperative outcomes., Patients and Methods: A total of 300 patients with preoperative CT with early arterial contrast phase were identified from a cohort of 544 consecutive patients undergoing surgical extirpation for suspected renal cancer. A deep neural network approach was used to automatically segment kidneys and tumours, and then geometric algorithms were used to measure the components of the concordance index (C-Index), Preoperative Aspects and Dimensions Used for an Anatomical classification of renal tumours (PADUA), and tumour contact surface area (CSA) nephrometry scores. Human scores were independently calculated by medical personnel blinded to the AI scores. AI and human score agreement was assessed using linear regression and predictive abilities for meaningful outcomes were assessed using logistic regression and receiver operating characteristic curve analyses., Results: The median (interquartile range) age was 60 (51-68) years, and 40% were female. The median tumour size was 4.2 cm and 91.3% had malignant tumours. In all, 27% of the tumours were high stage, 37% high grade, and 63% of the patients underwent partial nephrectomy. There was significant agreement between human and AI scores on linear regression analyses (R ranged from 0.574 to 0.828, all P < 0.001). The AI-generated scores were equivalent or superior to human-generated scores for all examined outcomes including high-grade histology, high-stage tumour, indolent tumour, pathological tumour necrosis, and radical nephrectomy (vs partial nephrectomy) surgical approach., Conclusions: Fully automated AI-generated C-Index, PADUA, and tumour CSA nephrometry scores are similar to human-generated scores and predict a wide variety of meaningful outcomes. Once validated, our results suggest that AI-generated nephrometry scores could be delivered automatically from a preoperative CT scan to a clinician and patient at the point of care to aid in decision making., (© 2024 BJU International.)

Objective: Achieving clear surgical margins is one of the primary surgical goals in treating oral squamous cell carcinoma (OSCC) and thus aiming to improve overall and disease-specific survival. Therefore, we developed the Goal-Oriented Assessment for Intraoperative Margin ('GAIM') protocol, a novel intraoperative approach for margin assessment, and present here our 5-year experience and outcomes., Methods: 'GAIM' is a 7-step procedure comprising systematic ruler-aided resection of labeled tumor-bed margins, frozen section (FS) co-produced by both pathologists and operating surgeons, and immediate extension of resection according to FS findings. Data from all patients operated using the 'GAIM' protocol at a single tertiary center between 2018 to 2022 were analyzed, including margin status on FS and final pathology (FP) records, recurrence, and mortality., Results: A total of 196 patients were included, 56.6% (n = 111) stages I-II, and 43.4% (n = 85) stages III-IV. Using the 'GAIM' protocol, we achieved an overall 94.4% of clean and revised clean surgical margins. Patients with a 2-year and longer follow-up (n = 141) had local recurrence in 3.5% when both FS and final margins were clean, 8.1% when FP margins were clean, and 16.7% with close/positive final margins., Conclusions: The proposed 'GAIM' protocol is a novel, effective, reproducible, and safe approach for margin evaluation that can be systematically applied. It can increase the rate of final clean surgical margins and potentially improve patients' outcomes., Level of Evidence: 3 Laryngoscope, 134:1725-1732, 2024., (© 2023 The Authors. The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: Define clinical spectrum and long-term outcomes of gut malrotation. With new insights, an innovative procedure was introduced and predictive models were established., Methods: Over 30-years, 500 patients were managed at 2 institutions. Of these, 274 (55%) were children at time of diagnosis. At referral, 204 (41%) patients suffered midgut-loss and the remaining 296 (59%) had intact gut with a wide range of digestive symptoms. With midgut-loss, 189 (93%) patients underwent surgery with gut transplantation in 174 (92%) including 16 of 31 (16%) who had autologous gut reconstruction. Ladd's procedure was documented in 192 (38%) patients with recurrent or de novo volvulus in 41 (21%). For 80 patients with disabling gastrointestinal symptoms, gut malrotation correction (GMC) surgery "Kareem's procedure" was offered with completion of the 270° embryonic counterclockwise-rotation, reversal of vascular-inversion, and fixation of mesenteric-attachments. Concomitant colonic dysmotility was observed in 25 (31%) patients., Results: The cumulative risk of midgut-loss increased with volvulus, prematurity, gastroschisis, and intestinal atresia whereas reduced with Ladd's and increasing age. Transplant cumulative survival was 63% at 10-years and 54% at 20-years with best outcome among infants and liver-containing allografts. Autologous gut reconstruction achieved 78% and GMC had 100% 10-year survival. Ladd's was associated with 21% recurrent/de novo volvulus and worsening (P > 0.05) of the preoperative National Institute of Health patient-reported outcomes measurement information system gastrointestinal symptom scales. GMC significantly (P ≤ 0.001) improved all of the symptomatology domains with no technical complications or development of volvulus. GMC improved quality of life with restored nutritional autonomy (P < 0.0001) and daily activities (P < 0.0001)., Conclusions: Gut malrotation is a clinicopathologic syndrome affecting all ages. The introduced herein definitive correction procedure is safe, effective, and easy to perform. Accordingly, the current standard of care practice should be redefined in this orphan population., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc.)

Activating alterations in PIK3CA , the gene coding for the catalytic subunit of phosphoinositide-3-kinase (PI3K), are prevalent in head and neck squamous cell carcinoma (HNSCC) and thought to be one of the main drivers of these tumors. However, early clinical trials on PI3K inhibitors (PI3Ki) have been disappointing due to the limited durability of the activity of these drugs. To investigate the resistance mechanisms to PI3Ki and attempt to overcome them, we conducted a molecular-based study using both HNSCC cell lines and patient-derived xenografts (PDXs). We sought to simulate and dissect the molecular pathways that come into play in PIK3CA-altered HNSCC treated with isoform-specific PI3Ki (BYL719, GDC0032). In vitro assays of cell viability and protein expression indicate that activation of the mTOR and cyclin D1 pathways is associated with resistance to PI3Ki. Specifically, in BYL719-resistant cells, BYL719 treatment did not induce pS6 and pRB inhibition as detected in BYL719-sensitive cells. By combining PI3Ki with either mammalian target of rapamycin complex 1 (mTORC1) or cyclin D1 kinase (CDK) 4/6 specific inhibitors (RAD001 and abemaciclib, respectively), we were able to overcome the acquired resistance. Furthermore, we found that PI3Ki and CDK 4/6 inhibitors have a synergistic anti-tumor effect when combined in human papillomavirus (HPV)-negative/PIK3CA-WT tumors. These findings provide a rationale for combining PI3Ki and CDK 4/6 inhibitors to enhance anti-tumor efficacy in HNSCC patients., Competing Interests: The authors declare no conflict of interest.

Background: Pouch prolapse is a rare pouch complication which often leads to pouch failure in inflammatory bowel disease (IBD) patients. Its exact cause remains unknown. Floppy pouch complex (FPC) was defined as the presence of any one of the following pouch disorders: pouch prolapse, afferent limb syndrome (ALS), redundant loop, and pouch folding. We aimed to explore the role of peripouch fat area in the occurrence of pouch prolapse and FPC., Methods: Pouch patients with available pouchoscopy and abdominal CT scans who were followed up between 2011 and 2017 in Cleveland Clinic were reviewed. Peripouch fat was measured on CT images., Results: Of the 93 included patients, 31 were females; 87 had J pouches and 6 had S pouches. The median duration of pouch was 8.0 (interquartile range [IQR] 5.0-16.5) years. A total of 18 cases (19.4%, 18/93) were identified as FPC, including 12 pouch prolapse, 5 ALS, 1 redundant loop, and 3 pouch folding. Patients with pouch prolapse had lower peripouch fat area (13.6 (9.3-18.5) vs. 27.6 (11.0-46.2)cm 2 , P = 0.022) than those without. Patients with FPC had lower peripouch fat area (15.4 (11.4-20.6) vs. 27.6 (11.0-46.9)cm 2 , P = 0.040) than those without. Univariate and multivariate analyses demonstrated that lower peripouch fat area, lower weight, and family history of IBD were independent predictors of pouch prolapse and FPC., Conclusions: A lower peripouch fat area was observed in inflammatory bowel disease patients with pouch prolapse and FPC. Longitudinal studies are needed to further elucidate the role of peripouch fat in the pathogenesis of pouch prolapse and FPC.

This article proposes a consensus nomenclature for fat-containing renal and adrenal masses at MRI to reduce variability, improve understanding, and enhance communication when describing imaging findings. The MRI appearance of "macroscopic fat" occurs due to a sufficient number of aggregated adipocytes and results in one or more of: 1) intratumoral signal intensity (SI) loss using fat-suppression techniques, or 2) chemical shift artifact of the second kind causing linear or curvilinear India-ink (etching) artifact within or at the periphery of a mass at macroscopic fat-water interfaces. "Macroscopic fat" is most commonly observed in adrenal myelolipoma and renal angiomyolipoma (AML) and only rarely encountered in other adrenal cortical tumors and renal cell carcinomas (RCC). Nonlinear noncurvilinear signal intensity loss on opposed-phase (OP) compared with in-phase (IP) chemical shift MRI (CSI) may be referred to as "microscopic fat" and is due to: a) an insufficient amount of adipocytes, or b) the presence of fat within tumor cells. Determining whether the signal intensity loss observed on CSI is due to insufficient adipocytes or fat within tumor cells cannot be accomplished using CSI alone; however, it can be inferred when other imaging features strongly suggest a particular diagnosis. Fat-poor AML are homogeneously hypointense on T 2 -weighted (T 2 W) imaging and avidly enhancing; signal intensity loss at OP CSI is uncommon, but when present is usually focal and is caused by an insufficient number of adipocytes within adjacent voxels. Conversely, clear-cell RCC are heterogeneously hyperintense on T 2 W imaging and avidly enhancing, with the signal intensity loss observed on OP CSI being typically diffuse and due to fat within tumor cells. Adrenal adenomas, adrenal cortical carcinoma, and adrenal metastases from fat-containing primary malignancies also show signal intensity loss on OP CSI due to fat within tumor cells and not from intratumoral adipocytes. Level of Evidence: 5 Technical Efficacy Stage: 3 J. Magn. Reson. Imaging 2019;49:917-926., (© 2019 International Society for Magnetic Resonance in Medicine.)

Purpose: Acute kidney injury often leads to chronic kidney disease in the general population. The long-term functional impact of acute kidney injury observed after partial nephrectomy has not been adequately studied., Materials and Methods: From 2004 to 2014 necessary studies for analysis were available for 90 solitary kidneys managed by partial nephrectomy. Functional data at 4 time points included preoperative serum creatinine, peak postoperative serum creatinine, new baseline serum creatinine 3 to 12 months postoperatively and long-term followup serum creatinine more than 12 months postoperatively. Adjusted acute kidney injury was defined by the ratio, observed peak postoperative serum creatinine/projected postoperative serum creatinine adjusted for parenchymal mass loss to reveal the true effect of ischemia. The long-term change in renal function (the long-term functional change ratio) was defined as the most recent glomerular filtration rate/the new baseline glomerular filtration rate. The relationship between the grade of the adjusted acute kidney injury and the long-term functional change was assessed by Spearman correlation analysis and multivariable regression., Results: Median patient age was 64 years and median followup was 45 months. Median parenchymal mass preservation was 80%. Adjusted acute kidney injury occurred in 42% of patients, including grade 1 injury in 20 (22%) and grade 2/3 in 18 (20%). On univariable analysis the degree of the adjusted acute kidney injury did not correlate with the long-term glomerular filtration rate change (p = 0.55). On multivariable analysis adjusted acute kidney injury was not associated with a long-term functional change (p >0.05) while diabetes and warm ischemia were modestly associated with a long-term functional decline (each p <0.05)., Conclusions: Acute kidney injury after partial nephrectomy was not a significant or independent predictor of long-term functional decline in our institutional cohort. A prospective study with larger sample sizes and longer followup is required to evaluate factors associated with long-term nephron stability., (Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate contact surface area (CSA) between the tumor and parenchyma as a predictor of ipsilateral parenchyma and function preserved after partial nephrectomy (PN). Previous studies suggested that CSA is a strong predictor of functional outcomes but the limitations of CSA have not been adequately explored., Patients and Methods: Four hundred nineteen patients managed with standard PN for solitary tumor with necessary studies to evaluate and analyze ipsilateral preoperative or postoperative parenchymal mass and function. Parenchymal mass and CSA were measured using contrast-enhanced computed tomography <2 months prior and 3-12months after PN. CSA was calculated: 2πrd, where r = radius and d = intraparenchymal depth. Pearson-correlation evaluated relationships between CSA and ipsilateral parenchymal mass or function preserved. Multivariable regression assessed predictors of function preserved. Conceptually, the CSA paradigm should function better for exophytic tumors than endophytic ones., Results: Median tumor size was 3.5 cm and R.E.N.A.L. was 8. Median global and ipsilateral glomerular filtration rate preserved were 89% and 79%, respectively. Median ipsilateral parenchymal mass preserved was 85% and significantly higher for exophytic masses (P = .001). Median CSA was 22.8 cm 2 and significantly less for exophytic masses (P = .02). CSA associated with both ipsilateral function and mass preserved (both P < .05), but the correlations were only modest (r = 0.25 and 0.36, respectively). On multivariable analysis, CSA associated with function preserved for exophytic masses (P = .01), but not for endophytic ones (P = .27)., Conclusion: CSA associates with functional outcomes after standard PN, although the strength of the correlations was modest, unlike previous studies, and CSA was not an independent predictor for endophytic tumors. Further study will be required to evaluate the utility of CSA in various clinical settings., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: There are no published studies on the impact of peripouch fat on pouch outcomes in inflammatory bowel disease (IBD) patients., Methods: Patients with pelvic MRI-DIXON scans from our prospectively maintained Pouch Database between 2002 and 2016 were evaluated. Peripouch fat area was measured on MRI-DIXON-F images at the middle height level of the pouch (area M) and the highest level of the pouch (area H)., Results: Of all 1863 patients in the database, 197 eligible patients were included in this study. The median of area M was 52.4 cm2, so the 197 patients were classified into 2 groups: group 1 (Area-M <52.4 cm2) and group 2 (Area-M ≥52.4 cm2). Compared with group 1, group 2 was found to have thicker perianal fat, more Caucasian and more males. Group 2 also had a higher Area-H, more weight, height, and body mass index, along with greater age at IBD diagnosis, age at pouch construction and pouch age, and a higher frequency of total pouch complication (86.7% versus 66.7%, P = 0.001), chronic pouch complication (68.4% versus 51.5%, P = 0.016), and chronic antibiotic-refractory pouchitis (16.3% versus 7.1%, P = 0.043). Multivariate logistic analysis showed that Area-M was an independent risk factor for chronic antibiotic-refractory pouchitis (odds ratio [OR]: 1.025; 95% confidence interval [CI]: 1.007-1.042, P = 0.005). The 22 patients with 2 or more pelvic MRI-DIXON scans were further classified into 2 groups by the change from the initial to latest MRI-DIXON scans. Patients with Area-M increase ≥10% and Area-M/height increase ≥10% were found to have shorter pouch survivals than those with increase <10%., Conclusions: A new method was established for measuring peripouch fat using pelvic MRI-DIXON-F image. Our study suggests that accumulation of peripouch fat may be associated with poor outcomes in selected IBD patients suspected of inflammatory or mechanical disorders of the pouch. Whether this association is causal warrants further investigation.

Purpose: Parenchymal mass loss is the predominant factor associated with functional outcomes after partial nephrectomy. It is primarily due to excised and/or devascularized parenchymal mass. We evaluated the importance of excised and devascularized parenchymal mass relative to functional recovery after partial nephrectomy., Materials and Methods: In 168 patients who underwent partial nephrectomy the necessary studies were done to determine excised and devascularized parenchymal mass, and evaluate parenchymal mass changes and functional loss of the operated kidney. Parenchymal mass loss in the ipsilateral kidney was measured on contrast enhanced computerized tomography less than 2 months before and 3 to 12 months after partial nephrectomy. Excised parenchymal mass was estimated by subtracting tumor volume from specimen volume. Devascularized parenchymal mass was defined as total parenchymal mass loss minus excised parenchymal mass. We used the Pearson correlation to evaluate relationships between glomerular filtration rate preservation and parenchymal mass loss. Multivariable analysis was done to assess factors associated with devascularized parenchymal mass., Results: Median tumor size was 3.4 cm and median R.E.N.A.L. (radius, exophytic/endophytic tumor properties, nearness of tumor to collecting system or sinus, anterior/posterior and location relative to polar lines) score was 7. Warm and cold ischemia was used in 100 and 68 patients, respectively. Median excised parenchymal and devascularized parenchymal mass was 9 and 16 cm 3 , respectively (p <0.001). Total parenchymal mass loss and devascularized parenchymal mass were associated strongly with glomerular filtration rate preservation in the operated kidney (each r ≥0.55, p <0.001). However, excised parenchymal mass was only weakly associated with functional outcomes (r = 0.23). The preoperative glomerular filtration rate and endophytic status were associated with devascularized parenchymal mass on multivariable analysis., Conclusions: To our knowledge we report the first study to specifically evaluate the relative contributions of devascularized and excised parenchymal mass to functional recovery after partial nephrectomy. Our study suggests that devascularized parenchymal mass has more impact, which may have implications regarding surgical technique. Prospective study is required to further evaluate the relative contributions of excised and devascularized parenchymal mass in various settings., (Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

A total of 27 pouch patients with inflammatory bowel diseases, who underwent pelvic MRI-DIXON and CT scan within one year, were included. Peripouch fat areas were measured at the middle height level of pouch (AreaM) and the highest level of pouch (AreaH). Our results demonstrated that measurements of perianal fat thickness, AreaM and AreaH based on MRI image were accurate and reproducible (correlation efficiency(r): intraobserver: 0.984-0.991; interobserver: 0.969-0.971; all P < 0.001). Bland-Altman analysis showed that more than 92.593% (25/27) of dots fell within the limits of agreement. We also identified strong agreements between CT and MRI image in measuring perianal fat thickness(r = 0.823, P < 0.001), AreaM (r = 0.773, P < 0.001) and AreaH (r = 0.862, P < 0.001). Interchangeable calculating formula to normalize measurements between CT and MRI images were created: Thickness&#95;CT = 0.610 × Thickness&#95;MRI + 0.853; AreaM&#95;CT = 0.865 × AreaM&#95;MRI + 1.392; AreaH&#95;CT = 0.508 × AreaH&#95;MRI + 15.001. In conclusion, pelvic MRI image is a feasible and reproducible method for quantifying peripouch fat. Pelvic MRI and CT images are interchangeable in retrospective measurements of peripouch fat, which will foster future investigation of the role of mesentery fat in colorectal diseases.

Objectives: The aim of this study was to determine the association of visceral adiposity with severe outcomes in acute pancreatitis (AP)., Methods: This retrospective study included consecutive patients with AP admitted to a tertiary care hospital between January 2010 and January 2015 who underwent a computed tomography scan. The visceral adipose tissue (VAT) volume was estimated using the method of Linder and colleagues. Multivariable logistic regression analysis was conducted to assess VAT as a predictor of severe AP compared with other validated predictors of severity., Results: Five hundred and seventy four patients were admitted during the study period, of which 252 had a computed tomography scan available. Patients with severe AP had a larger VAT area compared with those with mild or moderate AP (mean: 184.9 cm vs 79.9 cm, P = 0.006). Patients who developed multisystem organ failure or had acute necrotic collections had a larger VAT area than those who did not (150.6 cm vs 91.0 cm, P = 0.004 and 174.0 cm vs 91.9 cm, P = 0.003, respectively). Visceral adipose tissue area demonstrated superior discrimination of severe AP compared with other severity predictors., Conclusions: Increased VAT area is a strong predictor of severe pancreatitis, necrosis, and multisystem organ failure.

Objective: Sarcopenia, or the age-related loss of skeletal muscle mass and function, has been investigated as a potential marker of adverse outcomes among surgical patients. Our aim was to assess for changes in psoas muscle volume (PMV) following administration of neoadjuvant chemotherapy (NAC) in patients with bladder cancer and to examine whether changes in PMV following NAC are predictive of perioperative complications, pathologic response or survival. Methods: During the period of 2009-2013, patients undergoing NAC and radical cystectomy (RC) at our institution with pre and post NAC cross sectional images available were included. Bilateral total psoas muscle volume (PMV) was obtained from pre- and post- NAC images and the proportion of PMV change was calculated by dividing the change PMV by pre-NAC PMV. Analyses for the assessment of factors predicting PMV loss, partial/complete pathologic response (pPR/pCR), complications, readmission, cancer specific (CSS), recurrence-free (RFS) and overall survival (OS) were performed. Results: Total of 60 patients had complete radiological data available. Post-NAC PMV and BMI declines were statistically significant, 4.9% and 0.05%, respectively. NAC dose reduction/delay was a significant predictor of PMV loss (coefficient B 4.6; 95% CI 0.05-9.2; p  = 0.047). The proportion of PMV decline during NAC was not a predictor of pPR, pCR, complications, readmission, CSS, RFS, or OS. Conclusions: We observed an interval decline in PMV during the period of NAC administration and this decline was more than it could be appreciated with changes in BMI during the same period. PMV decline was associated with the need for dose reduction/dose delay during NAC. In our series, PMV changes occurring during NAC administration were not predictive of pathologic response to chemotherapy, postoperative complications or survival.

Background: Proteinuria is included in the Kidney Disease: Improving Global Outcomes (KDIGO) risk stratification for chronic kidney disease (CKD) in the general population. However, the importance of proteinuria in patients with renal cancer has not been adequately studied., Objective: To evaluate the prognostic impact of preoperative proteinuria on overall survival (OS) and renal function stability (RFS) for patients managed with renal cancer surgery., Design, Setting, and Participants: From 1999 to 2008, 977 patients who underwent renal cancer surgery had preoperative data recorded for the glomerular filtration rate (GFR) estimated using the CKD Epidemiology Collaboration equation (G1 ≥90, G2 60-89, G3a 45-59, G3b 30-44, G4 15-29, and G5 <15ml/min/1.73 m 2 ) and proteinuria status according to a dipstick assay (A NEG , negative or trace protein; A POS , ≥30mg/dl). Median follow-up was 8.7 yr (range 7.0-10.7)., Intervention: Renal cancer surgery., Outcome Measurements and Statistical Analysis: OS and RFS (avoidance of a decline in GFR of ≥50% and of dialysis) were analyzed using the Kaplan-Meier method. We performed multivariable Cox regression to evaluate independent predictors for both outcomes., Results and Limitations: The 326 patients (33%) with A POS proteinuria status had compromised 5-yr OS compared with A NEG patients (65% vs 77%; p<0.001). They also had lower RFS at 5 yr (72% vs 86%; p<0.001). However, significant differences in OS according to proteinuria status were only observed in the G1, G2, and G3a groups, and differences in RFS in the G3a group. On multivariable analysis for all patients and for the G1, G2, and G3a groups, proteinuria was an independent prognostic factor for OS (both p<0.05). On multivariable analysis for all patients and for those in the G3a group, proteinuria was an independent prognostic factor for RFS (both p<0.05). Limitations include the retrospective study design and potential ascertainment bias., Conclusions: Proteinuria appears to be a significant and independent predictor of OS and RFS in patients undergoing renal cancer surgery, particularly for certain cohorts, and should be sensibly incorporated into routine management. Further studies, ideally prospective, are required to evaluate the importance of the degree of proteinuria. The generalizability of our findings will also require further investigation., Patient Summary: Protein in the urine (proteinuria) is a sign of kidney damage, and kidney cancer patients with proteinuria have worse outcomes after surgery. Assessment of proteinuria should be routinely included in the preoperative evaluation of patients with kidney cancer., (Copyright © 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Tissue expansion using implantable expanders is a useful means of generating surplus tissue for reconstruction of defects such as scarring following burns. The authors describe their technique of incisions distant to the desired location of expander placement, and remote dissection of the expander pocket with hydrodissection and blunt forceps. A total of 81 expanders were placed in 30 consecutive patients, 81% of whom had burn scars due for reconstruction. During preparation, no complications, such as bleeding, were encountered, except one case with severe subdermal fibrosis, in which bleeding was stopped through brief application of pressure. Postoperatively, no complications were encountered in 76% of patients; however, 16.6% exhibited surgical site infection, which was managed conservatively and was correlated with a high number of expanders implanted at once. One patient experienced hematoma formation that resolved spontaneously, and one instance of expander extrusion and subsequent removal occurred. Receiving ≥2 expanders at the same time was statistically associated with higher risk for complication(s). The authors' complication rates were moderate and comparable with open or endoscopic approaches. Time of expansion is reduced compared with the open approach due to distant incision placement and immediate usability. Cost effectiveness appeared to be better using only inexpensive forceps, rather than elaborate and costly endoscopic equipment.

Background: Acute increase of serum creatinine (SCr) after partial nephrectomy (PN) is primarily due to parenchymal mass reduction or ischemia; however, only ischemia can impact subsequent functional recovery., Objective: We evaluate etiologies of acute kidney injury (AKI) after PN and their prognostic significance., Design, Setting, and Participants: From 2007-2014, 83 solitary kidneys managed with PN had necessary studies for detailed analysis of function and parenchymal mass before/after surgery. AKI was classified by Risk/Injury/Failure/Loss/Endstage classification and defined by either standard criteria (comparison to preoperative SCr) or proposed criteria (comparison to projected postoperative SCr based on parenchymal mass reduction). Subsequent recovery was defined as percent function preserved/percent mass saved., Intervention: PN., Outcome Measurements and Statistical Analysis: Predictive factors for AKI were evaluated by logistic regression. Relationship between AKI grade and subsequent functional recovery was assessed by linear regression., Results and Limitations: Median duration warm ischemia (n=39) was 20 min and hypothermia (n=44) was 29 min. Median parenchymal mass reduction was 11%. AKI occurred in 45 patients based on standard criteria and 38 based on proposed criteria, and reflected injury/failure (grade = 2/3) in 23 and 16 patients, respectively. On multivariable analysis, only ischemia time associated with AKI occurrence (p=0.016). Based on the proposed criteria, median recovery from ischemia was 99% in patients without AKI and 95%/90%/88% for patients with grades 1/2/3 AKI, respectively. The coefficient for association between AKI grade based on proposed criteria and subsequent functional recovery was -4.168 (p=0.018). Main limitation is limited patient cohort., Conclusions: Parenchymal mass reduction and ischemia both contribute to acute changes in SCr after PN. Classification of AKI by proposed criteria significantly associates with subsequent functional recovery. However, more robust numbers will be needed to further assess the merits of the proposed criteria. While AKI is associated with suboptimal recovery, even patients with grade 2/3 AKI reached 88-90% of recovery expected., Patient Summary: Acute decline in function after partial nephrectomy associates with more prolonged ischemia time, and appears to impact subsequent functional recovery. However, most kidneys eventually recover strongly, even if their function is sluggish in the first few days after surgery., (Copyright © 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Hyperhomocysteinemia is associated with increased cardiovascular risk, but treatment with folic acid has no effect on outcome in unselected patient populations., Objectives: To confirm previous observations on the association of homozygosity for the TT MTHFR genotype with B12 deficiency and endothelial dysfunction, and to investigate whether patients with B12 deficiency should be tested for 677MTHFR genotype., Methods: We enrolled 100 individuals with B12 deficiency, tested them for the MTHFR C677T polymorphism and measured their homocysteine levels. Forearm endothelial function was checked in 23 B12-deficient individuals (13 with TT MTHFR genotype and 10 with CT or CC genotypes). Flow-mediated dilatation (FMD) was tested after short-term treatment with B12 and folic acid in 12 TT MTHFR homozygotes., Results: Frequency of the TT MTHFR genotype was 28/100 (28%), compared with 47/313 (15%) in a previously published cohort of individuals with normal B12 levels (P = 0.005). Mean homocysteine level was 21.2 ± 16 μM among TT homozygotes as compared to 12.3 ± 5.6 μM in individuals with the CC or CT genotype (P = 0.008). FMD was abnormal ( 6%) in 9/13 TT individuals with B12 deficiency (69%), and was still abnormal in 7/12 of those tested 6 weeks after B12 and folic treatment (58%)., Conclusions: Among individuals with B12 deficiency, the frequency of the TT MTHFR genotype was particularly high. The TT polymorphism was associated with endothelial dysfunction even after 6 weeks of treatment with B12 and folic acid. Based on our findings we suggest that B12 deficiency be tested for MTHFR polymorphism in order to identify potential vascular abnormalities and increased cardiovascular risk.

Aim: To compare radiation dose surrogates [volume CT dose index (CTDIvol), dose-length product (DLP), size-specific dose estimate (SSDE), and effective dose] and image noise in a cohort of patients undergoing hepatocellular carcinoma screening who underwent both single-energy CT (SECT) and dual-energy CT (DECT)., Materials and Methods: In this institutional review board-approved, Health Insurance Portability and Accountability Act-compliant retrospective study, 74 adults (mean age 59.5 years) underwent 64 section SECT (120 kVp and weight-based reference mAs) and 128 section dual-source DECT (100/Sn 140 kVp and CTDIvol, adjusted to match the CDTIvol of the SECT protocol) on different occasions. Noise levels were measured in the liver, inferior vena cava (IVC), retroperitoneal (RP) fat, and aorta. Generalized linear models were constructed to compare dose and noise, adjusting for effective diameter., Results: The total DLP (1371.11 mGy-cm, SD = 527.91) and effective dose (20.57 mSv, SD = 7.92) with SECT were significantly higher than the DLP (864.84 mGy-cm, SD = 322.10) and effective dose (12.97 mSv, SD = 4.83) with DECT (p < 0.001). The differences between SECT and DECT increased as the patient's effective diameter increased (p < 0.001). Noise levels in the liver (22.4 versus 21.9 HU), IVC (22.3 versus 23.4 HU), and RP fat (23.5 versus 23 HU) were similar for DECT and SECT (p > 0.05) but were significantly lower in the aorta for DECT (25.3 versus 26.4 HU; p = 0.006)., Conclusion: DECT imaging of the abdomen can achieve noise levels comparable to those seen with SECT imaging without a dose penalty to patients., (Copyright © 2014 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Background: Lower T-junction wound dehiscence following breast reduction surgery or mastopexy constitutes a vexing and grievous complication both to the surgeon and the patient. Treatment modalities that can expedite wound healing and reepithelialization rates are highly craved. The objective of this study was to assess wound healing and epithelialization rates of open wounds following breast reduction and mastopexy wound dehiscence treated with charged polystyrene microspheres (CPM)., Materials and Methods: Five female patients with wound dehiscence and subsequent open wounds following breast reduction and mastopexy were treated with daily with CPMsoaked dressings. Wound closure rates were documented., Results: The wounds showed both accelerated granulation tissue formation as well as swift epithelialization rates. No complications or side effects were encountered., Conclusions: Charged polystyrene microspheres may offer a new and efficacious way to heal open wounds due to wound dehiscence following aesthetic breast surgery. Further research with a larger patient population is still needed to verify these findings. .

Background: Flap necrosis following facial rhytidectomy constitutes a vexing and grievous complication to the patient and the surgeon. Treatment modalities that can expedite wound healing and re-epithelialization rates are highly desired., Objectives: To assess wound healing and re-epithelialization rates of open wounds following postrhytidectomy flap necrosis treated with commercially available charged polystyrene microspheres (Polyheal-1, Polyheal Ltd, Israel)., Methods: Flap necrosis following rhytidectomy with open wounds in three female patients were treated using dressings soaked with Polyheal-1. Wound closure rates were documented., Results: The wounds demonstrated both accelerated granulation tissue formation and rapid re-epithelialization rates. No complications or side effects were encountered., Conclusions: Charged polystyrene microspheres may offer a new and efficacious way to treat open wounds due to flap necrosis following facial rhytidectomy. Further research with larger patient numbers is still needed to verify these findings.

Introduction: Choosing the right burn patient that transfers to a rehabilitation facility following acute hospitalization is a difficult decision. In our study we characterize demographic, injury and hospitalization related variables that predict a burn patient's transfer to a rehabilitation facility., Methods: We analyzed the data of 974 burn patients with burns of the second degree and deeper, spanning 20% TBSA (total body surface area) or more, that were admitted to all 5 hospitals that operate a burn unit in Israel, between the years 1998 and 2005., Results: The results of the multivariate logistical regression model in which the predicted variable is discharge to rehabilitation showed that the most predictive variables were inhalation injury, surgical procedures and hospitalization period. Execution of a surgical procedure was the most influential factor over discharge to rehabilitation (odds ratio=6.202) followed by inhalation injury (OR=4.706) and finally, the hospitalization period (OR=1.026) (an increase of 1.026 times in the likelihood to be sent to rehabilitation with any additional day of hospitalization)., Discussion: In this study we examined patients who were sent to a rehabilitation facility upon completion of their acute care in an attempt to evaluate common initial clinical variables that assist in making an educated decision regarding the patient rehabilitation transfer. This is one of the first attempts at examining and revealing evidence based parameters that might determine the correct burn patient to send to rehabilitation after his hospitalization., (Copyright © 2012 Elsevier Ltd and ISBI. All rights reserved.)

Objective: The purpose of this article is to evaluate the effect of sinogram-affirmed iterative reconstruction (SAFIRE) on contrast-to-noise ratio (CNR) compared with filtered back projection (FBP) and to determine whether SAFIRE improves low-contrast object detection or conspicuity in a low-contrast object phantom and in the liver on full- and low-dose examinations., Subjects and Methods: A low-contrast object phantom was scanned at 100%, 70%, 50%, and 30% dose using a single-source made of a dual-source MDCT scanner, with the raw data reconstructed with SAFIRE and FBP. Unenhanced liver CT scans in 22 patients were performed using a dual-source MDCT. The raw data from both tubes (100% dose) were reconstructed using FBP, and data from one tube (50% dose) were reconstructed using both FBP and SAFIRE. CNR was measured in the phantom and in the liver. Noise, contrast, and CNR were compared using paired Student t tests. Six readers assessed sphere detection and conspicuity in the phantom and liver-inferior vena cava conspicuity in the patient data. The phantom and patient data were assessed using multiple-variable logistic regression., Results: The phantom at 70% and 50% doses with SAFIRE had decreased noise and increased CNR compared with the 100% dose with FBP. In the liver, the mean CNR improvement at 50% dose with SAFIRE compared with FBP was 31.4% and 88% at 100% and 50% doses, respectively (p < 0.001). Sphere object detection and conspicuity improved with SAFIRE (p < 0.001). However, smaller spheres were obscured on both FBP and SAFIRE images at lower doses. Liver-vessel conspicuity improved with SAFIRE over 50%-dose FBP in 67.4% of cases (p < 0.001), and versus 100%-dose FBP, improved in 38.6% of cases (p = 0.085). As a predictor for detection, CNR alone had a discriminatory ability (c-index, 0.970) similar to that of the model that analyzed dose, lesion size, attenuation difference, and reconstruction technique (c-index, 0.978)., Conclusion: Lower dose scans reconstructed with SAFIRE have a higher CNR. The ability of SAFIRE to improve low-contrast object detection and conspicuity depends on the radiation dose level. At low radiation doses, low-contrast objects are invisible, regardless of reconstruction technique.

HALT PKD consists of two ongoing randomized trials with the largest cohort of systematically studied patients with autosomal dominant polycystic kidney disease to date. Study A will compare combined treatment with an angiotensin-converting inhibitor and receptor blocker to inhibitor alone and standard compared with low blood pressure targets in 558 early-stage disease patients with an eGFR over 60 ml/min per 1.73 m(2). Study B will compare inhibitor-blocker treatment to the inhibitor alone in 486 late-stage patients with eGFR 25-60 ml/min per 1.73 m(2). We used correlation and multiple regression cross-sectional analyses to determine associations of baseline parameters with total kidney, liver, or liver cyst volumes measured by MRI in Study A and eGFR in both studies. Lower eGFR and higher natural log-transformed urine albumin excretion were independently associated with a larger natural log-transformed total kidney volume adjusted for height (ln(HtTKV)). Higher body surface area was independently associated with a higher ln(HtTKV) and lower eGFR. Men had larger height-adjusted total kidney volume and smaller liver cyst volumes than women. A weak correlation was found between the ln(HtTKV) and natural log-transformed total liver volume adjusted for height or natural log liver cyst volume in women only. Women had higher urine aldosterone excretion and lower plasma potassium. Thus, our analysis (1) confirms a strong association between renal volume and functional parameters, (2) shows that gender and other factors differentially affect the development of polycystic disease in the kidney and liver, and (3) suggests an association between anthropomorphic measures reflecting prenatal and/or postnatal growth and disease severity.

Background and Objectives: Autosomal dominant polycystic kidney disease (ADPKD) is associated with a substantial cardiovascular disease burden including early onset hypertension, intracranial aneurysms, and left ventricular hypertrophy (LVH). A 41% prevalence of LVH has been reported in ADPKD, using echocardiographic assessment of LV mass (LVM). The HALT PKD study was designed to assess the effect of intensive angiotensin blockade on progression of total kidney volume and LVM. Measurements of LVM were performed using cardiac magnetic resonance (MR)., Design, Setting, Participants, & Measurements: Five hundred forty-three hypertensive patients with GFR >60 ml/min per 1.73 m(2) underwent MR assessment of LVM at baseline. LVM was adjusted for body surface area and expressed as LVM index (LVMI; g/m(2))., Results: Baseline BP was 125.1 ± 14.5/79.3 ± 11.6 mmHg. Average duration of hypertension was 5.79 years. Prior use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers was present in 59.5% of patients. The prevalence of LVH assessed using nonindexed LVM (g) was 3.9% (n = 21, eight men and 13 women) and 0.93% (n = 5, one man and four women) using LVMI (g/m(2)). In exploratory analyses, the prevalence of LVH using LVM indexed to H(2.7), and the allometric index ppLVmass(HW), ranged from 0.74% to 2.23% (n = 4 to 12). Multivariate regression showed significant direct associations of LVMI with systolic BP, serum creatinine, and albuminuria; significant inverse associations with LVMI were found with age and female gender., Conclusions: The prevalence of LVH in hypertensive ADPKD patients <50 years of age with short duration of hypertension, and prior use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers is low. Early BP intervention in ADPKD may have decreased LVH and may potentially decrease cardiovascular mortality.

Superior soft-tissue contrast affords magnetic resonance imaging (MRI) some advantages compared to computed tomography (CT) in both detection and characterization of focal liver lesions. Because of its relatively recently introduction into clinical practice, a growing number of articles in the literature have demonstrated the usefulness of the hepatobiliary-specific MRI contrast agent gadoxetic acid disodium (Gd-EOB-DTPA) in liver imaging. The purpose of this review is to demonstrate the typical enhancement patterns of the most common liver lesions using Gd-EOB-DTPA in daily clinical scenarios and briefly describe its mechanism of action. Radiologists interpreting liver MRI studies with this agent must be familiar with the appearance of focal lesions in the hepatocyte phase to avoid misinterpretation., (Copyright © 2011 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Background: Pouchitis is associated with dysbiosis and dysregulated mucosal immunity, although secondary pouchitis with special etiologic factors, such as ischemia, can occur. The aim was to describe a disease phenotype of the ileal pouch with an endoscopic appearance suggestive of ischemia., Methods: We identified consecutive patients with endoscopic asymmetric inflammation of the pouch (inflammation of side of the pouch with a completely normal other limb of the pouch one limb and a sharp demarcation along the staple suture line). Patients with Crohn's disease (CD) of the pouch or antibiotic-responsive pouchitis, matched for duration of the pouch, served as controls. Histology slides of mucosal biopsies were re-reviewed independently by 2 blinded gastrointestinal pathologists. Demographic, clinical, endoscopic, histologic, and imaging characteristics were compared between the groups., Results: Ten patients with "ischemic" pouchitis, 15 with CD of the pouch, and 15 with antibiotic-responsive pouchitis were studied. Pyloric gland metaplasia was observed only in the groups with CD of the pouch (23.1%) or antibiotic-responsive pouchitis (13.3%). Of patients with "ischemic" pouchitis, 80% had extracellular hemosiderin or hematoidin deposits (versus 30.8% those with CD of the pouch and 13.3% of those with pouchitis, P = 0.003). The majority of patients (80%) with "ischemic" pouchitis did not respond to conventional antibiotic therapy. It appeared that subsequent abdominal surgeries after pouch construction and a history of postoperative portal vein thrombi were associated with "ischemic" pouchitis., Conclusions: Endoscopic asymmetric inflammation of the pouch may represent an ischemia-associated pouchitis with characteristic clinical, radiographic, and histologic features. Its hemodynamic, cellular, and molecular basis of mechanism warrants further study.

Aim: To investigate the accuracy of percutaneous cryoablation for kidney tumors performed under combined real-time ultrasonography (US) and three-dimensional (3D) CT scan navigation in a porcine model., Materials and Methods: After percutaneously injecting 2 to 6 tumor mimic lesions in 11 pigs, a CT scan was performed and digital data were saved into a navigation system (Real-Time Virtual Sonography [RVS]) that allows 3D reconstruction and synchronization with real-time US images. The cryoprobe was guided percutaneously into the kidney tumor mimic, and ice ball formation was monitored continuously during cryoablation using the RVS system. Kidneys were harvested and sent for gross pathologic and histopathologic analysis at days 0, 15, and 30 postoperatively., Results: Thirty-five renal tumor mimics were created and treated by percutaneous cryotherapy; tumor mimic locations were as follows: 16 tumors (46%) in the lower pole, 14 (40%) in the central region, and 5 (14%) in the upper pole. Eleven tumor mimics (31%) were intraparenchymal, and 24 (69%) subcapsular. The synchronization between the CT scan 3D reconstructed images and real-time US was successful in all cases. The mean tumor size was 2 cm (range, 1.2-4 cm). Mean cryonecrosis size was 3.3, 3.7, and 2.8 cm at days 0, 15, and 30, respectively. Three (8.5%) positive margins were found on the macroscopic and microscopic analysis., Conclusions: RVS imaging system synchronizing real-time US with preoperative CT scan is a feasible and safe technique for percutaneous probe ablation of kidney tumors.

Purpose: We present 5 to 11-year (median 8) oncological outcomes after laparoscopic renal cryoablation., Materials and Methods: Between September 1997 and October 2008 we performed renal cryoablation in 340 patients, of whom 80 treated laparoscopically by a single surgeon before October 2003 had a minimum 5-year followup. Followup involved magnetic resonance imaging on postoperative day 1, at 3, 6 and 12 months, and annually thereafter. Cryolesion biopsy was performed at 6 months. All data were prospectively accrued., Results: In the 80 patients with minimum 5-year followup mean age was 66 years, mean tumor size was 2.3 cm (range 0.9 to 5.0), median American Society of Anesthesiologists score was 3 and mean body mass index was 28 kg/m(2). Five patients had local recurrence, 2 had locoregional recurrence with metastasis and 4 had distant metastasis without locoregional recurrence. Six patients died of cancer. In the 55 patients with biopsy proven renal cell cancer at a median followup of 93 months (range 60 to 132) 5-year overall, disease specific and disease-free survival rates were 84%, 92% and 81%, and 10-year rates were 51%, 83% and 78%, respectively. On multivariate analysis previous radical nephrectomy for RCC was the only significant predictor of disease-free and disease specific survival (p = 0.023 and 0.030, respectively)., Conclusions: Laparoscopic renal cryoablation is effective oncological treatment for a renal mass in select patients. A disease specific survival rate of 92% at 5 years and 83% at 10 years is possible. Preceding radical nephrectomy for renal cell carcinoma was the only independent factor predicting disease-free and disease specific survival., (2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)