Thursday, October 31, 2013

Endocrine diseases list


Within each renal lobe are hundreds of thousands of nephrons, the function unit of the kidney. Each nephron originates in the cortex, at the renal corpuscle associated with glomerular capillaries. Extending from the corpuscle is the proximal convoluted tubule, then the nephron loop (of Henle) into the medulla and back to the cortex, then the distal convoluted tubule and collecting tubule which merges into a collecting duct for urine transport to the calyx. All nephrons are located completely within the cortex except for their medullary loops. Juxtamedullary nephrons usually have much longer loops than cortical nephrons. Each kidney contains 1–1.4 million functional units called nephrons (Figure 2). The major divisions of each nephron are:
Renal corpuscle, an initial dilated portion in the cortex
Proximal convoluted tubule, located primarily in the cortex
Thin and thick limbs of the nephron loop (loop of Henle), which descend into the medulla, then ascend back to the cortex
Distal convoluted tubule
Collecting tubule.
Collecting tubules from several nephrons converge into collecting ducts which carry urine to the calyces and the ureter. Cortical nephrons are located almost

completely in the cortex while juxtamedullary nephrons close to the medulla have long loops in the medulla (Figure 2).
Figure 2


Each kidney has a concave medial border, the hilum—where nerves enter, the ureter exits, and blood and lymph vessels enter and exit—and a convex lateral surface, both covered by a thin fibrous capsule (Figure 1). The expanded upper end of the ureter, called the renal pelvis, divides into two or three major calyces. Smaller branches, the minor calyces, arise from each major calyx. The area surrounding the calyces, called the renal sinus, usually contains considerable adipose tissue.

                                                                                 Figure 1.
Each kidney is bean-shaped, with a concave hilum where the ureter and the renal artery and veins enter. The ureter divides and subdivides into several major and minor calyces, around which is located the renal sinus containing adipose tissue. Division of the parenchyma into cortex and medulla can also be seen grossly. Attached to each minor calyx is a renal pyramid, a conical region of medulla delimited by extensions of cortex. A renal pyramid with associated cortex constitutes a renal lobe. The cortex and hilum are covered with a fibrous capsule.
The kidney has an outer cortex and an inner medulla (Figures 1 and 2). In humans, the renal medulla consists of 8–15 conical structures called renal pyramids, which are separated by cortical extensions called renal columns. Each medullary pyramid plus the cortical tissue at its base and along its sides constitutesa renal lobe (Figure 1).


The urinary system consists of the paired kidneys and ureters, the bladder, and the urethra. This system helps maintain homeostasis by a complex combination of processes that involves the following:
Filtration of cellular wastes from blood
Selective reabsorption of water and solutes
Excretion of the wastes and excess water as urine.

Urine produced in the kidneys passes through the ureters to the bladder for temporary storage and is then released to the exterior through the urethra. The two kidneys produce about 125 mL of filtrate per minute, of which 124 mL is reabsorbed in these organs and 1 mL is released into the ureters as urine. About 1500 mL of urine is formed every 24 hours. The kidneys also regulate the fluid and electrolyte balance of the body and are the site of production of renin, a protease that participates in the regulation of blood pressure by cleaving circulating angiotensinogen to angiotensin I. Erythropoietin, a glycoprotein that stimulates the production of erythrocytes, is also produced in the kidneys. The steroid prohormone vitamin D, initially produced in skin keratinocytes, is hydroxylated in kidneys to an active form (1,25-dihydroxyvitamin D3 or calcitriol) involved in regulating calcium balance.

Berek and Novak's Gynecology (14th Edition)

BRS General Surgery

Efficacy of Mirabegron in Patients With and Without Prior Antimuscarinic Therapy for Overactive Bladder

Mirabegron provided numerical improvements in incontinence and micturition frequency in treatment-naïve patients and in patients who had received prior antimuscarinic therapy and discontinued due to insufficient efficacy or poor tolerability. In prior antimuscarinic users who discontinued due to insufficient efficacy, mirabegron showed numerical improvements in both outcomes whereas re-treatment with the antimuscarinic, tolterodine, produced an effect size similar to placebo. The efficacy and tolerability profile of mirabegron suggest that it may represent a valuable therapeutic option for patients with OAB who experience insufficient benefit from antimuscarinic therapy and in those who are intolerant of the associated AEs (e.g., dry mouth, constipation). In patients who received mirabegron in the overall trial, dry mouth, the most common[6,7]and bothersome side effect of antimuscarinic agents,[8]occurred with a similar incidence as with placebo (2.6–2.8%) and a three-fold lower incidence than in patients receiving tolterodine ER 4 mg (10.1%). This post hoc analysis provides valuable insights but confirmation of its results will be required in randomized prospective trials of OAB patients with and without prior antimuscarinic therapy.


1- The commonly used anticoagulant heparin:
A. Has a half-life of 6 hours.
B. Is administered orally.
C. Activity is measured by PTT.
D. Works by inhibiting platelet aggregation.
E. Inhibits factors V and VII.

2- Risk factors for inguinal hernias in adults include:
A. Sedentary lifestyle.
B. Chronic obstructive pulmonary disease.
C. Anorexia nervosa.
D. Hypertension.
E. Irritable bowel syndrome.

3- A hernia that arises lateral to the inferior epigastric vessels is which of the following?
A. Indirect inguinal hernia.
B. Direct inguinal hernia.
C. Femoral hernia.
D. Obturator hernia.
E. Sliding hernia

4- The most lateral femoral structure in the anatomic position of the groin is:
A. Artery.
B. Lymphatics.
C. Empty space.
D. Nerve.
E. Vein.

5- Incarceration of the antimesenteric portion of the bowel wall is referred to as which
of the following?
A. Umbilical hernia.
B. Richter hernia.
C. Femoral hernia.
D. Indirect inguinal hernia.
E. Hiatal hernia

Wednesday, October 30, 2013

PET/MRI could be alternative to PET/CT for liver lesions

October 28, 2013 -- PET/MRI is more than adequate in characterizing liver lesions and provides greater lesion conspicuity than PET/CT, offering clinicians a powerful alternative for oncologyimaging, according to a German study published in the November issue of the European Journal of Radiology.

PET/MRI provided better diagnostic confidence due to soft-tissue contrast and complementary information from different MRI sequences, according to lead author Dr. Karsten Beiderwellen and colleagues from University Hospital Essen, University of Duisburg-Essen, and University of Dusseldorf (EJR, Vol. 82:11, pp. e669-e675).

"The inherent soft-tissue contrast coupled with the higher spatial resolution of MRI is the main advantage over PET/CT, providing the overall higher conspicuity of liver lesions," Beiderwellen wrote in an email to "Plus, diffusion-weighted [MRI] helps in delineating even small lesions and offers complementary information to PET."

Concurrence of villous adenoma and non-muscle invasive bladder cancer arising in the bladder: a case report and review of the literature

Villous adenoma first reported by Norbury LE in 1928 [1] is now recognized as a premalignant polyp of the gastrointestinal tract. Up to two-thirds of the lesion occurs in the rectum. There are no differences in distribution between men and women and a peak incidence in the 60’s and 70’s. Whenever possible, local excision and sphincter preservation is the procedure of choice for accessible lesions with favorable characteristics. However, the recurrence is seen in up to 40% of cases even despite complete excision in the rectal.
On the other hand, the villous adenoma in the urinary tract is rare. The most common coexisting tumor is adenocarcinoma which is associated with urachus tumors. Typical clinical presentations are hematuria and irritative symptoms. The prognosis of pure villous adenoma in the urinary tract is excellent.

Monday, October 28, 2013

fat loss factor

Acute scrotal swelling: a sign of neonatal adrenal haemorrhage.


Two neonates presented with acute scrotal swelling suggestive of testicular torsion. Surgical exploration in one patient revealed an infected haematoma. Subsequent investigations including ultrasonography and urinary catecholamine determination disclosed adrenal haemorrhage as the cause of the scrotal haematoma. A second patient in whom a purplish discolouration of the right hemiscrotum was noted was also investigated with ultrasonography, which revealed a normal right testis and a right adrenal haematoma. Both cases of adrenal haemorrhage resolved spontaneously on conservative treatment. Adrenal haemorrhage should be considered as a possible cause of acute scrotal swelling in neonates. Ultrasonography assessment should be performed in such cases to examine the intra-abdominal organs especially the adrenal glands.

Sunday, October 27, 2013

Psammoma bodies

A psammoma body is a round collection of calcium, seen microscopically. The term is derived from the Greek word psammos meaning "sand."


Psammoma bodies are associated with the papillary (nipple like) histomorphology and are thought to arise from
(1) The infarction and calcification of papillae tips and
(2) Talcification of intralymphatic tumor thrombi. 

Psammoma bodies are commonly seen in certain tumors such as:
·         Papillary thyroid carcinoma
·         Papillary renal cell carcinoma
·         Ovarian papillary serous cystadenocarcinoma
·         Endometrial adenocarcinomas (Papillary serous carcinoma ~3%-4%)
·         Meningiomas, in the central nervous system
·         Peritoneal and Pleural Mesothelioma
·         Somatostatinoma (pancreas)
·         Prolactinoma of the pituitary 
·         Mesothelioma, in membranes that line body cavities

Benign lesions
Micrograph of a psammomatous melanoticschwannoma with a psammoma body, as may be seen in Carney complex. H&E stain.

Psammoma bodies may be seen in:
·         Endosalpingiosis
·         Psammomatous melanotic schwannoma
·         Melanocytic nevus

Psammoma bodies usually have a laminar appearance, are circular, acellular and basophilic.

Saturday, October 26, 2013


Philips Awards


- Short term award “ECR 2015″: to be announced by April conference next year in Alexandria: ‘Multi Modalities Collaboration in Diagnostic or Interventional Imaging’

Dead line for submitting published articles: March 1, 2014

- Long term award “RSNA 2014″: to be announced by September 2014 at ICR 2014 in Sharm Elshiekh: “Ultra low dose imaging” in any modalities (IXR, DXR, CT, PET, Mammo, etc.)

Dead line for submitting published articles: August 1, 2014

Friday, October 25, 2013

Drugs used to treat hyperlipidemia

Outpatient Flexible Cystoscopy and Transurethral Laser Ablation (TULA) of Urothelial Tumours Using the 1470nm Diode Laser

Outpatient based TULA of TCC using the 1470nm Diode laser, provides a safe and cost-effective, efficient alternative to
theater-based procedures with high patient satisfaction in an elderly multi-morbid population. It also reduces the demand on theater and inpatient capacity.

Association of Lower Urinary Tract Symptom/Benign Prostatic Hyperplasia Measures With International Index of Erectile Function 5 in Middle-aged Policemen of Korea and the Role of Metabolic Syndrome and Testosterone in Their Relationship

IPSS is the most powerful predictor of ED among the LUTS/BPH measures in middle-aged policemen. In addition, MetS might be a plausible explanation for the relationship between LUTS/BPH and ED.

Thursday, October 24, 2013

Continuing Education for the Healthcare Team

Canadian guideline on genetic screening for hereditary renal cell cancers

The Kidney Cancer Research Network of Canada Genetics Initiative will review the guideline at least every 2 years.

SPECIAL FEATURE: Female Genital Mutilation: The Scar of a Lifetime

The World Health Organization (WHO) estimates that about 140 million girls and women worldwide live with the health consequences of female genital cutting/mutilation —101 million of these women live in Africa, mainly in the sub-Saharan areas.1,2 

In support of this growing concern, the SIU has collaborated with the African Journal of Urology to share with you the editorial paper by SIU member, Dr. Ismail Khalaf, entitled, “Female Genital cutting/mutilation in Africa deserves special concern: An overview. 
The September 2013 issue of the journal features articles focusing on the theme of female genital cutting/mutilation (FGM) and aims to address such FGM-related topics as epidemiology, public misconceptions, challenges ahead and religious perspectives of FGM, health implications, to name a few. 

To read similar articles like this one, visit the African Journal of Urology website at: 
African Journal of Urology website. 

“This issue is an appeal to all who are connected with the problem, including health service providers. No longer should women's rights continue to be ignored, or FGM continue to be tolerated as part of communities’ rituals الطقوس and cultures, nor camouflaged as religious doctrine مذهب.” 3 

1 WHO . Female genital mutilation, fact sheet. 2013;updated February 2013 
2 WHO . Fact sheet no. 241. 2012 February; 
3 Ismail Khalaf. Female genital cutting/mutilation in Africa deserves special concern: An overview. African Journal of Urology. September 2013:19(3):119-122. 

* Permission to post this publication on the SIU Academy portal has been received from Elsevier. 

Wednesday, October 23, 2013

Detection and characterisation of prostate cancer through transrectal quantitative shear wave elastography, "Beyond the Abstract," by Sarfraz Ahmad, MBBS, PhD, MRCSI, MRCSEd

Published on 21 October 2013
BERKELEY, CA ( - Standard greyscale transrectal ultrasound (TRUS) guided prostate biopsies are routinely used for men suspected to have prostate cancer (PCa). However, the grey- scale TRUS is not a reliable modality in differentiating cancer and normal hyperplasia of prostate. In this protocol-driven feasibility study, we used a quantitative shear wave imaging (SWI) for prostate cancer diagnosis. SWI is quantitative and has much less operator dependence, thus potentially can improve detection and characterisation of cancers. In the study, men (n = 50) suspected to have PCa were subjected to 12-core systematic biopsies under grey-scale ultrasound, and only one additional biopsy was taken if region of interest (ROI) detected by SWI was found outside the previously biopsied areas. Among these patients, 66% had PCa. In patients with PSA < 20 μg/L, the sensitivity and specificity of SWI for PCa detection was 0.9 and 0.88, respectively. While in patients with PSA > 20 μg/L, the sensitivity and specificity was 0.93 and 0.93, respectively. This indicates potential advantage of SWI in detecting cancer foci within the prostate gland. In addition, PCa had significantly higher stiffness values compared to benign tissues (p < 0.05), with a trend toward stiffness differences in different Gleason grades. These results suggest a better diagnostic accuracy of SWI than grey-scale ultrasound imaging.
Training model for SWI
Before conducting study on patients and to address the issue of adequate training with SWI, a commercially available phantom (Model 066 Prostate Elastography Phantom/CIRS Tissue Simulation and Phantom Technology, Virginia, USA) was used. This model contains 3 iso-echoic lesions that are three times stiffer than the simulated surrounding prostate tissue. Under greyscale ultrasound they cannot be detected, but are readily visible on SWI (see figure).

Additionally, the phantom was used for optimisation of the prostate gland sonographic examination technique and assessment of inter-observer variations.

Figure - Greyscale (B-mode; bottom rows) ultrasound and overlaid SWI information (top rows) for the prostate phantom - The abnormal nodules (representative of cancerous tissues) within the phantom were only visible with SWI (shown as yellow (medium stiffness)- in figures i & ii).
Reproducibility of observations was assessed between 2 independent operators analysing the same image pairs acquired using the phantom. The observers recorded stiffness (minimum, maximum and mean with SD) in ROI by placing a cursor over the colour-coded area. As the cursor is moved around the ROI (i.e., stiffer area of the phantom), values are instantaneously displayed on the screen in a data box. Stiffness values averaged over 3 images were used for analysis.
The abnormal foci within the prostate phantom were visible only on SWI (with a higher stiffness than surrounding areas). At least three independent experiments were performed using the phantom (see table). The mean (±SD) Young modulus (kPa) values of the representative stiff nodule (61.3 kPa (±1.5) within the phantom was much higher than of the surrounding normal areas (22.5kPa (±0.9). The mean stiffness on each pair of SWI images acquired by these 2 independent operators led to an intraclass correlation coefficient of 0.93 (95% CI 0.62 to 0.99).

Table - Summary of the results of three independent experiments on single Prostate Elastography Phantom – the stiffness of the the tumour nodules was nearly three times higher than surrounding normal phantom tissues in all three examinations. Furthermore, this difference was statistically significant (p < 0.05).
Transrectal SWI is much closer to a standard TRUS clinical examination as it does not require any additional compression. Still, there is a learning curve to fully master the use of SWI. The pre-clinical part of our study on phantoms suggested that around 10 independent experiments (personal experience) on phantoms are required to gain adequate experience in the identification of abnormal stiffness patterns within the prostate.
§  The numbers of participants in this preliminary study were relatively small. The study was limited to a single-centre, and the numbers of observers and operators were therefore relatively small. However, these results strongly suggest the importance of performing similar studies in multiple centres on a larger cohort of patients.
§  The impact of distance of cancer foci from the rectal probe on SWI sensitivity is not addressed in this study. This may have an important implication and need to be addressed in future studies.
§  On a per-patient basis, we do not really know how much more likely one was to find cancer in an SWI-targeted biopsy versus standard systematic biopsy. This is an important issue, however; it can only be addressed with randomised clinical trials comparing SWI and greyscale-targeted systematic biopsies.

Conclusions and future directions
§  SWI can reliably differentiate between benign and malignant prostate tissue and, in most cases, can aid in targeting abnormal foci by needle biopsy. The stiffness of cancer foci was 50 % higher than of the benign tissues (133.7 kPa (±57.6) vs 74.9 kPa (± 47.3), respectively).
§  SWI provides quantitative data and is a reproducible technique. Quantitative assessments of maximum and mean stiffness measurements were found to be highly reliable and consistent across multiple SWI acquisitions though multiple operators in the phantom part of the study. Through such characteristics, the real time quantitative SWI imaging reported in this study has the potential to change clinical practice of PCa by improving the localisation and allowing limited targeted biopsies of suspicious areas, thereby reducing both the complications and cost associated with the current standard of care.
Furthermore the accurate localisation may play a role in focal therapy for PCa, and SWI can be utilised to differentiate a “significant” PCa from an “indolent” one.

Written by:

Sarfraz Ahmad, MBBS, PhD, MRCSI, MRCSEd as part of Beyond the Abstract on This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Academic Section of Urology, Division of Cancer, Medical Research Institute, Ninewells Hospital, University of Dundee, Dundee, DD1 4HN, UK

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