This document discusses the evaluation of urolithiasis (urinary stones). It provides an overview of diagnostic evaluation including history, blood tests, urine analysis, imaging, and stone analysis. It describes the goals and characteristics of metabolic evaluation to prevent recurrent stone formation. Both abbreviated and extensive protocols for metabolic evaluation are outlined, including details on 24-hour urine collection and components analyzed. The roles of various imaging modalities like KUB, ultrasound, and intravenous pyelography are also summarized.
Retrograde Intrarenal Ureteroscopic Surgery (RIRS)Urovideo.org
Gerhard J. Fuchs, M.D., Dr. med., F.A.C.S.
Professor of Urology, UCLA School of Medicine
Vice Chair, Cedars Sinai Department of Surgery
Medallion Chair in Minimally Invasive Urology
Cedars-Sinai Medical Center
Los Angeles, USA
Retrograde Intrarenal Ureteroscopic Surgery (RIRS)Urovideo.org
Gerhard J. Fuchs, M.D., Dr. med., F.A.C.S.
Professor of Urology, UCLA School of Medicine
Vice Chair, Cedars Sinai Department of Surgery
Medallion Chair in Minimally Invasive Urology
Cedars-Sinai Medical Center
Los Angeles, USA
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
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neurochemical systems and has rewarding and addictive properties. It
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AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
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The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
1. D E P T O F U R O L O G Y
G O V T R O Y A P E T T A H H O S P I T A L A N D K I L P A U K M E D I C A L C O L L E G E
C H E N N A I
EVALUATION OF
UROLITHIASIS
2. Moderators:
Professors:
Prof. Dr. G. Sivasankar, M.S., M.Ch.,
Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
Dr. J. Sivabalan, M.S., M.Ch.,
Dr. R. Bhargavi, M.S., M.Ch.,
Dr. S. Raju, M.S., M.Ch.,
Dr. K. Muthurathinam, M.S., M.Ch.,
Dr. D. Tamilselvan, M.S., M.Ch.,
Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai.
2
3. 1. Diagnostic Evaluation
2. Use Of Stone Analysis
3. Role Of Imaging
4. Economics Of Metabolic
Evaluation
5. Classification – Diagnostic
Criteria
3
Dept of Urology, GRH and KMC, Chennai.
4. Diagnostic Evaluation
Symptomatic episodes of urinary calculi are
associated with
• Significant patient discomfort
• Morbidity of surgical treatment
• Financial pain
4
Dept of Urology, GRH and KMC, Chennai.
6. GOALS
WHY ?
To prevent recurrent stone formation in
high risk patient
To prevent growth of any existing stone
To prevent extrarenal complication in
associated systemic disorders
6
Dept of Urology, GRH and KMC, Chennai.
7. CHARACTERISTICS
Simple to perform
Economically viable
Providing information that can be applied
towards a selective , rational therpay of
stone disease
7
Dept of Urology, GRH and KMC, Chennai.
8. Metabolic Problem Include
Distal RTA
Primary HPT
Enteric hyperoxaluria
Cystinuria
Gouty diathesis
8
Dept of Urology, GRH and KMC, Chennai.
9. SELECTION OF PATIENT
The risk of recurrence in first-time stone
formers is at least 50% at 10 years.
Annual incidence : 5- 10 % of population.
Men>women
Calcium stones (calcium oxalate or phosphate) -
most common stone type
9
Dept of Urology, GRH and KMC, Chennai.
10. • Shared decision of patient & physician
• Formation of first stone may be the harbinger
of more severe underlying systemic disorder
such as RTA, bone disease or hypercalcemia
due to Hyperparathyroidism
• In such patient , metabolic evaluation is
justified solely to make correct diagnosis in
order to prevent extrarenal complications
10
Dept of Urology, GRH and KMC, Chennai.
12. Who Needs Metabolic Work Up ?
Recurrent stone formers
Strong family history of stones
Intestinal disease (particularly chronic diarrhea)
Bilateral or multiple stones
All Children - renal damage & long-term sequelae
Pathologic skeletal fractures
Osteoporosis
12
Dept of Urology, GRH and KMC, Chennai.
13. Who Needs Metabolic Work Up ?
History of urinary tract infection with calculi
Personal history of gout
Infirm health (unable to tolerate repeated stone
episodes)
Solitary kidney
Renal insufficiency
Stones composed of cystine, uric acid, or struvite
13
Dept of Urology, GRH and KMC, Chennai.
14. Metabolic Work Up- TIMING
At least 1 month after stone passage or stone
removal>>> allowing the patient to return to
their normal routine
Contraindications
Gross haematuria
Renal obstruction
14
Dept of Urology, GRH and KMC, Chennai.
15. HOW TO DO IT
ABBREVIATED
PROTOCOL
EXTENSIVE
DIAGNOSTIC
EVALUATION
PROTOCOL
15
Dept of Urology, GRH and KMC, Chennai.
16. ABBREVISTED PROTOCOL
Low Risk , Single Stone Formers
COMPONENTS
• History
• Multichannel blood screen
• Urine examination
• Radiography
• Stone analysis
16
Dept of Urology, GRH and KMC, Chennai.
17. History
OCCUPATION
• sedentary occupation predisposes to stone
formation more then manual work
• Low activity level predisposes to bone
demineralization and hypercalciuria
• Physical activity agitate urine and dislodge
crystal aggregartion
17
Dept of Urology, GRH and KMC, Chennai.
18. DIET
half the increased levels of urinary calcium,
oxalate, and uric acid seen in stone-forming
patients may be attributed to a diet rich in animal
protein
Milk ingestion can cause hypercalciuria
salt - high salt intake is associated with increased
urinary sodium, calcium, PH & decreased urinary
citrate
inadequate fluid intake or excessive fluid loss
18
Dept of Urology, GRH and KMC, Chennai.
19. CLIMATE
Summer is the season of urinary stone formation
and dehydration is the key factor
Concentarted urine – low ph >> encourage cystine
& uric acid stone formation
Exposure of sunlight may also increase
endogenous vitamin D production, leading to
hypercalciuria
19
Dept of Urology, GRH and KMC, Chennai.
20. FAMILY HISTORY
Incidence increases with positive family history
Familial diseases like
• cystinuria – AR ( transmembrane
cystine absorption )
• RTA
20
Dept of Urology, GRH and KMC, Chennai.
21. PAST HISTORY
PREVIOUS SURGERY - Bowel resection,
Bariatric Surgery
Inflammatory bowel syndrome
Systemic diseases
Gout
Hyperparathyroidism
Sarcoidosis
21
Dept of Urology, GRH and KMC, Chennai.
25. URINE EXAMINATION
URINALYSIS
Albumin
Sugar
RBC
WBC
PH pH > 7.5: infection lithiasis
pH < 5.5: uric acid lithiasis
Sediment for crystalluria
25
Dept of Urology, GRH and KMC, Chennai.
26. Various Urinary Crystals Morphology
Calcium phosphate–apatite Amorphous
Struvite Coffin lid
Calcium oxalate dihydrate Envelope, tetrahedral
Calcium oxalate monohydrate Hourglass
Cystine Hexagonal
Uric acid Amorphous shards, plates
Brushite Needle shaped
26
Dept of Urology, GRH and KMC, Chennai.
27. URINE CULTURE & SENSITIVITY
Urea-splitting organisms: suggestive of infection
lithiasis
NITROPRUSSIDE TEST - cystine
27
Dept of Urology, GRH and KMC, Chennai.
28. EXTENSIVE DIAGNOSTIC
EVALUATION
INDICATIONS
performed in patient with recurrent
nephrolithiasis
stone formers at increased risk stone formation
To identify underlying physiologic derangement
28
Dept of Urology, GRH and KMC, Chennai.
29. Patient to discontinue
Any medication that interfere with metabolism of
calcium, uric acid, or oxalate ( vit.D, Calcium
suppliment, Antacids, Diuretics , Acetazolamide)
Any current medication for stone treatment
( thiazide, phosphate, allopurinol, magnesium)
29
Dept of Urology, GRH and KMC, Chennai.
30. OUTLINE
It involves two outpatient visits . Three 24
hour urine samples are collected
First two 24-hour specimens : on random
diet – reflective of their usual dietary intake
Third 24- hour sample: after 1 week, on a
calcium, sodium & oxalate restricted diet
30
Dept of Urology, GRH and KMC, Chennai.
31. 24 Hour Urine Collection
Preservative (acid) solution
5% Thymol in Isopropanol, or
6 mols HCL (only if not testing for uric
acid)
Acidification of 24 hour urine
1. Prevents precipitation of calcium salts
2. Prevents oxidation of ascorbic acid to
oxalate
31
Dept of Urology, GRH and KMC, Chennai.
32. Validation of 24-hour urine specimen
• By checking total urinary creatinine
• Production of creatitnine
Male – 15-20 mg/kg BW/24 hour
FEMALE – 10-15 mg/kg BW/ 24 hour
• Significant abberation in values imply
- Incomplete collection
- Overcollection
- Greater/lesser than expected muscle mass
32
Dept of Urology, GRH and KMC, Chennai.
33. Extensive Metabolic Evaluation - Urine
Analysis
The first morning void is discarded
Urine with added preservatives collected till the
next morning including the first void
24 Hour Urine
pH, Volume, Specific Gravity
Calcium, Phosphate, Uric acid, Oxalate,
Creatinine, Sodium & Citrate
Optional: Magnesium, Ammonium, Cystine
33
Dept of Urology, GRH and KMC, Chennai.
34. FAST & CALCIUM LOAD TEST
NEED
Essential before placing a patient on a calcium-
binding agents ( absorptive hypercalciuria)
Differentiates b/w various forms of
hypercalciuria
If 24 hour Calcium > 250 mg (Hypercalciuria)
No response to medication / diet
No longer performed by most physicians
34
Dept of Urology, GRH and KMC, Chennai.
35. Normal fasting urinary calciun - < 0.11 mg/dl GF
Normal postload urinary calcium - <0.2 mg/mg
creatinine
TIMING – Morning of Second visit
35
Dept of Urology, GRH and KMC, Chennai.
36. OUTLINE OF TEST
7 days before – diet restriction starts
12 hours before – fasting started , 300 ml
distilled water
9 hours before – 300 ml of distilled water
2 hours before – empty bladder completely (
discarded) >> 600 ml of distilled water
Over 2 hours – pooled urine sample collected –
FASTING URINE
Over 10 min – 1 Gm of oral calcium load
Over next 4 hours – pooled urine sample –
Postload urine
36
Dept of Urology, GRH and KMC, Chennai.
39. All patients : basic metabolic screening ,
searching for systemic disorders
High risk stone patient – more extensive
metabolic evaluation based on two 24-hour urine
samples
Cornerstone of simplified protocol –
development of urine preservation method that
allows collection of urine without refrigeration
Urinary Assessment – calcium, oxalate, citrate ,
total volume, sodium, Magnesium, potassium,
PH, Uric acid & Sulphate
39
Dept of Urology, GRH and KMC, Chennai.
42. STONE ANALYSIS
Most stones are mixture of more than one
component
Relative ratio or predominance of any particular
molecule has predictive value
Used to determine metabolic abnormality and aid
in preventive therapy
Stone composition can direct metabolic
investigation
May obviate the need for a complete metabolic
evaluation
42
Dept of Urology, GRH and KMC, Chennai.
43. Ca apatite & mixed ca
oxalate-ca apatite
Pure & mixed uric A.
Brushite stones
Infection stones
Cystine stone
RTA
PHP
Gouty diathesis
RTA
Infection
cystinuria
43
Dept of Urology, GRH and KMC, Chennai.
45. PLAIN X-RAY (KUB)
90 % of urological stones are radio-opaque
Not useful if stones are
Radiolucent
Smaller than 4 mm
Lies over sacrum or any other bony structure
Bowel gases obscures its efficacy
Cannot differentiate between
Stone
Calcified lymph nodes
Phleboliths
Sensitivity for diagnosis of stones in 50-70%
45
Dept of Urology, GRH and KMC, Chennai.
49. USG (KUB)
Usually done to compliment x-ray KUB
Sensitivity – 95 %
Very sensitive for diagnosis of obstruction & can
detect radiolucent stones missed on KUB
Non-invasive
May miss small stone & ureteral stone
Particularly important in pregnant patient
49
Dept of Urology, GRH and KMC, Chennai.
54. INTRAVENOUS PYELOGRAPHY
• Useful - Radiolucent Stones, Anatomic
Abnormalities
• Invasive precedure predisposing patient to highly
allergic IV contrast
• Require proper patient preparation
• Very prolonged procedure takes hours
• Not good imaging modality in acute renal colic
54
Dept of Urology, GRH and KMC, Chennai.
55. • Agent - 76% Urograffin
• Dose – 1 ml/kg
• usual 5-, 10-, and 20-minute urographic films
• Delayed films may be obtained several hours after
the injection of contrast material till contrast
completely washout from bladder.
55
Dept of Urology, GRH and KMC, Chennai.
56. Phases of IVP
• SCOUT film
To look for the calcification overlying the region of the
kidney, ureter and bladder
• Nephrogram phase
Taken immediately after IV contrast
Produced by filtered contrast within the lumen of PCT
• Pyelogram phase
Much denser than the nephrogram phase
Concentrated contrast accumated in the PCS
56
Dept of Urology, GRH and KMC, Chennai.
57. Obstruction by stone is confirmed
- delay in the appearance of contrast medium
- dilated PCS and ureter proximal to obstruction.
57
Dept of Urology, GRH and KMC, Chennai.
60. COMPUTED TOMOGRAPHY
• Non enhanced spiral CT – investigation of
choice.
• Sensitivity – 97 %
• Specificity – 95 %
• signs of ureteral obstruction
hydroureter
hydronephrosis
nephromegaly
stranding of perinephric fat
60
Dept of Urology, GRH and KMC, Chennai.
61. • HU measurement - characterises the
composition of stone
• Significant difference in HU b/w Uric acid stones
& other stone types
• DECT – Dual Energy CT
HU rations
DECT slope algorithm
DECT attenuation values
distinguish b/w relatively pure cystine, struvite,
ca.ox., ca. phosphate & brushite stones
61
Dept of Urology, GRH and KMC, Chennai.
62. ADVANTAGES DISADVANTAGES
• Rapid
• No need for experienced
radiological technician
• No need for IV Contrast
• Uric acid stone are also
visualised
• accurately measure the size
of the stone
• additional advantage -
detect nonurologic
abnormalities
Distal ureteric calculi
can be confused with
phlebolith
Images do not give
anatomical detailed as
seen on an IPV
NCCT
62
Dept of Urology, GRH and KMC, Chennai.
64. MAGNETIC RESONANCE IMAGING
• Contrast to CT, MRI unable to visualize most stones
clinically, this modality is not useful for
characterizing the composition of these stones
• Indication –
Renal impairment
allergy to intravenous contrast agents
when x-rays are contraindicated .
• Magnetic resonance (MR) urography has been
reported to be effective in detecting urinary tract
dilatation
64
Dept of Urology, GRH and KMC, Chennai.
65. ECONOMICS
Peak incidence – 20-60 years
The cost a/w the treatment of nephrolithiasis are
substancial
Hospital based outpatient services
Emergency room charges
Additional societal cost of lost productivity and
social service support
Office visits, serum studies and 24 hour urine
studies have their own costs
65
Dept of Urology, GRH and KMC, Chennai.
66. Medical management of first stone former is not cost
effective & individual decision should be determined
by local costs
However, recurrent stones formers should be treated
medically after a simplified evaluation , because of
the high recurrence rate of stone formation.
66
Dept of Urology, GRH and KMC, Chennai.
