Treatment for Renal Transitional Cell Carcinoma (TCC)

Treatment for Renal Transitional Cell Carcinoma (TCC) Dear All, Thank you for the new images Roz – it is interesting to follow this case as it unfolds. After reviewing the new CT images I would agree with Susie that they could indicate an alternative diagnosis of a transitional cell carcinoma (TCC) of the left kidney and ureter. I would like to investigate a couple of the many treatment options available for TCC and aim to answer the question put forward by Susie – ‘What treatment options are available to the patient?’ Renal transitional cell carcinoma (TCC) is a malignant tumour that stems from theepithelial cells lining the urinary tract. Upper urinary tract TCCs (UUTUC) – in this patient’s case involving the left kidney and ureter are uncommon. They account for only 5-10% of urothelial carcinomas (Siegel et al, 2012) although evidence indicates an increase in these malignancies (Jemal et al, 2009). The predisposition UUTUCs have for recurrence, metastases and their multi focal nature mandates aggressive clinical intervention (Cai et al, 2011). Treatment is strongly influenced by tumour stage, which correlates closely with prognosis. Surgical intervention is usually the preferred method of treatment for localised disease. Radical nephroureterectomy Radical nephroureterectomy (RNU) with excision of the bladder cuff is the gold standard treatment for UTUC (Margulis et al, 2009). The aim of surgery is to prevent tumour seeding via bypass of the urinary tract during tumour resection. Since the risk of tumour recurrence is considerable, resection of the distal ureter and its orifice is also performed. Recent research by Lughezzani et al, (2010) concluded that this method – removing the distal ureter and bladder cuff significantly improves survival rates. The traditional open surgical approach to RNUs is being challenged by less invasive approaches, e.g. laparoscopic. Simone et al, (2009), a prospective randomised study of 80 patients with non-metastatic UUUC demonstrated no superior effectiveness of laparoscopic surgery over open RNU, whilst the majority of recent research concludes superior outcomes for a laparoscopic versus open surgical approach (Ariane et al, 2012) and (Ni et al, 2012). Endoscopic Treatment Endoscopic ablation is sometimes indicated in patients with a solitary kidney, in bilateral kidney disease and where major surgery is contraindicated. Although now slightly dated, research by Keeley et al, (1997) is commonly cited in recent literature. Their study looked at the ureteroscopic management of 38 patients (41 kidneys) with upper tract urothelial tumours graded 1 3. After endoscopic treatment, 16 of the 21 (76%) with grade 1 disease were tumour free 4 had recurrences at a mean follow-up of 40.3 months. 9 of the 14 (64%) of grade 2 disease were tumour free 4 had recurrent disease at a mean follow-up of 27.6 months. Finally, 2 of the 5 (40%) grade 3 tumours were tumor free at a mean follow-up of 21 months – no recurrence rates were reported for this group. They concluded that ureteroscopic treatment of the upper urinary tract TCC minimises morbidity and provides excellent success rates in patients with solitary, low-grade tumours. Despite these findings, the tract recurrence risk is hard to calculate because relatively few endoscopic ablation treatments have been performed. Additionally, there is a reported risk of understating and under grading the disease with endoscopic management alone. In order to determine the optimal treatment pathway for a patient with TCC – renal function, tumour grade, stage and location must first be evaluated. I have only examined two of the treatment options available for TCC – would anybody else like to expand upon Susies question by examiningothers? I will not add any further questions as there are a few already outstanding. Kind Regards, Alana Show parent See this post in context RDM032_PRD1_A_2014-15 -> On-Line Case Discussions -> Case 12 -> Re: Case 12 by Alana McInally Wednesday, 19 November 2014, 11:51 PM Dear All, Thank you for posting this interesting case and uploaded images Susie. It appears that Noorayen and I have been working on the same topic over the last few days so although this post is likely to overlap in places, I hope to add insight and an alternative slant. I would like to examine the images and a possible diagnosis. In the right lobe of the liver, there appears to be large 67 x 49 mm, well-defined, heterogeneous mass predominantly hyperechoic in nature. Appearances are in keeping with a solid, rather than cystic, lesion. In the second ultrasound image, the liver lesion looks more isoechoic in echotexture with some internal and peripheral vascularity demonstrated when colour Doppler is applied. The sagittal section of the unenhanced CT abdo-pelvis image also highlights this area of low attenuation in the right lobe. These are unusual findings given the patient’s symptoms acute LIF pain. It would be interesting to know whether the patient has had any other tests carried out, for example any blood work prior to the scans? I agree with Noorayen that ultrasound appearances such as these could represent a Focal nodular hyperplasia (FNH). An FNH is a benign hyperplastic process which results in the normal constituents of the liver being arranged in an abnormally organised pattern – this is caused bya response to a congenital arteriovenous malformation'(Khan et al, 2013). An FNH is considered the second most common tumour of the liver following hepatic hemangiomas (Kang et al, 2010). In the majority of situations (80-95%), FNH arises as a solitary lesion, however, multiple lesions have been known to present themselves (Khan et al, 2013). Ultrasound characteristics of these lesions can vary, making diagnosis using one modality challenging. Lesions can range from hypoechoic, isoechoic to hyperechoic when compared to that of the surrounding liver tissue (Bates, 2011). Venturi et al, (2007) as well as other recent research – state that typical lesions usually demonstrate a large, well circumscribed mass, with a central feeding artery and a radiating spoke-wheel pattern of blood flow (Bates, 2011). It could be suggested that the second ultrasound image shows central blood flow within the lesion, in keeping with the typical appearances described. Although FNHs are normally asymptomatic, which is not in keeping with the patient’s LIF pain, it may indicate that the LIF pain and the liver lesion (located in the RUQ) are unrelated that the liver lesion is instead an incidental finding; this is consistent with the typical diagnosis of an FNH. Most diagnoses occur when patients undergo cross-sectional imaging or surgery for other problems and / or routine medicals (Palladino et al, 2014). Although the use of contraceptive agents is not proven to cause FNH, they may have a role in the development of these lesions. Additionally, they can also act as an irritant causing haemorrhage or infarctions to occur – resulting in symptomatic patients. Malignant transformation of FNH has not been reported (Chung and DeGirolamo, 2011) and FNHs rarely bleed or grow. As a result, the diagnosis of an FNH rarely impacts the patient’s medical management other than the accurate diagnosis of the lesion to prevent unnecessary biopsies, surgery, and further imaging of the lesion. Despite advances in medical imaging, it is difficult to discern an FNH from other focal hepatic lesions. As a relatively recent imaging modality, the use of Contrast-Enhanced Ultrasound (CEUS) to identify focal liver lesions is becoming increasingly common (Bartolotta et al, 2009). I will reiterate one of the three outstanding questions does anyone have any further differential diagnoses? Kind regards, Alana Show parent See this post in context RDM032_PRD1_A_2014-15 -> On-Line Case Discussions -> Case 3 -> Re: Case 3 by Alana McInally Tuesday, 18 November 2014, 9:38 PM Dear All, Lucy’s post on the function of the spleen in particular, the implications when it is removed was interesting to read, especially as the spleen’s function and morphology have, in the past, remained unstudied (Lahey and Norcross, 1948). Although they havebecomeless common, as the spleensimportance as an organ isrecognised, splenectomies are still performed and I would like to address Lucy’s question ‘What are the indications for a splenectomy?’. A splenectomy consists of the total or partial surgical removal of the spleen. Literature sources provide a wide spectrum of clinical scenarios for when a splenectomy may be indicated. A general consensus exists for a handful of diagnoses which require a splenectomy. These include: primary cancers of the spleen (very rare), splenic trauma and hematologic diseases. One blood disorder – Hereditary spherocytosis (HS) – often requires treatment via a splenectomy. It involves the loss of specific proteins in the red blood cell membrane, resulting in fragile cells which are further damaged when they pass through the spleen (Encyclopedia of Surgery). This damage ceases once the spleen is removed. Another hematologic disease primary immune thrombocytopenia (ITP) shows the highest cure rate (60-70%) after a splenectomy versus other treatments (Ghanima et al, 2012). Trauma to the spleen can result from damage or rupture from both blunt and penetrating injuries to the abdomen. Studies suggest 25% of trauma injuries are originally caused by medical intervention to the abdomen (Rull, 2012). Laparoscopic splenectomies are often indicated in splenic trauma to prevent internal hemorrhaging and potentially death (NHS Choices, 2014). There are also numerous other conditions where a splenectomy may be indicated / recommended these include: Splenic artery aneurysms surgical resection is often indicated in the presence of large splenic artery aneurysms (over 2 cm in diameter), because the risk of hemorrhage and rupture can be fatal if not treated (Bates, 2011). Multiple splenic abscesses relatively uncommon but have an associated high mortality rate (Provenzale et al, 2012). Some view percutaneous drainage combined with antibiotic therapy as the best management for solitary abscesses (Bates, 2011) whereas other research proposes a splenectomy is the best treatment for multiple abscesses. Splenomegaly – an enlarged spleen (more than 12 cm) (Bates, 2011) as an isolated indicator for a splenectomy is often unjustified. Best practice is to now investigate the underlying cause. Surgery is only indicated if the enlarged spleen is causing serious complications and/or if the underlying cause cannot be identified (NHS Choices, 2014). As Lucy mentioned, there are benefits and risks of a splenectomy. Most research recognises the associated life-long risk of bacterial infection following a splenectomy (Schilling, 2009), combined with the risks of invasive surgery. The general consensus shifts towards a conservative approach – attempting to preserve the spleen as opposed to invasive treatment (Akinkuolie et al, 2010). In our trust I found it hard to locate hospital guidelines and protocols for when splenectomies were considered appropriate. However, I came across one case where a patient had a partial laparoscopic splenectomy using wedge resection to treat splenic trauma. This allowed him to retain some splenic function and additionally he was fortunate enough to have an accessory spleen (present in 30% of the population) – which has the ability to grow and function when a large portion has been removed (Arra et al, 2013). Consequently his splenic function was comparable to that prior to surgery. This technique supports the recent advance towards a conservative outlook on splenectomies. It would be interesting if anyone else is aware of the guidelines in their local hospital for when a splenectomy is indicated? Kind regards, Alana

International Aspirations of an Emerging Market Firm

International Aspirations of an Emerging Market Firm Arcadia, a Turkish appliance manufacturer controlled by Turkeys largest conglomerate company named Crock Group. From the beginning, Recall products more than half of Turkeys appliances, including air conditioners, dishwashers machines, cooking appliances, and refrigerators. But since trade barriers declined in sass and sass, many competitors such as SSH, Hairier, General Electronic, Whirlpool, and Electrocute were threatening Recalls market share.In global household appliance industry, consumers tend to view home appliances as commodities, and often value low prices. Some applicants carry small profit and have long life span, using automated manufacturing plants and low-cost labor Is only help in short run for the manufacturers. In order to sell in premium price and increase profit margins, some appliance makers differentiate their product by Innovative, value-added technology and features. However, innovation is costly. Which caus ed most major appliance manufacturers began to globalize (Cassavas, Knight, & Rosenberg, 2008, up. 277-278).Arcadia sees its best prospect In emerging, fast-growing markets in Eastern Europe, Asia, and Latin America. Perhaps Singapore could be one of those markets that allow Arcadia to be a lead player in the industry as its aims. Issues Economic in Singapore. Singapore economic is the first issue that attracts Arcadia to enter Into this emerging market. Singapore GAP shows Gingersnap's buying power, which also affects Arsenic's products. Analysis Economic in Singapore. According to Political Risk Yearbook: Singapore Country Report stated; â€Å"real GAP growth for the second quarter of 2010 surged to anIncreasable rate of nearly 19%, on top of registering nearly 1 7% growth in the first quarter, and that performance has now positioned Singapore to be one of the fastest growing economies in the world. † (2010, p. 4). Singapore is one of the world's leading business centers an d a major destination for foreign Investment. The first reason Is monetary stability In Singapore Is good. Second, the legal and regulatory framework for the financial sector is transparent and efficient. The government influence in the sector is gradually being reduced.Third, anti-corruption laws are strong and well enforced. Moreover, foreign and domestic Investors are treated equally, and openness to global commerce fosters competitiveness. With prudent and sound banking practices, the financial sector has weathered the global financial turbulence relatively well (Miller and Holmes, Para. 3). These should be good enough reasons to attract Arcadia entering Singapore market. Issues Singapore Consumer Lifestyle. The second Issue that Recall need to know before doing business in Singapore Is consumer lifestyle.In order to know which products appropriate to consumer lifestyle in Singapore, Arcadia should be marketed precisely; ongoing research in Singapore consumer lifestyle will defi nitely help Arcadia reaching their goal. Analysis Singapore Consumer Lifestyle. According to Global Marketing Information Database (GIMP), point out that Singapore have their busy lifestyle. They spend more time on working, and spending less time in other thing else. As Gingersnaps become busier, the demand for convenience has been on the rise. Thus, the household appliances should sales something that help Singapore save time such as microwaves and freezers.As Gingersnaps workers have less time for grocery hopping, having a freezer will help them to purchase more food. Likewise, microwaves will be great help to save time in cooking for Singapore busy worker. Moreover, Singapore is very attuned to high-technology lifestyles, and technology- based products and services are extremely popular. On the other hand, over the short-term the economic downturn will drive many consumers to be much more discerning, and they will search hard for the best deals (GIMP, 2011, Para. 1-13). Commercia l risks in Singapore.The last issue that Arcadia need to study carefully is attention risks in Singapore, including country risks or political risks, cross-cultural risks, commercial risks, and currency risks. Although Singapore has lower rate of corruption than other Asian countries and its Singapore Dollar (SAG) is quite strong, there is commercial risks that need to be considered. Analysis Commercial risks in Singapore. Although the Business Monitor International mentioned that the Singapore Dollar (SAG) is safe, there are commercial risks in Singapore.From Smog's information, Arcadia may adapt its products, prices, and promotions in order to minimize commercial risks while doing business in Singapore. In addition, there are several competitors who already have niches in Singapore should appliances market share such as, LEG Electronics, Panasonic, Samsung, and Careful. In order to compete with those strong competitors, Arcadia could apply its advantage, which is its knowledge of how to produce products for lower-income countries. â€Å"It operates 11 manufacturing plants in Turkey, Romania, Russia and China.Arcadia is a member of the Koch Group of companies, which holds a majority stake in the company. † (Denominator, 2010, p. 50). All those manufacturing plants allow Arcadia to produce appliances less expensively than some competitors. The retailers in Singapore are also important to Arcadias business. The main retail chains selling home appliances in Singapore are Harvey Norman, Best Dense, Courts and Gain City. Large department stores such as Tasmania and Siesta also carry a variety of major brands of home appliances.Conclusion Arcadia should expect to be better in emerging market such as, Singapore because this county offers good opportunity to household appliance businesses. Singapore has strong position in economic and continuously growth in household occupants. Arcadia should be attracted by consumer demand by households. In order to maximize company performance, Arcadia could study Singapore consumer life style and adapts its products to meet Gingersnap's demands. Reclaim has strong distribution network with close to 4,500 dealers in Turkey and 366 aboard.

Childe Harold’s Pilgrimage Essay

Childe Harold’s Pilgrimage is a travelogue written by a melancholic, passionate and expressive tourist. Byron wrote this poem on his travels trough Spain, Portugal, Albania, Greece, Belgium, Switzerland, the Alps and Italy. The hero of the poem, Childe (an ancient term for a young noble awaiting knighthood) Harold is a young extremely emotional man who turns away from the regular society and humanity and wanders through life caring the heavy guilt of mysterious vices of his past. The poem reflects Lord Byron’s views regarding nature and society. In Byron’s Childe Harold’s Pilgrimage we find two opposing forces, one of which is highly idolized by Byron, while the second one is definitely less admired. On one side we are facing the glorious nature, the freedom, the joys of the wilderness and the power of the ocean, while the opposing side is represented by the society, man’s humility, man’s weakness, political and spiritual slavery, illusionary freedom and false love. Byron worships the nature and constantly attempts to escape the madness of the society. Byron was devoted to nature above all, as it is the only thing capable of bringing a man closer to God, eternity and understanding of the unknown. â€Å"To mingle with the Universe, and feel, what I can ne’er express, yet cannot all conceal†, thus, nature is man’s only way of roughly touching the mystifying beyond, the inexpressible, that colossal feeling of the grandeur of creation, which we can not express, yet the most emotional of us are at least able to feel. Nature is our only link to the glorious power of life and universe. Our only way of understanding our selves, our souls and minds is through facing the nature. Lines like: â€Å"Art, Glory, Freedom fail, but Nature still is fair†, reflect Byron’s belief that nature is above all, and that when everything fails, nature is the only thing capable of helping one overcome his emotional troubles. As if he would say that despite the remarkable glory of all those human virtues, none of them is comparable to the force and magnificence of nature. While one force is our society which has a tendency of producing: â€Å"Wealth, vice, corruption – barbarism at last†, the other force is nature, which is named â€Å"nursing nature† by Byron, as he believed that nature is the only thing capable of healing one’s heart and saving one’s soul. He presents an escapist vision of nature, representing nature as an escape from the â€Å"madding crowd†, introducing what we might call some â€Å"environmentalist† ideas. In Childe Harold’s Pilgrimage the society is characterized by the â€Å"hum of human cities torture†, while nature is the escape, a place to which â€Å"the soul can flee†, breaking unrestricted into â€Å"the sky, the peak, the heaving plain of ocean, or the stars†. Byron sees society as a passing phase. â€Å"From society we learn to live† writes Byron, meaning that our physical fatal existence in this world is united and represented by the society, while: â€Å"‘Tis solitude should teach us how to die†, meaning that the true eternity, spirituality and one’s connection to his soul is achievable only through one’s relationship with nature, thus, through a relationship with â€Å"mountains, leaves, and flowers†. Byron is not rejecting the society, but his real object of worship is definitely nature. He declares that there is no truth beyond nature and wilderness, yet the society is not rejected: â€Å"I love not man the less, but Nature more†, thus, man is beautiful and capable of achieving greatness, yet he is mortal and incomparable to the eternal brilliance of nature. Byron never completely rejected society, but his object of adoration and astonishing love is definitely the Nature: â€Å"Nature† with a capital â€Å"N†, as a religious person would spell â€Å"God† with a capital â€Å"G†. Indeed Byron worships nature as one religious fanatic would worship god. Lord Byron believed in Nature above all, as Nature was the only real truth for him.

Converting Cubic Inches to Cubic Feet

Converting cubic inches to cubic feet is a common problem. Here is the conversion factor and a worked example. Conversion Factor 1728 cubic inches 1 cubic foot 0.000578704 cubic feet 1 cubic inch Simple Example Convert 54.9 cubic inches into cubic feet. You can multiply by the conversion factor: 54.9 cubic inches x 0.000578704 cubic feet per cubic inch 0.0318 cubic feet or you could simply divide  the value in cubic feet by 1728: 54.9 cubic inches / 1728 cubic feet per cubic inch 0.0318 cubic feet Worked Example You measure a box and find it is 12 inches long, 5 inches high, and 3 inches deep. The volume of the box is length x width x height so the volume of the box is: 12 x 5 x 3 volume in cubic inches 180 cubic inches Now, to convert this to cubic feet, you know there are 1728 cubic inches in 1 cubic foot: 180 cubic inches x (1 cubic foot / 1728 cubic inches) volume in cubic feet 180 cubic inches x 0.000578704 cubic feet/cubic inch volume in cubic feet 0.1042 cubic feet