No abstract

We sought to analyze utilization and survival outcomes of cytoreductive nephrectomy in patients with metastatic renal cell carcinoma (RCC) before and after introduction of targeted therapy. We identified patients with metastatic RCC between 1993 and 2010 in the SEER registry and examined temporal trends in utilization. We performed a joinpoint regression to determine when changes in utilization of cytoreductive nephrectomy occurred. We fitted multivariable proportional hazard models in full and propensity score-matched cohorts. We performed a difference-in-difference analysis to compare survival outcomes before and after introduction of targeted therapy. The proportion of patients undergoing cytoreductive nephrectomy increased from 1993 to 2004, from 29% to 39%. We identified a primary joinpoint of 2004, just prior to the introduction of targeted therapy. Beginning in 2005, there was a modest decrease in utilization of cytoreductive nephrectomy. Cytoreductive nephrectomy was associated with a lower adjusted relative hazard (0.41, 95% confidence interval 0.34 to 0.43). Median survival among patients receiving cytoreductive nephrectomy increased in the targeted therapy era (19 versus 13 months), while median survival among patients not receiving cytoreductive nephrectomy increased only slightly (4 versus 3 months). Difference-in-difference analysis showed a significant decrease in hazard of death among patients who received cytoreductive nephrectomy in the targeted therapy era. Despite decreased utilization in the targeted therapy era, cytoreductive nephrectomy remains associated with improved survival. Prospective randomized trials are needed to confirm the benefit of cytoreductive nephrectomy among patients with metastatic RCC treated with novel targeted therapies.

Despite advances in the evaluation, treatment, and pathophysiological understanding of necrotizing soft-tissue infections, Fournier's gangrene remains a life-threatening urological emergency. Although the condition can affect patients of any age and gender, it might be more prevalent in some high-risk groups with certain comorbidities. Several prognostic and diagnostic tools have been developed to assist with clinical decision-making once the diagnosis is made - primarily based on the physician's physical exam and potentially supported by laboratory and imaging findings. Expedited treatment with resuscitation, antibiotic administration, and rapid, wide surgical debridement are key elements of the initial management. These procedures must be followed by meticulous wound care and liberal use of planned subsequent surgical debridements. Once the patient has overcome the associated systemic illness, several reconstructive options for the genitalia and perineum can be considered to improve functionality and cosmesis.

The visual modality typically dominates over our other senses. Here we show that after inducing an extreme conflict in the left hand between vision of touch (present) and the feeling of touch (absent), sensitivity to touch increases for several minutes after the conflict. Transcranial magnetic stimulation of the posterior parietal cortex after this conflict not only eliminated the enduring visual enhancement of touch, but also impaired normal tactile perception. This latter finding demonstrates a direct role of the parietal lobe in modulating tactile perception as a result of the conflict between these senses. These results provide evidence for visual-to-tactile perceptual modulation and demonstrate effects of illusory vision of touch on touch perception through a long-lasting modulatory process in the posterior parietal cortex.