Survival after incidental prostate cancer diagnosis at transurethral resection of prostate: 10-year outcomes

BACKGROUND

The most appropriate management of incidental prostate cancers diagnosed at transurethral resection of prostate has been debated. It is important to determine the long-term outcomes to establish an appropriate management in patients with incidental prostate cancer.

AIMS

We aim to determine 10-year survival and to identify the factors of worse prognosis of incidental prostate cancers diagnosed at transurethral resection of prostate.

METHODS

A retrospective analysis of patients with pT1a-pT1b prostate cancers diagnosed between 1998 and 2003. Medical notes, PSA and pathology results were reviewed. Overall and cancer specific survival was calculated at mean 10-year follow-up.

RESULTS

Sixty patients with incidental prostate cancer were identified (pT1a = 18, pT1b = 42). Fifty-one percents of the patients were managed on a watchful waiting strategy with overall 84% survival and 9.7% cancer specific mortality. Twenty patients (all with pT1b) received hormone therapy. Overall survival in this cohort was 50% with 20% cancer specific mortality. Nine patients received curative therapy (Radical prostatectomy = 4, Radiotherapy = 5). In this group, overall survival was 88% with no cancer specific mortality.

CONCLUSIONS

Stage pT1a disease and preoperative low PSA were associated with favourable survival. However, for pT1b and/or high Gleason score (≥7), mortality was comparatively higher. Hence, patients with high Gleason score and/or pT1b disease should be considered for curative therapy. Additionally, active surveillance may have a role in selected men with incidental prostate cancer.

Reciprocal expression of IL-25 and IL-17A is important for allergic airways hyperreactivity

BACKGROUND

Interleukin (IL)-25 (IL-17E) is a potent inducer of the type-2 immune effector response. Previously we have demonstrated that a neutralizing anti-IL-25 antibody, given during the establishment of ovalbumin-specific lung allergy, abrogates airways hyperreactivity.

OBJECTIVE

Blocking IL-25 results in the suppression of IL-13, a cytokine known to exacerbate pulmonary inflammation, and an unexpected reciprocal increase in IL-17A. The role of IL-17A in asthma is complex with reports of both pro-inflammatory and anti-inflammatory functions. Our aim was to determine the influence of IL-17A in regulating IL-25-dependent lung allergy.

METHOD

Neutralizing antibodies to IL-25 and/or IL-17A were administered during an experimental model of allergic asthma. Bronchoalveolar cell infiltrates and lung cytokine production were determined to assess lung inflammation. Invasive plethysmography was undertaken to measure lung function.

RESULTS

Neutralization of IL-25 correlated with a decrease in IL-13 levels and an increase in IL-17A production, and an accompanying prevention of airway hyperresponsiveness (AHR). Notably, the blocking of IL-17A reversed the protective effects of treating with anti-IL-25 antibodies, resulting in the re-expression of several facets of the lung inflammatory response, including IL-13 and eotaxin production, eosinophilia and AHR. Using mice over-expressing IL-13 we demonstrate that treatment of these mice with anti-IL-25 fails to suppress IL-13 levels and in turn IL-17A levels remain suppressed.

CONCLUSIONS AND CLINICAL RELEVANCE

IL-13 is known to be an important inducer of lung inflammation, causing goblet cell hyperplasia and promoting airways hyperreactivity. Our data now demonstrate that IL-13 also plays an important role in the genesis of lung inflammation downstream of IL-25 by suppressing a protective IL-17A response. These findings also highlight the important reciprocal interplay of the IL-17 family members, IL-25 and IL-17A, in regulating allergic lung responses and suggest that the balance of IL-17A, together with IL-25, will be an important consideration in the treatment of allergic asthma.

Toxoplasma gondii peroxiredoxin promotes altered macrophage function, caspase-1-dependent IL-1β secretion enhances parasite replication

Alternatively activated macrophages (AAM) are a key feature Th2 immunity and have been associated with a variety of roles during helminth infection. The role this cell subset plays in protzoan infection remain relatively unexplored, herein we describe the effects of a redox enzyme (rTgPrx) derived from Toxoplasma gondii on murine macrophage phenotype in vitro. RTgPrx has been previously associated with the maintainence of parasite oxidative balance. Here our experiments show that rTgPrx promotes AAM as indicated by high arginase-1 (arg-1), YM1 and FIZZ expression via both signal transducer and activator of transcription (STAT)6-dependent and -independent mechanisms. Additionally rTgPrx treatment reduced caspase-1 activity and IL-1β secretion, while simultaneously increasing IL-10 release. Furthermore the in vitro replication of T. gondii (RH strain) was enhanced when macrophages were treated with rTgPrx. This is in contrast with the previously described effects of a Plasmodium berghei ANKA 2-cys-peroxiredoxin that promotes pro-inflammatory cytokine production. These results highlight the role of T. gondii derived redox enzymes as important immune modulators and potentially indicate a role for AAM in modulating immunopathology and promoting parasite replication during T. gondii infection.

A retrospective investigation into risk factors of sarcoptic mange in dogs

This retrospective study of sarcoptic mange in dogs aimed to identify risk factors for this disease and determine their influence on treatment outcome. Data regarding dog demographics, clinical presentation, diagnostic method, treatment, and outcome were analyzed. No statistical association was found between sex and incidence of sarcoptic mange. However, age of dogs was found to be a risk factor which could increase the chances of dogs contracting sarcoptic mange. The results indicate that the disease predominantly affects young dogs, of all breeds and both sexes, implicating age-related immunity. The most common clinical feature reported was pruritus, with the ear margins preferentially affected. Additionally, contact with other animals played an important role in occurrence of the disease indicating the highly transmissible nature of the disease.

Coordinating innate and adaptive immunity in Fasciola hepatica infection: implications for control

The helminth parasite Fasciola hepatica is responsible for major economic losses in agriculture throughout temperate regions of the globe. Control measures are heavily reliant on chemotherapy resulting in the emergence of drug resistant parasite populations. Novel control strategies based on vaccination ultimately require a deeper knowledge of host-parasite interactions. Herein we discuss recent advances in the understanding of the immune response to F. hepatica placing them in context with previous knowledge and developments from other model systems. Advances in RNAi and proteomics in the context of helminth research should make target identification and characterisation more rapid. In parallel, integration of these technologies with better immunological understanding will be crucial for future research into F. hepatica control measures.

IL-10 and TGF-beta1 are associated with variations in fluke burdens following experimental fasciolosis in sheep

Infection with Fasciola hepatica causes an economically important disease in ruminants. Variability in parasite load may indicate innate differences in the host immune system. This study aimed to investigate the immunological mechanisms that are associated with variability in parasite burden following experimental F. hepatica infection in cross-bred sheep. Of a total of 16 animals, four were randomly chosen as uninfected controls, and the remainder infected with 100 viable metacercariae. Uninfected animals were used as the control group for evaluation of cytokine gene expression levels. For comparative analysis, specific animals were selected on the basis of extremes of fluke burdens, and were categorised into light (n = 4) and heavy burdened (n = 3) cohorts. Serum antibody levels, haematological parameters, and expression of IL-4 and IFN-gamma genes in hepatic lymph nodes were equivalent in both groups. However, significant differences in mitogen-specific lymphocyte proliferation in vitro and in expression of TGF-beta1 and IL-10 genes in hepatic lymph nodes were observed at acute and chronic phases of infection, respectively. These results provide useful information in developing further understanding of natural resistance to fasciolosis in sheep.

Co-Infection of cattle with Fasciola hepatica and Mycobacterium bovis- immunological consequences

Fasciola hepatica, the liver fluke, is a common parasite of cattle in much of the world. Previously, we have shown that cattle infected with F. hepatica have altered responsiveness (delayed type hypersensitivity reaction and cytokine responses) to M. bovis BCG infection. We hypothesized that co-infection with F. hepatica would, likewise, alter the immune response of cattle to virulent M. bovis infection, with possible implications for disease diagnosis and disease progression. Our previous work with F. hepatica/M. bovis BCG-infected cattle demonstrated a reduction in interferon (IFN)-gamma responsiveness in co-infected animals. Similar findings are reported here with virulent M. bovis following aerosol infection. The epidemiological significance of these findings, also, require exploration, particularly in view of the considerable resources devoted to the diagnosis and eradication of bovine tuberculosis, and the high prevalence of F. hepatica infection in areas where eradication has proved difficult.

The roles of IL-10 and TGF-beta in controlling IL-4 and IFN-gamma production during experimental Fasciola hepatica infection

Hosts infected with Fasciola hepatica experience immunosuppression during the acute and chronic phases of the disease. This immunosuppression may allow parasite survival in the face of an ongoing immune response. In bovine hosts early IL-4 and continued IgG1 production is one of the few remaining features of the characteristic type 0/2 helper (Th0/2) response present in the chronic stage of disease. Here we demonstrate elevated levels of parasite-specific, in vitro peripheral blood mononuclear cell (PBMC)-derived transforming growth factor (TGF)-beta1 from the early phases of infection and increasing levels of IL-10 as the infection becomes chronic. In vitro neutralisation of these cytokines during culture of PBMCs from experimentally-infected cattle increased IL-4 and IFN-gamma production in response to parasite-specific and non-specific stimulation. At 4 weeks p.i. neutralisation of TGF-beta results in an increase in parasite driven IL-4, while also having a greater role, compared with IL-10, in influencing specific and non-specific IFN-gamma. At 12 weeks p.i. ex vivo parasite driven IL-4 was not restored by inhibiting either IL-10 or TGF-beta. However IL-10 influenced both parasite-specific and non-specific IFN-gamma production at this time. This highlights the roles of IL-10 and TGF-beta in fasciolosis, however the cellular sources of these have yet to be defined. This suggests that suppression of IFN-gamma production by parasite molecules occurs during infection and it is possible that the suppression of IFN-gamma production may mediate parasite survival in this disease.

Alternative activation of ruminant macrophages by Fasciola hepatica

The helminth parasite, Fasciola hepatica, has a worldwide distribution and infects a wide variety of mammalian hosts, including ruminants and man. In response to infection, these hosts mount a type 2 helper (Th2) response that is highly polarized and results in the downregulation of type 1 helper (Th1) mechanisms. In a murine macrophage model F. hepatica induces alternative activation of macrophages. These macrophages differ from classically activated cells in that they preferentially use arginase instead of inducible nitric oxide synthase (iNOS) for metabolism of nitrogen. In this study we sought to characterize macrophage phenotype following stimulation of the ovine cell line MOCL7 with recombinant F. hepatica enzymes and crude parasite extracts. An in vitro model using the MOCL7 cell line was established and arginase levels in cells were used to determine the activation status of cells. Stimulation of this cell-line in vitro with F. hepatica products induces alternative activation. We have also found a chitinase-like protein in supernatants which is capable of differentiating alternatively activated from classically activated macrophages.

Experimental Fasciola hepatica infection alters responses to tests used for diagnosis of bovine tuberculosis

Fasciola hepatica is a prevalent helminth parasite of livestock. Infection results in polarization of the host's immune response and generation of type 2 helper (Th2) immune responses, which are known to be inhibitory to Th1 responses. Bovine tuberculosis (BTB) is a bacterial disease of economic and zoonotic importance. Control polices for this disease rely on extensive annual testing and a test-and-slaughter policy. The correct diagnosis of BTB relies on cell-mediated immune responses. We established a model of coinfection of F. hepatica and Mycobacterium bovis BCG to examine the impact of helminth infection on correct diagnosis. We found the predictive capacity of tests to be compromised in coinfected animals and that F. hepatica infection altered macrophage function. Interleukin-4 and gamma interferon expression in whole-blood lymphocytes restimulated in vitro with M. bovis antigen was also altered in coinfected animals. These results raise the question of whether F. hepatica infection can affect the predictive capacity of tests for the diagnosis of BTB and possibly also influence susceptibility to BTB and other bacterial diseases. Further studies on the interplay between helminth infection and BTB are warranted.

Cross-validated factor structures and factor-based subscales for PASS and PASSING

Program Analysis of Service Systems (PASS 3) and Program Analysis of Service Systems' Implementation of Normalization Goals (PASSING) are used internationally to assess service quality in mental retardation and other fields. In two studies, we derived and cross-validated the factor structures of these program evaluation instruments. In Study 1, based on 626 PASS 3 evaluations, four factors provided a good fit to the cross-validation data. In Study 2, based on 633 PASSING evaluations, three factors furnished a good fit to the cross-validation data. Similarities between the two factor structures, parallels with the structural and functional service dimensions emphasized in ecological approaches to evaluation, and practical uses in program evaluation of subscales based on the factors were discussed.

Endoscopic laser ablation of the prostate (ELAP): changes in magnetic resonance imaging and clinical outcome at 1 year

OBJECTIVE

To assess the ability of magnetic resonance imaging (MRI) to detect tissue changes immediately after laser ablation of the prostate and to correlate these changes with clinical outcome by detecting changes that may improve the outcome by allowing the laser dosimetry to be adjusted during therapy by monitoring effects on gland morphology.

PATIENTS AND METHODS

Eight men with proven bladder outlet obstruction had a standard four-quadrant laser ablation of the prostate with a side-firing non-contact fibre. MRI scans were performed before, during and immediately after treatment and again after one week, 3 months and one year.

RESULTS

The clinical outcome was a decrease in the American Urological Association (AUA)-7 symptom score from a pre-operative mean of 21.3-12.0 1 year after treatment and a corresponding increase in peak urinary flow rates from a mean of 8.9 mL/s to 12.3 mL/s. Immediately after treatment, MRI showed marked swelling of the gland (mean increase in volume 34%, range 12-75) with the loss of internal architecture. A low-signal thin periurethral band was present in six of the eight patients after 1 week and was replaced by a wider periurethral ring at 3 months in four of the six patients. No patient had evidence of prostatic cavitation after treatment or a significant reduction in prostate volume at 1 year.

CONCLUSION

MRI can detect tissue changes after laser ablation of the prostate. The marked swelling seen on MRI immediately after laser prostatectomy may explain the delayed improvement in symptoms. The periurethral ring may indicate the depth to which laser energy has an effect on the tissue and could delineate an area of necrosis. The lack of cavitation at one year questions the durability of the effect of laser treatment delivered in this way.

Long-term follow-up of patients with erectile dysfunction commenced on self injection with intracavernosal papaverine with or without phentolamine

OBJECTIVES

To determine the usage, complications and satisfaction with intracavernosal agents in patients with erectile dysfunction commenced on self-injection treatment at home.

PATIENTS AND METHODS

A total of 344 patients who had commenced intracavernosal treatment before December 1992 and had requested a repeat prescription were sent a questionnaire to determine the usage, complications, satisfaction and reasons for discontinuing treatment.

RESULTS

Replies were received from 216 patients; of those who replied, only 126 were still using the treatment. The mean duration of treatment was 3.9 years in those continuing treatment. Whilst satisfaction ratings were high in those continuing therapy, most patients had experienced some side-effects.

CONCLUSION

The long-term follow-up revealed a high attrition rate and a significant number of complications. Patients receiving auto-injection therapy should be offered regular long-term follow-up.

Endoscopic laser ablation of the prostate: MR appearances during and after treatment and their relation to clinical outcome

OBJECTIVE

Endoscopic laser ablation is a new treatment for benign prostatic hypertrophy. The objectives of this study were to determine the appearances of the prostate on MR images obtained during, 1 week after, and 3 months after this procedure and to determine if a correlation exists between the MR findings and the clinical outcome. Such appearances could then be used to guide the application of laser energy during the procedure in order to optimize the clinical result.

SUBJECTS AND METHODS

Eight consecutive men 58-74 years old with symptoms of bladder outflow obstruction caused by benign prostatic hypertrophy underwent endoscopic laser ablation of the prostate under spinal or epidural anaesthesia. Imaging was done on a 0.5-T Picker Asset system with an endorectal receiver coil and conventional T1-weighted spin-echo, T2-weighted spin-echo, and gradient-recalled-echo sequences. T1-weighted magnetization transfer images were obtained in three patients. Images were obtained preoperatively, after ablation of the left-sided quadrants, immediately after completion of the procedure, and 1 week and 3 months later. Preoperative and 3-month postoperative symptom scores, peak urine flow rates, and bladder residual volumes were studied. Images were visually assessed for signal-intensity changes and the presence of cavitation by three radiologists in conference. The results were quantitatively analyzed by measuring prostatic volumes on the gradient-recalled-echo images and by measuring the width and area of regions of signal-intensity change on the T2-weighted images.

RESULTS

MR images made immediately after treatment showed an increase in the volume of the prostate (mean, 34%) and a poorly defined, low-signal-intensity region around the urethra on the T2-weighted images in six patients. This probably represented coagulative necrosis. The prostate was smaller on MR images made 1 week after treatment, and after 3 months the prostate returned to its preoperative size. After 1 week, the low-signal-intensity periurethral region on the T2-weighted images was less obvious, and at 3 months it was replaced in four patients by a well-demarcated low-signal-intensity ring on the T2-weighted and gradient-recalled-echo images. No evidence of cavity formation in the prostate was seen on MR images in any patient. Symptom scores and peak urinary flow rates improved after 3 months, with a significant difference between the mean increase in symptom scores in the patients with and without the periurethral changes seen immediately after treatment. However, we found no significant difference between the mean increase in peak urinary flow rates in the patients with and without periurethral changes seen either immediately or at 3 months after treatment. No statistically significant correlation was found between the amount of prostatic swelling and the improvement in symptom scores or peak urine flow rates.

CONCLUSION

In patients who have had laser prostatectomy, MR imaging shows significant immediate glandular swelling, which may account for the delayed improvement in symptoms reported with this technique. The presence of the periurethral changes immediately after treatment was correlated with a subsequent improvement in symptom scores. After 3 months, no cavity could be seen in the prostate. This may account for the poorer long-term clinical outcome reported with endoscopic laser ablation of the prostate compared with transurethral prostatectomy.

Quality of institutional and community human service programs in Canada and the United States

This methodological and substantive study was based on Wolfensberger and Thomas' (1983) Program Analysis of Service Systems' Implementation of Normalization Goals (PASSING), a program evaluation method used by teams of trained raters to assess the quality of human service programs. PASSING is based on Social Role Valorization, an internationally influential theoretical and philosophical approach to structuring human services, particularly services for persons with handicaps or other potentially devaluing conditions. The data for this study were derived from a sample of 213 programs evaluated with PASSING during 1983-88 in Canada (45%), the United States (51%), and the United Kingdom (4%). The programs served mainly mentally retarded persons (40%), subgroups of clients with "mixed" (different) impairments and conditions (38%), or psychiatrically impaired persons (6%). The results showed that PASSING has adequate internal consistency and interrater reliability and yields data suitable for statistical treatment with interval-level, parametric procedures. The average level of quality of services in the sample on the total PASSING scale and its five subscales (Program Relevance, Intensity, Integrativeness, Image Projection, and Felicity) was only modest, however. Community group residences (n = 77) were of significantly better quality than community vocational programs (n = 56), and both were superior to institutional residences (n = 20). Also, Canadian programs (n = 76) were of significantly better quality than U.S. programs (n = 77). An outstanding vocational program that was not part of the study sample was used to illustrate concrete ways in which the quality of many human service programs could be greatly improved, typically at little cost.

Single dose oral H2-antagonists do not affect plasma lidocaine levels in the parturient

We studied whether a single oral dose of either cimetidine or ranitidine affects the disposition of epidurally administered lidocaine in the parturient. Patients given epidural analgesia for elective caesarean section were randomly pretreated with either cimetidine 400 mg (n = 5), ranitidine 150 mg (n = 7) or no H2 receptor antagonist (n = 5). Following the administration of 400 mg of lidocaine 2% with adrenaline 1:200,000 no difference was found in peak plasma lidocaine levels or area under the plasma concentration/time curve (AUC) between the three groups. A single oral dose of cimetidine or ranitidine does not affect lidocaine disposition in the obstetric patient.

Effect of intravenous cimetidine on lignocaine disposition during extradural caesarean section

We studied whether an intravenous bolus of cimetidine altered the disposition of extradurally administered lignocaine in the parturient. Mothers who requested extradural analgesia for elective Caesarean section were randomly pretreated with either cimetidine 200 mg intravenously (n = 5) or no H2-receptor antagonist (n = 5). No difference was found between peak plasma lignocaine levels or area under the plasma concentration/time curve between the two groups after administration of 6 mg/kg lignocaine 2% with adrenaline 1:200,000. There was no evidence for an effect of a single intravenous dose of cimetidine on lignocaine disposition in the obstetric patient. In addition, the extradural administration of 6 mg/kg lignocaine produces plasma levels well below toxic levels.

A comparison between propofol and thiopentone as induction agents in obstetric anaesthesia

Two comparable series of 21 patients who had elective Caesarean section had general anaesthesia induced by thiopentone sodium 4.53 (SD 0.65) mg/kg or propofol 2.15 (SD 0.26) mg/kg. Maintenance was similar for both groups. Blood pressure was lower in the propofol group during the induction-delivery interval. Umbilical/maternal vein ratios for thiopentone and propofol were 8.5 and 7.2 respectively. Infant wellbeing as judged by Apgar score and cord blood analysis showed little difference between the two induction agents. Factors associated with uterine relaxation and bleeding were similar in the two groups.

Australian Stringhalt--epidemiological, clinical and neurological investigations

An investigation of 78 cases of typical Australian Stringhalt from 52 properties in Victoria was carried out from 1985 to 1987. Horses were either examined in the field (n = 52), referred to the Veterinary Clinical Centre (n = 13) or clinical details were obtained verbally (n = 13). In addition 10 cases of false or atypical stringhalt were examined. Detailed soil and pasture analysis was carried out on 14 properties where Australian Stringhalt had occurred. Information was also obtained on epidemiology of the condition from a survey of practitioners. Fifty of the 52 cases examined in the field occurred in horses that were dependent upon poor quality unimproved dry pasture. In all but a few cases, there was no pasture improvement or fertiliser application, leading to the development of weed-dominated pastures, particularly by flatweed, Hypochaeris radicata. The range of clinical signs exhibited by horses with Australian Stringhalt was described and a grading system proposed to classify horses according to severity of signs. Laryngeal abnormalities were present in 10 of 11 cases examined endoscopically and these horses exhibited increased electromyographic (EMG) activity in the long digital extensor muscle at rest and during hindlimb flexion. To a large extent, the EMG changes disappeared and digital extensor muscle atrophy improved in two horses that were monitored to recovery. Deep peroneal nerve conduction studies in four horses with Australian Stringhalt showed a substantial reduction in nerve conduction velocity and when stimulated at 50 Hz were unable to sustain activation of the long digital extensor muscle. EMG and evoked responses appeared to be sensitive indicators of the state of the disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of single-dose omeprazole on intragastric acidity and volume during obstetric anaesthesia

Various antacid or antisecretory agents are used to reduce the risk to patients of aspiration of gastric contents during general anaesthesia and a trial of the gastric proton pump inhibitor, omeprazole, is reported here. Twenty women admitted for elective Caesarean section under general anaesthesia received a single 80-mg oral omeprazole dose at 2000 hours on the evening before surgery. Intragastric pH and volume were measured immediately after induction of anaesthesia and on completion of surgery. Eighty-five percent of pH measurements at induction and extubation and 80% and 95% of volume measurements at induction and extubation respectively met the defined success criteria (pH greater than or equal to 2.5, volume less than 25 ml). Omeprazole treatment was well tolerated by the women and Apgar scores and subsequent progress of the babies were acceptable. These results indicate that gastric acidity and volume were acceptable in the majority of women after omeprazole treatment, but the interval from drug administration to induction of anaesthesia may have been too long in some cases and resulted in unacceptably low pHs.