Treatment trends and Medicare reimbursements for localized prostate cancer in elderly patients

INTRODUCTION

The absolute and proportional numbers of elderly patients diagnosed with localized prostate cancer (PCa) are on the rise. We examined treatment trends and reimbursement figures in localized PCa patients aged ≥80 years.

METHODS

Between 2000 and 2008, we identified 30 217 localized PCa patients aged ≥80 years in Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database. Alternative treatment modalities consisted of conservative management (CM), radiation therapy (RT), radical prostatectomy (RP), and primary androgen-deprivation therapy (PADT). For all four modalities, utilization and reimbursements were examined.

RESULTS

PADT was the most frequently used treatment modality between 2000 and 2005. CM became the dominant treatment modality from 2006-2008. RP rates were marginal. RT ranked third, and its annual rate increased from 20.77% in 2000 to 29.13% in 2008. Median individual reimbursement of RT was highest and ranged from $29 343 in 2000 to $31 090 in 2008, followed by RP (from $20 560 in 2000 to $19 580 in 2008), PADT (from $18 901 in 2000 to $8000 in 2008), and CM (from $1824 in 2000 to $1938 in 2008). RT contributed to most of the cumulative annual reimbursements from 2003 (49.24%) to 2008 (72.97%). PADT ranked first from 2000 (54.56%) to 2002 (50.49%), but decreased by 19.40% in 2008. CM's contribution increased from 4.42% in 2000 to 6.96% in 2008. RP's share of reimbursements was stable during the study period.

CONCLUSIONS

Our results, focusing on localized PCa treatment in patients aged ≥80 years, showed an important increase in rates, median cost, and proportion of cumulative cost related to RT.

The Effect of Obesity on Perioperative Outcomes Following Percutaneous Nephrolithotomy

OBJECTIVES

To test if obesity predisposes to higher rates of adverse outcomes after percutaneous nephrolithotomy (PCNL).

MATERIALS AND METHODS

Within the Nationwide Inpatient Sample (NIS), we identified patients treated with PCNL between 1998 and 2010 for kidney stones. We examined the temporal trends in PCNL use and charges among obese and nonobese patients. We then tested the effect of obesity on perioperative complications, transfusions, length of stay (LOS), and total hospital charges (THCs). LOS and THCs were defined as a continuous variable and were also dichotomized according to the 75th percentile into prolonged LOS (pLOS) and increased THCs (iTHCs). Then, multivariable models were fitted.

RESULTS

Overall, a weighted sample of 90,529 individuals treated with PCNL between 1998 and 2010 was examined. Of those patients, 9300 were obese (10.3%). The proportion of PCNLs performed in obese patients increased throughout the years from 7.4% to 16.7% (p < 0.001). Overall complication rates were 21.6% vs 22.0% (p = 0.3) and transfusion rates were 4.3% vs 4.0% (p = 0.1) for obese and nonobese patients, respectively. Obese patients had fewer genitourinary complications (13.4% vs 15.0%, p < 0.001), but had higher rates of sepsis (1.7% vs 1.3%, p = 0.009) as well as respiratory (3.0% vs 2.5%, p = 0.002) and vascular complications (0.3% vs 0.2%, p = 0.007). Conversely, pLOS (20.9% vs 18.8%, p < 0.001) and iTHCs (30.8% vs 24.4%, p < 0.001) were more frequently recorded in obese patients. In multivariable analyses, obesity was neither associated with higher rates of overall complications (odds ratio [OR], p = 0.3) nor with higher rates of transfusions (p = 0.3). However, obesity was associated with pLOS (OR: 1.21, p = 0.002) as well as iTHCs (OR: 1.17, p = 0.002).

CONCLUSIONS

PCNL in obese patients did not result in higher rates of individual complications or transfusions. However, it resulted in higher rates of pLOS and iTHCs.

Survival After Conservative Management Versus External Beam Radiation Therapy in Elderly Patients With Localized Prostate Cancer

PURPOSE

To compare survival in elderly men with clinically localized prostate cancer (PCa) according to treatment type, defined as radiation therapy (RT) with or without androgen deprivation therapy (ADT) versus conservative management (observation).

METHODS AND MATERIALS

In the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database, we identified 23,790 patients aged 80 years or more with clinically localized PCa treated with either RT or observation between 1991 and 2009. Competing risks analyses focused on cancer-specific mortality and other-cause mortality, after accounting for confounders. All analyses were repeated after stratification according to grade (well-differentiated vs moderately differentiated vs poorly differentiated disease), race, and United States region, in patients with no comorbidities and in patients with at least 1 comorbidity. Analyses were repeated within most contemporary patients, namely those treated between 2001 and 2009.

RESULTS

Radiation therapy was associated with more favorable cancer-specific mortality rates than observation in patients with moderately differentiated disease (hazard ratio [HR] 0.79; 95% confidence interval [CI] 0.66-0.94; P=.009) and in patients with poorly differentiated disease (HR 0.58; 95% CI 0.49-0.69; P<.001). Conversely, the benefit of RT was not observed in well-differentiated disease. The benefit of RT was confirmed in black men (HR 0.54; 95% CI 0.35-0.83; P=.004), across all United States regions (all P≤.004), in the subgroups of the healthiest patients (HR 0.67; 95% CI 0.57-0.78; P<.001), in patients with at least 1 comorbidity (HR 0.69; 95% CI 0.56-0.83; P<.001), and in most contemporary patients (HR 0.55; 95% CI 0.46-0.66; P<.001).

CONCLUSIONS

Radiation therapy seems to be associated with a reduction in the risk of death from PCa relative to observation in elderly patients with clinically localized PCa, except for those with well-differentiated disease.

Medical management of benign prostatic hyperplasia: Results from a population-based study

INTRODUCTION

In men with bothersome lower urinary tract symptoms (LUTS), medical treatment usually represents the first line. We examined the patterns of medical management of benign prostatic hyperplasia (BPH) in the Montreal metropolitan area, within the context of a case control study focusing on incident prostate cancer.

METHODS

Cases were 1933 men with incident prostate cancer. Population controls included 1994 age-matched men. In-person interviews collected sociodemographic characteristics and medical history, including BPH diagnosis, its duration, and type of medical treatment received. Baseline characteristics were compared by the chi-square likelihood test for categorical variables and by the students t-test for continuously coded variables.

RESULTS

Overall, 1120 participants had history of BPH; of those 53.7% received medical treatment for BPH. Individuals with medically treated BPH, compared to individuals with medically untreated BPH, were older at index date [mean: 66.9 vs. 64.9 years, p<0.001)] and at diagnosis of BPH [mean: 62.3 vs. 60.3 years, p<0.001]. They also had a longer duration of BPH-history [mean: 4.7 vs. 4.0 years, p=0.02]. Regarding medical treatment, mono-therapy was more often used than combination therapy [87.6% vs. 12.4%, p<0.001]. Alpha-blockers (69.9%) were most commonly used as monotherapy, followed by 5alpha-reductase inhibitors (5ARIs) (26.6%). Alpha-blockers plus 5ARIs were the most common combination therapy (97.3%).

CONCLUSIONS

Despite evidence from randomized, controlled trials for better efficacy with use of combination therapy, monotherapy consisting of alpha-blockers or 5ARI, in that order, is most frequently used. Additionally, 5ARI use was more common than previously reported (27% vs. 15%).

Local tumour ablation for localized kidney cancer: Practice patterns in Canada

INTRODUCTION

Local tumour ablation (LTA) is a recommended option for the treatment of localized kidney cancer in nonsurgical candidates. We performed a survey to describe the practice patterns of this procedure in Canada.

METHODS

An electronic survey was sent by email to all urologists registered to the Canadian Urological Association (CUA). Urologists were queried about general demographic information, LTA availability at their institution (and reasons for non-availability, if it was the case), as well as the type and context of LTA use.

RESULTS

Overall, 103 individual responses were obtained (response rate of 19.5%). Of those, 58 (56.3%) had access to LTA at their institution. Urologists who had access to LTA were more likely to work at an academic institution (69 vs. 16%, p<0.001). Among individuals who did not use LTA, the main reasons were lack of staff, such as radiologists, who can assist and/or perform the procedure (64%); and lack of expertise with the procedure (62%). Among urologists who had access to LTA, percutaneous radiofrequency and cryoablation were the most commonly used (72% and 21%, respectively); however, urologists were rarely involved in those procedures (12%).

CONCLUSIONS

In this national survey, we found that a significant proportion of Canadian urologists did not have access to LTA. We also found that when LTA was performed, urologists were rarely involved in the procedures. Those findings represent significant areas for improvement in the access to LTA. The conclusions of this study are limited by the low response rate.

Population-based assessment of cancer-specific mortality after local tumour ablation or observation for kidney cancer: a competing risks analysis

OBJECTIVES

To examine, using competing risks regression, differences in cancer-specific mortality (CSM) that might distinguish between local tumour ablation (LTA) and observation (OBS) for patients with kidney cancer.

PATIENTS AND METHODS

The study focused on 1 860 patients with cT1a kidney cancer treated with either LTA or OBS between 2000 and 2009 in the Surveillance Epidemiology and End Results-Medicare database. Propensity-score matching was used. The study outcome was CSM. Multivariable competing risks regression analyses, adjusting for other-cause mortality as well as patient (including comorbidities) and tumour characteristics, were fitted.

RESULTS

Overall, fewer patients underwent LTA than OBS (30 vs 70%; n = 553 vs n = 1 307). Compared with patients in the OBS group, those in the LTA group were younger (median age 77 vs 78 years; P < 0.001), more likely to be white (84 vs 78%; P = 0.005), more frequently married (59 vs 52%; P = 0.02) and more frequently of high socio-economic status (54 vs 45%; P = 0.001). After propensity-score matching, 553 patients who underwent LTA and 553 who underwent OBS remained for subsequent analyses. The mean standardized differences of patient characteristics between the two groups were <10%, indicating a high degree of similarity. After LTA or OBS, the 5-year CSM estimates from Poisson regression-derived smoothed plots were 3.5 and 9.1%, respectively. In multivariable competing risks regression analyses, LTA use was found to have a protective effect on CSM (hazard ratio 0.47 [95% confidence interval 0.25-0.89]; P = 0.02).

CONCLUSIONS

After adjustment for comorbidity and tumour characteristics in elderly patients with kidney cancer, LTA was associated with a clinically and statistically significant protective effect on CSM, compared with OBS. This advantage of LTA deserves consideration when obtaining informed consent.

Factors predicting prolonged operative time for individual surgical steps of robot-assisted radical prostatectomy (RARP): A single surgeon's experience

INTRODUCTION

We evaluated the average time required to complete individual steps of robotic-assisted radical prostatectomy (RARP) by an expert RARP surgeon. The intent is to help establish a time-based benchmark to aim for during apprenticeship. In addition, we aimed to evaluate preoperative patient factors, which could prolong the operative time of these individual steps.

METHODS

We retrospectively identified 247 patients who underwent RARP, performed by an experienced robotic surgeon at our institution. Baseline patient characteristics and the duration of each step were recorded. Multivariate analysis was performed to predict factors of prolonged individual steps.

RESULTS

In multivariable analysis, obesity was a significant predictor of prolonged operative time of: docking (odds ratio [OR] 1.96), urethral division (OR 3.13), and vesico-urethral anastomosis (VUA) (OR 2.63). Prostate volume was also a significant predictor of longer operative time in dorsal vein complex ligation (OR 1.02), bladder neck division (OR 1.03), pedicle control (OR 1.04), urethral division (OR 1.02), and VUA (OR 1.03). A prolonged bladder neck division was predicted by the presence of a median lobe (OR 5.03). Only obesity (OR 2.56) and prostate volume (OR 1.04) were predictors of a longer overall operative time.

CONCLUSIONS

Obesity and prostate volume are powerful predictors of longer overall operative time. Furthermore, both can predict prolonged time of several individual RARP steps. The presence of a median lobe is a strong predictor of a longer bladder neck division. These factors should be taken into consideration during RARP training.

Prevalence and risk factors of contralateral extraprostatic extension in men undergoing radical prostatectomy for unilateral disease at biopsy: A global multi-institutional experience

INTRODUCTION

We assessed the incidence of contralateral prostate cancer (cPCa), contralateral EPE (cEPE) and contralateral positive surgical margins (cPSM) in patients diagnosed preoperatively with unilateral prostate cancer and evaluated risk factors predictive of contralateral disease extension.

METHODS

The occurrence of cPCa, cEPE and cPSM and the side-specific nerve-sparing technique performed were collected postoperatively from 327 men diagnosed with unilateral prostate cancer at biopsy. Parameters, such as the localization, proportion, and percentage of cancer in positive cores, were prospectively collected.

RESULTS

Overall, 50.5% of patients had bilateral disease, and were at higher risk when associated with a positive biopsy core at the apex (p = 0.016). The overall incidence of ipsilateral EPE and cEPE were 21.4% and 3.4%, respectively (p < 0.001). Compared to cPCa, ipsilateral disease was at an almost 4-fold higher risk of extending out of the prostate (p < 0.001). None of the criteria tested were identified as useful predictors for cEPE. The low incidence of cEPE in our cohort could limit our ability to detect significance. The overall incidence of ipsilateral PSM and cPSM were 15.3% and 5.8%, respectively (p < 0.001). More aggressive nerve-sparing was not associated with a higher incidence of PSM. Prostate sides selected for more aggressive nerve-sparing were associated with younger patients (p < 0.001), a smaller prostate (p = 0.006), and a lower percentage of cancer in biopsy material (p = 0.008).

CONCLUSION

Although the risk of cPCa is high in patients diagnosed with unilateral prostate cancer at biopsy, the risk of cEPE and cPSM is low, yet not insignificant. Contralateral aggressive nerve-sparing should be used with caution and should not compromise oncological outcome.

Comparison of renal function detriments after local tumor ablation or partial nephrectomy for renal cell carcinoma

PURPOSE

Local tumor ablation (LTA) and partial nephrectomy (PN) represent treatment alternatives for patients diagnosed with small renal mass and both may result in renal function detriments. The aim of the study was to compare renal function detriments after LTA or PN.

METHODS

A Surveillance epidemiology and End Results-Medicare-linked retrospective cohort of 2850 T1 kidney cancer patients who underwent LTA or PN was abstracted. Short-term outcomes consisted of 30-day acute kidney injury (AKI) and 30-day dialysis rates. Long-term outcomes consisted of episodes of AKI, mild and moderate-severe chronic kidney disease (CKD), end-stage renal disease, hemodialysis and anemia in CKD. Analyses consisted of propensity score matching, logistic and Cox regression.

RESULTS

After propensity score matching, 1122 patients remained. The 30-day incidence of AKI was 4.6 % after LTA and 9.4 % after PN. In multivariable analyses (MVAs), LTA was associated with a lower AKI rate (OR 0.42; p = 0.001). The 30-day incidence of any dialysis was <2 % after either LTA or PN. In MVA, LTA was not associated with a lower rate of any dialysis (OR 0.43; p = 0.2). At long-term assessment, both the unadjusted and adjusted rates of all six examined end points were not different between LTA and PN (all p > 0.5).

CONCLUSIONS

LTA offers short-term protective effect from AKI. The short-term rates of any dialysis treatment are similar after either LTA or PN. At long-term assessment, LTA and PN renal function detriment rates are not different. Concern for long-term functional outcomes should not be a barrier for PN.

Robot-assisted versus laparoscopic nephroureterectomy for upper-tract urothelial cancer: A population-based assessment of costs and perioperative outcomes

INTRODUCTION

We compared short-term outcomes and costs between robotic-assisted nephroureterectomy (RANU) and laparoscopic radical nephroureterectomy (LNU) in a large population-based cohort of patients with upper-tract urothelial carcinoma (UTUC).

METHODS

Overall, 1914 patients with UTUC treated with RANU or LNU between 2008 and 2010 within the Nationwide Inpatient Sample were abstracted. Propensity-score matching was performed to account for inherent differences between patients undergoing RANU and LNU. Multivariable logistic regression models were fitted to compare postoperative complications, blood transfusions, prolonged length of stay, and costs between the 2 procedures.

RESULTS

Overall, a weighted estimate of 1199 (62.6%) and 715 (37.4%) patients received LNU and RANU, respectively. In multivariable analyses no significant differences were observed in postoperative transfusion and length of stay between the 2 surgical approaches (all p > 0.1). However, patients undergoing RANU were less likely to experience any complications compared to their counterparts undergoing LNU (p = 0.04). The utilization of RANU was associated with substantially higher costs compared to the laparoscopic approach. Our study is limited by its retrospective nature and the lack of adjustment for tumour stage and grade.

CONCLUSIONS

Our results support the safety and feasibility of RANU for the treatment of UTUC. Indeed, the use of the robotic approach was associated with lower probability of experiencing perioperative complications compared to LNU. On the other hand, the utilization of RANU is associated with higher costs compared to LNU.

Early radiotherapy after radical prostatectomy improves cancer-specific survival only in patients with highly aggressive prostate cancer: validation of recently released criteria

OBJECTIVES

To test the effect of radiotherapy administered within 6 months after radical prostatectomy on cancer-specific mortality in prostate cancer patients after stratification according to a risk score.

METHODS

Overall, 7616 patients with pT3/4 N0/1 prostate cancer treated with radical prostatectomy between 1995 and 2009 within the Surveillance Epidemiology and End Results Medicare-linked database were included in the study. Competing-risks regression models were carried out to test the effect of early radiotherapy on cancer-specific mortality in the entire cohort, and after stratifying patients according to the risk score based on the number and nature of adverse pathological characteristics (Gleason score 8-10; pT3b/4, lymph node invasion).

RESULTS

The risk score was associated with increasing 5- and 10-year cancer-specific mortality rates (P < 0.001). When considering only patients with a risk score ≥ 2, 5- and 10-year cancer-specific mortality rates were significantly lower for individuals undergoing early radiotherapy compared with their counterparts not receiving early radiotherapy (2.9 and 6.9 vs 5.7 and 16.2%, respectively; P = 0.002). The corresponding number required to treat to prevent one death from prostate cancer at 10-year follow up was 10. Early radiotherapy was not associated with lower cancer-specific mortality rates overall and in patients with a risk score <2. This was confirmed in multivariable analyses, where early radiotherapy decreased the risk of cancer-specific mortality only in patients with a risk score ≥ 2 (P ≤ 0.02).

CONCLUSIONS

The presence of two or more of the following pathological features might be used to identify patients who benefit from early radiotherapy: Gleason score 8-10, pT3b/4 and lymph node invasion.

Impact of the Site of Metastases on Survival in Patients with Metastatic Prostate Cancer

BACKGROUND

Limited data exist on the impact of the site of metastases on survival in patients with stage IV prostate cancer (PCa).

OBJECTIVE

To investigate the role of metastatic phenotype at presentation on mortality in stage IV PCa.

DESIGN, SETTING, AND PARTICIPANTS

Overall, 3857 patients presenting with metastatic PCa between 1991 and 2009, included in the Surveillance Epidemiology and End Results-Medicare database were evaluated.

OUTCOME MEASUREMENTS AND STATISTIC ANALYSES

Overall and cancer-specific survival rates were estimated in the overall population and after stratifying patients according to the metastatic site (lymph node [LN] alone, bone, visceral, or bone plus visceral). Multivariable Cox regression analyses tested the relationship between the site of metastases and survival. All analyses were repeated in a subcohort of patients with a single metastatic site involved.

RESULTS AND LIMITATIONS

Respectively, 2.8%, 80.2%, 6.1%, and 10.9% of patients presented with LN, bone, visceral, and bone plus visceral metastases at diagnosis. Respective median overall survival and cancer-specific survival were 43 mo and 61 mo for LN metastases, 24 mo and 32 mo for bone metastases, 16 mo and 26 mo for visceral metastases, and 14 mo and 19 mo for bone plus visceral metastases (p<0.001). In multivariable analyses, patients with visceral metastases had a significantly higher risk of overall and cancer-specific mortality versus those with exclusively LN metastases (p<0.001). The unfavorable impact of visceral metastases persisted in the oligometastatic subgroup. Our study is limited by its retrospective design.

CONCLUSIONS

Visceral involvement represents a negative prognostic factor and should be considered as a proxy of more aggressive disease in patients presenting with metastatic PCa. This parameter might indicate the need for additional systemic therapies in these individuals.

PATIENT SUMMARY

Patients with visceral metastases should be considered as affected by more aggressive disease and might benefit from the inclusion in clinical trials evaluating novel molecules.

Distribution of metastatic sites in patients with prostate cancer: A population-based analysis

BACKGROUND

There is few data on what constitutes the distribution of metastatic sites in prostate cancer (PCa). The aim of our study was to systematically describe the most common sites of metastases in a contemporary cohort of PCa patients.

METHODS

Patients with metastatic PCa were abstracted from the Nationwide Inpatient Sample (1998-2010). Most common metastatic sites within the entire population were described. Stratification was performed according to the presence of single or multiple (≥ 2 sites) metastases. Additionally, we evaluated the distribution of metastatic sites amongst patients with and without bone metastases.

RESULTS

Overall, 74,826 patients with metastatic PCa were identified. The most common metastatic sites were bone (84%), distant lymph nodes (10.6%), liver (10.2%), and thorax (9.1%). Overall, 18.4% of patients had multiple metastatic sites involved. When stratifying patients according to the site of metastases, only 19.4% of men with bone metastases had multiple sites involved. Conversely, among patients with lymph nodes, liver, thorax, brain, digestive system, retroperitoneum, and kidney and adrenal gland metastases the proportion of men with multiple sites involved was 43.4%, 76.0%, 76.7%, 73.0%, 52.2%, 60.9%, and 76.4%, respectively. When focusing exclusively on patients with bone metastases, the most common sites of secondary metastases were liver (39.1%), thorax (35.2%), distant lymph nodes (24.6%), and brain (12.4%).

CONCLUSIONS

Although the majority of patients with metastatic PCa experience bone location, the proportion of patients with atypical metastases is not negligible. These findings might be helpful when planning diagnostic imaging procedures in patients with advanced PCa.

The health care burden of skeletal related events in patients with renal cell carcinoma and bone metastasis

PURPOSE

We examined temporal trends in skeletal related events and associated charges in patients with renal cell carcinoma metastatic to bone. We also identified patient and hospital characteristics associated with skeletal related events and related mortality.

MATERIALS AND METHODS

Using the Nationwide Inpatient Sample we abstracted data on patients with renal cell carcinoma who were diagnosed with concomitant bone metastasis between 1998 and 2010. Patients who experienced a skeletal related event were identified and hospital charges were calculated. Multivariate regression models fitted with generalized estimating equations were used to examine predictors of skeletal related events and related in-hospital mortality.

RESULTS

Between 1998 and 2010 a weighted estimate of 144,889 renal cell carcinoma hospital visits of patients with bone metastasis was identified in the Nationwide Inpatient Sample, of which 20.8% involved a skeletal related event. In these cases from 1998 to 2010 the inflation adjusted mean yearly costs associated with hospital admission increased by 207% in 2013 United States dollars (estimated annual percent change 8.94%, p<0.001). Conversely, the rates of skeletal related events and skeletal related event associated mortality decreased significantly (estimated annual percent change -1.11% and -2.9%, respectively, each p<0.001).

CONCLUSIONS

The prevalence and in-hospital mortality of skeletal related event associated hospitalization for metastatic renal cell carcinoma is decreasing but such charges to health care in the United States are increasing at an alarming rate. These findings highlight the need for cost-effective treatment strategies to prevent or treat these morbid complications.

Emergency department visits in the United States for upper urinary tract stones: trends in hospitalization and charges

PURPOSE

Using the Nationwide Emergency Department Sample (NEDS) we examined trends in visits, hospitalization and charges for patients with upper urinary tract stones who presented to the emergency department in the United States.

MATERIALS AND METHODS

All visits with a primary diagnosis of kidney calculus (ICD-9-CM code 592.0), ureter calculus (592.1) or urinary calculus unspecified (592.9) were extracted from NEDS between 2006 and 2009. A weighted sample was used to calculate incidence rates. Temporal trends were quantified by the estimated annual percent change. Patient and hospital characteristics associated with hospitalization were evaluated using logistic regression models adjusted for clustering.

RESULTS

Between 2006 and 2009 there were 3,635,054 emergency department visits for upper urinary tract stones. The incidence increased from 289 to 306/100,000 individuals. More men visited than women but women showed significant increases in visits (estimated annual percent change 2.85%, p = 0.018). Total monthly emergency department visits ranged from 5.8% in February to 8.4% in August. Overall 12.0% of patients were hospitalized and the hospitalization rate remained stable (estimated annual percent change -1.02%, p = 0.634). Patients were more likely to be hospitalized if they were female, more ill, seen at an urban teaching or low volume hospital, or had Medicaid or Medicare (each p <0.001). Sepsis was associated with the highest likelihood of hospital admission (OR 69.64, p <0.001). In 2009 charges for emergency department visits increased to $5 billion (estimated annual percent change 10.06%, p = 0.003).

CONCLUSIONS

Women showed significant annual increases in emergency department visits for upper urinary tract stones. While emergency department charges increased substantially, hospitalization rates remained stable. Greater use of computerized tomography and medical expulsive therapy could be the reasons for this observation, which warrants further study.

IκB-Kinase-ε (IKKε/IKKi/IκBKε) expression and localization in prostate cancer tissues

BACKGROUND

Advanced prostate cancer (PCa) remains a one of the leading causes of cancer related death and is often due to the progression from a hormone sensitive (HS) to a castrate resistant (CR) state for which therapeutic alternatives remain palliative. Molecular events involved in the progression to CR-PCa remain largely unknown. A previous study reported significantly higher levels of Iκ-B kinase-epsilon (IKKε) expression in CR compared to androgen-responsive cell lines. In the present study, we evaluate IKKε expression in human prostate tissue.

METHODS

In order to evaluate the modulation of IKKε expression in PCa tissue IKKε immunostaining was performed on paraffin-embedded prostate tissue microarrays containing cores from normal tissues (n = 47), non-malignant tissues adjacent to the tumor (n = 53), prostatic intraepithelial neoplasia (PIN) (n = 28), HS (n = 62), and CR tumors (n = 31).

RESULTS

We found a low cytoplasmic expression of IKKε in non-malignant tissue. HS tumors showed a significant increase in cytoplasmic IKKε expression compared to non-malignant tissues. CR tissues presented the highest cytoplasmic IKKε expression levels. We also report, for the first time, the presence of a nuclear localization of IKKε in prostate epithelial cells, in particular we observed an increase of IKKε nuclear localization in HS malignant tissues. Finally, we found a strong link between an increase of IKKε cytoplasmic expression in PCa and metastatic progression.

CONCLUSION

This study strongly suggests the role of IKKε as a PCa oncogene that may be involved in the emergence of a CR state.

Phytochemical and biological analysis of skullcap (Scutellaria lateriflora L.): a medicinal plant with anxiolytic properties

The phytochemistry and biological activity of Scutellaria lateriflora L. (American skullcap) which has been traditionally used as a sedative and to treat various nervous disorders such as anxiety was studied. In vivo animal behaviour trials were performed to test anxiolytic effects in rats orally administered S. laterifolia extracts. Significant increases in the number of entries into the center of an "open-field arena"; number of unprotected head dips, number of entries and the length of time spent on the open arms of the Elevated Plus-Maze were found. The identification and quantification of the flavonoid, baicalin in a 50% EtOH extract (40 mg/g) and its aglycone baicalein in a 95% EtOH extract (33 mg/g), as well as the amino acids GABA in H2O and EtOH extracts (approximately 1.6 mg/g) and glutamine in a H2O extract (31 mg/g), was performed using HPLC. These compounds may play a role in anxiolytic activity since baicalin and baicalein are known to bind to the benzodiazepine site of the GABAA receptor and since GABA is the main inhibitory neurotransmitter.

Gabapentin in naive childhood absence epilepsy: results from two double-blind, placebo-controlled, multicenter studies

Efficacy and safety of gabapentin monotherapy were evaluated in 33 children with newly diagnosed absence epilepsy in two identical, double-blind, placebo-controlled trials in which a 2-week double-blind treatment phase was followed by a 6-week open-label phase. Primary efficacy criterion was seizure frequency change from baseline to end of double-blind treatment derived from quantified electroencephalograms. Primary efficacy analyses compared treatment differences in the 2-week double-blind phase. Gabapentin did not significantly decrease or increase seizure frequency compared with placebo. Low dosages with possibly subtherapeutic plasma levels may have contributed to the lack of demonstrable efficacy. Somnolence and dizziness were the only adverse events reported by at least two patients during gabapentin treatment. No clinically important changes in laboratory assessments or other safety parameters were observed. Gabapentin monotherapy at dosages ranging from 9.7 through 19.1 mg/kg/day is well tolerated in pediatric patients aged 4 through 12 years with absence epilepsy.

AIDS education strategies: evaluating the fear response

1. Despite educational interventions, evidence suggests that negative attitudes about AIDS risk persist among clinical hospital staff. In diverse study populations, associations have been found between psychosocial phenomena and on the job accidents and injuries. 2. This article describes a pilot study to explore whether fearful attitudes of clinicians contribute to the adverse behaviors of needlestick injuries and mucosal splashes. The authors sought to demonstrate whether desensitization therapy would be effective in reducing fear response. 3. A serendipitous finding of the study was that organizational and interpersonal conflict frequently provoked fear and anxiety responses. There is a continued need to examine the domain of AIDS related fears among clinical staff, as well as a need to seek a better understanding of this fear as part of the tensions of organizational dynamics in hospitals. 4. Occupational health nurses working in hospitals are in a unique position to uncover relationships among all types of incidents that may indicate fear and anxiety among clinical staff.

Season and social environment influence the membrane integrity of ejaculated boar spermatozoa as assessed by ouabain sensitivity

Eight adult Landrace boars were housed for 12 months in one of two social environments. Socially nonrestricted boars were penned near estrual females and socially restricted boars were penned behind solid walls to eliminate visual and physical contact with other pigs. All animals were subjected to natural changes in day length. The sensitivity of ejaculated spermatozoa to ouabain (in inhibitor of Na+-K+ ATPase) was determined on 4 consecutive weeks in November, March-April, and July-August. Semen was diluted in Tyrode's solution (pH 7.4) with and without 10(-3) M ouabain. Duplicate samples of control and ouabain-treated spermatozoa were incubated at 37 degrees C for 4 h, and percent motile sperm, motility type, and motility index (combination of percent and type) were determined at hourly intervals. Ouabain-induced decreases in most motility parameters varied with season (season X treatment, P less than 0.05). At hour 4, induced decreases in percent motile sperm were more pronounced in November and July-August than in March-April for socially nonrestricted boars. Decreases in motility type were greater (P less than 0.05) in November and July-August than in March-April for socially nonrestricted boars and were greater (P less than 0.01) in November than in July-August for restricted boars. In March-April motility type decreased (P less than 0.01) to a greater extent for socially restricted vs. nonrestricted boars. Similar season and social environment differences were observed for motility index values. Given the interrelationships between ouabain sensitivity, the functional integrity of sperm cells, and fertilizing capacity, season and social environment differences in ouabain-induced motility depression probably reflect qualitative changes in boar spermatozoa.

Effect of season and social environment on testis size and semen quality of the adult Landrace boar

Eight adult Landrace boars were housed for 12 mo in one of two social environments. Socially nonrestricted boars were penned adjacent to and allowed minimal physical contact with ovariectomized gilts hormonally induced into estrus every 2 wk. Socially restricted boars were penned behind solid walls to eliminate visual and physical contact with other pigs. All animals were subjected to natural changes in daylength. Semen was collected weekly; gel-free volume, gel weight, sperm concentration and number per ejaculate, sperm motility (percent and type) and semen pH were determined. Total protein, citric acid contents and alkaline phosphatase activity were measured in seminal plasma. Testis length and width and various body temperature measurements were recorded monthly. Except for percent motile sperm and alkaline phosphatase activity, all semen characteristics varied (P less than .05) with month. The pattern of seasonal change in semen volume was modified by social environment (group X month, P less than .05). Sperm numbers were highest in winter and lowest in spring and summer. Ejaculate protein and citric acid contents were highest in fall and winter; decreases in spring were associated with moderate ambient temperatures and increases in daylength (r = -.80, P less than .05). Testicular length for socially nonrestricted boars was maximum in November through January and minimum in April through July, and did not vary as extensively for socially restricted boars. Scrotal temperature was elevated during periods of high ambient temperature, but not to values detrimental to spermatogenic function.(ABSTRACT TRUNCATED AT 250 WORDS)