Sensitivity of larval and juvenile freshwater mussels (unionidae) to ammonia, chloride, copper, potassium, and selected binary chemical mixtures

In aquatic environments, organisms such as freshwater mussels are likely exposed to complex contaminant mixtures related to industrial, agricultural, and urban activities. With growing interest in understanding the risk that chemical mixtures pose to mussels, this investigation focused on the effects of various waterborne contaminants (ammonia, chloride, copper, and potassium) and selected binary mixtures of these chemicals following a fixed-ratio design to Villosa iris glochidia and juvenile Lampsilis fasciola. In individual exposures, 48-h EC₅₀ values were determined for V. iris glochidia exposed to ammonia chloride (7.4 [95% confidence interval (CI) 6.6-8.2] mg N/L), ammonia sulfate (8.4 [7.6-9.1] mg N/L), copper sulfate (14.2 [12.9-15.4] μg Cu²⁺/L), potassium chloride (12.8 [11.9-13.7] mg K⁺/L), potassium sulfate (10.1 [8.9-11.2] mg K⁺/L), and sodium chloride (480.5 [435.5-525.5] mg Cl^-/L). The 7-d LC₅₀ values for juvenile L. fasciola were determined for potassium sulfate (45.0 [18.8-71.2] mg K⁺/L), and sodium chloride (1738.2 [1418.6-2057.8] mg Cl^-/L). In Ontario these waterborne contaminants have been reported to co-occur, with concentrations exceeding the EC₁₀ for both life stages at some locations. Data from binary mixture exposures for V. iris glochidia (chloride-ammonia, chloride-copper, and copper-ammonia) and juvenile L. fasciola (chloride-potassium) were analyzed using a regression-based, dose-response mixture analysis modeling framework. Results from the mixture analysis were used to determine if an additive model for mixture toxicity [concentration addition (CA) or independent action (IA)] best described the toxicity of each mixture and if deviation towards dose-ratio (DR) or dose-level (DL) synergism/antagonism (S/A) occurred. For all glochidia binary mixture exposures, CA was the best fit model with DL deviation reported for the chloride-copper mixture and DR deviation reported for the copper-ammonia mixture. Using the model deviation ratio (MDR), the observed toxicity in all three glochidia mixture exposures were adequately described by both CA (mean = 0.71) and IA (mean = 0.97) whereas the juvenile mixture exposure was only adequately described by CA (mean = 0.64; IA mean = 0.05).

Systemic and tumor-directed therapy for oligometastatic prostate cancer: study protocol for a phase II trial for veterans with de novo oligometastatic disease

BACKGROUND

The treatment paradigm for metastatic hormone-sensitive prostate cancer (mHSPC) patients is evolving. PET/CT now offers improved sensitivity and accuracy in staging. Recent randomized trial data supports escalated hormone therapy, local primary tumor therapy, and metastasis-directed therapy. The impact of combining such therapies into a multimodal approach is unknown. This Phase II single-arm clinical trial sponsored and funded by Veterans Affairs combines local, metastasis-directed, and systemic therapies to durably render patients free of detectable disease off active therapy.

METHODS

Patients with newly-diagnosed M1a/b prostate cancer (PSMA PET/CT staging is permitted) and 1-5 radiographically visible metastases (excluding pelvic lymph nodes) are undergoing local treatment with radical prostatectomy, limited duration systemic therapy for a total of six months (leuprolide, abiraterone acetate with prednisone, and apalutamide), metastasis-directed stereotactic body radiotherapy (SBRT), and post-operative fractionated radiotherapy if pT ≥ 3a, N1, or positive margins are present. The primary endpoint is the percent of patients achieving a serum PSA of < 0.05 ng/mL six months after recovery of serum testosterone ≥150 ng/dL. Secondary endpoints include time to biochemical progression, time to radiographic progression, time to initiation of alternative antineoplastic therapy, prostate cancer specific survival, health related quality-of-life, safety and tolerability.

DISCUSSION

To our knowledge, this is the first trial that tests a comprehensive systemic and tumor directed therapeutic strategy for patients with newly diagnosed oligometastatic prostate cancer. This trial, and others like it, represent the critical first step towards curative intent therapy for a patient population where palliation has been the norm.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT03298087 (registration date: September 29, 2017).

Engaging Physician Learners Through a Web-Based Platform: Individualized End-of-Life Education

BACKGROUND

Web-based modules provide a convenient and low-cost education platform, yet should be carefully designed to ensure that learners are actively engaged. In order to improve attitudes and knowledge in end-of-life (EOL) care, we developed a web-based educational module that employed hyperlinks to allow users access to auxiliary resources: clinical guidelines and seminal research papers.

METHODS

Participants took pre-test evaluations of attitudes and knowledge regarding EOL care prior to accessing the educational module, and a post-test evaluation following the module intervention. We recorded the type of hyperlinks (guideline or paper) accessed by learners, and stratified participants into groups based on link type accessed (none, either, or both). We used demographic and educational data to develop a multivariate mixed-effects regression analysis to develop adjusted predictions of attitudes and knowledge.

RESULTS

114 individuals participated. The majority had some professional exposure to EOL care (prior instruction 62%; EOL referral 53%; EOL discussion 56%), though most had no family (68%) or personal experience (51%). On bivariate analysis, non-partnered (p = .04), medical student training level (p = .03), prior palliative care referral (p = .02), having a family member (p = .02) and personal experience of EOL care (p < .01) were all associated with linking to auxiliary resources via hyperlinks. When adjusting for confounders, β coefficient estimates and least squares estimation demonstrated that participants clicking on both hyperlink types were more likely to score higher on all knowledge and attitude items, and demonstrate increased score improvements.

CONCLUSION

Auxiliary resources accessible by hyperlink are an effective adjunct to web-based learning in end-of-life care.

Emergency department revisits for patients with kidney stones in California

OBJECTIVES

Kidney stones affect nearly one in 11 persons in the United States, and among those experiencing symptoms, emergency care is common. In this population, little is known about the incidence of and factors associated with repeat emergency department (ED) visits. The objective was to identify associations between potentially mutable factors and the risk of an ED revisit for patients with kidney stones in a large, all-payer cohort.

METHODS

This was a retrospective cohort study of all patients in California initially treated and released from EDs for kidney stones between February 2008 and November 2009. A multivariable regression model was created to identify associations between patient-level characteristics, area health care resources, processes of care, and the risk of repeat ED visits. The primary outcome was a second ED visit within 30 days of the initial discharge from emergent care.

RESULTS

Among 128,564 patients discharged from emergent care, 13,684 (11%) had at least one additional emergent visit for treatment of their kidney stone. In these patients, nearly one in three required hospitalization or an urgent temporizing procedure at the second visit. On multivariable analysis, the risk of an ED revisit was associated with insurance status (e.g., Medicaid vs. private insurance; odds ratio [OR] = 1.52, 95% confidence interval [CI] = 1.43 to 1.61; p < 0.001). Greater access to urologic care was associated with lower odds of an ED revisit (highest quartile OR = 0.88, 95% CI = 0.80 to 0.97; p < 0.01 vs. lowest quartile). In exploratory models, performance of a complete blood count was associated with a decreased odds of revisit (OR = 0.86, 95% CI = 0.75 to 0.97; p = 0.02).

CONCLUSIONS

Repeat high-acuity care affects one in nine patients discharged from initial emergent evaluations for kidney stones. Access to urologic care and processes of care are associated with lower risk of repeat emergent encounters. Efforts are indicated to identify preventable causes of ED revisits for kidney stone patients and design interventions to reduce the risk of high-cost, high-acuity, repeat care.

A Scalable Web-Based Module for Improving Surgical and Medical Practitioner Knowledge and Attitudes about Palliative and End-of-Life Care

BACKGROUND

We built a web-based, interactive, self-directed learning module about end-of-life care.

OBJECTIVE

The study objective was to develop an online module about end-of-life care targeted at surgeons, and to assess the effect of the module on attitudes towards and knowledge about end-of-life care.

METHODS

Informed by a panel of experts in supportive care and educational assessment, we developed an instrument that required approximately 15 minutes to complete. The module targets surgeons, but is applicable to other practitioners as well. We recruited general surgeons, surgical subspecialists, and medical practitioners and subspecialists from UCLA and the GLA-VA (N=114). We compared pre- and post-intervention scores for attitude and knowledge, then used ANOVA to compare the pre- and postmodule means for each level of the covariate. We performed bivariable analyses to assess the association of subject characteristic and change in score over time. We ran separate analyses to assess baseline and change scores based on the covariates we had selected a priori.

RESULTS

Subjects improved meaningfully in all five domains of attitude and in each of the six knowledge items. Individuals younger than 30 years of age had the greatest change in attitudes about addressing pain, addressing end-of-life goals, and being actively involved as death approached; they also had the most marked improvement in total knowledge score. Having a family member die of cancer within the last five years or a personal experience with palliative care or hospice were associated with higher change scores.

CONCLUSIONS

A web-based education module improved surgical and medical provider attitudes and knowledge about end-of-life care.

Whole organism responses and intersex severity in rainbow darter (Etheostoma caeruleum) following exposures to municipal wastewater in the Grand River basin, ON, Canada. Part A

Municipal wastewater effluents (MWWEs) contain anthropogenic substances that can exhibit endocrine-disrupting activity. These complex mixtures have been observed to exert adverse effects on fish. Rainbow darter (Etheostoma caeruleum, RBD) is a small benthic fish that is widespread throughout the Grand River, Ontario, Canada, and has been previously shown to be adversely affected by MWWE exposure in this watershed. The objectives of this study were to quantify biological responses in this sentinel species and intersex severity in male fish, in relation to the area of urbanization. It focused on RBD populations adjacent to wastewater outfalls in the Grand River watershed. In May 2011, nine sites across the urban gradient were selected to evaluate the impact of MWWEs. Endpoints for energy storage (i.e. condition factor, k; liversomatic index, LSI) as well as reproductive endpoints (i.e. gonadosomatic index, GSI; gonad development, hormone production), and intersex were assessed in the fish. Rainbow darter showed a high incidence of intersex downstream of the wastewater outfalls, especially below the largest treatment plant outfall at Kitchener (∼85%). We applied an intersex index (score from 0 to 7) that considers the number of eggs within the testis and the stage of maturation of the egg. RBD exposed downstream of the largest wastewater outfall at Kitchener had a score of 3.81±0.37 compared to upstream to the urban areas where there were no intersex males found other than a single individual with a score 1 (average intersex score of site 0.06±0.06). In addition, several fish associated with the Kitchener outfall had macroscopic vitellogenic eggs in the testes (intersex scores 5 and 6). The sub-population of fish located at the wastewater outfall also showed a tendency towards skewed sex ratios (greater proportion of females to male fish) compared to the population at the reference sites. Male fish inhabiting the urbanized area of the Grand River also showed reduced levels of testosterone (T) and 11-ketotestosterone (11KT). Intersex males had the lower levels of 11KT relative to the upstream reference fish but could not be distinguished from normal males collected at the exposed sites. Despite the high levels of intersex at these sites, no relationships were evident among intersex severity and other measured endpoints such as GSI, LSI or in vitro steroid production. The effects observed appear to be associated with urbanization and exposure to treated MWWEs in the watershed. Although intersex incidence and severity was a very good indicator of wastewater exposure, intersex could not be directly linked to other effects in this wild population. The effects of MWWEs on transcriptional changes in adult RBD exposed to the effluents are reported in the corresponding report (Part B).

Community-Partnered Collaboration to Build an Integrated Palliative Care Clinic

Background:

We partnered with patients, families, and palliative care clinicians to develop an integrated urology–palliative care clinic for patients with metastatic cancer. We assessed clinician satisfaction with a multidisciplinary palliative care clinic model.

Methods:

We conducted semi-structured interviews with 18 clinicians who practice in our integrated clinic. We analyzed transcripts using a multistage, cutting-and-sorting technique in an inductive approach based on grounded theory analysis. Finally, we administered a validated physician job satisfaction survey.

Results:

Clinicians found that referring a patient to palliative care in the urology clinic was feasible and appropriate. Patients were receptive to supportive care, and clinicians perceived that quality of care improved following the intervention.

Conclusion:

An integrated, patient-centered model for individuals with advanced urologic malignancies is feasible and well received by practitioners.

Reducing inappropriate PSA-based prostate cancer screening in men age 75 or older with a highly specific computerized clinical decision support tool

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Background: The value of PSA-based screening for prostate cancer is a topic of intense debate, however the Veterans Health Administration's (VHA) national clinical policy is to use age as a proxy for life expectancy and avoid screening in men ≥ age 75. To facilitate this we developed and implemented a highly specific computerized clinical decision support (CCDS) reminder to remind providers of current guidelines, at the moment of entering an inappropriate PSA order. Methods: We defined screening PSA as: any PSA ordered on men excluding those a) with a diagnosis of existing malignant prostate disease or “elevated prostate specific antigen”, b) who are using either enhancers or suppressors of testosterone, or d) who had a PSA of 2.5ng/ml or greater on either of the two most recent PSA tests. We measured PSA-based prostate cancer screening rates using this definition and on a monthly basis from 07/2011 to 07/2013. Using an interrupted time-series design, we turned the reminder on from 6/2012-8/2012 and then again from 1/2013-4/2013. Results: There were a total of 24,705 men eligible for screening during the two year period of analysis and 1,524 men who were screened. The mean screening rate during the 12 months prior to the study period was 7.8% among men, and during the 12 months of the intervention period it was 4.3%. During the 12 month baseline period the screening rate declined by 29.3%. During the two periods when the CCDS tool was turned on the screening rate feel by 59.7% and 29.8%, whereas during the two periods when it was off, it rose by 84.3% and 18.4%. Conclusions: The overall reduction in screening rate before and after the intervention period is likely substantially confounded by the secular event of the May, 2012 release of the USPSTF grade D recommendation against all PSA-based screening and its substantial media coverage. Despite this, the striking correlation between rate of change in screening rate and the turning on and off of the CCDS tool, suggests that this highly specific CCDS tool was able to reduce inappropriate PSA-based screening, even in an era of significant public discussion of the merits of PSA-based prostate cancer screening.

Introduction of a tobacco-screening initiative for those at risk for bladder cancer in a high volume urology clinic

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Background: Tobacco use is causal or contributory in 50% of bladder cancer diagnoses. Continued use after diagnosis may negatively impact recurrence, progression, and mortality. Despite its relevance, tobacco screening was infrequently occurring in a regional urology clinic. We hypothesized that the clinic was fertile ground for a tobacco-screening initiative given the number of referrals for bladder cancer, hematuria, and other tobacco-related urologic conditions. Methods: An EMR-based tobacco-screening prompt was designed using the same informatics architecture and clinical reporting system used in primary care. The prompt was introduced for all new patient encounters beginning January 2010. We prospectively collected the proportion of patients asked about tobacco use, advised to quit, and assisted with smoking cessation. Results: For the two years ending December 2011, 4,617 patients were seen in urologic consultation; 31% (n = 1,444) were referred for tobacco-related urologic diagnoses, 36% (n = 518) of whom were referred for bladder cancer or hematuria. The tobacco-screening prompt was used 57% (n = 2,626) of the time. Attending physicians utilized the template in 17% of their encounters, resident physicians in 71%, and nurse practitioners in 97% (p < 0.001). 49% (n = 255) of those referred for bladder cancer or hematuria were screened for tobacco use. Active smokers comprised 21% (n = 558) of screened patients. Relative to former and never smokers, active smokers were more likely referred for bladder cancer or hematuria (p = 0.005). 40% (n = 225) of active smokers desired to quit. Those counseled by an attending physician were more likely ready to quit and trended toward a more intensive cessation program (p = 0.004 and p = 0.07, respectively). Conclusions: Our data suggest that urology clinics may be important sites for tobacco-screening initiatives, particularly for those with tobacco-related urologic diagnoses. Screening patients referred for bladder cancer or hematuria is likely high yield due to the increased proportion of active smokers. Given the disparate utilization of the prompt, identification of provider-level facilitators and barriers to tobacco screening is worthy of study.

Avenues to integrate and improve care: Surgeon attitudes toward end-of-life care

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Background: To examine urology trainees’ views about the quality and current practices of end-of-life care, and to explore strategies for improving integration and quality of care. Methods: We conducted semi-structured interviews with 20 urology trainees from four institutions in different regions of the United States. Stage of training ranged from intern to senior urologic oncology fellow; all were clinically active at busy academic institutions caring for many patients with advanced malignancies. Open-ended questions allowed participants to express themselves independently, and follow-up discussions explored their perception of current end-of-life practices, as well as avenues for future integration and improvement. We analyzed transcripts using a multi-stage, cutting-and-sorting technique in an inductive approach based on grounded theory analysis. Results: Clinicians unanimously agreed that their patients do not currently receive ideal care and were unanimously interested in joining a team geared towards improving care at the end-of-life. They expressed a preference for a multidisciplinary team, although the precise role each wanted to play within the team varied. Better identification of depression, pain, and patient-centered goals to allow value-congruent care were high in priorities for improvement. Trainees sited the lack of an educational curriculum on end-of-life care as a barrier to improving care, and expressed a desire for formal education on this topic. Conclusions: Urology trainees do not think that current care at the end-of-life is ideal for patients, and are interested in participating as part of a multidisciplinary team to better care for these individuals. There was a unanimous consensus that end-of-life care should be formally taught to all intern and resident physicians, and care at the end-of-life must be integrated to pursue value-congruent care for each patient. In response to the information gathered, we built a web-based, interactive, self-directed learning module emphasizing high-quality end-of-life care, issues to address with patients during clinic visits, and integration of end-of-life care. We have also integrated palliative care into the team caring for our patients with advanced disease.

Exclusion of the uniform tetraploid cells significantly improves specificity of the urine FISH assay

The urine fluorescence in situ hybridization (FISH) assay (UroVysion™), with the current scoring criteria, has a higher sensitivity than routine cytopathology but a lower specificity. Among 215 urine FISH tests we performed, 45 had associated histopathology and clinical follow up. In this study, a cell with four signals for each probe was classified as a uniform tetraploid cell (UTC); a presumed reparative cell which is currently classified as an abnormal cell in the FDA approved assay. By using the existing criteria, the tests were scored as positive or negative before and after exclusion of the UTCs. Before the exclusion, 24 positive, 13 negative, seven false positive, and one false negative result were obtained with 96% sensitivity and 65% specificity. After the exclusion, the results changed to 22 positive, 19 negative, one false positive, and three false negatives resulting in a 88% sensitivity of 88% and a 95% specificity; a significant improvement in the specificity. We conclude that exclusion of the UTCs as abnormal cells would result in a more solid performance of the FISH assay.

Carcinoma of the prostate presenting as a painful parotid mass with mandibular invasion: a case report

Prostate cancer metastatic to the parotid gland is exceedingly rare, as only 10 cases have been previously reported in the literature. Symptoms may mimic a parotid infection or suggest a primary parotid tumor. We report a new case of carcinoma of the prostate metastatic to the parotid. The tumor was painful and had invaded the mandible. Fine-needle aspiration of the mass and immunohistochemical staining for prostate-specific antigen confirmed the diagnosis. The patient died 1 month later of an unrelated cause.

Supraclavicular lymph node: incidence of unsuspected metastatic prostate cancer

An uncommon presentation of prostate carcinoma to the supraclavicular lymph nodes is herein reviewed. With prompt diagnosis and treatment, patient survival can be extended. A high index of suspicion is necessary to make the diagnosis. The clinical features of four cases involving metastatic prostate carcinoma will be discussed.

Towards more effective use of decision support in clinical practice: what the guidelines for guidelines don’t tell you

The Brisbane Cardiac Consortium Clinical Support Systems Program used multiple strategies in optimising quality of care of patients with either of two cardiac conditions. One of these strategies was the development and active implementation of decision support systems centred on evidence-based, locally agreed clinical practice guidelines. Our experience in undertaking this task highlighted numerous operational challenges for which solutions were difficult to extract from existing published literature. In the present article we provide a methodology grounded in both theory and real-world experience that may assist others in developing and implementing systems of guideline-based decision support.

Neuropeptide release influences brain edema formation after diffuse traumatic brain injury

The mechanisms associated with edema formation after traumatic brain injury (TBI) have not been fully elucidated. In peripheral tissue injury, the neurogenic component of inflammation plays a significant role in increased vascular permeability and edema formation. However, few studies have examined the role of neuropeptide induced neurogenic inflammation following TBI. Adult male Sprague-Dawley rats were either left untreated, or pre-treated with capsaicin (125 mg/kg s.c.) or equal volume vehicle, and injured 14 days later using the 2-meter impact-acceleration model. Subgroups of animals were assessed for blood brain barrier (BBB) permeability (Evans Blue), brain edema (wet weight/dry weight) and functional outcome (Barnes maze and Rotarod) for up to 2 weeks post-trauma. Increased BBB permeability was present in untreated animals between 3 and 6 h after injury but not at later time-points. Edema was maximal at 5 h after trauma, declined and then significantly increased over the 5 days post-trauma. In contrast, capsaicin pre-treated, neuropeptide-depleted animals exhibited no significant increase in BBB permeability or edema compared to vehicle treated animals after injury. Notably, motor and cognitive impairments were significantly reduced in the capsaicin-pretreated animals. We conclude that neurogenic inflammation contributes to the development of edema and posttraumatic deficits after diffuse TBI.

Neurogenic inflammation is associated with development of edema and functional deficits following traumatic brain injury in rats

The present study has used capsaicin-induced neuropeptide depletion to examine the role of neurogenic inflammation in the development of edema and functional deficits following traumatic brain injury (TBI). Adult, male rats were treated with capsaicin (neuropeptide-depleted) or equal volume vehicle (controls) 14 days prior to induction of moderate/severe diffuse TBI. Injury in vehicle treated control animals resulted in acute (4-5 h) edema formation, which was confirmed as being vasogenic in origin by diffusion weighted magnetic resonance imaging and the presence of increased permeability of the blood-brain barrier (BBB) to Evans blue dye. There was also a significant decline in brain magnesium concentration, as assessed by phosphorus magnetic resonance spectroscopy, and the development of profound motor and cognitive deficits. In contrast, capsaicin pre-treatment resulted in a significant reduction in post-traumatic edema formation (p < 0.001), BBB permeability (p < 0.001), free magnesium decline (p < 0.01) and both motor and cognitive deficits (p < 0.001). We conclude that neurogenic inflammation may play an integral role in the development of edema and functional deficits following TBI, and that neuropeptides may be a novel target for development of interventional pharmacological strategies.

Quality of care of patients hospitalized with congestive heart failure

BACKGROUND

Congestive heart failure (CHF) is an increasingly prevalent poor-prognosis condition for which effective interventions are available. It is -therefore important to determine the extent to which patients with CHF receive appropriate care in Australian hospitals and identify ways for improving suboptimal care, if it exists.

AIM

To evaluate the quality of in-hospital acute care of patients with CHF using explicit quality indicators based on published guidelines.

METHODS

A retrospective case note review was -performed, involving 216 patients admitted to three teaching hospitals in Brisbane, Queensland, Australia, between October 2000 and April 2001. Outcome measures were process-of-care quality -indicators calculated as proportions of all, or strongly -eligible (ideal), patients who received -specific interventions.

RESULTS

Assessment of underlying causes and acute precipitating factors was undertaken in 86% and 76% of patients, respectively, and objective evaluation of left ventricular function was performed in 62% of patients. Prophylaxis for deep venous thrombosis (DVT) was used in only 29% of ideal patients. Proportions of ideal patients receiving pharmacological treatments at discharge were: (i) angiotensin--converting enzyme inhibitors (ACEi) (82%), (ii) target doses of ACEi (61%), (iii) alternative vasodilators in patients ineligible for ACEi (20%), (iv) beta-blockers (40%) and (v) warfarin (46%).

CONCLUSIONS

Opportunities exist for improving quality of in-hospital care of patients with CHF, -particularly for optimal prescribing of: (i) DVT prophylaxis, (ii) ACEi, (iii) second-line vasodilators, (iv) beta-blockers and (v) warfarin. More research is needed to identify methods for improving quality of in-hospital care.

Quality of care of patients hospitalized with acute coronary syndromes

BACKGROUND

Measurement and improvement of quality of care is a priority issue in health care. Patients hospitalized with acute coronary syndromes (ACS) constitute a high-risk population whose care, if shown to be suboptimal on the basis of available research evidence, may benefit from quality improvement interventions.

AIM

To evaluate the quality of in-hospital care for patients with ACS, using explicit quality indicators.

METHODS

Retrospective case note review was undertaken of 397 patients admitted to three teaching hospitals in Brisbane, Queensland, Australia, between 1 October 2000 and 17 April 2001. The main outcome measures were 12 process-of-care quality indicators, calculated as either: (i) the proportion of all patients who received specific interventions or (ii) the proportion of ideal patients who received specific interventions (i.e. patients with clear indications and lacking contraindications).

RESULTS

Quality indicators with values above 80% included: (i) patient selection for thrombolysis (100%) and discharge prescription of beta-blockers (84%), (ii) antiplatelet agents (94%) and (iii) lipid-lowering agents (82%). Indicators with values between 50% and 80% included: (i) timely performance of electrocardiogram (ECG) on admission (61%), (ii) early coronary angiography (75%), (iii) measurement of serum lipids (71%) and (iv) discharge prescription of angiotensin-converting-enzyme (ACE) inhibitors (73%). Indicators with values <50% included: (i) timely administration of thrombolysis (35%), (ii) non-invasive risk assessment (23%) and (ii) formal in-hospital, and post-hospital cardiac rehabilitation (47% and 7%, respectively).

CONCLUSION

There were delays in performing ECG and administering thrombolysis to patients who presented to emergency departments with ACS. Improvement is warranted in use of non-invasive procedures for identifying high-risk patients who may benefit from coronary revascularization as well as use of serum lipid measurements, ACE inhibitors and cardiac rehabilitation.

Patient and partner satisfaction with Viagra (sildenafil citrate) treatment as determined by the Erectile Dysfunction Inventory of Treatment Satisfaction Questionnaire

OBJECTIVES

To assess the efficacy and safety of Viagra (sildenafil citrate) in male outpatients with erectile dysfunction and patient and partner satisfaction with treatment using the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS).

METHODS

A total of 247 patients with erectile dysfunction of broad-spectrum etiology were treated in a randomized, double-blind, parallel-group, multicenter study conducted at outpatient clinics. Patients receiving oral sildenafil (25, 50, and 100 mg) were compared with patients receiving placebo during a 12-week period. The principal efficacy measures were responses to question 3 (ability to achieve an erection) and question 4 (ability to maintain an erection) on the International Index of Erectile Function and three global efficacy questions. Patient and partner satisfaction with treatment were assessed, for the first time, using the EDITS questionnaire.

RESULTS

Efficacy scores for the International Index of Erectile Function questions and the global efficacy questions were significantly higher for patients receiving sildenafil than for those receiving placebo (P <0.001). Both patients and partners receiving sildenafil also had significantly higher EDITS scores than those receiving placebo (P <0.001). Adverse events were chiefly mild or moderate. Two patients receiving sildenafil and none receiving placebo discontinued treatment because of adverse events.

CONCLUSIONS

Sildenafil was an effective, well-tolerated treatment for erectile dysfunction in an outpatient setting. Partner evaluations corroborated patient assessments. The results from the EDITS questionnaire indicated that after 12 weeks of receiving sildenafil both patients and partners reported higher levels of treatment satisfaction relative to placebo.

Comparison of bone marrow extracellular matrices

We have compared the structure and composition of adult and fetal bovine bone marrow extracellular matrices. In contrast to fetal bone marrow, adult bone marrow has more oval fenestration and accumulation of adipocytes as well as lower protein content. These differences could be due to remodeling of bone marrow tissue as it develops. Zymogram analysis of matrix metalloproteinase (MMP) and tissue inhibitor of MMP (TIMP) activities showed that fetal, but not adult bone marrow extract contained a 96-kDa MMP and TIMP-1 and -2. These activities may contribute to the structural differences between adult and fetal bone marrow tissues.

Tissue expression and subcellular localization of CLN3, the Batten disease protein

Juvenile neuronal ceroid lipofuscinosis (Batten disease) is a progressive neurologic disorder which results from mutations in the CLN3 gene, which normally produces a 48-kDa polypeptide of unknown function. To help characterize the CLN3 protein, we have studied its tissue distribution and subcellular localization in human tissues using three epitope-specific polyclonal antibodies to human CLN3 by immunoblot, immunocytochemical, and immunoelectron microscopic analysis. The most abundant CLN3 protein expression was in the gray matter of the brain, where it was localized to astrocytes, capillary endothelium, and neurons. CLN3 was also evident in peripheral nerve, in pancreatic islet cells, and within the seminiferous tubules in the testis. Staining was generally diffuse within the cytoplasm with some nuclear reactivity. Subcellular localization identified the CLN3 protein within the nucleus and along cell membranes. These results were contrasted with the cellular distribution of palmitoyl-protein thioesterase (PPT), the enzyme whose deficiency is responsible for infantile neuronal ceroid lipofuscinosis (CLN1). PPT was most abundant in brain and visceral macrophages where it displayed a coarse granular staining pattern typical of lysosomal distribution. Immunoelectron microscopy confirmed that PPT immunoreactivity was limited to lysosomes.

The 28K protein in urinary bladder, squamous metaplasia and urine is triosephosphate isomerase

OBJECTIVES

The objective of this study was to establish the identity of a protein found in high concentrations in squamous metaplasia of the bladder.

DESIGN AND METHODS

The protein was isolated and subjected to a series of physical, chemical, and catalytic studies.

RESULTS

In the normal urothelium the protein was confined to a juxtanuclear pattern on the luminal side of the umbrella cells; in squamous metaplasia and squamous cell carcinoma the protein was increased and exhibited a more diffuse intracellular distribution. The protein was found to be identical to triosephosphate isomerase (EC 5.3.1.1; TPI) with respect to its immunological properties, native and subunit molecular weights, electrophoretic mobility, catalytic activity, and amino acid sequence.

CONCLUSIONS

While the basis for the altered distribution of TPI remains to be established, the increased amounts of the protein in urine or bladder tissue may be indicative of squamous metaplasia, squamous cell carcinoma, or other bladder injuries.

Adverse prognostic features of collagen injection therapy for urinary incontinence following radical retropubic prostatectomy

PURPOSE

We identified and characterized predictive factors associated with an unfavorable outcome of collagen injection therapy in post-radical prostatectomy incontinence.

MATERIALS AND METHODS

A total of 46 patients, 49 to 85 years old (mean age 67) and incontinent after radical retropubic prostatectomy, underwent a mean of 2.8 transurethral injections of collagen (mean cumulative volume injected 31 ml.). Preoperatively, all patients underwent fluoroscopic multichannel video urodynamics including determination of Valsalva's leak point pressure. Stress urinary incontinence was subjectively graded as 1 (0 to 1 pad per day), 2 (2 to 3 pads per day) and 3 (greater than 3 pads per day). Patient age, duration and severity of pretreatment incontinence, presence of detrusor instability and anastomotic strictures, number of injections, total volume of collagen delivered and the impact of a nerve sparing procedure plus adjuvant radiation therapy were assessed and correlated with treatment outcome.

RESULTS

Of the patients 11 (24%) became completely dry (9 after 3 or fewer treatments), 21 (41%) improved (17 after 3 or fewer treatments) and 14 (30%) showed no benefit (after more than 3 treatments). Of the 14 patients in whom treatment failed 6 had undergone adjuvant radiation treatment, pretreatment urinary incontinence was grade 3 in all, and concomitant detrusor instability was present in 11 (79%). All patients had received more than 3 treatments (mean total volume injected 37 ml.).

CONCLUSIONS

Notwithstanding the need for multiple treatments, the prospect for cure by collagen injection of the post-radical prostatectomy incontinent patient is significantly affected by the severity of pretreatment incontinence, concomitant detrusor overactivity and exposure to radiation therapy. Age, duration of incontinence, presence of mild to moderate anastomotic strictures and a nerve sparing technique did not seem to influence treatment outcome.

The effect of urethral introducer tip catheters on the incidence of urinary tract infection outcomes in spinal cord injured patients

PURPOSE

We attempted to determine whether an introducer tip catheter reduces urinary tract infection in spinal cord injured patients on intermittent catheterization.

MATERIALS AND METHODS

The introducer tip catheter bypasses the colonized 1.5 cm. of the distal urethra. Enrolled patients were prospectively entered into the study in alternate groups depending on whether they reflex voided: group 1--on intermittent catheterization with the introducer tip catheter but not voiding spontaneously or wearing an external urinary catheter, group 2--same as group 1 but using a nonintroducer tip catheter; group 3--on intermittent catheterization with the introducer tip catheter, voiding by reflex and wearing an external urinary catheter, and group 4--same as group 3 but using a nonintroducer tip catheter.

RESULTS

Statistical significance was shown when comparing patients using versus not using the introducer tip catheter regardless of whether an external urinary catheter was worn (p = 0.0121). A greater difference was noted between patients using and not using the introducer tip catheter in the intermittent catheterization only group (p = 0.0093).

CONCLUSIONS

The introducer tip catheter decreased urinary tract infections in hospitalized men with spinal cord injury on intermittent catheterization.

Is combined modality therapy necessary for advanced Hodgkin's disease?

PURPOSE

To determine whether single-modality therapy is optimal management for patients with Stage III-IV Hodgkin's disease.

METHODS AND MATERIALS

All patients with advanced (Stage III and IV) Hodgkin's disease treated at the University of Florida from 1964 through 1989 (n = 141) were studied retrospectively for factors predictive of good outcome with single-modality therapy. Treatment modalities varied and were distributed as follows: combined-modality therapy (CMT), 55 patients; chemotherapy alone (CX), 50 patients; and radiotherapy alone (RT), 36 patients.

RESULTS

Ten-year rates of freedom from relapse and overall survival for all Stage III patients were 66% and 59% compared with 36% and 35% for Stage IV patients. The RT subset was highly selected with the majority of patients having nonbulky Stage IIIA disease. Within the RT group, multivariate analysis identified the degree of splenic involvement and age as the factors most associated with freedom from relapse. In patients treated with CX, multivariate analysis identified bulky tumor (maximum transverse tumor dimension > 6 cm) as the most important prognostic factor for relapse. In patients without bulky disease (< or = 6 cm), the probabilities of freedom from relapse and overall survival at 10 years, respectively, according to treatment group were 53% and 58% for RT patients, 60% and 56% for CX patients, and 83% and 71% for CMT patients. For patients without bulky disease, the probability of freedom from relapse was significantly better for the CMT group than for CX patients (p = 0.03) or RT patients (p = 0.04), but there was no statistical difference in overall survival among the three groups. In patients with bulky disease (> 6 cm), the probabilities of freedom from relapse and overall survival at 10 years were 44% and 45% for RT patients, 9% and 0% for CX patients, and 72% and 58% for CMT patients. Freedom from relapse and overall survival were significantly better (p = 0.0001) for CMT patients compared with CX patients. Fatal hematopoietic disorders developed in 10 patients: 2 of 36 RT patients, 2 of 50 CX patients, and 6 of 55 CMT patients. Nine patients had received chemotherapy, and eight had six or more cycles of alkylator-based chemotherapy.

CONCLUSION

This retrospective study suggests that combined-modality therapy is preferable to single-modality therapy in the majority of patients with advanced Hodgkin's disease.

Urethral cultures in female patients with a spinal cord injury

Quantitative cultures of the urethral meatus were obtained from women with SCI undergoing intermittent catheterization. When compared with the urethral cultures of a group of female subjects, women with SCI had a greater number of isolates of Klebsiella pneumonia and Pseudomonas aeruginosa in the urethral flora. However there was not a significantly greater number of isolates or log numbers of E. coli or Enterococcus sp. in the urethral flora. The E. coli and Enterococcus sp. isolated from the urine were not isolated from the urethra of female patients with SCI in one third of the patients. This poor correlation between the simultaneous urethral and urine cultures of female subjects with SCI may reflect colonization of the urine with organisms that were unable to adhere to the mucosa and colonize the urethra. To what extent these organisms colonize or are temporary residents may be important in the pathogenicity of the infection.

Lower urinary tract reconstruction in the female using the Kock ileal reservoir with bilateral ureteroileal urethrostomy: update of continence results and fluorourodynamic findings

OBJECTIVES

To update continence results and present fluorourodynamic data in 17 female patients undergoing orthotopic lower urinary tract reconstruction with the Kock ileal urethrostomy following cystectomy.

METHODS

Continence results, voiding pattern, and overall patient satisfaction were evaluated by means of patient survey. Fluorourodynamic data and abdominal leak point pressures were obtained in 6 patients.

RESULTS

Complete daytime urinary continence was reported in 93% of patients, whereas complete nighttime continence was reported by 87% of patients. Fluorourodynamic studies demonstrated excellent neobladder capacity with low reservoir pressure in all cases. Abdominal leak point pressure measurements confirmed normal urethral sphincter function.

CONCLUSIONS

Excellent results with respect to urinary continence, voiding pattern, patient satisfaction, and reservoir function can be expected in women undergoing orthotopic lower urinary tract reconstruction.

Epidemiology of current treatment for sexual dysfunction in spinal cord injured men in the USA model spinal cord injury centers

This study is a prospective multicenter cooperative survey of the evaluation and treatment of erectile dysfunction in men with spinal cord injury (SCI). Uniform database questionnaires were completed prospectively by patients seeking therapy for erectile dysfunction. Eighty-five SCI men aged 17-68 years (mean age = 26 +/- 17) were enrolled. Mean duration of traumatic SCI was 3 +/- 3.2 years (Range = 0.3-18 years). The level of injury was cervical in 20 patients, thoracic in 31, lumbar in 29 and sacral in five. Patients were fully evaluated and then counseled as to their therapeutic options. Twenty-eight chose to use a vacuum erection device (VED), 26 preferred pharmacological penile injection and five used both intracorporeal therapy and VED. The remainder were managed with marriage and sexual counseling in 10 patients, three underwent penile prosthesis placement and two used topical pharmacotherapy. Four patients used other forms of treatment and in nine no therapy was recommended. Of the patients that used pharmacologic injection only, 74 percent used papaverine as a single agent, 20 percent used papaverine with phentolamine, five percent used prostaglandin E (PGE1) alone and one percent used a mixture. Patients using injection therapy report sexual intercourse a mean of 3 +/- 3.4 times per month as compared with 5 +/- 3.2 times per month in those using VED. Five intracorporeal injection patients developed priapism while two patients using the VED developed subcutaneous bleeding and one developed penile ischemia. We conclude that although a spectrum of erectile dysfunction treatment is present among SCI centers, VED and pharmacological penile injection are by far the two most popular methods of treatment and papaverine is the most common drug. The incidence of complications is small in the model centers.

Selecting the appropriate urinary diversion procedure in the spinal cord injured: a poignant reminder

Lower urinary tract reconstruction has been performed on the spinal injured population at our institution since 1988. Careful pre-operative evaluation including a detailed history, physical examination and radiographic and/or urodynamic studies are usually obtained to determine which type of procedure would be most beneficial for each individual patient. Typically, patients receive either a cutaneous (i.e., Kock or Indiana) diversion or undergo a form of bladder augmentation (usually ileocystoplasty). Pre-operative findings and the patient's history are carefully considered prior to choosing the appropriate procedure. Occasionally, a particular finding influences the decision. We describe a patient who received a hemi-Kock ileocystoplasty with a continent abdominal stoma who, in retrospect, would have benefitted from a supravesical diversion.

Fluorourodynamic and clinical evaluation in males following construction of a Kock ileal-urethral reservoir

OBJECTIVES

Since 1986, we have offered the option of lower urinary tract reconstruction with the Kock ileal-urethral reservoir in selected male patients requiring diversion. This study provides insight into the functional characteristics of the Kock ileal-urethral reservoir and its effect on continence.

METHODS

Twenty-four of the initial 225 male patients undergoing this procedure at our institution were evaluated by fluorourodynamics within 2 years of neobladder construction. Information regarding continence was also obtained by means of a patient interview and questionnaire.

RESULTS

The average resting neobladder pressure was 8.5 cm H2O (range, 0 to 18). Reservoir capacity averaged 741 cc (range, 225 to 1400). Afferent nipple failure with bilateral grade II vesicoureteral reflux was noted in 1 patient (4%). Unsatisfactory daytime continence was seen in 2 patients (8%). Unsatisfactory nighttime continence was seen in 6 patients (25%). Patient satisfaction was high with an average rating of 8.6 on a scale of 1 to 10.

CONCLUSIONS

Fluorourdynamic data demonstrate a low-pressure, high-capacity reservoir with a low incidence of reflux. The rate of continence is acceptable and patient satisfaction is excellent. The Kock ilealurethral reservoir is an excellent alternative to standard diversion for the male patient undergoing cystectomy.

The nonrefluxing ileal conduit: a new form of urinary diversion

PURPOSE

We describe a variation of the ileal conduit that includes a nonrefluxing nipple valve designed to protect the upper urinary tracts.

MATERIALS AND METHODS

A total of 13 patients underwent urinary diversion with the nonrefluxing ileal conduit. The nonrefluxing nipple valve is created by intussuscepting the ileum into the conduit.

RESULTS

Followup ranged from 3 to 35 months. No patient demonstrated radiographic deterioration of the upper tracts or a clinically significant increase in serum creatinine level during followup.

CONCLUSIONS

The nonrefluxing ileal conduit appears to be a viable treatment option in select patients with neurogenic bladder dysfunction.

Comparison of bladder management complication outcomes in female spinal cord injury patients

A total of 70 female spinal cord injury patients was retrospectively analyzed for outcomes of long-term bladder management. Three groups were defined: 1) 23 patients on intermittent catheterization, 2) 25 treated by reflex voiding and incontinence padding, and 3) 22 with an indwelling catheter. Mean years of using the specific bladder management technique were 8.5 +/- 4.7, 15.8 +/- 7.3 and 16.7 +/- 9.0 for the 3 groups, respectively. All patients were evaluated for long-term complications. There were 4 major complications (17%) in the intermittent catheterization group, 10 (40%) in the padding group and 58 (greater than 200%) in the indwelling catheter group. The aggregate difference in complication rates among the 3 group was highly significant (p < 0.00001). Of comparable long-term patients (11 to 23 years) there were no major complications among 6 on intermittent catheterization, 8 among 14 who use padding and 21 among 9 with an indwelling catheter. The differences among the groups remained significant (p < 0.00001). Additional analyses showed highly significant differences between the catheter group and the other 2 groups (intermittent catheterization p = 0.0009 and padding p = 0.0005), and a difference that approached significance between the intermittent catheterization and padding groups (p = 0.085). The results strongly support intermittent catheterization as the optimal management of female patients following spinal cord injury given that other factors, in particular independent hand function or the need for appropriate assistance, are considered.

Management of sphincter dyssynergia using the sphincter stent prosthesis in chronically catheterized SCI men

This effort represents a subset analysis of the long-term Multicenter North American Trial of the UroLume sphincter stent prosthesis to determine the effect of the sphincter stent prosthesis in SCI men afflicted with detrusor-external sphincter dyssynergia (DESD) and chronically managed with an indwelling urinary catheter. Forty-one of 153 male patients in this study were evaluated urodynamically before and after placement of the sphincter stent prosthesis. Of the 41 patients, 34 (81 percent) suffered cervical-level injury while 10 patients (25 percent) had been treated previously with external sphincterotomy. Forty patients (98 percent) were troubled with recurrent urinary tract infections (UTI), with a mean of 4.6 +/- 3 episodes of UTI per year. Seven patients (17 percent) demonstrated hydronephrosis prior to stent placement. Follow-up ranged from six to 44 months. Voiding pressures decreased from a mean of 77 +/- 23 cmH2O preoperatively to 35 +/- 18 cmH2O at 12 months (n = 34) and 33 +/- 20 cmH2O at 24 months (n = 22) after stent insertion (p = 0.001). Post-void residual urinary volume decreased from 202 +/- 187 ml preinsertion to 64 +/- 69 ml at 24 months (p = 0.001) postinsertion. Maximum cystometric capacity remained constant at 201 +/- 144 ml preinsertion to 203 +/- 79 ml at 24 months (p = 0.75) postinsertion. No significant changes in any of the urodynamic parameters occurred after 24 months of follow-up between patients with (n = 10) and without (n = 31) previous external sphincterotomy. Neither hemorrhage requiring blood transfusion, obstructive hyperplastic epithelial overgrowth, stent encrustation or stone formation, nor soft tissue erosion occurred in any patient.(ABSTRACT TRUNCATED AT 250 WORDS)

Differences in urinary tract infections in male and female spinal cord injury patients on intermittent catheterization

Intermittent catheterization has gained wide acceptance for use in hospitalized patients following spinal cord injury. Most studies evaluating this procedure, however, look only at the infection rate in the male SCI population. In this study the rate and type of infection encountered in the male and female SCI population were evaluated in an inpatient hospital environment. Fifty four patients who were undergoing intermittent catheterization with the MMG/O'Neil catheter system were evaluated. All patients were similar with regard to level of injury and bladder management. There were 45 males and nine females in our study group (n = 45). A total of 10,945 catheterizations were performed with 75 infections indentified. The overall infection rate was 0.68% or one infection for every 146 catheterizations. Of the 45 males there were 58 infections of which 11 (18%) were E. coli. This contrasts with the female population (9) in which there were 17 infections with nine (53%) being E. coli. While a variety of infecting organisms were present in males, females were colonized with either E. coli, enterococcus or Klebsiella. While hospital based intermittent catheterization would appear to be associated with an acceptable low incidence of urinary tract infections (0.68%), infected females have a higher incidence of E. coli (53%) compared to the male population (18%). This study also demonstrated that female patients had a significantly higher infection rate than males (nine females with 17 infections compared to 45 males with 58 infections over the same time period). The higher incidence of urinary tract infections in females with E. coli perhaps is related to the proximity of bowel/stool contamination.

Radiation therapy for giant cell tumor of bone

PURPOSE

Giant cell tumor of bone is usually treated with surgical curettage. For recurrent tumors, tumors that are inoperable because of location, and tumors that would require amputation or another radical procedure limiting function, does radiotherapy provide an alternative for local control?

METHODS AND MATERIALS

Sixteen patients with histologically confirmed, giant cell tumor of bone were treated at the University of Florida with irradiation between March 1973 and September 1988. Minimum follow-up was 32 months; 63% of the patients had follow-up for at least 5 years, 44% for greater than 10 years. All sites received doses of 35 Gy or more, and all were treated with megavoltage irradiation.

RESULTS

In 12 (75%) of 16 patients, the tumor was controlled locally with irradiation. The four failures occurred at 8, 13, 13, and 25 months following initiation of treatment. Surgical salvage was successful in all four failures for an overall local control rate of 100%. One patient developed pulmonary metastasis 1 month after surgical salvage and is alive without evidence of disease after multiple courses of chemotherapy, surgical resection, and whole-lung irradiation. All patients tolerated the treatment well with no severe or chronic complications. No secondary soft-tissue sarcomas have occurred within the irradiated areas.

CONCLUSION

Giant cell tumor of bone is not a radioresistant tumor as once believed, and complications seen with modern treatment regimens are minor.