The long-term effect on surgery-free survival of biological compared to conventional therapy in Crohn's disease in real world-data: a retrospective study

BACKGROUND

The introduction of biological drugs has led to great expectations and growing optimism in the possibility that this new therapeutic strategy could favourably change the natural history of Inflammatory Bowel Disease (IBD) and, in particular, that it could lead to a significant reduction in surgery in the short and long term. This study aims to assess the impact of biological versus conventional therapy on surgery-free survival time (from the diagnosis to the first bowel resection) and on the overall risk of surgery in patients with Crohn's disease (CD) who were never with the surgical option.

METHODS

This is a retrospective, double-arm study including CD patients treated with either biological or conventional therapy (mesalamine, immunomodulators, antibiotics, or steroids). All CD patients admitted at the GI Unit of the S. Salvatore Hospital (L'Aquila. Italy) and treated with biological therapy since 1998 were included in the biological arm. Data concerning the CD patients receiving a conventional therapy were retrospectively collected from our database. These patients were divided into a pre-1998 and post-1998 group. Our primary outcome was the evaluation of the surgery-free survival since CD diagnosis to the first bowel resection. Surgery-free time and event incidence rates were calculated and compared among all groups, both in the original population and in the propensity-matched population.

RESULTS

Two hundred three CD patients (49 biological, 93 conventional post-1998, 61 conventional pre-1998) were included in the study. Kaplan-Meier survivorship estimate shows that patients in the biological arm had a longer surgery-free survival compared to those in the conventional arm (p = 0.03). However, after propensity matching analysis, conducted on 143 patients, no significant difference was found in surgery-free survival (p = 0.3). A sub-group analysis showed shorter surgery-free survival in patients on conventional therapy in the pre-biologic era only (p = 0.02; Hazard Ratio 2.9; CI 1.01-8.54) while no significant difference was found between the biologic and conventional post-biologic groups (p = 0.15; Hazard Ratio 2.1; CI 0.69-6.44).

CONCLUSION

This study shows that the introduction of biological therapy has only a slight impact on the eventual occurrence of surgery in CD patients over a long observation period. Nevertheless, biological therapy appears to delay the first intestinal resection.

Transobturator tape and mini-sling methods in stress urinary incontinence: Results of a randomized clinical trial

Background:

Stress urinary incontinence is one of the most common types of incontinence in premenopausal women, accounting for almost 50% of such cases. Mid-urethral slings are currently the most widely used surgical method for stress urinary incontinence. This study aimed at comparing the efficacy, complications, urodynamic changes and the sexual function status between mini-sling surgery and transobturator tape to help us select the best method in such patients.

Method:

In this randomized controlled trial, 80 cases were studied and randomly assigned to either the mini-sling or transobturator tape group (n = 40). A full medical history was taken and the Q.tip and cough tests were performed for each patient to record their urinary incontinence and hypermobility. Abdominal and pelvic ultrasound study was requested by specifying PVR and urodynamic testing. The International Consultation on Incontinence Modular Questionnaire-6 was filled by the patients and the Female Sexual Functioning Index questionnaire by the physician. The patients were followed-up 8 weeks after discharge by urodynamic tests, ultrasound study, and the International Consultation on Incontinence Modular Questionnaire test.

Results:

The mean age, body mass index, and parity were not significantly different between the two groups. The mean surgical time, amount of bleeding, hospitalization period, and pain index were significantly less in the mini-sling group. The International Consultation on Incontinence Modular Questionnaire and Female Sexual Functioning Index indices before and after surgery showed no significant difference between the two groups. The difference in urodynamic test parameters was also insignificant.

Conclusion:

In the mini-sling method which is a less invasive method compared to transobturator tape, the intraoperative bleeding, surgical time, hospitalization period, pain, and surgical complications were far less while its efficacy was similar to transobturator tape; therefore, it is recommended in treating stress urinary incontinence among women.

Impact of prostate needle biopsy on erectile function: A prospective study

Background:

Needle biopsy of the prostate is a diagnostic method for prostate cancer which is a relatively safe method with low risk of serious complications. The evidences regarding the occurrence of erectile dysfunction following prostate biopsy are controversial. Herein, we aimed at determining the rate of erectile dysfunction in those undergoing transrectal ultrasound-guided prostate biopsy.

Method:

All candidates for prostate biopsy were enrolled. The International Index of Erectile Function-5 was completed 1 m before and 1, 3, and 6 months after ultrasound-guided prostate biopsy by each patient for erectile dysfunction. Patients with a previous history of erectile dysfunction which due to a positive pathology had received any type of treatment were excluded from the study.

Results:

Eighty patients with the mean age of 64.8 years, the mean prostate-specific antigen level of 11.64 ng/dL, and the mean prostate volume of 62.43 cc were included. The prostate biopsy result was positive in 38.8% of the cases. No significant relationship was found between erectile dysfunction and prostate-specific antigen level, prostate volume, and the pathology result (P = 0.320, 0.509, and 0.131). The mean questionnaire score 1 month before and after the biopsy was 23 and 18, respectively; it demonstrated a significant difference (P < 0.001). The same score was 17 and 14.5 three and six months after biopsy. The mean score 1 m before and 3 m after biopsy also revealed a significant difference (P < 0.001).

Conclusion:

Transrectal ultrasound-guided needle biopsy of the prostate causes progressive erectile dysfunction in these patients. This relationship is not affected by the biopsy result, prostate volume, or the prostate-specific antigen level.

Effectiveness of the addition of tadalafil to tamsulosin in the treatment of acute urinary retention in patients with benign prostatic hyperplasia: A randomized clinical trial

INTRODUCTION

Acute urinary retention is one of the most significant complications of benign prostatic hyperplasia. Until now, standard treatments include catheterization and use of α-blockers. Tadalafil has been recently seen to also play a role in the treatment of urinary symptoms caused by benign prostatic hyperplasia. The aim of this study was to survey the addition of tadalafil to tamsulosin in the treatment of acute urinary retention in patients with benign prostatic hyperplasia.

MATERIALS AND METHODS

This is a randomized, double-blind placebo-controlled clinical trial. In all, 80 patients with benign prostatic hyperplasia-related acute urinary retention referred to the emergency department of the hospital were divided into two groups of 40 each and randomly assigned to receive either 0.4 mg tamsulosin plus placebo or 0.4 mg tamsulosin plus 10 mg tadalafil daily for 7 days. At the same first visit, the catheter was removed and the ability to void in 24 h and 1 week later was assessed in each group.

RESULTS

The differences in age, urine retention volume, history of drug use, lower urinary tract symptoms, and previous acute urinary retention were not significant between the two groups ( p = 0.619, 0.149, 0.501, 0.284, and 0.371, respectively). After catheter removal, 23 (57.5%) patients in the placebo group and 26 (65%) in the tadalafil group voided successfully at 24 h ( p = 0.491). After 1 week, 29 (72.5%) patients taking placebo and 26 (65%) taking tadalafil could void, yet indicating no significant difference ( p = 0.469).

CONCLUSION

Addition of tadalafil to α-blockers has no significant advantage in improving benign prostatic hyperplasia-related acute urinary retention versus tamsulosin alone.

The role of blood neutrophil count and the neutrophil-to-lymphocyte ratio as a predictive factor for prostate biopsy results

BACKGROUND:

It is apparent that prostate cancer has harmful effects on the erythrocytes, leucocytes, and platelets. In addition, it has been suggested that the toxic granules in neutrophils lead to inflammation in the cancerous tissues besides the activation of monocytes, so in this study we aimed to evaluate the blood neutrophil count besides the neutrophil-to-lymphocyte ratio as a predictive factor for prostate biopsy results and their relationship with prostate cancer grade in patients undergoing biopsy of the prostate.

METHODS:

For all men with irritative lower urinary tract symptoms visiting Hasheminezhad Hospital from January to July 2015, in case of having a suspicious digital rectal examination or aged above 40 years, prostate-specific antigen was requested and in case of abnormal results, they underwent prostate biopsy. In order to examine the study hypothesis, the blood neutrophil count and the neutrophil-to-lymphocyte ratio were measured and compared with the abnormal prostate-specific antigen results and suspicious digital rectal examination.

RESULTS:

Among the 500 referred samples for biopsy, 352 (70.4%) had a negative biopsy result, while it was positive in the other 148 (29.6). The mean neutrophil count showed no statistical difference regarding the biopsy results (p = 0.381). When measuring the neutrophil-to-lymphocyte ratio again with biopsy results, no statistically significant difference was obtained based on the biopsy results (p = 0.112).

CONCLUSION:

Neutrophil count and neutrophil-to-lymphocyte ratio cannot be predictive factors for positive prostate cancer biopsy.

Evaluation of the success rate and complications of conventional varicocelectomy: Do we need microscopic surgery really?

Objective:

Varicocele is the most commonly curable cause of infertility in men. Varicocele is found in 15% of the total male population, 35% of men with primary infertility, and 75%–81% of men with secondary infertility. Generally, patients seek microscopic surgery via surfing the Internet, which is not an available option in all medical centers. The purpose of this study was to determine the success rate and complications of conventional varicocelectomy and to compare it with that of the microscopic method.

Methods:

In this descriptive cross-sectional study, 88 patients with varicocele who underwent non-microscopic varicocele surgery in the 15th Khordad Hospital during 2013–2015 were evaluated by the census method.

Results:

The mean age of patients with varicocele was 27.30 years; 52 patients underwent bilateral varicocelectomy and 36 left varicocelectomy. Surgical complications of non-microscopic varicocelectomy in the studied patients included bleeding and hydrocele formation both in 0.7% and recurrence in 2.8%. Testicular atrophy was not observed in any case.

Conclusion:

The incidence of recurrence, hydrocele formation, atrophy, and bleeding in non-microscopic varicocelectomy, if done in accordance with its principles, is not more than the microscopic approach and therefore it could be recommended as a safe surgical treatment in centers where microscopic surgery is not available.

Extremely rare presentation of burned-out testicular tumor

It is commonly accepted to consider retroperitoneal germ cell tumors as the metastasis of a viable or burned-out testicular tumor. In such cases, orchiectomy should be performed since the burned-out site in the testis could continue to harbor malignancy despite systemic chemotherapy. A 45-year-old male presented as an outpatient with complaints of back pain. He was diagnosed with a retroperitoneal mass and a palpable testis mass. He underwent radical orchiectomy. Pathological study revealed a burned-out tumor. Following chemotherapy, retroperitoneal lymph node dissection was performed. Despite the residual and enhanced retroperitoneal lymph nodes in his computed tomography scan, none of the resected lymph nodes showed a viable tumor. This is the first reported case of a palpable and hypoechoic burned-out testicular tumor.

Elderly patient with atypical leiomyoma of the bladder presenting as flank pain: A case report

Atypical leiomyoma is a rare tumor of the bladder whose correct diagnosis with imaging techniques and cystoscopy is difficult. This tumor is prevalent in females and more common in middle age. In the present study we report a rare case of atypical leiomyoma presenting as flank pain and history of recurrent urinary tract infections in an elderly female. Ultrasound (US) showed that the wall of bladder was thickening and irregular, especially in the lower part of the bladder. US revealed hypoechoic solid mass with dimensions of 37 x 26 mm in the posterior bladder wall protruding into the bladder. Computed Tomography scan of the patient showed a mass with dimensions of 29 x 38 mm in the posterior wall of the bladder that infiltrated the mesenteric fat and also seemed to be invading the intestinal wall. According to the general condition and age of our patient, we removed all of the mass under spinal anesthesia by transurethral bladder resection (TURBT). Biopsy results showed atypical leiomyoma. About 6 months after the patient follow-up, no recurrence was observed and symptoms had completely resolved. According to the non-specificity of the imaging, of the age of presentation and of clinical manifestations of atypical leiomyoma differential diagnosis for bladder cancer it is recommended. Only with histopathologic findings, the diagnosis can be confirmed.

A 40-year-old man with testicular torsion and large bilateral spermatoceles

Testicular torsion is a rare disease that mostly involves children. Peak incidence is in infancy and in adolescence. Testicular torsion is rarely seen in men over 40 years of age and has only once been accompanied with spermatocele. We report the case of a 40-year-old man with testicular pain one day prior to visiting our clinic. The patient's visit to the clinic was delayed due to history of occasional testicular pain related to his bilateral spermatoceles. On arrival, a color Doppler ultrasound test was performed, which revealed heterogeneous echo in the right testis with no vascular flow, suggestive of torsion, as well as two cystic lesions in the right and left scrotums indicating spermatoceles. The patient was immediately transferred to the operating room where the bilateral spermatoceles were resected and after detorting, the right testis was saved. After four months, a normal left testis along with partial right testicular atrophy was observed. It is highly recommended to educate patients with spermatocele who have no indication for surgical treatment to visit their physician in case any new testicular pain is experienced. Furthermore, testicular pain regardless of the co-existing pathology may always be treated as an indicator of suspected torsion.

Testis-sparing surgery in testicular mass: Testicular epidermoid cysts

We present 3 patients with testicular epidermoid cysts who experienced testis-sparing surgery. These patients had a palpable painless testicular mass and underwent inguinal testicular exploration. Intraoperative frozen section revealed no evidence of malignancy and therefore enucleation of the tumour was performed. We demonstrate that careful intraoperative frozen-section examination helps to avoid unnecessary orchidectomy in testicular epidermoid cysts.

Electrical somatosensory stimulation improves movement kinematics of the affected hand following stroke

AIM

The effect of electrical somatosensory stimulation on motor performance of the affected hand was investigated in 12 chronic subcortical stroke subjects.

METHODS

Subjects performed index finger and hand tapping movements as well as reach-to-grasp movements with both the affected and unaffected hand prior to (baseline conditions) and following (1) 2 h of electrical somatosensory stimulation (trains of five pulses at 10 Hz with 1 ms duration delivered at 1 Hz with an intensity on average 60% above the individual somatosensory threshold) of the median nerve of the affected hand or (2) 2 h of idle time on separate occasions at least 1 week apart. The order of sessions was counterbalanced across subjects.

RESULTS

Somatosensory stimulation of the median nerve of the affected hand, but not a period of idle time, enhanced the frequency of index finger and hand tapping movements and improved the kinematics of reach-to-grasp movements performed with the affected hand, compared with baseline. Somatosensory stimulation did not impact on motor performance of the unaffected hand.

DISCUSSION

The data suggest that electrical somatosensory stimulation may improve motor function of the affected hand after stroke; however, further studies are needed to test if the implementation of somatosensory stimulation in rehabilitation of hand function also impacts on manual activities of daily life after stroke.

Post traumatic tricuspid insufficiency: when to intervene?

Isolated post traumatic tricuspid insufficiency is a rare entity with an increasing incidence. It is associated with insidious yet unequivocal hemodynamic alterations leading to severe incapacity. Early surgery rather than medical treatment is the therapeutic modality of choice.

[Malignant melanoma of nasal cavities. Case contributions]

Primitive melanoma of nasal cavities is a rare clinical event. Its pathogenesis is due to the neoplastic development of melanocytes of neuroectodermal origin which are located in the nasal mucosa. Characteristics clinical symptoms are nasal obstruction and recurrent nose-bleeding. In spite of new therapeutic approaches the prognosis of this disease remains severe. No case of primitive malignant melanoma of the nasal cavities has been treated with radiotherapy, according to the authors experience. Sometimes it may be difficult to recognize a cutaneous malignant melanoma because of regression. It may be found after the evidentiation of its recurrences and/or metastasis in different sites. One of the cases here reported came to the authors' attention as ethmoido-frontal metastasis.

Surgical treatment of hydatid cysts of the heart: report of six cases

Six patients with hydatid cysts of the heart have undergone successful enucleation of the cysts with the aid of cardiopulmonary bypass. Various locations of the cysts and their consequences are discussed in detail. The findings have been confirmed by clinical, radiologic, electrocardiographic, echocardiographic, cardiac catheterization, cardioangiographic, and coronary angiographic studies. All patients are in good condition. Length of follow-up is reported.

[Metastatic location in the temporal bone of a primary bladder carcinoma]

The authors on basis of literature point out, the relative shortage in human beings of metastatic locations to the temporal bone from primitive tumours to another seat. After an examination of the anatomopathological report they describe a case, occurred to their observation, of massive metastases to the temporal bone of bladder carcinoma painting out its exceptionality.

Combined vascular and neurogenic claudication

Eight patients with combined vascular and neurogenic claudication were presented. In the adult with coexistent neurospinal and vascular disease, a careful history and examination often suggested the pathology more productive of symptomatology. Among patients presenting with predominately vascular claudication, six of six patients had calf pain as part of the pain pattern, and in three of six patients the pain was crampy. Five of six patients had a consistent exercise tolerance pain pattern and obtained relief of symptoms by resting the leg. Among patients presenting with mainly neurogenic claudication. Only four of eight patients had associated calf pain, and none experienced crampy pain. Five of eight patients had a variable exercise tolerance pain pattern and obtained complete relief of symptoms only by assuming the recumbent position. Doppler testing was very helpful as the initial step in the evaluation of the significance of an arterial lesion and in the follow-up assessment of these patients after vascular surgery. Lumbosacral-spine, cardiovascular, and neurologic examination was similar in the two groups of patients.

Calcified left ventricular aneurysm and non-atherosclerotic myocardial infarction in a child

A 14-year-old boy, admitted with intractable chest pain, was found to have an enlarged heart and calcification in the apical region, with electrocardiographic features of massive inferolateral myocardial infarction. Left ventricular angiography revealed a large left ventricular aneurysm. He died following resection of the aneurysm and post mortem examination showed changes of a non-specific chronic myocarditis. A vasculitis involving small coronary arterioles was also found in the vicinity of the aneurysm, and the possibility of a rheumatic vasculitis was suggested by a transient episode of an erythema marginatum-like eruption. It is concluded that the association of infarction pattern on the electrocardiogram together with calcification of the heart in children is highly suggestive of a ventricular aneurysm secondary to a myocarditis or a vasculitis involving small, intramyocardial branches of the coronary arteries.