Transcervical Radiofrequency Ablation of Symptomatic Uterine Fibroids: 2-Year Results of the SONATA Pivotal Trial.

Objective: To report 2-year results of sonography-guided transcervical fibroid ablation (TFA) using the Sonata® system in women with symptomatic uterine fibroids. Design: This is a prospective multicenter single-arm interventional trial. Methods: Premenopausal women with up to 10 clinically relevant uterine fibroids, each ranging from 1 to 5 cm in diameter, were treated with sonography-guided TFA on an outpatient basis and returned for regular follow-up visits for 2 years. Assessed outcomes included changes in symptom severity, heath-related quality of life, general health status, work and activity limitations, treatment satisfaction, adverse events, surgical reintervention, and occurrence of pregnancy and associated outcomes. Results: Among 147 enrolled women, 125 (85%) returned for follow-up at 2 years. Compared with baseline, symptom severity decreased from 55 ± 19 to 24 ± 18 (p < 0.001), health-related quality of life increased from 40 ± 21 to 83 ± 19 (p < 0.001), and EuroQol 5-Dimension scores increased from 0.72 ± 0.21 to 0.89 ± 0.14 (p < 0.001). Overall treatment satisfaction at 2 years was 94%. The mean percentage of missed work time, overall work impairment, and activity impairment significantly decreased at follow-up. Through 2 years, surgical reintervention for heavy menstrual bleeding was performed in 5.5% of patients. One singleton pregnancy occurred with a normal peripartum outcome. Conclusions: TFA treatment with the Sonata system provides significant clinical improvement through 2 years postablation, with a low incidence of surgical reintervention. Other favorable outcomes included a rapid return to work and substantial improvements in quality of life, symptom severity, work productivity, and activity levels.

68Ga-PSMA PET/CT vs. mpMRI for locoregional prostate cancer staging: correlation with final histopathology.

BACKGROUND: Prostate-specific membrane antigen (PSMA) positron emission tomography (PET) can be used to locate lesions based on PSMA avidity, however guidelines on its use are limited by its infancy. We aimed to compare multiparametric magnetic resonance imaging (mpMRI) and PSMA PET/CT to prostatectomy histopathology. METHODS: We conducted a chart review from February 2015 to January 2017 of 50 male patients staged for prostate cancer using PSMA PET/CT and mpMRI who then underwent radical prostatectomy. Pre-operative PSMA PET/CT and mpMRI were paired with corresponding histopathology. Correlations, sensitivity, and specificity were used for comparisons. RESULTS: A total of 81 lesions were confirmed by histopathology. Fifty index lesions were detected by histopathology, all of which were detected by PSMA PET/CT (100% detection), and 47 by mpMRI (94% detection). Thirty-one histologically confirmed secondary lesions were detected, 29 of which were detected by PSMA PET/CT (93.5% detection), and 16 by mpMRI (51.6% detection). PSMA had better sensitivity for index lesion localization than mpMRI (81.1 vs. 64.8%). Specificity was similar for PSMA PET/CT and mpMRI (84.6 vs. 82.7%). SUVmax of index lesions ranged from 2.9 to 39.6 (M = 9.27 ± 6.41). Index lesion SUVmax was positively correlated with PSA (rho = 0.48, p < 0.001) and ISUP grade (rho = 0.51, p < 0.001). CONCLUSIONS: PSMA-PET/CT provided superior detection of prostate cancer lesions with better sensitivity than mpMRI. PSMA-PET/CT can be used to enhance locoregional mpMRI to provide improved detection and characterization of lesions.

An evaluation of a chest pain diagnostic protocol to exclude acute cardiac ischemia in the emergency department.

BACKGROUND: Although accelerated diagnostic protocols are being increasingly used in emergency departments to diagnose acute cardiac ischemia, there have been no prospective evaluations of a chest pain diagnostic protocol with serial determinations of creatine kinase MB isoenzyme and mandatory exercise electrocardiography (ExECG). METHODS: Prospective cross-sectional study in which chest pain protocol results were compared with final (reference) diagnoses of acute cardiac ischemia (including acute myocardial infarction and unstable angina). Patients in need of hospital admission but at low probability (by a validated algorithm) for acute myocardial infarction were examined for exclusions: known coronary artery disease, cardiac complications, severe comorbidities, or inability to perform exercise testing. A 12-hour diagnostic protocol included serial measurements of creatine kinase MB, ECG, and clinical assessments followed by ExECG for those with negative initial serial testing. Reference diagnoses were established during hospitalization and diagnostic accuracy was assessed. RESULTS: The study group of 317 patients was 54% male and 65% black, and had a mean age of 46.6 years; 9.5% had a final diagnosis of acute cardiac ischemia. For this diagnosis, the protocol had a sensitivity of 90.0% (95% confidence interval, 72.3%-97.4%); specificity, 50.5% (95% confidence interval, 44.6%-56.4%); positive predictive value, 16.0%; and negative predictive value, 98.0%. Creatine kinase MB, serial ECGs, and ExECG each made a contribution to improved sensitivity and accuracy, whereas clinical reassessments were less discriminating, as indicated by protocol's receiver operating characteristic curve. CONCLUSIONS: A chest pain diagnostic protocol achieved high sensitivity and improved specificity over the standard emergency department workup. There were no adverse advents associated with early ExECG.

Development and evaluation of a micropipette tip washing system.

A tip washing system has been developed for use with disposable polypropylene micropipette tips of different sizes. The primary hardware components of the system are constructed from polyvinyl chloride (PVC) and Plexiglas. The system relies on a low concentration of detergent, gravity or aspirator-assisted feed and flush of minimal volumes of distilled/deionized water, and air or oven drying of the tips. Comparative analyses of new versus washed tips in FAO/IAEA radioimmunoassay (RIA) and enzyme linked immunosorbent assay (ELISA) protocols indicated that disposable polypropylene micropipette tips of various sizes (e.g. 5-300 and 50-1000 microl) can be washed and reused at least ten times without introducing detectable variability into the results of either assay, if the tips are properly washed and dried using this system. Recovery cost of the system can be achieved after approximately eight reuses of 1000 tips, excluding technician time.

Nephrogenic adenoma of the bladder in renal transplant and non-renal transplant patients: a review of 22 cases.

OBJECTIVES: To review diagnoses of nephrogenic adenoma and in particular to evaluate its association with transitional cell carcinoma (TCC) of the bladder and its relationship to renal transplantation. METHODS: A retrospective review of 22 cases of nephrogenic adenoma (NA) diagnosed between 1989 and 1996 was conducted, 7 of which were in renal transplant patients. Data collected in each case included demographic details, predisposing factors, associated urologic pathology, mode of presentation, cystoscopic finding, management, and follow-up. RESULTS: There was a 3:1 predominance of men. Mean follow-up was 21.4 months (range 3 to 50). Six patients (27%) had one or more recurrences. All 22 patients had some form of previous bladder insult or surgery, including recurrent urine infections, urinary tract instrumentation, placement of ureteric stents, cystodiathermy, and open bladder surgery. Six cases were associated with TCC of the bladder, of which 4 had NA lesions directly over or close to the site of previous fulguration. In 4 patients, there was a temporal relationship between the administration of intravesical doxorubicin hydrochloride or bacille Calmette-Guérin (BCG) and the onset of NA lesions. One case was associated with an inverted papilloma that had not been described before. In 7 renal transplant cases, 3 lesions were found contralateral to the side of the ureterovesical anastomosis. All 22 cases were benign histologically, but one NA was found within a low-grade baldder TCC. Nineteen cases were followed up regularly with no malignant transformation. Three patients were lost to follow-up. CONCLUSIONS: This study has demonstrated an association between NA and bladder cancer. Patients with NA, especially those treated with intravesical chemotherapy or BCG, should have regular cystoscopies. Fulguration or transurethral resection appear to be sufficient treatment. No renal transplant patients had vesical TCC and NA simultaneously. Neither immunosuppression nor ureterovesical anastomosis appeared to be a significant predisposing factor in the transplant patients.

Advantages of polytetrafluoroethylene arteriovenous loops in the thigh for hemodialysis access.

BACKGROUND: The upper thigh is an alternative but infrequently used site to the forearm for placement of subcutaneous polytetrafluoroethylene (PTFE) arteriovenous conduits in patients requiring hemodialysis for end stage renal failure. This site has the great advantage of easier accessibility for self-cannulation. METHODS: The outcome was reviewed for 74 PTFE loops placed in 61 patients between 1985 and 1991. RESULTS: Mean loop survival time was 99.8 weeks (SD 78.0) when patients with early failure (<1 week), and those patients whose loops functioned adequately until transplantation or death were excluded. Infection occurred in 12 of 74 loops. CONCLUSIONS: Thigh PTFE loops provide satisfactory medium- to long-term vascular access for hemodialysis although, like all other forms of access currently available, they fall short of the ideal for prolonged dialysis.

A criterion audit of women's awareness of blood transfusion in pregnancy.

BACKGROUND: In the Confidential Enquiry into Maternal Deaths (CEMD) Report, the very high risk of mortality in women who refuse blood transfusions is highlighted. The objectives were to establish current knowledge about, and views of transfusion in our pregnant population and to establish the level of compliance with the set audit standard. METHOD: Questionnaire survey of 228 women, including both high and low risk pregnancies, attending ante-natal clinic between 2-9 May 2000 at the North Staffordshire Maternity Hospital, Stoke on Trent. RESULTS: The response rate was 100%. Only 43% were aware of the possible need for blood transfusion in pregnancy. If a blood transfusion was required, 92% stated that they would accept a blood transfusion in pregnancy. Four percent stated that they would not accept a transfusion because of religious reasons and risk of infection and the remaining four percent did not declare a reason. CONCLUSIONS: This short survey identified that 57% of women were not aware of the possible need for blood transfusion during pregnancy. There is a need for more information to be shared on this subject with all antenatal women. Women who would refuse a transfusion need to be identified at booking and be referred for counselling and a management plan made for pregnancy, labour and delivery.

Efficacy of Punica granatum extract on in-vitro and in-vivo control of Trichomonas vaginalis.

Trichomoniasis vaginalis is now an important worldwide health problem. Metronidazole has so far been used in treatment, but the metronidazole-resistant strains and unpleasant adverse effects have been developed. Treatment of patients with metronidazole refractory vaginal trichomoniasis constitutes a major therapeutic challenge and treatment options are extremely limited. The last 7 years have seen over seven times as many publication indexed by Midline dealing with pomegranate (Punica granatum) than in all the years preceding them, because of this, and the virtual explosion of interest in pomegranate as a medicinal and nutritional product that has followed, this work is accordingly launched. Natural plant extract purified from Pomegranate (Roman) was in-vitro investigated for its efficacy against T. vaginalis on Diamond media. Besides, infection women (18/20) who accepted to be treated with P. granatum juice were completely curedand followed-up for two months. The anti-trichomoniasis vaginalis activity of P. granatum extract (in-vitro and in-vivo) gave very promising results.

Diagnosis of Toxoplasma gondii by ELISA and PCR in mothers and their infants.

Congenital Toxoplasma gondii infection may lead to abortion, stillbirth, neonatal death as well as severe congenital toxoplasmosis in the newborn infants. No doubt, early and proper diagnosis of infection pregnant women or her baby pave the way to effective treatment and minimize complications. In this study; the PCR and ELISA-IgM were used to diagnose active toxoplasmosis. The results revealed that PCR detected very recently infection (23/70 subjects) than ELISA-IgM (18/70 ones). However, the use of both ELISA-IgM and PCR together improved the diagnostic sensitivity and specificity.

Interactive urology: an evaluation.

BACKGROUND: Interactive Urology is a multimedia software program that has been written to provide computer-assisted interaction for medical students at the University of Sydney during their surgical term in urology. An evaluation sought to establish how the software will be used by medical students in the learning context and to explore the efficacy of the software in the transfer of content as well as problem-solving skills. METHODS: Interactional analysis during student computer sessions and pre- and post-testing included a total of 80 medical students to evaluate Interactive Urology. RESULTS: The software package appeared to promote higher-order thinking skills with brainstorming activities occupying about half the time available. utilizing pre- and post-testing, Interactive Urology was found to be efficacious in the transfer of content and problem-solving skills. It was also found to be as effective as text in transferring content and problem-solving skills. The sequence of text and computer assisted learning (CAL) did not alter learning efficacy. CONCLUSION: It was concluded from the present study that Interactive Urology is an effective and valuable learning resource for medical students.

The acceptance of computer assisted learning by medical students.

The use of computer assisted learning (CAL) in the medical undergraduate curriculum is increasing. Little is known regarding the acceptability of CAL among medical students. The present study was conducted to investigate the possible anxiety generated by and the acceptability of CAL among medical students. One hundred and twenty-six students completed a questionnaire after using a software package which has been as an adjunct in teaching urology. The present study demonstrates that there was little anxiety experienced by the students when using CAL and furthermore that there was a high level of acceptance for this type of instruction. This is encouraging for medical educators involved in producing multimedia packages for teaching medicine and surgery.

A longitudinal, patient-centred, integrated curriculum: facilitating community-based education in a rural clinical school.

The Greater Murray Clinical School (GMCS) was founded with two main aims in mind one, to provide a community-based learning environment offering diversified clinical educational experiences, and two, by doing so, to help address the doctor shortage for Australians living in rural and remote areas. The GMCS is a community-orientated and community-based clinical school, which has replaced the typical discipline-based curriculum with a longitudinal, patient-centred one. Students are attached to patients--called "the longitudinal patient"--whom they follow through all stages of their care. They share with patients their experience of illness and disease, their varying care needs, and how these are addressed by different service providers. The philosophy of the course, its implementation and our initial experiences are described.

Sympathetic nervous system effects on feline bladder wall compliance throughout continence.

The urinary bladder is a compliant organ, high compliance being essential for useful urine storage. The extent to which the sympathetic nervous system promotes the storage of urine by increasing bladder compliance is unclear. The aim of the present study was to determine the range of bladder volumes over which the sympathetic nervous system increased bladder wall compliance. In supine, anaesthetized cats, the bladder was filled at twice the rate of natural filling, the continence cycle being interrupted at five stages. These stages were when the bladder had become globular, during prodromal contractions, soon after non-micturating contractions had commenced, approximately two-thirds of the way through the continence cycle and just prior to micturition. During each of these interruptions, bladder volume was held constant while pelvic nerve afferent activity and bladder pressure were recorded. Recordings were obtained before and during the intravenous infusion of trimethaphan, the resulting partial ganglion blockade decreasing arterial pressure by a third. Bladder pressure as well as afferent nerve activity increased significantly when the sympathetic drive was transiently blocked, indicating that there had been a prevailing net sympatho-inhibitory effect promoting bladder wall relaxation. This effect was observed during prodromal contractions and continued until the onset of micturition. This net sympatho-inhibitory effect is a potential therapeutic path for the treatment of bladder storage disorders.

The application of ultrastructural studies in the diagnosis of bladder dysfunction in a clinical setting.

PURPOSE: We examine the ultrastructural changes reported to be present in dysfunctional bladders and determine whether they can be used as a predictor of urodynamic diagnosis in a clinical setting. MATERIALS AND METHODS: Subjects who required urodynamic diagnosis and cystoscopy as part of clinical management were recruited for this study. After urodynamic diagnosis cases were classified into 1 of 5 dysfunction groups as normal bladder outflow obstruction, idiopathic sensory urgency, obstruction with detrusor instability and pure detrusor instability. A detrusor muscle biopsy was taken from the lateral wall of the bladder at cystoscopy for subsequent electron microscopy. RESULTS: Of the 27 cases 6 were normal, 9 had bladder outflow obstruction and detrusor instability, 8 had pure detrusor instability and 4 had idiopathic sensory urgency. The obstructed group showed the myohypertrophy pattern previously reported. In contrast to previous reports, abnormal junctions were found in all patients. For each patient the ratios of abnormal-to-normal junctions were calculated. Mean and standard error ratios were 1.1+/-0.1, 2.7+/-0.2, 6.1+/-1.2, 13.3+/-4.4 for normal, idiopathic sensory urgency, obstruction with detrusor instability and pure detrusor instability, respectively (p = 0.0003, 0.0042 and 0.04). CONCLUSIONS: There are distinct morphological changes in the detrusor associated with bladder dysfunction. The ratio of abnormal-to-normal junctions is a novel measurement and can be used to predict urodynamic dysfunction. Ultrastructural studies may be useful as an adjunct in the diagnosis of bladder dysfunction.

Renal parenchyma-sparing surgery in carcinoma.

BACKGROUND: There is controversy regarding the role of renal-sparing surgery in patients with kidney cancer who have a functioning contralateral kidney. METHODS: The present study aimed to review the recent experience of renal-sparing surgery at Royal Prince Alfred Hospital (RPAH), Sydney. Eighteen consecutive patients undergoing conservative surgery for kidney tumours at RPAH between February 1987 and January 1995, were reviewed. Eleven patients had imperative indications for conservative surgery and the remaining seven patients had elective indications. Ten patients had modified enucleation with a margin of normal parenchyma. Six patients underwent partial nephrectomy and two had wedge resections. Patients were followed up at 1, 6 and 12 months, and thence every 6-12 months. Follow-up ranged from 9 to 104 months (mean: 46.2 months, median: 48 months). RESULTS: Sixteen of the 18 patients were still alive at the end of the follow-up (October 1995), with no clinical evidence of local or distant metastasis. The two deaths were not related to the fact that these patients had conservative surgery. The average tumour dimensions were 43 mm x 49 mm, with an average volume of 194 mm3. All resections were complete, with margins ranging between 1.0 and 20.0 mm (mean: 8.7 mm). The survival rate in the present study is comparable to those found by other researchers. CONCLUSIONS: Conservative surgery is indicated in renal tumours where radical surgery would render the patient anephric. Conservative surgery, however, is controversial in a patient with a normal contralateral kidney. The present study has shown that renal parenchyma-preserving surgery for localized tumours provides a feasible treatment option.

Surgeon, don't heal thyself: a study of the health of Australasian urologists.

BACKGROUND: Modern surgical practice is stressful and anxiety-producing. We investigated urologists health and their attitude to their own health care. METHODS: Two hundred and seventy-five Australasian urologists were surveyed to ascertain their attitudes to their physical and psychological health; 205 responses were received. RESULTS: Ten per cent reported serious physical illnesses. Fewer than half had their own general practitioner (GP), and fewer than one-third had seen a doctor in the previous 12 months. A majority had, at some time, prescribed themselves medication, including antibiotics, narcotic and non-narcotic analgesia and benzodiazepams. Nearly all reported that aspects of their urological practice caused them anxiety. More felt that this anxiety was the result of pressures experienced outside the operating theatre than problems directly related to performing surgery. A small number of psychological problems were reported, and fewer than 10 per cent had ever a visited a psychiatrist. It was evident that most Australasian urologists were unwilling to discuss any psychological problems that they may have. Even when a specific problem had been identified, few sought the appropriate care. CONCLUSIONS: It would be advantageous for Australasian urologists and doctors in general to see their GP more regularly, and be more willing to discuss any psychological difficulties that they may experience.

Community based medical education in a rural area: a new direction in undergraduate training.

The Greater Murray Clinical School provides a community based medical education programme for the clinical years at the University of New South Wales. Being a new clinica school in rural Australia allowed the development of a patient-centred longitudinal curriculum. Students follow patients through the health care system, with each exposure stimulating the learning about different aspects of a patient problem. The paper outlines the conceptual approach towards the development and implementation of this novel approach to community based medical education.

The influence of age and gender on normal appendicectomy rates.

Epidemiological data from a retrospective analysis of 1307 pathology reports of appendicectomy specimens from four Hunter Valley Hospitals, having a 100% tissue audit, showed that there was a significant difference in normal appendicectomy (histologically normal appendix following appendicectomy for suspected acute appendicitis) rates for the young (male and female 0-12 years) and reproductive female (13-50 years) groups when compared with the elderly (over 60 years) and the rest (male 13-59, female 51-59 years) of the population. The overall normal appendicectomy rate was 26%, and the perforation rate 3.6%. These data suggest that suspected acute appendicitis in the Hunter Valley is managed in an appropriate way. The perforation rate was significantly higher in the elderly group, and management of these patients will remain a problem due to delayed and atypical presentation. Continuing audit programmes and area-wide review should contribute to improved accuracy in the diagnosis of acute appendicitis.