Clinical, Biomarker, and Research Tests Among US Government Personnel and Their Family Members Involved in Anomalous Health Incidents.

Importance: Since 2015, US government and related personnel have reported dizziness, pain, visual problems, and cognitive dysfunction after experiencing intrusive sounds and head pressure. The US government has labeled these anomalous health incidents (AHIs). Objective: To assess whether participants with AHIs differ significantly from US government control participants with respect to clinical, research, and biomarker assessments. Design, Setting, and Participants: Exploratory study conducted between June 2018 and July 2022 at the National Institutes of Health Clinical Center, involving 86 US government staff and family members with AHIs from Cuba, Austria, China, and other locations as well as 30 US government control participants. Exposures: AHIs. Main Outcomes and Measures: Participants were assessed with extensive clinical, auditory, vestibular, balance, visual, neuropsychological, and blood biomarkers (glial fibrillary acidic protein and neurofilament light) testing. The patients were analyzed based on the risk characteristics of the AHI identifying concerning cases as well as geographic location. Results: Eighty-six participants with AHIs (42 women and 44 men; mean [SD] age, 42.1 [9.1] years) and 30 vocationally matched government control participants (11 women and 19 men; mean [SD] age, 43.8 [10.1] years) were included in the analyses. Participants with AHIs were evaluated a median of 76 days (IQR, 30-537) from the most recent incident. In general, there were no significant differences between participants with AHIs and control participants in most tests of auditory, vestibular, cognitive, or visual function as well as levels of the blood biomarkers. Participants with AHIs had significantly increased fatigue, depression, posttraumatic stress, imbalance, and neurobehavioral symptoms compared with the control participants. There were no differences in these findings based on the risk characteristics of the incident or geographic location of the AHIs. Twenty-four patients (28%) with AHI presented with functional neurological disorders. Conclusions and Relevance: In this exploratory study, there were no significant differences between individuals reporting AHIs and matched control participants with respect to most clinical, research, and biomarker measures, except for objective and self-reported measures of imbalance and symptoms of fatigue, posttraumatic stress, and depression. This study did not replicate the findings of previous studies, although differences in the populations included and the timing of assessments limit direct comparisons.

Neuroimaging Findings in US Government Personnel and Their Family Members Involved in Anomalous Health Incidents.

Importance: US government personnel stationed internationally have reported anomalous health incidents (AHIs), with some individuals experiencing persistent debilitating symptoms. Objective: To assess the potential presence of magnetic resonance imaging (MRI)-detectable brain lesions in participants with AHIs, with respect to a well-matched control group. Design, Setting, and Participants: This exploratory study was conducted at the National Institutes of Health (NIH) Clinical Center and the NIH MRI Research Facility between June 2018 and November 2022. Eighty-one participants with AHIs and 48 age- and sex-matched control participants, 29 of whom had similar employment as the AHI group, were assessed with clinical, volumetric, and functional MRI. A high-quality diffusion MRI scan and a second volumetric scan were also acquired during a different session. The structural MRI acquisition protocol was optimized to achieve high reproducibility. Forty-nine participants with AHIs had at least 1 additional imaging session approximately 6 to 12 months from the first visit. Exposure: AHIs. Main Outcomes and Measures: Group-level quantitative metrics obtained from multiple modalities: (1) volumetric measurement, voxel-wise and region of interest (ROI)-wise; (2) diffusion MRI-derived metrics, voxel-wise and ROI-wise; and (3) ROI-wise within-network resting-state functional connectivity using functional MRI. Exploratory data analyses used both standard, nonparametric tests and bayesian multilevel modeling. Results: Among the 81 participants with AHIs, the mean (SD) age was 42 (9) years and 49% were female; among the 48 control participants, the mean (SD) age was 43 (11) years and 42% were female. Imaging scans were performed as early as 14 days after experiencing AHIs with a median delay period of 80 (IQR, 36-544) days. After adjustment for multiple comparisons, no significant differences between participants with AHIs and control participants were found for any MRI modality. At an unadjusted threshold (P < .05), compared with control participants, participants with AHIs had lower intranetwork connectivity in the salience networks, a larger corpus callosum, and diffusion MRI differences in the corpus callosum, superior longitudinal fasciculus, cingulum, inferior cerebellar peduncle, and amygdala. The structural MRI measurements were highly reproducible (median coefficient of variation <1% across all global volumetric ROIs and <1.5% for all white matter ROIs for diffusion metrics). Even individuals with large differences from control participants exhibited stable longitudinal results (typically, <±1% across visits), suggesting the absence of evolving lesions. The relationships between the imaging and clinical variables were weak (median Spearman ρ = 0.10). The study did not replicate the results of a previously published investigation of AHIs. Conclusions and Relevance: In this exploratory neuroimaging study, there were no significant differences in imaging measures of brain structure or function between individuals reporting AHIs and matched control participants after adjustment for multiple comparisons.

Serum NfL and GFAP as biomarkers of progressive neurodegeneration in TBI.

BACKGROUND: We examined spatial patterns of brain atrophy after mild, moderate, and severe traumatic brain injury (TBI), the relationship between progression of brain atrophy with initial traumatic axonal injury (TAI), cognitive outcome, and with serum biomarkers of brain injury. METHODS: A total of 143 patients with TBI and 43 controls were studied cross-sectionally and longitudinally up to 5 years with multiple assessments, which included brain magnetic resonance imaging, cognitive testing, and serum biomarkers. RESULTS: TBI patients showed progressive volume loss regardless of injury severity over several years, and TAI was independently associated with accelerated brain atrophy. Cognitive performance improved over time. Higher baseline serum neurofilament light (NfL) and glial fibrillary acidic protein (GFAP) were associated with greater rate of brain atrophy over 5 years. DISCUSSSION: Spatial patterns of atrophy differ by injury severity and TAI is associated with the progression of brain atrophy. Serum NfL and GFAP show promise as non-invasive prognostic biomarkers of progressive neurodegeneration in TBI. HIGHLIGHTS: In this longitudinal study of patient with mild, moderate, and severe traumatic brain injury (TBI) who were assessed with paired magnetic resonance imaging (MRI), blood biomarkers, and cognitive assessments, we found that brain atrophy after TBI is progressive and continues for many years even after a mild head trauma without signs of brain injury on conventional MRI. We found that spatial pattern of brain atrophy differs between mild, moderate, and severe TBI, where in patients with mild TBI , atrophy is mainly seen in the gray matter, while in those with moderate to severe brain injury atrophy is predominantly seen in the subcortical gray matter and whiter matter. Cognitive performance improves over time after a TBI. Serum measures of neurofilament light or glial fibrillary acidic protein are associated with progression of brain atrophy after TBI.

Headaches in Traumatic Brain Injury: Improvement Over Time, Associations With Quality of Life, and Impact of Migraine-Type Headaches.

OBJECTIVE: To describe headache characteristics over time in patients with traumatic brain injury (TBI). SETTING: Patients enrolled and followed at the National Institutes of Health Clinical Center between 2011 and 2020. PARTICIPANTS: There were 147 patients with TBI, with 74 mild TBI (mTBI), 49 moderate (modTBI), 24 severe (sTBI), and 20 individuals without brain injury (IWBIs). DESIGN: Regular surveys of headache characteristics in patients with TBI were conducted. Patients were enrolled as early as 30 days post-injury and followed up to 5 years, for 419 total visits and 80 patients with multiple return visits. MAIN MEASURES: Surveys of headache characteristics, including headache severity, were measured on a 0- to 10-point Likert scale and headache frequency quantified as headaches per month. Patients with migraine-type headaches ( n = 39) were identified by a clinician-administered tool. Functional outcomes were measured using the Glasgow Outcome Scale-Extended (GOS-E) and quality of life by the Satisfaction with Life Scale (SWLS) and the 36-item Short Form Survey (SF-36). RESULTS: At their initial visit, patients with TBI had more severe and frequent headaches than IWBIs (median 5 vs 2.5, P < .001; median 2 vs 0.2, P < .001), as did patients with mTBI compared with modTBI/sTBI (all P ≤ .01). Migraines were associated with lower SWLS and SF-36 scores. Migraines and young age were associated with higher headache severity and frequency across time points. Longitudinally, time post-injury correlated with improvement in headache severity and frequency without differences by injury severity. However, time post-injury did not correlate with improvement in headache characteristics in a patient subgroup with moderate/severe headaches. CONCLUSION: Our findings suggest that patients with mild, moderate, or severe TBI see improvement in headaches over time. However, patients should be counseled that improvement is modest and seen more in patients with milder headache symptoms. Patients with migraine headaches in particular are at risk for worse headache characteristics with greater impact on quality of life.

Decisional Conflict is Associated with Treatment Modality and not Disease Knowledge in South African Men with Prostate Cancer: Baseline Results from a Longitudinal Prospective Observational Study.

BACKGROUND: Decisional conflict (DC) is a psychological construct that an individual experiences in making a decision that involves risk, loss, regret, or challenges to one's values. This study assessed DC in a cohort of South African men undergoing curative treatment for localised prostate cancer (LPC). The objectives were to (1) to examine the association between DC and prostate cancer knowledge (PCK), demographics, state anxiety, prostate cancer anxiety and time to treatment and (2) to compare levels of DC between treatment groups [prostatectomy (RP) and external beam radiation (RT)]. METHOD: Data, comprising the Decisional Conflict Scale (DCS), Prostate Cancer Knowledge (PCK), State-Trait Anxiety Inventory (STAI-S), the Memorial Anxiety Scale for Prostate Cancer (MAX-PC) and demographic data from 83 participants of a larger prospective longitudinal observational study examining depression, anxiety and health related quality of life (DAHCaP) were analysed. RESULTS: The mean age of participants was 63 years (RP 61yrs and RT 65yrs; p< 0.001). Most were of mixed ancestry (72.3%). The total DCS scores between the treatment groups (RP 25.00 and RT 18.75; p = 0.037) and two DCS sub-scores-uncertainty (p = 0.033), and support (p = 0.048), were significantly higher in the RP group. A statistically significant negative correlation was observed between state anxiety and time between diagnosis and treatment in the RP group (Spearman's rho = -0.368; p = 0.030). There was no correlation between the DCS score and PCK within each treatment group (Spearman's rho RP = -0.249 and RT = -0.001). CONCLUSION: Decisional conflict was higher in men undergoing RP. Men were more anxious in the RP group regarding the time treatment was received from diagnosis. No correlation was observed between DC and PCK. Pre-surgical management of DC should include shared decision making (SDM) which is cognisant of patients' values facilitated by a customised decision aid.

Depression, Anxiety, and Their Association to Health-Related Quality of Life in Men Commencing Prostate Cancer Treatment at Tertiary Hospitals in Cape Town, South Africa.

BACKGROUND: Comorbid depression and anxiety in men with localised prostate cancer (CaP) largely go undiagnosed and untreated and their effects on health-related quality of life (HRQOL) in men with CaP should not be underestimated. We examined the prevalence of depression and anxiety and its association with HRQOL in men about to commence treatment for CaP and the differences between treatment groups, radical prostatectomy (RP) and radiation therapy (RT). METHOD: One hundred and seven participants from a longitudinal prospective observational study assessing depression, anxiety and HRQOL in men with localised CaP (DAHCaP), were used in this cross-sectional analysis. Data were collected shortly before participants were scheduled to receive their treatment. The Centre for Epidemiologic Studies Depression Scale (CES-D), the State Trait Anxiety Inventory (STAI), the Memorial Anxiety Scale for Prostate Cancer (MAX-PC), the European Organisation for Research and Treatment in Cancer Quality of Life questionnaire (EORTC QLQ-C30) and (EORTC QLQ-PR25) were used in this analysis. RESULTS: Symptoms of depression pre-treatment were noted in 39.3%, state anxiety 28%, trait anxiety 31.4% and prostate cancer anxiety in 12.1% of participants. Statistically significant correlations (P ≤ .05) with the CES-D and a cluster of symptoms on the EORTC QLQ-C30 domains for Global Health (rs = -.35), fatigue (rs = .38), pain (rs = .32), dyspnoea (rs = .28), insomnia (rs = .30) and finance (rs = .26) and EORTC QLQ-PR25 domains for urinary symptoms (rs = .43), bowel (rs = .43) and hormone replacement therapy (HRT) (rs = .41) were observed.Statistically significant correlations were also noted between the STAI-S and EORTC QLQ-C30 and EORTC QLQ-PR25. No statistically significant difference was noted between treatments. CONCLUSION: More men were depressed than anxious with significant associations with HRQOL prior to commencement of treatment. CaP treatments should focus not only on the prevailing indisposition but include a psychooncological and HRQOL assessment at pre-treatment in high-risk individuals.

Awareness of European practitioners toward uncommon tropical diseases: are we prepared to deal with mass migration? Results of an international survey.

PURPOSE: The recent rise in migration from Africa through the Mediterranean basin into Europe has resulted in an increased incidence of uncommon diseases such as schistosomiasis and genito-urinary tuberculosis, which were previously largely unknown in this region. This study aimed to evaluate the insight of European urologists into diagnosing and managing these disease conditions and to determine whether they were adequately prepared to deal with the changing disease spectrum in their countries. METHODS: A survey including specific questions about the diagnosis and management of 'tropical' urological diseases was distributed among urologists working in Europe and Africa. Multivariate logistic regression models were performed to detect the continent (African or European) effect on knowledge of and insight into tropical urological diseases. RESULTS: A total of 312 surveys were administered. African and European respondents accounted for 109 (36.09%) and 193 (63.91%) respondents, respectively. The multivariate logistic regression analysis demonstrated a significant deficiency in the knowledge of tropical urological diseases in the European cohort compared with the African cohort (p < 0.05). Moreover, in the European cohort, markedly superior knowledge of tropical urological diseases was observed for respondents who had previously worked in a developing country. CONCLUSIONS: Though European urologists are not required to have the same insight as African urologists, they showed a very unsatisfactory knowledge of tropical urological diseases. The experience of working in a developing country could improve the knowledge of European urologists regarding tropical urological diseases.

Supporting the role of penile trauma and micro-trauma in the etiology of Peyronie's disease. Prospective observational study using the electronic microscope to examine two types of plaques.

OBJECTIVES: The etiopathogenesis of Peyronie's disease (PD) remains not clearly understood. The most accepted theory attributes the histological lesions of PD to the effects of trauma to the corpora cavernosum of the penis. The aim of our study is to verify whether similar histological features exist between these two tissues, providing new evidence in favor of the traumatic theory in the etiopathogenesis of Peyronie's disease. MATERIALS AND METHODS: A prospective observational study was carried out at our institution from January 2013 to June 2018, involving patients having undergone surgery for PD and those with delayed surgery for penile trauma. Both excised PD and post-traumatic plaques were analyzed by blind pathologists with an 80kV potential acceleration electron microscope. RESULTS: Five patients were identified with a post-traumatic plaque (Group 1) and therefore an equal number of PD patients were enrolled for Group 2. The ultrastructural characteristics of the two types of preparations were very similar. In all the samples we showed an inflammatory reaction of the structure of the tunica albuginea, a production of the disorganized extracellular matrix, a proliferation of inflammatory cells and fibroblasts. Furthermore, we have found an increase in the density and collagen deposits grouped in the extracellular space and within the fibroblasts. CONCLUSIONS: These findings support the theory that attributes lesions and symptoms typical of PD to the effects of cavernous body trauma.

In response to an argument against penile transplantation.

Moodley and Rennie's paper arguing against penile transplantation stated out of context arguments and wrongly quoted statements. The cost of penile transplantation is much less than portrayed. The burden of cases is much less than is communicated. The men on our penis transplantation programme represent the poorest of the poor and are one of the most discriminated against groups of humans on earth. The false hope said to be created by Moodley is indeed not false hope at all as there is a real possibility that most patients on our waiting list may be transplanted. Moodley argues that government has, in the context of penile transplantation, no duty to cure those who lost a penis after ritual circumcision, but only an obligation to prevent this from happening. A 'yuk' reaction, similarly described in facial transplantation, may be present in colleagues arguing against penile transplantation.

Traumatic microbleeds persist for up to five years following traumatic brain injury despite resolution of other acute findings on MRI.

OBJECTIVE: The primary objective of this study was to track the incidence and progression of traumatic microbleeds (TMBs) for up to five years following traumatic brain injury (TBI). METHODS: Thirty patients with mild, moderate, or severe TBI received initial MRI within 48 h of injury and continued in a longitudinal study for up to five years. The incidence and progression of MRI findings was assessed across the five year period. In addition to TMBs, we noted the presence of other imaging findings including diffusion weighted imaging (DWI) lesions, extra-axial and intraventricular hemorrhage, hematoma, traumatic meningeal enhancement (TME), fluid-attenuated inversion recovery (FLAIR) hyperintensities, and encephalomalacia. RESULTS: TMBs were observed in 60% of patients at initial presentation. At one-year follow-up, TMBs were more persistent than other neuroimaging findings, with 83% remaining visible on MRI. In patients receiving serial MRI 2-5 years post-injury, acute TMBs were visible on all follow-up scans. In contrast, most other imaging markers of TBI had either resolved or evolved into ambiguous abnormalities on imaging by one year post-injury. CONCLUSIONS: These findings suggest that TMBs may serve as a uniquely persistent indicator of TBI and reinforce the importance of acute post-injury imaging for accurate characterization of persistent imaging findings.

Ethical and societal challenges in penis transplantation.

PURPOSE OF REVIEW: To review the current understanding of the ethical and societal difficulties of penile transplantation. RECENT FINDINGS: Penile transplantation, as with other forms of vascularized composite allotransplantation, has increasing acceptance in society but is still not entirely accepted. Guidelines aiming to help guide future penile transplant programs in an ethical and scientific safe manner were created. Controversies regarding the economic impact, patient safety, and the rights of the patients choosing penile transplant remains. SUMMARY: Penile transplantation has excellent functional and cosmetic results in the short-term and medium-term. The penis, similar to the face in facial transplantation, carries emotional gravity that relates to visible body parts of another that live forth in a tangible manner contributing to psychological and ethical challenges for both the individual and society more broadly, healthcare administrators, and healthcare workers. In the context of these challenges, controversies emerge related to issues of judgment about what society can and wants to afford. Effects of toxic immunosuppression in a nonlife saving life-enhancing procedure, as well as costs, become arguments that have to be considered in the context of ethical and societal challenges.

Surgical Training in South Africa: An Overview and Attempt to Assess the Training System from the Perspective of Foreign Trainees.

BACKGROUND: Currently, there are no objective reports evaluating the quality of the South African surgical training. The aim of this study is to evaluate the current state of surgical training in South Africa from an external impartial point of view and to rate the experience of short-term supernumerary registrars and fellows (STSRF) within the South African training system. METHODS: A 29-item survey was distributed via e-mail and social media to non-South African trainees who worked in South Africa as STSRF for a period of at least 1 month during the past 5 years. The survey evaluated the surgical, clinical and academic training received during their elective period in a South African department. RESULTS: Sixty-four STSRF replied to the survey. Sixty-two percent of STSRF attended a trauma unit during their experience. For the majority of respondents, open and emergency surgical exposure, as well as experience as first surgeon, is significantly higher in the South African system, while minimally invasive and endoscopic surgery exposure is significantly less. Research project involvement is significantly less, for the STSRF, as opposed to lectures and teaching that constitute a higher percentage. No significant difference was found regarding exposure to hands-on activities. CONCLUSIONS: The South African system still provides excellent surgical and clinical exposure as well as teaching. However, minimally invasive surgery training and research are generally lacking for the STSRF. Exchange programs between South African and developed country institutes should be improved and encouraged in order to gain mutual benefits.

Penile allotransplantation for penis amputation following ritual circumcision: a case report with 24 months of follow-up.

INTRODUCTION: Ritual circumcision complicated by gangrene is a leading cause of penile loss in young men in South Africa. This deeply rooted cultural tradition is unlikely to be abolished. Conventional reconstructive techniques using free vascularised tissue flaps with penile implants are undesirable in this often socioeconomically challenged group because donor site morbidity can hinder manual labour and vigorous sexual activity might lead to penile implant extrusion. The psychosociological effects of penile loss in a young man are devastating and replacing it with the same organ is likely to produce the maximum benefit. METHODS: We first performed a cadaver-to-cadaver penile transplantation as preparation. After approval from the Human Research Ethics Committee was obtained, we recruited potential recipients. We screened the potential participants for both physical and psychological characteristics, including penile stump length, and emotional suitability for the procedure. A suitable donor became available and the penis was harvested. We surgically prepared the penile stump of the recipient and attached the penile graft. Immunosuppression treatment with antithymyocyte globulin, methylprednisolone, tacrolimus, mycophenolate mofetil, and prednisone were commenced. Tadalafil at 5 mg once per day was commenced after 1 week as penile rehabilitation and was continued for 3 months. We collected on quality-of-life scores (Short Form 36 version 2 [SF-36v2] questionnaires) before surgery and during follow-up and measured erectile function (International Index for Erectile Function [IIEF] score) and urine flow rates at 24 months post transplant. FINDINGS: The warm ischaemia time for the graft after removal was 4 min and the cold ischaemia time was 16 h. The surgery lasted 9 h. An arterial thrombus required urgent revision 8 h after the operation. On post operative day 6, an infected haematoma and an area of proximal skin necrosis were surgically treated. The recipient was discharged after 1 month and first reported satisfactory sexual intercourse 1 week later (despite advice to the contrary). The recipient reported regular sexual intercourse from 3 months after the operation. An episode of acute kidney injury at 7 months was reversed by reducing the tacrolimus dose to 14 mg twice per day. At 8 months after surgery, the patient had a skin infection with phaeohyphomycosis due to Alternaria alternata, which we treated with topical antifungal medication. Quality-of-life scores improved substantially after the operation (SF-36v2 mental health scores improved from 25 preoperatively, to 57 at 6 months and 46 at 24 months post transplant; physical health scores improved from 37 at baseline to 60 at 6 months and 59 at 24 months post-transplant). At 24 months, measured maximum urine flow rate (16·3 mL/s from a volume voided of 109 mL) and IIEF score (overall satisfaction score of 8 from a maximum of 10) were normal, showing normal voiding and erectile function, respectively. INTERPRETATION: Penile transplantation restored normal physiological functions in this transplant recipient without major complications in the first 24 months. FUNDING: Department of Health, Western Cape Government.

Urinary tract tuberculosis in a child with late presentation posterior urethral valves.

A case is reported of urinary tract tuberculosis in a 7-year-old boy with a history of late presentation posterior urethral valves. Persistent hydroureteronephrosis after valve ablation at the age of 5 years and a draining urinary fistula from the site where a suprapubic catheter had been inserted prior to valve surgery alerted to the possibility of urinary tract tuberculosis.

Retroperitoneoscopic live donor nephrectomy: review of the first 50 cases at Tygerberg Hospital, Cape Town, South Africa.

BACKGROUND: Changing from an open to a laparoscopic live renal donor programme poses challenges and may affect donor and graft outcomes. OBJECTIVES: To evaluate donor safety and graft outcomes for the first 50 retroperitoneoscopic live donor nephrectomies performed at Tygerberg Hospital, Cape Town, South Africa. METHODS: The procedures were performed by a single surgeon from 8 April 2008 to 3 April 2012. Operative and anatomical data were prospectively collected. A flank approach with lateral and posterior placements was used. Vascular control was achieved with Hem-o-lok clips in the majority of cases. RESULTS: The mean age of the donors was 31.5 years (range 18 - 50), 28 (56.0%) were male, and the left kidney was harvested in 28 (56.0%) of cases. The mean operating time was 149.8 minutes (range 75 - 250), mean warm ischaemic time (WIT) 181.3 seconds (107 - 630), mean blood loss 139.7 ml (5 - 700) and mean hospital stay 3.2 days (2 - 5). Mean WIT was significantly longer for right-sided than left-sided nephrectomy (213 v. 162 seconds). In two right-sided cases the renal vein was too short and vena profunda femoris was used to create length. No donor received a blood transfusion. Comparing the last 25 with the first 25 cases showed a significant decrease in mean WIT (158 v. 204 seconds) and operating time (128 v. 172 minutes). No major complications occurred. CONCLUSION: Our initial 50 retroperitoneoscopic live donor nephrectomies were performed without major complications. Donor safety was maintained during the early learning curve of the transition to minimal-access donor nephrectomy.

Clinical (non-histological) diagnosis of advanced prostate cancer: Evaluation of treatment outcome after androgen deprivation therapy.

Introduction. Transrectal biopsy in suspected adenocarcinoma of the prostate (ACP) may cause significant morbidity and even mortality. A strong association between serum prostate-specific antigen (PSA) and tumour burden exists. If biopsy can be avoided in advanced disease, much morbidity and cost may be saved.Objective. To evaluate the reliability of using PSA and clinical features to establish a non-histological diagnosis of ACP.Methods. Androgen deprivation therapy (ADT) was used in 825 (56.2%) of 1 467 men with ACP. The diagnosis of ACP was made histologically in 607 patients (73.6%) and clinically alone in 218 (26.4%), based on a serum PSA level of >60 ng/ml, and/or clinical evidence of a T3 - T4 tumour on digital rectal examination, and/or imaging evidence of metastases. We compared two randomly selected groups treated with bilateral orchidectomy (BO) based on a clinical-only (n=90) v. histological (n=96) diagnosis of ACP.Results. There was no significant difference between the groups with regard to mean follow-up (26.1 v. 26.8 months), documented PSA relapse (70% v. 67.7%), and patients alive at last follow-up (91.1% v. 95.8%). ZAR1 068 200 (US$1 = ZAR8) was saved by treating men with advanced ACP on the basis of a clinical (non-histological) diagnosis only, and a total of ZAR24 321 000 was saved by using BO instead of luteinising hormone-releasing hormone agonists as ADT.Conclusion. A reliable clinical (non-histological) diagnosis of advanced ACP can be made based on serum PSA and clinical features. This avoids the discomfort and potentially serious complications of biopsy and saves cost.

Microbial biofilm formation and catheter-associated bacteriuria in patients with suprapubic catheterisation.

PURPOSE: Catheter-associated bacteriuria (CAB) with transurethral catheters is almost inevitable. Suprapubic catheters (SPCs) are widely considered to decrease the risk of CAB. However, SPCs are implants similarly prone to microbial biofilm formation. The spectrum of colonising pathogens has not been investigated. The aim of this prospective study was: (1) to assess the diversity of microbial suprapubic catheter colonisation (MSPCC), (2) to identify risk factors and (3) to investigate its association with CAB and catheter-associated urinary tract infection (CA-UTI). METHODS: A total of 218 SPCs from 112 patients were studied. Urine specimens were obtained after device replacement or removal. Sonication was performed to dislodge adherent microorganisms. Data of patient sex, age, indwelling time, and underlying disease were recorded. RESULTS: Sonicate-fluid culture (SFC) detected MSPCC in 95 %. Increasing indwelling time correlated with MSPCC (p < 0.05). Negative SFC was more frequent when antibiotic prophylaxis was applied at time of catheter placement (15 vs. 2 %, p < 0.05). Most commonly isolated were Enterobacteriaceae (45.8 %), followed by Enterococcus spp. (25.7 %) and Pseudomonas aeruginosa (10.3 %). CAB and CA-UTI were observed in 95 and 11 %, respectively. CONCLUSIONS: This study provides the first analysis of MSPCC. Indwelling time increases, whereas antibiotic prophylaxis decreases the risk of MSPCC. The spectrum of pathogens is comparable to the one obtained from urethral catheter biofilms. Urine specimens could not demonstrate the microbial diversity of MSPCC. SPCs are not preferable to urethral catheters to reduce CAB. Whether the risk of CA-UTI could be minimised by SPCs remains to be clarified.

Standardization of isothermal microcalorimetry in urinary tract infection detection by using artificial urine.

PURPOSE: Isothermal microcalorimetry (IMC) has recently been reported as a new method to rapidly detect urinary tract pathogens (UTP). However, further application of microcalorimetry in the clinical setting requires a standardized procedure. An important step toward such standardization is to use a reproducible growth medium. In this study, we investigated the potential of artificial urine in combination with microcalorimetry for detection of common UTP. METHODS: A microcalorimeter equipped with 48 channels was used. Detection was accomplished, and growth was monitored for four bacterial strains in artificial urine at 37 °C by measuring metabolic heat flow (µW = µJ/s) as a function of time. The strains were Escherichia coli, Proteus mirabilis, Enterococcus faecalis, and Staphylococcus aureus. RESULT: Bacterial growth was detected after 3-32 h with decreasing inoculums down to 1 CFU. The gram-negative strains grew and were detected faster than their gram-positive counterparts. The growth rates the different strains were 0.75 ± 0.11 for E. coli, 0.74 ± 0.10 for E. faecalis, 1.31 ± 0.04 for P. mirabilis, and 0.56 ± 0.20 for S. aureus. The shape of individual heat flow curves was characteristic for each species independent of its initial concentration. CONCLUSIONS: IMC allows rapid detection of UTP in artificial urine. Clearly, different heat flow patterns enable accurate pathogen differentiation. UTP detection after only 4 h is realistic. The rapid detection of UTP tested in standardized artificial urine proves the diagnostic potential of IMC and warrants further microcalorimetric studies in the clinical setting of urinary tract infections.

Comparison of the roll-plate and sonication techniques in the diagnosis of microbial ureteral stent colonisation: results of the first prospective randomised study.

BACKGROUND: Microbial ureteral stent colonisation (MUSC) is one leading risk factor for complications associated with ureteral stent placement. As MUSC remains frequently undetected by standard urine cultures, its definitive diagnosis depends on microbiological investigation of the stent. However, a standard reference laboratory technique for studying MUSC is still lacking. MATERIALS AND METHODS: A total of 271 ureteral stents removed from 199 consecutive patients were investigated. Urine samples were obtained prior to device removal. Stents were divided into four parts. Each part was separately processed by the microbiology laboratory within 6 h. Ureteral stents were randomly allocated to roll-plate or sonication, respectively, and analysed using standard microbiological techniques. Demographic and clinical data were prospectively collected using a standard case-report form. RESULTS: Overall, roll-plate showed a higher detection rate of MUSC compared with sonication (35 vs. 28 %, p < 0.05) and urine culture (35 vs. 8 %, p < 0.05). No inferiority of Maki's technique was observed even when stents were stratified according to indwelling time below or above 30 days. Compared with roll-plate, sonication commonly failed to detect Enterococcus spp., coagulase-negative staphylococci (CoNS) and Enterobacteriaceae. In addition, sonication required more hands-on time, more equipment and higher training than roll-plate in the laboratory. CONCLUSIONS: This prospective randomised study demonstrates the superiority of Maki's roll-plate technique over sonication in the diagnosis of MUSC and that urine culture is less sensitive than both methods. The higher detection rate, simplicity and cost-effectiveness render roll-plate the methodology of choice for routine clinical investigation as well as basic laboratory research.

The start of sexual health curriculum development and evaluation at Stellenbosch University.

BACKGROUND: Stellenbosch University's (SU) Faculty of Medicine and Health Sciences (FMHS), developed a sexual health course to be integrated throughout the revised medical curriculum. AIM: To use the Sexual Health Education for Professionals Scale (SHEPS) to gather baseline and future follow-up data to inform curriculum development and evaluation. SETTING: The first-year medical students (N = 289) of the FMHS SU. METHODS: The SHEPS was answered before the start of the sexual health course. The knowledge, communication and attitude sections were answered with a Likert-type scale. Students had to describe their perceived confidence in their knowledge and communication skills to care for patients within specific sexuality-related clinical scenarios. The attitude section measured the students' level of agreement or disagreement on sexuality-related opinion statements. RESULTS: The response rate was 97%. Most students were female, and 55% of the class were first taught about sexuality in the age group 13-18 years. The students had more confidence in their communication skills than knowledge before any tertiary training. The attitude section revealed a binomial distribution, ranging from acceptance to a more restrictive attitude towards sexual behaviour. CONCLUSION: It is the first time the SHEPS has been used in a South African context. The results provide novel information about the range of perceived sexual health knowledge, skills and attitudes of first-year medical students before they start tertiary training.Contribution: Findings from this study will guide content development and evaluation of the sexual health course at the institution where the study was conducted, as well as allow for culture sensitive education.