Ureteral stricture rate after endoscopic treatments for urolithiasis and related risk factors: systematic review and meta-analysis.

PURPOSE: We aimed to accurately determine ureteral stricture (US) rates following urolithiasis treatments and their related risk factors. METHODS: We conducted a systematic review and meta-analysis following the PRISMA guidelines using databases from inception to November 2023. Studies were deemed eligible for analysis if they included ≥ 18 years old patients with urinary lithiasis (Patients) who were subjected to endoscopic treatment (Intervention) with ureteroscopy (URS), percutaneous nephrolithotomy (PCNL), or shock wave lithotripsy (SWL) (Comparator) to assess the incidence of US (Outcome) in prospective and retrospective studies (Study design). RESULTS: A total of 43 studies were included. The pooled US rate was 1.3% post-SWL and 2.1% post-PCNL. The pooled rate of US post-URS was 1.9% but raised to 2.7% considering the last five years' studies and 4.9% if the stone was impacted. Moreover, the pooled US rate differed if follow-ups were under or over six months. Patients with proximal ureteral stone, preoperative hydronephrosis, intraoperative ureteral perforation, and impacted stones showed higher US risk post-endoscopic intervention with odds ratio of 1.6 (P = 0.05), 2.6 (P = 0.009), 7.1 (P < 0.001), and 7.47 (P = 0.003), respectively. CONCLUSIONS: The overall US rate ranges from 0.3 to 4.9%, with an increasing trend in the last few years. It is influenced by type of treatment, stone location and impaction, preoperative hydronephrosis and intraoperative perforation. Future standardized reporting and prospective and more extended follow-up studies might contribute to a better understanding of US risks related to calculi treatment.

PSMA-PET and micro-ultrasound potential in the diagnostic pathway of prostate cancer.

PURPOSE: To compare the diagnostic performance of 68Ga-PSMA PET/TC with PRI-MUS (prostate risk identification using micro-ultrasound) in the primary diagnosis of prostate cancer (PCa). METHODS: From September till December 2018, we prospectively enrolled 25 candidates to 68Ga-PSMA PET/TRUS (transrectal ultrasound) fusion biopsy and compared them with PRI-MUS. This included patients with persistently elevated PSA and/or PHI (prostate health index) suspicious for PCa, negative digital rectal examination, with either negative or contraindication to mpMRI, and at least one negative biopsy. The diagnostic performance of the two modalities was calculated based on pathology results. RESULTS: Overall, 20 patients were addressed to 68Ga-PSMA PET/TRUS fusion biopsy. Mean SUVmax and SUVratio for PCa lesions resulted significantly higher than in benign lesions (p = 0.041 and 0.011, respectively). Using optimal cut-off points, 68Ga-PSMA PET/CT demonstrated an overall accuracy of 83% for SUVmax ≥ 5.4 and 94% for SUVratio ≥ 2.2 in the detection of clinically significant PCa (GS ≥ 7). On counterpart, PRI-MUS results were: score 3 in nine patients (45%), score 4 in ten patients (50%), and one patient with score 5. PRI-MUS score 4 and 5 demonstrated an overall accuracy of 61% in detecting clinically significant PCa. CONCLUSION: In this highly-selected patient population, in comparison to PRI-MUS, 68Ga-PSMA PET/CT shows a higher diagnostic performance.

How to decide which infant can have robotic surgery? Just do the math.

BACKGROUND: In pediatric urology, robot-assisted surgery has overcome several impediments of conventional laparoscopy. However, workspace has a major impact on surgical performance. The limited space in an infant can significantly impede the mobility of robotic instruments. There is currently no consensus on which infant can undergo robotic intervention and no parameters to help make this decision, especially for those surgeons at the start of their learning curve. OBJECTIVE: We sought to evaluate our experience with infants to create an objective standard to determine which patients may be most suitable for robotic surgery. STUDY DESIGN: We prospectively evaluated 45 infants (24 males, 21 females), aged 3-12 months old, who underwent a robotic intervention for either upper or lower urinary tract pathology. At the preoperative office visit the attending surgeon measured the distance between both anterior superior iliac spines (ASIS) as well as the puboxyphoid distance (PXD), regardless of whether the approach was for upper or lower tract disease. Patients' weights were also noted. During surgery, we recorded the number of robotic collisions as well as console time. All surgeries were performed utilizing the da Vinci Si Surgical System by a single surgeon. RESULTS: There were no differences in ASIS, PXD, collisions or console time when stratified by gender, age or weight. When arranging by upper or lower tract approach, there was no difference in the number of collisions. There was a strong inverse relationship between both ASIS distance and PXD and the number of collisions. Additionally, there was a strong correlation between the number of collisions and console time (Fig. 1). Using a cutoff of 13 cm for the ASIS, there were significantly fewer collisions in the >13 cm group as compared to the ≤13 cm group. This was also true for the PXD using a cutoff of 15 cm: there were significantly fewer collisions in the >15 cm group as compared to the ≤15 cm group. DISCUSSION: Safe proliferation of robotic technology in the infant population is, in part, dependent on careful patient selection. Our data demonstrated a reduction in instrument collisions and console time with increasing anterior superior iliac spine and puboxyphoid distances. Neither age nor weight was correlated with these measurements, the number of instrument collisions or console time. Limitations include that this is a single institution study with all infants being operated on by a single surgeon. Therefore, the findings of this study may not be generalizable to a less experienced surgeon. Yet, we believe that ASIS and PXD measurements can be used as a guide for the novice surgeon who is beginning to perform robotic-assisted surgery in infants. CONCLUSION: We found that surgeon ability to perform robotic surgery in an infant is restricted by collisions when the infant has an ASIS measurement of 13 cm or less or a PXD of 15 cm or less. Objective assessment of anterior superior iliac spine and puboxyphoid distance can aid in selecting which infants can safely and efficiently undergo robotic intervention with a minimum of instrument collision, thereby minimizing operative time.

Geocoding health data with Geographic Information Systems: a pilot study in northeast Italy for developing a standardized data-acquiring format.

INTRODUCTION: Geographic Information Systems (GIS) have become an innovative and somewhat crucial tool for analyzing relationships between public health data and environment. This study, though focusing on a Local Health Unit of northeastern Italy, could be taken as a benchmark for developing a standardized national data-acquiring format, providing a step-by-step instructions on the manipulation of address elements specific for Italian language and traditions. METHODS: Geocoding analysis was carried out on a health database comprising 268,517 records of the Local Health Unit of Rovigo in the Veneto region, covering a period of 10 years, starting from 2001 up to 2010. The Map Service provided by the Environmental Research System Institute (ESRI, Redlands, CA), and ArcMap 10.0 by ESRI(®) were, respectively, the reference data and the GIS software, employed in the geocoding process. RESULTS: The first attempt of geocoding produced a poor quality result, having about 40% of the addresses matched. A procedure of manual standardization was performed in order to enhance the quality of the results, consequently a set of guiding principle were expounded which should be pursued for geocoding health data. High-level geocoding detail will provide a more precise geographic representation of health related events. CONCLUSIONS: The main achievement of this study was to outline some of the difficulties encountered during the geocoding of health data and to put forward a set of guidelines, which could be useful to facilitate the process and enhance the quality of the results. Public health informatics represents an emerging specialty that highlights on the application of information science and technology to public health practice and research. Therefore, this study could draw the attention of the National Health Service to the underestimated problem of geocoding accuracy in health related data for environmental risk assessment.

Older adults in Emergency Department: management by clinical severity at triage.

BACKGROUND: The elderly are involved in an ever-increasing proportion of Emergency Department (ED) visits, consuming a large share of the available resources. The aim of this study was to assess elderly individuals' demand for ED hospital care, in terms of the management process and outcomes by level of urgency at triage. METHODS: The design was a retrospective cohort study. Details on ED attendance were drawn from the 2010 dataset of the Local Health Agency n°18 (n=18,648) in the Veneto Region, North-East Italy and the participants were resident seniors seen at the ED aged 65 or more. RESULTS: At triage on arrival, their priority was most often (in 38.63% of cases) considered non-urgent (white triage tag - Wt). In the majority of these cases, the elderly patients were self-referred, although about 1 in 5 of them had been referred by their General Practitioners. The consumption of resources for specialist visit and routine X-rays is higher for non-urgent patients. Injuries, requests for specialist examinations and musculoskeletal disorders account for a large proportion of the reasons why elderly people classified as Wt at triage had gone to the ED. CONCLUSIONS: Our findings show that older patients have high rates of non-urgent ED attendance, especially for minor traumatic events or requests to see a specialist. This picture emphasizes the need to develop new organizational models for delivering care to meet the most common health care needs of this special frail population.

Health consequences of road accidents: insights from local health authority registries.

BACKGROUND: Road accidents are a major public health problem that affect all age groups but their impact is most striking among the young. The aim of this study is to quantify the burden of road traffic injuries, their mortality and direct in-patient economic costs and to identify the age classes at highest risk for severe road traffic injuries, through analysis of data collected by information systems of an Italian Local Health Authority. METHODS: The study was conducted in a Local Health Authority of Veneto Region. Injured people were selected from Emergency Department (2006-2010). Data were linked to the Hospital Information System for hospital admissions and to the Mortality Registry to check 30-day mortality. The direct costs associated to hospitalizations were estimated through Diagnosis Related Group reimbursement rates. Multivariate analysis was performed using hospitalization and mortality as the dependent variables and gender, age, day of week when accident occurred as the independent variables. Traffic injury, hospitalization and mortality incidence rates were calculated by gender and age per 100,000 residents per year. RESULTS: The road traffic injuries were 9,192, decreasing from 2,112 in 2006 to 1,980 in 2010. Among injured persons 55.3% were male (68.1% among 15-19 age class); 41.7% young people aged 15-34 years (43.9% among male, 39.0% among female). Total hospitalisation rate was 5.9%. Overall mortality rate was 0.3% (0.9% among aged 65 or older). The cost of hospital admission was euro 2,742,505 (hospitalization mean cost euro 5,097). Risk of hospitalization and death was higher in male, in elderly and during week end. Young people aged 15-19 had the highest incidence of visits (2,258.4 per 100,000) and high hospitalisation weekend and mortality rates (respectively 101.5 and 8.5). CONCLUSIONS: Analysis at local level, using current data sources, permits to estimate the burden of injuries caused by road-traffic, to describe the characteristics of injured persons and finally to estimate costs of care. All this information could be used to make the population aware of its own risk for road accidents. Linkage of these data with police and transport data is required to focus prevention on higher risk groups and to adopt effective local road safety strategies.

Robotic-assisted laparoscopic surgery in pediatric urology: an update.

Laparoscopic procedures for urological diseases in children, such as nephrectomy, pyeloplasty and orchiopexy, have proven to be safe and effective with outcome comparable to the open procedure. However, main drawback has been the relatively steep learning curve for this procedure because of technical difficulties of suturing and anastomosis. More recently, robotic-assisted laparoscopic surgery (RAS) has gained enormous popularity in adult urology and is increasingly being adopted around the world; however, few pediatric urology series have been reported. RAS has several advantages over conventional laparoscopic surgery, with the main advantage being simplification and precision of exposure and suturing because of allowing movements of the robotic arm in real time with increased degree of freedom and magnified 3-dimentional view. These features render RAS ideal for complex reconstructive surgery in a pediatric urological population. This review discusses the role of RAS in pediatric urology, and provides some technical aspects of RAS and a critical summary of current knowledge on its indications and outcome. Almost all operations that are classically performed as open or conventional laparoscopic reconstructive surgery for children with urological anomalies could be replaced by RAS, which may be established as an alternative minimally invasive surgery in the future.

Robotic pediatric urology.

The minimally invasive surgery using robotic assistance is evolving fast in the field of pediatric urology. The freedom afforded by these surgical actuators is real and here to stay. The da Vinci surgical system (Intuitive Surgical, Sunnyvale, CA, USA) provides delicate manipulation, coalesced with three-dimensional visualization and a superior magnification. It has bridged the gap between laparoscopy and open surgery. Nonetheless, it should be made clear that in case of robotic malfunction laparoscopic skills are of paramount importance. Robotic pediatric urologic procedures such as pyeloplasty, ureteral reimplantation, partial or total nephrectomy with or without ureteral stump removal are now done on a regular basis at select centers offering robotic expertise. Reconstructive surgeries such as appendico-vesicostomy can be performed, however, such complex surgeries are still in their infancy.

Importance of premeal injection time in insulin therapy: Humalog Mix25 is convenient for improved post-prandial glycemic control in type 2 diabetic patients with Italian dietary habits.

We investigated the use, in a short period, of Humalog Mix25 (Mix25) in a twice-daily administration regimen compared to a twice-daily injection therapy with Humulin 30/70 (30/70) in diabetic patients with Italian dietary habits. We studied 33 type 2 diabetic patients aged 59.1 +/- 8.1 years, BMI 29.8 +/- 2.7 kg/m2, duration of diabetes and insulin therapy of 14.4 +/- 9.8 and 4.2 +/- 4.6 years, respectively. After a 4-day lead-in period of twice-daily human insulin 30/70 treatment, patients were randomized to one of two treatment sequences: (1) a twice-daily regimen with Mix25 just 5 minutes before the morning and evening meals for 12 days, followed by a twice-daily therapy with human insulin 30/70 given 30 minutes before the morning and evening meals for an additional 12 days; or (2) the alternate sequence. Each patient underwent a mixed meal test: Humulin 30/70 was administered 30 minutes before the meal, while Mix25 was given 5 minutes before. The 2-hour post-prandial glucose concentration after breakfast was significantly lower during treatment with Mix25 than with Humulin 30/70 (157 +/- 43.2 vs. 180 +/- 43.2 mg/dl, p<0.05). The glycemic excursion after dinner on Mix25 treatment was significantly lower than with Humulin 30/70 (12.2 +/- 48.01 vs. 35.5 +/- 36.92 mg/dl, p<0.05). AUCglucose after Mix25 was lower than after Humulin 30/70. Glycemia after test meal was significantly lower with Mix25 than with Humulin 30/70. Insulin and free insulin concentrations after the test meal were significantly higher with Mix25 in comparison to Humulin 30/70. AUC serum insulin and free insulin curves after Mix25 were significantly higher than after Humulin 30/70 (p=0.028 and p=0.005, respectively). Twice-daily injections of Humalog Mix25, compared to human insulin 30/70 in type 2 diabetic patients with Italian dietary habits, provide improved and lasting post-prandial glycemic control, with the great convenience of the injection just before the meal.

The 6Fr Angio-Seal arterial closure device: results from a multimember prospective registry.

Femoral closure devices help early ambulation after cardiac catheterization without incurring additional risk to the patients. This report summarizes the safety and efficacy data of the 6Fr Angio-Seal device.

Combination enoxaparin and abciximab therapy during percutaneous coronary intervention: "NICE guys finish first".

Data from randomized clinical trials support the administration of both enoxaparin and platelet glycoprotein IIb/IIIa blockade to patients who present with non-ST segment evaluation acute coronary syndromes. Enoxaparin does not activate platelets, has a more predictable dose response that facilitates weight-adjusted dosing and may have enhanced antithrombotic (increased anti-Xa activity) and safety (reduced anti-IIa activity) properties when compared with unfractionated heparin. Abciximab administration during percutaneous coronary intervention reduces the incidence of ischemic adverse outcomes and may improve survival in long-term follow-up. The preliminary experience with combining abciximab and intravenous enoxaparin during percutaneous coronary intervention in the NICE-4 Trial demonstrates a low incidence of minor/major bleeding (TIMI definition) and transfusion and infrequent major cardiac events to 30 days follow-up. Future algorithms to facilitate the transition of patients from the clinical service who have received subcutaneous administration of enoxaparin to the cardiac catheterization laboratory prior to percutaneous coronary intervention are forthcoming and will provide seamless integration of "optimal" adjunctive pharmacology through the course of hospitalization for patients with non-ST elevation acute coronary syndromes.

Independent value of tumor size and DNA ploidy for the prediction of disease progression in patients with organ-confined renal cell carcinoma.

BACKGROUND: Greater than 20% of patients with apparently localized renal cell carcinoma (RCC) present with disease progression after surgery. The objective of the current study was to improve the ability of clinicians to predict prognosis in patients with localized RCC. METHODS: The authors studied 154 patients with organ-confined RCC classified as pT1 to pT2-pN0-M0 who underwent radical nephrectomy. Follow-up ranged from 24-128 months (median, 72 months). Several morphologic parameters of the tumor were considered. DNA content was analyzed by flow cytometry and tumor size was determined from the surgical specimen. A Cox proportional hazards regression model was used to identify significant independent prognostic factors for disease progression. RESULTS: At 5 and 10 years of follow-up, disease free survival was found to be 87% and 86%, respectively. Univariate analysis revealed that DNA content, Furhman grade, and tumor size had a statistically significant predictive value for disease progression, whereas, with regard to grade, the difference was significant only between patients with Grade 3 tumors and all other patients with Grade 1-2 tumors (P < 0. 0001). Although DNA content was found to correlate with tumor size (P < 0.0001), multivariate analysis showed that these were the only significant independent predictors of disease progression. The sum of DNA content and tumor size therefore was considered to distinguish separate risk groups. For a patient with diploid RCC, the risk of progression increased from 4% if the tumor size was 3 cm to 43% if the tumor size was 10 cm. For a patient with nondiploid RCC, this risk was 32% if the tumor size was 3 cm, increasing to 99% for tumors measuring 10 cm. CONCLUSIONS: Stratification of organ-confined RCC according to tumor size and DNA content could possibly provide more information that could be useful in the selection of individuals with significantly different risks of disease progression.

Hormone-refractory prostate cancer? Anti-androgen withdrawal and intermittent hormone therapy.

OBJECTIVE: To separate hormone-dependent from hormonally relapsed prostate cancers, a D3 category has been proposed. The term has become synonymous with a hormone-refractory state with the implication that any further hormonal treatment would not be beneficial. In this review we examine some data on androgen receptor expression, anti-androgen withdrawal syndrome and intermittent androgen deprivation (IAD) in patients with advanced prostate cancer. MATERIALS: The literature on the mechanism of the withdrawal phenomenon in patients with prostate cancer submitted to hormone therapy was reviewed. Experimental and clinical data are reported. RESULTS: The progression of prostate cancer in patients treated with combined androgen blockade (CAB) is associated with the activation of previously androgen-repressed genes, some of which may code for autocrine and paracrine growth factors that substitute for androgens in maintaining the viability of the tumorigenic stem cells. If androgens are replaced before progression begins, the surviving stem cells should give rise to an androgen-dependent tumor, which would be amenable to retreatment by CAB. This theory provides the rationale for intermittent androgen deprivation. We suggest that IAD could be more effective in patients with initial prostate-specific antigen (PSA) progression after radical prostatectomy. CONCLUSIONS: Response to withdrawal therapies or second-line treatments is an example of a "hormonal" therapy that may benefit a proportion of patients with hormone-refractory disease, suggesting that the tumor is still androgen-dependent. Whether IAD enhances progression-free survival or overall survival must be verified in randomized clinical trials. Until further studies have been completed, the therapeutic concept of IAD should be treated as experimental.

[Limitations on the interpretation of prostate-specific antigen serum levels]. / Limiti nell'interpretazione dei livelli sierici dell'antigene specifico prostatico (PSA).

Recent data suggest that PSA expression can be directly influenced by some factors, independently from the variation in prostate cell growth. Some growth factors such as fibroblast growth factor, transforming growth factor beta and epidermal growth factor, seem to be directly involved in the regulation of mRNA-PSA expression, whereas androgens could have an indirect activity. On the basis of these experimental data, this review tries to analyze some limits of PSA and some recent data on the role of PSA-isoforms, in particular in the follow-up of prostate cancer patients submitted to radical prostatectomy or hormone-therapy. Moreover, relevant informations can be obtained analyzing the variance of PSA in patients submitted to intermittent androgen deprivation.

Can the intraprostatic concentration of epidermal growth factor influence the variance of serum prostate specific antigen levels in patients with benign prostatic hyperplasia?

PURPOSE: Except for prostate volume, little is known about the factors influencing serum prostate specific antigen (PSA) levels. Considering that dihydrotestosterone and epidermal growth factor are regulators of the proliferation and differentiation in the epithelial component of human prostate tissue and that PSA is produced only by the epithelial cells of the gland, studies were performed on patients with a histological diagnosis of benign prostatic hyperplasia (BPH) to establish whether a significant association exists between the intraprostatic concentration of dihydrotestosterone or epidermal growth factor and serum PSA levels. MATERIALS AND METHODS: A total of 20 patients with BPH who had not been previously treated were part of a larger study on the correlation among PSA, prostate volume and age, and were evaluated according to the algorithm in the guidelines of the international consultation on BPH. All men underwent open suprapubic prostatectomy to enucleate the entire adenoma and in each case sections were made in the periurethral, subcapsular and intermediate zones of the BPH tissue. Dihydrotestosterone and epidermal growth factor concentrations were evaluated by radioimmunoassay in the periurethral zone and in total BPH tissue. RESULTS: In these 20 patients with BPH serum PSA levels were significantly associated with epidermal growth factor but not with dihydrotestosterone concentrations in total BPH tissue (r = 0.7762, p = 0.00002836 and r = 0.3923, p = 0.0956307, respectively). A stronger association was found between PSA levels and the periurethral concentration of epidermal growth factor and dihydrotestosterone (r = 0.8117, p = 0.000005 and r = 0.5656, p = 0.0098326, respectively). On the contrary, epidermal growth factor and dihydrotestosterone were not significantly associated with prostate volume (p = 0.957415 and p = 0.531439, respectively). CONCLUSIONS: To our knowledge this study is the first report in the literature to demonstrate an association between serum PSA, and dihydrotestosterone and epidermal growth factor levels, particularly in the periurethral zone of human BPH tissue. These data suggest the importance of epidermal growth factor and dihydrotestosterone in influencing serum PSA levels.

Penile metastasis from carcinoma of the prostate in a patient with high serum prostate specific antigen levels.

Prostatic carcinoma metastasizing to the penis is rare. Prognosis is poor with survival ranging from 1 to 24 months. A patient with prostate cancer and a serum Prostate Specific Antigen (PSA) level over 200 ng/ml, submitted to radical retropubic prostatectomy (RRP) and after 2 months presenting with two painful nodules in the penis, is described.

New aspects on prostate cancer: hereditary form, developmental estrogenization and differentiation therapy.

Three new different aspects of prostate cancer have been considered in this review: the existence of an hereditary form, the role of estrogens as predisposing factors and the efficacy of differentiation therapies. Prostate cancer shows a stronger familial aggregation than colon and breast carcinoma. Hereditary prostate cancer is distinguished by early age at onset and autosomal dominant inheritance within families. However, only 2% of all prostate cancer in United States white men occur in those 55 years old or younger. Thus, the impact of hereditary prostate cancer in the population is the greatest at younger ages but this accounts for only a small proportion of the total disease burden. Using the developmentally estrogenized mouse model, an alternative role for estrogens as a predisposing factor for prostate diseases was proposed: estrogen exposure during development may initiate cellular changes in the prostate which would require estrogens and/or androgens later in life for promotion to neoplasia. A combination therapy employing both differentiation therapy and hormone therapy may be effective in the treatment of advanced prostate cancers. Recent advances in the field of differentiation therapy have resulted in the development of novel retinoic acid metabolism blocking agents. Unlike previous differentiating agents such as the retinoids, these agents increase the endogenous levels of retinoic acid by inhibiting its breakdown in cancer cells.

Molecular resolution of marine turtle stock composition in fishery bycatch: a case study in the Mediterranean.

Based on an extensive sampling regime from both nesting populations and bycatch, frequency analyses of mitochondrial (mt) DNA control region haplotypes in the Mediterranean were used to assess the genetic structure and stock composition of the loggerhead sea turtle, Caretta caretta, in different marine fisheries. The analyses show the following. (i) In drifting longline fisheries working in Mediterranean pelagic habitats 53-55% of turtles caught originated from the Mediterranean stock; (ii) In bottom-trawl fisheries all turtle bycatch is derived from this regional stock; (iii) This regional stock contribution to fishery bycatch suggests that the population size of the Mediterranean loggerhead nesting population is significantly larger than previously thought. This is consistent with a recent holistic estimate based on the discovery of a large rookery in Libya. (iv) Present impact of fishery-related mortality on the Mediterranean nesting population is probably incompatible with its long-term conservation. Sea turtle conservation regulations are urgently needed for the Mediterranean fisheries. (v) The significant divergence of mtDNA haplotype frequencies of the Turkish loggerhead colonies define this nesting population as a particularly important management unit. Large immature and adult stages from this management unit seem to be harvested predominantly by Egyptian fisheries. (vi) Combined with other data, our findings suggest that all the nesting populations in the Mediterranean should be considered as management units sharing immature pelagic habitats throughout the Mediterranean (and possibly the eastern Atlantic), with distinct and more localized benthic feeding habitats in the eastern basin used by large immatures and adults. (vii) Between the strict oceanic pelagic and the benthic stages, immature turtles appear to live through an intermediate neritic stage, in which they switch between pelagic and benthic foods.

Patients treated by cardiologists have a lower in-hospital mortality for acute myocardial infarction.

OBJECTIVES: We sought to determine the effect of specialty care on in-hospital mortality in patients with acute myocardial infarction. BACKGROUND: There has been increasing pressure to limit access to specialists as a method to reduce the cost of health care. There is little known about the effect on outcome of this shift in the care of acutely ill patients. METHODS: We analyzed the data from 30,715 direct hospital admissions for the treatment of acute myocardial infarction in Pennsylvania in 1993. A risk-adjusted in-hospital mortality model was developed in which 12 of 20 clinical variables were significant independent predictors of in-hospital mortality. To determine whether there were factors other than patient risk that significantly influenced in-hospital mortality, multiple logistic regression analysis was performed on physician, hospital and payer variables. RESULTS: After adjustment for patient characteristics, a multiple logistic regression analysis identified treatment by a cardiologist (odds ratio=0.83 [confidence interval ¿CI¿=0.74 to 0.94] p < 0.003) and physicians treating a high volume of acute myocardial infarction patients (odds ratio=0.89 [CI=0.80 to 0.99] p < 0.03) as independent predictors of lower in-hospital mortality. Treatment by a cardiologist as compared to primary care physicians was also associated with a significantly lower length of stay for both medically treated patients (p < 0.01) and those undergoing revascularization (p < 0.01). CONCLUSIONS: Treatment by a cardiologist is associated with approximately a 17% reduction in hospital mortality in acute myocardial infarction patients. In addition, patients of physicians treating a high volume of patients have approximately an 11% reduction in mortality. This has important implications for the optimal treatment of acute myocardial infarction in the current transformation of the health care delivery system.

[The role of prostate specific antigen and its derivatives (age-specific PSA, PSA density, velocity, free/total PSA) in the diagnosis of prostate cancer]. / Ruolo dell'antigene prostatico specifico e dei suoi indici derivati (PSA età-specifico, densità-PSAD, velocità-PSAV, PSA libero-f-PSA) nella diagnosi del carcinoma della prostata.

PSA is the most useful tumor marker for the diagnosis and treatment of prostate cancer. Its clinical use, however, still lacks the necessary sensitivity and specificity to be considered as ideal. In fact PSA is not specific for adenocarcinoma of the prostate: an elevated serum level of the marker does not necessarily mean malignant growth and normal levels too often hide an occult and potentially lethal cancer. With the discovery of different molecular PSA forms in the serum, an improved discrimination between benign prostate hyperplasia (BPH) and prostate cancer appears possible. This may be particularly useful in cases with equivocal PSA values and unpalpable prostate neoplasm to reduce the number of unnecessary prostate biopsies and increase the number of biopsies in cases without palpable or ultrasonic visible anomalies. The clinical use of PSA age-referenced levels is discussed. Their use is invaluable in screening programs where the routine adoption of age-specific values can help to pick-up younger patients with potentially curable prostate cancer and older patients with BPH where additional tests would be unnecessary. The role of PSA velocity (PASAV) s also discussed. An elevation rate of PSA of 0.75 ng/ml over 18 months on 3 serial samples appears to be the best cut-off to distinguish BPH from prostate cancer. However, the use of PSAV seems to be less useful in patients with elevated PSA levels and negative biopsy results. Free to total PSA ratio is probably the best parameter to reduce the number of unnecessary biopsies in men with a serum total PSA of 4 to 10 ng/ml. The advantages and limitations for different levels of cut-off are shown. A flow chart illustrating the role of various PSA "derivatives" in screening and subsequent evaluation of men over 50 years of age is also presented.