Phosphodiesterase type 5 inhibitors usage and prostate cancer: a match-paired analysis.

BACKGROUND: To treat erectile dysfunction (ED), phosphodiesterase type 5 inhibitors (PDE5i) are commonly used. However, to date, only a few studies exist evaluate a possible effect on the incidence of prostate cancer. One such study completed by the authors' institution suggested men who use PDE5i for ED may have a lower incidence of prostate cancer. This study was meant to address some of the shortcomings of the former study and further characterize the link between prostate cancer and PDE5i use. METHODS: A retrospective, match-paired analysis was undertaken: 5,717 patients were identified between 2000 and 2011; a 1:2 match pair analysis ultimately identified 394 cases with cancer and 788 controls without cancer. Pairs were matched based on age, ethnicity, and PSA value. RESULTS: No correlation existed between PDE5i use and prostate cancer [OR 1.02, 95% confidence interval (CI): 0.78-1.35, P=0.8842] or diabetes mellitus and prostate cancer (OR 1.12, 95% CI: 0.84-1.48, P=0.4499). A statistically significant correlation was demonstrated with PSA and prostate cancer (OR 1.48, 95% CI: 1.38-1.58, P<0.0001). CONCLUSIONS: The data suggest that there is essentially no association with PDE5i use and prostate cancer.

Comparison of polypropylene versus polyester mesh in the Lichtenstein hernia repair with respect to chronic pain and discomfort.

BACKGROUND: Inguinal hernias are the most common operative procedure performed by general surgeons, and tension-free mesh techniques have revolutionized the procedure. While hernia recurrence rates have decreased, chronic postoperative pain has become recognized more widely. New mesh products offer the potential to decrease pain without compromising recurrence rates. Polyester mesh is a softer material than traditional polypropylene and may offer the benefit of causing less postoperative pain and improved quality of life. METHODS: Prospective, single-blind, randomized controlled trial involving 78 patients assigned to receive Lichtenstein type repair with either polyester (n = 39) or polypropylene (n = 39) mesh. Attempt was made to identify ilioinguinal, iliohypogastric, and genitofemoral nerves intraoperatively and document their handling. Patients were interviewed and examined preoperatively and postoperatively at 2 weeks and 3 months. Inguinal Pain Questionnaire (IPQ) and VAS scores were obtained and analyzed using two sample t test for continuous variables and Chi-square test for categorical variables. RESULTS: VAS scores at 3 months were 0.46 for the polyester group versus 0.56 for the polypropylene group (P = 0.6727). At 3 months, 82.3% of the polyester and 76.4% of the polypropylene group had VAS = 0 (P = 0.5486). There was no significant difference between the two groups' VAS scores at 3 months. IPQ did not show any difference between the two groups with the exception of "catching or pulling" being reported in 34.3% of polyester and 5.7% of polypropylene groups (P = 0.0028). CONCLUSIONS: Polyester mesh does not decrease the amount of chronic pain at 3 months. Outcomes with polyester mesh are comparable to polypropylene mesh for Lichtenstein inguinal hernia repair with regards to postoperative pain and quality of life. The sample size in this study was small and limits the significance of the results. Further studies are needed to find the optimal mesh for inguinal hernia repair.

Elevated body mass index in Texas Head Start children: a result of heredity and economics.

OBJECTIVE: The problem of high body mass index (BMI) for age in the Head Start population in Texas is of great concern. The primarily Mexican American population is at high risk for diabetes and cardiovascular disease. This study examines the prevalence of elevated BMI for age in the Head Start population in a sampling of South Texas border counties and a Central Texas county from 2003-2008, and compares it to the Centers for Disease Control and Prevention (CDC) and National Health and Nutrition Examination Survey (NHANES) data for Hispanic preschool children. METHODS: 18,462 age/gender-adjusted BMI measurements obtained by Texas Head Start centers for 2-5 year old children were analyzed to determine the prevalence of BMI for age at the 97th, 95th, and 85th percentiles. RESULTS: In the overall Texas population, 40.79% of males and 36.73% of females were overweight (85th percentile and above) and 20.01% of the males and 19.04% of the females were obese (95th percentile and above). The prevalence of high BMI for age was stable between 2003-2008; however, the overweight cohort increased with the age of the children over that period of time. CONCLUSION: The observed prevalence of elevated BMI in the Texas population is significantly higher than the results for the 2000 age-adjusted gender specific CDC growth charts for Mexican-American children ages 2-5 years old in the NHANES data for 2003-2006. The Texas-Mexico border counties had the highest prevalence of elevated BMI, demonstrating a critical need for dietary and exercise interventions in this medically underserved area.

Factors associated with atomoxetine efficacy for treatment of attention-deficit/hyperactivity disorder in children and adolescents.

OBJECTIVES: The aims of this study were to determine if relationships exist between the efficacy of atomoxetine for treatment of attention-deficit/hyperactivity disorder (ADHD) and demographic characteristics, specific co-morbid diagnoses, subtype of ADHD, and/or additional use of a stimulant medication. METHOD: A retrospective chart review was performed using data from an institutional electronic medical record system. Children aged 5-17 years who were diagnosed with ADHD and prescribed atomoxetine were included; 432 study subjects were categorized as treatment success (TS), treatment failure (TF), or undetermined. Co-morbid diagnoses, demographic factors, subtype of ADHD, and additional use of stimulant medications were examined for association with TS. RESULTS: A total of 88 children were categorized as TS, 197 as TF, and 147 as undetermined. More subjects in the TS group were receiving stimulant medication in addition to the atomoxetine than in the TF group (p = 0.0319; 95% Wald confidence interval [CI], 1.064-3.972). There was no significant difference between groups for any demographic characteristic, the presence of any co-morbid diagnosis, or type of ADHD. In particular, the presence of anxiety or depression was not associated with a response to atomoxetine. CONCLUSION: Children who were prescribed a stimulant medication in addition to atomoxetine had better outcomes in treating ADHD than those receiving only atomoxetine.

Amelioration of metabolic acidosis in patients with low GFR reduced kidney endothelin production and kidney injury, and better preserved GFR.

Metabolic acidosis often accompanies low glomerular filtration rate and induces secretion of endothelin, which in turn might mediate kidney injury. Here we tested whether treatment of metabolic acidosis in patients with low glomerular filtration rate reduced the progression of kidney disease. Fifty-nine patients with hypertensive nephropathy and metabolic acidosis had their blood pressure reduced with regimens that included angiotensin-converting enzyme inhibition. Thirty patients were then prescribed sodium citrate, and the remaining 29, unable or unwilling to take sodium citrate, served as controls. All were followed for 24 months with maintenance of their blood pressure reduction. Urine endothelin-1 excretion, a surrogate of kidney endothelin production, and N-acetyl-beta-D-glucosaminidase, a marker of kidney tubulointerstitial injury, were each significantly lower, while the rate of estimated glomerular filtration rate decline was significantly slower. The estimated glomerular filtration rate was statistically higher after 24 months of sodium citrate treatment compared to the control group. Hence it appears that sodium citrate is an effective kidney-protective adjunct to blood pressure reduction and angiotensin-converting enzyme inhibition.

Evaluating the status of "translating research into practice" at a major academic healthcare system.

OBJECTIVES: The aim of this study was to assess the status of translating research findings into practice at a major academic healthcare system in Central Texas. METHODS: We conducted a cross-sectional survey addressing knowledge of and participation in translational research of physicians, residents, nurses and third- and fourth-year medical students in a major academic healthcare system in Central Texas. RESULTS: Out of 508 respondents, 428 (84.3 percent) completed all questions. A total of 68.9 percent of faculty reported having sufficient education and training to conduct research versus 44.4 percent of residents and 35.6 percent of nurses. Fifty-eight percent of faculty, 53 percent of residents and 9 percent of nurses reported current involvement in research activity. A total of 55.6 percent of residents reported that their departments provide them with protected time for research versus 18.4 percent of faculty and 10.3 percent of nurses. In addition, 33.9 percent of nurses reported interest in participating in research but do not know how to start. There were 86.4 percent of faculty, 77.8 percent of residents, and 58 percent of nurses who indicated they were familiar with translational research. However, only 42.7 percent of faculty, 46.7 percent of residents and 35.6 percent of nurses indicated they were aware of any changes in the delivery of care that resulted from research projects. CONCLUSIONS: The study results suggested failure to leverage members of the healthcare team in a systematic process to ensure translation of research findings into practice. Results highlighted the need to merge culture of safety and quality improvement with research while dealing with the daily pressures of patient care.

OB/GYN boot cAMP using high-fidelity human simulators: enhancing residents' perceived competency, confidence in taking a leadership role, and stress hardiness.

OBJECTIVES: To evaluate the effectiveness of an obstetrical and gynecologic (Ob/Gyn) Boot Camp simulation training on perceived technical competency, confidence in a leadership role, and stress hardiness of resident training. METHODS: We conducted a prospective pilot study on the effectiveness of an Ob/Gyn Boot Camp on resident training. Residents participated in an intensive immersion in clinical simulation of common obstetrical emergencies including shoulder dystocia, neonatal resuscitation, postpartum hemorrhage, and ruptured ectopic pregnancy. After the training, residents completed a Web-based survey on their perceptions of how the Ob/Gyn Boot Camp affected their 1) technical competency in the assessment and management of their patients, 2) confidence in taking a leadership role, and 3) stress hardiness. Residents rated their perceptions on a Likert scale of 1 to 5, 1 = poor to 5 = excellent. RESULTS: Twenty-three (14 Ob/Gyn and 9 family medicine) residents participated in this pilot study. Eighteen (78%) residents completed the online survey; 4 Ob/Gyn and 1 family medicine resident did not complete the survey. The residents reported that the simulation training stimulated an interest in learning key skills for obstetrical and gynecologic emergencies. Ob/Gyn residents reported significant improvement in their perceived technical competence and stress hardiness after the Boot Camp. However both Ob/Gyn and family medicine residents reported no significant improvement of confidence in their leadership abilities during obstetrical emergencies after the Boot Camp. CONCLUSION: Boot Camp simulation training early in the curriculum has the potential for enhancing residents' self-assessments of confidence, competency, and stress hardiness in managing obstetrical emergencies.

Using simulation to orient code blue teams to a new hospital facility.

OBJECTIVES: Prompt and successful cardiopulmonary resuscitation during a sudden cardiac arrest can be hindered by multiple variables, ie, ineffective communication, stress, lack of training, and an unfamiliar environment, such as a new hospital facility. The main objective of the study was to use high-fidelity simulations to orient Code Blue Teams (CBTs) to critical events in a new hospital facility. A secondary objective was to elucidate factors that may have contributed to responses by debriefing teams. METHODS: Mock Code Blue exercises using high-fidelity simulation were implemented in real workplace settings to orient CBTs to critical events. We measured arrival time of first responder, crash cart to code site, first six CBT responders, first chest compression, and first electrical shock. After each mock code, participants were debriefed to assess any barriers to effective response and decision making. RESULTS: Twelve mock codes were conducted at different locations of the new facility. Sixty-nine percent of the participants reported that the training was beneficial. The median time of arrival of the first responders was 42 seconds and the first CBT member was 66 seconds. The median time to initiation of chest compressions was 80 seconds, crash cart arrival was 68 seconds, and first electrical shock was 341 seconds. An additional outcome of the study was the identification of facility and systems issues that had the potential to impact patient safety. CONCLUSIONS: Clinical simulation can be effectively used to orient CBTs and identify critical safety issues in a newly constructed healthcare facility.

Pharmacokinetics of topical and intravenous cefazolin in patients with clean surgical wounds.

BACKGROUND: Surgical-site infection is a common postoperative nosocomial infection. Surgeons frequently treat operative patients with protective antibiotics and often choose cefazolin as the drug. Treatment schemes include both preoperative intravenous dosing and intraoperative dosing by irrigation. This study was designed to measure cefazolin concentrations both in serum and in wound drain fluid after intravenous dosing and after irrigation. METHODS: The authors conducted an institutional review board-approved study involving randomized allocation of breast reduction patients to group 1 (preoperative intravenous dosing) or group 2 (intraoperative dosing by irrigation). Each patient had serum and wound drainage specimens measured over time for cefazolin concentrations. Cefazolin dosing was based on preparations commonly used in the authors' hospital. Results from 24 patients are reported. RESULTS: Patients treated by conventional preoperative intravenous dosing displayed the expected serum degradation curve. These patients also demonstrated wound drainage concentrations (peak, 22.49 microg/ml) for approximately 4 to 5 hours. Measured concentrations were above the minimum therapeutic concentration (8 microg/ml) for Staphylococcus aureus. Patients treated by wound irrigation also demonstrated serum concentrations above minimum therapeutic concentration. In addition, these patients' wound drain fluid demonstrated very high cefazolin concentrations (peak, 4185.93 microg/ml), which remained high for 24 hours. CONCLUSIONS: Protective cefazolin concentrations in the wound can be achieved by both intravenous and irrigation delivery. Wound irrigation produces higher concentrations for longer periods of time.

Randomized trial of a hypnosis intervention for treatment of hot flashes among breast cancer survivors.

PURPOSE: Hot flashes are a significant problem for many breast cancer survivors. Hot flashes can cause discomfort, disrupted sleep, anxiety, and decreased quality of life. A well-tolerated and effective mind-body treatment for hot flashes would be of great value. On the basis of previous case studies, this study was developed to evaluate the effect of a hypnosis intervention for hot flashes. PATIENTS AND METHODS: Sixty female breast cancer survivors with hot flashes were randomly assigned to receive hypnosis intervention (five weekly sessions) or no treatment. Eligible patients had to have a history of primary breast cancer without evidence of detectable disease and 14 or more weekly hot flashes for at least 1 month. The major outcome measure was a bivariate construct that represented hot flash frequency and hot flash score, which was analyzed by a classic sums and differences comparison. Secondary outcome measures were self-reports of interference of hot flashes on daily activities. RESULTS: Fifty-one randomly assigned women completed the study. By the end of the treatment period, hot flash scores (frequency x average severity) decreased 68% from baseline to end point in the hypnosis arm (P < .001). Significant improvements in self-reported anxiety, depression, interference of hot flashes on daily activities, and sleep were observed for patients who received the hypnosis intervention (P < .005) in comparison to the no treatment control group. CONCLUSION: Hypnosis appears to reduce perceived hot flashes in breast cancer survivors and may have additional benefits such as reduced anxiety and depression, and improved sleep.

Double origin of the posterior inferior cerebellar artery: association with intracranial aneurysm on catheter angiography.

OBJECTIVE: Double origin of the posterior inferior cerebellar artery (PICA) is a congenital anomaly in which the PICA forms from two separate vessels arising from the vertebral artery. The prevalence of double origin of the PICA on catheter angiography is unknown because only four case reports have been published. Because some congenital intracranial vascular oddities are associated with an elevated incidence of aneurysm formation, we sought to determine the association between intracranial aneurysm and double origin of the PICA and to measure the prevalence of double origin of the PICA on catheter angiography. MATERIALS AND METHODS: A retrospective review was done over a 27-month period to identify patients with double origin of the PICA. Patients were excluded if both PICAs were not adequately visualized on catheter angiography. The cohort was then divided into two groups consisting of patients with and those without intracranial aneurysm. RESULTS: A total of 207 patients (101 males, 106 females) met the inclusion criteria. One or more cerebral aneurysms were found in 35.3% and double origin of the PICA in 1.45% of the patients. Double origin of the PICA was present in 4.1% of the patients with an aneurysm, and none of the patients without an aneurysm had double origin of the PICA (p = 0.043). A majority of the seven known cases of double origin of the PICA described by angiography in the peer-reviewed literature have associated intracranial aneurysm disease. CONCLUSION: Our data show that double origin of the PICA is seen in 4.1% of patients with intracranial aneurysm and on 1.45% of catheter angiograms. Double origin of the PICA has an increased association with intracranial aneurysmal disease and may represent a risk factor for subsequent development of intracranial aneurysm.

Urinary levels of matrix metalloproteinase 9 and 2 and tissue inhibitor of matrix metalloproteinase in patients with coronary artery disease.

OBJECTIVES: To evaluate the feasibility of an assay for urinary levels of matrix metalloproteinases (MMPs) and the potential usefulness of urinary MMPs as a marker of coronary atherosclerosis or acute coronary syndromes (ACS). METHODS AND RESULTS: We measured urine and plasma MMP-9, MMP-2 and urine tissue inhibitor of metalloproteinase (TIMP-1) in patients with ACS (n=27), patients with coronary artery disease (CAD), but no clinical instability (n=47) and a group of healthy volunteers (n=15) who were <35 years of age, had no risk factors for CAD and did not undergo angiography. Compared with volunteers, patients with ACS and CAD had higher urine MMP-9, urine TIMP-1, plasma MMP-9 and plasma MMP-2 levels, but these did not differ between those with CAD and ACS. Using the volunteers to roughly establish an upper limit of normal, 84% of the urine TIMP-1 values and 95% of the urine MMP-9 values were abnormally elevated among those with CAD and ACS. CONCLUSIONS: Urine MMP-9 and TIMP-1 levels are elevated in patients with CAD and ACS compared with healthy volunteers. A high percent of patients with CAD or ACS had elevated urine values of MMP-9 and TIMP-1 suggesting these variables might be a useful marker of atherosclerotic disease.

Effects of local variation, specialty, and beliefs on antiviral prescribing for influenza.

In 2004, we conducted a survey of physician knowledge, attitudes, and practices regarding influenza diagnosis and treatment at Baystate Medical Center in Massachusetts and Scott & White Hospital and Clinic in Texas. Of the 579 physicians we contacted, 336 completed the survey. Sixty-one percent of the respondents prescribed antivirals, and 62% used rapid testing. Prescribing practices were associated with location, practice size, use of rapid testing, and belief in the efficacy of antivirals.

Complementary and alternative medicine use by psychiatric inpatients.

82 psychiatric inpatients hospitalized for acute care were interviewed about their use of complementary and alternative medicine (CAM) modalities. The clinical diagnoses of respondents included Depressive Disorder (61%), Substance Abuse (26%), Schizophrenia (9%), and Anxiety Disorders (5%). Analysis indicated that 63% used at least one CAM modality within the previous 12 mo. The most frequently used modality was herbal therapies (44%), followed by mind-body therapies such as relaxation or mental imagery, hypnosis, meditation, biofeedback (30%), and spiritual healing by another (30%). Physical modalities such as massage, chiropractic treatment, acupuncture, and yoga were used by 21% of respondents. CAM therapies were used for a variety of reasons ranging from treatment of anxiety and depression to weight loss. However, most respondents indicated they did not discuss such use with their psychiatrist or psychotherapist.

Prevalence of anxiety among patients undergoing colorectal surgery.

To assess prevalence of anxiety 36 consecutive patients undergoing colorectal surgery with general anesthesia were interviewed on the day of surgery and completed the State-Trait Anxiety Inventory. Postsurgical ratings of pain and anxiety were obtained within 24 hours after surgery. Analysis indicated that 29 scored moderate or higher on the State Anxiety scale prior to surgery. The correlations for scores on presurgical Trait Anxiety with postsurgical pain and Trait Anxiety scores were significant (p<.01) but not that for pre- and postsurgical State Anxiety

Use of a numeric visual analog anxiety scale among patients undergoing colorectal surgery.

The aim of this study was to evaluate the utility of a Numeric Visual Analog Anxiety Scale (NVAAS) as a potentially accurate and efficient way to determine presurgery anxiety among patients undergoing colorectal surgery. A secondary aim was to determine the relationship between NVAAS ratings of anxiety and postsurgery pain. Thirty-six patients scheduled for colorectal surgery were asked to rate their state anxiety on the NVAAS and to complete the State-Trait Anxiety Inventory (STAI). The NVAAS correlated significantly with STAI-state anxiety (0.64, p <.0001). The NVAAS measure of presurgery anxiety also correlated significantly with STAI-trait anxiety (0.46, p <.005) and postsurgery Visual Analog Scale pain ratings (0.35, p <.038). The NVAAS appears to be a valid and sensitive measure of anxiety among patients undergoing colorectal surgery. The NVAAS also has the advantage of being convenient and easy to use at bedside, increasing its clinical utility in medical nursing care.

Clinical hypnosis for smoking cessation: preliminary results of a three-session intervention.

This study presents preliminary data regarding hypnosis treatment for smoking cessation in a clinical setting. An individualized, 3-session hypnosis treatment is described. Thirty smokers enrolled in an HMO were referred by their primary physician for treatment. Twenty-one patients returned after an initial consultation and received hypnosis for smoking cessation. At the end of treatment, 81% of those patients reported that they had stopped smoking, and 48% reported abstinence at 12 months posttreatment. Most patients (95%) were satisfied with the treatment they received. Recommendations for future research to empirically evaluate this hypnosis treatment are discussed.