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AIMS: To determine the bleeding risk in patients taking anticoagulants (AC) and antiplatelets (AP) before onabotulinumtoxinA (BoNT-A) injections and improve peri-operative decision making and counseling. METHODS: We performed a retrospective review of patients having intravesical BoNT-A in three teaching hospitals from January 2016 to July 2018. Demographic data, indication for intravesical BoNT-A injection, and side-effects of significant bleeding requiring intervention were recorded. RESULTS: Five hundred and thirty-two patients had intravesical BoNT-A injections during this time. Sixty-three patients of mean age 69 years (range 19-89) had a total of 114 separate rounds of BoNT-A injections whilst on treatment dose AC/AP therapy. Of the 63, there were 33 males, with 46 having idiopatic detrusor overactivity and 17 with neurogenic detrusor overactivity. Each patient had between 1 and 7 repeat injections during the studied period. AC/AP use across the 114 episodes included; aspirin 44, clopidogrel 37, warfarin 19, and NOAC (novel/non-vitamin K oral anticoagulant) 14. Patients on warfarin who had point of care testing all had international normalized ratio less than 3. BoNT-A dose varied from 100U to 300U-modal dosage was 200U.1/114(0.88%) injection episodes resulted in postinjection hematuria requiring overnight admission. This resolved spontaneously, with an overnight catheter. This patient was on rivaroxaban and had 300U of BoNT-A injected through 20 sites, on a background of previous prostate radiotherapy and self-catheterization. CONCLUSIONS: Continuation of AP/AC therapy during intravesical BoNT-A injection treatment appears to be safe-with a 0.88% rate of spontaneously resolving hematuria.
Subject(s)
Botulinum Toxins, Type A , Urinary Bladder, Overactive , Administration, Intravesical , Adult , Aged , Aged, 80 and over , Anticoagulants/adverse effects , Botulinum Toxins, Type A/adverse effects , Humans , Male , Middle Aged , Retrospective Studies , Treatment Outcome , Urinary Bladder, Overactive/drug therapy , Young AdultABSTRACT
PURPOSE OF REVIEW: Intraductal biliary radiofrequency ablation (RFA) is an emerging therapeutic modality that directly targets malignant biliary strictures during endoscopic retrograde cholangiopancreatography. This article reviews the technology, endoscopic technique, and reported outcomes of endoscopic RFA in the management of malignant biliary strictures. RECENT FINDINGS: Biliary RFA is feasible and has a high technical success rate. Infectious complications and major hemobilia are the main adverse events requiring intervention. It is unclear whether RFA prolongs biliary stent patency or decreases the need for repeated endoscopic interventions. Retrospective studies suggest a possible survival benefit with RFA. SUMMARY: Intraductal biliary RFA is a promising modality for management of malignant biliary obstruction. Prospective randomized studies are required to determine whether RFA truly confers a survival benefit or decreases the number of biliary interventions.
Subject(s)
Bile Duct Neoplasms/complications , Bile Ducts/surgery , Catheter Ablation , Cholestasis/surgery , Bile Ducts/pathology , Cholestasis/etiology , Cholestasis/pathology , Constriction, Pathologic/etiology , Constriction, Pathologic/surgery , HumansABSTRACT
OBJECTIVES: To assess the impact on suspected cancer referral burden and new cancer diagnosis of Public Health England's recent Be Clear on Cancer 'blood in pee' mass media campaign. METHODS: A retrospective cohort study design was used. For two distinct time periods, August 2012 to May 2013 and August 2013 to May 2014, all referrals of patients deemed to be at risk of urological cancer by the referring primary healthcare physician to Imperial College NHS Healthcare Trust were screened. Data were collected on age and sex and whether the referral was for visible haematuria, non-visible haematuria or other suspected urological cancer. In addition to referral data, hospital episode data for all new renal cell (RCC) and upper and lower tract transitional cell carcinoma (TCC), as well as testicular and prostate cancer diagnoses for the same time periods were obtained. RESULTS: Over the campaign period and the subsequent 3 months, the number of haematuria referrals increased by 92% (P = 0.013) when compared with the same period a year earlier. This increase in referrals was not associated with a significant corresponding rise in cancer diagnosis; instead changes of 26.8% (P = 0.56) and -3.3% (P = 0.84) were seen in RCC and TCC, respectively. CONCLUSIONS: This study has shown that the Be Clear on Cancer 'blood in pee' mass media campaign significantly increased the number of new suspected cancer referrals, but there was no significant change in the diagnosis of target cancers across a large catchment. Mass media campaigns are expensive, require significant planning and appropriate implementation and, while the findings of this study do not challenge their fundamental objective, more work needs to be done to understand why no significant change in target cancers was observed. Further consideration should also be given to the increased referral burden that results from these campaigns, such that pre-emptive strategies, including educational and process mapping, across primary and secondary care can be implemented.
Subject(s)
Carcinoma, Renal Cell/prevention & control , Carcinoma, Transitional Cell/prevention & control , Health Promotion/methods , Hematuria/etiology , Mass Media , Urologic Neoplasms/prevention & control , Early Detection of Cancer , Humans , Kidney Neoplasms/prevention & control , Patient Education as Topic/methods , Referral and Consultation/statistics & numerical data , Retrospective StudiesABSTRACT
Objectives: The objective of this study is to determine the long-term efficacy and safety of office-based Holmium:YAG laser ablation for the treatment of recurrent non-muscle-invasive bladder cancer (NMIBC). Methods: We retrospectively reviewed the medical records of all consecutive patients who underwent office-based laser ablation for recurrent bladder cancer between 2008 and 2016. The following data were collected: original histology, date of original histology, date of laser ablation, number of repeat laser ablation procedures required, date of tumor recurrence or progression, number of general anesthesia procedures (transurethral resection or cystodiathermy) required after first laser ablation, and number and severity of complications. Kaplan-Meier survival curves were produced for recurrence-free survival, progression-free survival, and overall survival. Results: A total of 97 patients, with an average age of 84 (62-98) years and an average Charlson Comorbidity Index of 6.9 (4-13), were included. The median follow-up was 61 (2-150) months. Fifty-five (56.7%) patients presented with tumor recurrence, and the median recurrence-free survival time was 1.69 years (95% CI 1.20-2.25). Only 9 (9.3%) patients had evidence of tumor progression to a higher grade or stage, 8 (89%) of which initially had low-grade tumors; however, no patient progressed to muscle-invasive disease. The median progression-free survival time was 5.70 years (95% CI 4.10-7.60), and the median overall survival time was 7.60 years (95% CI 4.90-8.70). No patient required emergency inpatient admission after laser ablation. Conclusion: Office-based Holmium:YAG laser ablation offers a safe and effective alternative method for treating low-volume, low-grade recurrent NMIBC, especially in elderly patients with significant co-morbidity, while avoiding general anesthesia and inpatient admission.
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OBJECTIVES: To determine the safety of urological admissions and procedures during the height of the COVID-19 pandemic using "hot" and "cold" sites. The secondary objective is to determine risk factors of contracting COVID-19 within our cohort. PATIENTS AND METHODS: A retrospective cohort study of all consecutive patients admitted from March 1 to May 31, 2020 at a high-volume tertiary urology department in London, United Kingdom. Elective surgery was carried out at a "cold" site requiring a negative COVID-19 swab 72-hours prior to admission and patients were required to self-isolate for 14-days preoperatively, while all acute admissions were admitted to the "hot" site.Complications related to COVID-19 were presented as percentages. Risk factors for developing COVID-19 infection were determined using multivariate logistic regression analysis. RESULTS: A total of 611 patients, 451 (73.8%) male and 160 (26.2%) female, with a median age of 57 (interquartile range 44-70) were admitted under the urology team; 101 (16.5%) on the "cold" site and 510 (83.5%) on the "hot" site. Procedures were performed in 495 patients of which eight (1.6%) contracted COVID-19 postoperatively with one (0.2%) postoperative mortality due to COVID-19. Overall, COVID-19 was detected in 20 (3.3%) patients with two (0.3%) deaths. Length of stay was associated with contracting COVID-19 in our cohort (OR 1.25, 95% CI 1.13-1.39). CONCLUSIONS: Continuation of urological procedures using "hot" and "cold" sites throughout the COVID-19 pandemic was safe practice, although the risk of COVID-19 remained and is underlined by a postoperative mortality.
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OBJECTIVES: Expression of prostaglandin biosynthetic pathway enzymes in mucinous pancreatic cysts is unknown. Cyclooxygenase-2 (COX-2) inhibition is a potential cancer chemoprevention strategy for these lesions. We evaluated the expression of COX-2, cytosolic phospholipase A2 (cPLA2), and protein kinase B (AKT) in the epithelium of pancreatic cysts and correlated enzyme expression with aspirin (ASA) use and cyst fluid prostaglandin E2 (PGE2) concentration. METHODS: Pathology of 80 resected pancreatic cysts was reviewed. Expression of COX-2, cPLA2, and AKT was quantified by tissue immunohistochemistry immunoreactivity scores (IRSs). IRS values were compared between cyst types and (in 30 cases) with matched cyst fluid PGE2 concentrations. RESULTS: The mean IRS was higher in the epithelium of mucinous vs nonmucinous cysts for COX-2 (6.1 ± 4.7 vs 3.2 ± 2.8, P = 0.01) and cPLA2 (6.9 ± 3.0 vs 2.9 ± 2.9, P < 0.001). Cyst epithelial COX-2 expression was higher in mucinous cysts with low-grade dysplasia vs those with high-grade dysplasia or invasive carcinoma (IRS 8.0 ± 3.9 vs 1.5 ± 2.9, P < 0.001), whereas the opposite was found for cPLA2 (6.2 ± 3.0 vs 8.6 ± 2.3, P = 0.005). Cyst fluid PGE2 concentrations did not correlate with either the IRS or a history of low- to moderate-dose ASA use. CONCLUSIONS: COX-2 and cPLA2 are overexpressed in the epithelium of mucinous pancreatic cysts. COX-2 and/or cPLA2 inhibition might prevent the emergence or progression of mucinous pancreatic cysts, but higher doses of ASA or nonsteroidal anti-inflammatory drugs may be necessary to substantially inhibit cyst epithelial COX-2 activity.
Subject(s)
Carcinoma, Pancreatic Ductal/pathology , Cyclooxygenase 2/metabolism , Pancreatic Cyst/pathology , Pancreatic Neoplasms/pathology , Phospholipases A2, Cytosolic/metabolism , Adult , Aged , Aged, 80 and over , Aspirin/pharmacology , Aspirin/therapeutic use , Carcinoma, Pancreatic Ductal/prevention & control , Cyclooxygenase Inhibitors/pharmacology , Cyclooxygenase Inhibitors/therapeutic use , Cyst Fluid/chemistry , Dinoprostone/analysis , Dinoprostone/metabolism , Epithelium/drug effects , Epithelium/pathology , Female , Humans , Male , Middle Aged , Pancreas/drug effects , Pancreas/pathology , Pancreatic Cyst/drug therapy , Pancreatic Neoplasms/prevention & control , Proto-Oncogene Proteins c-akt/metabolism , Retrospective Studies , Young AdultABSTRACT
Galanin (GAL) is a 29 amino acid peptide, first identified from the porcine intestine and widely distributed within the brain and peripheral tissues. Among GAL biological functions, its role as a potent appetite-stimulating peptide is probably the most studied. With galanin's established role in the modulation of food intake in fish, this study aims to evaluate the effects of GAL on the intestinal motility of the goldfish, Carassius auratus, using an organ bath system. Our results found that application of GAL to the organ bath causes a significant concentration-dependent decrease in the amplitude of spontaneous contractions of goldfish gut. Preincubations of intestinal strips with acetylcholine (ACh) and GAL showed that GAL increases the force of ACh-induced contractions of the goldfish gut. These results provide the first evidence for a role of GAL in gut motility in goldfish. This also suggests a crosstalk between the effects of GAL and ACh in such functions, thus pointing to a putative joint role between the two molecules. These findings offer novel information that strengthens the role of the galaninergic system in fish feeding.
Subject(s)
Acetylcholine/physiology , Galanin/physiology , Gastrointestinal Motility , Acetylcholine/administration & dosage , Animals , Female , Galanin/administration & dosage , Gastrointestinal Motility/drug effects , Goldfish , Male , Muscle Contraction/drug effectsABSTRACT
Galanin-like peptide (GALP) is a 60 amino acid neuropeptide originally discovered from porcine hypothalamus, and is involved in the regulation of food intake in mammals. Since its discovery, GALP and its receptors (GALR1 and GALR2) have been characterized in mammals, but no publications are available on GALP in fish and other non-mammals. The present study aimed to characterize brain and intestinal GALP and its receptors using immunohistochemistry in a teleost, the goldfish (Carassius auratus), and to study its effects on feeding behavior. Immunostaining of brain sections shows the presence of GALP- and GALR1- and GALR2-like immunoreactive cells in different encephalic areas, including the telencephalon, some hypothalamic nuclei, the optic tectum, the torus longitudinalis and the cerebellum. Signal for GALP was also observed in the fasciculus retroflexus. In the gut, GALP-and GALR1 and GALR2 immunoreactive cells were detected in the mucosa. Results from the feeding study demonstrate that intracerebroventricular administration of GALP (1ng/g bodyweight) increases goldfish food intake at 1h post-injection. These observations form the first report on the presence of GALP in the fish brain and gut, and also on its modulatory role on fish feeding behavior. GALP, as in mammals, appears to be a functional neuropeptide in goldfish.
Subject(s)
Eating/physiology , Galanin-Like Peptide/metabolism , Galanin/metabolism , Receptor, Galanin, Type 1/metabolism , Receptor, Galanin, Type 2/metabolism , Animal Feed , Animals , Body Weight/physiology , Brain/metabolism , Female , Goldfish , Injections, Intraventricular/methods , MaleABSTRACT
BACKGROUND: Post-operative single dose intravesical chemotherapy (PSDIVC) in patients with non-muscle invasive bladder cancer has been shown to reduce recurrence rates by up to 39%. However, some studies have suggested poor compliance with PSDIVC stating logistical issues and reluctance to give chemotherapy prior to histological confirmation as some of the reasons. OBJECTIVES: This study aims to analyse appropriate administration of PSDIVC practice in St. Mary's Hospital against European Association of Urology guidelines and implement an intervention bundle to improve practice. PATIENTS AND METHODS: All patients that underwent transurethral resection of bladder tumour (TURBT) between March 2012 and February 2013 were analysed retrospectively to review indication for post-operative chemotherapy, instillation rates and limiting factors preventing appropriate instillation. An intervention bundle including pre-operative delivery of mitomycin C (MMC) to the theatre suite, proforma placed in the operative notes and designated roles for PSDIVC induction was introduced to improve instillation and documentation rates. Prospective re-audit data was collected over six months between July 2013 and December 2013 following intervention. RESULTS: Sixty-four patients in group A underwent TURBT prior to introduction of the intervention bundle. Fifty-four patients had non-muscle invasive bladder cancer (NMIBC), which would have been eligible for PSDIVC. Fifteen (28% of NMIBC) were administered PSDIVC. Twenty-three (36% of all patients) were either given PSDIVC or had a documented contraindication. Thirty-one patients in group B underwent TURBT following induction of intervention bundle. Twelve (50% of NMIBC) patients were given PSDIVC. Twenty-eight (90% of all patients) were either given PSDIVC or had a documented contraindication. CONCLUSIONS: The intervention bundle prompted increased administration of PSDIVC and documentation. Similar centres may benefit from an intervention to improve compliance.
ABSTRACT
A 74-year-old man presented with a history of collapse and abdominal pain. Initial imaging showed a left sided preirenal collection. The initial working diagnosis was perirenal hematoma secondary to renal trauma. Subsequent patient deterioration led to further imaging which led to the diagnosis of a duodenal perforation with tracking of duodenal contents into the left perirenal space. This important differential should be a consideration in cases of perinephric collections of unknown etiology.
ABSTRACT
Galanin is a well characterized multifunctional neuropeptide in mammals. Galanin has been identified from several fishes, amphibians, reptiles and birds. A large set of data is available on galanin-like protein distribution and peptide and/or mRNA sequences in non-mammalian vertebrates. Galanin receptor sequences from fishes and birds are known, but its distribution and mechanisms of actions are poorly understood. While some biological actions of galanin are known in non-mammals, the functional role of galanin in lower vertebrates is limited. For example, galanin has been shown to regulate feeding, pituitary hormone secretion and gut motility in fishes. Several aspects of galanin biology remain unknown, yet, there is enough evidence to implicate galanin as an important physiological modulator in lower vertebrates. Majority of the research articles on galanin in non-mammals arise from studies that used fishes. The objective of this chapter is to provide a summarized discussion of current knowledge on galanin peptide and gene sequences and organization, distribution of galanin gene and protein, and physiological functions of galanin in non-mammalian vertebrates with a special focus on fishes.