Epidemiology and evaluation of chronic pelvic pain syndrome in men.

Chronic pelvic pain syndrome (CPPS), formerly known as chronic abacterial prostatitis, is characterised by pelvic or perineal pain without evidence of urinary tract infection. It manifests as pain in a variety of areas including the perineum, rectum, prostate, penis, testicles and abdomen [Litwin MS, McNaughton-Collins M, Fowler Jr FJ, Nickel JC, Calhoun EA, Pontari MA, et al. The National Institutes of Health chronic prostatitis symptom index: development and validation of a new outcome measure. Chronic Prostatitis Collaborative Research Network. J Urol 1999;2:369-75]. It is also frequently associated with symptoms including urinary urgency, frequency, hesitancy and poor or interrupted flow. CPPS may be associated with white cells in the prostatic secretions (inflammatory) (NIH-3A), or white cell absence in the prostatic secretions (non-inflammatory) (NIH-3B) [Krieger JN, Nyberg Jr L, Nickel JC. NIH consensus definition and classification of prostatitis. JAMA 1999;3:236-7].

Unilateral open extravesical ureteral reimplanation with contralateral dextronomer/hyaluronic acid injection performed as an outpatient therapy.

INTRODUCTION: Historically, patients with unilateral high-grade vesicoureteral reflux (VUR) and contralateral low-grade or resolved VUR have been treated with bilateral intravesical ureteral reimplantation, which requires postoperative admission. If the high-grade VUR side is treated alone, then the contralateral side is at risk of developing recurrent or worsening VUR. Bilateral subureteric injection of dextronomer/hyaluronic acid (DHA) is another option that can be performed as an outpatient therapy, but a single injection is less effective for high-grade VUR. OBJECTIVE: The safety and efficacy of an outpatient combination of open extravesical ureteral reimplantation (EVUR) and contralateral DHA injection were investigated. STUDY DESIGN: A retrospective review of children who had concomitant EVUR and subureteric injection of DHA between January 2005 and December 2015 was performed. Exclusion criteria were diagnosis other than VUR, repeat procedures, and patients with no follow-up. Patient characteristics, postsurgical complications, and follow-up imaging were evaluated. Febrile urinary tract infection (fUTI) was defined as ≥50,000 Colony Forming Units (CFU) of an organism from clean-catch or catheterized urine and temperature ≥ 101.5 F. Clinical success is defined as no fUTI for 1 year after the initial operation. Univariate analyses were used to identify risk factors for treatment failure. RESULTS: A total of 117 patients met inclusion criteria. Mean age at surgery was 6.0 years, and 85% were female. The mean pre-operative grade of VUR was 3.3 on the EVUR side and 0.6 on the contralateral side (42% resolved before treatment). Median follow-up was 12.2 months (interquartile range, 3.1-25.4). Sixteen patients (14%) had documented fUTI within 1 year, with a clinical success rate of 86%. Of these, five had a postoperative imaging showing resolution of VUR, increasing overall success to 91%. Postoperative fUTI was more common in patients with pre-operative bowel and bladder dysfunction (BBD) (P = 0.003), but this was not associated with a higher reoperation rate (P = 0.168). There were 11 total complications, with three grade 3 complications. DISCUSSION: This study is the first to report safety and outcomes of EVUR and contralateral DHA injection for patients with high-grade VUR with contralateral low-grade or resolved VUR. It was shown that it is an effective and safe treatment that can be performed as an outpatient therapy. Limitations to this study include the retrospective design and the clinical definition of success that is used in a cohort of patients from across the mountain west region without routine postoperative voiding cystourethrogram. CONCLUSION: Extravesical ureteral reimplantation and contralateral DHA injection can safely be performed as an outpatient therapy and are effective in the treatment of higher grade VUR with contralateral low-grade or resolved VUR. Treatment failure is more likely in patients with BBD.

Evaluation of the Live Biotherapeutic Product, Asymptomatic Bacteriuria Escherichia coli 2-12, in Healthy Dogs and Dogs with Clinical Recurrent UTI.

BACKGROUND: Antimicrobial resistance is an emerging problem. HYPOTHESIS/OBJECTIVE: To investigate the safety and efficacy of a live biotherapeutic product, ASB E. coli 2-12 for UTI treatment. ANIMALS: Six healthy research dogs; nine client-owned dogs with recurrent UTI. METHODS: Prospective noncontrolled clinical trial. For safety data, research dogs were sedated, a urinary catheter was inserted into the bladder; 1010 CFU/mL of ASB E. coli 2-12 was instilled. Urine was cultured on days 1, 3, and 8 post-instillation and dogs were observed for lower urinary tract signs (LUTS). For client-owned dogs, ASB E. coli 2-12 was instilled similarly and urine cultures analyzed on days 1, 7, and 14 days postinstillation. RESULTS: No LUTS were noted in any of the 6 research dogs after ASB E. coli 2-12 infusion. Pulse field gel electrophoresis (PFGE) studies confirmed the bacterial strains isolated matched that ASB E. coli 2-12 strain. Four of the nine client-owned dogs had complete or nearly complete clinical cures by day 14. Of these four dogs, 3 also had microbiologic cures at day 14; one of these dogs had subclinical bacteriuria (in addition to ASB E. coli 2-12). Three of these four dogs had ASB E. coli 2-12 isolated from their urine at day 14. With the exception of mild, temporary, self-limiting, hyporexia in two dogs on the day of biotherapeutic administration, there were no major adverse effects. CONCLUSIONS AND CLINICAL IMPORTANCE: These results suggest ASB E. coli 2-12 is safe and should be investigated in a larger controlled study evaluating clinical UTI in dogs.

Catabolic properties of aglycofibrinogen synthesized by tunicamycin-treated human hepatoma (HepG2) cells and rabbit hepatocytes.

Human hepatoma cell (HepG2) or rabbit hepatocyte monolayers were incubated with [35S]methionine in presence or absence of tunicamycin, a potent inhibitor of asparagine-linked glycosylation. The 35S-labeled nonglycosylated and control fibrinogens purified from the media were used to evaluate the influence of the oligosaccharide on the catabolic properties of this glycoprotein. Plasmin, pronase, cathepsin D or cathepsin B each degraded the nonglycosylated and control fibrinogens similarly, as evidenced by the release of trichloroacetic acid-soluble radioactivity and by SDS-polyacrylamide gel electrophoresis and autoradiography of plasmic digests. Nonglycosylated and control fibrin clots also showed no differences in susceptibility to plasmic digestion. The two forms of fibrinogen demonstrated the same plasma half-life in rabbits. These data indicate that the oligosaccharide does not influence the proteolytic stability or the in vivo plasma survival of fibrinogen, and suggest that other biochemical determinants may influence the catabolic properties of this molecule.

[Acute splenic sequestration: a rare and severe complication of sickle cell anemia in adults. A case report]. / La séquestration splénique aiguë: une complication rare et grave des syndromes drépanocytaires majeurs de l'adulte. A propos d'un cas.

INTRODUCTION: Acute splenic sequestration, a well-recognized complication of sickle cell syndromes, is characterized by a sudden decrease in haemoglobin concentration and marked painless splenomegaly. We report a case illustrating the outcome and the treatment options of this complication. CASE REPORT: A 45-year old homozygous woman developed acute splenic sequestration with severe anemia. Red blood cells transfusion led to transient improvement but a relapse-required splenectomy. Long-term outcome was favorable. CONCLUSION: Acute splenic sequestration is a severe complication mainly observed in children. Despite the severity of this complication, prompt diagnosis and appropriate therapy, and particularly red blood cells transfusions, led to a complete recovery. Splenectomy is required in the more severe form of the disease.

A dinuclear Ru(II) complex capable of photoinduced ligand exchange at both metal centers.

{[Ru(CH3CN)3]2(tppz)}(4+) (tppz = tetra-2-pyridylpyrazine) undergoes photoinduced CH3CN exchange with λirr ≥ 610 nm in H2O. In contrast, cis-{[Ru(tpy)(L)]2(bpm)}(4+) (tpy = 2,2':6',2''-terpyridine, bpm = 2,2'-bipyrimidine, L = CH3CN) is not reactive, but the complex with L = DMSO is photoactive. These complexes are potentially useful for the release of multiply caged drugs.

Acute arterial obliteration: a new feature of the POEMS syndrome?

The POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammapathy, and skin changes) syndrome is a rare variant of plasma cell dyscrasia with multisystemic manifestations. We present 4 cases with arterial symptoms typical of acute arterial obliteration (AAO) and review 9 similar cases in the literature. The clinical course of AAO was unusual and particularly severe when affecting the lower limbs; recurrent events required amputations. As demonstrated by angiographic and histologic studies, thrombotic and atheromatous lesions were the main pathologic features of AAO. Atherosclerotic risk factors were absent or moderate in 3 of our cases, and no cause of thrombosis other than the POEMS syndrome was found. A high production of cytokines was found in all cases, with elevated serum levels of interleukin-1 beta (9/9 samples), interleukin-6 (7/9 samples), and tumor necrosis factor-alpha (6/9 samples). We suggest that arterial manifestations should be added to the spectrum of manifestations of the POEMS syndrome. Cytokines may mediate the POEMS syndrome-associated AAO, as previously proposed for the other systemic manifestations of this disorder.

Multiclinic study of norfloxacin for treatment of urinary tract infections.

A multicenter open study of 477 patients with urinary tract infections was undertaken. The patients were treated with 400 mg of norfloxacin twice daily for seven to 30 days. Four hundred eight (98 percent) of 417 gram-negative organisms and 58 (94 percent) of 62 gram-positive organisms were susceptible to norfloxacin. The infecting organisms were eradicated in 276 of 307 evaluable patients (90 percent). Of the 31 bacteriologic failures, two organisms were initially resistant to norfloxacin and four organisms acquired resistance to norfloxacin and persisted despite treatment. Twenty-eight patients (10 percent) had recurrent infections; 24 of the 25 organisms involved in these infections were susceptible to norfloxacin. Seventeen patients (3.5 percent) experienced clinical adverse effects that were probably or definitely related to the drug. One adverse reaction was serious. Although norfloxacin was discontinued in two patients because of clinical side effects, none of the patients experienced laboratory adverse effects that were either serious or drug related.

Acquired hemophilia due to factor VIII inhibitors in 34 patients.

BACKGROUND: Acquired hemophilia is a rare disease caused by the development of auto-antibodies against factor VIII. SUBJECTS AND METHODS: We studied the characteristics and outcomes of 34 patients (19 women and 15 men) with acquired hemophilia from 1980 to 1997. RESULTS: The mean age of the patients was 61 years (range, 22-93 years). An underlying disease was observed in 18 (53%) patients: 5 patients had cancer, 4 an autoimmune disorder, 2 a dermatologic disorder, 3 asthma, 3 were postpartum, and 1 had an adverse reaction to ampicillin. Factor VIII level was <5% in 30 (90%) patients; factor VIII antibodies were elevated (>10 Bethesda units) in 23 (69%) patients. Bleeding requiring transfusions was reported in 25 (75%) patients. Human factor VIII was given to 14 patients and porcine factor VIII to 5. Six patients received prothrombin complex concentrates and one desmopressin. Several immunosuppressive treatments were used, mainly corticosteroids, cyclophosphamide, and intravenous immunoglobulin. Bleeding stopped in all but one patient within 2 weeks. Most patients achieved complete remission, although two relapses were observed subsequently. CONCLUSION: This large study helps to clarify the presentation and clinical course of acquired hemophilia. Prospective studies are needed to determine the efficacy of treatment.

Prolongation of cardiac conduction times by intravenous aprindine in man.

The acute electrophysiologic effects of intravenous aprindine were evaluated in 48 patients to assess the effect on conduction times and refractoriness in patients with severe cardiac disease and arrhythmias. The patients had not responded to conventional antiarrhythmic medications or had been unable to tolerate effective doses of conventional medications because of side effects. Eleven patients had an abnormal H-V interval, 9 had prolonged QRS duration and 22 had evidence of severe left ventricular dysfunction. Aprindine prolonged conduction transiently in the atria, the atrioventricular (A-V) node, the His-Purkinje system and the ventricles. The refractory times of the atria, the A-V node and the ventricles increased insignificantly, both functionally and statistically. Atrioventricular block did not develop in any patient, and side effects were minor. Thus, aprindine can be safely administered intravenously (10 to 15 mg/min) to severely ill patients with arrhythmias that are refractory to other medications even in the presence of underlying conduction system and myocardial disease.

Suppression of the repetitive ventricular response: an index of long-term antiarrhythmic effectiveness of aprindine for ventricular tachycardia in man.

The repetitive ventricular response, defined as the production of two or more ventricular premature complexes in response to a single ventricular pacing stimulus, is common in patients with serious ventricular arrhythmias. Twenty-seven patients with refractory ventricular tachycardia were studied to determine whether acute suppression of the repetitive ventricular response by aprindine predicts long-term effectiveness of this agent. Twenty-three of the 27 patients had the repetitive ventricular response before intravenous administration of aprindine, whereas only 6 had the response after aprindine. All patients were maintained on a regimen of oral aprindine and evaluated repeatedly for a mean of 12 months. Twenty of the 21 patients who had no repetitive ventricular response after intravenous aprindine manifested clinical improvement compared with only 1 of the 6 in whom the repetitive response was present after aprindine (P less than 0.0005). Aprindine is a useful agent in refractory ventricular tachycardia, and the absence of the repetitive ventricular response after its intravenous administration predicts long-term clinical responsiveness to the oral form.

Mechanism of the repetitive ventricular response in man.

The electrophysiologic characteristics of the repetitive ventricular response that followed an electrically induced single premature ventricular complex were evaluated to determine its mechanism during atrial pacing or sinus rhythm in 30 patients. Seven patients had preexisting bundle branch block. His bundle or right bundle branch deflections did not precede the repetitive complex in 29 of the 30 patients, which implies that the proximal His-Purkinje system was not involved in the reentry circuit. In 24 of 30 patients the QRS axis ot the repetitive complex was divergent 45 degrees or more from the stimulated complex. In 22 of 30 patients the reprtitive complex had a right bundle branch block configuration. In 14 of 18 patients with two or more repetitive complexes, the QRS pattern changed from beat to beat, which implies that either the reentry pathway or conduction was changing. Thus, the repetitive ventricular response, which can be associated with clinically important ventricular arrhythmias, probably represents intraventricular rather than proximal His-Purkinje system reentry.

Identification of intracellular stages of Cyclospora species by light microscopy of thick sections using hematoxylin.

Cyclospora sp is a recently identified coccidia responsible for enteric infection in humans. Most reports have failed to detect this parasite in intestinal biopsies by light microscopy, although the different stages have been ultrastructurally described in jejunum enterocytes. Very recently, some investigators have reported the detection by light microscopy of parasitophorous vacuoles in intestinal biopsies; however, only transmission electron microscopy (TEM) could clearly identify the parasitic stages. To improve the histological diagnosis without using TEM, we have tested different staining methods in biopsies obtained from a patient infected by the human immunodeficiency virus who was shedding Cyclospora oocysts. Hematoxylin stain alone for 15 minutes on 5 micrometer-thick sections of duodenal biopsies was found to be the most efficient method for observing different stages of the parasite. In particular, the banana-shaped merozoites were visualized and appeared very similar to the human coccidia Isopora belli. This simple technique may be useful in diagnosing Cyclospora infection.

Left innominate vein stenosis as a late complication of central vein catheterization.

A patient was seen for acute exercise-induced left superior limb swelling. Phlebography disclosed left innominate vein stenosis and the lack of subclavian vein thrombosis. Ten months earlier, the patient underwent repeated and prolonged central vein catheterization procedures. No other cause of central vein stenosis was evidenced. Emphasis is placed on the symptomatic presenting event, the very late discovery, and the site of stenosis.

Pulmonary embolism; lung scanning interpretation: about words.

OBJECTIVE: To assess clinicians' agreement on how they interpret lung scan reports with regard to the diagnosis of pulmonary embolism. DESIGN: In this prospective study, nuclear medicine physicians provided two types of reports for each lung scan: a routine descriptive report and a short form with a standardized conclusion on the likelihood of pulmonary embolism: "high probability," "no conclusion," and "diagnosis excluded." Three independent blinded senior clinicians reviewed all routine reports and chose one of the following conclusions: "high probability," "no conclusion," or "diagnosis excluded." SETTING: An acute care teaching hospital near Paris. SUBJECTS: Eighty-two lung scans were studied. MAIN OUTCOME MEASUREMENTS: Inter-clinician agreement and agreement between clinicians' conclusions and the nuclear medicine physicians' standardized reports were analyzed using the kappa index. RESULTS: The distribution of the clinicians' conclusions from routine reports strongly differed (p < 0.001). Agreement among the three clinicians was observed in 40.2% of the routine reports, and the inter-clinician agreement was poor to moderate (kappa range, 0.28 to 0.52). A complete agreement among the three clinicians and the nuclear medicine physicians' standardized conclusions was observed for 32.9% of the reports. The agreement between each clinician and the standardized conclusions was also poor to moderate (kappa range, 0.32 to 0.55). CONCLUSION: Reading the same routine reports, clinicians reached different conclusions. Furthermore these differed greatly from the nuclear medicine physicians' standardized conclusions. These results support the notion that physicians should be given standardized reports.

Costs and benefits of measures to prevent needlestick injuries in a university hospital.

OBJECTIVE: To document the costs and the benefits (both in terms of costs averted and of injuries averted) of education sessions and replacement of phlebotomy devices to ensure that needle recapping did not take place. DESIGN: The percentage of recapped needles and the rate of needlestick injuries were evaluated in 1990 and 1997, from a survey of transparent rigid containers in the wards and at the bedside and from a prospective register of all injuries in the workplace. Costs were computed from the viewpoint of the hospital. Positive costs were those of education and purchase of safer phlebotomy devices; negative costs were the prophylactic treatments and follow-up averted by the reduction in injuries. SETTING: A 1,050-bed tertiary-care university hospital in the Paris region. RESULTS: Between the two periods, the proportion of needles seen in the containers that had been recapped was reduced from 10% to 2%. In 1990, 127 needlestick (12.7/100,000 needles) and 52 recapping injuries were reported versus 62 (6.4/100,000 needles) and 22 in 1996 and 1997. When the rates were related to the actual number of patients, the reduction was 76 injuries per year. The total cost of information and preventive measures was $325,927 per year. The cost-effectiveness was $4,000 per injury prevented. CONCLUSION: Although preventive measures taken to ensure reduction of needlestick injuries appear to have been effective (75% reduction in recapping and 50% reduction in injuries), the cost of the safety program was high.

Urinary tract infections in urology: a urologist's view of chronic bacteriuria.

Urine culture performed during and after antimicrobial therapy will differentiate unresolved urinary tract infections from recurrent infections. Recurrent infections with the same organism and at close intervals are frequently caused by a focus of bacterial persistence within the urinary tract, and infections with different organisms and/or at longer intervals are characteristic of reinfections with bacteria from outside the urinary tract. Unresolved infections are usually due to resistant bacteria and are treated by modification of therapy based on antimicrobial sensitivity testing. When unresolved bacteriuria is caused by organisms sensitive to the initial antimicrobial therapy, azotemia or a large bacterial mass density should be suspected. Recurrent infections at close intervals and/or with the same organism are usually caused by a bacterial focus in an acquired or congenital abnormality of the urinary tract such as infection stones, which must be removed to cure the recurrent infections. If the bacterial focus within the urinary tract cannot be removed, long-term low-dose antimicrobial prophylaxis can prevent the morbidity of recurrent infections. Reinfection requires careful bacteriologic monitoring and low-dose prophylactic, intermittent, or post-intercourse antimicrobial therapy.

Urinary tract infection in urology, including acute and chronic prostatitis.

Heightened awareness of patients with increased risk for severe or potentially severe UTIs is paramount for early diagnosis and treatment. Urologic assessment of these patients is frequently necessary for cure and to prevent significant sequelae. Unresolved infections are usually caused by resistant bacteria and are treated by modification of therapy based on antimicrobial sensitivity testing. When unresolved bacteriuria is caused by organisms sensitive to the initial antimicrobial therapy, azotemia or a large bacterial mass density should be suspected. Recurrent infections at close intervals or with the same organism are usually caused by a bacterial focus in an acquired or congenital abnormality of the urinary tract, such as infection stones. The bacterial focus must be removed to cure the recurrent infections. If the bacterial focus within the urinary tract cannot be removed, long-term, low-dose antimicrobial suppression will prevent the morbidity of recurrent infections. Reinfection requires careful bacteriologic monitoring and low-dose prophylactic, intermittent, or postintercourse antimicrobial therapy. In the setting of prostatitis syndrome, the patient must first be classified into one of three categories: bacterial prostatitis, nonbacterial prostatitis, or pelviperineal pain syndrome. Bacterial prostatitis frequently responds to appropriate antimicrobial agents, whereas nonbacterial prostatitis and pelviperineal pain require an empiric multimodal approach.

Pathogenesis of recurrent urinary tract infection: use of understanding as therapy.

Understanding bacterial adherence and explaining it to patients is essential in the management of recurrent urinary tract infection. Bowel flora, usually Escherichia coli, colonize first the vaginal introitus, then the urethral mucosa, and they subsequently ascend to the bladder. The essential step is bacterial adhesion to receptor sites on uroepithelial cells. Women who suffer recurrent infections have more receptive cells than the cells of other women. Long-term antimicrobial therapy reduces susceptibility to reinfection. Bringing patients into an understanding of their infectious process and into a partnership in the alleviation of their suffering is a powerful therapeutic tool.