Efficacy of Percutaneous Tibial Nerve Stimulation for Overactive Bladder in Women and Men at a Safety Net Hospital.

PURPOSE: We investigated efficacy and compliance related to percutaneous tibial nerve stimulation in patients treated for overactive bladder at a large, urban safety net hospital. MATERIALS AND METHODS: Consecutive patients who underwent percutaneous tibial nerve stimulation at Grady Memorial Hospital from May 2015 through January 2019 were included in our cohort and records were reviewed retrospectively. Primary outcomes of interest included self-reported urinary symptoms and episodes of urinary incontinence. Our secondary outcome of interest was patient compliance, defined as completion of 12 or more treatment sessions. Descriptive analysis and paired t-tests were performed. RESULTS: Of the 50 patients with a mean ± SD age of 59 ± 12 years 80% were black, 52% were male, 34% were uninsured and 54% subscribed to government insurance. Prior treatment included behavioral modification in 100% of cases, anticholinergics in 86% and mirabegron in 4%. Patients completed a mean of 10.7 ± 2.7 of the 12 planned weekly percutaneous tibial nerve stimulation treatments. Of the patients 70% completed all 12 weekly treatments and 77% of those who completed 12 treatments continued to maintenance treatment. After percutaneous tibial nerve stimulation treatment average symptoms improved across all metrics, including mean daytime frequency (from 11.0 to 6.6 episodes per day or -24.5%), nighttime frequency (from 4.8 to 2.5 episodes per night or -47.1%), urgency score (from 3.4 to 1.9 or -42.1%) and incontinence (from 1.6 to 0.4 episodes per day or -79.6%) (each p <0.001). A total of 43 patients (86%) reported symptom improvement. CONCLUSIONS: Percutaneous tibial nerve stimulation had favorable efficacy and compliance in a traditionally underserved patient population. This should be considered as a feasible modality to manage overactive bladder symptoms in patients in a similar demographic.

Safety and Efficacy of Ureteral Stent Placement at the Bedside Using Local Anesthesia.

PURPOSE: Ureteral stent placement for decompressing renal units obstructed by calculi is safe and can be potentially lifesaving in the prompt resolution of the sequelae of renal obstruction, infection and an obstructing stone. At many institutions there can be prolonged delay in getting patients to the operating room for stent placement. We hypothesized that it is safe and efficacious to attempt ureteral stent placement using local anesthesia at the bedside without live fluoroscopic guidance. MATERIALS AND METHODS: Patients presenting with symptomatic, obstructing ureteral calculi were given the option of bedside ureteral stent placement. Viscous lidocaine was placed into the urethra before flexible cystoscopic examination. A 260 cm Glidewire® was used as initial access with only 1 attempt at passage. All stent placements were confirmed with immediate post-procedure radiograph. Prospectively collected data were retrospectively analyzed for all patients who underwent attempted bedside ureteral stent placement. RESULTS: A total of 42 patients underwent attempted bedside stent placement under local anesthesia without fluoroscopic guidance. Mean stone size was 8.3 mm and 71% of stones were in the proximal ureter. Ureteral stent placement was pursued in 14% of patients for infection and in 59% for intractable pain. Ureteral stent placement was successful in 30 patients (71%). Statistical analysis did not reveal any significant predictors of successful stent placement in this cohort of patients. CONCLUSIONS: In our cohort bedside ureteral stent placement was well tolerated, safe and efficacious, thus expediting upper tract decompression in the setting of obstructed renal units in more than 70% of patients.

Amplicon-Based Pyrosequencing Reveals High Diversity of Protistan Parasites in Ships' Ballast Water: Implications for Biogeography and Infectious Diseases.

Ships' ballast water (BW) commonly moves macroorganisms and microorganisms across the world's oceans and along coasts; however, the majority of these microbial transfers have gone undetected. We applied high-throughput sequencing methods to identify microbial eukaryotes, specifically emphasizing the protistan parasites, in ships' BW collected from vessels calling to the Chesapeake Bay (Virginia and Maryland, USA) from European and Eastern Canadian ports. We utilized tagged-amplicon 454 pyrosequencing with two general primer sets, amplifying either the V4 or V9 domain of the small subunit (SSU) of the ribosomal RNA (rRNA) gene complex, from total DNA extracted from water samples collected from the ballast tanks of bulk cargo vessels. We detected a diverse group of protistan taxa, with some known to contain important parasites in marine systems, including Apicomplexa (unidentified apicomplexans, unidentified gregarines, Cryptosporidium spp.), Dinophyta (Blastodinium spp., Euduboscquella sp., unidentified syndinids, Karlodinium spp., Syndinium spp.), Perkinsea (Parvilucifera sp.), Opisthokonta (Ichthyosporea sp., Pseudoperkinsidae, unidentified ichthyosporeans), and Stramenopiles (Labyrinthulomycetes). Further characterization of groups with parasitic taxa, consisting of phylogenetic analyses for four taxa (Cryptosporidium spp., Parvilucifera spp., Labyrinthulomycetes, and Ichthyosporea), revealed that sequences were obtained from both known and novel lineages. This study demonstrates that high-throughput sequencing is a viable and sensitive method for detecting parasitic protists when present and transported in the ballast water of ships. These data also underscore the potential importance of human-aided dispersal in the biogeography of these microbes and emerging diseases in the world's oceans.

Should we reconsider lung transplantation through uncontrolled donation after circulatory death?

Lung transplantation through controlled donation after circulatory death (cDCD) has slowly gained universal acceptance with reports of equivalent outcomes to those through donation after brain death. In contrast, uncontrolled DCD (uDCD) lung use is controversial and requires ethical, legal and medical complexities to be addressed in a limited time. Consequently, uDCD lung use has not previously been reported in the United States. Despite these potential barriers, we present a case of a patient with multiple gunshot wounds to the head and the body who was unsuccessfully resuscitated and ultimately became an uDCD donor. A cytomegalovirus positive recipient who had previously consented for CDC high-risk, DCD and participation in the NOVEL trial was transplanted from this uDCD donor, following 3 h of ex vivo lung perfusion. The postoperative course was uneventful, and the recipient was discharged home on day 9. While this case represents a "best-case scenario," it illustrates a method for potential expansion of the lung allograft pool through uDCD after unsuccessful resuscitation in hospitalized patients.

Evaluation and management of patients with nocturia.

Nocturia, or awakening one or more times to void at night, becomes clinically significant with two or more voids a night. In the past, nocturia has typically been viewed as a symptom of benign prostatic hyperplasia and/or overactive bladder syndrome. However, newer evidence supports that this is no longer just a symptom but a medical condition that warrants further workup and treatment given its effect on quality of life. The negative effects of nocturia include sleep fragmentation, decreased productivity at work, and increased risk of falls and fractures. A workup to find the underlying cause of nocturia will help guide treatment, which may include pharmacologic agents.

Treatment of separated piggery anaerobic digestate liquid using woodchip biofilters.

The Irish nitrates directive restricts the land area suitable for landspreading of pig manure, so anaerobic digestion warrants consideration. In this study, six identical Lodgepole pine woodchip biofilters were set up to treat the separated liquid fraction of digestate after anaerobic digestion of pig manure. Two hydraulic loading rates were examined: 5 L/m2/d (LLR) and 10 L/m2/d (HLR). Following a start-up period of 70 days, an average of 90% and 71% of NH4(+)-N was removed at LLR and HLR, respectively. LLR resulted in higher total nitrogen removals than HLR (p < 0.05). Efficient nitrification occurred at LLR as indicated by the lower NH4(+)-N (p < 0.05) and higher NO3(-)-N (p < 0.05) concentrations in the biofilter effluent. A batch experiment testing the capacity of saturated woodchips in removing total oxidized nitrogen (TON) from the effluent of the woodchip biofilters showed that TON was reduced by 323 mg/L from 663 mg/L in 360 h, indicating that the aerobic woodchip biofilters should incorporate a saturated layer ofwoodchips at the base ofthe biofilters to enhance nitrogen removal.

Effects of oral rehydration and external cooling on physiology, perception, and performance in hot, dry climates.

Only limited research evaluates possible benefits of combined drinking and external cooling (by pouring cold water over the body) during exercise. Therefore, this study examined cold water drinking and external cooling on physiological, perceptual, and performance variables in hot, dry environments. Ten male runners completed four trials of walking 90 min at 30% VO(2max) followed by running a 5-km time trial in 33 ± 1 °C and 30 ± 4% relative humidity. Trials examined no intervention (CON), oral rehydration (OR), external cooling (EC), and oral rehydration plus external cooling (OR + EC). Investigators measured rectal temperature, skin temperatures, heart rate, thirst, thermal sensation, and ratings of perceived exertion (RPE). Oral rehydration (OR and OR + EC) significantly lowered heart rate (P < 0.001) and thirst (P < 0.001) compared with nondrinking (CON and EC) during low-intensity exercise. External cooling (EC and OR + EC) significantly reduced chest and thigh temperature (P < 0.001), thermal sensation (P < 0.001), and RPE (P = 0.041) compared with non-external cooling (CON and OR) during low-intensity exercise. Performance exhibited no differences (CON = 23.86 ± 4.57 min, OR = 22.74 ± 3.20 min, EC = 22.96 ± 3.11 min, OR + EC = 22.64 ± 3.73 min, P = 0.379). Independent of OR, pouring cold water on the body benefited skin temperature, thermal sensation, and RPE during low-intensity exercise in hot, dry conditions but failed to influence high-intensity performance.

Colorectal cancer care in the COVID-19 era: outcomes from a 'mixed site' model.

INTRODUCTION: The COVID-19 pandemic has presented many challenges to colorectal cancer (CRC) care. Many organisations opted to perform CRC resections in 'cold' sites. Infrastructure in Northumbria Healthcare NHS Foundation Trust (NHCT) necessitated co-locating CRC care with 'hot' COVID streams but with additional precautions. This study aimed to evaluate that approach for a consecutive series of CRC cases, diagnosed before and during the COVID-19 pandemic. METHODS: A prospectively populated data set of CRC patients diagnosed between 1 April 2019 and 30 September 2020 was used. Patients presenting before 1 April 2020 were considered 'pre-COVID' and those presenting subsequently as 'COVID era'. RESULTS: Some 344 cases were diagnosed in the 12 months 'pre-COVID' and 166 in the 6 months of the 'COVID era'. The median numbers of days from referral to diagnosis (21 vs 20, p=0.373) and operation (63 vs 61, p=0.208) were unchanged. The 'COVID era' saw an increase in the proportion of radiological diagnoses (39.5% vs 53.0%, p=0.004) with an associated decrease in endoscopic diagnoses (56.7% vs 45.8%, p=0.021). Rates of inoperable (1.5% vs 1.2%, p=0.821), obstructing (11.0% vs 16.2%, p=0.272) and perforated tumours (0.6% vs 1.5%, p=0.492) remained the same. One patient developed COVID-19 perioperatively. Rates of laparoscopic operation (59.5% vs 61.8%, p=0.751), anastomotic leak (6.4% vs 5.9%, p=0.891), re-operative surgery (10.4% vs 4.4%, p=0.138), primary stoma (40.5% vs 32.4%, p=0.244) and 90-day mortality (0.6% vs 1.5%, p=0.492) did not change. CONCLUSIONS: With appropriate infection control measures, it may be safe to continue providing standard elective and urgent CRC care without access to a 'COVID clean' site.

An unusual presentation of a mixed epithelial and stromal tumor in an elderly male.

Mixed epithelial and stromal tumors (MESTs) of the kidney are rare renal neoplasms characterized by mixed cystic and solid components. These tumors are typically present in middle-aged women as a flank mass, or as a cause of flank pain or hematuria. We outline the case of an older male who presented with an enlarging abdominal mass causing symptoms that suggested a partial small bowel obstruction. Management of the patient and a brief review are discussed.

Donor-derived disease transmission events in the United States: data reviewed by the OPTN/UNOS Disease Transmission Advisory Committee.

Donor-derived disease transmission is increasingly recognized as a source of morbidity and mortality among transplant recipients. Policy 4.7 of the Organ Procurement and Transplantation Network (OPTN) currently requires reporting of donor-derived events. All potential donor-derived transmission events (PDDTE) reported to OPTN/UNOS were reviewed by the Disease Transmission Advisory Committee (DTAC). Summary data from January 1, 2005-December 31, 2007, were prepared for presentation. Reports of PDDTE have increased from 7 in 2005, the first full year data were collected, to 60 in 2006 and to 97 in 2007. More detailed information is available for 2007; a classification system for determining likelihood of donor-derived transmission was utilized. In 2007, there were four proven and one possible donor-derived malignancy transmissions and four proven, two probable and six possible donor-derived infectious diseases transmissions. There were nine reported recipient deaths attributable to proven donor transmissions events arising from eight donors during 2007. Although recognized transmission events resulted in significant morbidity and mortality, transmission was reported in only 0.96% of deceased donor donations overall. Improved reporting, through enhanced recognition and communication, will be critical to better estimate the transmission risk of infection and malignancy through organ transplantation.

Avoiding the Need for Bowel Anastomosis during Pelvic Exenteration-Urinary Sigmoid or Descending Colon Conduit-Short and Long Term Complications.

OBJECTIVE: To educate surgeons of distal colon urinary diversion as an alternative to ileal conduit. To assess perioperative outcomes of distal colon conduit in pelvic exenteration including conduit-related, gastrointestinal, infectious, metabolic, and wound complications within 30 days, 31-89 days, and greater than 90 days from the time of surgery. MATERIALS AND METHODS: Forty-one patients who underwent distal colon urinary diversion for malignancy, fistula, or neurogenic bladder were identified in our IRB approved database from 1/2007 to 7/2017. RESULTS: Twenty-six (63.4%) were male with mean age of 54.1 years. Complications were stratified by early (≤30 days), intermediate (31-89 days), and late (≥90 days). Within 30 days, 2 (4.9%) had partial small bowel obstructions requiring nasogastric tube (NGT) placement and total parenteral nutrition (TPN); 8 (19.5%) prolonged ileus with 6 (14.6%) requiring TPN and 5 (12.2%) requiring NGT placement; 1 (2.4%) enterocutaneous fistula; 1 (2.4%) conduit hemorrhage, 10 (24.4%) treated urinary tract infections (UTIs). Between 31 and 89 days, 1 patient (2.4%) had urinary conduit leak and 3 (7.3%) treated UTIs. At ≥90 days, 2 (4.9%) had partial small bowel obstructions requiring NGT placement, 4 (9.8%) ureterocolonic strictures and 1 (2.4%) parastomal hernia, 3 (7.3%) treated UTIs. Readmission rate in ≤30 days was 10 (24.4%), 31-89 days was 13 (31.7%), and 90+ days was 16 (39%). Long-term metabolic complications at ≥90 days included 16 (39%) with hypokalemia, 10 (24.4%) with hyperchloremia, and 14 (34.1%) with metabolic acidosis. CONCLUSION: Distal colon urinary conduit is a relatively safe and feasible option and obviates the need for small bowel anastomosis and possible associated complications.

Perforated diverticulitis: To anastomose or not to anastomose? A systematic review and meta-analysis.

BACKGROUND: No consensus has been reached in the management of perforated diverticulitis. Many surgeons opt for a Hartmann's procedure to avoid the risk of an anastomotic leak. We hypothesise that resection with primary anastomosis is a safe alternative in selected patients. We aim to conduct a systematic review and meta-analysis on the available literature. METHODS: Studies that compared emergency Hartmann's with primary anastomosis in perforated left sided colonic diverticulitis were systematically reviewed. The search strategy included all study types that compared primary anastomosis to Hartmann's in perforated diverticulitis and reported on morbidity and mortality. 5 databases (PubMed, MEDLINE via PubMed, OVID, EMBASE via OVID and The Cochrane Collaboration). The Cochrane's Bias Methods Group tool was used to assess the risk of bias and a meta-analysis of the relevant studies was conducted. RESULTS: The review retrieved 1933 abstracts of which 14 studies (2 RCTs, 4 prospective non-randomised and 8 retrospective non-randomised) with 765 patients in total, 482 in the Hartmann's group and 283 in the primary anastomosis group, met the inclusion criteria. This showed a significantly lower mortality with primary anastomosis (10.6%) compared to Hartmann's (20.7%) (p = 0.0003). Morbidity was also significantly lower (41.8% vs. 51.2%) (p = 0.0483). The RR for mortality was 0.92 in favour of primary anastomosis (p = 0.0019). The average anastomotic leak rate was 5.9%. CONCLUSION: Resection and primary anastomosis should be considered as a feasible and safe operative strategy in selected patients with perforated diverticulitis. There is however a paucity of high level evidence and further research is needed.

The Clinical Course of Patients With Prostate-Specific Antigen ≥100 ng/ml: Insight Into a Potential Population for Targeted Prostate-Specific Antigen Screening.

OBJECTIVE: To characterize men presenting to a tertiary care safety-net hospital with prostate-specific antigen (PSA) values ≥100 ng/mL and to identify a potential population for targeted PSA screening. MATERIALS AND METHODS: Retrospective review of 100 randomly selected patients of a total of 204 who presented to Grady Memorial Hospital from 2004 to 2011 with initial PSA ≥100 ng/mL was performed. Demographics, disease characteristics, and survival status were obtained via the Tumor Registry and a combination of electronic medical records and older paper charts, with missing data from paper charts excluded on analyses. RESULTS: Sixty-five patients were newly diagnosed with prostate cancer on presentation and 35 were previously diagnosed. Median PSA at presentation was 405.5 ng/mL (minimum, 100 and maximum, 7805), 81% had metastatic disease, and 94% had Gleason ≥7. Median Cancer of the Prostate Risk Assessment score was 8. Median age at presentation was 67.4 years (minimum, 40.8 and maximum, 90.6). Eighty-nine percent of patients were African American, 24% lived alone, 12% were homeless or incarcerated, 51% were insured by Medicare or Medicaid, and 47% were uninsured. Only 1% had human immunodeficiency virus, 19% had diabetes, and 13% had chronic kidney disease. Of the 65 newly diagnosed patients, only 23% had ever been screened and 9% were previously biopsied. Median time from presentation to death was 17.8 months (minimum, 0.16 and maximum, 107.1). CONCLUSION: Among men presenting with PSA ≥100 ng/ml at a safety-net hospital, the majority were African American, of lower socioeconomic status, and had metastatic disease. Uniform absence of prostate cancer screening may expose greater numbers of at-risk men to similar outcomes. Discussion is needed regarding targeted PSA screening in higher risk, vulnerable patients.

An investigation into the removal of Salmonella and enteric indicator bacteria from the separated liquid fraction of raw or anaerobically digested pig manure using novel on-farm woodchip biofilters.

The objective was to investigate the removal of Salmonella and enteric indicator bacteria from the liquid fraction of raw and anaerobically digested (AD) pig manure in woodchip biofilters over a 14 week (98 day) period. Antibiotic susceptible Salmonella Infantis was detected in one influent material (liquid fraction of raw manure) on two occasions but was not found in the effluent at any time point. Furthermore, mean coliform reductions of 56% were observed in the biofilters treating the liquid fraction of raw manure. However, a mean increase of 228% was found in those treating the liquid from AD manure, despite the fact that the microbial challenge to these biofilters was lower. In addition, relatively high coliform counts were still present in the effluent from both biofilter treatments, especially in the systems treating the liquid fraction of AD manure. However, findings for Escherichia coli and Enterococcus were more promising, with reductions observed for both treatments (10 and 18.5% for E. coli and 71 and 87% for Enterococcus). Moreover, E. coli and Enterococcus were at, or just above, the limit of detection in the final effluents. Overall, although, there are no microbial limits for discharge or washwaters, the woodchip filter effluent would appear safe for discharge to waterways or use on-farm as regards Salmonella, E. coli and Enterococcus but not coliform. In conclusion, woodchip biofilters offer potential as a low-cost sustainable novel treatment option for the removal of pathogens from the liquid fraction of pig manure.

Left upper lobe mass and diffuse reticular-nodular infiltrate.

We encountered a clinical problem in a young man who presented with a left upper lobe mass and a diffuse reticular-nodular infiltrate. We thought we had appropriately applied Murphy's Law (the famed bank robber who "went where the money is"), and Ockham's Razor (the philosopher William of Ockham [1285 to 1349]-"Entities are not to be multiplied beyond necessity") as we rapidly diagnosed the lung mass with computed tomography, scintigraphy, and fine-needle aspiration. However, when his invaluable previous chest radiographs arrived, bronchoscopy with transbronchial biopsy, bronchoalveolar lavage, brushings, and postbronchoscopy sputum revealed the more ominous diagnosis in this patient. This case illustrates the complementary nature of current imaging and bronchoscopy techniques; but, even more importantly, it demonstrates the value of the history coupled with the previous radiograph. Even an unusual case can provide lessons in cost containment.

Simultaneous cadaver renal and pancreas transplantation in type I diabetes.

Between February 1985 and April 1986, we performed 11 simultaneous cadaver kidney and segmental pancreatic transplants in patients with type I diabetes. There were nine men and two women ranging in age from 25 to 47 years (mean, 38.5 years). All pancreatic grafts were extraperitoneal, and the pancreatic duct was managed by pancreaticocystostomy utilizing an internal stent. Three patients died from two to six weeks postoperatively of septic complications. Four pancreatic grafts were functioning at 2, 5, 11, and 14 months after operation, and eight patients had had functioning renal allografts from two to 14 months (mean, 6.8 months) with a mean serum creatinine level of 2.4 mg/dL (210 mumol/L). Graft failure occurred in the other four patients from vascular thrombosis (three patients) or hemorrhagic pancreatitis (one patient). Significant morbidity included an infected arterial anastomosis (two patients), pancreatic fistulas (four patients), and bladder leak (four patients). In conclusion, this procedure is an effective option for selective diabetics with end-stage renal disease. Although technical complications were frequent, no adverse effect on renal allograft function was evident. With technical refinements, this procedure should be applicable to most type I diabetics with renal failure.

Selective posttransplantation bilateral native nephrectomy. Indications and results.

Twenty-five patients underwent bilateral native nephrectomy one to 68 months (mean, 15.6 months) following renal transplantation. The indications were erythrocytosis in two patients, recurrent urinary tract infection in three, medically uncontrolled hypertension in 18, and hypertension and urinary tract infection in two. One patient died two months after the nephrectomy, and one allograft was lost because of acute tubular necrosis. Both patients with erythrocytosis had prompt return of the hematocrit level and RBC mass to normal. Native nephrectomy eradicated the infection in each of the five patients with recurrent urinary tract infections. Results of nephrectomy for hypertension were classified as excellent in six patients, good in nine, and poor in four. Native renal-vein renin ratios of patients with excellent or good responses were not statistically different when compared with those of poor responders.

Separated pyelocolocutaneous diversion after bilateral ureterectomy and radical cystectomy for transitional cell carcinoma.

OBJECTIVES: To report a technique for excision of bilateral ureteral transitional cell carcinoma which preserves renal function and provides ready access for endoscopic follow-up and therapy of the renal pelvis. METHODS: The operative procedure of bilateral ureterectomy with construction of a separated pyelocolocutaneous diversion utilizing transverse colon is described and the clinical course of 4 patients is reported. RESULTS: All 4 patients maintained excellent renal function and normal electrolytes. Conduit urine cytologic studies and renal pelvis endoscopic examinations have remained normal. Parastomal herniation was the most frequently observed postoperative complication. CONCLUSIONS: This approach is well suited for the treatment of bilateral ureteral transitional cell carcinoma. Long-term complications are minimal and renal function is preserved. Periodic endoscopic visualization of each renal pelvis with resection and fulguration and/or instillation of immunotherapeutic or chemotherapeutic agents for recurrent renal pelvic lesions is readily accomplished.