Unpacking the 'black box' of total pathogen burden: is number or type of pathogens most predictive of all-cause mortality in the United States?

A 'black box' paradigm has prevailed in which researchers have focused on the association between the total number of pathogens for which individuals are seropositive (i.e. total pathogen burden) and various chronic diseases, while largely ignoring the role that seropositivity for specific combinations of pathogens may play in the aetiology of such outcomes and consequently mortality. We examined the association between total pathogen burden as well as specific pathogen combinations and all-cause mortality in the United States. Data were from individuals aged ⩾25 years tested for cytomegalovirus (CMV), herpes simplex virus (HSV)-1, HSV-2 and Helicobacter pylori, with mortality follow-up to 31 December 2006 in the National Health and Nutrition Examination Survey (NHANES) III (N = 6522). We did not observe a statistically significant graded relationship between total pathogen burden level and all-cause mortality. Furthermore, compared to those seronegative for all four pathogens, the greatest statistically significant rate of all-cause mortality was for those CMV+/HSV-2+ (hazard ratio 1·95, 95% confidence interval 1·13-3·35) adjusting for age, gender, race/ethnicity, education level, body mass index (kg/m2) and smoking status. Interventions targeting prevention or treatment of particular pathogens may be more effective for reducing mortality than those focused solely on reducing overall pathogen burden.

Surgical treatment of prostatic hyperplasia.

BACKGROUND: For more than seven decades prostates have been enucleated surgically, and for almost six decades they have been resected endoscopically. Results have been impressive and increasingly better, and the procedure has been reasonably safe. Variations to these two approaches have abounded and have made it safer, quicker, and easier, but never cheaper. METHODS: Currently, an abundance of alternatives have surfaced and for a variety of reasons. All alternatives share several shortcomings: results are not predictable, there is no tissue, and serendipitous prostate cancer could be missed. In addition, it may be categorically said that rarely does any of the alternatives achieve the effectiveness of prostatectomy that is appropriately indicated and properly performed. RESULTS: Urologists should participate in an objective assessment of the comparative merits and deficiencies of the variations of and alternatives to prostatectomy. Assessment of outcomes, safety, efficacy, and cost, as well as the development of guidelines, should continue. CONCLUSIONS: With our counsel and the government's reimbursement, the public will decide which alternatives are safe and reasonably effective and should survive.

Acute pyelonephritis after transrectal ultrasonographically guided biopsy of the prostate: diagnosis by computed tomography.

Acute pyelonephritis developed in a 67-yr-old man after transrectal ultrasonographically guided biopsy of the prostate. The clinical presentation and results of excretory urography were nondiagnostic. Diagnosis was made by computed tomography, which was delayed 12 h after i.v. administration of contrast medium.

Is the neodymium:YAG laser effective therapy for invasive bladder cancer?

The neodymium:YAG (yttrium-aluminum-garnet) laser can cause transmural coagulation necrosis of bladder tumor or bladder wall. Pathologic specimens of 18 patients prospectively treated with the neodymium:YAG laser before radical cystectomy were reviewed to compare the initial clinical stage of bladder tumor with the final pathologic stage and to assess the destructive tissue effects of neodymium:YAG laser therapy. Eleven of 18 patients were unchanged pathologically in stage of tumor or had tumor progression. Seven patients had a lower pathologic tumor stage; 3 of these patients had pathologic Stage T0 with no residual tumor, with the remainder of patients showing superficial disease. One asymptomatic small bowel injury was discovered at operation. Healing lesions showed marked granulation tissue, coagulation necrosis, and persistent ulceration.

Balloon dilatation of the prostate.

It is important to be objective in selecting candidates for this procedure and in evaluating their outcome. The size of the prostate does not seem to be relevant. Alpha blockers and balloons still produce unpredictable results, and neither alternative duplicates the results of transurethral resection. If, however, the patient is not in serious voiding trouble and is willing to exercise genuine patience, one approach could be a blocker if he has early symptoms and is not in trouble; otherwise, use the balloon. When either or both fail, TURP is required if the patient's condition permits, for TURP remains the standard. Objective assessment with an open mind is essential. Balloon dilatation is a safe, simple, but unpredictable alternative to transurethral resection. It may be done on an ambulatory basis, although it requires anesthesia, and has led to neither impotence or incontinence. It may be performed on the limited-risk patient. It has succeeded in two thirds of patients in retention or who did not respond to alpha blockers. Nonetheless, objective measures of success rarely duplicate those regularly achieved by TURP.

Neurocutaneous syndromes and retroperitoneal tumors.

A patient with multiple basal cell carcinoma syndrome, a symptom complex characteristized by nevoid basal cell carcinomas of the skin, jaw cysts, skeletal abnormalities, and hyporesponsiveness to parathormone is presented. In addition, the patient had a retroperitoneal lymphagiomyoma, a hamartomatous lesion, causing ureteral obstruction. The association of neuroectodermic syndromes and retroperitoneal and intra-abdominal tumors is reviewed.

Optimal nutritional support in surgery for bladder cancer: preservation of visceral protein by amino acid infusions.

Seventeen patients undergoing 19 major urological operations for bladder cancer or rectal leiomyosarcoma (1 case) were studied after randomization for 3 hypocaloric dietary regimens, preoperative keto-adaptation by a carbohydrate-free, oral protein diet continued in the postoperative period by isotonic amino acid infusions, postoperative amino acid infusions only and 5 per cent dextrose infusions. In these normally nourished patients serum transferrin (plus 13 mg./dl. minus 30 mg./dl., minus 69 mg./dl., p less than 0.05 for the first and combined amino acid groups against the third group) and 2 other short half-life hepatic secretory proteins, prealbumin and retinol-binding protein, represented sensitive indexes of visceral protein and nutritional support, superior to nitrogen balance, anthropometric assays, delayed hypersensitivity skin test reactivity and serum albumin. Near isotonic amino acid infusions were more effective in preserving visceral protein status than 5 per cent dextrose but preoperative keto-adaptation was not shown to have any increased benefit over protein-sparing therapy given only after an operation.

Hamartoma and renal transplant implications.

A 19-year-old woman with tuberous sclerosis, bilateral renal hamartomas and polycystic kidneys required separate nephrectomies for severe hemorrhages 6 months apart. The case is presented, the diagnoses of the disease in relation to a negative family history are considered and the importance of early diagnosis in a potential transplant recipient and the use of leukocyte-free transufusions are discussed.