Liver fibrosis assessment in pediatric population - can ultrasound elastography be an alternative method to liver biopsy? A systematic review.

Liver diseases of various etiologies are becoming increasingly common in the pediatric population. So far, the gold diagnostic standard in these disorders is liver biopsy. This procedure is invasive, painful and requires general anesthesia in this group of patients. Due to the continuous development of new research techniques, such as liver elastography, it is necessary to evaluate them in the context of their diagnostic usefulness. Ultrasound elastography, as a quick and effective method, is being used more and more often in the assessment and monitoring of liver dysfunction in both adults and children. There are several techniques of liver elastography, such as transient elastography, shear wave elastography consisting of various subtypes such as two-dimensional shear wave elastography, acoustic radiation force impulse and point shear wave elastography, which differ in terms of the measurement technique and the achieved results. The purpose of our review was to determine whether techniques of liver elastography could replace liver biopsy. Although now, based on the analyzed papers, elastography cannot replace liver biopsy, in our opinion, the role of this tool in monitoring pediatric patients with liver diseases will grow in the coming years.

Patient Reported Outcomes of Transperineal Prostate Biopsy With Tumescent Local Anesthesia.

OBJECTIVE: To report the outcomes of performing transperineal prostate biopsy in the office setting using the novel anesthetic technique of tumescent local anesthesia. We report anxiety, pain, and embarrassment of patients who underwent this procedure compared to patients who underwent a transrectal prostate biopsy using standard local anesthesia. MATERIALS AND METHODS: Consecutive patients undergoing either a transperineal prostate biopsy under tumescent local anesthesia or a transrectal prostate biopsy with standard local anesthetic technique were prospectively enrolled. The tumescent technique employed dilute lidocaine solution administered using a self-filling syringe. Patients were asked to rate their pain before, during, and after their procedure using a visual analog scale. Patient anxiety and embarrassment was assessed using the Testing Modalities Index Questionnaire. RESULTS: Between April 2021 and June 2022, 430 patients underwent a transperineal prostate biopsy using tumescent local anesthesia and 65 patients underwent a standard transrectal prostate biopsy. Patients who underwent a transperineal biopsy had acceptable but significantly higher pain scores than those who underwent a transrectal prostate biopsy (3.9 vs 1.6, P-value <.01). These scores fell to almost zero immediately following their procedure. Additionally, transperineal biopsy patients were more likely to experience anxiety (71% vs 45%, P < .01) and embarrassment (32% vs 15%, P < .01). CONCLUSION: Transperineal biopsy using local tumescent anesthesia is safe and well-tolerated. Despite the benefits, patients undergoing a transperineal prostate biopsy under tumescent anesthesia still experienced worse procedural pain, anxiety, and embarrassment. Additional studies examining other adjunctive interventions to improve patient experience during transperineal prostate biopsy are needed.

Hair embedding after transperineal prostate biopsy: two case reports.

BACKGROUND: Transperineal prostate biopsy is gradually becoming the standard methodology for diagnosing prostate cancer because of its high accuracy and low risk of infection, but careful preparation is not always highlighted before a transperineal biopsy. we reported two cases of hair embedding during transurethral resection of the prostate following transperineal puncture biopsy with a Bard MC1820 disposable biopsy needle. Histological examination did not find the hair follicle structure required for hair growth. The hair source was suspected to be percutaneously brought in by needle during the biopsya simulated experiment was used to analyze and reconstruct the process of hair embedding in prostate tissue. CONCLUSION: Hair embedding caused by perineal prostate biopsy is a consumable-related adverse event, and skin preparation before a transperineal prostate biopsy is recommended.

A systematic review on the outcomes of local anaesthetic transperineal prostate biopsy.

OBJECTIVE: To conduct a systematic review of the literature to assess the diagnostic ability, complication rate, patient tolerability, and cost of local anaesthetic (LA) transperineal prostate biopsy. METHODS: Two reviewers searched Medline, the Cochrane Library, and Embase for publications on LA transperineal prostate biopsy up to March 2021. Outcomes of interest included cancer detection rates, complication rates, pain assessments and cost. RESULTS: A total of 35 publications with 113 944 men were included in this review. The cancer detection rate for LA transperineal prostate biopsy in patients undergoing primary biopsy was 52% (95% confidence interval [CI] 0.45-0.60; I2 = 97) and the clinically significant cancer detection rate (Gleason≥3 + 4) was 37% (95% CI 0.24-0.52; I2 = 99%). The rate of infection-related complications in the included studies was 0.15% (95% CI 0.0000-0.0043; I2 = 86). The LA transperineal procedures had a low rate of procedural abandonment (26/6954, 0.37%), with the greatest pain scores measured during LA administration. No formal cost analyses on LA transperineal prostate biopsies were identified in the literature. The overall risk of bias in the included studies was high, with considerable study heterogeneity and publication bias. CONCLUSION: Transperineal prostate biopsy performed under LA is a viable option for centres interested in avoiding the risk of infection associated with transrectal biopsy, and the logistical burden of general anaesthesia. Further investigation into LA transperineal prostate biopsy with comparative studies is warranted for its consideration as the standard in prostate biopsy technique.

Diagnostic value and safety of medical thoracoscopy under local anesthesia for unexplained diffuse interstitial lung disease: A retrospective study.

OBJECTIVE: We aimed to explore the safety and diagnostic value of medical thoracoscopic lung biopsy in patients with unexplained diffuse interstitial lung disease (ILD) in a single center pilot study. METHOD: We retrospectively analyzed clinical and pathological diagnostic data from 52 patients with diffuse ILD undergoing medical thoracoscopic lung biopsy. RESULTS: Forty-four cases of diffuse ILD were confirmed pathologically, giving a diagnostic rate of 84.6%. Among these 44 patients, 11 patients were diagnosed with cancer, including eight patients with lung adenocarcinoma, three patients with metastases; two from a gastrointestinal malignancy, and one from a granulosa cell tumor of the ovary. There were 17 cases of idiopathic interstitial pneumonia, including nine cases of usual interstitial pneumonia (UIP), four cases of non-specific interstitial pneumonia (NSIP), three cases of cryptogenic organizing pneumonia (COP), and one case of acute interstitial pneumonia (AIP). There were 12 cases of rare interstitial pneumonias, which included six cases of pulmonary alveolar proteinosis, one case each of pulmonary Langerhans cell histiocytosis (LCH) and pulmonary lymphangiomyomatosis, two cases of nodular sarcoidosis, and two cases of chronic eosinophilic pneumonia. We recorded various complications, including bleeding, infection, and pneumothorax. A total of 28 patients (53.8%) experienced at least one of the above complications, but there were no deaths associated with biopsy. CONCLUSIONS: Medical thoracoscopic lung biopsy appears a safe and effective method for diagnosing diffuse ILD of unknown cause but further prospective studies, with larger numbers, including comparison with other established techniques are required.

High-risk Disease and Poor Follow-up: The Importance of Renal Mass Biopsy in a Cohort of Veterans.

OBJECTIVE: To assess the clinical utility of renal mass biopsy (RMB) in our multistate system. RMB is useful in the management of masses ≤4 cm (T1a), but evaluation of RMB in the uniquely vulnerable Veteran population is lacking. METHODS: About 136 RMB in 130 patients performed between 06/2015 and 11/2020 were identified in this Quality Improvement analysis. Demographics, size, pathology, treatment, and biopsy complications were analyzed. Of 101 T1a masses, 89 were either diagnostic or not decompressed cysts and 77 met inclusion criteria for follow-up imaging compliance analysis. RESULTS: The median age was 66 years. The diagnostic rate was 94.1% (128/136) for all masses and 94.1% (95/101) for T1a renal masses, with a complication rate of 2.2%. Among solid T1a masses, unexpectedly aggressive lesions (Fuhrman Grade 4, Type 2 papillary or sarcomatoid features) were identified in 8/89 (9.0%). Fifty-seven (64%) patients were treated with cryoablation or surgery and 32 (36%) patients elected active surveillance (AS). A neoplastic finding (oncocytoma or renal cell carcinoma (RCC)) was present in 16 patients choosing AS (50%) compared to 52 patients choosing treatment (91%). Compliance with National Comprehensive Cancer Network-recommended imaging was 50% and 47% for AS and treatment groups, respectively. CONCLUSION: In this VA cohort, we found a significant incidence of high-risk lesions and poor compliance with follow-up imaging. Aggressive biopsy protocols with high consideration of treatment may be appropriate to limit risk in those lost to follow-up. Given that 9% of our small renal masses were highly aggressive, biopsy may be critical in the selection of AS candidates.

Quiste inflamatorio con tejido calcificado: presentación de un caso clínico / Inflammatory cyst with calcified tissue: presentation of a clinical case

Objetivo: Describir un caso de quiste odontogénico in- flamatorio cuya presentación imagenológica no es la habitual. Caso clínico: Acude a la clínica profesional de Pato- logía Oral de la Universidad Andrés Bello una paciente de género femenino de 13 años, sin antecedentes mórbidos, con un hallazgo radiográfico de lesión mixta ubicada entre los premolares inferiores derechos. Es derivada al posgrado de cirugía oral y maxilofacial para que le realicen una biopsia excisional de la lesión con una hipótesis diagnóstica de tumor odontogénico adenomatoide. Una vez realizado el estudio histopatológico, se define la lesión como quiste odontogénico inflamatorio, que por las características clínicas-radiográficas podría corresponder con un quiste residual de un diente tem- poral. Debido a la variabilidad en la presentación clínica e ima- genológica de las lesiones quísticas maxilofaciales, el estudio anatomopatológico es imprescindible para un correcto diag- nóstico y tratamiento (AU)

Aim: To present a case of inflammatory odontogenic cyst with unusual imaging presentation. Clinical case: A 13-year-old female patient, with no history of morbidity, with a radiographic finding of a mixed lesion located between the lower right premolars. The patient visited the professional Oral Pathology clinic of the Andrés Bello University and was referred to postgraduate oral and maxillofacial surgery for an excisional biopsy of the lesion, with a diagnostic hypothesis of adenomatoid odontogenic tu- mor. After the histopathological study, the lesion was defined as an inflammatory odontogenic cyst, which, based on clini- cal-radiographic characteristics, could be a residual cyst of a primary tooth. Due to the variability in the clinical and imaging pres- entation of maxillofacial cystic lesions, anatomopathological study is essential for correct diagnosis and treatment (AU)

Outpatient transperineal prostate biopsy under local anaesthesia is safe, well tolerated and feasible.

BACKGROUND: Transperineal biopsy (TPB) of the prostate has been increasingly utilized as it has reduced infection risks. Traditionally however, it is performed under general anaesthesia, thus it carries a differing set of risks. Recently, new studies have performed TPB under local anaesthesia with success. In the present study, we explored our experience of performing TPB under local anaesthesia in an Australian cohort. METHODS: In this prospective study based at a metropolitan outpatient clinic, patients were provided with TPB under local anaesthesia. We assessed prostate cancer detection rates, complication rates and patient tolerability. Pain tolerability was assess using patient reported pain score on the visual analogue scale. Follow up data was collected at days 7 and 30 post-biopsy via telephone interview. RESULTS: A total of 48 patients were enrolled in this study between June 2020 and March 2021. Median age was 65.5 years and median PSA was 6.95 ng/mL. Clinically significant prostate cancer was detected in 58% of patients. During the procedure, pain scores were rated the highest during infiltration of local anaesthetic agent with a median score of 5. By the conclusion of the procedure, median pain score was 1. Vast majority of patients (85.4%) would opt for a repeat TPB under local anaesthesia should the need for prostate biopsy arise again. Two of our patients experienced infectious complications, and one experienced urinary retention. CONCLUSION: Our data is in line with currently available data and confirms that TPB under local anaesthesia can be achieved in a safe and tolerable manner.

'Pain-free TRUS B': a phase 3 double-blind placebo-controlled randomized trial of methoxyflurane with periprostatic local anaesthesia to reduce the discomfort of transrectal ultrasonography-guided prostate biopsy (ANZUP 1501).

OBJECTIVE: To determine whether the addition of inhaled methoxyflurane to periprostatic infiltration of local anaesthetic (PILA) during transrectal ultrasonography-guided prostate biopsies (TRUSBs) improved pain and other aspects of the experience. PATIENTS AND METHODS: We conducted a multicentre, placebo-controlled, double-blind, randomized phase 3 trial, involving 420 men undergoing their first TRUSB. The intervention was PILA plus a patient-controlled device containing either 3 mL methoxyflurane, or 3 mL 0.9% saline plus one drop of methoxyflurane to preserve blinding. The primary outcome was the pain score (0-10) reported by the participant after 15 min. Secondary outcomes included ratings of other aspects of the biopsy experience, willingness to undergo future biopsies, urologists' ratings, biopsy completion, and adverse events. RESULTS: The mean (SE) pain scores 15 min after TRUSB were 2.51 (0.22) in those assigned methoxyflurane vs 2.82 (0.22) for placebo (difference 0.31, 95% confidence interval [CI] -0.75 to 0.14; P = 0.18). Methoxyflurane was associated with better scores for discomfort (difference -0.48, 95% CI -0.92 to -0.03; P = 0.035, adjusted [adj.] P = 0.076), whole experience (difference -0.50, 95% CI -0.92 to -0.08; P = 0.021, adj. P = 0.053), and willingness to undergo repeat biopsies (odds ratio 1.67, 95% CI 1.12-2.49; P = 0.01) than placebo. Methoxyflurane resulted in higher scores for drowsiness (difference +1.64, 95% CI 1.21-2.07; P < 0.001, adj. P < 0.001) and dizziness (difference +1.78, 95% CI 1.31-2.24; P < 0.001, adj. P < 0.001) than placebo. There was no significant difference in the number of ≥ grade 3 adverse events. CONCLUSIONS: We found no evidence that methoxyflurane improved pain scores at 15 min, however, improvements were seen in patient-reported discomfort, overall experience, and willingness to undergo repeat biopsies.

PET/CT scan and biopsy-driven approach for safe anti-PD-1 therapy discontinuation in patients with advanced melanoma.

BACKGROUND: Limited data exist on safe discontinuation of antiprogrammed cell death protein 1 (PD-1) therapy in responding patients with advanced melanoma. The use of 18fluorodeoxyglucose (18FDG)-PET/CT scan and tumor biopsy for assessment of active disease may be an effective predictive biomarker to guide such treatment decisions. METHODS: A retrospective study of 122 patients with advanced melanoma treated with anti-PD-1 monotherapy or anti-PD-1/anticytotoxic T-lymphocyte-associated protein 4 combination therapy at Georgetown Lombardi Comprehensive Cancer Center was conducted. Uveal melanoma patients and those receiving concurrent experimental therapy were excluded. Baseline characteristics, treatment outcomes, and survival were analyzed. Patients who decided to come off treatment typically after 12 months using CT scan radiographic complete response (CR), 18FDG-PET/CT scan complete metabolic response (CMR) or tumor biopsy of a non-CR/CMR tumor site negative for active disease (possible pathological CR) were identified and compared with patients who discontinued treatment due to toxicity while their disease was in control. Event-free survival (EFS) was assessed from the last dose of anti-PD-1 therapy to progression requiring subsequent treatment (surgery, radiation, and/or systemic therapy) or referral to hospice/death due to melanoma. RESULTS: 24 (20%) patients discontinued treatment by choice with no active disease and 28 (23%) patients discontinued treatment due to toxicity with disease control after 12-month and 4-month median treatment durations, respectively. Similar baseline characteristics were observed between cohorts except higher prior receipt of ipilimumab (29% vs 7%; p=0.036) and fewer BRAF mutant positive disease (17% vs 41%; p=0.064) in patients off treatment by choice. Three-year EFS rates were 95% and 71%, respectively. No significant associations between EFS and sex, disease stage, lactate dehydrogenase elevation, BRAF status, prior systemic therapy, ECOG performance status, presence of brain metastases, or combination versus monotherapy were observed. Tumor biopsies led to alternative management in 3/10 patients due to active metastatic melanoma or second malignancy. CONCLUSIONS: Anti-PD-1 therapy discontinuation after 12 months when no active disease is observed on CT scan, PET/CT scan or tumor biopsy may have low rates of disease relapse in patients with advanced melanoma. Biopsy of residual disease may frequently lead to a change in management. These findings are undergoing validation in the EA6192 trial.

Right ventricular endomyocardial biopsy in patients with cardiac magnetic resonance showing left ventricular myocarditis.

AIMS: The aim of this study was to evaluate the sensitivity of right ventricular endomyocardial biopsy (EMB) in myocarditis patients with cardiac magnetic resonance (CMR) and electroanatomical mapping (EAM) showing left ventricular abnormalities. METHODS: We performed right ventricular EMB in 144 consecutive patients (66% men, age 43 ±â€Š15 years) with acute symptoms and CMR-proved diagnosis of left ventricular myocarditis. Right ventricular EMB sensitivity has been evaluated in patients with different localization and extension of abnormal substrate at both CMR and -- when performed -- EAM. Abnormal substrate was defined, respectively, by late gadolinium enhancement (LGE) and low-voltage areas (LVAs). RESULTS: Globally, right ventricular EMB sensitivity was 87.5%. EMB-negative cases had significantly smaller fragment sizes (cumulative area 2.8 ±â€Š1.7 vs. 3.8 ±â€Š1.8 mm2, P = 0.023), and lower LGE surface extension (24.7 ±â€Š14.2 vs. 38.5 ±â€Š20.2%, P = 0.006) and transmurality (32.0 ±â€Š26.1 vs. 49.3 ±â€Š22.6, P = 0.003). Right ventricular EMB sensitivity in patients with LGE involving both right ventricular and interventricular septum (IVS), isolated right ventricular or IVS, and remote left ventricular areas (n = 10, 49 and 67 cases) was 83.3, 84.4 and 90.5%, respectively (P = 0.522). Overall, 34 patients (23.6%) underwent EAM. On the basis of EAM, right ventricular EMB sensitivity was 85.3%: in detail, it was 50.0, 88.2 and 86.7% in patients with both right ventricular and IVS, isolated right ventricular/IVS and distant left ventricular involvement (n = 2, 17 and 15, respectively, P > 0.05). Sample size area was the only factor associated with right ventricular EMB sensitivity (hazard ratio = 1.6/mm2, 95% confidence interval 1.1-2.4, P = 0.013). CONCLUSION: Right ventricular EMB is still an accurate technique to confirm diagnosis in patients with CMR-proved left ventricular myocarditis. In particular, provided there is an adequate sample size, its sensitivity is comparable among patients with heterogeneous LGE or LVA localization.

Ground-glass hepatocellular inclusions are associated with polypharmacy.

Ground-glass (GG) hepatocytes are classically associated with chronic hepatitis B (HBV) infection, storage disorders, or cyanamide therapy. In a subset of cases, an exact etiology cannot be identified. In this study, we sought to characterize the clinical, histological, and ultrastructural findings associated with HBV-negative GG hepatocytes. Our institutional laboratory information system was searched from 2000 to 2019 for all cases of ground-glass hepatocytes. Ten liver biopsies with GG hepatocellular inclusions and negative HBV serology, no known history of storage disorders, or cyanamide therapy were reviewed. Half of the patients had history of organ transplantation and/or malignancy. These patients took on average 8.1 medications (range: 3-14) with the most common medications being immunosuppressive and health supplements. Histologically, GG hepatocytes show either peri-portal or centrizonal distribution. The inclusions are PAS-positive and diastase sensitive. Electron microscopy showed intracytoplasmic granular inclusions with low electron density, consistent with unstructured glycogen. In summary, GG hepatocytes are a rare finding in liver biopsies, but are more common in patients with hepatitis B. They can also be seen in HBV-negative patients who have polypharmacy. In these cases, they are the result of unstructured glycogen accumulation putatively due to altered cell metabolism.

Hemimandibulectomía por ameloblastoma multiquístico. A propósito de un caso / Multicystic ameloblastoma hemimandibulectomy. A propos of a case

RESUMEN El ameloblastoma es un tumor odontogénico benigno, localmente agresivo y recidivante, con predilección por la región posterior de la mandíbula. Se caracteriza por su agresividad local con muy baja tendencia a metastizarse. El objetivo fue reportar el caso clínico de un paciente con ameloblastoma multiquístico derecho, tratado a través de hemimandibulectomía. Se presentó un paciente masculino, de 44 años de edad, que refirió aumento de volumen del lado derecho de la mandíbula desde hacía aproximadamente un año, acompañado también de otros síntomas, atendido en el Servicio de Cirugía Maxilofacial del Hospital Militar Principal/Instituto Superior, en Luanda, Angola. Los estudios imagenológicos incluyeron radiografía panorámica y tomografía axial computarizada. El diagnóstico clínico patológico fue de ameloblastoma multiquístico. Este tipo de tumor requiere de un adecuado diagnóstico sobre la base de la presentación clínica, localización, tamaño, edad y tipo histológico; de ahí la importancia de conocer las características clínicas e imagenológicas, pues el tratamiento conlleva gran dificultad (AU).

ABSTRACT Ameloblastoma is a benign odontogenic tumor, locally aggressive and recidivist with predilection for back of the jaw, characterized by local aggressiveness and low tendency to metastasize. The aim was reporting the clinical case of a patient with right multicystic ameloblastoma treated through hemimandibulectomy. We presented a male patient aged 44 years, who referred a volume increase of the jaw right side for around a year, accompanied also by other symptoms; he attended the Maxillofacial Surgery Service of the Main Military Hospital/High Institute of Luanda, in Angola. The image studies included panoramic radiography and computerized axial tomography the clinical pathological diagnosis was multicystic ameloblastoma. This kind of tumor requires an adequate diagnosis based on the clinical presentation, location, size, age and histological kind, therefore the importance of knowing the clinical and image characteristics, because the treatment is very difficult (AU).

Tinción con azul de toluidina en biopsia dirigida de lesiones displásicas de la mucosa bucal: informe de casos clínicos / Toluidine blue guided biopsy of dysplastic lesions of the oral mucosa: clinical cases report

Objetivo: Los desórdenes de mucosa bucal potencialmente malignos pueden presentar áreas displásicas. En estos casos, la biopsia es un procedimiento imprescindible para un correcto diagnóstico. La inspección visual y la palpación, como método de selección del área de biopsia, ofrecen sensibilidad y especificidad adecuadas pero mejorables. El objetivo de este artículo es presentar una serie de casos clínicos en los que se describen el empleo y la interpretación de la tinción vital con azul de toluidina como método complementario para contribuir a una mejor elección del área de biopsia. Casos clínicos: Se trata de siete casos de lesiones con sospecha de displasia epitelial en mucosa bucal. En cada uno se detalla la correlación de las áreas teñidas con las manifestaciones clínicas y con el diagnóstico de displasia. Además, se muestran patrones de tinción considerados falsos positivos. En la interpretación de la tinción positiva, se tuvieron en cuenta el aspecto superficial y el color de la lesión teñida. El empleo combinado de inspección, palpación y tinción vital podría constituir un procedimiento integral de utilidad para obtener mayor precisión en la determinación del sitio de biopsia en comparación con los mismos procedimientos aplicados de manera individual. En la interpretación de la tinción positiva con azul de toluidina deberían considerarse el aspecto superficial y el color de la lesión teñida (AU)

Aim: Potentially Malignant Disorders in the oral cavity can present dysplastic areas. In these cases, the biopsy is an essential procedure for a correct diagnosis. Visual inspection and palpation, are adequate methods to select the area for the biopsy, however there is margin for improvement. The objective of this article is to present a series of clinical cases in which the use and interpretation of vital staining with Toluidine Blue is described as a complementary method to contribute to a better choice of the biopsy area. Clinical cases: Seven clinical cases that presented lesions with suspected epithelial dysplasia in the oral mucosa were presented. The correlation of the stained areas with the clinical manifestations and with the diagnosis of dysplasia is detailed in each case. Staining patterns considered false positives are also shown. In the interpretation of the positive staining, the superficial appearance and color of the stained lesion were considered. The combined use of inspection, palpation and vital staining could constitute a useful comprehensive procedure to obtain greater precision in determining the biopsy site in relation to the same procedures applied individually. In the interpretation of the positive staining with Toluidine Blue, the superficial appearance and color of the stained lesion should be considered (AU)

Hyperbaric oxygen therapy to prevent central airway stenosis after lung transplantation.

BACKGROUND: Central airway stenosis (CAS) is a severe airway complication after lung transplantation associated with bronchial ischemia and necrosis. We sought to determine whether hyperbaric oxygen therapy (HBOT), an established treatment for tissue ischemia, attenuates post-transplant bronchial injury. METHODS: We performed a randomized, controlled trial comparing usual care with HBOT (2 atm absolute for 2 hours × 20 sessions) in subjects with extensive airway necrosis 4 weeks after transplantation. Endobronchial biopsies were collected at 4, 7, and 10 weeks after transplantation for a quantitative polymerase chain reaction. Coprimary outcomes were incidence of airway stenting and acute cellular rejection (ACR) at 1 year. RESULTS: The trial was stopped after enrolling 20 subjects (n = 10 per group) after a pre-planned interim analysis showed no difference between usual care and HBOT groups in stenting (both 40%), ACR (70% and 40%, respectively), or CAS (40% and 60%, respectively). Time to first stent placement (median [interquartile range]) was significantly shorter in the HBOT group (150 [73-150] vs 186 [167-206] days, p < 0.05). HIF gene expression was significantly increased in donor tissues at 4, 7, and 10 weeks after transplantation but was not altered by HBOT. Subjects who developed CAS or required stenting had significantly higher HMOX1 and VEGFA expression at 4 weeks (both p < 0.05). Subjects who developed ACR had significant FLT1, TIE2, and KDR expression at 4 weeks (all p < 0.05). CONCLUSIONS: Incidence of CAS is high after severe, established airway necrosis after transplantation. HBOT does not reduce CAS severity or stenting. Elevated HMOX1 and VEGFA expressions appear to associate with airway complications.

Local anaesthetic transperineal (LATP) prostate biopsy using a probe-mounted transperineal access system: a multicentre prospective outcome analysis.

OBJECTIVES: To assess the feasibility of local anaesthetic transperineal (LATP) technique using a single-freehand transperineal (TP) access device, and report initial prostate cancer (PCa) detection, infection rates, and tolerability. PATIENTS AND METHODS: Observational study of a multicentre prospective cohort, including all consecutive cases. LATP was performed in three settings: (i) first biopsy in suspected PCa, (ii) confirmatory biopsies for active surveillance, and (iii) repeat biopsy in suspected PCa. All patients received pre-procedure antibiotics according to local hospital guidelines. Local anaesthesia was achieved by perineal skin infiltration and periprostatic nerve block without sedation. Ginsburg protocol principles were followed for systematic biopsies including cognitive magnetic resonance imaging-targeted biopsies when needed using the PrecisionPoint™ TP access device. Procedure-related complications and oncological outcomes were prospectively and consecutively collected. A validated questionnaire was used in a subset of centres to collect data on patient-reported outcome measures (PROMs). RESULTS: Some 1218 patients underwent LATP biopsies at 10 centres: 55%, 24%, and 21% for each of the three settings, respectively. Any grade PCa was diagnosed in 816 patients (67%), of which 634 (52% of total) had clinically significant disease. Two cases of sepsis were documented (0.16%) and urinary retention was observed in 19 patients (1.6%). PROMs were distributed to 419 patients, with a 56% response rate (n = 234). In these men, pain during the biopsy was described as either 'not at all' or 'a little' painful by 64% of patients. Haematuria was the most common reported symptom (77%). When exploring attitude to re-biopsy, 48% said it would be 'not a problem' and in contrast 8.1% would consider it a 'major problem'. Most of the patients (81%) described the biopsy as a 'minor or moderate procedure tolerable under local anaesthesia', while 5.6% perceived it as a 'major procedure that requires general anaesthesia'. CONCLUSION: Our data suggest that LATP biopsy using a TP access system mounted to the ultrasound probe achieves excellent PCa detection, with a very low sepsis rate, and is safe and well tolerated. We believe a randomised controlled trial comparing LATP with transrectal ultrasound-guided biopsy (TRUS) to investigate the relative trade-offs between each biopsy technique would be helpful.

Implementing Continuous Quality Improvement in an Integrated Community Urology Practice: Lessons Learned.

OBJECTIVE: To determine the effectiveness of 2 different continuous quality improvement interventions in an integrated community urology practice. We specifically assessed the impact of audited physician feedback on improving physicians' adoption of active surveillance for low-risk prostate cancer (CaP) and adherence to a prostate biopsy time-out intervention. MATERIALS AND METHODS: The electronic medical records of Genesis Healthcare Partners were analyzed between August 24, 2011 and September 30, 2020 to evaluate the performance of 2 quality interventions: audited physician feedback to improve active surveillance adoption in low-risk CaP patients, and audited physician feedback to promote adherence to an electronic medical records embedded prostate biopsy time-out template. Physician and Genesis Healthcare Partners group adherence to each quality initiative was compared before and after each intervention type using ANOVA testing. RESULTS: For active surveillance, we consistently saw an increase in active surveillance adoption for low risk CaP patients in association with continuous audited feedback (P < .001). Adherence to the prostate biopsy time-out template improved when audited feedback was provided (P < .001). CONCLUSION: The implementation of clinical guidelines into routine clinical practice remains challenging and poses an obstacle to the improvement of United States healthcare quality. Continuous quality improvement should be a dynamic process, and in our experience, audited feedback coupled with education is most effective.