Developing guidelines to support injured workers who live and work with chronic pain.

BACKGROUND: Living and working with chronic pain requires persons to alter lifestyles and have the knowledge as well as support to manage unforeseen challenges. Knowledge for persons living with pain who want to participate in meaningful paid and unpaid work is not easily accessible. While there is literature on chronic pain management, work transitions and return to work, less emphasis has been placed on the complexity of living and working with chronic pain. The Creating a Way Forward Project was envisioned to address this gap and to identify the informational needs of workers with pain, health/helping professionals (workers' advisors, return to work specialists, legal representatives), and stakeholders. The overarching aim of the project was to use evidence and experiential knowledge to inform the development of a foundation for educational guides and toolkits to support workers with pain to achieve their outcomes for remaining at work. METHODS: Phase one of the project involved a scoping review of chronic pain and work. Phase two involved stakeholder consultations, a focus group and knowledge integration of the literature and experiential insights. Knowledge synthesis drew on a Template Analysis of multiple sources of data. RESULTS: Knowledge domains and key components were identified for persons with pain and for the health/helping professions. CONCLUSION: These domains reflect a foundation for knowledge in practical training and the development of curriculum for education in self-management program and in inter professional health profession education. These knowledge domains provide a basis for future research in integrated approaches and knowledge use toward improving transitions for persons living with chronic pain who want to participate in productive paid and unpaid work. Ongoing research in knowledge domains that health providers and persons with pain need will expand the potential for improving health outcomes in living with and managing pain.

Genitourinary Complications of Gender-Affirming Surgery.

PURPOSE OF REVIEW: Gender-affirming surgery has become a more common procedure in the last 5 years. Feminizing genitoplasty typically involves inversion of penile skin as a neovagina, urethral shortening, and glans reduction to create a neoclitoris. Masculinizing genitoplasty is more complex, typically is performed in multiple stages, and has more inherent urologic risks. RECENT FINDINGS: The most common urologic complications involve voiding dysfunction, specifically meatal stenosis or fistula to the urinary tract. Urethral stricture, fistula, urinary retention, and voiding dysfunction are very common and require early recognition and intervention. This includes placement of catheter drainage, if necessary with the appropriate urologic instrumentation. Genital risks relating to phallus health are rare, but risks associated with placement of penile prosthesis for sexual function are common and require immediate attention. Urological complications after gender-affirming surgery are common, and the general urologist and urogynecologist should be able to identify and treat problems in this population after review of this chapter.

Robot-Assisted Excision of Congenital Mega-Seminal Vesicle Associated with Zinner's Syndrome.

Background: Abnormalities of mesonephric ducts are rare congenital conditions, which can present with vague symptoms in otherwise healthy men. Zinner's syndrome is the association of an enlarged seminal vesicle cyst with ipsilateral renal agenesis, which can be symptomatic and require operative interventions. Case: We present the case of an otherwise healthy 24-year-old man who presented with a symptomatic 15 cm seminal vesicle cyst, which was completely excised using a robot-assisted approach. Conclusion: Use of robotic surgery for excision of large seminal vesicle cysts is a safe and effective operative procedure.

Effect of Topical Anesthetic Cream on Pain During Periareolar Injection of Technetium Tc99m Sulfur Colloid for Sentinel Lymph Node Biopsy in Breast Cancer: A Randomized Control Trial.

BACKGROUND: Injection of Tc99m to localize nodes for sentinel lymph node biopsy is reported by patients as very painful. The purpose of this study was to determine if anesthetic cream reduces pain associated with periareolar injection of Tc99m and to help elucidate conflicting literature regarding the efficacy of anesthetic cream for this procedure. METHODS: A randomized, double-blind, placebo-controlled methodology was used for adult females with breast cancer undergoing periareolar injection of Tc99m for sentinel lymph node biopsy. Pain levels were compared using anesthetic cream (2.5% lidocaine/2.5% prilocaine) vs. placebo. Patient exclusion criteria included use of opioids or adjuvant pain medication or injecting Tc99m the day before surgery. The Numerical Rating Scale was used to assess pain levels immediately after the injections. RESULTS: Comparing 23 experimental and 26 control patients, there was no significant difference between the experimental (median = 4) and the control group (median = 5) on level of pain experienced U= 0.492, P > .05. CONCLUSIONS: The experimental group had a slightly lower median pain score; however, there was no statistically significant difference between those who used the cream compared with those who used a placebo, supporting the conclusion that anesthetic cream does not reduce pain during Tc99m injections. This study adds to the current literature to provide a stronger position that there is no benefit to using anesthetic cream for this procedure.

Adverse pathologic characteristics in the small renal mass: implications for active surveillance.

INTRODUCTION: Evidence has demonstrated that tumor size is related to adverse oncologic outcomes in small renal tumors (≤ 4 cm). We evaluated the association of adverse pathologic features (APF) with tumor size and survival in patients with a small renal mass (SRM). MATERIALS AND METHODS: We retrospectively reviewed the pathologic characteristics of 380 surgically resected SRMs from a single institution. APFs included lymphovascular invasion, coagulative necrosis, sarcomatoid/rhabdoid features, papillary type II histology, and perinephric fat/renal sinus invasion. The number and type of APFs were compared with tumor size. Survival analysis was performed using the Kaplan-Meier method. RESULTS: There were 244 (64.2%) males and 136 (35.8%) females. The median age was 61 years, and median tumor size was 2.7 cm. The median follow up time was 65 months. A significant association was found between tumor size and presence of APFs (p = 0.018). At least 1 APF could be found in 22%, 32%, 36%, and 49% of tumors ≤ 1 cm, 1 cm-2 cm, 2 cm-3 cm, and 3 cm-4 cm, respectively. There were no differences in overall survival or recurrence free survival when compared by tumor size at diagnosis (p = 0.22 and 0.15 respectively). Compared to patients with ≤ 1 APFs, disease specific survival was worse for patients with ≥ 2 APFs (p < 0.002). CONCLUSION: Our data support that aggressive tumor biology in a SRM is associated with greater size. In patients with a SRM, the decision to pursue active surveillance and the trigger for intervention should take tumor size and APFs into consideration as this may have future oncologic implications.

The effect of hypogonadism and testosterone-enhancing therapy on alkaline phosphatase and bone mineral density.

OBJECTIVE: To evaluate the relationship of testosterone-enhancing therapy on alkaline phosphatase (AP) in relation to bone mineral density (BMD) in hypogonadal men. PATIENTS AND METHODS: Retrospective review of 140 men with testosterone levels of <350 ng/dL undergoing testosterone-enhancing therapy and followed for 2 years. Follicle-stimulating hormone, luteinising hormone, free testosterone, total testosterone, sex hormone binding globulin, calcium, AP, vitamin D, parathyroid hormone, and dual-energy X-ray absorptiometry (DEXA) scans were analysed. A subgroup of 36 men with one DEXA scan before and one DEXA 2 years after initiating treatment was performed. RESULTS: Analysis of the relationship between testosterone and AP at initiation of therapy using stiff linear splines suggested that bone turnover occurs at total testosterone levels of <250 ng/dL. In men with testosterone levels of <250 ng/dL, there was a negative correlation between testosterone and AP (R(2) = -0.347, P < 0.001), and no correlation when testosterone levels were between 250 and 350 ng/dL. In the subgroup analysis, the mean (sd) testosterone level was 264 (103) ng/dL initially and 701 (245), 539 (292), and 338 (189) ng/dL at 6, 12, and 24 months, respectively. AP decreased from a mean (sd) of 87 (38) U/L to 57 (12) U/L (P = 0.015), 60 (17) U/L (P < 0.001), and 55 (10) U/L (P = 0.03) at 6, 12, and 24 months, respectively. The BMD increased by a mean (sd) of 20 (39)% (P = 0.003) on DEXA. CONCLUSION: In hypogonadal men, the decrease in AP is associated with an increase in BMD on DEXA testing. This result suggests the use of AP as a marker of response to therapy.

Severe testicular atrophy does not affect the success of microdissection testicular sperm extraction.

PURPOSE: Men with azoospermia and severe testicular atrophy may be counseled to avoid sperm retrieval due to perceived limited success. We evaluated the outcomes of microdissection testicular sperm extraction in men with severe testicular atrophy (volume 2 ml or less). MATERIALS AND METHODS: We reviewed the records of 1,127 men with nonobstructive azoospermia who underwent microdissection testicular sperm extraction followed by intracytoplasmic sperm injection. They were classified into 3 groups based on average testicular volume, including 2 ml or less, greater than 2 to less than 10 and 10 or greater. Sperm retrieval, clinical pregnancy and live birth rates were calculated. Clinical features evaluated included age, follicle-stimulating hormone level, cryptorchidism history, Klinefelter syndrome, varicocele and testicular histology on diagnostic biopsy. RESULTS: Testicular sperm were successfully retrieved in 56% of the men. The sperm retrieval rate in those with a testicular volume of 2 ml or less, greater than 2 to less than 10 and 10 or greater was 55%, 56% and 55%, respectively. Clinical pregnancy and live birth rates were similar in men in the 3 groups who underwent sperm retrieval (55.2%, 50.0% and 47.0%, and 47.2%, 43.0% and 42.2%, respectively). Of the 106 men with an average testis volume of 2 ml or less those from whom sperm were retrieved were younger (31.1 vs 35.2 years) and more likely to have a history of Klinefelter syndrome (82.2% vs 55.6%) than men in whom sperm were not found (p <0.05). Men in this group had a higher prevalence of Klinefelter syndrome than men with a testis volume of greater than 2 ml (72.6% vs 5.3%, p <0.0001). Men younger than 30 years with Klinefelter syndrome had a higher sperm retrieval rate than men older than 30 years without Klinefelter syndrome (81.8% vs 33%, p <0.01). There was no cutoff point for age beyond which sperm could not be retrieved in men with small testes. On multivariable analysis younger age was the only preoperative factor associated with successful sperm retrieval in men with small testes (2 ml or less). CONCLUSIONS: Testicular volume does not affect the sperm retrieval rate at our center for microdissection testicular sperm extraction. Of men with the smallest volume testes those who were younger with Klinefelter syndrome had the highest sperm retrieval rate. Severe testicular atrophy should not be a contraindication to microdissection testicular sperm extraction.

Localization of sperm during microdissection testicular sperm extraction in men with nonobstructive azoospermia.

PURPOSE: We determined the location where sperm were identified during microdissection testicular sperm extraction and characterized the subset of patients for whom complete bilateral exploration was most beneficial. MATERIALS AND METHODS: A total of 900 men underwent a first attempt at microdissection testicular sperm extraction. Sperm extraction began with an initial wide incision in the larger testis. If no sperm were identified, the deeper tissue was extensively microdissected. A similar technique was used on the contralateral testis if no sperm were found on the initial side. RESULTS: In 474 men (52.6%) sperm were identified at the first microdissection testicular sperm extraction. Of these men 308 (65%) had sperm identified through the initial wide incision alone. In men with lower preoperative follicle-stimulating hormone, larger testicular volume, a varicocele history and hypospermatogenesis on preoperative or intraoperative diagnostic biopsy there was a greater chance of finding sperm in the initial wide incision alone (p <0.05). Only 40 of the 506 men (8%) who underwent bilateral testicular microdissection had sperm found on the contralateral side when no sperm were identified on the initial side. In men with Klinefelter syndrome and small testes the chance of sperm retrieval was higher on the contralateral side after negative unilateral microdissection (p <0.05). CONCLUSIONS: More than a third of the men with nonobstructive azoospermia required complete microdissection of the testes to identify sperm. Sperm were found on the contralateral side in up to 8% of the men in whom no sperm were identified in the initial testis.

Overweight men with nonobstructive azoospermia have worse pregnancy outcomes after microdissection testicular sperm extraction.

OBJECTIVE: To evaluate the effect of obesity on the outcome of testicular sperm extraction (TESE) and assisted reproductive technology. DESIGN: Clinical retrospective study. SETTING: Center for reproductive medicine at a tertiary-care university hospital. PATIENT(S): Nine hundred seventy patients with nonobstructive azoospermia. INTERVENTION(S): Microdissection TESE followed by intracytoplasmic sperm injection (ICSI). MAIN OUTCOME MEASURE(S): Sperm retrieval rate and clinical pregnancy rate. RESULT(S): Testicular sperm were successfully retrieved in 55% of men overall. Of those with sperm found, clinical pregnancy rate was 51% and live birth rate 40%. Sperm retrieval rates were similar in men with body mass index (BMI) <25 kg/m(2), 25-30 kg/m(2), and >30 kg/m(2) (59%, 57%, and 54%, respectively). Mean BMI of men who contributed to pregnancy (27.3 ± 4.9 kg/m(2)) was lower than for men whose sperm did not contribute to a pregnancy (28.2 ± 5.4 kg/m(2)). No man with BMI >43 kg/m(2) (n = 11) contributed to a successful pregnancy, even though sperm were found in men with BMI up to 57 kg/m(2). On multivariable logistic regression analysis, male BMI was the only predictor of successful pregnancy among the variables analyzed, including male age, female age, and female BMI. CONCLUSION(S): Overweight men have lower clinical pregnancy rate after microdissection TESE and ICSI compared with men with normal BMI. Men with BMI >43 kg/m(2) did not contribute to any pregnancies, despite successful sperm retrieval.

A scoping review on occupational and self identity after a brain injury.

OBJECTIVE: Persons with brain injury experience a shift in their self identity that is underpinned by work loss and changes to their worker role. However, little is known on how to assist a worker with a brain injury re-establish their occupational identity. Thus, the objective of this article is to present the results of a scoping review undertaken to examine the literature on occupational identity and self identity after a brain injury. METHODS: A scoping review was performed using the keywords traumatic, acquired brain injury, occupational, and self identity. Articles were narrowed through three phases which involved reviewing articles to ensure a thorough discussion of identity after a brain injury was included and to highlight the research questions. RESULTS: In total 16 articles and 3 theses were included. No articles were retrieved on occupational identity after a brain injury. Fourteen articles discussed the loss of self identity experienced after a brain injury while three articles highlighted rehabilitation programs. CONCLUSIONS: Research indicates there are extensive changes to identity after a brain injury and this impacts returning to previous occupations. This knowledge can further our understanding of returning to occupations after a brain injury and the impact on occupational identity.

GITR pathway activation abrogates tumor immune suppression through loss of regulatory T cell lineage stability.

Ligation of GITR (glucocorticoid-induced tumor necrosis factor (TNF) receptor-related gene, or TNFRSF18) by agonist antibody has recently entered into early phase clinical trials for the treatment of advanced malignancies. Although the ability of GITR modulation to induce tumor regression is well-documented in preclinical studies, the underlying mechanisms of action, particularly its effects on CD4(+)foxp3(+) regulatory T cells (Treg), have not been fully elucidated. We have previously demonstrated that GITR ligation in vivo by agonist antibody DTA-1 causes a >50% reduction of intra-tumor Treg with down modulation of Foxp3 expression. Here we show that the loss of Foxp3 is tumor-dependent. Adoptively-transferred Foxp3(+)Treg from tumor-bearing animals lose Foxp3 expression in the host when treated with DTA-1, whereas Treg from naïve mice maintain Foxp3 expression. GITR ligation also alters the expression of various transcription factors and cytokines important for Treg function. Complete Foxp3 loss in intra-tumor Treg correlates with a dramatic decrease in Helios expression and is associated with the upregulation of transcription factors T-Bet and Eomes. Changes in Helios correspond with a reduction in IL-10 and an increase in IFNγ expression in DTA-1-treated Treg. Together, these data show that GITR agonist antibody alters Treg lineage stability inducing an inflammatory effector T cell phenotype. The resultant loss of lineage stability causes Treg to lose their intra-tumor immune suppressive function, making the tumor susceptible to killing by tumor-specific effector CD8(+) T cells.

Role of tissue digestion and extensive sperm search after microdissection testicular sperm extraction.

OBJECTIVE: To report the chance of sperm discovery in the laboratory when sperm were not identified in the operating room (OR). DESIGN: Clinical retrospective study. SETTING: Department of urology at a tertiary university hospital. PATIENT(S): A total of 1,054 men with nonobstructive azoospermia who underwent microdissection testicular sperm extraction. INTERVENTION(S): Preoperative and intraoperative parameters were analyzed relative to the chance of sperm identification using a tissue digestion protocol in the laboratory if no sperm were observed in the OR. MAIN OUTCOME MEASURE(S): Sperm retrieval, clinical pregnancy, and live birth rates. RESULT(S): Sperm were found in the OR in 52.5% of the 1,054 men. Of the 501 men for whom sperm were not identified by andrologists in the OR, sperm were found in the laboratory for an additional 35 (7%). On multivariable logistic regression analysis, the presence of germ cells intraoperatively was the only predictor of identifying sperm in the laboratory after tissue digestion. CONCLUSION(S): In men undergoing microdissection testicular sperm extraction, when sperm were not observed in the OR despite extensive mechanical processing, sperm were observed in the laboratory for 7% of the men. This information is valuable in counseling couples in the immediate postoperative period when no sperm were identified intraoperatively.

Perspectives on prevention, assessment, and rehabilitation of low back pain in WORK.

INTRODUCTION: The aim of this review was to describe the low back pain (LBP) knowledge base developed in WORK and to discuss its relevance to current perspectives in the broader literature on LBP and employment. METHOD: A scoping review of the literature in WORK on LBP and employment was conducted using published articles from 1990-2009. Articles were organized into geographical regions and summarized for contributions to the domains of WORK: prevention, assessment, and rehabilitation. Methodological accordance of the articles was also assessed. RESULTS: Fifty articles were extracted and organized into contributions from authors within North America (n=34) and outside North America (n=16). In total there were 26 prevention, 7 assessment, and 12 rehabilitation articles in this review. Five articles were also classified as 'understanding' articles. More than half of the articles retrieved employed quantitative methodology. CONCLUSIONS: WORK has contributed a broad realm of publications to the knowledge base on LBP and employment. Two thirds of the articles were contributed from authors within North America, with a greater emphasis on prevention. This article highlights the similarities and differences in the international knowledge base in the management of LBP in WORK. Future directions for research are elaborated drawing on current perspectives of two experts on the management of LBP.