Multi-institutional Outcomes and Associations After Excision and Primary Anastomosis for Radiotherapy-associated Bulbomembranous Urethral Stenoses Following Prostate Cancer Treatment.

OBJECTIVE: To evaluate the outcomes of excision and primary anastomosis (EPA) for radiation-associated bulbomembranous stenoses using a multi-institutional analysis. The treatment of radiation-associated urethral stenosis is typically complex owing to the adverse impact of radiation on adjacent tissue. METHODS: An IRB-approved multi-institutional retrospective review was performed on patients who underwent EPA for bulbomembranous urethral stenosis following prostate radiotherapy. Preoperative patient demographics, operative technique, and postoperative outcomes were abstracted from 1/2007-6/2018. Success was defined as voiding per urethra without the need for endoscopic treatment and a minimum follow-up of 12 months. RESULTS: One hundred and thirty-seven patients from 10 centers met study criteria with a mean age of 69.3 years (50-86), stenosis length of 2.3 cm (1-5) and an 86.9% (119/137) success rate at a mean follow-up 32.3 months (12-118). Univariate Cox regression analysis identified increasing patient age (P = .02), stricture length (P <.0001) and combined modality radiotherapy (P = .004) as factors associated with stricture recurrence while body mass index (P = .79), diabetes (P = .93), smoking (P = .62), failed endoscopic treatment (P = .08) and gracilis muscle use (P = .25) were not. On multivariate analysis, increasing patient age (H.R.1.09, 95%CI 1.01-1.16; P = .02) and stenosis length (H.R.2.62, 95%CI 1.49-4.60; P = .001) remained associated with recurrence. Subsequent artificial urinary sphincter was performed in 30 men (21.9%), of which 25 required a transcorporal cuff and 5 developed cuff erosion. CONCLUSIONS: EPA for radiation-associated urethral stenosis effectively provides unobstructed instrumentation-free voiding. However, increasing stenosis length and age are independently associated with surgical failure. Patients should be counseled that further surgery for incontinence may be necessary.

Current and future international patterns of care of neurogenic bladder after spinal cord injury.

PURPOSE: We aim to summarize the literature on international patterns of care for patients with neurogenic bladder (NGB) from spinal cord injury (SCI). METHODS: We performed a PubMed database search, hand review of references, communication with professional societies, and registry evaluations for pertinent data. RESULTS: Established patterns of care, including SCI registries and specialty centers, are available in high-resource countries such as the US and UK. As such, mortality rates from complications of NGB/SCI are lower. Access to intermittent catheterization supplies, among other resources, may be inadequate in many low-income regions. Cultural and religious beliefs may also hinder integration of proper bladder management in SCI patients. While guidelines exist in many parts of the world, it is unclear how rigorously they are disseminated or followed. CONCLUSIONS: While there is a paucity of high-level evidence, the differences in patterns of care are closely related to socioeconomic status and resources of the geographic area. Future research efforts should focus on improving access to diagnostic modalities, supplies, and specialists in these areas.

Semen parameters are unaffected by statin use in men evaluated for infertility.

The effects of statin use on conventional semen parameters in humans are largely unknown and have not been previously studied in subfertile men. We retrospectively reviewed data from 10,140 patients seen at our fertility clinic between 2002 and 2013 to assess the effects of statin use on semen parameters. Men who used any statins for >3 months before semen sample collection were included as cases. Data were gathered on patient age, medication use and conventional semen parameters. A total of 118 patients (126 samples) used statins for at least 3 months before semen sample collection. Data from 7698 patients (8,760 samples), who were not using any medications, were used as controls. In age-adjusted regression models, statin use was not associated with statistically significant changes in semen parameters. When used in combination with other nonspermatotoxic medications, it was associated with 0.3 ml decrease in semen volume (95% confidence interval: 0.02 to 0.58 ml, p-value = .04). In conclusion, statin use was not adversely associated with semen parameters other than semen volume in subfertile patients. These findings from our large-scale retrospective study suggest that there are no clinically relevant deleterious effects from statin use on conventional semen parameters.

The safety and efficacy of clomiphene citrate in hypoandrogenic and subfertile men.

Our objective was to evaluate the safety and efficacy of clomiphene citrate (CC) in infertile and hypoandrogenic men through a retrospective study between September 2013 and May 2014. We identified 47 men between 18 and 55 years placed on 50 mg CC every other day. We evaluated the effect of CC on testosterone after 2 weeks, rates of adverse effects and predictors of CC response. Mean baseline testosterone, bioavailable testosterone and estradiol were 246.8 ng dl(-1), 125.5 ng dl(-1) and 20.8 pg dl(-1), respectively. At 2 weeks, mean testosterone, bioavailable testosterone and estradiol increased to 527.6 ng dl(-1), 281.8 ng dl(-1) and 32.0 pg dl(-1) (all P<0.001). Two patients at 2 weeks and one patient at 3 months had a paradoxical decrease in testosterone. Mean total motile count (TMC) and concentration increased from 59.7 million (s.e.m.: 16.5) and 50.7 millions ml(-1) (s.e.m.: 11.1) at baseline to 90.9 million (s.e.m.: 25.9) and 72.5 millions ml(-1) (s.e.m.: 17.5), respectively, at 3 months, although this was nonsignificant (P=0.09, 0.09). No patient on CC experienced a paradoxical decrease in TMC or sperm concentration. On age-adjusted regression analysis, age, BMI, longitudinal testis axis, baseline follicle-stimulating hormone, LH and estradiol did not correlate with improvement in bioavailable testosterone at 2 weeks. CC improves testosterone and may improve semen parameters, although a small percentage of men may not demonstrate improvement in testosterone.

[Osteocartilaginous exostoses (osteochondromas)].

Osteochondroma is the most common true bone neoplasm formed by a cartilage capped bony projection arising on the external surface of a bone containing a marrow cavity that is continuous with that of the underlying bone. Osteochondromas generally arise in the bones preformed by cartilage. Osteochondromas may be solitary and multiple. Most reported cases have been in the first 3 decades with no known sex predilection. The lesion has three layers - perichondrium, cartilage and bone. The cartilage cap is usually less than 2.0 cm thick, superficial chondrocytes are clustered, the ones close to the transition to the bone resemble a growth plate, they are organized into chords and undergo enchondrial ossification. Loss of the architecture of cartilage, wide fibrous bands, myxoid change, increased chondrocyte cellularity, mitotic activity, significant chondrocyte atypia and necrosis are all features that may indicate secondary malignant transformation.

Vascular endothelial growth factor (VEGF) gene therapy using a nonviral gene delivery system improves erectile function in a diabetic rat model.

Erectile dysfunction (ED) is a cause of decreased quality of life in more than 70% of diabetic men. Vascular endothelial growth factor (VEGF) has shown to improve overall endothelial and smooth muscle cell dysfunction in models of ED. We describe a novel technique for nonviral, in vivo gene transfection of VEGF in the rat corpus cavernosum. Diabetic rats were transfected with DNA encoding a fusion VEGF/green fluorescent protein (GFP) complex and fluorescence microscopy was used to monitor the expression of VEGF-GFP fusion protein. Western blot and PCR analyses confirmed the expression of the GFP-VEGF fusion protein and mRNA. Functional studies using cavernous nerve stimulation revealed maximal intracavernous pressures (ICPs) of 63.1 mm Hg, and 30.7 mm Hg in the normal and diabetic control groups, respectively, and 47.4 mm Hg in VEGF-GFP-transfected diabetic group. Immunohistochemical analysis of the cavernosal tissue from transfected rats showed increased smooth muscle content compared with the diabetic control group. We show for the first time in our animal model that expression of the transfected VEGF in cavernosal tissue leads to an overall improvement of maximal ICP and smooth muscle content. On the basis of these results, it is tempting to speculate that our nonviral vector system offers an excellent system for gene delivery into cavernosal tissue, and that VEGF gene therapy using this system could be useful in improving erectile function in diabetic men.

Vaginal discharge and bleeding in girls younger than 6 years.

PURPOSE: Persistent unexplained vaginal discharge or bleeding in the pediatric population may be the only manifestation of a serious underlying medical or social problem. Therefore, these symptoms require careful and complete evaluation to identify the primary pathology accurately. We retrospectively reviewed charts of patients who presented for evaluation of persistent vaginal discharge or bleeding to determine if noninvasive imaging was a sensitive means of screening for gynecological pathology. MATERIALS AND METHODS: The records of 24 girls younger than 6 years who presented with vaginal discharge or bleeding were reviewed retrospectively. All patients were evaluated with noninvasive imaging, a pelvic examination while under anesthesia, vaginoscopy and cystoscopy. RESULTS: Noninvasive imaging was useful in identifying 5 of 7 vaginal foreign bodies. However, noninvasive imaging identified only 2 of 6 malignancies. These malignancies consisted of rhabdomyosarcoma (3 patients) and endodermal sinus tumor (3). Two girls also had benign vaginal mullerian papillomas that were not identified by noninvasive imaging. Noninvasive imaging did not aid in the diagnosis of sexual abuse. CONCLUSIONS: Based on these data, we recommend that all girls younger than 6 years who present with persistent vaginal discharge or bleeding be evaluated with pelvic examination while under anesthesia, to be followed by vaginoscopy and cystoscopy if no readily identifiable pathology is found by simple genital examination alone, regardless of the results of noninvasive imaging studies.

Neuromuscular and biomechanical characteristic changes in high school athletes: a plyometric versus basic resistance program.

BACKGROUND: In order to improve neuromuscular and biomechanical characteristic deficits in female athletes, numerous injury prevention programs have been developed and have successfully reduced the number of knee ligament injuries. However, few have investigated the neuromuscular and biomechanical changes following these training programs. It is also largely unknown what type of program is better for improving the landing mechanics of female athletes. OBJECTIVES: To investigate the effects of an 8 week plyometric and basic resistance training program on neuromuscular and biomechanical characteristics in female athletes. METHODS: Twenty seven high school female athletes participated either in a plyometric or a basic resistance training program. Knee and hip strength, landing mechanics, and muscle activity were recorded before and after the intervention programs. In the jump-landing task, subjects jumped as high as they could and landed on both feet. Electromyography (EMG) peak activation time and integrated EMG of thigh and hip muscles were recorded prior to (preactive) and subsequent to (reactive) foot contact. RESULTS: Both groups improved knee extensor isokinetic strength and increased initial and peak knee and hip flexion, and time to peak knee flexion during the task. The peak preactive EMG of the gluteus medius and integrated EMG for the gluteus medius during the preactive and reactive time periods were significantly greater for both groups. CONCLUSIONS: Basic training alone induced favourable neuromuscular and biomechanical changes in high school female athletes. The plyometric program may further be utilised to improve muscular activation patterns.

Multiple myeloma involving the myocardium and coronary vessels.

We report a case of metastatic plasmacytoma to the myocardium and coronary vessels in a 57-year-old man with multiple myeloma. Originally, the patient had a large plasmacytoma in his left chest wall and lung. He received local radiation and chemotherapy. Subsequently, the patient presented with symptoms of congestive heart failure. He had no prior history of cardiac disease. The patient was treated medically and later died from respiratory failure. At autopsy, a metastatic plasmacytoma was identified within the myocardium and externally compressing the coronary arteries. The tumor infiltrated into the coronary sinus. It is difficult to speculate whether the patient's symptoms were due to cardiac involvement since the tumor burden in his chest was also considerable. To our knowledge, coronary vessel involvement with plasmacytoma has not been previously described.

An acute, traumatic supraspinatus lesion in an intercollegiate football player: a case report.

OBJECTIVE: To describe the evaluation, management, and rehabilitation of an acute, supraspinatus tendon injury in an intercollegiate football player. BACKGROUND: While attempting to block a defender, a 19-year-old collegiate football player slipped on the artificial turf and landed on his right elbow, causing an injury to his right shoulder. The athlete was initially seen by the head athletic trainer and then referred to the team physician for further evaluation. DIFFERENTIAL DIAGNOSIS: acromioclavicular joint sprain, brachial plexopathy, subacromial impingement syndrome, supraspinatus lesion. TREATMENT: The athlete was managed surgically with an open acromioplasty and a 3-bone tunnel repair of the supraspinatus tendon. After surgery, the athlete underwent a 4-month rehabilitation protocol in preparation for return to competition. UNIQUENESS: This case involved a teenage athlete rather than the older individuals who normally sustain rotator cuff lesions. Also, the mechanism was a compressive force on the supraspinatus tendon rather than the tensile force common to rotator cuff lesions. CONCLUSIONS: By presenting this case report, we hope to give sports medicine clinicians a better understanding of rotator cuff injuries and how to successfully manage and rehabilitate supraspinatus lesions.

The role of the sensorimotor system in the athletic shoulder.

OBJECTIVE: To discuss the role of the sensorimotor system as it relates to functional stability, joint injury, and muscle fatigue of the athletic shoulder and to provide clinicians with the necessary tools for restoring functional stability to the athletic shoulder after injury. DATA SOURCES: We searched MEDLINE, SPORT Discus, and CINAHL from 1965 through 1999 using the key words "proprioception," "neuromuscular control," "shoulder rehabilitation," and "shoulder stability." DATA SYNTHESIS: Shoulder functional stability results from an interaction between static and dynamic stabilizers at the shoulder. This interaction is mediated by the sensorimotor system. After joint injury or fatigue, proprioceptive deficits have been demonstrated, and neuromuscular control has been altered. To restore stability after injury, deficits in both mechanical stability and proprioception and neuromuscular control must be addressed. A functional rehabilitation program addressing awareness of proprioception, restoration of dynamic stability, facilitation of preparatory and reactive muscle activation, and implementation of functional activities is vital for returning an athlete to competition. CONCLUSIONS/RECOMMENDATIONS: After capsuloligamentous injury to the shoulder joint, decreased proprioceptive input to the central nervous system results in decreased neuromuscular control. The compounding effects of mechanical instability and neuromuscular deficits create an unstable shoulder joint. Clinicians should not only address the mechanical instability that results from joint injury but also implement both traditional and functional rehabilitation to return an athlete to competition.

Syncope and atypical chest pain in an intercollegiate wrestler: a case report.

OBJECTIVE: To present the case of a 20-year-old collegiate wrestler who suffered from atypical chest pains and syncope after rigorous exercise, dehydration, and ingestion of a metabolic stimulant. BACKGROUND: As a result of pressure to obtain a lower body weight for competition, wrestlers often pursue practices to lose a substantial amount of weight in a short period of time. These practices include rigorous exercise, starvation, dehydration, laxatives, diuretics, and over-the-counter stimulants. Our case involves an athlete who ingested a metabolic stimulant containing ma huang (ephedrine) and suffered from syncope and atypical chest pains during a bout of rigorous exercise and dehydration to lose weight for competition. DIFFERENTIAL DIAGNOSIS: Hypertrophic cardiomyopathy, electrolyte imbalance, drug overdose, traumatic head injury, myocardial infarction, syncope. TREATMENT: The emergency medical services transported the athlete to the emergency room, and he was hospitalized for 2 days. After discharge, the team physician counseled the athlete in the dangers of metabolic stimulants and excessive weight-loss techniques. UNIQUENESS: This case is unique because it presents an athlete who ingested an over-the-counter stimulant to lose weight and suffered from syncope and atypical chest pains during a bout of rigorous exercise and dehydration. CONCLUSIONS: Athletic trainers must understand not only the dangers of excessive weight loss, but also the dangers of using unregulated ephedrine-containing stimulants to aid in weight loss.

Proprioception and neuromuscular control of the shoulder after muscle fatigue.

OBJECTIVE: To examine the effects of fatigue on proprioception and neuromuscular control of the shoulder. DESIGN AND SETTING: Subjects were randomly assigned to either an experimental group or control group. Subjects were tested using either the active angle-reproduction or the single- arm dynamic stability test. The subjects were then fatigued using a dynamometer performing continuous, concentric rotation exercises of the shoulder. Once fatigued, the subjects were posttested using the same test. One week later, the subjects returned and were pretested, fatigued, and posttested using the other test. SUBJECTS: Thirty-two college-age (18 to 25 years) subjects (16 males, 16 females) with no history of glenohumeral instability or upper extremity injury volunteered for this study. MEASUREMENTS: Absolute angular error was measured using an electrogoniometer present within the isokinetic dynamometer, while sway velocity was measured using a force-plate system. RESULTS: Repeated-measures analysis of variance revealed a significant difference between the pretest and posttest values for absolute angular error in the experimental group, whereas no significant difference was revealed between pretest and posttest sway velocity for either the control or experimental group. CONCLUSIONS: Fatigue of the internal and external rotators of the shoulder decreased proprioception of the shoulder, while having no significant effect on neuromuscular control.

A recurrent nonrandom translocation (3;7)(q27;p12) associated with BCL-6 gene rearrangement in B-cell diffuse large cell lymphoma.

Two cases of B-cell diffuse large cell lymphoma associated with the t(3;7)(q27;p12) and BCL-6 rearrangement are described. Cytogenetic studies revealed [case 1] 47,XY,t(3;7)(q27;p12),+12 and [case 2] 45,X,-Y,t(3;7)(q27;p12),del(6)(q21q25),+16,-21. The translocation of each case had a non-random chromosomal change involving a 3q27 locus associated with BCL-6 gene rearrangement identified by Southern blot analysis. Both cases involved multiple lymph nodes and extranodal regions, such as stomach and peritoneal cavity in case 1, extranodal retroperitoneal space, subcutis, probable liver, and colon in case 2. Chemotherapy provided only short survival after onset: 17 and 16 months, respectively. Altered expression of adhesion molecules CD44, CD54 (case 1) and CD11a and CD18 (case 2) may help to explain the poor outcome of these patients.

The laboratory diagnosis of cytomegalovirus infections.

Rapid and accurate diagnosis of cytomegalovirus (CMV) infection is imperative with the advent of effective antiviral therapy (gangiclovir, foscarnet, CMV hyperimmune globin). Applications of conventional cell culture (CC), shell vial assay (SV), serological testing, antigenemia assay (AG) as well as molecular methods [polymerase chain reaction (PCR), branch DNA (b-DNA) and hybrid capture (HC)] to various patient populations and specimen types are discussed. A three year study of 670 specimens [354 urines, 205 peripheral blood leukocytes (PBLs), 56 upper respiratory and 55 tissues] compared CMV CC and SV isolation rates. Of the total, 124 (18.5%) were positive by either or both techniques. For each specimen type the number of positives detected by SV was greater than CC (urine 28 vs 15, PBLs, 12 vs 2). However, of 124 positives, 21 were solely CC positive. A comparison of SV to AG in 230 PBLs yielded a sensitivity of 100% and specificity of 68.3%. The low specificity when compared to SV may be due to the increased sensitivity of AG. Fifty-nine PBLs were examined for differing immunostaining techniques [immunoperoxidase (IP) vs Immunofluorescence (IF)]. IF stained PBLs showed an increased number of positive cells per preparation and greater stain intensity for ease of interpretation.

Pyoderma gangrenosum and cranial osteolysis: case report and review of the paediatric literature.

Pyoderma gangrenosum is a poorly understood, ulcerating cutaneous disorder which is rarely seen in the paediatric age-group. We report a 3-year-old boy who developed an ulcer over the left frontoparietal scalp at the age of 1 year. A 9-cm area of underlying cranial bone was destroyed. The appearance on radiographs and CT scan was suggestive of eosinophilic granuloma, osteomyelitis, or other destructive processes. Biopsies of the scalp lesion and calvaria showed granulation tissue and degenerating bone. After the biopsies the scalp lesion increased in size, and wound dehiscence occurred. Ulceration developed at the site of a PPD skin test, which on biopsy was consistent with the diagnosis of pyoderma gangrenosum. Pyoderma gangrenosum should be added to the differential diagnosis of cutaneous disorders which can result in osteolytic/osteonecrotic defects.