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1.
Int. braz. j. urol ; 45(3): 572-580, May-June 2019. tab, graf
Artigo em Inglês | LILACS-Express | ID: biblio-1012316

RESUMO

ABSTRACT Purpose: To better characterize metabolic stone risk in patients with neurologically derived musculoskeletal deficiencies (NDMD) by determining how patient characteristics relate to renal calculus composition and 24-hour urine parameters. Materials and Methods: We performed a retrospective cohort study of adult patients with neurologically derived musculoskeletal deficiencies presenting to our multidisciplinary Kidney Stone Clinic. Patients with a diagnosis of NDMD, at least one 24-hour urine collection, and one chemical stone analysis were included in the analysis. Calculi were classified as primarily metabolic or elevated pH. We assessed in clinical factors, demographics, and urine metabolites for differences between patients who formed primarily metabolic or elevated pH stones. Results: Over a 16-year period, 100 patients with NDMD and nephrolithiasis were identified and 41 met inclusion criteria. Thirty percent (12 / 41) of patients had purely metabolic calculi. Patients with metabolic calculi were significantly more likely to be obese (median body mass index 30.3kg / m2 versus 25.9kg / m2), void spontaneously (75% vs. 6.9%), and have low urine volumes (100% vs. 69%). Patients who formed elevated pH stones were more likely to have positive preoperative urine cultures with urease splitting organisms (58.6% vs. 16.7%) and be hyperoxaluric and hypocitraturic on 24-hour urine analysis (37mg / day and 265mg / day versus 29mg / day and 523mg / day). Conclusions: Among patients with NDMD, metabolic factors may play a more significant role in renal calculus formation than previously believed. There is still a high incidence of carbonate apatite calculi, which could be attributed to bacteriuria. However, obesity, low urine volumes, hypocitraturia, and hyperoxaluria suggest an underrecognized metabolic contribution to stone formation in this population.

2.
BJU Int ; 123(6): 968-975, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30758125

RESUMO

OBJECTIVES: To describe the rate and determinants of palliative care use amongst Medicare beneficiaries with bladder cancer and encourage a national dialogue on improving coordinated urological, oncological, and palliative care in patients with genitourinary malignancies. PATIENTS AND METHODS: Using Surveillance, Epidemiology, and End Results-Medicare data, we identified patients diagnosed with muscle-invasive bladder cancer (MIBC) between 2008 and 2013. Our primary outcome was receipt of palliative care, defined as the presence of a claim submitted by a Hospice and Palliative Medicine subspecialist. We examined determinants of palliative care use using logistic regression analysis. RESULTS: Over the study period, 7303 patients were diagnosed with MIBC and 262 (3.6%) received palliative care. Of 2185 patients with advanced bladder cancer, defined as either T4, N+ , or M+ disease, 90 (4.1%) received palliative care. Most patients that received palliative care (>80%, >210/262) did so within 24 months of diagnosis. On multivariable analysis, patients receiving palliative care were more likely to be younger, female, have greater comorbidity, live in the central USA, and have undergone radical cystectomy as opposed to a bladder-sparing approach. The adjusted probability of receiving palliative care did not significantly change over time. CONCLUSIONS: Palliative care provides a host of benefits for patients with cancer, including improved spirituality, decrease in disease-specific symptoms, and better functional status. However, despite strong evidence for incorporating palliative care into standard oncological care, use in patients with bladder cancer is low at 4%. This study provides a conservative baseline estimate of current palliative care use and should serve as a foundation to further investigate physician-, patient-, and system-level barriers to this care.

3.
Urology ; 123: 32, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30598222
4.
Int Braz J Urol ; 45(3): 572-580, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30676304

RESUMO

PURPOSE: To better characterize metabolic stone risk in patients with neurologically derived musculoskeletal deficiencies (NDMD) by determining how patient characteristics relate to renal calculus composition and 24-hour urine parameters. MATERIALS AND METHODS: We performed a retrospective cohort study of adult patients with neurologically derived musculoskeletal deficiencies presenting to our multidisciplinary Kidney Stone Clinic. Patients with a diagnosis of NDMD, at least one 24-hour urine collection, and one chemical stone analysis were included in the analysis. Calculi were classified as primarily metabolic or elevated pH. We assessed in clinical factors, demographics, and urine metabolites for differences between patients who formed primarily metabolic or elevated pH stones. RESULTS: Over a 16-year period, 100 patients with NDMD and nephrolithiasis were identified and 41 met inclusion criteria. Thirty percent (12 / 41) of patients had purely metabolic calculi. Patients with metabolic calculi were significantly more likely to be obese (median body mass index 30.3kg / m2 versus 25.9kg / m2), void spontaneously (75% vs. 6.9%), and have low urine volumes (100% vs. 69%). Patients who formed elevated pH stones were more likely to have positive preoperative urine cultures with urease splitting organisms (58.6% vs. 16.7%) and be hyperoxaluric and hypocitraturic on 24-hour urine analysis (37mg / day and 265mg / day versus 29mg / day and 523mg / day). CONCLUSIONS: Among patients with NDMD, metabolic factors may play a more significant role in renal calculus formation than previously believed. There is still a high incidence of carbonate apatite calculi, which could be attributed to bacteriuria. However, obesity, low urine volumes, hypocitraturia, and hyperoxaluria suggest an underrecognized metabolic contribution to stone formation in this population.


Assuntos
Cálculos Renais/química , Cálculos Renais/urina , Doenças Musculoesqueléticas/urina , Doenças do Sistema Nervoso/urina , Adulto , Feminino , Humanos , Concentração de Íons de Hidrogênio , Masculino , Pessoa de Meia-Idade , Doenças Musculoesqueléticas/etiologia , Doenças do Sistema Nervoso/complicações , Valores de Referência , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Fatores de Tempo
5.
Urology ; 2018 Nov 10.
Artigo em Inglês | MEDLINE | ID: mdl-30423302

RESUMO

OBJECTIVE: To determine the rate and determinants of neoadjuvant chemotherapy noncompletion in patients with muscle-invasive bladder cancer. METHODS: Using Surveillance, Epidemiology, and End Results-Medicare data, we identified all patients who underwent cystectomy between 2008-2013 and received chemotherapy within 6 months. Of these, 594 patients received neoadjuvant chemotherapy, defined as the presence of a claim for chemotherapy within the 180 days preceding cystectomy. Our primary outcome was noncompletion of neoadjuvant chemotherapy. We determined regimen-specific cut points for noncompletion based on clinical trials and national guidelines. RESULTS: Over the study period, 174 of 594 patients (29%) did not complete neoadjuvant chemotherapy. Noncompleters and completers received a median interquartile range of 4.4 (3.0-8.0) and 10.0 (7.7-11.2) weeks of chemotherapy, respectively. A total of 391 (66%) patients received a cisplatin-based regimen and 203 (34%) patients received an alternative regimen, with 27% and 33% not completing chemotherapy, respectively. After adjusting for covariates, age and geographic region were independently associated with failing to complete chemotherapy. CONCLUSION: Nearly 30% of patients who received neoadjuvant chemotherapy did not complete their regimen. Advanced age and nonclinical factors, such as practice patterns in certain geographic regions, may influence a patient's likelihood of successfully completing chemotherapy.

6.
Urol Oncol ; 36(8): 364.e9-364.e14, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29887239

RESUMO

BACKGROUND: Recent studies suggest that anesthetic technique during radical prostatectomy for prostate cancer may affect recurrence or progression. This association has previously been investigated in series that employ epidural analgesia. The objective of this study is to determine the association between the use of a multimodal analgesic approach incorporating paravertebral blocks and risk of biochemical recurrence following open radical prostatectomy. PATIENTS AND METHODS: Using a prospective database of 3,029 men undergoing open radical prostatectomy by a single surgeon, we identified 2,909 men who received no neoadjuvant androgen deprivation and had at least 1 year of follow up. We retrospectively compared patients who received general analgesia with opioid analgesia (1999-2003, n = 662) to those who received general analgesia with multimodal analgesia incorporating paravertebral blocks (2003-2014, n = 2,247). The primary outcome was time to biochemical recurrence. Biochemical recurrence-free interval was assessed using the Kaplan-Meier technique and compared using a multivariate Cox-proportional hazards regression model. RESULTS: In total, 395 patients (14%) experienced biochemical recurrence following radical prostatectomy, including 265 (12%) who received multimodal analgesia and 130 (20%) who did not (adjusted P = 0.27). After adjusting for age, race, body mass index, preoperative prostate specific antigen, grade, stage, perineural invasion, margin status, percent of tumor in the gland, and diameter of the dominant nodule, there was no difference in recurrence-free interval between groups (HR = 0.92, 95% CI: 0.73-1.17). CONCLUSION: Use of a multimodal analgesic approach incorporating paravertebral blocks is not associated with a reduced risk of biochemical recurrence following radical prostatectomy.


Assuntos
Analgesia/métodos , Manejo da Dor/métodos , Prostatectomia/métodos , Progressão da Doença , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
7.
Urology ; 119: 127-132, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-29752972

RESUMO

OBJECTIVE: To describe the phenotype, referral pattern, and trends of urologic management for children with megacystis microcolon intestinal hypoperistalsis syndrome. MATERIALS AND METHODS: We performed a retrospective review of all patients with megacystis microcolon intestinal hypoperistalsis syndrome treated at a large tertiary children's medical center over a 14-year period. Our primary outcomes included the rate of urology referral, urodynamic characteristics of bladder function, and the proportion of patients managed with clean intermittent catheterization. RESULTS: Twenty-six patients were evaluated at our institution with a median age at presentation of 1.3 years (73% female, 19 of 26). Most patients presented for intestinal transplantation evaluation and were dependent on parenteral nutrition. Megacystis was diagnosed prenatally in 15 patients and postnatally in 11 patients. Twenty patients (77%, 20 of 26) were evaluated by a pediatric urologist. Six patients (23%, 6 of 26) had varying degrees of vesicoureteral reflux. Early bladder management consisted of clean intermittent catheterization in 13 patients and vesicostomy in 8 patients. CONCLUSION: Megacystis microcolon intestinal hypoperistalsis syndrome is a severe form of intestinal failure and bladder atony with substantial urologic morbidity. Parents should be counseled accordingly and prompt urologic consultation should be included in the multidisciplinary approach to these complex patients.

9.
Case Rep Urol ; 2016: 6980843, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27195168

RESUMO

The obese patient undergoing radical cystectomy faces a unique set of challenges. We present the case of a 68-year-old gentleman who presented to our institution with Bacillus Calmette-Guerin refractory disease, a body mass index of 38.5, and a large pannus. The present paper describes our technique for performing radical cystectomy with ileal conduit urinary diversion and concomitant panniculectomy. We discuss the impact of obesity on patients undergoing radical cystectomy and how this may be mitigated by panniculectomy.

10.
J Surg Res ; 192(1): 34-40, 2014 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-25015749

RESUMO

BACKGROUND: Surgical burden is a large and neglected global health problem in low- and middle-income countries. With the increasing trauma burden, the goal of this study was to evaluate the trauma capacity of hospitals in the central plateau of Haiti. MATERIALS AND METHODS: The World Health Organization Emergency and Essential Surgical Care survey was adapted with a focus on trauma capacity. Interviewers along with translators administered the survey to key hospital staff. RESULTS: Seven hospitals in the region were surveyed. Of the hospitals surveyed, 3/7 had functioning surgical facilities. None of the hospitals had trauma registries. 71% of the hospitals had no formal trauma guidelines. 2/7 hospitals had a general surgeon available 100% of the time. All surgical facilities had oxygen cylinders available 100% of the time, but three of the primary level hospitals only had it available 51%-90% of the time. Intubation equipment was available at 57% of the facilities. Ventilators were only available in the operating room. Only the largest hospital had a computed tomography scanner. Other hospitals (66%) had a functioning x-ray machine 76%-90% of the time. Hospitals (57%) had an ultrasound machine. The most common reasons for referral were lack of appropriate facilities and supplies at the primary level care centers or lack of trained personnel at higher-level facilities. CONCLUSIONS: Trauma capacity in the central plateau of Haiti is limited. There is a great need for more personnel, trauma training at all staff levels, emergency care guidelines, trauma registries, and imaging equipment and training, specifically in ultrasonography. To accomplish this, coordination is needed between the Haitian government and local and international nongovernmental organizations.


Assuntos
Países em Desenvolvimento/estatística & dados numéricos , Número de Leitos em Hospital/estatística & dados numéricos , Respiração Artificial/estatística & dados numéricos , Centro Cirúrgico Hospitalar/estatística & dados numéricos , Centros de Traumatologia/estatística & dados numéricos , Estudos Transversais , Equipamentos e Provisões Hospitalares/estatística & dados numéricos , Saúde Global/estatística & dados numéricos , Haiti/epidemiologia , Pesquisas sobre Serviços de Saúde , Humanos , Oxigenoterapia/estatística & dados numéricos , Atenção Primária à Saúde/organização & administração , Atenção Primária à Saúde/estatística & dados numéricos , Centros de Cuidados de Saúde Secundários/estatística & dados numéricos , Centro Cirúrgico Hospitalar/organização & administração , Centros de Atenção Terciária/organização & administração , Centros de Atenção Terciária/estatística & dados numéricos , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Centros de Traumatologia/organização & administração , Ultrassonografia/estatística & dados numéricos
11.
J Surg Educ ; 71(6): 871-7, 2014 Nov-Dec.
Artigo em Inglês | MEDLINE | ID: mdl-24913428

RESUMO

OBJECTIVES: The proportion of US medical students participating in global health has increased by 24%. These experiences are generally self-directed and lack a formal educational component. This article describes a structured, comprehensive, community-driven global surgery elective for senior-year students. DESIGN: "Surgery and Global Health" is a monthlong elective during which students shadow in the university hospital, lead discussions of an assigned text, attend lectures, and participate in a clinical rotation in rural Haiti. The first week is didactic and takes place in Atlanta, GA. Weeks 2 through 4 are clinical and are conducted in Haiti. Urological and general surgery procedures are performed during weeks 2 and 3, while the final week is reserved for follow-up care. This experience was institutionally supported. SETTING: Emory University Hospital, Atlanta, GA; L'Hôpital St. Thérèse, Hinche, Centre, Haiti. PARTICIPANTS: Emory University School of Medicine students, years 2 through 4, supervised by faculty from the departments of Urology, General Surgery, and Anesthesiology. Senior-year students spent 21 days in central Haiti working in a rural clinical setting. RESULTS: Students participated in all facets of surgical care including preoperative clearance, postanesthesia care, discharge planning, and follow-up. Students felt a level of supervised responsibility that was not afforded at their home institution and were able to take on more advanced clinical roles. CONCLUSIONS: Students planned and executed this innovative experience with multidisciplinary, departmental, and institutional support. Stateside components introduced students to Haitian culture, global surgery ethics, and humanitarian surgical trip logistics. Structured global health experiences such as this give students practical skills and incentive to pursue careers involving global surgery.


Assuntos
Altruísmo , Educação de Graduação em Medicina/organização & administração , Cirurgia Geral/educação , Saúde Global , Procedimentos Cirúrgicos Urológicos/educação , Currículo , Feminino , Georgia , Haiti , Humanos , Masculino
12.
Int Braz J Urol ; 40(2): 198-203, 2014 Mar-Apr.
Artigo em Inglês | MEDLINE | ID: mdl-24856486

RESUMO

PURPOSE: The incidence of lower urinary tract symptoms (LUTS) as the sole presenting symptom for bladder cancer has traditionally been reported to be low. The objective of this study was to evaluate the prevalence and clinical characteristics of newly diagnosed bladder cancer patients who presented with LUTS in the absence of gross or microscopic hematuria. MATERIALS AND METHODS: We queried our database of bladder cancer patients at the Atlanta Veteran's Affairs Medical Center (AVAMC) to identify patients who presented solely with LUTS and were subsequently diagnosed with bladder cancer. Demographic, clinical, and pathologic variables were examined. RESULTS: 4.1% (14/340) of bladder cancer patients in our series presented solely with LUTS. Mean age and Charlson Co-morbidity Index of these patients was 66.4 years (range = 52-83) and 3 (range = 0-7), respectively. Of the 14 patients in our cohort presenting with LUTS, 9 (64.3%), 4 (28.6%), and 1 (7.1%) patients presented with clinical stage Ta, carcinoma in Situ (CIS), and T2 disease. At a median follow-up of 3.79 years, recurrence occurred in 7 (50.0%) patients with progression occurring in 1 (7.1%) patient. 11 (78.6%) patients were alive and currently disease free, and 3 (21.4%) patients had died, with only one (7.1%) death attributable to bladder cancer. CONCLUSIONS: Our database shows a 4.1% incidence of LUTS as the sole presenting symptom in patients with newly diagnosed bladder cancer. This study suggests that urologists should have a low threshold for evaluating patients with unexplained LUTS for underlying bladder cancer.


Assuntos
Carcinoma in Situ/epidemiologia , Sintomas do Trato Urinário Inferior/epidemiologia , Neoplasias da Bexiga Urinária/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Biópsia , Carcinoma in Situ/patologia , Progressão da Doença , Detecção Precoce de Câncer , Feminino , Humanos , Sintomas do Trato Urinário Inferior/patologia , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Recidiva Local de Neoplasia , Fatores de Risco , Estatísticas não Paramétricas , Neoplasias da Bexiga Urinária/patologia
13.
Int. braz. j. urol ; 40(2): 198-203, Mar-Apr/2014. tab
Artigo em Inglês | LILACS | ID: lil-711681

RESUMO

PurposeThe incidence of lower urinary tract symptoms (LUTS) as the sole presenting symptom for bladder cancer has traditionally been reported to be low. The objective of this study was to evaluate the prevalence and clinical characteristics of newly diagnosed bladder cancer patients who presented with LUTS in the absence of gross or microscopic hematuria.Materials and MethodsWe queried our database of bladder cancer patients at the Atlanta Veteran’s Affairs Medical Center (AVAMC) to identify patients who presented solely with LUTS and were subsequently diagnosed with bladder cancer. Demographic, clinical, and pathologic variables were examined.Results4.1% (14/340) of bladder cancer patients in our series presented solely with LUTS. Mean age and Charlson Co-morbidity Index of these patients was 66.4 years (range = 52-83) and 3 (range = 0-7), respectively. Of the 14 patients in our cohort presenting with LUTS, 9 (64.3%), 4 (28.6%), and 1 (7.1%) patients presented with clinical stage Ta, carcinoma in Situ (CIS), and T2 disease. At a median follow-up of 3.79 years, recurrence occurred in 7 (50.0%) patients with progression occurring in 1 (7.1%) patient. 11 (78.6%) patients were alive and currently disease free, and 3 (21.4%) patients had died, with only one (7.1%) death attributable to bladder cancer.ConclusionsOur database shows a 4.1% incidence of LUTS as the sole presenting symptom in patients with newly diagnosed bladder cancer. This study suggests that urologists should have a low threshold for evaluating patients with unexplained LUTS for underlying bladder cancer.


Assuntos
Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Carcinoma in Situ/epidemiologia , Sintomas do Trato Urinário Inferior/epidemiologia , Neoplasias da Bexiga Urinária/epidemiologia , Biópsia , Carcinoma in Situ/patologia , Progressão da Doença , Detecção Precoce de Câncer , Sintomas do Trato Urinário Inferior/patologia , Gradação de Tumores , Recidiva Local de Neoplasia , Fatores de Risco , Estatísticas não Paramétricas , Neoplasias da Bexiga Urinária/patologia
15.
Am J Surg ; 206(2): 280-6, 2013 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-23481029

RESUMO

BACKGROUND: Concerns about international training experiences in medical school curricula include the effect on student learning. We studied the educational effect of an international elective integrated into a traditional third-year (M3) surgical clerkship. METHODS: A 1-week surgical elective in Haiti was available to M3 students during the conventional 8-week surgical clerkship each year for the 4 academic years 2008 to 2011. The authors collected student and surgeon perceptions of the elective using a mixed-methods web-based survey. Statistical analysis compared the academic performance of participating M3s relative to nonparticipating peers. RESULTS: Twenty-eight (100%) students (41 trip weeks) and 3 (75%) surgeons responded. Twenty-five (89%) students believed the elective provided appropriate clinical training. Surgeon responses were consistent with students' reported perceptions. Strengths included unique clinical experiences and close interactions with faculty. Criticisms included recurring overwhelming clinical responsibilities and lack of local provider involvement. Academic performance of participants versus nonparticipants in the same clerkship term were statistically insignificant. CONCLUSIONS: This study demonstrates the feasibility of integrating global health experiences into traditional medical student clinical curricula. The effects on less tangible attributes such as leadership skills, fostering teamwork, and cultural competency require future investigation.


Assuntos
Estágio Clínico , Competência Clínica , Currículo/tendências , Cooperação Internacional , Adulto , Estágio Clínico/estatística & dados numéricos , Estágio Clínico/tendências , Docentes de Medicina , Estudos de Viabilidade , Feminino , Haiti , Humanos , Relações Interprofissionais , Liderança , Masculino , Estudantes de Medicina , Ensino , Viagem , Estados Unidos
16.
Int Immunol ; 24(10): 661-71, 2012 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-22899673

RESUMO

IL-7 signaling is required for thymocyte development and its loss has a severe deleterious effect on thymus function. Thymocyte-stromal cell interactions and other mechanisms tightly regulate IL-7 expression. We show that disruption of that regulation by over-expression of IL-7 inhibits T-cell development and promotes extensive B-cell lymphopoiesis in the thymus. Our data reveal that high levels of IL-7 negate Notch-1 function in thymocytes found in IL-7 transgenic mice and in co-culture with OP9-DL1 cells. While high levels of IL-7R are present on thymocytes, increased suppressor of cytokine signaling-1 expression blunts IL-7 downstream signaling, resulting in hypo-phosphorylation of proteins in the PI3K-Akt pathway. Consequently, GSK3ß remains active and inhibits Notch-1 signaling as observed by decreased Hes-1 and Deltex expression in thymic progenitors. This is the first demonstration that high levels of IL-7 antagonize Notch-1 signaling and suggest that IL-7 may affect T- versus B-lineage choice in the thymus.


Assuntos
Linfócitos B/citologia , Diferenciação Celular , Interleucina-7/imunologia , Linfopoese , Receptor Notch1/metabolismo , Linfócitos T/citologia , Timócitos/citologia , Animais , Técnicas de Cocultura , Interleucina-7/genética , Camundongos , Camundongos Endogâmicos C57BL , Camundongos Transgênicos , Transdução de Sinais , Células Estromais/citologia , Células Estromais/imunologia , Proteínas Supressoras da Sinalização de Citocina/imunologia , Timo/citologia , Timo/crescimento & desenvolvimento , Timo/imunologia , Timo/metabolismo
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