Predictors of early treatment discontinuation in a cohort of patients treated with boceprevir-based therapy for hepatitis C infection.

In this real-world cohort, 49% of patients stopped boceprevir-based hepatitis C therapy early, with only 20% stopping due to treatment futility. Having more comorbidities was significantly associated with early discontinuation. Tolerability of boceprevir-based regimens may be substantially worse than reported in clinical trials, particularly for patients with comorbidities.

Measuring fast neutrons in Hiroshima at distances relevant to atomic-bomb survivors.

Data from the survivors of the atomic bombs serve as the major basis for risk calculations of radiation-induced cancer in humans. A controversy has existed for almost two decades, however, concerning the possibility that neutron doses in Hiroshima may have been much larger than estimated. This controversy was based on measurements of radioisotopes activated by thermal neutrons that suggested much higher fluences at larger distances than expected. For fast neutrons, which contributed almost all the neutron dose, clear measurement validation has so far proved impossible at the large distances (900 to 1,500 m) most relevant to survivor locations. Here, the first results are reported for the detection of 63Ni produced predominantly by fast neutrons (above about 1 MeV) in copper samples from Hiroshima. This breakthrough was made possible by the development of chemical extraction methods and major improvements in the sensitivity of accelerator mass spectrometry for detection of 63Ni atoms (refs 8-11). When results are compared with 63Ni activation predicted by neutron doses for Hiroshima survivors, good agreement is observed at the distances most relevant to survivor data. These findings provide, for the first time, clear measurement validation of the neutron doses to survivors in Hiroshima.

Fast neutrons measured in copper from the Hiroshima atomic bomb dome.

The first measurements of (63)Ni produced by A-bomb fast neutrons (above approximately 1 MeV) in copper samples from Hiroshima encompassed distances from approximately 380 to 5062 m from the hypocenter (the point on the ground directly under the bomb). They included the region of interest to survivor studies (approximately 900 to 1500 m) and provided the first direct validation of fast neutrons in that range. However, a significant measurement gap remained between the hypocenter and 380 m. Measurements close to the hypocenter are important as a high-value anchor for the slope of the curve for neutron activation as a function of distance. Here we report measurements of (63)Ni in copper samples from the historic Hiroshima Atomic Bomb Dome, which is located approximately 150 m from the hypocenter. These measurements extend the range of our previously published data for (63)Ni providing a more comprehensive and consistent A-bomb activation curve. The results are also in good agreement with calculations based on the current dosimetry system (DS02) and give further experimental support to the accuracy of this system that forms the basis for radiation risk estimates worldwide.

Long-term follow-up of urethral reconstruction for blunt urethral injury at a young age: urinary and sexual quality of life outcomes.

INTRODUCTION: Little is known about long-term patient-reported outcomes following surgical repair for pediatric blunt urethral trauma. OBJECTIVE: The purpose was to evaluate long-term urinary outcomes, sexual function, and quality of life (QOL) of patients who undergo urethroplasty for blunt urethral trauma in childhood. STUDY DESIGN: After IRB approval, we retrospectively reviewed the records of patients who sustained blunt urethral injury at ≤18 years and underwent urethroplasty at our institution between 1978 and 2013. We then used a web-based survey to assess urinary/sexual/ejaculatory function and overall QOL using validated questionnaires. RESULTS: Of 68 eligible patients, 15 were able to be contacted (table). Median age of injury, age at urethroplasty, and age at follow-up were 17 (4-18), 17 (5-20), and 19 (13.5-21.5) years, respectively. The stricture was membranoprostatic in eight and bulbar in seven patients, with median length of 2 (1.6-2.6) cm. Excision/primary anastomosis was performed in all but three patients who required a buccal graft. Overall, 80% were 'very satisfied' and 20% were 'satisfied' with surgery. One patient reported a subsequent urethral intervention. On urethral stricture surgery patient-reported outcome measurement, the median bother (0 least, 24 worst) was 10 (8-12.5). The force of urine stream (1 strongest, 4 weakest) was 2 (1.5-2), with no report of urinary incontinence. The median Sexual Health Inventory for Men score (0 worst, 25 perfect) was 24 (22.5-24). The median ejaculatory function score (0 worst, 15 normal) was 14 (13-14.75). Six patients had fathered children and none reported infertility. Three patients reported <30° penile curvature not interfering with sex. Median QOL (0 worse, 10 best) was 8 (7.5-8). CONCLUSIONS: Urethroplasty after blunt urethral injury in young adult population is associated with a high long-term success rate with a low rate of long-term urinary and sexual consequences in adulthood.

Studies of immunoglobulins, bentonite flocculation and IgE, IgG and IgM antibodies in serum from patients with trichinosis.

Serial serum samples were obtained from two patients from a family of four who ingested raw pork at a known time and in whom trichinosis developed. Single and occasionally two serum samples were obtained from other patients with proved trichinosis. Studies of these serum samples showed that elevations of serum immunoglobulin E (IgE) levels do occur but not in all serum samples and that even when these levels are elevated, they are not high enough to be of diagnostic value. This is also true for serum immunoglobulin M (IgM). Using a solid phase radioimmunoadsorbent test, IgE, IgG and IgM antibodies were detected in the serums. The IgE antibody activity appeared early but was not present in all samples. The IgM antibody activity appeared later than the IgE and IgG antibody activity, and there was a statistically significant correlation between IgM antibodies as determined by radioimmunoassay and the bentonite flocculation titers suggesting that the bentonite flocculation is due to IgM antibody. IgM antibodies detected by radioimmunoassay were positive in all serum samples from patients with trichinosis except for a sample obtained 3 days after the onset of symptoms. The early increase in IgG antibodies and the occurrence of these antibodies in all serum samples obtained more than 3 days after onset of symptoms suggest a potential diagnostic use if serial samples are available early in the course of the disease.

Self-performed bilateral orchiectomy in transsexuals.

This paper reviews three cases of self-performed bilateral orchiectomy seen within a 2-year period at San Francisco General Hospital. All three cases were male to female transsexuals. The patients were not considered psychotic by the psychiatric consultant, although two patients admitted to past suicide attempts and psychiatric treatment. The patients' histories and treatment are reviewed and suggestions for diagnosis, management, and treatment planning are offered.

Acute renal artery thrombosis following blunt trauma.

Forty-one cases of renal artery thrombosis following blunt trauma have been reported previously. Most injuries resulted from acute deceleration, and the left kidney was involved more frequently than the right kidney. An additional case, a nineteen-year-old victim of a motorcycle accident, had immediate surgery following an early diagnosis. Although the kidney was viable, arterial repair was unsuccessful, and a nephrectomy was performed. Following blunt trauma, patients with microhematuria should have an immediate excretory urogram and retrograde cystogram. With nonvisualization of the kidney, arteriography is necessary to establish the diagnosis. Prompt operation is mandatory if the kidney is to be saved.

Renal abscesses: classification and review of 40 cases.

Renal abscesses are misdiagnosed often and, consequently, mistreated or treated too late. Forty cases of renal abscesses divided into anatomic categories--perinephric, renal cortical, and corticomedullary--are reviewed. Various conditions seem to predispose to renal abscesses: urinary tract infections, vesicoureteral reflux, calculi, or other medical problems. This retrospective study discloses that a high correlation exists between organisms found in the patients' urine cultures and those organisms cultured from all 3 categories of abscesses. Accurate and complete urine bacteriologic study is therefore an essential tool for diagnosis.

Avascular renal adenocarcinoma: variations and characteristics.

Six cases (men ranging in ages from thirty-seven to seventy-seven years) illustrate the varied characteristics of avascular renal adenocarcinoma. These tumors frequently stimulat benign lesions. All modalities including intravenous pyelography, nephrotomography, ultrasonography, cyst puncture with cystic fluid assessment, angiography, and operation with tissue specimens submitted for pathologic examination may be required before diagnosis is established. An orderly approach to the evaluation of lesions will allow accurate diagnosis approaching 100% with minimum morbidity. Attention to the finer details of vascular patterns on angiography has proved to be a most helpful diagnostic aid. Cyst puncture with histochemical, cytologic, and radiographic examinations appears to offer additional help in diagnosing these elusive lesions.

Primary squamous cell carcinoma of anterior male urethra.

Primary squamous cell carcinoma of the anterior male urethra, which accounts for most carcinomas in that site, is a rare lesion. Ten cases having occurred in the last ten years were divided into distal and proximal anterior urethral lesions. Analysis of these cases confirms the need for a high index of suspicion for the lesion in patients who have chronic stricture disease; surgical treatment as the primary therapeutic modality; the fact that distal lesions generally have a better prognosis than proximal lesions, thus may sometimes be treated more conservatively; and the fact that adenopathy (especially of the pelvic nodes) usually heralds a poorer prognosis. Retrograde urethrography, endoscopy with biopsy, and bimanual examination are all essential for proper diagnosis, staging, and management.

When and how to use buccal mucosal grafts in adult bulbar urethroplasty.

OBJECTIVES: To evaluate the efficacy of buccal mucosa in the repair of adult urethral stricture disease, we report our experience with its use as a nontubularized onlay graft during bulbar urethral reconstruction. METHODS: From June 1993 to January 1996, 75 men underwent anterior urethral reconstruction for stricture disease. Single-stage urethroplasty with an onlay patch graft of buccal mucosa was performed in 13 patients with complex, refractory strictures of the bulbar urethra. In all cases, a two-team approach was used in which one team harvested the graft from the mouth while the perineal team simultaneously exposed and calibrated the stricture. RESULTS: The length of buccal mucosa ranged from 3.5 to 17 cm (average length 6.2). In 8 patients, other reconstructive techniques were used concomitantly, including fasciocutaneous penile flap or stricture excision and primary anastomosis, depending on the length and severity of the scarred area. Median follow-up time was 18 months. Excellent results were obtained in all 13 patients, and none has required urethral dilation or instrumentation subsequently. Operative time was significantly less than with other forms of substitution urethroplasty. CONCLUSIONS: Excellent results can be expected when buccal mucosa is used for urethral substitution in men with refractory bulbar strictures. For patients with long or dense strictures, buccal mucosal grafts may easily be combined with other reconstructive techniques. In patients with less complex stricture disease, the reduced operative time of this two-team approach may be beneficial.

Ultrasonographic appearance of necrotizing gangrene: aid in early diagnosis.

In 2 seriously ill patients with scrotal swelling of uncertain origin, scrotal and perineal ultrasonography demonstrated gas in the soft tissue before crepitus was detected on physical examination. Necrotizing infections of the scrotum and perineum have characteristic ultrasonographic features that can facilitate earlier diagnosis and treatment.

Polyglycolic acid mesh in repair of renal injury.

To evaluate the use of a polyglycolic acid (PGA) mesh graft for partial nephrectomy, we replaced the upper pole of the left kidney in 12 New Zealand white rabbits with a free omental fat graft and the lower pole with PGA mesh. The mesh stopped the bleeding immediately during the operation. At forty-eight hours, the fibers were still intact, with an organized clot on the surface of the mesh. Between two weeks and two months, the fibers had begun to be digested by histiocytes, with formation of giant cells and fibroblastic proliferation with collagen deposition around the mesh. At three months, there was complete resorption of the PGA mesh and formation of a new fibrous capsule. There was no renal reaction and no difference between the PGA mesh and the omental fat graft. We believe that PGA mesh can be helpful in repairing injured kidneys by securing hemostasis and serving as a scaffold for the formation of a new capsule.

Vasectomy with transurethral resection of prostate.

A retrospective study was made of 200 patients undergoing transurethral prostatectomy. Half of these patients received bilateral vasectomies. The vasectomized patients had a 5-percent incidence of epididymitis as compared with a 2-percent incidence in the nonvasectomized patients. Vasectomy failed to provide adequate protection against postoperative epididymitis and cannot be recommended as a routine procedure with a transurethral prostatectomy.

PIP: Transurethral prostatectomy was performed on 200 patients from the Lettermen Army Medical Center. The patients were divided into 2 groups: group 1 (N=100) consisted of those who had bilateral vasectomies immediately before transurethral resection, while group 2 consisted of those who did not have vasectomy and had no prior history of vasectomy or epididymitis (defined as tenderness, swelling, and/or induration of the epididymitis with or without fever). The 2 groups were followed up from 3 months to 6 years. Group 1 exhibited a 5% incidence of epididymitis compared with group 2's 2% incidence. A significant difference observed between the 2 groups was the duration of hospital stay: group 1 averaged 16 days while group 2 averaged 13.25 hospital days. Although prolonged hospital stay has been associated with risk of iatrogenic wound infections, it is not known whether it is a factor in postprostatectomy epididymitis. One possible explanation for the mechanism of epididymitis is the reflux of infected urine into the vas deferens; this is the rationale for performing vasectomy to prevent epididymitis. Incidence of postprostatectomy epididymitis can be reduced by using better equipment and optics (for more accurate resectioning), early treatment of prostatism, and shorter hospital stay. The findings of this study suggest that vasectomy does not reduce incidence of epididymitis and hence cannot be used as a routine procedure with a transurethral prostatectomy.

Skin graft reconstruction of chronic genital lymphedema.

OBJECTIVES: We present a simple, reliable method of scrotal and penile reconstruction yielding satisfactory cosmetic and functional results for patients with disabling chronic genital lymphedema. METHODS: Nine patients were treated with wide excision of the affected genital skin and subsequent coverage of exposed areas with split-thickness skin grafts in a single-stage procedure. RESULTS: All patients have had excellent cosmetic results without recurrence of genital lymphedema or compromise of sexual function postoperatively. CONCLUSIONS: Single-stage reconstruction for idiopathic genital lymphedema by radical skin excision and split-thickness skin grafting provides gratifying functional and cosmetic results.

Ureteral obstruction of solitary kidneys by iliac artery aneurysms.

Two patients with solitary kidneys had ureteral obstruction caused by iliac artery aneurysms. Both patients were treated successfully with ureterolysis and temporary proximal diversion. Iliac artery aneurysms generally remain asymptomatic; however, patients may have urologic complaints (such as hematuria, flank pain, anuria, or a pulsatile urinary stream), and severe complications may develop as a result of an obstructive uropathy. Diagnosis is confirmed by cystoscopy when a mass is present, intravenous pyelography, retrograde pyelography, and arteriography. Treatment must be individualized with consideration of the etiology of the aneurysm and condition of the patient. Surgical correction of the aneurysm may be appropriate. Ureterolysis, with proximal diversion as a temporary safety valve, is a useful procedure particularly when the patient has a solitary kidney.

Magnetic resonance imaging of vascular lesions of the scrotum and penis.

We report 2 rare cases of vascular lesions in the scrotum and penis: an arteriovenous malformation in a young man and a lymphohemangioma in a boy. Both patients had undergone previous treatment and had recurrent lesions. Magnetic resonance imaging was performed preoperatively for detailed information regarding lesion extent and involvement of adjacent structures.

Vasoseminal vesiculography in staging adenocarcinoma of prostate.

We found vasoseminal vesiculography useful in staging adenocarcinoma of the prostate and in measurement of radiotherapy ports. In 12 patients who had radical prostatectomies, the histologic findings correlated well with the vasoseminal vesiculograms. Criteria for reading benign prostatic hyperplasia and prostatic carcinoma have been well established in the literature and are reviewed.

Pubectomy in repair of membranous urethral stricture.

The use of pubectomy in the repair of urethral strictures has not been favored because of the supposed excessive blood loss and operative time and long-term pain. However, in our experience with 30 patients with traumatic urethral rupture, we have found that pubectomy provides excellent exposure with a mean blood loss of 800 ml and few postoperative problems. The technique should nonetheless be reserved for selected patients and performed only by experienced surgeons.

Management of genital skin loss.

Figure 12 is an algorithm outlining the methods of management. In most patients, partial skin loss can be managed by closure with remaining local skin. Tensive partial loss of penile skin may require grafting. Potent patients should have thick split-thickness grafts or full-thickness grafts. Impotent patients should have coverage with meshed split-thickness grafts or scrotal flaps when available. Partial scrotal loss is seldom a problem, as local flaps and closure of the defect with the remaining scrotal skin can usually be accomplished. After total scrotal loss, the testicles should be placed temporarily in thigh pouches. Later, a new scrotum can be created with meshed split-thickness grafts or thigh-based cutaneous flaps. Aggressive wound care, appropriate timing of reconstruction, and adherence to basic principles of reconstructive surgery will result in functional recovery and a cosmetically acceptable appearance.