Sexual rehabilitation and penile pain associated with intracavernous alprostadil after radical prostatectomy.

INTRODUCTION: Intracavernous alprostadil injection (IAI) is widely used for sexual rehabilitation (SR) after radical prostatectomy (RP). However, the rate of spontaneous erection recovery with IAI remains unclear, and IAI causes pain that may hinder SR. AIMS: To assess SR in IAI users after RP and to evaluate the course and impact on SR of postinjection penile pain. METHODS: We prospectively studied 87 patients who underwent nerve-sparing laparoscopic RP, reported normal preoperative erectile function, and used IAI for 12 months. Patients started with 2.5 µg alprostadil and were advised to increase the dose gradually until erection hardness allowed vaginal penetration. MAIN OUTCOME MEASURES: At 6 and 12 months, the International Index of Erectile Function (IIEF-15) and Erection Hardness Score (EHS) were determined with and without IAI, and injection-related penile pain was assessed using a numeric rating scale. Correlations linking penile pain, IIEF-15, and EHS scores were evaluated. RESULTS: The mean alprostadil dose was 8.1 µg after 6 months and 9.9 µg after 12 months. With/without IAI, mean IIEF-15 scores for erectile and orgasmic function and mean EHS score were 14.6/4.6, 4.1/2.1, and 2.5/0.4, respectively, after 6 months; and 17.2/5.4, 4.9/2.6, and 2.7/0.9 after 12 months. Pain scores were 3.2±2.5/10 and 2.5±2.5/10 after 6 and 12 months, respectively. Pain intensity correlated with erectile function (r=-0.23), intercourse satisfaction (r=-0.23), and overall satisfaction (r=-0.24) after 6 months but not after 12 months. Follow-up was short and only patients who used IAI for 12 months were included. CONCLUSIONS: In patients who were willing and able to use IAI, erectile function improved after 1 year but remained below preoperative levels. The adverse impact of pain on SR was significant during the first 6 months and diminished over time. These data may help to counsel IAI users with painful erections.

Motor cortex stimulation for the treatment of refractory peripheral neuropathic pain.

Epidural motor cortex stimulation (MCS) has been proposed as a treatment for chronic, drug-resistant neuropathic pain of various origins. Regarding pain syndromes due to peripheral nerve lesion, only case series have previously been reported. We present the results of the first randomized controlled trial using chronic MCS in this indication. Sixteen patients were included with pain origin as follows: trigeminal neuralgia (n = 4), brachial plexus lesion (n = 4), neurofibromatosis type-1 (n = 3), upper limb amputation (n = 2), herpes zoster ophthalmicus (n = 1), atypical orofacial pain secondary to dental extraction (n = 1) and traumatic nerve trunk transection in a lower limb (n = 1). A quadripolar lead was implanted, under radiological and electrophysiological guidance, for epidural cortical stimulation. A randomized crossover trial was performed between 1 and 3 months postoperative, during which the stimulator was alternatively switched 'on' and 'off' for 1 month, followed by an open phase during which the stimulator was switched 'on' in all patients. Clinical assessment was performed up to 1 year after implantation and was based on the following evaluations: visual analogue scale (VAS), brief pain inventory, McGill Pain questionnaire, sickness impact profile and medication quantification scale. The crossover trial included 13 patients and showed a reduction of the McGill Pain questionnaire-pain rating index (P = 0.0166, Wilcoxon test) and McGill Pain questionnaire sensory subscore (P = 0.01) when the stimulator was switched 'on' compared to the 'off-stimulation' condition. However, these differences did not persist after adjustment for multiple comparisons. In the 12 patients who completed the open study, the VAS and sickness impact profile scores varied significantly in the follow-up and were reduced at 9-12 months postoperative, compared to the preoperative baseline. At final examination, the mean rate of pain relief on VAS scores was 48% (individual results ranging from 0% to 95%) and MCS efficacy was considered as good or satisfactory in 60% of the patients. Pain relief after 1 year tended to correlate with pain scores at 1 month postoperative, but not with age, pain duration or location, preoperative pain scores or sensory-motor status. Although the results of the crossover trial were slightly negative, which may have been due to carry-over effects from the operative and immediate postoperative phases, observations made during the open trial were in favour of a real efficacy of MCS in peripheral neuropathic pain. Analgesic effects were obtained on the sensory-discriminative rather than on the affective aspect of pain. These results suggest that the indication of MCS might be extended to various types of refractory, chronic peripheral pain beyond trigeminal neuropathic pain.

Magnetic targeting of iron-oxide-labeled fluorescent hepatoma cells to the liver.

The purpose of this study was to determine whether an external magnet field can induce preferential trafficking of magnetically labeled Huh7 hepatoma cells to the liver following liver cell transplantation. Huh7 hepatoma cells were labeled with anionic magnetic nanoparticles (AMNP) and tagged with a fluorescent membrane marker (PKH67). Iron-uptake was measured by magnetophoresis. Twenty C57Bl6 mice received an intrasplenic injection of 2 x 10(6) labeled cells. An external magnet (0.29 T; 25 T/m) was placed over the liver of 13 randomly selected animals (magnet group), while the remaining 7 animals served as controls. MRI (1.5 T) and confocal fluorescence microscopy (CFM) were performed 10 days post-transplantation. The presence and location of labeled cells within the livers were compared in the magnet group and controls, and confronted with histological analysis representing the standard of reference. Mean iron content per cell was 6 pg. Based on histology, labeled cells were more frequently present within recipient livers in the magnet group (p < 0.01) where their distribution was preferentially peri-vascular (p < 0.05). MRI and CFM gave similar results for the overall detection of transplanted cells (kappa = 0.828) and for the identification of peri-vascular cells (kappa = 0.78). Application of an external magnet can modify the trafficking of transplanted cells, especially by promoting the formation of perivascular aggregates.

Mother-to-child transmission of human immunodeficiency virus type 1 in relation to the season in Yaounde, Cameroon.

A public health program to prevent mother-to-child transmission (MTCT) of human immunodeficiency virus type 1 (HIV-1) by treatment with nevirapine has been ongoing in Yaounde, Cameroon since January 2000. After 24 months, plasma samples from 119 children born to HIV-1-positive mothers were tested for HIV-1 RNA between six and eight weeks after birth. Thirteen (10.9%) tested positive (95% confidence interval = 5.2-16.7%). Risk factors associated with MTCT in this study were maternal viral load (P < 0.05), low birth weight (chi2 for trend = 8.78, P = 0.01), and birth during the second half of the year. A high correlation was repeatedly observed between rainfall in a given month and the risk of MTCT of HIV-1 in children born three months later (r = 0.634, P < 0.001). Although we cannot rule out other tropical infections related to the rainy season, the role of malaria is highly suspected since the interval of three months we observed between the peaks of rainfall and the rate of transmission is consistent with the Plasmodium life cycle.

Patient knowledge of their disease: a French multicenter study in ankylosing spondylitis.

OBJECTIVES: To assess knowledge of ankylosing spondylitis (AS) by patients and to identify factors associated with knowledge. METHODS: Ninety patients receiving follow-up in France for AS completed a disease knowledge auto-questionnaire yielding a correct answer score [CAS] and a correct item score [CIS]. Correlations between these scores and other factors were examined. RESULTS: Mean CAS was 16.4/25 (SD = 4.8) and mean CIS 7.3 +/- 3.1/14. Female gender, higher educational level, having read about AS, being aware of AS support groups, and having received longer tertiary-care hospital management were associated with better knowledge. In the multivariate analysis, only three factors were independently associated with the level of knowledge in this population: "reading about AS", "level of general education", and "awareness of an AS support group". CONCLUSION: Knowledge of AS by French patients was lower than previously reported in a British population. Although education should be offered to all AS patients, the need may be greater in those with limited formal schooling. Booklets on the disease and contact with patient groups seem to be useful tools for improving knowledge of the disease.

Ex vivo MRI of axillary lymph nodes in breast cancer.

PURPOSE: To provide a strategy for precise co-localization of lymph nodes on axillary lymph-node dissection (ALND) specimens both on pathology and MR. To identify nodal features suggestive of metastatic involvement on a node-to-node basis. MATERIALS AND METHODS: National Institutional review-board approved this prospective study of 18 patients with breast cancer referred for ALND. Ex vivo T1 and inversion recovery (IR) T2 WI of ALND specimens tightly positioned within scaled plastic cranes was performed immediately after surgery. The correspondence of MR-based or pathologically based nodes location was assessed. The MR size and morphological presentation of metastatic and normal nodes were compared (Student's t-test or Mann-Whitney test). Quantitative variables were compared using Pearson coefficient. RESULTS: 207 nodes were retrieved on pathology and 165 on MR. MR-pathological correlation of nodes location was high regarding MR-identified nodes (r=0.755). An MR short axis threshold of 4mm yielded the best predictive value for metastatic nodal involvement (Se=78.6%; Sp=62.3%). Irregular contours (Se=35.7%; Sp=96.7%), central nodal hyper-intensity on IR T2 WI (Se=57.1%; Sp=91.4%), and a cortical thickness above 3mm (Se=63.6%; Sp=83.2%) were significantly associated with metastatic involvement. CONCLUSION: Ex vivo MR allows node-to-node correlation with pathology. Morphological MR criteria can suggest metastatic involvement.

Impact of point-of-care testing in the emergency department evaluation and treatment of patients with suspected acute coronary syndromes.

OBJECTIVES: To assess the impact of point-of-care testing (POCT) for troponin I (cTnI) measurement on the time to anti-ischemic therapy (TAIT) for patients with suspected non-ST-segment elevation acute coronary syndrome (NSTE-ACS) presenting to the emergency department (ED). METHODS: This was an open-label, randomized, single-center trial conducted in a university-affiliated hospital. cTnI measurement of patients with suspicion of NSTE-ACS coming to the ED was randomly allocated to POCT or central hospital laboratory testing (CHLT). The authors compared patients' baseline characteristics, time to anti-ischemic therapy, and medical outcomes between the randomized groups, in all study participants and in high-risk NSTE-ACS (cTnI level >or= 0.10 microg/mL), and in those with low suspicion ACS (no chest pain and no ST deviation). RESULTS: Of the 860 patients enrolled, 113 were high-risk NSTE-ACS patients, including 53 (46.9%) allocated to POCT and 60 (53.1%) to CHLT. POCT was associated with decreased time to anti-ischemic therapy of about three-quarters of an hour, which was due to a shorter time to physician notification of cTnI level, in both all and subgroup participants. In contrast, neither ED length of stay nor medical outcomes differed between study groups. CONCLUSIONS: Point-of-care testing for cTnI measurement might be clinically relevant for ED patients with a suspicion of NSTE-ACS, particularly for high-risk patients with a low suspicion of ACS.

Estimation of the Bath Ankylosing Spondylitis Disease Activity Index cutoff for perceived symptom relief in patients with spondyloarthropathies.

OBJECTIVE: To estimate the best Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) cutoff based on patients' perceptions of symptom relief collected in a large population of patients with spondyloarthropathies (SpA), in comparison to the BASDAI cutoff determined by experts. METHODS: A survey of patient perceptions about current disease control was conducted among the members of Spondylis, one of the main not-for-profit SpA patient organizations in France. BASDAI was among data collected by the questionnaire. To estimate the best BASDAI cutoff for discriminating between poor and well perceived controlled groups, we plotted the receiver operating characteristic (ROC) curve. We also determined the cutoff separately in male and female patients. RESULTS: Of the 1000 mailed questionnaires, 485 were returned without any missing data regarding perceived disease control and the BASDAI. Of these patients, 55.3% perceived inadequate control of their disease. The mean BASDAI in the overall population was 43.5 +/- 22.9, 30.4 +/- 19.9 in the well controlled group and 54 +/- 19.4 in the poorly controlled group (p < 0.001). The best BASDAI cutoff for discriminating between patients in the 2 groups was 39 (sensitivity 74.6% and specificity 72.4%). According to gender, the best cutoff was 44 for women and 36 for men. CONCLUSION: The best BASDAI cutoff of 39 based on patients' perceptions was very similar to that selected by international experts, i.e., 40. Gender affected the cutoff for perceived symptom relief in our study. These results need to be confirmed by further studies collecting the opinions of both patients and physicians.

Utilisation of medications recommended for chronic heart failure and the relationship with annual hospitalisation duration in patients over 75 years of age. A pharmacoepidemiological study.

OBJECTIVES: Trials in chronic heart failure (CHF) include few patients older than 75 years, who represent a large proportion of CHF patients. We evaluated the influence of age on CHF-medication use and of CHF medications on hospitalisation in patients older than 75 years. METHODS: Included in our nested case-control study were 281 patients admitted in 2000 to a French teaching hospital with a main diagnosis of CHF and monitored over a 12-month period. Patient characteristics, medications at discharge, outpatient medications and hospitalisation frequency and duration were compared by means of univariate and multivariate analyses. RESULTS: Patients older than 75 years (n=150) and 75 years or younger (n=131) were similar with regard to NYHA class and ejection fraction. At discharge, diuretic use was similar in the two groups, but fewer older patients were prescribed angiotensin-converting enzyme (ACE) inhibitors (48% versus 63%, P<0.01) or beta-blockers (19% versus 37%, P<0.001). During follow-up, total re-admission rate and mean number of re-admissions were similar; however, total hospitalisation duration was greater in patients older than 75 years (38+/-77 days) than in those 75 years or younger (26+/-59 days) (P<0.01). In patients over 75 years, shorter 12-month hospitalisation duration was associated with prescription of diuretics (P<0.001), ACE inhibitors (P<0.001), beta-blockers (P<0.01) and digitalis (P<0.05). CONCLUSIONS: Recent advances in CHF therapy are generally applied less to patients over 75 years of age-associated with longer annual hospitalisation duration in this population. Appropriate CHF medications at hospital discharge appear to reduce annual hospitalisation duration in patients older than 75 years.

Genetic biodiversity of Mycobacterium tuberculosis complex strains from patients with pulmonary tuberculosis in Cameroon.

We analyzed DNA polymorphisms in 455 Mycobacterium tuberculosis complex isolates from 455 patients to evaluate the biodiversity of tubercle bacilli in Ouest province, Cameroon. The phenotypic and genotypic identification methods gave concordant results for 99.5% of M. tuberculosis isolates (413 strains) and for 90% of Mycobacterium africanum isolates (41 strains). Mycobacterium bovis was isolated from only one patient. Analysis of regions of difference (RD4, RD9, and RD10) proved to be an accurate and rapid method of distinguishing between unusual members of the M. tuberculosis complex. Whereas M. africanum strains were the etiologic agent of tuberculosis in 56% of cases 3 decades ago, our results showed that these strains now account for just 9% of cases of tuberculosis. We identified a group of closely genetically related M. tuberculosis strains that are currently responsible for >40% of smear-positive pulmonary tuberculosis cases in this region of Cameroon. These strains shared a spoligotype lacking spacers 23, 24, and 25 and had highly related IS6110 ligation-mediated (LM) PCR patterns. They were designated the "Cameroon family." We did not find any significant association between tuberculosis-causing species or strain families and patient characteristics (sex, age, and human immunodeficiency virus status). A comparison of the spoligotypes of the Cameroon strains with an international spoligotype database (SpolDB3) containing 11,708 patterns from >90 countries, showed that the predominant spoligotype in Cameroon was limited to West African countries (Benin, Senegal, and Ivory Coast) and to the Caribbean area.

Recent increase in meningitis Caused by Neisseria meningitidis serogroups A and W135, Yaoundé, Cameroon.

From 1991 to 1998, Neisseria meningitidis serogroups A, B, and C represented 2%-10% of strains isolated from cases of bacterial meningitis in Yaoundé. During 1999 to 2000, the percentage of meningococci reached 17%, a proportion never reported since recordkeeping began in 1984. The increase of serogroup A meningococci and the emergence of W135 strains highlight the need for increased surveillance for better diagnosis and prevention.

Low rate of mother-to-child transmission of HIV-1 after nevirapine intervention in a pilot public health program in Yaoundé, Cameroon.

OBJECTIVE: To determine the percentage of infected children for whom nevirapine (NVP) was used to prevent peripartum mother-to-child transmission (MTCT) of HIV in Yaoundé, Cameroon. DESIGN: The study was a prospective Public Health Pilot Program covering a 3-year period (January 2000-December 2002). METHODS: Counseled and consenting HIV-1-positive pregnant women were given a single dose of NVP at the onset of labor. Babies were given 2 mg/kg NVP syrup within the first 72 hours of life. NVP-treated children were regularly followed up and examined for HIV-1 infection at 6-8 weeks and 5-6 months through plasma viral load (VL) quantification with the bDNA system. RESULTS: One hundred twenty-three children were diagnosed with perinatal HIV-1 infection at 6-8 weeks and 5-6 months. Thirteen children (10.6% [13/123]; 95% confidence interval, 5.1-16) were infected and presented with high VLs, in general >500,000 copies/mL. Two children had intermediate VLs (between 50 and 3500 copies/mL) at both time points. One hundred seven children (87%) were considered not infected at 6-8 weeks of age. CONCLUSIONS: Our results indicate that the HIV-1 MTCT rate 6-8 weeks after NVP administration was not >13% (16/123), thus demonstrating the effectiveness of NVP for lowering the risk of HIV-1 MTCT in real-life settings.