Management of BCG failures in superficial bladder cancer: a review

OBJECTIVE: Review management of bacillus Calmette-Guérin (BCG) failures in superficial bladder cancer. METHOD: Search of published literature and meeting abstracts. RESULTS: Patients in whom BCG fails are not a uniform group. Failure cannot be predicted but high-risk patients can be identified. In case of failure and progression the outcome is bad. Conservative but investigative alternatives are BCG/interferon-alpha, intravesical hyperthermia/chemotherapy, or photodynamic therapy. Standard treatment in failing patients remains cystoprostatectomy. CONCLUSION: BCG failures need careful and individualized therapy in experienced hands.     

Management of hepatic granulomatous tuberculosis complicating intravesical BCG for superficial bladder cancer

Intravesical bacille Calmette-Guérin (BCG) therapy is the most effective treatment for high-risk superficial bladder cancer. Severe systemic complications are rare, but may occur in approximately 1% of cases. We report a severe complication of intravesical BCG: a disseminated Mycobacterium bovis infection with biopsy-proven granulomatous hepatitis in a patient with bladder cancer. We also elaborate on the different management alternatives.     

Increased Length of Stay and Costs Associated with Inpatient Management of Vascular Access Failures

The creation and maintenance of vascular access for hemodialysis patients is responsible for a significant amount of morbidity and hospital expenses which continue to escalate with increasing population of ESRD patients. A retrospective review of patient charts were performed from 2008 to May 2011 at an academic tertiary care center who had a diagnosis of vascular access failure based on ICD 9 coding. Data regarding demographic information, length of stay (LOS), source of insurance, hospital expenses, and discharge status were obtained. Based on strict inclusion criteria we identified 172 total patients. The mean age among all patients was 60.53 ± 15.35 years and the majority of patients were Hispanic (n = 81). The Mean LOS was 5.30 ± 4.64 days. Mean hospital costs were 41,896 ± 20,318 US$. Patients admitted for tunneled dialysis placement had greater length of stay (p‐value = 0.011) as did patients with hypertension (p‐value = 0.030). Hospital expenses were significantly higher for patients admitted for arterio‐venous fistula complications (55,456 ± 23,779 US$) compared with admissions for catheter or dialysis graft related complications (p‐value = 0.004). Patients on Medicare had significantly lower length of stay (3.98 ± 3.32 days) compared with patients with Medicare/Medical (6.59 ± 5.69 days), p‐value = 0.047. Inpatient management of vascular access failure is associated with increased length of stay, and significant hospital expenses. Timely referral to vascular access centers can prevent unnecessary hospitalizations and provide cost‐saving benefits.     

重组卡介苗和传统卡介苗免疫原性的比较

目的 观察分泌人白细胞介素(IL)-2的重组卡介苗(rBCG)和传统卡介苗(BCG)对小鼠免疫应答的影响,评价其免疫原性,初步探讨rBCG免疫治疗的作用机制.方法 连续6周对BALB/C小鼠尾静脉注射rBCG和BCG,分别在第2、4和6周后杀死小鼠取腹腔巨噬细胞和脾脏.以一氧化氮(NO)释放量检测巨噬细胞吞噬活性,以淋巴细胞刺激指数(SI)反映细胞增殖能力,以流式细胞仪测定T淋巴细胞CD亚群分化和酶联免疫吸附试验(ELISA)法检测小鼠脾淋巴细胞培养上清细胞因子分泌的变化,比较rBCG治疗组和BCG治疗组之间的差异.结果 在连续6周观察期间,随着免疫时间的延长,rBCG对小鼠脾脏T淋巴细胞的增殖能力逐渐增强,CD4+、CD8+T细胞和CD4+/CD8+的比例逐渐增高,腹腔巨噬细胞的吞噬活性逐渐增高,诱导小鼠脾淋巴细胞分泌的Th1型和Th2型细胞因子逐渐增多.在同一时点上,不同rBCG和BCG的上述作用均高于空白对照组(P均0.01),差异有统计学意义;rBCG治疗组的上述作用均高于BCG治疗组.结论 rBCG具有良好的免疫原性,能明显增强BALB/c小鼠的免疫应答反应.rBCG诱导的T细胞免疫应答主要是CD4+T细胞依赖的,CD4+细胞免疫应答主要是以Th1型细胞因子参与为主,Th2型细胞因子也发挥一定作用.     

Management beim "vergessenen" DJ-Stent

Zusammenfassung DJ-Stents sind eine komfortable und den Patienten kaum belastende Möglichkeit, um die Urinpassage zu sichern. Der hohe Komfort mit fehlender oder geringer Beeinträchtigung der körperlichen Aktivität birgt aber den Nachteil, dass ein eingelegter DJ-Stent auch "vergessen" werden kann. Durch die Inkrustration des DJ-Stents kann die Stententfernung problematisch werden. In einigen Fällen kann es auch zum Stentabriss kommen.Um inkrustrierte DJ-Stents zu entfernen, finden alle modernen minimal-invasiven endourologischen Techniken Anwendung. In Einzelfällen ist allerdings eine chirurgische Sanierung unumgänglich. Um diese Problematik zu umgehen und eine beginnende Inkrustration frühzeitig zu erkennen, sind Patienten mit DJ-Stent engmaschig zu kontrollieren. Bei Patienten, bei denen der DJ-Stent nur passager erforderlich ist, sollte die DJ-Stententfernung so früh wie möglich durchgeführt werden.

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Clinical experience with BCG alone versus BCG plus epirubicin

BACKGROUND: Bacillus Calmette-Guérin (BCG) and epirubicin have both been shown to be effective in the treatment of superficial bladder cancer. We studied whether the alternating combination of these agents could improve the efficacy with tolerable side-effects in the treatment of high-risk superficial bladder tumors. METHODS: Forty-one patients with high-risk superficial bladder transitional carcinoma were included in this study. Twenty-one patients were randomized into the BCG group and 20 patients were treated with sequential BCG and epirubicin. The patients were followed for 9-24 months (mean 18 months). Recurrence rates, median time to the first recurrence, progression rate and complications were compared. RESULTS: Fifteen percent of the patients in the BCG and epirubicin group and 19% of the patients in the BCG alone group developed tumor recurrence. Tumor progression was observed in 4.7% and 10% in the BCG/epirubicin group and the BCG alone group, respectively. Median time to first recurrence was 11 months for the BCG/epirubicin group and 16 months for the BCG group (P > 0.05). Three patients in the BCG/epirubicin treatment group developed serious side-effects, which necessitated antituberculosis treatment. CONCLUSION: Because the efficacy of combination was no better than the standard treatment and the alternating combination seemed to be related to a higher incidence of side-effects, this study albeit small, does not recommend combination therapy of BCG and epirubicin in high risk patients with superficial bladder cancer.     

Failures of hallux valgus surgery

More than 150 corrective procedures for hallux valgus exist and an incorrect choice of procedure leads to insufficient correction. Distal first metatarsal osteotomy cannot correct large deformities and degenerative changes at the metatarsophalangeal joint impede functional recovery. Incongruence of the joint must be corrected during surgery. Recurrence is most often caused by insufficient correction, especially of the first metatarsal bone. Overcorrection is often due to technical problems with the initial metatarsal osteotomy. This also applies to insufficiency of the first ray due to shortening or dorsal angulation. Partial first metatarsal head necrosis occasionally occurs but complete necrosis is rare. Non-union is mostly caused by incorrect osteosynthesis. During postoperative treatment the hallux must be held in the correct position to avoid failure.     

Failures in through-knee amputation

Long-term results over a period of more than 10 years give evidence of the superiority of the through-knee compared to the above-knee stump. However, failures in through-knee stumps before, during and after operation and pitfalls in prosthetic fitting are still too frequent. They are mostly due to errors because the peculiarities of the stump and the prosthetic management are not recognised. This paper emphasizes frequent causes of failure in the selection of the level of amputation, the operative technique, post-operative treatment and prosthetic rehabilitation in order to reduce the complication rate.