Could inflammation be a key component in the progression of benign prostatic hyperplasia?

PURPOSE OF REVIEW: This review covers recent developments in the role of chronic inflammation in the pathogenesis and progression of benign prostatic hyperplasia (BPH). RECENT FINDINGS: A paper on the subanalysis of the Medical Therapy of Prostate Symptoms study highlighted the role of chronic inflammation in the progression of BPH as determined by the pathological tissue obtained in the 4.5-year study. It shows patients with inflammation had significantly larger prostates, higher serum prostate specific antigen and a greater risk of urinary retention. This follows several other in-situ studies which demonstrated that elevated expression of pro-inflammatory cytokines in BPH. IL-6, IL-8 and IL-17 may perpetuate chronic immune response in BPH and induce fibromuscular growth by an autocrine or paracrine loop or via induction of COX-2 expression. Immune reaction may be activated via Toll-like receptor signalling and mediated by macrophages and T cells. Conversely, anti-inflammatory factors such as macrophage inhibitory cytokine-1 decreased in symptomatic BPH tissues. Animal models provided evidence for the presence of unique T-cell subsets which may suppress autoimmunity in healthy Sprague-Dawley rats resistant to chronic nonbacterial prostatitis. SUMMARY: The pathogenesis of BPH is still unresolved, although chronic inflammation may play a significant role in disease progression. Further research is required to determine the putative (auto)antigen, the influence of infiltrating inflammatory cells on the stromal/epithelial cell crosstalk and a new classification of BPH quantifying local and systemic inflammatory/immune reactions in relation to clinical relevance. New treatments for BPH investigating these specific inflammatory pathways may arise as we learn more about the way they work.     

Is there a role of preservation of the spleen in distal pancreatectomy?

BACKGROUND: The spleen may be preserved during distal pancreatectomy (DP) for benign disease. The aim of this retrospective study was to compare the postoperative course of DP with or without splenectomy. STUDY DESIGN: From June 1992 to June 1997, 40 adult patients without chronic pancreatitis underwent elective DP for benign lesions. Fifteen underwent spleen-preserving DP (Conservative Group) and 25 DP with splenectomy (Splenectomy Group). In spleen-preserving DP, we attempted to preserve the splenic artery and vein. RESULTS: Spleen-preserving DP was successfully performed in all 15 cases. Patient groups were comparable for clinical features, indication for DP, and surgical procedure. There were no postoperative deaths. The overall incidence of pancreatic fistula was 23%, but was significantly higher in the Conservative Group (40%) than in the Splenectomy Group (12%; p < 0.05). Subphrenic abscesses were more frequently observed in the Conservative Group than in the Splenectomy Group (p < 0.05). The mean duration of postoperative hospital stay was 19 days (range 6 to 46 days) in the Conservative Group and 12.5 days (range 7 to 45 days) in the Splenectomy Group (p < 0.05). At the end of mean followup of 30 months (range 8 to 40 months), no severe postsplenectomy sepsis was observed in the Splenectomy Group. CONCLUSIONS: In our experience, DP with splenectomy has a lower morbidity rate and we consider it to be the best procedure for benign pancreatic disease.     

Is there a role of a small dose of propofol in the treatment of laryngeal spasm?

BACKGROUND: Propofol has been found to depress the laryngeal reflexes. We studied whether this property could be utilized to relieve laryngeal spasm. METHODS: This study was conducted over a period of 3 years, and included children aged 3-10 years, ASA status I and II. Most of the children were undergoing minor surgical procedures, under general anaesthesia with Laryngeal Mask Airway (LMA trade mark ) and caudal epidural analgesia. RESULTS: During this period, 20 patients developed laryngeal spasm on removal of the LMA at the end of surgery. Initially, they all were treated with 100% O2, with gentle positive pressure ventilation. Out of 20 patients, seven responded well with 100% O2 and gentle positive pressure ventilation. The remaining 13 were treated with a small dose of propofol (0.8 mg.kg-1 body weight). Laryngeal spasm was relieved successfully in 10 patients and three patients required intubation to improve their oxygenation. CONCLUSIONS: Propofol in a small dose (0.8 mg.kg-1 body weight) was a useful drug to relieve laryngeal spasm in most children (76.9%) following the removal of the LMA. Because it was not found to be effective in all patients, succinylcholine still has a role to play in critical conditions. However, we recommend propofol as a suitable alternative for relieving laryngeal spasm in situations where succinylcholine is contraindicated.     

Is excision of a choledochal cyst in the neonatal period necessary?

Purpose

Although the incidence of choledochal cyst (CC) diagnosed in the prenatal or neonatal period is increasing, excision of CC in early infancy is not universally recommended. To validate the rationale of excision of CC in the neonatal period, operative complications and the histologic grade of liver fibrosis at the time of excision of CC were compared in three age groups.

Methods

198 patients who underwent excision of CC, were divided into three age groups, i.e., within 30 days old (group 1, n = 11), 1 to 12 month-old (group 2, n = 40) and over 12 month-old (group 2, n = 147). Retrospective review of their medical records was performed.

Results

The overall operative complications were 12 (7 cholangitis, 4 bleeding, 1 ileus). No complication occurred in the group 1. The grade of liver fibrosis had statistically significant positive correlation among groups.

Conclusion

Excision of CC in the neonatal period is a safe procedure. The grade of liver fibrosis increased with age. These results support the rationale of early excision of CC.     

Is there a role for surgery in the treatment of mastalgia?

Breast pain is a common condition affecting most women at some stage in their reproductive life. Mastalgia is resistant to treatment in 6% of cyclical and 26% non-cyclical patients. Surgery is not widely used to treat this condition and only considered in patients with severe mastalgia resistant to medication. The aims of this study were to audit the efficacy of surgery in severe treatment resistant mastalgia and to assess patient satisfaction following surgery. This is a retrospective review of the medical records of all patients seen in mastalgia clinic in the University Hospital of Wales, Cardiff since 1973. A postal questionnaire was distributed to all patients who had undergone surgery. Results showed that of the 1054 patients seen in mastalgia clinic, 12 (1.2%) had undergone surgery. Surgery included 8 subcutaneous mastectomies with implants (3 bilateral, 5 unilateral), 1 bilateral simple mastectomy and 3 quadrantectomies (1 having a further simple mastectomy). The median duration of symptoms was 6.5 years (range 2-16 years). Five patients (50%) were pain free following surgery, 3 developed capsular contractures and 2 wound infections with dehiscence. Pain persisted in both patients undergoing quadrantectomy. We conclude that surgery for mastalgia should only be considered in a minority of patients. Patients should be informed of possible complications inherent of reconstructive surgery and warned that in 50% cases their pain will not be improved.     

Is the treatment of keloid scars still a challenge in 2006?

BACKGROUND: Several options are described to treat keloid scars, none of them being 100% successful. Radiotherapy is suggested to have the most significant effect on recurrence rate. OBJECTIVES: The aim of the study is to confirm the effectiveness of iridium brachytherapy combined with surgery and to evaluate patient satisfaction. PATIENTS AND METHODS: We retrospectively enrolled 24 patients with 30 keloids, treated by surgical excision and iridium 192 high-dose-rate (HDR) brachytherapy. RESULTS: We observed a significant difference in scar thickness before and after the treatment (P < 0.001). With regard to patient satisfaction and complaints, 79.1% of them had no pain and irritation after treatment, 79.2% of patients would recommend this treatment to other patients, and 87.5% would undergo this treatment again if necessary. CONCLUSIONS: Our results confirm the effectiveness of surgical keloid excision followed by HDR brachytherapy in primary treatment or if other alternative methods have failed.     

Is there a role of radial rigidity in the evaluation of erectile dysfunction?

RigiScan has been the most widely utilized device for measuring erectile rigidity. However, the use of the RigiScan in the evaluation of erectile dysfunction has questionable because the RigiScan device does not directly determine axial rigidity. The aim of this study is to clarify that radial rigidity measured by RigiScan reflects the intracorporeal pressure and erectile capability efficiently. From January 1998 to May 1999, a total of 23 patients with erectile dysfunction were involved in the study. They were evaluated by RigiScan and duplex ultrasonography after intracorporeal injection of prostaglandin E1. We investigated the relationship between radial rigidity and the resistance index. The results of radial rigidity were also compared with that of the degree of erection. For the entire group, significant correlations were found between radial rigidity and the resistance index (r=0.680, P<0.001 for tip rigidity; r=0.703, P<0.001 for base rigidity). In addition, for 12 patients whose tip rigidity exceeded 60% and for 10 whose base rigidity exceeded 60%, the correlations between radial rigidity and the resistance index remained (r=0.659, P=0.020 for tip rigidity; r=0.759, P=0.011 for base rigidity). Based on the response determined by patients, radial rigidity represented the degree of erection efficiently.Our findings suggest that RigiScan is a useful diagnostic tool. Radial rigidity represents the intracorporeal pressure efficiently and has an acceptable role in the evaluation of erectile dysfunction.     

Is there a significance of histamine in the control of the human male sexual response?

Although histamine has been suggested to be involved in the control of male sexual function, including the induction of penile erection, its role in the human corpus cavernosum penis is still poorly understood. The aim of our study was to evaluate the course of histamine plasma levels through different stages of sexual arousal in the systemic and cavernous blood of healthy male subjects. Thirty four (34) healthy men were exposed to erotic stimuli to elicit penile erection. Blood was aspirated from the corpus cavernosum and a cubital vein during the penile conditions flaccidity, tumescence, rigidity and detumescence. Blood was also collected in the post-ejaculatory period. Plasma levels of histamine (ng ml(-1)) were determined by means of a radioimmunoassay. Histamine slightly decreased in the cavernous blood when the penis became tumescent. During rigidity, histamine decreased further but remained unaltered in the phase of detumescence and after ejaculation. In the systemic circulation, no alterations were observed with the initiation or termination of penile erection, whereas a significant drop was registered following ejaculation. Results are not in favour of the hypothesis of an excitatory role of histamine in the control of penile erection. Nevertheless, the amine might mediate biological events during the post-ejaculatory period.     

Is the Trauma Mortality Prediction Model (TMPM-ICD-9) a valid predictor of mortality in pediatric trauma patients?

Background/Purpose

Researchers are constantly challenged to identify optimal mortality risk adjustment methodologies that perform accurately in pediatric trauma patients. This study evaluated the new Trauma Mortality Prediction Model (TMPM-ICD-9) in pediatric trauma patients.

Methods

Data were analyzed on 107,104 pediatric trauma patients included in the NTDB® in 2010 who had both a valid ISS and probability of death using TMPM-ICD-9. Discrimination was compared using the area under the receiver operator characteristic curve (AUC) and by age, blunt vs penetrating, intent, Glasgow Coma Scale (GCS), and number of injuries.

Results

The AUC for TMPM-ICD-9 demonstrated excellent discrimination in predicting mortality versus ISS overall, 11 to 17 years of age (0.96 vs 0.93), by injury type, intent, and in the lowest GCS scores. The TMPM-ICD-9 showed superior discrimination over ISS in patients with more than two injuries.

Conclusions

The TMPM demonstrated superior discrimination compared to ISS. The TMPM shows promise of a much needed and simple to use risk adjustment tool with application to both adult and pediatric patients. Researchers should continue to validate this tool in robust pediatric data sets.     

Is partial cystectomy a justified intervention in the treatment of bladder tumors?

The authors present their experience of 122 partial cystectomy cases made on a number of 288 vesical tumors in our clinic, during 5 years (1986-1991) from which 23 are superficial tumors and 99 are infiltrative ones. The treatment of vesical tumors can be done in many ways; this partial cystectomy must be completed with an other therapeutic method: irradiation on chemotherapy in conformity with the anatomo-pathological form, the steady and tumoral grading.     

Is kidney size a useful predictor of renal function in the elderly?

Despite its widespread use, the diagnostic yield of ultrasonography to detect early stages of reduced renal function in the elderly remains doubtful. METHOD: Sixty-two patients (age: 74.8 +/- 6.7 years, 30 females) attending a geriatric ward were examined. Non-insulin-dependent diabetes was present in 28 patients and 32 were hypertensive. Exclusion criteria were previously known renal failure, an elevated serum creatinine above 2 mg/dl at admission or apparent cognitive impairment. Inulin clearance (C(IN)), Cockcroft estimation and urinary albumin excretion rate (UAER) were determined. Renal parenchymal volume, renal volume and mean renal length were calculated using data obtained by ultrasonography. RESULTS: A multiple regression analysis identified C(IN) as the main determining factor on renal parenchymal volume (beta = 0.360; p = 0.004). Body height showed additional influence (beta = 0.295; p = 0.018), but age, gender, diabetes, UAER and hypertension did not. Cockcroft estimation, ultrasonographic markers of renal size and further confounding variables were evaluated in a subsequent multiple regression analysis. Cockcroft estimation explained the major part of the variance (beta = 0.783; p < 0.001) and the occurrence of diabetes showed a borderline additional effect. But there was no supplementary influence of any ultrasonographic parameter. In 11 patients, C(IN) was reduced to < or = 60 ml/min. ROC analysis revealed poor diagnostic efficacy of all ultrasonographic parameters (AUC < 0.7336) compared to Cockcroft estimation (AUC = 0.8718). CONCLUSION: Although a linear relation between C(IN) and renal parenchymal volume could be shown, ultrasonography cannot replace or complement Cockcroft estimation in order to detect early reduced renal function in the elderly. Nevertheless, reduced renal parenchymal volume may occur prior to elevation of serum creatinine in the elderly and should be noted carefully on routine ultrasonographic examinations.