Recurrence risk is associated with preoperatively advanced prolapse stage: Is there a difference between women with stage 2 and those with stage 3 or 4 cystocele?

Introduction and hypothesis

Pelvic organ prolapse (POP) recurrence after surgery is a major problem. POP that is more advanced preoperatively is associated with a higher risk of recurrence postoperatively. We hypothesized that women with a stage 2 cystocele differ from those with a stage 3 or 4 cystocele. The aim of this study was to compare the baseline characteristics of women with mild and those with more advanced cystocele.

Methods

Patients had participated in one of two multicenter prospective cohort studies on women undergoing conventional anterior colporrhaphy without previous POP surgery. This was a secondary analysis of these data. Women with a preoperative cystocele stage 2 were compared with women with a stage 3 or 4 cystocele. Logistic regression models were employed to calculate odds ratios (OR) and 95% confidence intervals (CI).

Results

Two hundred and sixty-nine women were assessed, of whom 132 (49.1%) had an advanced cystocele. Only older age was significantly associated with advanced cystocele preoperatively, with an OR of 1.07 (95% CI 1.04–1.10). There were no significant differences between women with advanced or stage 2 cystocele in body mass index, vaginal deliveries, assisted delivery, positive family history of POP, concurrent rectocele, concurrent uterine of vaginal vault prolapse, major levator ani muscle defects, or levator hiatal area.

Conclusions

Women with advanced cystocele were significantly older than women with stage 2 cystocele. This raises the question whether it would be favorable to perform POP surgery in an earlier stage, i.e., at a younger age, in order to prevent POP recurrence.

     

Is aggressive local treatment necessary for diffuse liver involvement in patients with progression of stage 4s neuroblastoma to stage 4?

Three patients with stage 4S neuroblastoma without MYC-N amplification who progressed to stage 4 with persistent liver involvement, were treated with iodine 131-meta-iodobenzylguanidine therapy, chemotherapy, and surgery. Successive histologic examination of the liver showed differentiation of the tumor in 2 patients and fibrosis in the third. One patient died of brain metastases at the age of 30 months. The other 2 patients are alive at 50 and 44 months. Diffuse liver involvement in patients with stage 4 progression of previous stage 4S without MYC-N amplification may differentiate after treatment. The aim of this report is to draw attention to major liver surgery that it may not be necessary in tumors without MYC-N amplification, despite the persistence of lesions in the liver.     

Can bladder preservation therapy come to the center stage?

Decision‐making in urological cancer care requires a multidisciplinary approach for refinement, but its impact on urothelial carcinoma of the bladder has not been fully addressed for the past three decades, except for the latest immunological checkpoint inhibitor approved by the U.S. Food and Drug Administration for metastatic muscle‐invasive bladder cancer that is resistant to platinum‐based chemotherapy. For the time being, radical cystectomy is the gold standard of curative therapy for muscle‐invasive bladder cancer. Trimodal therapy that combines chemotherapy for the purpose of radiation sensitization, external beam radiotherapy and transurethral resection of bladder tumor has emerged as a potential alternative treatment option that preserves the bladder. In lack of randomized studies for bladder preservation therapy compared with surgery, the principles of management of urothelial carcinoma of the bladder have evolved in recent times, with an emphasis on bladder preservation. A number of bladder preservation techniques are available to the surgeon; however, appropriately selected patients with muscle‐invasive bladder cancer should be offered the opportunity to discuss various treatment options, including organ‐sparing trimodal therapy. The aim of the present study was to compare the primary outcomes of the available treatment methods and identify the sources of variance among studies. A review of various bladder preservation techniques in vogue for the management of urothelial carcinoma of the bladder is discussed.     

Can maturation arrest occur at the stage of spermiogenesis?

This article attempts to clarify the pathological condition during which the maturation of the germinal epithelium is unable to evolve beyond a certain stage and is characterized as maturation arrest. Emphasis is given to the histological entity named spermiogenic arrest.     

Elective lymph node dissection in stage I melanoma--necessary or not?

The management of patients with malignant melanoma is somewhat controversial. The most important prognostic factor is depth of invasion. Criteria by both Clark and Breslow are of value. Therapy must not be "standardized," but individualized for each patient.     

Renal parenchymal malacoplakia: a different stage of xanthogranulomatous pyelonephritis?

Malacoplakia is a rare inflammatory condition characterized by demonstrative Michaelis-Gutmann bodies, which are foamy histiocytes with distinctive basophilic inclusions. Malacoplakia is caused by the inadequate elimination of bacteria by macrophages or monocytes as a result of defective phagocytic activity. Xanthogranulomatous pyelonephritis is characterized by the destruction of renal parenchyma and its replacement by solid sheets of foamy lipid-laden macrophages. Prolonged infection of the kidney, which is frequently caused by an obstruction of the urinary tract, is the pathologic mechanism of that condition. We present a 6-year-old patient with a poorly functioning kidney who had a prolonged recurrent urinary tract infection. The results of histologic analysis revealed an inflammatory infiltration consisting predominantly of foamy and epithelioid histiocytes that contained round intracytoplasmic concretions characteristic of Michaelis-Gutmann bodies. We suggest that malacoplakia might be a stage of xanthogranulomatous pyelonephritis.     

Why do we need outcomes research in end stage renal disease?

Despite effective therapeutic strategies to slow or arrest the progression of chronic renal diseases, the number of patients entering renal replacement programs is increasing, with a dramatic burden in terms of morbidity, mortality and resource consumption. While in the past the attention was mainly devoted to the improvement of dialysis care, it has recently been argued that the timing and quality of care before dialysis is started may significantly affect the prognosis. Problems of transfer of research results, together with differences in physicians' attitudes and beliefs as well as in structural and organisational aspects make pre-end-stage renal disease (ESRD) care extremely heterogeneous. This lack of uniformity in medical practice has stimulated extensive inquiry into the relation between the use of clinical services and their end results--the outcomes. Outcomes research investigates medical effectiveness, meaning how well prevailing treatments work in different clinical practice settings. It is thus an important tool to help patients, providers and purchasers to make sound decisions, based on a deeper knowledge of how different choices affect the patient's life. By using a broad array of outcome measures, this research serves to evaluate the effectiveness of complex health care strategies from the different points of view of patients, providers and purchasers, reconciling their needs. Starting from these premises, initiatives aimed to evaluate the avoidability of ESRD morbidity and mortality are urgently needed. To this purpose, the care delivered to ESRD patients and its impact on clinical variables, quality of life and resource consumption need to be longitudinally monitored. Outcomes research thus represents a unique opportunity to increase our knowledge on pre-ESRD care and to identify those strategies more likely to reduce the unwanted outcomes related to the initiation of dialytic treatment.     

Outcomes of stage 1–5 chronic kidney disease in Mainland China

Objective: This study aims to quantify and compare the risks of death and end stage renal disease (ESRD) in a prospective cohort of patients with chronic kidney disease (CKD) stages 1–5 under renal management clinic at Peking University Third Hospital and to evaluate the risk factors associated with these two outcomes. Method: This was a prospective cohort study. Finally, 1076 patients at CKD stage 1–5 short of dialysis were recruited from renal management clinic. Patients were monitored for up to Dec, 2011 or until ESRD and death. Glomerular filtration rate was estimated (eGFR) according to the using the CKD Epidemiology Collaboration (CKD-EPI) formula. Results: At the end of follow-up, 111 patients (10.1%) developed ESRD (initiated dialysis or kidney transplantation (ESRD)) and 24 patients (2.2%) had died. There were more ESRD occurrence rate in patients with baseline diabetic nephropathy, lower eGFR, hemoglobin <100?g/L and 24?h urinary protein excretion ≥3.0?g. By multivariate Cox regression model, having heavy proteinuria and CKD stage were the risk factors of ESRD. For all-cause mortality, the most common cause was cardiovascular disease, followed by infectious disease and cancer. But we failed to conclude any significant variable as risk factors for mortality in multivariate analysis. Conclusions: Our study indicated that baseline diabetic nephropathy, lower hemoglobin level, lower baseline GFR and heavy proteinuria were the risk factors of ESRD. In this CKD cohort, patients were more likely to develop ESRD than mortality, and cardiovascular mortality was the leading cause of death, and then followed by infectious diseases and cancer in this population.     

Is IL-33 useful to detect early stage of renal failure?

IL-33 is a proinflammatory cytokine that is a member of IL-1 family. Previously the effect of IL-33 on kidney injury is showed in animal models. In this study, we searched if we can use IL-33 to show the early stage of kidney injury in diabetic patients. Three groups are identified: 26 patients in Group 1: Healthy group, that do not have any chronic diseases and not taking any medication; 42 patients in Group 2: DM (diabetes mellitus) group without any known kidney disease and with normal kidney functions; 32 patients in Group 3: DM?+?MA (microalbuminuria) group that are assumed to have nephropathy. IL-33 level of DM patient group is greater than healthy group; also IL-33 level of DM?+?MA patient group is greater than healthy group; but there is not any difference between DM and DM?+?MA group. The increase in IL-33 levels in diabetic nephropathy is not associated with kidney injury but the increase could be resulting because of diabetes. So IL-33 cannot be used in early recognition of diabetic nephropathy.     

VATS lobectomy in stage I lung cancer: standard or experimental procedure

Video-assisted thoracoscopic surgery (VATS) for lobectomy in stage?I non-small cell lung cancer (NSCLC) was introduced in 1991 and has been accompanied by concerns in terms of safety and oncological adequacy over a long period. Only few randomised controlled trials including a small number of patients have been performed, demonstrating non-inferiority of the technical feasibility, patient comfort and long-term prognosis compared with the open technique. The evolving acceptance of VATS lobectomy, however, is based on case-control series and case series including up to 1100?patients as well as reviews and metaanalyses demonstrating its overall advantages. Presuming appropiate training the VATS procedure can be accomplished rapidly, safely and without violation of oncological principles. Patients experience a less traumatic procedure and a shorter recovery. The 5-year survival is not different from that after open thoracotomy. In conclusion, VATS lobectomy may be regarded as standard in stage?I NSCLC as long as the preconditions in terms of surgical training, patient selection and infrastructure are fulfilled.     

Do synovial leptin levels correlate with pain in end stage arthritis?

Purpose

We evaluated whether synovial fluid (SF) leptin concentrations correlate with pain severity in patients with hip or knee endstage osteoarthritis (OA) and whether they mediate the association between increased joint pain and (1) female gender and (2) obesity.

Methods

We conducted a cross-sectional study including patients with primary hip and knee OA undergoing joint replacement between January and December 2010. SF leptin concentrations obtained on the day of surgery were assessed. Main outcome was pain severity measured pre-operatively using WOMAC and VAS pain scales.

Results

A total of 219 patients were included, 123 hip and 96 knee arthroplasties. Mean age was 72 years, 59 % were women. Mean SF leptin levels were 22.9 (±25.6) ng/ml in women and 5.4 (±5.9) ng/ml in men. Levels >19.6 ng/ml (highest quartile) were significantly associated with increased pain on both WOMAC (mean difference −9.6, 95 % CI −15.1 to −4.0) and VAS scale (mean difference 0.8, 95 % CI 0.2–1.3). Associations remained unchanged after adjusting for age, co-morbidities, contra-lateral arthritic joint, OA site, and disability. The associations observed between increased pain and female gender or obesity were substantially reduced after adjusting for SF leptin.

Conclusion

Joint pain is associated with SF leptin concentrations. Increased pre-operative pain observed in women and obese may be related to high intra-articular leptin levels.