Role of pelvic drain and timing of urethral catheter removal following RARP: a systematic review and meta-analysis

Objectives

To assess the clinical value of routine pelvic drain (PD) placement and early removal of urethral catheter (UC) in patients undergoing robot-assisted radical prostatectomy (RARP), as perioperative management such as the necessity of PD or optimal timing for UC removal remains highly variable.

Methods

Multiple databases were searched for articles published before March 2022 according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) statement. Studies were deemed eligible if they investigated the differential rate of postoperative complications between patients with/without routine PD placement and with/without early UC removal, defined as UC removal at 2–4 days after RARP.

Results

Overall, eight studies comprising 5112 patients were eligible for the analysis of PD placement, and six studies comprising 2598 patients were eligible for the analysis of UC removal. There were no differences in the rate of any complications (pooled odds ratio [OR] 0.89, 95% confidence interval [CI] 0.78–1.00), severe complications (Clavien–Dindo Grade ≥III; pooled OR 0.95, 95% CI 0.54–1.69), all and/or symptomatic lymphocele (pooled OR 0.82, 95% CI 0.50–1.33; and pooled OR 0.58, 95% CI 0.26–1.29, respectively) between patients with or without routine PD placement. Furthermore, avoiding PD placement decreased the rate of postoperative ileus (pooled OR 0.70, 95% CI 0.51–0.91). Early removal of UC resulted in an increased likelihood of urinary retention (OR 6.21, 95% CI 3.54–10.9) in retrospective, but not in prospective studies. There were no differences in anastomosis leakage and early continence rates between patients with or those without early removal of UC.

Conclusions

There is no benefit for routine PD placement after standard RARP in the published articles. Early removal of UC seems possible with the caveat of the increased risk of urinary retention, while the effect on medium-term continence is still unclear. These data may help guide the standardisation of postoperative procedures by avoiding unnecessary interventions, thereby reducing potential complications and associated costs.     

Does photodynamic transurethral resection of bladder tumour improve the outcome of initial T1 high‐grade bladder cancer? A long‐term follow‐up of a randomized study

OBJECTIVE

To evaluate, in a long‐term follow‐up of T1 high‐grade bladder cancer treated in a prospective, randomized trial, whether fluorescence diagnosis (FD) increases recurrence‐free survival (RFS) or reduces progression to muscle‐invasive stages.

PATIENTS AND METHODS

In all, 191 patients with suspected superficial bladder cancer were treated with transurethral resection under white light (WL) or with FD; 46 presented with initial T1 high‐grade BC (WL, 25; FD, 21). There were no differences in multifocality of tumours, concomitant carcinoma in situ or tumour size in either group.

RESULTS

Patients were followed for a median of 7.3 (WL) and 7.5 (FD) years to evaluate RFS. In the WL group there were 11, and in the FD group three, recurrent tumours of the same stage and grade. The RFS at 4 and 8 years was 69% and 52% in the WL, and 91% and 80% in FD group, respectively. With FD, the RFS was significantly longer according to Kaplan‐Meier analysis (P = 0.025). In the WL group, three (12%), and in the FD group four (19%) patients progressed to muscle‐invasive stages (≥ T2).

CONCLUSION

In initial T1 high‐grade bladder cancer, FD is significantly better than conventional WL transurethral resection for RFS. However, the progression rate to muscle‐invasive disease was not reduced by FD. Thus the clinical course (progression) of T1 high‐grade bladder cancer remains unaffected by FD.     

Operative Treatment and Soft Tissue Management of Open Distal Tibial Fractures – Pitfalls and Results

Open tibial fractures usually result from high-energy trauma. Severe soft-tissue injuries are often combined with open fractures of the distal tibia. A consecutive series of 42 patients with open extraarticular distal tibial fractures (Gustilo I–IIIc) operated on between July 2006 and February 2009 were included in the study reported here. We performed open reduction and internal fixation for the Gustilo I cases. Soft tissue was closed directly after antibiotic beads had been temporarily applied. For the Gustilo II and III cases, our treatment protocol included soft-tissue debridement of all devitalized soft tissue and bone fragments, pulsatile jet irrigation, and external stabilization. Soft tissue was temporarily closed with Epigard_ after the application of antibiotic beads. A second-look operation was scheduled after 3–5 days. Gustilo II patients needed an average of 1.1 (0–3) revisions until wound closure, compared to the average of 2.1 revisions necessary for the Gustilo III patients. It took 5.6 (0–16) days to obtain definitive wound closure in the Gustilo II patients and 9.9 (3–28) days in the Gustilo III patients. Skin grafting was sufficient for definitive softtissue closure in ten cases, local flaps in eight cases, and free musculocutaneous flaps were needed in six cases. Gustilo II patients with primary wound closure remained hospitalized for 11 days, while patients with secondary wound closure stayed in hospital for an average of 20 days. Our early results concerning infection rate, number of reoperations, and time to bony consolidation can be compared with other studies. Functional results will have to be evaluated at clinical follow-up.     

Hydrogen peroxide contrast echocardiography

Several agents are used as echocardiographic contrast agents, but their unreliability discourages routine clinical use. Studies from the early 1960s suggest that dilute hydrogen peroxide (H₂O₂) is a safe intravascular agent. Its use was evaluated in contrast echocardiography. To obtain dense opacification reliably, H₂O₂ (3%) was passed through a sterile 0.2 μ Millipore filter and diluted with heparinized saline solution to make a 0.1 to 0.2% solution. A drop of blood was withdrawn from an indwelling peripheral venous needle into a syringe containing 0.5 to 2.0 ml of the dilute H₂O₂ and the contents injected. Studies in dogs, normal adults and 36 patients with noncyanotic congenital and acquired cardiac disorders produced dense opacification with no complications. In vitro mixture of H₂O₂ (0.3%) with leukocyte-poor blood or plasma produced only a few microbubbles, while addition to whole blood or buffy coat produced many, suggesting a role for leukocyte peroxidase. H₂O₂ contrast echocardiography is simple, inexpensive, and reliably provides dense, sustained opacification. This study and previous studies suggest that intravenous injection of 0.2% H₂O₂ can be done safely. Great caution should be exercised in patients with severe pulmonary hypertension or large right-to-left shunts because little clinical experience with H₂O₂ is available.     

Oxygenation Status in Chronic Leg Ulcer After Topical Hemoglobin Application May Act as a Surrogate Marker to Find the Best Treatment Strategy and to Avoid Ineffective Conservative Long-term Therapy

Purpose

Chronic leg ulcers can be a challenge to treat and long-term therapy a significant cost factor in western public health budgets. Objective wound assessment assays enabling selection of appropriate wound therapy regimes would be desirable. Oxygenation status in ulcer tissue has obtained increased attention as a relevant factor in wound healing. To increase oxygenation in wounds, a topical hemoglobin spray was developed. Although favorable results have been noted, the link between clinical efficacy and the mode of action has not been demonstrated. The aims were to determine if changes in tissue oxygenation can be measured after topical application of hemoglobin on chronic wounds and to evaluate the findings in terms of therapy strategies.

Procedures

Photoacoustic imaging was used to measure the local oxygen saturation (StO₂) in leg ulcers before and after hemoglobin spray treatment. Sclerosis of the leg ulcers was histopathologically graded and the change in wound size was documented in a follow-up examination.

Results

Measuring 49 patients, an increase in StO₂ after topical hemoglobin application from on average 66.1 to 71 % (p = 0.017) after 20 min was observed. Depending on the increase in StO₂ (>10 % or <10 %) patients were stratified into a Responder and a Non-Responder group. Wound size significantly decreased in the Responder Group (p = 0.001), while no significant difference in the Non-Responder group (p = 0.950) was noted.

Conclusion

Our findings suggest that the likelihood of wound healing under conservative therapy can be predicted by measuring changes in StO₂ after topical hemoglobin application. This assay may reduce treatment time and costs by avoiding ineffective conservative long-term therapy.

Trial Registration

German Clinical Trials Register: DRKS00005993

     

Flu and Finances: Influenza Outbreaks and Loan Defaults in US Cities, 2004–2012

Objectives. We examined the association between influenza outbreaks in 83 metropolitan areas and credit card and mortgage defaults, as measured in quarterly zip code–level credit data over the period of 2004 to 2012.Methods. We used ordinary least squares, fixed effects, and 2-stage least squares instrumental variables regression strategies to examine the relationship between influenza-related Google searches and 30-, 60-, and 90-day credit card and mortgage delinquency rates.Results. We found that a proxy for influenza outbreaks is associated with a small but statistically significant increase in credit card and mortgage default rates, net of other factors. These effects are largest for 90-day defaults, suggesting that influenza outbreaks have a disproportionate impact on vulnerable borrowers who are already behind on their payments.Conclusions. Overall, it appears there is a relationship between exogenous health shocks (such as influenza) and credit default. The results suggest that consumer finances could benefit from policies that aim to reduce the financial shocks of illness, particularly for vulnerable borrowers.Seasonal influenza is a viral airborne disease that generally spreads each fall and winter, causing an estimated 1.5 million people to get sick and 200 000 to be hospitalized in a typical year in the United States.1,2 Symptoms can range from mild and hardly distinguishable from a common cold to severe and life-threatening. Influenza accounts for at least 500 000 deaths in the United States in the past 3 decades.3For employed individuals, influenza can make attending work difficult, because of either personal illness or caring for sick household members. This generates significant costs to employers and employees. Estimates from 2007 suggest that annual influenza outbreaks lead to $16.3 billion in lost productivity and wages, and $10.4 billion in medical costs,4 although these costs vary considerably across place.5Although there is a robust literature on the economic costs of influenza, we know little about how such unexpected health shocks are associated with other aspects of the economy, such as loan defaults. We built on existing knowledge of the economic costs of influenza by examining how influenza outbreaks influence credit card and mortgage default rates in US cities.In the wake of the Great Recession, loan defaults have increased, with negative financial consequences for families.6 For loans due on a monthly basis, such as mortgages and credit cards, past-due balances and late fees accumulate each month. Three missed payments (90-day delinquent) is a signal of a loan at high risk for failure and in most states triggers legal collections processes.7In the microeconomic literature, illness is seen as a shock—an unexpected event—that can affect household income and expenses. If the shock results in a disruption to income, households will respond with shifts in consumption and expenditure patterns.8 We contend that influenza, as a health shock, has the potential to trigger loan default by constraining a family’s budget because of personal illness or caretaking burdens. Influenza may also trigger inattention to household financial management and a lack of planning for future bill payments.9–11 This may be especially problematic for borrowers who are already behind on their payments, whom we define as vulnerable borrowers. For these borrowers, who also tend to be economically vulnerable and disadvantaged in other ways,12,13 an influenza outbreak could increase the likelihood of further missed payments. A recent study supports this notion, and shows that economically vulnerable households are more likely to borrow and borrow more in the event of a health shock than less vulnerable households.14 However, this study did not examine credit default.A growing literature examines the complex and potentially multidirectional relationship between health and default.15–19 Most research examines whether defaults influence health,15,19,20 and less examines how health may have an impact on default risk.21 However, a key problem inherent in this literature is that health status is endogenous, and it is difficult if not impossible to disentangle processes of causation, selection, and reverse causation with survey data.Our interest in influenza provides us with a unique opportunity to improve causal estimates of health shocks on default. Influenza occurs to varying degrees in every city and year in the United States, and the intensity of the outbreak is an ostensibly exogenous health shock for communities. Thus, influenza outbreaks provide a natural experiment in which we use variation in influenza severity across time and place to identify the effects of a particular health shock on default. Specifically, we ask whether influenza outbreaks in US metropolitan statistical areas (MSAs) are associated with defaults from the first quarter (March) of 2004 (Q1 2004) to the second quarter (June) of 2012 (Q2 2012).We make 3 contributions with this study. First, we extended the literature on the economic costs of influenza. Second, we contributed to the literature on health shocks and default by providing a stronger test of the potential causal impacts of health shocks on loan default. Third, we considered whether effects vary across types of default, including 30-, 60-, and 90-day defaults. We predicted that influenza may have the greatest effect on borrowers who are already in default, such that the association between influenza and default should be stronger for borrowers who are farther behind.     

Hair analysis of antidepressants and antipsychotics—Overview of quantitative data

Antidepressant and antipsychotic drugs are regularly encountered in different aspects of forensic toxicology, and some cases require the examination of hair samples. In this study, common antidepressant and antipsychotic drugs regarding hair concentrations over the past decades were reviewed. Although numerous publications around method validations, case reports, or controlled dose studies were found, apparently there is a lack of comprehensive data for many substances. Information on the hair length and dosage across the publications varied largely, and case numbers were generally low except for several retrospective controlled dose studies. Many substances were described only in method validations or case reports, and data were obtained from small case numbers. On the contrary, clozapine, haloperidol, amitriptyline, nortriptyline, risperidone and its metabolite, methylphenidate, citalopram, chlorpromazine, chlorprothixene, and quetiapine had a well‐founded database as these substances were investigated in controlled dose studies with higher case numbers. Given the advancements made in analytical techniques over the past years, gas chromatography–mass spectrometry and liquid chromatography with tandem mass spectrometry techniques were the methods of choice and allowed the detection of chemical compounds at low concentrations. The controversy around a potential use of hair analysis to estimate the dosage remains as dose‐concentration studies provided divergent results. A harmonization on the investigated hair length as well as on the extraction protocol would be of favor to achieve better comparability. Although hair analysis research focused mainly on drug abuse, availability of more data on antidepressants and antipsychotics would help to gain better knowledge and assist other forensic investigators.