Clinical Diagnosis of Bladder Outlet Obstruction in Patients with Benign Prostatic Enlargement and Lower Urinary Tract Symptoms: Development and Urodynamic Validation of a Clinical Prostate Score for the Objective Diagnosis of Bladder Outlet Obstruction

Purpose

We attempted to improve the method of objective clinical evaluation of patients with benign prostatic enlargement and lower urinary tract symptoms.

Materials and Methods

We compared the results of free uroflowmetry and transrectal ultrasound prostate size determination with those of pressure-flow analysis of bladder outlet obstruction in 871 consecutive elderly men.

Results

Maximal flow, prostate size, and post-void residual and voided volumes were correlated with bladder outlet obstruction to derive a clinical prostate score.

Conclusions

Clinical prostate score shows a superior correlation with bladder outlet obstruction than isolated objective parameters or symptom scores.     

Comparison between 360° and 180° data sampling in thallium-201 rest-redistribution single-photon emission tomography to predict functional recovery after revascularization

Whether 360° or 180° imaging should be used in cardiac thallium-201 single-photon emission tomography (SPET) studies to detect coronary artery disease remains controversial. Moreover, the relative diagnostic accuracy of 360° and 180°²⁰¹Tl SPET for the assessment of myocardial viability has never previously been studied. The aim of this study was to perform a direct comparison between 180° and 360° data sampling to detect viable myocardium in patients undergoing revascularization; in order to allow optimal detection of viability a rest-redistribution protocol was used. The²⁰¹Tl results were compared with improvement of regional wall motion abnormalities after the revascularization, which was considered as the gold standard for myocardial viability. Thirty-two patients, scheduled for revascularization, underwent rest-redistribution²⁰¹Tl SPET, using a 360° arc. Raw data along a 180° arc (45° RAO to LPO) were selected from the original 360° data sets (both early an late²⁰¹Tl images). All SPET data were analysed semi-quantitatively using circumferential profiles of the short-axis images; the data were displayed in polar maps. Criteria for viability included percentage²⁰¹Tl redistribution and percentage²⁰¹Tl activity on the late image. Regional wall motion was assessed with two-dimensional echocardiography before and 3 months after revascularization. The sensitivities of 360° and 180° imaging for the prediction of functional recovery were 82% and 89%, respectively, whereas the specificities were 51% and 55%, respectively. The diagnostic accuracy of 360° imaging was 62% and that of 180° imaging 67%. This study shows that 360° and 180° imaging have comparable diagnostic accuracy in the prediction of functional recovery after revascularization. With the newer dual-head gamma camera systems with each detector opposing each other, 360° imaging may be preferred.     

Psychosocial risk factors for cardiovascular disease in women: The role of social support

Lack of social support is becoming increasingly important as a psychosocial risk factor in the study of coronary heart disease (CHD). There may also be an association between vital exhaustion and lack of social support. Because most research has focused on men, we decided to explore the associations between structural and functional social support and first myocardial infarction (MI) in women. Subjects were 79 women hospitalized with a First MI (mean age 59.3; SD = 9.3) and 90 women hospitalized with an acute surgical event (mean age 57.4: SD = 9 1). MI cases reported more vital exhaustion than did controls (p < ,040), and exhausted women reported less structural (p < .001) and functional support (p < .000). After controlling for age, hypertension, diabetes, menopausal status, smoking, nonanginal pain, and vital exhaustion, multiple logistic regression analysis showed that poor structural support was associated with an increased risk for MI. These results suggest that social support is associated with vital exhaustion, which is a well-known risk factor for CHD. Furthermore, it is suggested that women with only a few confidants are more at risk for MI even after adjustment for well-known risk factors for CHD.     

Adjuvant Chemotherapy for Superficial Transitional Cell Bladder Carcinoma: Long-term Results of a European Organization for Research and Treatment of Cancer Randomized Trial Comparing Doxorubicin, Ethoglucid and Transurethral Resection Alone

Purpose

We compared the efficacy of transurethral resection alone or transurethral resection followed by bladder instillations of doxorubicin or ethoglucid for 1 year in patients with superficial bladder carcinoma, and followed them long term for the incidence of progression to muscle invasion.

Materials and Methods

A total of 443 patients with superficial transitional cell carcinoma of the bladder was randomized. After randomization of 206 patients the control arm was closed to patient entry based on the results of an interim analysis showing a significant difference in favor of those receiving adjuvant chemotherapy.

Results

Final analysis of treatment results for recurrence included 432 patients at a median followup of 3.4 years for time to first recurrence, 5 years for analysis of time to invasion (Category T2 disease or worse) and 10.7 years for duration of survival. Time to first recurrence was significantly prolonged by both drugs compared to transurethral resection alone (doxorubicin versus transurethral resection alone p <0.001 and ethoglucid versus control p <0.001). Recurrence rate per year was 0.30 for both adjuvant treatment arms and 0.68 for the resection only group. Progression to muscle invasion was rare (15.1% of cases) and not apparently different in the 3 treatment arms. Of the 423 patients death from any cause in 199 and from malignant disease in 59 was not correlated with treatment. However, there was a strong correlation between death from malignant disease, and T category and tumor grade.

Conclusions

In regard to time to first recurrence and recurrence rate per year this study indicates that adjuvant chemotherapy with doxorubicin and ethoglucid using the indicated schedule is superior to transurethral resection alone. However, progression in stage or survival was not influenced by the treatment regimen.     

Discordant fetal growth in multiple pregnancy: intervention should be based on chorionicity]

In three women, aged 28, 35, and 38 years, with multiple pregnancies and discordant foetal growth, the question arose what to do in case of (threatening) intrauterine death of one twin. In one monochorionic pregnancy with single foetal death the survivor suffered irreversible neurological damage and died at the age of five months, in one monochorionic pregnancy the survivor was born healthy and in one dichorionic pregnancy both twins were born healthy although one twin showed severe intrauterine growth retardation. The problem concerning single foetal death in a monochorionic pregnancy is whether to terminate the pregnancy and accept the risk of premature birth to the surviving twin, or to continue the pregnancy and accept the risk of damage to the survivor. In a dichorionic pregnancy foetal death of one twin does not entail any great risk of damage to the survivor; in such a pregnancy single foetal death in a premature phase may be accepted and the pregnancy may be continued. Sonographic determination of the chorionicity in multiple pregnancy at an early stage is essential because it also determines the policy if foetal problems occur.     

Techniques and short-term outcomes for total minimally invasive Ivor Lewis esophageal resection in distal esophageal and gastroesophageal junction cancers: pooled data from six European centers

Introduction

Esophagectomy for cancer can be performed in a two-stage procedure with an intrathoracic anastomosis: the Ivor Lewis esophagectomy. A growing incidence of distal and gastroesophageal junction adenocarcinomas and increasing use of minimally invasive techniques have prompted interest in this procedure. The aim of this study was to assess short-term results of minimally invasive Ivor Lewis esophagectomy (MIE-IL).

Methods

A retrospective cohort study was performed from June 2007 until September 2014, including patients that underwent MIE-IL for distal esophageal and gastroesophageal junction cancer in six different hospitals in the Netherlands and Spain. Data were collected with regard to operative techniques, pathology and postoperative complications.

Results

In total, 282 patients underwent MIE-IL, of which 90.2 % received neoadjuvant therapy. Anastomotic leakage was observed in 43 patients (15.2 %), of whom 13 patients (4.6 %) had empyema, necessitating thoracotomy for decortication. With an aggressive treatment of complications, the 30-day and in-hospital mortality rate was 2.1 %. An R0-resection was obtained in 92.5 % of the patients. After neoadjuvant therapy, 20.1 % of patients had a complete response.

Conclusions

Minimally invasive Ivor Lewis esophagectomy for distal esophageal and gastroesophageal junction adenocarcinomas is an upcoming approach for reducing morbidity caused by laparotomy and thoracotomy. Anastomotic leakage rate is still high possibly due to technical diversity of anastomotic techniques, and a high percentage of patients treated by neoadjuvant chemoradiotherapy. An aggressive approach to complications leads to a low mortality of 2.1 %. Further improvement and standardization in the anastomotic technique are needed in order to perform a safe intrathoracic anastomosis.

     

Selecting relevant and feasible measurement instruments for the revised Dutch clinical practice guideline for physical therapy in patients after stroke

Purpose: To select relevant and feasible instruments for the revision of the Dutch clinical practice guideline for physical therapy in patients with stroke.

Methods: In this implementation study a comprehensive proposal for ICF categories and matching instruments was developed, based on reliability and validity. Relevant instruments were then selected in a consensus round by 11 knowledge brokers who were responsible for the implementation of the selected instruments. The feasibility of the selected instruments was tested by 36 physical therapists at different work settings within stroke services. Finally, instruments that were deemed relevant and feasible were included in the revised guideline.

Results: A total of 28 instruments were recommended for inclusion in the revised guideline. Nineteen instruments were retained from the previous guideline. Ten new instruments were tested in clinical practice, seven of which were found feasible. Two more instruments were added after critical appraisal of the set of the measurement instruments.

Conclusions: The revised guideline contains 28 relevant and feasible instrument selected and tested in clinical practice by physical therapists. Further education and implementation is needed to integrate instruments in clinical practice. Further research is proposed for developing and implementing a core set of measurement instruments to be used at fixed time points to establish data registries that allow for continuous improvement of rehabilitation for stroke patients.

• Implications for Rehabilitation

• The revised Dutch Stroke Physical Therapy Guideline recommends a total of 28 instruments, that are relevant and feasible for clinical practice of physical therapist in the different settings of stroke rehabilitation.

• The selection of instrument in daily practice should be part of the clinical reasoning process of PTs and be tailored to individual patients’ needs and the degree of priority of the affected ICF category.

• Suggested education strategies for further integration of instruments in of the daily practice of PTs in Stroke Rehabilitation are: ‘Training on the job’ and ‘peer assessment in clinical situations’.