GreenLight HPS™ 120-W laser vaporization vs transurethral resection of the prostate (<60 mL): a 2-year randomized double-blind prospective urodynamic investigation

Study Type – Therapy (RCT) Level of Evidence 1b What's known on the subject? and What does the study add? Photovaporization of the prostate (PVP) is now challenging TURP as the standard treatment for lower LUTS caused by BPH. The learning curve for PVP is short and the main advantages of this method over TURP are a shorter period of hospitalization, a shorter period of postoperative vesical catheterization, lower levels of retrograde ejaculation, rare development of dilutional hyponatraemia syndrome, the lack of a need for postoperative vesical irrigation as a result of extremely low indices of postoperative haematuria, and the lack of a need to suspend anticoagulant medication for the surgery. Traditionally, comparisons of the effectiveness of TURP vs PVP have involved parameters such as peak flow urinary rate and post‐void residual urine volume measurements, and have employed questionnaires such as the IPSS and the International Index of Erectile Function instruments. However, studies evaluating detailed urodynamic parameters remain scarce and non‐comparative The present study compared postoperative, medium‐term urodynamic parameters among patients receiving TURP and high‐power PVP. We consider the present study to be distinctive because it involved a double‐blind, detailed functional analysis of the vesical emptying stage over the course of 2 years, and did not simply comprise an evaluation of clinical parameters and uroflowmetrics. We saw a reduction of infravesical obstruction, as shown by the significant reduction of ≥20 cm H₂O in the mean micturition pressure for the groups studied, as well as a significant reduction in bladder outlet obstruction index. Thus, the present data show that high‐power PVP can achieve and maintain the same results as TURP over a period of 24 months regarding an aspect that is particularly important for maintaining vesical health (i.e. detrusor pressure during the evacuation of the bladder). Such urodynamic data describing the functional outcome of PVP are currently missing from the literature.

OBJECTIVE

• ? To assess the impact of GreenLight HPS^TM 120‐W (American Medical System Incorporation, Minnetonka, MN, USA) laser photovaporization of the prostate (PVP) compared to transurethral resection of the prostate (TURP) on urodynamic results, voiding function and sexual function.

PATIENTS AND METHODS

• ? In total, 20 men with intermediate/severe lower urinary tract symptoms as a result of benign prostatic hyperplasia (BPH) were randomly selected and equally divided into two groups: TURP and PVP.
• ? Urodynamic evaluation was performed and International Prostate Symptom Score (IPSS), International Index of Erectile Function‐5 and International Consultation on Incontinence Questionnaire – Short Form questionnaires were completed.
• ? The results were assessed at 2 years.

RESULTS

• ? Mean IPSS scores were reduced in both groups, although they did not differ between the TURP and PVP groups.
• ? There was no significant change in International Index of Erectile Function‐5 scores.
• ? Half of the patients in the PVP group developed urge urinary incontinence with spontaneous resolution.
• ? The urodynamic parameters analyzed showed an improvement for both groups, although the values in the TURP group values were not significantly different from those in the PVP group.

CONCLUSIONS

• ? Bladder storage symptoms may represent a major concern, although they are of limited duration in patients undergoing PVP.
• ? High‐power PVP can achieve and maintain the same results as TURP over a period of 24 months.

     

Progression of Periodontitis and Tooth Loss Associated with Glycemic Control in Individuals Undergoing Periodontal Maintenance Therapy: A 5‐Year Follow‐Up Study

Background: Prospective studies that investigated the influence of glycemic control in the progression of periodontitis and tooth loss during periodontal maintenance therapy (PMT) programs have not previously been reported. The aim of the present study is to evaluate associations between glycemic control status and progression of periodontitis and tooth loss among individuals during PMT. Methods: A total of 92 individuals, all recruited from a prospective cohort with 238 participants undergoing PMT, participated in this study. Diabetes control was assessed according to percentage of glycated hemoglobin (HbA1c). Individuals were matched for sex and smoking and were divided into three groups: 23 individuals with diabetes and poor glycemic control (PGC), 23 individuals with diabetes and good glycemic control (GGC), and 46 controls with no diabetes (NDC). Full‐mouth periodontal examination, including bleeding on probing (BOP), probing depth (PD), and clinical attachment level, was performed at all PMT visits during a 5‐year interval. Results: Progression of periodontitis and tooth loss were significantly higher among PGC compared to GGC and NDC. The final logistic model in the final examination included: 1) for the progression of periodontitis, HbA1c ≥6.5% (odds ratio [OR] = 2.9), smoking (OR = 3.7), and BOP in >30% of sites (OR = 4.1); and 2) for tooth loss, HbA1c ≥6.5% (OR = 3.1), smoking (OR = 4.1), and PD 4 to 6 mm in ≤10% of sites (OR = 3.3). Conclusions: PGC individuals, especially smokers, presented with a higher progression of periodontitis and tooth loss compared to NDC and GGC individuals. This result highlights the influence of glycemic control in maintaining a good periodontal status.     

Sentinel lymph node biopsy in cases of skin melanoma: initial experiences at a center in northeastern Brazil

The incidence of skin melanoma is increasing worldwide. The presence of lymph node metastasis is the most important prognostic factor of this disease, the thicker the lesion the greater the likelihood of lymph node involvement. Approximately 20% of patients with Breslow depth 1-4 mm have lymph node metastasis. Sentinel lymph node biopsy is standard procedure in the management of patients with skin melanoma, reflecting progress in the treatment of this disease since this procedure avoids an unnecessary radical lymphadenectomy, thus reducing the morbidity of treatment. This paper describes a series of cases involving sentinel lymph node biopsy in melanoma patients in Teresina, Piauí, Brazil between 2008 and 2009.     

The Dental Aesthetic Index and dental health component of the Index of Orthodontic Treatment Need as tools in epidemiological studies

The present study assesses the validity and reproducibility of two occlusal indices for epidemiological studies--the Dental Aesthetic Index (DAI) and the Dental Health Component of the Index of Orthodontic Treatment Need (DHC-IOTN) for the identification of orthodontic treatment needs. The total of 131 study models was examined by an examiner (orthodontic specialist) for the determination of the DAI and DHC-IOTN. Thirty days later, further assessment was performed to determine the reproducibility. The duration of each exam was measured in seconds with a stopwatch. The indices were compared by a panel of three experts in orthodontics to evaluate validity. The intra-examiner reliability evaluation resulted in an intraclass correlation coefficient of 0.89 for the DAI (95% CI = 0.64 to 1.0) and 0.87 for the DHC-IOTN (95% CI = 0.56 to 0.96). The time spent on the evaluation of the DHC-IOTN was less than the time spent on that of the DAI (P < 0.001). The accuracy of the indices, as reflected by the area under the receiver-operating characteristic curve, was 61% for the DAI (95% CI = 51 to 70; p = 0.037) and 67% for the DHC-IOTN (95% CI = 58 to 77; p = 0.001). Both indices presented good reproducibility and validity.     

Greater inhibition of platelet procoagulant activity by antibody-derived glycoprotein IIb--IIIa inhibitors than by peptide and peptidomimetic inhibitors

Antibody-derived GPIIb-IIIa antagonists, such as the c7E3 Fab fragment abciximab, have been shown to inhibit platelet procoagulant activity as well as platelet aggregation. Whether low-molecular-weight peptide-derived and peptidomimetic antagonists also inhibit platelet procoagulant activity in a similar manner has not been fully investigated. We compared the effects of the antibody-derived antagonists c7E3 Fab and m10E5 IgG, the peptide-derived antagonists eptifibatide, MK-852 and RGDS, and the peptidomimetic RO44--9883 on platelet procoagulant activity and on the stimulated cytosolic calcium increases that promote procoagulant activity. Procoagulant activity was measured as prothrombinase activity in gel-filtered platelets, activated by collagen plus thrombin or collagen alone, with and without stirring. The stimulated increases in cytosolic calcium were measured in parallel samples of platelets loaded with fura-2AM. Both c7E3 and m10E5 inhibited prothrombinase activity by 40--50% under all conditions of activation tested and inhibited cytosolic calcium increases to a similar extent in stirred, but not unstirred, platelets. The low-molecular-weight antagonists caused significantly less inhibition of prothrombinase activity in collagen plus thrombin-stimulated platelets, and produced no inhibition but rather a slight enhancement of activity in platelets stimulated by collagen alone. These antagonists also had little or no effect on the cytosolic calcium increases in stirred platelets. These differential effects of antibody-derived versus non-antibody GPIIb-IIIa antagonists on procoagulant activity may be a factor contributing to the differing anti-thrombotic effects of these antagonists seen in clinical trials.     

The storage defects in grey platelet syndrome and αδ-storage pool deficiency affect α-granule factor V and multimerin storage without altering their proteolytic processing

Among proteins stored in alpha-granules, multimerin and factor V share unusual features: they bind to each other, are proteolysed to unique forms and are stored eccentrically in alpha-granules. These unique features of their processing led us to study these proteins in alpha delta storage pool deficiency (alphadelta-SPD) and grey platelet syndrome (GPS, alpha-SPD), two conditions known to impair alpha-granule protein storage. Platelet factor V and multimerin were severely reduced in GPS, whereas they ranged from reduced to normal in alphadelta-SPD. The platelet levels of factor V and multimerin in these disorders indicated multimerin deficiency was not predictive of platelet factor V deficiency, although it reduced the amount of multimerin associated with platelet factor V. In GPS only, the defect in storing proteins was associated with increased multimerin and multimerin-factor V complexes in plasma. Like normal platelets, GPS and alphadelta-SPD platelets contained factor V mainly in granules. Platelet factor V and multimerin were proteolysed to normal platelet forms in GPS and alphadelta-SPD platelets, indicating that these conditions preserve some aspects of normal alpha-granule protein processing. Although we found factor V can be stored in platelets deficient in multimerin, our data indicate that multimerin storage influences the point at which multimerin binds factor V.     

Impaired platelet response to thromboxane-A2 and defective calcium mobilization in a patient with a bleeding disorder

Platelet aggregation, secretion, and thromboxane formation induced by various agonists, including arachidonate, prostaglandin-G2 (PGG2), and thromboxane-A2 (TxA2), were examined in a patient with a bleeding disorder who was previously reported to have a TxA2-related defect. Aggregation and 14C-5HT secretion were decreased, and no TxB2 formation occurred in response to adenosine diphosphate (ADP), epinephrine, or collagen. Arachidonate-induced aggregation and TxB2 formation, and PGG2- induced aggregation (but not TxB2 formation) were impaired at low agonist concentrations. The patient's platelets did not aggregate in response to TxA2 generated from arachidonate in normal platelets, but were capable of synthesizing TxA2 from both arachidonate and PGG2. In addition, aggregation and secretion induced by low concentrations of the ionophore A23187 were impaired in platelet-rich plasma (PRP) and in gel-filtered platelets in the absence of extracellular calcium; these responses became normal at higher A23187 concentrations or, in GFP, at low A23187 concentrations in the presence of exogenous calcium. These findings indicate that the TxA2 defect in this patient does not result from a thromboxane synthetase deficiency, but may be due to impaired mobilization of platelet calcium, and thus are consistent with the possibility that TxA2 may act as a calcium ionophore.     

Inability of divalent cation complexes of A23187 to induce platelet secretion

Extracellular calcium produces a dose-dependent inhibition of the early time course of A23187-induced 14C-5HT secretion in human platelets which is independent of the occurrence of aggregation. Pre-incubation of A23187 with calcium to form the A23187-Ca complex results in markedly prolonged lag periods prior to the onset of secretion at Ca concentrations of 0.25 - 1.0 mM and total abolition of the secretion response at 2.0 mM Ca, indicating that these effects of extracellular Ca are due to specific interactions of Ca and A23187. Under conditions which favor dissociation, the complexes of A23187 with Sr, Ca, and Mg, but not Mn, all induce platelet secretion but produce an inhibition of the early secretion response which generally parallels their relative complex stabilities, i.e., Sr less than Ca approximately equal to Mg less than Mn. Under conditions which prevent dissociation, none of these complexes induce secretion. These results indicate that the complexes of A23187 with divalent cations, including Ca, are unable to induce platelet secretion, most likely because of an inability to penetrate the platelet plasma membrane.     

Prior depth information can bias motion perception

Previous studies of the motion aperture problem have shown that the direction of grating motion can be biased by using binocular disparity to designate borders of the aperture as intrinsic (belonging to the grating) or extrinsic (resulting from occlusion of the grating). Observers report motion in the direction of the extrinsic border, as if the grating was extended and moving underneath an occluding surface. Here we investigate whether prior information about depth ordering, given by structure-from-motion, can bias the perceived motion direction of a subsequent moving grating in a similar manner. We presented an aperture stimulus that rotated about its vertical and horizontal axes, revealing the depth relationships (intrinsic and extrinsic) of the aperture borders. The grating then translated within the aperture and observers reported the direction of perceived motion. The test stimulus contained no information about the depth ordering of the scene. We found that observers' reported motion shifted toward the direction of the occluding edges, consistent with the intrinsic-extrinsic border predictions. These results indicate that prior scene information, not just depth information explicitly defined in the test stimulus, is used to help solve the motion aperture problem.