Studies of nontraumatic osteonecrosis. Manometric and histologic studies of the femoral head after chronic steroid treatment: an experimental study in rabbits

High-dose methylprednisolone was administered to adult rabbits over a five- to nine-week period, according to previously described experimental models of nontraumatic osteonecrosis (NON). Manometric studies were performed using a sensitive computer-directed microvolume flow system. Osteocyte viability within the femoral head was assessed by counting empty osteocyte lacunae in five random high-power fields of hematoxylin- and eosin-stained sections. There was no significant elevation of intramedullary pressure or venous outflow resistance in femoral heads of animals receiving steroids, and a significant random loss of osteocytes was observed in these femoral heads. The clinical relevance of these studies is as follows. NON associated with steroids may not simply be the result of progressive ischemia. Ischemia and elevated intramedullary pressure may be epiphenomena, and a direct cytotoxic effect of steroids on osteocytes may be the earliest event in the development of nontraumatic osteonecrosis. The stress test, as it is currently being used in the clinical setting, may be unreliable.     

Resection of the inferior vena cava or intraluminal vena caval tumor thrombectomy during retroperitoneal lymph node dissection for metastatic germ cell cancer: indications and results.

A total of 42 patients underwent inferior vena caval resection (40) or intraluminal tumor thrombectomy (2) during retroperitoneal lymph node dissection for bulky abdominal metastatic nonseminomatous germ cell cancer (7% of all post-chemotherapy retroperitoneal lymph node dissection cases). The 3 indications for vena caval resection included tumor clearance (38%), vena caval scar occlusion (14%) and vena caval tumor thrombus (48%). En bloc vena caval resection to achieve tumor clearance was justified by subsequent nodal pathology (cancer in 63% of the specimens and teratoma in 31%). Vena caval resection in the presence of scar occlusion was de facto required by virtue of its incorporation in the specimen. Vena caval resection or thrombectomy is indicated for intraluminal tumor thrombus because thrombus pathology (cancer 35%, teratoma 45% and fibrosis 20%) reflected nodal pathology in 71% of the patients with cancer, 78% with teratoma and 100% with fibrosis. The complications of vena caval resection were generally transitory. The 71% survival rate justifies this intensive surgical approach because these patients had exhausted all chemotherapy options.     

Viral gastroenteritis induced by the Hawaii agent: Jejunal histopathology and serologic response

Peroral jejunal biopsies were performed in seven normal volunteer subjects prior to, 48 hours after and two weeks after the administration of the Hawaii agent of viral gastroenteritis. Light and electron microscopic examination revealed an intact mucosa with blunted villi, shortened and distorted microvilli, swollen mitochondria and intercellular edema. These histologic changes were seen only in acutely ill volunteer subjects and were absent two weeks after illness in three of four who were previously ill. This reversible lesion was similar to, but not identical with, that previously described in viral gastroenteritis induced by the Norwalk agent.Serum antibody increases in response to the Hawaii agent as measured by immune electron microscopy were present in three of four ill volunteer subjects and in none of three who remained well.     

Post‐Procedural Bivalirudin Infusion Following Primary PCI to Reduce Stent Thrombosis

Background

Prolonging infusions may abrogate the acute stent thrombosis (ST) associated with bivalirudin use during primary PCI but at an increased cost. We hypothesized that continuing the bivalirudin infusion commenced during the procedure at the PCI recommended dose until infusion end would prevent excess early ST.

Methods

Baseline demographics, procedural data and outcomes were gathered prospectively on 1395 consecutive patients undergoing primary PCI. The choice of bivalirudin versus heparin was at the cardiologist's discretion. Local protocol recommended continuation of the procedural bivalirudin at the PCI dose until infusion end.

Results

Patients' mean age was 62.8 ± 13.1years with 11.4% presenting with shock. The majority of patients underwent PCI using bivalirudin with fewer using heparin (87.7 vs. 12.3%, P < 0.0001). Glycoprotein inhibitor bailout rates were 6.1% with bivalirudin and 36.3% with heparin (P < 0.0001). Calculated on an individual patient basis the median intra‐procedure duration of the bivalirudin infusion was 30(IQR 21‐43) minutes and post‐procedure 49(32–66) minutes. The acute (<24‐hours) ST rates were 4/1224 with bivalirudin ± GPI (0.3%) and 0/171 with heparin ± GPI (0%, P = 0.41). The sub‐acute (24‐hours to 30‐days) ST rates were 3/1224 for bivalirudin ± GPI (0.3%) and 2/171 with heparin ± GPI (1.2%, P = 0.11). In total the early (<30‐days) ST rates were 7/1224 for bivalirudin ± GPI (0.6%) and 2/171 with heparin ± GPI (1.2%, P = 0.31). Acute ST was significantly more likely to occur in clopidogrel‐loaded patients than prasugrel/ticagrelor patients (2.7 vs. 0.5%, P = 0.003).

Conclusion

Continuing the bivalirudin infusion commenced during the procedure at the PCI recommended dose until infusion end combined with potent P₂Y12 inhibitors ameliorates excess early stent thrombosis. (J Interven Cardiol 2016;29:129–136)

     

The incidence and relevance of prostate cancer in radical cystoprostatectomy specimens

Purpose

To review the incidence, histopathological features and clinical outcomes of patients with incidental prostate cancer (CaP) found in cystoprostatectomy specimens (CP) excised for bladder cancer and to determine whether these prostate cancers could affect the follow-up strategy.

Patients and methods

We retrospectively reviewed the records of 110 patients who underwent CP for bladder cancer (1998?C2011) at our institution. CaP grade, stage, volume and surgical margin status were recorded. Prostatic involvement by bladder tumour or carcinoma in situ (CIS) was studied. Pre-operative prostate assessment and follow-up in those diagnosed with incidental CaP were analysed.

Results

Incidental CaP was identified in 35 patients (32.5?%), 4 with prostatic PIN alone and 2 patients with diagnoses of CaP prior to cystectomy were excluded from study. Of the CaP cases, 28.5?% had clinically significant disease: 5 with Gleason score 7, 2 with Gleason score 9, who also had extracapsular invasion of tumour, and three with positive surgical margins. All patients were pN0 for CaP. Of the 108 patients, 16.5?% had prostatic urethral involvement with CIS or TCC. In the subgroup of patients with the incidentally diagnosed CaP who developed local recurrence of bladder tumour and/or metastatic disease, none originated from their CaP.

Conclusion

The majority of incidental CaP in CP specimens are organ confined and do not influence oncological outcome. The prognosis of such patients is primarily determined by bladder cancer. Our findings support previous reports and autopsy studies elsewhere.     

Prospective randomised controlled trial comparing trigone-sparing versus trigone-including intradetrusor injection of abobotulinumtoxinA for refractory idiopathic detrusor overactivity

Background

Botulinum toxin A is effective for treatment of idiopathic detrusor overactivity (IDO). The trigone is generally spared because of the theoretical risk of vesicoureteric reflux (VUR), although studies assessing injection sites are lacking.

Objective

Evaluate efficacy and safety of trigone-including versus trigone-sparing intradetrusor injections of abobotulinumtoxinA in patients with IDO.

Design, setting, and participants

Twenty-two patients from one centre were randomised to trigone-including or trigone-sparing injections.

Intervention

Injection of 500 U abobotulinumtoxinA diluted to 20 ml into 20 trigone-including or trigone-sparing sites.

Measurements

The primary outcome measure was total overactive bladder symptom score (OABSS) at 6 wk. The OABSS questionnaire was completed at 0, 6, 12, and 26 wk. Baseline and postinjection urodynamic studies and micturating cystourethrograms were performed. Baseline values and subsequent time points were compared by t test. A mixed-effect model was used for repeated measures in time.

Results and limitations

For symptom scores at baseline compared with scores at 6 wk postinjection, the mean total OABSS improved from 22.4 to 8.7 (p < 0.001) in the trigone-including group compared with 22.7 to 13.4 (p < 0.03) in the trigone-sparing group. The difference in mean change from baseline was 4.4 points in favour of the trigone-including group (p = 0.03). The total OABSS at 12 and 26 wk and the urgency subscale scores at 6, 12, and 26 wk showed significant improvement in favour of the trigone-including group. Mean postvoid residual volumes and clean intermittent self-catheterisation rates between the two groups were similar. No patients developed VUR. Performing injections under general anaesthetic was a limitation, as tolerability under local anaesthetic was not assessed. A further limitation is the lack of a trigone-only arm.

Conclusions

Trigone-including injections are superior to trigone-sparing injections for the treatment of refractory IDO and did not cause VUR in this study.     

CLIENT PERCEPTIONS OF A RURAL-BASED CARDIAC REHABILITATION PROGRAM: A GROUNDED THEORY APPROACH

ABSTRACT: A grounded theory approach was used in an attempt to generate theory about client perceptions and experiences of a cardiac rehabilitation program conducted in a rural community. A series of interviews was conducted with a selection of people who had experienced a life-threatening cardiac event. The cohort was divided into two groups: those who attended a cardiac rehabilitation program and those who did not. The findings, though not generalisable, allowed the generation of a number of theories (which may come to be the genesis of future research) regarding the differences in the physiological, psychological, sociological and vocational well-being between the groups. The findings also suggested that location of the program, the times it was conducted, and the communication skills of significant healthcare workers who recruited participants were important factors affecting attendance.