Ischaemic lumbosacral plexopathy in acute vascular compromise: case report

Anterior spinal artery syndrome (ASAS) is a well reported cause of spinal cord injury (SCI) following thoracoabdominal aortic surgery. The resultant deficits are often incomplete, typically attributed to the variable nature of the vascular distribution. Our Physical Medicine and Rehabilitation (PM and Rehabilitation) service was consulted about a 36-year-old patient with generalised deconditioning, 3 months after a stab wound to the left ventricle. Physical examination revealed marked lower extremity weakness, hypotonia, hyporeflexia, and a functioning bowel and bladder. Further questioning disclosed lower extremity dysesthesias. Nerve conduction studies showed slowed velocities, prolonged distal latencies and decreased amplitudes of all lower extremity nerves. Electromyography revealed denervation of all proximal and distal lower extremity musculature, with normal paraspinalis. Upper extremity studies were normal. Recently, 3 cases of ischaemic lumbosacral plexopathy, mimicking an incomplete SCI, have been reported. This distinction is particularly difficult in the polytrauma patient with multiple musculoskeletal injuries or prolonged recuperation time, in addition to a vascular insult, as in this patient. The involved anatomical considerations will be discussed. A review of the electrodiagnostic data from 30 patients, with lower extremity weakness following acute ischaemia, revealed a 20% incidence of spinal cord compromise, but no evidence of a plexopathy.     

Predictors of oncological outcomes in T1G3 patients treated with BCG who undergo radical cystectomy

Purpose

To evaluate the oncological impact of postponing radical cystectomy (RC) to allow further conservative therapies prior to progression in a large multicentre retrospective cohort of T1-HG/G3 patients initially treated with BCG.

Methods

According to the time of RC, the population was divided into 3 groups: patients who did not progress to muscle-invasive disease, patients who progressed before radical cystectomy and patients who experienced progression at the time of radical cystectomy. Clinical and pathological outcomes were compared across the three groups.

Results

Of 2451 patients, 509 (20.8%) underwent RC. Patients with tumors?>?3 cm or with CIS had earlier cystectomies (HR?=?1.79, p?=?0.001 and HR?=?1.53, p?=?0.02, respectively). Patients with tumors?>?3 cm, multiple tumors or CIS had earlier T3/T4 or N?+?cystectomies. In patients who progressed, the timing of cystectomy did not affect the risk of T3/T4 or N?+?disease at RC. Patients with T3/T4 or N?+?disease at RC had a shorter disease-specific survival (HR?=?4.38, p?<?0.001), as did patients with CIS at cystectomy (HR?=?2.39, p?<?0.001). Patients who progressed prior to cystectomy had a shorter disease-specific survival than patients for whom progression was only detected at cystectomy (HR?=?0.58, p?=?0.024)

Conclusions

Patients treated with RC before experiencing progression to muscle-invasive disease harbor better oncological and survival outcomes compared to those who progressed before RC and to those upstaged at surgery. Tumor size and concomitant CIS at diagnosis are the main predictors of surgical treatment while tumor size, CIS and tumor multiplicity are associated with extravesical disease at surgery.

     

The melanocortin pathway: effects of voluntary exercise on the melanocortin-4 receptor knockout mice and ACTH(1-24) ligand structure activity relationships at the melanocortin-2 receptor

The melanocortin pathway consists of endogenous agonists, antagonists, G-protein coupled receptors, and ancillary proteins that mediate the function of the endogenous antagonists. The melanocortin-4 receptor (MC4R) is involved in the regulation of obesity and the melanocortin-2 receptor (MC2R) is involved in the regulation of steroidogenesis. Herein, we present the effects of voluntary exercise on the MC4R knockout mice in terms of bypassing the morbid obesity and hyperphagia phenotypes associated with this genetic obesity model. Additionally, a systematic truncation study of the adrenocorticotropin hormone (ACTH 1-24) has been performed and characterized at the cloned MC2R.     

Under-documentation of chronic kidney disease in the electronic health record in outpatients

Objective

To ascertain if outpatients with moderate chronic kidney disease (CKD) had their condition documented in their notes in the electronic health record (EHR).

Design

Outpatients with CKD were selected based on a reduced estimated glomerular filtration rate and their notes extracted from the Columbia University data warehouse. Two lexical-based classification tools (classifier and word-counter) were developed to identify documentation of CKD in electronic notes.

Measurements

The tools categorized patients'' individual notes on the basis of the presence of CKD-related terms. Patients were categorized as appropriately documented if their notes contained reference to CKD when CKD was present.

Results

The sensitivities of the classifier and word-count methods were 95.4% and 99.8%, respectively. The specificity of both was 99.8%. Categorization of individual patients as appropriately documented was 96.9% accurate. Of 107 patients with manually verified moderate CKD, 32 (22%) lacked appropriate documentation. Patients whose CKD had not been appropriately documented were significantly less likely to be on renin-angiotensin system inhibitors or have urine protein quantified, and had the illness for half as long (15.1 vs 30.7 months; p<0.01) compared to patients with documentation.

Conclusion

Our studies show that lexical-based classification tools can accurately ascertain if appropriate documentation of CKD is present in a EHR. Using this method, we demonstrated under-documentation of patients with moderate CKD. Under-documented patients were less likely to receive CKD guideline recommended care. A tool that prompts providers to document CKD might shorten the time to implementing guideline-based recommendations.     

Induction of latency-associated peptide (transforming growth factor-β(1)) expression on CD4+ T cells reduces Toll-like receptor 4 ligand-induced tumour necrosis factor-α production in a transforming growth factor-β-dependent manner

CD4(+) T cells expressing the latent form of transforming growth factor-β [latency-associated peptide (LAP) (TGF-β(1))] play an important role in the modulation of immune responses. Here, we identified a novel peptide ligand (GPC(81-95) ) with an intrinsic ability to induce membrane-bound LAP (TGF-β(1)) expression on a subpopulation of human CD4(+) T cells (using flow cytometry; ranging from 0·8% to 2·6%) and stimulate peripheral blood mononuclear cells to release LAP (TGF-β(1) ) (using ELISPOT assay; ranging from 0·03% to 0·16%). In spite of this low percentage of responding cells, GPC(81-95) significantly reduced Toll-like receptor 4 ligand-induced tumour necrosis factor-α production in a TGF-β(1) - and CD4(+) T-cell-dependent manner. The results demonstrate that GPC(81-95) is a useful tool to study the functional properties of a subpopulation of LAP (TGF-β(1))(+) CD4(+) T cells and suggest a pathway that can be exploited to suppress inflammatory response.     

Mesonephric remnant hyperplasia: an unusual benign mimicker of prostate cancer

Mesonephric remnant (MR) hyperplasia in the prostate is a rarely reported condition that is usually distinguished from prostatic adenocarcinoma by the absence of cytologic atypia as well as the absence of prostatic markers (prostate-specific antigen and prostatic acid phosphatase) expression. We report a case of prostatic MR hyperplasia with architectural and cytologic atypia in a 56-year-old man. The microscopic appearance strongly suggested malignancy, but immunohistochemistry allowed the diagnosis to be corrected. The presence of MRs in prostate tissues may be more common than appreciated or reported. Once the possibility is considered, the diagnosis is easily confirmed using immunochemistry.     

Psychological processing of transplantation in lung recipients: A quantitative study of organ integration and the relationship to the donor

Objectives Lung recipients undergo a complex psychological process, including organ integration and processing of attitudes towards the organ donor. Design Seventy‐six lung recipients were asked to participate in a cross‐sectional questionnaire study on the psychological processing of lung transplants. Methods The questionnaire consisted of statements describing aspects of organ integration and the patient's relationship with the donor. Furthermore, chronic stress/psychological distress (Screening Scale of the Trier Inventory; Symptom Checklist SCL‐K‐9) and the emotional effects of transplantation/immunosuppression (Transplant Effects Questionnaire; Medication Experience Scale for Immunosuppressants) were assessed. Results In general, lung recipients perceive the transplant as part of themselves (97.4%) and not as a foreign object (90%). One‐third of patients still have frequent thoughts about the donor, whilst the majority (80.3%) do not believe that they have adopted the donor's characteristic traits. Factor analysis reveals the two‐dimensional structure of the questionnaire items ‘organ integration’ (factor 1) and ‘relationship to the donor’ (factor 2). Poor organ integration predicts low adherence, low disclosure and high feelings of guilt, whilst a close donor relationship predicts chronic stress and psychological distress. Conclusions Poor organ integration and a close relationship to the donor should be borne in mind in psychosocial treatment regarding the patient's adherence behaviour and psychological distress.     

Prostate cancer diagnosis in the new millennium: strengths and weaknesses of prostate‐specific antigen and the discovery and clinical evaluation of prostate cancer gene 3 (PCA3)

The decision to take a prostate biopsy is traditionally guided by a digital rectal examination and measurement of serum total prostate‐specific antigen (tPSA). However, both techniques are subject to inherent weaknesses. The prostate cancer gene 3 (PCA3), a gene‐based marker, specific for prostate cancer, supplements the predictive power of tPSA to improve diagnosis of disease. Including this new marker in the standard of care for men at risk of prostate cancer should be considered, as it presents marked potential for better decision making for a prostate biopsy and for improving overall patient care.