Long-term patient reported outcome and satisfaction after oral mucosa graft urethroplasty for hypospadias

PURPOSE: There is a paucity of long-term patient reported outcome data on surgery for hypospadias. We sought to evaluate genitourinary function and satisfaction after oral mucosa graft urethroplasty (OMGU) for hypospadias. MATERIALS AND METHODS: We identified 65 patients who had undergone OMGU at our institution between 1992 and 2003, and surveyed these patients to evaluate oral health, urinary function and satisfaction with outcomes. RESULTS: We located 51 patients who had undergone OMGU, of whom 43 (84%) agreed to participate in the study. Median followup was 6.9 years. Mean study age was 15.1 years. Of the patients 47% had severe hypospadias with failed previous repair and 42% had severe hypospadias with previous first stage surgery. Oral complaints were rare and primarily cosmetic. No patient whose oral harvest was limited to the cheek (vs lip) had cosmetic complaints. Urinary spray and stream deviation were reported by 11 patients (26%) and 12 patients (28%), respectively. American Urological Association symptom scores were generally low (mean 5.6 +/- 6.0, range 0 to 21) but 7 patients (16%) had moderate symptoms and 2 (5%) had severe symptoms. Of the patients 60% were mostly satisfied or better with urinary function. Although satisfaction with penile appearance varied (51% of patients were satisfied), most patients (84%) were satisfied with the overall hypospadias care. Urinary symptom scores were significantly worse among patients who had post-OMGU complications (p = 0.004). Of these patients 38% had moderate or severe urinary symptoms, while 95% of patients without complications had mild symptoms (p = 0.01). CONCLUSIONS: Many patients report good long-term outcomes of OMGU, although a subset of patients has significant urinary and cosmetic complaints that are more prevalent in association with surgical complications.     

Surgical repair of bladder exstrophy in the modern era: contemporary practice patterns and the role of hospital case volume

PURPOSE: Bladder exstrophy is a rare condition, and data are lacking regarding practice patterns in its surgical management. We used a large nationwide database to investigate practice patterns of bladder exstrophy repair. MATERIALS AND METHODS: We used the Nationwide Inpatient Sample (1988 to 2000) to identify patients who underwent surgical repair of bladder exstrophy (International Classification of Disease-9 code 578.6). We analyzed factors affecting practice patterns and outcomes. Hospital volume was based on caseload during the highest volume year of study participation (high volume 5 or more, mid volume 3 to 4 and low volume less than 3 cases). RESULTS: We identified 407 cases. Approximately half of the patients (53.2%) were hospitalized within 24 hours of birth, although 28% of patients were older than 1 year. Of the patients 54% were male. Exstrophy repair is extremely resource intensive. In this series mean length of hospital stay (LOS) was 24.6 +/- 22.8 days, and mean inflation adjusted hospital charges were 62,302 dollars (median 39,978 dollars). High volume hospitals (HVHs) had lower hospital charges (37,370 dollars) than mid volume (51,778 dollars) or low volume hospitals (LVHs, 50,474 dollars, p = 0.0095). On multivariate regression HVHs had lower charges even after controlling for other significant predictors, including LOS (p <0.0001). Patients at HVHs were more likely to undergo osteotomy (p = 0.007). Six patients died after exstrophy repair (1.5%), all of whom had been born prematurely (p <0.0001). Although death was more likely at LVHs, this was due to the fact that more patients at LVHs were born prematurely (4.2% at HVHs vs 5.9% at mid volume hospitals and 11.1% at LVHs, p = 0.027). CONCLUSIONS: Bladder exstrophy repair carries a high risk of morbidity and is resource intensive. Variations between high and low volume hospitals in practice patterns and case mix may contribute to observed differences in resource use, LOS and clinical outcomes.     

Six strategies to identify and assist patients burdened by out-of-pocket prescription costs

Many patients find that their out-of-pocket costs of medications are burdensome. Physicians can help, first by remembering to ask about the problem, and then by applying simple strategies to limit the patient's costs.     

Is androgenic alopecia a result of endocrine effects on the vasculature?

Congenital long QT syndrome (LQTS) is a cardiac electrophysiological disorder due to genetic mutations. Patients with LQTS, if untreated, have a high incidence of ventricular tachycardia and cardiac arrest. Adrenergic activities are believed to play a major role in triggering the onset of cardiac events. The current mainstay of therapy for LQTS is oral beta-blockers, which improves clinical symptoms and reduces the incidence of sudden cardiac death in approximately 70% of the patients. Left cardiac sympathetic denervation (LCSD) is an alternative therapy for patients who are resistant to beta-blockers. Its clinical use, however, has been hindered by the complexity of the procedure and complications after the surgery. Video-assisted thoracoscopic sympathectomy has been used to treat patients with palmar and axillary hyperhidrosis. We suggest that the use of the microinvasice thoracoscopic technique may greatly simplify the LSCD procedure, making it the first-line therapy for LQTS.     

The prevalence of men with National Institutes of Health category IV prostatitis and association with serum prostate specific antigen

PURPOSE: We evaluated the prevalence and relationship of serum prostate specific antigen (PSA) levels in a screening population of men diagnosed with National Institutes of Health (NIH) category IV prostatitis. MATERIALS AND METHODS: In September of 2001, 300 men were randomly selected from our prostate cancer awareness screening program to be evaluated for NIH category IV prostatitis. After informed consent was obtained all patients completed the NIH prostate cancer awareness survey and had a serum sample obtained for PSA before examination. Expressed prostatic secretions were obtained from 227 of the 300 participants. Patients were classified according to findings on examination of the expressed prostatic secretions. The records were entered into our data base and subsequently reviewed. RESULTS: The prevalence of NIH category IV prostatitis was 32.2% in our population of men. Patient age, American Urological Association symptom scores and clinical prostate gland size did not differ between men with or without evidence of prostatitis on expressed prostatic secretion examination. Men with NIH category IV prostatitis had a mean serum PSA level of 2.3 which was significantly higher (p <0.0004) than those without prostatitis (mean PSA 1.4). CONCLUSIONS: These data suggest that NIH category IV prostatitis is fairly prevalent (32.2%) among men in the general population who present for prostate cancer screening and appears to contribute to increased serum PSA levels in some men.     

Extracorporeal shock wave lithotripsy in the pediatric population

Following the successful introduction for treatment of urolithiasis in adults in the early 1980s, shock wave lithotripsy (SWL) rapidly became a standard treatment for children with urolithiasis as well. SWL in children results in stone-free rates of 60–80% with contemporary equipment. Complication rates appear to be very low, although long-term risks remain uncertain. Laboratory studies in animal studies have identified deleterious effects of shock waves on renal tissue, and some have suggested that the immature or developing kidney may be more susceptible to such effects. However, clinical studies in pediatric human patients treated with SWL have not consistently identified serious long-term consequences of SWL. Therefore, despite advances in endoscopic equipment and techniques that facilitate endourologic management of pediatric urolithiasis, SWL continues to be an apparently safe and effective option in children with stones.     

Impacts of Maternal Nutrition on Vascularity of Nutrient Transferring Tissues during Gestation and Lactation

As the demand for food increases with exponential growth in the world population, it is imperative that we understand how to make livestock production as efficient as possible in the face of decreasing available natural resources. Moreover, it is important that livestock are able to meet their metabolic demands and supply adequate nutrition to developing offspring both during pregnancy and lactation. Specific nutrient supplementation programs that are designed to offset deficiencies, enhance efficiency, and improve nutrient supply during pregnancy can alter tissue vascular responses, fetal growth, and postnatal offspring outcomes. This review outlines how vascularity in nutrient transferring tissues, namely the maternal gastrointestinal tract, the utero-placental tissue, and the mammary gland, respond to differing nutritional planes and other specific nutrient supplementation regimes.     

Vandetanib for the treatment of lung cancer

INTRODUCTION: VEGF and EGFR are validated pathways for targeted therapy in non-small cell lung cancer (NSCLC). Once considered to be separate targets, VEGF and EGFR are now shown to have interconnected downstream pathways, potentiating the effectiveness of their dual signaling inhibition in cancer therapy. Molecules such as vandetanib that inhibit VEGFR and EGFR have also been reported to inhibit other receptors, including RET and additional kinases, and may be beneficial in treating patients with solid tumors. AREAS COVERED: This review covers the significance of targeting VEGF and EGFR in the treatment of NSCLC and the rationale behind their dual inhibition. Clinical trials that evaluate the use of vandetanib in the setting of refractory NSCLC are also explored. EXPERT OPINION: Vandetanib is currently not approved in the setting of NSCLC. However, its approval for medullary thyroid cancer makes it promising for identifying markers and potentially a NSCLC patient population who will benefit from the treatment.