Measuring the urologic iceberg: design and implementation of the Boston Area Community Health (BACH) Survey

OBJECTIVES: To describe the Boston Area Community Health (BACH) survey, a National Institutes of Health-supported epidemiological study of symptoms suggestive of the following urologic conditions: urinary incontinence, benign prostatic hyperplasia, interstitial cystitis, chronic pelvic pain of bladder origin, prostatitis, hypogonadism, erectile dysfunction, and female sexual dysfunction. METHODS: BACH used a two-stage stratified cluster design to recruit a community-based random sample of 5506, divided between males (2301) and females (3205), three racial/ethnic groups (black, Hispanic, and white), and four age groups (30-39, 40-49, 50-59, 60-79 yr). Validated questionnaires were used to collect information on urologic symptoms, comorbidities, prescribed and over-the-counter medications, reproductive history, quality of life, health care utilization, physical activity, depressive symptoms, interpersonal stress, smoking, alcohol use, fluid intake, nutrition, menopausal status, sexual activity, abuse, anthropometrics (measured height, weight, hip and waist circumference, pulse rate, blood pressure), and sociodemographics including country of origin, marital status, employment status, and income. Blood samples were collected from 68% of all subjects. RESULTS: A large representative community-based sample was successfully recruited to provide both cross-sectional and eventually longitudinal data to address important urologic questions. CONCLUSIONS: BACH has features distinguishing it from most other epidemiological studies in urology. It uses a random community-based sample of people who are racially/ethnically diverse and includes a broad age range (30-79 yr). It includes both males and females The study focuses on symptoms rather than variably defined disease conditions, it is multidisciplinary, and it is designed to become longitudinal.     

Central mesenteric lymph node BER-Ep4+ cells in colorectal cancer: challenge to sentinel node concept?

BACKGROUND: The role of sentinel lymph nodes in colorectal cancer remains unclear. METHODS: Cryosections from central para-aortic mesenterial lymph nodes were stained using mAb BER-Ep4. Overall survival and distant recurrence were calculated using Kaplan-Meier plots. RESULTS: All patients (n = 48) were free of distant metastases and curatively resected (R0). 23 pN0, 13 pN1 and 12 pN2 stages were found. 21/48 patients (44%) showed BER-Ep4+ cells in their central lymph nodes (7/23 pN0, 8/13 pN1, 6/12 pN2). In 6/23 pN0 patients, BER-Ep4+ cells were also found in locoregional nodes (p = 0.03, Fisher's exact test). pN status predicted overall survival (p = 0.006, Kaplan-Meier curve, log-rank test). An impact was exerted by central mesenteric BER-Ep4+ cells on overall survival (p = 0.009 in pN0 patients, p = 0.07 for all pN) and distant recurrence-free survival (p = 0.001 in pN0 patients, p = 0.007 for all pN). Multivariate analysis showed an independent prognostic effect on overall survival in pN0 patients (p = 0.022). CONCLUSION: Central lymph nodes are sentinels of disease not amenable to extended lymphadenectomy and might identify patients at risk of distant organ recurrence.     

Changes in Calcaneal Trabecular Bone Structure Assessed with High-Resolution MR Imaging in Patients with Kidney Transplantation

The purpose of this study was to use high-resolution magnetic resonance (HR-MR) imaging to analyze the trabecular bone structure of the calcaneus in patients before and after renal transplantation and to compare this technique with bone mineral density (BMD) in predicting therapy-induced bone loss and osteoporotic fracture status. HR-MR imaging (voxel size: 0.195×0.195×1 mm) was performed at 1.5 T with an axial and sagittal orientation in 48 patients after transplantation, 12 patients before renal transplantation and 20 healthy controls. Structure measures analogous to standard histomorphometry and fractal dimension were determined in these images. BMD measurements of the lumbar spine and the proximal femur were obtained in the healthy female controls and the patients. Vertebral and peripheral fracture status were determined in all patients. The structural measures app.BV/TV, Tb.Sp, Tb.Th and Tb.N showed significant differences between controls and patients (p<0.05) while fractal dimension showed no significant differences. Neither the structural measures nor BMD showed significant differences between patients before and after transplantation. Correlations between time after transplantation versus structural measures and BMD were not significant. Differences between fracture and nonfracture patients were significant for the structural measures app.BV/TV, Tb.Sp and Tb.N (axial images) as well as for app.Tb.Th (sagittal images) and spine BMD (p<0.05) but not for hip BMD. Using odds ratios the strongest discriminators between patients with and without fractures were app. BV/TV, app.Tb.Sp (axial images) and app.Tb.Th (sagittal images), even after adjustment for age and BMD. Using receiver operating characteristic analysis the highest diagnostic performance was found for a combination of BMD and structural measures. In conclusion, our results indicate that structural measures obtained from HR-MR images may be used to characterize fracture incidence in kidney transplant patients; the best results, however, are obtained using a combination of BMD and structural measures. Received: 25 October 2000 / Accepted: 1 August 2001     

Metastatic involvement of the heart and pericardium: CT and MR imaging.

Metastases to the heart and pericardium are much more common than primary cardiac tumors and are generally associated with a poor prognosis. Tumors that are most likely to involve the heart and pericardium include cancers of the lung and breast, melanoma, and lymphoma. Tumor may involve the heart and pericardium by one of four pathways: retrograde lymphatic extension, hematogenous spread, direct contiguous extension, or transvenous extension. Metastatic involvement of the heart and pericardium may go unrecognized until autopsy. Impairment of cardiac function occurs in approximately 30% of patients and is usually attributable to pericardial effusion. The clinical presentation includes shortness of breath, which may be out of proportion to radiographic findings in patients with pericardial effusion or may be the result of associated pleural effusion. Patients may also present with cough, anterior thoracic pain, pleuritic chest pain, or peripheral edema. The differential diagnosis of pericardial effusion in a patient with known malignancy includes malignant pericardial effusion, radiation-induced pericarditis, drug-induced pericarditis, and idiopathic pericarditis. Any disease process that causes thickening or nodularity of the pericardium or myocardium or masses within the cardiac chambers can mimic metastatic disease.     

MR imaging-guided stent placement in iliac arterial stenoses: a feasibility study

PURPOSE: To assess the feasibility of magnetic resonance (MR) imaging-guided stent placement in iliac arterial stenoses. MATERIALS AND METHODS: Thirteen patients with 14 iliac arterial stenoses were examined prospectively. Angioplasty was performed through a femoral sheath by using a conventional 1.5-T MR imaging system. Stents and catheters were visualized on the basis of their artifacts. Nitinol stents were placed with gradient-echo MR imaging guidance. Angioplasty balloons were inflated with gadolinium-based contrast material. Results were evaluated clinically and with both digital subtraction angiography (DSA) and contrast material-enhanced MR angiography. RESULTS: Ten of 13 patients were treated with technical success by using MR imaging-guided intervention alone. Three patients were treated with additional fluoroscopic guidance, because complications (ie, panic attack, subintimal recanalization, and stent misplacement) occurred with MR guidance. The quality of the postinterventional contrast-enhanced MR angiograms of three of 12 lesions with stents was limited owing to stent-induced signal loss of the lumen. The mean stenosis degree after stent placement was significantly higher at contrast-enhanced MR angiography than at DSA (24.6% vs 6.2%). The mean MR imaging-guided procedure time was 74 minutes. CONCLUSION: MR imaging-guided stent placement in iliac arteries is feasible in select patients. The presented technique has limitations-that is, long procedure times, lack of real-time monitoring, and stent artifacts-that necessitate further modifications before it can be recommended for clinical use.     

The novel nomogram of Gleason sum upgrade: Possible application for the eligible criteria of low dose rate brachytherapy

Objective: To examine the rate of Gleason sum upgrading (GSU) from a sum of 6 to a Gleason sum of ≥7 in patients undergoing radical prostatectomy (RP), who fulfilled the recommendations for low dose rate brachytherapy (Gleason sum 6, prostate‐specific antigen ≤10 ng/mL, clinical stage ≤T2a and prostate volume ≤50 mL), and to test the performance of an existing nomogram for prediction of GSU in this specific cohort of patients. Methods: The analysis focused on 414 patients, who fulfilled the European Society for Therapeutic Radiation and Oncology and American Brachytherapy Society criteria for low dose rate brachytherapy (LD‐BT) and underwent a 10‐core prostate biopsy followed by RP. The rate of GSU was tabulated and the ability of available clinical and pathological parameters for predicting GSU was tested. Finally, the performance of an existing GSU nomogram was explored. Results: The overall rate of GSU was 35.5%. When applied to LD‐BT candidates, the existing nomogram was 65.8% accurate versus 70.8% for the new nomogram. In decision curve analysis tests, the new nomogram fared substantially better than the assumption that no patient is upgraded and better than the existing nomogram. Conclusions: GSU represents an important issue in LD‐BT candidates. The new nomogram might improve patient selection for LD‐BT and cancer control outcome by excluding patients with an elevated probability of GSU.     

Use of T-Stat to predict colonic ischemia during and after endovascular aneurysm repair: a case report

As surgeons become more aggressive in treating aneurysms with endovascular techniques, traditional surgical principles of preserving internal iliac arteries and the inferior mesenteric artery have been challenged. A case is presented where the T-Stat device (Spectros Corp, Portola Valley, Calif), an optical real-time sensor approved by United States Food and Drug Administration for measuring colon ischemia, was used as an adjunctive measure to assist in the successful endovascular aneurysm repair in a patient at high risk for colon ischemia.     

Toxicity and effects of adjuvant therapy in colon cancer: results of the german prospective, controlled randomized multicenter trial fogt-1

In this adjuvant three-arm multicenter trial, we studied whether modulating the standard 5-fluorouracil (S-FU) treatment with either folinic acid (FA) or interferon-alpha-2_a (IFN-α) was superior to the recommended standard of adjuvant treatment in RO resected colon cancer, 5-FU plus levamisole (LEV) for 12 months, in terms of toxicity and outcome. From July 1992 to October 1999, a total of 813 patients with resected colon cancer in stage II (T4N0M0; n = 63) or stage III (TxNl-3M0; n = 750) were randomized into three treatment groups and stratified according to N stage and participating centers (64 hospitals). The patients received a postoperative loading dose of S-FU (450 mg/m² on days 1 to 5 [arms A and C]) or S-FU (450 mg/m²) plus FA (Rescuvolin, Medac, Hamburg, Germany, 200 mg/m² on days 1 to 5 [arm BJ). After completion of the first chemotherapy cycle, LEV was administered orally at a dosage of 1.50 mg per day on days 1 to 3, once every 2 weeks. After a 4-week chemotherapy-free interval, the treatment was continued weekly for 52 weeks. Treatment in one arm A ("standard") (n = 279) consisted of 5-FU intravenously (450 mg/m² on day 1, once a week) plus LEV 5-FU plus LEV was modulated in arm B (n = 283) with FA (200 mg/m² on day 1, once a week) and in arm C (n = 251) with IFN-α at 6 million units three times a week repeated weekly. Treatment dosages were adjusted if toxic events above WHO grade 2 occurred. Patients were closely followed to determine recurrence and survival; the latter was calculated according to Kaplan-Meier analysis. Toxic events above WHO grade 2, mainly leukopenia, diarrhea, and nausea, occurred in 113 (14%) of 649 patients who had completed treatment in arms A (8.4%), B (13.5%), and C (31.7%). Discontinuance rates were as follows: 28% for all patients, 29% in arm A, 21% in arm B, and 34% in arm C. Overall relapse rates were 27% for all patients, 30% in arm A, 24% in arm B, and 28% in arm C. Relapses were local (8%) distant (78%), or combined (12%). Fouryear overall survival rates in arms A, B, and C were 66.1%, 77.5%, and 66.2%, respectively. The 4-year survival rate in arm B was significantly higher compared to arm A (P <0.02, log-rank test) with arm A being equal to arm C. Adjuvant therapy with 5-FU plus FA plus LEV for 12 months is superior to the recommended standard (5-FU + LEV for 12 months). IFN-α modulation of 5-FU (plus LEV) adds to the toxicity with no therapeutic benefit.     

Pullout strength of pedicle screws versus pedicle and laminar hooks in the thoracic spine

While the biomechanical properties of pedicle screws have proven to be superior in the lumbar spine, little is known concerning pullout strength of pedicle screws in comparison to hooks in the thoracic spine. In vitro biomechanical pullout testing was performed to evaluate the axial pullout strength of pedicle screws versus pedicle and laminar hooks in the thoracic spine with regard to surgical correction techniques in scoliosis. Nine human cadaveric thoracic spines were harvested and disarticulated. To simulate a typical posterior segmental scoliosis instrumentation, standard pedicle hooks were used between T4 and T8 and supralaminar hooks between T9 and T12 and tested against pedicle screws. The pedicle screws were loaded strictly longitudinal to their axis; the hooks were loaded perpendicular to the intended rod direction. In total, 90 pullout tests were performed. Average pullout strength of the pedicle screws was significantly higher than in the hook group (T4-T8: 531 N versus 321 N, T9-T12: 807 N versus 600 N, p < 0.05). Both screw diameter and the bone mineral density (BMD) had significant influence on the pullout strength in the screw group. For scoliosis correction, pedicle screws might be beneficial, especially for rigid thoracic curves, since they are significantly more resistant to axial pullout than both pedicle and laminar hooks.     

A Randomized Clinical Trial of Cognitive Processing Therapy for Veterans With PTSD Related to Military Sexual Trauma

In this randomized controlled clinical trial, the authors evaluated the effectiveness of cognitive processing therapy (CPT) in the treatment of self‐reported and clinician‐assessed posttraumatic stress disorder (PTSD) related to military sexual trauma (MST), along with depressive symptoms. Eighty‐six veterans (73 female, 13 male) randomly assigned to receive 12 individual sessions of either CPT or present‐centered therapy (PCT) were included in analyses. Blinded assessments occurred at baseline, posttreatment, and 2, 4, and 6 months posttreatment. Mixed‐effects model analysis revealed a significant interaction between groups (p = .05, d = ?0.85): At posttreatment, veterans who received CPT had a significantly greater reduction in self‐reported, but not clinician‐assessed, PTSD symptom severity compared to veterans who received PCT. All three primary outcome measures improved significantly, both clinically and statistically, across time in both treatment groups. Pre‐ and posttreatment effect sizes were mostly moderate to large (d = 0.30–1.02) and trended larger in the CPT group. Although the study was impacted by treatment fidelity issues, results provide preliminary evidence for the effectiveness of CPT in reducing self‐reported PTSD symptoms in a population of veterans with MST, expanding on established literature that has demonstrated the effectiveness of CPT in treating PTSD related to sexual assault in civilian populations.