Trends in regionalization of radical cystectomy in three large northeastern states from 1996 to 2009

ObjectivesTo assess regionalization trends and short-term clinical outcomes in patients undergoing radical cystectomy for urothelial carcinoma.Materials and methodsUsing 1996–2009 discharge data from New York (NY), New Jersey (NJ) and Pennsylvania (PA), all patients ≥18 years with urothelial carcinoma undergoing cystectomy were identified using ICD-9 coding. We assigned hospital volume status by quintiles based on relative proportions of cystectomies performed on a per hospital basis in 1996; very low volume hospitals: 0–2 (VLVH), low: 3–4 (LVH), moderate: 5–8 (MVH), high: 9–31 (HVH), and very high: ≥32 (VHVH). Changes in the proportion of procedures performed by volume categories were assessed over time, and patient characteristics were compared between groups.ResultsA total of 14,404 patients met inclusion criteria. For each year increase from 1996 to 2009, the odds of having surgery performed at a VHVH increased by 22% (odds ratio [OR] 1.22, confidence interval [CI] 1.04–1.44). Patients undergoing surgery at a VHVH were less likely to be African American (OR 0.59 [CI 0.39–0.91]), or insured through Medicaid (OR 0.65 [CI 0.50–0.84]) or Medicare (OR 0.84 [CI 0.75–0.94]). Controlling for year treated, total procedures performed, and patient characteristics, median hospital length of stay (HLOS) was shorter (median difference ?0.89 days [CI ?1.12 to ?0.66]), and patients were significantly less likely to die during their hospital stay if treated at a VHVH compared with a VLVH (OR 0.33 [CI 0.22–0.49]).ConclusionsThere has been extensive regionalization of cystectomy to VHVHs in NY, NJ, and PA since 1996. Despite apparent improvements in mortality and HLOS in patients treated at higher volume centers in our sample, future investigations more rigorously adjusting for hospital structural characteristics and patient severity are necessary to confirm these findings. Disparities in access to VHVH care are still evident and must be addressed.     

High rates of advanced disease,complications, and decline of renal function after radical nephroureterectomy

ObjectivesRecurrences remain common following radical nephroureterectomy (RNU) for locally advanced upper-tract urothelial carcinoma (UTUC). We review a cohort of RNU patients to identify the incidence of locally advanced disease, decline in renal function, complications, and utilization of adjuvant chemotherapy (AC).MethodsInstitutional databases from 7 academic medical centers identified 414 RNU patients treated between 2003 and 2012 who had not received neoadjuvant chemotherapy. Glomerular filtration rate was estimated using the Modification of Diet in Renal Disease equation. Complications were classified according to the modified Clavien system. Cox proportional hazard modeling and Kaplan-Meier analysis determined factors associated with cancer-specific survival.ResultsOf 414 patients, 177 (43%) had locally advanced disease, including 118 pT3N0/Nx, 13 pT4N0/Nx, and 46 pTanyN+. Estimated 3- and 5-year cancer-specific survival was 47% and 34%, respectively. Only 31% of patients with locally advanced UTUC received AC. Mean estimated glomerular filtration rate declined from 59 to 51 ml/min/1.73 m² following RNU, including a new-onset decline below 60 and 45 ml/min/1.73 m² in 25% and 15% of patients, respectively (P<0.001 for both). Complications occurred in 46 of 177 (26%) patients, of which one-quarter were grade III or IV. Increasing age (Hazard Ratio (HR) 1.4, P = 0.03), positive surgical margins (HR 2.1, P = 0.01), and positive lymph nodes (HR 4.3, P<0.001) were associated with an increased risk of death from UTUC, whereas receipt of AC (HR 0.85, P = 0.05) was associated with a decrease in UTUC mortality.ConclusionsUnder one-third of RNU patients with locally advanced UTUC cancers received AC. Perioperative complications and decline in renal function may have contributed to this low rate. Such data further underscore the need for continued discussion regarding the use of chemotherapy in a neoadjuvant setting for appropriately selected patients with UTUC.     

Gestational Weight Gain,Early Pregnancy Maternal Adiposity Distribution,and Maternal Hyperglycemia

To estimate the effects of gestational weight gain (GWG), central adiposity and subcutaneous fat on maternal post-load glucose concentration, pregnant women [n = 413, 62 % black, 57 % with pregravid body mass index (BMI) ≥25] enrolled in a cohort study at ≤13 weeks gestation. GWG was abstracted from medical records. In a sub-sample of women (n = 214), waist circumference (WC), and biceps and triceps skinfold thicknesses were measured at enrollment. At 24–28 weeks gestation, post-load glucose concentration was measured using a 50-g 1-h oral glucose tolerance test. After adjustment for pre-pregnancy BMI, age, parity, race/ethnicity, smoking, marital status, annual family income, education, family history of diabetes, and gestational age of GDM screening, each 0.3-kg/week increase in weight in the first trimester was associated with a 2.2 (95 % CI 0.1, 4.3)-mg/dl increase in glucose concentration. Each 8.6-mm increase in biceps skinfold thickness and each 11.7-mm increase in triceps skinfold thickness was associated with 4.3 (95 % CI 0.2, 8.5)-mg/dl increase in maternal glucose, independent of BMI and other confounders. Neither GWG in the second trimester nor WC at ≤13 weeks was significantly associated with glucose concentration after confounder adjustment. Independent of pre-pregnancy BMI, high early pregnancy GWG and maternal subcutaneous body fat may be positively associated with maternal glucose concentrations at 24–28 weeks.     

Bladder neck contracture

Bladder neck contracture (BNC) is a well-described complication of the surgical treatment of benign and malignant prostate conditions. Nevertheless, etiologies of BNC development are highly dependent on the primary treatment modality undertaken with BNC also occurring after pelvic radiation. The treatment options for BNC can range from simple, office-based dilation procedures to more invasive, complex abdomino-perineal reconstructive surgery. Although numerous strategies have been described, a patient-specific approach is usually necessary in the management of these complex patients. In this review, we highlight various therapeutic maneuvers described for the management of BNC and further delineate a tailored approach utilized at our institution in these complicated patients.     

Associations of perceived prenatal stress and adverse pregnancy outcomes with perceived stress years after delivery

Archives of Women's Mental Health - Maternal stress is a risk factor for adverse pregnancy outcomes (APOs). This study evaluates the associations of prenatal stress and APOs with maternal...     

Additional antibiotic use and preterm birth among bacteriuric and nonbacteriuric pregnant women

OBJECTIVES: To determine the magnitude of and factors associated with spousal abuse during pregnancy in women presenting to tertiary care hospitals in Karachi, Pakistan. METHODS: Five hundred women who delivered a live singleton baby were interviewed. Physical and/or emotional abuse during pregnancy (PEAP) was the primary outcome measure as determined by the World Health Organization's domestic violence module. Frequencies of different forms of abuse were measured and the relationship between PEAP and the risk factors was determined using multiple logistic regression. RESULTS: Of the women interviewed, 44% reported abuse during the index pregnancy; and of these, 43% experienced emotional abuse and 12.6% reported physical abuse. Factors independently associated with PEAP were number of living children (adjusted odds ratio [AOR] 1.34; CI, 1.08-1.65), interfamilial conflicts (AOR 3.03; CI, 1.85-4.96), husband's exposure to maternal abuse (AOR, 2.38; CI, 1.41-4.02), and husband's use of tobacco (AOR 1.59; CI, 1.05-2.42). Women who had adequate social support were less likely to be abused by their husbands (AOR 0.65; CI, 0.51-0.82). CONCLUSIONS: Almost half of the pregnant women interviewed were either physically or emotionally abused. Strong social support helps protect against abuse.     

The effect of the anti-inflammatory cytokines interleukin-4 and interleukin-10 on lipopolysaccharide-stimulated production of prostaglandin E2 by cultured human decidual cells

OBJECTIVE: We hypothesized that interleukin-4 (IL-4) and interleukin-10 (IL-10) diminish production of PGE2 by lipopolysaccharide (LPS)-stimulated cultured human decidual cells. STUDY DESIGN: Decidual cells from six women undergoing elective cesarean delivery without labor at term were cultured to confluence and incubated with LPS (10 ng/mL) with and without IL-4 and IL-10 (10 ng/mL) and the supernatant assayed for PGE2. RESULTS: PGE2 concentration in non-treated cells (NT) was 16,693+/-8991 pg/mL and in cells incubated with IL-4 alone was 13,490+/-5729 pg/mL, not statistically different from that of the NT cells. Incubation with LPS increased PGE2 concentration (32,540+/-18,795 pg/mL) compared to NT cells (p=0.02). PGE2 concentration in cells co-incubated with IL-4 and LPS (8975+/-5249 pg/mL) was lower than in the LPS-alone group (p=0.005). PGE2 concentration in cells co-incubated with IL-10 and LPS was 29,644+/-25,085 pg/mL, not different from the LPS-alone group. CONCLUSIONS: IL-4 reduced LPS-stimulated PGE2 production in decidual cells while IL-10 did not. IL-4 is a potential immunomodulatory agent in decidual inflammation.