Urinary Retention Following Inguinal Herniorrhaphy: Role of Neuromuscular Blockade Reversal.

BACKGROUND: Nondepolarizing neuromuscular blockade is reversed with neostigmine/glycopyrrolate or sugammadex. Anticholinergic glycopyrrolate decreases bladder detrusor muscle contractility, potentially leading to postoperative urinary retention (POUR). POUR commonly complicates inguinal herniorrhaphy. In this study we assess association between reversal technique and POUR. METHODS: Records of adult patients undergoing unilateral inguinal herniorrhaphy with neuromuscular blockade from January 2013 to September 2020 were reviewed for POUR (unplanned postoperative insertion of urinary catheter). A propensity-adjusted analysis was performed to assess POUR in neostigmine/glycopyrrolate versus sugammadex using inverse probability of treatment weighting (IPTW) to adjust for potential confounding. RESULTS: We identified 181 patients who underwent herniorrhaphy with amnio-steroidal neuromuscular blockers, 75 (41.4%) who received sugammadex and 106 (58.6%) neostigmine/glycopyrrolate. Compared with sugammadex, neostigmine/glycopyrrolate group had longer surgical course [unweighted standardized difference (USTD)=0.38, P=0.004], received more intraoperative opioids (USTD=0.704, P<0.001), more often performed via laparoscopic approach (USTD=0.407, P=0.012), and less often with periprocedural urinary catheter insertion (USTD=0.452, P=0.003). POUR was observed in 2 (3%) of patients in the sugammadex group, and 16 (15%) in neostigmine/glycopyrrolate [unadjusted odds ratio (OR)=0.15; 95% confidence interval (CI): 0.03-0.69; P=0.015, and IPTW OR=0.13; 95% CI: 0.03-0.64; P=0.012]. Results remained similar with further analysis adjusted for opioid administration in the postanesthesia care unit (adjusted IPTW OR=0.18; 95% CI: 0.04-0.88; P=0.034). Of the POUR patients, 9 required unplanned overnight admission and 4 emergency room visit. CONCLUSION: These results suggest that neuromuscular blockade reversal with sugammadex is associated with lower rates of POUR following unilateral inguinal herniorrhaphy. Our results need to be reconfirmed in a randomized prospective study.

Machine intelligence for nerve conduit design and production.

Nerve guidance conduits (NGCs) have emerged from recent advances within tissue engineering as a promising alternative to autografts for peripheral nerve repair. NGCs are tubular structures with engineered biomaterials, which guide axonal regeneration from the injured proximal nerve to the distal stump. NGC design can synergistically combine multiple properties to enhance proliferation of stem and neuronal cells, improve nerve migration, attenuate inflammation and reduce scar tissue formation. The aim of most laboratories fabricating NGCs is the development of an automated process that incorporates patient-specific features and complex tissue blueprints (e.g. neurovascular conduit) that serve as the basis for more complicated muscular and skin grafts. One of the major limitations for tissue engineering is lack of guidance for generating tissue blueprints and the absence of streamlined manufacturing processes. With the rapid expansion of machine intelligence, high dimensional image analysis, and computational scaffold design, optimized tissue templates for 3D bioprinting (3DBP) are feasible. In this review, we examine the translational challenges to peripheral nerve regeneration and where machine intelligence can innovate bottlenecks in neural tissue engineering.

Microphysical and kinematic processes associated with anomalous charge structures in isolated convection.

Microphysical and kinematic characteristics of two storm populations, based on their macroscale charge structures, are investigated in an effort to increase our understanding of the processes that lead to anomalous (or inverted charge) structures. Nine normal polarity cases (mid-level negative charge) with dual-Doppler and polarimetric coverage that occurred in northern Alabama, and six anomalous polarity cases (mid-level positive charge) that occurred in northeastern Colorado are included in this study. The results show that even though anomalous polarity storms formed in environments with similar instability, they had significantly larger and stronger updrafts. Moreover, the anomalous polarity storms evidently have more robust mixed-phase microphysics, based on a variety of metrics. Anomalous polarity storms in Colorado have much higher cloud base heights and shallower warm cloud depths in this study, leading us to hypothesize that anomalous polarity storms have lower amounts of dilution and entrainment. We infer positively charged graupel, and therefore high supercooled water contents, in the mid-levels of the anomalous storms based on the relationship between colocations of graupel and inferred positive charge from Lightning Mapping Array data. Using representative updraft speeds and warm cloud depths, the time required for a parcel to traverse from cloud base to the freezing level was estimated for each storm observation. We suggest this metric is the key discriminator between the two storm populations and leads us to hypothesize that it strongly influences the amount of supercooled water and the probability of positive charge in the midlevels, leading to an anomalous charge structure.

A study of amber and copal samples using FT-Raman spectroscopy.

FT-Raman spectra were collected from fossil resins originating from a variety of geographical locations. The spectral profiles of most of the fossil resins could be related to modern resins containing diterpenoid components with predominantly labdane skeletons. The spectra collected from the fossil resin sample from Borneo differed from other fossil resins and was found to contain triterpenoid components. The differences in the spectral profile of fossil resins containing diterpenoid components are shown to relate to differences in level of maturation rather than geographical origin. FT-Raman spectra of fossil resins cannot be used to distinguish source although the degree of maturation can be used as an indicator to narrow the range of possible geographical origins.

Factors predicting for postimplantation urinary retention after permanent prostate brachytherapy.

PURPOSE: Urinary retention requiring catheterization is a known complication among prostate cancer patients treated with permanent interstitial radioactive seed implantation. However, the factors associated with this complication are not well known. This study was conducted to determine these factors. METHODS AND MATERIALS: Ninety-one consecutive prostate cancer patients treated with permanent interstitial implantation at our institution from 1996 to 1999 were evaluated. All patients underwent pre-implant ultrasound and postimplant CT volume studies. Isotopes used were (125)I (54 patients) or (103)Pd (37 patients). Twenty-three patients were treated with a combination of 45 Gy of external beam radiation therapy as well as seed implantation, of which only 3 patients were treated with (125)I. Mean pretreatment prostate ultrasound volume was 35.4 cc (range, 10.0-70.2 cc). The mean planning ultrasound target volume (PUTV) was 39.6 cc (range, 16.1-74.5 cc), whereas the mean posttreatment CT target volume was 55.0 cc (range, 20.2-116 cc). Patient records were reviewed to determine which patients required urinary catheterization for relief of urinary obstruction. The following factors were analyzed as predictors for urinary retention: clinical stage; Gleason score; prostate-specific antigen; external beam radiation therapy; hormone therapy; pre-implant urinary symptoms (asymptomatic/nocturia x 1 vs. more significant urinary symptoms); pretreatment ultrasound prostate volume; PUTV; PUTV within the 125%, 150%, 200%, 250%, 300% isodose lines; postimplant CT volume within the 125%, 150%, 200%, 250%, 300% isodose lines; D90; D80; D50; ratio of post-CT volume to the PUTV; the absolute change in volume between the CT volume and PUTV; number of needles used; activity per seed; and the total activity of the implant. Statistical analyses using logistic regression and chi2 were performed. RESULTS: Eleven of 91 (12%) became obstructed. Significant factors predicting for urinary retention were the total number of needles used (p < 0.038); the pretreatment ultrasound prostate volume (p < 0.048); the PUTV (p < 0.02); and the posttreatment CT volume (p < 0.021). Two of 51 patients (3.9%) requiring 33 or fewer needles (median) experienced obstruction vs. 9 of 40 (22.5%) requiring more than 33 (p < 0.007). If the pretreatment ultrasound prostate volume was 35 cc or less (median), 3 of 43 (7%) vs. 8 of 36 (22%) with a volume greater than 35 cc experienced obstruction (p < 0.051). CONCLUSION: The number of needles required (perhaps related to trauma to the prostate) and the prostate volumes were significant factors predicting for urinary retention after permanent prostate seed implantation.

Role of registered dietitians in dysphagia screening.

OBJECTIVE: To examine the ability of registered dietitians to identify patients at risk for dysphagia and make appropriate diet/feeding recommendations in comparison with the speech-language pathologist, and to determine screening criteria for the registered dietitian to use for prediction of dysphagia risk. DESIGN: The dietitian and speech-language pathologist performed dysphagia screening on subjects independently through questioning and/or mealtime observation to identify signs and symptoms of dysphagia. Presence of dysphagia risk and diet/feeding recommendations were determined and results from the dietitian and speech-language pathologist were compared. SUBJECTS/SETTING: Thirty-four patients admitted during a 2-month period to a neuroscience unit at an urban teaching hospital were analyzed prospectively. STATISTICAL ANALYSES PERFORMED: kappa Statistics were used to assess agreement between the dietitian and speech-language pathologist. A kappa level of less than 0.4 indicated weak agreement, 0.4 to 0.7 indicated moderate agreement, and greater than 0.7 indicated strong agreement. Logistic regression methods were used to evaluate screening criteria as potential predictors of dysphagia risk. RESULTS: Moderate agreement (0.61) was found between the dietitian and speech-language pathologist in determination of dysphagia risk. The dietitian predicted the ability of the patient to consume an oral diet with strong agreement with the speech-language pathologist (1.0); various diet consistencies with moderate agreement (0.61); and the need for liquid restrictions with strong agreement (1.0). The most significant screening variables for prediction of dysphagia risk (P < .05) were age (P = .018), history of dysphagia (P = .042), difficulty swallowing solids (P = .0007), observed facial weakness (P < .0001), and a change in voice quality (P = .0007). Self-reported screening variables significantly related to dysphagia risk included drooling of liquids (P = .0009) and solids (P = .0080), facial weakness (P = .0006), change in voice quality (P = .0010), and prolonged eating time (P = .0157). APPLICATIONS/CONCLUSIONS: Dietitians can effectively identify patients with dysphagia. Screening for dysphagia can be implemented as part of standard nutrition assessments and may aid in decreasing dysphagia-related complications.

Parents cannot detect mild hearing loss in children. First place--Resident Clinical Science Award 1998.

Otitis media with effusion is among the most common illnesses of childhood and is often associated with chronic or persistent middle ear effusion (MEE). Our goal was to develop and validate a self-administered parent survey that would identify children at high risk for mild hearing loss caused by MEE. We evaluated 115 children. Parents rated their child's hearing using the HL-7, a 7-item self-administered survey, and a global visual-analog scale. Static admittance and gradient were recorded. Test-retest reliability, internal consistency, and validity of the HL-7 were compared with the 4-frequency pure-tone average (PTA) hearing level (HL) for the better hearing ear. The HL-7 had good test-retest reliability and internal consistency. Survey scores correlated well with the global hearing rating (R = 0.67, P < 0.001) but did not correlate with PTA (R = 0.10, P = 0.29). Tympanometric gradient was unrelated to ear-specific PTA, but not abnormal static admittance (<0.2 cc), which produced a mean 7-dB HL decrease in hearing (ANOVA, P = 0.02). The HL-7 is a reliable and internally consistent measure of parent perception of child hearing, but unfortunately these perceptions are inaccurate for mild hearing loss. Abnormal static admittance is a risk factor for hearing loss.

Differential transactivation by alternative EWS-FLI1 fusion proteins correlates with clinical heterogeneity in Ewing's sarcoma.

The t(11;22)(q24;q12) translocation is present in up to 95% of cases of Ewing's sarcoma and results in the formation of an EWS-FLI1 fusion gene which encodes a chimeric transcription factor. The proximate role of EWS-FLI1 in the pathogenesis of Ewing's sarcoma is thought to involve the activation of as yet largely unknown target genes. Many alternative forms of EWS-FLI1 exist because of variations in the locations of the EWS and FLI1 genomic breakpoints. The most common form, designated "type 1," consists of the first seven exons of EWS joined to exons 6-9 of FLI1 and accounts for approximately 60% of cases. The "type 2" EWS-FLI1 fusion also includes FLI1 exon 5 and is present in another 25%. We and others have observed previously that the type 1 fusion is associated with a significantly better prognosis than the other fusion types. Because EWS-FLI1 is an aberrant transcription factor, we investigated whether these differences in clinical behavior may be correlated to functional differences by comparing transactivation by the type 1 EWS-FLI1 with other types in both heterologous cells (HeLa, NIH3T3) and homologous cells (Ewing's sarcoma cell lines). In a panel of seven Ewing's sarcoma cell lines, we found transactivation of a transiently transfected FLI1-responsive reporter construct to be significantly lower in cell lines with the type 1 fusion than in cell lines with the type 2 fusion (P = 0.003). Cotransfection of the same reporter construct with each of a series of seven EWS-FLI1 expression constructs (corresponding to the two major fusion types and five less common types) also showed that type 1 EWS-FLI1 was a significantly weaker transactivator than the type 2 product in both HeLa and NIH3T3 cells (P = 0.003, and P = 0.033, respectively). Electromobility shift assays showed equivalent binding of the type 1 and type 2 EWS-FLI1 to the consensus FLI1-responsive binding site, indicating that differences in transactivation were not due simply to differences in DNA binding affinity. The finding that the type 1 EWS-FLI1 fusion, associated with less aggressive clinical behavior, encodes a less active chimeric transcription factor may provide the basis for a molecular explanation of clinical heterogeneity in Ewing's sarcoma.

Immunohistochemical detection of hepatitis C antigen by monoclonal antibody TORDJI-22 compared with PCR viral detection.

We sought to determine the sensitivity and specificity of immunohistochemistry using the TORDJI-22 MoAb (BioGenex, San Ramon, Calif), which is specific for the C-100 protein of the hepatitis C virus, compared with reverse transcriptase-polymerase chain reaction (RT-PCR) of tissue for viral RNA. RT-PCR had been performed on 52 fixed tissue specimens. Immunohistochemistry was performed using prediluted antibody with the alkaline phosphatase/fast red (BioGenex) technique. Predigestion with Protease XXIV (BioGenex) and other procedures followed the manufacturer's protocols. Positive immunohistochemistry was narrowly defined as tightly clumped, perinuclear red granules in hepatocytes. Of the specimens, 28 were positive by RT-PCR. With RT-PCR as the standard of comparison, immunohistochemistry yielded a sensitivity of 70% and specificity of 84%. Positive cells, when present, were usually very rare. With stringent criteria, immunohistochemistry with the TORDJI-22 monoclonal antibody is a very specific, fairly sensitive diagnostic test for hepatitis C virus in fixed liver tissues.

Exploring teenagers' accounts of bad communication: a new basis for intervention.

Interventions to enhance young people's communication are rarely based on research into adolescent communication, but take a more general, analytic, skills-based approach. This paper argues that evidence of young people's communication experiences is an important resource to inform the targeting and content of interventions, which has hitherto been overlooked. An exploratory, hypothesis-generating study of teenagers' accounts of their communication experiences was carried out. Four thousand and forty-eight adolescents aged 13-19 described a recent communication experience with (i) a family member, (ii) a friend or (iii) a non-family adult (professional or official). Self-reported bad communication experiences outweighted good ones only in adolescents' communications with adults outside the family, and there were significant variations across contexts in terms of the purposes, explanations and attributions for perceived bad communication. Implications of the research for future interventions are discussed.

Frontal sinus outflow anatomy.

Most of the studies of frontal sinus anatomy were completed 50 to 70 years ago. The information they provide is not necessarily relevant or helpful to the modern rhinologic surgeon who approaches the frontal sinus transnasally and endoscopically. We performed anatomical dissections of the outflow tract of 82 frontal sinuses in 41 cadaver heads to illustrate the various drainage patterns from the frontal sinus to the nose and to correlate these drainage sites with the distance and angle from the pyriform aperture. We found that the frontal sinus drained anterior to the uncinate process in 24 specimens (29.3%) with an average distance of 3.65 cm from the pyriform aperture and 58 degrees from the nasal floor. The frontal sinus drained posterior to the uncinate process in 56 specimens (68.3%) with an average distance of 4.10 cm and 65 degrees from the nasal floor. In this latter group, most of the sinuses (51 specimens) drained into the ethmoid infundibulum. Two of the specimens had a hypoplastic frontal sinus with no outflow tract at all. These findings are different from those described in the early 20th century.

Physician-hastened death. Advisory guidelines for the San Francisco Bay area from the Bay Area Network of Ethics Committees.

Recent high court opinions and pending Supreme Court rulings on the legality of physician-hastened death necessitate a pragmatic response from the medical profession. Adopting a "harm reduction" perspective on this contentious topic, the Bay Area Network of Ethics Committees developed practice guidelines for responding to a patient request for hastened death. The guidelines will be offered to the local medical community for use by individuals and health care institutions if the practice of physician-hastened death becomes legal. A multidisciplinary consensus process was used in developing the guidelines, which address clinical, ethical, and procedural concerns.

Immune complex glomerulonephritis in patients coinfected with human immunodeficiency virus and hepatitis C virus.

Human immunodeficiency virus-associated nephropathy (HIVAN), characterized by heavy proteinuria, rapidly progressive renal failure, "collapsing" glomerulopathy, and tubulointerstitial abnormalities, is the most common finding in HIV-infected patients undergoing a renal biopsy and predominantly affects blacks. We describe the clinical features and renal pathologic findings of 12 intravenous drug users (IVDUs) coinfected with HIV and hepatitis C virus (HCV) who were selected for renal biopsy because they presented with features different from typical HIVAN, including hypertension, microscopic hematuria, and cryoglobulinemia. There were seven black and five Hispanic patients. Eleven patients had immune complex glomerulonephritis (ICGN); one had glomerulosclerosis with immune complex deposits. Ten individuals had evidence of past hepatitis B viral infection, but none had persistent hepatitis B surface antigenemia. No other underlying cause for immune complex glomerulonephritis was identified. Renal biopsy showed membranoproliferative glomerulonephritis in five patients, mesangial proliferative glomerulonephritis in five, membranous nephropathy in one, and "collapsing" glomerulopathy with immune complex deposits in one. Hepatitis C virus RNA was detected by reverse transcription-polymerase chain reaction (RT-PCR) in the renal tissue and/or serum of nine of the 11 patients tested, and also in the renal biopsy tissue of four of eight patients with clinical and pathologic features of typical HIVAN without immunofluorescence evidence of immune complex deposits. One patient presented with renal failure, five patients developed end-stage renal disease (ESRD) requiring hemodialysis (mean time, 6.5 months), and six had stable renal function after a mean follow-up of 29.1 months (range, 2 to 72 months). Liver function abnormalities were present in seven of the 12 individuals, including four of the six patients who developed renal failure. These findings indicate that in some patients coinfected with HIV and HCV, the development of ICGN may dominate the clinical course of the disease. The occurrence of ICGN among black patients at risk for HIVAN may be related to the relatively high prevalence of HCV infection among IVDUs in this group.

Molecular analysis of the fusion of EWS to an orphan nuclear receptor gene in extraskeletal myxoid chondrosarcoma.

The pathogenesis of myxoid chondrosarcoma (CS) is poorly understood. A recurrent translocation, t(9;22) (q22;q12), has been recognized in CS, specifically in extraskeletal myxoid CS. Recently, this translocation has been shown to represent a rearrangement of the EWS gene at 22q12 with a novel gene at 9q22 designated CHN (or TEC). Sequence analysis suggests that CHN encodes a novel orphan nuclear receptor with a zinc finger DNA-binding domain. The structure of this gene fusion has been characterized in only a limited number of extraskeletal myxoid CSs and its presence in other types of CS has not been extensively examined. We studied 46 cases of CS (8 extraskeletal myxoid, 4 skeletal myxoid, 4 mesenchymal, and 30 other) for the EWS/CHN gene fusion by reverse transcriptase polymerase chain reaction, Southern blotting, and long-range DNA polymerase chain reaction. The EWS/CHN gene fusion was present in 6 of 8 extraskeletal myxoid CSs and was not detected in any of the remaining cases, including the 4 skeletal myxoid CSs. The negative findings in the latter cases suggest that skeletal myxoid CS is pathogenetically distinct from its extraskeletal counterpart. Notably, 2 cases of extraskeletal myxoid CS showed neither an EWS/CHN fusion transcript nor EWS/CHN genomic fusion nor EWS or CHN genomic rearrangement, suggesting genetic heterogeneity within extraskeletal myxoid CS. Finally, we also provide evidence for alternative splicing of the 3' end of the fusion transcript. Extraskeletal myxoid CS thus represents yet another sarcoma type containing a gene fusion involving EWS.

Physician responses to a hospital policy allowing them to not offer cardiopulmonary resuscitation.

OBJECTIVE: To determine whether physicians followed a hospital policy permitting them to not offer cardiopulmonary resuscitation (CPR) to patients considered unlikely to benefit from this therapy. DESIGN: Prospective series. SETTING: San Francisco General Hospital, a university-affiliated public hospital. PATIENTS: Attending physicians were interviewed about patients admitted over a period of 5 consecutive months for whom do-not resuscitate (DNR) orders were written. Only the first patient for whom each physician wrote a DNR order was included. MAIN OUTCOME MEASURES: Responses of physicians to questions regarding their initiation of DNR orders for these patients. RESULTS: Sixty-nine physicians responded to questions about DNR orders written for 69 patients. Fifty-seven of these physicians said that they were aware of the hospital policy, and 49 of the 57 physicians said that they generally agreed with it. Thirty-three physicians felt that CPR should be offered only to patients likely to benefit from it. In contrast, 36 physicians said that CPR should be offered to all patients, regardless of benefit. CPR was offered to 41 patients and 15 surrogates; 27 of these patients were considered to be unlikely to benefit from CPR. CONCLUSION: Despite a policy that allows them to do otherwise, physicians usually offered CPR to patients, regardless of benefit. Most physicians believed that CPR should be offered to all patients. These findings suggest that policies such as that of San Francisco General Hospital may not be compelling because physicians hold attitudes that are inconsistent with the policies.