Perioperative Medical Optimization of Symptomatic Benign Prostatic Hyperplasia Is an Economically Justified Infection Prevention Strategy in Total Joint Arthroplasty.

BACKGROUND: Abnormal voiding dynamics may be a modifiable risk factor for prosthetic joint infection (PJI) after total joint arthroplasty (TJA), but the cost-effectiveness of their optimization in the perioperative setting is unknown. Using a break-even analysis, we calculated the economic viability of perioperative voiding optimization for infection prevention after TJA in patients with symptomatic benign prostatic hyperplasia (BPH). METHODS: A perioperative voiding optimization algorithm was created to represent a common approach to treating symptomatic BPH before TJA. Treatment is initiated with a 6-week trial of tamsulosin (pathway 1), followed by 6 months of combination tamsulosin/finasteride therapy (pathway 2) if symptoms persist. Patients with unremitting symptoms after medical management undergo surgical correction with transurethral resection of the prostate (pathway 3). Costs associated with each pathway were derived from the literature and institutional purchasing records. A break-even economic model was constructed to calculate the absolute risk reduction (ARR) in the infection rate and number needed to treat necessary for cost-effectiveness. RESULTS: Pathway 1 was cost-effective if it prevented 1 infection of 113 (ARR = 0.883%) TKAs or 140 (ARR = 0.714%) THAs. Pathway 2 was cost-effective if it obviated infection in 1 of 69 TKAs (ARR = 1.445%) or 86 THAs (ARR = 1.169%). Pathway 3 was only deemed cost-effective assuming a cost of $400,000 to treat a PJI (number needed to treat = 71, ARR = 1.406%). Cost-effectiveness for pathways 1 and 2 was maintained with varying voiding optimization costs, infection rates, and PJI costs. CONCLUSION: Perioperative medical management of symptomatic BPH is an economically justified PJI prevention strategy, whereas surgical interventions appear to be financially substantiated only when considering the long-term societal costs of a PJI.

Herpes-zoster associated urinary retention in a 57-year-old immunocompromised male.

Herpes zoster-associated urinary retention is a rare but acknowledged phenomenon. It is usually a bladder areflexia resulting from a viral infection in the sacral dermatomes. We describe a 57-year-old immunosuppressed male patient with delayed urinary retention, following an outbreak of shingles in the setting of supratherapeutic immunosuppressive medications and poorly-controlled diabetes mellitus. The patient received a foley catheter, failed a trial of void in the acute treatment setting, completed zoster treatment with antivirals and corticosteroids, and fully recovered bladder function 6 weeks later.

Muscle-invasive bladder cancer following radiotherapy for prostate adenocarcinoma.

We present a case of muscle-invasive bladder cancer arising in a man who had previously been diagnosed with prostate cancer. His prostate cancer diagnosis and subsequent treatment with external beam radiation therapy occurred over 20 years prior to being diagnosed with bladder cancer. Biopsies of the bladder mass revealed a high-grade urothelial carcinoma with prostatic invasion and MRI showed significant concern for invasion into the pelvic floor. Metastatic lesions on his right rib and left clavicle were discovered on bone scan.

Assessing the role of race in pathological upstaging of renal cell carcinoma: Results from the National Cancer Database.

PURPOSE: Pathologic upstaging in renal cell carcinoma (RCC) is common and confers a significant risk of poor surgical and survival outcomes. Preoperative predictors of upstaging are of great clinical relevance but empirical evidence specific to racial minorities remains scarce. METHODS: National Cancer Database (NCDB) analysis of T3a-specific upstaging among White, African-American, Hispanic and Asian Pacific Islander (API) patients with AJCC cT1N0M0 RCC who underwent partial or radical nephrectomy between 2010 and 2015. Independent preoperative predictors of tumour upstaging were identified using multivariate logistic regression analyses. RESULTS: A total of 81 002 patients met the criteria for inclusion (5.6% T3a-specific upstaging). Increased age, increased Charlson-Deyo comorbidity index, clinical stages cT1b and unspecified cT1, and increased Fuhrman nuclear grade were identified as independent risk factors for upstaging. Independent protective factors for upstaging were younger age, female sex, African-American race and papillary, chromophobe, and unspecified RCC histologic subtypes. Significant risk factors and protective factors within individual racial subgroups were highly consistent with those observed in the overall study sample. All independent factors identified on race-specific subgroup analyses were significant in the same direction relative to the overall study sample. Variables found to be non-significant in the overall study sample remained non-significant across all racial subgroup analyses. CONCLUSION: The present study of nationally representative data found no clinically significant differences in upstaging risk across individual racial subgroups relative to the overall study sample. Preoperative factors that can be used to predict pT3a-specific tumour upstaging in CT1N0M0 RCC likely persist across different racial groups.

Regional variability in corneal endothelial cell density between guttae and non-guttae areas in Fuchs endothelial corneal dystrophy.

OBJECTIVE: To assess the regional variability of corneal endothelial cell density (ECD) between guttae and non-guttae areas in subjects with Fuchs endothelial corneal dystrophy (FECD) using non-contact specular microscopy and confocal microscopy. DESIGN: Retrospective chart review from 2009 to 2014 at the Massachusetts Eye and Ear Infirmary. PARTICIPANTS: One hundred fifteen eyes of 73 subjects with FECD. METHODS: Subjects with FECD underwent same-day specular and confocal microscopy in the same eye. Clinical stage of disease was documented on the day of image acquisition. Regional variability of ECD associated with guttae and non-guttae areas was assessed. Manual endothelial cell counts were performed. RESULTS: Thirty-two percent of subjects had high quality endothelial images by both specular and confocal microscopy. Of these subjects, 83% were classified clinically as early-stage FECD. There was a significant association between stage of disease and the ability to obtain high quality specular images (χ2; p = 0.0012). There was no difference in mean ECD derived from specular (1363 ± 594 cells/mm2) or confocal (1391 ± 493 cells/mm2; p = 0.75) images. There was a statistically significant decrease of 31.8 ± 21.7% in mean ECD in areas surrounding guttae (1296 ± 560 cells/mm2) compared to non-guttae areas (1926 ± 674 cells/mm2; p < 0.0001) as determined by confocal microscopy. CONCLUSION: These findings support confocal microscopy as an alternative to specular microscopy for evaluating the corneal endothelium of patients with FECD, especially those with advanced disease. Confocal microscopy also revealed regional differences in ECD in guttae and non-guttae areas in patients with FECD.

Is There a Role for Preoperative 5 Alpha Reductase Inhibitors in Reducing Prostate Vascularity and Blood Loss?

Benign prostatic hyperplasia (BPH) and the related medical problems are a major burden as health care costs and as a cause of patient morbidity. The introduction of medical therapy largely offered an alternative to surgical therapy, and these medications have been linked with multiple positive BPH-related outcomes. With ubiquitous use, however, a variety of adverse side effects and unsupported claims to these medications have been reported both in scientific literature and popular press. The use of 5 alpha reductase inhibitors (5ARIs) to reduce recurrent bleeding due to BPH is a reasonable option for men with recurrent trips to the physician or hospital. After a largely anecdotal report of their use in the preoperative period to reduce bleeding during BPH surgery, there was interest in the use of 5ARIs for this indication considering the effusive bleeding that can occur during BPH-related surgery, a dreaded and not uncommon complication. While the pathophysiology for the use of 5ARI to reduce BPH-related bleeding is sound, the actual clinical outcomes still require scrutiny to determine if the efficacy is both scientifically valid and clinically significant. This report will review the current literature on this topic and make attempts to determine if the use of a 5ARI before BPH-related surgery should be encouraged.

A summary of the controversy surrounding off-label medications in men's health.

While there are common and accepted practices in men's health, barriers exist to treatment of these disorders with Food and Drug Administration (FDA) approved medications. In male factor infertility, these barriers include studies that are often underpowered for desired outcomes. This has led to the use of medications previously examined in females in an off-label fashion for treatment of male infertility. Issues surrounding the treatment of hypogonadism in men are more complex, becoming increasingly so in the last few years. Drug companies have developed compounds for treatment of hypogonadism for particular subgroups of men. However, the indicated groups for these medications are narrow leading to these medications being regularly used for an indication the FDA considers to be part of "normal aging". This work will examine the controversy surrounding the use of off-label medications in men's health and how factors like pharma advertising, FDA regulation and difficulties in creating adequate studies has affected the current paradigm.

Quantification of global cerebral atrophy in multiple sclerosis from 3T MRI using SPM: the role of misclassification errors.

PURPOSE: We tested the validity of a freely available segmentation pipeline to measure compartmental brain volumes from 3T MRI in patients with multiple sclerosis (MS). Our primary focus was methodological to explore the effect of segmentation corrections on the clinical relevance of the output metrics. METHODS: Three-dimensional T1-weighted images were acquired to compare 61 MS patients to 30 age- and gender-matched normal controls (NC). We also tested the within patient MRI relationship to disability (eg, expanded disability status scale [EDSS] score) and cognition. Statistical parametric mapping v. 8 (SPM8)-derived gray matter (GMF), white matter (WMF), and total brain parenchyma fractions (BPF) were derived before and after correcting errors from T1 hypointense MS lesions and/or ineffective deep GM contouring. RESULTS: MS patients had lower GMF and BPF as compared to NC (P<.05). Cognitively impaired patients had lower BPF than cognitively preserved patients (P<.05). BPF was related to EDSS; BPF and GMF were related to disease duration (all P<.05). Errors caused bias in GMFs and WMFs but had no discernable influence on BPFs or any MRI-clinical associations. CONCLUSIONS: We report the validity of a segmentation pipeline for the detection of MS-related brain atrophy with 3T MRI. Longitudinal studies are warranted to extend these results.