Supply the demand: Assessment of the feasibility of local nonurologists in relieving the burden of chronic indwelling catheters in a low-income country.

INTRODUCTION: Despite the high prevalence rates of urinary retention in sub-Saharan Africa, regional deficiencies in urological care have culminated in inadequate medical management and a backlog of urology cases. Our study examined the efficacy and safety of a surgical camp enlisting local non-urologists performing simple open prostatectomy on the rate of chronic catheter usage secondary to urinary retention. METHODS: We reported on a prospective case series of patients with chronic indwelling catheters who underwent open simple prostatectomy during a one-week urology camp in the Machinga District of Malawi. All operations were performed by a locally trained general surgeon and a clinical officer. RESULTS: Twenty-three (47.9%) of 48 male patients with urinary retention assessed for eligibility for open simple prostatectomy were deemed eligible and underwent the procedure. Of the patients who underwent an open simple prostatectomy, histopathological findings demonstrated benign prostatic hyperplasia in 19 patients (82.6%), while six patients (26.1%) had coincidental malignancy. At postoperative followup, the entire cohort was catheter-free and reported regular sexual activity and the ability to return to work, while 87.0% noted improvements in social integration and 34.8% cited higher self-esteem. Two patients required treatment for infection and one patient experienced fascial dehiscence. Two months following prostatectomy, all patients were catheter-free and able to void independently. CONCLUSIONS: Local surgical practitioners without formal urology training can successfully perform open simple prostatectomy to relieve patients of chronic indwelling catheters and assist in addressing the disease burden in a low-resource setting.

Supply the demand: Assessment of the feasibility of local non-urologists in relieving the burden of chronic indwelling catheters in a low-income country.

INTRODUCTION: Despite the high prevalence rates of urinary retention in sub-Saharan Africa, regional deficiencies in urological care have culminated in inadequate medical management, and a backlog of urology cases. Our study examined the efficacy and safety of a surgical camp enlisting local non-urologists performing simple open prostatectomy on the rate of chronic catheter usage secondary to urinary retention. METHODS: We reported on a prospective case series of patients with chronic indwelling catheters who underwent open simple prostatectomy during a one-week urology camp in the Machinga District of Malawi. All operations were performed by a locally trained general surgeon and a clinical officer. RESULTS: Twenty-three (47.9%) of 48 male patients with urinary retention assessed for eligibility for open simple prostatectomy were deemed eligible and underwent the procedure. Of the patients who underwent an open simple prostatectomy, histopathological findings demonstrated benign prostatic hyperplasia in 19 patients (82.6%), while six patients (26.1%) had coincidental malignancy. At postoperative followup, the entire cohort was catheter-free and reported regular sexual activity and the ability to return to work, while 87.0% noted improvements in social integration and 34.8% cited higher self-esteem. Two patients required treatment for infection and one patient experienced fascial dehiscence. Two months following prostatectomy, all patients were catheter-free and able to void independently. CONCLUSIONS: Local surgical practitioners without formal urology training can successfully perform open simple prostatectomy to relieve patients of chronic indwelling catheters and assist in addressing the disease burden in a low-resource setting.

Predicting the Gleason sum of a patient with a prostate biopsy core Gleason ≤7 and a prostate biopsy core Gleason ≥8.

INTRODUCTION: We review a subset of men who had discordant prostate biopsy sums and were treated with radical prostatectomy. METHODS: Consecutive patients treated with radical prostatectomy at The Ottawa Hospital between 2000 and 2012 were reviewed. Those with at least 1 prostate biopsy core of Gleason sum ≥8 and at least 1 prostate biopsy core of Gleason sum ≤7 cancer were included. RESULTS: Of the 764 radical prostatectomies, 661 (87%) were eligible for the study and 35 (5%) met inclusion criteria. Of these, only 16 (46%) had prostatectomy Gleason sum of ≥8. When the highest biopsy core was Gleason sum 8 (n = 24), only 7 (29%) had a prostatectomy Gleason sum ≥8. When the highest biopsy core was Gleason 9 (n = 11), 9 (82%) had a prostatectomy Gleason sum ≥8 (relative risk [RR] 2.8; p = 0.004). Patients with clinical T3 tumours were at higher risk of Gleason sum ≥8 compared to cT1 patients (RR 3.7; p = 0.008). Patient age (p = 0.89), preoperative prostate-specific antigen (p = 0.34), prostate volume (p = 0.86), number of biopsy cores (p = 0.18), and proportion of biopsy cores with cancer (p = 0.96) were not strongly associated with risk of prostatectomy Gleason sum ≥8. CONCLUSION: These data should be considered when assigning patients into prognostic risk categories based on prostate biopsy information. Further study to verify our findings using larger samples is warranted.

Effect of respiration on the static rear stability of wheelchairs.

OBJECTIVE: To test the hypothesis that the static rear stability of an occupied wheelchair is greater during full inspiration than expiration. DESIGN: Within-subject comparisons. SETTING: Rehabilitation center. PARTICIPANTS: Able-bodied participants (N=10). INTERVENTION: None. MAIN OUTCOME MEASURES: We measured the static rear stability (brakes unlocked) of an occupied wheelchair on a test platform according to International Organization for Standardization standards. We also used the Exhalation Threshold Test. The Exhalation Threshold Test was positive if, having been positioned at the maximum degree of platform tilt needed to maintain stability during full inspiration, the wheelchair tipped backward when the participant exhaled. RESULTS: The mean static rear stability values at full inspiration and expiration +/- SD were 16.5 degrees +/-2.3 degrees and 16.1 degrees +/-2.4 degrees , with a mean difference of .46 degrees +/-.24 degrees (3%; P=.002). The Exhalation Threshold Test was positive in 19 (95%) of 20 trials. CONCLUSIONS: Respiration has a slight but statistically significant effect on the rear stability of occupied wheelchairs, with greater stability at full inspiration. This has potential clinical implications for stability testing and the training of wheelchair skills, but further study is needed.

Predictors of implantable cardioverter-defibrillator use in patients with ischemic cardiomyopathy.

OBJECTIVES: The objective of this study was to identify and examine ICD utilization in a large group of eligible coronary artery bypass grafting (CABG) patients with impaired left ventricular function. METHODS: We conducted a retrospective study of ICD eligible patients who had previously undergone CABG surgery between March 1, 1995 and June 30, 2008 at a single tertiary care institution. All patients with a pre-operative left ventricular ejection fraction (LVEF) ≤ 35% were considered ICD eligible. The events of interest were ICD implantation and mortality, based on administrative data linkage. RESULTS: A total of 1,169 out of 11,931 CABG patients operated on during the same period had LVEF ≤ 35% and were defined as ICD eligible (mean EF = 27.3% +/- 6.4%). Of these eligible patients, only 101 received an ICD during follow-up (8.6%). The median time to implant was 255 days (14-1078). The single variable that independently predicted eventual ICD implantation was a history of arrhythmia (OR = 7.4; CI, 4.4-12.2). The variables that predicted not having an ICD implanted during follow-up included the need for urgent CABG (OR = 0.5; CI, 0.2-0.9), age > 70 years (OR = 0.5; CI, 0.3-0.8), female gender (OR = 0.2; CI,0.1-0.6), or having chronic obstructive lung disease (OR = 0.5; CI,0.3-0.8). As a data validation step, a series of consecutive patient records were reviewed (n=80) showing that fewer than 23% underwent appropriate follow-up EF assessment post revascularization. CONCLUSION: Our findings suggest that CABG patients with ischemic cardiomyopathy have low rates of ICD utilization. This is particularly evident among females and elderly patients. Furthermore our data suggests that few patients post-revascularization undergo follow-up EF assessment despite current guidelines likely contributing to the low rates of ICD utilization.

Heat shock treatment prior to myocardial infarction results in reduced ventricular remodeling.

BACKGROUND: Heat shock (HS) treatment has been suggested to confer myocardial protection following ischemia. However, the effects of HS on left ventricular (LV) remodeling weeks after infarction have yet to be described. METHODS: Myocardial infarction (MI) was created by coronary ligation in Lewis rats. Two experimental groups of animals were created: HS+MI group (n = 13) and MI group (n = 13). HS treatment consisted of an elevation in core temperature to 42 degrees C for 15 min, 24 hr prior to MI. LV remodeling was assessed by transthoracic echocardiography (day 0, 1, 7, and 28) and by morphometric histology (day 28). RESULTS: There was no significant difference in infarct size (TTC stain 24 hr) between HS+MI and MI groups. Using transthoracic echo there was a significant preservation of LV ejection fraction and fractional shortening in the HS+MI group as compared to MI group (7 and 28 days). Similar trends were seen by histology at 28 days but failed to reach significance. HSP27 expression by myocardial cells was shown to remain up-regulated (at 28 days) in both groups at the edges of the infarct area as compared to control myocardium. CONCLUSIONS: Our findings suggest that HS treatment prior to MI can result in a significant decrease in LV remodeling independent of a reduction in infarct size.

Heat shock treatment results in increased recruitment of labeled PMN following myocardial infarction.

One of the proposed mechanisms for the myocardial protective effects of heat shock (HS) treatment has been a reduction in the inflammatory response. The objective of the present study was to evaluate the impact of HS treatment in an established model of polymorphonuclear cell (PMN) migration following myocardial infarction (MI). Isolated purified PMNs (10 x 10(6) cells) labeled with (51)Cr were injected into Lewis rats following a left thoracotomy and ligation of the left anterior descending coronary artery causing MI. Two experimental groups of animals were created: MI group (n = 11) and HS+MI group (n = 7). HS treatment consisted of an elevation in core temperature to 42 degrees C for 15 min 24 h prior to MI. An additional group of control animals underwent sham thoracotomy (n = 5). All animals were euthanized at 24 h after MI, and gamma counts were obtained to estimate PMN migration. Myocardial injury was confirmed in all experimental animals (histology and echocardiography). The serum troponin I and infarct size (triphenyltetrazolium chloride) were similar in both groups. Labeled PMN migration was significantly higher in HS+MI animals (14.3 x 10(4) +/- 3.7 x 10(4) PMN) compared with MI group (9.5 x 10(4) +/- 3.6 x 10(4); P = 0.01), suggesting increased PMN migration as a result of HS treatment. HS treatment did not affect PMN migration to positive skin control sites (LPS). ICAM-1 myocardial expression was not significantly increased in HS+MI compared with MI group. In summary, HS treatment results in increased PMN migration into myocardium following MI independent of ICAM-1. These findings suggest that the proposed cardioprotective effect of HS may not be entirely due to a downregulation of myocardial inflammation as previously proposed.

Infiltration of polymorphonuclear cells into the post-ischaemic myocardium is dependent on beta2 and alpha4 integrins.

Polymorphonuclear cells (PMN) are believed to be important effector cells responsible the myocardial damage seen following ischaemia. However, the exact kinetics of their migration remains controversial. Isolated PMN (10 x 10(6) cells) labelled with (51)Cr were injected into four groups of Lewis rats: 0 h (T0h; n = 13), 2 h (T2h; n = 7), 4 h (T4h; n = 7) or 6 h following ischaemia (T6h; n = 4). In all recipients, a left thoracotomy and ligation of the left anterior descending coronary was performed. Control animals underwent sham thoracotomy (n = 10). All animals were killed at 24 h and the radioactivity in the tissue measured to estimate labelled PMN migration. Monoclonal antibody blockade was also performed in experimental animals to assess the contribution of beta2 and alpha4 integrins to the PMN migration (n = 32). Labelled PMN migration to the myocardium was similar in all experimental groups, T0-T6h (7.2-11 x 10(5) labelled PMN) and significantly higher than sham controls (2.2 x 10(5) labelled PMN; P = 0.03). In contrast PMN migration to dermal inflammatory sites was highest in T0h group, and reached background level in the T4h and T6h groups. beta2 integrin blockade inhibited labelled PMN migration by 32%. Blockade of alpha4 integrin inhibited PMN migration by 30% while the combined beta2 + alpha4 blockade resulted in 63% inhibition of labelled PMN migration compared to treatment with isotype control antibody (P = 0.035). PMN migration following myocardial ischaemia persists over several hours after myocardial infarction and does not follow similar migration kinetics to dermal inflammation. Our findings also suggest that PMN migration is dependent equally on beta2 and alpha4 integrins.

Long-term outcomes in patients requiring stay of more than 48 hours in the intensive care unit following coronary bypass surgery.

BACKGROUND: The primary objective of this study was to determine the long-term outcomes of all patients requiring prolonged intensive care unit (ICU) stay following coronary bypass surgery (CABG) surgery. METHODS: All patients undergoing CABG surgery between 1998 and 2002 were reviewed. Prolonged ICU stay was defined as more than 48 hours. Short-term (in-hospital) and long-term (postdischarge) outcomes were evaluated using available databases. RESULTS: Of 3139 patients who underwent CABG surgery, 598 required an ICU stay of more than 48 hours (19%). The in-hospital mortality for patients requiring prolonged ICU stay was 10.0% as compared with 1.2% for the remainder of patients (P < .0001). The median length of hospitalization for patients requiring prolonged stay was 11 days (IQR 7-18) as compared to 6 days (IQR 5-7). The median follow-up of patients who survived to discharge was 31 months with a 100% follow-up. Using Cox proportional hazard ratio, patients who required a prolonged ICU stay were found to have a significant lower survival and freedom from cardiac readmission to the hospital. Prolonged ICU stay was an independent predictor of composite outcome (death + readmission) with a hazard ratio of 1.8 (1.5-2.1). CONCLUSIONS: Prolonged ICU stay following CABG resulted in increased early and late mortality and lower freedom from readmission to hospital for cardiac reasons.