Evidence for polymicrobial communities in explanted vascular filters and atheroma debris.

RATIONALE: Microbial communities have been implicated in a variety of disease processes and have been intermittently observed in arterial disease; however, no comprehensive unbiased community analysis has been performed. We hypothesize that complex microbial communities may be involved in chronic vascular diseases as well and may be effectively characterized by molecular assays. OBJECTIVE: The main objective is to survey vascular debris, atheroma, and vascular filters for polymicrobial communities consisting of prokaryotic and eukaryotic microbes, specifically eukaryotic microbes. METHODS AND RESULTS: We examined vascular aspirates of atheromatous debris or embolic protection filters in addition to matched peripheral blood samples, from fifteen patients, as well as three cadaveric coronary arteries from two separate patients, for microbial communities. General fluorescence microscopy by Höechst and ethidium bromide DNA stains, prokaryotic and eukaryotic community analysis by Next Generation DNA Sequencing (NGS), and a eukaryotic microbial 9 probe multiplexed quantitative PCR were used to detect and characterize the presence of putative polymicrobial communities. No prokaryotes were detected in peripheral blood; however, in 4 of 9 sequenced filters and in 2 of 7 sequenced atheroma debris samples, prokaryotic populations were identified. By DNA sequencing, eukaryotic microbes were detected in 4 of 15 blood samples, 5 of the 9 sequenced filters, and 3 of the 7 atheroma debris samples. The quantitative multiplex PCR detected sequences consistent with eukaryotic microbes in all 9 analyzed filter samples as well as 5 of the 7 atheroma debris samples. Microscopy reveals putative polymicrobial communities within filters and atheroma debris. The main contributing prokaryotic species in atheroma debris suggest a diverse and novel composition. Additionally, Funneliformis mosseae, an arbuscular mycorrhizal fungus in the Glomeraceae family, was detected in the coronary hard plaque from two patients. Well studied biofilm forming bacteria were not detectable in circulating peripheral blood and were not universally present in atheroma or filters. Analyses of the sequenced eukaryotes are consistent with a diverse of array poorly studied environmental eukaryotes. In summary, out of 15 patients, 6 exhibited molecular evidence of prokaryotes and 14 had molecular evidence of eukaryotic and/or polymicrobial communities in vivo, while 2 post-mortem coronary plaque samples displayed evidence of fungi. CONCLUSION: Prokaryotes are not consistently observed in atheroma debris or filter samples; however, detection of protozoa and fungi in these samples suggests that they may play a role in arterial vascular disease or atheroma formation.

Electronic nutritional intake assessment in patients with urolithiasis: A decision impact analysis.

PURPOSE: To evaluate a physician's impression of a urinary stone patient's dietary intake and whether it was dependent on the medium through which the nutritional data were obtained. Furthermore, we sought to determine if using an electronic food frequency questionnaire (FFQ) impacted dietary recommendations for these patients. MATERIALS AND METHODS: Seventy-six patients attended the Stone Clinic over a period of 6 weeks. Seventy-five gave consent for enrollment in our study. Patients completed an office-based interview with a fellowship-trained endourologist, and a FFQ administered on an iPad. The FFQ assessed intake of various dietary components related to stone development, such as oxalate and calcium. The urologists were blinded to the identity of patients' FFQ results. Based on the office-based interview and the FFQ results, the urologists provided separate assessments of the impact of nutrition and hydration on the patient's stone disease (nutrition impact score and hydration impact score, respectively) and treatment recommendations. Multivariate logistic regressions were used to compare pre-FFQ data to post-FFQ data. RESULTS: Higher FFQ scores for sodium (odds ratio [OR], 1.02; p=0.02) and fluids (OR, 1.03, p=0.04) were associated with a higher nutritional impact score. None of the FFQ parameters impacted hydration impact score. A higher FFQ score for oxalate (OR, 1.07; p=0.02) was associated with the addition of at least one treatment recommendation. CONCLUSIONS: Information derived from a FFQ can yield a significant impact on a physician's assessment of stone risks and decision for management of stone disease.

Gracilis muscle interposition flap repair of urinary fistulae: pelvic radiation is associated with persistent urinary incontinence and decreased quality of life.

PURPOSE: The primary goal of urinary fistulae repair is to improve continence and quality of life. Irradiated patients are predisposed to development of bladder outlet dysfunction (BOD), defined as bladder neck contracture or stress urinary incontinence. Here, we review our experience with gracilis flap repairs for rectourinary fistulae (RUF) and urinary cutaneous fistulae (UCF) in patients who underwent pelvic radiation. METHODS: Twenty-seven patients underwent repair of a RUF/UCF with gracilis flap between 2003 and 2013. Patients were assessed for postoperative fistula closure and BOD, and quality of life was assessed with the Expanded Prostate Index Composite (EPIC) questionnaire administered via telephone at the time of final follow-up. RESULTS: Mean age was 60 years (50-73) with median follow-up of 28.7 months (1.0-128). Flap failure was noted in 5/20 radiated patients versus 3/7 non-radiated patients (p = 0.63). Of the 8 flap failures, 7 underwent secondary repair: repeat gracilis flap (2), coloanal pull-through (2), rectal advancement flap (1), sliding flap (1), and omental flap (1). Median time to revision was 7.2 months (3.5-24.9). In irradiated patients, 18/20 (90 %) developed BOD compared with 1/7 (14 %) who were not radiated (p = 0.0006). Radiation was associated with worse scores on the urinary incontinence domain of the EPIC questionnaire compared with non-radiated patients (p = 0.0458). CONCLUSIONS: Urinary fistula repairs in radiated patients should be undertaken with caution. Even if the fistula is successfully repaired, patients may still have bladder outlet dysfunction and decreased quality of life. Consequently, patients should be counseled about all possible procedures, including permanent urinary diversion as primary therapy.

Pelvic radiation is associated with urinary fistulae repair failure and need for permanent urinary diversion.

OBJECTIVE: To review our experience with nonmuscle flap repairs of enterourinary fistulae (EUF) and urinary cutaneous fistulae (UCF). EUF and UCF can be treated either with temporary urinary diversion allowing for healing by secondary intention or primary closure of the defect using an interposing omental, sliding, or muscle flap. Even after successful fistula repair, permanent urinary diversion can be required because of persistent urinary incontinence. MATERIALS AND METHODS: We reviewed 86 patients who underwent treatment of EUF or UCF at Washington University between the years 1998 and 2013. Of these, 39 patients underwent fistula repair, whereas 47 patients underwent either surgical or nonsurgical urinary diversion. Outcomes measured included postoperative fistula closure, need for permanent urinary diversion, and urinary incontinence. RESULTS: The mean age in our series was 59 years (21-87 years) at the time of surgery, with median follow-up of 20 months (1-137 months). Among patients who underwent surgical repair, radiation was associated with higher rates of repair failure (P = .0002), postsurgical incontinence (P <.0001), and the need for permanent urinary diversion (P = .0076). At the time of final follow-up, 32 of the 44 radiated patients had required permanent diversion (72%) compared with 3 of the 42 nonradiated patients (7%; P <.0001). CONCLUSION: Patients who undergo pelvic radiation before EUF and UCF repairs are at higher risk for developing repair failure and postsurgical incontinence. Many patients eventually require permanent urinary diversion. Therefore, EUF and UCF repairs in radiated patients should be undertaken with caution, and patients should be counseled about the possibility of urinary diversion as primary therapy.