Prevalence and clinical characteristics of pulmonary TB among pregnant and post-partum women.

SETTING: Antenatal care (ANC) and postpartum care (PPC) clinic in Manhiça District, Mozambique.OBJECTIVE: To estimate the prevalence of TB among pregnant and post-partum women and describe the clinical characteristics of the disease in a rural area of Southern Mozambique.METHODS: We conducted a cross-sectional TB prevalence study among pregnant and post-partum women recruited from September 2016 to March 2018 at the Manhiça Health Care Center (MHC). We recruited two independent cohorts of women consecutively presenting for routine pregnancy or post-partum follow-up visits.RESULTS: A total of 1,980 women from the ANC clinic and 1,010 from the PPC clinic were enrolled. We found a TB prevalence of 505/100,000 (95% CI: 242-926) among pregnant women and 297/100,000 (95% CI: 61-865) among post-partum women. Among HIV-positive pregnant women, TB prevalence was 1,626/100,000 (95% CI: 782-2,970) and among postpartum HIV-positive women, TB prevalence was 984/100,000 (95% CI: 203-2,848).CONCLUSIONS: The burden of TB was not higher in postpartum women than in pregnant women. Most TB cases were detected in HIV-positive women. TB screening and diagnostic testing among pregnant and postpartum women attending ANC and PPC clinics in Manhiça District is acceptable and feasible.

Enrolment and programmatic trends and predictors of antiretroviral therapy initiation from president's emergency plan for AIDS Relief (PEPFAR)-supported public HIV care and treatment sites in rural Mozambique.

Many countries in sub-Saharan Africa have made antiretroviral therapy (ART) available in urban settings, but the progress of treatment expansion into rural Africa has been slower. We analysed routine data for patients enrolled in a rural HIV treatment programme in Zambézia Province, Mozambique (1 June 2006 through 30 March 2009). There were 12,218 patients who were ≥15 years old enrolled (69% women). Median age was 25 years for women and 31 years for men. Older age and higher level of education were strongly predictive of ART initiation (P < 0.001). Patients with a CD4+ count of 350 cells/µL versus 50 cells/µL were less likely to begin ART (odds ratio [OR]: 0.19, 95% confidence interval [CI]: 0.16-0.23). In rural sub-Saharan Africa, HIV testing, linkage to care, logistics for ART initiation and fears among some patients to take ART require specialized planning to maximize successes. Sustainability will require improved health manpower, infrastructure, stable funding, continuous drug supplies, patient record systems and, most importantly, community engagement.

A meta-analysis of the vascular-related safety profile and efficacy of alpha-adrenergic blockers for symptoms related to benign prostatic hyperplasia.

OBJECTIVES: To evaluate the safety profile and efficacy of alpha1-adrenergic receptor blockers (A1Bs) currently prescribed for benign prostatic hyperplasia (BPH). DATA SOURCES: A systematic literature search of MEDLINE, the Cochrane Database and the Food and Drug Administration Web site through December 2006 identified double-blinded, prospective, placebo-controlled trials, evaluating agents commercially available by prescription for the symptomatic treatment of BPH. REVIEW METHODS: Data were reviewed by two investigators with the use of a standardised data abstraction form. Studies were evaluated for methodological quality using the Jadad scale. Studies with a score of < 3 were considered of weaker methodology. RESULTS: Of 2389 potential citations, 25 were usable for evaluation of safety data, 26 for efficacy. A1B use was associated with a statistically significant increase in the odds of developing a vascular-related event [odds ratio (OR) 2.54; 95% confidence interval (CI): 2.00-3.24; p < 0.0001]. The odds of developing a vascular-related adverse event were: alfuzosin, OR 1.66, 95% CI: 1.17-2.36; terazosin, OR 3.71, 95% CI: 2.48-5.53; doxazosin, OR 3.32, 95% CI: 2.10-5.23 and tamsulosin, OR 1.42, 95% CI: 0.99-2.05. A1Bs increased Q(max) by 1.32 ml/min (95% CI: 1.07-1.57) compared with placebo. Difference from placebo in American Urological Association symptom index/International Prostate Symptom Score was -1.92 points (95% CI: -2.71 to -1.14). CONCLUSIONS: Alfuzosin, terazosin and doxazosin showed a statistically significant increased risk of developing vascular-related events compared with placebo. Tamsulosin showed a numerical increase that was not statistically significant. All agents significantly improved Q(max) and symptom signs compared with placebo.

Neonatal thyrotoxicosis and conjugated hyperbilirubinemia.

We report a case of neonatal thyrotoxicosis secondary to maternal Graves' disease. In addition to presenting with symptoms of hyperthyroidism, the infant developed conjugated hyperbilirubinemia, a finding not previously reported in children with this condition.

Opportunities to improve prevention and services for HIV-infected women in nonurban Alabama and Mississippi.

OBJECTIVE: The intent of this study was to identify opportunities for improving the effectiveness of HIV prevention before nonurban (rural and small-city resident) Southern women are infected and the medical and social services offered to them after they are infected. METHODS: At several HIV clinics in nonurban Alabama and Mississippi, women with HIV infection (who reside in small cities and towns outside of Birmingham) were identified and interviewed about the period during which they probably acquired HIV and about their needs and the services provided after they were found to be infected with HIV. RESULTS: Before they were infected, these 211 young (mean age, 33 years), mainly African-American (67%) women often reported being seen at HIV testing sites (37%) and, among drug users, at drug treatment facilities (30%), where they presumably received counseling to prevent becoming infected. Once infected, many (21%) said they were not directed to HIV treatment sites, half (50%) were sexually active in the month before they were interviewed, many (13%) sought treatment of sexually transmitted diseases in the 12 months before the interview, and many (36%) reported unmet needs for HIV treatment related to having no insurance or Medicaid. CONCLUSIONS: Prevention and treatment of HIV for nonurban Southern women are not fully effective. Given the continued sexual activity of these women, more focus on preventing transmission from persons who are already infected is warranted.

Hand-assisted laparoscopic radical nephrectomy: comparison to open radical nephrectomy.

OBJECTIVES: Hand-assisted laparoscopic surgery is easier to learn than standard laparoscopy and simplifies intact specimen removal. We present our experience performing hand-assisted laparoscopic radical nephrectomy (HALRN) and compare it with contemporary open radical nephrectomy performed at our institution. METHODS: We performed 18 HALRNs for renal tumors ranging in size from 2 to 11 cm (average 4.5). Patients ranged in age from 40 to 83 years (average 62.9). All patients underwent HALRN with intact removal through a 7 to 8-cm vertical midline incision through an impermeable wound protector. Two or three working ports were used. We retrospectively compared our results with the results of 18 open radical nephrectomies performed during the same period, with the patients matched for age, body mass index, and American Society of Anesthesiologists' score. RESULTS: In the HALRN group, the average operating room time was 220.5 minutes, average length of stay 3.9 days, average time to return to normal activity 15.8 days, and average time to return to work 26.8 days. The median time to return to 100% normal was 28.0 days. No conversions or re-explorations were necessary in the HALRN series. The final pathologic examination revealed renal cell carcinoma in 15, oncocytoma in 1, angiomyolipoma in 1, and a complex cyst in 1. At a maximum of 48 months of follow-up (average 12.2), no recurrences were identified. Three deaths occurred in the series; 2 patients died with no evidence of disease and 1 patient died of metastatic disease (the nephrectomy was palliative). In the open group, the average operating room time was 117.8 minutes, average length of stay 5.1 days, average time to return to normal activity 23.5 days, and average time to return to work 52.2 days. The median time to return to 100% normal was 150 days, with 3 patients never returning to 100% normal. CONCLUSIONS: Our series demonstrated that HALRN is a safe, effective, minimally invasive option for treating renal cell carcinoma and provides a shorter hospital stay (P = 0.02), earlier return to work (P = 0.04), and earlier return to 100% normal (P = 0.0002) than open radical nephrectomy.

Cell relationship in a Wistar rat model of spontaneous prostatitis.

PURPOSE: Prostatitis in men is a painful, noninfectious inflammatory condition. It is similar to interstitial cystitis which is associated with increased bladder mast cell and sensory nerve fiber density as well as suprapubic pain. Certain strains of rats may provide a useful model for studies of the development of spontaneous prostatitis. We evaluated the time course, and involvement of mast cells and sensory nerve fibers in this process using Wistar rats. MATERIALS AND METHODS: The prostates of 4, 6, 8, 10 and 13-week-old male Wistar rats were examined for the degree of inflammation, innervation, mast cell density and nerve mast cell relationship using histochemical and immunocytochemical studies. Bacterial cultures of tissue were performed at 13 weeks. RESULTS: The inflammatory cell index increased progressively with age. Inflammation was moderate and consisted mostly of lymphocytes and macrophages associated with occasional glandular epithelial necrosis and edema. The density of nerve fibers immunoreacting with the neuronal marker protein gene produce 9.5 increased gradually with age and fibers immuno-positive for the sensory neuropeptide calcitonin gene-related peptide more than doubled by 13 weeks compared with by 4 weeks. The density of visible mast cells declined after 4 weeks in a pattern that corresponded with the increased percent of mast cells undergoing degranulation. For the mast cells with calcitonin gene-related peptide immuno-positive nerve fibers within a distance of 40 microm. distance correlated significantly with the degree of degranulation. Bacterial cultures were negative at 13 weeks. CONCLUSIONS: Our results confirm previous reports of spontaneous prostatitis in Wistar rats and indicate that moderate inflammation may occur in 80% of rats at as early as age 13 weeks. While the correlation of the nerve mast cell axis with mast cell degranulation does not prove our hypothesis of mast cell mediated inflammatory mediator release in the development of nonbacterial prostatitis, it suggests that such a relationship is possible.

Alpha-blockers: an effective treatment for prostatitis?

Chronic prostatitis is a multifaceted problem affecting men that is both poorly understood and poorly treated. It is inevitable, therefore, that no single treatment will benefit all patients. However, data suggest that some patients' problems can be treated effectively with alpha-blockers. The prostate is rich in alpha-adrenergic receptors, and some urodynamic studies have shown a failure of the bladder neck to relax during voiding. Other studies have demonstrated turbulent flow in the prostate leading to prostatic duct reflux. Because urine is acidic, reflux into the prostatic ducts will cause inflammation and pain. Thus alpha-blockers are an effective treatment for men with prostatitis caused by dysfunctional voiding.

Prostate cancer.

Prostate cancer is the second leading cause of cancer death in men. Recommendations for screening and treatment are usually made, especially in the popular press, without regard to patient age or medical health. This article focuses on the trade-off between the benefits and side effects of screening and treatment.

HIV/AIDS in nonurban Alabama: risk activities and access to services among HIV-infected persons.

BACKGROUND: Because AIDS is increasing in rural areas and small cities of the United States, we sought to further describe the epidemiology of HIV/AIDS in nonurban Alabama. METHODS: Extensive interviews of HIV-infected residents of Alabama living outside of urban Birmingham were conducted at clinics throughout the state. RESULTS: Of the 417 HIV-infected persons interviewed from January 1995 through January 1997, 310 (74%) were male, 229 (55%) were white, and 179 (43%) were black. Over time, increasing proportions of HIV infections have likely been acquired in nonurban areas. Of the 417 subjects, 43 (10%) had visited an STD clinic in the past year, and 31 (7%) had smoked crack-cocaine during the past month. Of the 166 persons who had been sexually active in the past month, 59 (36%) had used alcohol before sex and 56 (34%) used condoms inconsistently. Of the 417 subjects, 161 (39%) currently had no health insurance, and 68 (16%) had lost medical insurance since becoming HIV-infected. CONCLUSION: HIV-infected persons in nonurban Alabama are likely to have practiced high-risk behavior, to have acquired HIV in nonurban settings, and to have inadequate health insurance.

Mucinous vacuolar change of porcine urothelium induced by regional embolism or cryoablation.

Porcine urinary tract epithelium responds to systemic infections with an increase in mucin secretion that has been called "mucinous degeneration." Here we describe similar changes in calyceal, pelvic, and ureteric urothelium in pig renal tracts 14 days after local embolism and cryoablation (four kidneys) or cryoablation alone (six kidneys). Large mucin-filled vacuoles surrounded by smaller cytoplasmic vesicles were present in the affected urothelium but were rare in calyceal urothelium of normal kidneys. These mucinous vacuolar changes were proportional to the extent of renal necrosis and could be important in the pathologic responses of xenotransplanted pig kidneys.

Elevated tryptase, nerve growth factor, neurotrophin-3 and glial cell line-derived neurotrophic factor levels in the urine of interstitial cystitis and bladder cancer patients.

PURPOSE: The 2 prominent features of interstitial cystitis are pain and increased numbers of mast cells in the bladder. In this pilot study we determined the concentration of soluble mediators associated with activation of sensory neurons and/or mast cells that were present in the urine. MATERIALS AND METHODS: The study groups included 4 interstitial cystitis patients, 7 kidney donors with no history of bladder disease as negative controls, 6 bladder cancer patients and 7 patients with urinary tract infection as reference controls. Urine samples were assayed for different soluble mediators using immunoassays for tryptase (a marker for mast cell activation), neurotrophic factors (markers of neuronal plasticity) and chemokines (markers of inflammatory cell activity). Results were normalized based on creatinine concentration. RESULTS: There was a marked increase in the average amounts of tryptase and 3 neurotrophic factors in patient urine. Interestingly, the mediator profile in the urine of bladder cancer patients was indistinguishable from that of interstitial cystitis patients with respect to these same 4 proteins. There was no difference between normal control and urinary tract infection urine samples. CONCLUSIONS: These findings may account for several clinical and pathological features found in interstitial cystitis and bladder cancer. Although preliminary due to the limited numbers of patients, they also suggest that increased levels of neurotrophin-3, nerve growth factor, glial cell line-derived neurotrophic factor and tryptase in the urine could serve as a basis for adjunct diagnosis, monitoring and treatment of interstitial cystitis.

Identification of microtacks in the bladder after laparoscopic pelvic surgery.

Laparoscopic techniques are simplified and the operative time is reduced with the use of laparoscopic stapling and tacking devices. We present our experience in identifying and removing surgical tacks in 2 patients after laparoscopic pelvic surgery.

Laparoscopic cryosurgery of the kidney in the porcine model: an acute histological study.

OBJECTIVES: To verify histologically whether cryosurgery of the kidney can be accomplished reproducibly without injuring adjacent structures, using a combination of ultrasound and laparoscopic guidance. MATERIALS AND METHODS: Six kidneys from three domestic female farm pigs were utilized in the study. Under general anesthesia and after obtaining pneumoperitoneum, the lower pole of the kidney was mobilized laparoscopically and the ureter and adjacent bowel were protected with saline-soaked gauze. Two 3.8 mm-cryoprobes were placed percutaneously into the lower pole and cryoablation was carried out under laparoscopic and ultrasound guidance using a double-freeze technique (10-minute freeze and 5-minute thaw cycles to a probe temperature of -185 degrees C to -196 degrees C) in five kidneys (one control). The kidneys, adjacent ureter and bowel were harvested acutely, and macroscopic, histologic, and electron microscopic evaluation of all specimens was performed. RESULTS: Macroscopically, clear margins of cryodestruction corresponded with the ultrasound images of the iceball. In all five treated kidneys, reproducible cell death corresponding to visible margins of cryodestruction were verified histologically. Cell death was further corroborated by electron microscopy. Adjacent structures (ureter and bowel) were sectioned and no significant damage was noted. Blood pressure remained constant throughout the procedure. A crack in the renal parenchyma of one kidney was noted during the thaw phase; at harvest that animal was found to have an intraperitoneal hemorrhage. CONCLUSION: Combined laparoscopic and ultrasound-guided cryoablation of the lower pole of the kidney can be accomplished reproducibly in the porcine model without injury to adjacent structures.

Hand assisted laparoscopic nephrectomy: comparison to standard laparoscopic nephrectomy.

PURPOSE: We report our initial experience with hand assisted laparoscopic nephrectomy, and compare it to our results of standard laparoscopic nephrectomy. MATERIALS AND METHODS: The results of 21 hand assisted and standard laparoscopic nephrectomies (15 simple and 4 radical nephrectomies, and 2 nephroureterectomies) were reviewed. Hand assisted laparoscopic nephrectomy was performed with a hand placed intra-abdominally using the Pneumo Sleeve,* in addition to standard laparoscopic instruments manipulated through laparoscopic ports. Standard laparoscopic nephrectomy was performed using laparoscopic instruments alone. Perioperative data were recorded and questionnaires, including visual analog pain scales, were administered prospectively to 17 of 21 cases. RESULTS: The average operative time for 13 hand assisted laparoscopic nephrectomies was 240 minutes, which was significantly less than the 325-minute average for 8 standard laparoscopic nephrectomies (p = 0.04). Major complications tended to be more frequent in the standard group (38 versus 8%, p = 0.10). Hospital stay, return to normal activity and corrected 2-week abdominal/flank pain score in the hand assisted group (3.1 days, 14 days and 0.8, respectively) were not significantly different from the standard group (3.0 days, 10 days and 0.2, respectively). CONCLUSIONS: Compared to standard laparoscopic techniques, hand assistance appears to facilitate the operative speed and safety of laparoscopic nephrectomy without sacrificing the benefits of minimally invasive surgery. Hand assistance may make laparoscopic nephrectomy more appealing to urologists without advanced laparoscopic experience, may facilitate the laparoscopic management of demanding pathological conditions and is particularly useful when intact specimens are required. Hand assistance, by improving manipulative ability and tactile sense, is helpful for select cases of laparoscopic nephrectomy.

CT angiography of potential renal transplant donors.

Renal transplantation has grown rapidly over the past 30 years, resulting in an inadequate supply of organs to meet the ever-increasing demand. This has led to an increase in the number of living-related donors. Advances in imaging technology now allow safe, rapid, and relatively noninvasive evaluation of potential donors. Helical computed tomographic (CT) angiography is a fast, minimally invasive procedure that is quickly becoming the imaging modality of choice for preoperative evaluation of potential renal transplant donors. Helical CT, combined with low-osmolar intravenous contrast materials, has enabled CT angiography to depict arterial and venous anatomy accurately. Between July 1995 and March 1997, CT angiography was performed in 205 potential renal donors. Correlation with surgical findings in 136 donor nephrectomies helped confirm a high level of accuracy for CT angiography in the assessment of the renal vasculature: Sensitivity and specificity for identifying specific vessels was 99.6% and 99.6% for main renal arteries, 76.9% and 89.9% for polar arteries, and 98.7% and 95.5% for main renal veins, respectively. CT angiography allows the radiologist to provide the transplant surgeon with precise preoperative anatomy of the renal vasculature, thus reducing the risks and complications associated with the harvesting procedure and improving the chances for a successful outcome. However, accurate radiologic interpretation depends on the radiologist's experience level, attention to detail, and commitment to careful image evaluation.

Overcoming cellular senescence in human cancer pathogenesis.

Elevation of p16, the CDKN2/p16 tumor suppressor gene (TSG) product, occurs at senescence in normal human uroepithelial cells (HUC). Immortal HUCs and bladder cancer cell lines show either alteration of p16 or pRb, the product of the retinoblastoma (RB) TSG. In addition, many human cancers show p16 or pRb alteration along with other genetic alterations that we associated with immortalization, including +20q and -3p. These observations led us to hypothesize that p16 elevation plays a critical role in senescence cell cycle arrest and that overcoming this block is an important step in tumorigenesis in vivo, as well as immortalization in vitro. Using a novel approach, we tested these hypotheses in the present study by examining p16 and pRb status in primary culture (P0) and after passage in vitro of transitional cell carcinoma (TCC) biopsies that represented both superficial bladder tumors and invasive bladder cancers. We demonstrated that all superficial TCCs showed elevated p16 after limited passage in vitro and then senesced, like normal HUCs. In contrast, all muscle invasive TCCs contained either a p16 or a pRb alteration at P0 and all spontaneously bypassed senescence (P = 0.001). Comparative genomic hybridization (CGH) was used to identify regions of chromosome loss or gain in all TCC samples. The application of a statistical model to the CGH data showed a high probability of elevated alteration rates of +20q11-q12 (0.99) and +8p22-pter (0.94) in the immortal muscle invasive TCCs, and of -9q (0.99) in the superficial TCCs. Three myoinvasive TCCs lost 3p13-p14. In this study, four of six myoinvasive TCCs also showed TP53 mutation that associated well with genome instability (P = 0.001), as previously hypothesized. Notably, TP53 mutation, which has been used as a marker of tumor progression in many human cancers, was less significant in associating with progression in this study (P = 0.04) than was p16 or pRb alteration (P = 0.001). Thus, these data support a new model in which overcoming senescence plays a critical role in human cancer pathogenesis and requires at least two genetic changes that occur in several combinations that can include either p16 or pRb loss and at least one additional alteration, such as +20q11-q12, -3p13-p14, or -8p21-pter.

Laparoscopic renal cryotherapy in swine: comparison of puncture cryotherapy preceded by arterial embolization and contact cryotherapy.

Variable results of open, percutaneous, and laparoscopic cryosurgery of the kidney have been reported. Minimally invasive approaches to lower-pole renal ablation were prospectively compared in swine: laparoscopic puncture cryoablation preceded by arterial embolization, laparoscopic contact cryosurgery, and arterial embolization alone. Eighteen kidneys in nine domestic pigs were randomized to one of three treatment groups of six organs each: (1) puncture cryotherapy preceded by selective lower-pole arterial embolization; (2) contact cryotherapy alone; and (3) arterial embolization alone. Under general anesthesia, appropriate animals underwent selective arterial embolization of the lower pole via femoral cutdown using Gelfoam pledgets. Animals randomized to cryotherapy underwent dissection of the lower pole of the kidney using a single 12-mm umbilical and two midclavicular-line ports in the lateral position. Under external ultrasound guidance, two 3-mm cryoprobes (Cryomedical Sciences, Rockville, MD) were positioned in the lower pole of the kidney, and double-freeze technique to -190 degrees C was performed using puncture or contact application. Ultrasonography was used to guide probe insertion during puncture cryotherapy only. Kidneys were harvested 11 to 14 days after the procedure. Both puncture and contact kidneys demonstrated cell death and subsequent necrosis by light microscopy and electron micrography. On average, puncture lesions were heavier than contact lesions, 19.3 g v 10.1 g (P = 0.02; unpaired t-test), whereas the kidneys were equivalent in weight: 74.1 g v 74.1 g. Puncture lesions represented 26.4% of total kidney weight v 13.5% in the contact group (P = 0.002; unpaired t-test). Only focal infarcts were identified in the embolization group. No evidence of adjacent visceral injury was identified in any of the groups, and no animal required conversion to open laparotomy. One kidney bled after contact cryotherapy, and hemostasis was achieved laparoscopically. Laparoscopic cryotherapy is reproducible and effective using either the puncture technique preceded by arterial embolization or the contact technique, without evidence of damage to adjacent structures. Contact lesions were less voluminous and more peripheral than puncture lesions. Embolization alone produces focal infarcts and focal zones of cell death.

Immunology of chronic prostatitis: etiological and therapeutic considerations.

Immunological studies of prostatitis have developed from findings of antibody coated bacteria in the 1970s to the more recent studies of various models of autoimmunity. This review presents data suggesting that possible causes for prostatitis (bacterial or otherwise) may be explained under an immunological umbrella.

Urinary symptomatology in younger men.

OBJECTIVES: We surveyed a "population" of younger men (20 to 49 years old) for lower urinary tract symptomatology and for symptomatology associated with prostatitis. METHODS: A National Guard unit was surveyed by mail with a 58-question urinary symptom questionnaire. Surveys were returned anonymously by mail. RESULTS: International Prostate Symptom Score (IPSS) of 8 or greater was seen in 5% of men in their 20s and rose to 15% of those in their 40s. Approximately 5% (0% to 7%) reported a history of prostatitis. Caffeine caused symptoms in 2% to 13%, while exercise and smoking were not associated with symptoms. Individual prostatitis symptoms were only seen occasionally across this age group. CONCLUSIONS: As measured by the IPSS, urinary symptoms increased during the 20 to 49-year age period. A history of prostatitis in much less common than most nonpopulation studies suggest.