Practices to prevent non-ventilator hospital-acquired pneumonia: a narrative review.

Nosocomial infection has significant consequences in health care, both at the individual level due to increased morbidity and mortality, and at the organizational level due to increased costs. Hospital-acquired pneumonia (HAP) is the most common nosocomial infection, and is associated with high excess mortality, frequent use of broad-spectrum antimicrobials and increased length of stay. This review explores the preventative strategies that have been examined in non-ventilator HAP (NV-HAP). The management of aspiration risk, interventions for oral hygiene, role of mobilization and physiotherapy, modification of environmental factors, and vaccination are discussed. Many of these interventions are low risk, acceptable to patients and have good cost-benefit ratios. However, the evidence base for prevention of NV-HAP is weak. This review identifies the lack of a unified research definition, under-recruitment to studies, and variation in intervention and outcome measures as limitations in the existing literature. Given that the core risk factors for acquisition of NV-HAP are increasing, there is an urgent need for research to address the prevention of NV-HAP. This review calls for a unified definition of NV-HAP, and identification of a core outcome set for studies in NV-HAP, and suggests future directions for research in NV-HAP. Improving care for people with NV-HAP will reduce morbidity, mortality and healthcare costs significantly.

Clinical challenge of diagnosing non-ventilator hospital-acquired pneumonia and identifying causative pathogens: a narrative review.

Non-ventilated hospital-acquired pneumonia (NV-HAP) is associated with a significant healthcare burden, arising from high incidence and associated morbidity and mortality. However, accurate identification of cases remains challenging. At present, there is no gold-standard test for the diagnosis of NV-HAP, requiring instead the blending of non-specific signs and investigations. Causative organisms are only identified in a minority of cases. This has significant implications for surveillance, patient outcomes and antimicrobial stewardship. Much of the existing research in HAP has been conducted among ventilated patients. The paucity of dedicated NV-HAP research means that conclusions regarding diagnostic methods, pathology and interventions must largely be extrapolated from work in other settings. Progress is also limited by the lack of a widely agreed definition for NV-HAP. The diagnosis of NV-HAP has large scope for improvement. Consensus regarding a case definition will allow meaningful research to improve understanding of its aetiology and the heterogeneity of outcomes experienced by patients. There is potential to optimize the role of imaging and to incorporate novel techniques to identify likely causative pathogens. This would facilitate both antimicrobial stewardship and surveillance of an important healthcare-associated infection. This narrative review considers the utility of existing methods to diagnose NV-HAP, with a focus on the significance and challenge of identifying pathogens. It discusses the limitations in current techniques, and explores the potential of emergent molecular techniques to improve microbiological diagnosis and outcomes for patients.

Functional Laryngeal Assessment in Patients with Tracheostomy Following COVID-19 a Prospective Cohort Study.

To explore laryngeal function of tracheostomised patients with COVID-19 in the acute phase, to identify ways teams may facilitate and expedite tracheostomy weaning and rehabilitation of upper airway function. Consecutive tracheostomised patients underwent laryngeal examination during mechanical ventilation weaning. Primary outcomes included prevalence of upper aerodigestive oedema and airway protection during swallow, tracheostomy duration, ICU frailty scores, and oral intake type. Analyses included bivariate associations and exploratory multivariable regressions. 48 consecutive patients who underwent tracheostomy insertion as part of their respiratory wean following invasive ventilation in a single UK tertiary hospital were included. 21 (43.8%) had impaired airway protection on swallow (PAS ≥ 3) with 32 (66.7%) having marked airway oedema in at least one laryngeal area. Impaired airway protection was associated with longer total artificial airway duration (p = 0.008), longer tracheostomy tube duration (p = 0.007), multiple intubations (p = 0.006) and was associated with persistent ICU acquired weakness at ICU discharge (p = 0.03). Impaired airway protection was also an independent predictor for longer tracheostomy tube duration (p = 0.02, Beta 0.38, 95% CI 2.36 to 27.16). The majority of our study patients presented with complex laryngeal findings which were associated with impaired airway protection. We suggest a proactive standardized scoring and review protocol to manage this complex group of patients in order to maximize health outcomes and ICU resources. Early laryngeal assessment may facilitate weaning from invasive mechanical ventilation and liberation from tracheostomy, as well as practical and objective risk stratification for patients regarding decannulation and feeding.

Cardiovascular subphenotypes in patients with COVID-19 pneumonitis whose lungs are mechanically ventilated: a single-centre retrospective observational study.

Unsupervised clustering methods of transthoracic echocardiography variables have not been used to characterise circulatory failure mechanisms in patients with COVID-19 pneumonitis. We conducted a retrospective, single-centre cohort study in ICU patients with COVID-19 pneumonitis whose lungs were mechanically ventilated and who underwent transthoracic echocardiography between March 2020 and May 2021. We performed latent class analysis of echocardiographic and haemodynamic variables. We characterised the identified subphenotypes by comparing their clinical parameters, treatment responses and 90-day mortality rates. We included 305 patients with a median (IQR [range]) age 59 (49-66 [16-83]) y. Of these, 219 (72%) were male, 199 (65%) had moderate acute respiratory distress syndrome and 113 (37%) did not survive more than 90 days. Latent class analysis identified three cardiovascular subphenotypes: class 1 (52%; normal right ventricular function); class 2 (31%; right ventricular dilation with mostly preserved systolic function); and class 3 (17%; right ventricular dilation with systolic impairment). The three subphenotypes differed in their clinical characteristics and response to prone ventilation and outcomes, with 90-day mortality rates of 22%, 42% and 73%, respectively (p < 0.001). We conclude that the identified subphenotypes aligned with right ventricular pathophysiology rather than the accepted definitions of right ventricular dysfunction, and these identified classifications were associated with clinical outcomes.

The changing characteristics of COVID-19 presentations. A regional comparison of SARS-CoV-2 hospitalised patients during the first and second wave.

BACKGROUND: This study assesses COVID-19 hospitalised patient demography and outcomes during wave 1 and wave 2, prior to new variants of the virus. METHODS: All patients with a positive SARS-CoV-2 swab between 10th March 2020 and 5th July 2020 (wave 1) and 1st September 2020 and 16th November 2020 (wave 2) admitted to University Hospitals Birmingham NHS Foundation Trust were included (n=4856), followed for 28 days. RESULTS: Wave 2 patients were younger, more ethnically diverse, had less co-morbidities and disease presentation was milder on presentation. After matching for these factors, mortality was reduced, but without differences in intensive care admissions. CONCLUSION: Prior to new SARS-CoV-2 variants, outcomes for hospitalised patients with COVID-19 were improving but with similar intensive care needs.

Renal impairment and its impact on clinical outcomes in patients who are critically ill with COVID-19: a multicentre observational study.

Renal impairment is common in patients who are critically ill with coronavirus disease-19 (COVID-19). We examined the association between acute and chronic kidney disease with clinical outcomes in 372 patients with coronavirus disease-19 admitted to four regional intensive care units between 10 March 2020 and 31 July 2020. A total of 216 (58%) patients presented with COVID-19 and renal impairment. Acute kidney injury and/or chronic kidney disease was associated with greater in-hospital mortality compared with patients with preserved renal function (107/216 patients (50%) (95%CI 44-57) vs. 32/156 (21%) (95%CI 15-28), respectively; p < 0.001, relative risk 2.4 (95%CI 1.7-3.4)). Mortality was greatest in patients with renal transplants (6/7 patients (86%) (95%CI 47-100)). Mortality rates increased in patients with worsening renal injury according to the Kidney Disease: Improving Global Outcomes classification: stage 0 mortality 33/157 patients (21%) (95%CI 15-28) vs. stages 1-3 mortality 91/186 patients (49%) (95%CI 42-56); p < 0.001, relative risk 2.3 (95%CI 1.7-3.3). Survivors were less likely to require renal replacement therapy compared with non-survivors (57/233 patients (24%) vs. 64/139 patients (46%), respectively; p < 0.001, relative risk 1.9 (95%CI 1.4-2.5)). One-fifth of survivors who required renal replacement therapy acutely in intensive care continued to require renal support following discharge. Our data demonstrate that renal impairment in patients admitted to intensive care with COVID-19 is common and is associated with a high mortality and requirement for on-going renal support after discharge from critical care. Our findings have important implications for future pandemic planning in this patient cohort.

A time-sensitive analysis of the prognostic utility of vasopressor dose in septic shock.

It is unclear whether the association between vasopressor dose and mortality is affected by duration of administration. We examined whether prognostication in septic shock is feasible through the use of daily median vasopressor doses. We undertook a single-centre retrospective cohort study. We included patients with a diagnosis of septic shock admitted to the intensive care unit at Queen Elizabeth Hospital, Birmingham, UK, between April 2016 and July 2019. The primary outcome measure was 90-day mortality. We defined vasopressor dose as the median norepinephrine equivalent dose (equivalent infusion rates of all vasopressors and inotropes) recorded for each day, for the first four days of septic shock. We divided patients into groups by vasopressor dose quintiles and calculated their 90-day mortality rate. We examined area under the receiver operator characteristic curves for prognostic ability. In total, 844 patients were admitted with septic shock and had a 90-day mortality of 43% (n = 358). Over the first four days, median vasopressor dose decreased in 93% of survivors and increased in 56% of non-survivors. The mortality rate associated with a given vasopressor dose quintile increased on sequential days of septic shock. The area under the receiver operator characteristic curves of daily median vasopressor dose against mortality increased from day 1 to day 4 (0.67 vs. 0.86, p < 0.0001). By day 4, a median daily vasopressor dose > 0.05 µg.kg-1 .min-1 had an 80% sensitivity and specificity for mortality. The prognostic utility of vasopressor dose improved considerably with shock duration. Prolonged administration of small vasopressor doses was associated with a high attributable mortality.

Applying a COVID Virtual Ward model, assessing patient outcomes and staff workload.

A COVID virtual ward (CVW) is recommended by NHS England, but 'usual care' outcomes have not been reported. A retrospective study of all adults with COVID-19 attending Queen Elizabeth Hospital Birmingham between 01/06/2020-31/01/2021, assessed against CVW criteria and followed for 28 days. Of 2301 COVID-19 patients, 571(25%) would have met CVW criteria. Of these, 325(57%) were discharged after review and 246(43%) admitted. Of admitted patients who met CVW criteria, 81% required hospital-supported therapies; 11% died. Of the 325 discharged, 13% re-presented, 9% with COVID-related symptoms, 2% required intensive care admission, and one died (0.3%). In this comparison, discharging patients without a CVW did not lead to more re-presentations, re-admissions, ITU escalations or deaths compared to published outcomes for hospitals with a CVW.

To What Extent do Social Determinants of Health Modulate Presentation, ITU Admission and Outcomes among Patients with SARS-COV-2 Infection? An Exploration of Household Overcrowding, Air Pollution, Housing Quality, Ethnicity, Comorbidities and Frailty.

Background: Internationally, researchers have called for evidence to support tackling health inequalities during the severe acute respiratory syndrome coronavirus 2 (COVID19) pandemic. Despite the 2020 Marmot review highlighting growing health gaps between wealthy and deprived areas, studies have not explored social determinants of health (ethnicity, frailty, comorbidities, household overcrowding, housing quality, air pollution) as modulators of presentation, intensive care unit (ITU) admissions and outcomes among COVID19 patients. There is an urgent need for studies examining social determinants of health including socioenvironmental risk factors in urban areas to inform the national and international landscape. Methods: An in-depth retrospective cohort study of 408 hospitalized COVID19 patients admitted to the Queen Elizabeth Hospital, Birmingham was conducted. Quantitative data analyses including a two-step cluster analysis were applied to explore the role of social determinants of health as modulators of presentation, ITU admission and outcomes. Results: Patients admitted from highest Living Environment deprivation indices were at increased risk of presenting with multi-lobar pneumonia and, in turn, ITU admission whilst patients admitted from highest Barriers to Housing and Services (BHS) deprivation Indies were at increased risk of ITU admission. Black, Asian and Minority Ethnic (BAME) patients were more likely, than Caucasians, to be admitted from regions of highest Living Environment and BHS deprivation, present with multi-lobar pneumonia and require ITU admission. Conclusion: Household overcrowding deprivation and presentation with multi-lobar pneumonia are potential modulators of ITU admission. Air pollution and housing quality deprivation are potential modulators of presentation with multi-lobar pneumonia. BAME patients are demographically at increased risk of exposure to household overcrowding, air pollution and housing quality deprivation, are more likely to present with multi-lobar pneumonia and require ITU admission. Irrespective of deprivation, consideration of the Charlson Comorbidity Score and the Clinical Frailty Score supports clinicians in stratifying high risk patients.

Vitamin D and critical illness: what endocrinology can learn from intensive care and vice versa.

The prevalence of vitamin D deficiency in intensive care units ranges typically between 40 and 70%. There are many reasons for being or becoming deficient in the ICU. Hepatic, parathyroid and renal dysfunction additionally increases the risk for developing vitamin D deficiency. Moreover, therapeutic interventions like fluid resuscitation, dialysis, surgery, extracorporeal membrane oxygenation, cardiopulmonary bypass and plasma exchange may significantly reduce vitamin D levels. Many observational studies have consistently shown an association between low vitamin D levels and poor clinical outcomes in critically ill adults and children, including excess mortality and morbidity such as acute kidney injury, acute respiratory failure, duration of mechanical ventilation and sepsis. It is biologically plausible that vitamin D deficiency is an important and modifiable contributor to poor prognosis during and after critical illness. Although vitamin D supplementation is inexpensive, simple and has an excellent safety profile, testing for and treating vitamin D deficiency is currently not routinely performed. Overall, less than 800 patients have been included in RCTs worldwide, but the available data suggest that high-dose vitamin D supplementation could be beneficial. Two large RCTs in Europe and the United States, together aiming to recruit >5000 patients, have started in 2017, and will greatly improve our knowledge in this field. This review aims to summarize current knowledge in this interdisciplinary topic and give an outlook on its highly dynamic future.

Can nomograms improve our ability to select candidates for active surveillance for prostate cancer?

BACKGROUND: Our goal was to compare the ability of active surveillance (AS) criteria and preoperative nomograms to identify patients with pathologically low-risk prostate cancer. METHODS: The study cohort consisted of 402 radical prostatectomy patients with Gleason 6 prostate cancer on at least 10-core biopsy. In this group, we analyzed the ability of Kattan and Truong nomograms to select patients with Gleason 3+3 or 3+4 organ-confined prostate cancer, and compared it with that of AS criteria of John Hopkins (JH) and University of California at San Francisco (UCSF) medical centers, and Prostate Cancer Research International: Active Surveillance (PRIAS) study. The performance of each tool was evaluated with respect to discrimination and predictive accuracy. RESULTS: About 30% of patients were upgraded and 8% were upstaged in the final pathology. The nomograms demonstrated slightly higher discrimination in detecting organ-confined Gleason 3+3 and 3+4 disease. The predictive accuracy of the nomograms in selecting patients with low-grade organ-confined prostate cancer was superior to that of JH and UCSF criteria but not to PRIAS criteria. Furthermore, the nomograms were unable to select larger subgroups of patients with the same prevalence of Gleason 3+3 organ-confined prostate cancer as in men who met the PRIAS criteria. No difference was seen between the studied nomograms and AS criteria in their ability to identify patients with Gleason 3+4 organ-confined prostate cancer. CONCLUSIONS: PRIAS criteria demonstrate optimal balance between sensitivity and specificity and are not inferior to the available pathological nomograms in selecting patients with low-grade organ-confined prostate cancer.

Axl receptor tyrosine kinase is a potential therapeutic target in renal cell carcinoma.

BACKGROUND: Axl plays multiple roles in tumourigenesis in several cancers. Here we evaluated the expression and biological function of Axl in renal cell carcinoma (RCC). METHODS: Axl expression was analysed in a tissue microarray of 174 RCC samples by immunostaining and a panel of 11 normal tumour pairs of human RCC tissues by western blot, as well as in RCC cell lines by both western blot and quantitative PCR. The effects of Axl knockdown in RCC cells on cell growth and signalling were investigated. The efficacy of a humanised Axl targeting monoclonal antibody hMAb173 was tested in histoculture and tumour xenograft. RESULTS: We have determined by immunohistochemistry (IHC) that Axl is expressed in 59% of RCC array samples with moderate to high in 20% but not expressed in normal kidney tissue. Western blot analysis of 11 pairs of tumour and adjacent normal tissue show high Axl expression in 73% of the tumours but not normal tissue. Axl is also expressed in RCC cell lines in which Axl knockdown reduces cell viability and PI3K/Akt signalling. The Axl antibody hMAb173 significantly induced RCC cell apoptosis in histoculture and inhibited the growth of RCC tumour in vivo by 78%. The hMAb173-treated tumours also had significantly reduced Axl protein levels, inhibited PI3K signalling, decreased proliferation, and induced apoptosis. CONCLUSIONS: Axl is highly expressed in RCC and critical for RCC cell survival. Targeting Axl is a potential approach for RCC treatment.

Excess subcutaneous tissue may preclude intramuscular delivery when using adrenaline autoinjectors in patients with anaphylaxis.

Intramuscular adrenaline is the gold standard treatment for anaphylaxis. Intramuscular injection provides more rapid and higher plasma concentrations than subcutaneous routes. Given the increasing epidemic of obesity patients are at increased risk of subcutaneous delivery, we therefore assessed the depth of subcutaneous tissue in a population of patients with anaphylaxis. Patients already prescribed adrenaline autoinjectors (AAIs) for anaphylaxis were examined with ultrasound, and measurements of skin-to-muscle depth (STMD) at anterolateral thigh and anterior thigh were performed. Twenty-eight patients (23 female, 5 male) with an age range of 18-75 took part in the study, and in 68%, the STMD was greater than AAI needle length (15.02 mm), using the anterolateral thigh as the recommended administration site. The key predictors for increased STMD were female gender (P=0.0003) and a BMI > 30 (P=0.04). AAIs require longer needles to ensure intramuscular administration, and ultrasound at point of prescription would aid needle length selection.

Current status of robotic and laparoscopic techniques in radical cystectomy and diversion procedures for bladder cancer: review.

Across the world there has been an increased interest in minimally invasive approaches in extirpative and reconstructive surgery for bladder cancer. Minimally invasive approaches i.e. robotic and pure laparoscopic radical cystectomy have the greatest advantage of reduced blood loss, postoperative pain, quicker recovery of bowel function and earlier convalescence. Compared to established open techniques, there have been increasing reports of equivalent oncologic out comes and reduced complication rates in short and intermediate follow-ups. There have been several reports on urinary diversions achieved through minimal invasion and there is increasing interest to perform with robotic assistance. This review aims to review the currently published literature, technical aspects of the procedure, perioperative, oncologic and functional outcomes.

Stabilization of HIF-2α through redox regulation of mTORC2 activation and initiation of mRNA translation.

Hypoxia inducible factor-2α (HIF-2α) has a critical role in renal tumorigenesis. HIF-2α is stabilized in von Hippel-Lindau (VHL)-deficient renal cell carcinoma through mechanisms that require ongoing mRNA translation. Mammalian target of rapamycin (mTOR) functions in two distinct complexes: Raptor-associated mTORC1 and Rictor-associated mTORC2. Rictor-associated mTORC2 complex has been linked to maintaining HIF-2α protein in the absence of VHL; however, the mechanisms remain to be elucidated. Although Raptor-associated mTORC1 is a known key upstream regulator of mRNA translation, initiation and elongation, the role of mTORC2 in regulating mRNA translation is not clear. Complex assembly of the mRNA cap protein, eukaryotic translation initiation factor 4 (eIF4)E, with activators (eIF4 gamma (eIF4G)) and inhibitors (eIF4E-binding protein 1 (4E-BP1)) are rate-limiting determinants of mRNA translation. Our laboratory has previously demonstrated that reactive oxygen species, mediated by p22(phox)-based Nox oxidases, are enhanced in VHL-deficient cells and have a role in the activation of Akt on S473, a site phosphorylated by the mTORC2 complex. In this study, we examined the role of Rictor-dependent regulation of HIF-2α through eIF4E-dependent mRNA translation and examined the effects of p22(phox)-based Nox oxidases on TORC2 regulation. We demonstrate for the first time that mTORC2 complex stability and activation is redox sensitive, and further defined a novel role for p22(phox)-based Nox oxidases in eIF4E-dependent mRNA translation through mTORC2. Furthermore, we provide the first evidence that silencing of p22(phox) reduces HIF-2α-dependent gene targeting in vitro and tumor formation in vivo. The clinical relevance of these studies is demonstrated.

Kidney pericytes: a novel therapeutic target in interstitial fibrosis.

Chronic Kidney Disease affects approximately 8% of the population and contributes considerably to premature morbidity and mortality. Recently reported studies have highlighted an important role for resident microvascular pericytes in the pathogenesis of kidney fibrosis. Pericytes are emerging as the predominant source of the activated, matrix depositing, stromal cell population seen in progressive fibrosis. Further, pericyte activation leads to their detachment from the vasculature, triggers unstable microvasculature and leads to rarefaction. Strategies to modulate pericyte function in these processes are therefore therapeutically attractive. In this review we will first describe our current understanding of the structure and function of the pericyte and the role these cells play in angiogenesis and the pathogenesis of renal fibrosis. Novel therapeutic approaches targeting pericytes in murine models of renal disease will then be considered.

An oral selective M3 cholinergic receptor antagonist in COPD.

Cholinergic antagonists have been used since the early 1900s as bronchodilators for chronic obstructive pulmonary disease (COPD). The present study investigated whether an oral muscarinic M3-selective anticholinergic agent (OrM3) would provide an improved therapeutic advantage compared with an inhaled anticholinergic agent in patients with COPD. A 6-week, multicentre, randomised, placebo- and active-controlled, parallel-group study was performed at 56 sites in the USA. In total, 412 male and female patients (aged 35-86 yrs) with a clinical history consistent with COPD were randomised to receive OrM3 0.5, 2, 3 or 4 mg orally once daily, ipratropium bromide 36 mug by inhalation four times daily or placebo. OrM3 demonstrated a significant dose-related improvement in serial forced expiratory volume in one second and a trend for dose-related improvement in patient-reported symptoms compared with placebo. However, at a dose that provided efficacy less than that of ipratropium, the incidence of dose-related, mechanism-based side-effects for OrM3 exceeded those observed for ipratropium. In patients with chronic obstructive pulmonary disease, the oral M3-selective agent did not offer a therapeutic advantage over inhaled ipratropium. These results do not support the hypothesis that high selectivity for muscarinic M3 receptors over airway neuronal M2 receptors will represent a more effective therapy than current inhaled anticholinergics in obstructive airway disease.

A kinetic model of aqueous-phase alkali hydrolysis of 2,4,6-trinitrotoluene.

Alkali hydrolysis of 2,4,6-trinitrotoluene (TNT) was studied using batch experiments with starting pH values 11 and 12 in glass conical flasks covered with aluminum foil. Isothermal (25 and 40 degrees C) as well as non-isothermal experiments were conducted. Experiments starting at pH 12 resulted in >95% reduction in the concentration of TNT; those starting at pH 11 had a maximum reduction of 20-25% in TNT concentration. In all the experiments, one major stable intermediate was produced but it could not be identified. The experimental data were used to determine the overall stoichiometry of TNT and hydroxyl ions. Approximately 100 M (standard deviation 11.4) of hydroxyl ions were consistently consumed per mole of TNT. However, control experiments showed that all but 13 M (standard deviation 2) of hydroxyl ions were consumed in reactions not related to TNT. A simple kinetic model involving formation of the intermediate was proposed to account for changes in concentrations of TNT and hydroxyl ions. The rate constants and activation energies of the reactions were identified using isothermal data and the kinetic model was then used to predict the experimental data in the non-isothermal experiments reasonably well.

Health related quality of life assessment after radical prostatectomy in men with prostate specific antigen only recurrence.

PURPOSE: The health related quality of life assessment is becoming increasingly important among patients with prostate cancer. Meanwhile, treatment of patients with increasing prostate specific antigen (PSA) after radical retropubic prostatectomy remains controversial. We attempt to define the impact of PSA recurrence on the health related quality of life of patients after radical retropubic prostatectomy. MATERIALS AND METHODS: Of 604 consecutive patients who underwent radical retropubic prostatectomy between March 1991 and September 1998, 510 (84%) were available for followup. Each patient was mailed the RAND 36-Item Health Survey and University of California, Los Angeles, Prostate Cancer Index questionnaire. A total of 348 (70%) questionnaires were returned. Health related quality of life scores were then compared between patients with and without PSA recurrence. A multivariate analysis was also performed to elucidate further the cause of differences between the groups. RESULTS: Overall, 88 (25%) patients had PSA recurrence. In regard to health related quality of life there were small (less than 10%) but statistically significant differences in 2 of 4 physical health domains (RAND 36-Item Health Survey). There was a significant decrease in only 1 category of the mental health domain for patients with PSA recurrence. Only sexual function was statistically lower on the University of California, Los Angeles, Prostate Cancer Index. This result reflects the lower incidence of nerve sparing in these patients, as confirmed by the multivariate analysis. Overall patient satisfaction was similar between those with and without PSA recurrence (76% and 79%, respectively). CONCLUSIONS: Our study demonstrates small health related quality of life differences in patients with biochemical PSA recurrence versus those without. These findings provide a baseline assessment of general and disease specific health related quality of life domains among these patients. Future studies should focus on differences in the measure of cancer anxiety before and after administration of adjuvant therapy in these asymptomatic patients.

The use of radiography, urodynamic studies and cystoscopy in the evaluation of voiding dysfunction.

PURPOSE: Children with dysfunctional voiding disorder often undergo radiological, cystoscopic or urodynamic evaluation to identify an anatomical or organic cause. We determined the role of these studies in the evaluation, management and ultimate outcome of a large patient population with voiding dysfunction at a single institution. MATERIALS AND METHODS: We retrospectively evaluated the records of 1, 153 children with dysfunctional voiding disorder treated from 1990 to 1999. A thorough history and physical examination with specific emphasis on voiding patterns were done and urinalysis was performed in all cases. Ultrasound of the urinary system and excretory urography were done in 1,050 (91%) and 24 (2%) patients, respectively, while voiding cystourethrography was performed in 672 (58%), including 564 with a history of nonfebrile urinary tract infection. Cystoscopy and a formal urodynamic study were performed in 61 (5%) and 40 (3.5%) cases, respectively. RESULTS: Mean patient age at referral was 6 years (range 3 to 14). Of the children 74% were girls and 26% were boys. Physical examination of the abdomen, back, genitalia and neurological system was unremarkable in all cases. Ultrasound of the upper urinary system was normal in 1,018 patients (97%) and showed insignificant pyelectasis in 32 (3%). All 24 excretory urography studies were normal and voiding cystourethrography was normal in 470 of 672 cases (70%). Unilateral and bilateral low grade, and unilateral high grade reflux was present in 108, 19 and 3 patients, respectively. Urodynamic studies were performed in 40 children who did not respond to standard treatment. We noted detrusor instability in 16 patients, detrusor-sphincter dyssynergia in 6 and sensory abnormality in 3, while the study was completely normal in 10. Cystoscopy revealed normal findings in 17 cases, trabeculations in 21, inflammation in 20 and type 1 posterior urethral valves in 2. CONCLUSIONS: The incidence of upper tract changes and positive anatomical findings in children with voiding dysfunction is too low to justify routine radiological evaluation and cystoscopy. However, in those who present with a nonfebrile urinary tract infection there remains an important role for voiding cystourethrography. We do not recommend routine urodynamics in children with voiding disorder because this study does not change therapy or influence the final outcome. Thorough history and physical examination lead to the correct diagnosis and treatment in the majority of children. A focus on correcting faulty voiding behavior with the judicious administration of antibiotics and anticholinergic therapy leads to a favorable outcome in most cases.