Utility of exercise testing to assess athletes for post COVID-19 myocarditis.

Purpose: This study assessed a functional protocol to identify myocarditis or myocardial involvement in competitive athletes following SARS-CoV2 infection. Methods: We prospectively evaluated competitive athletes (n = 174) for myocarditis or myocardial involvement using the Multidisciplinary Inquiry of Athletes in Miami (MIAMI) protocol, a median of 18.5 (IQR 16-25) days following diagnosis of COVID-19 infection. The protocol included biomarker analysis, ECG, cardiopulmonary stress echocardiography testing with global longitudinal strain (GLS), and targeted cardiac MRI for athletes with abnormal findings. Patients were followed for median of 148 days. Results: We evaluated 52 females and 122 males, with median age 21 (IQR: 19, 22) years. Five (2.9%) had evidence of myocardial involvement, including definite or probable myocarditis (n = 2). Three of the 5 athletes with myocarditis or myocardial involvement had clinically significant abnormalities during stress testing including ventricular ectopy, wall motion abnormalities and/or elevated VE/VCO2, while the other two athletes had resting ECG abnormalities. VO2max, left ventricular ejection fraction and GLS were similar between those with or without myocardial involvement. No adverse events were reported in the 169 athletes cleared to exercise at a median follow-up of 148 (IQR108,211) days. Patients who were initially restricted from exercise had no adverse sequelae and were cleared to resume training between 3 and 12 months post diagnosis. Conclusions: Screening protocols that include exercise testing may enhance the sensitivity of detecting COVID-19 related myocardial involvement following recovery from SARS-CoV2 infection.

Abnormalities of the axial and proximal appendicular skeleton in adults with Laron syndrome (growth hormone insensitivity).

OBJECTIVE: To investigate abnormalities in the skeleton (with the exclusion of the skull, cervical spine, hands and feet) in patients with Laron syndrome, who have an inborn growth hormone resistance and congenital insulin-like growth factor-1 (IGF-1) deficiency. DESIGN AND PATIENTS: The study group was composed of 15 untreated patients with Laron syndrome (seven male and eight female) aged 21-68 years. Plain films of the axial and appendicular skeleton were evaluated retrospectively for abnormalities in structure and shape. The cortical width of the long bones was evaluated qualitatively and quantitatively (in the upper humerus and mid-femur), and the cortical index was calculated and compared with published references. Measurements were taken of the mid-anteroposterior and cranio-caudal diameters of the vertebral body and spinous process at L3, the interpedicular distance at L1 and L5, and the sacral slope. Thoracic and lumbar osteophytes were graded on a 5-point scale. Values were compared with a control group of 20 healthy persons matched for age. RESULTS: The skeleton appeared small in all patients. No signs of osteopenia were visible. The cortex of the long bones appeared thick in the upper limbs in 11 patients and in the lower limbs in four. Compared with the reference values, the cortical width was thicker than average in the humerus and thinner in the femur. The vertebral diameters at L3 and the interpedicular distances at L1 and L5 were significantly smaller in the patients than in the control subjects (P<0.001); however, at L5 the canal was wider, relative to the vertebral body. The study group had a higher rate of anterior osteophytes in the lumbar spine than the controls had, and their osteophytes were also significantly larger. In the six patients for whom radiographs of the upper extremity in its entirety were available on one film, the ulna appeared to be rotated. In one 22-year-old man, multiple epiphyses were still open. CONCLUSION: Congenital IGF-1 deficiency leads to skeletal abnormalities characterized by small bones, narrow spinal canal, and delayed bone age. The limitation in elbow distensibility common to patients with Laron syndrome may be related to a marked retroversion of the humeral head.

Factors affecting tube dwelling time after percutaneous nephrolithotomy.

BACKGROUND AND PURPOSE: Little is known about the impact of nephrostomy tubes on morbidity and quality of life. PATIENTS AND METHODS: The tube dwelling time and the factors influencing it were determined in 165 patients undergoing percutaneous nephrolithotomy (PCNL). RESULTS: The mean tube dwelling time was 21+/-30 days. The duration of tube drainage after PCNL was 13+/-17 days. Most of this time was preoperative when the tube was inserted for urgent reasons--obstruction or sepsis (31+/-33 days). On multivariate analysis, the number of secondary PCNLs and postoperative complications were the most significant factors affecting tube dwelling time. Age correlated with intubation time but did not reach statistical significance (P < 0.09). Neither the stone's side and type nor the patient's sex had a significant influence. CONCLUSIONS: A significant factor affecting the duration of tube drainage is preoperative medical evaluation and patient preparation, and these steps should be completed expeditiously in order to minimize the time to PCNL. Completion of PCNL in one session should shorten the postoperative intubation time.

The impact of prostate biopsy on patient well-being: a prospective study of voiding impairment.

PURPOSE: We studied the possible association of transrectal ultrasound guided prostate biopsy with voiding impairment. MATERIALS AND METHODS: A total of 211 consecutive patients were prospectively enrolled. International Prostate Symptom Score (I-PSS), subjective voiding complaints and retention were recorded in 3 personal interviews before biopsy, and on postoperative days 7 and 30. RESULTS: Of the 204 patients who voided via the urethra at biopsy 52 (25%) reported subjective voiding impairment on postoperative day 7, including 12% who defined difficult voiding as mild-1 to 2 points on a 0 to 5 scale, 8% as moderate-3/5 and 5% as severe-4 to 5/5. In 5 of the latter cases (2.5%) acute urinary retention necessitated urethral catheter insertion. Transition zone volume, which was 42 ml. or larger in all patients in urinary retention, was the only independent variable associated with patient report of subjective difficult voiding and acute urinary retention during week 1 after biopsy (p = 0.03). Baseline I-PSS greater than 20 points indicated a risk of an acute transient increase in I-PSS on postoperative day 7. CONCLUSIONS: Transient voiding impairment may be precipitated by ultrasound guided prostate biopsy. To decrease this morbidity appropriate evaluation and possible treatment for bladder outlet obstruction are justified in patients with a larger transition zone and in those with preoperative baseline I-PSS greater than 20 points.

The impact of prostate biopsy on patient well-being: a prospective study of pain, anxiety and erectile dysfunction.

PURPOSE: We prospectively studied the impact of transrectal ultrasound guided prostate biopsy on patient well-being. MATERIALS AND METHODS: We enrolled 211 consecutive men who underwent a total of 218 biopsy events in a questionnaire based survey focusing on pain, anxiety and erectile dysfunction risk factors. Surveys were administered before, and immediately, 1 week and 1 month after biopsy. Quantitative information on the intensity of symptoms and signs was obtained using a uniform grading system. RESULTS: Intraoperative pain considered severe in 20% of the biopsy events was associated with pain in the first 24 hours postoperatively, leading to analgesic use in 10%. Inflammatory infiltrate in the biopsy core and younger patient age correlated with persistent pain on days 2 and 7 after biopsy, respectively. Preoperative anxiety was reported in 64% of biopsy events and predictive of intraoperative pain. Anxiety peaked before result disclosure. Erectile dysfunction attributed to anxiety in anticipation of biopsy was reported in 7% of cases. At days 7 and 30, 15% of previously potent patients reported erectile dysfunction. CONCLUSIONS: The impact of prostate biopsy on patient well-being begins while waiting for the scheduled procedure. Shortening the anticipation period before results are disclosed and administering pre-biopsy anxiety decreasing measures may benefit patients. Analgesic therapy is recommended in younger patients, those reporting moderate to severe intraoperative pain and those with known prostatic inflammatory infiltrate. The risk of acute erectile dysfunction should be discussed cautiously with patients who are potent before biopsy.

Cryosurgical ablation for prostate cancer: preliminary results of a new advanced technique.

BACKGROUND: Cryosurgery is a minimally invasive treatment option for prostate cancer. OBJECTIVES: To report on the first series of cryosurgical ablation for prostate cancer performed in Israel. METHODS: Cryosurgical ablation of the prostate was undertaken in 12 patients aged 53-72 diagnosed with adenocarcinoma of the prostate. The procedures were performed percutaneously and were monitored by real-time trans-rectal ultrasound. The CRYOHIT machine applying Argon gas was used with standard or ultra-thin cryoprobes. The average follow-up was 12.8 months postsurgery (range 1-24 months). RESULTS: No rectal or urethral injuries occurred and all patients were discharged from hospital within 24-48 hours. The duration of suprapubic drainage was 14 days in 10 patients and prolonged in 2. Early complications included penoscrotal edema in four patients, perineal hematoma in three, hemorrhoids in two and epidydimitis in one. Long-term complications included extensive prostatic sloughing in one patient and a perineal fistula in another, both of whom required prolonged suprapubic drainage. Minimal stress incontinence was noted in two patients for the first 8 weeks after surgery. None of the patients has yet regained spontaneous potency. A prostate-specific antigen nadir of less than 0.5 ng/ml was achieved in eight patients and an undetectable PSA level below 0.1 ng/ml in five patients. CONCLUSION: Cryoablation for prostate cancer is safe and feasible, and the preliminary results are encouraging. Further study is needed to elucidate the efficacy of the procedure.

Elevated prostate specific antigen serum levels after intravesical instillation of bacillus Calmette-Guerin.

PURPOSE: We determined whether intravesical bacillus Calmette-Guerin (BCG) instillation is associated with elevated prostate specific antigen (PSA). MATERIALS AND METHODS: We treated 36 consecutive patients with bladder cancer with a 6-week course of BCG, followed by cystoscopy at 6 weeks. Blood samples for PSA determination were obtained before each BCG instillation and at cystoscopy with each patient also serving as a control. PSA elevation was defined as 2-fold the baseline level in at least 2 specimens and any PSA level greater than 4 ng./ml. was considered clinically significant. Digital rectal examination was done to identify firm nodules and prostate size. The prostate was examined histologically by transrectal ultrasound guided biopsy or after radical cystectomy. RESULTS: We observed elevated PSA in 27 men (75%) during BCG treatment, of whom 15 (41.6%) had a clinically significant elevation. Overall average PSA increased from 1.3 ng./ml. before BCG instillation to 3.8 during treatment (range 0.1 to 21.5, p <0.0001). In those with a clinically significant elevation average PSA increased from 2.31 ng./ml. at baseline to 6.97 during treatment (p <0.0001) and returned to 3.86 ng./ml. 3 months after treatment. Palpation demonstrated prostatic findings in 10 patients, including firm nodules in 7, while there was significantly elevated PSA in 5 with firm nodules and 2 with diffuse prostatic enlargement. Histological examination of the prostate in 10 patients was diagnostic for granulomatous prostatitis, nonspecific inflammation and benign prostatic hyperplasia in 3, 3 and 4, respectively, of whom none had prostate cancer. CONCLUSIONS: Intravesical BCG therapy is associated with significantly elevated PSA in up to 40% of cases. This effect is self-limited and PSA reverts to normal in 3 months. Therefore, we suggest that prostate biopsy be withheld in such patients and PSA monitored.

[Gastrointestinal hemorrhage of obscure origin].

Gastrointestinal bleeding of obscure origin consists of recurrent bouts of acute or chronic bleeding for which no definite source is discovered in routine endoscopic and barium contrast studies of the upper and lower gastrointestinal tracts. Usually its cause is angiodysplasia of the intestine, but many cases are due to tumors, mostly of the small bowel, which may be malignant. In patients under the age of 50, the proportion with malignancy is relatively high (up to 14%) as compared to older patients. We describe a 45-year-old woman who suffered from gastrointestinal bleeding for 3 years. The cause of bleeding was not found despite extensive work-up. In her last admission for acute gastrointestinal hemorrhage she was given a total of 30 units of blood. A tumor of the small intestine found by angiography was excised and found to be a stromal tumor of uncertain malignant potential. 1 year after operation she is asymptomatic without bleeding and her hemoglobin is stable without treatment.

Prostate cryoablation without an insertion kit using direct transperineal placement of ultrathin freezing probes.

A modified technique for prostate cryoablation is described. Prostate cryoablation was performed with a gas-based cryomachine using multiple 17-gauge probes. The 17-gauge probes were inserted via a transperineal route directly into the prostate without using an insertion kit. Probe insertion and positioning are simplified, and operative time is reduced. The perineum is less crowded with devices and tubes. Miniaturizing the cryoprobes and their tubing is feasible. The smaller diameter enables direct insertion without an insertion kit. The surgical result does not seem to be inferior to that of conventional ablation, and penetrating trauma to the prostate is minimal. To the best of our knowledge, this is the first report of transperineal prostate cryoablation performed without an insertion kit.

Predicting CAP in patients with intermediate PSA using modified PSA indices.

OBJECTIVES: To test a new PSA index: peripheral zone fraction PSA (PSA-PZ) and evaluate its' predictive value in patients with intermediate PSA. METHODS: Fifty seven of 273 patients with serum PSA 4-10 ng/ml had CAP (21%). Total prostate volume and transition zone volume were calculated. Different cut-off points were used to calculate specificity, sensitivity, efficacy, positive and negative predictive values for PSA, PSAD, PSA-TZ and PSA-PZ (PSA-PZ= serum PSA((Total gland volume-TZ volume)/(Total gland volume)) RESULTS: The distribution of PSA-PZ is presented. PSA-PZ is shown to be effective in DRE negative patients with serum PSA 4-10 ng/ml. For patients with PSA-PZ (1.5 ng/ml the biopsy may be spared with no cancer being missed. CONCLUSIONS: The mathematical formula for PSA-PZ is straightforward and easy to use. Its application is convenient in the clinical setting. We suggest the use of PSA-PZ mainly in DRE negative patients having large glands and serum PSA between 4-10.

Ureteral catheterization and patient mobilization: is bed restriction mandatory?

OBJECTIVES: We determined whether patient mobilization influences ureteral catheter position in the collecting system. METHODS: 26 consecutive patients (28 renal units) who underwent ureteral catheterization for the purpose of retrograde pyelography or the relief of ureteral obstruction, were included. The position of the catheter's tip within the collecting system and versus the vertebrae was determined for each patient in the baseline supine position; standing upright, and supine again after walking a distance of 5 m. Catheteral displacement was determined by comparing its position in the upright and supine post-walking postures to its original position with the patient supine before any maneuver was undertaken. RESULTS: Assuming the upright position caused an average downward displacement of ureteral catheters by 7.8 mm (ranges 36 mm downward to 14 mm upward displacements, p = 0.0014). In the supine posture following a 5-meter walk, the catheters were downward displaced by 0. 36 mm on average (ranges 12 mm downward and 30 mm upward displacements p = 0.8). None of the ureteral catheters migrated below the uretero-pelvic junction during any phase of the above maneuvers. CONCLUSION: The position of ureteral catheters remains unchanged within the collecting system when patients stand or walk for 5 m. Therefore, mandatory bed restriction is not justified in patients with ureteral catheters.

Relaxation of micro indentations in calcium oxalate urinary stones.

PURPOSE: We define energy requirements for stone micro indentation as a quantifiable event equivalent to in vivo energy delivery and investigate the change in indentation characteristics with time. MATERIALS AND METHODS: The 7 stones extracted from 7 patients were cut, embedded in resin and polished. Multiple micro indentations were performed on each stone section using a diamond Vickers micro indentor with a 500x light microscope and video system. The resulting indentations were observed by optical and scanning electron microscopy as a function of time. Organic matrix content was determined by dissolving stones in ethylenediaminetetraacetic acid solution. RESULTS: The energy requirement for stone indentation varies among stones (median range 43.6 to 109.9 kg/mm2) and at different locations in the same stone. Indentations relaxed by 10 to 70% during the first 2 weeks after indentation. Stones with a high organic matrix content were ductile and the phenomenon of indentation relaxation was pronounced. Brittle, low matrix stones relaxed to a lesser extent. CONCLUSIONS: The relaxation phenomena may have a practical implementation when considering repeat shock wave lithotripsy. A significant fraction of the energy invested in a stone which did not cause fracture or critical cracks is lost within 1 to 2 weeks after the procedure, particularly in elastic stones with a high organic matrix content. We suggest that the preferred interval for repeat shock wave lithotripsy be less than 2 weeks.

Transrectal ultrasonographically assisted radical retropubic prostatectomy.

Radical prostatectomy is associated with difficulty in determining the division site of the urethra adjacent to the apical region of the prostate. We present the results of a feasibility clinical trial in three patients to determine whether intraoperative transrectal ultrasonography may assist during radical retropubic prostatectomy. Using this technique the apex is readily identified and a detailed view of the urethral stump could be obtained. In one case residual apical tissue was identified and excised. The creation of the vesicourethral anastomosis was documented and its water tightness was demonstrated. We conclude that transrectal ultrasonography can be performed during radical retropubic prostatectomy and may be helpful in selected cases.

Postejaculation serum prostate-specific antigen level.

OBJECTIVE: This study was carried out to determine whether ejaculation may modify the serum prostate-specific antigen (PSA) level and to investigate whether postejaculation serum PSA may play a role in male hypofertility work-up. METHODS: Serum PSA concentration was determined before and 1 h after ejaculation in 18 healthy men (group A) and in 16 men with male-factor infertility (group B). PSA change (delta) was recorded and analyzed. RESULTS: Postejaculation serum PSA differed significantly from basal levels (p = 0.0037 by the Wilcoxon signed rank test). Following ejaculation, a rise was noticed in 74% of subjects. The median relative change in PSA concentration was 54%. No difference in respect to mean, median and relative change was observed between study groups. In two cases (6%), PSA rose from normal level to more than 4 ng/ml. CONCLUSION: A significant postejaculation serum PSA elevation does occur, it is thus recommended that men abstain from ejaculation for 24 h prior to PSA sampling. Postejaculation PSA was not found to significantly correlate with hypofertility.

A genetic sequence change in the 3'-noncoding region of the androgen receptor gene in prostate carcinoma.

OBJECTIVE: We intended to identify structural changes in the hormone-binding domain and C-terminal region of the androgen receptor (AR) gene in carcinoma of prostate specimens. METHODS: Twelve prostate cancer specimens from prostate resections were analyzed for the presence of mutations in the E-H exons and part of the 3'-untranslated region of the AR cDNA, using RT-PCR and direct sequencing. RESULTS: A polymorphic sequence spanning 17 nucleotides was identified in the 3'-untranslated region of the AR cDNA from one prostate carcinoma tissue, suggesting the presence of a somatic mutation. No mutations were identified in the coding sequence of the hormone-binding domain of the AR cDNA. CONCLUSION: These results suggest that AR mutations are probably uncommon molecular events in the early stages of prostate cancer.

[Percutaneous choledochoscopic electrohydraulic lithotripsy].

Treatment of biliary stones impacted in the distal, common bile duct is a technical challenge. We report 2 consecutive patients, a woman aged 80 years and a man aged 64, in whom all operative attempts failed. In both, the stone was removed by percutaneous, choledochoscopic, electrohydraulic lithotripsy in a single session. To the best of our knowledge these are the first such cases reported in Israel.

Autoantibodies to prostate specific antigen in patients with benign prostatic hyperplasia.

PURPOSE: We tested for a possible autoimmune process in benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: Titers of IgG antibodies to prostate specific antigen (PSA) were measured in the sera of 85 BPH patients, 20 controls and 17 chronic prostatitis patients by enzyme-linked immunosorbent assay. RESULTS: The mean anti-PSA titers in the BPH group were significantly higher than in the controls and prostatitis group (p < 0.0005). Accordingly, 59% of BPH patients could be defined as responders to PSA compared to none among the controls (p < 0.0005). CONCLUSIONS: Circulating autoantibodies to PSA were shown to exist in the sera of BPH patients. This observation suggests that autoimmune processes may have a role in BPH.

Shock wave lithotripsy with the Dornier MFL 5000 lithotriptor using an external fixed rate signal.

PURPOSE: We examine the effects of fixed rate shock wave administration on the cardiac rhythm and treatment efficacy of a tubless lithotriptor (Dornier MFL 5000*). A secondary goal was to examine the treatment efficacy of fixed shock wave administration compared to R wave triggered lithotripsy. MATERIALS AND METHODS: In this prospective study Holter monitoring was used before, during and after nonR wave triggered shock wave lithotripsy. RESULTS: An increase in premature ventricular contractions was noted during shock wave lithotripsy. However, there were no episodes of significant ventricular ectopia, ventricular tachycardia, asystole or heart block as a result of nonR wave triggered shock wave administration. NonR wave gated shock wave lithotripsy expedited patient treatment and (mean treatment time 46 +/- 21 minutes)., minimized the use of sedation during treatment and produced results similar to R wave gated shock wave lithotripsy with the MFL 5000 lithotriptor. CONCLUSIONS: With adequate precautions, fixed rate shock wave administration would appear to be a reasonable option to treat urolithiasis with the MFL 5000 lithotriptor as with other newer lithotriptors.

Spontaneous ureteral stent fragmentation.

A series of spontaneous multiple fragmentations of 3 ureteral stents presenting with a variety of clinical features is reported. Physical analysis measuring the tensile mechanical properties was done of the retrieved fragments together with 2 new stents, as well as electron microscopy scanning of the retrieved fragments. This methodology in evaluating fractured stents is unique in its capability to determine the accelerated aging process of stent material and to our knowledge has not been reported previously in this context. The retrieved catheters were moderately incrusted. The tensile elongation (maximal elongation at break point), known to be a sensitive indicator of the aging process of plastic materials, was dramatically decreased in the retrieved stents. The fractures in all catheters retrieved as well as in the new stents were found to pass exclusively through the side holes. Fragmented catheters had a distinctive electron microscopic appearance and physical properties, which may be defined in a systematic manner and may contribute to further refinement of stent quality.