Natural History of Artificial Urinary Sphincter Erosion: Long-term Lower Urinary Tract Outcomes and Incontinence Management.

OBJECTIVE: To describe long-term lower urinary tract outcomes and incontinence management after AUS erosion, including risk factors associated with each outcome. METHODS: We retrospectively reviewed our prospectively maintained AUS database for men undergoing device explantation for urethral erosion from January 1, 1986 to October 10, 2023. Outcomes included development of urethral stricture and management of post-explant incontinence (eg, pads/clamp, catheter, salvage AUS, supravesical diversion). Risk factors were tested for association with stricture formation and repeat AUS erosion using logistic regression. RESULTS: Around 1943 unique patients underwent AUS implantation during the study period, and 217 (11%) had a device explantation for urethral erosion. Of these, 194 had complete records available and were included for analysis. Median follow-up from implantation was 7.5 years (IQR 2.7-13.7) and median time to erosion was 2 yrs (IQR 0-6). Ninety-six patients (49%) underwent salvage AUS placement. Of those, 38/96 (40%) were explanted for subsequent erosion. On multivariable analysis, no factors were significantly associated with risk of salvage AUS erosion. On multivariable model, pelvic radiation (OR 2.7; 95% CI 1.0-7.4) and urethral reapproximation during explant for erosion (OR 4.2; 95% CI 1.5-11.2) were significantly associated with increased risk of urethral stricture (P <.05). At the time of last follow-up, 69/194 (36%) patients had a functioning salvage AUS, including both initial and subsequent salvage implants. CONCLUSION: Following AUS erosion, radiation history and urethral reapproximation at explantation were risk factors for development of urethral stricture. Salvage AUS replacement can be performed, but has a higher rate of repeat urethral erosion.

Evaluation of an Opioid-free Pathway for Perineal Reconstructive Surgery: A 1-year Pilot Study.

OBJECTIVE: To evaluate the impact of a standardized perioperative pain management pathway on postoperative opioid prescribing practices following male perineal reconstructive surgery at our institution. METHODS: Patients undergoing perineal reconstructive surgery (urethroplasty, artificial urinary sphincter, urethral sling) by a single surgeon from July 2022 to June 2023 were prospectively followed. A standardized nonopioid pathway was implemented in the perioperative period. Intraoperative local anesthetic included liposomal bupivacaine mixed with 0.25% bupivacaine. Opioids are administered in the recovery room at the discretion of anesthesiology providers. As of July 2022, our standard practice does not include a postoperative opioid prescription unless pain is poorly controlled in the recovery area. Postoperative communication encounters and opioid prescriptions were tracked through the electronic health record (EHR) in order to assess the efficacy of an opioid-free pathway. RESULTS: Sixty-seven patients met the criteria during the study period, 64/67 performed in an outpatient setting. 6/67 (9%) patients were prescribed an opioid postoperatively; 4 related to post-surgical pain, and 2 related to chronic pain. No refills were prescribed. Of the 26 patients who received an opioid in the recovery area, 2 (7.6%) were prescribed an opioid at discharge. 15/67 (22%) patients had a communication encounter related to pain within 30 days, most commonly related to bladder spasm management. Only 2 of these encounters resulted in an electronic opioid prescription. CONCLUSION: An opioid-free pathway is appropriate for opioid naive men undergoing perineal reconstructive surgery. When necessary, electronic opioid prescribing should be employed following discharge for breakthrough pain.

Approach to the elderly patient with vertebral fracture due to bone fragility. / Abordaje del adulto mayor con fractura vertebral por fragilidad ósea.

Osteoporosis is a metabolic and systemic disease characterized by alterations at the level of bone tissue with loss of bone mineral density, changes in microarchitecture, mineralization and remodeling that determine greater bone fragility and risk of fracture. Falls in the elderly are a risk factor closely related to fragility fractures and numerous studies demonstrate this relationship. Vertebral fractures are a major cause of morbidity and mortality. The epidemiology differs from osteoporotic fractures at other skeletal sites, as only one-third are clinically recognized. In the elderly, the approach to osteoporotic vertebral fracture involves comprehensive evaluation of the patient, since it is both a cause and a consequence of multiple geriatric syndromes. This fracture, in its acute phase and subsequently, can lead to destabilization of other organs and systems of the elderly, medical complications at different levels, functional deterioration, dependence, and even the need for institutionalization. Therefore, it is important to carry out a multiple assessment of patients with vertebral fractures, addressing not only the history and risk factors of osteoporosis, but also those factors that lead to falls, as well as a comprehensive geriatric assessment and the complications closely associated with it. In this chapter we address each of these aspects that are necessary in the individual and multidimensional approach to the elderly patient with vertebral fracture due to bone fragility.

Antioxidant activity of glucosamine and its effects on ROS production, Nrf2, and O-GlcNAc expression in HMEC-1 cells.

Glucosamine (GlcN) is the most used supplement for osteoarthritis treatment. In vitro studies have related GlcN to beneficial and detrimental effects on health. The aim of this study was to evaluate the effects of O-linked-N-acetylglucosaminylation (O-GlcNAc) on GlcN-induced ROS production and Nrf2 expression in human dermal microvascular endothelial cells-1 (HMEC-1) and to evaluate the antioxidant capacity of GlcN compared to well-known antioxidants. For this, we evaluate the antioxidant capacity by in vitro assays. Besides, the GlcN (5-20 mM) effects on cell viability, reactive oxygen species (ROS) production, O-GlcNAc, and nuclear factor erythroid-2-related factor 2 (Nrf2) expression with and without the O-GlcNAc inhibitor OSMI-1 (10 µM) in HMEC-1 were evaluated. GlcN showed high inhibitory concentration (low scavenging activity) against superoxide (O2•─, IC20 = 47.67 mM), 2,2-diphenyl-1-picrylhydrazyl (DPPH•, IC50 = 21.32 mM), and hydroxyl (HO•, IC50 = 14.04 mM) radicals without scavenging activity against hydrogen peroxide (H2O2) and low antioxidant capacity determined by oxygen radical absorbance capacity (ORAC, 0.001 mM Trolox equivalent) and ferric reducing antioxidant power (FRAP, 0.046 mM Trolox equivalent). In cell culture, GlcN (20 mM) reduced cell viability up to 26 % and induced an increase in ROS production (up to 70 %), O-GlcNAc (4-fold-higher vs. control), and Nrf2 expression (56 %), which were prevented by OSMI-1. These data suggest an association between O-GlcNAc, ROS production, and Nrf2 expression in HMEC-1 cells stimulated with GlcN.

Time Matters: Importance of Circadian Rhythms, Disruption, and Chronotherapy in Urologic Malignancies.

The human body was evolutionarily programmed to run on cycles, termed circadian rhythms, which integrate human behavior and bodily function with the environment. Disruptions to these rhythms via desynchronization have been deemed a probable carcinogen by the WHO. Subsequent research has identified alterations in multiple core clock genes when comparing tumor and benign tissues. This review will discuss core clock genes associated with urogenital malignancies and highlight impactful research regarding circadian biology use in treatment. Chronotherapy, treatment alignment with an individual's biological rhythm, remains a relatively untouched field within urology that should be explored to possibly enhance therapeutic outcomes.

The Serious Side of Supplements: An Ischemic Stroke in a Healthy 38-year-old Female.

The incidence of ischemic stroke in the young is on the rise. With young stroke victims, providers must consider both typical risk factors and other rare causes. We present a case of a healthy, 38-year-old female military dependent who presented with an ischemic right posterior central gyrus stroke in the setting of a patent foramen ovale and supplement diindolylmethane use. This case serves as a reminder of the hazards associated with supplement use and the importance of a thorough investigation of etiology in medical cases of ischemic stroke in the young.

The human fecal microbiome contributes to the biotransformation of the PFAS surfactant 8:2 monosubstituted polyfluoroalkyl phosphate ester.

Polyfluoroalkyl phosphate esters (PAPs) can be found throughout society due to their numerous commercial applications. However, they also pose an environmental and health concern given their ability to undergo hydrolysis and oxidation to several bioactive and persistent products, including the perfluorocarboxylic acids (PFCAs). The metabolism of PAPs has been shown to occur in mammalian liver and intestine, however metabolism by the gut microbiome has not yet been investigated. In this study, human fecal samples were used to model the microbial population of the colon, to test whether these anaerobic microbes could facilitate 8:2 monosubstituted PAP (monoPAP) transformation. In vitro testing was completed by incubating the fecal samples with 8:2 monoPAP (400-10,000 nM) up to 120 minutes in an anaerobic chamber. Reactions were then terminated and the samples prepared for GC- and LC-MS/MS analysis. Metabolites of interest were the immediate hydrolysis product, the 8:2 fluorotelomer alcohol (FTOH), and 11 additional metabolites previously shown to form from 8:2 FTOH in both oxic and anoxic environments. The kinetics of 8:2 monoPAP transformation by gut microbiota were compared to those in human S9 liver and intestine fractions, both of which have active levels of hydrolyzing and oxidative enzymes that transform 8:2 monoPAP. Transformation rates from 8:2 monoPAP to 8:2 FTOH were highest in liver S9 > intestine S9 > fecal suspensions. The gut microbiome also produced a unique composition of oxidative metabolites, where the following intermediate metabolites were more abundant than terminal PFCAs: 8:2 fluorotelomer unsaturated carboxylic acid (FTUCA) > 8:2 fluorotelomer carboxylic acid (FTCA) > 7:2 Ketone ≈ perfluorohexanoic acid (PFHxA). Hydrolytic and oxidative metabolites contributed up to 30% of the molar balance after microbial 8:2 monoPAP transformation. Together, the results suggest that the gut microbiome can play a notable role in PAP biotransformation.

Computerized Games versus Crosswords Training in Mild Cognitive Impairment.

BACKGROUND: Mild cognitive impairment (MCI) increases the risk of dementia. The efficacy of cognitive training in patients with MCI is unclear. METHODS: In a two-site, single-blinded, 78-week trial, participants with MCI - stratified by age, severity (early/late MCI), and site - were randomly assigned to 12 weeks of intensive, home-based, computerized training with Web-based cognitive games or Web-based crossword puzzles, followed by six booster sessions. In mixed-model analyses, the primary outcome was change from baseline in the 11-item Alzheimer's Disease Assessment Scale-Cognitive (ADAS-Cog) score, a 70 point scale in which higher scores indicate greater cognitive impairment at 78 weeks, adjusted for baseline. Secondary outcomes included change from baseline in neuropsychological composite score, University of California San Diego Performance-Based Skills Assessment (functional outcome) score, and Functional Activities Questionnaire (functional outcome) score at 78 weeks, adjusted for baseline. Changes in hippocampal volume and cortical thickness on magnetic resonance imaging were assessed. RESULTS: Among 107 participants (n=51 [games]; n=56 [crosswords]), ADAS-Cog score worsened slightly for games and improved for crosswords at week 78 (least squares [LS] means difference, -1.44; 95% confidence interval [CI], -2.83 to -0.06; P=0.04). From baseline to week 78, mean ADAS-Cog score worsened for games (9.53 to 9.93) and improved for crosswords (9.59 to 8.61). The late MCI subgroup showed similar results (LS means difference, -2.45; SE, 0.89; 95% CI, -4.21 to -0.70). Among secondary outcomes, the Functional Activities Questionnaire score worsened more with games than with crosswords at week 78 (LS means difference, -1.08; 95% CI, -1.97 to -0.18). Other secondary outcomes showed no differences. Decreases in hippocampal volume and cortical thickness were greater for games than for crosswords (LS means difference, 34.07; SE, 17.12; 95% CI, 0.51 to 67.63 [hippocampal volume]; LS means difference, 0.02; SE, 0.01; 95% CI, 0.00 to 0.04 [cortical thickness]). CONCLUSIONS: Home-based computerized training with crosswords demonstrated superior efficacy to games for the primary outcome of baseline-adjusted change in ADAS-Cog score over 78 weeks. (Supported by the National Institutes of Health, National Institute on Aging; ClinicalTrials.gov number, NCT03205709.).

Psychometric Properties of the Personality Inventory for DSM-5-Brief Form in a Community Sample with High Rates of Trauma Exposure.

In the current study, we used a sample of predominantly African-American women with high rates of trauma exposure (N = 434) to examine psychometric properties of the Personality Inventory for DSM-5-Brief Form (PID-5-BF). We compared model fit between a model with five correlated latent factors and a higher-order model in which the five latent factors were used to estimate a single "general pathology" factor. Additionally, we computed estimates of internal consistency and domain interrelations and examined indices of convergent/discriminant validity of the PID-5-BF domains by examining their relations to relevant criterion variables. The expected five-factor structure demonstrated good fit indices in a confirmatory factor analysis, and the more parsimonious, higher-order model was retained. Within this higher-order model, the first-order factors accounted for more variance in the criterion variables than the general pathology factor in most instances. The PID-5-BF domains were highly interrelated (rs = .38 to .66), and convergent/discriminant validity of the domains varied: Negative Affectivity and Detachment generally showed the hypothesized pattern of relations with external criteria, while Antagonism and Disinhibition displayed less consistent and discriminant relations. Results are discussed in terms of the costs and benefits of using brief pathological trait measures in samples characterized by high levels of psychopathology.

Factores determinantes de estancia hospitalaria, mortalidad y evolución funcional tras cirugía por fractura de cadera en el anciano / Predictive factors of hospital stay, mortality and functional recovery after surgery for hip fracture in elderly patients

Objetivos. Analizar las características de los pacientes ingresados por fractura de cadera y su evolución 6 meses tras la cirugía para determinar los factores potencialmente relacionados con estancia hospitalaria, complicaciones médicas, mortalidad y recuperación funcional tras esta enfermedad tan prevalente y con graves consecuencias. Material y métodos. Estudio prospectivo de un grupo de 130 pacientes mayores de 75 años hospitalizados por fractura de cadera de perfil osteoporótico. Se evaluaron sus antecedentes médicos, situación mental y física previas a la caída, tipos de fractura y tratamiento quirúrgico, complicaciones hospitalarias, así como evolución funcional y social tras la hospitalización. Resultados. Los pacientes que tenían mayor grado de deterioro físico y mental previamente a la fractura y los institucionalizados tuvieron peor capacidad de recuperación tras la cirugía. El empleo de terapias alternativas a la transfusión para el tratamiento de la anemia se relacionó con disminución de estancia hospitalaria y mejor capacidad de deambulación a medio plazo. Las principales complicaciones médicas en el ingreso fueron infección e insuficiencia cardiaca, e implicaron prolongación de la hospitalización. La prescripción de suplementos nutricionales en pacientes adecuadamente seleccionados se relacionó con mejor evolución funcional. Conclusiones. La valoración de la situación mental, física y social previas a la fractura debe ser la base de un plan de tratamiento individualizado por ser claramente determinante de pronóstico. Los equipos multidisciplinares con seguimiento médico continuado simultáneo al quirúrgico son importantes para prevenir y tratar precozmente las frecuentes complicaciones perioperatorias. La administración de ferroterapia intravenosa y la prescripción de suplementos de nutrición pueden mejorar la recuperación física a medio plazo del paciente intervenido fractura de cadera (AU)

Objectives. Due to its high prevalence and serious consequences it is very important to be well aware of factors that might be related to medical complications, mortality, hospital stay and functional recovery in elderly patients with hip fracture. Material and methods. A prospective study of a group of 130 patients aged over 75 years admitted for osteoporotic hip fracture. Their medical records, physical and cognitive status prior to the fall, fracture type and surgical treatment, medical complications and functional and social evolution after hospitalization were evaluated. Results. Patients with greater physical disability, more severe cognitive impairment and those who lived in a nursing home before the fracture had worse functional recovery after surgery. Treatment with intravenous iron to reduce transfusions reduced hospital stay and improved walking ability. Infections and heart failure were the most frequent medical complications and were related to a longer hospital stay. The prescription of nutritional supplements for the patients with real indication improved their physical recovery after the hip fracture. Conclusions. Evaluation of physical, cognitive and social status prior to hip fracture should be the basis of an individual treatment plan because of its great prognostic value. Multidisciplinary teams with continuous monitoring of medical problems should prevent and treat complications as soon as possible. Intravenous iron and specific nutritional supplements can improve functional recovery six months after hip fracture (AU)

Predictive factors of hospital stay, mortality and functional recovery after surgery for hip fracture in elderly patients. / Factores determinantes de estancia hospitalaria, mortalidad y evolución funcional tras cirugía por fractura de cadera en el anciano.

OBJECTIVES: Due to its high prevalence and serious consequences it is very important to be well aware of factors that might be related to medical complications, mortality, hospital stay and functional recovery in elderly patients with hip fracture. MATERIAL AND METHODS: A prospective study of a group of 130 patients aged over 75 years admitted for osteoporotic hip fracture. Their medical records, physical and cognitive status prior to the fall, fracture type and surgical treatment, medical complications and functional and social evolution after hospitalization were evaluated. RESULTS: Patients with greater physical disability, more severe cognitive impairment and those who lived in a nursing home before the fracture had worse functional recovery after surgery. Treatment with intravenous iron to reduce transfusions reduced hospital stay and improved walking ability. Infections and heart failure were the most frequent medical complications and were related to a longer hospital stay. The prescription of nutritional supplements for the patients with real indication improved their physical recovery after the hip fracture CONCLUSIONS: Evaluation of physical, cognitive and social status prior to hip fracture should be the basis of an individual treatment plan because of its great prognostic value. Multidisciplinary teams with continuous monitoring of medical problems should prevent and treat complications as soon as possible. Intravenous iron and specific nutritional supplements can improve functional recovery six months after hip fracture.

Chiral amplification of disodium cromoglycate chromonics induced by a codeine derivative.

Chromonic liquid crystals (CLC) are lyotropic phases formed by discotic mesogens in water. Simple chiral dopants such as amino acids have been reported to turn chromonic liquid crystals into their cholesteric counterparts. Here we report a chirality amplification effect in the nematic phase of a 9 wt% disodium cromoglycate (DSCG) lyotropic liquid crystal (LLC) upon doping with a water-soluble codeine derivative. The transition on cooling the isotropic to the nematic phase showed the presence of homochiral spindle-shaped droplets (tactoids). NMR DOSY experiments on a triple gradient probe revealed a small degree of diffusion anisotropy for the alkaloid embedded in the liquid crystal structure. These results in combination with XRD, CD and POM experiments agree with a supramolecular aggregation model based on simple columnar stacks.

Nanoobjects formed by ionic PAMAM dendrimers: hydrophilic/lipophilic modulation and encapsulation properties.

In this paper, we present the preparation and properties of some ionic PAMAM derivatives, which combine hydrophilic and lipophilic carboxylic acid chains as counter-ions for all protonable inner and outer amino groups. The amphiphilic nature of the final ionic codendrimers and, hence, their self-assembling features can be modulated by using different ratios between hydrophilic and lipophilic chains. In the bulk, these new materials self-organize into smectic A liquid crystal phases. In water, they self-assemble into different types of nano-objects depending on the molecular composition. The study of the morphology of these nano-structures, their cytotoxicity and their capability to encapsulate a lipophilic anticancer drug are reported herein. Some of these nanoobjects are non-cytotoxic and present good drug trapping ability, which make them interesting nanocarriers for applications in nanotechnology and biomedicine.

Diarrea asociada a Clostridium difficile en el paciente anciano. Perspectiva integral. Réplica / Diarrhea associated to Clostridium dificcile in an elderly patient. Global perspective. Response

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Informe de situación de diálisis y trasplante en España, 2004 / Dialysis and transplant situation, Spain 2004

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[Clostridium difficile associated diarrhea in the elderly patient]. / Diarrea asociada a Clostridium difficile en el paciente anciano.

Clostridium difficile is the leading cause of infectious nosocomial diarrhea in the elderly. It may cause colitis of variable severity and extraintestinal involvement. Hand transmission is the most important, and it is related to prolonged antibiotic therapies in elderly patients with severe baseline disease. Diagnosis is based on culture and immunological tests to detect its toxins. When there is no response to conservative treatment (withdrawal of the antibiotic and support therapy), metronidazole or vancomycin should be given. Recurrences, up to 20%, are frequent. Preventive measures of its spreading are essential due to the elevated transmission through health care personnel and instruments. Detection of new, more virulent, gene variants of Clostridium difficile have increased the importance of this disease.

The relationship of meteorological conditions to the epidemic activity of respiratory syncytial virus.

Our aim was to obtain knowledge of how meteorological conditions affect community epidemics of respiratory syncytial virus (RSV) infection. To this end we recorded year-round RSV activity in nine cities that differ markedly in geographic location and climate. We correlated local weather conditions with weekly or monthly RSV cases. We reviewed similar reports from other areas varying in climate. Weekly RSV activity was related to temperature in a bimodal fashion, with peaks of activity at temperatures above 24-30 degrees C and at 2-6 degrees C. RSV activity was also greatest at 45-65% relative humidity. RSV activity was inversely related to UVB radiance at three sites where this could be tested. At sites with persistently warm temperatures and high humidity, RSV activity was continuous throughout the year, peaking in summer and early autumn. In temperate climates, RSV activity was maximal during winter, correlating with lower temperatures. In areas where temperatures remained colder throughout the year, RSV activity again became nearly continuous. Community activity of RSV is substantial when both ambient temperatures and absolute humidity are very high, perhaps reflecting greater stability of RSV in aerosols. Transmission of RSV in cooler climates is inversely related to temperature possibly as a result of increased stability of the virus in secretions in the colder environment. UVB radiation may inactivate virus in the environment, or influence susceptibility to RSV by altering host resistance.

Diarrea asociada a Clostridium difficile en el paciente anciano / Clostridium difficile associated diarrhea in the elderly patient

Clostridium difficile es la causa más importante de diarrea infecciosa de transmisión nosocomial en ancianos. Puede producir grados de colitis de intensidad variable y afectación de órganos extraintestinales. Se transmite por vía feco-oral, a veces de forma epidémica en centros sanitarios, y se relaciona con la administración de gran variedad de antibióticos de forma prolongada en pacientes con patología severa de base. El cultivo en medios específicos o la detección de sus toxinas son los métodos habituales de diagnóstico. En caso de no haber respuesta al tratamiento conservador (retirada del antibiótico y terapia de soporte) se administrará metronidazol o vancomicina. Son frecuentes las recurrencias (hasta un 20%). Las medidas preventivas de su diseminación son imprescindibles, por la elevada transmisión a través del personal e instrumental sanitario. La detección de nuevas cepas de mayor virulencia y peor respuesta al tratamiento convencional hace de esta enfermedad nosocomial una entidad de importancia creciente

Clostridium difficile is the leading cause of infectious nosocomial diarrhea in the elderly. It may cause colitis of variable severity and extraintestinal involvement. Hand transmission is the most important, and it is related to prolonged antibiotic therapies in elderly patients with severe baseline disease. Diagnosis is based on culture and immunological tests to detect its toxins. When there is no response to conservative treatment (withdrawal of the antibiotic and support therapy), metronidazole or vancomycin should be given. Recurrences, up to 20%, are frequent. Preventive measures of its spreading are essential due to the elevated transmission through health care personnel and instruments. Detection of new, more virulent, gene variants of Clostridium difficile have increased the importance of this disease

Evaluating the strengths and weaknesses of tuberculosis educational activities for prisoners in Honduras.

SETTING: Prisons throughout Honduras. OBJECTIVE: To assess the strengths, weaknesses, and opportunities to improve non-standardized tuberculosis (TB) educational campaign materials utilized in prisons. DESIGN: A qualitative assessment was conducted. Prison staff completed a survey describing development and implementation of educational activities at each prison (n=25). Completed surveys with photographs or copies of educational materials were collected and cataloged. The content, literacy demand, illustrations, learning stimulation, and cultural appropriateness of cataloged items were assessed using an adapted version of the Suitability Assessment of Materials Instrument. Results from this assessment were examined in conjunction with information collected through focus groups conducted with prisoners and interviews with prison staff. RESULTS: Campaign strengths included the development and dissemination of print materials appropriate for individuals with low literacy levels. By actively engaging prisoners in the campaigns, materials often incorporated the language, values, and experiences encountered within prison culture. Content of print materials and presentations focused on correcting misperceptions and facilitating acceptance of TB control activities. Campaign weaknesses included the creation of illustrations that could perpetuate the stigma associated with TB and use of some materials in which the purpose was not apparent. CONCLUSIONS: The campaigns were generally suitable, and the evaluation allowed for their improvement.