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IsoPSA is a blood-based test that assesses prostate cancer (CaP) risk by partitioning and detecting cancer-specific structural isoforms of prostate specific antigen (PSA) with an aqueous 2- phase system.To validate the diagnostic performance of IsoPSA for High-Grade CaP and Any CaP risk on biopsy in men age ≥ 50 with total PSA ≥ 4 ng/ml.Prospective, multicenter study of 888 men scheduled for prostate biopsy at 8 academic and community sites between August 2015 and August 2020.IsoPSA test.Receiver operating characteristic and likelihood ratio analysis used to validate diagnostic performance for previously established IsoPSA Index cutoffs for High-Grade CaP (Gleason Score ≥ 7) and Any CaP (Gleason Score ≥ 6), compare IsoPSA to total PSA and % free PSA, and evaluate subgroups (total PSA 4-10 ng/ml, total PSA10 ng/ml, biopsy naïve, prior negative biopsy).The disease prevalence was 35.6% (High-Grade CaP) and 58.9% (Any CaP). The area under the receiver operating characteristic curve was 0.783 (High-Grade CaP) and 0.770 (Any CaP). IsoPSA outperformed total PSA and % free PSA on area under the receiver operating characteristic curve, specificity, positive and negative predictive value at similar sensitivity. Using selected IsoPSA Index cutoffs, an estimated 46% (High-Grade CaP) and 42% (Any CaP) of biopsies could be avoided in low-risk patients. IsoPSA displayed statistically informative likelihood ratio-based predictive characteristics. IsoPSA maintained accuracy in clinically relevant subgroups.IsoPSA diagnostic performance and predictive value is validated for High-Grade CaP and Any CaP in men age ≥ 50 with total PSA ≥ 4 ng/ml undergoing diagnostic biopsy. IsoPSA outperforms total and % free PSA in discriminating the risk of prostate cancer on biopsy.IsoPSA has the potential to reduce unnecessary biopsies and improve the risk-benefit ratio for CaP early detection.

Study objective Online educational resources such as blogs are increasingly used for education by emergency medicine clinicians. The Social Media Index was developed to quantify their relative impact. The Medical Education Translational Resources: Indicators of Quality (METRIQ) study was conducted in part to determine the association between the Social Media Index score and quality as measured by gestalt and previously derived quality instruments. Methods Ten blogs were randomly selected from a list of emergency medicine and critical care Web sites. The 2 most recent clinically oriented blog posts published on these blogs were evaluated with gestalt, the Academic Life in Emergency Medicine Approved Instructional Resources (ALiEM AIR) score, and the METRIQ-8 score. Volunteer raters (including medical students, emergency medicine residents, and emergency medicine attending physicians) were identified with a multimodal recruitment methodology. The Social Media Index was calculated in February 2016, November 2016, April 2017, and December 2017. Pearson's correlations were calculated between the Social Media Index and the average rater gestalt, ALiEM AIR score, and METRIQ-8 score. Results A total of 309 of 330 raters completed all ratings (93.6%). The Social Media Index correlated moderately to strongly with the mean rater gestalt ratings (range 0.69 to 0.76) and moderately with the mean rater ALiEM AIR score (range 0.55 to 0.61) and METRIQ-8 score (range 0.53 to 0.57) during the month of the blog post's selection and for 2 years after. Conclusion The Social Media Index's correlation with multiple quality evaluation instruments over time supports the hypothesis that it is associated with overall Web site quality. It can play a role in guiding individuals to high-quality resources that can be reviewed with critical appraisal techniques.

We evaluated hospitalized patients with a history of methicillin-resistant Staphylococcus aureus (MRSA) for persistent colonization and need for contact precautions. Up to 3 daily cultures of nares, skin, and any present wounds were compared with a single nasal polymerase chain reaction (PCR) assay. Most patients (76.2%) were no longer colonized with MRSA. A single PCR assay was sufficient to exclude persistent colonization and environmental contamination and remove the contact precautions.

To describe the incidence of difficult and failed intubations in obstetric patients during a 6 year period monitored by a quality assurance program together with American Society of Anesthesiologists Physical Status (ASA PS) scores, and obesity (body mass index30 kg/mFollowing Institutional Review Board approval, data about obstetric patients who experienced unanticipated difficult or failed intubations from 2010 to 2015 was obtained from the quality assurance database of a large, community-based anesthesiology group practice. The database employs standardized definitions for difficult intubation (3 laryngoscopic attempts by experienced providers) and failed intubation (inability to intubate leading to surgical airway or waking up the patient). ASA PS scores and comorbidities were also identified for obstetric general anesthetics using an internally developed quality assurance program, Quantum Clinical Navigation System.There were 2802 obstetric general anesthetics in the database of which 1085 (38.7%) were deemed as emergencies. There were no cases of failed intubation and seven cases of unanticipated difficult intubations (1:400 cases, 0.25% of all obstetric general anesthetics, 95% confidence interval 0.1-0.5%), six of which occurred during emergency surgery. There was an increase in obesity (p = .003) and ASA PS (p = .02) over the period of the study. The incidence of difficult intubation was not found to be significantly changed (p = .68).Despite an increase in ASA PS score and obesity, there was no increase in the incidence of difficult intubation in obstetric patients. Limitations of the study include its retrospective design, and the small number of difficult intubation cases identified.

Study objective Open educational resources such as blogs are increasingly used for medical education. Gestalt is generally the evaluation method used for these resources; however, little information has been published on it. We aim to evaluate the reliability of gestalt in the assessment of emergency medicine blogs. Methods We identified 60 English-language emergency medicine Web sites that posted clinically oriented blogs between January 1, 2016, and February 24, 2016. Ten Web sites were selected with a random-number generator. Medical students, emergency medicine residents, and emergency medicine attending physicians evaluated the 2 most recent clinical blog posts from each site for quality, using a 7-point Likert scale. The mean gestalt scores of each blog post were compared between groups with Pearson's correlations. Single and average measure intraclass correlation coefficients were calculated within groups. A generalizability study evaluated variance within gestalt and a decision study calculated the number of raters required to reliably (>0.8) estimate quality. Results One hundred twenty-one medical students, 88 residents, and 100 attending physicians (93.6% of enrolled participants) evaluated all 20 blog posts. Single-measure intraclass correlation coefficients within groups were fair to poor (0.36 to 0.40). Average-measure intraclass correlation coefficients were more reliable (0.811 to 0.840). Mean gestalt ratings by attending physicians correlated strongly with those by medical students (r=0.92) and residents (r=0.99). The generalizability coefficient was 0.91 for the complete data set. The decision study found that 42 gestalt ratings were required to reliably evaluate quality (>0.8). Conclusion The mean gestalt quality ratings of blog posts between medical students, residents, and attending physicians correlate strongly, but individual ratings are unreliable. With sufficient raters, mean gestalt ratings provide a community standard for assessment.

Total joint arthroplasty (TJA) is one of the most successful operations. There is little in the literature regarding weight change following TJA, particularly in a young cohort.Retrospective analysis of 181 primary total hip arthroplasty (THA) and 185 primary total knee arthroplasty (TKA) patients was conducted. We reviewed preoperative and post-operative weights and post-operative body mass index at 3 and 6 months, 1 year, 2 and 3 years. We evaluated expected versus actual weight gain, and performed subgroup analyses of obese versus non-obese patients and active duty versus civilian patients. We used a minimal clinically meaningful weight change from baseline of ≥5%.One hundred and fifty-one (41.3%) patients were active duty military service members with the mean age of 53 ± 11.1 years. In TKA patients, statistically significant differences were found in mean weights at 3 months (-1.8%, P ≤ 0.0001) and 2 years (+1.9%, P = 0.0006). In THA patients, statistically significant weight gains were found at 6 months (+1.1%, P = 0.006). For obese TKA patients, significant weight changes were observed at 3 months (-2.5%, P ≤ 0.0001), and none in the obese THA group. There were no statistical or clinically meaningful weight changes in the non-obese TKA or THA groups. There was a clinically meaningful weight gain in active duty TKA patients at 3 years (5.18%, P = 0.17).Despite a theoretical ability to lose weight following TJA, patients maintain their preoperative weight following TJA. We found a clinically meaningful weight gain at 3 years post-operatively only in active duty TKA patients. Overall, however, we found no clinically significant weight changes following TJA at 3-year follow-up.

The incidence of metastatic lymph node involvement in prostate cancer has decreased with the advent of prostate specific antigen testing. Various algorithms have been designed to assess the probability of lymphatic involvement, resulting in the omission of lymph node dissection in many cases. However, recent reports suggest an underestimation of lymph node involvement. Meticulous lymph node dissection may provide a survival benefit by addressing micrometastatic disease. We analyzed the current literature on extended pelvic lymphadenectomy in prostate cancer.The pelvic lymphadenectomy literature was reviewed using a MEDLINE search, focusing on the prevalence of positive nodes, staging vs extended lymphadenectomy and therapeutic benefits.Staging pelvic lymphadenectomy provides valuable prognostic data and it may be therapeutic. Extended lymph node dissection increases the detection of positive nodes. The number of positive or negative nodes resected may increase survival. The observed survival benefits may be due to the elimination of micrometastatic disease.The role, indications and extent of lymphadenectomy remain controversial. Extended lymph node dissection should be performed in all patients at high risk to increase staging accuracy and provide a potential survival benefit. Detailed, meticulous dissection of the internal iliac lymph tissue is required. The benefit of extended lymph node dissection in patients at low risk remains to be determined.

Cerebrovascular deposition of the amyloid beta-protein (A beta) is a common pathologic event in patients with Alzheimer's disease (AD) and certain related disorders including hereditary cerebral hemorrhage with amyloidosis Dutch-type (HCHWA-D). A beta deposition occurs primarily in the medial layer of the cerebral vessel wall in an assembled fibrillar state. These deposits are associated with several pathological responses including degeneration of the smooth muscle cells in the cerebral vessel wall. Severe cases of cerebrovascular A beta deposition are also accompanied by loss of vessel wall integrity and hemorrhagic stroke. Although the reasons for this pathological consequence are unclear, altered proteolytic mechanisms within the cerebral vessel wall may be involved. Recent studies from our laboratory have shown that cell-surface assembly of A beta into fibrillar structures causes cellular degeneration via an apoptotic pathway and creates an altered proteolytic microenvironment on the cell surface of human cerebrovascular smooth muscle cells (HCSM cells). For example, HCSM cell-surface A beta fibrils serve as a site for tight binding of cell-secreted amyloid beta-precursor protein (A beta PP). Since A beta PP is a potent inhibitor of key proteinases of coagulation cascade, its enhanced localization on the A beta fibrils would provide an strong anticoagulant environment. In addition, HCSM cell-surface A beta fibrils are potent stimulators of tissue plasminogen activator (tPA) creating a profibrinolytic milieu. Our findings indicate that A beta fibril assembly on the HCSM cell surface causes cellular degeneration and results in both a strong anticoagulant and fibrinolytic environment. Together, these altered proteolytic events could create a setting that is conducive to loss of vessel wall integrity and hemorrhagic stroke.

To evaluate the safety of tubeless percutaneous nephrolithotomy in patients undergoing supracostal percutaneous renal access.Between October 1999 and October 2010, 302 patients underwent percutaneous nephrolithotomy via a supracostal access tract. Two hundred forty-eight (82.1%) patients had a nephrostomy tube placed at the end of the case and 54 (17.9%) did not. The medical records of both cohorts were compared regarding patient demographics (age, sex, body mass index, preoperative creatinine level), operative characteristics (estimated blood loss, length of stay, treatment efficacy), and complication rates (overall, thoracic, hemorrhage necessitating transfusion).Patient demographics did not differ between the tubeless and nephrostomy tube groups. Estimated blood loss was significantly less in the tubeless patients (67 mL vs 123 mL; P=0.019). The tubeless group had a shorter mean length of stay than the nephrostomy tube group (2.5 vs 3.4 days, P0.01). Treatment success was comparable between the two groups (tubeless 81.5% vs nephrostomy tube 77.8%; P=0.553). Overall complication (P=0.765) and blood transfusion (P=0.064) rates were equivalent. Chest complications were higher in the tubeless group (22.2%) compared with the nephrostomy tube patients (10.9%) (P=0.024). Nevertheless, chest complications necessitating intervention were not different (P=0.152).Tubeless supracostal percutaneous nephrolithotomy was associated with less intraoperative blood loss and a shorter hospital stay. Although the tubeless group experienced more chest complications overall, the need for intervention was no different among the two cohorts. Tubeless supracostal percutaneous nephrolithotomy appears safe.

Objectives To report 8 cases using the Yang-Monti channel with ileum for adult continent cutaneous urinary diversion. Methods From 2004 to 2006, 108 patients underwent urinary diversion, 8 of whom had a continent cutaneous reservoir using the Yang-Monti principle. Channels were created by transversely retubularizing 2 to 3 cm of ileum. Indications, technique, complications, and outcomes, such as continence and ease of channel catheterization, are reported. Results Five patients underwent a right colon reservoir urinary reconstruction after extirpative surgery. Orthotopic neobladders were not performed, owing to anatomic or oncologic concerns. Two additional patients underwent an augmentation, with 1 undergoing an Indiana pouch revision. All urinary reservoirs but 1 were connected to the umbilicus. Two strictures occurred, which were treated with in-office dilation. Incontinence was identified in 2 patients and successfully treated with dextran microspheres injections. All patients were continent at final follow-up. Seven patients continue to perform intermittent catheterization, and 1 patient is managed with an indwelling catheter, owing to comorbidities. Conclusions The Yang-Monti channel using ileum is an alternative as a neo-appendicoumbilicostomy in construction of continent cutaneous urinary diversion. The channel is surgically versatile and can be used in the creation of a right colon pouch when the appendix is unavailable.

An algorithm was developed for performing bilateral nephrectomies for specific indications before or at renal transplantation in patients with autosomal dominant polycystic kidney disease. Outcomes for the living donor arm of the algorithm are reported.Patients with autosomal dominant polycystic kidney disease and end stage renal disease were evaluated for transplantation. Patients with recurrent pyelonephritis, hemorrhage, pain, early satiety or kidneys that extended into the true pelvis underwent bilateral nephrectomies. Bilateral nephrectomies with concurrent renal transplantation were performed if a living renal donor was identified. If no living donor was identified, pre-transplantation bilateral nephrectomies were done and the patients were listed for cadaveric donor renal transplantation. The living renal donor arm of the algorithm was evaluated by comparing certain parameters for 15 and 17 patients with autosomal dominant polycystic kidney disease who underwent pre-transplantation and concurrent bilateral nephrectomies, respectively, including patient and graft survival, delayed graft function, graft function, length of stay for each surgery, transfusions and complications.No deaths, graft failures or delayed graft function occurred. In the delayed renal transplant group median time from nephrectomy to living donor transplantation was 124 days. Serum creatinine at discharge home and 1 year after transplantation for the pre-transplantation nephrectomy cohort was 2.0 and 1.3 mg/dl, respectively. Seven of the 17 patients with concurrent nephrectomy underwent transplantation before starting renal replacement therapy. A longer mean total hospital stay in the pre-transplantation nephrectomy cohort was the only statistically significance outcome variable.Selective bilateral nephrectomies at living donor renal transplantation results in decreased total length of stay without compromising patient or graft outcomes and it allows preemptive renal transplantation. Concurrent nephrectomy is safe and it further validates the algorithm for selective, concurrent bilateral nephrectomies for patients with autosomal dominant polycystic kidney disease who undergo living donor renal transplantation.

Targeting of cyclooxygenase-2 (COX-2) for cancer chemoprevention is well supported for several tumor types, most notably colon cancer. In contrast, the data for its role in prostate cancer carcinogenesis are correlative only. Thus, we compared the COX-2 expression, activity, and effects of inhibition in prostate cancer cells on COX-2-dependent colon cancer cells. COX-2 levels in benign and malignant human prostate tissue were determined by immunohistochemistry. Compared to colon cancer cells, prostate cancer cells expressed lower levels of COX-2, produced less PGE 2 , and were resistant to selective COX-2 inhibition. Examination of benign prostatic epithelium from prostatectomy samples demonstrated rare foci of COX-2. Whereas, human prostate cancer sections were uniformly negative for COX-2. In conclusion, these studies indicate the lack of a putative role for COX-2 in prostate cancer development. Direct evidence for the involvement of COX-2 in prostate cancer carcinogenesis is desperately needed.

A 66-year-old man with androgen-independent prostate cancer was treated with abarelix, a gonadotropin-releasing hormone antagonist, for 20 weeks in an experimental protocol. He did not respond to therapy, but his serum prostate-specific antigen level dropped from 15.8 ng/mL to a confirmed 0.8 ng/mL after abarelix was stopped. His prostate-specific antigen level did not return to greater than 15.8 ng/mL for 14 months. This is the first report of a withdrawal response after therapy with a gonadotropin-releasing hormone antagonist, a new class of agents for prostate cancer. Additional observations are needed to determine whether this is an isolated case or a harbinger of a more common phenomenon.