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Robot-assisted nephroureterectomy (RANU) is the primary treatment for upper tract urothelial carcinoma (UTUC) at our hospital for patients with clinical stage less than T2, and for patients with invasive tumours, but unfit for major surgery.To assess peri-operative conditions and outcomes of RANU at our unit, and to evaluate the safety of the procedure.The medical records of all 166 patients undergoing RANU for suspected UTUC and followed for more than three months in a large university hospital in Sweden were reviewed retrospectively. After the exclusion of twenty patients because of previous cystectomy, simultaneous surgical procedure, or other tumour types than UTUC in the pathological report, 146 patients remained for the analyses. The primary endpoint was complication rate according to Clavien-Dindo at 90 days. Secondary endpoints were perioperative bleeding, violation of oncological surgical principles, hospital stay, and re-admission within 90 days.The median age was 75 [(Inter Quartile Range) IQR 70-80] years and 57% of the patients had an ASA score above 2. According to Clavien-Dindo, one patient had a grade 3 complication, and no patient had a grade 4-5 complication. The median blood loss was 50 (IQR 20-100) ml and the median hospital stay was 6 (IQR 5-7) days. Twelve patients were re-admitted to the hospital within 90 days (eight with urinary tract infection/haematuria, one with hematoma, and three with other diseases).Robot-assisted nephroureterectomy is a safe procedure for patients with upper tract urothelial carcinoma, with a low risk of major surgical complications.

Nonalcoholic fatty liver disease (NAFLD) is a global public health problem. However, the natural history of NAFLD is incomplete. This is a retrospective cohort study of patients identified with NAFLD by diagnosis codes in a large, community-based health care delivery system. The objectives were (1) to follow patients from initial NAFLD presentation through progression to cirrhosis and/or decompensated cirrhosis to liver cancer, liver transplant, and death for up to 10 years; and (2) to conduct disease progression analysis restricted to patients with NAFLD identified as having diabetes at baseline. A total of 98,164 patients with full NAFLD and 26,488 with diabetes were divided into three baseline prevalent states: (1) no cirrhosis, (2) compensated cirrhosis, and (3) decompensated cirrhosis. In baseline patients without cirrhosis, annual rates of compensated cirrhosis, decompensated cirrhosis, and death were 0.28%, 0.31%, and 0.63% per year, respectively. With baseline compensated cirrhosis, the annual rates of decompensation and death were 2.4% and 6.7% per year. Finally, in those with decompensated cirrhosis at baseline, the death rate was 8.0% per year. In those without cirrhosis and with cirrhosis at baseline, the rates of liver cancer and death were increased approximately 2-fold in the diabetic subpopulation compared with the full NAFLD cohort. Age and comorbidities increased with increasing disease severity. Cox proportional hazards regression analysis showed that cirrhosis was strongly associated with death and liver cancer, and that diabetes was associated with a significant increase in the hazard of both liver cancer and death (2.56 [2.04-3.20] and 1.43 [1.35-1.52]), respectively. Conclusion: The findings of this community-based study further our understanding of the natural history of NAFLD and demonstrate that diabetes is a major factor in the progression of this disease.

Introduction. Hip fracture is a major cause of morbidity and mortality in older adults. Intertrochanteric hip fractures often are treated surgically using cephalomedullary nails (CMN), in either a short or long length. Their outcomes are documented in the literature; however, outcomes of the intermediate-length CMN have not been well described. Methods. A retrospective review was conducted of older adults with intertrochanteric hip fractures that were treated with cephalomedullary nail fixation using an intermediate-length (235 mm Synthes Trochanteric Fixation® nail or 240 mm Stryker Gamma 3®) nail. Outcome data were collected during the inpatient stay and 16 months post-operatively. Results. Seventy-seven patients met inclusion criteria and were reviewed during inpatient stay; however, only 42 had documented post-operative outcomes. Of those, two patients died post-discharge and were not included in the 16-month follow-up. Comparison of results to published literature suggested that intermediate-length nails are comparable to short-length nails with regard to time in the operating room and estimated blood loss. The rate of blood transfusion was lower and length of hospital stay was shorter than in comparable studies of both short- and long-length nails. There were no post-operative periprosthetic fractures in the 16-month follow-up. This rate was lower than published rates for short and long nails. The hardware failure rate (3/42, 7.1%) of intermediate-length nails was higher than comparison studies of both short- and long-length nails. Conclusions. Patient outcomes for intermediate-length nails were similar to outcomes of shorter length nails. Utilization of the intermediate-length nail appears to be an effective treatment option for repair of intertrochanteric femur fractures. However, direct comparison is difficult since periprosthetic fracture rate may increase over time and nail length and hardware failure are not defined consistently in the literature. Further study is needed with a larger sample size followed over a longer period of time to confirm our findings.

Introduction. All-terrain vehicles (ATVs) are associated with injury,mortality, and healthcare costs. ATV related injuries are less severewhen consistent safety practices are followed, however, ATV safetyregulations are varied among states. This study sought to surveyKansas ATV dealers and track owners to determine safety promotionpractices. Methods. A cross-sectional telephone survey was conducted ofKansas ATV dealers and tracks. Survey questions included promotionand sale of safety equipment, provision of ATV safety information,and respondent characteristics. Results. Of those contacted, 32% of dealers and 31% of tracksresponded to the survey. Most ATV dealers sell safety gear (70% -100%) and all recommend safety gear to buyers and riders. All ATVtracks reported requiring helmets (100%) but were varied regardingother forms of safety gear. The majority of ATV dealers (77%) recommendedsafety courses, but only 31% of dealers and 40% of tracksoffered courses. Eighty percent of ATV tracks and 52% of dealers feltthey had a professional responsibility to educate riders/owners onsafety. Conclusions. Safety promotion by ATV dealers in Kansas consistentlywas recommended, but often limited to the sales of safety gear(helmets and gloves) or the provision of manufacturer provided safetymaterials. Further, ATV dealers reported rarely offering skills tests orsafety courses to buyers. In Kansas, safety promotion at the point ofsale or track level could be improved to increase public awareness ofATV safety practices. KS J Med 2017;10(4):76-78.

PURPOSE: The demand for objective and outcome-based facts about surgical results after radical prostatectomy (RP) is increasing. Systematic feedback is also essential for each surgeon to improve his/her performance. METHODS: RP outcome data (e.g., pT-stage and margin status) have been registered at Sahlgrenska University Hospital (SUH) since 1988 and patient-related outcome measures (PROM) have been registered since 2001. The National Prostate Cancer Registry (NPCR) has covered all Regions in Sweden since 1998 and includes PROM-data from 2008. Initially PROM was on-paper questionnaires but due since 2018 all PROMs are collected electronically. In 2014 an on-line "dashboard" panel was introduced, showing the results for ten quality-control variables in real-time. Since 2017 all RP data on hospital, regional, and national levels are publicly accessible on-line on " www.npcr.se/RATTEN ". RESULTS: The early PROM-data from SUH have been used for internal quality control. As national clinical and PROM-data from the NPCR have been made accessible on-line and in real-time we have incorporated this into our pre-existing protocol. Our data are now internally available as real-time NPCR reports on the individual surgeons' results, as well as ePROM data. We can compare the results of each surgeon internally and to other departments' aggregated data. The public can access data and compare hospital level data on "RATTEN". CONCLUSIONS: The process of quality control of RP locally at SUH, and nationally through the NPCR, has been long but fruitful. The online design, with direct real-time feedback to the institutions that report the data, is essential.

Pediatric weight or body mass index often is underestimated by providers when relying solely upon visual cues. This study sought to determine physician assistant (PA) students' and recent graduates' ability to accurately assess BMI for age in patients ages 3 to 5 years using visual cues.PA students and recent graduates visually assessed pictures of three children ages 3 to 5 years-one obese, one overweight, and one with healthy weight-for BMI categorization via online survey. Responses were scored for accuracy.Ninety-eight PA students and recent graduates completed the assessment. Accuracy for BMI categorization was low, especially in the obese and overweight children for visual assessment alone. Accuracy improved slightly when height and weight data were provided.PA student and recent graduate visual assessment for categorization of BMI is unreliable, similar to studies with other providers. PAs should be aware of discrepancy and not rely on visual assessment to determine weight-related interventions.

Introduction Sepsis is recognized as an often-lethal disease. Recommended guidelines are complex and time sensitive. Response teams (RTs) have demonstrated success in implementation of quality initiatives. The purpose of this study was to evaluate variations in noncompliance with recommended sepsis guidelines overall and between a sepsis-focused RT and standard care. Methods This retrospective chart review categorized septic patients based on treatment by a sepsis response team (SRT) versus standard care (non-SRT). Guideline compliance was based upon the Surviving Sepsis evaluation and treatment guidelines. Results Patient records for 123 identified septic patients post first-year implementation were evaluated. Overall, compliance rates were low and there were variations in compliance between the treatment providers. The SRT was more compliant than the non-SRT. SRT noncompliance was more often due to failure to achieve therapeutic goals within the recommended time. Mortality benefit was not statistically significant between groups; however mortality was higher in the non-SRT group. Conclusion Noncompliance is more complex than simple failure to initiate, especially in time-dependent therapies. The development and education of an RT demonstrates improvement in application of sepsis-focused therapies over standard care.

The results of a measurement of the proton structure function F_2(x,Q^2)and the virtual photon-proton cross section are reported for momentum transfers squared Q^2 between 0.35 GeV^2 and 3.5 GeV^2 and for Bjorken-x values down to 6 10^{-6} using data collected by the HERA experiment H1 in 1995. The data represent an increase in kinematic reach to lower x and Q^2 values of about a factor of 5 compared to previous H1 measurements. Including measurements from fixed target experiments the rise of F_2 with decreasing x is found to be less steep for the lowest Q^2 values measured. Phenomenological models at low Q^2 are compared with the data., Comment: 27 pages, 10 Figures

Background Tuberosity healing correlates with clinical outcomes after hemiarthroplasty for 4-part proximal humeral fractures (4PHFs). We seek to examine variables that affect tuberosity healing. Methods This was a retrospective comparative study. At 1 year postoperatively, patients who underwent hemiarthroplasty for 4PHFs were divided into 2 groups: those with anatomically healed tuberosities and those with tuberosity nonunion. The primary variables included time between injury and surgery, prosthesis fenestration, cement mantle classification, and both vertical and horizontal tuberosity reduction. Secondary demographic factors included age, gender, osteoporosis status, diabetes status, and smoking status. Results There were 84 individuals who met the inclusion criteria: 37 (44%) had anatomically healed tuberosities, and 47 (56%) did not. Individuals with anatomic healing had cement near or under the tuberosities 32% of the time, whereas individuals with nonunion or resorption had cement near the tuberosities 66% of the time ( P = .002). There was no association between tuberosity healing and fenestration of the humeral stem ( P = .84). Anatomic reduction between tuberosities was associated with healing ( P .001), whereas greater tuberosity–to–head height was not ( P = .25). There were no significant differences in age, osteoporosis status, smoking status, diabetes status, or time to surgery between groups. Male patients had nearly double the rate of healing ( P = .03). Discussion and Conclusion The classification and effect of cement technique on tuberosity healing have not previously been described. We suggest limiting cementation to a minimum of 5 mm below the level of the tuberosity fracture. The ideal candidate for hemiarthroplasty for a 4PHF is a male patient with anatomic tuberosity reduction and limited use of cement.

Cannulation of an artery for the purpose of monitoring a patient’s hemodynamic status is a common procedure in the critical care environment (Tiru and McGee, Anesth Clin Res 3(5):1000209, 2012; Mignini et al., Crit Care 10(2):R43, 2006; Cousins and O'Donnell, Aana J 72(4):267-71, 2004; Bowdle, Anesthesiol Clin North America 20(3):571-88, 2002). Continuous measurement of blood pressure through an arterial line is considered to be the most accurate measurement of systemic blood pressure and is the most common form of invasive monitoring (Tiru and McGee, Anesth Clin Res 3(5):1000209, 2012; Bowdle, Anesthesiol Clin North America 20(3):571-88, 2002). Advanced practice clinicians working in the ICU commonly perform arterial cannulation (Nyberg et al., JAAPA 23(1):35-7, 41, 2010) and therefore should have knowledge of indications and contraindications, relevant anatomy, technique, and potential complications from the procedure (Tiru and McGee, Anesth Clin Res 3(5):1000209, 2012; Tegtmeyer et al., N Engl J Med 354(15):e13, 2006).

Background and Aims: Previous studies have shown increased hepatic decompensation in patients with cirrhosis undergoing surgery. However, there are little data available in cirrhotics undergoing orthopedic surgery compared to cirrhotics who did not undergo surgery. The aim of this study was to examine the demographics, comorbid conditions, and clinical factors associated with hepatic decompensation within 90 days in cirrhotics who underwent orthopedic surgery. Methods: This is a retrospective matched cohort study. Inclusion criteria were cirrhosis diagnosis, age > 18 years, ≥ 6 months continuous health plan membership, and a procedure code for orthopedic surgery. Up to five cirrhotic controls without orthopedic surgery were matched on age, gender, and cirrhosis diagnosis date. Data abstraction was performed for demographics, socioeconomics, clinical, and decompensation data. Chart review was performed for validation. Multivariable analysis estimated relative risk of decompensation. Results: Eight hundred fifty-three orthopedic surgery cases in cirrhotics were matched with 4,263 cirrhotic controls. Among the cases and matched controls, the mean age was 60.5 years, and 52.2% were female. Within 90 days after surgery, cases had more decompensation compared to matched controls (12.8% vs 4.9%). Using multivariable analysis, orthopedic surgery, a 0.5 g/dL decrease in serum albumin, and a 1-unit increase in Charlson Comorbidity Index were associated with a significant increase in decompensation within 90 days of surgery. Diabetes, chronic obstructive pulmonary disease, and chronic kidney disease were seen with increased frequency in cases vs. matched controls. Conclusions: Cirrhotics who underwent orthopedic surgery had a significant increase in hepatic decompensation within 90 days of surgery compared to matched controls. An incremental decrease in serum albumin and an incremental increase in the Charlson Comorbidity Index were significantly associated with hepatic decompensation after surgery.

Research indicates patients want to discuss spirituality/religious (S/R) beliefs with their healthcare provider. This was a cross-sectional study of Kansas physician assistants (PA) regarding S/R in patient care. Surveys included questions about personal S/R beliefs and attitudes about S/R in patient care. Self-reported religious respondents agreed (92%) they should be aware of patient S/R; 82% agreed they should address it. Agreement with incorporating S/R increased significantly based on patient acuity. This research indicates Kansas PAs' personal S/R beliefs influence their attitudes toward awareness and addressing patient S/R.

This study consisted of a 28-day oral repeat dose (repeat dose toxicity [RDT]) phase and a developmental and reproductive (developmental and reproductive toxicity [DART]) phase with rats. Rats were treated with Dechlorane Plus at doses of 0, 750, 1500, or 5000 mg/kg by gavage. For the RDT phase, no effects were observed on in-life parameters or clinical or anatomic pathology. In the DART phase, no effects were observed on reproductive or fertility indices, or fetal development through lactation day (LD) 4. No effects were noted on gestation day (GD) 20 implantation data, fetal indices, or external and visceral examinations. Mortalities occurred across all dose groups, although these were gavage-related errors and not compound related. Microscopic evidence of gavage-related errors included adhesions, inflammation, and fibrosis in the thoracic and pleural cavities. These findings were not test article related as they were observed only in animals with evidence of gavage injury. The no-observable-effect level (NOEL) in both phases of study was 5000 mg/kg.

Immobilization of patients utilizing rigid spine boards (RSBs) is standard practice in the management of trauma patients. Pressure ulcers have been associated with prolonged immobilization, and the possibility exists that formation may begin when the patient is initially immobilized on the RSB. The effects may not be fully recognized because of limited research on the direct tissue effects of prolonged immobilization. Near-infrared spectroscopy is an emerging tool to measure peripheral tissue oxygen saturation (StO(2)). The purpose of this research was to study the effects of prolonged spinal immobilization on an RSB on sacral tissue oxygenation of healthy volunteers.This experimental study measured StO(2) in healthy volunteers at baseline and again after 30 minutes of immobilization on an RSB at two sites: the sacral area (intervention) and 8-10 cm above the buttocks (control). Tissue oxygenation was measured with the InSpectra Tissue Oxygenation Monitor (Hutchinson Technology, Hutchinson, MN) by placing the probe at the measurement site and waiting for 15 seconds for equilibration prior to recording StO(2). Data were analyzed utilizing mixed-model and within-subjects analysis of variance (ANOVA), chi-square, and t-tests.Seventy-three participants were included in the analysis. A slight majority of participants were female (55%), the average age was 38 years, the average height was 170 cm, and the average weight was 82 kg. There was a significant increase in the StO(2) percentage at the sacral (intervention) area following immobilization, p0.001, point biserial correlation (r(pb)) = 0.48. Significant changes in oxygenation were not noted at the control site.An increase in sacral tissue oxygenation following immobilization was a finding consistent with other research. This is likely a result of initial, rapid tissue reperfusion at the time of pressure release. Rapid reperfusion indicates that a period of previous hypoperfusion has occurred. This research indicates that there are detrimental effects of spine board immobilization in healthy volunteers, which suggests that pressure ulcer formation may begin prior to hospital admission with immobilization on an RSB.

Purpose Amitriptyline is frequently used to treat patients with interstitial cystitis/painful bladder syndrome. The evidence to support this practice is derived mainly from a small, single site clinical trial and case reports. Materials and methods We conducted a multicenter, randomized, double-blind, placebo controlled clinical trial of amitriptyline in subjects with interstitial cystitis/painful bladder syndrome who were naive to therapy. Study participants in both treatment arms received a standardized education and behavioral modification program. The drug dose was increased during a 6-week period from 10 up to 75 mg once daily. The primary outcome was a patient reported global response assessment of symptom improvement evaluated after 12 weeks of treatment. Results A total of 271 subjects were randomized and 231 (85%) provided a global response assessment at 12 weeks of followup. Study participants were primarily women (83%) and white (74%), with a median age of 38 years. In an intent to treat analysis (271) the rate of response of subjects reporting moderate or marked improvement from baseline in the amitriptyline and placebo groups was 55% and 45%, respectively (p = 0.12). Of the subgroup of subjects (207) who achieved a drug dose of at least 50 mg, a significantly higher response rate was observed in the amitriptyline group (66%) compared to placebo (47%) (p = 0.01). Conclusions When all randomized subjects were considered, amitriptyline plus an education and behavioral modification program did not significantly improve symptoms in treatment naive patients with interstitial cystitis/painful bladder syndrome. However, amitriptyline may be beneficial in persons who can achieve a daily dose of 50 mg or greater, although this subgroup comparison was not specified in advance.

No standard case definition exists for interstitial cystitis/painful bladder syndrome for patient screening or epidemiological studies. As part of the RAND Interstitial Cystitis Epidemiology study, we developed a case definition for interstitial cystitis/painful bladder syndrome with known sensitivity and specificity. We compared this definition with others used in interstitial cystitis/painful bladder syndrome epidemiological studies.We reviewed the literature and performed a structured, expert panel process to arrive at an interstitial cystitis/painful bladder syndrome case definition. We developed a questionnaire to assess interstitial cystitis/painful bladder syndrome symptoms using this case definition and others used in the literature. We administered the questionnaire to 599 women with interstitial cystitis/painful bladder syndrome, overactive bladder, endometriosis or vulvodynia. The sensitivity and specificity of each definition was calculated using physician assigned diagnoses as the reference standard.No single epidemiological definition had high sensitivity and high specificity. Thus, 2 definitions were developed. One had high sensitivity (81%) and low specificity (54%), and the other had the converse (48% sensitivity and 83% specificity). These values were comparable or superior to those of other epidemiological definitions used in interstitial cystitis/painful bladder syndrome prevalence studies.No single case definition of interstitial cystitis/painful bladder syndrome provides high sensitivity and high specificity to identify the condition. For prevalence studies of interstitial cystitis/painful bladder syndrome the best approach may be to use 2 definitions that would yield a prevalence range. The RAND Interstitial Cystitis Epidemiology interstitial cystitis/painful bladder syndrome case definitions, developed through structured consensus and validation, can be used for this purpose.

Objective: Census data published by professional organizations indicate an upward trend in the number of physician assistants (PAs) working in many specialty fields, including the subspecialty of trauma surgery. As the role of hospitalbased PAs and nurse practitioners (NPs) continues to evol

Aims of Study The Bladder Pain Syndrome Committee of the International Consultation on Incontinence was assigned the task by the consultation of reviewing the syndrome, formerly known as interstitial cystitis, in a comprehensive fashion. This included the topics of definition, nomenclature, taxonomy, epidemiology, etiology, pathology, diagnosis, symptom scales, outcome assessment, principles of management, specific therapies, and future directions in research. Study Design, Materials, Methods The emphasis was on new information developed since the last consultation 4 years previously. Where possible, existing evidence was assessed and a level of recommendation was developed according to the Oxford system of classification. Results The consultation decided to refer to the condition as “bladder pain syndrome” (BPS) because the designation is more descriptive of the clinical condition and better fits standard classification taxonomy. Reasonable definitions of BPS include the definition of the ESSIC European group and a slight modification made at a SUFU sponsored Miami meeting in early 2008. Males or females with pain, pressure, or discomfort that they perceive to be related to the bladder with at least one urinary symptom, such as frequency not obviously related to high fluid intake, or a persistent urge to void should be evaluated for possible BPS. The initial assessment consists of a frequency/volume chart, focused physical examination, urinalysis, and urine culture. Urine cytology and cystoscopy are recommended if clinically indicated. Treatment progresses from conservative management through various oral and intravesical therapies, with most surgical therapies reserved for unresponsive cases. Pain management is critical throughout the treatment process. The consultation believes that the disorder is best viewed as one of a group of chronic pain syndromes, rather than as primarily an inflammatory bladder disorder. Recommendations for future research pathways are suggested. Neurourol. Urodynam. 29: 191–198, 2010. © 2009 Wiley-Liss, Inc.

Background Benign prostatic hyperplasia (BPH), a common condition among older men, confers its morbidity through potentially bothersome lower urinary tract symptoms. Treatments for BPH include drugs such as alpha-adrenergic receptor blockers and 5-alpha reductase inhibitors, minimally invasive therapies that use heat to damage or destroy prostate tissue, and surgery including transurethral resection of the prostate. Complementary and alternative medicines are gaining popularity in the US. Two phytotherapies commonly used for BPH are extracts of the fruit of Serenoa repens, the Saw palmetto dwarf palm that grows in the Southeastern US, and extracts of the bark of Pygeum africanum, the African plum tree. Purpose The objective of the Complementary and Alternative Medicines for Urological Symptoms (CAMUS) clinical trial is to determine if phytotherapy is superior to placebo in the treatment of BPH. Methods CAMUS was originally designed as a 3300-participant, four-arm trial of S. repens, P. africanum, an alpha-adrenergic blocking drug, and placebo with time to clinical progression of BPH, a measure of long-term efficacy, as the primary endpoint. Before enrollment started, a randomized, double-blind, placebo-controlled, single institution clinical trial showed that S. repens at the usual dose did not demonstrate any benefit over placebo with respect to symptom relief at 1 year. Consequently, the focus of CAMUS shifted from evaluating long-term efficacy to determining if any short-term (6—18 months) symptom relief could be achieved with increasing doses of S. repens, the phytotherapy most commonly used in the US for BPH. Results Results are anticipated in 2011. Conclusions Trial design occurs in an environment of continually evolving information. In this case, emerging results from another trial suggested that a study of long-term efficacy was premature, and that an effective dose and preparation of S. repens had to be established before proceeding to a long-term clinical trial. Clinical Trials 2009; 6: 628—636. http://ctj.sagepub.com

Objectives To determine the feasibility of conducting a randomized clinical trial designed to compare two methods of manual therapy (myofascial physical therapy (MPT) and global therapeutic massage (GTM)) among patients with urologic chronic pelvic pain syndromes.

A survey of moulds and mycotoxins was performed on 99 rice samples taken from the Swedish retail market. The main objective was to study the mould and mycotoxin content in basmati rice and rice with a high content of fibre. Samples of jasmine rice as well as long-grain rice were also included. The samples were analysed for their content of ochratoxin A (high-performance liquid chromatography (HPLC)), aflatoxin B(1), B(2), G(1), and G(2) (HPLC, RIDA(R)QUICK), and mould (traditional cultivation methods in combination with morphological analysis). The majority of samples were sampled according to European Commission Regulation 401/2006. Subsamples were pooled and mixed before milling and both mould and mycotoxin analyses were performed on milled rice. The results showed that the majority of basmati rice (71%) and many jasmine rice samples (20%) contained detectable levels of aflatoxin B(1) (level of quantification = 0.1 microg aflatoxin kg(-1) rice). Two samples of jasmine rice and ten basmati rice samples contained levels over the regulated European maximum limits of 2 microg kg(-1) for aflatoxin B(1) or 4 microg kg(-1) for total aflatoxins. Aspergillus was the most common mould genus isolated, but also Penicillium, Eurotium, Wallemia, Cladosporium, Epicoccum, Alternaria, and Trichotecium were found. The presence of Aspergillus flavus in 21% of the samples indicates that incorrect management of rice during production and storage implies a risk of mould growth and subsequent production of aflatoxin. Rough estimates showed that high rice consumers may have an intake of 2-3 ng aflatoxin kg(-1) bodyweight and day(-1) from rice alone. This survey shows that aflatoxin is a common contaminant in rice imported to Europe.

OBJECTIVE Although diabetes is known to result in lower urinary tract symptoms (LUTS) in men, it remains unclear if glycemic control can mitigate urinary symptoms. We studied how diabetic characteristics are related to LUTS in the men who completed the urological assessment component (UroEDIC) of the Epidemiology of Diabetes Interventions and Complications (EDIC) follow-up study of the Diabetes Control and Complications Trial (DCCT) participants. RESEARCH DESIGN AND METHODS Study participants were men who completed the UroEDIC questionnaire at the year 10 DCCT/EDIC follow-up examination, which included data on genitourinary tract function and the American Urological Association Symptom Index (AUASI). Analyses were conducted to assess how treatment arm and diabetes characteristics were associated with LUTS using logistic regression. RESULTS Of the 591 men who completed the AUASI questions, nearly 20% (n = 115) had AUASI scores in the moderate to severe category for LUTS (AUASI score ≥8). No associations were observed between LUTS and treatment arm, or A1C levels at the DCCT baseline or end-of-study or at the year 10 EDIC (UroEDIC) examination. Of the diabetes complications studied, only erectile dysfunction at the UroEDIC examination was associated with LUTS. CONCLUSIONS These data from the UroEDIC cohort do not support the assumption that intensive glycemic control results in decreased lower urinary tract symptom severity in men with type 1 diabetes. This result may be due to a true lack of effect, or it may be due to other factors, for example, the relatively young age of the cohort.

ObjectiveOur goal is to determine if antimicrobial prophylaxis with trimethoprim/sulfamethoxazole prevents recurrent urinary tract infections and renal scarring in children who are found to have vesicoureteral reflux after a first or second urinary tract infection.Design, Participants, and MethodsThe Randomized Intervention for Children With Vesi-coureteral Reflux (RIVUR) study is a double-blind, randomized, placebo-controlled trial. Six hundred children aged 2 to 72 months will be recruited from both primary and subspecialty care settings at clinical trial centers throughout North America. Children who are found to have grades I to IV vesicoureteral reflux after the index febrile or symptomatic urinary tract infection will be randomly assigned to receive daily doses of either trimethoprim/sulfamethoxazole or placebo for 2 years. Scheduled follow-up contacts include in-person study visits every 6 months and telephone interviews every 2 months. Biospecimens (urine and blood) and genetic specimens (blood) will be collected for future studies of the genetic and biochemical determinants of vesicoureteral reflux, recurrent urinary tract infection, renal insufficiency, and renal scarring.ResultsThe primary outcome is recurrence of urinary tract infection. Secondary outcomes include time to recurrent urinary tract infection, renal scarring (assessed by dimercaptosuccinic acid scan), treatment failure, renal function, resource utilization, and development of antimicrobial resistance in stool flora.ConclusionsThe RIVUR study will provide useful information to clinicians about the risks and benefits of prophylactic antibiotics for children who are diagnosed with vesicoureteral reflux after a first or second urinary tract infection. The data and specimens collected over the course of the study will allow researchers to better understand the pathophysiology of recurrent urinary tract infection and its sequelae. Pediatrics 2008;122:240-250

Because of the frequency of urinary tract infections in children, off-label use of antimicrobial prophylaxis is often the usual treatment of children with vesicoureteral reflux, and such use is increasingly being called into question; hence, a definitive study to determine the value of antimicrobial prophylaxis with regard to the recurrence of urinary tract infection and the incidence of renal scarring is essential. The currently recommended follow-up procedures (repeated urine cultures, renal and genitourinary imaging, antimicrobial therapy and prophylaxis, as well as other factors including cleanliness, adequate bladder and bowel emptying, and compliance with protocols) are expensive (in terms of time, attention to detail, and cost) and cumbersome. Such recommendations should be evidence-based.

Aims The Urinary Incontinence Treatment Network (UITN) was established in 2000 as a multi-disciplinary, multi-institutional network by the National Institute for Diabetes, Digestive, and Kidney Diseases (NIDDK) to investigate treatments for urinary incontinence in women.

Purpose: In the present analysis we examined data from the MTOPS (Medical Therapy of Prostatic Symptoms) trial to determine the effect of long-term finasteride treatment, either alone or in combination with doxazosin, on total prostate volume across the full range of baseline total prostate volume values in men enrolled in this study.Materials and Methods: In this trial a total of 3,047 patients with lower urinary tract symptoms were randomized to placebo, doxazosin (4 to 8 mg), finasteride (5 mg) or the combination of doxazosin and finasteride (average length of treatment 4.5 years). Total prostate volume was measured by transrectal ultrasound in all patients at baseline, yearly and at study end or at termination of participation.Results: Long-term treatment with finasteride led to a consistent reduction of approximately 25% in total prostate volume compared to placebo in men with a relatively small prostate (less than 25 to 30 ml), as well as in those with a moderate size (30 to less than 40 ml) or enla...

Multislice computed tomography technology has enabled sophisticated insights into the evaluation of collateral venous pathways in the thorax. A small but well-established body of literature has described the multiple venous pathways in patients with central venous obstruction. In unusual circumstances, however, physiologically maladaptive pathways have been described involving systemic to pulmonary venous shunts. This paper describes 21 patients with systemic to pulmonary venous shunts having a wide spectrum of etiologies. Clinical presentations typically include cardiopulmonary symptomatology and paradoxical emboli. Ultrafast magnetic resonance and multislice computed tomography established the diagnosis of this uncommon but important entity.

We evaluated the longer term response in patients with interstitial cystitis who initially responded to intravesical bacillus Calmette-Guerin or placebo in a randomized clinical trial.Patients with interstitial cystitis who responded positively to treatment with bacillus Calmette-Guerin or placebo after 34 weeks of followup in a double-blind clinical trial were followed for an additional 34 weeks in an observational study to assess response durability. Outcomes at 68 weeks included a patient reported global response assessment, 24-hour voiding diary, and pain, urgency and validated interstitial cystitis symptom indexes.Of responders to bacillus Calmette-Guerin or placebo in the clinical trial 38 continued extended followup in the observational study. A total of 12 (75%) responders who received placebo and 19 (86%) who received bacillus Calmette-Guerin considered themselves to remain moderately or markedly improved at week 68. Improved symptom outcomes were also generally maintained during followup in the 2 groups.Most patients who respond to therapy with intravesical bacillus Calmette-Guerin or placebo maintain improved symptoms for up to 68 weeks after the initiation of therapy. However, initial response rates are low and placebo responders demonstrated essentially the same durability of response as bacillus Calmette-Guerin responders. These results argue against the routine use of bacillus Calmette-Guerin in this patient group.

We measured candidate urine biomarkers and bladder cell DNA cytometry in interstitial cystitis (IC) patients randomized to receive intravesical Bacillus Calmette Guerin (BCG) or placebo in a multicenter trial. Participants received 6 weekly instillations and were followed for 34 weeks. Urine was collected at baseline, prior to fourth treatment, and at study end. Antiproliferative factor (APF) activity was determined by 3H-thymidine incorporation assay; heparin-binding epidermal growth factor-like growth factor (HB-EGF) and epidermal growth factor-like growth factor (EGF) levels were determined by ELISA. Cellular DNA content was measured by image analysis to determine the mean hyperdiploid fraction (HDF) of the urine cell pellet. Associations between marker levels, and treatment or symptoms, were examined. Baseline APF positivity rate and mean levels of the other biomarkers were similar to previous smaller studies. During the week 34 follow-up, mean HDF decreased (P = 0.0003) and HB-EGF increased (P < 0.0001); both correlated weakly with decreased urgency. There was no difference in any biomarker between symptom responders and non-responders, but the percentage of responders was low and not significantly different for BCG versus placebo. APF positivity, decreased HB-EGF, increased EGF, and increased HDF were confirmed at baseline in IC patients. Changes in HDF and HB-EGF levels correlated weakly with changes in urgency, but the low BCG response rate prevented identification of additional associations between biomarker changes and treatment or symptoms.

Isotonic saline is a widely-used infusion fluid, although the associated chloride load may cause metabolic acidosis and impair kidney function in young, healthy volunteers. We wished to examine whether these effects also occurred in the elderly, and conducted a crossover study in 13 men with a mean age of 73 years (range 66-84), who each received intravenous infusions of 1.5 l of Ringer's acetate and of isotonic saline. Isotonic saline induced mild changes in plasma sodium (mean +1.5 mmol.l(-1) ), plasma chloride (+3 mmol.l(-1) ) and standard bicarbonate (-2 mmol.l(-1) ). Three hours after starting the infusions, 68% of the Ringer's acetate and 30% of the infused saline had been excreted (p0.01). The glomerular filtration rate increased in response to both fluids, but more after the Ringer's acetate (p0.03). Pre-infusion fluid retention, as evidenced by high urinary osmolality (700 mOsmol.kg(-1) ) and/or creatinine (7 mmol.l(-1) ), was a strong factor governing the responses to both fluid loads.

The U.S. Department of Energy (DOE) Energy Information Administration (EIA) projects nonhydro renewable electric energy increases of 140% and liquid transportation biofuels growing by 32,200 barrels a day between 2012 and 2040 (U.S. Energy Information Administration, 2014). This is the EIA base case scenario, and this outlook could be a low estimate depending on the many assumptions involved in making such projections, not the least of which are climate change and the resultant legislation. The climate change postulate is based on increasing levels of CO2 being introduced into the atmosphere through anthropogenic activity such as fossil fuel combustion for energy use. Renewable energy, and biomass conversion to energy in particular, is a net-zero CO2 emission generator. When biomass is converted to energy, it emits CO2; however, this CO2 is balanced in a cycle where the production of biomass removes CO2 from the atmosphere for growth and then releases it back into the atmosphere to be taken up by new growth of biomass feedstocks for energy. In comparison, fossil fuels are examples of CO2 that has been removed from the atmosphere and sequestered and which, when converted to energy, is a new addition to the atmospheric levels of CO2, which has more » been linked to climate change. While recent advances in technology used for extracting oil and gas from tight formations have increased the availability of fossil fuels for energy, the end game needs to focus on providing sustainable energy sources for the United States as well as the world. If, in the future, legislation is enacted that places a fee on atmospheric CO2 emissions, this may make the use of biomass for energy more economically attractive, increasing its use. Research that focuses on the future sustainability of energy production is part of the answer to bringing about game-changing technologies that can provide energy in a timely, reliable, sustainable fashion. « less

Cognitive/behavioral and environmental variables are significant predictors of patient adjustment in chronic pain. Using a biopsychosocial template and selecting several pain-relevant constructs from physical, cognitive/behavioral, and environmental predictors, outcomes of pain and disability in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) were explored. Men (n = 253) from a North American multi-institutional NIH-funded Chronic Prostatitis Cohort Study in 6 US and 1 Canadian centers participated in a survey examining pain and disability. Measures included demographics, urinary symptoms, depression, pain, disability, catastrophizing, control over pain, pain-contingent rest, social support, and solicitous responses from a significant other. Regressions showed that urinary symptoms (beta = .20), depression (beta = .24), and helplessness catastrophizing (beta = .29) predicted overall pain. Further, affective pain was predicted by depression (beta = .39) and helplessness catastrophizing (beta = .44), whereas sensory pain was predicted by urinary symptoms (beta = .25) and helplessness catastrophizing (beta = .37). With regard to disability, urinary symptoms (beta = .17), pain (beta = .21), and pain-contingent rest (beta = .33) were the predictors. These results suggest cognitive/behavioral variables (ie, catastrophizing, pain-contingent rest) may have significant impact on patient adjustment in CP/CPPS. Findings support the need for greater research of such pain-related variables in CP/CPPS.This article explores predictors of patient adjustment in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Cognitive/behavioral variables of catastrophizing and pain-contingent rest respectively predicted greater pain and disability. Catastrophic helplessness was a prominent pain predictor. These findings inform clinicians and researchers on several new variables in CP/CPPS outcomes and suggest future research.

OBJECTIVE—Diabetes is associated with increased risk of urinary incontinence. It is unknown whether women with pre-diabetes, or impaired fasting glucose (IFG), have increased prevalence of incontinence. We determined the prevalence of, and risk factors for, incontinence among U.S. women with diabetes and IFG. RESEARCH DESIGN AND METHODS—The 2001–2002 National Health and Nutrition Examination Survey measured fasting plasma glucose and obtained information about diabetes and urinary incontinence among 1,461 nonpregnant adult women. Self-reported weekly or more frequent incontinence, both overall and by type (urge and stress), was our outcome. RESULTS—Of the 1,461 women, 17% had diabetes and 11% met criteria for IFG. Prevalence of weekly incontinence was similar among women in these two groups (35.4 and 33.4%, respectively) and significantly higher than among women with normal fasting glucose (16.8%); both urge and stress incontinence were increased. In addition to well-recognized risk factors including age, weight, and oral estrogen use, two microvascular complications caused by diabetes, specifically macroalbuminuria and peripheral neuropathic pain, were associated with incontinence. CONCLUSIONS—Physicians should be alert for incontinence, an often unrecognized and therefore undertreated disorder, among women with diabetes and IFG, in particular those with microvascular complications. The additional prospect of improvements in their incontinence may help motivate some high-risk women to undertake difficult lifestyle changes to reduce their more serious risk of diabetes and its sequelae.

The general aspects of CO bonding in carbonyls and on metal surfaces are discussed in terms of a molecular orbital description, based on calculations and direct experimental measurements. In particular, the excellent agreement between experiment and theory for CO adsorbed on Ni(100) is the starting point to derive in the same theoretical approach the orbital-based electronic structure of the carbonyls Ni(CO) 4 , Fe(CO) 5 , Cr(CO) 6 and CO coordinated to the heme group. A frontier orbital interaction scheme involving only the 2π* and the 5σ orbitals is shown to be inadequate for the description of the electronic structure; all orbitals change due to the interaction. Instead, we demonstrate how the formation of an allylic configuration in the π-system, involving both the 1π and 2π* orbitals, gives a more complete description of the π electronic structure. The rearrangement of the σ orbitals involves mainly mixing of occupied CO and metal orbitals resulting in Pauli repulsion. The latter is minimized by polarization of charge away from the CO–Me bond. The bonding picture for CO in organometallic systems is very similar to the surface adsorption case; the main idea of repulsive σ and bonding π interactions seems generally valid when CO interacts with metals.

OBJECTIVE—Diabetes is associated with increased urinary incontinence risk. Weight loss improves incontinence, but exercise may worsen this condition. We examined whether an intensive lifestyle intervention or metformin therapy among overweight pre-diabetic women was associated with a lower prevalence of incontinence. RESEARCH DESIGN AND METHODS—We analyzed data from the Diabetes Prevention Program, a randomized controlled trial in 27 U.S. centers. Of the 1,957 women included in this analysis, 660 (34%) were randomized to intensive lifestyle therapy, 636 (32%) to metformin, and 661 (34%) to placebo with standard lifestyle advice. The main outcome measure was incontinence symptoms by frequency and type by a validated questionnaire completed at the end-of-trial visit (mean 2.9 years). RESULTS—The prevalence of total (stress or urge) weekly incontinence was lower among women in the intensive lifestyle group (38.3%) than those randomized to metformin (48.1%) or placebo (45.7%). This difference was most apparent among women with stress incontinence (31.3% for intensive lifestyle group vs. 39.7% for metformin vs. 36.7% for placebo, P = 0.006). Changes in weight accounted for most of the protective effect of the intensive lifestyle intervention on stress incontinence. CONCLUSIONS—Less-frequent urinary incontinence may be a powerful motivator for women to choose lifestyle modification to prevent diabetes.

We compared intravesical bacillus Calmette-Guerin (BCG) to placebo instillations in patients with treatment refractory interstitial cystitis (IC).Subjects who met the National Institutes of Health-National Institute for Diabetes and Digestive and Kidney Diseases criteria for IC, and reported at least moderate pain and frequency for a minimum of 6 months before study entry, were randomized to 6 weekly double-blinded intravesical instillations of either BCG or placebo, and then followed for a total of 34 weeks. The primary outcome was a patient reported global response assessment at week 34, supplemented with medications for IC during weeks 31 to 34. Secondary outcomes included a 24-hour voiding diary, pain, urgency, validated IC symptom indexes and adverse events. The target sample size was 260 participants, designed to detect a difference in response rates between placebo and BCG of 30% and 50%, respectively.A total of 265 participants were randomized and 17 (6%) patients withdrew from study. The response rates for the primary outcome were 12% for placebo and 21% for BCG (p = 0.062). Small improvements were observed for all secondary outcomes, some more so with BCG, but these differences were of borderline statistical significance. Although a large number of adverse events were reported in the BCG arm, there was no statistically significant difference between the treatment arms in overall adverse event rates.Although the BCG safety profile was acceptable, the response rate for the primary outcome was low. Effective medical treatment for patients with moderate to severe interstitial cystitis remains elusive.