Retrospective study of sacral neuromodulator implantations in a French hospital center: Lifespan and hospital costs assessment

PURPOSE

Sacral nerve neuromodulation (SNM) is a safe and effective therapy for the management of fecal and/or urinary incontinence. The generators InterStim™ and InterStim™ II (Medtronic™) are non-rechargeable active implantable medical devices with a limited lifespan. The aims of this study were to assess the generators' median lifespan for all indications and the long-term hospital costs of the therapy.

METHODS

This was a retrospective monocentric study that included 215 patients aged over 18 years who were treated by SNM for fecal incontinence and/or urinary incontinence. Lifespan was considered as the amount of time between definitive implantation and observed battery depletion by the surgeon and was assessed by the Kaplan-Meier method. Costs were assessed according to the activity-based pricing of the French public health care system.

RESULTS

The median observed lifetime of stimulators implanted in our center was 7.29 years and 5.9 years for InterStim™ and InterStim™ II, respectively. The difference observed between the two generations was statistically significant. The modelling of primary implantation and renewal costs allowed us to observe that the decrease in the lifetime of Interstim™ II is associated with an increase in hospital costs over time. The retrospective study design is one limitation and we did not take into consideration stimulation's settings.

CONCLUSIONS

The InterStim™ II lifespan is shorter than the first-generation device. This is associated with an increase of the long-term hospital costs. Additional information about the new neuromodulator will be required to choose the most appropriate IPG for the patient while optimizing the costs.

Early Exposure of Kidney Transplant Recipients with Chronic Antibody-Mediated Rejection to Tocilizumab-A Preliminary Study

Tocilizumab prevents clinical worsening of chronic antibody-mediated rejection (CAMR) of kidney transplant recipients. Optimization of this treatment is necessary. We identified the determinants of early tocilizumab exposure (within the first three months) and investigated the relationship between early plasma tocilizumab exposure and graft function. Patients with CAMR who started treatment with tocilizumab were retrospectively included. Demographic, clinical, and biological determinants of the tocilizumab trough concentration (Cmin) were studied using a linear mixed effect model, and the association between early exposure to tocilizumab (expressed as the sum of Cmin over the three first months (M) of treatment (ΣCmin)) and the urinary albumin-to-creatinine ratio (ACR) determined at M3 and M6 were investigated. Urinary tocilizumab was also measured in seven additional patients. Seventeen patients with 51 tocilizumab Cmin determinations were included. In the multivariate analysis, the ACR and time after tocilizumab initiation were independently associated with the tocilizumab Cmin. The ΣCmin was significantly lower (p = 0.014) for patients with an ACR > 30 mg/mmol at M3 and M6 than for patients with an ACR < 30 mg/mmol. Tocilizumab was detected in urine in only 1/7 patients. This study is the first to suggest that early exposure to tocilizumab may be associated with macroalbuminuria within the first six months in CAMR patients.

Relationship between hospital size and teaching status on outcomes for reverse shoulder arthroplasty

BACKGROUND

The use of reverse shoulder arthroplasty (RSA) continues to grow with expanding indications and increased surgeon awareness. Previous data for other lower extremity joint replacements indicate that high-volume centers have better outcomes, with lower complication rates, decreased length of stay, and complications for both hemiarthroplasty and total shoulder arthroplasty. The purpose of this study is to evaluate the effects of hospital size and setting on adverse events for RSA.

MATERIALS AND METHODS

The National Inpatient Sample database was queried for RSA performed using ICD-9 codes. Primary outcomes included length of stay (LOS), total hospital charges, discharge disposition, and postoperative complications. Odds ratios were used to assess the risk of inpatient postoperative complications.

RESULTS

A weighted national estimate of 24,056 discharges for patients undergoing RSA was included in the study. Patients at larger hospitals experienced higher total charges, increased average LOS, and slightly higher complication rates compared to those of small and medium hospitals. Patients in larger hospitals had significantly increased rates of genitourinary and central nervous system complications, while patients in small/medium hospitals experienced higher rates of hematoma/seroma.

CONCLUSION

Results from this study indicate that large and non-teaching hospitals overall tend to burden the patients with higher hospital charges, longer hospital stay, and more frequent non-routine discharges. Also, larger hospitals are associated with higher risk of genitourinary and central nervous system complications rates, whereas non-teaching hospitals are associated with lower risk of infection and higher risk of anemia after RSA. With the growth in RSA in the USA, continued attention needs to be placed on improving outcomes and resource utilization for RSA patients even in larger hospitals.

CAEV: Vorläufige Ergebnisse eines alternativen Protokolls zur Kontrolle der CAE in einem Ziegenbetrieb der Rasse »Passeirer Gebirgsziege«

Gegenstand und Ziel: In der vorliegenden Arbeit wird über ein alternatives Protokoll zur Kontrolle der CAE berichtet, das die Gegebenheiten des Betriebes (hohe Seroprävalenz, seltene Ziegenrasse mit hohem Zuchtwert, gemeinsame Alpung) berücksichtigte. Das Ziel war, die Krankheit bzw. die klinischen Symptome zurückzudrängen und das hohe genetische Potenzial dieser Ziegenherde möglichst zu erhalten. Material und Methode: Die Neugeborenen wurden vom Muttertier getrennt und mit Rinderkolostrum/-milch aufgezogen. Im Alter von fünf bis sechs Monaten hatten sie auf der Weide Kontakt zu den Adulten. Seropositive Tiere wurden nicht a priori geschlachtet. Ziegen mit geringem Zuchtwert wurden verkauft oder geschlachtet, jene mit hohem Zuchtwert wurden so lange wie möglich in der Herde belassen. Ergebnisse und Schlussfolgerung: Obwohl eine Infektion erwartungsgemäß nicht verhindert werden konnte, blieben die Krankheitsfälle bis dato aus. Im vorliegenden Betrieb dürfte eine aerogene und sexuelle Übertragung eine nicht unerhebliche Rolle gespielt haben. Das hohe genetische Potenzial dieser Ziegenherde ließ sich weitgehend erhalten. Klinische Relevanz: Bei der Erstellung eines »Sanierungsmodells« müssen Ziel, Wille und Ausdauer des Besitzers und das Umfeld mitberücksichtigt werden. Die beschriebene Methode scheint zum derzeitigen Zeitpunkt als geeignet, wenn der Betrieb überdurchschnittlich wertvolle Ziegen hält, die Seroprävalenz bereits hoch ist und die benachbarten Ziegen einen unbekannten serologischen Status aufweisen. Eine erneute Beurteilung zu einem späteren Zeitpunkt ist gewiss erforderlich. Die Nachteile umfassen die Viruspersistenz und den großen Arbeitsaufwand durch die jährliche mutterlose Aufzucht der Neugeborenen.

Pedunculated liposarcoma of the esophagus

Polypoid tumours of the esophagus present diagnostic and therapeutic problems. Liposarcomas are infrequent among them. We report a recent case. A 73-year-old male patient was seen in May 1995 in the Ear, Nose and Throat (ENT) Department, Clinica Modelo de Morón, with intermittent dysphagia and dyspnoea due to recurrent vomiting. A laryngeal lineal tomography showed a subglottic obstruction due to extrinsic compression. The patient was referred to the Gastroenterology Department, where an upper gastrointestinal (upper GI) series demonstrated mega-esophagus with abundant retained food. Endoscopy showed a large intraluminal mass covered by normal mucosa which arose on the posterior wall. Videofluoroscopy and chest CT diagnosed a probable polypoid lipoma due to its densitometric characteristics. The tumour was resected by left cervicotomy and left esophagotomy. The patient's progress to date is favourable. Pathology studies showed a well-differentiated liposarcoma. According to the literature, the first case was reported in 1983, and ours is only the seventh case in the world to be documented.

The effect of deltoid lengthening on functional outcome for reverse shoulder arthroplasty

PURPOSE

Reverse shoulder arthroplasty (RSA) is based on the biomechanical advantages of lengthening the deltoid while medializing its center of rotation (COR). Little evidence exists describing the clinical benefits of these biomechanical advantages. The purpose of this study is to assess the relationship between deltoid lengthening and medialization of the COR with functional outcomes for RSA patients.

METHODS

We retrospectively reviewed patients treated with primary RSA. Radiographic measurements of deltoid length and COR, assessment of forward elevation (FE) and external rotation (ER), and functional outcome scores were obtained pre- and postoperatively. Linear regression analyses were performed to assess the relationship between these radiographic measurements and changes in shoulder functionality.

RESULTS

On average, patients improved significantly in function and functional outcome scores. Postoperative COR correlated weakly with postoperative FE. There were weakly negative correlations between increase in acromion to greater tuberosity distance and postoperative FE, and between deltoid lengthening and FE improvement.

CONCLUSIONS

Our results suggest that deltoid lengthening does not correlate with improvements in active FE or ER. These findings could indicate that change in deltoid length is less important than previously thought. Furthermore, the negative correlations seen could indicate that there is over-tensioning of the deltoid in specific cases. Further studies are needed to better assess the role of deltoid length and other factors that may impact RSA outcomes.

Ease-of-use protocol for the rapid detection of third-generation cephalosporin resistance in Enterobacteriaceae isolated from blood cultures using matrix-assisted laser desorption ionization-time-of-flight mass spectrometry

An ease-of-use protocol for the identification of resistance against third-generation cephalosporins in Enterobacteriaceae isolated from blood culture bottles was evaluated using matrix-assisted laser desorption ionization-time-of-flight mass spectrometry. A cefotaxime hydrolysis assay from chocolate agar subcultures using antibiotic discs and without inoculum standardization was developed for routine work flow, with minimal hands-on time. This assay showed good performance in distinguishing between cefotaxime-susceptible and cefotaxime-resistant strains, with excellent results for Escherichia coli (sensitivity 94.7%, specificity 100%). However, cefotaxime resistance was not detected reliably in Enterobacteriaceae expressing AmpC genes or carbapenemase-producing Klebsiella pneumoniae.

Immunohistochemical analysis of the hypothalamic-pituitary-adrenal axis in dogs: Sex-linked and seasonal variation

This study evaluated sexual dimorphism and seasonal variations in corticotrophs and adrenal zona fasciculata in dogs, as well as the expression of oestrogen receptor alpha (ERα). An immunohistochemical analysis was conducted in pituitaries for ACTH and in adrenal glands for ERα and for the melanocortin-2-receptor (MC2R) in winter and summer. Double immunofluorescence was performed to identify ERα in corticotrophs. Females had a greater proportion of corticotrophs per field (p<0.01), with a greater cellular area and optical density (p<0.001) than males. Optical density of corticotrophs was greater in winter for both sexes (p<0.001). In zona fasciculata, ERα and MC2R expression was greater in females (p<0.001) and was greater in winter (p<0.001). ERα was identified in corticotrophs. This study is the first to demonstrate ERα expression in corticotrophs and the adrenal cortex in dogs, providing evidence for sexual dimorphism and seasonal variations.

Fertilization defects in sperm from Cysteine-rich secretory protein 2 (Crisp2) knockout mice: implications for fertility disorders

STUDY HYPOTHESIS

We hypothesize that fertility disorders in patients with aberrant expression of Cysteine-RIch Secretory Protein 2 (CRISP2) could be linked to the proposed functional role of this protein in fertilization.

STUDY FINDING

Our in vivo and in vitro observations reveal that Crisp2-knockout mice exhibit significant defects in fertility-associated parameters under demanding conditions, as well as deficiencies in sperm fertilizing ability, hyperactivation development and intracellular Ca(2+) regulation.

WHAT IS KNOWN ALREADY

Testicular CRISP2 is present in mature sperm and has been proposed to participate in gamete fusion in both humans and rodents. Interestingly, evidence in humans shows that aberrant expression of CRISP2 is associated with male infertility.

STUDY DESIGN, SAMPLES/MATERIALS, METHODS

A mouse line carrying a deletion in the sixth exon of the Crisp2 gene was generated. The analyses of the reproductive phenotype of Crisp2(-/-) adult males included the evaluation of their fertility before and after being subjected to unilateral vasectomy, in vivo fertilization rates obtained after mating with either estrus or superovulated females, in vitro sperm fertilizing ability and different sperm functional parameters associated with capacitation such as tyrosine phosphorylation (by western blot), acrosome reaction (by Coomassie Blue staining), hyperactivation (by computer-assisted sperm analysis) and intracellular Ca(2+) levels (by flow cytometry).

MAIN RESULTS AND THE ROLE OF CHANCE

Crisp2(-/-) males presented normal fertility and in vivo fertilization rates when mated with estrus females. However, the mutant mice showed clear defects in those reproductive parameters compared with controls under more demanding conditions, i.e. when subjected to unilateral vasectomy to reduce the number of ejaculated sperm (n = 5; P< 0.05), or when mated with hormone-treated females containing a high number of eggs in the ampulla (n ≥ 5; P< 0.01). In vitro fertilization studies revealed that Crisp2(-/-) sperm exhibited deficiencies to penetrate the egg vestments (i.e. cumulus oophorus and zona pellucida) and to fuse with the egg (n ≥ 6; P< 0.01). Consistent with this, Crisp2-null sperm showed lower levels of hyperactivation (n = 7; P< 0.05), a vigorous motility required for penetration of the egg coats, as well as a dysregulation in intracellular Ca(2+) levels associated with capacitation (n = 5; P< 0.001).

LIMITATIONS, REASONS FOR CAUTION

The analysis of the possible mechanisms involved in fertility disorders in men with abnormal expression of CRISP2 was carried out in Crisp2 knockout mice due to the ethical and technical problems inherent to the use of human gametes for fertilization studies.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings in mice showing that Crisp2(-/-) males exhibit fertility and fertilization defects under demanding conditions support fertilization defects in sperm as a mechanism underlying infertility in men with aberrant expression of CRISP2. Moreover, our observations in mice resemble the situation in humans where fertility disorders can or cannot be detected depending on the accumulation of own individual defects or the fertility status of the partner. Finally, the fact that reproductive defects in mice are masked by conventional mating highlights the need of using different experimental approaches to analyze male fertility.

STUDY FUNDING AND COMPETING INTERESTS

This study was supported by the World Health Organization (H9/TSA/037), the National Research Council of Argentina (PIP 2009-290), the National Agency for Scientific and Technological Promotion of Argentina (PICT 2011, 2023) and the Rene Baron Foundation to P.S.C. and by the MEXT of Japan to M.I. The authors declare that there are no conflicts of interest.

Topical use of phytotherapic cream (Capilen® cream) to prevent radiodermatitis in breast cancer: a prospective historically controlled clinical study

AIM

The purpose of this study was to evaluate the ability of a topical phytotherapic product (Capilen® cream) to limit acute radiodermitis and delay the use of corticosteroids in patients with breast cancer (BC).

METHODS

From January 2012 to August 2012, 30 consecutive patients, undergoing radiotherapy with adjuvant intent, were invited to use Capilen® cream two times daily two weeks before and during radiotherapy. An historical group was used as an external control. Acute skin toxicity was scored weekly according to RTOG/EORTC criteria. Time of occurrence of acute skin toxicity was taken as endpoint.

RESULTS

Compliance was good. Overall, no significative statistical difference was observed in rate of acute radiation dermatitis, 46.7% in experimental arm versus 63.3% in the historical control group, although only 3.3% of Capilen® cream treated patients had a G3 acute radiation dermatitis versus 10% of the control group. A delay in the onset of radition dermatitis in patients treated with Capilen® cream (P=0.04) was showed.

CONCLUSION

Our findings suggested that Capilen® cream plays a role in reducing acute radiation dermatitis in breast cancer patients treated with adjuvant radiotherapy. Further evidence is needed to confirm these results.

309 MORPHOMETRICAL ANALYSIS OF THE LAMA GLAMA SPERM HEAD

During the last decades, the interest in breeding South American Camelids has increased, not only as companion animals but also for their high- quality fiber. Although several studies have been carried out on artificial insemination in Lama glama, this technique has not been widely applied in reproductive programs, principally due to the difficulty in collecting raw semen from males and the lack of knowledge about freezing/thawing techniques and semen characteristics. The aim of the present study was to objectively characterize llama sperm morphometry by a computer-assisted system, thereby increasing the knowledge on male llama physiology, leading to further developement of reproductive biotechnologies such as artificial insemination. Five semen samples were obtained by electroejaculation from each of 8 males, 6- to 10-year-old llamas of proven fertility. Smears were prepared from each sample and stained with Tinción 15® (Biopur S.R.L., Rosario, Argentina) and observed at x 1000 magnification. Images of sperm heads were captured by a Leica DC180 camera (Leica Microsystems Co., Wetzlar, Germany), obtaining 200 images from each sample. Binary images were obtained and area, length, width, equivalent circle diameter, curve length, curve width, perimeter, convex perimeter, roundness, and elongation were measured using QWin Plus (Leica Microsystems Co.). A total of 8005 sperm heads were measured. Descriptive statistics of the complete population was performed, with the following results obtained (mean ± SD): area (μm2) 20.09 ± 0.6, length (μm) 6.6 ± 0.3, width (μm) 4.14 ± 0.1, equivalent diameter ((μm) 5.06 ± 0.1, curve length (μm) 5.8 ± 0.3, curve width (μm) 3.48 ± 0.3, perimeter (μm) 18.54 ± 0.1, convex perimeter (μm) 17.34 ± 0.3, roundness 1.28 ± 0.04, and elongation 1.6 ± 0.01. Coefficients of variation were between 0.47 and 8.72%. A design considering the male as a fixed factor and the ejaculate as a nested factor was used for the purpose of identifying differences in morphometry between ejaculates of the same male and/or between males. Normality was tested using the Kolmogorov test. Significant differences between ejaculates of some males were found for curve length, curve width, perimeter, roundness, and elongation (P < 0.05). There were no intra-male differences for sperm head area, length, width, equivalent circle diameter, and convex perimeter. Of the parameters, there were significant differences between males for sperm area, length, equivalent circle diameter, and convex perimeter (P < 0.05). The differences found in sperm morphometry confirm the great polymorphism observed when subjectively evaluating llama semen morphology and make the establishment of a single pattern of normal llama sperm morphometry impossible.