Botulinum toxin injection in the pediatric population with medically refractory neuropathic bladder

INTRODUCTION

Botulinum toxin injection (BTI) has been advocated as a second line therapy in management of neuropathic bladder in pediatric population for refractory patients to conventional medical management such as anticholinergics. The purpose was to review the safety and efficacy of BTI in children with neuropathic bladder refractory to conservative non-surgical measures. We hypothesized that BTI would be an effective alternative to bladder augmentation in certain patients but not all.

METHODS

We retrospectively identified 22 patients with neuropathic bladder due to any condition who underwent urologic BTI at our hospital since 2010. Multiple clinicopathologic variables were examined including the following: demographics, use of anticholinergics, the presence of anticholinergic refractoriness or intolerance, dosage of BTI, urodynamic variables, and continence status.

RESULTS

The mean patient age at time of BTI was 10 years with a follow up of 12 months. Indications for BTI were anti-cholinergic refractory (AR) urodynamic parameters and/or incontinence and anticholinergic intolerance (AI). Nearly all patients received 300 Units at BTI into detrusor. No complications occurred from BTI. Overall 54% had improved continence after the initial BTI whereas 45% had achieved complete continence between catheterizations. Cystometric capacity increased by 46% and maximum detrusor pressure decreased by 43% following initial BTI (See Table). 75% of AI patients were continent between CIC after BTI compared to 50% of AR patients (P = 0.002). The observed mean duration of clinical improvement after initial BTI was 4.6 months and four patients underwent repeat BTI. Pre BTI % of age expected bladder capacity Post BTI % of age expected bladder capacity % Improvement in Urodynamic Parameter P value Cystometric Capacity (mL) 227 60 331 87 46 0.008 Maximum Detrusor Pressure (cm H2O) 63 44 43 0.002 Compliance (mL/cm H2O) 4.3 8.8 104 0.001.

DISCUSSION

Our results are comparable to existing literature with respect to urodynamic parameters. The observed differences may be due to heterogenous patient population of various etiologies of neuropathic bladder and no uniform criteria to proceed with bladder augmentation. The AR patients in our cohort may have had a higher degree of bladder fibrosis which BTI would be less likely to impact and explain the differences in clinical response between AR and AI patients.

CONCLUSIONS

BTI is a safe and effective treatment option for pediatric patients with neuropathic bladder refractory to standard therapy. The degree of continence observed after BTI in our series was higher for AI rather than AR patients.

Risk factors associated with incident sexually transmitted infections in HIV-positive patients in the Australian HIV Observational Database: a prospective cohort study

OBJECTIVES

We established a subcohort of HIV-positive individuals from 10 sexual health clinics within the Australian HIV Observational Database (AHOD). The aim of this study was to assess demographic and other factors that might be associated with an incident sexually transmitted infection (STI).

METHODS

The cohort follow-up was from March 2010 to March 2013, and included patients screened at least once for an STI. We used survival methods to determine time to first new and confirmed incident STI infection (chlamydia, gonorrhoea, syphilis or genital warts). Factors evaluated included sex, age, mode of HIV exposure, year of AHOD enrolment, hepatitis B or C coinfection, time-updated CD4 cell count, time-updated HIV RNA viral load, and prior STI diagnosis.

RESULTS

There were 110 first incident STI diagnoses observed over 1015 person-years of follow-up, a crude rate of 10.8 [95% confidence interval (CI) 9.0-13.0] per 100 person-years. Factors independently associated with increased risk of incident STI included younger age [≥ 50 vs. 30-39 years old, adjusted hazards ratio (aHR) 0.4; 95% CI 0.2-0.8; P < 0.0001]; prior STI infection (aHR 2.5; 95% CI 1.6-3.8; P < 0.001), and heterosexual vs. men who have sex with men (MSM) as the likely route of exposure (aHR 0.2; 95% CI 0.1-0.6; P < 0.001).

CONCLUSIONS

In this cohort of individualsbeing treated with antiretroviral drugs, those who were MSM, who were 30-39 years old, and who had a prior history of STI, were at highest risk of a further STI diagnosis.

Training community-based primary care physicians in the screening and management of mental health disorders among Latino primary care patients

OBJECTIVE

To evaluate a quality improvement intervention to improve the screening and management (e.g., referral to psychiatric care) of common mental disorders in small independent Latino primary care practices serving patient populations of predominantly low-income Latino immigrants.

METHODS

In seven practices, academic detailing and consultation/liaison psychiatry were first implemented (Stage 1) and then supplemented with appointment scheduling and reminders to primary care physicians (PCPs) by clinic staff (Stage 2). Acceptability and feasibility were assessed with independent patient samples during each stage.

RESULTS

Participating PCP found the interventions acceptable and noted that referrals to language-matched specialty care and case-by-case consultation on medication management were particularly beneficial. The academic detailing and consultation/liaison intervention (Stage 1) did not significantly affect PCP screening, management or patient satisfaction with care. When support for appointment scheduling and reminders (Stage 2) was added, however, PCP referral to psychiatric services increased (P=.04), and referred patients were significantly more likely to follow through and have more visits to mental health professionals (P=.04).

CONCLUSION

Improving the quality of mental health care in low-resourced primary care settings may require academic detailing and consultation/liaison psychiatric intervention supplemented with staff outreach to achieve meaningful improvement in the processes of care.

Toward a cultural adaptation of pharmacotherapy: Latino views of depression and antidepressant therapy

Relative to non-Latino Whites, Latinos in the United States with major depressive disorder (MDD) show low engagement in antidepressant therapy, whether engagement is defined as pharmacotherapy access, medication initiation, pill-taking, or treatment retention. One potential reason for this disparity in depression care is the low cultural congruence of pharmacotherapy for this population. To examine Latinos' views of depression and antidepressant therapy, we conducted qualitative interviews with 30 Latino outpatients initiating antidepressants prior to their first treatment visit using the semistructured Treatment Adherence and Retention Questionnaire. These baseline interviews were randomly selected from data collected for a randomized controlled trial testing a novel intervention to enhance engagement by depressed Latino outpatients. Participant narratives were analyzed using open coding and the iterative analytical approach derived from grounded theory. Patient views about depression addressed stigmatizing views held by others in their social circle. Most participants directly refuted these views by providing alternate explanations to depression experiences. Antidepressant therapy narratives also revealed marked stigmatization, but participants tended not to refute these views. Instead, patients expressed concerns about antidepressants and showed marked ambivalence about seeking psychiatric care. Participants, however, did suggest ways in which clinicians and patients might collaborate to address their concerns about antidepressants. Some cultural views, such as concerns about addiction to or dependence on medication, may be negotiable barriers to treatment. Prescribing clinicians should address cultural views and concerns in order to improve Latino engagement in antidepressant therapy.

Time trends of baseline demographics and clinical characteristics of HIV infected children enrolled in care and treatment service in Dar es Salaam, Tanzania

BACKGROUND

Few studies have described time-based trends of clinical and demographic characteristics of children enrolling in HIV and AIDS care and treatment services. We present findings of a study that explored time-based trends of baseline characteristics among children enrolling into 26 public HIV care facilities in Dar es Salaam, Tanzania.

METHODS

Children enrolled between October 2004 and September 2011 was included in these analyses. The year of enrollment was used as the primary predictor of interest, and log linear and linear regressions model were used to analyze dichotomous and continuous variables respectively. P-values under 0.05 were considered significant.

RESULTS

Among the 6,579 children enrolled, the proportion with advanced disease at enrollment increased from 35% to 58%, mean age increasing from 5.0 to 6.2 years (p < 0.0001), proportion of children less than 2 years decreased from 35% to 29%. While the median hemoglobin concentration rose from 9.1 g/dl to 10.3 g/dl (P <0.0001), proportion with a history of past TB dropped from 25% to 12.8% (P < 0.0001). Over time, health centers and dispensaries enrolled more children as compared to hospitals (P < 0.0001). Temeke district, which has the lowest socioeconomic status among the three districts in Dar es Salaam, had a significant increase in enrollment from 22% to 25% (P = 0.02).

CONCLUSION

We found that as time progressed, children were enrolled in care and treatment services at an older age sicker status as evidenced by increase in mean age and more advanced disease stage at first contact with providers. We recommend more efforts be focused on scaling up early HIV infant diagnosis and enrollment to HIV care and treatment.

Aspen shaving versus chip bedding: effects on breeding and behavior

The choice of laboratory cage bedding material is often based on both practical and husbandry issues, whereas behavioral outcomes rarely appear to be considered. It has been noted that a breeding success difference appears to be associated with the differential use of aspen chip and aspen shaving bedding in our facility; therefore, we sought to analyze breeding records maintained over a 20-month period. In fact, in all four mouse strains analyzed, shaving bedding was associated with a significant increase in average weanlings per litter relative to chip bedding. To determine whether these bedding types also resulted in differences in behaviors associated with wellbeing, we examined nest building, anxiety-like, depressive-like (or helpless-like), and social behavior in mice housed on chip versus shaving bedding. We found differences in the nests built, but no overall effect of bedding type on the other behaviors examined. Therefore, we argue that breeding success, perhaps especially in more challenging strains, is improved on shaving bedding and this is likely due to improved nest-building potential. For standard laboratory practices, however, these bedding types appear equivalent.

A review of the evidence supporting the use of lithium augmentation therapy for the reduction of suicidal behavior in patients with unipolar depression: Revisiting an overlooked benefit of an older medication

Major depressive disorder is a serious, recurrent condition with significant impact on a person's quality of life and functioning, which carries a significant risk of premature death due to suicide. There is evidence that supports the effectiveness of lithium as an augmentation strategy for treatment-resistant depression, as well as for reducing suicidality in this population. This review introduces several theories regarding the proposed mechanism behind lithium's anti-suicidal effects and summarizes a selection of the pertinent literature supporting lithium's beneficial effects on suicidality.

Pulmonary hypertensive crisis following ethanol sclerotherapy for a complex vascular malformation

Anhydrous ethanol is a commonly used sclerotic agent for treating vascular malformations. We describe the case of a full-term 15-day-old female with a complex venolymphatic malformation involving the face and orbit. During treatment of the lesion with ethanol sclerotherapy, she suffered acute pulmonary hypertensive crisis. We discuss the pathophysiology of pulmonary hypertension related to ethanol sclerotherapy, and propose that hemolysis plays a significant role. Recommendations for evaluation, monitoring and management of this complication are also discussed.

Burden and Determinants of Severe Anemia among HIV-Infected Adults: Results from a Large Urban HIV Program in Tanzania, East Africa

BACKGROUND AND METHODS

This cross-sectional study aimed at determining the prevalence and risk factors for severe anemia, severe microcytic anemia, and severe normocytic anemia among HIV-infected individuals aged >15 years. Univariate and multivariate analyses were performed to identify the risk factors for anemia.

RESULTS

Data from 40 408 patients were analyzed, showing an overall prevalence of 22% for severe anemia. The risk of developing severe anemia increased by 49% among patients with a body mass index of <18.5 kg/m(2), by approximately 2-fold among patients with the World Health Organization (WHO) stage III, and by 3-fold among patients with WHO stage IV illness. Severe normocytic anemia was uniquely increased among patients aged ≥50 years, among those with chronic diarrhea and Kaposi's sarcoma, and those taking cotrimoxazole.

CONCLUSION

There was a high prevalence of severe anemia among adults infected with HIV. Focused identification of anemia should be based on the hemoglobin and mean corpuscular volume measurements.