Primary urethral squamous cell carcinoma: a unique manifestation of a penile tumor

This case report describes a unique manifestation of a primary urethral squamous cell carcinoma (SCC) as the underlying pathology in an 80-year-old male patient who underwent partial penectomy due to an enlarging penile mass. Persistent pain in the right knee was discovered to be a pathologic fracture using magnetic resonance imaging. Computed tomography-guided biopsy confirmed metastatic SCC. Whole-body positron emission tomography revealed systemic dissemination to multiple sites. Orthopedic knee replacement was performed in combination with local radiotherapy. Palliative chemotherapy was rejected due to poor performance status. Primary urethral SCC is rare and an uncommon cause of advanced penile cancer. These findings could be of great interest to clinicians for two reasons. First, a tumor’s appearance can be misleading. Consequently, histological work-up in accordance with clinical guidelines is necessary for accurate diagnosis. Second, a more comprehensive investigation is required when clinical symptoms persist despite the use of conventional treatment. Our case is an instance in which persistent pain masked the presence of downstream metastasis. We believe that these aforementioned points are of significant clinical importance and present a salient learning opportunity.

Protocol for a phase II, open-label exploratory study investigating the efficacy of fesoterodine for treatment of adult patients with spinal cord injury suffering from neurogenic detrusor overactivity for amelioration of autonomic dysreflexia

INTRODUCTION

Managing and preventing risk factors associated with cardiovascular and cerebrovascular impairment is well studied in able-bodied individuals. However, individuals with spinal cord injury (SCI) at or above the spinal segment T6 are prone to experience autonomic dysreflexia (AD) but also to suffer from neurogenic detrusor overactivity (NDO). Treatment of NDO would not only improve lower urinary tract function but could also reduce the severity and frequency of life-threatening episodes of AD. Fesoterodine, an antimuscarinic drug, has been successfully employed as a first-line treatment for detrusor overactivity in individuals without an underlying neurological disorder. Thus, our aim is to investigate the efficacy of fesoterodine to improve NDO and ameliorate AD in individuals with SCI.

METHODS AND ANALYSIS

This phase II, open-label exploratory, non-blinded, non-randomised, single-centre study will investigate the efficacy of fesoterodine to improve NDO and ameliorate AD in individuals with chronic SCI at or above T6. During screening, we will interview potential candidates (with a previous history of NDO and AD) and assess their injury severity. At baseline, we will perform cardiovascular and cerebrovascular monitoring (blood pressure (BP), heart rate and cerebral blood flow velocity) during urodynamics (UDS) and 24-hour ambulatory BP monitoring (ABPM) during daily life to assess severity and frequency of AD episodes (ie, maximum increase in systolic BP). The primary outcome is a reduction of artificially induced (during UDS) and spontaneous (during daily life) episodes of AD as a display of treatment efficacy. To answer this, we will repeat UDS and 24-hour ABPM during the last cycle of the treatment phase (12 weeks overall, ie, three cycles of 4 weeks each). At the end of each treatment cycle, participants will be asked to answer standardised questionnaires (AD symptoms and quality of life) and present bladder and bowel diaries, which will provide additional subjective information.

ETHICS AND DISSEMINATION

The University of British Columbia Research Ethics Boards (H15-02364), Vancouver Coastal Health Research Institute (V15-02364) and Health Canada (205857) approved this study. The findings of the study will be published in peer-reviewed journals and presented at national and international scientific meetings. This protocol adheres to the Standard Protocol Items: Recommendations for Interventional Trials and CONsolidated Standards Of Reporting Trials statements.

TRIAL REGISTRATION NUMBER

NCT02676154; Pre-results.

[The philosophical roots of "connectedness": The care clinic]

If suicide remains "the only really serious philosophical problem" (A. Camus), historically a certain number of philosophers have legitimized it while others have condemned it. Among the philosophers who admitted that suicide could be a possibility, some showed understanding and others remained more modest. Kierkegaard's philosophical stance, demonstrating that one can never decide for the other where existential problems are concerned, opens a third way. Following him, Michel Cornu coined the expression "ethics of concern". That restlessness, etymologically, can be understood at the same time at the epistemological level (lack of a single constituted knowledge, hence the need to resort to a fully interdisciplinary approach of the "suicide" object), but as a relational attitude as well, namely a restlessness vis-à-vis the other, in other words concern for the other. This concept of concern does not exist in philosophical literature as such, but it has been addressed by philosophers. Therefore, it is essential to begin with a differential reflection on the notions of concern, care and solicitude. Then three "philosophies of solicitude" will be developed, those of Heidegger (concern in itself), Ricœur (concern as reciprocity) and Levinas (concern as responsibility). The monitoring devices, which will be widely discussed in other articles of this special issue, are based on philosophical notions borrowed from Heidegger (thoughtful solicitude), or Ricœur (solicitude) and Levinas (responsibility) or Cornu (ethics of concern). In addition, throughout our text we have mentioned a certain number of tensions inherent to these notions themselves, such as that intrinsic to the term solicitude (both care and concern), or peculiar to the authors' work (substitutive solicitude - thoughtful solicitude for Heidegger), or related to the debate of ideas (solicitude for Ricœur - responsibility for Levinas). Implementing these monitoring devices in clinical practice as well as in the territories will raise other problems, in particular, between benevolence and monitoring, but also between justice and equity, which will be our conclusion.

The Determination of Antithrombin III

At III levels were measured with six methods in 36 people: 10 healthy controls, 10 women taking a progestagen Lynestrenol and 16 women taking a combined oestrogen-progestagen contraceptive pill.

The reproducibility and the sensitivity of these methods as well as the correlation between methods were studied.

The Hensen and Loeliger technique had a poor reproducibility and the results obtained with the Howie technique were not in good correlation with those obtained with the other methods, especially in the group taking oral contraceptives. The two amidolytic methods using chromogenic substrates were found to be very accurate for antithrombin III activity determination. The rocket Immunoelectrophoresis was more accurate and more practical than the radial immunodiffusion.

With all methods - except the one of Howie–the 10 women taking progestagen Lynestrenol and the 16 taking combined oestrogen-progestagen had a low AT III and differed significantly from the 10 normals tested. No difference was observed between women taking progestagen only or an oestrogen-progestagen combination.

The Activation of Plasma Factor XIII with the Snake Venom Enzymes Ancrod and Batroxobin Marajoensis

The snake venom enzymes Ancrod and Batroxobin marajoensis are able to activate human plasma factor XIII as shown by the formation of the γ-dimers. The concentration of γ-dimers increases with the concentration of the activating enzymes. Factor XIII activated by Ancrod or Batroxobin marajoensis is, however, unable to catalyse the incorporation of the amine dansylcadaverine into casein. The partially activated factor XIII is therefore not demonstrable by means of the artificial test system. This factor XIII loses little activity and remains activable by thrombin.

[French Society for Biological Psychiatry and Neuropsychopharmacology and Fondation FondaMental task force: Formal Consensus for the management of treatment-resistant depression]

Major depression represents among the most frequent psychiatric disorders in the general population with an estimated lifetime prevalence of 16-17%. It is characterized by high levels of comorbidities with other psychiatric conditions or somatic diseases as well as a recurrent or chronic course in 50 to 80% of the cases leading to negative repercussions on the daily functioning, with an impaired quality of life, and to severe direct/indirect costs. Large cohort studies have supported that failure of a first-line antidepressant treatment is observed in more than 60% of patients. In this case, several treatment strategies have been proposed by classical evidence-based guidelines from internationally recognized scientific societies, referring primarily on: I) the switch to another antidepressant of the same or different class; II) the combination with another antidepressant of complementary pharmacological profile; III) the addition of a wide range of pharmacological agents intending to potentiate the therapeutic effects of the ongoing antidepressant medication; IV) the association with appropriate psychological therapies; and, V) the use of non-invasive brain stimulation techniques. However, although based on the most recently available data and rigorous methodology, standard guidelines have the significant disadvantage of not covering a large variety of clinical conditions, while currently observed in everyday clinical practice. From these considerations, formalized recommendations by a large panel of French experts in the management of depressed patients have been developed under the shared sponsorship of the French Association of Biological Psychiatry and Neuropsychopharmacology (AFPBN) and the Fondation FondaMental. These French recommendations are presented in this special issue in order to provide relevant information about the treatment choices to make, depending particularly on the clinical response to previous treatment lines or the complexity of clinical situations (clinical features, specific populations, psychiatric comorbidities, etc.). Thus, the present approach will be especially helpful for the clinicians enabling to substantially facilitate and guide their clinical decision when confronted to difficult-to-treat forms of major depression in the daily clinical practice. This will be expected to significantly improve the poor prognosis of the treatment-resistant depression thereby lowering the clinical, functional and costly impact owing directly to the disease.

Influence of different surface treatments of poly(n-butyl acrylate) networks on fibroblasts adhesion, morphology and viability

BACKGROUND

Physical and chemical characteristics of implant materials determine the fate of long-term cardiovascular devices. However, there is still a lack of fundamental understanding of the molecular mechanisms occurring in the material-tissue interphase. In a previous study, soft covalently crosslinked poly(n-butyl acrylate) networks (cPnBA) were introduced as sterilizable, non-toxic and immuno-compatible biomaterials with mechanical properties adjustable to blood vessels. Here we study the influence of different surface treatments in particular oxygen plasma modification and fibrinogen deposition as well as a combinatorial approach on the adhesion and viability of fibroblasts.

MATERIAL AND METHODS

Two types of cPnBA networks with Young's moduli of 0.19±0.01 MPa (cPnBA04) and 1.02±0.01 MPa (cPnBA73) were synthesized and post-modified using oxygen plasma treatment (OPT) or fibrinogen coating (FIB) or a combination of both (OPT+FIB). The water contact angles of the differently post-treated cPnBAs were studied to monitor changes in the wettability of the polymer surfaces. Because of the key role of vascular fibroblasts in regeneration processes around implant materials, here we selected L929 fibroblasts as model cell type to explore morphology, viability, metabolic activity, cell membrane integrity as well as characteristics of the focal adhesions and cell cytoskeleton on the cPnBA surfaces.

RESULTS

Compared to non-treated cPnBAs the advancing water-contact angles were found to be reduced after all surface modifications (p < 0.05, each), while lowest values were observed after the combined surface treatment (OPT+FIB). The latter differed significantly from the single OPT and FIB. The number of adherent fibroblasts and their adherence behavior differed on both pristine cPnBA networks. The fibroblast density on cPnBA04 was 743±434 cells·mm-2, was about 6.5 times higher than on cPnBA73 with 115±73 cells·mm-2. On cPnBA04 about 20% of the cells were visible as very small, round and buckled cells while all other cells were in a migrating status. On cPnBA73, nearly 50% of fibroblasts were visible as very small, round and buckled cells. The surface functionalization either using oxygen plasma treatment or fibrinogen coating led to a significant increase of adherent fibroblasts, particularly the combination of both techniques, for both cPnBA networks. It is noteworthy to mention that the fibrinogen coating overruled the characteristics of the pristine surfaces; here, the fibroblast densities after seeding were identical for both cPnBA networks. Thus, the binding rather depended on the fibrinogen coating than on the substrate characteristics anymore. While the integrity of the fibroblasts membrane was comparable for both polymers, the MTS tests showed a decreased metabolic activity of the fibroblasts on cPnBA.

CONCLUSION

The applied surface treatments of cPnBA successfully improved the adhesion of viable fibroblasts. Under resting conditions as well as after shearing the highest fibroblast densities were found on surfaces with combined post-treatment.

Prediction of autonomic dysreflexia during urodynamics: a prospective cohort study

BACKGROUND

Autonomic dysreflexia is a severe and potentially life-threatening condition in patients with spinal cord injury, as it can lead to myocardial ischemia, brain hemorrhage, or even death. Urodynamic investigation is the gold standard to assess neurogenic lower urinary tract dysfunction due to spinal cord injury and reveal crucial pathological findings, such as neurogenic detrusor overactivity. However, neurogenic detrusor overactivity and urodynamic investigation are known to be leading triggers of autonomic dysreflexia. Therefore, we aimed to determine predictors of autonomic dysreflexia in individuals with spinal cord injury during urodynamic investigation.

METHODS

This prospective cohort study included 300 patients with spinal cord injuries and complete datasets of continuous non-invasive cardiovascular monitoring, recorded during same session repeat urodynamic investigation. We used logistic regression to reveal predictors of autonomic dysreflexia during urodynamic investigation.

RESULTS

We found that level of injury and presence of neurogenic detrusor overactivity were the only two independent significant predictors for autonomic dysreflexia during urodynamic investigation. A lesion at spinal segment T6 or above (odds ratio (OR) 5.5, 95% CI 3.2-9.4) compared to one at T7 or below, and presence of neurogenic detrusor overactivity (OR 2.7, 95% confidence interval (CI) 1.4-4.9) were associated with a significant increased odds of autonomic dysreflexia during urodynamic investigation. Both odds persisted after adjustment for age, sex, and completeness and stage of injury (adjusted OR (AOR) 6.6, 95% CI 3.8-11.7, and AOR 2.2, 95% CI 1.1-4.5, respectively). Further stratification by lesion level showed level-dependent significantly increased adjusted odds of autonomic dysreflexia, i.e., from C1-C4 (AOR 16.2, 95% CI 5.9-57.9) to T4-T6 (AOR 2.6, 95% CI 1.3-5.2), compared to lesions at T7 or below.

CONCLUSIONS

In patients with neurogenic lower urinary tract dysfunction due to spinal cord injury, autonomic dysreflexia is independently predicted by lesion level and presence of neurogenic detrusor overactivity. Considering the health risks associated with autonomic dysreflexia, such as seizures, stroke, retinal bleeding, or even death, we recommend both continuous cardiovascular monitoring during urodynamic investigation in all spinal cord-injured patients with emphasis on those with cervical lesions, and appropriate neurogenic detrusor overactivity treatment to reduce the probability of potentially life-threatening complications.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01293110 .

Autonomic Nervous System in Paralympic Athletes with Spinal Cord Injury

Individuals sustaining a spinal cord injury (SCI) frequently suffer from sensorimotor and autonomic impairment. Damage to the autonomic nervous system results in cardiovascular, respiratory, bladder, bowel, and sexual dysfunctions, as well as temperature dysregulation. These complications not only impede quality of life, but also affect athletic performance of individuals with SCI. This article summarizes existing evidence on how damage to the spinal cord affects the autonomic nervous system and impacts the performance in athletes with SCI. Also discussed are frequently used performance-enhancing strategies, with a special focus on their legal aspect and implication on the athletes' health.

Intermittent Catheterization: The Devil Is in the Details

During the last few years, the international community debated urinary tract infection and re-use of catheters when managing neurogenic lower urinary tract dysfunction (NLUTD) among individuals with spinal cord injury (SCI). In this respect, the 2014 Cochrane review by Prieto and colleagues, "Intermittent catheterisation for long-term bladder management," became one of the leading documents that captured the minds and attention of clinicians around the world. Although numerous countries had switched to single-use catheters for management of NLUTD following SCI, the opinion that was expressed in the 2014 Cochrane review had a strong influence on healthcare providers and agencies to recommend re-use of catheters. However, many clinicians have expressed concern regarding the conclusions in the 2014 Cochrane review by Prieto and colleagues. We therefore conducted an independent appraisal of the data and analyses presented in the review. Our appraisal identified crucial discrepancies of data extraction and analyses within the review. In appraisal to that of Prieto and colleagues' review, our analysis revealed a trend to favor single over multiple use of catheters. After addressing our concerns to Cochrane's acting Editor-in-Chief, the most recent version of the 2014 Cochrane review was withdrawn from publication.

Functional connectivity changes following interpersonal reactivity

Attachment experiences substantially influence emotional and cognitive development. Narratives comprising attachment-dependent content were proposed to modulate activation of cognitive-emotional schemata in listeners. We studied the effects after listening to prototypical attachment narratives on wellbeing and countertransference-reactions in 149 healthy participants. Neural correlates of these cognitive-emotional schema activations were investigated in a 7 Tesla rest-task-rest fMRI-study (23 healthy males) using functional connectivity (FC) analysis of the social approach network (seed regions: left and right Caudate Nucleus, CN). Reduced FC between left CN and bilateral dorsolateral prefrontal cortex (DLPFC) represented a general effect of prior auditory stimulation. After presentation of the insecure-dismissing narrative, FC between left CN and bilateral temporo-parietal junction, and right dorsal posterior Cingulum was reduced, compared to baseline. Post-narrative FC-patterns of insecure-dismissing and insecure-preoccupied narratives differed in strength between left CN and right DLPFC. Neural correlates of the moderating effect of individual attachment anxiety were represented in a reduced CN-DLPFC FC as a function of individual neediness-levels. These findings suggest specific neural processing of prolonged mood-changes and schema activation induced by attachment-specific speech patterns. Individual desire for interpersonal proximity was predicted by attachment anxiety and furthermore modulated FC of the social approach network in those exposed to such narratives.

[French translation and validation of a short version of the Suicide Intervention Response Inventory-2 (SIRI-2-VF)]

OBJECTIVES

Training health professionals about suicidal crisis is one major line of suicide prevention worldwide. France has one of the highest suicide rates in Europe, and although crisis intervention training has been set up since 2001, there presently is no training assessment tool in the French language for health professionals trained in suicide prevention. In the four levels of Kirpatrick's education pyramid, training that takes place in France today solely assesses level one status, that is to say relative to the level of satisfaction of participants (self-report). This study proposes a validated short French version of the Suicide Intervention Response Inventory-2 (SIRI-2) of Neimeyer & Mc Innes. The SIRI-2 questionnaire assesses the ability of first line intervention in dealing with suicidal individuals.

METHODS

The translation methodology was inspired from Vallerand's model of cross-cultural back translation. This method is regularly used for translating from the English language to a French version. In order to translate the English version, we used an extensive 7-step methodology implicating several bilingual translators, expert reviewers (psychologists and psychiatrists) and a scientific committee. Participants were 107 students from different French universities and study programs: psychology, medicine and nursing (17 were men; average age was 26.6). Fifteen of these participants answered the SIRI-2-VF on two occasions (separated by a 15-day interval) in order to estimate the temporal stability of the instrument. The scores of the students were compared to six French experts in suicide prevention and with the original expert group who worked on the development of SIRI-2 (n=7). We used Student t Test for construct validity, Cronbach's Alpha for internal consistency and Pearson's correlation coefficient for temporal stability.

RESULTS

Following a fidelity comparison of the results of the French experts with those of the American experts, ten items presenting the least good fidelity were suppressed in order to obtain a short version of the SIRI-2 containing 15 questions (SIRI-2-VF). Statistical analyses of the short version (15 questions, SIRI-2-VF) showed good validity (difference between experts and subjects is significant: t=31.5, P<0.001) and reliability (good internal consistency: α=0.850 for positive statements and α=0.830 for negative statements, and a temporal stability: r=0.827, bilateral test, P<0.001).

CONCLUSIONS

This tool should improve the range of specific instruments in French suicidology adapted for French culture of suicide intervention. It is the first tool in France that reaches level 2a of Kirkpatrick's pyramid to assess clinical skills after training in suicidology.