A career exploration didactic and simulation-based session increases student knowledge in and exposure to urology

INTRODUCTION

Though urology attracts well-qualified applicants, students are not typically provided exposure to this smaller specialty until later in their medical education. While simulation-based training continues to supplement medical education, there is a lack of programming to teach specialty-specific procedural skills to medical students and those outside the specialty. We report a half-day simulation and didactic-based approach to increase exposure to urology to interested second-year medical students.

METHODS

A half-day didactic- and simulation-based session was offered to second-year medical students (N=57). After a didactic-based overview of the specialty performed by urology providers and a surgical educator, the students participated in small-group simulations, including hands-on simulations. The students completed a post-curriculum survey measuring knowledge gains and soliciting feedback on the session.

RESULTS

Students were 57.1% Caucasian, 66.7% female, with a mean age of 24.2 years; 80% stated they were potentially interested in pursuing a surgical specialty such as urology prior to the start of the session. Students reported pre- to post-curriculum gains in knowledge (mean=37%) about a career in urology and basic urologic procedures (p<0.001). Participants were also likely to recommend the curriculum to their peers (p<0.001).

CONCLUSIONS

Given that exposure to urology in medical school is usually limited and offered later in training, a half-day didactic- and simulation-based experience for second-year students provides an early introduction and experience within the specialty and its common bedside procedures.

What Is New in Neuromodulation?

Neuromodulation encompassing sacral and peripheral modalities is an established, effective, and safe higher-order treatment option approved in the USA for managing refractory overactive bladder, non-obstructive urinary retention, and fecal incontinence. This review highlights the most recent literature, indications, treatment durability, and the latest innovations in this field. Regarding sacral neuromodulation (SNM), recent work suggests improved parameters for optimal lead placement, increased data to support the lasting effects of treatment, and novel applications of this technology to other pelvic disorders. In addition, there are emerging technologies with smaller MRI compatible devices. Newer data on percutaneous tibial nerve stimulation (PTNS) suggests it may be more beneficial for certain patients. With new technology, implantable tibial nerve stimulators are ushering in a new frontier of nerve stimulation in the comfort of the patient's home.

Urologic applications of botulinum toxin

The neuromuscular blocker botulinum toxin has a wide variety of medical applications, including overactive bladder and neurogenic detrusor overactivity in patients in whom drug therapy fails or is not well tolerated. Botulinum toxin therapy for these conditions has been shown to be safe and effective in several large multicenter randomized controlled trials. Off-label uses in urology include detrusor external sphincter dyssynergia and pelvic pain syndromes.

Evaluation of patients' perceptions of mesh usage in female pelvic medicine and reconstructive surgery

OBJECTIVE

To evaluate if new patients presenting to a female pelvic medicine and reconstructive surgery clinic are aware of the US Food and Drug Administration (FDA) announcement regarding transvaginal mesh placement for pelvic organ prolapse repair and do they believe there is a mesh recall.

METHODS

A voluntary anonymous 25-question survey was administered to new-clinic patients. Participants were aged at least 18 years and had either urinary incontinence or pelvic organ prolapse. Appropriate statistical tests were performed for continuous and categorical variables. Logistic regression was used for univariate and multivariable analysis. Significance was considered for P values <.05.

RESULTS

Two hundred fourteen surveys were included for final analysis. Of the 214 patients, 157 (73.4%) had urinary incontinence as their sole presentation. Of 204 patients, 126 (61.8%) were aware the FDA-released information regarding mesh use in transvaginal surgery, and 88 of 169 (52%) believed there is a "recall" on mesh being used for transvaginal surgery. Of 156 patients, 108 (69.2%) listed television as a source of information. On multivariable analysis, television as a source was significantly associated with awareness of the FDA announcement (odds ratio, 7.12; 95% confidence interval, 2.69-18.84; P = .0001) and belief in a "recall" (odds ratio, 3.01; 95% confidence interval, 1.28-7.06; P = .01).

CONCLUSION

Although almost 2 of 3 participants were aware of the FDA announcement, more than half falsely believed there was a recall. Television was significantly associated with both awareness of the FDA announcement and belief in a recall suggesting patients derive most of their perceptions from the television.

Improved sexual and urinary function in women with sacral nerve stimulation

OBJECTIVES

  Urinary and sexual function improve following sacral nerve stimulation (SNS) for refractory overactive bladder. No significant associations between these changes have been found. Whether improvements in sexual function are independent of or secondary to improvements in urinary function remains unclear. The aim of this study was to analyze changes in urinary and sexual function in a homogeneous sample of patients undergoing SNS for urge urinary incontinence and subsequently identify associations between the two.

MATERIALS AND METHODS

  A prospective database was created. Enrollees underwent a full history and physical examination at the first office visit. Multiple-day voiding diaries with validated and investigator-designed questionnaires were administered at baseline and follow-up as standard implantation procedures and to assess changes in urinary and sexual function, respectively. Analyses were completed using data from patients who were sexually active at baseline and follow-up.

RESULTS

  Statistically significant improvements in urinary and sexual function occurred according to multiple metrics. Patient global impression scales categorized all patients' urinary conditions as improved, with most being less severe. Validated urinary symptom and quality of life scores improved significantly. After treatment, most patients were incontinent less often with sexual activity and felt less restricted from sexual activity by fear of incontinence. Validated quantification of sexual function demonstrated significant improvements in overall sexual function, arousal, and satisfaction. No significant associations between changes in urinary and sexual function were noted; however, trends appeared to exist between the two.

CONCLUSIONS

  Improved sexual function was not significantly associated with improved urinary function after SNS despite apparent trends between the two. Larger samples are required to definitively demonstrate this conclusion.

Cardiac allograft rejection correlates with increased expressions of Toll-like receptors 2 and 4 and allograft inflammatory factor 1

BACKGROUND

Evidence suggests that injury-induced activation of the recipient's innate immune response determines the outcome of allograft transplantation. The mechanism responsible for the induction of such innate immune response is not clear yet. We hypothesized that in cardiac transplantation settings, the initial myocardial ischemia and postischemia graft reperfusion may release allograft inflammatory factor (AIF) 1, causing Toll-like receptor (TLR)-mediated activation of macrophages and dendritic cells, leading to the production of cytokines and the activation of adaptive alloimmunity. Therefore, our goal was to validate the presence of these biomarkers in the peripheral blood and biopsy specimens of patients presenting allograft rejection.

METHODS

We studied 90 peripheral blood and 30 endomyocardial biopsy specimens from patients who had undergone cardiac transplantation. Specimens were tested by quantitative reverse-transcription polymerase chain reaction to determine TLR-2 and -4 and AIF-1 expression levels, correlating with clinical rejection grades. The group differences for mRNA transcript levels between the rejection grades were determined by 1-way analysis of variance. The level of significance was set at P < .05 for comparison between the groups.

RESULTS

The mean ± SEM level of TLR-2 mRNA expression was increased 1.7-fold in monocytes (P < .05) and 4.2-fold in biopsy samples from groups with grade 3A compared with grade 1A or grade 0 rejection (P < .0001). AIF-1 expression was increased 2.4-fold in monocytes (P < .05) and 4.2-fold in biopsy samples comparing grade 3A versus 1A rejections. The TLR-4 mRNA expression was also increased in the group with 3A rejections; however, the difference was only significant in biopsy specimens (P < .0001).

CONCLUSIONS

Our data demonstrated that expression profiles of AIF-1 and TLR-2 correlated with biopsy-proven allograft rejection in both peripheral blood and local tissue, suggesting their potential as diagnostic biomarkers for early detection of allograft rejection.

Fallopian tube prolapse presenting as a peritoneovaginal fistula

INTRODUCTION

Peritoneovaginal fistula is an extremely rare cause of persistent vaginal leakage following a hysterectomy. Likewise, fallopian tube prolapse is an uncommon but known complication of hysterectomy. Fallopian tube prolapse resulting in peritoneal leakage has yet to be reported in the literature.

CLINICAL CASE

A 27-year-old female presented with a two year history of continuous leakage per vagina. The leakage started shortly after an abdominal hysterectomy. Examination noted clear fluid emanating from a vaginal lesion located at the level of the vaginal cuff. An extensive workup ruled out vesicovaginal and ureterovaginal fistula. Surgical exploration noted that the lesion was a prolapsed fallopian tube, which was resected vaginally.

DISCUSSION

This is the first reported case of peritoneovaginal fistula associated with a prolapsed fallopian tube.

CONCLUSION

Vaginal resection of the fallopian tube remnant and reclosure of the vaginal cuff results in cure of the leakage.

The bladder epithelium and overactive bladder: What we know

Although the urothelium has been traditionally thought of as a passive barrier between urine and detrusor muscle, new studies have shown that the urothelium is a highly specialized structure involved in antigen presentation, micturition reflex, metabolic secretion, inflammatory regulation, and sensory afferent functioning. Data from several laboratories have shown that the urothelium can respond to thermal, mechanical, and chemical stimuli. The earlier findings (activation of urothelial transient receptor potential channel vanilloid 1 producing the second messenger nitric oxide, which in turn triggers suburothelial sensory nerves) demonstrate how the urothelium acts as a transducer, releasing chemicals that target adjacent bladder cells and sensory neurons. We now know that bladder urothelium acts also as a transducer whereby afferent neurons, via urothelial mechanoafferent transduction, are involved in the micturition process and the pathogenesis of bladder disorders. This paper highlights the important role that the urothelium has in bladder pathophysiology.

Role of prostate biopsy schemes in accurate prediction of Gleason scores

OBJECTIVES

To determine whether improved prostate sampling by the extended biopsy scheme also improves the accuracy of the biopsy Gleason score (bGS). Because most prostate cancer cases are now detected at an early stage with a low prostate-specific antigen level, the bGS may be the most important factor in therapeutic decision-making. Sextant biopsy schemes had poor correlation with prostatectomy Gleason scores. Extended prostate biopsies have replaced the sextant scheme because of the former's greater cancer detection rate.

METHODS

We identified 426 patients whose biopsy and prostatectomy specimens were reviewed at our center. To minimize the effect of stage migration, all patients before 1997 were excluded. Of the 426 included patients, 221 men had undergone sextant biopsy and 205 men extended biopsy before prostatectomy. The rate of grading concordance and the effect of different variables on the concordance rate was determined.

RESULTS

The overall accuracy of the extended and sextant schemes was 68% and 48% (P <0.001), respectively. Upgrading of the bGS was significantly less likely with the extended scheme (17% versus 41%, P <0.001). The sextant biopsy was more likely to be upgraded for a bGS of 6 or less (44% versus 25%, P <0.002) and a bGS of 7 (14% versus 3%, P <0.02). On multivariate analysis, the biopsy scheme was the only independent predictor of accurate Gleason scoring (P <0.001) and age, prostate-specific antigen level, digital rectal examination findings, prostate size, clinical stage, and number of positive cores were not.

CONCLUSIONS

The use of an extended prostate biopsy scheme significantly improves the correlation between the bGS and prostatectomy Gleason score and reduces the risk of upgrading to a worse Gleason group at prostatectomy.

PROGNOSTIC SIGNIFICANCE OF HIGH GRADE PROSTATIC INTRAEPITHELIAL NEOPLASIA AND ATYPICAL SMALL ACINAR PROLIFERATION IN THE CONTEMPORARY ERA

PURPOSE

High grade prostatic intraepithelial neoplasia (HGPIN) and atypical small acinar proliferation (ASAP) in the sextant biopsy had been associated with a high risk of prostate cancer. We determined whether the extended biopsy schemes used in the contemporary era have altered the prognostic value of these lesions at repeat biopsies.

MATERIALS AND METHODS

From 1998 to 2003, 105 of 1,188 men had at least 1 repeat extended biopsy due to the presence of HGPIN (33 men) or ASAP (72 men) in a previous extended biopsy. Median biopsy interval for HGPIN and ASAP was 15 and 10 weeks (p <0.05), respectively. Differences in cancer detection rates were analyzed using the Pearson chi-square test.

RESULTS

In the HGPIN group only 1 of 22 (4.5%) men had cancer on 1st repeat biopsy and 0 of 11 men had cancer on 2nd repeat biopsy. In men with ASAP 19 of 53 (36%, p <0.005) had cancer on 1st repeat biopsy, and 3 of 19 (16%) had cancer on 2nd repeat biopsy. Cancer was confined to a single core in 16 of 22 (73%) men. Median Gleason score was 6. Patient age, digital rectal examination status, prostate specific antigen, free prostate specific antigen, number of cores and biopsy interval were not independent predictors of cancer in men with ASAP.

CONCLUSIONS

HGPIN found in the contemporary extended biopsy does not warrant repeat biopsy. ASAP continues to be associated with a high risk of cancer and requires at least 1 repeat biopsy using the extended biopsy scheme.

Relationship of mass of obstructed rat bladders and responsiveness to adrenergic stimulation

PURPOSE

The effects of experimental partial bladder outlet obstruction on the bladder response to nerve stimulation and contractile agonists have been well characterized. Mildly obstructed bladders have small increases in mass and increased contractile responses to electrical field stimulation. More severely obstructed bladders become decompensated with large increases in mass and decreased functional responses. Little is known about relaxant mechanisms after obstruction. We investigated the relationship of the increase in rat bladder mass induced by outlet obstruction and responses to alpha and beta-adrenergic stimulation.

MATERIALS AND METHODS

Male Sprague-Dawley rats were divided into 3 groups, namely control, sham operated and obstructed. Surgical obstruction was done by tying a 2-zero silk ligature around the urethra. The ligature was placed around the urethra and removed in sham operated rats. At 2 and 6 weeks bladders from all groups were harvested, weighed and cut into strips. Contractile responses to electrical field stimulation and norepinephrine in the presence of propranolol were measured. Relaxant responses to norepinephrine and isoproterenol were measured after pre-contraction with KCl.

RESULTS

All strips from control and sham operated rats relaxed completely in response to norepinephrine. Obstructed bladders that weighed 2 to 3-fold more than control or sham operated bladders also relaxed. In contrast, bladders that were 5 to 10-fold heavier failed to relax by at least 50% in response to norepinephrine, independent of duration of bladder outlet obstruction. These were called nonresponders. Two week nonresponders relaxed completely in response to isoproterenol, but 6-week nonresponders did not, suggesting that the duration of decompensation is important. All nonresponders relaxed in response to pinacidil (Sigma-Aldrich Corp., St. Louis, Missouri). Nonresponders tended to contract in response to norepinephrine in the presence of propranolol. Strips from the other rats were less responsive, suggesting an increase in alpha1-receptors with decompensation. Contractile responses to field stimulation were increased in obstructed strips that relaxed to norepinephrine, while responses of nonresponders were decreased compared with controls and sham operated rats.

CONCLUSIONS

Severely obstructed bladders had an increase in mass and a decreased response to field stimulation, indicative of decompensation. This response was accompanied by decreased ability to relax to beta-agonists and an increased response to alpha-agonists. These changes were not seen in smaller, compensated bladders. Our findings suggest a change in detrusor alpha1 and beta-adrenergic receptor density. An increase in detrusor alpha-receptors may explain the clinical efficacy of alpha-blockers in alleviating irritative voiding symptoms in men with benign prostatic hyperplasia.

Relationship of mass of obstructed rat bladders and responsiveness to adrenergic stimulation

PURPOSE

The effects of experimental partial bladder outlet obstruction on the bladder response to nerve stimulation and contractile agonists have been well characterized. Mildly obstructed bladders have small increases in mass and increased contractile responses to electrical field stimulation. More severely obstructed bladders become decompensated with large increases in mass and decreased functional responses. Little is known about relaxant mechanisms after obstruction. We investigated the relationship of the increase in rat bladder mass induced by outlet obstruction and responses to alpha and beta-adrenergic stimulation.

MATERIALS AND METHODS

Male Sprague-Dawley rats were divided into 3 groups, namely control, sham operated and obstructed. Surgical obstruction was done by tying a 2-zero silk ligature around the urethra. The ligature was placed around the urethra and removed in sham operated rats. At 2 and 6 weeks bladders from all groups were harvested, weighed and cut into strips. Contractile responses to electrical field stimulation and norepinephrine in the presence of propranolol were measured. Relaxant responses to norepinephrine and isoproterenol were measured after pre-contraction with KCl.

RESULTS

All strips from control and sham operated rats relaxed completely in response to norepinephrine. Obstructed bladders that weighed 2 to 3-fold more than control or sham operated bladders also relaxed. In contrast, bladders that were 5 to 10-fold heavier failed to relax by at least 50% in response to norepinephrine, independent of duration of bladder outlet obstruction. These were called nonresponders. Two week nonresponders relaxed completely in response to isoproterenol, but 6-week nonresponders did not, suggesting that the duration of decompensation is important. All nonresponders relaxed in response to pinacidil (Sigma-Aldrich Corp., St. Louis, Missouri). Nonresponders tended to contract in response to norepinephrine in the presence of propranolol. Strips from the other rats were less responsive, suggesting an increase in alpha1-receptors with decompensation. Contractile responses to field stimulation were increased in obstructed strips that relaxed to norepinephrine, while responses of nonresponders were decreased compared with controls and sham operated rats.

CONCLUSIONS

Severely obstructed bladders had an increase in mass and a decreased response to field stimulation, indicative of decompensation. This response was accompanied by decreased ability to relax to beta-agonists and an increased response to alpha-agonists. These changes were not seen in smaller, compensated bladders. Our findings suggest a change in detrusor alpha1 and beta-adrenergic receptor density. An increase in detrusor alpha-receptors may explain the clinical efficacy of alpha-blockers in alleviating irritative voiding symptoms in men with benign prostatic hyperplasia.

Stretch-induced membrane type matrix metalloproteinase and tissue plasminogen activator in cardiac fibroblast cells

In the normal heart, cardiomyocytes are surrounded by extracellular matrix (ECM) and latent matrix metalloproteinases (MMPs), which are produced primarily by cardiac fibroblasts. An activator of latent MMPs might be induced by ischemic conditions or pressure-induced stretching. To test the hypothesis that an activator of latent MMP is induced in the ischemic heart during transformation of a compensatory hypertrophic response to a decompensatory failing response in cardiac fibroblast cells, we stretched the human cardiac fibroblasts at 25 cycles/min in serum-free or 5% serum culture condition. The membrane type (MT)-MMP activity in stretched cells was measured by zymography and immuno-blot analyses using MT-MMP-2 antibody. The MT-MMP activity was further characterized by transverse-urea gradient (TUG)-zymography. The results suggested that stretch induced a membrane MMP in the fibroblasts that was similar to the MT-MMP induced in ischemic heart. Furthermore, we observed that membrane MMP has distinct mobility in TUG-zymography. To localize the MT-MMP and tissue plasminogen activator (tPA) of latent MMPs, the membrane and cytosol were separated by a method employing a detergent and sedimentation. The MT-MMP and tPA activities of cytosol and membrane fractions were measured by gelatin- and plasminogen-zymography, respectively. Differential-display mRNA analysis was performed on control and stretched cells. In situ immuno-labelling was performed to localize the MT-MMP. The results indicate that induction of MT-MMP occurred in the membrane fractions. The secretion of tPA was elevated in the stretched cells. The MT-MMP activity was inhibited by prior incubation with an antibody generated to membrane MMP. The tPA activity was inhibited by using tPA antibody. These results suggest that, under stretched conditions, neutral transmembrane matrix proteinases are induced in the cardiac fibroblasts. This may lead to activation of adverse ECM remodeling, cardiac dilatation, and failure.

Treatment of end stage dilated cardiomyopathy

Patients should be referred for cardiac transplantation only after all other means of management of congestive heart failure have been attempted and have been unsuccessful (table 3). An adequate therapeutic trial of conventional and experimental agents including beta blockade and vesnarinone should be completed and be shown to be unsuccessful before transplantation is considered in patients in NYHA class III. Prospective clinical trials need to be completed to define the role of newer therapeutic options. The scarcity of donor organs will probably preclude the use of cardiac transplantation in all patients who may benefit. Alternative methods of cardiac replacement (such as dynamic cardiomyoplasty, permanent implantable mechanical circulatory assistance, and xenografting) must be developed. These methods coupled with better pharmacological treatment will greatly improve the outcome of patients with dilated cardiomyopathy.

Acute effects of dobutamine on myocardial oxygen consumption and cardiac efficiency measured using carbon-11 acetate kinetics in patients with dilated cardiomyopathy

OBJECTIVES

The aim of this study was to use positron emission tomography (PET)-derived carbon (C)-11 acetate kinetics to determine the effects of dobutamine on oxidative metabolism and its effects on myocardial efficiency in a group of patients with dilated cardiomyopathy.

BACKGROUND

Dobutamine is known to improve myocardial function but may do so at the expense of myocardial oxygen consumption, which could be a potential deleterious effect. Carbon-11 acetate kinetics correlate with myocardial oxygen consumption as shown in animal models. Combining these scintigraphic measurements of oxygen consumption with estimates of cardiac work results in a work-metabolic index, which reflects cardiac efficiency.

METHODS

Eight patients with nonischemic dilated cardiomyopathy underwent dynamic PET imaging, echocardiography and hemodynamic measurements. Seven of these patients were also studied while receiving dobutamine. Direct measurements of myocardial oxygen consumption using coronary sinus catheterization were obtained with eight of the PET studies to validate C-11 acetate in patients with cardiomyopathy.

RESULTS

The mean (+/- SD) C-11 clearance rate significantly increased with dobutamine from 0.105 +/- 0.027 to 0.155 +/- 0.023 min-1 (p = 0.001). Directly measured myocardial oxygen consumption had a linear relation to the mean C-11 clearance rate (r = 0.8, p = 0.018). Dobutamine was noted to significantly reduce systemic vascular resistance as well as the severity of mitral regurgitation. The work-metabolic index determined using hemodynamic variables and PET data increased from 2 +/- 0.7 x 10(4) to 2.6 +/- 0.6 x 10(4) (p = 0.04). Efficiency, estimated by employing the oxygen consumption to k2 relation, also increased from 13 +/- 4.5% to 16.9 +/- 6.4% (p = 0.04).

CONCLUSIONS

Despite an increase in myocardial oxygen consumption, dobutamine led to an increase in work-metabolic index in patients with dilated nonischemic cardiomyopathy. Dobutamine reduced systemic vascular resistance and mitral regurgitation, suggesting that in this group of patients, it had important vasodilatory action in addition to its inotropic effects. The use of the C-11 acetate PET for determining myocardial oxygen consumption and estimating efficiency could potentially complement existing clinical measures of ventricular performance and may allow improved and objective evaluation of therapy in patients with heart failure.

Aspergillus terreus as a cause of invasive pulmonary aspergillosis

A 70-year-old woman with nodular, poorly differentiated lymphocytic lymphoma is the third reported patient with invasive pulmonary aspergillosis caused by Aspergillus terreus. This case differs from the two previously reported in that neither neutropenia nor broad spectrum antibiotics preceded the infection. A terreus should not be dismissed as a laboratory contaminant in pulmonary specimens, especially those from immunosuppressed patients.

Hyperactivity and child abuse

The role of a child in his/her physical abuse was reviewed with particular attention to hyperactive children. A retrospective analysis of the records of children referred to a university-based hyperactive children's clinic revealed that children both with and without Attention Deficit Disorder (ADD) were more often physically abused than children in the general population. The period prevalence of physical abuse in children with ADD did not differ significantly from that in children without ADD. This suggests that hyperactivity may either contribute to, or result from, physical abuse.

Nitrogen balance, abomasal crude protein and amino acids in wethers fed formaldehyde-treated coastal bermudagrass and infused with methionine, glucose or monensin

A 5 X 5 Latin square design was used to study the effects on nitrogen balance, wool growth and plasma amino acids of infusing methionine and (or) glucose into the abomasum of growing wethers fed formaldehyde-treated Coastal bermudagrass (F-CBG) or untreated Coastal bermudagrass hay. Daily treatments were: (1) CBG; (2) F-CBG + 3 g methionine (met); (4) F-CBG + 96 g glucose and (5) F-CBG + 3 met + 96 g glucose. Glucose infusion decreased (P < .005) moles/100 g of total essential amino acids in plasma; moles/100 g of lysine, valine, leucine and isoleucine were also reduced (P < .005). Moles/100 g of methionine in plasma were increased significantly by methionine infusion, but nitrogen retention was not affected (P > .10). The grams digestible protein to megacalorie digestible energy (DE) ratio was 36.6, 35.9 and 32.4 for CBG, F-CBG and F-CBG + glucose, respectively. The decrease (36.6 to 32.4) resulted in increased nitrogen retained (P < .05), increased percentage nitrogen intake retained (P < .05) and increased percentage digested nitrogen retained (P < .01). Urinary nitrogen excretion was lower (P < .01) in wethers receiving the F-CBG + glucose treatment than in those receiving the F-CBG treatment (3.60 vs 5.09 g/day). Effects of formaldehyde treatment of CBG and rumen infusion of monensin on quantities of various crude protein (CP) components reaching the abomasum were also determined in a 4 X 4 Latin square design experiment. Total CP reaching the abomasum increased (P < .01) with formaldehyde treatment and resulted in increased quantities of amino acids reaching the abomasum (P < .05). Monensin had no effect on these two parameters, and no interaction between monensin and formaldehyde was observed. Dietary CP reaching the abomasum increased with formaldehyde treatment (P < .005) and with infusion of monensin (P < .025). Total microbial protein (MP) and MP reaching the abomasum per 100 g dry matter digested were not influenced by either formaldehyde or monensin.