Feasibility of outpatient daycase local anaesthestic Rezūm™ without sedation

BACKGROUND

Rezūm™ is a relatively new bladder outflow obstruction (BOO) procedure that uses thermal energy through water vapour to cause necrosis of prostatic tissue. The standard delivery of this treatment is in an operating theatre under a general or spinal anaesthetic, or under local anaesthetic with sedation that requires patient monitoring.

METHODS

We propose an outpatient daycase method of delivering Rezūm™ under local anaesthetic without sedation, using a prostatic local anaesthetic block and cold local anaesthetic gel instillation into the urethra.

RESULTS

Preliminary results of our first thirteen patients demonstrate the feasibility of this new technique, with a mean pain score of 2.1 out of 10 on a visual analogue scale, a successful trial without catheter in all 13 patients (one patient voided successfully on second trial), a reduction in mean International Prostate Symptom Score (IPSS) from 20.6 to 5.4, and improvement in maximum flow from 8.8 ml/s to 14.4 ml/s. The complications were minor (Clavien-Dindo less than III) and included a UTI, minor bleeding not requiring admission, and retrograde ejaculation.

CONCLUSIONS

We demonstrate that an outpatient local anaesthetic daycase service without sedation is feasible. This can be delivered in a clinic setting, reduce waiting times for BOO surgery, and increase availability of operating theatre for other general anaesthetic urological procedures.

Suprascapular nerve injury during robot-assisted radical prostatectomy: a case report

This case report aims to encourage teams to readjust the operating table during prolonged robotic cases, especially in those patients with a high body mass index. We present the case of a 59-year-old male who developed neuropathic pain involving the suprascapular nerve distribution following a prolonged robotic-assisted radical prostatectomy.

Patient experiences of hospital care during the COVID-19 pandemic in Ireland

Introduction

The COVID-19 pandemic has greatly impacted healthcare service delivery. This study explored patient experiences of hospital care during the COVID-19 pandemic in Ireland, using National Inpatient Experience Survey (NIES) 2021 data.

Methods

NIES is a repeat cross-sectional survey of inpatient experiences in all public acute hospitals in Ireland. Patients who spent 24+ hours in hospital and were discharged in September 2021 were eligible to participate. 7 questions addressed experiences specific to the pandemic. Comparisons between 2019 and 2021 were conducted using t-tests. Effect sizes (d) are reported. Qualitative data were thematically analysed.

Results

10,743 patients participated (42% response rate). While 68% did not feel at risk of catching COVID-19, 9% felt at risk. 35% reported that staff always helped them to keep in touch with family. There were small, statistically significant differences between 2019 and 2021 ratings, with questions on opportunity for family to talk to a doctor (d=-.328), provision of information to family (d=-.136), and being able to find staff to talk to about worries and fears (d=-.167) recording the biggest decreases. Scores for cleanliness of wards (d = 0.063) and bathrooms (d=.075), and privacy during examination or treatment in the ED (d = 0.085) improved significantly. Patients commented on their appreciation of staff, but missed having visitors, with restrictions posing challenges for those with sensory or physical impairments.

Conclusions

Given the unique challenges experienced by acute healthcare services during the COVID-19 pandemic, comparisons with pre-pandemic patient experiences should be interpreted with caution. Continuing to gather patient feedback during a pandemic presents a unique opportunity to understand the resilience of healthcare systems as they continue to operate under unprecedented pressure, with the potential to inform responses and delivery of care during future pandemics or other emergencies.

Key messages

• Visiting restrictions posed many challenges for patients and affected communication both between patients and their family members, as well as between healthcare staff and patients’ family.

• Gathering patient feedback during a pandemic presents a unique opportunity to inform responses and delivery of care during future pandemics or other emergencies.

1328 A Risk Stratified Post-Nephrectomy Surveillance Protocol – 5-Year Assessment of Performance

Introduction

Recurrence rate of surgically treated localised renal cell carcinoma (RCC) is reported to be approximately 20%. There is lack of consensus on the optimal surveillance regimen. We assess the performance of our surveillance protocol based upon prognostic histological factors. We report the outcome of our first cohort to reach 5 years follow up.

Method

A retrospective analysis was performed of patients who underwent a radical or partial nephrectomy between March 2014 and October 2015. Patients were classified as high, intermediate, or low risk based on pathology; with each group undergoing individualised radiological follow up.

Results

80 patients with pathologically confirmed RCC who underwent partial or radical nephrectomy were identified. Recurrence was noted in 24% (n = 19), and a third of those patients (n = 7) died within the 5-year follow-up period. 79% (n = 15) of patients with recurrence were of intermediate or high-risk group. 90% of recurrences were picked up on surveillance scans, 5% due to symptoms related to the recurrence and 5% incidentally. 70% occurred within the first 2 years post-surgery. 92% (n = 6) of those who died had an ASA of 2 or higher. In the whole cohort, total number of deaths was 13. 38% (n = 5) died of RCC, 54% (n = 7) died of other causes and in 8% (n = 1) cause of death of was unclear.

Conclusions

Our risk stratified surveillance protocol identified 90% of recurrences within the 5-year follow-up. Future refinement of our protocol could include an assessment of performance status which may influence the schedule of radiological surveillance.

Blood levels of patients with profound refractory OCD who are on supra-normal dosages of sertraline

Introduction

Patients with OCD usually require higher dosages of serotonin reuptake inhibiting (SRI) drugs than is used for the treatment of depression. This observation resulted in treatment-refractory patients being occasional prescribed selective SRI drugs above the normal upper limit of prescribing. Previous studies have shown that these high doses are well tolerated.

Objectives

We decided to investigate the blood levels of patients on dosages of sertraline that were above the normal therapeutic range.

Method

Successive patients treated by the National Inpatient Service for OCD/BDD who were treatment refractory and prescribed > 200 mg sertraline per day were included. All had previously received 2+ trials of different SRIs for > 3months each as well as been offered augmentation with dopamine blockers and at 2+ trials of exposure and response-prevention. All patients scored in the profoundly ill range of the Yale Brown Obsessive Compulsive Scale.

Sertraline was titrated in 50 mg increases every 2–4 weeks up to a maximum of 400 mg. Blood samples were taken after their morning dose. This was after the patients had stabilised for at least 2 weeks on the higher doses.

Results

Seventeen patients were included in the study and received sertraline dosages ranging from 225 mg to 400 mg per day. Blood levels were within therapeutic range or below for all patients. Following treatment within the service, these patients generally showed an improvement of an average of improvement of 43% on the YBOCS.

Conclusions

A subgroup of patients with profound refractory OCD seem to either malabsorb or rapidly metabolise sertraline resulting in lower than therapeutic blood levels.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

New IR imaging modalities for cancer detection and for intra-cell chemical mapping with a sub-diffraction mid-IR s-SNOM

We present two new modalities for generating chemical maps. Both are mid-IR based and aimed at the biomedical community, but they differ substantially in their technological readiness. The first, so-called "Digistain", is a technologically mature "locked down" way of acquiring diffraction-limited chemical images of human cancer biopsy tissue. Although it is less flexible than conventional methods of acquiring IR images, this is an intentional, and key, design feature. It allows it to be used, on a routine basis, by clinical personnel themselves. It is in the process of a full clinical evaluation and the philosophy behind the approach is discussed. The second modality is a very new, probe-based "s-SNOM", which we are developing in conjunction with a new family of tunable "Quantum Cascade Laser" (QCL) diode lasers. Although in its infancy, this instrument can already deliver ultra-detailed chemical images whose spatial resolutions beat the normal diffraction limit by a factor of ∼1000. This is easily enough to generate chemical maps of the insides of single cells for the first time, and a range of new possible scientific applications are explored.

Obsessive-compulsive disorder in the elderly: A report from the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS)

INTRODUCTION

Obsessive-compulsive disorder (OCD) is a highly disabling condition, with frequent early onset. Adult/adolescent OCD has been extensively investigated, but little is known about prevalence and clinical characterization of geriatric patients with OCD (G-OCD≥65years). The present study aimed to assess prevalence of G-OCD and associated socio-demographic and clinical correlates in a large international sample.

METHODS

Data from 416 outpatients, participating in the ICOCS network, were assessed and categorized into 2 groups, age<vs≥65years, and then divided on the basis of the median age of the sample (age<vs≥42years). Socio-demographic and clinical variables were compared between groups (Pearson Chi-squared and t tests).

RESULTS

G-OCD compared with younger patients represented a significant minority of the sample (6% vs 94%, P<.001), showing a significantly later age at onset (29.4±15.1 vs 18.7±9.2years, P<.001), a more frequent adult onset (75% vs 41.1%, P<.001) and a less frequent use of cognitive-behavioural therapy (CBT) (20.8% vs 41.8%, P<.05). Female gender was more represented in G-OCD patients, though not at a statistically significant level (75% vs 56.4%, P=.07). When the whole sample was divided on the basis of the median age, previous results were confirmed for older patients, including a significantly higher presence of women (52.1% vs 63.1%, P<.05).

CONCLUSIONS

G-OCD compared with younger patients represented a small minority of the sample and showed later age at onset, more frequent adult onset and lower CBT use. Age at onset may influence course and overall management of OCD, with additional investigation needed.

Stressor-induced alterations of the splenic plaque-forming cell response: strain differences and modification by propranolol

The effects of stressor application on the splenic plaque-forming cell (PFC) response was assessed in two strains of mice: the BALB/cByJ strain, which is highly responsive to stressors; and the more hardy DBA/2J strain. Both strains exhibited a peak PFC response 120 h following administration of sheep red blood cells (SRBC; 5 x 106 cells). Stressor exposure reduced the immune response; however, the appearance of such an outcome was dependent upon the time at which the stressor was applied relative to SRBC inoculation. In DBA/2J mice, foot-shock applied either immediately after SRBC inoculation or at the time of the peak immune response (120 h) resulted in suppression of the PFC response. In BALB/cByJ mice, both stressor severities provoked an immunosuppression when applied 120 h after inoculation, but when applied 96 h after immunization only foot-shock reduced the PFC response. At other intervals, the stressors were without effect. Pretreatment with the beta-norepinephrine antagonist propranolol precluded the immunosuppression elicited by a stressor applied 96 h after inoculation, but did not affect the reduction of the PFC response elicited by a stressor applied 120 h after inoculation. It is suggested that several factors may contribute to stressor-provoked alterations of the immune response, and that the contribution of these factors vary over the course of an immune response being mounted.

The metabolism of 1,6-dinitropyrene in rat hepatocytes

This paper reports investigations using hepatocytes to study the metabolism and DNA binding of the environmental contaminant, 1,6-dinitropyrene. Since 1,6-dinitropyrene is not believed to be mutagenic per se, metabolites were synthesized and the metabolism of 1,6-dinitropyrene was subsequently studied in rat hepatocytes. The mode of activation of dinitropyrenes is reduction of one of the nitro groups. Nitroreduction has been shown previously to be oxygen sensitive and therefore the effect of oxygen on the metabolic pattern and DNA binding was investigated by comparing results from aerobic and anaerobic conditions. The binding of [14C]1,6-dinitropyrene equivalents to rat hepatocyte DNA was increased by 15% in the presence of oxygen. Although there was little difference in the rate of 1,6-dinitropyrene metabolism, with or without O2, there was a difference in the metabolic pattern. Under anaerobic conditions there was an increase in the level of the terminal reduction product 1-amino-6-nitropyrene.

The stereoselectivity of 1,2-phenylethanediol and mandelic acid metabolism and disposition in the rat

1. The steps involved in determining the chirality of the mandelic acid excreted by rats after administration of ethylbenzene and styrene were investigated by studying the fate of racemic, (R)- and (s)1,2-phenylethanediol, a precursor of mandelic acid. These investigations indicate the occurrence of two alternative routes of metabolism for 1,2-phenylethanediol, one involving retention of configuration and the other resulting in the loss of the chiral centre. 2. The stereoselectivity of the disposition of mandelic acid was investigated; rats were dosed with mandelic acid either as the racemate or as the individual enantiomers, G.1.c.-mass spectrometry and h.p.l.c. were used to determine the enantiomers of mandelic acid. 3. There were at least two routes by which mandelic acid could be metabolized and/or excreted; there is a stereoselective pathway in rat for (s)-mandelic acid, which gives rise to phenylglyoxylic acid. 4. The chiral inversion of (s)-mandelic acid to (R)-mandelic acid is reported; although this has been observed in bacteria it has not previously been observed in mammals. 5. The extent to which mandelic acid is metabolized to phenylglyoxylic acid is dependent on the enantiomeric composition of the mandelic acid administered. There is no evidence to indicate significant ketone-alcohol conversion, that is phenylglyoxylic acid is not significantly reduced to mandelic acid in vivo.

The metabolism of ethylbenzene and styrene to mandelic acid: stereochemical considerations

1. The stereochemistry of mandelic acid, produced as a major urinary metabolite of ethylbenzene and styrene in rat and man has been investigated. Although these solvents are both achiral they are metabolized to chiral metabolites, via a series of chiral intermediates. 2. Analytical methods (g.l.c.-mass spectrometry, h.p.l.c. and 19F-n.m.r.) have been developed for the determination of the enantiomeric composition of mandelic acid in urine. 3. These methods have been applied to the study of the metabolic stereochemistry of ethylbenzene and styrene in rats dosed orally (100 mg/kg body weight) and in human volunteers exposed to atmospheres containing these solvents at the upper limits prescribed for workplaces by the UK Health and Safety Executive (100 ppm in air). 4. Results show that whereas only the R-enantiomer of mandelic acid was excreted after ethylbenzene exposure, the mandelic acid formed from styrene was essentially racemic. In three workers occupationally exposed to styrene, ratios of R to S isomers of 1.16, 1.27 and 1.14 were found. A synthetic R/S mixture of mandelic acid had an R/S ratio of 1.03. 5. The implications of these findings for the biological monitoring of workers occupationally exposed to stryrene and/or ethylbenzene are discussed.

Biological monitoring of workers exposed to benzene in the coke oven industry

Workers in the coke oven industry are potentially exposed to low concentrations of benzene. There is a need to establish a well validated biological monitoring procedure for low level benzene exposure. The use of breath and blood benzene and urinary phenol has been explored in conjunction with personal monitoring data. At exposures of about 1 ppm benzene, urinary phenol is of no value as an indicator of uptake/exposure. Benzene in blood was measured by head space gas chromatography but the concentrations were only just above the detection limit. The determination of breath benzene collected before the next shift is non-specific in the case of smokers. The most useful monitor at low concentrations appears to be breath benzene measured at the end-of-shift.

Development of increased serum immunoblot reactivity against a 45,000-dalton polypeptide of Treponema pallidum (Nichols) correlates with establishment of chancre immunity in syphilitic rabbits

Rabbits developed chancre immunity 5.0 to 7.5 weeks after intradermal infection with 10(3) Treponema pallidum (Nichols). The serological response against T. pallidum antigen during this 2.5-week period was examined by Western immunoblotting. Sera from rabbits infected for 5.0 weeks contained antibodies against 7 of 13 major T. pallidum immunogens, with strongest binding detected against a polypeptide of Mr 47,000. By 7.5 weeks of infection, syphilitic rabbit sera recognized 10 of 13 antigens; the most evident increase in serological reactivity was directed against a polypeptide of Mr 45,000, suggesting that the development of a strong serological response against this polypeptide correlated with the onset of chancre immunity.

Secondary lesions in rabbits experimentally infected with Treponema pallidum

Thirty rabbits infected with 10(3) of either Nichols or Melbourne 1 strains of Treponema pallidum were observed for the development of secondary lesions, which appeared outside areas inoculated with viable treponemes. More rabbits infected with Melbourne 1 strain (eight of 15 rabbits) than were infected with the Nichols reference strain (three of 15 rabbits) developed secondary lesions. The mean (SD) incubation periods of secondary lesions were 52 (8) days for rabbits infected with Melbourne 1 and 56 (4) days for rabbits infected with Nichols strain. These mean incubation periods did not correlate with appreciably increased concentrations of immune complexes or glycosaminoglycans in the serum of infected rabbits.

Polyanions in syphilis: evidence that glycoproteins and macromolecules resembling glycosaminoglycans are synthesised by host tissues in response to infection with Treponema pallidum

We investigated by means of radiolabelled precursors the source and nature of the polyanionic macromolecules present in rabbit tissues during active syphilis infection. Previous studies indicated that Treponema pallidum itself does not synthesise glycosaminoglycans, at least in vitro. In replicate experiments on unilaterally infected rabbits, tissue from the orchitic testis incorporated two to three times more 35S-sulphate and 3H-glucosamine (on a wet weight basis) than tissue from the non-orchitic contralateral testis. Incorporation of 35S-sulphate was independent of the number of viable T pallidum organisms present in the infested tissue, which suggested that incorporation represented biosynthesis by the host and not the treponeme. Testes from syphilitic rabbits two days after treatment with high doses (100 mg/kg) of penicillin incorporated less 35S-sulphate than untreated infected testes, but more than normal uninfected rabbit testes. This suggests that active syphilitic infection was necessary for maximum biosynthesis of the macromolecule(s) by host tissue. Hydrodynamic profiles showed incorporation of radiolabelled precursors into two distinct fractions of different sizes, which may represent a proteoglycan and a sulphated glycoprotein. Alcian blue staining of syphilitic testes at or after peak orchitis showed focal deposition of newly synthesised polyanionic components during peak orchitis and a more generalised fibrosis in testes after peak orchitis.

Immunization of rabbits with Spirochaeta aurantia does not induce resistance to Treponema pallidum

Rabbits were immunized with viable Spirochaeta aurantia, a free-living, facultative anaerobic spirochete that is similar in some biochemical characteristics to Treponema pallidum, a parasitic, microaerophilic spirochete. Single and multiple immunizations with living S. aurantia, with or without Freund's incomplete adjuvant, Freund's complete adjuvant, or heat-killed T. pallidum, were carried out over a four-month period. Living S. aurantia was neither toxic nor virulent for rabbits. Immunized rabbits produced a high level of agglutinating antibody to S. aurantia but no antibody to T. pallidum, as determined by the T. pallidum hemagglutination test. Immunized rabbits were challenged with multiple intradermal inoculations of 100 viable T. pallidum (Nichols strain) and compared to unimmunized rabbits similarly infected. Immunization with S. aurantia did not protect against T. pallidum infection. Thus S. aurantia appears not to be suitable as a potential vaccine against infection with T. pallidum.

The role of respiratory protection on increased survival of Treponema pallidum (Nichols) when cocultivated with mammalian cells in vitro

The ability of mammalian cells in tissue culture to protect against oxygen toxicity for Treponema pallidum was examined. Addition of catalase to the incubation medium enhanced T. pallidum survival when co-incubation was carried out under aerobic conditions. When co-incubation was carried out under 3% oxygen, catalase had no enhancing effect on survival despite the fact it was still highly stimulatory when T. pallidum was incubated under 3% oxygen in the same medium with no tissue culture cells present. Inactivation of the catalase present endogenously in the mammalian cells by the addition of the catalase inhibitor 3-amino-1,2,4-triazole largely eliminated the enhancing effect of mammalian cells on the survival of T. pallidum under 3% oxygen. Increasing the oxygen consumption of the host mammalian cells with 0.1 mM 2,4-dinitrophenol enhanced T. pallidum under both aerobic and microaerobic conditions; a much greater effect was seen under aerobic conditions. The results indicated that mammalian cells offer significant protection against toxic oxygen reduction products for T. pallidum in vitro under microaerobic conditions.

Changes in brain ATPases in rats fed on chlordane mixed with iron-sufficient and deficient diet

The in vivo effects of chlordane on brain Na+-K+, oligomycin-sensitive (O.S) and oligomycin-insensitive (O.I) Mg2+ ATPases in rats were investigated. The rats were fed on 0, 25, 50 and 100 ppm chlordane mixed with iron-sufficient (I.S) and deficient (I.D) diets for 12 weeks. The enzyme activities were determined in the brain P2 fraction of rats at the end of 4, 8 and 12 weeks after treatment. Na+-K+ ATPase activity was reduced in a dose-dependent and time-dependent manner in rats fed on chlordane mixed with I.S and I.D diets. The reduction in the enzyme activity was more pronounced in the rats fed on chlordane mixed with I.D diet as compared to those fed on I.S diet. The brain O.S Mg2+ ATPase was also reduced in rats receiving chlordane. The reduction of O.S Mg2+ ATPase was higher than Na+-K+ ATPase. However, the O.I Mg2+ ATPase activity in rats fed on chlordane was not altered at any dose level. These results indicate that the rat brain ATPases may be particularly sensitive to chlordane.

Effect of cadmium on ATPase activities in rats fed on iron-deficient and sufficient diets

Male Sprague-Dawley rats were fed on different levels of cadmium mixed with purified diets containing iron or no iron for 8 weeks. The body weight gain, tissue weights, hemoglobin, hematocrit, liver and brain ATPase were measured at 2, 4 and 8 weeks after feeding. The hemoglobin and hematocrit values were the same in all rats fed on cadmium. The rats fed on iron-deficient diets mixed with cadmium showed a significant decrease in body weight gain. However, the rats receiving only the 100 ppm of cadmium in iron-sufficient diet showed a significant decrease in body weight gain. There were no significant changes in the weights of thymus, spleen, kidney, heart, brain and testes. However, the liver weights were decreased in the highest treatment of cadmium but the liver weight/body ratios were uneffected. Na+-K+ activated ATPase activity in brains of rats fed on cadmium were significantly decreased at 2, 4 and 8 weeks of treatment. The decrease was more pronounced in rats fed on iron-deficient diets. Oligomycin-sensitive (Mitochondrial) Mg2+ ATPase activity was also significantly decreased in liver and brain tissues of rats fed on cadmium. Oligomycin-insensitive Mg2+ ATPase activity, however, was not altered in any tissues tested. It appears that cadmium may be interfering with energy (ATP) production and utilization processes in rat brain and liver tissues.

Inhibition of rat hepatic microsomal cytochrome P-450 system by cobaltous chloride and reversal of inhibition by iron in vivo

The effects of preexposure of rats to cobaltous chloride (CO) mixed in iron-sufficient (I.S) and -deficient (I.D) diets on hepatic microsomal electron transfer system was investigated. Male Sprague-Dawley rats were fed for 4 weeks on I.D diets mixed with 0, 100 and 200 ppm CO. At the end of 4 weeks three rats from each group were transferred to I.S diets mixed with the same amount of CO. Liver microsomal NADPH - Cytochrome C reductase, NADPH - dehydrogenase, cytochrome P-450 and aniline binding were determined in both batches of rats. The rats receiving CO in the I.D diets showed a 35, 60, 75 and 40% decrease in NADPH - Cyt. C reductase, dehydrogenase, Cyt. P-450 and aniline binding respectively. The rats transferred from I.D diet to I.S diet showed a complete recovery of the inhibition of the microsomal electron transfer system. The rats receiving 200 ppm mixed with I.S diets did not show any changes in any biochemical parameter measured.