Evaluating Patient Tolerability for Urological Procedures Under Conscious Sedation: A Prospective Study

OBJECTIVE

To prospectively evaluate patient-reported tolerability and surgical outcomes of urologic procedures with conscious sedation with or without local anesthesia. Administration of general or spinal anesthesia is associated with anesthetic-related complications, long wait times, and high costs. Using intravenous conscious sedation and/or local anesthesia is an emerging alternative for a myriad of urologic procedures.

METHODS

Patients were enrolled from June-August 2021 at a tertiary care hospital. All procedures were completed using fentanyl, midazolam, or both with patient and procedural data recorded upon completion. Patients were telephoned 4-6 weeks post-procedure with a standardized patient tolerability questionnaire. A multivariable adjusted logistic regression analysis was performed to evaluate whether a patient would opt for conscious sedation again as opposed to general anesthesia.

RESULTS

A total of 196 procedures were performed by 6 attending urologists with an overall success rate of 98.5% and 0% intraoperative complication rate. At 4-6 weeks follow-up, 85.6% of patients reported they would opt for conscious sedation as opposed to general anesthesia. Predictors of opting for conscious sedation in the future were older age (Odds Ratio (OR): 1.049; P = .017) and surgeon perceived level of patient tolerability (OR: 2.124; P <.001, scored 1-10).

CONCLUSION

Physician directed, nursing administered IV conscious sedation is a viable alternative for various urologic procedures and has minimal risk of perioperative complications.

Comparison of different definitions of metabolic syndrome and their associations with non-alcoholic fatty liver disease: a retrospective study

Background

Metabolic syndrome (MetS) is considered an important risk factor for non-alcoholic fatty liver disease (NAFLD). The aim of this study was to measure the prevalence of MetS based on six different MetS definitions and compare the performance of various definitions for identifying diabetes, hypertension, and dyslipidemia among NAFLD patients.

Methods

The definitions compared were those developed by the World Health Organization (WHO), National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III), International Diabetes Federation (IDF), American Association of Clinical Endocrinologists (AACE), American Heart Association/National Heart, Lung and Blood Institute (AHA/NHLBI), and Interim Joint Statement "harmonized" criteria. Receiver operator characteristic (ROC) curves were plotted for the six MetS definitions with NAFLD diagnosis. The diagnosis for NAFLD was established based on liver imaging or biopsy compatible with fatty liver disease.

Results

A total of 500 NAFLD patients were analyzed. The mean age was 61.2 (SD 13.2) years, and BMI was 32.7 (SD 8.0) kg/m2. The most prevalent MetS component was dyslipidemia (83%), followed by hypertension (60%), obesity (61%), and diabetes (57%). The prevalence of MetS according to the WHO, NCEP/ATP-III, IDF, AACE, AHA/NHLBI, and harmonized criteria was 69%, 59%, 54%, 64%, 78%, and 79%, respectively. The highest area under the ROC curve for diabetes and hypertension was with the WHO definition (0.7405) and (0.8120), respectively.

Conclusions

The prevalence of MetS in NAFLD patients varies according to the definitions of MetS employed. The modified WHO definition appeared to be most useful for the screening of MetS in NAFLD patients.

The impact of misinformation on patient perceptions at a men's health clinic: a cross-sectional study

Misinformation is a rising concern for providers and patients alike. We aimed to assess where patients acquire information prior to their andrological urologic appointment and assess patients' perception regarding the reliability of this information. A cross-sectional study was conducted at an outpatient men's health clinic between June and August of 2022 with questionnaires distributed to adult males seen for their primary visit. The study included 314 consenting adult patients who independently completed the questionnaire (mean age: 51.2 ± 17.2). Overall, 55.1% of patients indicated they searched for their condition online. However, 39.2% and 27.7% of respondents agreed and strongly agreed, respectively, that misinformation is a concern when searching for health information. Only 59.9% of patients discussed their concerns with others and those that did not chose not wanting to (65.1%) as their top choice. However, 27.4% of respondents were embarrassed to do so. Finally, 38.2% and 12.4% of patients agreed and strongly agreed, that learning information prior to your appointment affects their relationship with the physician. These findings emphasize the need for urologists to be aware of where their patients are gathering health information and to address concerns regarding misinformation.

Liver enzymes and fibrosis markers in patients with non-alcoholic fatty liver disease and concomitant chronic viral hepatitis

The impact of non-alcoholic fatty liver disease (NAFLD) on patients with chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infections has yet to be determined. In this retrospective, cross-sectional analysis, untreated chronic HBV, hepatitis B e-antigen (HBeAg)-positive patients with NAFLD had similar liver biochemistry and FIB-4 values as age-, gender-, and viral-load-matched HBeAg-positive patients without NAFLD. Among HBeAg-negative patients with NAFLD, although liver biochemistry findings were similar, mean FIB-4 values were significantly lower (0.98, SD 1.46, versus 1.51, SD 4.04, respectively; p < 0.05) and the percentage of patients with FIB-4 values in keeping with advanced fibrosis or cirrhosis was less (0.3% versus 3.9%, p < 0.015) than that of matched HBeAg-negative patients without NAFLD. Chronic HCV-infected patients with NAFLD had higher mean serum aminotransferase values than those without NAFLD (123 U/L, SD 247, versus 90 U/L, SD 128, respectively; p < 0.05). These results suggest that NAFLD adversely affects chronic HCV infections but not HBV infections.

Low serum alkaline phosphatase levels in patients with chronic liver diseases: Possible contributions to disease pathogenesis

OBJECTIVES

A low serum alkaline phosphatase (ALP) level is an uncommon finding in patients with chronic liver disease (CLD). The prevalence of this finding and whether low ALP expression influences CLD remain to be determined. The objectives of this study were: (1) to document the prevalence of low serum ALP levels in adult CLD patients and (2) compare features of CLD in patients with low versus normal or elevated serum ALP levels.

METHODS

An adult, outpatient liver disease database was searched for patients with low serum ALP levels (<40 IU/L). Hepatic inflammation, function, fibrosis and disease severity were determined by serum aminotransferases, albumin, bilirubin and INR levels, Fib-4 calculations and MELD scores respectively.

RESULTS

Of 19,037 patients entered into the database, 47 (0.25%) had consistently low serum ALP levels, 51 (0.27%) low levels on the majority and 469 (2.44%) on the minority of determinations. Patients with consistently low levels were matched (1:2) by age, gender and nature of the underlying liver disease to patients with normal or elevated serum ALP levels. Matched patients with consistently low ALP levels had significantly lower serum aminotransferase and bilirubin levels at their initial visit and throughout the follow-up period (p < 0.05 respectively) while Fib-4 levels and MELD scores were similar at the initial and last follow-up visit.

CONCLUSIONS

These results establish the prevalence of low serum ALP levels in adult CLD patients and describe a hitherto unreported association between low serum ALP levels and less biochemical evidence of active disease.

The effects of hyperthermia on human hepatocellular carcinoma stem and mature cancer cells

INTRODUCTION AND OBJECTIVES

Hepatocellular carcinoma (HCC) can recur following radiofrequency ablation and other hyperthermic treatment modalities. Cancer stem cells (CSCs) are a subpopulation of HCC cells that are difficult to eradicate and largely responsible for tumor recurrences. Thus, the principal objective of this study was to determine whether human HCC CSCs are relatively thermal-resistant compared to non-stem or mature cancer cells (MCCs).

MATERIALS AND METHODS

Epithelial cell adhesion molecule (EpCAM) positive enriched CSCs and EpCAM^- MCCs were derived from a human HCC cell line using fluorescence activated cell sorting. Each cell population was exposed to 65°C heat for 0-16min and survival documented at various time points.

RESULTS

Cell survival curves were similar in CSC and MCCs throughout the 16min heat exposure period. Maximum killing was obtained after 12-14min of heat exposure. Cytoprotective, heat shock proteins-70 (HSP70) and -90 (HSP90) mRNA expression were not disproportionately increased in CSCs.

CONCLUSIONS

These results suggest that human HCC CSCs are not more thermal resistant than MCCs and therefore, do not support the hypothesis that HCC recurrences following hyperthermic treatment reflect CSC thermal-resistance.

The impact of primary biliary cholangitis on non-alcoholic fatty liver disease

BACKGROUND

The impact of chronic cholestatic liver diseases such as primary biliary cholangitis (PBC) on non-alcoholic fatty liver disease (NAFLD) has yet to be described.

OBJECTIVES

To document and compare the severity and course of liver disease in patients with NAFLD/PBC versus NAFLD alone.

METHODS

In this retrospective, case-control study 68 adult NAFLD/PBC patients were matched 1:2 for age and sex with 136 NAFLD alone patients. Disease activity and severity were documented by serum aminotransferases, albumin, bilirubin and international normalized ratio (INR) values and hepatic fibrosis by Fib-4 and aspartate aminotransferase/platelet ratio indices (APRI).

RESULTS

On presentation (baseline), NAFLD/PBC patients had similar serum aminotransferase, albumin and bilirubin levels but lower INR values than NAFLD alone patients. Fib-4 and APRI levels were similar. Despite longer follow-up (favouring more advanced disease) in NAFLD/PBC patients, serum aminotransferases and bilirubin values were similar but albumin and INR levels significantly lower in NAFLD/PBC versus NAFLD alone patients at the end of follow-up. NAFLD/PBC patients also had significantly lower and less worsening of Fib-4 values at the end of follow-up. Transition from intermediate Fib-4 levels to those compatible with no or limited fibrosis was higher in NAFLD/PBC patients.

CONCLUSION

These findings suggest PBC does not adversely affect the severity or course of NAFLD.

Liver disease referrals to an urban, hospital-based hepatology outpatient clinic over the past 25 years

Background

Additional hepatologists are required to manage the rapidly increasing number of patients with liver disease. One disincentive to trainees considering a career in hepatology is the longstanding perception that outpatient hepatology consists largely of managing patients with alcohol‐induced liver disease (ALD).

Objectives

To document the types of liver diseases and changes in liver disease referrals to an urban outpatient liver disease clinic over the past 25 years.

Methods

The nature of the liver disorder, age, gender, and socioeconomic status of patients referred to an urban, hospital‐based, liver diseases outpatient program were documented from 1992 to 2017. Joinpoint analysis was performed to identify significant trends in referral prevalence rates of various disorders.

Results

In 1992/1993, hepatitis C virus (HCV), followed by hepatitis B virus (HBV), “other”, non‐alcoholic fatty liver disease (NAFLD), and primary biliary cholangitis (PBC) were the most common underlying liver diseases in referred patients (39, 36, 12, 4.5, and 3.5% respectively), whereas in 2016/2017, NAFLD, HBV, HCV, “other,” and ALD were most common (60, 15, 12, 8.7, and 3.3%, respectively). Aside from NAFLD referrals, which consistently increased over the 25‐year period, the prevalence of all other liver disease referrals fluctuated but generally declined. Recently referred patients were significantly older (38 ± 13 years in 1992/1993 and 49 ± 15 years in 2016/2017, P < 0.0001), while gender and socioeconomic status have not changed.

Conclusions

Hepatology is a diverse, dynamic subspecialty where ALD continues to constitute less than 5% of all patient referrals.