A-02 Concussion at One-Year Post-Injury and Anxiety Do Not Predict Head Protective and Jump Landing Functional Reaction Time

Purpose: Individuals with a concussion history are more likely to sustain subsequent concussions and/or musculoskeletal injuries. Underlying mechanisms are unclear; reaction time (RT) deficits associated with anxiety may play an important role. The primary aim of this study was to determine if anxiety and recent concussion history predict functional RT (i.e., head protective, jump landing) under single and dual-task conditions. Methods: 40 participants (concussion:healthy = 20:20; time since concussion = 11.8 months) completed the State–Trait Anxiety Inventory, anxiety ratings before and after each task, and performed RT tasks. We used a virtual reality environment and motion capture laboratory to collect RTs for head protective and jump landing, respectively. Participants completed assessments under both single-task (i.e., “Focus solely on completing the task as quickly as possible”) and dual-task (i.e., “Subtract as quickly and accurately as possible as you await your visual stimulus”) conditions. Instructions gave equal weight to speed and accuracy. All RTs were calculated (ms) as the time from visual onset of stimuli to first movement ≥3 cm of hands (head protective) or sacral body (jump landing). A series of linear regression models determined if the independent variables predicted RTs. Results: Regression models did not explain a significant proportion of the variance in head protective (single- R2 = 0.05; p = 0.78; dual- R2 = 0.09; p = 0.49), or jump landing (single- R2 = 0.21; p = 0.08; dual- R2 = 0.12; p = 0.32) RTs. Conclusions: In a low anxiety sample, recent concussion history and anxiety do not predict clinical or functional reaction times at twelve-months post-concussion. If these differences exist, they are likely resolved by this time.

Examining Optimism Bias in Predicting Concussion Reporting Intentions and Behaviors Among Student-Athletes

Purpose

The purpose of this study was to determine whether optimism bias is associated with concussion reporting intentions. We hypothesized that student-athletes who are optimistic about whether they will suffer a concussion have lower concussion reporting intentions, relative to those that are neutral or pessimistic.

Methods

Student-athletes from three Georgia universities (Divisions I, II, III) completed an optimism bias survey (n=333, age=19.86–1.52 years, males=217, females=116, response rate=28.2%). The optimism bias survey assesses the student-athletes’ beliefs regarding how likely an event is to occur (e.g. “sustained prolong recovery following concussion”). Participants were grouped into three categories: pessimists (above median), neutral (at median), and optimists (below median). Student-athletes rated their agreement with statements regarding symptom and concussion reporting intentions. Higher average score across items is indicative of greater intentions to report. A priori α was set to p=.05.

Results

Optimism bias category significantly predicted symptom reporting intentions (F(2, 329)=4.5, p=.012, r2=.026) and a trend for concussion reporting intentions (F(2, 329)=3.0, p=.052, r2=.018). Being categorized as neutral and optimists, as compared to pessimists, would be expected to decrease symptom reporting intentions by 0.48 (β=-.178, p=.013) and 0.50 (β=-.203, p=.005) respectively, and concussion reporting intention by 0.34 (β=-.169, p=.018) and 0.26 (β=-.140, p=.05).

Conclusion

Optimism bias has a small, but significant influence on concussion reporting intentions, with pessimists having better reporting intentions compared to those that are neutral or optimistic regarding their risk for suffering a concussion. Therefore, incorporating optimism bias could further educate healthcare professionals on student-athletes' risk when compared to others.

Post-concussion Driving Management Practices Among Certified Athletic Trainers

Purpose

To describe post-concussion driving management practices and opinions among athletic trainers (ATs) and to compare practices across highest earned degree, setting, and years certified.

Methods

A survey weblink was emailed to a convenience sample of 8,723 ATs (10.8% response rate [945/8723]; years certified=14.5±10.7; years worked clinically=12.4±9.4). The validated survey captured AT driving management practices and opinions (agreement on a seven-point Likert scale). We compared the percentage of patients instructed to refrain from driving across highest earned degree, setting, and years certified using Kruskal-Wallis tests (alpha=0.05).

Results

When asked whether they recommended concussed patients refrain from driving, 58.5% of ATs responded “sometimes” (n=553/945), 37.9% responded “always” (n=358/945), and 3.6% responded “never” (n=34/945). ATs most commonly: recommended patients refrain from driving until symptom resolution (44.7%, n=399/892); utilized their clinical exam to determine readiness to return-to-drive (64.9%, n=579/892); and provided instructions verbally (94.2%, n=840/892). ATs agreed that “patients that are impaired by a concussion are a danger on the road”, but only somewhat agreed that “patients with suspected concussion should not drive a motor vehicle until cleared to do so by a medical professional” (median=5). High school (60.5±37.6%) and clinic-based ATs (66.5±31.2%) trended towards higher percentages of patients instructed to refrain from driving relative to college (52.3±38.2%; H(2)=5.92,p=0.052). No other differences observed.

Conclusion

ATs recommend driving restrictions to some, but not all, concussed patients. ATs recognize post-concussion driving dangers, but do not strongly endorse refraining from driving after concussion. High school and clinic-based ATs may manage more adolescent novice drivers and, therefore, act more conservatively.

Detecting Sandbagging Performance on CNS Vital Signs Concussion Baseline Testing

Purpose

To determine CNS Vital Signs validity indicator accuracy in detecting coached suboptimal performance (i.e. sandbagging) on neurocognitive testing.

Methods

Fifty college-aged students (age=20.8–1.1 years, range 18–25) were randomly assigned to two groups of 25. We compared neurocognitive test performance for two groups completing CNS Vital Signs instructed through verbal scripts to either (1) try their best (control) or (2) purposely sandbag. Participants rated their effort after completing neurocognitive testing on a Visual Analog Scale (0mm=no effort, 100mm=maximum effort). A one-way MANOVA was used to determine domain score differences between the control and sandbagging groups (alpha=0.05) and percent flagged as invalid. A series of ANOVA’s was used to post-hoc the MANOVA.

Results

Significant raw domain score group differences were identified (V=0.67, F=7.13, p<0.001) such that the sandbagging group performed significantly worse on visual memory, psychomotor speed, reaction time, complex attention, cognitive flexibility, processing speed, executive function, and motor speed compared to the control group. Built-in CNS Vital Signs invalidity indicators successfully identified approximately 70% (17/25) of coached sandbaggers. Approximately 12% of control group participants (3/25) fell below the validity cutoff for simple attention despite instructions to perform their best. All participants on average reported less than optimal effort (mean= 6.8–2.5).

Conclusion

Built-in CNS Vital Signs validity indicators do an overall good job at identifying those attempting to purposefully sandbag the test. Given that 30% of intentional sandbaggers went undetected, clinicians should consider additional safeguards beyond test algorithms to detect these individuals at baseline.

Dynamic Reaction Time: Jumping into the Future of Concussion Management

Purpose

To explore the relationship between reaction time (RT) on a commonly used post-concussion computerized neurocognitive assessment and dynamic RT during sport-like movements, with and without a cognitive task.

Methods

Fourteen healthy individuals (7 females; age=22.3±2.5yrs, height=169.1±14.0cm, mass=71.1±16.8kg) completed a computerized Stroop task (CNS Vital Signs), where the individual presses the space bar when the color of the word does not match the word, and two dynamic RT tasks (jump landing [4 trials], anticipated cutting [8 trials]). Dynamic RT tasks were performed with (dual-task) and without (single-task) a cognitive task (subtracting by 6’s or 7’s). Participants jumped off of a 30cm box and then either performed a maximum vertical jump landing or an anticipated cut at 45. Dynamic RT, recorded using high-speed 3D-motion capture (Qualisys), was the average time (seconds) between visual stimulus and when participants’ sacrum moved >3cm in the sagittal or transverse plane. Pearson correlation coefficients (α=0.05) were calculated between all RT measures.

Results

Stroop RT (0.67±0.01s) was not significantly correlated with jump landing single-task (p=0.45; r=0.22), jump landing dual-task (p=0.10; r=0.45), anticipated cutting single-task (p=0.7; r=0.11), or anticipated cutting dual-task (p=0.85; r=0.06) RTs. We found positive correlations between all single- and dual-task dynamic RTs (p=.03, r=.56).

Conclusion

Stroop RT was not correlated with dynamic RTs, which may more closely reflect RT associated with sport participation. Commonly used computerized RT assessments may not fully represent the dynamic RT athletes need in sport tasks. Further investigation is warranted in order to develop the most appropriate RT assessments for post-concussion return-to-play.

A geometrical optics polarimetric bidirectional reflectance distribution function for dielectric and metallic surfaces

A polarimetric bidirectional reflectance distribution function (pBRDF), based on geometrical optics, is presented. The pBRDF incorporates a visibility (shadowing/masking) function and a Lambertian (diffuse) component which distinguishes it from other geometrical optics pBRDFs in literature. It is shown that these additions keep the pBRDF bounded (and thus a more realistic physical model) as the angle of incidence or observation approaches grazing and better able to model the behavior of light scattered from rough, reflective surfaces. In this paper, the theoretical development of the pBRDF is shown and discussed. Simulation results of a rough, perfect reflecting surface obtained using an exact, electromagnetic solution and experimental Mueller matrix results of two, rough metallic samples are presented to validate the pBRDF.

Ferroelectricity in ultrathin BaTiO3 films: probing the size effect by ultraviolet Raman spectroscopy

We demonstrate the dramatic effect of film thickness on the ferroelectric phase transition temperature Tc in strained BaTiO3 films grown on SrTiO3 substrates. Using variable-temperature ultraviolet Raman spectroscopy enables measuring Tc in films as thin as 1.6 nm, and a film thickness variation from 1.6 to 10 nm leads to Tc tuning from 70 to about 925 K. Raman data are consistent with synchrotron x-ray scattering results, which indicate the presence of 180 degrees domains below Tc, and thermodynamic phase-field model calculations of Tc as a function of thickness.

Esomeprazole induces upper gastrointestinal tract transmucosal permeability increase

BACKGROUND

Proton pump inhibitors (PPIs) are one of the most widely used drug classes in the US and are now frontline medications for gastro-oesophageal reflux disease (GERD) and dyspepsia. In a previous work, we observed that a transmucosal, upper gastrointestinal (GI) leak exists in Barrett's oesophagus (BO) patients. PPI medications are commonly used by Barrett's patients.

AIM

To examine if the PPI, esomeprazole, affects the barrier function of the upper GI tract.

METHODS

The sucrose permeability test (SPT) was used to assess the possible effect of the PPI, esomeprazole, on upper GI leak in 37 first-time-presenting GERD patients and 25 healthy controls.

RESULTS

Esomeprazole induced a significant transmucosal leak in the upper GI tract of patients taking the drug for the first time. The leak occurred quickly, within days of first taking the drug. The leak was also reversed within days of stopping the medication.

CONCLUSIONS

This is the first patient-based study showing that a PPI compromises upper GI barrier function. There are potential implications for transmucosal leak of other medications that a patient on a PPI may be taking, as well as possible leak of endogenous peptides/proteins. The clinical consequences of this phenomenon are currently unknown, but are potentially important.

Isolated prostate cancer recurrence presenting as pelvic mass nine years after radical retropubic prostatectomy

Pelvic seeding from radical retropubic prostatectomy for adenocarcinoma of the prostate is uncommon. We describe a patient who presented with a prostate-specific antigen recurrence and was found to have a solitary metastasis adjacent to his pubic bone 9 years after radical prostatectomy. Computed tomography scanning followed by surgery documented the pelvic recurrence.

Transepithelial leak in Barrett's esophagus

Using orally administered sucrose as a probe of gastrointestinal permeability, this study focused on determining whether Barrett's metaplasia exhibits a paracellular transepithelial leak to small nonelectrolytes. Subjects in five separate classes (nonendoscoped, asymptomatic controls; endoscoped, asymptomatic controls; gastroesophageal reflux disease without mucosal complications; grossly visible esophagitis; and Barrett's esophagus) consumed a sucrose solution at bedtime and collected all overnight urine. Urine volume was measured and sucrose concentration was determined by high-performance liquid chromatography. Patients with Barrett's were observed to exhibit a transepithelial leak to sucrose whose mean value was threefold greater than that seen in healthy control subjects or patients with reflux but without any mucosal defect. A parallel study of claudin tight junction proteins in endoscopy biopsy samples showed that whereas Barrett's metaplasia contains dramatically more claudin-2 and claudin-3 than is found in normal esophageal mucosa, it is markedly lower in claudins 1 and 5, indicating very different tight junction barriers.

Simple perineal prostatectomy: lessons learned from a modern series

PURPOSE

Experience with simple perineal prostatectomy has not been well described in the recent literature. We describe our operative technique and compare objective demographic, preoperative, intraoperative and postoperative parameters in patients undergoing open prostatectomy for benign prostatic hyperplasia via 3 routes, namely perineal, retropubic, and suprapubic.

MATERIALS AND METHODS

We retrospectively reviewed all cases of open prostatectomy at Veterans Affairs Medical Center, San Diego between August 2001 and September 2002. A total of 22 patients were identified. Objective parameters were recorded and compared, including patient age, history of urinary retention, ultrasound volume, prostate specific antigen, patient and specimen weight, operative time, estimated blood loss, transfusion requirement, days of hospitalization and postoperative analgesic requirement.

RESULTS

In the 22 patients who underwent open prostatectomy the operative approach was perineal in 6, retropubic in 8 and suprapubic in 8. Operative time and hospital stay were significantly less in the perineal prostatectomy group.

CONCLUSIONS

Simple perineal prostatectomy is a viable alternative for most patients considered candidates for open prostatectomy and it is our preferred approach for obese patients. With perineal prostatectomy patients may expect shorter hospitalization and less analgesic requirement but likely require a longer period of catheter drainage.

Urology practice patterns after residency training in radical perineal prostatectomy

OBJECTIVES

To assess the impact of residency training in radical perineal prostatectomy (RPP) on subsequent use of RPP in urology practice.

METHODS

Urologists who completed residency training at Tulane University and the University of California, San Diego, Medical Center from 1977 to 1999 were surveyed by anonymous questionnaire for their practice demographics, operative experience in RPP during residency, the role of RPP in their current practice, and the reasons they do or do not perform RPP.

RESULTS

Of 91 former residents, 61 (67%) responded. RPP was in current use by 41% of the urologists trained in RPP during residency and by 13% of those with no residency RPP training. Those who had performed 10 or more RPPs during residency reported a higher rate of current RPP use (53%) than did those who had performed fewer than 10 RPPs during residency (21%). Urologists trained in RPP during residency cited partner preference (28%) and inadequate exposure (26%) as reasons they did not perform RPP; respondents with no residency RPP training cited inadequate exposure (25%), difficulty of the operation (25%), and time required to perform the operation (25%).

CONCLUSIONS

A urologist with residency training in RPP is more likely to perform RPP in practice than is a urologist without such training. The intensity of training, in the form of greater operative experience during residency, had a positive impact on the future use of this specialized surgical technique.

Identification of a human telomerase reverse transcriptase peptide of low affinity for HLA A2.1 that induces cytotoxic T lymphocytes and mediates lysis of tumor cells

Telomerase reverse transcriptase (TRT) is a tumor-associated antigen expressed in the vast majority of human tumors and is presently one of the most promising target candidates for a therapeutic cancer vaccine. TRT is also expressed at low level in selected tissues and should be considered a self antigen. In the present study we sought to develop cytotoxic T lymphocytes (CTL) responses directed against human (h)TRT peptides with low relative affinity for which the available repertoire is to be preferentially spared from tolerance. This was accomplished by using analogue peptides of hTRT whose relative affinity for the MHC was increased by a targeted (-->Tyr) substitution in position one. By immunizing HLA A2.1 transgenic mice with these analogue peptides, we identified one such low relative affinity peptide (p572) that is endogenously processed and presented by HLA A2.1 in tumor cells, and is recognized by specific CTL. We used the highly immunogenic analogue peptide to successfully induce TRT-specific CTL in cancer patients and normal donors. CTL against p572-lysed human and mouse tumor cells but not activated autologous B cells. This peptide represents, therefore, an important candidate component of a cancer vaccine based on a TRT substrate and validates the strategy of targeting peptides with low affinity for the MHC for cancer immunotherapy.

Ileal conduit perforation-iatrogenic injury and conservative management

The ileal conduit was popularized by Bricker in the 1950s. Since then, surveillance of the upper urinary tract has been accomplished with intravenous urography, ultrasonography, or loopography. Loopography is used as an imaging modality at our institution because of its safety and avoidance of intravenous contrast. We report the first case of an iatrogenic rupture of an ileal conduit during loopography.

Cytotoxic T cell immunity against telomerase reverse transcriptase in humans

Telomerase is a ribonucleoprotein enzyme which has been linked to malignant transformation in human cells. Telomerase activity is increased in the vast majority of human tumors, making its gene product the first molecule common to all human tumors. The generation of endogenously processed telomerase peptides bound to Class I MHC molecules could therefore target cytotoxic T lymphocytes (CTL) to tumors of different origins. This could advance vaccine therapy against cancer provided that precursor CTL recognizing telomerase peptides in normal adults and cancer patients can be expanded through immunization. We demonstrate here that the majority of normal individuals and patients with prostate cancer immunized in vitro against two HLA-A2.1 restricted peptides from telomerase reverse transcriptase (hTRT) develop hTRT-specific CTL. This suggests the existence of precursor CTL for hTRT in the repertoire of normal individuals and in cancer patients. Most importantly, the CTL of cancer patients specifically lysed a variety of HLA-A2(+) cancer cell lines, demonstrating immunological recognition of endogenously processed hTRT peptides. Moreover, in vivo immunization of HLA-A2.1 transgenic mice generated a specific CTL response against both hTRT peptides. Based on the induction of CTL responses in vitro and in vivo, and the susceptibility to lysis of tumor cells of various origins by hTRT CTL, we suggest that hTRT could serve as a universal cancer vaccine for humans.

Proliferative actinic keratosis: three representative cases

OBJECTIVE

This article describes a new subtype of actinic keratosis that exhibits proliferative characteristics both histologically and clinically. We describe three representative cases occuring in the presence of infiltrative squamous cell carcinoma (SCC) and/or basal cell carcinoma (BCC).

METHODS

Histories of each lesion in the three cases discussed were obtained. The lesions were removed by Mohs micrographic surgery. Permanent sections, stained with hematoxylin and eosin, were examined and studied under light microscopy.

RESULTS

All three lesions had failed conventional treatment with liquid nitrogen and/or 5-fluorouracil (5-FU). Histologic examination of the lesions revealed sheets of dysplastic cells growing along the basal layer of the epidermis and migrating down hair follicles and sweat ducts. An associated infiltrative SCC and/or BCC was found in each case.

CONCLUSIONS

Proliferative actinic keratosis is resistant to standard therapies because of deep migration of abnormal cells along hair follicles and sweat ducts. It has a strong propensity to develop infiltrative SCC and may occur concomitantly with BCC.

New indications for radical prostatectomy

PURPOSE

Radical prostatectomy is considered the gold standard for treatment of localized prostate cancer, either as primary or salvage therapy. Recently with the advent of increased organ transplantation, use of prostatic specific antigen for cancer detection and cryoablation as an alternative treatment, more men with prostate cancer can be considered for radical surgery. We review these new indications.

MATERIALS AND METHODS

Clinically localized untreated prostate cancers were identified in 3 men being considered for cardiac or lung transplantation (group 1), and 4 men originally treated with transperineal cryoablation had local relapse (group 2). All 7 men underwent radical prostatectomy.

RESULTS

Organ confined cancer (pT2C) was found in all 3 patients in group 1. All 3 men underwent successful cardiac or lung transplantation 1 to 12 months after radical prostatectomy, and they are disease-free at short-term followup. Of the group 2 patients 2 had organ confined disease (pT2b and c) and 2 had extensive extraprostatic disease (pT3cN1 and pT3cN0). Only 2 patients remain disease-free and do not require adjuvant endocrine therapy. Major perioperative complications of rectotomy and total incontinence occurred only in group 2 patients.

CONCLUSIONS

Patients being considered for heart and lung transplantation need to be free of concurrent malignancy because of immunosuppressive therapy. Radical prostatectomy can achieve this goal in select patients. Cases of failed cryoablation can be salvaged with radical prostatectomy but with less chance of success and with greater risk of complications.

Elevated stress protein in transitional cells exposed to urine from interstitial cystitis patients

BACKGROUND

It has been hypothesized that urine from interstitial cystitis (IC) patients may contain one or more toxic factors not present in "normal" urine. Bladder tissues exposed to these toxic factors could have elevated stress proteins. If this assumption is correct, stress protein levels could be a useful marker for identifying patients at risk for developing this syndrome.

METHODS

To experimentally investigate this possibility, a sensitive assay (ELISA) was used to measure levels of the 72 kDa stress protein in urothelial target cells after in vitro exposure to urine from IC patients.

RESULTS

We observed a modest 12% increase in 72 kDa stress protein in cells treated with urine from IC patients compared to cells exposed to normal urine (1.12 compared to 0.99 ng/microg extracted protein; P < 0.05). In addition, it was possible to demonstrate the 72 kDa stress protein in histologic sections obtained from mucosal biopsies of IC patients. Stress protein was located primarily in the surface urothelial cells of the mucosa.

CONCLUSIONS

These results seem to indicate that stress protein could play an important protective role at this particular site. They further suggest that IC urine is more toxic than normal urine and, in contact with underlying urothelial and deeper bladder tissue, may upregulate genes involved in stress protein responses. This may be an important concept in the etiology of IC.

Prostate cryoablation: update 1998

Transrectal ultrasound-guided percutaneous transperineal prostate cryoablation has many attractive features both to the patient and to the urologist. The procedure typically can be done in a period of 2 hours or less on an outpatient basis with minimal blood loss and with the patient under regional or general anesthesia. With more experience in using the equipment and the techniques described, urologists can treat all stages of localized prostate cancer with relatively little morbidity. The results of this technique in the treatment of prostate cancer continue to appear promising. With follow-up of 5 years or more available in several series, cryoablation appears to be an effective modality for the eradication of localized prostate cancer, particularly low-volume cancer (PSA less than 10 ng/ml and Gleason score less than 7). Improved results, i.e., undetectable postcryoablation PSA levels and negative biopsies, may occur with modifications such as double freezing and pullback apical freezing. However, the complication rate also may increase with increased tissue destruction. To date, most complications reported have been relatively minor and require limited intervention. Notably, complications, especially incontinence, are significantly greater, in spite of successful eradication of residual tumor, in patients who undergo salvage cryoablation for recurrent disease after radiation therapy. In our experience, transrectal ultrasound-guided prostate cryoablation appears to be effective in controlling local prostate cancer in 81% of patients with minimal morbidity. As with radical prostatectomy and irradiation techniques, longer follow-up is required; however, at this time prostate cryosurgery can be considered in the following situations: as a primary treatment alternative to surgery or irradiation, as salvage treatment for recurrent cancer after irradiation, and for debulking of large symptomatic primary tumors. We look forward to the prospective randomized clinical trial comparing prostate cryoablation with external irradiation.

Cryoablation for carcinoma of the prostate

Percutaneous transperineal cryoablation of the prostate is now available in the armamentarium for treatment of prostate cancer. Technical advances in real-time transrectal imaging of the prostate and improvements in cryosurgical equipment have brought this modality into the limelight of available prostate cancer management. Cryosurgery can be offered to many patients with prostate cancer. However, the main indications for its use include primary treatment for localized disease, salvage therapy after failure of traditional methods, and relief of local symptoms. A historical background, description of the technique, and clinical experience at several medical centers including the University of California San Diego, Allegheny General Hospital, University of Texas M.D. Anderson Cancer Center, and Crittenton Hospital, are presented.

Adjuvant therapy for clinical localized prostate cancer treated with surgery or irradiation

OBJECTIVE

Because of efficacy demonstrated with chemotherapy in patients with metastatic disease, the National Prostate Cancer Project in 1978 initiated two protocols evaluating adjuvant therapy following surgery (Protocol 900) and irradiation (Protocol 1000) for patients with localized disease at high risk for relapse.

METHODS

All patients underwent staging pelvic lymph node dissection. Following definitive treatment, patients were randomized to either cyclophosphamide 1 g/m2 intravenously every 3 weeks for 2 years, estramustine phosphate 600 mg/m2 orally daily for 2 years or to observation only. Accession closed in 1985 and included 184 patients in Protocol 900 (170 evaluable) and 253 in Protocol 1000 (233 evaluable).

RESULTS

Nodal involvement was identified in 198 patients (49% of total): 29% in Protocol 900 and 63% in protocol 1000. Median progression-free survival (PFS) and survival have been greater for patients in Protocol 900 regardless of adjuvant, reflecting their lower pathologic stage. Median PFS is significantly greater for patients in Protocol 1000 receiving estramustine (52.2 months) compared to cyclophosphamide (35.0 months). Median PFS for patients with nodal involvement in Protocol 1000 receiving estramustine is increased (43.5 months) compared to no treatment (21.5 months). Patients with limited nodal involvement in Protocol 1000 have a longer median PFS (45.6 months) compared to patients with extensive disease (23.6 months). But in the latter group patients receiving estramustine experienced a significantly longer median PFS (43.5 months) compared to cyclophosphamide (29.1 months) or no adjuvant (13.5 months). Increased PFS with estramustine adjuvant was also noted in stage C patients (only Protocol 900) and in those with high-grade (grade 3) tumors (both protocols).

CONCLUSIONS

With now over 10 years mean follow-up for this series of patients, we conclude that adjuvant estramustine is beneficial for prostate cancer patients receiving definitive irradiation. This benefit is particularly noted in those patients with extensive nodal involvement (N+, D-1).

Evaluation of adjuvant estramustine phosphate, cyclophosphamide, and observation only for node-positive patients following radical prostatectomy and definitive irradiation. Investigators of the National Prostate Cancer Project

In 1978 the National Prostate Cancer Project launched two protocols evaluating adjuvant therapy following surgery (Protocol 900) or irradiation (Protocol 1,000) for clinically localized prostate cancer. All patients underwent staging pelvic lymphadenectomy. Following definitive treatment, patients were randomized to either cyclophosphamide 1 gram/m2-IV every 3 weeks for 2 years, estramustine phosphate 600 mg/m2-po daily for up to 2 years, or to observation only. Patient accession closed in 1985 and includes 184 to Protocol 900 (170 evaluable) and 253 to Protocol 1,000 (233 evaluable). Lymph node involvement was identified in 198 patients (49% of total), 29% in Protocol 900, 63% in Protocol 1,000. Median progression-free survival (PFS) for patients with nodal involvement in Protocol 1,000 receiving estramustine phosphate adjuvant was longer (37.3 mo) compared to cyclophosphamide (30.9 mo) and to no treatment (20.9 mo). Median PFS for patients with limited nodal disease in Protocol 1,000 was longer (39.9 mo), regardless of adjuvant, compared to extensive nodal disease (20.7 mo). However for patients with extensive nodal involvement, those receiving adjuvant estramustine phosphate experienced a significantly longer median PFS (32.8 mo) compared to adjuvant cyclophosphamide (22.7 mo) and no adjuvant (12.9 mo). We conclude that adjuvant estramustine phosphate is of benefit in prostate cancer patients with extensive pelvic node involvement receiving irradiation as definitive treatment.

Transrectal ultrasound-guided transperineal cryoablation in the treatment of prostate carcinoma: preliminary results

PURPOSE

We studied ultrasound-guided percutaneous cryoablation for treatment of prostate carcinoma.

MATERIALS AND METHODS

Our series includes 83 individuals who underwent transrectal ultrasound-guided transperineal percutaneous cryoablation of the prostate. Prostate specific antigen levels, biopsy results and complications were assessed at 3 months.

RESULTS

Of 61 biopsies 8 (13.1%) were positive for carcinoma (half showed stage D disease). Of patients with stages T1 to T3 cancer 92.6% were free of disease at 3 months. Prostate specific antigen levels were significantly decreased by an average of 1.90 ng./ml. (p < 0.05). Major complications were infrequent, including bladder perforation in 1 patient, urethral strictures in 3, bladder outlet obstruction in 2 and partial incontinence in 2. Impotence was frequent but transient.

CONCLUSIONS

Transrectal ultrasound-guided transperineal percutaneous cryoablation of the prostate produces few major complications and appears at 3 months to be effective in eradicating local prostate tumors. Longer followup is required to test the original hypothesis.

Primary yolk sac tumor of the prostate in a patient with Klinefelter's syndrome

Primary yolk sac (endodermal sinus) tumor of the prostate is extremely rare with only 2 cases reported in the literature. We describe a case of primary yolk sac tumor of the prostate in a man with Klinefelter's syndrome. Treatment included 4 courses of combination chemotherapy followed by retroperitoneal lymph node dissection, cystoprostatectomy and ileal conduit urinary diversion. We review the association of Klinefelter's syndrome with extragonadal germ cell tumor along with the management of this rare disease.

MRI of pelvic neurofibromatosis

Pelvic neurofibromatosis is a rare disease and rarely involves the prostate. A 19-year-old male presented with irritative and obstructive voiding symptoms. Magnetic resonance imaging showed a large mass extending from the sacral promontory to the perirectal and perivesical spaces and to the proximal root of the penis. The mass also involved the prostate. The characteristics of the mass were highly suggestive for neurofibroma. Prostate biopsy showed neurofibroma, and the immunohistochemistry stain for S-100 protein was positive.

Treatment of interstitial cystitis with intravesical heparin

OBJECTIVE

To control the symptoms of interstitial cystitis with chronic self-administered intravesical heparin and determine whether the drug's continued use can sustain remission.

PATIENTS AND METHODS

A total of 48 patients were selected to undergo intravesical heparin therapy, 10,000 units in 10 ml sterile water, three times per week for 3 months. For patients who attained a good clinical remission, therapy was available for up to a further 9 months.

RESULTS

At 3 months 27 of 48 patients (56%) attained good clinical remissions. All were offered continuous therapy and 23 elected for an additional 3 months. Twenty of the 23 continued in remission. Sixteen of these patients elected to have a further 6 months of therapy (12 months total) and 15 of 16 remained in remission.

CONCLUSION

In over half of the patients studied, intravesical heparin controls the symptoms of interstitial cystitis with continued improvement even after one year of therapy.

Distribution and quantification of venous reflux in lower extremity chronic venous stasis disease with duplex scanning

PURPOSE

The purpose of this study was to use color-flow duplex scanning to identify the anatomic distribution of venous reflux and to quantify venous reflux times in patients with various stages of chronic venous insufficiency (CVI).

METHODS

Color-flow-assisted duplex scanning was used to identify the anatomic distribution of venous reflux and to quantify reflux times in the deep and superficial venous systems of patients with symptomatic (CVI). Two hundred two patients with class I to III CVI were examined.

RESULTS

Only 11% (22 patients) had a documented history of phlebothrombosis. Of the 403 limbs evaluated, 192 had venous ulcers whereas 211 were classified as having class I or II CVI. Nonocclusive venous obstruction was found in only 16 limbs (4%). Venous ulceration was significantly associated with reflux in multiple venous segments as opposed to reflux in isolated venous segments (p < 0.001). Total limb reflux time (Rt) was determined by summing the reflux times of all the venous segments in a limb. The mean Rt of patients with venous ulcerations was significantly longer than the mean Rt of limbs with class I and II CVI (p < 0.01). A total limb reflux time of greater than 9.66 seconds was predictive of ulceration. Total limb deep segment reflux time and total limb superficial segment reflux time were also determined by summing the reflux times of the appropriate segments in the limb. The mean deep segment reflux time was prolonged in limbs with venous ulcers when compared with limbs with class I and II CVI disease. The mean superficial segment reflux time of limbs with class I and II CVI and limbs with venous ulcers could not be used to distinguish between the two groups. In assessing the contribution of segments of the deep system to ulceration, reflux times of different segments were compared with wound duration and area. Reflux in the common femoral vein was significantly associated with wound area and duration (p < 0.05) whereas reflux time in the distal posterior tibial vein was associated with wound duration (p < 0.05).

Polyarteritis nodosa presenting as acute orchitis: a case report and review of the literature

We report a case of polyarteritis nodosa initially presenting as acute orchitis and review 4 similar reports in the literature. Of the cases 2 were diagnosed preoperatively. In 2 cases in which immunological markers were measured abnormal values were obtained. All 5 cases required biopsy for diagnosis.

Adjuvant therapy for localized prostate cancer

BACKGROUND

In 1978, the National Prostatic Cancer Project launched two protocols evaluating adjuvant therapy after surgery (Protocol 900) or irradiation (Protocol 1000) for clinically localized prostate cancer. All patients underwent staging pelvic lymphadenectomy.

METHODS

After definitive treatment, the patients were randomized either to receive cyclophosphamide 1 g/m2 intravenously every 3 weeks for 2 years or estramustine phosphate 600 mg/m2 orally daily for up to 2 years or to undergo observation only. Patient accession closed in 1985 and includes 184 patients in Protocol 900 (170 evaluable) and 253 in Protocol 1000 (233 evaluable).

RESULTS

Lymph node involvement was identified in 198 patients (49% of total), 29% in Protocol 900 and 63% in Protocol 1000. The median progression-free survival (PFS) and survival were greater for patients in Protocol 900 compared with 1000, regardless of the adjuvant therapy. This reflected the greater proportion of patients with lower pathologic stage disease in the surgically treated group. The median PFS was significantly greater for all patients in Protocol 1000 receiving estramustine phosphate adjuvant (48.2 months) compared with patients randomized to receive cyclophosphamide (35.6 months). The median PFS for patients with nodal involvement in Protocol 1000 who received estramustine phosphate adjuvant was prolonged significantly (37.3 months) compared with no treatment (20.9 months). The median PFS for patients with limited nodal disease in Protocol 1000 was longer (39.9 months), regardless of the adjuvant therapy, compared with those with extensive nodal disease (20.7 months). However, in the latter patient group, those receiving adjuvant estramustine phosphate had a significantly longer median PFS (32.8 months) compared with those receiving adjuvant cyclophosphamide (22.7 months) or no adjuvant therapy (12.9 months).

CONCLUSION

Adjuvant estramustine phosphate was beneficial in patients with prostate cancer and pelvic node involvement who received irradiation as definitive treatment.

Clinical diagnosis of prostate cancer

BACKGROUND

The clinical diagnosis of localized prostate carcinoma in the asymptomatic male has been based on a careful digital rectal examination (DRE).

METHODS

The DRE, prostate specific antigen (PSA), transrectal ultrasonography (TRUS), prostate needle biopsy (PNB), and other modalities are examined for their role in prostate cancer diagnosis.

RESULTS

Up to 20% of localized prostatic cancer is still diagnosed "retrospectively" on transurethral resection (TURP) for clinically benign disease and prostatism. The role of fine-needle aspiration (FNA), flow cytometric study (FCM), and magnetic resonance imaging (MRI) in the diagnosis of prostate cancer is limited.

CONCLUSIONS

Those men older than 50 years of age who have lower tract symptoms, either obstructive or irritative, or who have abnormal serum levels of PSA, regardless of DRE findings, are advised to undergo TRUS with ultrasound-guided PNB.

Natural history of an adrenal myelolipoma

Adrenal myelolipomas are rare, benign neoplasms composed of mature fat and bone marrow elements. Most are small, asymptomatic tumors found incidentally at postmortem examination. We report the natural history of an adrenal myelolipoma in a middle-aged woman during a 4-year interval.

Post-prostatectomy urinary incontinence: response to behavioral training

Urinary incontinence after prostatectomy can be psychologically and socially disabling. We reviewed our experience with 27 patients who were incontinent between 5 and 198 months after either radical retropubic, total perineal or transurethral prostatectomy. These patients were entered into our bladder behavior clinic, which was administered by nursing staff with physician supervision. Patients were strongly encouraged to discontinue the incontinence devices, and were then evaluated for the type and extent of incontinence. Perineal exercises were demonstrated in detail, tested for their correct use via simultaneous rectal and abdominal examination, and applied to the pattern of incontinence. Patients were evaluated frequently for compliance and their progress was followed with instruction repeated as needed. Pharmaceutical agents were not used. Among the 24 patients evaluable over-all improvement in the number of incontinent episodes was 56.6% (p less than 0.001). Two patients (8.3%) achieved total continence, 10 (42%) improved greatly, 4 showed moderate improvement and 8 (33%) showed essentially no change. Transurethral and perineal prostatectomy patients improved by 74 and 61%, respectively, versus only 33% in the radical retropubic group (p = 0.14). In addition, patients who previously underwent transurethral resection before total prostatectomy did worse (18%) than did those who did not (67%). We conclude that a significant number of patients who are incontinent after prostatectomy (especially those without a prior transurethral resection) can improve dramatically with a behavioral training program that provides a strong support system.

Extracorporeal shock-wave lithotripsy for stones in solitary kidney

Twelve extracorporeal shock-wave lithotripsy (ESWL) treatments were performed on 10 patients with a solitary kidney. Nine patients had a ureteral stent placed pretreatment. Nine patients were available for follow-up. Seven (78%) were stone free or had insignificant fragments at three months. Complications were seen in 4 patients, including two instances of pyelonephritis. Failures were associated with an increased stone burden. ESWL is an effective and safe treatment for upper urinary tract stones in patients with a solitary kidney. We recommend pretreatment stenting in patients with a solitary kidney.

Identification and significance of dysmorphic versus isomorphic hematuria

Hematuria may be of glomerular or nonglomerular origin. Dysmorphic erythrocytes are found in the urine of patients with glomerular bleeding, whereas isomorphic erythrocytes characterize nonglomerular or urological hematuria. Urine specimens from 100 patients with microscopic hematuria were collected: 50 had a known glomerular pathological condition and 50 had urological disease. Scanning electron microscopy of the urine specimens showed a marked difference in morphology between dysmorphic and isomorphic red blood cells. This differentiation can be made with a simpler instrument, the standard Coulter counter. Accurate prediction of glomerular versus nonglomerular hematuria was made in 97 of the 100 patients by Coulter counter analysis. The test is rapid, simple and readily reproducible. A permanent graphic record of the red blood cell morphology can be obtained for each patient. Identification of glomerular versus nonglomerular hematuria can be of practical use in the clinical management of patients.

Prognosis in stage D-1 prostate cancer relative to anatomic sites of nodal metastases. National Prostatic Cancer Treatment Group

The investigators of the National Prostatic Cancer Treatment Group (NPCTG) have entered 212 patients with surgically confirmed stage D-1 prostate cancer in studies to determine the efficacy of adjuvant therapy after either definitive surgery (Protocol 900) or definitive radiotherapy (Protocol 1000). Follow-up indicates that this group represents 70% of all patients with recurrent disease. Because patients with less than 20% nodal involvement were found to have a statistically significant better progression-free-survival (PFS) than those with greater than 20% nodal involvement, we examined the exact anatomic sites of nodal metastases. The status of obturator, external iliac, internal iliac, and common iliac nodes was compared to PFS and overall survival in 198 patients with D-1 disease in both protocols. Results demonstrate no significant difference in either PFS or overall survival relative to anatomic sites of positive nodes. These data suggest that although minimal pelvic nodal metastasis is consistent with improved PFS, there is no predictable anatomic distribution of disease consonant with that better prognosis.

Peyronie's disease: surgical experience and presentation of a proximal approach

A total of 29 patients underwent 32 operations for correction of penile curvature. Of these patients 22 underwent placement of a semirigid prosthesis and 94 per cent of those available for followup were able to resume coitus. Of the 8 patients who underwent operative correction of penile curvature and who maintained potency only 3 (38 per cent) were able to resume intercourse. Vascular compromise and/or skin slough after degloving of the penile skin was noted in 3 patients. A proximal approach to penile reconstruction is presented.

Reversible inactivation of bladder surface glycosaminoglycan antibacterial activity by protamine sulfate

Prior studies in our laboratory have shown that the bladder surface is lined with glycosaminoglycans which appear to be an important antibacterial defense mechanism that operates by resisting bacterial adherence and infection. The present study further implicates bladder surface glycosaminoglycans as the key antiadherent factor and also suggests a potential model for diseases (such as urinary tract infections) whereby the antiadherent surface of the bladder is inactivated biochemically. Protamine sulfate treatment of bladder tissue was found to significantly increase bacterial adherence to the urinary bladder by approximately 2.3-fold. This effect was reversed by a second treatment of the bladder with pentosanpolysulfate (a polysaccharide known to duplicate the surface antiadherent effect). Protamine sulfate had no effect on bacterial viability or bacterial adherence when bacteria were pretreated with it.

National survey of patterns of care for testis cancer

A national survey of testicular cancer documented recent trends in disease characteristics, treatment, and outcome, providing a basis for progress being achieved on a community basis. A long-term study of 3285 patients diagnosed between 1970 and 1975 was compared with a short-term study of 1887 patients diagnosed in 1983. An increase of the symptom of a lump in the testis from 23.1% to 31.2% and a mass as a sign of cancer from 44.5% to 53.8% suggests earlier detection of testis cancer by the patient and physician. Changes in the methods of diagnosis reflect the changing technology of tumor diagnosis. The 10-year survival rates for pathologic Stage I seminoma (82.6% of all seminomas) exceeded 96%. For pathologic Stage I nonseminomatous germ cell tumors (51.7% of all NSGCT), 10-year survival was 87.1%; whereas for Stage III (18.7% of all NSGCT) it was 22.1%. The impact of the important advances in chemotherapy is reflected in the increase of 1-year survival of Stage III NSGCT from 50.5% to 78.4%. Testis cancer can be cured in most patients.

Trends in patterns of care for prostatic cancer, 1974-1983: results of surveys by the American College of Surgeons

Data from a recent survey of patterns of care for prostatic cancer sponsored by the American College of Surgeons suggest several trends compared to similar data from a decade ago. The observed differences include increased diagnosis of localized cancer, and increased use of acid phosphatase determinations, bone scans, radical retropubic prostatectomy, radiotherapy (particularly interstitial techniques) and orchiectomy. In contrast, use of bone surveys, perineal prostatectomy and hormonal therapy has decreased. Transurethral resection continues to be the most common means to establish the diagnosis of prostatic cancer but the data do suggest that in more patients the tumors are being staged and graded. Five-year survival rates appear to be improving for all stages, and for white and black patients. Survival of black patients continues to lag behind that of white subjects, presumably owing to the more advanced stage of disease at diagnosis observed in these data. These findings may have important implications for understanding trends in survival of patients with this disease.