Natural history of early, localized prostate cancer: a final report from three decades of follow-up

BACKGROUND

Most localized prostate cancers are believed to have an indolent course. Within 15 yr of diagnosis, most deaths among men with prostate cancer (PCa) can be attributed to other competing causes. However, data from studies with extended follow-up are insufficient to determine appropriate treatment for men with localized disease.

OBJECTIVE

To investigate the long-term natural history of untreated, early-stage PCa.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a population-based, prospective-cohort study using a consecutive sample of 223 patients with untreated, localized PCa from a regionally well-defined catchment area in central Sweden. All subjects were initially managed with observation. Androgen deprivation therapy was administered when symptomatic tumor progression occurred.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Based on >30 yr of follow-up, the main outcome measures were: progression-free, cause-specific, and overall survival, and rates of progression and mortality per 1000 person-years.

RESULTS AND LIMITATIONS

After 32 yr of follow-up, all but 3 (1%) of the 223 men had died. We observed 90 (41.4%) local progression events and 41 (18.4%) cases of progression to distant metastasis. In total, 38 (17%) men died of PCa. Cause-specific survival decreased between 15 and 20 yr, but stabilized with further follow-up. All nine men with Gleason grade 8-10 disease died within the first 10 yr of follow-up, five (55%) from PCa. Survival for men with well-differentiated, nonpalpable tumors declined slowly through 20 yr, and more rapidly between 20 and 25 yr (from 75.2% [95% confidence interval, 48.4-89.3] to 25% [95% confidence interval, 22.0-72.5]). It is unclear whether these data are relevant for tumors detected by elevated prostate-specific antigen levels.

CONCLUSIONS

Although localized PCa most often has an indolent course, local progression and distant metastasis can develop over the long term, even among patients considered low risk at diagnosis.

Synthesis of Activated 3-Arylindoles

A wide range of substituted 3-aryl-4,6-dimethoxyindoles (6) has been synthesized from the related α-anilinoacetophenones (5), in which the nitrogen atom is protected by a trifluoroacetyl or acetyl group. This method has led to the synthesis of a 3,7′-biindolyl (12).

FBXW7 regulates DISC1 stability via the ubiquitin-proteosome system

Disrupted in schizophrenia 1 (DISC1) is a multi-functional scaffolding protein that has been associated with neuropsychiatric disease. The role of DISC1 is to assemble protein complexes that promote neural development and signaling, hence tight control of the concentration of cellular DISC1 in neurons is vital to brain function. Using structural and biochemical techniques, we show for we believe the first time that not only is DISC1 turnover elicited by the ubiquitin proteasome system (UPS) but that it is orchestrated by the F-Box protein, FBXW7. We present the structure of FBXW7 bound to the DISC1 phosphodegron motif and exploit this information to prove that disruption of the FBXW7-DISC1 complex results in a stabilization of DISC1. This action can counteract DISC1 deficiencies observed in neural progenitor cells derived from induced pluripotent stem cells from schizophrenia patients with a DISC1 frameshift mutation. Thus manipulation of DISC1 levels via the UPS may provide a novel method to explore DISC1 function.

Muscle mercury and selenium in fishes and semiaquatic mammals from a selenium-deficient area

The aim of this study was to investigate and compare total mercury (Hg), selenium (Se), and Se:Hg molar ratios in fish muscles (phytophages n=3; benthophages n=32; predators n=5) and semiaquatic carnivores, including piscivores (the European otter n=8, the feral American mink n=7) and the omnivorous raccoon (n=37) from a riverine European ecosystem in a Se-deficient area. The Hg concentration in fish reached 0.337μg/g dry weight, dw (0.084μg/g wet weight, ww). We found significant differences among Hg levels in tested vertebrate groups (predators vs benthophages: 0.893 vs 0.281μg/g; piscivores vs omnivores: 6.085 vs 0.566μg/g dw). Fish groups did not differ in Se concentrations, with a mean value of 0.653μg/g dw. Significant differences were revealed between Se levels in piscivorous and omnivorous carnivores (0.360 vs 0.786μg/g dw, respectively). Fish Se:Hg molar ratio values were >2.2. Benthophages had higher the ratio than predators but similar to phytophages. Among carnivores, piscivores had much lower the ratio than raccoon (0.14 vs 3.75) but raccoon and fish medians did not significantly differ. We found almost two times higher Se levels in fish and raccoons compared to piscivores, possibly resulting from lower fish Se digestibility by piscivores in contrast to higher absorption of plant Se by many fish and omnivorous raccoons. Considering that a tissue Se:Hg molar ratio <1 may be connected with a Hg toxicity potential increase, we assume that piscivores in Se-deficient area are in worse situation and more exposed to Hg than fish and omnivores.

Brains of Native and Alien Mesocarnivores in Biomonitoring of Toxic Metals in Europe

Mercury (Hg), lead (Pb) and cadmium (Cd) are involved in mammalian brain damage. However, little is known about Pb and Cd brain levels in wildlife that reflect the geochemical background. The aims of the study include the estimation of Hg, Pb and Cd concentrations, and the determination of relationships between these elements in the brains of 94 mesocarnivores. Road-killed or hunted animals were obtained from north-western Poland near the Polish-German border. The investigation covered the native Eurasian otter Lutra lutra, badger Meles meles, pine marten Martes martes, beech marten M. foina, European polecat Mustela putorius, red fox Vulpes vulpes, and alien species: feral and ranch American mink Neovison vison, raccoon Procyon lotor and raccoon dog Nyctereutes procyonoides. Depending on the diet and environmental pollution, the carnivore brains accumulated toxic metals in varying amounts. The highest median Hg levels (in mg/kg dry weight, dw) were found in the piscivorous Eurasian otter and feral mink (2.44 and 3.96), Pb in the omnivorous raccoon (0.47), while Cd in minks (~0.06). We indicated that Pb-based ammunition is a significant source of the element in scavengers from hunting area, and we also found a significant correlation between Pb and Cd levels in the fox brain. Finally, this study is the first to suggest background levels for brain Pb and Cd in mesocarnivores (<0.50 and <0.04 mg/kg dw, respectively).

A NEW DICROCOELIID FROM THE BANK VOLE CLETHRIONOMYS GLAREOLUS (RODENTIA: MICROTIDAE) FROM POLAND

A new dicrocoeliid trematode, Brachylecithum glareoli n. sp., is described from the biliary ducts of the bank vole, Clethrionomys glareolus, in southwest Poland. This is the first dicrocoeliid species described in rodents from Poland. It is characterized mainly by the maximum body width at the level of the vitellaria; large, longitudinally oval testes; round, or transversely oval, ovary that is smaller than the testes; vitellaria located in the midbody; cirrus sac dorsally overlapping ventral sucker, but never reaching beyond half of its length; and large, distinctly elongated eggs.

Worldwide Use of Antiretropulsive Techniques: Observations from the Clinical Research Office of the Endourological Society Ureteroscopy Global Study

INTRODUCTION

Retropulsion, defined as unintended migration of a stone under the influence of the fragmentation device in ureteroscopy (URS) procedures, occurs in 2% to 60% of the cases. Antiretropulsive devices (ARDs) have been studied in experimental and small clinical studies. The current study aims at describing the worldwide usage of ARD and the outcomes related to their usage.

METHODS

The Clinical Research Office of the Endourological Society URS Global Study enrolled 11,885 patients who underwent URS and stone fragmentation for ureteral and/or renal stones. Of the 11,885 treated patients, 9877 were treated for ureteral stones, and data were available on stone migration and ARD use.

RESULTS

Of all procedures, 14.5% were performed with the use of an ARD. Less stone migration (-2.0%; p = 0.050), higher stone-free rates (SFRs) (2.8%; p < 0.001), and shorter length of stay (-4.7%; p = 0.001) were observed in the antiretropulsive group.

CONCLUSIONS

When an ARD is used during URS, less migration, higher SFRs, and shorter length of hospital stay are observed. This effect is independent from baseline differences and corrected for other treatment characteristics.

Searching for ivermectin resistance in a Strongylidae population of horses stabled in Poland

BACKGROUND

There are no available studies describing the possible resistance of strongyles to ivermectin in horses in Poland. One hundred seventy three horses from nine stud farms from South-Western Poland were studied. The effectiveness of ivermectin was studied on the 14th day after ivermectin administration using the fecal egg count reduction test, and a long-term observation of the egg reappearance period was carried out. The fecal study was carried out using a modified McMaster method, which typically detects 20 eggs per gram of stool. The results were subjected to statistical analysis that enabled quantification of the eggs in the stool samples.

RESULTS

The study revealed high efficacy of ivermectin on the 14th day after administration without a shortening of the egg reappearance period.

CONCLUSION

The results indicate that strongyles resistance to ivermectin in Poland is not a serious problem.

[A mobile app for patients suffering from kidney stones]

BACKGROUND AND OBJECTIVES

Kidney stone disease has become an important worldwide socioeconomic issue. However, metaphylaxis fails due to low compliance rates. Therefore, we developed a mobile app (StoneMD: Kidney Stones) for patients with kidney stones to increase compliance in stone metaphylaxis.

MATERIALS AND METHODS

To identify the most appropriate design of the app, we searched through the App Store and the Google Play Store and integrated the clinical recommendations of the European Association of Urology (EAU) and the American Urological Association (AUA). To test the value of this app, a questionnaire was developed in which the patient should answer questions about the drinking behavior and the subjective use of the app in the field of metaphylaxis.

RESULTS

StoneMD: Kidney Stones offers the opportunity to calculate the individual risk of a new stone episode. In addition, the app offers several features to raise awareness of lifestyle modification, including hydration as metaphylaxis of urolithiasis, reminder of inserted ureteral stents and document the self-measured urine pH. A total of 49 patients participated in the questionnaire: 89.8% (n = 46) of these patients had a smartphone, 73.9% reported a daily intake of <2.5 l, 76.5% of these patients believe that their drinking behavior is positively influenced by the app, 71.7% stated that the app for relapse prevention is more suitable than traditional information brochures, 56.5% want to continue to use the app.

CONCLUSIONS

StoneMD: Kidney Stones is the first mobile app for stone metaphylaxis. StoneMD might help to improve patient compliance and might lower the risk of stone formation.

Finding the optimal candidate for shock wave lithotripsy: external validation and comparison of five prediction models

We aimed to externally validate five previously published predictive models (Ng score, Triple D score, S3HoCKwave score, Kim nomogram, Niwa nomogram) for shock wave lithotripsy (SWL) single-session outcomes in patients with a solitary stone in the upper ureter. The validation cohort included patients treated with SWL from September 2011 to December 2019 at our institution. Patient-related variables were retrospectively collected from the hospital records. Stone-related data including all measurements were retrieved from computed tomography prior to SWL. We estimated discrimination using area under the curve (AUC), calibration, and clinical net benefit based on decision curve analysis (DCA). A total of 384 patients with proximal ureter stones treated with SWL were included in the analysis. Median age was 55.5 years, and 282 (73%) of the sample were men. Median stone length was 8.0 mm. All models significantly predicted the SWL outcomes after one session. S3HoCKwave score, Niwa, and Kim nomograms had the highest accuracy in predicting outcomes, with AUC 0.716, 0.714 and 0.701, respectively. These three models outperformed both the Ng (AUC: 0.670) and Triple D (AUC: 0.667) scoring systems, approaching statistical significance (P = 0.05). Of all the models, the Niwa nomogram showed the strongest calibration and highest net benefit in DCA. To conclude, the models showed small differences in predictive power. The Niwa nomogram, however, demonstrated acceptable discrimination, the most accurate calibration, and the highest net benefit whilst having relatively simple design. Therefore, it could be useful for counselling patients with a solitary stone in the upper ureter.

The risk of cholelithiasis in patients after heart transplantation

INTRODUCTION

Extended immunosuppressive treatment in patients after heart transplantation modifies etiopathogenesis and occurrence of many diseases in this population. The aim of the present study was to evaluate the frequency and to define risk factors for cholelithiasis after heart transplantation (HTX).

MATERIAL AND METHODS

The study population consisted of 176 subjects. Of them, 24 patients (group A) presented with symptomatic cholelithiasis. Another group of 24 patients without cholelithiasis (group B) served as controls. Both groups were similar with respect to age, gender and follow-up after the transplant. Clinical interview, surgical and hospitalization data were collected from medical records.

RESULTS

The groups did not differ in demographic features. There were statistical differences (p < 0.05) between group A and B in rejection reaction, doses of immunosuppressive drugs, type 2 diabetes, serum lipid disorders and acute rejection episodes. These events were caused by modification of treatment, especially the immunosuppressive regimen. Group A consisted of 75% men and 25% women. The frequency of symptomatic cholelithiasis was 11.7% in men and 27.3% in women, on average 19.5%. Mean time to cholelithiasis following HTX was 37.9 ±4.9 (Me = 41.5) months, 27.7 ±8.2 (Me = 30.0) months in women and 41.3 ±5.9 (Me = 41.5) months in men. The female to male ratio was 2.3: 1.

CONCLUSIONS

Cholelithiasis following HTX was significantly more frequent as compared with the non-transplant population. Patients with cholelithiasis required more aggressive immunosuppression because of more frequent episodes of acute transplant rejection. Patients with cholelithiasis significantly more frequently showed increased glycemia and blood lipids, which could be the side effect of intensive immunosuppressive therapy.

Ureteroscopy: a population based study of clinical complications and possible risk factors for stone surgery

Introduction

The aim of this study was to describe the complications of ureteroscopy (URS) and to investigate whether performing URS outside normal working hours leads to increased risk for clinically significant complications.

Material and methods

A cohort of 486 consecutive patients treated with URS, with a total of 567 sessions between 2009 and 2015 at Helsingborg/Ängelholm Hospital, Sweden, was analyzed. Outcome was complications within 14 days after URS treatment.

Results

We found no increased risk of complications related to URS performed outside normal working hours. Stone-free rate (SFR) in the distal third of the ureter was 95.2% (315/331), in the middle ureter 92.8% (90/97), in the proximal ureter 84.0% (63/75) and 69.0% (40/58) in renal pelvis. The overall complication rate was 10.6% (n = 60). None of the potential risk factors for complications showed any significance when adjusted for age and gender. We found an inverse relationship between stenting and SFR (p = 0.002). The most common preoperatively cultured bacteria was Escherichia coli. With adequate antibiotics, there was no increased risk of complications. There was an increased risk of complications after URS related to age, but not with gender.

Conclusions

URS in modern setting provides excellent results with adequate SFR and low morbidity. Time of day, the presence of urological specialized operating nurses did not affect the risk of complications and we found no other significant risk factors for complications. Escherichia coli was the most commonly found bacteria in preoperative cultures. The risk of complications increases with age. For patients >65 years old, this should be considered in preoperative counseling.

Total Mesorectal Excision for Mid-Rectal Cancer Without Anastomosis: Low Hartmann’s Operation or Intersphincteric Abdomino-Perineal Excision?

Background and Aims:

In mid-rectal cancer, the low colorectal anastomosis is, although feasible, sometimes avoided. The aim was to compare low Hartmann’s procedure with intersphincteric abdomino-perineal excision of the rectum, in patients operated with total mesorectal excision for mid-rectal cancer in whom the low anastomosis was technically feasible but for patient-related reasons undesired.

Material and Methods:

A total of 64 consecutive patients with mid-rectal cancer who underwent low Hartmann’s procedure (n = 34) or intersphincteric abdomino-perineal excision (n = 30) at one colorectal unit were compared regarding patient demography, short-term oncology, surgical outcome at 3 and 24 months, and long-term overall survival.

Results:

There were no significant differences between intersphincteric abdomino-perineal excision and Hartmann’s procedure regarding age, gender distribution, body mass index, preoperative radiotherapy, tumor level, or cancer stages. Operation time was shorter in Hartmann’s procedure as compared with intersphincteric abdomino-perineal excision, median 174 and 256 min, (P < 0.001), and intraoperative blood loss was increased, 600 and 500 mL, respectively (P = 0.045). Number of lymph nodes and circumferential resection margin were comparable. In Hartmann’s procedure compared with intersphincteric abdomino-perineal excision, the need for reoperation was 24% and 3%, (P = 0.020), complications classified as Clavien–Dindo 3–4 occurred in 32% and 10%, (P = 0.031), pelvic abscess in 21% and 10%, (P = 0.313), and mortality within 90 days was 3% and 0%, respectively, (P = 0.938). In intersphincteric abdomino-perineal excision, the perineal wound was not healed at 3 months in 13%, and in Hartmann’s procedure 15% had chronic secretion from the anorectal remnant at 2 years postoperatively.

Conclusion:

The results from this study suggest that intersphincteric abdomino-perineal excision might be an alternative to Hartmann’s procedure in patients with mid-rectal cancer, in whom a low colorectal anastomosis is undesired.

Radiological signs of stone impaction add no value in predicting spontaneous stone passage

Stone size and location are key factors in predicting spontaneous stone passage (SSP), but little attention has been paid to the influence of radiological signs of stone impaction (RSSI). This research aims to determine whether RSSI, alongside stone size, can predict SSP and to evaluate the consistency of ureteral wall thickness (UWT) measurements among observers. In this retrospective study, 160 patients with a single upper or middle ureteral stone on acute non-enhanced computed tomography (NCCT) were analysed. Patient data were collected from medical records. Measurements of RSSI, including UWT, ureteral diameters, and average attenuation above and below the stone, were taken on NCCT by four independent readers blind to the outcomes. The cohort consisted of 70% males with an average age of 51 ± 15. SSP occurred in 61% of patients over 20 weeks. The median stone length was 5.7 mm (IQR: 4.5-7.3) and was significantly shorter in patients who passed their stones at short- (4.6 vs. 7.1, p < 0.001) and long-term (4.8 vs. 7.1, p < 0.001) follow-up. For stone length, the area under the receiver operating characteristic curve (AUC) for predicting SSP was 0.90 (CI 0.84-0.96) and only increased to 0.91 (CI 0.85-0.95) when adding ureteral diameters and UWT. Ureteral attenuation did not predict SSP (AUC < 0.5). Interobserver variability for UWT was moderate, with ± 2.0 mm multi-reader limits of agreement (LOA). The results suggest that RSSI do not enhance the predictive value of stone size for SSP. UWT measurements exhibit moderate reliability with significant interobserver variability.

Impact of emergency computed tomography on treatment and time to treatment for renal colic

OBJECTIVE

The aim of this study was to evaluate the utilization and impact of emergency computed tomography (CT) on the management of renal colic, focusing on treatment decisions, time to treatment and the subsequent need for additional emergency department (ED) visits.

MATERIALS AND METHODS

Retrospective analysis of patient visits to the ED in Helsingborg with a diagnosis of urolithiasis (ICD codes N20-23) between July 1, 2019 and June 30, 2020.  Results: Out of 64,263 visits, 1.4% (880) visits were related to urolithiasis, involving 612 patients. Emergency CT (within 24 h) was performed in 43% of the cases, with an additional 9% undergoing CT at a subsequent emergency visit. Radiological confirmation of kidney or ureteral stone was found in 324 patients, of which 63% (204) required no treatment. Comparison between patients who underwent emergency CT and those who did not, revealed a significantly shorter time to treatment and closure in the emergency CT group. The median time to treatment was 28 days for those with an emergency CT and 59 days for those without (P < 0.001), acute surgery excluded. The median time to closure was 31 days for emergency CT compared to 37 days without emergency CT (P < 0.010), acute surgery excluded.

CONCLUSION

In this study, the use of emergency CT shortened the time to treatment and rendered the patient stone free earlier compared to deferred diagnostics, with a note of caution that emergency CT may have led to increased surgical treatments for stones that might otherwise have passed spontaneously.

CLINICALTRIALS

gov Identifier: NCT06535711.