Need For Invasive Interventions Research Articles

Light-degradable hydrogels as dynamic triggers for gastrointestinal applications.

Triggerable materials capable of being degraded by selective stimuli stand to transform our capacity to precisely control biomedical device activity and performance while reducing the need for invasive interventions. Here, we describe the development of a modular and tunable light-triggerable hydrogel system capable of interfacing with implantable devices. We apply these materials to two applications in the gastrointestinal (GI) tract: a bariatric balloon and an esophageal stent. We demonstrate biocompatibility and on-demand triggering of the material in vitro, ex vivo, and in vivo. Moreover, we characterize performance of the system in a porcine large animal model with an accompanying ingestible LED. Light-triggerable hydrogels have the potential to be applied broadly throughout the GI tract and other anatomic areas. By demonstrating the first use of light-degradable hydrogels in vivo, we provide biomedical engineers and clinicians with a previously unavailable, safe, dynamically deliverable, and precise tool to design dynamically actuated implantable devices.

Cardiac Rhythm Management Devices and Ablation Procedures in Psychiatric Patients

Psychiatric patients often present with symptoms similar to those indicating the need for a cardiac rhythm management device or even cardiac arrhythmia ablation. However, due to the unreliability of symptom self-reporting, the ability of the underlying neuropsychiatric condition to elicit similar phenomena, and the perceived reduced compliance and increased complication rates among this population, both of the above approaches remain underutilized with often detrimental effects. In the present case series, it is attempted to describe an alternative, electrophysiology study-guided approach to these patients, aiming to both firmly establish the need for invasive intervention (including implantation of pacemakers – three cases, implantable cardioverter-defibrillators – three cases, and electrophysiological ablations – two cases), as well as dispel preconceptions, bordering on stigma, regarding their outcomes.

Evaluation of clinical risk factors for developing pleural empyema secondary to liver abscess

BackgroundThe aim of this study was to investigate the clinical manifestation and predictive risk factors of pleural empyema developing during treatment of the pyogenic liver abscess.MethodsMedical records of patients with the liver abscess in our institution were reviewed retrospectively. Enrolled patients were classified into four groups; Group 1: patients without pleural effusion, Group 2: patients with pleural effusion and who were treated noninvasively, Group 3: patient with pleural effusion and who were treated with thoracentesis, and Group 4: patients with pleural effusion that developed into empyema. Patient characteristics, clinical manifestation, and possible risk factors in development of empyema were analyzed.ResultsA total of 234 patients was enrolled in this study. The incidence rate of empyema was 4.27% (10 patients). The mean interval for developing pleural effusion was 5.6 ± 6.35 days. In multivariate analysis, risk factors for developing pleural effusion included the location of the liver abscess near the right diaphragm (segment 7 and 8, OR = 2.30, p = 0.048), and larger diameter of the liver abscess (OR = 1.02, p = 0.042). Among patients who developed pleural effusions, presences of mixed microorganisms from culture of liver aspirates (OR = 10.62, p = 0.044), bilateral pleural effusion (OR = 46.72, p = 0.012) and combined biliary tract inflammation (OR = 21.05, p = 0.040) were significantly associated with the need for invasive intervention including surgery on effusion.ConclusionThe location of the liver abscess as well as pleural effusion, elevated inflammatory markers, and combined biliary tract inflammation may be important markers of developing pleural complication in patients with pyogenic liver abscess.

Reduction of invasive interventions in severely obese with osteoarthritis after bariatric surgery.

Osteoarthritis (OA) affects 56,000,000 Americans, 30% with obesity. Their risk of developing OA is 5 times higher. With each extra kilogram above ideal weight, the risk of OA increases to 13%. The study aim is to describe changes in OA treatment after undergoing bariatric surgery (BS). After IRB approval, we conducted a retrospective analysis of all severely obese patients and OA that underwent laparoscopic adjustable gastric banding, laparoscopic sleeve gastrectomy (LSG), and laparoscopic Roux-en-Y gastric bypass from 2004 to 2018. Changes of OA severity were assessed based on the requirement of invasive intervention (INI) at 12 and 24months after BS. INI was defined as the need for surgical drainage; articular injection; and surgical interventions such as meniscectomy, total hip replacement, and total knee replacement. A total of 11.52% (N = 486) had OA diagnosed prior to BS, the most common location being unilateral hip 31.1% (N = 151). A total of 35.2% (N = 159) of patients required pain management (PM) for OA at 12months. Of these, 90% (N = 144) required only INI and 5.6% (N = 9) required PM only. Baseline and postoperative BMI were associated to need for INI. At 12months, the 66.7% (N = 301) who did not require INI had a baseline BMI of 44.70 ± 8.22 and total weight loss percent (TWL%) of 14.29 ± 13 (P = 0.05; 95% CI 0.96-1.00). LSG patients were the majority compared to other procedures (44.5%; N = 134). On the other hand, 64.3% (N = 175) did not require INI at 24months and had a baseline BMI of 17.82±17.4 and TWL% of 2.43 ± 6 (P = 0.003; 95% CI 1.04-1.25). The risk to require INI was reduced by 69.9% at 12months and 80% at 24months. Need for pain medications at 12months was reduced by 96.9%. According to this study data, bariatric surgery reduces the need for INI in patients with OA. The effect seems to be related to the amount of weight loss. Additional studies conducted on a larger scale are necessary to validate findings.

Can the Need for Invasive Intervention in Tubo-ovarian Abscess Be Predicted? The Implication of C-reactive Protein Measurements

To evaluate the clinical parameters of hospitalized patients with pelvic inflammatory disease (PID) for the presence of tubo-ovarian abscess (TOA) and predict the need for intervention. A prospective cohort study. A tertiary care university medical center. Ninety-four patients were diagnosed with complicated PID and hospitalized between 2015 and 2017. Patients with PID were treated with parenteral antibiotics according to Centers for Disease Control guidelines. Demographic, clinical, sonographic, and laboratory data for patients with PID were analyzed. Inflammatory markers including C-reactive protein (CRP), white blood cells (WBCs), erythrocyte sedimentation rate (ESR), and clinical parameters were collected at admission and during hospitalization. Forty-eight of 94 patients (51.1%) hospitalized with complicated PID were diagnosed with TOA sonographically. CRP levels were the strongest predictor of TOA, followed by WBC count, ESR, and fever on admission. The areas under the receiver operating characteristic (ROC) curve for CRP, WBC, ESR, and fever were .92, .75, .73 and .62, respectively. CRP specificity was 93.4% and sensitivity was 85.4% for predicting TOA, with cutoff value of 49.3 mg/L. Twelve patients (25%) failed conservative management and underwent surgical intervention including laparoscopy (n = 7), computed tomography (CT)-guided drainage (n = 4), and laparotomy (n = 1). In this group, CRP levels significantly increased from admission to day 1 and day 2 during hospitalization (128.26, 173.75, and 214.66 mg/L, respectively; p < .05 for both). In the conservative management group, CRP levels showed a plateau from admission to day 1 and then a decrease until day 3 (110, 120.49, 97.52, and 78.45 mg/L, respectively). CRP is a sensitive, specific inflammatory marker for predicting TOA in patients with complicated PID, and levels >49.3 mg/L suggest the presence of TOA. In the TOA group, CRP level trends correlated well with success or failure of conservative management. Increasing CRP levels during treatment may be used as an indicator of the need for invasive intervention, and daily CRP measurements can help predict the need for invasive intervention.

Fatal reversible cerebral vasoconstriction syndrome: A systematic review of case series and case reports

ObjectiveTo describe patient characteristics, radiological findings and the clinical course of adults with fatal reversible cerebral vasoconstriction syndrome (RCVS). MethodsA systematic literature search from January 1, 2000, until December 31, 2018, was performed using PubMed, EMBASE, Scopus, Cochrane reviews, LILACS and Scielo. Studies reporting RCVS in adult patients with fatal outcomes were included. Results430 studies were initially identified, 179 full-text articles were reviewed, and 9 publications describing 12 subjects were included. The vast majority of the reports were from the U.S. Most of the female cases occurred during postpartum. All patients had a headache on initial presentation, although only 42% had thunderclap headache. A CT scan was performed on 67% of the patients. Imaging results were diverse, with a tendency toward cerebral hemorrhage followed by mixed cases. The main course of treatment included steroids (58% of the patients), with only 42% receiving nimodipine. The time to death ranged from 4 to 14 days, with a median of 9.2 days (SD ± 3.2). ConclusionWe found that the majority of fatal cases reported in the literature are most likely related to postpartum angiopathy. We established a tendency in the onset of brain hemorrhage and the combination of infarction and brain hemorrhage. We described various markers for poor prognosis, including focal signs, the presence of hemorrhage and infarct in the first diagnostic image obtained and the need for invasive interventions. The majority of fatal cases in our report occurred in women, with over half of those cases during the puerperium period.

Minimally invasive hepatectomy reduces major morbidity and hospital resource utilization in the elderly

Background: Elderly patients undergoing liver resection are at increased risk for surgical morbidity and mortality. Previous studies suggest minimally invasive hepatectomy (MIH) is associated with some improved peri-operative outcomes compared to open hepatectomy (OH), such as decreased length of stay (LOS) and blood loss. We aimed to determine whether MIH (laparoscopic, robotic, both, or assisted) compared to OH may mitigate increased peri-operative risks in elderly patients undergoing liver resection for all indications. Methods: 13,775 patients undergoing elective liver resections (sub-segmentectomy excluded) from 2014-2016 were identified in the participant use file from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) with hepatectomy targeted procedure variables. Elderly (Age ≥ 75 years) were compared to non-elderly patients with respect to risk-adjusted surgical mortality, major morbidity, and hospital resource utilization. Major morbidity was defined as any reoperation, invasive intervention, or end organ failure. Major hepatectomy was defined as any trisectionectomy or hemihepatectomy compared to partial hepatectomy. Multivariable logistic regression models were constructed to evaluate outcomes between MIH and OH in the elderly subgroup, controlling for variables identified on baseline demographic analysis to be significant confounders of the intervention-outcome association. Effect modification by extent of hepatectomy was also evaluated. Results: On multivariable analysis, elderly patients had increased risk of 30-day mortality (OR = 2.8, P < 0.001), major morbidity (OR = 1.2, P = 0.021), post-hepatectomy liver failure (OR = 1.5, P = 0.015), prolonged LOS (OR = 1.5, P < 0.001), and discharge to destination other than home (OR = 4.2, P < 0.001). When examining the effect of MIH on outcomes in the elderly subgroup on multivariable analysis, MIH compared to OH was associated with decreased risk of major morbidity (OR = 0.66, P = 0.038), postoperative invasive interventions (OR = 0.47, P = 0.018), bleeding requiring transfusion (OR = 0.37, P < 0.001), and prolonged LOS (OR = 0.49, P < 0.001), but no effect on mortality and other relevant outcomes was seen [Table]. These results were not modified by the extent of hepatectomy performed. Conclusion: In a prospective, multi-center, and nationally representative sample, MIH compared to OH improves perioperative major morbidity, need for invasive interventions, bleeding requiring transfusion, and prolonged LOS in the elderly. There were no significant differences between MIH and OH in the elderly with respect to mortality, reoperation, post hepatectomy liver failure, bile leak, discharge disposition other than home, and readmission. Elderly patients may benefit from MIH for both major and minor hepatectomy.

Can We Predict the Need for Invasive Intervention in Tubo-Ovarian Abscess? The Implication of C-Reactive Protein Measurements

Objective: To evaluate the clinical parameters of hospitalized patients presenting with pelvic inflammatory disease (PID) for the presence of tubo-ovarian abscess (TOA) and predicting the need for invasive intervention in patients with TOA.

Diagnosis of Intramuscular Cysticercosis by High-resolution Ultrasonography: A Prospective Hospital Based Study

Background: Cysticercosis is one of the common infectious disease, the extraneural tissues are usually involved synchronously or metachronously with the brain in this disease. Isolated infestation of soft tissue and muscle in the absence of neural involvement is more common than previously known. High resolution ultrasonography has evolved now as an investigation of choice with proven sonological patterns of soft tissue cysticercosis which has reduced the need for invasive interventions. Methods: Prospective evaluation of total 9 cases of extraneural cysticercosis over a period of 6 months at Prakash institute of Medical Sciences and Research. HRUSG analysis of 9 cases was done to evaluate and classify the various classic sonomorphological features of isolated cysticercosis involving soft tissue and muscles. FNAC was done only in 3 cases. Results: Around 9 patients were selected on the basis of inclusion and exclusion criteria. Among 9 cases, 5 were male and 4 were female patients. Three individuals were vegetarian and five were non vegetarian. Mean age was 35 years. All cases were diagnosed on HRUSG. Intramuscular lesion was identified in 7 cases and 2 cases had subcutaneous involvement with anterior abdominal wall in muscular plane as the commonest site in three patients. FNAC was done in 3 cases confirming the cysticercosis and was treated surgically. Conclusions: With the advent of high resolution ultrasonography and increased clinical awareness of the isolated soft tissue-intramuscular cysticercosis especially in endemic zone, a more conservative non-invasive approach can be applied both in diagnosis and treatment of these isolated cases of cysticercosis.

Pattern of MRI Findings in Patients with Low Back Pain at National Orthopaedic Hospital, Enugu Nigeria

BACKGROUND: Low back pain is a major cause of referral to the Spine clinic. In the adult population 50% - 90% may present with low back pain at least once in their life time. Currently, the gold standard for diagnosing the etiology of low back pain is MRI. The protocol at NOHE is to request MRI for patients whose clinical patterns are indicative for invasive intervention. OBJECTIVE: To determine the pattern of MRI findings in patients with low back pain attending spine clinic at NOHE. METHODS: This is a retrospective study of 60 MRI of adult patients with low back pain with clinical need for invasive intervention. The scan was carried out with A Basda BTI 0.35T MRI System using the standard protocol, with sagital and axial T1 and T2-weighted and STIR. Images were from Onis 2.5 digital co. limited. RESULT: Thirty five (58.3%) were males while 25 (41.7%) were females with majority aged between 40 - 59 years. About 90% of the images had disc prolapse while 73% had disc height reduction. The commonest cause of spinal canal stenosis was disc prolapse, thickened ligamentum flavum, spondylolisthesis and osteophytes. Six (10%) of the patient did not have any lesion on MRI. L4/5 was the commonest affected segment while 90% of abnormal cases had multilevel involvement. CONCLUSION: There is high yield of diagnosis with MRI scan among low back pain patients with clinical need for invasive intervention, hence an excellent navigating tool. L4/L5 disc level remains the commonest culprit.

High-Risk Prehospital Mechanisms in Tier II Trauma Codes: An Analysis of Under-Triage at a Level II Trauma Center

Under-triage is used as a surrogate for trauma quality. We sought to analyze factors that may impact under-triage at our institution by a detailed analysis of prehospital mechanisms and patient factors that were associated with the need for invasive intervention, intensive care unit monitoring, or death. Patients admitted to our Level II trauma center who met the criteria for under-triage using the Cribari method were studied, n = 160, and prominent mechanisms were motor vehicle collisions (MVCs). Patient demographics, detailed mechanism characteristics, ED vital signs, operative intervention, and outcomes were studied. The age of the study group and injury severity score were 42 ± 20 and 22 ± 6, respectively. Alcohol or drug use was common as were high-speed frontal collisions. Overall, 38 per cent of patients required surgery, and a monitored bed was required in 60 per cent of patients. Logistic regression identified drug use as predictive of mortality and MVC speeds ≥40 mph as predictive of intensive care unit admission. Patients requiring surgery had a high incidence of frontal collisions, 40 per cent. MVCs were predominant in under-triaged trauma patients. Operative intervention, intensive care unit monitoring, and deaths were associated with frontal impacts, high speeds, and drug use. Further study is warranted to assess the incorporation of high-risk injury patterns in triage algorithms aimed at enhancing trauma quality.

An international multicenter study of early intravenous fluid administration and outcome in acute pancreatitis.

Early aggressive fluid resuscitation in acute pancreatitis is frequently recommended but its benefits remain unproven. The aim of this study was to determine the outcomes associated with early fluid volume administration in the emergency room (FVER) in patients with acute pancreatitis. A four-center retrospective cohort study of 1010 patients with acute pancreatitis was conducted. FVER was defined as any fluid administered from the time of arrival to the emergency room to 4 h after diagnosis of acute pancreatitis, and was divided into tertiles: nonaggressive (<500 ml), moderate (500 to 1000 ml), and aggressive (>1000 ml). Two hundred sixty-nine (26.6%), 427 (42.3%), and 314 (31.1%) patients received nonaggressive, moderate, and aggressive FVER respectively. Compared with the nonaggressive fluid group, the moderate group was associated with lower rates of local complications in univariable analysis, and interventions, both in univariable and multivariable analysis (adjusted odds ratio (95% confidence interval): 0.37 (0.14-0.98)). The aggressive resuscitation group was associated with a significantly lower need for interventions, both in univariable and multivariable analysis (adjusted odds ratio 0.21 (0.05-0.84)). Increasing fluid administration categories were associated with decreasing hospital stay in univariable analysis. Early moderate to aggressive FVER was associated with lower need for invasive interventions.

Effects of early contrast-enhanced computed tomography onclinical course and complications in patients with acute pancreatitis.

To investigate the effect of an early contrast-enhanced computed tomography (CECT) on clinical course and complications of acute pancreatitis (AP). 58 patients with AP who had at least one CECT examination were analyzed retrospectively. Laboratory as well as clinical data, and results from the assessment of disease severity (CT severity index (CTSI) and its modified (MCTSI) version) were analyzed. The primary endpoint was the development of severe complications, defined as death, respiratory failure, acute renal failure, and the need for invasive interventions. Patients were divided into two groups: an early group (CECT within the first 48 h after the onset of symptoms, n = 32) and a late group (CECT > 48 h after the onset of symptoms, n = 26). Multivariate regression analysis was performed to identify risk factors for severe complications. There were no statistically significant differences between both groups concerning baseline characteristics, CTSI, and MCTSI. Complications occurred more often in the early CECT group (p = 0.008). Multivariate logistic regression analysis identified an early CECT and a severe MCTSI as independent risk factors for the occurrence of severe complications (p = 0.02 and p = 0.002, respectively). CECT performed within the first 48 h after the onset of symptoms is associated with an unfavorable outcome in AP.

Tuberous Sclerosis and Bilateral Renal Angiomyolipomas: A Case Report and Literature Review of Emerging Treatment Strategies.

Tuberous sclerosis complex is a rare multisystemic genetic disorder associated with the development of benign hamartomas. Angiomyolipomas are one such characteristic finding that may be seen in 55–80% of tuberous sclerosis complex patients. While being normally asymptomatic, they can also cause significant morbidity and mortality. We present the case of a patient with tuberous sclerosis complex and recently discovered bilateral renal angiomyolipomas, admitted for hematuria who underwent left renal artery embolization; however, worsening renal function necessitated subsequent nephrectomy. Despite still being mainstays of treatment, invasive interventions are now being recommended for specific patient populations as demonstrated in our case. Emerging strategies targeting the PI3K/AKT/mTOR pathway have been shown to reduce the size of angiomyolipomas and are now used to treat asymptomatic cases >3 cm. Our review discusses these treatment options with the intention of increasing awareness of current recommendations and hopefully leading to increased application of these novel therapies that will reduce the need for invasive interventions.

Fibrinogen concentrate versus placebo for treatment of postpartum haemorrhage: study protocol for a randomised controlled trial.

BackgroundPostpartum haemorrhage (PPH) is a major cause of maternal morbidity. Bleeding is caused by a combination of physical causes, such as failure of the uterus to contract or operations, and is made worse by impairment of the blood clotting system. A number of studies have shown that low levels of the blood clotting factor fibrinogen are associated with progression of bleeding, the need for invasive interventions and transfusions of red blood cells and fresh frozen plasma (FFP). This trial will investigate whether early infusion of fibrinogen concentrate during a major PPH, with the aim of correcting a low fibrinogen to a level that is normal for delivery, based on the Fibtem test, reduces the total number of allogeneic blood products (red blood cells, FFP, cryoprecipitate and platelets) transfused after study medication until discharge, compared to placebo.Methods/designThis is a prospective, randomised, double-blind placebo controlled trial. Women will enter an observational phase and if their Fibtem levels fall they will be randomised in the interventional phase. A total of 60 women will be randomised and women are eligible for the trial if they meet all of the following inclusion criteria: age 18 years or over, gestation ≥24 + 0 weeks, haemorrhage of about 1500 ml and on-going bleeding without another complication or haemorrhage of about 1000 ml and caesarean section/uterine atony/placental abruption/placenta praevia/cardiovascular instability or microvascular oozing. Participants with a Fibtem A5 < 16 mm will be randomly allocated to receive either a bolus infusion of fibrinogen concentrate or placebo (isotonic saline). The dose of fibrinogen concentrate or placebo will be calculated based on the woman’s ideal body weight for height and the measured Fibtem A5 with the aim of increasing the Fibtem A5 to 23 mm.DiscussionThe trial aims to provide evidence on the efficacy and safety of fibrinogen concentrate during acute bleeding in an obstetric setting.Trial registrationISRCTN ref: ISRCTN46295339 (01.07.2013); EudraCT: 2012-005511-11 (28.11.2012), UKCRN ref: 13940.

Risk Factors and Outcome of Splanchnic venous thrombosis in Patients with necrotizing acute pancreatitis

BackgroundSplanchnic venous thrombosis (SVT) is considered a rare but important complication in patients with acute pancreatitis (AP) and literatures regarding this topic were sparse. The aim of the present study was to investigate the risk factors of SVT in necrotizing acute pancreatitis (NAP) and assess the prognosis of these patients. MethodsBoth univariate and multivariate logistic regression analyses were applied using 15 indices including age, gender, Acute Physiology and Chronic Health Evaluation II scores (APACHE II), CRP (C - reactive protein) levels, etc to explore potential risk factors for the development of SVT in NAP patients. Moreover, clinical outcome measures such as mortality, organ failure and length of hospital and ICU stay were also compared between NAP patients with or without SVT. ResultsAccording to the statistical results, only intra-abdominal pressure (IAP) was proved to be an independent risk factor for SVT (OR, 1.283; 95% CI, 1.091–1.509,P=0.003). In addition, Balthazar’s CT score and occurrence of IPN (infected pancreatic necrosis) also reached statistical significance (P=0.040 and 0.047, respectively), but the 95% confidence interval shown in the multivariate logistic regression suggested that the observed ORs are not significant (1.326;95% CI 0.984-1.787 and 2.61;95 CI 0.972-7.352, respectively), which indicates weaker association between the two parameters and SVT. Regarding the clinical outcomes, patients with SVT showed higher mortality, longer hospital and intensive care unit duration, higher rates of a variety of complications and more utilization of invasive interventions. ConclusionsIAP is an independent risk factor for the development of SVT in patients with NAP, while Balthazar’s CT score and occurrence of IPN are also associated with SVT, although not as strong as IAP. Moreover, occurrence of SVT relates with extremely poor prognosis in NAP patients, evidenced by increased mortality, morbidity and need for invasive interventions.

The predictive value of proteinuria in acute pancreatitis

Background/objectivesAcute pancreatitis has a highly variable clinical course. Early and reliable predictors for the severity of acute pancreatitis are lacking. Proteinuria appears to be a useful predictor of disease severity and outcome in a variety of clinical conditions. This study aims to investigate the predictive value of proteinuria on admission for the severity of acute pancreatitis compared with other commonly used predictors; the APACHE II score, Modified Glasgow score and C-reactive protein (CRP). MethodsThis is a post-hoc analysis of 64 patients admitted with acute pancreatitis treated in one teaching hospital, who participated in a previous randomized trial. Proteinuria was defined as a Protein/Creatinine (P/C) ratio >23 mg/mmol. The primary endpoint was severe acute pancreatitis. Secondary endpoints included infectious complications, need for invasive intervention, ICU stay and in-hospital mortality. ResultsProteinuria was present in 30/64 patients (47%). Eleven patients (17%) had severe acute pancreatitis. There was no difference in incidence of severe acute pancreatitis between patients with and without proteinuria: 6/30 patients (20%) versus 5/34 patients (15%) respectively (p = 0.58). Likewise, the occurrence of infectious complications, need for intervention and ICU stay and mortality did not differ significantly (p = 0.58, p = 0.99, p = 0.33 and p = 0.60 respectively). The diagnostic performance of the P/C ratio for the prediction of severe pancreatitis was inferior to the Modified Glasgow score (p = 0.04) and CRP (p = 0.03). ConclusionProteinuria on admission does not seem to be a reliable predictor for disease severity in acute pancreatitis. The diagnostic performance of the P/C ratio is inferior to the Modified Glasgow score and CRP.

A palliative care intervention for pain refractory to a percutaneous cordotomy

Intrathecal analgesia and radiofrequency techniques for tumor ablation are employed for palliation of symptoms. These interventions are efficacious in a select number of patients for controlling pain and improving quality of life. Careful selection of an appropriate candidate must be performed to prevent needless, invasive, and costly interventions, as interventional pain management alone will not treat total pain in cancer patients. We describe here a patient who experienced intractable pain and unsuccessfully underwent cordotomy but responded to the interdisciplinary (IDT) palliative care approach in an acute palliative care unit (APCU). A middle-aged female with ovarian cancer metastatic to the left psoas muscle and the supraclavicular and retroperitoneal lymph nodes was admitted with severe left thigh and flank pain. She had been unsuccessfully treated with different opioid regimens, hypogastric nerve block, epidural steroid injection, and cordotomy. The palliative care team was consulted while awaiting placement of an intrathecal pump. The patient was subsequently transferred to the APCU for symptom management and transition to hospice. On admission, her morphine equivalent daily dose (MEDD) was 660 mg. Our IDT--composed of a physician, fellow, nurse practitioner, counselor, chaplain, social worker, and physical and occupational therapists--was able to identify several sources of distress that likely contributed to her expression of pain. Our IDT focused on frequent counseling, improving her function, provided medication education, discussed goals of care, and educated about hospice. She was discharged to hospice care with good pain control and an 85% reduction in her MEDD. An APCU approach involving an IDT alleviated the need for invasive interventions by diagnosing and treating the psychosocial, emotional, and spiritual distress contributing to the patient's total pain expression. Successful management must be reflective of rigorous assessment of the physical, psychological, spiritual, social, and practical aspects before consideration of more invasive treatments.

Alpha-blockers as medical expulsive therapy for ureteral stones

Urinary stone disease is one of the most common reasons for patients visiting a urology practice, affecting about 5% to 10% of the population. Annual costs for stone disease have rapidly increased over the years and most patients with ureteral colic or other symptoms seek medical care. Stone size and location are important predictors of stone passage. In most cases medical expulsive therapy is an appropriate treatment modality and most studies have been performed with alpha-blockers. Alpha-blockers tend to decrease intra-ureteral pressure and increase fluid passage which might increase stone passage. Faster stone expulsion will decrease the rate of complications, the need for invasive interventions and eventually decrease healthcare costs. A study on the effect of alpha-blockers as medical expulsive therapy in ureteral stones is therefore warranted. This review aimed to answer the following question: does medical treatment with alpha-blockers compared to other pharmacotherapy or placebo impact on stone clearance rate, in adult patients presenting with symptoms of ureteral stones less than 10 mm confirmed by imaging? Other clinically relevant outcomes such as stone expulsion time, hospitalisation, pain scores, analgesic use and adverse effects have also been explored. We searched the Cochrane Renal Group's Specialised Register to 9 July 2012 through contact with the Trials Search Co-ordinator using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE and EMBASE, handsearching conference proceedings, and searching the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. Randomised controlled trials (RCTs), comparing alpha-blockers with other pharmacotherapy or placebo on ureteral stone passage in adult patients were included. Two authors independently assessed study quality and extracted data. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes. Reporting bias was investigated using funnel plots. Subgroup analysis was used to explore possible sources of heterogeneity. Sensitivity analysis was performed removing studies of poor methodological quality. Thirty-two studies (5864 participants) were included. The stone-free rates were significantly higher in the alpha-blocker group (RR 1.48, 95% CI 1.33 to 1.64) when compared to standard therapy. Stone expulsion time was 2.91 days shorter with the use of alpha-blockers (MD -2.91, 95% CI -4.00 to -1.81). Use of alpha-blockers reduced the number of pain episodes (MD -0.48, 95% CI -0.94 to -0.01), the need for analgesic medication (diclofenac) (MD -38.17 mg, 95% CI -74.93 to -1.41) and hospitalisation (RR 0.35, 95% CI 0.13 to 0.97). Patients using alpha-blockers were more likely to experience adverse effects when compared to standard therapy (RR 2.74, 95% CI 1.38 to 5.45) or placebo (RR 2.73, 95% CI 1.50 to 4.96). Most adverse effects were mild of origin and did not lead to cessation of therapy, and several studies reported no adverse events in either the treatment or control group.In 7/32 studies patients and doctors were both blinded. In the other studies blinding was not described in the methods or no blinding had taken place. Two studies described incomplete data and only one study showed a relatively high number of patients who withdrew from the study. These factors limited the methodological strength of the evidence found. The use of alpha-blockers in patients with ureteral stones results in a higher stone-free rate and a shorter time to stone expulsion. Alpha-blockers should therefore be offered as part of medical expulsive therapy as one of the primary treatment modalities.

Clinical characteristics and management of late symptom flare following stereotactic body radiation therapy for clinically localized prostate cancer.

194 Background: Stereotactic body radiation therapy (SBRT) is increasingly utilized as primary treatment for clinically localized prostate cancer. While acute urinary symptoms are well recognized, late toxicities of SBRT have not been fully described. Here, we characterize the clinical features of late symptom flare and describe symptom management approaches. Methods: Two hudred sixteen patients with clinically localized prostate cancer were treated with SBRT between February 2008 and January 2011 at Georgetown University Hospital. Twenty-nine patients who experienced late-symptom flare were included in this retrospective analysis. Treatment was delivered using the CyberKnife (35 Gy to 36.25 Gy in five fractions). Prevalence of urinary toxicities was determined using CTCAE v.4. Patient-reported urinary symptoms were assessed using the American Urological Association Symptom Score (AUA) and the Expanded Prostate Cancer Index Composite (EPIC) short form. Results: Median age was 66 with 55% being of African descent. Late grade 2 frequency/urgency peaked at 12 months (17.2%), then returned to baseline at 18 months. Late grade 2 retention peaked at 18 months (65.5%), then returned to baseline at 24 months. Late grade greater than or equal to 1 dysuria peaked at nine months (25.0%), then returned to baseline at 24 months. Alpha-antagonist usage peaked at 18 months (85%) then decreased at 24 months. At 12 months, 21% required anti-inflammatories and/or urethral analgesics. Median AUA score rose from a baseline of 6 to 15 at 12 months, then returned to baseline by 24 months. EPIC urinary function and bother scores dropped to a nadir at 9 to 12 months post-treatment, then returned to baseline at 24 months. Conclusions: Symptom flare is a late syndrome consisting of various degrees of urinary frequency/urgency, retention and dysuria. It occurs approximately one year following SBRT, resolves spontaneously, and urinary function returns to baseline by two years. Early identification and initiation of conservative symptomatic management may decrease the need for invasive interventions. Anticipatory counseling prior to treatment may limit bother due to these transient urinary symptoms.