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Nebraska Hospital Uses Team Approach to Reduce UTIs in Rehab Patients

In a 300-bed Nebraska rehabilitation hospital, nurses, occupational and physical therapists, case managers and education staff have successfully implemented a team approach to dramatically reduce infections from urinary catheters, the most common type of infection contracted from healthcare settings.

According to an abstract presented at the 38th Annual Educational Conference and International Meeting of the Association for Professionals in Infection Control and Epidemiology (APIC), the team reduced catheter associated urinary tract infections (CAUTIs) by 89 percent over a 14-month period.

The team worked to decrease the use of catheters, which are a known risk factor for UTIs, discontinuing their use unless medically necessary.  In cases where urinary catheters were necessary, the team educated nursing staff, family members and patients on proper care to reduce the chance of infection.  The team was led by infection preventionist Kristina Felix, BA, RN, CRRN, CIC.

When the project started in February 2010, the CAUTI prevalence rate was 36.6 percent but dropped to 6.6 percent three months later.  The original pilot concluded in April 2011.  The team identified reasons for catheter use when medical necessity was in question.  These factors included patients admitted to rehabilitation settings from acute care facilities with catheters in place, and patients whose families viewed catheters as a more convenient way to manage incontinence.

This task force improved bladder management protocols and standards, balancing the medical requirements of the patient with the need for patients to be infection-free, continually re-assessing the appropriateness for each catheter.

Felix estimates that this program prevented up to thirty UTIs each month and saved the facility about $1,000 per infection avoided.  No additional costs were associated with implementing these interventions.

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No Significant Association Found Between Androgen Deprivation Therapy and Cardiovascular Death

Treatment with androgen deprivation therapy (ADT) does not significantly increase the risk of cardiovascular mortality according to evaluation of mortality data in a large registry of men treated for prostate cancer.

ADT is commonly used to treat prostate cancer.  Some studies have shown that it may increase the risk of cardiovascular disease, but other studies have not confirmed the association and it remains controversial.  The authors of the recent study tried to explore the evidence further by analyzing the patients registry CAPSURE (Cancer of the Prostate Strategic Urologic Research Endeavor), which includes men with confirmed prostate cancer recruited from 40 mostly community-based US urological practices.

Men who are diagnosed with localized prostate cancer between 1995 and 2007 were included in the analysis, and in order to try to control for factors that may confound the relationship between ADT and cardiovascular death, patients who used and did not use ADT were matched by their propensity to receive ADT.  These patients were categorized into three groups: primary ADT monotherapy, local treatment plus ADT, and watchful waiting/active surveillance (WW/AS).  Initial outcomes were associations between treatment and cardiovascular cause, prostate cancer, and other causes.  Study investigators assessed cause of death using death certificates.

At the point of data capture, there were 13,887 men in the registry, of whom 7,248 were eligible for the analysis.  The majority (71.3%) received local treatment only, 6.7% received local treatment plus ADT, 15% received primary ADT, and 7 percent WW/AS.  It was found that 21.7% received AFT at some point.  Nine hundred seventy six of these men died during the study period, 1.4% from prostate cancer, 2.7% from cardiovascular disease, and 9.4 percent due to other causes.  Patients treated with ADT or WW/AS had a higher likelihood of death due to prostate cancer than those treated just with local therapy.

The largest risk of cardiovascular death was in those treated with WW/AS compared to those only receiving local therapy.  The difference for those treated with local therapy plus ADT was not significant.

The authors’ conclusion is that the increased rate of cardiovascular death in the WW/AS group compared to the ADT group suggests that there are possibly unmeasured variables that affect treatment selection and that confound the association between ADT and cardiovascular death.  The research team notes that when patients were match on propensity to receive ADT, there was no significant association.  The limitation so the study included the relatively small number of deaths in some groups, and the assignment of cause of death from death certificates.

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Botox Approved in Ireland for Treatment of Urinary Incontinence

The Irish Medicines Board has approved Botulinum toxin type A to treat urinary incontinence management in adults with neurogenic detrusor overactivity (NDO).

Neurogenic detrusor overactivity results from nuerogenic bladder due to multiple sclerosis or stable sub-cervical spinal cord injury.

Allergan Inc. has said that this step is important in securing national licenses in fourteen European countries that are involved in the Mutual Recognition Procedure.  The positive opinion came after the Irish regulatory agency evaluated Allergan’s successful global Phase III program.

Bladder dysfunction affects approximately 60 percent to 80 percent of people with multiple sclerosis (MS) and 75 percent to 80 percent of those with spinal cord injury (SCI), including urinary incontinence.

Both MS and SCI patients often have bladders which contract during the filling stage, during which time they should be relaxed.  This condition is known as neurogenic detrusor overactivity, which can result in uncontrolled urinary leakage, known as urinary incontinence.

When Botox is injected into the bladder muscle, the involuntary contractions subside and bladder activity increases, resulting in fewer urinary leaking incidents.  Sometimes the problem is completely resolved.

Urinary incontinence can often be a socially isolating and disabling condition. People who suffer from it frequently experience low self esteem, loss of independence, embarrassment, and depression.   MS and SCI patients with urinary incontinence are also more likely to develop skin irritations and ulcers, recurrent and kidney failure.

Douglas Ingram, President of Allergan in Europe, Africa and the Middle East, said that Allergan was pleased about the Irish Medicines Board’s decision.

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Saturation Biopsy Detects More Cancers

According to a new report, analysis of 20 to 24 biopsy cores is superior to analysis of 12 to 14 cores for detecting prostate cancer in men who’ve had a normal prostate biopsy in the past.

J. Stephen Jones, M.D., from Cleveland Clinic, Ohio said, “We have shown that transrectal saturation biopsy is as easy and safe to perform as standard biopsy while detecting almost 1/3 more cancers. With these findings, we are confident that this approach offers benefit with negligible downside.”

Jones did however caution that it would be premature to suggest that this should be made universal for a number of reasons.  First, this has only been shown in one study.  Second, this must be balanced against the potential to detect clinically insignificant cancers that we might be better not knowing about even though saturation biopsy detected almost a third more cancers and had equivalence complication rates.

Jones and colleagues compared the results of extended and saturation prostate biopsy protocols in a first repeat prostate biopsy population of 1056 men (393 with a 12 to 14-core extended biopsy and 663 with a 20 to 24-core saturation biopsy.  The authors reported their findings in the Journal of Urology. The detection rate was significantly higher in the saturation biopsy group than in the extended biopsy group.  Over a third of the positive biopsies (37.8%), however, met predetermined criteria for clinical insignificance, and there was a trend toward increased detection of clinically insignificant cancer in saturation compared to extended biopsies (40.1 percent compared to 32.6 percent).

For higher-risk populations, detection rates were higher for saturation biopsy than for extended biopsy, but the differences did not reach statistical significance.  The increased detection with saturation biopsy was significant for men whose initial biopsy was completely normal.

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Study Finds Strong Association Between Smoking and Risk for Bladder Cancer

Data from a large cohort study showed that smoking’s contribution to bladder cancer risk increased over the past 25 years, and the attributable risk in women caught up with that of men.

Current smokers increased risk of bladder cancer by four times compared to people who never smoked.  The risk among former smokers two times that of people who never smoked.  Previous cohort studies had shown about a threefold increased risk of bladder cancer among current smokers.

According to a recent article published in JAMA, smoking accounted for about half of the population-attributable risk of bladder cancer in men and women alike.

This apparent association between smoking and bladder cancer could reflect changes in cigarette manufacturing.

From the 1980s, the rates of bladder cancer in the U.S. has remained stable, ranging from 123.8 to 142.2 cases per 100,000 person-years in men, and from 32.5 to 33.2 cases per 100,000 person-years in women.

The authors noted in their introduction that the prevalence of smoking and cigarette composition have changed considerably during the same period, which perhaps changes the nature of the association between smoking and bladder cancer.

Neal D. Freedman, PhD, of the National Cancer Institute in Bethesda, Md., and co-authors revisited risk estimates for smoking and bladder cancer by examining data from the National Institutes of Health-American Association of Retired Persons (NIH-AARP) Diet and Health Study.

The NIH-AARP cohort study had follow-up data through December 31, 2006.  The participants, who were ages 50 to 71 at enrollment, completed a lifestyle questionnaire during 1995 and 1996.  This follow-up continued until the end of the study, a diagnosis of bladder cancer, a move outside the study’s catchment area, or death.

State cancer registries provided bladder cancer diagnoses information.  The foma; analysis included 281,394 men and 186,134 women.  During 4,518,941 person-years of follow up, 3,896 men had new diagnoses of bladder cancer, resulting in an incidence of 144 per 100,000 person-years.  During this same follow-up period, 627 women had a new diagnosis of bladder cancer for an incidence of 34.5 per 100,000 person-years.  Rates among people who never smoked were 69.8 and 16.1 per 100,000 person-years in men and women, respectively.  These rates increased to 154.6 and 276.4 per 100,000 person-years among men who were former or current smokers. Corresponding rates in women were 40.7 and 73.6 per 100,000 person-years.

The research team performed a systematic review and meta-analysis of prospective cohort studies of current smoking and bladder cancer started between 1963 and 1987.

Limitations of the study included lack of information on the year smoking had started and lack of follow-up data on smoking after the baseline survey to know how many people may have quit.

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Stem Cell Injections Better than Collagen Injections in Treating Stress Urinary Incontinence

A new study from Austria has found that injections of stem cells and other cells obtained from a woman’s own body can treat stress urinary incontinence with dramatically better results than conventional collagen injections.

These results mimic those from U.S. research that is underway and might also be long-lasting.

The study appears in The Lancet. The Austrian researchers, led by Hannes Strasser, MD, from the Medical University of Innsbruck, compared the effects of the stem cell injections with conventional injections of collagen in 63 women with stress urinary incontinence.

The team first performed a small muscle biopsy on the upper arms of the 42 women assigned to get stem cell injections.  In the laboratory, the women received myoblasts, a type of muscle stem cell, and fibroblasts, cells which form the structural framework for many body tissues.  According to Strasser, both types of cells have been shown to be effective in reconstructing the lower urinary tract in animal studies.

Then, Strasser’s team injected the cells back into the women’s sphincter and surrounding area using the ultrasound.

Traditional collagen injections, which do not generally have a high success rate for incontinence, were given to the other 21 women. Collagen treatments work by bulking up the area to compress the urethra, helping to hold urine.

After 12 months, 38 of the 42 women given the stem cell and other cell injections were completely continent. The other four showed either slight or substantial improvement. Only two of the 21 who got collagen injections were continent; seven others showed either slight or substantial improvement.

From ultrasound exams after the injections, it could be seen that the thickness of the sphincter had increased 59 percent in the women given cell injections but just nine percent in the collagen-treated group.  Muscle contractibility increased much more in the cell group.  Increases in the sphincter thickness and muscle contractibility are thought to help improve symptoms.  The women who were treated with the injections of cells reported higher quality of life than the women treated with collagen.  No one in the study reported any adverse side effects.

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Sacral Neuromodulation Treats Refractory Idiopathic Urge Urinary Incontinence

According to Dutch researchers, sacral neuromodulation could be a safe, if impermanent, way to treat refractory idiopathic urge urinary incontinence.

Sacral neuromodulation, also known as sacral nerve stimulation, involves the implantation of a programmable stimulator subcutaneously which delivers low amplitude electrical stimulation through a lead to the sacral nerve, usually accessed via the S3 forament.

In a new study published in a recent issue of the Journal of Urology, Jan Groen, Ph.D., Bertil F.M. Blok, M.D., Ph.D., and J.L.H. Ruud Bosch, M.D., all from the Erasmus Medical Center in Rotterdam and University Medical Center Utrecht (JLHRB), Utrecht, The Netherlands, report on 60 women who had leads for sacral neuromodulation implanted by open surgery.

Eighty-seven percent of the women had at least a 50 percent decrease in incontinence episodes or the number of pads used daily at one month.

By five years, however, only 62 percent of the women were still reporting at least a 50 percent decrease from baseline.  Additionally, only 15 percent were completely continent.  Over half (32 patients) had 57 adverse events; most involved hardware or pain and discomfort. None were serious.

The study’s lead author Groen said that despite its decreasing effectiveness, neuromodulation “remains our first choice, especially in younger patients, as the technique is safe, does not need frequent re-treatment and is not accompanied by a possible need for self-catheterization.”

He does, however, acknowledge that the relative place of neuromodulation in the treatment algorithm and the role of its most important alternative option, botulinum toxin, are evolving.

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Pre-op Counseling For Prostate Surgery Not Effective

Researchers have found that over half of men undergoing radical prostatectomy have unrealistic expectations about some of the outcomes.

Daniela Wittmann, MSW, and colleagues at the University of Michigan Comprehensive Cancer Center in Ann Arbor, Michigan found that despite a pre-operative education program, 61 percent of men expected the same or better sexual function a year after surgery as they had before.  Sixty percent of men expected difficulties with urinary incontinence to be the same or better.  These findings were published in the Journal of Urology.

Wittmann and colleagues found that a substantial proportion of patients, 17 percent and 12 percent, respectively for both effects, expected better performance a year after surgery than before even though they had been told that such an outcome was improbable.  The researchers argued that this finding suggests that pre-op education should be followed up with post-surgery support for prostate cancer survivors.

The research team asked men undergoing radical prostatectomy to fill out the short form of the Expanded Prostate Index Composite questionnaire, both before and a year after surgery to get an idea of their urinary, bowel, hormonal, and sexual function.

The men were also asked, after pre-op counseling but before surgery, to fill out the Expanded Prostate Index Composite-Expectations questionnaire, which detailed what level of function they expected a year later.  Both questionnaires assess five domains: incontinence, urinary irritative symptoms, bowel function, hormonal function, and sexual function.

Analysis of the 152 participants showed that 36 percent and 40 percent expected the same function at one year as at baseline in urinary incontinence and sexual function, respectively, while 12 percent and 17 percent expected better function.  Forty-seven percent and 44 percent of patients had lower than expected function for urinary incontinence and sexual function, respectively.  Expectations matched or were better than outcomes for 78 percent of patients for urinary irritative symptoms.  Expectations of bowel and hormonal function largely matched outcomes, with 92 percent and 86 percent, respectively, having outcomes that were the same as or better than expected.

Wittmann said that these differences may arise from the way that the pre-op counseling is given.  The research tem cautioned that the study had a low response rate.  Out of 526 patients who signed consent forms, only 152 completed all the questionnaires.  This makes it difficult to generalize the findings.  Also, while the counseling on sexual matters was standardized, the information provided by surgeons on other outcomes was not.

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Surgery Improves Longevity and Quality of Life for cT3 Prostate Cancer Patients

Researchers at the Mayo Clinic, a leading nonprofit institution providing medical care, research and education for people from all walks of life based in Rochester, Minnesota, have found that long-term survival rates for patients with advanced prostate cancer suggest that they can be good candidates for surgery.  The research team found a twenty-year survival rate for 80 percent of patients diagnosed with cancer that has potentially spread locally from inside the prostate to immediately outside of it, known as cT3 prostate cancer, and who had been treated with radical prostatectomy, which is surgery to remove the prostate gland.  These findings were presented at the annual meeting of the American Urological Association in Washington.

Previously, patients who had cT3 prostate cancer were offered radiation or hormone treatment but not radical prostatectomy.

R. Jeffrey Karnes, MD, an Assistant Professor at the Mayo Clinic’s Department of Urology said that the identification and expansion of candidates for surgery that results in improved and longer outcomes for patients has improved. Other study investigators from the Mayo Clinic include Christopher Mitchell, M.D., Eric Umbreit, M.D., Rachel Carlson and Laureano Rangel.

The 80 percent survival rate for cT3 diagnoses at 20 years is compared to 90 percent for cT2, which is cancer confined to the prostate.  The study included patients with cT3 diagnoses and who were operated on between 1987 and 1997.  Ongoing research will continue to examine the current data.  This long-term follow-up is an important advance in understanding the quality outcomes for these cT3 patients.

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Reprogrammed Kidney Cells Could Make Transplants and Dialysis Obsolete

A recently published article in the Journal of the American Society Nephrology (JASN) indicates that patients’ own kidney cells can be gathered and reprogrammed, which means that in the future, fewer patients with kidney disease would need complicated, expensive procedures that affect their quality of life.

Sharon Ricardo, PhD, from Monash University in Clayton, Austria and her colleagues took cells from an individual’s kidney and reprogrammed them into progenitor cells, allowing the immature cells to form any type in the kidney.  The team inserted several key programming genes into the renal cells that made them capable of forming other cells.

In another study, Miguel Esteban, MD, PhD, of the Chinese Academy of Sciences in Guangzhou, China and his colleagues found that kidney cells collected from the patients’ urine can also be reprogrammed in this way.  The use of urine cells is easy to implement in a clinical setting, and the urine cells can be frozen and later thawed before they are reprogrammed.

If researchers are able to expand the reprogrammed cells, known as induced pluripotent stem cells (iPSCs), and return them to the patient, these IPSCs may restore the kidneys’ health and vitality.  The breakthroughs might help investigators to study the causes of kidney disease and to screen new drugs that could be used to treat them.

Ian Rogers, PhD, from Mount Sinai Hospital in Toronto wrote in an accompanying editorial that the two studies “demonstrate the feasibility of using kidney cells as a source o iPSCs and efficient production of adult iPSCs from urine means that cells can be collected at any time.”

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