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D'Silva K.A.,University of Toronto | Dahm P.,University of Florida | Dahm P.,Malcom Randall Veterans Affairs Medical Center | Wong C.L.,University of Toronto | Wong C.L.,Li Ka Shing Knowledge Institute
JAMA - Journal of the American Medical Association | Year: 2014

IMPORTANCE: Early, accurate diagnosis of bladder outlet obstruction in men with lower urinary tract symptoms may reduce the need for invasive testing (ie, catheter placement, urodynamics), and prompt early treatment to provide symptomatic relief and avoid complications. OBJECTIVES: To systematically review the evidence on (1) the diagnostic accuracy of office-based tests for bladder outlet obstruction in men with lower urinary tract symptoms; and (2) the accuracy of the bladder scan as a measure of urine volume because management decisions rely on measuring postvoid bladder residual volumes. DATA SOURCES AND STUDY SELECTION: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (1950-March 2014), along with reference lists from retrieved articles were searched to identify studies of diagnostic test accuracy among males with lower urinary tract symptoms due to bladder outlet obstruction. MEDLINE, EMBASE, CINAHL, and the Cochrane Library (1950-March 2014) were searched to identify studies of urine volumes measured with a bladder scanner vs those measured with bladder catheterization. Prospective studies were selected if they compared 1 or more office-based, noninvasive diagnostic test with the reference test or were invasive urodynamic studies, and if urine volumes were measured with a bladder scanner and bladder catheterization. DATA EXTRACTION AND SYNTHESIS: For the bladder outlet obstruction objective, 8628 unique citations were identified. Ten studies (1262 patients among 9 unique cohorts) met inclusion criteria. For the bladder scan objective, 2254 unique citations were identified. Twenty studies (n = 1397 patients) met inclusion criteria. MAIN OUTCOMES AND MEASURES: The first main outcome and measurewas the diagnostic accuracy of individual symptoms and questionnaires compared with the reference standard (urodynamic studies) for the diagnosis of bladder outlet obstruction in males with lower urinary tract symptoms. The second was the correlation between urine volumes measured with a bladder scanner and those measured with bladder catheterization. RESULTS: Among males with lower urinary tract symptoms, the likelihood ratios (LRs) of individual symptoms and questionnaires for diagnosing bladder outlet obstruction from the highest quality studies had 95% CIs that included 1.0, suggesting they are not significantly associated with one another. An International Prostate Symptom Score cutoff of 20 or greater increased the likelihood of bladder outlet obstruction (positive LR, 1.5; 95% CI, 1.1-2.0), whereas scores of less than 20 had an LR that included 1.0 in the 95% CI (negative LR, 0.82; 95% CI, 0.67-1.00). We found no data on the accuracy of physical examination findings to predict bladder outlet obstruction. Urine volumes measured by a bladder scanner correlated highly with urine volumes measured by bladder catheterization (summary correlation coefficient, 0.93; 95%CI, 0.91-0.95). CONCLUSIONS AND RELEVANCE In patients with lower urinary tract symptoms, the symptoms alone are not enough to adequately diagnose bladder outlet obstruction. A bladder scan for urine volume should be performed to assess patients with suspected large postvoid residual volumes. Copyright 2014 American Medical Association. All rights reserved.

Hwang M.,University of Florida | Berceli S.A.,University of Florida | Berceli S.A.,Malcom Randall Veterans Affairs Medical Center | Garbey M.,University of Houston | And 2 more authors.
Biomechanics and Modeling in Mechanobiology | Year: 2012

Although vein bypass grafting is one of the primary options for the treatment of arterial occlusive disease and provides satisfactory results at an early stage of the treatment, the patency is limited to a fewmonths in many patients. When the vein is implanted in the arterial system, it adapts to the high flow rate and high pressure of the arterial environment by changing the sizes of its layers, and this remodeling is believed to be a precursor of future graft failure. Hemodynamic forces, such as wall shear stress (WSS) and wall tension, have been recognized as major factors impacting vein graft remodeling. Although a wide range of experimental evidence relating hemodynamic forces to vein graft remodeling has been reported, a comprehensive mathematical model describing the relationship among WSS, wall tension, and the structural adaptation of each individual layer of the vein graft wall is lacking. The current manuscript presents a comprehensive and robust framework for treating the complex interaction between the WSS, wall tension, and the structural adaptation of each individual layer of the vein graft wall.We modeled the intimal and medial area and the radius of external elastic lamina, which in combination dictate luminal narrowing and the propensity for graft occlusion. Central to our model is a logistic relationship between independent and dependent variables to describe the initial increase and later decrease in the growth rate. The detailed understanding of the temporal changes in vein graft morphology that can be extracted from the current model is critical in identifying the dominant contributions to vein graft failure and the further development of strategies to improve their longevity. © Springer-Verlag 2011.

Bruins H.M.,Radboud University Nijmegen | Veskimae E.,University of Tampere | Hernandez V.,Hospital Universitario Fundacion Alcorcon | Imamura M.,University of Aberdeen | And 15 more authors.
European Urology | Year: 2014

Context Controversy exists regarding the therapeutic value of lymphadenectomy (LND) in patients undergoing radical cystectomy (RC) for muscle-invasive bladder cancer (MIBC).Objective To systematically review the relevant literature assessing the impact of LND on oncologic and perioperative outcomes in patients undergoing RC for MIBC. Evidence acquisition Medline, Medline In-Process, Embase, the Cochrane Central Register of Controlled Trials, and the Latin American and Caribbean Center on Health Sciences Information (LILACS) were searched up to December 2013. Comparative studies reporting on no LND, limited LND (L-LND), standard LND (S-LND), extended LND (E-LND), superextended LND (SE-LND), and oncologic and perioperative outcomes were included. Risk-of-bias and confounding assessments were performed. Evidence synthesis Twenty-three studies reporting on 19 793 patients were included. All but one study were retrospective. Planned meta-analyses were not possible because of study heterogeneity; therefore, data were synthesized narratively. There were high risks of bias and confounding across most studies as well as extreme heterogeneity in the definition of the anatomic boundaries of LND templates. All seven studies comparing LND with no LND favored LND in terms of better oncologic outcomes. Seven of 14 studies comparing (super)extended LND with L-LND or S-LND reported a beneficial outcome for (super)extended LND in at least a subset of patients. No difference in outcome was reported in two studies comparing E-LND and S-LND. The comparative harms of different extents of LND remain unclear.Conclusions Although the quality of the data was poor, the available evidence indicates that any kind of LND is advantageous over no LND. Similarly, E-LND appears to be superior to lesser degrees of dissection, while SE-LND offered no additional benefits. It is hoped that data from ongoing randomized clinical trials will clarify remaining uncertainties.Patient summary The current literature suggests that removal of lymph nodes in bladder cancer surgery is beneficial and might result in better outcomes in terms of prolonging survival; however, the quality of the available studies is poor, and high-quality studies are needed. © 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Bril F.,University of Florida | Lomonaco R.,University of Florida | Cusi K.,University of Florida | Cusi K.,Malcom Randall Veterans Affairs Medical Center
Clinical Lipidology | Year: 2012

Nonalcoholic fatty liver disease (NAFLD) is much more common than previously believed, affecting at least a third of the overall adults and two-thirds of obese subjects. The disease is strongly associated with the metabolic syndrome and Type 2 diabetes mellitus. Recent studies have shown that it may be also associated with cardiovascular disease. Among the many potential mechanisms for the association of NAFLD with cardiovascular disease, it is believed that abnormal lipoprotein metabolism plays a major role. Elevated plasma triglycerides, low HDL-cholesterol and increased apoB levels characterize dyslipidemia in NAFLD. Given the potential for dyslipidemia to increase cardiovascular disease in NAFLD, patients should be diagnosed early and treated aggressively. Paradoxically, most patients with NAFLD are denied lipid-lowering drugs as they frequently have elevated liver aminotransferases, and there is a perception of an increased risk of hepatotoxicity among clinicians treating these patients. We recommend starting low-dose statins with titration based on close monitoring, which overall appears to be safe, although there is a need for long-term studies. The available literature also suggests that fibrate therapy, with or without associated statin use, is, in general, well tolerated and safe. In summary, this review will address the clinical implications of dyslipidemia in NAFLD and the common dilemmas that healthcare providers face when lipid-lowering therapy is needed in these patients. © 2012 Future Medicine Ltd.

Gupta M.,University of Florida | McCauley J.,University of Florida | Farkas A.,University of Florida | Gudeloglu A.,University of Florida | And 6 more authors.
Journal of Urology | Year: 2015

Purpose Clinical practice guidelines are increasingly being used by leading organizations to promote high quality evidence-based patient care. However, the methodological quality of clinical practice guidelines developed by different organizations varies considerably. We assessed published clinical practice guidelines on the treatment of localized prostate cancer to evaluate the rigor, applicability and transparency of their recommendations. Materials and Methods We searched for English based clinical practice guidelines on treatment of localized prostate cancer from leading organizations in the 15-year period from 1999 to 2014. Clinical practice guidelines limited to early detection, screening, staging and/or diagnosis of prostate cancer were excluded from analysis. Four independent reviewers used the validated AGREE II instrument to assess the quality of clinical practice guidelines in 6 domains, including 1) scope and purpose, 2) stakeholder involvement, 3) rigor of development, 4) clarity of presentation, 5) applicability and 6) editorial independence. Results A total of 13 clinical practice guidelines met inclusion criteria. Overall the highest median scores were in the AGREE II domains of clarity of presentation, editorial independence, and scope and purpose. The lowest median score was for applicability (28.1%). Although the median score of editorial independence was high (85.4%), variability was also substantial (IQR 12.5-100). NICE and AUA clinical practice guidelines consistently scored well in most domains. Conclusions Clinical practice guidelines from different organizations on treatment of localized prostate cancer are of variable quality and fall short of current standards in certain areas, especially in applicability and stakeholder involvement. Improvements in these key domains can enhance the impact and implementation of clinical practice guidelines. © 2015 American Urological Association Education and Research, Inc.

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