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Biomedical subjects

Kevin R Loughlin

Publications and source records attributed to Kevin R Loughlin.

At least 19 recordsLinked to original sources
PubMed2007

Urologic radiology during pregnancy.

The pregnant patient presents a unique diagnostic challenge to the urologist because the well-being of both the mother and fetus must be considered. Radiation exposure to the fetus during gestation presents risks such as cell death and teratogenic effects, carcinogenesis, and genetic effects, which must be considered when selecting diagnostic tests. However, with the exercise of good clinical judgment and the use of the armamentarium of diagnostic imaging modalities available, the pregnant patient can be managed with minimal, if any radiation exposure to the fetus.

Algorithms↗
PubMed2006

The use of hemostatic agents and sealants in urology.

PURPOSE: While hemostatic agents and sealants have long been used in the fields of surgery and urology, confusion persists about their indications for use and the optimal agent choice. We comprehensively defined and evaluated the scientific basis for hemostatic agent and sealant use in urology, and provide a conceptual framework for future research and discussion. MATERIALS AND METHODS: A MEDLINE search of all available literature concerning hemostatic agents in urology was performed, including topical hemostats, anti-fibrinolytics, fibrin sealants and matrix hemostats. Select references were also chosen from the broader surgical literature. Animal studies, case reports, retrospective and prospective studies, and opinion articles were reviewed. RESULTS: Hemostatic agents include a wide range of components. Recent literature has focused on fibrin sealants and matrix agents. Two main indications exist for hemostatic agents, including 1) hemostasis and 2) sealant. The best evidence for efficacy and safety exists for hemostasis, especially for nephrectomy and trauma. Newer data highlight urinary tract reconstruction, fistula and percutaneous tract closure, suture line strengthening and infertility as potential uses. Novel drug delivery and tissue engineering are areas with large clinical potential. CONCLUSIONS: Hemostatic agent use is promising and yet unproven for most conditions currently treated in urology. Hemostasis continues to be the main indication, which is well established. Few trials have examined comparative efficacy among hemostatic agents and further prospective studies are needed to justify additional indications as well as determine the optimal mode of use. Minimally invasive surgery will further drive the use of hemostatic agents and sealants. Cost-effective, evidence based hemostatic agent use will continue to challenge all urologists.

Anastomosis, Surgical↗
PubMed2006

Medical malpractice liability in clinical urology: a survey of practicing urologists.

PURPOSE: The current medical malpractice environment is in crisis. Costs associated with litigation as well as medical malpractice insurance premiums have increased during the last decade. In fact as of March 2004 the American Medical Association has identified 19 states as crisis states. We investigated the way in which the medical malpractice environment has affected urologists and the manner in which they practice medicine. MATERIALS AND METHODS: A survey of 31 questions was electronically mailed to the American Urological Association's database of practicing urologists in the United States. Data were gathered on each urologist's malpractice history as well as their clinical practice. A total of 5,919 surveys were mailed and 683 (12%) were returned. Urologists from 47 states responded. RESULTS: The mean medical malpractice premium in 2003 was 30,665 dollars (median 22,500 dollars, range 6,000 dollars to 120,000 dollars). Of responding urologists 63% report being named in a medical malpractice lawsuit a mean of 2.1 times. Mean length of time practicing urology was 19 years. Of the lawsuits 28% involved urological oncology, 12% involved endourology and 10% involved female urology. All other urological specialties individually generated less than 10% of the lawsuits. In only 3.5% of the cases was the patient successful at trial, compared to 13.2% of the cases where the urologist was successful at trial. The case was dropped or dismissed without financial settlement 46.9% of the time. However, 36.3% of the time the case was settled with a pretrial financial settlement. The mean amount awarded to a patient at trial was 213,855 dollars (median 100,000 dollars, range 2,400 dollars to 1,000,000 dollars). When a patient was awarded pain and suffering at trial, the mean amount awarded was 270,000 dollars (median 85,000 dollars, range 30,000 dollars to 900,000 dollars). The mean amount given to the patient as pretrial settlement was 196,706 dollars (median 70,000 dollars, range 1,500 dollars to 5,000,000). The mean time a urologist spent defending their first lawsuit was 21.8 days. Given the current medical malpractice environment, 58% of responding urologists are considering referring difficult cases, 60% are considering limiting the scope of their practice, 26% are considering changing the state in which they practice and 41% are considering leaving the practice of medicine. CONCLUSIONS: Our experience has shown that the medical malpractice crisis has had a profound and real effect on the urological community. When the data are stratified according to those urologists who practice in a crisis state, we consistently see a pattern whereby the crisis state urologists are carrying a larger proportion of the malpractice burden. Most concerning is how the malpractice environment has changed the way in which urologists approach their practice. A larger percentage of urologists from crisis states are reporting that they are considering limiting the scope of their practice, moving their practice to a state with a more favorable malpractice environment and considering leaving the practice of urology altogether. Clearly the urologist is not immune from the current malpractice environment.

Liability, Legal↗
PubMed2006

Measurement of plasma levels of vascular endothelial growth factor in prostate cancer patients: relationship with clinical stage, Gleason score, prostate volume, and serum prostate-specific antigen.

PURPOSE: This study focused on circulating levels of vascular endothelial growth factor in patients with prostate cancer compared to a normal population. METHODS: We analyzed 26 normal individuals and 80 patients with prostate cancer. Blood was drawn from all subjects, and plasma was extracted to determine the concentration of vascular endothelial growth factor using a quantitative immunoassay technique (ELISA-enzyme-linked immunosorbent assay). RESULTS: The median plasma level of vascular endothelial growth factor was significantly elevated in patients with metastatic disease compared to patients with localized disease and with healthy controls. Patients with serum prostate-specific antigen > 20 ng/mL had significantly higher levels of plasma vascular endothelial growth factor than patients with serum prostate-specific antigen < 20 ng/mL. There was a trend for patients with a Gleason score of 8 to 10 to have higher levels of plasma vascular endothelial growth factor when compared to patients with lower Gleason scores. No relationship was found between plasma vascular endothelial growth factor and clinical staging, or between plasma vascular endothelial growth factor and prostate volume, in patients with localized prostate cancer. CONCLUSION: This study indicates that patients with metastatic prostate cancer have higher plasma vascular endothelial growth factor levels than patients with localized disease or in healthy controls.

Adult↗
PubMed2005

The management of malignant ureteral obstruction treated with ureteral stents.

PURPOSE: We developed an algorithm for the management of ureteral obstruction due to malignant extrinsic compression. MATERIALS AND METHODS: We retrospectively reviewed all ureteral stents placed for noncalculous reasons at our institution from January 1, 1990 to January 1, 2004. Further clinical information was gathered from 157 patients with malignant extrinsic ureteral compression. Failure was defined as recurrent ureteral obstruction or an inability to place stents cystoscopically. RESULTS: A total of 157 patients underwent retrograde ureteral stent attempt for malignant extrinsic ureteral obstruction. Mean patient age was 54.7 years (range 23 to 83) and average followup was 13.6 months. Of our patients 61% were women, and the most common cancer diagnoses were ovarian cancer (in 26), lymphoma (17) and cervical cancer (16). A total of 24 patients required immediate percutaneous nephrostomy (PCN) referral. There were 32 patients who experienced a late failure and required PCN (average 180 days after initial stent), and 83 patients in our series (52.9%) who experienced 110 major complications. Type of cancer did not predict need for PCN. However, when invasion into the bladder was noted on cystoscopy, 55.9% (19 of 34, p = 0.008) progressed to PCN referral. A total of 77 patients underwent stent replacement on average 2.8 times and with an interval of 95 days. CONCLUSIONS: In our series patients with malignant extrinsic ureteral compression presenting for ureteral stent(s) experienced a failure rate of 35.7% (56 of 157). Invasion at cystoscopy had a significant predictive value for progression to PCN. We present an algorithm on the management of extrinsic malignant ureteral obstruction.

Adult↗
PubMed2004

Nephrolithiasis and pregnancy.

PURPOSE OF REVIEW: Urolithiasis during pregnancy is not common, however, it is a difficult condition to both diagnose and treat. There are many safety concerns that must be considered for both the mother and fetus. In this review we detail the different options available to the urologist and we highlight a treatment algorithm that we use when faced with a pregnant patient suspect of having a urinary calculus. RECENT FINDINGS: Changes in ultrasound, limited intravenous urograms and magnetic resonance imaging have improved our ability to diagnose urolithiasis in pregnancy. Additionally ureteroscopy has emerged not only as a diagnostic tool but also as a modality for definitive treatment that can safely be used during the intrapartum period. SUMMARY: When diagnosing urolithiasis in the gravid patient, the first line study should be ultrasound, using change in resistive index and transvaginal ultrasound. If these are not diagnostic, then a limited intravenous urograms should be performed. Once a diagnosis has been established, initial treatment should be conservative since 70-80% of patients will pass their stones. When intervention is necessary, the placements of an internal stent or percutaneous nephrostomy tube or ureteroscopy with definitive stone treatment are all reasonable options.

Female↗
PubMed2004

A diagnostic test for prostate cancer from gene expression profiling data.

PURPOSE: Multiple recent studies show excellent classification accuracy using bioinformatics tools applied to expression profiling data on various tumors. However, the clinical applicability of these techniques remains unfulfilled because of difficulty in translating complex multigene mathematical algorithms into reproducible, platform independent tests. We recently developed a broadly applicable platform independent method based on simple ratios of gene expression to diagnose and predict outcome in cancer. In the current study we applied this technique to the diagnosis of prostate cancer. MATERIALS AND METHODS: We developed a ratio based predictive model using a training set of 32 samples with previously published gene profiling data. We then tested and refined the model using additional independent samples with previously published microarray data from another source (that is the test set of 34 samples). Finally, the optimal ratio based test was examined with quantitative reverse transcriptase-polymerase chain reaction for data acquisition in a third cohort of samples consisting of 10 frozen normal and 10 tumor prostate tissues. RESULTS: A 3-ratio test using 4 genes was 90% accurate (18 of 20 samples) for distinguishing normal prostate and prostate cancer samples obtained at surgery (Fisher's exact test p = 0.0007). This test did not result in any false-negative findings. CONCLUSIONS: We describe and validate a new gene ratio based test for the diagnosis of prostate cancer, which was developed from the analysis of extensive gene profiling data for the diagnosis of prostate cancer. This test can be easily adapted to the clinical arena without the need for complex computer software or hardware. We anticipate that the gene ratio based diagnosis of prostate cancer using fine needle aspirations could serve as a useful adjunct to standard histopathological techniques.

Gene Expression Profiling↗
PubMed2003

Urologists on a tightrope--do we have a net?

PURPOSE: The purpose of this review is to analyze the current health care environment and its impact on urological practice. MATERIALS AND METHODS: The medical and lay literature as it pertains to the socioeconomics of health care was reviewed. RESULTS: Analysis of the political and economic factors that influence the delivery of health care today reveals alarming realities. More than 40 million Americans remain uninsured, and with a retrenched economy that number is likely to increase. Neither government nor the private sector has been either willing or able to address the health care problem in a coherent or comprehensive way. As the population ages, the Medicare and Medicaid programs will become further stressed. Employers are increasingly unwilling to finance the health care expenses of their employees. Academic medical centers are facing unique exigencies that, if left uncorrected, will jeopardize the future training of physicians. CONCLUSIONS: In the current environment of a depressed economy, further proposed tax cuts and increased military spending it appears inevitable that the economic restraints on medical care will increase substantially in the foreseeable future.

Delivery of Health Care↗