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We describe a patient with marked elevations of creatine kinase following institution of clozapine treatment. The enzyme levels promptly subsided with discontinuation of clozapine. The clinical features did not meet any of the published criteria for neuroleptic malignant syndrome. [ABSTRACT FROM AUTHOR]

Objective: To determine if a weight check and heart failure symptom evaluation with each wound care visit could impact wound healing in patients with heart failure and chronic leg wounds., Methods: This was a descriptive, correlational study at an outpatient wound healing center in the Pacific Northwest. A convenience sample of individuals currently enrolled at the center with leg wounds and heart failure was identified from standardized electronic medical records. The comparison group received standard care. The intervention group received a body weight check via digital scale and heart failure self-assessment via a standardized assessment tool. Outcome measures included healing rates with weight exacerbation, number of referrals, and hospitalizations for exacerbations., Results: A total of four participants received the intervention, and three were in the control group. Descriptive analysis showed no significant differences between groups or between weight and left ventricle ejection fraction to wound surface area change. A significant positive correlation was observed between past referrals and past hospitalization (rs = 0.79; P = .033; 95% confidence interval, 0.10-0.97). The intervention group had abnormal spikes in wound size that coincided with weight gain. There were no referrals or hospitalizations during the intervention phase, and it is possible that heart failure self-assessment with every wound care visit prevented exacerbations., Conclusions: Despite the use of an evaluation tool, the intervention and comparison groups had no significantly different outcomes. It is unclear if the intervention was not effective because of the methodology or study limitations. Further research with a larger sample, standardized tools for wound assessment, and a lengthier intervention phase is recommended., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Despite the growing number of patients with limited English proficiency in the United States, not all medical schools offer medical language courses to train future physicians in practicing language-concordant care. Little is known about the long-term use of non-English languages among physicians who took language courses in medical school. We conducted a cross-sectional study to characterize the professional language use of Harvard Medical School (HMS) alumni who took a medical language course at HMS and identify opportunities to improve the HMS Medical Language Program., Methods: Between October and November 2019, we sent an electronic survey to 803 HMS alumni who took a medical language course at HMS between 1991 and 2019 and collected responses. The survey had questions about the language courses and language use in the professional setting. We analyzed the data using descriptive statistics and McNemar's test for comparing proportions with paired data. The study was determined not to constitute human subjects research., Results: The response rate was 26% (206/803). More than half of respondents (n = 118, 57%) cited their desire to use the language in their future careers as the motivation for taking the language courses. Twenty-eight (14%) respondents indicated a change from not proficient before taking the course to proficient at the time of survey whereas only one (0.5%) respondent changed from proficient to not proficient (McNemar's p-value < 0.0001). Respondents (n = 113, 56%) reported that clinical electives abroad influenced their cultural understanding of the local in-country population and their language proficiency. Only 13% (n = 27) of respondents have worked in a setting that required formal assessments of non-English language proficiency., Conclusions: HMS alumni of the Medical Language Program reported improved language proficiency after the medical language courses' conclusion, suggesting that the courses may catalyze long-term language learning. We found that a majority of respondents reported that the medical language courses influenced their desire to work with individuals who spoke the language of the courses they took. Medical language courses may equip physicians to practice language-concordant care in their careers.

Many amorphous solid dispersions (ASDs) are thermodynamically unstable. Thus, the active pharmaceutical ingredient (API) might crystallize over time. The crystallization kinetics and therewith the long-term stability of ASDs depends on the storage conditions temperature and relative humidity (RH) as they determine the molecular mobility of the API in the polymer. To quantify the molecular mobility, the rheological behavior of two different ASDs with ibuprofen and either poly(vinyl acetate) or poly(vinylpyrrolidone-co-vinyl acetate) was analyzed as function of temperature and relative humidity by means of an oscillatory rheometer. The plasticizing effect of ibuprofen and absorbed water on the zero-shear viscosity of the polymer could be fully explained by the reduction of the glass-transition temperature of the mixture compared to the one of the pure polymer. Moreover, this work proposes an approach to predict the zero-shear viscosity of an ASD based on only the temperature dependence of the zero-shear viscosity of the pure polymer as well as the predicted water content in the ASD at certain RH using the Perturbed-Chain Statistical Associating Fluid Theory (PC-SAFT)., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Spermatozoal abnormalities are present in up to 40% of infertile couples. Multiple etiologies may be responsible for these disorders, including pretesticular, testicular, and ductal causes. An adequate andrologic consultation, including history, physical examination, and repeated semen analysis, should be performed routinely in these cases. Evaluation of the basic sperm parameters, including sperm concentration, motion parameters (as evaluated by computer-assisted semen analysis), and sperm morphology (as judged by strict criteria), constitute the first obligatory step for a critical evaluation of male factor patients. Patients in whom fertilization disorders are suspected should be evaluated through bioassays of sperm-oocyte interaction, including the heterologous sperm penetration assay and hemizona assay, a bioassay of sperm-zona binding capacity highly predictive of in vitro fertilization outcome. Male disorders can be subjected to specific therapies (surgical or medical), or to empiric therapeutic modalities. Assisted reproductive technologies have enhanced our understanding of the physiopathology of spermatozoal disorders and also have ostensibly improved pregnancy rates in male factor patients.

Severe renin-mediated hypertension was noted in 2 children as a result of selective renal damage from vesicoureteral reflux during the early years of life. In each case the reflux had been corrected successfully long before hypertension developed. In 1 case the late damage involved only 1 kidney and nephrectomy resulted in immediate relief of the hypertension. In the second case, even though both kidneys showed segmental scarring from calicectasis and chronic pyelonephritis, removal of the atrophied lower pole of 1 kidney made hypertension amenable to medical treatment and reduced excessive renin output to a fraction of the original high levels. The mechanism of renin-mediated hypertension in kidneys with segmental scars of chronic pyelonephritis is believed to be ischemia of the relatively normal renal cortex in proximity to areas of interstitial fibrosis, within which are tortuous interlobular and smaller arterioles with severe intimal thickening. Hypertrophy of normal renal segment occurs in young patients with segmental chronic pyelonephritis. To accommodate this enlargement the original calix develops an extension or elongation readily distinguishable from other dilated calices.

The term "hypospadias cripple" is an apt one. The successful surgery of this condition requires radical correction of all deformities, preferably in a single stage. In doing this one must be conversant with virtually all the existing methods of hypospadias repair and be able to apply them appropriately.

A case is reported of rhabdomyolysis and acute tubular necrosis following an exaggerated knee-chest position to repair a urethral stricture. To our knowledge this is the first case reported of this syndrome occurring after a urologic procedure.

To evaluate the incidence and significance of an enlarged prostatic utricle in hypospadiac patients without underlying intersex 44 patients with the meatus located in the perineum, penoscrotal junction or proximal two-thirds of the penis were evaluated with cystourethroscopy immediately before the operation. There was an abnormally enlarged utricle in 57 per cent of the perineal, 10 per cent of the penoscrotal and none of the penile hypospadias and intersex revealed a high incidence of enlarged utricle or the presence of a vagina masculinus. Utricular enlargement in itself doses not indicate intersexuality but careful cystoscopic examination of its vault needs to be undertaken, searching for a cervix. An enlarged utricle can be a manifestation of delayed mullerian duct regression or decreased androgenic stimulation of the urogenital sinus.

Sertoli and Leydig cell function was evaluated in patients with oligospermia. Testicular biopsy specimens were incubated in vitro with follicle-stimulating hormone (FSH) or luteinizing hormone (LH), and the amount of cyclic adenosine 3':5'-monophosphate (cyclic AMP) generated was measured. Cyclic AMP has been shown to be intracellular mediator for the pituitary gonadotropins FSH and LH. The amount generated by the Sertoli cells response to FSH, and by the Leydig cells in response to LH, was contrasted with that in age-matched, normal control subjects. The Leydig cell response was similar in both groups. However, the amount of cyclic AMP generated by the Sertoli cells from oligospermic males was much less when compared with normal control subjects. This finding suggests a possible metabolic abnormality in the Sertoli cells of patients with oligospermia which might, in turn, alter spermatogenesis.

The in vitro effects of FSH and LH on cAMP generation by unilateral undescended testes and contralateral descended testes were investigated. Biopsy tissue was preincubated at 37 C for 5 min in 1 ml Krebs-Ringer bicarbonate buffer (KRB) containing 10 mM aminophylline. Half of each specimen was frozen in liquid nitrogen to assess basal levels of cAMP. The other half was incubated for 20 min at 37 C in 1 ml fresh KRB containing aminophylline and FSH (10 microgram) or LH (10 microgram). The mean concentration of cAMP in the descended testes was 1.03 +/- 0.04 pmol/mg protein, whereas in the undescended testes the level was 1.98 +/- 0.07 pmol/mg protein (P less than or equal to 0.01). After the 20-min incubation period with FSH the concentrations of cAMP in the descended and undescended testes were 10.85 +/- 0.86 pmol/mg protein and 11.21 +/- 1.1 mol/mg protein, respectively. Incubation with LH resulted in the generation of equivalent levels of cAMP in both the descended (2.76 +/- 0.30 pmol/mg protein) and undescended (3.0 +/- 0.17 pmol/mg protein) testes. Although marked histological differences were observed in the germinal epithelium, the appearance and numbers of Leydig and Sertoli cells were comparable. The data suggest that the Sertoli cell is the primary receptor for FSH. Leydig and Sertoli cell functions of the undescended testes, at least in terms of cAMP generation, are similar to normal descended testes.

We studied 20 men who failed to resume coitus after a dermal graft repair for Peyronie's disease. Psychogenic causes were found in 15 men, 10 of whom were treated locally by the sex counselors who interviewed all the couples. Psychogenic dysfunction was related to waiting for healing or for a specified period, then approaching first coitus either with idealized expectations or as if it were a test. Of the 10 treated men 3 also had marital conflict and 5 others had lack of a partner or poor motivation, including 1 who also suffered some instability of erection possibly of structural cause. In most of the treated men relief of anxiety and conflict proved effective, and coitus was restored. We are now evaluating possible improved results in new operative candidates through preoperative and postoperative counseling, which emphasizes a less pressured approach to coitus postoperatively.

Of 62 hospitalized patients with Peyronie's disease 18 (29 per cent) had abnormal nocturnal penile tumescence studies that were characterized as indicating organic impotence. However, the majority of these patients had some underlying disease or factor other than the plaque itself to explain the altered nocturnal penile tumescence. In only 5 per cent of these patients could the abnormal nocturnal penile tumescence be attributable to the plaque itself. Primary excision of the plaque and dermal grafting improved erectile function in all except a minority of patients who required insertion of a penile prosthesis to alleviate continued erectile impotence. For this reason we do not recommend insertion of a penile prosthesis during plaque excision. The plaque of Peyronie's disease does not appear to impede vascular flow distal to the plaque. However, previous excision may result in altered hemodynamics that can result in erectile impotence.

To evaluate the incidence and significance of an enlarged prostatic utricle in hypospadiac patients without underlying intersex 44 patients with the meatus located in the perineum, penoscrotal junction or proximal two-thirds of the penis were evaluated with cystourethroscopy immediately before the operation. There was an abnormally enlarged utricle in 57% of the perineal, 10% of the penoscrotal and none of penile hypospadiacs, for an over-all incidence of 14%. Concurrent analysis of a series of phenotypic male patients with hypospadias and intersex revealed a high incidence of enlarged utricle or the presence of a vagina masculinus. Utricular enlargement in itself does not indicate intersexuality but careful cystoscopic examination of its vault needs to be undertaken, searching for a cervix. An enlarged utricle can be a manifestation of delayed müllerian duct regression or decreased androgenic stimulation of the urogenital sinus.

Idiopathic female intersex can present with a varying phenotypic expression but generally includes clitoromegaly in association with either urogenital and/or cloacal anomalies. Additionally, absence of corporeal bodies may exist, resulting in either a markedly enlarged empty phallus or a megalourethra if developmental anomalies of the urogenital sinus occur in association with corporeal agenesis. Herein we report 2 cases to illustrate the spectrum of this disorder.

Three cases of the unusual entity, müllerian duct cyst, are presented. Each was managed differently, demonstrating that with appropriate patient selection either aspiration alone, aspiration and instillation of a sclerosing agent, or transurethral resection of bladder base to establish communication and cyst drainage are successful.

Chronic pyelonephritis secondary to vesicoureteral reflux has been shown to cause occasionally systemic hypertension. The hypertension may occur in the presence or absence of bacterial urinary infection, is renin-mediated and may develop years after ureteral reimplantation. Surgical excision of a scarred atrophic renin-producing segment may result in amelioration of the hypertension or at least provide better medical control with less toxic antihypertensive agents. Surgical removal of renal tissue is not recommended in patients with depressed renal function unless the hypertension is malignant and uncontrolled.