Can sonography be used to help differentiate between radial scars and breast cancers?

The aim of this study was to determine whether sonography can help differentiate radial scars (RS) from breast cancers. Series of 75 consecutive mammographic screen-detected RS and carcinomas were reviewed: shape, orientation, echotexture, halo, acoustic attenuation and architectural distortion were compared for sonographic RS and cancers. RS were 43% sonopositive (25/58 examined) vs. 93% sonopositive carcinomas (68/73 examined); P<0.001. Of 22 RS and 66 cancers available for film review, findings were: echogenic halo in zero RS vs. 38 cancers (0% vs. 58%); tiny sonographic cysts in 3 RS vs. zero carcinomas (14% vs. 0%); assessment category malignant vs. indeterminate/suspicious (8% vs. 59%, P<0.001); breast architecture disruption (43% vs. 91%, P<0.001); sound attenuation (55% vs. 86%, P<0.005), taller-than-wide shape (36% vs. 56%, P=0.11). RS showed echogenic components more than cancers (32% vs. 9%, P=0.016). Jagged margins were equally seen (77% vs. 76%, P=0.89). The findings suggest that sonographic differences can help discriminate between RS and carcinomas.     

Urinary urgency and frequency, and chronic urethral and/or pelvic pain in females. Can doxycycline help?

PURPOSE: Persistent urinary urgency and frequency, and chronic urethral and/or pelvic pain in women are often a diagnostic and therapeutic challenge. This can be frustrating for patients and physicians. The search for an infectious agent often proves futile and after multiple ineffective treatment regimens patients may be classified as having interstitial cystitis or referred to a psychiatrist as the last option. We evaluated whether treatment with doxycycline of the patient and her sexual partner would be beneficial. MATERIALS AND METHODS: Women presenting with a history of urinary urgency and frequency, and chronic urethral and/or pelvic pain often associated with dyspareunia and/or a history of recurrent urinary tract infection were evaluated. Initial examinations included urethral and cervical/vaginal swabs, serum analysis, urine examination and culture, and bladder barbitage. A total of 103 women with a median age of 46 years (range 21 to 84) and with a median symptoms history of 60 months (range 3 to 480) were included. All patients had trigonal leukoplakia at cystoscopy, in 15% an infectious organism was identified and 30% had leukocyturia. All were treated with doxycyclines, and a vaginal antimicrobic and/or antimycotic agent following the same regimen, including treatment of the sexual partner. RESULTS: After treatment with doxycycline 71% of the women were symptom-free or had a subjective decrease in symptoms. CONCLUSIONS: Treatment with doxycycline is effective in more than two-thirds of patients complaining of persistent frequency and urgency, chronic urethral and/or pelvic pain, and dyspareunia as well as a history of recurrent urinary tract infections. In women with negative urinary cultures but a history of urgency/frequency probative treatment with doxycycline is justified and endoscopic findings may support the hypothesis of chronic infection. This should be done especially before contemplating psychiatric treatment or diagnosing the patient with interstitial cystitis. We attribute this high success rate to simultaneous treatment of the sexual partner, who may be an asymptomatic carrier, although this remains to be proved.     

Can molecular similarity-activity models for intravenous general anaesthetics help explain their mechanism of action?

Background. The importance of molecular shape and electrostaticpotential in determining the activities of 11 structurally-diversei.v. general anaesthetics was investigated using computationalchemistry techniques. Methods. The free plasma anaesthetic concentrations that abolishedthe response to noxious stimulation were obtained from the literature.The similarities in the molecular shapes and electrostatic potentialsof the agents to eltanolone (the most potent anaesthetic agentin the group) were calculated using Carbo indices, and correlatedwith in vivo potency. Results. The best model obtained was based on the similaritiesof the anaesthetics to two eltanolone conformers (r²=0.820).This model correctly predicted the potencies of the R- and S-enantiomersof ketamine, but identified alphaxalone as an outlier. Exclusionof alphaxalone substantially improved the activity correlation(r²=0.972). A bench mark model based on octanol/water partitioncoefficients (r²=0.647) failed to predict the potency orderof the ketamine enantiomers. Conclusions. The results demonstrate that a single activitymodel can be formulated for chiral and non-chiral i.v. anaestheticagents using molecular similarity indices. Br J Anaesth 2002; 88: 166–74     

Bladder contractility and urethral resistance relation: What does a pressure flow study tell us?

Hydrodynamic analysis of a pressure flow study is the only reliable method to determine the presence or absence of a bladder outlet obstruction, especially benign prostatic obstruction. To interpret the results of pressure flow study in benign prostatic obstruction, understanding the outlines of the basic theory about evaluation of the relationship between bladder contractility and urethral resistance relation is of paramount importance. In contrast, hydrodynamic analysis of pressure flow study in conditions other than benign prostatic obstruction is complicated by the limits of theories about the hydrodynamics of the lower urinary tract. In this review, the proposed hydrodynamic theories about the relationship between bladder contractility and urethral resistance relation are outlined. Then, problems encountered in the application of hydrodynamic analysis of pressure flow study to diseases other than benign prostatic obstruction are discussed.     

Can skin surface pressure under a cast reveal intracompartmental pressure?

Although monitoring intracompartmental pressure (IP) under a cast is very important, it is not possible to measure it in every patient undergoing cast treatment. This study aims to answer the question of whether skin surface pressure (SSP) under a cast can reveal IP. A plaster cast was applied to a sculpted inflatable forearm model with dorsal and volar compartments. SSP under the cast was measured at five different localizations from both dorsal and volar sides of the model and compared to the corresponding IP. In the second experiment, a posterior tibial compartment syndrome model was created in both limbs of five rabbits. Correlation analysis was performed between IP and SSP under the cast. All of the SSP measurements taken from the dorsal and volar side of the sculpted forearm model correlated with IP. Mean correlation coefficient of the measurements was 0.995 (P = 0.000) (SD 0.002, range 0.992–0.999). SSP and IP correlation analysis in the posterior tibial compartment syndrome model of 10 limbs in five rabbits revealed a high correlation. The mean correlation coefficient was 0.973 (P = 0.000) (SD 0.024, range 0.916–0.997). Measuring the pressure between the skin and cast can monitor IP. SSP monitoring can help the physician, patient or parents in the follow-up of patients undergoing cast treatment. Received: 25 November 1998     

Discrepancies in office and ambulatory blood pressure in adolescents: help or hindrance?

The goal of this commentary is to review the most relevant topics concerning the clinical utility of ambulatory blood pressure (BP) monitoring, such as the state of the art “reference BP values”, the importance of the discrepant situations between office and ambulatory BP (white-coat and masked hypertension) and those of the recommended clinical indications to now. From a small number of studies, operational thresholds to define hypertension have been established. They are useful tools even though more studies are necessary to create strong reference values. Ambulatory BP measurement is increasingly recognized as being indispensable to the diagnosis and management of hypertension, and it has contributed significantly to our understanding of hypertension by revealing or “unmasking” BP phenomena that were not readily apparent using traditional techniques of measurement in clinical practice. Ambulatory BP monitoring should be performed in adolescents with either office mild essential hypertension before starting antihypertensive drug treatment or a strong family history of hypertension or an early cardiovascular event. Obese children with normal office BP values will also benefit from ambulatory BP monitoring. Other indications are the assessment of refractory hypertension or drug-induced hypotension. Finally, additional BP information in chronic renal failure, diabetes, and autonomic neuropathy can be obtained by using ambulatory BP monitoring None of the authors has a conflict of interest to declare. The corresponding author had final responsibility for the decision to submit for publication.     

Traumatic urethral injuries: Does the digital rectal examination really help us?

Introduction

The digital rectal examination (DRE) has been commonly employed as a trauma screening tool since the inception of the ATLS program. Because of weak evidence, its utility as a screening test has recently been questioned. The primary goal of this study was to identify the sensitivity of the DRE for detecting blunt urethral injuries in a level 1 trauma center. The secondary goal was to evaluate the interaction of DRE with additional clinical indices of urethral trauma.

Methods

A retrospective review of all blunt injured patients diagnosed with a urethral disruption at an urban level 1 trauma center from 1995 to 2008 was performed. Urethral injuries were diagnosed by retrograde urethrogram, urethroscopy and operative exploration. Demographics and injury data were collected. The value of the DRE in diagnosing urethral trauma was assessed (p = 0.05).

Results

Urethral injuries were diagnosed in 41 male patients (mean age = 39 years), 34 (83%) of whom were injured via a motor vehicle (median ISS = 21). Associated injuries were present in 40 (95%) patients, including 39 (95%) pelvic fractures. No clinical signs of urethral injury were evident on initial examination in 25 (61%) patients. All patients had hematuria after catheter insertion. An abnormal prostate on DRE, blood at the urethral meatus, and hematuria prior to catheter insertion was present in 1 (2%), 8 (20%) and 7 (17%) patients, respectively. Both meatal blood and hematuria were better screening tests than the DRE (p < 0.05).

Discussion

The sensitivity of the DRE for identifying urethral disruption is 2%. The majority of patients with urethral trauma undergo urinary catheterization prior to diagnosis of the injury. Additional signs of disruption including meatal blood and hematuria detected prior to catheter insertion are also infrequent. While the DRE remains clinically indicated in patients with penetrating trauma in the vicinity of the rectum, pelvic fractures, and spinal cord injuries, it appears to be insensitive for detecting blunt urethral injuries.     

Can computer-based assessment help us understand children's pain?

Good measures for self-report of pain in children are important, particularly as other informants tend to underestimate children's pain. This paper describes the development of a new computer-assisted approach to assessment of pain in children. The child can represent a range of different types of pains on body maps, and use two scales to indicate the size of the pain and the 'throb' or intensity. Facial expressions of associated emotions can also be incorporated into the figure. A series of 'pain pages' is included in the program. The pages allow changes in pain to be tracked over time, building up a cumulative record. The child can also report on different experiences and give retrospective accounts. Potential applications are suggested, for example in facilitating communication with children who find it difficult to give a clear verbal account of their pain, due to emotional difficulties, language or disability. Research directions are outlined.     

Urethral pressure measurement in stress incontinence: does it help?

Introduction and objectives  The resting urethral pressure profile (UPP), used for the assessment of women with stress incontinence, is routine in many urodynamic units. It is time- and effort-consuming, and its diagnostic value is controversial, as well as its value in the prediction of outcome of anti-incontinence surgery. Herein, we assessed its value in the prediction of the outcome of surgery. Patients and methods  Sixty women were randomized to fascial sling or TVT. Urodynamics were performed preoperatively, 6 months and annually thereafter. After filling and voiding cystometry, resting UPP was performed while sitting. Automated catheter pulling, at a rate of 1 mm/s, was adopted. Averaged readings were obtained. Comparison of maximum urethral closure pressure (MUCP) in success and failure, as well as in sling and TVT, was performed, utilizing ANOVA. Results  Preoperative MUCP and functional urethral length (FUL) were 72.9 ± 27.9 cmH2O and 2.4 ± 0.7 cm. At last follow-up, they were 71.1 ± 20.7 cmH2O and 2.7 ± 0.7 cm, respectively. The differences between sling and TVT as regards value of MUCP and FUL were not significant. The relationship of the outcome of surgery and UPP parameters showed no statistical difference. No significant effect was shown for the success of surgery, duration of follow-up, and interaction of outcome and time over MUCP (P = 0.82, 0.56 and 0.69, respectively) or FUL (P = 0.82, 0.11 and 0.67, respectively). Conclusion  The routine use of resting UPP has no added value in terms of the prediction of success of incontinence surgery. It does not help with follow-up and adds to the time and cost of the examination.     

Can botulinum toxin help in managing children with functional constipation and obstructed defecation?

BackgroundFunctional constipation (FC) is a common pediatric healthcare problem worldwide. Obstructed defection syndrome (ODS) is frequently presented with an inability to coordinate the bowel movement with pelvic floor muscles. Botulinum toxin (BT) intraanal sphincteric injection can improve the obstructed defecation by relaxing the anal sphincter and reducing the required force to propel the stools.PurposeThis study aimed to compare the changes in Rintala scores (as a mean of assessing defecatory function), in children with FC and ODS, managed by BT injection, bowel management program (BMP), and senna based laxatives (SBL), versus a control group managed by BMP and SBL only.MethodsProspective randomized controlled study, started at December 2017 on 40 pediatric patients, divided into 2 equal groups (group A: managed by BMP and SBL, group B: like group A with once intraanal sphincteric BT injection) suffering from FC, ODS, with contrast enema showing persistence of ≤ 90 rectoanal angle (RAA) even with trials of defecation. Patients were excluded if they have neuromuscular abnormalities, hypothyroidism, previous colorectal or anal surgery. Rintala score was assessed before treatment, at 2 months, and 6 months after management.ResultsThe study included 18 females (45%) and 22 males (55%).Group A had equal gender distribution and mean age of 6.9 years, while group B had 12 males with mean age of 7.35 years. The mean follow up period was 11.35 months in group A and 11.6 months in group B. Mean Rintala scores of both groups at initial presentation, 2 months and 6 months follow up were: group A: 9.10, 9.40, 10.90; group B: 9.30, 10.70, 11.05 respectively, and showed no statistically significant difference (p value: 0.884, 0.294, 0.923 respectively).No complications were detected from BT injection like allergic reactions, neuromuscular urinary or lower limbs disturbances.ConclusionIntraanal sphincteric injection of botulinum toxin by the mentioned technique and dose, did not result in additional defecatory functional improvement (when assessed by Rintala score) over the routine protocol (using bowel management program and laxatives) of managing functional constipation with obstructed defecation.Announcementa preliminary report of this work was presented in the 34th Egyptian pediatric surgery association (EPSA) meeting in Cairo in November 2019.Type of studyTreatment/prospective study.Level of evidenceLevel I.