The evolving physiology of the lower urinary tract: What we are learning and where we need to go

Much of the current research on the physiology of the lower urinary tract is focused on afferent mechanisms, and we are learning how to control two of the identified signaling pathways by which afferent information is generated and conveyed to the central nervous system: the myogenic and urothelial (mucosal) pathways. The myogenic pathway is activated via “in series” mechanoreceptors responding to distention and via spontaneous contractile activity in units of myocytes generating “afferent noise.” The mucosal pathway is a functional unit consisting of the urothelium itself, suburothelial interstitial cells, and afferent nerves that signal via muscle-mucosal mechanoreceptors, mucosal mechanoreceptors, and chemoreceptors. To control micturition when it is dysfunctional, we need to know more about all the components involved in normal micturition regulation. These include central control mechanisms. More information is needed to understand brain control of bladder function and to develop centrally acting agents to control bladder activity.     

Virtual reality aided design of parts and assemblies

Current virtual reality (VR) systems provide an enormous potential for enhancing the visualization of 3D-design drafts. Based on new navigation techniques the designer is able to interact, model in a more intuitive and efficient way. In our contribution we present a novel interaction metaphor that facilitates the synthesis of efficient virtual reality interaction and visualization techniques with modern feature based CAD systems. We present “NAVIMODE”, an alternative approach for navigation, manipulation and selection, to combine the advantages of VR and CAD systems. The design engineer has the chance to design in his/her habitual environment using the advantage of virtual reality concurrently.     

Innovative assembly process for modular train and feasibility analysis in virtual environment

The present paper deals with the manufacturing process of a railway carriage. In the first part of the paper, the authors focus on a “virtual railway factory” that uses a very innovative assembly cycle, if compared to the traditional manufacturing processes in the railway field. The case study refers to a railway carriage consisting of four modules, that are singularly set up of furnishings and other systems in dedicated workplaces. On one hand, the virtual simulation has highlighted several critical aspects to be improved, in order to achieve a greater feasibility and to reduce time and cost. On the other hand, the designers have been able to evaluate the movements of the parts and the assembly sequences of the components, by considering each geometric, functional and technological constraint and also some safety requirements. The second part of the paper deals with the simulation of the assembling operations and the analysis of tolerance chains, which have been performed through a Computer Aided Tolerancing system. In particular, the precision requirements have been also evaluated and we have compared the accumulation of dimensional and geometric deviations when using both rivets and traditional welds to fasten the modules.     

Is this “My’ patient? Development and validation of a predictive model to link patients to primary care providers

BACKGROUND: Evaluating the quality of care provided by individual primary care physicians (PCPs) may be limited by failing to know which patients the PCP feels personally responsible for. OBJECTIVE: To develop and validate a model for linking patients to specific PCPs. DESIGN: Retrospective convenience sample. PARTICIPANTS: Eighteen PCPs from 10 practice sites within an academic adult primary care network. MEASUREMENTS: Each PCP reviewed the records for all outpatients seen over the preceding 3 years (16,435 patients reviewed) and designated each patient as “My Patient” or “Not My Patient.” Using this reference standard, we developed an algorithm with logistic regression modeling to predict “My Patient” using development and validation subsets drawn from the same patient set. Quality of care was then assessed by “My Patient” or “Not My Patient” designation by analyzing cancer screening test rates. RESULTS: Overall, PCPs designated 11,226 patients (68.3%, range per provider 15% to 93%) to be “My Patient.” The model accurately categorized patients in development and validation subsets (combined sensitivity 80.4%, specificity 93.7%, and positive predictive value 96.5%). To achieve positive predictive values of >90% for individual PCPs, the model excluded 19.6% of PCP “My Patients” (range 5.5% to 75.3%). Cancer screening rates were higher among model-predicted “My Patients.” CONCLUSIONS: Nearly one-third of patients seen were considered “Not My Patient” by the PCP, although this proportion varied widely. We developed and validated a simple model to link specific patients and PCPs. Such efforts may help effectively target interventions to improve primary care quality. Presented in part at the annual meeting of the Society of General Internal Medicine, New Orleans, LA in May, 2005. Supported by institutional funding through the Massachusetts General Hospital Primary Care Operations Improvement program.     

Tissue-type plasminogen activator activity in morphologically normal tissues adjacent to gastrointestinal carcinomas is associated with the degree of tumor progression

Purpose: To investigate whether the level of plasminogen activator (PA) activity assayed in gastrointestinal carcinomas and the “morphologically normal tissues” adjacent to them is associated with the degree of tumor progression. Methods: Tumor and “normal tissues” were obtained from gastrointestinal surgical samples to assess urokinase-type (u-PA) and tissue-type plasminogen activator (t-PA) activities by radial caseinolytic assay and the expression of PA inhibitor-1 (PAI-1) by ELISA. We compared the PA system between the tumor and “normal tissues” and we investigated the existence of correlations between: (a) PA production in the tumor and “normal tissues”, (b) different components of the PA system, and (c) PA system and the degree of tumor progression. Results: (1) Total PA activity, u-PA activity and PAI-1 expression are significantly higher in tumor than in “normal tissues”, whereas t-PA activity does not differ between them. (2) Total PA activity mainly correlates with u-PA activity in tumor tissues and similarly with u-PA and t-PA activities in “normal tissues”. (3) There is a significant association between t-PA activity in tumor and “normal tissues” and the degree of tumor progression. Conclusions: “Morphologically normal tissues” adjacent to carcinomas present abnormal t-PA activity that is associated with the degree of tumor progression. Assaying of this activity could be useful as a predictive parameter.     

Evaluation of quality of life in patients with previously untreated advanced prostate cancer receiving maximum androgen blockade therapy or LHRHa monotherapy: a multicenter, randomized, double-blind, comparative study

Purpose  To assess quality of life (QOL) data from a double-blind Phase III study evaluating bicalutamide (Casodex™) 80 mg as part of maximum androgen blockade (MAB) in patients with previously untreated advanced prostate cancer. Methods  Patients with untreated stage C/D prostate cancer were randomized to MAB with bicalutamide plus a luteinizing hormone-releasing hormone agonist (LHRHa) or LHRHa monotherapy. QOL was evaluated at baseline and at weeks 1, 5, and 24 using the Japanese version of the Functional Assessment of Cancer Therapy-Prostate (FACT-P) questionnaire. Results  A total of 203 patients were assessed for QOL. The MAB group had more rapid and greater improvements in “emotional well-being” and “prostate cancer-specific issues” domain scores than the monotherapy group. Further analysis of “prostate cancer-specific issues” revealed that, compared with monotherapy, MAB provided a greater improvement in “micturition disorder”-related QOL. Complete improvement rates for items related to “pain and micturition disorder” were also higher with MAB. Item scores of “pain and micturition disorder” did not correlate strongly with prostate-specific antigen levels or tumor size. Fewer patients who had deterioration in their “pain and micturition disorder” item scores at week 1 in the MAB group than the monotherapy group. Conclusions  Maximum androgen blockade with bicalutamide plus LHRHa did not reduce the overall QOL of patients with previously untreated advanced prostate cancer. MAB was superior to monotherapy in achieving early improvement of QOL related to micturition disorder and pain.     

Measuring educational needs among patients with rheumatoid arthritis using the Dutch version of the Educational Needs Assessment Tool (DENAT)

The Educational Needs Assessment Tool (ENAT) was developed in the United Kingdom (UK) to systematically assess the educational needs of patients with arthritis. The aim of the present study was to describe the educational needs of Dutch patients with rheumatoid arthritis (RA) by using the Dutch version of the ENAT (DENAT). The original UK version of the ENAT, comprising 39 items grouped into seven domains, was translated into Dutch according to international guidelines for cross-cultural translation and adaptation. The DENAT was then sent to a random sample of 319 RA patients registered at the outpatient clinic of a university hospital. For each domain (score range 1–5, equalling low–high educational needs), a median score with the inter-quartile range was computed. The Kruskal–Wallis test was used to determine possible associations between educational needs and age, disease duration, gender and educational background. The response rate was 165 out of 319 (52%). The median educational needs scores were 2.5 for “managing pain”, 3.0 for “movement”, 2.0 for “feelings”, 4.0 for “arthritis process”, 4.0 for “treatments from health professionals”, 3.5 for “self-help measures” and 2.5 for “support systems”. Lower age and shorter disease duration were associated with more educational needs in the domain “support systems”. In addition, younger patients had more educational needs regarding managing pain and feelings than older patients. There were no associations between gender or educational background and educational needs. The DENAT has demonstrated its ability to identify individual educational needs of Dutch patients with RA. The lower age and shorter disease duration were associated with more educational needs. The practical applicability of the DENAT needs further research. An erratum to this article can be found at     

Coping with arthritis is experienced as a dynamic balancing process. A qualitative study

The aim of this study was to investigate the process of coping in people living with chronic inflammatory arthritis. Semi-structured individual face-to-face interviews with 26 persons having rheumatoid arthritis, psoriatic arthritis or unspecified polyarthritis were performed. The informants were asked how they experienced to live with arthritis and how they coped with challenges due to the arthritis. The main finding was that the informants experienced the process of coping with arthritis as a dynamic, iterative, balancing process. They balanced between different states, entitled “go on as usual”, “listen to the body”, “adjustments” and “attitude towards life”. The informants preferred to be in a “go on as usual” state as this was seen as normal life. However, disease fluctuations with pain, fatigue and stiffness disturbed the balance and made the informants “listen to the body”, a state where they became aware of how the disease affected them, followed by the “adjustment” state. Adjustments were composed of different efforts to ease the arthritis influence and for regaining balance. The “attitude towards life” influenced the overall process of coping. A redefined view of what the informants considered to be normal life thus happened through longer periods of imbalance. The process of coping with arthritis was found to be a dynamic, iterative, balancing process where patients redefined what they considered as normal life through the course of the disease.     

Teaching durability in automotive applications using a reliability approach

Fatigue phenomena, which appear generally below the yield stress, is the cause of more than 80% of in-service mechanical failures. However, the optimization of the weight and cost when designing mechanical components or structures, linked to improved performance, leads to increasingly stressed components. Therefore, a fatigue design approach must be done by the engineer. This paper shows the experience gained over five academic years of teaching fatigue, the assessment of automotive components using a reliability approach to predict probability of failure, in the engineering school, Arts et Métiers ParisTech, in France. The choice was made to present a comprehensive fatigue assessment approach using a method, initially developed in the automotive industry and since extended to the aeronautical and mechanical industries. This method is known as the “stress–strength interference analysis”. The “stress” represents the distribution of the driver severity, and the “strength” represents the distribution of the fatigue strength of all the components. A suspension arm is used to illustrate the approach. The Dang Van multi-axial fatigue criterion is implemented in a finite-element code and a danger coefficient is visualized on the meshed structure. The fatigue analysis is interpreted with respect to the target reliability sought by the car manufacturer.     

Preventive home visitation programmes for older people: the role of municipality organisation

The organisational influence on benefits of preventive home visitation programmes for older people has escaped scientific evaluation. This study aims to investigate organisational structures and processes in relation to preventive home visits. As part of a randomised controlled trial investigating whether educational intervention towards municipality health care professionals could enhance active life expectancy, information of municipality leadership, home visit approach, strengths and limitations of communication within the organisation were obtained using individual and focus group interviews. Thirty-four municipalities in four counties participated. Data was systematically condensed using a phenomenological approach upon which general patterns were categorised into a theory-based formal typology of the preventive home visitation management in the municipalities. Three distinct strategies for preventive home visitation programmes were identified. Eighteen municipalities were categorised as “Framework Management”, 15 as “Management by Rules” and one as “Project Management”. Small municipality size was associated with the “Framework Management” type. “Management by Rules” municipalities had higher population densities and their overall expenses for older people were higher. “Framework Management” municipalities used more resources on preventive home visits, communicated better, experienced less staff changing and had higher social capital than “Management by Rules” municipalities. Municipality structures and management processes of preventive home visitation programmes varied considerably in 34 Danish municipalities, but the majority could be categorised as using either a “Framework Management” or a “Management by Rules” strategy. Each strategy is associated with particular advantages and disadvantages, which may explain differences in the overall benefit of the programme between municipalities. This study was supported by grants from the Danish Medical Research Council, the Research Foundation for General Practice and Primary Care, Eastern Danish Research Forum, the County Value-Added Tax Foundation and the Danish Ministry of Social Affairs.     

Massage therapy for fibromyalgia symptoms

Massage therapy is widely used by patients with fibromyalgia seeking symptom relief. We performed a review of all available studies with an emphasis on randomized controlled trials to determine whether massage therapy can be a viable treatment of fibromyalgia symptoms. Extensive narrative review. PubMed, PsychInfo, CINAHL, PEDro, ISI Web of Science, and Google Scholar databases (inception-December 2009) were searched for the key words “massage”, “massotherapy”, “self-massage”, “soft tissue manipulation”, “soft tissue mobilization”, “complementary medicine”, “fibromyalgia” “fibrositis”, and “myofascial pain”. No language restrictions were imposed. The reference lists of all articles retrieved in full were also searched. The effects of massage on fibromyalgia symptoms have been examined in two single-arm studies and six randomized controlled trials. All reviewed studies showed short-term benefits of massage, and only one single-arm study demonstrated long-term benefits. All reviewed studies had methodological problems. The existing literature provides modest support for use of massage therapy in treating fibromyalgia. Additional rigorous research is needed in order to establish massage therapy as a safe and effective intervention for fibromyalgia. In massage therapy of fibromyalgia, we suggest that massage will be painless, its intensity should be increased gradually from session to session, in accordance with patient’s symptoms; and the sessions should be performed at least 1–2 times a week.     

Differential diagnosis of dementing diseases

Evaluation of the cognitively impaired patient necessitates documentation of dementia, with the help of standard and robust neuropsychological tests, followed by identification of focal, multifocal, or subcortical neurological signs which help differentiate the most common dementing diseases. The usual diagnostic dilemma is to distinguish Alzheimer’s disease from circulatory dementia. Until recently, Alzheimer’s disease was considered a diagnosis of exclusion, with confirmation only by pathological examination. Invasive tests, such as lumbar puncture for protein markers or skin biopsy for genetic markers, may aid in the antemortem diagnosis of Alzheimer’s. Noninvasively determined information which may provide diagnostic clues includes family history of dementia and fingerprint patterns. Circulatory dementia need not be confined to multi-infarct dementia, but may also include dementia accompanying cerebrovascular or cardiovascular disease. Features associated with circulatory dementia include remote history of urinary and gait disturbances, ear hair growth, and “infarcts” on MRI and CTT. Although the significance of “infarcts” on MRI is unclear, they are associated with high Hachinski ischemic score, hypertension, and cardiac arrhythmias. “Infarcts” on MRI are more sensitive, but less specific, than “infarcts” on CTT, in diagnosing circulatory dementia. Techniques of decision analysis can help determine the diagnostic utility of the Hachinski score and its components, as well as of imaging techniques and other diagnostic aids, in differential diagnosis. In drug trials for Alzheimer’s, where maximum sensitivity in the diagnosis of circulatory dementia is needed to exclude inappropriate subjects, the MRI is the imaging procedure of choice. Conversely, drug trials for circulatory dementia should use the CTT to enhance specificity. In the absence of specific therapeutic intervention, either procedure may be used, as overall diagnostic utility of the CTT and MRI, as determined by the Brier score, is comparable. Papers from the symposium “Aging of the Brain: Recent Advances” presented during the 17th Annual Meeting of Age will be published in the first three issues of AGE for 1988. This paper was part of the symposium.     

Perioperative Mechanical Circulatory Support in Children with Critical Heart Disease

The treatment of cardiovascular failure in the perioperative period with the use of mechanical circulatory support is a well-recognized, well-developed, and commonly utilized treatment modality. Regardless of the exact circumstances of initiation, the use of a support device is a “bridge.” Where there has been an acute myocardial insult, short-term assist devices can serve as a “bridge to immediate survival,” a “bridge to recovery,” or even a “bridge to the next decision.” Mechanical circulatory support can serve as a treatment of cardiovascular decompensation caused by myocarditis, acute myocardial insult, low cardiac output following surgery, and congenital heart disease. The utilization of such support carries significant risks such as bleeding, infection, and thrombosis. However, these can be minimized in order to allow for the safe and effective deployment of this therapeutic strategy. One specific therapeutic domain in which these devices provide immediate impact is during cardiac arrest. Although outcomes of cardiac arrest remain poor, use of a mechanical device as an intervention has allowed salvage of otherwise certain mortality. However, it is important to note that the utility of support was most pronounced in patients that were not on either extreme of the survival prediction curve. This can be best summarized by the concept of “not too early, not too late.” Therefore, it is the responsibility of the entire care team to find the appropriate patient population in which to “pull the trigger” on mechanical support as a therapy. This decision point is supported by a monitoring strategy that can be utilized to predict deterioration and intervene adequately. Most importantly, an effective monitoring strategy allows the practitioner to judge the effectiveness of treatment and support strategies and make adjustments in a timely manner, potentially with mechanical support in the perioperative period.     

Fad Diets in the Treatment of Diabetes

Use of the term “fad diet” reflects the contentious nature of the debate in the treatment of diabetes and generally targets diets based on carbohydrate restriction, the major challenge to traditional dietary therapy. Although standard low-fat diets more accurately conform to the idea of a practice supported by social pressure rather than scientific data, it is suggested that we might want to give up altogether unscientific terms like “fad” and “healthy.” Far from faddish, diets based on carbohydrate restriction have been the historical treatment for diabetes and are still supported by basic biochemistry, and it is argued that they should be considered the “default” diet, the one to try first, in diseases of carbohydrate intolerance or insulin resistance. The barrier to acceptance of low-carbohydrate diets in the past has been concern about saturated fat, which might be substituted for the carbohydrate that is removed. However, recent re-analysis of much old data shows that replacing carbohydrate with saturated fat is, if anything, beneficial. The dialectic of impact of continued hemoglobin A_1c versus effect of dietary saturated fat in the risk of cardiovascular disease is resolved in direction of glycemic control. Putting biased language behind us and facing the impact of recent results that point to the value of low-carbohydrate diets would offer patients the maximum number of options.     

A selective sandwich technique of adjuvant radiotherapy in the treatment of rectal cancer: A preliminary experience

Conclusion In this pilot study of 21 patients with rectal cancer, we found that the “selective sandwich technique” balances the risks and benefits of aggressive therapy for the treatment of rectal cancer without undue complications, and that it has considerable potential for improving the survival rate of patients with this disease. Supported in part by a fellowship from the American Cancer Society Supported in part by USPHS Grant # 11602 from the National Cancer Institute.     

Smoking as a Chronic Disease

Despite remaining the leading cause of preventable death in the United States, tobacco smoking does not garner the attention it deserves in the medical and public health communities. Smoking is often referred to merely as a “bad habit” that simply requires adequate willpower to conquer effectively. Fortunately, recent attitudes regarding smoking, as illustrated by the latest US Public Health Service Clinical Practice Guidelines, call for a “chronic disease model” for treating tobacco dependence. This article underscores the importance of viewing smoking as a chronic disease by illustrating the effects on morbidity and mortality, discussing the relapsing nature of addiction, outlining the need for continuum of care for different “severities” of illness, and describing the latest research regarding effective treatment components. Tobacco dependence treatments are safe, effective, and cost-saving, and their use should be encouraged and covered by health insurance analogous to other chronic conditions.     

Enthesitis in seronegative spondyloarthropathies with special attention to the knee joint by MRI: a step forward toward understanding disease pathogenesis

Seronegative spondyloarthropathies are a unique group of disorders sharing similar clinical characteristics (e.g., inflammatory back pain, spondylitis, sacroiliitis, uveitis, inflammatory bowel disease, skin rashes, and enthesitis). Clinical and genetic similarities suggest that they also share similar causes or pathophysiologies. Rheumatoid factor (RF) is characteristically negative in this group of disorders, hence collectively termed seronegative spondyloarthropathies (SpA). They include psoriatic arthritis, ankylosing spondylitis, reactive arthritis, ulcerative colitis, and Crohn’s disease. “Enthesitis”, the term used to describe inflammation at tendon, ligament, or joint capsule insertions, is considered a common feature in this domain and was included in the European Spondyloarthropathy Study Group criteria for the classification of SpA. Evaluation of entheseal-related changes at different joints by MRI became an important item on the research agenda in both differentiated and undifferentiated arthritis. Most of the research focused on MRI findings in the hand and wrist joints among patients with RA and SpA and support two patterns of inflammation “RA” phenotype where synovial involvement is the primary target of inflammation and “SpA” pattern where enthesitis comes first followed by synovitis. In this review, we summarize the literature on enthesitis in SpA and focus on MRI findings in the knee joint in the SpA group of disorders and subclinical synovitis among patients with skin psoriasis.     

Morphological changes in gastric carcinoma with progression

By combining morphological two indices, namely, (1) the degree of differentiation of glandular tubules (well or poor) and (2) the amount of intracellular mucus (rich or poor), we previously classified histological types of gastric carcinoma into four types. Using this histological classification, we studied the morphological changes of gastric carcinoma according to extra-gastric invasion in 200 autopsy and 200 resected cases. In cases in which the predominant histological type in the lamina propria was “tubular differentiation—well, mucus in cytoplasm—poor,” there was a greater incidence of co-existence with other histological types. In many of these cases, the predominant histological findings changed to “tubular differentiation—poor” in the subserosa, followed by direct invasion into neighboring extra-gastric tissues. In all cases in which the predominant histological type in the lamina propria was “tubular differentiation —poor”, the predominant histological type in the subserosa was also “tubular differentiation—poor”. To understand the mode of extension of gastric carcinoma in relation to the histological type, we must consider not only the characteristics of the predominant histological types of carcinoma but also those of coexisting types, especially in cases of “tubular differentiation—well, mucus in cytoplasm—poor”.     

Identifying Multiple Submissions in Internet Research: Preserving Data Integrity

Internet-based sexuality research with hidden populations has become increasingly popular. Respondent anonymity may encourage participation and lower social desirability, but associated disinhibition may promote multiple submissions, especially when incentives are offered. The goal of this study was to identify the usefulness of different variables for detecting multiple submissions from repeat responders and to explore incentive effects. The data included 1,900 submissions from a three-session Internet intervention with a pretest and three post-test questionnaires. Participants were men who have sex with men and incentives were offered to rural participants for completing each questionnaire. The final number of submissions included 1,273 “unique”, 132 first submissions by “repeat responders” and 495 additional submissions by the “repeat responders” (N = 1,900). Four categories of repeat responders were identified: “infrequent” (2–5 submissions), “persistent” (6–10 submissions), “very persistent” (11–30 submissions), and “hackers” (more than 30 submissions). Internet Provider (IP) addresses, user names, and passwords were the most useful for identifying “infrequent” repeat responders. “Hackers” often varied their IP address and identifying information to prevent easy identification, but investigating the data for small variations in IP, using reverse telephone look up, and patterns across usernames and passwords were helpful. Incentives appeared to play a role in stimulating multiple submissions, especially from the more sophisticated “hackers”. Finally, the web is ever evolving and it will be necessary to have good programmers and staff who evolve as fast as “hackers”.