Which bladder instillations are more effective? DMSO vs. bupivacaine/heparin/triamcinolone: a retrospective study

Introduction and hypothesis

Bladder pain syndrome/interstitial cystitis (BPS/IC) is a chronic and debilitating condition. Our objective was to compare two different bladder instillation treatments in patients with BPS/IC: dimethyl sulfoxide with triamcinolone (DMSO) vs. bupivacaine with heparin and triamcinolone (B/H/T). Our hypothesis was that both treatments are equally effective.

Methods

A retrospective cohort study of instillation-naïve patients was conducted comparing responses to either DMSO or B/H/T at our tertiary urogynecology center from 2012 to 2014. The primary outcome was patient-reported percent of overall improvement from baseline. Secondary outcomes were change in patient-reported daytime voiding frequency (hours) and change in number of nighttime voiding episodes. Variables analyzed as potential confounders included pelvic pain, cystoscopy findings, levator spasm, and fibromyalgia. The two-sided Student’s t test, chi-squared test, Poisson regression, and repeated-measure analysis of variance (ANOVA) were used for analyses.

Results

One hundred and ninety-three eligible patients were identified (45 receiving DMSO, 146 receiving B/H/T). Compared with baseline, DMSO patients reported 63% improvement (p?<?0.0001), increased time between daytime voids by 1.5 h (p?<?0.00), and a 40% reduction in nocturia episodes (p?<?0.00). B/H/T patients reported 51% improvement (p?<?0.00), increased time between daytime voids by 1.4 h (p?<?0.00), and an 8% reduction in nocturia episodes (p?=?0.26). When comparing the two treatments, DMSO resulted in a greater percentage of overall improvement (p?=?0.02) and a significant decrease in nocturia episodes when compared with B/H/T (p?=?0.02). There was no significant difference between treatments for daytime voiding frequency (p?=?0.50).

Conclusion

Bladder instillations with DMSO or B/H/T provide overall symptomatic improvement and improved frequency and nocturia. DMSO appears to provide greater improvement in nocturia and overall.

     

Clinical and urodynamic differences among women with overactive bladder according to the presence of detrusor overactivity

Introduction and hypothesis

We tried to determine whether clinical and urodynamic differences exist between women with and without detrusor overactivity (DO) using a large database of overactive bladder (OAB) patients.

Methods

We reviewed the medical records of 513 women who underwent urodynamic studies for OAB symptoms without neurogenic or anatomical conditions that affect micturition function. Clinical symptoms were evaluated using a 3-day frequency-volume chart (FVC) including the Urinary Sensation Scale and American Urological Association Symptom Index (AUA-SI). All clinical and urodynamic findings were compared between women with and without DO.

Results

The patients’ mean age was 58.9 years. DO was identified urodynamically in 167 (32.6 %) women. Those with DO were older (62.9 vs 57.0 years, p?<?0.001); however, no differences in AUA-SI, episodes of daytime voiding, and episodes of nocturia were observed between the groups. Functional bladder capacity was smaller in women with DO; however, this difference did not reach statistical significance. Women with DO had significantly more urgency incontinence symptoms than those without DO (55.1 vs 29.5 %, p?<?0.001). In urodynamic parameters, the volumes at first desire to void and strong desire to void and maximum cystometric capacity were significantly smaller, and detrusor pressure at the opening was significantly higher in women with DO compared to subjects without DO (26.2 vs 21.2 cmH₂O, p?=?0.004).

Conclusions

Our findings suggest a more severe disturbance of bladder function when DO exists, although no differences were observed in symptom scores and 3-day FVC parameters among women with OAB symptoms according to the presence of DO.     

Welchen Erfolg bringt die Sigmaresektion bei der akuten Sigmadivertikulitis tatsächlich?

Introduction

The correct therapeutic management of acute sigmoid diverticulitis (SD) is still controversially discussed. Essential to the success of therapy is primarily the long-term resolution of Patient symptoms after surgical or conservative therapy. The aim of this study was to compare the long-term outcome after conservative and surgical treatment of Patients with acute SD.

Patients and methods

Consecutive admissions of all Patients with acute SD were prospectively recruited from January 2005 to June 2008 with the exception of a free perforation. The following data were recorded: age, sex, first or recurrent episode of SD, computed tomography (CT) stage, white blood cell count, C-reactive protein, persistent symptoms and recurrence after conservative and surgical therapy. Furthermore, information on the rates of postoperative sexual and bladder dysfunction was collected. The long-term outcome was evaluated by a standardized questionnaire. In June 2008 all Patients were contacted using a standardized questionnaire.

Results

A total of 153 Patients were included in the study of whom 70 (45.8 ?%) presented with the first episode, 83 (54.2 ?%) had a prior history of SD and 40 Patients were treated conservatively whereas 113 Patients were surgically treated by sigmoid resection. Uncomplicated SD was seen in 16 Patients (conservative 4, surgical 12, p?=?0.961), phlegmonous SD was seen in 88 cases (conservative 29, surgical 59, p?=?0.026) and covered perforated SD in 49 cases (conservative 7, surgical 42, p?=?0.022). The median follow-up was 32 months (range 12–52 months). At follow-up 25? % of conservative and 8.8 ?% of Patients treated surgically complained about persistent symptoms (p?=?0.009). The following symptoms occurred (conservative vs. surgery): painful defecation (22.5? % versus 8.8 ?%, p?=?0.024.), constipation (25 ?% versus 8.8 ?%, p?=?0.009), abdominal cramp (22.5 % versus 4.4 ?%, p?=?0.001) and painful flatulence (25 ?% versus 8.8 ?%, p?=?0.009). Sexual or bladder dysfunction occurred postoperatively in 7 ?% and 9 ?%, respectively. Of the conservatively treated Patients 32.5? % had a recurrence of SD during follow-up compared to 3.5?% of surgically treated Patients (p?<?0.001).

Conclusions

Surgical treatment of acute SD is more effective than conservative therapy for the prophylaxis of recurrent SD and avoidance of persistent symptoms.     

Percutaneous dorsal root ganglion lysis with phenol for the treatment of pain associated with thoracic compression fracture

Background

Symptomatic thoracic compression fracture is one of the most common causes of back pain in elderly. Although vertebroplasty is widely utilized in patients when conservative treatment fails, we introduced an alternative percutaneous technique for the treatment of thoracic compression pain.

Methods

This in a retrospective study. The analysis was performed on 28 consecutive patients who underwent undergoing percutaneous dorsal root ganglion lysis with phenol for the treatment of pain associated with thoracic compression fracture. An acceptable treatment outcome was operationally defined as a pain intensity numerical rating scale (NRS) score of 3 or lower or EQ-5D index of 0.672 or higher. The primary outcome was pain relief and acceptable treatment outcome at 1 day, 1 week, 1 month, and 1 year.

Results

Of the 28 cases treated with our procedures, the change in mean NRS score between baseline and one day was ?2.5 (95 % CI ?1.6?～??3.4, p?<?0.001), between baseline and one week was ?4.7 (?4.1 to ?5.3, p?<?0.001), between baseline and one month was ?5.8 (?5.2 to ?6.5, p?<?0.001), and between baseline and one year was ?6.3 (?5.6 to ?7.1, p?<?0.001). An acceptable treatment outcome was 14 % one day after the procedure, 46 % at one week, 72 % at one month, and 84 % at one year. Complication rate was 3.6 %.

Conclusions

For thoracic compression fracture patients, percutaneous dorsal root ganglion lysis with phenol is an effective, and safe alternative treatment method worth considering. Pain relief is fast and persists for one year.     

Impact of intravesical hyaluronic acid and chondroitin sulfate on bladder pain syndrome/interstitial cystitis

Introduction and hypothesis

Intravesical instillations of hyaluronic acid (HA) and chondroitin sulfate (CS) may lead to regeneration of the damaged glycosaminoglycan layer in interstitial cystitis/bladder pain syndrome (IC/BPS).

Methods

Twenty-two patients with IC/BPS received intravesical instillations (40?ml) of sodium HA 1.6% and CS 2.0% in 0.9% saline solution (IALURIL?, IBSA) once weekly for 8?weeks, then once every 2?weeks for the next 6?months.

Results

The score for urgency was reduced from 6.5 to 3.6 (p?=?0.0001), with a reduction in pain scores from an average of 5.6 to 3.2 (p?=?0.0001). The average urine volume increased from 129.7 to 162?ml (p?p?p?p?Conclusion The treatment appeared to be effective and well tolerated in IC/BPS in this initial experience.     

Longitudinal observational cohort study about detrusor underactivity as a risk factor for bladder neck contracture after retropubic radical prostatectomy: preliminary results

Objectives

To evaluate the association between preoperative detrusor underactivity (DU) and symptomatic bladder neck contracture (BNC) in patients undergoing radical retropubic prostatectomy (RRP), in order to identify a possible new risk factor in the etiopathogenic mechanisms of BNC after RRP.

Methods

A total of 100 prostate cancer patients underwent RRP after preoperative complete urodynamic examination. Detrusor contractility was evaluated by bladder contractility index (BCI), power at maximum flow (WF-Q_max), and maximum velocity of detrusorial contraction (MVDC). Follow-up included uroflowmetry with bladder post-voiding volume evaluation at 3 and 6 months after surgery and repeated urodynamic examination at 12 months. Statistical evaluation was performed using the Student’s t test (P < 0.01).

Results

The mean patient age was 65.6 ± 5.4 years, and pathological stage ranged from T2a to T2c. A total of 40 patients (40 %) presented normal detrusor contractility, 47 (47 %) mild DU, and 13 (13 %) severe DU. Detrusor overactivity (DO) was observed in 12 patients (12 %), small cystometric capacity in 10 (10 %), low compliance in 16 (16 %), DO plus DU (mild or severe) in 6 (6 %), and DO plus small cystometric capacity together with low compliance in 5 (5 %). Normal urodynamics were observed in 38 patients (38 %). Overall BNC incidence was 12. All patients with BNC presented preoperative DU; none presented DO or low bladder compliance. DU severity and BNC occurrence were significantly correlated (P < 0.01) for all 3 urodynamic parameters (BCI, WF-Q_max, and MVDC).

Conclusions

We identify DU as a possible novel risk factor for BNC formation after radical prostatectomy that may contribute to its development.     

Prevalence and associated risk factors of nocturia and subsequent mortality in 1,301 patients with type 2 diabetes

Objective

To evaluate the correlates of nocturia and subsequent mortality in patients with type 2 diabetes mellitus (T2DM).

Methods

A self-administered questionnaire containing overactive bladder symptom score was obtained from subjects with T2DM. Nocturia and severe nocturia were defined as rising ≥2 or ≥3 per night to void, respectively. Patient characteristics and diabetes-related complications to risk of nocturia were evaluated.

Results

Of 1,301 consecutive subjects, 59.6 and 25.3 % reported having nocturia and severe nocturia, respectively. The presence and severity of nocturia increased with age and overactive bladder (OAB). The presence of OAB was 28.8 % in patients with nocturia and was significantly associated with nocturia (OR 2.26) after adjustment for age and duration of DM. The presence of stroke, calcium channel blocker use, hypertension, waist circumference greater than standard, albuminuria, and higher serum creatinine level, and high-sensitivity C-reactive protein was associated with nocturia and severe nocturia after adjustment for age, duration of DM, and the presence of OAB. Higher estimated glomerular filtration rate, hemoglobin, serum albumin, and male gender were less likely to have nocturia (OR <1). Severe nocturia increased mortality (OR 1.93) independent of age and DM duration and has a higher mortality rate compared to those without severe nocturia (6.1 vs. 2.4 %, P = 0.001) in 2.5 years follow-up.

Conclusions

While OAB is an important predictor of nocturia in T2DM patients, systemic issues, including stroke, hypertension, obesity, and chronic kidney disease, have further impact on nocturia independent of OAB. Severe nocturia is a marker for increased mortality.     

Characteristics and outcomes of varied treatment modalities for partially thrombosed intracranial aneurysms: a review of 35 cases

Objective

The purpose of this study was to analyze the characteristics of partially thrombosed intracranial aneurysms (PTIAs) in terms of location, shape, size, and symptoms, and to assess outcome according to the type of treatment.

Methods

We reviewed the radiological and clinical findings of 35 cases of PTIAs followed in our institution between 2006 and 2011. We divided all treatment modalities into two groups. Patients in group A (n?=?15) were treated by blood flow blockage from the lesion of the pathogenic segment of the parent where the PTIAs originated, and patients in group B (n?=?20) were only treated with obliteration of the remnant perfused aneurysmal sac. Radiological and clinical outcomes of treatment were compared between the two groups.

Results

Group A showed complete occlusion in 15 cases (100 %) compared to six cases (30.0 %) in group B (p?Conclusion PTIAs should be treated by preventing blood flow from the lesion of the pathogenic segment of the parent artery where PTIAs originate. This treatment approach is associated with better clinical and radiological outcomes.     

Accurate risk assessment of patients with asymptomatic hematuria for the presence of bladder cancer

Purpose

Bladder cancer is frequently diagnosed during a workup for hematuria. However, most patients with microscopic hematuria and many with gross hematuria are not appropriately referred to urologists. We hypothesized that in patients presenting with asymptomatic hematuria the risk of having bladder cancer can be predicted with high accuracy. Toward this end, we analyzed risk factors in patients with asymptomatic hematuria and developed a nomogram for the prediction of bladder cancer presence.

Methods

Data from 1,182 consecutive subjects without a history of bladder cancer undergoing initial evaluation for asymptomatic hematuria were collected at three centers. Clinical risk factors including age, gender, smoking status, and degree of hematuria were recorded. All subjects underwent standard workup including voided cytology, upper tract imaging, and cystourethroscopy. Factors associated with the presence of bladder cancer were evaluated by univariable and multivariable logistic regression analyses. The multivariable analysis was used to construct a nomogram. Internal validation was performed using 200 bootstrap samples.

Results

Of the 1,182 subjects who presented with asymptomatic hematuria, 245 (20.7?%) had bladder cancer. Increasing age (OR?=?1.03, p?<?0.0001), smoking history (OR?=?3.72, p?<?0.0001), gross hematuria (OR?=?1.71, p?=?0.002), and positive cytology (OR?=?14.71, p?<?0.0001) were independent predictors of bladder cancer presence. The multivariable model achieved 83.1?% accuracy for predicting the presence of bladder cancer.

Conclusions

Bladder cancer presence can be predicted with high accuracy in patients who present with asymptomatic hematuria. We developed a nomogram to help optimize referral patterns (i.e., timing and prioritization) of patients with asymptomatic hematuria.     

Versorgungsrealität in der laparoskopischen Chirurgie des Kolonkarzinoms in Deutschland

Background

Prospective randomized studies and meta-analyses have shown that laparoscopic resection for colonic cancer is equivalent to open resection with respect to the oncological results and has short-term advantages in the early postoperative outcome. The aim of this study was to investigate whether laparoscopic colonic resection has become established as the standard in routine treatment.

Methods

Data from the multicenter observational study ?Quality assurance colonic cancer (primary tumor)“ from the time period from 1 January 2009 to 21 December 2011 were evaluated with respect to the total proportion of laparoscopic colonic cancer resections and tumor localization and specifically for laparoscopic sigmoid colon cancer resections. A comparison between low and high volume clinics (<?30 versus ≥?30 colonic cancer resections/year) was carried out.

Results

Laparoscopic colonic cancer resections were carried out in 12 % versus 21.4 % of low and high volume clinics, respectively (p?<?0.001) with a significant increase for low volume clinics (from 8.0 % to 15.6 %, p?<?0.001) and a constant proportion in high volume clinics (from 21.7 % to 21.1 %, p?=?0.905). For sigmoid colon cancer laparoscopic resection was carried out in 49.7 % versus 47.6 % (p?=?0.584). Differences were found between low volume and high volume clinics in the conversion rates (17.3 % versus 6.6 %, p?<?0.001), the length of the resected portion (Ø 23.6 cm versus 36.0 cm, p?<?0.001) and the lymph node yield (Ø n?=?15.7 versus 18.2, p?=?0.008). There were no differences between the two groups of clinics regarding postoperative morbidity and mortality. The postoperative morbidity and length of stay were significantly lower for laparoscopic sigmoid resection than for conventional sigmoid resection.

Conclusion

The laparoscopic access route for colonic cancer resection is not the standard approach in the participating clinics. The laparoscopic access route has the highest proportion for sigmoid colon resection. The differences in the conversion rates, length of the resected portion and the number of lymph nodes investigated between the low volume and high volume clinics must be viewed critically and must be interpreted in connection with the long-term oncological results.     

Architectural design of the pelvic floor is consistent with muscle functional subspecialization

Introduction and hypothesis

Skeletal muscle architecture is the strongest predictor of a muscle’s functional capacity. The purpose of this study was to define the architectural properties of the deep muscles of the female pelvic floor (PFMs) to elucidate their structure–function relationships.

Methods

PFMs coccygeus (C), iliococcygeus (IC), and pubovisceral (PV) were harvested en bloc from ten fixed human cadavers (mean age 85 years, range 55–102). Fundamental architectural parameters of skeletal muscles [physiological cross-sectional area (PCSA), normalized fiber length, and sarcomere length (L_s)] were determined using validated methods. PCSA predicts muscle-force production, and normalized fiber length is related to muscle excursion. These parameters were compared using repeated measures analysis of variance (ANOVA) with post hoc t tests, as appropriate. Significance was set to α?=?0.05.

Results

PFMs were thinner than expected based on data reported from imaging studies and in vivo palpation. Significant differences in fiber length were observed across PFMs: C?=?5.29?±?0.32 cm, IC?=?7.55?±?0.46 cm, PV?=?10.45?±?0.67 cm (p?<?0.001). Average L_s of all PFMs was short relative to the optimal L_s of 2.7 μm of other human skeletal muscles: C?=?2.05?±?0.02 μm, IC?=?2.02?±?0.02 μm, PC/PR?=?2.07?±?0.01 μm (p?=?<0.001 compared with 2.7 μm; p?=?0.15 between PFMs, power?=?0.46). Average PCSA was very small compared with other human muscles, with no significant difference between individual PFMs: C?=?0.71?±?0.06 cm², IC?=?0.63?±?0.04 cm², PV?=?0.59?±?0.05 cm² (p?=?0.21, power?=?0.27). Overall, C had shortest fibers, making it a good stabilizer. PV demonstrated the longest fibers, suggesting that it functions to produce large excursions.

Conclusions

PFM design shows individual muscles demonstrating differential architecture, corresponding to specialized function in the pelvic floor.     

Polytraumaversorgung in Deutschland

Background

The aim was to survey the radiological diagnostics and type of primary radiological examination of polytraumatized patients treated in German hospitals at various levels in the three-tiered system.

Material and methods

A questionnaire was sent in October 2007 to every traumatology department registered in the DGU (German Society for Trauma Surgery) databank and forms returned by January 2008 were included in this study.

Results

A total of 273 (54.71 %) of forms were returned and were applicable to statistical analysis. In the three-tiered hospital system 35.9 % of returned questionnaires came from third-tier hospitals, 41.02 % from second-tier and 23.08 % from highest tier (maximum care) hospitals. With a higher hospital level of inpatient care more computed tomography (CT) scans were examined by a radiologist during 24 h daily (p?=?0.0014) and CT scanners were located closer to the resuscitation room (p?<?0.0001). We found significant differences in the ratios of primary whole-body CTs (WBCT) performed depending on the hospital level: third-tier hospitals 44 %, second tier hospitals 67 % and maximum care hospitals 84 % (p?<?0.05).

Conclusions

Standardized structures regarding radiological diagnostics of polytraumatized patients do not exist at either the same level of the three-tiered hospital system or between levels of care of German hospitals..     

The “bother” of urinary incontinence

Introduction and hypothesis

Patient reported measures are important for the evaluation of symptom-specific bother and the distinction between different types of urinary incontinence. The aim of the study was to assess the validity of physician administered visual analogue scales (VAS) for the bother from stress urinary incontinence (SUI) and urge urinary incontinence (UUI).

Methods

In this prospective cohort study based at a tertiary urogynecological unit, women attending for investigation of lower urinary tract symptoms (n?=?504) were asked to indicate their subjective bother from SUI and UUI on a 10-cm VAS. Clinical assessment, including multichannel urodynamic testing and 4D translabial ultrasound was performed for clinical diagnosis. Linear regression was used to model the average increase in VAS bother score of SUI and UUI for each explanatory variable.

Results

74 % (n?=?375) reported symptoms of SUI, with mean bother of 5.7 out of 10 (SD 2.8), and 73 % (n?=?370) symptoms of UUI, with a mean bother of 6.5 out of 10 (SD 2.6). Bother from UUI was positively associated with the symptoms of nocturia (p?<?0.0001) and frequency (p?=?0.002), and the urodynamic findings of detrusor overactivity (p?<?0.0001). Bother from SUI was positively related to the urodynamic diagnosis of USI (p?<?0.0001) and a low abdominal leak point pressure (ALPP) (p?=?0.002), as well as to the ultrasound findings of cystourethrocele (p?<?0.0001) and funnelling (p?=?0.04). All univariate associations remained highly significant on multivariate analysis, controlling for age, BMI, parity, previous incontinence/prolapse surgery and previous hysterectomy.

Conclusions

Physician-administered VAS are a valid, reliable and practicable tool to measure bother related to SUI and UUI.     

Consistent and significant improvement of nighttime voiding frequency (nocturia) with silodosin in men with LUTS suggestive of BPH: pooled analysis of three randomized,placebo-controlled,double-blind phase III studies

Objectives

Nocturia is prevalent and bothersome in men with lower urinary tract symptoms suggestive of BPH (LUTS/BPH). α-Adrenoceptor antagonists without subtype selectivity have inconsistently shown significant effects on nocturia in these patients. We explored the effects of the α_1A-adrenoceptor subtype-selective antagonist silodosin on nocturia by analyzing three placebo-controlled registration studies.

Methods

Responses to question 7 of the IPSS questionnaire were analyzed for the entire study population and patients with ≥2 voids/night at baseline. Improvement/worsening rates for nocturia were calculated for once-daily silodosin 8 mg and placebo. Silodosin effects on the mean number of nocturnal voids were compared with placebo, and the number of patients in whom nocturia was reduced to <2 times was calculated.

Results

In total, 1,479 men were treated with silodosin or placebo; 1,266 men (85 %) had ≥2 voids/night at baseline. Compared to placebo, more men treated with silodosin reported about nocturia improvement (53.4 vs. 42.8 %, p < 0.0001) and fewer patients about worsening (9.0 vs. 14.3 %, p < 0.0001). Silodosin significantly reduced nocturia within each study and pooled cohort compared to placebo (p < 0.001). In men with ≥2 nocturnal voids at baseline, 61 and 49 % of patients with silodosin and placebo had reductions of ≥1 voids/night, respectively (p = 0.0003), and significantly more patients with silodosin had <2 nocturia episodes at study end compared to placebo (29.3 vs. 19.0 %; p = 0.0002).

Conclusions

Although a weak impact on nocturia is already known from α-adrenoceptor antagonists without subtype selectivity, the individual placebo-controlled studies and the pooled data analysis showed that the α_1A-adrenoceptor subtype-selective antagonist silodosin consistently and significantly improves nocturia in men with LUTS/BPH.     

The Relationships Between IGF-1 and CRP, NO, Leptin, and Adiponectin During Weight Loss in the Morbidly Obese

Background

The relationship between C-reactive protein (CRP), nitric oxide (NO), leptin, adiponectin, and insulin growth factor 1 (IGF-1) is poorly defined in morbidly obese patients before and after gastric bypass and, in some cases, is controversial.

Methods

We examined the plasma of 34 morbidly obese patients before and 1, 6, and 12 months after Roux-en-Y gastric bypass surgery.

Results

Obese people had more CRP (21.3?±?1.8 μg/ml) and leptin (36.9?±?4.0 ng/ml) than those in the control group (nonobese people: CRP?= 6.9?±?0.9 μg/ml, p?<?0.0001; leptin?= 7.5?±?0.4 ng/ml, p?<?0.0001). However, they had less NO (30.4?±?2.7 nmol/ml), IGF-1 (77.5?±?6.6 ng/ml), and adiponectin (11.1?±?1.0 μg/ml) than those in the control group (NO?= 45.8?±?3.9 nmol/ml, p?=?0.0059; IGF-1?= 202.0?±?12.0 ng/ml, p?<?0.0001; adiponectin?= 18.0?±?2.0 μg/ml, p?<?0.0001). During weight loss, the amount of CRP and leptin decreased until they reached the nonobese values, but the level of NO remained lower than in nonobese people, even 1 year after surgery. The linear regression slopes were negative and very significant for leptin (p?=?0.0005) and CRP (p?=?0.0018) but were less significant for NO (p?=?0.0221). IGF-1 displayed a very good linear regression (both negative and significant) with some anthropometric parameters, including body mass index (p?=?0.0025), total fat (p?=?0.0177), and the percentage of fat (p?<?0.0001).

Conclusion

For the first time, we report the relationship between IGF-1 and CRP, NO, leptin, and adiponectin. For all these parameters, the best and most widely demonstrated improvements in comorbidities before and during weight loss in morbid obesity were associated with CRP and leptin.     

Changes in nerve growth factor level and symptom severity following antibiotic treatment for refractory overactive bladder

Introduction and hypothesis

Overactive bladder (OAB) has a multifactorial aetiology, and for some women symptoms may be associated with chronic urothelial inflammation secondary to bacterial colonisation. One marker of such inflammation may be urinary nerve growth factor (NGF). We hypothesised that for women with OAB and urothelial inflammation, urinary NGF would be reduced following antibiotic therapy.

Methods

Women with overactive bladder and urodynamic diagnosis of detrusor overactivity who were refractory to anticholinergics, and had histological evidence of urothelial inflammation were treated with a 6-week course of rotating antibiotics. Urinary NGF was measured by ELISA before and after treatment. Three-day bladder diaries, the Patients’ Perception of Intensity of Urgency Scale, the King’s Health Questionnaire and the Patients’ Perception of Bladder Condition questionnaire were used to assess subjective and objective outcomes of therapy.

Results

Thirty-nine women with refractory DO were recruited. The NGF levels decreased significantly after antibiotic therapy (Wilcoxon signed rank test; p?=?0.015). There were significant improvements in daytime frequency, nocturia and urgency (p?<?0.05), and 74 % of women reported improvement in perception of their bladder condition.

Conclusions

Urinary NGF is responsive to antibiotic therapy. Women with refractory overactive bladder and elevated NGF may benefit from antibiotic treatment.     

Long-term outcomes of intravesical dimethyl sulfoxide/heparin/hydrocortisone therapy for interstitial cystitis/bladder pain syndrome

Introduction and hypothesis

For decades, intravesical dimethyl sulfoxide (DMSO) cocktail therapy has been used for the treatment of interstitial cystitis/bladder pain syndrome (IC/BPS), but little is known about its long-term efficacy. We aimed to assess the long-term efficacy of intravesical DMSO/heparin/hydrocortisone/bupivacaine therapy in patients with IC/BPS.

Methods

Patients with IC/BPS from our institutions who underwent this therapy with >2 years follow-up were surveyed with O’Leary–Sant interstitial cystitis symptom and problem index questionnaires before and after therapy. Chart reviews and telephone surveys were then conducted to determine their posttherapy course.

Results

Of 68 eligible women, 55 (80.0%) with a median follow-up of 60 months (range 24–142) were surveyed. Their mean age at therapy onset was 44.8 years and their mean body mass index was 26.2 kg/m². There were statistically significant improvements in O’Leary–Sant and pain scores of 23–47% at both 6 weeks and the end of the follow-up period. At the end of the follow-up period, 19 of the 55 women (34.5%) were cured (requiring no further treatment) and 12 (21.8%) were significantly improved (requiring only ongoing oral medication). Univariate and multivariate analyses showed that DMSO treatment failure was more likely in patients with pretreatment day-time urinary frequency more than 15 episodes per day (OR 1.41), nocturia more than two episodes per night (OR 2.47), maximum bladder diary voided volume <200 ml (OR 1.39) and bladder capacity under anaesthesia <500 ml (OR 1.6).

Conclusions

At a median follow-up of 60 months, intravesical DMSO cocktail therapy appeared moderately effective for the treatment of IC/BPS. Treatment failure was more frequent in patients with pretreatment symptoms of reduced bladder capacity.

     

Evaluation of bladder capacity in Korean children younger than 24 months: a nationwide multicenter study

Purpose

Bladder capacity is an important factor in the diagnosis and treatment of children with voiding dysfunction. The purpose of this study was to define the normal maximal voided volume formula in Korean children younger than 2 years.

Methods

We measured the bladder capacities of 151 Korean children between 0 and 24 months of age (83 boys and 68 girls) who did not have clinical voiding dysfunction. The maximal voided volume was determined in all subjects using a 2-day frequency volume chart with a four-hour voiding observation. The largest voided volume for each patient was considered to be the maximal voided volume. Statistical analyses were carried out using linear regression analysis.

Results

The maximal voided volume increased with age and weight (P = 0.0001). There was no significant difference between males and females (P = 0.771). A formula that approximates bladder capacity with respect to age is the following: bladder capacity (ml) = [1.6 × age (months)] + 45 (t = 8.757, P = 0.0001). A formula that approximates bladder capacity with respect to weight is the following: bladder capacity (ml) = [4.1 × weight (kg)] + 28 (t = 10.152, P = 0.0001).

Conclusions

These formulas may be useful for the diagnosis of abnormal bladder capacity and the evaluation of voiding dysfunction in Korean children younger than 24 months.     

Changes in trabecular bone density in incident pediatric Crohn’s disease: a comparison of imaging methods

Summary

This study of changes in dual energy x-ray absorptiometry (DXA) spine BMD following diagnosis and treatment for childhood Crohn’s disease demonstrated that changes in conventional posteroanterior BMD results were confounded by impaired growth, and suggested that lateral spine measurements and strategies to estimate volumetric BMD were more sensitive to disease and treatment effects.

Introduction

We previously reported significant increases in peripheral quantitative CT (pQCT) measures of trabecular volumetric bone mineral density (vBMD) following diagnosis and treatment of pediatric Crohn’s disease (CD). The objective of this study was to compare pQCT trabecular vBMD and three DXA measures of spine BMD in this cohort: (1) conventional posteroanterior BMD (PA-BMD), (2) PA-BMD adjusted for height Z (PA-BMD_HtZ), and (3) width-adjusted volumetric BMD (WA-BMD) estimated from PA and lateral scans.

Methods

Spine DXA [lumbar (L1–4) for posteroanterior and L3 for lateral] and tibia pQCT scans were obtained in 65 CD subjects (ages 7–18 years) at diagnosis and 12 months later. BMD results were converted to sex, race, and age-specific Z-scores based on reference data in >650 children (ages 5–21 years). Multivariable linear regression models identified factors associated with BMD Z-scores.

Results

At CD diagnosis, all BMD Z-scores were lower compared with the reference children (all p values <0.01). The pQCT vBMD Z-scores (?1.46?±?1.30) were lower compared with DXA PA-BMD (?0.75?±?0.98), PA-BMD_HtZ (?0.53?±?0.87), and WA-BMD (?0.61?±?1.10) among CD participants. Only PA-BMD Z-scores were correlated with height Z-scores at baseline (R?=?0.47, p?<?0.0001). pQCT and WA-BMD Z-scores increased significantly over 12 months to ?1.04?±?1.26 and ?0.20?±?1.14, respectively. Changes in all four BMD Z-scores were positively associated with changes in height Z-scores (p?<?0.05). Glucocorticoid doses were inversely associated with changes in WA-BMD (p?<?0.01) only.

Conclusions

Conventional and height Z-score-adjusted PA DXA methods did not demonstrate the significant increases in trabecular vBMD noted on pQCT and WA-BMD scans. WA-BMD captured glucocorticoid effects, potentially due to isolation of the vertebral body on the lateral projection. Future studies are needed to identify the BMD measure that provides greatest fracture discrimination in CD.     

Use of risedronate to prevent bone loss following a single course of glucocorticoids: findings from a proof-of-concept study in inflammatory bowel disease

Summary

We performed a randomised controlled trial (RCT) to determine whether risedronate 35 mg once weekly prevents bone loss following an 8-week reducing course of prednisolone given for an exacerbation of inflammatory bowel disease (IBD). The greatest change in bone mineral density (BMD) was at Ward’s triangle (WT), which fell by 2.2% in the placebo group, compared with a reduction of 0.8% in the risedronate group.

Introduction

Whether bisphosphonates can prevent bone loss associated with intermittent glucocorticoid (GC) therapy is unknown, reflecting the difficulty in performing RCTs in this context.

Method

To explore the feasibility of RCTs to examine this question, lumbar spine (LS; L2–4) and hip dual X-ray absorptiometry (DXA) scans were performed in 78 patients commencing a GC therapy course for a relapse of IBD. They were then randomised to receive placebo or risedronate 35 mg weekly for 8 weeks, after which the DXA scan was repeated.

Results

For LS BMD, there was no change in the placebo group (0.1?±?0.4, p?=?0.9), but there was an increase after risedronate (0.8?±?0.4, p?=?0.04; mean%?±?SEM by paired Student’s t test). There were small decreases in both groups at the total hip (?0.5?±?0.3, p?=?0.04; ?0.5?±?0.3, p?<?0.05, placebo and risedronate, respectively). At WT, BMD fell after placebo (?2.2?±?0.5, p?=?0.001) but not risedronate (?0.8?±?0.5, p?=?0.09; p?=?0.05 for between-group comparison).

Conclusion

RCTs can be used to examine whether bisphosphonates prevent bone loss associated with intermittent GC therapy, providing metabolically active sites such as WT are employed as the primary outcome.