The relationship between cognition and sensation in determining when and where to void: the concept of cognitive voiding

Study Type – Aetiology (case series) Level of Evidence 4 What's known on the subject? and What does the study add? The factors taken into consideration when determining when and where to void are poorly understood. Studies on bladder sensations, obtained during cystometry of from voiding diaries, are proving difficult to transfer to everyday experiences. There is therefore a need to explore what does influence when and where to void. This study, using focus groups, highlights the fact that many voids are driven by behavioural factors not by sensations of desire or need to void. It is further noted that a key factor in the final decision to void is an awareness of bladder volume. The concepts of ‘cognitive voiding’ informed by ‘bladder awareness’ are introduced and, if correct, will influence the way studies are devised and interpreted to explore lower urinary tract dysfunction and pharmacotherapy. OBJECTIVE

• ? To investigate the inter‐relationship between conscious decision‐making processes and bladder sensation in determining the need, time and place to void

SUBJECTS AND METHODS

• ? The approach used interview focus groups and qualitative thematic analysis. In this preliminary study, 25 women were included (aged 21–90 years) meeting in groups of one to five on four occasions.

RESULTS

• ? The thematic analysis yielded six themes: temporal and cognitive maps, risk issues, habituation and opportunistic behaviour and awareness of the bladder.
• ? For most voids, the decision to void was not based on sensation but determined by multiple factors: personal knowledge of time of last void, anticipated time to next void, proximity of toilets, a risk assessment or habituated behaviour.
• ? As the bladder filled the subjects described an increasing awareness of their bladder. Such sensations were not immediately associated with desire to void. Rather, these sensations were described as influencing the cognitive processes of considering when and where to void.
• ? A sub‐group of subjects reported little awareness as their bladder filled, experiencing only sudden strong sensations that needed immediate action for fear of leakage.

CONCLUSIONS

• ? The decision to void is primarily a cognitive process influenced by multiple elements of which bladder awareness is only one.
• ? Mechanisms generating awareness may be intensified or lost reflecting possible different pathological states. The importance of these observations in relation to current views of normal and abnormal voiding is discussed.

     

Good quality white-light transurethral resection of bladder tumours (GQ-WLTURBT) with experienced surgeons performing complete resections and obtaining detrusor muscle reduces early recurrence in new non-muscle-invasive bladder cancer: validation across time and place and recommendation for benchmarking

Study Type – Diagnostic (exploratory cohort) Level of Evidence 2a What's known on the subject? and What does the study add? Staging of patients with prostate cancer is the cornerstone of treatment. However, after curative intended therapy a high portion of patients relapse with local and/or distant recurrence. Therefore, one may question whether surgical lymph node dissection (LND) is sufficiently reliable for staging of these patients. Several imaging methods for primary LN staging of patients with prostate cancer have been tested. Acceptable detection rates have not been achieved by CT or MRI or for that matter with PET/CT using the most common tracer fluoromethylcholine (FCH). Other more recent metabolic tracers like acetate and choline seem to be more sensitive for assessment of LNs in both primary staging and re‐staging. However, previous studies were small. Therefore, we assessed the value of [¹⁸F]FCH PET/CT for primary LN staging in a prospective study of a larger sample and with a ‘blinded’ review. After a study period of 3 years and >200 included patients, we concluded that [¹⁸F]FCH PET/CT did not reach an optimal detection rate compared with LND, and, therefore, it cannot replace this procedure. However, we did detect several bone metastases with [¹⁸F]FCH PET/CT that the normal bone scans had missed, and this might be worth pursuing.

OBJECTIVES

• ? To assess the value of [¹⁸F]fluoromethylcholine (FCH) positron emission tomography/computed tomography (PET/CT) for lymph node (LN) staging of prostate cancer.
• ? To evaluate if FCH PET/CT can replace LN dissection (LND) for LN staging of prostate cancer, as about one‐third of patients with prostate cancer who receive intended curative therapy will have recurrence, one reason being undetected LN involvement.

PATIENTS AND METHODS

• ? From January 2008 to December 2010, 210 intermediate‐ or high‐risk patients had a FCH PET/CT scan before regional LND.
• ? After dissection, the result of histological examination of the LNs (gold standard) was compared with the result of FCH PET/CT obtained by ‘blinded review’.
• ? Sensitivity, specificity, positive (PPV), and negative predictive values (NPV) of FCH PET/CT were measured for detection of LNe metastases.

RESULTS

• ? Of the 210 patients, 76 (36.2%) were in the intermediate‐risk group and 134 (63.8%) were in the high‐risk group. A medium (range) of 5 (1–28) LNs were removed per patient.
• ? Histological examination of removed LNs showed metastases in 41 patients. Sensitivity, specificity, PPV, and NPV of FCH PET/CT for patient‐based LN staging were 73.2%, 87.6%, 58.8% and 93.1%, respectively.
• ? Corresponding values for LN‐based analyses were 56.2%, 94.0%, 40.2%, and 96.8%, respectively.
• ? The mean diameter of the true positive LN metastases was significantly larger than that of the false negative LNs (10.3 vs 4.6 mm; P < 0.001).
• ? In addition, FCH PET/CT detected a high focal bone uptake, consistent with bone metastases, in 18 patients, 12 of which had histologically benign LNs.

CONCLUSIONS

• ? Due to a relatively low sensitivity and a correspondingly rather low PPV, FCH PET/CT is not ideal for primary LN staging in patients with prostate cancer.
• ? However, FCH PET/CT does convey important additional information otherwise not recognised, especially for bone metastases.

     

Nonsignificant relationship between participation in school-provided meals and body mass index during the fourth-grade school year

Data from four cross-sectional studies involving fourth-grade children were analyzed to investigate the relationship between participation in school-provided meals and body mass index (BMI), and the effect observed energy intake has on that relationship. Participation and BMI data were available on 1,535 children (51% black; 51% girls) for 4 school years (fall 1999 to spring 2003; one study per school year) at 13 schools total. Direct meal observations were available for a subset of 342 children (54% black; 50% girls) for one to three breakfasts and one to three lunches per child for a total of 1,264 school meals (50% breakfast). Participation in breakfast, lunch, and combined (both meals on the same day) was determined from nametag records compiled for meal observations for each study. Weight and height were measured. A marginal regression model was fit with BMI as the dependent variable; independent variables were breakfast participation, lunch participation, combined participation, sex, age, race, and study. For the subset of children, observed energy intake at breakfast, lunch, and combined was included in additional analyses. Participation in breakfast, lunch, and combined was not significantly associated with BMI regardless of whether analyses included observed energy intake (P values >0.181). The relationship between observed energy intake at breakfast and lunch, separately and combined, with BMI was positive (P values <0.01). In conclusion, these results do not support a relationship between school-meal participation and BMI but do support a relationship between observed energy intake at school meals and BMI during fourth grade.     

Human T-lymphotropic virus type I and type II infections and correlation with risk factors in blood donors from Sao Paulo, Brazil

BACKGROUND: Little is known about the prevalence of and risk factors for human T-lymphotropic virus type I and type II (HTLV-I, HTLV-II) infections in Brazil. STUDY DESIGN AND METHODS: Sera from 17,063 healthy Brazilian donors were screened by enzyme-linked immunosorbent assay for antibody to HTLV-I/II between August 1991 and July 1993. Repeatedly reactive samples were confirmed by Western blot, and discrimination between HTLV-I and HTLV-II was made by polymerase chain reaction or synthetic peptide enzyme-linked immunosorbent assay. A univariate analysis was performed on demographic and serologic data. RESULTS: HTLV-I infection was demonstrated in 83 percent of the 30 donors with reactive serologic tests (0.15% of the total tested [17,063]; 95% CI, 0.09-0.20) and HTLV-II infection in 17 percent (0.03% of the total tested [17,063]; 95% CI, 0.01-0.05). HTLV-I-positive donors were more likely than reference groups to be of Asian ethnicity (odds ratio [OR] 15.1; reference group: whites), more than 50 years old (OR 4.2; reference group: 20–29 years old), and positive for antibody to hepatitis C virus (anti-HCV) (OR 21.8) or to hepatitis B core (antigen) (anti-HBc) (OR 5.7). HTLV-II showed a significant association with anti-HCV (OR 75.2) and anti-HBc (OR 21.8). Eleven of the 25 HTLV-I- positive donors were counseled. Family origin in endemic areas of Japan (n = 4), prior blood transfusion (n = 3), or sexual contact with prostitutes (n = 1) were the risk factors reported by 8 donors. In 3 white men, no risk factors could be identified. CONCLUSION: Both HTLV-I and HTLV-II occur among Brazilian blood donors. HTLV-I is associated with Asian ethnicity, greater age, and the presence of anti-HCV and anti-HBc. Three HTLV-I-positive donors had a history of blood transfusion, which emphasizes the need for HTLV-I/II screening in Brazil.