The treatment of sphincter strictures

A group of 25 patients with strictures of the membranous urethra following transurethral resection of the prostate (TURP) were investigated and treated initially by careful urethral dilatation. This controlled the stricture in 14 patients, 6 of whom continued with occasional dilatation or self-catheterisation to maintain control; 8 required an artificial urinary sphincter (AUS) and 2 required a "clam" ileocystoplasty for detrusor instability. Eleven had persistent or recurrent strictures requiring urethroplasty. Nine underwent bulbo-prostatic anastomotic urethroplasty, 4 with simultaneous bladder neck reconstruction and 5 with subsequent implantation of an AUS; 2 had a preputial patch urethroplasty with subsequent implantation of an AUS. Four of the 9 patients with a urethroplasty and an AUS are satisfactory, 1 developed a recurrent stricture and 2 developed erosions. Two of those with a bulbo-prostatic anastomosis and bladder neck reconstruction are satisfactory and 2 are incontinent. These results were compared with those of 18 other patients who underwent bladder neck reconstruction and 12 who had a urethroplasty in conjunction with an AUS for reasons other than a post-TURP sphincter stricture. The success rate of bladder neck reconstruction was 55% and the success rate of urethroplasty in conjunction with an AUS was 83%, but the main complication of AUS implantation, erosion, was a more serious problem than failure of bladder neck reconstruction. However, the much higher success rate makes AUS implantation a more satisfactory procedure. Surgery should be avoided if at all possible and reliance placed on urethral dilatation.     

Evaluation of a latex agglutination test for Clostridium difficile in two nursing home outbreaks.

The Culturette Brand Clostridium difficile test (CDT; Marion Laboratories, Inc., Kansas City, Mo.) is a latex agglutination test for C. difficile. The recent controversy involving the identity of antigens detected by CDT has made decisions on its use difficult. We compared the test results with those of selective culture and stool cytotoxin assays in investigations of two nursing home outbreaks of C. difficile-associated disease in order to formulate usage recommendations. Selective culture for C. difficile identified 27 (19%) of 142 subjects as carriers. CDT and the stool cytotoxin assay identified only 52 and 48% of these carriers, respectively. Compared with the stool cytotoxin assay, CDT had a high sensitivity (92%) and specificity (89%) for the detection of C. difficile disease, but the positive predictive value of the test was only 17% when the prevalence of disease was 2%. We conclude that the CDT should not be used to identify carriers but that it is a sufficiently sensitive and specific screening test for diagnosing C. difficile disease. However, since the positive predictive value of the CDT is low when the prevalence of disease is low, positive test results should be confirmed by the stool cytotoxin assay.     

The nitric oxide pathway in pre-eclampsia: pathophysiological implications

Pre-eclampsia, one of the most significant health problems inhuman pregnancy, complicates 6-7% of all gestations and is theleading cause of fetal growth retardation, infant morbidityand mortality, premature birth and maternal death. Recent researchimplicates free radicals in the pathophysiology of pre-eclampsia.This review covers the biochemistry of nitric oxide (NO) andpossible interactions with other free radicals. Studies in therat show that pregnancy is associated with enhanced productionand responsiveness to NO in both reproductive tissues and bloodvessels. Rats infused with N^G-nitro-L-arginine methyl ester(L-NAME, a NO synthase inhibitor) have been used as an animalmodel of pre-eclampsia, and the effects of steroid hormoneson blood pressure in this model have been tested. Results suggestthat pre-eclampsia may be a state of NO deficiency. However,in humans there seem to be contradictions regarding the involvementof NO in maternal adaptation to pregnancy. It is suggested thatNO may be one of several systems that act in concert to maintaina symbiotic relationship between mother and fetus. However,the input of each system may be genetically determined.     

Surgical sperm retrieval and intracytoplasmic sperm injection as treatment of obstructive azoospermia

Male genital tract obstructions may result from infections, previous inguinal and scrotal surgery (vasectomy) and congenital bilateral absence of the vas deferens (CBAVD). Microsurgery can sometimes be successful in treating the obstruction. In other cases and in cases of failed surgical intervention, the patient can be treated by microsurgical or percutaneous epididymal sperm aspiration (MESA, PESA) or testicular sperm extraction (TESE) and intracytoplasmic sperm injection (ICSI). We present the results of 39 ICSI procedures for obstructive azoospermia in 24 couples. The aetiology of the obstruction was failed microsurgery in 11 patients, CBAVD in nine and genital infections in four. Sperm retrieval was accomplished via MESA in four cases, PESA in 18 cases and via TESE in 11 cases. TESE was only applied when PESA failed to produce enough spermatozoa for simultaneous ICSI. In six patients, the ICSI procedure was performed with cryopreserved spermatozoa after an initial PESA procedure. Fertilization occurred in 47% of the metaphase II oocytes; embryo transfer was performed in 92% of procedures and resulted in a clinical pregnancy in 13/39 procedures. Ongoing pregnancy was achieved in 10/39 procedures. One pregnancy was terminated early after prenatal investigation showed a cytogenetic abnormality (47,XX+18, Edwards syndrome). The other nine pregnancies resulted in the live birth of 10 children, without any congenital abnormalities. Epididymal and testicular retrieved spermatozoa were successfully used for ICSI to treat obstructive azoospermia, and resulted in an ongoing pregnancy in 10 of 24 couples (41.6%) after 39 ICSI procedures, a success rate of 25.6% per treatment cycle and of 27.7% per embryo transfer.      

EEG correlates of the development of infant joint attention skills

The development of the capacity for social attention coordination, or "joint attention," is a major milestone of infancy. Data from a recent study of handicapped infants have raised the hypothesis that the tendency to initiate bids for joint attention may reflect processes associated with the frontal cortex to a greater extent than other forms of infant attention coordination (R. Caplan et al., 1993). This hypothesis was examined in a longitudinal study of 32 normally developing infants. The results indicated that EEG data at 14 months indicative of left frontal, as well as left and right central cortical activity, was associated with the tendency to initiate joint attention bids (IJA) at 14 and 18 months. In contrast, a pattern of left parietal activation and right parietal deactivation at 14 months was associated with the development of the capacity to respond to the joint attention bids (RJA) of others at 14 and 18 months. These results were interpreted to be consistent with a general anterior-posterior model of attention development (M. Posner & S. Petersen, 1990). The implications of these results for current conceptualizations of joint attention development, as well as for understanding the disturbance of joint attention skill development in autism are discussed.     

The unstable bladder

The unstable bladder is a common clinical problem of uncertain etiology. Current in vitro studies of unstable human detrusor samples show differences in behavior and response to pharmacologic agents from normal detrusor. The fundamental urodynamic abnormality is the occurrence of involuntary detrusor contractions, which cause the cardinal symptom of urgency. The incidence of other symptoms is determined by the functional bladder capacity and the patient's ability to resist the unstable contractions. Having excluded outflow obstruction as a causative or associated factor, empirical treatment may reasonably be started on the basis of the findings of a 48-hour voided volume chart, reserving full urodynamic investigation for patients who fail to respond to treatment as expected. For those with minimal urodynamic dysfunction, bladder drill is the treatment of choice; when this fails or is inappropriate, drug treatment with oxybutynin is indicated, supplemented by other drugs when appropriate. When these standard conservative measures fail, then transvesical injection of the pelvic plexuses with phenol gives worthwhile results and is a trivial procedure. If this fails, and in men in whom the phenol procedure is contraindicated, "clam" ileocystoplasty is usually if not always curative.     

"Clam" ileocystoplasty for the treatment of refractory urge incontinence

Forty patients with refractory urge incontinence were treated by "clam" ileocystoplasty. Thirty patients were cured of their symptoms and are voiding spontaneously, six were cured of their symptoms and are on clean intermittent self-catheterisation and four had their symptoms significantly improved by the operation. Bladder compliance is usually improved by the operation and detrusor instability is either abolished or reduced to an insignificant level, but voiding dysfunction is a common post-operative problem and must be identified and treated.     

Romantic and Sexual Relationships with Adult Partners Among Pedohebephilic Men

This study examined reasons for romantic and sexual relationships with adult partners among men with pedohebephilic preferences (N?=?125). We also explored whether age sexual orientation impacted reasons for engaging in sex with adult partners. Pedohebephilic men endorsed both non-sexual and sexual reasons for engaging in adult-partnered relationships. The top reasons for sexual relationships with adult partners were pleasure, love and commitment, physical desirability, experience seeking, and practicality. The top reasons for romantic relationships with adult partners were to gain companionship, love toward romantic partner, to escape loneliness, to engage in sexual activities, and it seemed natural. The exclusivity of attraction to children was found to be significantly related to some of the factors. These findings support differential reasons for pedophilic men engaging in adult-partnered relationships. Professionals should seek to understand the nature of their clients’ relationships and age sexual orientation to determine whether such factors are relevant. Professionals can then support clients in their search for meaningful relationships.

     

Thio TEPA pharmacokinetics during intravesical chemotherapy and the influence of Tween 80

Summary A pharmacokinetic study of randomised crossover design was carried out in which eight patients with recurrent stage pTa or pT1 transitional cell carcinoma of the bladder were given thio TEPA (30 mg) in distilled water or in 10% (v/v) Tween 80 (30 ml) intravesically for 2 h, followed 3 months later by the alternative treatment. Thio TEPA and its primary metabolite, TEPA, were measured in plasma and urine using a sensitive and specific chromatographic assay. Large differences between patients were observed in the proportion of thio TEPA absorbed, ranging from 20%–78%. Peak plasma levels of thio TEPA were observed within 1 h of intravesical administration. By 2 h after administration the plasma levels of TEPA were similar to those of thio TEPA and, in contrast to those of the parent compound, remained at a similar level over the next 4 h. The rate of absorption of thio TEPA was not influenced by Tween 80, but it did cause statistically significant increases in mean peak plasma levels (from 101 to 154 ng/ml) and mean AUC values (from 0.376 to 0.496 g h per ml) and a decrease in the mean half-life (from 1.83 to 1.25 h). To obtain plasma levels similar to those achieved after instillation with thio TEPA alone, the dose should be reduced with Tween 80.