Detrusor sphincter dyssynergia,detrusor instability,and urethral sphincter spasticity as the urodynamic findings in the urethral syndrome: Role of treatment with a combined anticholinergic and alpha blocking agent,bladder drill,and antibiotics

The combined effect of isopropamide 5 mg plus trifluoperazine 1 mg (a combined anticholinergic and alpha-adrenergic antagonist) (Smith, Kline and French Canada Ltd, Ontario, Canada), antibiotics, and bladder drill was retrospectively assessed on 100 consecutive women, aged 16 to 47 years, presenting with the signs and symptoms of the urethral syndrome. Assessment included history, physical examination, routine bacterial and chlamydial cultures (cervical, urethral, vaginal, and urine), cystourethroscopy, and urodynamics. Urodynamic diagnoses included detrusor sphincter dyssynergia (n=84), detrusor instability (n =8), external urethral sphincter spasticity (n=4), and sensory urgency (n=1). Three patients with positive urine cultures were excluded. Urethrotrigonitis was visualized at cystourethroscopy in all patients. Only one case of chlamydial urethritis-cervicitis was identified by culture: 82% of patients had a history of prior antibiotic therapy for lower urinary tract symptoms and 21% were being treated with antibiotics at the time of their initial assessment.Following 1 month of treatment, 44 (45%) patients were cured of all symptoms, 49 (51%) were improved, 3 (3%) were unchanged and 1 (1%) was worse. Significant changes in uroflowmetry included a reduction in postvoid residual urine volume from 49 ± 28 ml to 14 ±21 ml (P=0.029) in the unstable bladder group and a conversion from intermittent to continuous uroflow patterns in the detrusor sphincter dyssynergia group (P <0.005, ²) and overall (P <0.005, ²). A statistically significant number of patients (P <0.025, ²) converted from increased to normal tracings on repeat perianal electromyography, suggesting that the pathophysiology of the urethral syndrome is urethral spasticity related to urethral inflammation rather than actual infection.We conclude that detrusor sphincter dyssynergia, bladder instability, and urethral sphincter spasticity are the common urodynamic findings in the urethral syndrome. A combination of anticholinergic and alpha blocking agent, antibiotics, and a bladder drill markedly improved (96%) symptoms in women with the urethral syndrome.     

Retropublic colpourethropexy with transabdominal anterior and/or posterior repair for the treatment of genuine stress urinary incontinence and genital prolapse

A new operative technique combining retropublic colpourethropexy with transabdominal internal anterior and/or internal posterior repair for the treatment of genuine stress incontinence (GSI) and genital prolapse is described in 75 cases. The overall success rate in correcting GSI was 92.0%, with a 94.8% success rate in the primary surgical group (n=58) and an 82.4% in the secondary group (n=17). Average follow-up has been 1.31 years (range 6 weeks–6 years). There was a 3.4% incidence of residual prolapse. Nine patients also underwent concomitant colpourethropexy. Overall surgical complications include febrile morbidity 4/75 (5.3%), wound infection 1/75 (1.3%), deep vein thrombosis 1/75 (1.3%) and partial ureteric obstruction 1/75 (1.3%). There were no statistically significant changes in multichannel urodynamic studies preoperatively and at 1 year following surgery. Onethird (2/6) of the GSI failures had low MUCP (<20 cm H₂O) prior to surgery and continued so at 1 year follow-up.EDITORIAL COMMENT: Genital prolapse is often present in patients who have GSI. If an operation is performed to correct the GSI, and those areas of weakness in the pelvic support system that are contributing to the genital prolapse are not treated, the genital prolapse will become more severe. In the operation which has been described, the colpopexy sutures will correct any cystourethrocele, and the removal of the wedge of tissue from the anterior superior vaginal wall will correct the cystocele. The removal of the wedge of tissue from the posterior superior vaginal wall will reduce the redundancy of the posterior vaginal fornix, but a culdeplasty of the Moschcowitz or Halban type is recommended to treat or prevent an enterocele and to place the vaginal apex in the hollow of the sacrum. Any coexistent rectocele must always be treated vaginally. If it is not treated, it will appear to be more advanced following elevation of the anterior vaginal wall by retropubic urethropexy and the anterior repair which has been recommended.Genital prolapse is best treated by a vaginal approach. When one must une an abdominal approach, ancillary procedures such as the authors have described should be considered. A bulbous upper vagina is ideal for childbearing but if the apical support system and vaginal wall is weakened it is predisposed to prolapse. If the surgeon, in operating for genital prolapse, which involves the upper vagina, will taper the vaginal apex and support it by obliteration of the cul-desac and shortening and reattachment of the uterosacralcardinal complex, postoperative prolapse will be less likely to recur.     

Der Künstler als Schmerzpatient

74 pop/rock/jazz musicians and 100 classical musicians were investigated by means of a specially designed questionnaire. Several social, musical, pain-, and health-related questions were asked. Pain of the musculoskeletal system was the main complaint of musicians in both group (75% classical; 64% rock-pop-jazz). Classical musicians suffer most from neck pain (35%) and the other group mostly from shoulder pain (30%). Specific instruments showed specific muscolosceletal pain patterns. 55% of the musicians in the classical field were treated by an orthopedic surgeon, whereas 43% of rock-pop-jazz musicians chose no therapy, although they suffered from pain. Only 32% of the classical musicians showed good compliance; 64% believe that medical therapy is not adjusted to the needs of musicians. 98% of the classical musicians and 89% of rock-pop-jazz musicians wish to have a doctor who is specially trained to deal with the needs of musicians.     

Die neue Kopfschmerzklassifikation der International Headache Society

A completely new classification system for headache disorders, cranial neuralgias and facial pain has been prepared by a headache classification committee working within the International Headache Society (IHS). The committee is made up of an international body of experts, who spent almost 3 years on the preparation of the classification, publishing it in 1988 (Cephalalgia 8 Suppl 7ratio1ff., 1988). The German translation appeared a year later (Nervenheilkunde 8ratio161-203, 1989). The new classification system is structured in 13 main groups, each with finer divisions into subgroups. Preliminary experience with application of the new classification in 243 patients is reported. The advantages and the problems encountered are discussed. On balance, the new IHS classification is proving to be a very useful basis for the diagnosis of painful conditions affecting the head and face. It is indispensable for a modern headache clinic.     

Physiodiagnostische Indikatoren bei Spannungskopfschmerzen

Practitioners often rely on physiodiagnostic indicators to corroborate the hypothesis of a muscular origin of headache. Although these indicators have been widely applied, their reliability and validity have seldom been tested empirically in headache sufferers. In a controlled double blind study, two trained raters palpated muscle tension and latent and active myogeloses of the left and right trapezius and sternocleidomastoideus muscles and measured passive head rotation flexibility. There were 28 subjects in the study, 14 suffering from tension headache and 14 matched controls. In spite of the training, interrater reliability of ratings concerning degree of muscle tension and number of latent myogeloses proved to be too low to justify subsequent use of these indicators. In keeping with the hypothesis, the various parameters of active myogeloses very clearly differentiated between the experimental groups. The hypothesis turned out not to be true for the parameters of head rotation flexibility. In subjects suffering from tension headache, no correlations could be found between the number of myogeloses of the right trapezius muscle and parameters recorded in long-term EMGs of this muscle, and no correlations could be found between the total number of myogeloses and the chronicity of headache.     

Technische Entwicklung der spinalen Neurostimulation

The rationale for the use of spinal cord stimulation (SCS) in the treatment of chronic pain arose from Melzack and Wall's gate theory of the control of pain (1965). Originally electrodes were placed directly on the spinal cord via open operation, while now they are placed by means of direct puncture the epidural space. In most cases, one of two different systems is used: (1) semi-implants, consisting of an implantable electrode, connection cable and receiver, and externally worn stimulator with antenna; (2) full implants, consisting of an implantable electrode, connection cable and a stimulator, which is also implanted. The implantation of an SCS system is a surgical procedure, which requires the highest standards in asepsis. The operation and its complications and ways of avoiding them are described.     

The insulin receptor: signalling mechanism and contribution to the pathogenesis of insulin resistance

Summary The insulin receptor is a heterotetrameric structure consisting of two -subunits of M_r135 kilodalton on the outside of the plasma membrane connected by disulphide bonds to -subunits of M_r95 kilodalton which are transmembrane proteins. Insulin binding to the -subunit induces conformational changes which are transduced to the -subunit. This leads to the activation of a tyrosine kinase activity which is intrinsic to the cytoplasmatic domains of the -subunit. Activation of the tyrosine kinase activity of the insulin receptor represents an essential step in the transduction of an insulin signal across the plasma membrane of target cells. Signal transduction on the post-kinase level is not yet understood in detail, possible mechanisms involve phosphorylation of substrate proteins at tyrosine residues, activation of serine kinases, the interaction with G-proteins, phospholipases and phosphatidylinositol kinases. Studies in multiple insulin-resistant cell models have demonstrated that an impaired response of the tyrosine kinase to insulin stimulation is one potential mechanism causing insulin resistance. An impairment of the insulin effect on tyrosine kinase activation in all major target tissues of insulin, in particular the skeletal muscle was demonstrated in Type 2 (non-insulin-dependent) diabetic patients. There is no evidence that the impaired tyrosine kinase response in the skeletal muscle is a primary defect, however, it is likely that this abnormality of insulin signal transduction contributes significantly to the pathogenesis of the insulin-resistant state in Type 2 diabetes.Given as the Minkowski Lecture, EASD Meeting, Lisbon, Portugal 1989.     

Prognostic value of galactose elimination capacity,aminopyrine breath test,and ICG clearance in patients with cirrhosis

Seventy-eight patients with cirrhosis were prospectively followed for up to 20 months, on the average. At entry into the study, galactose elimination capacity, aminopyrine breath test, and ICG clearance were measured. At the end of the study, 27 patients had died. Univariate analysis using the Kaplan-Meier method showed that both quantitative liver function tests (galactose elimination capacity:P<0.025; aminopyrine breath test:P<0.001; ICG clearance:P<0.005) and common clinical and biochemical data (encephalopathy:P<0.001; ascites:P<0.001; serum bilirubin:P<0.005; serum albumin:P<0.001; prothrombin index:P<0.05) were significant predictors of survival. To investigate whether quantitative liver function tests could contribute to a better definition of the prognosis, once Pugh score had already been taken into account, a multiple regression analysis according to the Cox model was performed. Pugh score and galactose elimination capacity resulted in the only independent prognostic covariates. From them a prognostic index was calculated, and the model was validated in an additional sample of 70 patients investigated according to the same protocol. The contribution GEC gave to the assessment of overall prognosis over that obtained using the Pugh score was slight, as estimated by the statistical parameters of the Cox's model, but was significant as assessed by a ROC curve analysis (P=0.05). These data show that all quantitative liver function tests were predictors of survival in cirrhosis, and that the galactose elimination capacity added some new prognostic information to those already available using the Child-Turcotte-Pugh classification.This study was supported in part by a grant from the Italian Ministry of Education (National Project Liver Cirrhosis). Part of this study was presented at the 22nd Meeting of the European Society for Clinical Investigation, Graz, Austria, April 20–23, 1988.     

Characterization of rat hyperplastic bile ductular epithelial cells in culture andin vivo

A novel intrahepatic biliary cell culture/in vivo transplantation system has been developed with an essentially pure population of bile ductular epithelial cells isolated from rat liver 6–12 weeks after bile duct ligation. In primary culture, these cells retain staining strongly for -glutamyltranspeptidase and glutathione S-transferase P. The cytoplasm of cultured bile ductular cells reacts with an anti-laminin antibody, but loses immunoreactivity with a monoclonal anti-cytokeratin 19 antibody. Semiconservative DNA synthesis in the cultured cells was dependent upon the continued presence of 10% fetal calf serum in the medium. Replicating bile ductular cells could be subcultured for a finite number of passages. In addition, freshly isolated bile ductular epithelial cells gave rise to well differentiated bile ductular structures when transplanted into the interscapular fat pads of syngeneic recipient rats.Presented at the Proceedings of the International Meeting on Normal and Neoplastic Growth in Hepatology, Bari, Italy, June 1989.This work was supported by USPHS Grant RO1 CA39225 to Dr. Sirica by the National Cancer Institute, Department of Health and Human Services.     

Current prevalence of hepatitis B,A and C in a healthy Spanish population. A seroepidemiological study

Summary A seroepidemiological study was carried out in order to determine the prevalence of markers of viral hepatitis infection in employees of five health-care companies and their cohabiting family members. Each participating family unit was required to fill out a questionnaire, in which, among other data, the employee was requested to indicate his or her job category. Markers of hepatitis B infection (anti-HBs, anti-HBc or HBsAg) were observed in 11.7% (58/497) of all subjects. When employees and family members were analysed according to the employee's job category, significant differences were found between staff (3%) and administrative personnel (13.3%; p<0.01) or factory workers (16.9%; p<0.01). Of 489 individuals tested for the presence of anti-HAV and anti- HCV, 59.1% and 0.6% respectively, were positive. There was a correlation between the prevalence of anti-HAV and age; a large proportion of the subjects under the age of 30 years had no evidence of prior HAV infection.

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Prävalenz der Hepatitis B, A und C in einer gesunden spanischen Bevölkerungsgruppe. Aktuelle seroepidemiologische Studie

Zusammenfassung Um die Prävalenz von Virus-Hepatitis-Markern zu ermitteln, wurde eine seroepidemiologische Studie durchgeführt, in die Beschäftigte von fünf pharmazeutischen Firmen und Familienmitglieder der Wohngemeinschaft aufgenommen wurden. Fragebogen, die alle teilnehmenden Familien auszufüllen hatten, enthielten unter anderem Daten zur Berufsbezeichnung. 58 von 497 untersuchten Seren (11,7%) wiesen Marker einer Hepatitis B Virus-Infektion auf (anti-HBs, anti-HBc oder HBsAg). Nach Berufskategorie aufgeschlüsselt, fanden sich zwischen Beschäftigten und Familienmitgliedern signifikante Unterschiede: Personen, die zum Staff gehörten, waren in 3% der Fälle positiv, Verwaltungspersonal in 13,3% (p<0,01), Fabrikarbeiter in 16,9% (p<0,01). Von den 489 auf anti- HAV getesteten Personen waren 59,1 % positiv, anti-HCV-Antikörper wiesen in derselben Gruppe 0,6% der Getesteten auf. Die Prävalenz von anti-HAV zeigte eine Altersabhängigkeit; ein großer Anteil der unter 30jährigen hatte keine Marker für eine durchgemachte HAV-Infektion.