Changes in bladder function following a surgical alteration in outflow resistance

The changes in bladder function occurring after a surgical alteration in bladder outflow resistance were studied in 20 males undergoing transurethral prostatectomy (TURP) and in 20 females undergoing an endoscopic bladder neck suspension (EBNS). Serial cystometrograms (CMG) were performed before operation, and on alternate days after spontaneous micturition was re-established, for 5 days in the males and for 21 days in the females. CMGs were repeated at 3 months and 1 year after operation. After TURP voiding pressures (P_det) fell rapidly from a mean of 118 cm H₂O before operation to 57 cm H₂O at 5 days, with an increase in flow rate during this time from 10.5 ml/s to 24 ml/s. Detrusor instability that had been present in 14 patients resolved within 2 days in 12. There was no further significant urodynamic change over the 1-year study period. After EBNS, there was an early rise in voiding pressure (P_det rose from 26 cm H₂O before operation to 42 cm H₂O at 3 days). This continued to increase up to 21 days particularly in those patients with initial large residuals. Three patients developed detrusor instability. Flow rates were greatly reduced at first (27 ml/s before operation and 13 ml/s at 3 days), and gradually increased in line with voiding pressures, yet were still diminished 1 year after operation. The urodynamic changes following a reduction in bladder outflow resistance by TURP are immediate and sustained and unlikely to be the result of structural changes within the bladder wall. EBNS produces an increase in outflow resistance and it can be several weeks before balanced voiding is achieved, with significantly increased detrusor pressures needed to achieve complete bladder emptying at a reduced flow rate.     

Recurrence after lumpectomy for comedo-type intraductal carcinoma of the breast

The morphologic subgroups of intraductal carcinoma in situ (DCIS) of the breast may be biologically different. Thirty-eight patients with comedo-type DCIS treated with local resection with or without radiotherapy are presented. Thirteen of 35 patients had a family history of breast cancer, with 11 patients having an affected first-degree relative. This is significantly increased over other series of breast cancer patients. Recurrence was ipsilateral in all patients and occurred at the site of the original disease. Recurrence occurred in 4 of 30 patients treated with local resection only and 2 of 8 treated with local resection plus radiotherapy. The length of mean follow-up was 39 months. Because of the paucity of studies, these results cannot be compared with others, but there does appear to be a significant incidence of local recurrence after resection for comedo-type DCIS. Immunohistochemical and oncogene studies as they relate to comedo-type DCIS are discussed.     

Epidural anaesthesia in the management of the painful bladder.

Bladder pain is a difficult symptom to manage. Epidural anaesthesia, which was used in 10 patients with sensory disorders, carries a low morbidity and helps to define those patients with severe bladder pain who might benefit from denervation procedures.     

Mixed organic brain syndrome as a manifestation of systemic mastocytosis

Systemic mastocytosis is a disease characterized by an excessive accumulation of mast cells, and associated with skin lesions, flushing, diarrhea, tachycardia, and psychiatric manifestations. In order to define more clearly the psychiatric manifestations, ten patients with this disorder underwent unstructured psychiatric interviews and a battery of psychologic testing. Both revealed a pattern of cognitive and affective changes in the majority of these patients, best categorized as an atypical or mixed organic brain syndrome. The cognitive changes consisted of diminished attention and memory, and the affective changes of anger, irritability, and, to a lesser extent, depression. These manifestations fluctuated with the level of disease activity, and appeared in some cases to respond to histamine antagonists and disodium cromoglycate, medications used to control the excessive mast cell activity. It is important for psychiatrists to be aware that mental status changes can represent psychiatric manifestations of mastocytosis, a readily treatable medical disorder.     

Swallowing food without chewing; a simple way to reduce postprandial glycaemia

1. The degree to which disruption by mastication affects the glycaemic response to four different carbohydrate foods was investigated in healthy human volunteers; each food was eaten by six subjects. 2. Subjects ate meals of sweetcorn, white rice, diced apple or potato on two occasions; on one occasion they chewed the food thoroughly, on the other occasion they swallowed each mouthful without chewing it. 3. When the foods were chewed the postprandial blood glucose levels rose to levels which varied according to the food ingested. 4. Swallowing without chewing reduced the glycaemic response to each food, achieving a similar effect as administration of viscous polysaccharides or 'slow-release' carbohydrates.     

Hereditary angioedema: A decade of management with stanozolol

Thirty-seven patients with hereditary angioedema, who, without therapy, had attacks of cutaneous angioedema, gastrointestinal colic, and/or upper respiratory symptoms at a frequency and severity sufficient to prompt treatment with an attenuated androgen, have been evaluated for the incidence of side effects and biochemical toxicity during various schedules leading to the minimal effective dose. Stanozolol was administered in a 2 mg daily dose, initially, and after the symptoms and signs were adequately controlled for 2 months at this dose or at 1 mg per day, the drug was administered every other day at 4 mg. Patients who responded adequately to this schedule were administered 2 or 1 mg every other day, and then the interval between doses was gradually increased to 1 week, after which the agent was stopped. Eighteen patients experienced adverse reactions to stanozolol while the minimal effective dose was attained. In each instance the side effect subsided with a reduction in dosage. The most common adverse reactions were biochemical evidence of hepatic dysfunction and, to a lesser extent, hirsutism and menstrual irregularities. Although 21 of 27 patients in an initial study of the minimal effective dose were maintained with daily therapy in 1980, by 1986 this group and 10 additional patients were distributed so that three patients were receiving daily maintenance, 18 were receiving alternate-day maintenance, and 16 patients were receiving no maintenance therapy [corrected]. Thus, stanozolol appears to be a safe and effective agent for management of hereditary angioedema when patients are continually monitored to define the minimal effective dose or the feasibility of stopping the drug.     

Is antibiotic prophylaxis necessary for routine urodynamic investigations? A controlled study in 100 patients

The value of a prophylactic antibiotic before a routine cystometrogram has been assessed in a controlled trial of 100 patients. The infection rate was low and not statistically different in both groups. Subsequent symptoms of dysuria and haematuria had a mechanical aetiology.     

Ictal brain imaging in presurgical evaluation of patients with medically intractable complex partial seizures

At the Indiana University Medical Center, 99 patients with medically intractable complex partial seizures (MI-CPS) had presurgical evaluation with subsequent anterior temporal lobectomy. The majority of the patients had single photon emission tomography (SPECT) performed interictally as well as during an actual epileptic seizure (ictal scan). Decreased regional cerebral perfusion (rCP) was seen in 54/94 (57%) of the interictal scans corresponding to the eventual site of the surgery. However, ictal scans provided a higher yield; increased rCP in the temporal lobe during an actual seizure was observed in 60/82 (73%) concordant to the side of surgery. SPECT is a useful, noninvasive method of localizing the epilepti-form focus in patients with MI-CPS considered for resective surgery. Both interictal and ictal SPECT need to be performed; combined interictal hypo-perfusion and ictal hyperperfusion in the same focal area are unique to epileptogenic lesions. Ictal SPECT studies can be performed in the majority of patients during the period of continuous video/EEG monitoring with only a little additional effort. Combining the results of functional brain imaging (interictal and ictal SPECT, PET) with clinical semiology of seizures, surface and sphenoidal EEG, magnetic resonance imaging and other non-invasive tests, anterior temporal lobectomy can be recommended in approximately two-thirds of the patients without resorting to potentially dangerous intracranial EEG monitoring.     

Brain cyclosporin A levels are determined by ontogenic regulation of mdr1a expression.

Cyclosporin A (CyA) toxicity is a common occurrence in pediatric organ transplant patients. We hypothesized that reduced mdr1a expression in newborn and developing mice would affect CyA accumulation within organs and/or toxicity. For functional studies, CyA was administered (5 mg kg(-1) i.p.) to 1-, 12-, and 19-day, and adult male and female mdr1a+/+ and mdr1a-/- mice. Peak blood CyA was lower in 1-, 12-, and 19-day-old (1000 ng ml(-1)) versus adult (1500 ng ml(-1)) mice but was similar in mdr1a+/+ and mdr1a-/- mice. Kidney mdr1a expression (measured by quantitative polymerase chain reaction) increased 2.5-fold in 19-day-old male and female mice and increased another 4-fold in adult females compared with adult males. Liver mdr1a expression increased 6-fold by day 12 compared with neonatal mice. Thereafter, maintenance of hepatic mdr1a expression in females and a reduction to neonatal levels in males was observed. Kidney/blood (8- to 9-fold) and liver/blood (12- to 15-fold) CyA levels were highest on days 12 and 19 and were not dependent on maturational changes in mdr1a mRNA levels. Adults had higher brain expression of mdr1a mRNA (3-fold), a corresponding 5-fold increase in immunodetectable P-glycoprotein, and 80% lower brain accumulation of CyA compared with 1-day-old mice. Conversely, in mdr1a-null mice, brain/blood CyA was similar in newborn and adult mice. A similar pattern was observed for the brain accumulation of the mdr1a substrate 3H-digoxin. We conclude that the risk for central nervous system drug toxicity could be higher in neonates or young children as a consequence of underdeveloped P-glycoprotein.