Cardiovascular risk management and its impact in Australian general practice patients with type 2 diabetes in urban and rural areas.

OBJECTIVE: To investigate the cardiovascular disease (CVD) risk management and its impact on Australian general practice patients with type 2 diabetes in urban and rural areas between 2000 and 2002, and to compare trends over time and differences between urban and rural areas. DESIGN AND METHODS: Population-based repeated cross-sectional study. 6305 patient records from 2000 to 2002 were extracted from registers of diabetes type 2 patients held by 16 Divisions of General Practice (250 practices) across Australia. Multivariate logistic regression comparing urban and rural patients at differing time-periods and comparing trend changes was conducted using multilevel analysis. RESULTS: Prescribing of antihypertensive and lipid-lowering medications was infrequent but increased in both urban and rural areas from 2000 to 2002 (p<0.05), while attendance at other allied health professionals did not. While the proportion of patients meeting targets for high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol increased in both areas over time, only in urban areas were there improvements in total cholesterol and blood pressure over time. The proportion of patients meeting targets for HDL-C, triglycerides and smoking cessation were higher in urban areas than in rural areas by 2002. CONCLUSIONS: Despite a number of national initiatives to improve general practice care and specifically support better care in rural areas, cardiovascular risk management and its impact in Australian general practice patients with type 2 diabetes was still suboptimal during the study period especially among patients from rural areas. Greater effort will be required to reduce the disparity in risk factor prevention for CVD between urban and rural people with type 2 diabetes in Australia.

Quality of diabetes care and coronary heart disease absolute risk in patients with type 2 diabetes mellitus in Australian general practice.

OBJECTIVE: To examine the quality of diabetes care and prevention of cardiovascular disease (CVD) in Australian general practice patients with type 2 diabetes and to investigate its relationship with coronary heart disease absolute risk (CHDAR). METHODS: A total of 3286 patient records were extracted from registers of patients with type 2 diabetes held by 16 divisions of general practice (250 practices) across Australia for the year 2002. CHDAR was estimated using the United Kingdom Prospective Diabetes Study algorithm with higher CHDAR set at a 10 year risk of >15%. Multivariate multilevel logistic regression investigated the association between CHDAR and diabetes care. RESULTS: 47.9% of diabetic patient records had glycosylated haemoglobin (HbA1c) >7%, 87.6% had total cholesterol >or=4.0 mmol/l, and 73.8% had blood pressure (BP) >or=130/85 mm Hg. 57.6% of patients were at a higher CHDAR, 76.8% of whom were not on lipid modifying medication and 66.2% were not on antihypertensive medication. After adjusting for clustering at the general practice level and age, lipid modifying medication was negatively related to CHDAR (odds ratio (OR) 0.84) and total cholesterol. Antihypertensive medication was positively related to systolic BP but negatively related to CHDAR (OR 0.88). Referral to ophthalmologists/optometrists and attendance at other health professionals were not related to CHDAR. CONCLUSIONS: At the time of the study the diabetes and CVD preventive care in Australian general practice was suboptimal, even after a number of national initiatives. The Australian Pharmaceutical Benefits Scheme (PBS) guidelines need to be modified to improve CVD preventive care in patients with type 2 diabetes.

Pseudoephedrine and guaifenesin urolithiasis: widening the differential diagnosis of radiolucent calculi on abdominal radiograph.

Unenhanced helical computed tomography has played an increasingly important role in the management of urinary tract stones, guiding diagnosis and control of calculus disease. We report computed tomographic and radiographic appearances of a renal calculus composed of pseudoephedrine and guaifenesin in a patient who abused over-the-counter allergy medication.

The intensification of rapid reactions in multiphase systems using slug flow in capillaries.

A multiphase microreactor based upon the use of slug flow through a narrow channel has been developed. The internal circulation, which is stimulated within the slugs by their passage along the channel, is responsible for a large enhancement in the interfacial mass transfer and the reaction rate. Mass transfer performance data has been obtained for a glass chip-based reactor in a 380 microm wide channel by monitoring the extraction of acetic acid from kerosene slugs as they moved along the reactor channel. Finally, the data was compared with that provided from other inter-phase contacting techniques.

Morphology and histology of the male reproductive system in two species of internally inseminating South American catfishes, Trachelyopterus lucenai and T. galeatus (Teleostei: Auchenipteridae).

As part of an effort to characterize reproductive modifications in internally inseminating catfishes, ovaries and male reproductive systems were examined histologically in two species of auchenipterid catfishes, Trachelyopterus lucenai and T. galeatus, from southeastern Brazil. Internal insemination was documented in both species by the presence of sperm within ovaries. Although there is some variation in gross morphology of the male reproductive systems between the two species, both have four main regions: spermatogenic lobes, sperm storage regions, and secretory and storage regions of the seminal vesicle. In both species, the anterior portion of the reproductive system is spermatogenic and divided into numerous finger-like lobes. Posterior to the spermatogenic area is the storage region of the seminal vesicle, a large median structure with a honeycomb-like appearance. This region is consistently larger in T. lucenai. Attached to the storage region of the seminal vesicle in both species are secretory lobes comprised of tubules lined by secretory cells. These lobes in T. lucenai are small and located on the anterior aspect of the storage region of the seminal vesicle, whereas in T. galeatus the lobes are much larger and located laterally. The sperm storage regions of T. lucenai consist of two large lobes located ventral to the storage region of the seminal vesicle. Highly compact sperm packets (spermatozeugmata) fill the lumina of the ramifying tubules of these regions. Each spermatozeugma consists of elongate nuclei tightly arranged parallel to one another. In T. galeatus two distinct sperm storage regions are present. Just posterior to the spermatogenic lobes a series of small lobes serve as anterior sperm storage regions. Posterior to the secretory lobes of the seminal vesicle is a series of lobes, at the most posterior aspect of the reproductive tract, that serve as posterior sperm storage regions. Both are identical, histologically, to the sperm storage regions of T. lucenai. An absence of compact spermatozeugmata in the T. galeatus specimens may be related to variations in their sexual activity. The descriptions presented here allow for consistent terminology for comparison of regions of the male reproductive system based on presumed function.

Successful management of a large xanthine calculus by percutaneous nephrolithotomy after failed SWL in a 5-year-old boy.

A 5-year-old child with a xanthine calculus resistant to SWL was made stone free by percutaneous ultrasonic lithotripsy.

A phytochemical investigation of Alchornea latifolia.

A phytochemical investigation of the chloroform leaf extract of Alchornea latifolia has been undertaken. Along with the triterpenoids taraxerone, friedelin, epifriedelinol, and taraxerol, the plant also contains seco-3,4-friedelin (dihydroputranjivic acid) (1) and seco-3,4-taraxerone (2). These A-ring-opened triterpenoids show in vitro cytotoxic activity against Hep-G2 and A-431 human cancer cell lines and are potent inhibitors of topoisomerase II.

Infection of the macrophage cell line NR8383 with Mycobacterium tuberculosis (H37Ra) leads to an increase in oligodeoxynucleotide accumulation.

Mycobacterium tuberculosis infection continues to be a daunting clinical challenge. Although it may well be one of the most studied bacteria in history, several aspects of its pathology remain a mystery. The resurgence of drug-resistant M. tuberculosis strains and with its unusual pathology have promoted a renewed basic and clinical research interest in developing new therapies to combat this pathogen. The primary localization site for M. tuberculosis is within alveolar macrophages. Drug delivery strategies and novel therapeutic agents designed to target alveolar macrophages may lead to efficient destruction of M. tuberculosis. Oligodeoxynucleotides (ODN) are short segments of nucleic acids that can interfere with transcription and translation processes. In this report, a monocyte-macrophage cell line was characterized in regard to ODN transport in the presence or absence of M. tuberculosis infection. The cells accumulated ODN in a time-dependent and concentration-dependent manner, regardless of the presence of serum. After 4 hours of incubation with M. tuberculosis (multiplicity of infection [MOI] 10:1), infected NR8383 cells demonstrated 1.5-7-fold increase in fluorescein isothiocyanate (FITC)-labeled phosphorothioate ODN accumulation as measured by flow cytometry. The increase in uptake was associated only with fluorescent-labeled ODN and not labeled markers of fluid phase endocytosis (e.g., tetramethylrhodamine isothiocyanate [TRITC], FITC-labeled dextran). NR8383 cells activated by phytohemagglutinin (PHA) did not demonstrate a significant increase in the uptake of either FITC-labeled dextran or FITC-labeled ODN. These studies demonstrate that NR8383 cells that have been infected with M. tuberculosis can specifically accumulate ODN, and this route of accumulation may lead to a means of drug targeting to mycobacteria-containing cells.

Biocontrol of Damping-off of Catharanthus roseus Caused by Pythium ultimum with Trichoderma virens and Binucleate Rhizoctonia Fungi.

Four isolates of Trichoderma (Gliocladium) virens (G-45, G-65, G-85, and G-93) and two isolates of binucleate Rhizoctonia spp. (BNR621 and P9023) were evaluated for biocontrol of preemergence damping-off of Catharanthus roseus (vinca) caused by Pythium ultimum. Putative biocontrol agents were amended to a soilless mix 1, 3, or 6 days prior to seeding and pathogen infestation to determine if colonization of the mix before infestation was important for biocontrol efficacy. Biocontrol of preemergence damping-off of vinca with the four isolates of T. virens was variable. Only isolate G-93 gave control of preemergence damping-off (10 to 18% disease) regardless of the length of time the mix was amended prior to seeding and infestation compared to the infested control (43% disease). In contrast, preemergence damping-off was 10 to 15% with SoilGard (based on isolate GL-21 of T. virens). For isolate G-65, preemergence damping-off of vinca was 0% in lots of mix amended 1 day prior to seeding, but over 60% in lots of mix amended 6 days prior to seeding, compared to 43% in the infested control. With the exception of isolate G-65 in the lot amended 6 days before seeding, the isolates of T. virens were as effective as metalaxyl (19% damping-off) for control of P. ultimum in lots of mix amended 1 to 6 days before seeding. In contrast to T. virens, biocontrol efficacy of isolates BNR621 and P9023 of binucleate Rhizoctonia spp. in a Pesta formulation improved as lots of mix were amended up to 6 days before seeding and infestation. As length of initial amendment increased from 1 to 6 days, preemergence damping-off decreased from 37 to 16% for BNR621, and from 42 to 22% for P9023. Preemergence damping-off was observed in vinca in control treatments with only the putative biocontrol agents (BNR621, 14% disease and P9023, 19.6%); therefore, additional bedding plant species were evaluated for susceptibility to the BNR isolates. In the absence of P. ultimum, isolates BNR621 and P9023 in a Pesta formulation caused an average 82.5, 56.5, and 5.8% damping-off of snapdragon, petunia, and impatiens, respectively. Our results suggest that binucleate Rhizoctonia isolates, although effective for biocontrol of P. ultimum on vinca, should be evaluated for pathogenicity on a crop by crop basis before use on other crops.

Live donor nephrectomy in patients with fibromuscular dysplasia of the renal arteries.

PURPOSE: We determine the suitability of patients with fibromuscular dysplasia of the renal arteries as renal donors. MATERIALS AND METHODS: We evaluated 37 patients with fibromuscular dysplasia who were potential renal donors. Renal artery lesions were graded I (mild) to IV (severe). Of the patients 19 underwent donor nephrectomy and 18 were rejected as donors. Reasons for rejection included severity of disease or availability of a better donor. Nephrectomy was performed on the side with fibromuscular dysplasia when disease was unilateral or on the side with more advanced disease when the lesions were bilateral. Patients were followed at 1 month, 1 year and then yearly. RESULTS: Of the 19 patients undergoing donor nephrectomy serum creatinine increased by a mean of 0.4 mg./dl. (range 0.1 to 1.1) on postoperative day 1. Effective renal plasma flow of the remaining kidney increased by 25% on postoperative day 5 and by 29% after 1 year. After a mean followup of 4.5 years no patient had hypertension, proteinuria or any significant change in serum creatinine compared to baseline values. Of the 18 patients not undergoing nephrectomy 11 were contacted at a mean followup of 4 years, and none had hypertension, proteinuria or abnormal serum creatinine. CONCLUSIONS: Patients with fibromuscular dysplasia may be acceptable renal donors. The decision to use a patient with fibromuscular dysplasia as a donor is based on patient age, the availability of other suitable donors, and the extent and severity of disease.

Nephron-sparing surgery compared with radical nephrectomy for renal tumors: current indications and results.

BACKGROUND: Small asymptomatic solid renal masses are being found more often through the frequent use of abdominal ultrasonography and computed tomography. Nephron-sparing renal surgery is being done more often to treat these small lesions. A retrospective review was done to determine the effectiveness of this treatment. METHODS: Patients who had nephron-sparing renal surgery (group 1-35 patients) were compared with those who had radical nephrectomy (group 2-71 patients) for renal cell carcinoma smaller than 5 cm. RESULTS: The two groups had only small differences in fall in hematocrit, transfusion rates, operative time, and hospital stay. Major surgical complications were more frequent in group 1. After a median follow-up of 3.1 years, there has been no recurrence of tumor and there were no surgery-related or cancer-related deaths in either group. CONCLUSION: Nephron-sparing renal surgery appears to be a safe and effective alternative to radical nephrectomy for localized small renal tumors.

Urological evaluation of adult renal transplant recipients.

We retrospectively reviewed the charts of 150 consecutive patients who underwent renal transplantation at our institution in 1990 to determine the effectiveness of our pre-transplantation urological evaluation. Of 100 patients who met the inclusion criteria 74 were evaluated solely with a history and physical examination, urinalysis and a urine culture, while the other 26 underwent additional tests because of either a history of urological problems or abnormalities at the initial evaluation. Urological complications occurred in 18 patients. In 10 patients the complications were related to the operation and included postoperative hematuria from bleeding at the site of the ureteral reimplantation, symptomatic lymphocele formation and urinary fistula resulting from necrosis of the distal ureter. These complications could not have been anticipated by the pre-transplant evaluation. Urological complications in the other 8 patients were a febrile urinary tract infection (4), temporary urinary retention (2), hematuria and back pain requiring bilateral native nephrectomy (1), and lower tract obstructive symptoms (1 who eventually required transurethral resection of the prostate 15 months after transplantation). Only 1 of these complications might have been averted with more extensive preoperative testing and in none of these patients did the urological complication compromise allograft function. We conclude that most patients with end stage renal disease require only minimal evaluation before renal transplantation. More extensive evaluation is necessary only in patients with a strong history of urological disease or with abnormalities found during the basic examination.

Ureteroscopy: an outpatient procedure?

Ureteroscopy is used in the diagnosis and treatment of many urological conditions. The technique of ureteroscopy has been simplified by the introduction of smaller ureteroscopes and by an increase in the variety of accessory instruments that can be passed through the ureteroscope. Despite those advances, recent reports indicate that ureteroscopy is still generally considered an inpatient procedure. Since 1987 we have performed most of our ureteroscopic procedures on an outpatient basis. We reviewed the records of 176 patients who underwent ureteroscopy between 1988 and 1990, of whom 84 (47.7%) underwent extracorporeal shock wave lithotripsy with the same anesthesia. We treated 134 patients (76.1% of the total group) as outpatients, while 20 (11.4%) chose to remain in the hospital overnight for personal reasons, 10 (5.7%) required additional surgery after ureteroscopy and 12 (6.8%) required hospitalization for preexisting medical problems or for problems that resulted from ureteroscopy. Of the 134 patients who were discharged from the hospital on the day of ureteroscopy only 4 (3.0%) required rehospitalization. The addition of extracorporeal shock wave lithotripsy to ureteroscopy during the same period of anesthesia did not increase the need for hospitalization. Ureteroscopy should be considered an outpatient procedure. The decision to hospitalize a patient after ureteroscopy should be based on preexisting medical problems or on problems that result from ureteroscopy. Routine hospitalization for observation is unnecessary.

Review of 333 living donor nephrectomies.

We reviewed the operative complications in 333 living related donor nephrectomies done at our institution over the past 12 years. The overall complication rate was 17.1%; only three patients (0.9%) had major complications, and none died. The major complications were a delayed splenectomy because of bleeding, an adrenalectomy, and acute renal failure in one patient in the immediate postoperative period. We concluded that donor nephrectomy done through a flank incision results in minimal morbidity.

Combination therapy for a partial staghorn calculus in an infant.

Branched renal calculi are extremely unusual in infants. We report a case of a partial staghorn calculus in a 9-month-old boy and discuss how techniques routinely used in the treatment of staghorn calculi in adults (extracorporeal shock wave lithotripsy, nephrostolithotomy, percutaneous irrigation) can be applied to the infant kidney.

A multicenter registry of patients with acute respiratory distress syndrome. Physiology and outcome.

In a multicenter registry conducted over 2 yr of patients with acute respiratory distress syndrome (ARDS), we enrolled 153 patients and collected data daily for 7 consecutive days and weekly thereafter until death or hospital discharge. The purposes of the registry were (1) to determine whether a more liberal definition of ARDS (PaO2/FIO2 < or = 250; bilateral pulmonary infiltrates within 7 days) than those commonly used would result in enrollment of patients earlier in their clinical course, and (2) to study the clinical course of the syndrome in survivors and nonsurvivors. The mortality rate was 54% and it was significantly greater in older versus younger patients (75% versus 37%) and in septic versus nonseptic patients (60% versus 43%). We found that the definition of ARDS used for the registry resulted in enrollment of patients 1 to 7 days earlier than was the case when other published definitions of ARDS were applied to the patient population. Fewer than 2% of the patients failed to meet one of the nonregistry definitions of ARDS within 7 days. The mortality rate was independent of the definition used to identify ARDS patients. Our results suggest that a more liberal definition of ARDS than those commonly used can result in identification of the same population of patients earlier in their clinical course.

Short-term and long-term changes in renal function after donor nephrectomy.

We retrospectively examined the effect of nephrectomy on renal function in 55 living related donors. Renal function was measured with 131iodine-orthoiodohippurate scans. All patients were studied preoperatively, and 1 week and 1 year postoperatively. In 20 patients 10-year followup was available. Compensatory hypertrophy was complete 1 week postoperatively: effective renal plasma flow of the remaining kidney was 32.5% higher than preoperatively. The increase remained stable for at least a year. The degree of compensatory hypertrophy was significantly greater in male patients (46.9% after 1 week) than in female patients (26.7%). Compensatory hypertrophy occurred in all age groups studied and it was most pronounced in patients less than 30 years old. In the patients followed for 10 years effective renal plasma flow decreased from 387.7 ml. per minute 1 week after nephrectomy to 367.4 ml. per minute at 10 years. This result is similar to the decrease seen in the normal population. According to our results, renal donation by living related persons does not lead to long-term decrease in renal function.

Renal function immediately after piezoelectric extracorporeal lithotripsy.

We evaluated changes in renal function in 14 patients treated for renal calculi with the Richard Wolf 2300 piezoelectric lithotriptor. Each patient received, 3,000 to 4,000 shocks at the maximal recommended voltage. Each patient was evaluated with 131iodine-orthoiodohippurate renal scans performed within 24 hours before and after treatment. Changes in total effective renal plasma flow, effective renal plasma flow of the treated kidney and differential renal function were compared by paired t testing. No significant changes were associated with lithotripsy. On the basis of the renal scans we conclude that piezoelectric lithotripsy causes no significant changes in renal function, even in the early post-treatment period based on renal scan studies.