A randomized trial comparing bladder infusion with standard catheter removal after transurethral resection of the prostate.

OBJECTIVE: To examine the effect of bladder infusion before catheter removal on patients' readiness for discharge and the day of discharge after transurethral resection of the prostate (TURP). PATIENTS AND METHODS: The study comprised 75 consecutive patients undergoing TURP who were randomized to either have their catheter removed in the standard manner (38 patients), or to undergo bladder infusion before a trial of voiding (ToV) on the second day after TURP (37 patients). RESULTS: In those undergoing bladder infusion, seven (19%) patients were discharged on the same day as their ToV, compared with five (13%) in the standard group. Of the 75 patients, 15 (68%) were discharged by the third day after TURP whether or not the bladder had been filled. In the infusion group, 23 (62%) were ready for discharge on the same day as their TOV, compared with only 14 (37%) in the standard group (P < 0.05). CONCLUSION: Bladder infusion before a ToV after TURP significantly increases the rate of readiness for discharge, allowing an early decision to discharge on the second day in a large proportion of patients.

Retroperitoneal surgery: its wider role in the management of malignant teratoma.

OBJECTIVE: To review the results of the use of laparotomy to excise retroperitoneal metastases in patients with malignant teratoma of the testis. PATIENTS AND METHODS: The results of surgery for retroperitoneal teratoma metastases in 37 patients during the 5-year period from 1988 to 1993 were reviewed. Information on sexual dysfunction was obtained using a postal questionnaire. RESULTS: Patients were divided into three groups: the first comprised 28 patients who underwent elective surgery (excision of residual disease) after platinum and bleomycin-based chemotherapy. The second group comprised four patients who underwent interventional surgery to excise disease not responding to treatment, after which they completed chemotherapy. The third group comprised five patients who underwent surgery for relapsed disease; two had suffered an early and three a late relapse. Overall, 34 patients are alive, four are considered to have residual disease and two have recently undergone re-operation. CONCLUSIONS: In addition to removing residual disease after primary chemotherapy, surgery has a wider role in the management of metastatic teratoma. Carefully timed interventional surgery for disease not responding to chemotherapy can be lifesaving. Surgery for early relapse should be preceded by chemotherapy but surgery alone is appropriate where relapse occurs several years after primary treatment, although raised levels of tumour markers or extensive recurrence might be an indication for preliminary chemotherapy.

Detection and distribution of heat shock proteins 27 and 90 in human benign and malignant prostatic tissue.

OBJECTIVE: To determine whether it is possible to predict the behaviour of prostate tumours by identifying cellular characteristics, specifically specific heat shock proteins (HSPs). MATERIALS AND METHODS: An immunohistochemical study staining for HSP 27 and 90 was undertaken on 15 benign and 13 malignant samples of freshly frozen prostatic tissue obtained from patients with a similar age range in each group (benign, mean age 71.6 years, range 61-86; malignant, mean age 72.7 years, range 58-87). Gleason scores for the tumours ranged from 2 to 8. RESULTS: Consistent patterns of cytoplasmic staining were seen in all sections of tissue from benign prostatic hyperplasia (BPH). The stroma stained strongly positive for HSP 27, but negatively for HSP 90 and glandular epithelium showed positive apical staining for both HSPs. Stromal patterns in prostatic carcinoma tissue were similar to that of BPH tissue for both HSP 27 and 90. Areas of prostatic intra-epithelial neoplasia stained as strongly as did adjacent areas of BPH. For HSP 27, there was varied staining of individual epithelial cells, suggesting cellular heterogeneity, with an apparent reduction in staining with increasing Gleason score and invasiveness. For HSP 90, this pattern was less marked, with a predominance for positive staining throughout all grades of carcinoma. CONCLUSIONS: The distribution of HSPs, primarily HSP 27, may aid in identifying different cell populations within prostatic carcinomas and thus help forecast biological behaviour.

Nephrectomy: changing indications, 1960-1990.

OBJECTIVE: To review the indications for nephrectomy over the period 1960-1990. PATIENTS AND METHODS: A total of 1470 nephrectomies were performed (excluding transplant-related nephrectomies) over this period. Data were collected by means of a pathology report review and the indications were classified according to aetiology. RESULTS: The total number of nephrectomies performed has not significantly changed over this 31-year period. There was a significant decrease in the number of partial nephrectomies performed and an increase in the number of nephrectomies performed for tumour. This change was equally distributed between both renal adenocarcinomas and transitional cell tumours. The number of nephrectomies for chronic pyelonephritis decreased over this period. The change seen was not as great as might have been anticipated in view of the advent of modern antibiotics. Nephrectomies performed for tuberculosis decreased, although this change was not established until the 1980s. In the 1960s and early 1970s, most tuberculous nephrectomies were performed in patients from the native community. By the 1980s, most patients in this category were from the ethnic Asian immigrant community. Nephrectomy rates for polycystic kidney and trauma remained unchanged. CONCLUSIONS: Despite changes in the investigation and management of renal tract pathologies, which contributed to a change in the indications for nephrectomy, the overall number of nephrectomies performed has remained constant over a 31-year period.

Epigastric impedance recording for measuring gastric emptying in children: how useful is it?

Epigastric impedance recording was used to measure gastric half-emptying time (t1/2) of orange squash in 45 healthy infants and children. The relationship between age, body size, and composition and the impedance increase after gastric filling was investigated, together with the effects on half-emptying time of adding fat, increasing viscosity, and increasing osmolality in the test meal. The mean t1/2 for orange squash was 13.5 min. The increase in impedence per unit volume ingested showed a significant inverse relationship with age (r = -0.62, p < 0.001), and with various anthropometric variables (r ranged from -0.48 to -0.80, p < 0.01). No relationship was observed between t1/2 and age, sex, body size, or composition. Addition of 1.25% triglyceride or a 600-fold increase in viscosity of the test meal were both accompanied by a significant lengthening of t1/2 (p = 0.005 and p < 0.001, respectively), but t1/2 did not alter with a fourfold increase in test meal osmolality. The test was well tolerated by all subjects, but its usefulness is limited by susceptibility to movement artefact, and also the necessity to use simple, liquid test meals.

New technology, physical facilities and the environment.

Technology assessment is already a powerful tool for dealing with issues of appropriateness and effectiveness of clinical technology; it can be significantly enhanced as a valuable process if it is extended to deal with issues of how best to integrate the considered technology with the physical environment and facilities in which it will be used. These issues include: staff and patient safety and comfort; code compliance; effective accommodation of work flow; staff training; and ongoing operational costs. The methodology of technology assessment can effectively assist health facility administrators in evaluating the appropriateness and effectiveness of energy conservation projects and in addressing environmental concerns. The constraints in funding available to the health care system will continue to challenge the creative energies of our managers to encourage them to develop innovative ways, using technology assessment, to make the physical facilities and environment safe, economical and comfortable for patients and staff.

Gastric emptying of liquids in cystic fibrosis.

Epigastric impedance recording was used to measure the rate of gastric emptying (GE) of a liquid test meal in 45 control children and 28 CF patients. Epigastric impedance was recorded in the fasting state and following ingestion of orange squash. In 8 controls and 8 CF patients the test was repeated with the addition of 1.25% fat to the test meal. Mean time to half-emptying (t1/2) was 13.5 min in controls and 15.6 min in CF patients (NS). The addition of fat to the test meal prolonged t1/2 in all controls and most CF patients. In those CF patients in whom GE of orange + fat was more rapid than orange alone, repetition of the test with added pancreatic enzymes reversed this effect. We concluded that GE of clear liquids in CF patients does not differ significantly from normal controls, and that most CF patients behave like controls in their response to fat in the test meal.

Peripheral nerve abnormalities in the diabetic mutant mouse.

Observations were made on the genetically diabetic C57BL/Ks (db/db) mouse. Morphometric observations were performed on the tibial nerve at 6, 9, and 15 mo and compared with those from nondiabetic (m/m) controls. Myelinated fiber size was less in the diabetic animals at all stages and affected cross-sectional axon area and myelin thickness equally. Unmyelinated axons were unaffected. The index of circularity of myelinated axons did not differ between diabetic and control animals. No definite absolute reduction in fiber size occurred and degenerative changes, which were slight, were equally frequent in the diabetic and control nerves. Axonal glycogenosomes, polyglucosan particles, and Schwann cell/axon networks, and Schwann cell Reich granules increased with age in both groups, but only glycogenosomes were consistently more numerous in the diabetic animals. Counts of membrane associated particles in both P and E faces revealed that these were reduced in number in the diabetic animals in myelin and in axolemma of unmyelinated axons, but not in the axolemma of myelinated fibers. Growth in tibial length was also reduced in the diabetic animals and this suggested that the reduced fiber diameter probably represented a maturational deficit. The absence of a selective reduction in axonal size did not favor a primary axonopathy as the cause.

Ambulation in labour.

In a randomised prospective study of 68 women in spontaneous labour half were allocated to an ambulant group and half to a recumbent group. The duration of labour was significantly shorter, the need for analgesia significantly less, and the incidence of fetal heart abnormalities significantly smaller in the ambulant group than in the recumbent group. Apgar scores at one and five minutes were also significantly greater in the ambulant group. More patients in the recumbent group required augmentations with oxytocic drugs. There was no statistically significant difference in the third stage loss in the two groups. Ambulation in labour should be encouraged: it may bring human benefits while allowing the advantages of hospital supervision.

Vascular and adjacent soft tissue injuries associated with fractures of the pelvis.

One hundred fifty-one patients with fractures of the pelvis and associated injuries have been reviewed. Patients who have these injuries are likely to have uncontrollable, fatal hemorrhage. Of this group, nine died, 11 had exploratory laparotomies, ten had bladder injuries, and two had rectal damage. Blood gas determinations, arterial catheterization, and pulmonary wedge pressure determinations are valuable in making and early diagnosis of pathologic changes resulting from internal hemorrhage.