Long-term results of bladder neck reconstruction for incontinence in children with classical bladder exstrophy or incontinent epispadias.

OBJECTIVE: To review the long-term results of bladder neck reconstruction (BNR) in patients with classical bladder exstrophy or epispadias, and to review the concept of continence surgery in these two groups, stressing the difficulty in finding an adequate balance between urine storage (which implies high outlet resistance and low storage pressure) and complete bladder emptying (which implies low outlet resistance and a transient increase in bladder pressure); surgery cannot achieve 'continence' (which implies active mechanisms) but only 'dryness' (which implies passive mechanisms). PATIENTS AND METHODS: Eighty patients with classical bladder exstrophy (52 male, 28 female) and 25 with incontinent epispadias (17 male, 18 female) had their bladder neck reconstructed after a Young-Dees-Leadbetter procedure, subsequently modified by Mollard. The treatment is detailed and results reviewed after a mean follow-up of 11 years. All patients were treated and followed in the same institution. RESULTS: In the exstrophy group, 36 (45%) patients presented with a dry interval of > 3 h, with urethral emptying after one BNR; 52 (65%) presented with recurrent urinary tract infections, 19 (24%) with urinary stones, 21 (26%) with dilated upper urinary tracts, 13 (16%) with bladder perforations and one with an adenocarcinoma of the bladder. Thirty-eight patients (48%) required further surgery; 51% of all patients required an endoscopic procedure within 3 months after the BNR and 26% had endoscopic procedures for late (> 3 months) urine retention. In the epispadias group, 13 (52%) patients presented with a dry interval of > 3 h with urethral emptying after one BNR; 12 (48%) had recurrent urinary tract infections, five (20%) upper tract dilatation, two (8%) bladder stones, one (4%) bladder perforation and one an adenocarcinoma of the bowels after a ureterosigmoidostomy. Ten (40%) children required further surgery. CONCLUSION: We compared the present results for continence with those in other published series; most complications encountered were related to the obstructive pattern of bladder emptying and the abnormal bladder urodynamic behaviour caused by BNR. We consider that BNR is unpredictable and the roles of the other factors in urinary continence are discussed. Alternative procedures are detailed. The concept of continence surgery in exstrophy and incontinent epispadias is reviewed, stressing the importance of favouring bladder development and limiting obstructive patterns of bladder emptying that cause severe and recurrent complications.

Effect of raloxifene on lowering lipid parameters in patients with osteoporosis.

The aim of this study was to show the effect of raloxifene on the lowering of lipid parameters in patients with osteoporosis. New investigations introduced selective estrogen receptor modulators (SERMs), such as raloxifene, as a potent drug in the lowering of lipid parameters. Raloxifene is known as a substance that works well in preventing and treating osteoporosis. We investigated the effect of raloxifene on the lowering of lipid parameters (cholesterol and triglycerides) in 94 women who took 60 mg/day of raloxifene for the treatment of osteoporosis. We performed three measurements of cholesterol and triglycerides, at the beginning of the study and at 3 and 12 months. Bone mineral density (BMD) was measured at the begining and at 12 months; spine BMD increased 2.7%. The mean value of cholesterol was 6.6961 mmol/l at the beginning, 6.060 mmol/l at 3 months and 5.826 mmol/l at 12 months. The difference between mean values was statistically significant at p < 0.01. Mean values of triglycerides were 2.153 mmol/l at the beginning, 1.970 mmol/l at 3 months and 1.680 mmol/l at 12 months. The difference between mean values at 3 months was statistically significant at p < 0.05 and at 12 months at p < 0.01. We concluded that raloxifene had significant effects on lowering cholesterol and triglycerides in postmenopausal women and that raloxifene is the best choice in the treatment of osteoporosis and moderate lipid disorders.

[The diabetic foot. The Croatian model--national consensus (clinical recommendations for diagnosis, prevention and therapy)]. / Dijabeticko stopalo. Hrvatski model--nacionalno usuglaseno misljenje (klinicke preporuke za dijagnostiku, prevenciju i lijecenje).

Diabetic foot occurs due to the loss of protective sense and circulation disorder and a marked proneness to infections. Mechanical stress of bone growths frequently leads to ulcerations. The prevention and timely treatment of diabetic foot requires the participation of both patients and all health care levels. This consensus is given for the purpose of procedure standardization. Education is the basis of prevention and should be carried out with every patient suffering from diabetes mellitus and those with a sensory defect in particular. Appropriate footwear significantly contributes to prevention and treatment of ulcers. As regards the treatment, the necessity of surgical approach with a long term and often manifold antibiotic therapy should be pointed out. Infections are usually mixed. The deeper the ulceration, the more likely the infection with anaerobes and Gram-negative bacteria occurs in addition to Gram-positive ones which are normally present in surface lesions. Strict metabolic control is a precondition for successful treatment. In conclusion, diabetic foot is a major health problem which requires multidisciplinary approach with permanent patient education as its essential part, and a specific cooperation of all levels and different health care specialties.