A longitudinal, patient-centred, integrated curriculum: facilitating community-based education in a rural clinical school.

The Greater Murray Clinical School (GMCS) was founded with two main aims in mind one, to provide a community-based learning environment offering diversified clinical educational experiences, and two, by doing so, to help address the doctor shortage for Australians living in rural and remote areas. The GMCS is a community-orientated and community-based clinical school, which has replaced the typical discipline-based curriculum with a longitudinal, patient-centred one. Students are attached to patients--called "the longitudinal patient"--whom they follow through all stages of their care. They share with patients their experience of illness and disease, their varying care needs, and how these are addressed by different service providers. The philosophy of the course, its implementation and our initial experiences are described.

A crossover randomized trial of transcutaneous electrical nerve stimulation and oxybutynin in patients with detrusor instability.

PURPOSE: Management of idiopathic detrusor instability is difficult in most patients mainly due to the lack of a complete understanding of the pathophysiology. Oxybutynin and transcutaneous electrical nerve stimulation have been used but to our knowledge no direct comparisons have been made. MATERIALS AND METHODS: Patients with frequency, urgency, urge incontinence and proved detrusor instability were studied with urodynamics, quality of life instruments, and frequency and volume charts. Patients were randomized to transcutaneous electrical nerve stimulation or oxybutynin. After 6 weeks of treatment, they were reassessed and after a washout of 2 weeks, they were started on the second arm of treatment and reassessed 6 weeks later. RESULTS: A total of 13 male and 30 female patients were studied. Functional capacity had increased and number of voids daily had decreased significantly compared with before treatment in both arms (p <0.005). There were significant improvements in symptom specific quality of life measures but no changes were found on the global Short Form 36 (SF-36) quality of life questionnaire. The volume to first desire to void and first unstable contraction had increased significantly with oxybutynin but not with transcutaneous electrical nerve stimulation. Of 23 patients 7 were stabilized with treatment, including 2 with oxybutynin only, 2 with either nerve stimulation or oxybutynin and the remaining 3 with only nerve stimulation. Total bladder capacity did not change significantly with either treatment but patients noticed side effects more commonly with oxybutynin. CONCLUSIONS: Both treatments clearly improved subjective parameters. However, only oxybutynin showed significant improvements in objective urodynamic parameters. Transcutaneous electrical nerve stimulation can be used in patients who cannot take oxybutynin. Further studies are needed to show the long-term efficacy and cost analyses of nerve stimulation.

Community based medical education in a rural area: a new direction in undergraduate training.

The Greater Murray Clinical School provides a community based medical education programme for the clinical years at the University of New South Wales. Being a new clinica school in rural Australia allowed the development of a patient-centred longitudinal curriculum. Students follow patients through the health care system, with each exposure stimulating the learning about different aspects of a patient problem. The paper outlines the conceptual approach towards the development and implementation of this novel approach to community based medical education.

The production of nerve growth factor by human bladder smooth muscle cells in vivo and in vitro.

OBJECTIVE: To measure the concentrations of nerve growth factor (NGF) in tissue biopsies taken from subjects with a normal bladder and from patients diagnosed to have idiopathic detrusor instability (associated with a reduction in the density of motor nerves), and to use an in vitro model to study the mechanisms of NGF expression. MATERIALS AND METHODS: Biopsy specimens were obtained during endoscopic and open surgery from patients undergoing routine bladder surgery. The patients were divided into two categories based upon urodynamic characterization. The NGF content in samples from 11 normal bladders and seven idiopathic unstable bladders were measured using an enzyme-linked immunosorbent assay. The mechanisms influencing net NGF production were explored using detrusor cells in vitro. RESULTS: The mean (SEM) NGF content was significantly higher in unstable tissues, at 0.96 (0.05) pg/microg protein, than in the normal bladder, at 0.53 (0.05) pg/microg protein. In the cell model, acetylcholine (10 micromol/L), noradrenaline (1 and 10 micromol/L) and ATP (1 micromol/L) caused a significant increase in net NGF production; acetylcholine at 1 micromol/L had no effect. Direct stimulation of protein kinase C (PKC) by phorbol ester (33 ng/mL) or elevation of cAMP using forskolin (10 micromol/L) increased NGF, suggesting that at least two intracellular pathways (PKC- and PKA-dependent) are involved. The expression of c-Fos was increased by phorbol 12-myristate 13-acetate added before NGF, suggesting that c-Fos may be involved in regulating NGF production. CONCLUSION: These data suggest a role for NGF in the physiology and pathophysiology of the human bladder, and indicate some of the possible mechanisms which might regulate NGF production.

A prospective analysis of 1,930 patients with hematuria to evaluate current diagnostic practice.

PURPOSE: The commonly accepted diagnostic algorithm for hematuria includes excretory urography (IVP) and cystoscopy. Some have suggested that ultrasound of the upper urinary tract is adequate and that cystoscopy is not necessary in younger patients with microscopic hematuria. We ascertain whether a less intensive algorithm could be adopted while retaining diagnostic efficacy. MATERIALS AND METHODS: A total of 1,930 patients were enrolled prospectively in the study at a hematuria clinic between October 1994 and March 1997. Evaluation consisted of basic demographics, history and examination, routine blood tests, urinalysis and cytology. All patients underwent plain abdominal radiography, renal ultrasound, IVP and flexible cystoscopy. RESULTS: A total of 1,194 males and 736 females with a mean age of 58 years (range 17 to 96) were included in the study. Overall, 61% of patients had no basis found for hematuria, 12% had bladder cancer, 13% had urinary tract infection and 2% had stones. Kidney and upper tract tumors were noted in 14 patients (0.7%), including 4 who presented with microscopic hematuria. If only ultrasound or IVP had been performed 4 of these cases would have been missed. Of 982 patients presenting with microscopic hematuria 51 had cancer. Bladder cancer was found in 7 patients younger than 40 years. CONCLUSIONS: Our findings suggest that cystoscopy cannot be safely avoided even in younger patients with microscopic hematuria. Only a combination of ultrasound and IVP detected all upper tract tumors.

The application of ultrastructural studies in the diagnosis of bladder dysfunction in a clinical setting.

PURPOSE: We examine the ultrastructural changes reported to be present in dysfunctional bladders and determine whether they can be used as a predictor of urodynamic diagnosis in a clinical setting. MATERIALS AND METHODS: Subjects who required urodynamic diagnosis and cystoscopy as part of clinical management were recruited for this study. After urodynamic diagnosis cases were classified into 1 of 5 dysfunction groups as normal bladder outflow obstruction, idiopathic sensory urgency, obstruction with detrusor instability and pure detrusor instability. A detrusor muscle biopsy was taken from the lateral wall of the bladder at cystoscopy for subsequent electron microscopy. RESULTS: Of the 27 cases 6 were normal, 9 had bladder outflow obstruction and detrusor instability, 8 had pure detrusor instability and 4 had idiopathic sensory urgency. The obstructed group showed the myohypertrophy pattern previously reported. In contrast to previous reports, abnormal junctions were found in all patients. For each patient the ratios of abnormal-to-normal junctions were calculated. Mean and standard error ratios were 1.1+/-0.1, 2.7+/-0.2, 6.1+/-1.2, 13.3+/-4.4 for normal, idiopathic sensory urgency, obstruction with detrusor instability and pure detrusor instability, respectively (p = 0.0003, 0.0042 and 0.04). CONCLUSIONS: There are distinct morphological changes in the detrusor associated with bladder dysfunction. The ratio of abnormal-to-normal junctions is a novel measurement and can be used to predict urodynamic dysfunction. Ultrastructural studies may be useful as an adjunct in the diagnosis of bladder dysfunction.

Quality of nucleic acids extracted from fresh prostatic tissue obtained from TURP procedures.

PURPOSE: The molecular genetic study of benign prostatic hyperplasia (BPH) requires high quality nucleic acids from BPH tissue. It has been generally assumed, but not experimentally proven, that the diathermy used in trans-urethral resection of the prostate (TURP) damages nucleic acids. MATERIALS AND METHODS: Total RNA, polyA+ RNA and genomic DNA isolated from fresh tissue obtained from TURP procedures were compared with those isolated from tissue obtained from open prostatectomy. RESULTS: On a formaldehyde agarose gel, there was an increase in low molecular weight RNA in the TURP derived samples, in comparison to that in the open prostatectomy derived samples. The 28S and 18S rRNA were present in all TURP specimens and although the two bands were reduced in some samples, there were samples in which the 2 bands were indistinguishable from the open prostatectomy derived samples. Low molecular weight fragments seen in total RNA were reduced greatly in polyA+ RNA and the difference in polyA+ RNA between the TURP and open prostatectomy derived samples was significantly diminished. RT-PCR of two ubiquitously expressed gene transcripts (Galpha11, 256 bp and HPRT, 847 bp) yielded products of similar size and intensity between TURP and open prostatectomy derived samples. Genomic DNA obtained from TURP derived specimens showed no difference in size or enzyme digestibility in comparison to that from open prostatectomy. CONCLUSIONS: Nucleic acids extracted from fresh prostatic tissue derived from TURP procedures can be used as readily as any other fresh tissue for RT-PCR based molecular genetic studies, although polyA+ RNA isolation is recommended if degradation-free RNA is required.

Surgeon, don't heal thyself: a study of the health of Australasian urologists.

BACKGROUND: Modern surgical practice is stressful and anxiety-producing. We investigated urologists health and their attitude to their own health care. METHODS: Two hundred and seventy-five Australasian urologists were surveyed to ascertain their attitudes to their physical and psychological health; 205 responses were received. RESULTS: Ten per cent reported serious physical illnesses. Fewer than half had their own general practitioner (GP), and fewer than one-third had seen a doctor in the previous 12 months. A majority had, at some time, prescribed themselves medication, including antibiotics, narcotic and non-narcotic analgesia and benzodiazepams. Nearly all reported that aspects of their urological practice caused them anxiety. More felt that this anxiety was the result of pressures experienced outside the operating theatre than problems directly related to performing surgery. A small number of psychological problems were reported, and fewer than 10 per cent had ever a visited a psychiatrist. It was evident that most Australasian urologists were unwilling to discuss any psychological problems that they may have. Even when a specific problem had been identified, few sought the appropriate care. CONCLUSIONS: It would be advantageous for Australasian urologists and doctors in general to see their GP more regularly, and be more willing to discuss any psychological difficulties that they may experience.

Advantages of polytetrafluoroethylene arteriovenous loops in the thigh for hemodialysis access.

BACKGROUND: The upper thigh is an alternative but infrequently used site to the forearm for placement of subcutaneous polytetrafluoroethylene (PTFE) arteriovenous conduits in patients requiring hemodialysis for end stage renal failure. This site has the great advantage of easier accessibility for self-cannulation. METHODS: The outcome was reviewed for 74 PTFE loops placed in 61 patients between 1985 and 1991. RESULTS: Mean loop survival time was 99.8 weeks (SD 78.0) when patients with early failure (<1 week), and those patients whose loops functioned adequately until transplantation or death were excluded. Infection occurred in 12 of 74 loops. CONCLUSIONS: Thigh PTFE loops provide satisfactory medium- to long-term vascular access for hemodialysis although, like all other forms of access currently available, they fall short of the ideal for prolonged dialysis.

Renal parenchyma-sparing surgery in carcinoma.

BACKGROUND: There is controversy regarding the role of renal-sparing surgery in patients with kidney cancer who have a functioning contralateral kidney. METHODS: The present study aimed to review the recent experience of renal-sparing surgery at Royal Prince Alfred Hospital (RPAH), Sydney. Eighteen consecutive patients undergoing conservative surgery for kidney tumours at RPAH between February 1987 and January 1995, were reviewed. Eleven patients had imperative indications for conservative surgery and the remaining seven patients had elective indications. Ten patients had modified enucleation with a margin of normal parenchyma. Six patients underwent partial nephrectomy and two had wedge resections. Patients were followed up at 1, 6 and 12 months, and thence every 6-12 months. Follow-up ranged from 9 to 104 months (mean: 46.2 months, median: 48 months). RESULTS: Sixteen of the 18 patients were still alive at the end of the follow-up (October 1995), with no clinical evidence of local or distant metastasis. The two deaths were not related to the fact that these patients had conservative surgery. The average tumour dimensions were 43 mm x 49 mm, with an average volume of 194 mm3. All resections were complete, with margins ranging between 1.0 and 20.0 mm (mean: 8.7 mm). The survival rate in the present study is comparable to those found by other researchers. CONCLUSIONS: Conservative surgery is indicated in renal tumours where radical surgery would render the patient anephric. Conservative surgery, however, is controversial in a patient with a normal contralateral kidney. The present study has shown that renal parenchyma-preserving surgery for localized tumours provides a feasible treatment option.

Interactive urology: an evaluation.

BACKGROUND: Interactive Urology is a multimedia software program that has been written to provide computer-assisted interaction for medical students at the University of Sydney during their surgical term in urology. An evaluation sought to establish how the software will be used by medical students in the learning context and to explore the efficacy of the software in the transfer of content as well as problem-solving skills. METHODS: Interactional analysis during student computer sessions and pre- and post-testing included a total of 80 medical students to evaluate Interactive Urology. RESULTS: The software package appeared to promote higher-order thinking skills with brainstorming activities occupying about half the time available. utilizing pre- and post-testing, Interactive Urology was found to be efficacious in the transfer of content and problem-solving skills. It was also found to be as effective as text in transferring content and problem-solving skills. The sequence of text and computer assisted learning (CAL) did not alter learning efficacy. CONCLUSION: It was concluded from the present study that Interactive Urology is an effective and valuable learning resource for medical students.

Sympathetic nervous system effects on feline bladder wall compliance throughout continence.

The urinary bladder is a compliant organ, high compliance being essential for useful urine storage. The extent to which the sympathetic nervous system promotes the storage of urine by increasing bladder compliance is unclear. The aim of the present study was to determine the range of bladder volumes over which the sympathetic nervous system increased bladder wall compliance. In supine, anaesthetized cats, the bladder was filled at twice the rate of natural filling, the continence cycle being interrupted at five stages. These stages were when the bladder had become globular, during prodromal contractions, soon after non-micturating contractions had commenced, approximately two-thirds of the way through the continence cycle and just prior to micturition. During each of these interruptions, bladder volume was held constant while pelvic nerve afferent activity and bladder pressure were recorded. Recordings were obtained before and during the intravenous infusion of trimethaphan, the resulting partial ganglion blockade decreasing arterial pressure by a third. Bladder pressure as well as afferent nerve activity increased significantly when the sympathetic drive was transiently blocked, indicating that there had been a prevailing net sympatho-inhibitory effect promoting bladder wall relaxation. This effect was observed during prodromal contractions and continued until the onset of micturition. This net sympatho-inhibitory effect is a potential therapeutic path for the treatment of bladder storage disorders.

The acceptance of computer assisted learning by medical students.

The use of computer assisted learning (CAL) in the medical undergraduate curriculum is increasing. Little is known regarding the acceptability of CAL among medical students. The present study was conducted to investigate the possible anxiety generated by and the acceptability of CAL among medical students. One hundred and twenty-six students completed a questionnaire after using a software package which has been as an adjunct in teaching urology. The present study demonstrates that there was little anxiety experienced by the students when using CAL and furthermore that there was a high level of acceptance for this type of instruction. This is encouraging for medical educators involved in producing multimedia packages for teaching medicine and surgery.

The justification for surgical treatment of metastatic melanoma of the gastrointestinal tract.

Fifty-six patients with symptomatic metastatic melanoma of the gastrointestinal tract (GIT) treated surgically at the Sydney Melanoma Unit between 1974 and 1989 were reviewed. The majority of these patients presented with abdominal pain or symptoms of anemia. The small intestine was the site of metastasis in more than 80 per cent. The mean over-all survival time was 11.7 months (range of one to 60 months) after surgical treatment of a first metastasis to the GIT and 3.6 months (range of zero to 12 months) postoperatively for a second GIT metastasis. Forty-four of the patients reported complete relief of their symptoms postoperatively. The results suggest that an aggressive approach to symptomatic GIT metastases from malignant melanoma is justified both to relieve distressing symptoms and to prolong life.