[Urinary tract injuries in polytraumatized patients]. / Verletzungen der ableitenden Harnwege bei polytraumatisierten Patienten.

BACKGROUND: Within the S3 Guideline Project of the European Association of Urology (EAU) an expert committee was set up to develop guidelines for the appropriate management of genitourinary trauma. These European guidelines were accepted in principle as national guidelines by the German Urological Society. Therefore, they also became the basis of the contribution of the German Urological Society to the S3 Guideline Project "Polytrauma" of the German Society for Trauma Surgery. METHOD: For the guideline "management of genitourinary trauma" all the requirements for classification as S3 guidelines were full-filled. The guideline itself was developed in accordance with the principles of "evidence-based medicine". A systematic analysis of literature published between 1966 and 2004 was carried out. The articles retrieved were assessed in respect of study design and clinical relevance and classified following the scheme of the Centre for Evidence-Based Medicine in Oxford. CONCLUSION: In suspected renal injuries the hemodynamic situation of the patient is the benchmark for the diagnostic and therapeutic algorithm. The diagnostic gold standard for the assessment of haemodynamically stable patients is CT scanning. Uncontrolled haemodynamic instability is an indication for immediate explorative laparotomy. Partial ureteral tears are managed by stenting; complete tears by immediate surgical repair. Pelvic fractures are often associated with bladder ruptures. Extraperitoneal bladder ruptures, identified by retrograde cystography, are in most cases safely managed by simple catheter drainage. Intraperitoneal ruptures require surgical intervention. Blood at the meatus may suggest a urethral lesion-blind urethral catheterization should not be attempted. Suprapubic cystostomy and delayed urethroplasty are recommended.

Management and follow-up of impacted ureteral stones.

INTRODUCTION: Impacted stones are those that remain unchanged in the same location for at least 2 months. MATERIALS AND METHODS: We evaluated 42 patients with impacted ureteral stones, and followed them for two and a half years to check for long-term results. The calculi location included all three segments of the ureter (proximal, mid and distal). Patients' age ranged from 22 to 83 years (mean 52.5 years). Primarily, patients were manipulated with extracorporeal shock wave lithotripsy (ESWL) in situ, or following stenting. If the result was not satisfactory, then we proceeded to retrograde ureteroscopy and ureterolithotripsy. Open ureterolithotomy was our final choice. RESULTS: Thirty-six of the 42 patients (85.7%) were stone-free without the need of an open procedure. Follow-up period ranged from 10 up to 40 months, with a median period of 30 months and was achieved in 30 patients (71.4%). Stone recurrence was noted in 4 cases, while hydronephrosis without evidence of stone presence in 2. CONCLUSIONS: The initial approach for the treatment of impacted lithiasis should be attempted by ESWL. If this fails, alternative therapeutic solutions such as endoscopy can result in removal of the stone.

[Urogenital lesions diagnosed incidentally during evaluation for blunt renal injuries]. / Lésions urogénitales diagnostiquées par hasard au cours du bilan pour des contusions fermées rénales.

OBJECTIVES: Pre-existing pathology of the urogenital system may interfere with the pathophysiology of trauma, alter the radiographic imaging and influence the way of therapeutic approach. The aim of our study was to record the pathological lesions of the urogenital tract found incidentally during evaluation for blunt renal trauma and subsequently comment on their importance. MATERIAL AND METHODS: The files of 675 patients referred to our department from 1982 to 1998 for further evaluation of possible blunt renal injury were reviewed. Our standard procedure is to perform an ultrasonogram and intravenous pyelography while CT scan and angiography are performed when indicated. No pediatric cases are encountered. RESULTS: Ultrasonographic and radiological evaluation revealed the presence of various congenital or acquired lesions of the urinary tract in 24 patients (3.5%). Lithiasis was the most common finding; multiple bladder stones and staghorn calculi were found in 8 and 4 cases, respectively. In 4 cases a renal mass other than hematoma was present while in 3 cases the trauma to the kidney was accompanied by rupture of large cortical cysts. Left renal agenesia was detected in 1 patient, a duplicated renal pelvis system in 1, bilateral ureterocele in 2, and retroperitoneal fibrosis in another patient. In 4 cases (2 with ruptured renal cyst, 1 with renal cell carcinoma and one with staghorn calculus) concomitant renal injury requiring immediate surgical intervention was detected. CONCLUSION: Lesions of the urinary tract found incidentally during evaluation for suspected renal injury are uncommon. However, they may complicate an otherwise negligible renal trauma while in some cases they may be of vital importance for the patient's final outcome.

Attention deficit disorder in adults and nicotine dependence: psychobiological factors in resistance to recovery?

The addictive nature of nicotine appears to depend on a number of psychobiological factors. This study explores the psychoactive effects of nicotine in relationship to the particular dysphoric aspects of Attention Deficit Disorder as a coincident factor in nicotine dependence and resistance to treatment. The psychological and behavioral effects of nicotine directly correspond to reduction in symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD) and the neurochemical effects of nicotine are qualitatively similar to stimulant medications used to treat ADHD. Aspects of the treatment of nicotine or other addictions in such comorbid situations are discussed in the context of self-medication.

The N15 component of the brainstem auditory evoked potential: a measure of hippocampal activity in schizophrenics?

The negative wave component of the brainstem auditory evoked potential at approximately 15 ms has been found to be related to activity in the hippocampus. Since hippocampal abnormalities have been reported among schizophrenic patients, it is obvious that a reliable electrophysiological measure of hippocampal activity might be useful in the study of schizophrenia. For instance, it may be hypothesized that the N15 wave of the BAEP would be abnormally reduced in amplitude for schizophrenics compared to controls, based on the previously reported misalignment of neurons in the hippocampus for schizophrenics. The measurement of the N15 is complicated by the presence of a postauricular muscle reflex in some individuals. We attempted an analysis of the N15 wave based on distributional characteristics for schizophrenics and control subjects. The nature of the N15 wave is described and potential lines of investigation are proposed.

Cerebral dominance, sleep and dream phenomena.

Evidence from human and animal studies is discussed in relation to the role played by the cerebral hemispheres in the genesis of sleep and particularly dream phenomena. The inconclusiveness of such research is commented upon and suggestions for further research are outlined.

Age, alcoholism and depression are associated with low levels of urinary melatonin.

Two normal control populations, separated by 8,000 miles and 24 degrees of latitude, had similar six-month mean values for overnight urinary melatonin concentrations. These values were significantly higher than six-month values for depressed subjects and abstinent alcoholic subjects, while the means for the two clinical populations were similar. Age and urinary melatonin concentration in the control and clinical populations were inversely related, but the slopes of the linear regression equations were ten times steeper for the control populations than for the clinical populations. Differences in age and sex distributions accounted for some of the differences in values between controls and the clinical populations, although controls still differed from the clinical populations, even after sex and age were factored out. The disparate slopes for age and melatonin concentrations may contribute to some of the conflicting findings of studies comparing populations of different ages. The total melatonin content in the samples from alcoholic subjects, but not the depressed subjects, was lower than that for controls. The difference in the urinary melatonin concentration between the controls and the two patient groups was not accounted for by difference in duration of urine collection period, hours of sleep or body weight.

Dental management of the patient with obsessive-compulsive disorder.

Individuals with obsessive-compulsive disorder frequently manifest bizarre behaviors that contribute to the oral disease development. The medications used to manage the disorder can cause profound xerostomia and compound the magnitude of oral pathology. The patient's behavioral alterations and drug therapy might require dental treatment modifications.

Schizophrenia, corpus callosum, and interhemispheric communication: a review.

The literature suggests that some schizophrenic patients may have a dysfunction in the transfer of information between the two cerebral hemispheres via the corpus callosum (CC). The presence of an abnormally thickened CC in some schizophrenic patients and an abnormally thin CC in others suggests a possible anatomic basis for abnormal organization of cognitive functions in these patients resulting from either increased or decreased communication between the two cerebral hemispheres. The findings of the anatomic studies have suggested a connection between a thickened CC and both early onset and negative symptom patterns in schizophrenic patients. Similarly, onset of symptoms later in life and positive symptom patterns have been associated with a thinner CC. Behavioral and electrophysiological findings appear to support the idea that the same subgroups may be associated with opposite patterns of effective transfer of information between the cerebral hemispheres. Careful analysis of the transfer of information between the cerebral hemispheres for selected groups of schizophrenic patients and normal controls could provide important information about cerebral organization and possible mechanisms operative in schizophrenia.