Systematic review and meta-analysis on management of acute urinary retention.

BACKGROUND: Acute urinary retention (AUR) is a common urological emergency. In this article, we review the current literature and present a structured summary in management of AUR. METHODS: A systematic review was conducted using the keywords 'acute AND retention AND urin*' within the title in search engines including Medline, EMBASE and EBM Review. The obtained literature was manually reviewed by the primary author (PDY) and was further refined by confining the subject to management of AUR. Exclusion criteria included paediatric and female population studies, case reports, reviews, surveys, economical assessment and articles on AUR in prostate cancer and post-operative patients. RESULTS: Total of 54 articles met our inclusion and exclusion criteria. The trial without catheter (TWOC) post-immediate catheterisation is widely practiced although there remains a significant variability in terms of type and duration of catheterisation required, use of concurrent medical therapy or post-catheterisation management. Our systematic review and subsequent meta-analysis has shown superiority of α1-adrenergic receptor blockers over placebo in achieving successful voiding in patients with AUR. Suprapubic catheter (SPC) is an alternative to urethral catheterisation (indwelling catheter (IDC)) and may provide several advantages. Clean intermittent self-catheterisation may be a safe and useful option for patients with AUR until their definitive management. The overall long-term outcome of in-and-out catheterisation remains promising in selected patients. Surgery is an end point in patients with unsuccessful TWOC as well as in those with significant lower urinary tract symptoms post-successful TWOC. CONCLUSIONS: We recommend use of α1-adrenergic receptor blockers before TWOC and discourage emergency operative management. Use of SPC over IDC in AUR is debatable. Duration of catheterisation is controversial but <3 days is a safe option in avoiding catheterisation-related complications. Although TURP remains the current gold standard, there has been an emergence of newer operative management utilising laser techniques.

Bruckner red light reflex test in a hospital setting.

BACKGROUND: Childhood blindness is a major problem in developing world including Nepal that needs to be addressed. OBJECTIVE: The objective of study was to measure the effectiveness of the Bruckner red reflex test for screening of posterior segment opacities in children. METHODS: Patients aged less than five years who came to the Tilganga Institute of Ophthalmology, Kathmandu from March to August, 2009 were recruited in this cross-sectional descriptive study. Children were screened with the Bruckner red light reflex test in a dark room. Patients with abnormal Bruckner tests had their eyes dilated for further investigations. Abnormalities were recorded. The number of patients with an abnormal Bruckner test was recorded and correlated with their potential pathology. RESULTS: A total of 172 patients with 97 boys and 75 girls were included. Twenty-three had abnormal Bruckner test results in either one or both eyes. Four of these twentythree patients had no pathology diagnosed; hence the sensitivity of the Bruckner screen to diagnose significant pathology was calculated at 82.6%. Of the 153 patients with normal results, two patients were found to have pathology detected, which included cataract and strabismus. Hence, the specificity of this test was 98.7%. The screening test had a positive predictive value of 90.5% and a negative predictive value of 97.4%. CONCLUSION: Bruckner test screening is a sensitive and specific marker for detecting the posterior segment opacities in children. We recommend utilizing the test to evaluate these problems where other technologies are rare.

Clinical results with left axillary to left anterior descending coronary artery bypass.

BACKGROUND: The minimally invasive direct coronary artery bypass procedure is not feasible if the left internal mammary artery has been used or has inadequate flow. We have applied a modified minimally invasive direct coronary artery bypass procedure, which uses a graft from the left axillary artery to the left anterior descending coronary artery in such situations. METHODS: The graft is anastomosed to the left axillary artery adjacent to the clavicle and tunneled underneath the vein, where it enters the thorax through the first interspace and courses to the left anterior descending coronary artery along the mediastinum. RESULTS: Since 1997 we have used this operation in 22 patients with a mean age of 70 years (range, 52 to 83 years). All patients were high-risk candidates because of advanced age (70 +/- 7 years), depressed left ventricular function (mean left ventricular ejection fraction, 38% +/- 6%), or previous heart operation (20 of 22, 91%). Conduits for the graft were saphenous vein (n = 18) or radial artery (n = 4). Ten patients were extubated in the operating room, and the mean duration of mechanical ventilation was 5.8 +/- 6 hours. There was one operative death (1 of 22, 4.5%). The mean length of intensive care unit and hospital stay was 1.5 days (range, 1 to 6 days) and 6 days (range, 2 to 15 days), respectively. At a mean follow-up of 6 months, all discharged patients are alive and functionally improved. None have required surgical or catheter-based revascularization of the left anterior descending coronary artery. CONCLUSIONS: The left axillary artery to left anterior descending coronary artery graft should be considered for high-risk patients in whom a minimally invasive direct coronary artery bypass procedure is not possible.

Regional effects of aortomyoplasty in acute ischemia.

BACKGROUND: Aortomyoplasty is a technique for achieving autogenous diastolic counterpulsation. This experiment was designed to determine if aortomyoplasty using conditioned latissimus dorsi muscle could improve regional myocardial function during coronary ischemia. METHODS: Six mongrel dogs underwent a staged operation in which the left latissimus dorsi was conditioned in situ for 4 weeks, then wrapped around the descending aorta and stimulated during diastole with each cardiac contraction. Regional ischemia was caused by occlusion of the left anterior descending coronary artery. Regional function was measured with somomicrometry in the region of ischemia and in a control area. An intraaortic balloon pump was inserted for comparison with aortomyoplasty performance. RESULTS: Coronary artery occlusion caused a significant decrease in the percentage of regional shortening (14.2 +/- 7.9 to -2.2 +/- 4.0; p = 0.001) and thickening (11.9 +/- 4.6 to -5.8 +/- 3.3; p < 0.001). Aortomyoplasty improved regional motion in both percentage shortening (-2.2 +/- 4.0 to 2.3 +/- 3.7; p = 0.008) and thickening (-5.8 +/- 3.3 to 2.8 +/- 1.9; p < 0.001). The intraaortic balloon pump also improved percentage shortening (-3.7 +/- 2.0 to 0.7 +/- 1.9; p = 0.01) and thickening (-5.0 +/- 2.8 to 2.4 +/- 3.8; p < 0.001), and was not significantly different than aortomyoplasty. CONCLUSIONS: These data show that aortomyoplasty has beneficial effects on ischemic left ventricular contractility, and may therefore be useful for treating inoperable coronary artery disease.

Myocardial regeneration. Transplanting satellite cells into damaged myocardium.

Millions of Americans suffer from chronic heart failure. Despite treatments with heart transplantation, cardiomyoplasty, and artificial assist devices, an ideal therapy is yet to be found. Since 1988, we have studied the transplantation of myogenic stem cells from skeletal muscle into injured myocardium in the hope that these cells would multiply and differentiate, thereby improving the function of the failing heart. We have achieved 2 goals thus far: the 1st was improving the culture technique to obtain high yield and purity of the satellite cells; the 2nd was successfully implanting cultured satellite cells in dog hearts and later identifying them as new myocardium. We share our findings here to encourage more study in this promising area.