Pain intensity and pressure pain thresholds after a light dynamic physical load in patients with chronic neck-shoulder pain.

BACKGROUND: To investigate the development of pain intensity and pressure pain thresholds during and 24 h after a light dynamic physical load among patients with chronic neck-shoulder pain. METHODS: Twenty-six patients with chronic neck-shoulder pain and 12 healthy controls were included. The participants arm-cycled on an ergometer. Effort was rated with the Borg Rating of Perceived Exertion scale (RPE), and pain intensity with an numeric rating scale (NRS). Pressure pain thresholds were measured by an algometer. Participants started a pain diary 1 week before the physical exercise and continued until 1 week after. Pain intensity was assessed before, during and the following two evenings after arm-cycling. Pressure pain thresholds were assessed before, 15 min after, 105 min after and 24 h after. RESULTS: The chronic pain group showed increased pain intensity during, and the following two evenings after the arm cycling, and decreased pain thresholds immediately after the arm cycling involving painful regions. In the patient group there were no impact on pain thresholds in the neck the following day. CONCLUSIONS: Patients with chronic neck-shoulder pain reported increased pain intensity during and in the evenings after a light dynamic load involving painful regions. In addition, they showed decreased pain thresholds close to the exercise, indicating mechanical hyperalgesia.

Time after surgery, symptoms and well-being in survivors of urinary bladder cancer.

OBJECTIVE: To evaluate how an increasing burden of symptoms influences well-being, anxiety and depression at different intervals after a radical cystectomy with urostomy for bladder cancer, as this therapy can induce long-term distressful symptoms. PATIENTS AND METHODS: Patients with bladder cancer undergoing radical cystectomy in Stockholm between 1969 and 1995 were matched with 434 controls from the normal population; all 404 patients operated on between 1985 and 1995 at three other hospitals in Sweden were invited to enter the study. The final analysis included 306 patients and 310 controls, all assessed for symptoms and well-being. RESULTS: A low or moderate level of well-being was reported by 35% of the patients having none or one of the symptoms studied, by 39% with two symptoms, by 45% with three symptoms and by 66% of those with four or more symptoms. The values, irrespective of symptom burden, were 45% after 2-5 years of follow-up, 58% after 6-10 years and 38% at>10 years after surgery. The total symptom burden also influenced the risk of anxiety and depression. Symptom prevalence remained largely unaffected by the duration of follow-up, except for defecation urgency. CONCLUSIONS: The number of long-term symptoms after radical surgery with a urostomy for urinary bladder cancer affects the risk of anxiety, depression and low or moderate well-being.

Primary adenocarcinoma of distal ileum used as outlet from a right colonic urinary reservoir.

A case of primary adenocarcinoma of distal ileum used as intussuscepted nipple valve and outlet from a right colonic reservoir is reported. The tumour was diagnosed 5.5 years after the patient was operated on with cystectomy and right colonic reservoir for a moderately differentiated, muscle-invasive transitional carcinoma of the bladder.

Benign prostatic hyperplasia in Sweden 1987 to 1994: changing patterns of treatment, changing patterns of costs.

OBJECTIVES: To assess health care use and costs for benign prostatic hyperplasia (BPH) in Sweden from 1987 to 1994 when minimal invasive procedures, including transurethral microwave therapy (TUMT) and drugs, were introduced, in addition to conventional surgery. METHODS: Cross-sectional annual data on health care utilization based on national information systems and surveys were used for calculation of direct 1994 cost. RESULTS: The total number of men in the age group at risk for BPH was virtually constant, and the total direct health care costs for BPH treatment increased from 1987 to 1992. A slight decrease was evident for the years 1993 and 1994, notwithstanding the introduction of new ambulatory procedures in 1991 and of new drugs in 1992. The number of physician office visits changed little during the study period, although this estimate may be low. TUMT procedures were introduced rapidly but decreased; nevertheless, their share was never more than 3% of total costs. Drug sales were 15-fold those in 1992 and accounted for 12% of the total costs in 1994. Conventional transurethral resection of the prostate (TURP) operations decreased markedly after the introduction of the new treatments. CONCLUSIONS: The new treatments were adopted differently. TUMT procedures decreased as rapidly as they were introduced. Three years after the introduction of the new drugs, drug sales indicated that the number of men receiving drug treatment was greater than the annual number of men receiving TURP operations and TUMT procedures combined. Yet the total costs showed a slight decrease, mainly due to the decreasing numbers of TURP operations.

An estimate of the life-time cost of surgical treatment of patients with benign prostatic hyperplasia in Sweden.

Two clinical series (n = 96 + 90) and one record-linkage study (n = 492) were used for estimation of the health care utilization for the treatment of BPH patients, mainly by TURP, in Sweden during one year before and 5-7 years after surgery. The total cost for a single patient amounted to ca. 33000 SEK in 1900 prices (5850 USD). Costs for surgery dominated and for a TURP amounted to about 70% of the Total. The costs during one year preoperatively and 5 years postoperatively each amounted to 15% of the total costs. In the present study the outcome of surgery was similar to other reports from the same period. The surgical mortality was 0.4% and the readmission rate because of complications of surgery or manifestations of BPH was 25% after 7 years of observation. Of the patients 11% were reoperated on within 7 years. When transurethral resection of the prostate (TURP) replaced open surgery in Sweden during the 1970's it had several of the attributes of the new methods introduced for treatment of benign prostate hyperplasia (BPH) currently in use. However, the spread of TURP resulted in wider indications for surgery and an increase in the total number of surgical procedures. An important argument for the adoption of the new, less invasive methods for treatment of BPH is the lower cost. To make a fair comparison of the costs of different methods for treatment of BPH the long-term costs have to be included in the calculation.

Estimated total costs of treating benign prostatic hyperplasia in Sweden.

New surgical methods and safe effective drugs for treating benign prostatic hyperplasia (BPH) have been introduced in recent years. The long-term effects of these measures and the patient categories for which each is best suited are not as yet known. Amid rapid changes in treatment policy, our study aims to establish a frame of reference in Sweden for the costs of treating BPH. In 1988 most treatment of BPH was surgical, with "watchful waiting" or indwelling urethral catheter as alternatives. Transurethral resection was the main surgical method. The costs of treating BPH in 1988 were calculated with a "prevalence" and an "incidence" approach. Direct costs accounted for 80-85% of the total were mainly hospital costs. The total economic burden of BPH treatment in Sweden was estimated as 305-390 million SEK, equivalent to 49-62 million US$ in 1988 prices. Because of the impending changes in management of BPH, follow-up of the financial consequences of these changes is important in order to secure effective use of health care resources.

Treatment of cystine urolithiasis by a combination of extracorporeal shock wave lithotripsy and chemolysis.

Minimally invasive surgical procedures are particularly desirable in patients with cystine stones because of their often multiple previous operations, complicated stone situations, and high risk of recurrences. Twenty-four treatment episodes for cystine stones were carried out, 12 with extracorporeal shock wave lithotripsy (ESWL) as monotherapy and 12 with a combination of ESWL and percutaneous irrigation with chemolytic solutions. In the ESWL monotherapy group, five of 12 renal units became stone-free and one more patient was discharged stone-free, except for an untreated stone in a calix diverticulum. Combined treatment, most often given in association with more complicated stone situations, rendered seven out of 12 kidneys stone-free. Even in this group, one patient was discharged with an untreated residual stone in a calix diverticulum. Our results show that even complicated cystine stone situations can be successfully treated in a minimally invasive way, with the best results obtained with a combination of ESWL and percutaneous chemolysis. Alkalization of urine seemed to be insufficient in preventing stone formation. No difference in recurrence rate was observed between our two treatment groups.

Recurrences during a 10-year follow-up after first renal stone episode.

Each of 92 patients in a Swedish district served by only one hospital had been treated for their first renal stone in 1977 and was evaluated 10 years later. Recurrent stone formation during the observation period was observed in 26% of the patients, with no difference between men and women. Of all the patients who had sought medical advice in 1977 because of urinary stone colic, 51% were experiencing their first stone episode. Ten years later 37% of the original patients were still classified as single stone formers. The recorded recurrence rate was lower than that previously reported in the literature.

Human bladder cancer associated antigens: evaluation of antigenicity in TCC tissues of different grades and in normal urothelium.

The expression of five antigens, associated with transitional cell carcinoma (TCC) of the urinary bladder on biopsies of tumors or normal urothelium, was studied by immunostaining with the corresponding monoclonal antibodies. Both tissue sections and single cell preparations were investigated with either indirect immunoperoxidase staining or immunofluorescence. All 5 antigens were expressed on the majority (70-90%) of sectioned tumor specimens from 44 TCC patients, and 4 of them were similarly expressed on single cell tumor preparations from 26 additional patients. However, in both types of preparation, the degree of expression of these antigens varied from scattered staining of less than 25% of the tumor cells to homogenous staining of all or almost all cells. This degree of expression varied individually for each of the antigens and was not related to the malignancy grade of the tumors. However, as most of the tumors were of grades II or III, no conclusions regarding the relationship of antigen expression to the aggressiveness of the tumors can be drawn. In any event, all tumors expressed at least one and mostly several of these antigens. Antigen expression on biopsies of normal bladder mucosa from TCC patients or on urothelial biopsies from patients with prostate hyperplasia was also observed on single cell specimens (34 patients) but not on sectioned material (9 patients). However, the frequency of positive specimens was much lower (4-20%). Moreover, the number of cells expressing one or, occasionally, several of the antigens in normal urothelium was small (usually less than 5%). Because of these marked differences in antigen expression between tumors and normal tissue, the results indicate that a combination of 3-5 of the antibodies used in this study may be suitable for diagnostic purposes.

Urine composition and stone formation during treatment with acetazolamide.

Twelve patients who formed renal stones during acetazolamide treatment for glaucoma were studied. Calcium phosphate was the dominating component in the stones. Long term treatment with acetazolamide decreased urinary citrate markedly, which will result in an increased ion-activity product of calcium phosphate and a decreased inhibiting property of urine on calcium phosphate crystallization. The treatment also increased urinary oxalate which together with a low citrate might increase the risk of calcium oxalate crystallization. However, an estimate of the ion-activity product of calcium oxalate in urine (AP [CaOx]-index) was unaffected by the treatment and calcium oxalate was a minor component of the stones.

Clinical experience with long-term bendroflumethiazide treatment in calcium oxalate stone formers.

Bendroflumethiazide was administered to 85 patients (62 men, 23 women) with recurrent calcium oxalate stone disease. Side effects leading to interrupted treatment were observed in 26 (31%) of the patients. Fifty-nine (40 men, 19 women) remained on treatment for a mean (+/- SD) period of 3.7 +/- 1.0 years, and 21 reported late side effects. Twenty patients were given 2.5 mg bendroflumethiazide daily (Group A), 27 were given 2.5 mg twice daily (Group B), and 12 were given 5 mg once daily (Group C). Eight patients (14%) formed new stones and another two demonstrated stone growth during treatment. A beneficial effect on stone formation was observed in Groups B and C but not in Group A. Patients who failed to respond to treatment had a pre-treatment stone formation rate of 0.74 stones per year compared with 0.22 in those who did not form new stones. Those with recurrence during treatment had a lower citrate excretion than other patients. No effect on urinary citrate was recorded during treatment, and long-term treatment with bendroflumethiazide did not affect oxalate excretion.

Biochemical effects in patients with calcium oxalate stone disease during combined treatment with bendroflumethiazide and magnesium oxide.

Thirteen patients with calcium oxalate stone disease were treated with 2.5 mg bendroflumethiazide and 200 mg magnesium oxide twice daily for 1 year, and the effects on serum and urine constituents were evaluated. Serum magnesium and potassium decreased, whereas urate increased during treatment. The association of decreased urinary calcium and increased urinary magnesium resulted in a reduced Ca/Mg quotient and apparently a lower risk of forming urine supersaturated with calcium oxalate. Combined treatment with a thiazide and magnesium appears to alter the composition of urine in a way that might be more favourable than treatment with either substance alone.

Diurnal variation of urine composition in calcium oxalate stone disease during treatment with bendroflumethiazide.

Urine samples, collected hourly between 6.00 and 23.00 h and in one single night fraction, were analyzed for calcium (Ca) and magnesium (Mg) before and during daily administration of 5 mg bendroflumethiazide to 13 Ca-oxalate (CaOx) stone formers. In some of them urinary oxalate (Ox), citrate and sodium were analyzed as well. Bendroflumethiazide was administered in divided doses to 7 and in a single dose to 6 patients. After 4-8 weeks of treatment urinary Ca decreased by approximately 25% in both groups and the reduction was evenly distributed over the day. The reduction of the Ca/Mg quotient and the CaOx risk index was most pronounced following meals. The AP(CaOx) index, an estimate of the CaOx ion activity product, was favorably reduced. No important differences were recorded for the different types of bendroflumethiazide administration and thus one single dose might be equally as efficient as two divided doses.

Studies on crystalluria in calcium oxalate stone formers.

The excretion of calcium oxalate and calcium phosphate crystals was studied in fractionated 24 h urine from 7 men with recurrent calcium oxalate stone disease, both before and during daily administration of 5 mg bendroflumethiazide. Urinary calcium, oxalate, magnesium, citrate, phosphate, pH, and inhibition of calcium oxalate crystal growth rate were analyzed in all samples. Exclusively calcium oxalate crystals were found in 30 per cent of the samples, all with a pH below 6.25, whereas calcium phosphate was the crystal type encountered in urine with a pH above 6.50. Bendroflumethiazide decreased the volume of calcium phosphate but not of calcium oxalate crystals. During the period of observation there was no correlation between calcium oxalate supersaturation and calcium oxalate crystal volume, but a relationship was demonstrated between calcium phosphate supersaturation and calcium phosphate crystal volume.

In vitro conversion of 3H-pregnenolone by human testicular tissue from fetal age to senescence.

The in vitro conversion of pregnenolone was studied in testicular tissue specimens from 6 fetuses, 3 prepubertal boys with undescended testes, 5 normal adult men, and 12 elderly males with prostatic carcinoma. Adult testicular tissue converted pregnenolone to testosterone mainly along the delta 5 metabolic pathway. Steroid intermediates that were converted from pregnenolone to delta 4 metabolites prior to the rate limiting C17-20 lyase step were "trapped" as 17 alpha-hydroxyprogesterone. The conversion patterns in testicular tissue from fetuses were similar to those in testicular tissue from adults and elderly men. In prepubertal testicular tissue, however, a significantly lower conversion was observed, mediated by the enzymes 3 beta-hydroxysteroid dehydrogenase/isomerase and 17 alpha-hydroxylase. The conversion mediated by 17 alpha-hydroxylase was significantly lower in testicular tissue from the elderly males than from younger adults, suggesting a relative steroidogenic insufficiency in the elderly males. Testicular tissue from an anencephalic fetus produced testosterone and steroid intermediates in vitro, although to a lesser extent than in testicular tissue from other fetuses. The enzymes 3 beta-hydroxysteroid dehydrogenase/isomerase and 17 alpha-hydroxylase appeared to be under gonadotropic control.

Variations in urine composition during the day in patients with calcium oxalate stone disease.

The diurnal variations of urine composition with respect to calcium, magnesium, oxalate, citrate and inhibition of calcium oxalate crystal growth were studied in patients with recurrent calcium oxalate stone disease. There was considerable variation in the excretion of the different urine constituents with meal-related peaks, which was most pronounced for calcium. The highest concentration of calcium was observed before noon, and between 7 and 11 p.m. Oxalate concentration was highest between 6 and 10 a.m. Consequently, the highest levels of supersaturation were recorded between 6 and 10 a.m., and 6 and 10 p.m. The inhibition index was at the highest level during the first morning hours and could be important in counteracting crystal growth at that time. The risk of exceeding a theoretical formation product of calcium oxalate appeared to be low, with a 24-hour urine volume more than 2,000 ml.

Bacteriological findings in 25 patients with Reiter's syndrome (reactive arthritis).

Extensive bacteriological testing was performed in 25 patients with complete or incomplete Reiter's syndrome. In 21 patients (84%), evidence of antecedent infection was found, based on culture and/or serological findings. Thus, infection with Chlamydia trachomatis (17 patients), Yersinia enterocolitica, serotype 3 (4 patients), and Campylobacter jejuni (1 patient) was identified.