Urological community nursing: a new concept in the delivery of urological care.

OBJECTIVE: To investigate the impact of a urological community nursing service on the mode of practice, efficiency, and quality of care in a urological practice. METHODS: A urological community nurse was appointed to investigate the possibility of performing various urological procedures in the community rather than in hospital, with a prospective audit of the results for a period of 1 year. The setting was a busy urological unit serving a mixed urban and rural catchment area of 300,000 people. The outcome was assessed by the number and type of procedures successfully transferred from hospital to community practice. RESULTS: In 1 year, 464 urological episodes were performed in the patients' homes which otherwise would have required transfer or admission to hospital for treatment or, in some cases, a cancelled operation. These episodes included tuition in clean intermittent self-catheterization and dilatation, changes and insertions of urethral, suprapubic and nephrostomy catheters, bladder instillations to treat cancer and interstitial cystitis, voiding trials with no catheter, urosheath fittings, and pre-operative visits and follow-up visits to avoid attendance at the clinic. CONCLUSIONS: The urological community nursing service transferred a significant number of routine urological procedures from hospital to community with considerable financial savings and improvement in the quality and efficiency of urological care.

Oligomerization of indole-3-carbinol in aqueous acid.

Indole-3-carbinol [I3C, also called 3-(hydroxymethyl)indole] is a naturally occurring modulator of carcinogenesis with a biological activity that is at least partially dependent on its conversion to active substances in acidic media. We compared the identities of the major oligomeric products of I3C produced under conditions approximating those found in gastric juice with the reported identities of products of 3-substituted indoles produced under enzymatic and other nonenzymatic conditions. After a 10-min treatment in aqueous HCl solution, I3C was converted in 18% yield to a mixture of acetonitrile-soluble products, the major components of which (as determined by HPLC) were diindol-3-ylmethane (5.9%), 5,6,11,12,17,18-hexahydrocyclononal[1,2-b:4,5-b':7,8-b"]triindo le (2.0%), and [2-(indol-3-ylmethyl)indol-3-yl]indol-3-ylmethane (5.9%). Tentative assignments were made for 3,3-bis(indol-3-ylmethyl)indolenine (0.59%), a symmetrical cyclic tetramer (0.64%), and a linear tetramer (1.1%). Indolo[3,2-b]carbazole (ICZ) was formed slowly in aqueous acidic solutions in low yields (2.0 ppm) which increased to greater than 90 ppm following addition of an organic solvent [tetrahydrofuran (THF) or dimethylformamide (DMF)] to a neutralized solution. Relative yields of trimers vs dimer increased with decreasing pH and with decreasing starting concentration of I3C. Evidence is presented that ICZ formation may not involve radical intermediates as is characteristic of photodynamic processes. A mechanistic rationale is presented for the formation of the identified products.

Effectiveness of continuous vs. intermittent amoxicillin to prevent episodes of otitis media.

The effectiveness of continuous compared with intermittent amoxicillin prophylaxis administered to subjects with a history of recurrent otitis media enrolled during the winter respiratory infection season was assessed in a prospective single blinded clinical trial. Patients with three or more chart-documented episodes of otitis media (OM) in the preceding 6 months were enrolled and randomly assigned to each treatment group. Patients in the continuous group received amoxicillin twice a day every day for up to 4 months. During the same period patients in the intermittent group received amoxicillin twice a day only when they developed respiratory symptoms of congestion, runny nose or cough. Among the 30 patients receiving continuous amoxicillin who were followed for at least 3 months, 22 (73%) had no OM episodes and 8 (28%) had one OM episode. Among the 25 patients receiving intermittent amoxicillin for at least 3 months, 13 (52%) had no OM episodes, 8 (32%) had 1 episode and 4 (16%) had 2 episodes. Significantly fewer patients had fewer than 2 OM episodes on continuous compared with intermittent amoxicillin (P less than 0.04). The incidence density was 0.46 episode/120 days at risk in the continuous treatment group compared with 1.10 episodes/120 days at risk for intermittent treatment (P less than 0.03). Among patients 12 months or older the incidence density of OM episodes per 120 days was 3.5 times higher in the intermittent amoxicillin group (0.80) compared with the continuous amoxicillin group (0.23) (P = 0.05). The incidence densities of the continuous vs. intermittent therapy groups did not differ significantly for patients younger than 12 months of age. The findings suggest that continuous amoxicillin prophylaxis may be more effective than intermittent treatment in preventing OM episodes in patients 12 months or older with a history of recurrent otitis media.

Aromatic hydrocarbon responsiveness-receptor agonists generated from indole-3-carbinol in vitro and in vivo: comparisons with 2,3,7,8-tetrachlorodibenzo-p-dioxin.

Indole-3-carbinol (I3C) is a secondary plant metabolite produced in vegetables of the Brassica genus, including cabbage, cauliflower, and brussels sprouts. I3C is both an anti-initiator and a promoter of carcinogenesis. Consumption of I3C by humans and rodents can lead to marked increases in activities of cytochrome P-450-dependent monooxygenases and in a variety of phase II drug-metabolizing enzymes. We have reported previously that the enzyme-inducing activity of I3C is mediated through a mechanism requiring exposure of the compound to the low-pH environment of the stomach. We report here the aromatic hydrocarbon responsiveness-receptor Kd values (22 nM-90 nM), determined with C57BL/6J mouse liver cytosol and the in vitro- and in vivo-molar yields (0.1-6%) of the major acid condensation products of I3C. We also show that indolo[3,2-b]carbazole (ICZ) is produced from I3C in yields on the order of 0.01% in vitro and, after oral intubation, in vivo. ICZ has a Kd of 190 pM for aromatic hydrocarbon responsiveness-receptor binding and an EC50 of 269 nM for induction of cytochrome P4501A1, as measured by ethoxyresorufin O-deethylase activity in murine hepatoma Hepa 1c1c7 cells. The binding affinity of ICZ is only a factor of 3.7 x 10(-2) lower than that of the highly toxic environmental contaminant and cancer promoter 2,3,7,8-tetrachlorodibenzo-p-dioxin. ICZ and related condensation products appear responsible for the enzyme-inducing effects of dietary I3C.

Management of chronic middle ear effusion with prednisone combined with trimethoprim-sulfamethoxazole.

Fifty-three patients were enrolled and evaluable in a randomized, double-blinded controlled clinical trial comparing prednisone for 7 days plus trimethoprim-sulfamethoxazole (TMP/SMZ) for 30 days vs. TMP/SMZ alone in treating chronic middle ear effusion (MEE). Clearing of the effusion in both ears or in one when only one was involved was called complete resolution; clearing in one of two affected ears was called partial resolution. The outcomes 2 weeks after initiation of therapy of 26 patients initially treated with prednisone plus TMP/SMZ were complete resolution in 20, partial resolution in three, and unchanged in three. The outcomes in 27 patients initially treated with TMP/SMZ alone were complete resolution in eight, partial resolution in three, unchanged in 13 and development of acute otitis media in three (P less than 0.01 for complete resolution). Two weeks after initiation of therapy, patients with a MEE that failed to clear were crossed over to the alternative regimen. Overall 29 of 41 patients (71%) who received oral prednisone plus TMP/SMZ initially or after the crossover had complete resolution of their middle ear effusion at 2 weeks after starting prednisone and TMP/SMZ. Five of 35 (14%) patients treated with prednisone plus TMP/SMZ and one of six (17%) patients treated with TMP/SMZ alone who had complete resolution at 4 weeks required subsequent referrals for tympanostomy tubes. A course of prednisone for 7 days plus TMP/SMZ for 30 days with monthly follow-up should be considered in children with MEE persisting beyond 6-8 weeks before referral for tympanostomy tube placement.

Medical management of chronic middle-ear effusion. Results of a clinical trial of prednisone combined with sulfamethoxazole and trimethoprim.

Prednisone for seven days plus the combination drug sulfamethoxazole and trimethoprim for 30 days was assessed in treating chronic middle-ear effusion present for at least eight weeks. Pneumatic otoscopy, tympanometry, and audiology at entry into the study, and one week and one month after therapy, documented the status of the middle-ear effusion. Clearing in both ears or in one when only one was involved was called complete resolution; clearing in one of two affected ears was called partial resolution. In the initial open trial, 13 of 24 patients experienced partial or complete resolution one month after therapy. Subsequently, 28 patients were enrolled in a randomized, double-blind, placebo-controlled clinical trial in which patients whose effusion failed to clear were crossed over to the alternative regimen. In this trial, ten treated children (71%) experienced partial or complete resolution one month after therapy compared with three (21%) in the control group. Patients enrolled in both trials whose effusion cleared were followed up monthly for six months. Seven of 29 patients required referral for ventilation tubes.

An XAD-2 resin method for efficient extraction of mutagens from fried ground beef.

4 methods of extraction of mutagens from fried ground beef were compared for total mutagen recovery and chromatographic profile of isolated substances. A method which employs Amberlite XAD-2 resin to isolate mutagenic activity from an initial aqueous acid extract of fried beef was found to yield approx. 4 times more activity than other aqueous or organic solvent extraction procedures. Chromatographic profiles of mutagenic extracts isolated by the 4 methods suggest that the XAD-2 resin method does not recover different mutagens, but is primarily a more efficient isolation procedure. The resin method is rapid, inexpensive, simple, and requires approx. half the time of the other methods.