Is postoperative cystography necessary after ureteral reimplantation?

OBJECTIVES: To evaluate the patients in our practice to determine whether postoperative cystography was useful in monitoring the outcome after ureteroneocystostomy. Surgical repair of vesicoureteral reflux is the treatment of choice after medical therapy failure. Radiographic evaluation by ultrasonography or voiding cystourethrography (VCUG) is commonly used postoperatively to evaluate for urinary tract obstruction or persistent reflux. However, imaging modalities are not without cost, both in monetary terms and in terms of radiation exposure and trauma to the child. METHODS: We reviewed the records of all patients who underwent ureteroneocystostomy without ureteral tapering at our institution between January 1, 1996 and December 31, 1999 for primary vesicoureteral reflux. These records were evaluated with respect to the type of surgical procedure, preoperative and postoperative clinical course, and radiographic studies performed. RESULTS: We performed reimplantation on 267 renal units in 153 patients. The surgical technique was the Cohen cross-trigonal in 120 renal units (45%), Glenn-Anderson ureteral advancement in 92 (35%), and modified Leadbetter-Politano ureteral advancement in 55 (20%). All patients underwent imaging with ultrasonography within 6 weeks of surgery. The follow-up ranged from 4 to 42 months (average 14.2). Between 3 and 8 months postoperatively, 61 patients underwent imaging with VCUG. We identified persistent reflux in six renal units. Four of six had marked improvement in their reflux. All the patients with persistent reflux were asymptomatic, including 2 patients who were no longer receiving antibiotics. Four patients developed febrile urinary tract infections postoperatively. Three of the four underwent imaging with VCUG after treatment; all three had no evidence of reflux. CONCLUSIONS: In our population, the addition of VCUG to the postoperative evaluation did not allow us to identify those patients at risk of febrile urinary tract infections. Patients in whom persistent reflux was identified were all asymptomatic. We continue to monitor patients with ultrasonography, but believe that VCUG often provides little benefit to these children.

Small intestinal submucosa as a urethral coverage layer.

PURPOSE: Urethrocutaneous fistula is the most common complication of hypospadias surgery. Numerous techniques have been used to decrease the incidence of this complication and the use of biocompatible materials in surgery has expanded the options in difficult situations. We hypothesized that porcine small intestinal submucosa may be used as a coverage layer after urethral surgery. We evaluated the histological changes associated with small intestinal submucosa when used as a coverage layer over the urethra in a rabbit model. METHODS AND METHODS: We performed urethral surgery in 16 New Zealand White rabbits divided into 4 animals each in groups 1-sham operation with penile degloving only, 2-penile degloving and small intestinal submucosa patch placement, 3-urethrotomy without a patch and 4-urethrotomy with a small intestinal submucosa patch. The graft edges were marked with permanent suture at surgery for later identification. All rabbits were maintained for 6 weeks before sacrifice. The urethra of each animal was then serially sectioned and examined histologically. RESULTS: Histological examination of animals with an small intestinal submucosa patch revealed a foreign body tissue reaction with an infiltrate of histiocytes, giant cells and lymphocytes in the area of graft placement. There was no histological evidence of remaining small intestinal submucosa patch in any sections. The urethral mucosa healed normally in all cases in which it was disrupted. There was no evidence of acute or chronic inflammation in any group 1 or 2 nonsmall intestinal submucosa animals and none in the animals with a small intestinal submucosa graft in areas other than the former graft site. There were also no urethrocutaneous fistulas in any of the 8 rabbits that underwent urethrotomy. CONCLUSIONS: Small intestine submucosa provides an adequate coverage layer in the rabbit penis after urethrotomy. Histologically the foreign material did not alter normal healing of the urethral mucosa, although it did appear to cause an infiltration of histiocytes, giant cells and lymphocytes. Small intestinal submucosa has previously been studied as a scaffold on which tissue may be remodeled or may regenerate. Our study shows that small intestinal submucosa did not interfere with normal tissue healing in this animal model. When used as a urethral coverage layer, it appears to provide extra tissue between the urethra and skin. Small intestinal submucosa may potentially decrease the incidence of urethrocutaneous fistula after urethral surgery.

Ratio of free-to-total prostate specific antigen correlates with tumor volume in patients with increased prostate specific antigen.

PURPOSE: We evaluated the relationship between the ratio of free-to-total prostate specific antigen (PSA) and prostate pathology, including grade, stage and tumor volume, among patients with prostate cancer who underwent radical prostatectomy. MATERIALS AND METHODS: We prospectively analyzed 54 consecutive patients with prostate cancer who underwent radical prostatectomy and in whom frozen serum was available for assessment of free-to-total PSA ratio. Pathological review was done with whole mount sections, and total tumor volume was determined by planimetry. Comparison between free-to-total PSA ratio and pathological parameters was performed using the Pearson correlation coefficient. RESULTS: Among the 54 patients mean total and free-to-total PSA ratio were 5.81 and 14.2 ng./ml., respectively, and free-to-total PSA ratio directly correlated with prostate volume (p = 0.037), and inversely correlated with Gleason score (p = 0.012) and extracapsular disease (p = 0.0074). Furthermore, there was a significant relationship between free-to-total PSA ratio and pathological stage pT2a/b in 39 cases versus pT3a/b in 15 (p = 0.005). Overall, there was no correlation between free-to-total PSA ratio and tumor volume. However, among 37 patients with an increased PSA, defined as greater than 4.0 ng./ml., a significant inverse relationship between free-to-total PSA ratio and tumor volume was identified (p = 0.01). Among this subset there was only a weak correlation with prostate volume (p = 0.049). CONCLUSIONS: Our findings suggest that free-to-total PSA ratio may be predictive of tumor biology among those patients with a total PSA of greater than 4 ng./ml. as evidenced by good correlation with tumor grade and volume. This finding appears to be independent of prostate volume. These preliminary results suggest the need for additional studies among patients with an increased PSA designed to evaluate the potential role of free-to-total PSA ratio in combination with traditional clinical variables in the prediction of prostate cancer pathology.

Prediction of tumour volume and pathological stage in radical prostatectomy specimens is not improved by taking more prostate needle-biopsy cores.

OBJECTIVE: To determine what, if any, additional prognostic information is available from the prostate needle biopsy by comparing the number of biopsy cores obtained with the pathology assessed from the radical retropubic prostatectomy (RRP) specimen. PATIENTS AND METHODS: The results from 135 consecutive patients who underwent RRP at a single institution were reviewed. Needle biopsy information (number of cores, percentage of positive cores, laterality of the positive cores, and Gleason sum) were compared with the pathological data of the RRP specimen, including stage, Gleason sum and tumour volume. Patients were further stratified into those with six or fewer cores (96 men) or more than six cores (39 men). Clinical data, including biopsy information and pathological findings, were compared using univariate and multivariate models. RESULTS: Overall, univariate analysis showed that the total prostate-specific antigen (PSA) level, number of positive cores, bilateral positive cores and percentage of positive cores were directly correlated with tumour volume (P=0.01). Also, PSA and percentage of positive cores were directly correlated with extracapsular extension (P=0.008 and P=0.01, respectively). In the multivariate model, the most important independent predictors of RRP tumour volume and pathological stage were the preoperative PSA level and percentage of cancer in the biopsy (P<0.01). There was no significant relationship between the number of cores obtained and the predicted pathology of the RRP specimen. There were no differences in the number of positive cores, bilateral positive cores or percentage tumour in the cores between men with more or less than six biopsies. In men with more than six core biopsies, there was no significant increase in prognostic information for tumour volume and extracapsular extension, or a correlation between the Gleason sum on biopsy and the RRP specimen. Taking more than six biopsies did not result in a significantly greater detection of potentially indolent tumours (defined as a tumour volume of <0.5 mL). CONCLUSIONS: While taking more prostate needle biopsy cores seems to improve the detection of prostate cancer, there appears to be no major improvement in prognostic information over that gained from traditional sextant biopsies. Furthermore, the results suggest that the percentage of positive cores is the best predictor of both pathological stage and tumour volume, from among the information readily available from prostate needle biopsy. Given the variability in the number of cores obtained for diagnosis in clinical practice, these results add credence to the use of the percentage of positive cores in the biopsy set, with known predictors such as PSA and Gleason score, into future models that attempt to predict tumour biology.

[Zoonoses control--new challenges in health protection of consumers]. / Zoonosenbekämpfung--Neue Herausforderungen beim gesundheitlichen Verbraucherschutz.

The eradication of bovine tuberculosis and brucellosis of domestic stock in Germany through the combined efforts of veterinary medicine, the agricultural section and the state was an historic achievement. Since the two diseases are zoonoses, their successful control can also be seen as a valuable contribution to public health. Both these zoonoses are classic animal diseases presenting themselves as clinical entities complete with gross pathological lesions. In contrast, today we are confronted with pathogens causing zoonoses characterised by latent, i.e. clinically inapparent herd infections that do not result in visible tissue changes. Nevertheless, through contaminated foodstuffs, these pathogens contribute to food-borne infections leading to the outbreak of genuine zoonoses in humans. It has been estimated that there could be as many as two million cases of food-borne infections annually in Germany. Among them are salmonellosis, campylobacteriosis, yersiniosis, infections with verotoxin producing E. coli, listeriosis and toxoplasmosis. While the national animal disease legislation only foresees the control of notifiable diseases, the basis for zoonoses control is laid down in the EU Zoonosis-Directive, which is presently awaiting its transposition into national law and into practice. In order, for instance, to combat the most important Salmonella infections of humans, Integrated Quality Systems (IQS) have been formulated as a means of implementing the proven HACCP concept in animal production units and ensuring animal health from the point of view of consumer protection. The aim of all measures must be to free infected herds of pathogens, to investigate and eliminate all sources with a potential for further pathogen introductions, to maintain pathogen-free herds--with a reduced pathogen challenge in mid-term time periods--, as well as to develop diagnostics capable of identifying pathogen carriers before slaughter. For the disinfection of stock, it is important to have epidemiological data collecting systems and information systems that allow complete diagnostic tracing from herd to slaughterhouse and vice versa. All sides, including research and surveillance, as well as producers are called upon to actively share in protecting the health of consumers as far as it is threatened by latent infections in domestic stock.

Treatment of elderly women with urge incontinence in middle tennessee: a single institution practice-based study.

INTRODUCTION AND OBJECTIVES: Urinary urge incontinence (UUI) is a major factor in reducing quality of life in elderly women. The treatment of UUI in the elderly population is complicated by comorbidities, polypharmacy, cost, and side effects. The purpose of this study was to examine our practice pattern in Middle Tennessee for the treatment of elderly women with UUI. METHODS: We retrospectively reviewed the medical records of all women over age 65 seen at our institution between January 1, 1998 and September 1, 1999 with an initial complaint of pure UUI. Diagnosis was based on history and physical examination by a single urologist (JJF). Initial treatment in all patients was medication as well as timed and double voids. Medication chosen was based on cost factors, co-morbidities, current medications, and outcome from previous treatment. RESULTS: Of 53 women ranging in age from 65-87 years of age (avg. 74.7) included in this study, 6/53 (11.3%) had a previous CVA, and 2/53 (3.7%) had grade I-II cystoceles. Initial pharmacologic treatment included anticholinergic medication in 47 patients (88.6%), and either imipramine or topical estrogen alone in the remaining 11.4%. Of the anticholinergics, hyoscyamine time capsules were used in 29, tolterodine in 7, standard oxybutynin in 5, oxybutynin XL in 1, and a combination with imipramine in 5. Thirty-four of the 53 total patients (64.1%) discontinued their medications because of no improvement 14 (41.1%), dry mouth 9 (26.4%), other side effects 9 (26.4%), cost 1, and other reasons in the remaining 2 patients. Only 17 patients (32%) stated they were doing well on their initial medications; 11 of those (64.7%) were taking hyoscyamine time capsules. Upon subjective failure, 22/36 patients (61.1%) had their medications changed, while 14/36 (38.8%) pursued behavioral therapy without additional medications. Urodynamic studies were done in 12 patients who failed empiric medical treatment (22.6%). CONCLUSIONS: Only 32% of elderly women treated medically for UUI were satisfied and continued therapy in this patient population. One-fourth of elderly women failed empiric medical management of UUI due to lack of efficacy, and one-third due to intolerable side effects. In this practice, hyoscyamine was continued more often than any other anticholinergic because of reasonable cost, efficacy, and side effect profile.

Influence of local treatment on the recurrence rate of ductal carcinoma in situ.

BACKGROUND: Screening mammography has resulted in a significant increase in the diagnosis of ductal carcinoma in situ (DCIS). The role of breast conservation therapy and the long-term recurrence rate are still controversial. This article compares mastectomy, wide excision alone, and wide excision with radiation as treatments for DCIS. STUDY DESIGN: One hundred twenty-four cases of DCIS were retrospectively reviewed and were found to be pure DCIS by a senior pathologist. The mean age at diagnosis was 60 years (range, 33 to 81). Originally, 101 patients (81 percent) presented with calcification on mammogram, and 23 (19 percent) presented with a palpable mass. Histologic data showed that 54 (44 percent) had noncomedo type lesions, 46 (37 percent) had comedo type, and 24 (19 percent) had unknown type DCIS. RESULTS: Four of the 124 patients had a recurrence during a mean follow-up period of 43 months. Recurrence is defined as any development of DCIS or invasive carcinoma in the ipsilateral breast. There was one (1.3 percent) recurrence in the 75 patients treated with mastectomy (an adenocarcinoma of the chest wall), which occurred at 59 months. Treatment was 5,750 cGy to the chest wall and the patient is free of disease 37 months postradiation. There were three (11 percent) recurrences at 14, 21, and 29 months, respectively, in the 28 patients treated with wide excision alone. All three recurrences were found by calcifications on mammogram and all patients had comedo type original lesions. Two recurrences were pure DCIS of the breast. Both patients were treated with mastectomy and are free of disease at 33 and five months, respectively. The third recurrence was an invasive colloid carcinoma of the breast. Treatment was a modified radical mastectomy; the patient is free of disease after 62 months. There were no recurrences in the 21 patients who were treated with wide excision and radiation. Average total dose of radiation was 5,835 cGy (range, 4,500 to 6,480). CONCLUSIONS: The results of this study indicate that both mastectomy and wide excision with radiation are associated with very low recurrence rates. Wide excision alone is associated with a higher recurrence rate. However, all recurrences were detected mammographically and all lesions were salvaged by mastectomy. Therefore, the ultimate local control and survival rates were similar for all three modalities.

Measurement of the components in meat patties by near infrared reflectance spectroscopy.

Near infrared calibrations have been derived and used routinely in the measurement of fat, moisture, protein, collagen free protein and starch in meat patties. The lower standard error of prediction (SEP) values for moisture, protein, fat and starch content determination were recorded with the first derivative calibration than with those of the second derivative treatment. The prediction for the moisture and protein content determinations with first derivative transforms were satisfactory, the correlation coefficients (r) being 0.99 and 0.98, respectively. Determining the fat content with both first and second derivative data showed excellent results, r amounting to more than 0.99. The result obtained for the starch and collagen free protein (CFP) content determination with the first derivative calibration, as well as with the second derivative treatment, showed a deviation from the chemical data and r was less than 0.97 in both cases. It is recommended that a sample preparation, such as demoisturizing or defatting, is needed to get a high correspondence with reference methods for starch and hydroxyproline determination in meat patties.

[Animal health, food quality and consumer protection as a unit--introduction to a topic]. / Tiergesundheit, Lebensmittelqualität und Verbraucherschutz als Einheit--Einführung in die Thematik.

As a consequence of widely spread latent infections, animal health and the necessary examination of livestock have become an indispensable level of quality assurance. While so far, legislation in epizootics did not provide for a control of latent infections with an inapparent clinical course, the EC Directive on Zoonoses which has come into force in 1993 requires such an approach for the first time. As a consequence of the further increase in the number of cases of acute gastroenteritis caused by bacteria of the genus Salmonella, veterinary medicine and agriculture have been compelled to join forces and institute control measures aimed at rendering stocks most of which are maintained under conditions of intensive keeping free from defined agents of zoonotic diseases. This approached requires four levels of action, i. e. a suitable diagnosis, a creation of healthy stocks, the use of suitable immunoprophylactic methods and a safeguarding of the hygienic status achieved. With the aid of methods of genetic engineering, several research groups try to create the necessary conditions for doing so. They take account of the established knowledge that the necessary consumer protection cannot be afforded any longer because the performance of ante-mortem and post-mortem examination of meat animals is a limited one, unless three limits of quality assurance are adopted, i. e. examination at the farm of origin, ante-mortem and post-mortem examination of meat animals and control of food establishments and foods.

[Salmonellae and consumer health protection]. / Salmonellen und gesundheitlicher Verbraucherschutz.

To a major extent, the dramatic increase of food-transmitted infections caused by Salmonella is due to latent Salmonella infections in animal stocks. At the moment, a uniform clone of the phage type 4 of Salmonella enteritidis is mainly responsible. It causes illness through eggs or egg-containing food. Control of salmonellosis is made more difficult by the fact that, apart from affecting animal stocks, it has now contaminated the environment including feed stuffs. In addition, secondary contamination, occurring during both food production and processing, is a constant threat to public health. The most important aim must be the creation of Salmonella-free animal stocks by carrying out regular hygiene control and vaccination programmes and implementing immune-prophylactic measures. Because of the EC Zoonoses Guideline, redevelopment efforts will have to concentrate in the first place on poultry stocks. It is expected from the EC Egg Regulation, in force since May 1993, that it will drastically diminish the risk of infection from the final product. This paper discusses the most recent registration statistics and inspection results regarding food, animal stocks, faeces, sewage, feedstuff and soil samples. Furthermore, epidemiological facts as well as ways and causes of infection are described. Finally, the author gives recommendations for the fight against salmonellosis.

Notes on technical progress in veterinary public health.

Scientific and technical progress in the field of veterinary public health (VPH) over the last one hundred years has contributed to the protection of consumer health and the environment. This report presents examples of the success achieved in the control of epizootics of tuberculosis, brucellosis, rabies and trichinellosis, which are also zoonotic diseases. The discussion also considers hygiene measures in relation to Listeria in food as well as certain challenges resulting from the spread of latent infections among farm animals. The increasing incidence of Salmonella infections among humans is also considered. Other important VPH tasks include the control of chemical residues of varying origin and of toxic biological substances in foods. Examples are also presented of measures taken and problems which arise in connexion with ensuring that meat is produced under hygienic conditions (meat inspection). The principles involved in efficient controls of establishments and products are outlined. Technical progress in consumer protection is exemplified by the processes of pasteurisation, cooling and freezing, and the limitation of additives. Other important tasks arise in the disposal of animal carcasses and wastes, and in the fields of animal welfare and genetic engineering. Future activities in VPH will depend upon proper education, onward and postgraduate training for veterinarians, and suitable infrastructures for research, examination and surveillance.

[Nutrition and consumer health protection]. / Ernährung und gesundheitlicher Verbraucherschutz.

Most individuals in our population consume healthy food. The conditions for doing so exist, i.e. an offer of a wealth of foods in the market. Yet there is still a need for joint action by science and research, food industry and government. When looking more closely, it will be seen that there are gaps in the health protection of the consumer: Wrong nutrition and overfeeding must be controlled by improved education. By doing so, it should be possible, at the same time to reduce the incidence of food-associated diseases such as cardiovascular diseases, cancer and metabolic disorders. While in this field of the protection of consumer health, so-called "visible" shortcomings of food intake are involved which can be influenced by nutritional medicine and the consumer, there are "hidden" ones if a contamination by infectious agents such as Salmonella bacteria or by chemical residues of e.g. heavy metals, pesticides, or additives is involved. This means that the consumer is unable to protect him/herself against the latter by his/her own means. For this reason, a particular responsibility has arisen for governmental authorities, to ward off risks arising from hidden shortcomings of food. A particular urgency has been found to exist for measures to eliminate pathogenic microorganisms from the food chain. Still, Salmonella bacteria are the most prominent target. There is a ratio of ca. 2/1 between salmonellosis and other forms of acute gastroenteric infections which are reportable under the Federal Communicable Diseases Act. On the whole, bacterial food poisoning is still on the rise, thus becoming the main problem of present-day control of communicable diseases. We should not be deceived by numerous improvements of technological and hygienic processes in the production of foods: in a long-term view, relief can be expected only from the creation of livestock which is free from infectious agents. Although a further reduction of chemical residues in certain foods has been achieved, it will remain a permanent task for government institutions to ensure that stipulated maximal amounts of foreign substances are not reached on a permanent basis and that, wherever possible, undesirable chemical residues are removed from the food chain. Cases of acute intoxication from chemical residues have remained single events. Nevertheless, there is a deficit of knowledge what concerns the toxicological and health evaluation of minimal levels of 1 microgram and less to which consumers have been exposed over years.(ABSTRACT TRUNCATED AT 400 WORDS)

The future role of the veterinarian in the control of zoonoses.

Developments in the rearing and the health status of meat animals is presented. Attention is drawn to the increase in latent infections, most of which are zoonotic diseases. Such infections escape official ante-mortem and post-mortem inspection as it is presently conducted in industrialised countries, which still rely on the classical rules established by Robert von Ostertag. This examination is thus in need of reform. Proposals submitted to the EEC Commission consist of a stepwise inclusion of the major herds of meat animals in systematic health control aimed at effective control of zoonoses and thus improved consumer protection. It is thus expected that the importance of meat inspection on the basis of pathological-anatomical changes will decrease the importance of establishing the health status during the animal's lifetime will increase. Nevertheless, there will be no complete substitution of classical meat inspection because there are numerous changes in the meat specific to the individual animal which can be detected only by meat inspection, and must be detected if the concept of consumer protection is properly applied. The reform of meat inspection which has become necessary will entail a variety of new tasks for research.

[Infection prevention in animal husbandry. A contribution to the improvement of the sanitary consumer protection]. / Infektionsprophylaxe in der Nutztierhaltung Ein Beitrag zur Verbesserung des gesundheitlichen Verbraucherschutzes.

The scientific and organizational development of an effective prophylaxis against infections in animal husbandry results from the fact that many zoonoses, like salmonellosis, campylobacteriosis, toxoplasmosis, leptospirosis, listeriosis, rickettsiosis (Q-Fever) and cysticercosis as well as certain important virus infections with regard to meat hygiene cannot be detected during official ante- and postmortem inspection. The cause of these infections is clinically inapparent and leaves no pathologic-anatomical lesions. Partly responsible for these latent infections is mass production with its specific forms of husbandry, particularly in poultry and pigs. The development of these animal production methods as well as the spread of the aforementioned zoonoses in man and animal is being discussed in this paper. The information on zoonoses is based on cases reported in accordance with the Federal Communicable Diseases Act and/or the regulations on notifiable animal diseases. The potential harmfulness to the consumer's health, especially in view of his food habits, is discussed in the light of the increase of foodborne infections and intoxications caused by Salmonella. Up until now, several regulations exist to keep causative agents of zoonoses away from animal farms. In view of the successful eradication of tuberculosis in cattle and brucellosis, it is recommended on a longterm basis, to eliminate those zoonoses from animal farms, which are of special importance from the meat-hygienic point of view. On a medium-term basis, examination of farm animals should be introduced voluntarily prior to the official ante- and postmortem inspection. It is of vital importance to establish the necessary diagnostic and practical conditions for the herd-tests. A recommendation worked out by the European Community for the examination of broiler-farms is welcomed as an example of prophylactic measures suitable for the improvement of consumer protection.