Interobserver delineation variation in lung tumour stereotactic body radiotherapy.

OBJECTIVES: In radiotherapy, delineation uncertainties are important as they contribute to systematic errors and can lead to geographical miss of the target. For margin computation, standard deviations (SDs) of all uncertainties must be included as SDs. The aim of this study was to quantify the interobserver delineation variation for stereotactic body radiotherapy (SBRT) of peripheral lung tumours using a cross-sectional study design. METHODS: 22 consecutive patients with 26 tumours were included. Positron emission tomography/CT scans were acquired for planning of SBRT. Three oncologists and three radiologists independently delineated the gross tumour volume. The interobserver variation was calculated as a mean of multiple SDs of distances to a reference contour, and calculated for the transversal plane (SD(trans)) and craniocaudal (CC) direction (SD(cc)) separately. Concordance indexes and volume deviations were also calculated. RESULTS: Median tumour volume was 13.0 cm(3), ranging from 0.3 to 60.4 cm(3). The mean SD(trans) was 0.15 cm (SD 0.08 cm) and the overall mean SD(cc) was 0.26 cm (SD 0.15 cm). Tumours with pleural contact had a significantly larger SD(trans) than tumours surrounded by lung tissue. CONCLUSIONS: The interobserver delineation variation was very small in this systematic cross-sectional analysis, although significantly larger in the CC direction than in the transversal plane, stressing that anisotropic margins should be applied. This study is the first to make a systematic cross-sectional analysis of delineation variation for peripheral lung tumours referred for SBRT, establishing the evidence that interobserver variation is very small for these tumours.

Should measurement of maximum urinary flow rate and residual urine volume be a part of a "minimal care" assessment programme in female incontinence?

OBJECTIVE: The aim of this study was to evaluate the value of routine measurements of urinary flow rate and residual urine volume as a part of a "minimal care" assessment programme for women with urinary incontinence in detecting clinical significant bladder emptying problems. MATERIAL AND METHODS: Four hundred and eight women were examined and treated in an open-access, interdisciplinary incontinence clinic. A standardized programme for investigation and primarily non-surgical treatment of incontinence was applied. RESULTS: Of the 408 women 43% reported subjectively incomplete bladder emptying. Twenty-six per cent had a maximum flow rate less than 15 ml/s, but only 4% at a voided volume > or =200 ml. Residual urine more than 149 ml was found in 6%. Two women had chronic retention with overflow incontinence. Both had typical symptoms with continuous leakage, stranguria and chronic cystitis. Another woman had an urethral stricture with massive bladder emptying symptoms. In the remaining 172 women with symptoms suggesting bladder emptying problems, all but 3 were managed by triple voiding and timed micturition. In these 3 patients, who also had chronic cystitis, the treatment was supplemented with clean intermittent self-catheterization. CONCLUSION: The few women (6 (1.5%)) in whom measurements of urinary flow rate and residual urine volume had a clinical therapeutic consequence, cannot justify these measurements to be routine in a "minimal care" programme for assessment of primary, uncomplicated female urinary incontinence. Thus, primary health care providers can assess women based on simple guidelines without expensive equipment for assessment of urine flow rate and residual urine.

Acute endogenous endophthalmitis due to Bartonella henselae.

A 45-year-old man presented with progressively worsening vitreitis of 1 week's duration. Treatment for cat-scratch disease 3 years prior to presentation and persistent vitreitis led to vitrectomy, and analysis of the vitrectomy specimen revealed inflammatory cells and necrotic debris; polymerase-chain-reaction analysis of the vitreous fluid sample, done by use of a novel heminested protocol, demonstrated the presence of Bartonella henselae DNA. Treatment with doxycycline led to improvement in the intraocular inflammation but resulted in a poor visual outcome.

Effect of vaginal devices on bladder neck mobility in stress incontinent women.

OBJECTIVE: To evaluate how vaginal continence products affect the bladder neck mobility and ability to contract the pelvic floor muscles. MATERIAL AND METHODS: Fifteen stress incontinent women with leakage >8 g/24 hours were assessed by a questionnaire, 24 hours pad test and vaginal ultrasonography of bladder neck position and mobility. The patients were examined without any device, with a commercially available device (Conveen Continence Guard, CCG, Coloplast A/S) and two new shaped test models (TM I/II). Bladder neck position was measured in relation to the midline of the pubic symphysis at rest, Valsalva and squeezing. RESULTS: About two-thirds of the women became subjectively continent with the device. The mean leakage per 24 hours was reduced 87% (61-96%) with a vaginal device. No difference was found between the effect of old and new product. Evaluated by ultrasonography, the devices worked by supporting the bladder neck and reduced the mobility from 34 degrees to 18 degrees with CCG and to 15 degrees with TM. Neither CCG nor TM had any adverse effect on the ability to elevate the bladder neck during squeezing. CONCLUSIONS: Vaginal devices are effective in alleviating stress incontinence and work by supporting a hypermobile bladder neck. The devices had no negative effect on the ability to contract the pelvic floor muscles. Ultrasonography is a fast and low invasive method to study effect of vaginal devices both in the individual patient and for testing new products.

Pro et contra pelvic floor exercises for female stress urinary incontinence.

Pelvic floor exercises are now established as a first line treatment for female urinary stress incontinence. This treatment modality can give substantial improvement in many patients. However, the incontinence is often not completely cured and the treatment requires a long term effort by the patient, which many are unable or unwilling to make. This paper discusses the pros and cons of pelvic floor exercises for stress incontinence and offers some guidelines for the selection of patients while emphasizing the importance of guided, intensive exercises and motivation to achieve the treatment goal.

Evaluation of a simple, non-surgical concept for management of urinary incontinence (minimal care) in an open-access, interdisciplinary incontinence clinic.

Our objective was to evaluate a new concept for assessment and treatment of urinary incontinence in an open-access, interdisciplinary incontinence clinic. A standardized program for investigation and treatment of incontinence was based on minimal relevant investigations, primarily non-surgical treatment with a limited consumption of resources ("minimal care"). This was a prospective observational study of 408 consecutive women examined and treated in the clinic. The main characteristics of the women were a high median age and a high prevalence of severe concomitant diseases with possible influence on lower urinary tract function. More than half of the patients had urge or mixed incontinence. Most of the patients were managed with conservative treatment. Fifteen percent were referred to in-hospital treatment, with 5% to incontinence surgery. In total 44% felt cured or very much improved. Before and after treatment one third of the women completed quality-of-life questions and voiding charts, while 43% completed the pad tests. Quality of life improved significantly. Objectively leakage on pad test and voiding charts was significantly improved. The patients were in general very satisfied with clinic's program. Almost one fourth of the women were followed up for 6 months after discharge. No significant deterioration in the subjective results were found compared to status at discharge. In conclusion, the results highlight the need for advice and treatment of patients with incontinence. The minimal care program and interdisciplinary structure in the incontinence clinic offer effective and low cost treatment for urinary incontinence. The open-access, interdisciplinary incontinence clinic model is recommended. Neurourol. Urodynam. 18:9-17, 2000.

Anal incontinence after obstetric third- /fourth-degree laceration. One-year follow-up after pelvic floor exercises.

The study was a 1-year follow-up of 48 women with obstetric third- /fourth-degree perineal laceration. After primary surgical repair the symptomatic patients were treated with pelvic floor exercises with or without transanal electrical stimulation. Various methods for assessing anal sphincter function were also evaluated. One month postpartum 10 women (21%) complained of anal incontinence, 8 for flatus only; 1 patient was reoperated on. After 1 year none complained of fecal incontinence, and 3 (7%) complained of flatus incontinence. We found relatively few women with anal incontinence after third- /fourth-degree laceration. The pelvic floor training program was effective, but electrical stimulation was abandoned because of anal pain. Grade IIIb lesion, dilution of the sphincter at anal ultrasonography, and sphincter weakness at palpation were significantly related to symptoms of anal incontinence. For routine follow-up after third- /fourth-degree laceration, palpation of the anal sphincter and pelvic floor seems sufficient as first-line assessment.

Follow-up after repair of vaginal vault prolapse with abdominal colposacropexy.

BACKGROUND: Vaginal vault prolapse after hysterectomy is a rare complication, with a prevalence of less than 1/2%. The vaginal depth an axis can be restored by colposacropexy with preservation of coital function. The aim of this follow-up study was to assess the results of colposacropexy with special attention to recurrence of prolapse and urogenital symptoms. METHODS: During a 4-year period 35 patients with vault prolapse were operated by colposacropexy. At follow-up the patients were interviewed about bladder, bowel and sexual symptoms. A pelvic examination and measurement of residual urine was done. Perioperative complications and any interim surgery was recorded. RESULTS: The patients were multioperated, because of prolapse or incontinence prior to colposacropexy. No serious perioperative complications were seen, except one case of severe bleeding from the presacral veins. Subjectively, 82% were cured of prolapse symptoms, one had recurrent vault prolapse and was reoperated, four had rectocele. Five patients developed urge incontinence, while urge incontinence, frequency, nocturia and voiding problems were cured in 75%, 80%, 50% and 100%, respectively. One patient developed fecal incontinence. No patients had coital problems due to the colposacropexy. Three patients were reoperated because of intestinal obstruction. CONCLUSION: Colposacropexy has a cure rate of vault prolapse of 97% (85 100%) and a positive effect on irritative bladder symptoms.

Techniques for imaging bladder support.

BACKGROUND: Imaging techniques of bladder support can be of diagnostic value to differ causes of urinary incontinence like misbuilding of the lower urinary tract, hypermobility of the bladderneck and urethral wall pathology, which is valuable prior to surgery for incontinence. METHOD: Literature about imaging techniques, especially, voiding cystourethrography, ultrasonography and MRI were studied and their diagnostic value evaluated. CONCLUSION: Dynamic ultrasonography is the first line imaging method for studying bladder support. Bladderneck hypermobility, as a sign of defect in the adjunctive closure forces is better correlated to stress incontinence than bladder morfology, diagnosed during static cystography. Voiding cystography has its place in diagnosing misbuildings of the lower urinary tract. MRI is just at the beginning of its clinical era, and seems relevant for studies of urethral pathology.

[The open, interdisciplinary incontinence clinic at Hvidovre Hospital. Preliminary experiences from the first 16 months]. / Den åbne, tvaerfaglige inkontinensklinik på Hvidovre Hospital. Praeliminaere erfaringer fra de første 16 måneder.

A "minimal care" program for examination and treatment of urinary incontinence in an open access incontinence clinic was assessed. The first 300 women and 27 men consecutively investigated in the clinic are described. A reference program based on minimal relevant work-up and non-operative treatment as first line with use of minimal resources was followed. Of 171 evaluated women, 100 received non-operative treatment besides general advice on voiding/toilet pattern and appropriate incontinence appliances. Subjectively 69% felt cured or very much improved, 25% experienced improvement while 6% did not report benefit of the treatment. Objectively, diminished leakage was demonstrated by pad-weighing test. Similar results were found in the treated men. Our preliminary results demonstrate, that an open access, interdisciplinary clinic is patient-accepted and effective for the evaluation and treatment of urinary incontinence.

Comparison of three commercially available enzyme immunoassays for the screening of autoantibodies to extractable nuclear antigens.

The initial screening test used in the diagnosis of connective tissue diseases is based on the detection of antinuclear antibodies (ANA) by indirect immunofluorescence (IFA). When the ANA screen is positive, it is often useful to determine the specificity of the autoantibody to a series of extractable nuclear antigens (ENA), a procedure that has been classically performed by double immunodiffusion. Testing large numbers of clinical specimens for autoantibodies to ENA by double diffusion techniques can be time-consuming and expensive. ENA screening systems that employ enzyme immunoassay (EIA) technology have recently become commercially available. We compared three EIA ENA assays to classic Ouchterlony double diffusion techniques. Furthermore, the sensitivity of each antigen and methodology (including ANA immunofluorescence using HEp-2 cells) was tested using ENA positive sera possessing single autoantibodies. Two of the three EIAs that detected immunoglobulin G type autoantibodies to Smith (Sm), ribonucleoprotein (RNP), Sjögren's syndrome-associated antigens Ro (SSA) and La (SSB), were provided by INOVA and Sigma Diagnostics. A third EIA, which also included scleroderma-associated antigen 70 (SCL-70/DNA-topoisomerase I) and histidyl-tRNA synthetase (Jo-1) in addition to the four previously stated antigens, was provided by Clark Laboratories. This latter ENA screen detected IgG, IgA, and IgM type autoantibodies. Included in the study were sera covering a wide variety of anti-nuclear and other autoantibodies. Sensitivity was 100% for all EIA ENA screens when compared to Ouchterlony double diffusion and specificity exceeded 95% in each case. Sensitivity studies showed Ouchterlony to be less sensitive than EIA when detecting low levels of autoantibodies to ENA.(ABSTRACT TRUNCATED AT 250 WORDS)

Bladder neck anatomy and mobility: effect of vaginal ultrasound probe.

OBJECTIVE: To evaluate the effect of a vaginal ultrasound probe on bladder neck anatomy and mobility. PATIENTS AND METHODS: Twenty women, 15 with urinary incontinence and five with other urological complaints, were studied. Colpocysto-urethrography (CCU) during rest. Valsalva and withholding manoeuvres were compared with and without simultaneous vaginal endosonography. The CCU diagnoses and measurements of bladder neck position and mobility in relation to the symphysis pubis were compared with and without the probe inserted. A small, 7 MHz vaginal probe (Brüel and Kjaer, type 1846) was used with the scanning field 45 degrees to the long axis of the probe. RESULTS: The CCU diagnoses as well as the measurements of bladder neck position and mobility relative to the symphysis pubis were unaffected by the insertion of this probe. CONCLUSION: Vaginal ultrasonography is a minimally invasive technique; it is convenient for routine, firstline evaluation of bladder neck anatomy and mobility in incontinent women.

Vaginal ultrasonography versus colpo-cysto-urethrography in the evaluation of female urinary incontinence.

To compare the information of bladder neck suspension given by colpo-cysto-urethrography (CCU) and vaginal ultra-sonography (US), 44 women with various grades of incontinence were examined by both methods. The criteria for evaluation of incontinence for each method were applied on both procedures. CCU-diagnoses of type of bladder neck descent were compared as well as US-measurements of bladder neck position and mobility in relation to the symphysis pubis during rest, Valsalva and withholding. The interobserver agreement of diagnosis was 58%, which is comparable to interobserver agreement for CCU. The measurements of bladder neck suspension by bladder to symphysis (BS)-distance and rotation-angle in relation to the symphysis pubis, revealed almost identical results for the two procedures. The US-measurements had a better accuracy than the CCU measurements. Furthermore, hypermobility of the bladder neck was related to grade of incontinence and to diagnoses including anterior suspension defects. Presence of a cysto- or rectocele affected the size of the rotation angles. Patients with a cystocele had a 16 degrees larger rotation angle by both procedures. Presence of a rectocele increased the rotation angle, measured by US, but decreased the angles, measured by CCU. Furthermore, the ability to withhold was decreased, when the patient had a rectocele. Since the same information of bladder neck suspension is provided by the two methods, and since the US-criteria revealed a better accuracy and a good clinical reliability, ultrasonography is recommended for evaluation of bladder neck anatomy--also for practical and economical reasons.

Ultrasonic evaluation of bladder neck position and mobility: the influence of urethral catheter, bladder volume, and body position.

The influence of urethral catheter, bladder volume, and body position on the ultrasonic assessment of bladder neck position and mobility was evaluated in 24 incontinent women. The bladder neck position was described by two independent parameters: BS-distance, from the bladder neck to the lower tip of the symphysis pubis, and the rotation angle between the BS-line and the symphyseal middline. Catheterisation resulted in apposition of the bladder neck towards the symphysis pubis, seen as a significant shortening of the BS-distance in postmenopausal women without estrogen replacement. The rotation angle was unaffected. Increasing the bladder volume to symptomatically full resulted in increased capacity to withhold, since the rotation angle decreased 6.6 degrees. Examination in the sitting position, compared to the supine resulted in bladder neck descent to a "lower level," and the rotation angle increased in average 16 degrees. Bladder neck mobility was unaffected by catheterisation and body position. Vaginal ultrasonic evaluation of bladder neck suspension is recommended to be performed without a catheter, with a comfortably full bladder in a convenient, but standardised examination position.

Twenty-four hour pad weighing test: reproducibility and dependency of activity level and fluid intake.

To evaluate the reproducibility of the 24 hour pad weighing test and the possible influence of fluid intake and level of activity to the test result, 14 women, referred for operation because of urinary incontinence, performed six 24 hour pad tests each under the following conditions: 2 tests on normal daily activity level and on normal fluid intake, 2 tests on high vs. low activity level, and 2 tests on high vs. low fluid intake. The study concludes that the results of the 24 hour pad weighing test are reproducible with moderate variation in fluid intake and activity level. Artificially low fluid intake or extreme variations in activity level could, however, significantly alter the urinary leakage. Small variations in fluid intake and activity level have no effect on the test result.

Inter- and intra-observer variation of colpo-cysto-urethrography diagnoses.

To evaluate the reliability of diagnosing type of bladder suspension defect in incontinent women by means of voiding colpo-cysto-urethrography (CCU), 93 CCU-series with exposures at rest, coughing, withholding and voiding were diagnosed. Three senior and one junior radiologists, a gynecologist and a urologist diagnosed the CCU-series twice with 3-6 months interval. The main diagnostic possibilities were anterior bladder suspension defects, posterior defects and normal, which were in accordance with general practice of choosing an abdominal suspension operation for the anterior suspension defects and a vaginal operation for the posterior defects. The intra-observer agreement varied between 99% and 72%, i.e. 1/5 to 1/4 of the patients changed from one main diagnostic group to another at the two examinations. The inter-observer agreement varied between 43% and 60%. Information of clinical patient data, given to the two clinicians, did not change their CCU-diagnoses significantly. We concluded, that CCU should not be recommended as a routine for evaluation of type of suspension defect since the intra-inter-observer variation was around 25% and 50% respectively. CCU might still be useful preoperatively in selected cases, since it gives an excellent visualisation of bladder base anatomy.

Bladder neck mobility evaluated by vaginal ultrasonography.

Factors involved in monitoring bladder neck mobility were studied by means of vaginal ultrasonography. Thirty-three continent, 28 incontinent and 39 patients who had undergone surgery for incontinence were examined in the supine and sitting positions during rest, the Valsalva manoeuvre and withholding urine. Bladder neck mobility can be described as a semicircular movement with the tip of the symphysis pubis as the centre and a line from the tip to the bladder neck as the radius (BS). Movement can be measured by 2 independent factors: BS distance and size of the angle between the BS line and the midline of the symphysis, at rest, during the Valsalva manoeuvre and withholding urine. The continent controls were characterised by a 90 degrees angle at rest, a long BS (2.4 cm) and a fixed bladder neck. The incontinent patients had a shorter BS (2.1 cm), angles at rest of approximately 100 degrees--the angle increased with the grade of incontinence--and a mobile bladder neck. If 2 of the 3 criteria (angle at rest > or = 95 degrees, BS < or = 2.3 cm and mobility > or = 20 degrees) are regarded as diagnostic of incontinence, diagnostic sensitivity was 84% and specificity 82%. In the surgical group, patients who failed to respond to treatment had a shorter BS, larger angles and greater bladder neck mobility than their successfully treated counterparts.