Self-removal of catheter after robot-assisted radical prostatectomy: a feasibility study

Self-removal of urinary catheter as an option after robot-assisted radical prostatectomy (RARP) has never been explored in literature. We report the feasibility and outcome of the first study of this novel concept in our hospital. We conducted a prospective audit of self-TWOC (trial without catheter) in men who underwent consecutive RARP in our centre between April 2022 and September 2022. Men who had self-TWOC filled a questionnaire about the outcomes of self-TWOC. Carbon footprint and carbon offset for each hospital TWOC avoided were calculated. Of the 129 who underwent self-TWOC, 112 filled the questionnaire and were hence included in the final analysis. Self-TWOC was successful in all the 112 (100%) men in the study. 99.1% of men were satisfied with self-TWOC at home. We managed to avoid 79.6 ± 36.72 km of travel and 77 min of travel time for every self-TWOC. This also saved 85£/patient on clinic expenses and fuel cost savings of 9.87-15.99£ per patient depending on car engine size/type. The carbon footprint calculated was 20 kg CO2 assuming average engine sized diesel/petrol cars and 10 kg CO2 for an average UK petrol hybrid car. The calculated carbon offset per patient for diesel/petrol cars: 0.32£, petrol hybrid: 0.16£. Self-TWOC for 80-160 patients will save the carbon emissions equivalent to that of a passenger on a London-New York Trans-Atlantic flight. Self-TWOC is safe, affordable and is sustainable to the environment. Widespread acceptance of this practice change will be a small, but steady step towards greener health systems across the world.

Functional and oncological outcomes of robot-assisted radical prostatectomy in obese men: a matched-pair analysis

Robot-assisted radical prostatectomy (RARP) in men with body mass index (BMI) ≥ 35 kg/m2 is considered technically challenging. We conducted a retrospective matched-pair analysis to compare the oncological and functional outcomes of RARP in men with BMI ≥ 35 kg/m2. We interrogated our prospectively maintained RARP database and identified 1273 men who underwent RARP from January 2018 till June 2021. Among them, 43 had BMI ≥ 35 kg/m2, and 1230 had BMI < 35 kg/m2. A 1:1 genetic matching was performed between these two groups for PSA, Gleason grades, clinical stage, D'Amico risk stratification, and nerve-spare extent. Continence rates and biochemical rates on 1-year follow-up were analysed. We performed statistical analysis using SPSS, and Paired tests were done using Wilcoxon sign rank-sum test. p < 0.05 was considered statistically significant. The two groups were comparable in almost all parameters except for age. Console time (p = 0.20) and estimated blood loss (p > 0.90) were not significantly different. There was no blood transfusion, open conversion or (Clavien-Dindo grade ≥ 3) intra/postoperative complication in either of the two groups. The two groups did not have any difference in biochemical recurrence rates (BCR) on 1-year follow-up (p > 0.90). Men with BMI ≥ 35 achieved continence rates equivalent to men with BMI < 35 within 1 year. On logistic regression analysis, age (p < 0.001) and extent of nerve sparing (p = 0.026) emerged as significant factors influencing continence recovery. RARP is safe in men with BMI ≥ 35 kg/m2. The 1-year continence and oncological outcomes are similar to matched men with BMI < 35 kg/m2 undergoing RARP.

Are staging bone scans necessary in patients with T3a prostate cancer? A multicentre study

Objective:

Studies reporting increased risk of metastases in T3a disease are based on clinical staging (Digital rectal examination) in the pre-multiparametric–magnetic resonance imaging (MRI) (mp-MRI) era. The aim of our study was to assess the rate of positive bone scans in patients ascribed with T3a prostate cancer on a pre-biopsy mp-MRI.

Methods:

We performed a multicentre, retrospective analysis of all patients with T3a prostate cancer staged by mp-MRI who had a bone scan between January 2017 and April 2020.

Results:

A total of 586 patients were diagnosed with T3a prostate cancer on mp-MRI, with a median age of 71 years (range: 47–87). The median presenting PSA was 11 ng/mL (range: 1–537); 125 patients (21.3%) had a PSA ⩽ 20 and either grade group (GG) 1 or 2 in their prostate biopsy; none of these patients had bone metastases. Eighteen patients (3.1%) were found to have bone metastases: 11 patients had GG ⩾ 3 disease on biopsy and nodal disease, 6 had GG ⩾ 3 without evidence of nodal disease and 1 had a PSA of 103.

Conclusion:

The use of bone scans in patients with T3a prostate cancer staged on mp-MRI but without other evidence of high-risk disease (GG ⩾ 3 and PSA > 20 ng/mL) appears to be unnecessary and could be safely avoided.

Level of evidence:

2b

Female urinary incontinence in sub-Saharan Africa

Urinary incontinence is highly prevalent amongst women around the world. In this review article we explore urinary incontinence, its consequences and treatment in sub-Saharan Africa, providing specific examples from Uganda and Malawi. In sub-Saharan Africa its prevalence is difficult to assess due to the wide variation in reporting consequent upon patients hiding their condition due to the associated stigma in many communities. Whilst much of the literature from low-or low-middle income countries focuses on urinary incontinence from pelvic floor fistula, recent evidence demonstrates that non-fistulous stress, urgency, and mixed urinary incontinence are highly prevalent in sub-Saharan Africa. Incontinence secondary to vesico-vaginal fistula can be related to obstetric causes, mainly obstructed labour. The risk factors for non-fistulous incontinence are similar to those identified in high income countries including high parity, vaginal and assisted delivery, gestational age, constipation, obesity, chronic cough and ageing. Urinary incontinence has significant social and emotional consequences with a high proportion of women in African countries reporting relationship problems, depression and suicidal ideation. There is a poor understanding of the perceived aetiology of incontinence in sub-Saharan Africa which may, in part, act as a barrier for women to seek medical advice. Innovative solutions have been found to manage the large amount of obstetric fistulae that are prevalent across Africa, but a lack of capacity in specialists trained to treat women with urinary incontinence means that more doctors, medical officers and better resource prioritisation will be required to help the as yet unquantified number of women with non-fistulous leakage. Better patient peri-natal education may reduce the incidence of fistula still further, especially if the stigma felt by women with incontinence is overcome and they are encouraged to seek treatment.

Real-world Early Outcomes and Retreatment Rates Following Water Vapour Ablative Therapy for Symptomatic Benign Prostatic Hyperplasia

Background

Rezūm water vapour ablation is an effective minimally invasive surgical therapy for the treatment of bladder outflow obstruction.

Objective

To present early outcomes and reoperation rates after Rezūm, including an analysis of retreatment rates to gain an insight into optimal patient selection and the durability of the procedure.

Design, setting, and participants

Data were prospectively collected for consecutive patients undergoing Rezūm for symptomatic benign prostatic hyperplasia between March 2017 and January 2020 at two hospital sites.

Intervention

Rezūm treatment of the prostate.

Outcome measurements and statistical analysis

Patients were reviewed at 6 wk and 3, 6, and 12 mo after their Rezūm procedure. We evaluated changes in urinary symptoms and the retreatment rate.

Results and limitations

A total of 461 patients undergoing Rezūm were analysed. The mean (±standard deviation) follow-up duration was 16.7 ± 10.4 mo. The mean patient age was 67.5 ± 7.8 yr and the mean prostate volume was 56.5 ± 24.0 ml. There was a significant improvement in mean maximum flow rate and postvoid residual volume and in International Prostate Symptom Score and quality-of-life scores (p < 0.0001). During the follow-up period, 21 patients (4.6%) required retreatment, of which 11 cases (2.4%) were within the first year. The retreatments included eight bladder neck incisions or resections, six transurethral resections of the prostate, four Greenlight laser photoselective vaporisations of the prostate, and three Rezūm procedures. The median length of time to a further operation was 11.5 mo (range 3–34). The most common findings at reoperation were an inadequately treated median lobe, an obstructing bladder neck, and in some cases asymmetry of the prostate cavity or recesses within the prostate gland.

Conclusions

This study demonstrates that the beneficial effects of Rezūm observed in the pivotal phase 2 randomised study are transferable to a real-world population with a comparable early retreatment rate. A range of procedures were used for retreatment. The factors dictating which option to select were based on patient concerns regarding side effects, gland volume, symptom profile, and cystoscopy findings.

Patient summary

We investigated outcomes for patients undergoing Rezūm, a water vapour treatment to reduce the size of the prostate in men with obstruction of the bladder outlet because of benign prostate enlargement. This technique yields significant improvements in symptoms and preserves sexual function. The proportion of men needing retreatment was 2.4% in the first year after their Rezūm procedure.

Retroperitoneal robotic-assisted laparoscopic pyeloplasty: A 10 year experience in a single institution

Introduction Pelvi-ureteric junction (PUJ) obstruction was traditionally treated with open pyeloplasty. In recent decades the development of minimally invasive techniques; including laparoscopic and later robotic surgery, has transformed treatment. The transperitoneal approach has most commonly been undertaken with few institutions reporting outcomes of the retroperitoneal approach. We report our 10 year experience of retroperitoneal robotic-assisted laparoscopic pyeloplasty (R-RALP). Methods A prospective database of 160 patients undergoing RALP between February 2010 and November 2019 was analysed. Data was recorded on demographics, operative details, complications and success rate. Success was determined as symptomatic improvement and/or an unobstructed renogram. Results 152 cases (95.0%) were performed using a retroperitoneal approach and 8 (5.0%) transperitoneal. Mean age was 45.317.4 years. Mean operating time was 139.445.6 minutes. A surgical drain was placed in 57 (71.3%) of the first 80 cases and 15 (18.8%) of the second 80 cases. Median hospital stay was 1 night (range 1-27). One case was converted to open pyeloplasty due to dense inflammatory tissue and one to robotic-assisted nephrectomy due to severe adhesions around the PUJ. There were no blood transfusions. There were 6 major (>grade 2 Clavien-Dindo) post-operative complications in 4 patients (2.5%). Two (1.3%) grade 3a complications: urine leak and pain after stent removal requiring nephrostomy. Three (1.9%) grade 3b complications: migrated stent requiring ureteroscopy, perirenal haematoma requiring open evacuation and stent re-insertion. One (0.6%) grade 4 complication requiring ventilatory support on intensive care. 18 patients received follow-up at an alternative hospital and 13 were lost to follow-up. Of the remaining cases 94.5% were successful. Conclusions R-RALP is a safe and effective treatment for PUJ obstruction allowing predictably rapid discharge from hospital without the need for a routine surgical drain. To our knowledge our study represents the largest single institution experience on RALP using a retroperitoneal approach.

Complications after radical nephrectomy according to age: analysis from the British Association of Urological Surgeons Nephrectomy Audit

Introduction To compare complication rates in radical nephrectomy for renal cell carcinoma across different age groups. Methods Retrospective analysis of the British Association of Urological Surgeons Nephrectomy Audit database between 1st January 2012 and 31st December 2017 was performed. Comparisons were made between different age groups (<60, 60-79, ≥80) in patients undergoing radical nephrectomy for renal cell carcinoma. Results 18438 patients with renal cell carcinoma underwent radical nephrectomy: 6128 (33.2%) aged <60, 10785 (58.5%) aged 60-79 and 1525 (8.3%) aged ≥80. There was a significantly lower pre-operative haemoglobin and eGFR with advancing age (p<0.001). Patients ≥80 had a higher Charlson co-morbidity index and WHO performance status (p<0.001). There was also significant variability in the approach to RN (p<0.001): laparoscopy was most commonly performed (68.8% vs. 69.3% vs. 75.0%). Patients ≥80 years were found to have the shortest operating time (p<0.001). There were significant differences in T stage between groups with patients aged ≥80 having a higher T stage (p<0.001). The incidence of intra-operative complications did not significantly differ between age groups (p=0.18). The incidence of post-operative complications was 15.7%, 18.2% and 20.5% and major post-operative complications was 1.4%, 2.1% and 2.8% in patients <60, 60-79 and ≥80, respectively (p<0.001). The most common complication in all age groups was blood transfusion (7.6% <60, 8.6% 60-79, 9.1% ≥80). Stepwise logistic regression analysis adjusting for additional variables found the odds of a post-operative complication increased with age with an odds ratio of 1.25 in patients ≥80 and an odds ratio of 1.09 in patients aged 60-70 compared with <60. Conclusion Overall complications in all age groups are low but advancing age should be considered as an independent risk factor for post-operative complications after radical nephrectomy and should be appropriately considered when counselling elderly patients prior to treatment.

Bladder endocervicosis: Recurrent presentations during pregnancy

Bladder endocervicosis describes the ectopic presence of endocervical tissue within the bladder. It is a rare condition with an unclear aetiology. We report the case of a 29-year-old woman who presented with bladder endocervicosis during her first pregnancy with recurrence during her second pregnancy. On both occasions, the patient was treated with transurethral resection and the lesion recurred. This is the first case in the literature of bladder endocervicosis presenting during pregnancy and suggests a hormonal stimulus is important in its development.

Holmium laser enucleation of the prostate: A single-centre case series of 1000 patients

Objective:

To describe the short and long-term complications of over 1000 cases of Holmium laser enucleation of the prostate (HoLEP) in a single centre.

Methods:

A prospective database of all HoLEP procedures performed between December 2003 and March 2017 was analysed.

Results:

A total of 1016 HoLEP procedures were performed. Median patient age was 72 years (range 41–95). There was a significant improvement in urinary flow, post-void residual volume, IPSS and QoL score ( p < 0.0001). Pre-operative acute urinary retention was present in 403 patients (39.7%). Post-operatively five patients (1.2%) continued with a long-term catheter. Early and late complications consisted of failed initial voiding trial (10.6%), stress incontinence (transient 6.5%; persistent 0.3%), frequency/dysuria (5.6%), urinary tract infection (5.3%), urethral stricture (4.8%), submeatal stenosis (1.9%), return to theatre (1.5%), bladder neck stenosis (1.3%), bleeding (1.2%), epididymitis (0.7%), confusion (0.3%), transurethral resection of the prostate conversion (0.2%), ureteric obstruction (0.2%), vomiting (0.2%), anuric renal failure (0.1%), chest infection (0.1%), chest pain (0.1%), myocardial infarction (0.1%), rectoprostatic fistula (0.1%), supraventricular tachycardia (0.1%) and urinary sepsis (0.1%). Five-year reoperation rate was 3.7%.

Conclusion:

HoLEP is a safe treatment for bladder outflow obstruction secondary to an enlarged prostate. It is associated with few early and late complications and has a low reoperation rate.

Level of evidence:

4

En bloc enucleation technique during holmium laser enucleation of the prostate: An analysis of its efficiency

OBJECTIVE

Despite the acknowledgment that holmium laser enucleation of the prostate (HoLEP) is a safe, efficacious procedure with benefits over traditional treatments, it is not widely adopted. Its steep learning curve is considered responsible, and the new en bloc technique (EBT) aims to improve this.

METHODS

A retrospective analysis of 268 consecutive patients (215 lobe technique [LT] and 53 EBT) who underwent HoLEP between May 2016 and April 2020 was performed. Data were collected on patient demographics, prostate volume, enucleation time, prostatic weight, and length of stay.

RESULTS

There was no difference in mean prostate volume and enucleated prostatic weight between the LT and EBT (99.2 mL vs 98.5 mL, P = .95216, and 71.7 g vs 69.3 g, P = .92034, respectively). There was a reduction in mean enucleation time with the EBT to 37.7 minutes compared with 53.3 minutes (LT) (P < .00001). This translated to an improved operative efficiency of 1.84 g/min (EBT) compared to 1.33 g/min (LT) (P < .00001). The EBT demonstrated a continuous improvement in operative efficiency with increasing prostate size unlike the LT where efficiency plateaus.

CONCLUSIONS

The EBT for HoLEP demonstrates a significant improvement in operative efficiency which has the potential to reduce the surgeons' learning curve and lead to more widespread adoption.

Nephrometry scores: a validation of three systems for peri-operative outcomes in retroperitoneal robot-assisted partial nephrectomy

OBJECTIVE

To externally validate the RENAL, PADUA and SPARE nephrometry scoring systems for use in retroperitoneal robot-assisted partial nephrectomy (RAPN).

MATERIALS AND METHODS

Nephrometry scores were calculated for 322 consecutive patients receiving retroperitoneal RAPN at a tertiary referral centre from 2017. Patients with multiple tumours were excluded. Scores were correlated with peri-operative outcomes, including the trifecta (warm ischaemia time <25 min, no peri-operative complications and a negative surgical margin), both as continuous and categorical variables. Comparisons were performed using Spearman correlation and ability to predict the trifecta was assessed using binomial logistical regression.

RESULTS

All three scoring systems correlated significantly with the main variables (operating time, warm ischaemia time and estimated blood loss), both as continuous and categorical variables. Only PADUA and SPARE were able to predict achievement of the trifecta (PADUA area under the curve [AUC] 0.623, 95% confidence interval [CI] 0.559-0.668; SPARE AUC 0.612, 95% CI 0.548-0.677).

CONCLUSION

This study validates the RENAL, PADUA and SPARE scoring systems to predict key intra-operative outcomes in retroperitoneal RAPN. Only PADUA and SPARE were able to predict achievement of the trifecta. As a simplified version of the PADUA scoring system with comparable outcomes, we recommend using the SPARE system.

Initial single centre experience of Aquablation of the prostate using the AquaBeam system with athermal haemostasis for the treatment of benign prostatic hyperplasia: 1-year outcomes

PURPOSE

Aquablation using the AquaBeam system combines real-time image guidance and robotics to enable precise and heat-free removal of prostatic tissue with a high velocity water jet. The aim of this study is to report the outcomes of Aquablation up to 1 year in a single centre within the UK employing an athermal approach to haemostasis.

METHODS

Fifty-five consecutive men underwent Aquablation between September 2017 and December 2018 (as part of OPEN WATER trial). Standard Aquablation was performed with the AquaBeam system (PROCEPT^® BioRobotics) with 2 passes of Aquablation followed by bladder washout with application of continuous bladder irrigation via a catheter on a continuous traction device. Patients were followed up at 3 and 12 months. The data were prospectively collected on patient demographics, uroflowmetry, prostate volume, International Prostate Symptom Score (IPSS), Male Sexual Health Questionnaire for Ejaculatory Dysfunction (MSHQ-EjD) and International Index of Erectile Function (IIEF-15).

RESULTS

The mean age was 64.1 ± 7.9 years. Operating time was 26.9 ± 9.2 min. Mean prostate volume decreased from 58.2 ± 23.9 cc to 33.2 ± 12.9 cc (p < 0.0001). There were significant improvements at the 12 month follow-up in maximum urinary flow rate (9.9 ± 5.1 ml/s vs. 23.9 ± 11.6 ml/s), IPSS (21.7 ± 7.4 vs. 6.1 ± 4.2) and quality of life score (4.8 ± 1.1 vs. 1.4 ± 1.4) (p < 0.0001). There was no significant change in IIEF-15 and MSHQ-EjD scores. There were 8 (14.5%) Clavien grade 2 or higher complications.

CONCLUSION

Our single centre experience suggests Aquablation using an entirely athermal approach is a safe cavitating procedure resulting in significant LUTS improvement comparable to standard cavitating procedures with greater preservation of sexual function.

Neutrophil gelatinase-associated lipocalin (NGAL) as a biomarker of renal injury in patients with ureteric stones: a pilot study

Objective:

The role of neutrophil gelatinase-associated lipocalin in renal obstruction remains unclear. The aim of this study is to assess neutrophil gelatinase-associated lipocalin kinetics and its potential role as a biomarker of renal damage in acute ureteric colic.

Methods:

Thirty-six patients with acute ureteric colic were prospectively recruited and compared with two control groups. Blood and urine samples for plasma neutrophil gelatinase-associated lipocalin and urinary neutrophil gelatinase-associated lipocalin levels were obtained at various time points.

Results:

There were significantly higher levels of urinary neutrophil gelatinase-associated lipocalin and the urinary neutrophil gelatinase-associated lipocalin/creatinine ratio at presentation when comparing patients with acute ureteric colic to healthy controls ( P=0.002 and P=0.004, respectively). In patients with acute ureteric colic managed with surgical intervention ( n=27) there was a significant reduction in plasma neutrophil gelatinase-associated lipocalin ( P=0.001) and an increase in the urinary neutrophil gelatinase-associated lipocalin/creatinine ratio 6 hours postoperatively ( P=0.03). Eight of nine patients managed conservatively for acute ureteric obstruction had spontaneous stone passage at follow-up (median 26 days) with a significant reduction in the urinary neutrophil gelatinase-associated lipocalin/creatinine ratio ( P=0.03).

Conclusion:

The observation of a reduction in plasma neutrophil gelatinase-associated lipocalin and urinary neutrophil gelatinase-associated lipocalin levels following relief of renal obstruction due to ureteric stones suggests the potential role of neutrophil gelatinase-associated lipocalin as a biomarker in this scenario and in the follow-up setting as a potential marker of relief of obstruction.

Level of evidence:

3b

Management of the Distal Ureter in Radical Laparoscopic Nephroureterectomy for Upper Tract Urothelial Carcinoma

Introduction: Management of the distal ureter during laparoscopic nephroureterectomy (LNU) for upper tract urothelial carcinoma (UTUC) is controversial. The aim of this review was to determine whether this affects oncological outcomes. Methods: A literature review was conducted searching MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials in June 2019. Studies reporting outcomes of LNU in UTUC using either open, laparoscopic, or endoscopic approaches to excise the distal ureter were identified. All eligible studies underwent critical appraisal and were excluded if not of sufficient quality. Cumulative analysis of the results was performed. Results: Nine studies with a total of 383 patients (168 open, 159 laparoscopic, and 56 endoscopic excision of distal ureter) were eligible for inclusion. Study design and outcome reporting were variable between studies. Mean age of patients was comparable (67.7 years versus 65.0 years versus 66.6 years). Mean follow-up duration was comparable between open and laparoscopic groups (46.2 months versus 45.5 months) but reduced in the endoscopic group (33.4 months). The open group had a higher proportion of high grade/G3 tumors and pT2-4 tumors when compared to the laparoscopic and endoscopic groups (P < .001 and P = .002). The open group had a higher rate of intravesical recurrence and the laparoscopic group had a higher rate of distant metastases (P < .001). Conclusion: This review has identified differences in oncological outcomes between different techniques of managing the distal ureter in LNU for UTUC. However, the poor reporting of potentially confounding factors does not enable any one technique to be recommended as superior and requires further research.

Laparoscopic Nephrectomy in Patients with Previous Abdominal Surgery

Laparoscopic nephrectomy is a minimally invasive procedure that provides significant benefits to the patient, such as reduced analgesic requirements and shorter recovery time. While the popularity of laparoscopy has grown substantially, there are associated risks of injury to the blood vessels and/or viscera during the insertion of the laparoscopic ports. Such injuries can lead to a significant increase in mortality rates. Patients who have had previous abdominal surgery have a higher risk of adhesions; this has been shown to increase the risk of complications from port placement. Consequently, previous abdominal surgery was viewed as a relative contraindication to laparoscopic surgery. However, studies have demonstrated the advantages of laparoscopic surgery over an open radical approach; hence, previous abdominal surgery is no longer viewed as a contraindication. Here, we describe the case of a 62-year-old man who presented with an incidental finding of right renal cell carcinoma (RCC). We performed a radical nephrectomy on this patient who had undergone multiple previous abdominal surgeries. During this procedure, a small bowel injury occurred. Herein, we review the available evidence and describe the risk factors and techniques to avoid injury from laparoscopic port-site placement in patients undergoing nephrectomy with a history of previous abdominal surgery.

Molecular biology and targeted therapy in metastatic renal cell carcinoma

The treatment of metastatic renal cell carcinoma is challenging as it has proven to be relatively resistant to conventional oncological treatments. An improved understanding of the molecular biology of renal cell carcinoma has led to the development of a number of targeted therapies in metastatic renal cell carcinoma. This includes vascular endothelial growth factor inhibitors, tyrosine kinase inhibitors, mammalian target of rapamycin inhibitors and most recently immune checkpoint inhibitors. This article will review the mechanisms of development and progression of renal cell carcinoma as well as the mechanisms of current approved treatments in metastatic disease.

Level of evidence: Not applicable for this multicentre audit.

Stem cell therapy for stress urinary incontinence

Stress urinary incontinence is the involuntary loss of urine on effort or physical exertion. It is a highly prevalent condition affecting both men and women. Treatment is performed in a step-wise approach involving conservative measures, such as weight loss and pelvic floor exercises, medical treatment with duloxetine and a variety of surgical treatment options. However, recent restrictions in the use of synthetic mesh and tape have limited the surgical treatment options, leading to the need for new and novel treatment for stress urinary incontinence. Stem cell therapy is a developing medical field and offers the potential to restore normal physiological function of the urethral sphincter. The effectiveness of stem cell therapy in stress urinary incontinence has been demonstrated in pre-clinical studies, leading to its evaluation in several clinical studies. This review assesses the current evidence for the safety and efficacy of stem cell treatment for patients with stress urinary incontinence who have failed conservative and/or medical management and have not undergone previous surgical treatment for stress urinary incontinence.

Evidence Level: Not applicable

Spontaneous haemorrhage of an adrenal angiomyolipoma: case report

Background

Angiomyolipomas are rare mesenchymal tumours arising from the perivascular epithelioid cells consisting of variable amounts of adipose, thick-walled blood vessels and smooth muscle cells. These benign tumours commonly occur in the kidney with only a few case reports of adrenal angiomyolipomas which have the potential to reach a large size and haemorrhage.

Case presentation

A 45-year-old lady presented with a 3-week history of right loin pain, nausea and vomiting. A CT scan revealed a right adrenal angiomyolipoma measuring 6.3 × 6.8 cm with associated haemorrhage. The lesion was successfully treated with right open adrenalectomy, and histology confirmed the diagnosis of adrenal angiomyolipoma. The patient remained well with no evidence of recurrence at the 36-month follow-up.

Conclusion

Adrenal angiomyolipomas are rare benign tumours that have the ability to reach a large size and potential to bleed. Here, we report the second case of spontaneous haemorrhage in an adrenal angiomyolipoma, which was successfully treated with open adrenalectomy.

Improving the quality of operation notes with electronic proformas

Introduction

Surgeons must ensure operative notes are legible and sufficiently detailed, outlined by 21 criteria in Good Surgical Practice guidelines (2014). Our aim was to introduce an electronic operating proforma to improve quality of operation notes.

Methods

Two audits were performed six months apart, after an education session and introduction of an electronic operating proforma, assessing adherence to the guidelines. Results were compared and analysed using Chi-square and Fisher’s exact tests.

Results

In both audits, notes for 187 operations performed over a two-week period were studied. In the first audit, six of the 21 criteria were recorded in ≥95% of operation notes, improving to nine in the second audit. In the second audit cycle, two subgroups were analysed, non-proforma (n = 30) and proforma (n = 157). In the proforma subgroup, 15 criteria were recorded in ≥95% of operation notes.

Conclusion

Quality of operation notes can be significantly improved by using a combination of education, electronic proformas and avoiding handwritten notes.

Age distribution and metabolic disorders in people with Type 1 diabetes in Beijing and Shantou, China: a cross-sectional study

AIMS

To examine whether the age profile of people with Type 1 diabetes differs from that of the general population and in what manner, and to study the clinical characteristics related to metabolic disorders among people with Type 1 diabetes in China.

METHODS

We sequentially enrolled 849 people with Type 1 diabetes from hospital records review, inpatient wards and outpatient clinics. Data were collected via face-to-face interviews, medical records and venous blood samples. Beijing census data for 2011 were used to provide the general population statistics. Descriptive analysis of the results and tests for differences were performed.

RESULTS

The median (interquartile range) age at diagnosis of diabetes was 16 (9-28) years and the duration of diabetes was 4 (1-8) years. The mean ± sd HbA_1c concentration was 76±28 mmol/mol (9.1±2.5%). Compared with the general population, the population with Type 1 diabetes comprised more young individuals and fewer elderly individuals. The overall prevalence of metabolic syndrome among those with Type 1 diabetes was 10.1% (95% CI 7.9-12.2). People with metabolic syndrome were older and were diagnosed with diabetes at an older age. Hypertension and dyslipidaemia were more common in obese individuals with Type 1 diabetes than in their non-obese counterparts.

CONCLUSIONS

Compared with the general population, people with Type 1 diabetes comprised more young and fewer elderly individuals. The prevalence of metabolic syndrome in the Type 1 diabetes population was 10.1%. Hypertension and dyslipidaemia were more prevalent in obese than non-obese individuals.

Fat4-Dchs1 signalling controls cell proliferation in developing vertebrae

The protocadherins Fat4 and Dchs1 act as a receptor-ligand pair to regulate many developmental processes in mice and humans, including development of the vertebrae. Based on conservation of function between Drosophila and mammals, Fat4-Dchs1 signalling has been proposed to regulate planar cell polarity (PCP) and activity of the Hippo effectors Yap and Taz, which regulate cell proliferation, survival and differentiation. There is strong evidence for Fat regulation of PCP in mammals but the link with the Hippo pathway is unclear. In Fat4(-/-) and Dchs1(-/-) mice, many vertebrae are split along the midline and fused across the anterior-posterior axis, suggesting that these defects might arise due to altered cell polarity and/or changes in cell proliferation/differentiation. We show that the somite and sclerotome are specified appropriately, the transcriptional network that drives early chondrogenesis is intact, and that cell polarity within the sclerotome is unperturbed. We find that the key defect in Fat4 and Dchs1 mutant mice is decreased proliferation in the early sclerotome. This results in fewer chondrogenic cells within the developing vertebral body, which fail to condense appropriately along the midline. Analysis of Fat4;Yap and Fat4;Taz double mutants, and expression of their transcriptional target Ctgf, indicates that Fat4-Dchs1 regulates vertebral development independently of Yap and Taz. Thus, we have identified a new pathway crucial for the development of the vertebrae and our data indicate that novel mechanisms of Fat4-Dchs1 signalling have evolved to control cell proliferation within the developing vertebrae.

Clinical presentation and referral characteristics of food protein-induced enterocolitis syndrome in the United Kingdom

BACKGROUND

Food protein-induced enterocolitis syndrome (FPIES) is a pediatric non-IgE-mediated allergic reaction to foods. The diagnosis of FPIES is clinical, with children presenting typically 2 to 4 hours after ingestion of a food protein. The most striking symptoms are vomiting, lethargy, and pallor. Misdiagnosis and delay in presentation to an allergist or gastroenterologist are common.

OBJECTIVES

To investigate the pathway of patients with FPIES presenting to a specialist clinic in the United Kingdom to ascertain whether they experienced delays or misdiagnoses and to investigate their symptoms and triggers.

METHODS

All patients with FPIES presenting over a 3-year period (2010-2013) in a tertiary pediatric allergy clinic in London were analyzed retrospectively. This was performed by searching electronically for all patients with a diagnosis of FPIES and manually reviewing paper notes. Presenting symptoms and management pathways were collated.

RESULTS

Fifty-four patients were identified, with an average age of onset at 8 months. They initially presented to medical professionals other than an allergist or gastroenterologist. The most frequent presenting symptom was vomiting followed by signs suggesting shock or hypotension and diarrhea. Differential diagnoses included gastroenteritis, sepsis, and surgical abnormalities. The main eliciting foods were cow's milk, fish, egg, soy, and wheat.

CONCLUSION

In the United Kingdom, FPIES typically has its onset at 8 months. Patients experience a delay of 12 months in the diagnosis of FPIES and frequently have multiple episodes and interim diagnoses. A great need remains for enhanced education of medical practitioners dealing with children about the varied presentations of FPIES.

Miniaturized Hairs Maintain Contact with the Arrector Pili Muscle in Alopecia Areata but not in Androgenetic Alopecia: A Model for Reversible Miniaturization and Potential for Hair Regrowth

BACKGROUND

Hair follicle miniaturization is the hallmark of male pattern hair loss (MPHL), female pattern hair loss (FPHL), and alopecia areata (AA). AA has the potential for complete hair regrowth and reversal of miniaturization. MPHL and FPHL are either irreversible or show only partial regrowth and minimal reversal of miniaturization.

HYPOTHESIS

The arrector pili muscle (APM) attachment to the hair follicle bulge, a recognized repository of stem cells may be necessary for reversal of hair follicle miniaturization.

MATERIALS AND METHODS

Sequential histological sections from MPHL, FPHL, AA, and telogen effluvium were used to create three-dimensional images to compare the relationship between the APM and bulge.

RESULTS

In AA, contact was maintained between the APM and the bulge of miniaturized follicles while in MPHL and FPHL contact was lost.

DISCUSSION

Contact between the APM and the bulge in AA may be required for reversal of hair follicle miniaturization. Maintenance of contact between miniaturized follicles in AA could explain the complete hair regrowth while loss of contact between the APM and the bulge in MPHL and FPHL may explain why the hair loss is largely irreversible. This loss of contact may reflect changes in stem cell biology that also underlie irreversible miniaturization.

Update on cicatricial alopecia

Cicatricial alopecia is an enigmatic group of hair disorders linked by the potential permanent loss of scalp hair follicles in involved areas. Progress in our understanding and treatment of these disorders has been stymied by the lack of clear diagnostic criteria for the current terms used to describe the various hair loss entities. Since all of these conditions evolve as the hair is destroyed or replaced, diagnosis is further made difficult by a lack of clinical and pathologic "snapshots" over the evolution of each disorder. Without some acceptance of general clinical and histological presentations in the early, mid and late stage of these disorders, one cannot begin to explore ways to make the diagnosis at a very early stage before significant follicular destraction has occurred (making the clinical diagnosis obvious) and when the damage is potentially repairable or progression preventable.

Tobacco smoking in Tanzania, East Africa: population based smoking prevalence using expired alveolar carbon monoxide as a validation tool

OBJECTIVES

To describe the prevalence of tobacco smoking in an urban East African population while using a simple validation procedure to examine the degree of under reporting in men and women.

DESIGN

A cross sectional population based study in adults (15 years and over) with sampling from a well maintained census register.

SETTING

Ilala Ilala, a middle income district of Dar es Salaam, Tanzania.

SUBJECTS

An age and sex stratified random sample of 973 men and women.

MAIN OUTCOME MEASURES

Self reported smoking status with correction by exhaled alveolar carbon monoxide (EACO).

RESULTS

From the 605 participants (response rate 67.9%) age standardised (new world population) smoking prevalence, based on questionnaire and EACO, was 27.0% (95% confidence interval (CI) 20.8% to 33.2%) in males and 5.0% (95% CI 2.8% to 7.2%) in females. The age specific prevalence of smoking was highest in the age group 35-54 years (34.3%) for men and in the over 54 years group (16%) for women. Of those classified as smokers, 7.3% of men and 27.3% of women were reclassified as current smokers based on EACO (> or = 9 parts per million), after they had reported themselves to be an ex- or non-smoker in the questionnaire.

CONCLUSIONS

The data suggest: (1) high rates of smoking among men in an urban area of East Africa; and (2) the importance of validating self reports of smoking status, particularly among women.

Clindamycin phosphate 1% gel in acne vulgaris

A 12-week study compared Clindagel, a unique water-based gel formulation of clindamycin phosphate 1%, administered once daily, and Cleocin T, a slightly different gel formulation indicated for twice-daily use, in the treatment of acne vulgaris. Clindagel was safe and effective and equivalent to Cleocin T gel, albeit with a better tolerability profile. Clindagel is a viable alternative to Cleocin T gel.

Activation of progelatinase A (MMP-2) by neutrophil elastase, cathepsin G, and proteinase-3: a role for inflammatory cells in tumor invasion and angiogenesis

Gelatinase A (MMP-2), a matrix metalloproteinase (MMP) involved in tumor invasion and angiogenesis, is secreted as an inactive zymogen (proMMP-2) and activated by proteolytic cleavage. Here we report that polymorphonuclear neutrophil (PMN)-derived elastase, cathepsin G, and proteinase-3 activate proMMP-2 through a mechanism that requires membrane-type 1 matrix metalloproteinase (MT1-MMP) expression. Immunoprecipitation of human PMN-conditioned medium with a mixture of antibodies to elastase, cathepsin G, and proteinase-3 abolished proMMP-2 activation, whereas individual antibodies were ineffective. Incubation of HT1080 cells with either purified PMN elastase or cathepsin G or proteinase-3 resulted in dose-and time-dependent proMMP-2 activation. Addition of PMN-conditioned medium to MT1-MMP expressing cells resulted in increased proMMP-2 activation and in vitro invasion of extracellular matrix (ECM), but had no effect with cells that express no MT1-MMP. MMP-2 activation by PMN-conditioned medium or purified elastase was blocked by the elastase inhibitor alpha(1)-antitrypsin but not by Batimastat, an MMP inhibitor, showing that elastase activation of MMP-2 is not mediated by MMP activities. The PMN-conditioned medium-induced increase in cell invasion was blocked by Batimastat as well as by alpha(1)-antitrypsin, showing that PMN serine proteinases trigger a proteinase cascade that entails proMMP-2 activation: this gelatinase is the downstream effector of the proinvasive activity of PMN proteinases. These findings indicate a novel role for PMN-mediated inflammation in a variety of tissue remodeling processes including tumor invasion and angiogenesis.

Androgen responsive genes as they affect hair growth

Finasteride has been shown to be an effective treatment for men with androgenetic alopecia (AGA) as it restores hair growth to miniaturized hair follicles on the top of the scalp [1]. Caspases are regulators of programmed cell death, and very likely some specific caspases may function as mediators of the hair growth cycle. It is unclear whether finasteride influences the regulation of apoptosis via caspases in the hair follicle. Very little information is available regarding the role of caspases present in human hair follicles in normal scalp and in androgenetic alopecia. In this study we have analyzed the family of caspases, 1-10 along with usurpin, and XIAP, in men with normal scalp and in men with androgenetic alopecia before and after 6 months treatment with 1 mg oral finasteride treatment. Caspases 1, 3, 8 and 9 were detected predominantly within the isthmic and infundibular hair follicle area for both normal and AGA patients, however the expression of all factors, especially caspase 3 was greater in the AGA group than in the normal scalp group. AGA men had the same caspase factors but with greater expression. In the same AGA men treated with finasteride for 6 months, the expression of these factors was similar to levels in the normal group. Results from our study indicate caspase 3 to be of primary importance in normal hair homeostasis and that DHT may be signaling greater expression of caspases, inducing apoptosis in androgenetic alopecia. In conclusion, DHT may selectively regulate the caspase genes which play an important role in signaling programmed cell death, affecting the hair growth cycle.

Effect of a desogestrel-containing oral contraceptive on the skin

OBJECTIVE

This pilot study evaluated the effects of a desogestrel-containing oral contraceptive (DSG-OC) on facial seborrhea (oiliness), acne and related factors in otherwise healthy women with moderate facial acne vulgaris.

METHODS

In this double-blind, placebo-controlled study, 41 women received DSG-OC (50/100/150 microg desogestrel plus 35/30/30 microg ethinylestradiol given in a 7/7/7 day regimen) and 41 received placebo for six cycles. Seborrhea and skin assessments, and hormone analyses were performed regularly.

RESULTS

Analyses of sebum output (measured using Sebutape) indicated that the effect of DSG-OC on the skin varied with facial area. Compared with placebo, DSG-OC had a statistically significant effect on the cheeks (60% relative reduction in sebum output; p = 0.02), and a non-significant effect on the forehead (30% relative reduction in sebum output). Acne lesion counts did not differ significantly between groups. Both patient and investigator assessments of skin condition (visual analog scale) indicated significant improvements with DSG-OC compared with placebo. The reduced sebum output with DSG-OC is associated with a three-fold increase in sex hormone binding globulin, as well as an expected decrease in free testosterone and other androgens that were found in this group.

CONCLUSION

These results suggest that DSG-OC reduces facial oiliness and may be a useful contraceptive choice for women with this problem.

Rural and urban differences in diabetes prevalence in Tanzania: the role of obesity, physical inactivity and urban living

A population-based survey in 1996 and 1997 of 770 adults (aged > or = 15 years) from an urban district of Dares Salaam and 928 from a village in rural Kilimanjaro district (Tanzania) revealed that the prevalence of diabetes, impaired fasting glucose (IFG), overweight, obesity, and physical inactivity was higher in the urban area for men and women. The difference between urban and rural prevalence of diabetes was 3.8 [1x1-6.5]% for men and 2x9 [0x8-4.9]% for women. For IFG, the difference was 2x8 [0x3-5x3]% for men and 3x9 [1x4-6x4]% for women; for overweight and obesity, the difference was 21.5 [15.8-27.1]% and 6.2 [3x5-8.9]% for men and 17x4 [11.5-23.3]% and 12.7 [8x5-16x8]% for women, respectively. The difference in prevalence of physical inactivity was 12x5 [7.0-18.3]% for men and 37.6 [31x9-43.3]% for women. For men with diabetes, the odds for being overweight, obese and having a large waist:hip ratio were 14.1, 5.3 and 12.5, respectively; for women the corresponding values were 9x0, 10x5 and 2x4 (the last not significant) with an attributable fraction for overweight between 64% and 69%. We conclude that diabetes prevalence is higher in the urban Tanzanian community and that this can be explained by differences in the prevalence of overweight. The avoidance of obesity in the adult population is likely to prevent increases in diabetes incidence in this population.

Comparison of alopecia areata in human and nonhuman mammalian species

Alopecia areata (AA) is a nonscarring form of inflammatory hair loss in humans. AA-like hair loss has also been observed in other species. In recent years the Dundee experimental bald rat and the C3H/HeJ mouse have been put forward as models for human AA. AA in all species presents with a wide range of clinical features from focal, locally extensive, diffuse hair loss, to near universal alopecia. Histologically, all species have dystrophic anagen stage hair follicles associated with a peri- and intrafollicular inflammatory cell infiltrate. Autoantibodies directed against anagen stage hair follicle structures are a consistent finding. Observations on AA pathogenesis suggest nonhuman species can provide excellent models for the human disease. Ultimately, animal models will be used to determine the genetic basis of AA, potential endogenous and/or environmental trigger(s), mechanism(s) of disease initiation and progression, and allow rapid evaluation of new and improved disease treatments.

Finasteride increases anagen hair in men with androgenetic alopecia

BACKGROUND

The growth of scalp hair is a cyclical process of successive phases of growth (anagen) and rest (telogen). In previous clinical trials in men with androgenetic alopecia, treatment with finasteride increased scalp hair counts in a defined area (i.e. increased hair density).

OBJECTIVES

The current study used a phototrichogram methodology to assess the effect of finasteride on the phases of the hair growth cycle.

PATIENTS/METHODS

Two hundred and twelve men, age 18-40 years, with androgenetic alopecia were randomized to receive finasteride 1 mg daily or placebo for 48 weeks. At baseline and at 24 and 48 weeks, macrophotographs were taken to measure total and anagen hair count in a 1-cm(2) target area of the scalp.

RESULTS

At baseline, mean total and anagen hair counts in the finasteride group were 200 and 124 hairs, respectively (% anagen = 62%) and the anagen to telogen ratio was 1.74 (geometric mean). In the placebo group, the respective values were 196 and 119 hairs (% anagen = 60%) and 1.57. At week 48, the finasteride group had a net improvement (mean +/- SE) compared with placebo in total and anagen hair counts of 17.3 +/- 2.5 hairs (8.3% +/- 1.4%) and 27.0 +/- 2.9 hairs (26% +/- 3.1%), respectively (P < 0.001). Furthermore, treatment with finasteride resulted in a net improvement in the anagen to telogen ratio of 47% (P < 0.001). In this study, treatment with finasteride 1 mg day(-1) for 48 weeks increased both total and anagen hair counts, and improved the anagen to telogen ratio.

CONCLUSIONS

These data provide direct evidence that finasteride 1 mg daily promotes the conversion of hairs into the anagen phase. These data support that finasteride treatment results in favourable effects on hair quality that contribute to the visible improvements in hair growth observed in treated patients.

The different faces of pili bifurcati. A review

Pili bifurcati is an uncommon hair shaft dysplasia characterized by bifurcation of the hair shaft. The two characteristics that define the dysplasia are: 1. Each bifurcation produces two separate parallel branches which fuse again to form a single shaft. 2. Each branch of the successive bifurcations is covered with its own cuticle. Currently, there is confusion between the terms "pili bifurcati" and "pili gemini". The name "pili gemini" is used to define a kinetic papilla that splits at the upper end from single to double-tipped during the anagen phase and consequently the same follicular matrix produces two different-sized hair shafts having separate cuticles that emerge through a single pilary canal. Pili gemini maintains the double tipped papilla and consequently the hair shaft does not fuse again. Papillar tips that divide into several tips will produce several hair shafts, that characteristically do not fuse again. When the same papilla changes its shape repeatedly during the anagen phase, it can produce hair shafts with bifurcations at irregular intervals: pili multibifurcati. And, as it is also possible for one of the new papillae to split again in two, the hair shaft may be doubly bifurcated: pili bi, bifurcati. Pili bifurcati should be distinguished from acquired splitting of hair shafts that do not represent true bifurcations because the two split parts are never surrounded by a complete cuticle. Such acquired splitting may be called "central trichoptilosis".

Age specific prevalence of impairment and disability relating to hemiplegic stroke in the Hai District of northern Tanzania. Adult Morbidity and Mortality Project

OBJECTIVES

To determine the age specific prevalence of impairment and disability relating to hemiplegic stroke in one rural area of Tanzania.

METHODS

During the yearly house to house census of the study population of 148 135 (85 152 aged 15 and over) in August 1994, specific questions were asked to identify those who might be disabled from stroke. People thus identified were subsequently interviewed and examined by one investigator. In those in whom the clinical diagnosis of stroke was confirmed a more detailed interview and examination relating to risk factors and recovery was carried out.

RESULTS

One hundred and eight patients, 61 men and 47 women, were identified with a median age of 70 (range 18-100). Median age at first stroke was 65 years. The age specific rates in this study were lower than previous studies in developed countries. All were cared for at home although 23 (21%) were bedbound.

CONCLUSIONS

Although prevalence of impairment and disability related to stroke in this population as a whole was low this is mainly explained by the age structure, with less than 6% being aged 65 and over. Age standardised rates for stroke with residual disability were about half those found in previous studies in developed countries. Death from stroke in Africa may be higher but data are limited. With the demographic transition stroke is likely to become a more important cause of disability in sub-Saharan Africa.

Stroke mortality in urban and rural Tanzania. Adult Morbidity and Mortality Project

BACKGROUND

Most data for stroke mortality in sub-Saharan Africa are hospital based. We aimed to establish the contribution of cerebrovascular disease to all-cause mortality and cerebrovascular disease mortality rates in adults aged 15 years or more in one urban and two rural areas of Tanzania.

METHODS

Regular censuses of the three surveillance populations consisting of 307,820 people (125,932 aged below 15 years and 181,888 aged 15 or more) were undertaken with prospective monitoring of all deaths arising in these populations between June 1, 1992 and May 31, 1995. Verbal autopsies were completed with relatives or carers of the deceased to assess, when possible, the cause of death.

FINDINGS

During the 3-year observation period 11,975 deaths were recorded in the three surveillance areas, of which 7629 (64%) were in adults aged 15 years or more (4088 [54%] of these in men and 3541 [46%] in women). In the adults, 421 (5.5%) of the deaths were attributed to cerebrovascular disease, 225 (53%) of these in men and 196 (47%) in women. The yearly age-adjusted rates per 100,000 in the 15-64 year age group for the three project areas (urban, fairly prosperous rural, and poor rural, respectively) were 65 (95% CI 39-90), 44 (31-56), and 35 (22-48) for men, and 88 (48-128), 33 (22-43), and 27 (16-38) for women, as compared with the England and Wales (1993) rates of 10.8 (10.0-11.6) for men and 8.6 (7.9-9.3) for women.

INTERPRETATION

We postulate that the high rates in Tanzania were due to untreated hypertension. Our study assessed mortality over a single time period and therefore it is not possible to comment on trends with time. However, ageing of the population is likely to lead to a very large increase in mortality from stroke in the future.

Neutrophil-derived serine proteinases enhance membrane type-1 matrix metalloproteinase-dependent tumor cell invasion

BACKGROUND

Matrix metalloproteinase-2 degrades a variety of basement membrane components and is essential for tumor invasion. We have previously reported that membrane type-1 matrix metalloproteinase (MT1-MMP) cooperates with neutrophil-derived serine proteinases (NDPs; elastase, cathepsin G, protease-3) to activate matrix metalloproteinase-2. We therefore hypothesized that NDPs enhance tumor-cell invasion.

METHODS

Clones of human HT1080 fibrosarcoma cells transfected with MT1-MMP sense (HT-SE) or antisense CDNA (HT-AS) were used. These cells express either high (HT-SE) or extremely low levels (HT-AS) of MT1-MMP relative to nontransfected HT1080 cells (HT-WT). The cells were incubated in the presence or absence of purified NDP, with or without alpha 1-antitrypsin or the MMP inhibitor batimastat. Cell invasion was measured with the use of Boyden chambers with polycarbonate membranes coated with a reconstituted extracellular matrix.

RESULTS

Under control conditions HT-WT and HT-SE cells were 4-fold more invasive than HT-AS cells. The addition of NDP increased HT-WT and HT-SE cell invasion 60% to 100% but had no effect on HT-AS cells. alpha 1-antitrypsin or batimastat did not decrease the baseline invasiveness of HT-WT and HT-SE cells; however, they abrogated the stimulatory effect of NDP.

CONCLUSIONS

HT1080 cell invasion depends on MT1-MMP expression. MT1-MMP overexpression does not increase invasiveness by itself. NDPs increase invasion by MT1-MMP expressing cells by activating matrix metalloproteinase-2.

Hypertension prevalence and care in an urban and rural area of Tanzania

OBJECTIVE

To describe the prevalence, detection, treatment and control of hypertension in an urban and rural area of Tanzania.

DESIGN

Two linked cross-sectional population-based surveys.

SETTING

A middle-income urban district of Dar es Salaam (Ilala) and a village in the relatively prosperous rural area of Kilimanjaro (Shari).

PARTICIPANTS

Seven hundred and seventy adults (> 15 years) in Ilala and 928 adults in Shari were studied.

RESULTS

Hypertension prevalence (blood pressure > or = 140 and/or 90 mmHg, or known hypertensives receiving anti-hypertensive treatment) was 30% (95% confidence interval, 25.1-34.9%) in men and 28.6% (24.3-32.9%) in women in Ilala, and 32.2% (27.7-36.7%) in men and 31.5% (27.8-35.2%) in women in Shari. Age-standardized hypertension (to the New World Population) prevalence was 37.3% (32.2-42.5%) among men and 39.1% (34.2-44.0%) in women in Ilala, and 26.3% (22.4-30.4%) in men and 27.4% (24A-30.4%) in women in Shari. In both areas, just under 20% of hypertensive subjects were aware of their diagnosis, approximately 10% reported receiving treatment and less than 1% were controlled (blood pressure < 140/90 mmHg). Hypertensive subjects were older, had greater body mass indices and waist: hip ratios, and had more risk factors for hypertension and its complications (smoking, heavy alcohol consumption, physical inactivity, obesity and diabetes) than non-hypertensives.

CONCLUSIONS

There is a high prevalence of hypertension in rural and urban areas of Tanzania, with low levels of detection, treatment and control. This demonstrates the need for cost-effective strategies for primary prevention, detection and treatment of hypertension and the growing public health challenge of non-communicable diseases in Sub-Saharan Africa.