Evaluation of Central Sensitisation in Bladder Pain Syndrome: A Systematic Review

INTRODUCTION AND HYPOTHESIS

Bladder pain syndrome (BPS) is a debilitating condition characterised by exaggerated bladder sensations and altered bladder function. It is still unknown whether the condition is a peripheral sensory problem or due to abnormal central sensory processing as seen in central sensitisation. This systematic review, which followed a published and Prospective Register of Systematic Reviews-registered protocol (CRD42021229962), is aimed at establishing the scope of central sensitisation in patients with BPS to aid optimal management and treatment.

METHODS

Four databases were searched, and appraisal of the identified studies was conducted by two independent reviewers based on eligibility criteria: patients with BPS being investigated for central sensitisation with or without comparison of controls, English-language articles, full text and publication in a peer-reviewed journal. The Methodological Index for non-Randomised Studies was used to determine study quality. We identified 763 papers in total, with 15 studies included in the final analysis. All studies were observational and had a low risk of bias. Measures included in the evaluation of CS were questionnaires, urodynamics, and quantitative sensory testing methods.

RESULTS

There was evidence of central sensitisation in patients with BPS in all papers evaluated (15 out of 15). In addition, more significant central sensitisation correlated with severe disease presentation (3 out of 3 papers) and concomitant chronic pain conditions (5 out of 5 papers).

CONCLUSIONS

Central sensitisation plays an integral role in BPS patient pathology. Many secondary measures are used to evaluate this condition. Stratification of patients based on their pathology (peripheral, central or a combination of the two) will aid in implementing an individualised management strategy.

Diffusion-weighted imaging in hyperacute haemorrhagic stroke patients presenting within thrombolysis window

INTRODUCTION

Diffusion-weighted imaging (DWI) in magnetic resonance imaging (MRI) has been proposed as the first line of neuroimaging for acute ischaemic stroke. The reliability of DWI in detecting intracranial haemorrhage, however, is still unproven, compared with susceptibility-weighted imaging (SWI) and CT scan which being considered the gold standard. This study seeks to establish the reliability of DWI as a first-line imaging modality to detect the intracranial haemorrhage in the patients present within the thrombolysis window.

MATERIALS AND METHODS

A retrospective cross-sectional analysis was performed on patients who presented to our institution from April 2020 until July 2021 for acute stroke and had MRI brain as first-line neuroimaging. A total of 31 subjects were included in this study. Two radiologists assessed the signal patterns in DWI sequence and compared them with SWI and CT Brain, whenever available, as the gold standard for observing the presence of intracranial haemorrhage.

RESULTS

The majority of patients with hyperacute bleed proven to be revealed on SWI or CT, thus showed characteristics of central hyperintensity and peripheral hypointense rim, on DWI. Slightly more than half (51.6%) presented with mild to moderate NIHSS scores (1-15). The sensitivity, specificity, positive predictive value and negative predictive value of DWI in detecting intracranial intra-axial haemorrhages were exceptionally high. There is strong interobserver level of agreement in identifying central haemorrhagic signal intensity [kappa = 0.94 (0.06), p < 0.05].

CONCLUSION

This study supported the DWI sequence as a reliable sequence in MRI, to detect intracranial haemorrhage in hyperacute stroke.

Efficacy and Safety of Brivaracetam in Persons With Epilepsy in a Real-World Setting: A Prospective, Non-Interventional Study

BACKGROUND AND AIM

Epilepsy stands out as one of the most prevalent neurological conditions. Brivaracetam (BRV) is a noteworthy antiseizure medication (ASM) distinguished by its pronounced and selective interaction with the synaptic vesicle protein 2A (SV2A) within the brain. Prior investigations, including regulatory trials, post-marketing assessments, and comparative meta-analyses, have consistently underscored BRV's equivalency in efficacy and superior tolerability when pitted against other antiseizure drugs. This study aimed to evaluate the effectiveness, safety, and acceptability of BRV in treating epileptic patients in the Pakistani population.

METHODS

This prospective observational study, conducted in Pakistan from February to December 2022, employed a non-probability consecutive sampling technique. This study included 368 adult patients diagnosed with epilepsy, with a focus on those aged 18 and above experiencing focal seizures. Demographic data, clinical history, seizure types, and epilepsy profiles were recorded. Patients were administered BRV (Brivera; manufactured by Helix Pharma Pvt Ltd., Sindh, Pakistan) monotherapy therapy under physician guidance and followed up for three months. The study assessed changes in seizure frequency, side effects, and drug resistance at baseline, 14th day, and 90th day. Safety aspects were monitored, including documenting any adverse effects associated with BRV therapy.

RESULTS

A total of 368 epileptic patients were included in this study, of which 287 (61.3%) were males and 181 (38.7%) were females. The mean age was 32.91±17.11 years. The mean number of seizures at the baseline visit was 5.74±6.21, at 14 days was 2.89±3.84 and at 90 days was 1.73±5.01 (p<0.001). Overall, a more than 50% reduction in seizure episodes was achieved in 178 (56.3%) patients at day 90, and less than 50% reduction in seizure episodes was achieved by 95 (26.8%) patients on Day 14, with a highly significant association between them (p<0.001). Among 316 patients, only 41 (4.4%) of all BRV-treated patients experienced adverse events; Of these 41 patients, 17 (41.7%) reported dizziness and 14(34.2%) reported behavioral issues.

CONCLUSIONS

Epileptic patients receiving BRV demonstrated a substantial reduction of greater than 50% seizure episodes at the end of follow-up visits. Moreover, BRV exhibited fewer adverse effects in individuals with epilepsy.

Proper understanding of recurrent stress urinary incontinence treatment in women (PURSUIT): a randomised controlled trial of endoscopic and surgical treatment

BACKGROUND

Women with stress urinary incontinence (SUI) experience urine leakage with physical activity. Currently, the interventional treatments for SUI are surgical, or endoscopic bulking injection(s). However, these procedures are not always successful, and symptoms can persist or come back after treatment, categorised as recurrent SUI. There are longstanding symptoms and distress associated with a failed primary treatment, and currently, there is no consensus on how best to treat women with recurrent, or persistent, SUI.

METHODS

A two-arm trial, set in at least 20 National Health Service (NHS) urology and urogynaecology referral units in the UK, randomising 250 adult women with recurrent or persistent SUI 1:1 to receive either an endoscopic intervention (endoscopic bulking injections) or a standard NHS surgical intervention, currently colposuspension, autologous fascial sling or artificial urinary sphincter. The aim of the trial is to determine whether surgical treatment is superior to endoscopic bulking injections in terms of symptom severity at 1 year after randomisation. This primary outcome will be measured using the patient-reported International Consultation on Incontinence Questionnaire - Urinary Incontinence - Short Form (ICIQ-UI-SF). Secondary outcomes include assessment of longer-term clinical impact, improvement of symptoms, safety, operative assessments, sexual function, cost-effectiveness and an evaluation of patients' and clinicians' views and experiences of the interventions.

DISCUSSION

There is a lack of high-quality, randomised, scientific evidence for which treatment is best for women presenting with recurrent SUI. The PURSUIT study will benefit healthcare professionals and patients and provide robust evidence to guide further treatment and improve symptoms and quality of life for women with this condition.

TRIAL REGISTRATION

International Standard Randomised Controlled Trials Number (ISRCTN) registry ISRCTN12201059. Registered on 09 January 2020.

Female Urgency, Trial of Urodynamics as Routine Evaluation (FUTURE study): a superiority randomised clinical trial to evaluate the effectiveness and cost-effectiveness of invasive urodynamic investigations in management of women with refractory overactive bladder symptoms

BACKGROUND

Overactive bladder (OAB) syndrome is a symptom complex affecting 12-14% of the UK adult female population. Symptoms include urinary urgency, with or without urgency incontinence, increased daytime urinary frequency and nocturia. OAB has a negative impact on women's social, physical, and psychological wellbeing. Initial treatment includes lifestyle modifications, bladder retraining, pelvic floor exercises and pharmacological therapy. However, these measures are unsuccessful in 25-40% of women (refractory OAB). Before considering invasive treatments, such as Botulinum toxin injection or sacral neuromodulation, most guidelines recommend urodynamics to confirm diagnosis of detrusor overactivity (DO). However, urodynamics may fail to show evidence of DO in up to 45% of cases, hence the need to evaluate its effectiveness and cost-effectiveness. FUTURE (Female Urgency, Trial of Urodynamics as Routine Evaluation) aims to test the hypothesis that, in women with refractory OAB, urodynamics and comprehensive clinical assessment is associated with superior patient-reported outcomes following treatment and is more cost-effective, compared to comprehensive clinical assessment only.

METHODS

FUTURE is a pragmatic, multi-centre, superiority randomised controlled trial. Women aged ≥ 18 years with refractory OAB or urgency predominant mixed urinary incontinence, and who have failed/not tolerated conservative and medical treatment, are considered for trial entry. We aim to recruit 1096 women from approximately 60 secondary/tertiary care hospitals across the UK. All consenting women will complete questionnaires at baseline, 3 months, 6 months and 15 months post-randomisation. The primary outcome is participant-reported success at 15 months post-randomisation measured using the Patient Global Impression of Improvement. The primary economic outcome is incremental cost per quality-adjusted life year gained at 15 months. The secondary outcomes include adverse events, impact on other urinary symptoms and health-related quality of life. Qualitative interviews with participants and clinicians and a health economic evaluation will also be conducted. The statistical analysis of the primary outcome will be by intention-to-treat. Results will be presented as estimates and 95% CIs.

DISCUSSION

The FUTURE study will inform patients, clinicians and policy makers whether routine urodynamics improves treatment outcomes in women with refractory OAB and whether it is cost-effective.

TRIAL REGISTRATION

ISRCTN63268739 . Registered on 14 September 2017.

A challenging road to diagnosing transthyretin cardiac amyloidosis and using technetium-99m pyrophosphate bone scintigraphy in nuclear cardiology - A case report

Cardiac amyloidosis (CA) is a rare form of protein deposition disease, leading to restrictive cardiomyopathy that often presents with signs and symptoms of unexplained heart failure with preserved ejection fraction (HFpEF). There are two main subtypes of CA, namely light chain amyloidosis (AL) and transthyretin amyloidosis (ATTR), which are conventionally confirmed by endomyocardial biopsy (EMB). The prognosis and treatment of the subtypes differ extensively, making it crucial to distinguish between the two. Although echocardiography (ECHO) and cardiac magnetic resonance imaging (CMR) are useful to aid in the diagnosis, they are unable to differentiate between the subtypes. Advantageously, the transthyretin cardiac amyloidosis (ATTR-CA) subtype can be diagnosed based on nuclear medicine bone scintigraphy imaging using Technetiumlabelled bone-seeking radiotracers. We report a case of a previously well, elderly gentleman who presented with acute heart failure symptoms, whereby ECHO findings were suspicious for CA. Technetium-99m pyrophosphate (99mTc- PYP) bone scintigraphy performed with complementary single photon emission computed tomography/computed tomography (SPECT/CT) at three hours post-injection revealed radiotracer uptake in the myocardium that was higher than the skeletal bone uptake. This corresponded to Perugini score of 3 along with an increased heart to contralateral lung ratio (H:CL) of 1.69. The bone scintigraphy findings together with his symptoms, ECHO, CMR, and laboratory results enabled the diagnosis of ATTR-CA to be made. In summary, bone scintigraphy offers a reliable and non-invasive method for the diagnosis of ATTR-CA. We also highlight the diagnostic pitfalls and recommendations in reporting bone scintigraphy for the indication of typing cardiac amyloidosis.

Cerebral Venous Thrombosis Associated with COVID-19 Infection: An Observational, Multicenter Study

Background and Purpose

Coronavirus disease 2019 (CO­VID-19) has an increased propensity for systemic hypercoagulability and thromboembolism. An association with cerebrovascular diseases, especially cerebral venous thrombosis (CVT), has been reported among these patients. The objective of the present study was to identify risk factors for CVT as well as its presentation and outcome in COVID-19 patients.

Methods

This is a multicenter and multinational observational study. Ten centers in 4 countries (Pakistan, Egypt, Singapore, and the United Arab Emirates) participated in this study. The study included patients (aged >18 years) with symptomatic CVT and recent COVID-19 infection.

Results

Twenty patients (70% men) were included. Their mean age was 42.4 years, with a male-to-female ratio of 2.3:1. Headache (85%) and seizures (65%) were the common presenting symptoms, with a mean admission Glasgow Coma Scale (GCS) score of 13. CVT was the presenting feature in 13 cases (65%), while 7 patients (35%) developed CVT while being treated for COVID-19 infection. Respiratory symptoms were absent in 45% of the patients. The most common imaging finding was infarction (65%), followed by hemorrhage (20%). The superior sagittal sinus (65%) was the most common site of thrombosis. Acute inflammatory markers were raised, including elevated serum D-dimer (87.5%), erythrocyte sedimentation rate (69%), and C-reactive protein (47%) levels. Homocysteine was elevated in half of the tested cases. The mortality rate was 20% (4 patients). A good functional outcome was seen in the surviving patients, with a mean modified Rankin Scale score at discharge of 1.3. Nine patients (45%) had a modified Rankin Scale score of 0–1 at discharge.

Conclusion

COVID-19-related CVT is more common among males at older ages when compared to previously reported non-COVID-19-related CVT cases. CVT should be suspected in COVID-19 patients presenting with headache or seizures. Mortality is high, but functional neurological outcome is good among survivors.

Preparedness and impact of COVID 19 infection at tertiary care neurology centers in Pakistan

Objective

We aimed to assess the response and impact of covid 19 pandemic at tertiary care centers in Pakistan especially pertaining to neurological care, facilities and training.

Methods

A pre-tested survey form was sent to 40 neurology tertiary care centers in all the provinces in the country in the first week of July 2020. 33 filled forms were received, out of which 18 were public (government) and 15 were private hospitals.

Results

Estimated 1300 HCW (faculty, medical officers, trainees and nurses) work at these 33 participating centers. There were 17 deaths among HCW (1.3%) at ten centers. Sufficient personal protective equipment (PPE) were provided to 158 HCW (12%). 129 (10%)HCW tested positive for COVID 19 at 31 centers including trainees/medical officers (39), consultants (29) and nursing and other staff (61). Due to low neurology admissions, 23/33 hospitals (70%) posted neurology trainees in COVID 19 units to contribute to covid care. Less than 50% hospitals did covid screening PCR before admission to neurology wards. Only 10% hospitals provide training and regular update to HCW. Neurology tele-health services were started for clinically stable patients at 15 (45%) centers. Only 60% neurology training programs were able to start online training. Ongoing research studies and trials focusing neurological manifestations of COVID-19 were done at 10 (30%) centers. Modification of facilities for COVID patients showed that 24(72%) hospitals strictly reduced the number of attendants accompanying patients. Only 10 (30%) centers had neurophysiological tests being conducted on COVID-19 patients. Mental health support services to HCW were provided at 12 (36%) centers.

Conclusions

Among HCW 10% tested positive for covid and 1.3% died. Mental health support services offered for HCW were available in 36% institutions. Neurology training was substantially affected due to low admissions, limited ward rounds and limited availability of online training.

Current process and outcomes of the surgical management of LUTS due to benign prostatic enlargement: how consistent are we? - results from the multi-institutional audit of surgical management of BPE (AuSuM BPE) in the United Kingdom

OBJECTIVE

In view of changing landscape of surgical treatment for LUTS secondary to BPE, this audit was undertaken to assess key aspects of the processes and outcomes of the current interventional treatments for BPE, across different units in the UK.

MATERIALS AND METHOD

A multi-institutional snapshot audit was conducted for patients undergoing interventions for LUTS/BPE over 8-week period. Using Delphi process two-part proforma was designed to capture data.

RESULTS

529 patients were included across 20 NHS trusts in England and Wales. Median age was 73 years. Indications for surgery were acute retention (47%) and LUTS (45%). 80% of patients had prior medical therapy. TURP formed the commonest procedure. 27% patients had <23 hour hospital stay. Immediate (21%) and delayed (18%) complications were Clavien-Dindo <2 category. High proportion of patients reported residual symptoms. Type and indication of surgery were significant predictor of complications, length of stay and failure of TWOC outcomes, on multivariate analyses. There were variations in departmental processes, 50% centres used PROMs.

CONCLUSION

Monopolar TURP still remains the commonest intervention for BPE. Most departments are adopting newer technologies. The audit identified opportunities for development of consistent, effective and patient centric practices as well as need for large-scale focused studies.

The relationship between marketing strategies and innovative market orientation on performance of halal-certified agro-food SMEs

Changes in Malaysian’s lifestyle have resulted in an increased demand for trusted agrofood products. Therefore, it is becoming a challenge for halal-certified agro-food SMEs in Malaysia to fulfil the demand by implementing marketing strategies and innovative market orientation. This study aimed to investigate the relationship between marketing strategies and innovative market orientation on performance of halal-certified agro-food SMEs. A systematic random sampling was used to select 321 halal-certified agro-food SMEs located in Peninsular Malaysia and a self-administered questionnaire using a structured questionnaire was employed to obtain responses from the target SMEs. Descriptive analysis, Chi-square analysis, and Pearson correlation analysis were carried out to analyse the data. Majority of the halal-certified agro-food SMEs involved in the study were categorised as small-sized companies with at least 5 to 75 employees. The finding revealed that there was no association between annual average sales and overall performance of halal-certified agro-food SMEs. The finding further indicated that there was a strong positive relationship between the performance (market share, sales, profitability, and growth rate) of halal-certified agro-food SMEs and marketing strategies and innovative market orientation. It is suggested that the halal-certified agro-food SMEs utilize their experience to develop more effective marketing strategies for better performance.

Stroke in the Middle-East and North Africa: A 2-year prospective observational study of intravenous thrombolysis treatment in the region. Results from the SITS-MENA Registry

BACKGROUND AND METHODS

Intravenous thrombolysis for acute ischemic stroke in the Middle-East and North African (MENA) countries is still confined to the main urban and university hospitals. This was a prospective observational study to examine outcomes of intravenous thrombolysis-treated stroke patients in the MENA region compared to the non-MENA stroke cohort in the SITS International Registry.

RESULTS

Of 32,160 patients with ischemic stroke registered using the SITS intravenous thrombolysis protocol between June 2014 and May 2016, 500 (1.6%) were recruited in MENA. Compared to non-MENA (all p < 0.001), median age in MENA was 55 versus 73 years, NIH Stroke Scale score 12 versus 9, onset-to-treatment time 138 versus 155 min and door-to-needle time 54 min versus 64 min. Hypertension was the most reported risk factor, but lower in MENA (51.7 vs. 69.7%). Diabetes was more frequent in MENA (28.5 vs. 20.8%) as well as smoking (20.8 vs. 15.9%). Hyperlipidemia was less observed in MENA (17.6 vs. 29.3%). Functional independence (mRS 0-2) at seven days or discharge was similar (53% vs. 52% in non-MENA), with mortality slightly lower in MENA (2.3% vs. 4.8%). SICH rates by SITS-MOST definition were low (<1.4%) in both groups.

CONCLUSIONS

Intravenous thrombolysis patients in MENA were younger, had more severe strokes and more often diabetes. Although stroke severity was higher in MENA, short-term functional independency and mortality were not worse compared to non-MENA, which could partly be explained by younger age and shorter OTT in MENA. Decreasing the burden of stroke in this young population should be prioritized.

Pleuritic chest pain and fever: An unusual presentation of aortic dissection

It remains a challenge to diagnose aortic dissection in primary care, as classic clinical features are not always present. This case describes an atypical presentation of aortic dissection, in which the patient walked in with pleuritic central chest pain associated with a fever and elevated C-reactive protein. Classic features of tearing pain, pulse differentials, and a widened mediastinum on chest X-ray were absent. This unusual presentation highlights the need for a heightened level of clinical suspicion for aortic dissection in the absence of classic features. The case is discussed with reference to the literature on the sensitivity and specificity of the classic signs and symptoms of aortic dissection. A combination of the aortic dissection detection risk score (ADD-RS) and D-dimer test is helpful in ruling out this frequently lethal condition.

Stroke in the Middle-East and North Africa: A 2-year prospective observational study of stroke characteristics in the region-Results from the Safe Implementation of Treatments in Stroke (SITS)-Middle-East and North African (MENA)

BACKGROUND AND METHODS

Stroke incidence and mortality are reported to have increased in the Middle-East and North African (MENA) countries during the last decade. This was a prospective observational study to examine the baseline characteristics of stroke patients in the MENA region and to compare the MENA vs. the non-MENA stroke cohort in the Safe Implementation of Treatments in Stroke (SITS) International Registry.

RESULTS

Of the 13,822 patients with ischemic and hemorrhagic stroke enrolled in the SITS-All Patients Protocol between June 2014 and May 2016, 5897 patients (43%) were recruited in MENA. The median onset-to-door time was 5 h (IQR: 2:20-13:00), National Institutes of Health Stroke Scale (NIHSS) score was 8 (4-13) and age was 65 years (56-76). Hypertension (66%) and diabetes (38%) were the prevailing risk factors; large artery stenosis > 50% (25.3%) and lacunar strokes (24.1%) were the most common ischemic stroke etiologies. In comparison, non-MENA countries displayed an onset-to-door time of 5:50 h (2:00-18:45), a median of NIHSS 6 (3-14), and a median age of 66 (56-76), with other large vessel disease and cardiac embolism as the main ischemic stroke etiologies. Hemorrhagic strokes (10%) were less common compared to non-MENA countries (13.9%). In MENA, only a low proportion of patients (21%) was admitted to stroke units.

CONCLUSIONS

MENA patients are slightly younger, have a higher prevalence of diabetes and slightly more severe ischemic strokes, commonly of atherosclerotic or microvascular etiology. Admission into stroke units and long-term follow-up need to be improved. It is suspected that cardiac embolism and atrial fibrillation are currently underdiagnosed in MENA countries.

Optical and magnetic properties of Al/NiFe and Al/Ge/NiFe nanosized films

Nanosized films with ferromagnetic layers are widely used in nanoelectronics, sensor systems and telecommunication. The physical and magnetic properties of nanolayers may significantly differ from those known for bulk materials due to fine crystalline structure, influence of interfaces, roughness, and diffusion. In this work, we are employing a spectral ellipsometry method, magneto-optical Kerr magnetometry and VSM to investigate the impact of layer thickness on the optical constants and magnetization processes for two and three layer films of the type Al/NiFe/sitall, Al/Ge/NiFe/sitall on sitall substrate for different thickness of the upper Al layers. The refractive indexes of two layer films are well resolved by spectral ellipsometry demonstrating their good quality. Modelling data for three-layer films show considerable discrepancy with the experiment, which can be related to a stronger influence of interfaces. The magnetization processes of two-layer films weakly depend on the type and thickness of the upper non-ferromagnetic layers. However, the coercivity of three layer films may significantly change with the thickness of the upper layer: more than twice when the thickness of Al layer increases from 4 to 20 nm.

The hyperdense basilar artery sign: a case of locked-in syndrome

Background

Locked-in syndrome, although a notoriously famous clinical entity, the rarity of the condition coupled with the variability of clinical features on acute presentation represents a potential diagnostic pitfall for the emergency physician.

Case

A previously healthy 25-year-old female was brought to our Emergency Department after being found unresponsive. On examination, she was conscious and alert with a Glasgow Coma Score of 9; on neurological examination, the patient was quadriplegic and unable to speak but was able to move her eyes and blink. Non-contrast brain computed tomography (CT) revealed a hyperdense basilar artery, and CT cerebral angiography confirmed basilar artery thrombosis.

Conclusion

This case highlights the need for a high index of suspicion to make a diagnosis of locked-in syndrome in the Emergency Department, especially in young patients with no apparent risk factors for an ischemic stroke. The hyperdense basilar artery sign is one of the earliest signs on non-contrast CT imaging and may be the only clue to guide further management in a patient with basilar artery occlusion.

Nocturia: risk factors and associated comorbidities; findings from the EpiLUTS study

OBJECTIVE

To evaluate the risk factors and comorbidities associated with nocturia in men and women aged ≥ 40 years.

MATERIAL AND METHODS

The EpiLUTS study was an Internet-based cross-sectional, population-representative survey involving 30,000 men and women from the USA, UK and Sweden evaluating lower urinary tract symptoms (LUTS) using the LUTS Tool. A secondary analysis of the EpiLUTS data using participants with nocturia was performed. Descriptive statistics were used to examine the data. Logistic regressions were used to analyse associations of comorbid conditions and risk factors in men and women with nocturia ≥ 2.

RESULTS

With a 59% response rate, nocturia ≥ 1 was quite common at 69% in men and 76% in women; 28% men and 34% women had nocturia ≥ 2. Age, body mass index (in women), Hispanic and Black responders, diabetes, high blood pressure, anxiety and depression and a history of bed-wetting were significantly associated with nocturia ≥ 2. Arthritis, asthma, diabetes, heart disease, inflammatory bowel disease, bladder infection, uterine prolapse, hysterectomy and menopausal status were all significantly associated with nocturia ≥ 2 in women. Prostatitis and prostate cancer were significant in men with nocturia ≥ 2. British and Swedish participants had a lesser risk of nocturia ≥ 2.

CONCLUSION

Nocturia is a highly prevalent condition associated with various risk factors and comorbidities. Treatment of nocturia should be aimed at these causes in a multidisciplinary fashion. Further studies are needed to look specifically at these conditions in the pathophysiology of nocturia.

Do the symptoms of obstructive sleep apnea syndrome exist in highly trained Malay security personnel?

OBJECTIVE

Obstructive Sleep Apnea Syndrome (OSAS) has been associated with excessive daytime sleepiness, which may lead to reduced alertness. This study determines the distribution of OSAS among highly trained Malay male security personnel, an occupation that requires constant alertness.

METHODS

Berlin questionnaires (Malay version) were distributed and the body mass index (BMI) and neck circumference were measured. This questionnaire asked for symptoms indicative of OSAS and consists of three categories: snoring, excessive daytime sleepiness/fatigue, and the presence of obesity or hypertension.

RESULTS

In total, 661 respondents were involved in this study. There was a range of prevalence of the main symptoms of OSAS with 45 subjects (6.8%, 95%CI: 5.0-9.0) categorized in the high risk group for OSAS. There was no significant difference in age, but the BMI and neck circumference were significantly higher in the high risk group (p<0.001).

CONCLUSION

The presence of OSAS symptoms in highly trained security personnel found in this study suggests the need to screen for this syndrome in individuals involved in high risk occupations.

Drug resistant neuroleptic malignant syndrome and the role of electroconvulsive therapy

Neuroleptic malignant syndrome is considered as a rare but potentially fatal complication of neuroleptic medications e.g.,antipsychotics, sedatives and anti emetics. It is characterized by hyperthermia, muscle rigidity, an elevated creatine kinase level and autonomic instability. The syndrome often develops after the start of antipsychotic or a sudden increase in dosage of the neuroleptic medication or in states of dehydration. Treatment is mainly supportive and includes withdrawal of the neuroleptic medication and, possibly, administration of drugs such as dantrolene and bromocriptine. In rare cases where drugs treatment remains ineffective a trial of electroconvulsive therapy is being given. The case presented is a drug resistant case of Neuroleptic Malignant Syndrome where finally electroconvulsive therapy was effective.

Management of recurrent stress urinary incontinence and urinary retention following midurethral sling insertion in women

INTRODUCTION

Synthetic midurethral slings are the most common operations performed for women with stress urinary incontinence (SUI). However, there is only very scarce evidence regarding the management of complications from these operations. The aim of this survey was to canvass expert opinion regarding the management of recurrent SUI and urinary retention following insertion of these slings.

METHODS

Expert urologists and urogynaecologists in the UK with an interest in SUI were identified. Three clinical scenarios on recurrent SUI and one on urinary retention following midurethral sling placements were emailed twice to the experts.

RESULTS

The majority of the experts chose a repeat synthetic midurethral retropubic transvaginal tape (TVT) as the procedure of choice for recurrent SUI in patients who had had a previous TVT or midurethral transobturator tape inserted. In patients who continued to suffer SUI after a failed second TVT, there were mixed results with experts choosing fascial slings, colposuspension and bulking agents as their preferred method of treatment. In women who develop urinary retention following a TVT, tape pull-down within two weeks was the preferred method among the experts. However, division of the tape within two to six weeks following the procedure was also popular.

CONCLUSIONS

Based on expert opinion, it is difficult to make a recommendation as to the best method of treating recurrent SUI or urinary retention following tape insertion. There is an urgent requirement for well conducted, multicentre, randomised clinical trials to look at the management of these complications and also the tools used to assess the patient before salvage surgical management.

Polymorphisms of UGT1A1*6, UGT1A1*27 & UGT1A1*28 in three major ethnic groups from Malaysia

BACKGROUND & OBJECTIVES

Genetic polymorphisms of uridine diphosphate glucuronyltransferase 1A1 (UGT1A1) have been associated with a wide variation of responses among patients prescribed with irinotecan. Lack of this enzyme is known to be associated with a high incidence of severe toxicity. The objective of this study was to investigate the prevalence of three different variants of UGT1A1 (UGT1A1*6, UGT1A1*27 and UGT1A1*28), which are associated with reduced enzyme activity and increased irinotecan toxicity, in the three main ethnic groups in Malaysia (Malays, Chinese and Indians).

METHODS

A total of 306 healthy unrelated volunteers were screened for UGT1A1*28, UGT1A1*6 and UGT1A1*27. Blood samples (5 ml) were obtained from each subject and DNA was extracted. PCR based methods were designed and validated for detection of UGT1A1*, UUGT1A1*27 and UUGT1A1*28. Direct DNA sequencing was performed to validate the results of randomly selected samples.

RESULTS

Malays and Indian have two-fold higher frequency of homozygous of UGT1A1*28 (7TA/7TA) which was 8 and 8.8 per cent, respectively compared to the Chinese (4.9%). However, the distribution of UGT1A1*6 and UGT1A1*27 showed no significant differences among them. UGT1A1*27 which has not been detected in Caucasian and African American population, was found in the Malaysian Malays (3.33%) and Malaysian Chinese (2.0%).

INTERPRETATION & CONCLUSIONS

There was interethnic variability in the frequency of UGT1A1*28 in the Malaysian population. Our results suggest that genotyping of UUGT1A1*6, UGT1A1*28 and UGT1A1*27 need to be performed before patients are prescribed with irinotecan due to their high prevalence of allelic variant which could lead to adverse drug reaction.

Dutasteride/tamsulosin fixed-dose combination for the treatment of benign prostatic enlargement

Fixed-dose dutasteride/tamsulosin is a combination therapy for lower urinary tract symptoms secondary to benign prostatic enlargement (LUTS/BPE), which is composed of two active ingredients, tamsulosin and dutasteride. Tamsulosin is an α-adrenoceptor blocker that is relatively selective for the α(1A)-adrenoceptor subtype within the prostatic smooth muscles. The inhibition of α(1A)-adrenoceptors results in smooth muscle relaxation. Dutasteride is an inhibitor of 5α-reductase, an enzyme that is responsible for the conversion of testosterone to its active form dihydrotestosterone. This occurs in the prostate, liver and skin. 5α-Reductase results in the shrinkage of the prostatic epithelium and reduction in the size of the prostate. No clinical studies have been performed on the fixed-dose dutasteride/tamsulosin combination, although several clinical trials have been conducted on the combination therapy of 5α-reductase and α-adrenoceptor blockers for LUTS/BPE. The CombAT study is a multicenter, randomized, double-blind trial in men with a clinical diagnosis of LUTS/BPE that is comparing tamsulosin or dutasteride as a monotherapy to tamsulosin and dutasteride as combination therapy (as separate tablets). The combination therapy was associated with significant improvements in the symptom score compared to tamsulosin or dutasteride as monotherapy. It is therefore logical to combine the two medications into one tablet.

Thinking beyond the bladder: antidiuretic treatment of nocturia

Nocturia is a bothersome and highly prevalent urological condition characterised by the need to wake to void at night. Contrary to popular misconception, nocturia is equally common in men and women, and although its prevalence increases with age, a significant proportion of younger people are also affected. Nocturia leads to repeated fragmentation of sleep and consequently to a serious decline in daytime functioning and in overall quality of life and health. As such, its impact should not be underestimated by clinicians. Traditionally, nocturia has been regarded as a symptom of benign prostatic enlargement and/or overactive bladder syndrome, with treatment therefore directed towards increasing the capacity of the bladder to hold urine. Such treatments have proven largely ineffective in many patients, likely because nocturnal polyuria (NP), a condition that results in overproduction of urine at night, has been found to be present in the majority of nocturia patients. As such, the traditional belief that nocturia is attributable to some other underlying pathological factors, is now being replaced by the acknowledgment that it can be a distinct clinical entity with specific pathogenesis. Frequency-volume charts are an invaluable tool, recommended for routine use in clinical practice, to determine whether nocturia is a result of excessive urine production at night, or of small voided volumes (indicating bladder storage problems), or indeed a combination of these factors. Given the specific antidiuretic action of desmopressin, a synthetic analogue of the body's own antidiuretic hormone, it should be considered as first-line therapy for patients with nocturia where NP is present.

Novel uses for antidiuresis

Overactive bladder (OAB) is a bothersome condition that affects millions of people worldwide. It consists of urgency, incontinence, frequency and nocturia. Treatment, in the form of lifestyle interventions, bladder training and pelvic floor muscle exercises, aim to alleviate symptoms. These treatment modalities have drawbacks, including being time consuming and require stamina on the part of the patient and treating physician. Drugs may be used if conservative measures fail or in combination with them. Antimuscarinics are the mainstay of OAB medication but may cause dry mouth, blurred vision or constipation. It is, therefore, crucial that new treatment modalities are sought to help with this potentially debilitating condition. Antidiuresis, using desmopressin, forms a potential candidate for a novel treatment. As the bladder fills with urine, symptoms of OAB are experienced by patients. It would be reasonable to hypothesise that if the rate of bladder filling is reduced then so would the symptoms of OAB. Desmopressin reduces the production of urine by the kidneys, therefore reducing the amount of urine in the bladder and, therefore, the symptoms of OAB. Desmopressin has been used previously in small single centre trials in neurogenic OAB patients with some success but recently two multi-centre, multinational randomised placebo controlled trials using this concept have been completed in idiopathic OAB sufferers and reported in the literature. The results were quite promising although there were minor side effects. These trials suggest that this potential novel treatment modality for OAB sufferers might avoid the necessity for invasive treatments, such as botulinum toxin, neuromodulation or surgery, in some instances. These trials also open the way to combination therapy with current treatment modalities of OAB.

The Arabic ICIQ-UI SF: an alternative language version of the English ICIQ-UI SF

AIMS

Urinary incontinence (UI) is a common and distressing condition. A variety of questionnaires are currently available to assess UI and its impact on patients' lives. However, most have not been adapted for international use. Following a systematic review of the literature and existing questionnaires the International Consultation on Incontinence short form questionnaire (ICIQ-UI SF) was developed, and has since been translated into many languages for local use. This paper reports the development and validation of the first UI questionnaire in the Arabic language. The development of this questionnaire will facilitate the assessment of UI in both clinical practice and research in the Middle-East.

METHODS

Translation and validation of the Arabic version of the ICIQ-UI is described. Standard methods of translation by native Arabic and English speakers (including translation and back translation) are followed. The psychometric properties of the questionnaire, including its validity, reliability and sensitivity to change, are examined. The validation of the questionnaire involved patients attending urology outpatient clinics in two Middle-Eastern countries.

RESULTS

The Arabic ICIQ-UI SF was found to be valid, reliable and responsive, indicating that the psychometric properties of the questionnaire have remained constant throughout the adaptation process. Furthermore, the findings of the psychometric testing confirm those found for the UK-English ICIQ-UI SF.

CONCLUSIONS

The development of this questionnaire will allow the study of Arabic speaking groups with UI in many countries around the world. This may act as an example to initiate the translation and validation of other patient reported outcomes into the Arabic language, thereby enabling more multinational and cross-cultural research into diseases in given areas.

Is the bladder a reliable witness for predicting detrusor overactivity?

PURPOSE

We determined how well the symptoms of OAB syndrome correlate with urodynamic DO using International Continence Society definitions.

MATERIALS AND METHODS

The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004. Patients were selected based on OAB syndrome symptoms (urgency, urgency urinary incontinence and frequency). The percent of patients who had symptoms alone or in combination and DO was calculated.

RESULTS

There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women. Of men 69% and 44% of women with urgency (OAB dry) had DO, while 90% of men and 58% of women with urgency and urgency urinary incontinence (OAB wet) had DO. Stress urinary incontinence seems to have accounted for the decreased rates in women since 87% of women with urgency urinary incontinence also had the symptom of stress urinary incontinence. The ICS definition does not specify what constitutes abnormal voiding frequency. Analysis of results showed that increasing voiding frequency did not have any effect on increasing the accuracy of diagnosis of DO except in women with 10 or more daytime micturition episodes.

CONCLUSIONS

The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO, more so in the OAB wet than in OAB dry patients.

Trying to predict 'dangerous' bladders in children: the area under the curve concept

OBJECTIVE

Children with neurological and non-neurological lower urinary tract dysfunction normally undergo video urodynamics. One reason is to try to diagnose 'dangerous' bladders. Currently, bladder compliance is used to predict 'dangerous' bladders; however, in children there are no standardized methods of measurement and thus no 'cut-off' values. Compliance may also be normal even though high-pressure detrusor overactivity waves may exist during the filling phase of urodynamics. We tried to determine whether measuring the area under the detrusor pressure curve (AUC) during the filling phase of urodynamics would be a useful parameter in predicting 'dangerous' bladders.

PATIENTS AND METHODS

Children referred to the urodynamics unit at Southmead Hospital, a tertiary referral centre, from 2000 to 2004 were investigated. Although 130 patients were identified, only 15 patients had raw data which were analysable using the available computer software.

RESULTS

There was no correlation between the AUC and predicting 'dangerous' bladders possibly due to limitations in the computer software.

CONCLUSION

Although the study did not reveal any correlation between the AUC and 'dangerous' bladders, it revealed the limitations of the available computer software in determining AUC, and highlighted the need for new standardized software and multinational, multi-centre trials to look into the concept of AUC. There is also a need for the International Continence Society to standardize methods and terminology in predicting 'dangerous' bladders.