A systematic review to examine the impact of psycho-educational interventions on health outcomes and costs in adults and children with difficult asthma

OBJECTIVES

Prior research has highlighted the importance of psychosocial factors in 'difficult' asthma. This study aimed to review the content, effectiveness and cost-effectiveness of psycho-educational interventions designed to address these factors in patients with severe and difficult asthma.

DATA SOURCES

Thirty-two electronic databases and other sources were searched for studies of educational, self-management, psychosocial and multifaceted interventions.

REVIEW METHODS

Abstracts were screened in duplicate, against prior definitions, to identify eligible interventions targeted to patients with forms of or risk factors for difficult asthma. Studies were classified by patient group (child, adult) and graded along two dimensions related to study design and relevance in terms of the degree to which they were judged to have targeted difficult asthma. Detailed data were extracted from studies meeting a minimum design and relevance threshold. Characteristics of studies were tabulated and results qualitatively synthesised. Where sufficiently similar studies reported adequate data about comparable outcomes, quantitative syntheses of results were undertaken using a random effects approach to calculate pooled relative risks (RR) or standardised mean differences (SMD), with 95% confidence intervals (CI).

RESULTS

Searches identified over 23,000 citations. After initial screening and removal of duplicates, 4240 possibly relevant abstracts were assessed. Papers associated with 188 studies were initially obtained and classified. Fifty-seven studies including control groups and those that were judged to have at least 'possible' targeting of difficult asthma (35 in children, 21 in adults, 1 in both) were selected for in-depth review. The delivery, setting, timing and content of interventions varied considerably even within broad types. Reporting of interventions and methodological quality was often poor, but studies demonstrated some success in targeting and following up at-risk patients. Studies reporting data suitable for calculation of summary statistics were of higher quality than those that did not. There was evidence from these that, compared to usual or non-psycho-educational care, psycho-educational interventions reduced admissions when data from the latest follow-ups reported were pooled across nine studies in children (RR = 0.64, CI = 0.46-0.89) and six studies with possible targeting of difficult asthma in adults (RR = 0.57, CI = 0.34-0.93). In children, the greatest and only significant effects were confined to individual studies with limited targeting of difficult asthma and no long-term follow-up. Limited data in adults also suggested effects may not extend to those most at risk. There was no evidence of pooled effects of psycho-educational interventions on emergency attendances from eight studies in children (RR = 0.97, CI = 0.78-1.21) and four in adults (RR = 1.03, CI = 0.82-1.29). There were overall significant reductions in symptoms, similar in different sub-groups of difficult asthma, across four paediatric studies that could be combined (SMD = -0.45, CI = -0.68 to -0.22), but mixed results across individual adult studies. A few individual studies in children showed mainly positive effects on measures of self-care behaviour, but with respect to all other outcomes in adults and children, studies showed mixed results or suggested limited effectiveness of psycho-educational interventions. No studies of psychosocial interventions were included in any quantitative syntheses and it was not possible to draw clear conclusions regarding the relative effectiveness of educational, self-management and multifaceted programmes. Data on costs were very limited. Of the two well-designed economic evaluations identified, both of multifaceted interventions, one in children suggested an additional cost of achieving health gain in terms of symptom-free days. Provisional data from the other study suggested that in adults the significantly increased costs of providing an intervention were not offset by any short-term savings in use of healthcare resources or associated with improvements in health outcomes.

CONCLUSIONS

There was some evidence of overall positive effects of psycho-educational interventions on hospital admissions in adults and children, and on symptoms in children, but limited evidence of effects on other outcomes. The majority of research and greatest effects, especially in adults, were confined to patients with severe disease but who lacked other characteristics indicative of difficult asthma or likely to put them at risk. A lack of good-quality research limited conclusions about cost-effectiveness. Although psycho-educational interventions may be of some benefit to patients with severe disease, there is currently a lack of evidence to warrant significant changes in clinical practice with regard to the care of patients with more difficult asthma. Further research is needed to: (1) standardise reporting of complex interventions; (2) extend and update this review; (3) improve identification of patients at risk from their asthma; (4) develop and test appropriate outcome measures for this group; and (5) design and evaluate, via the conduct of high-quality pragmatic RCTs, more powerful psycho-educational interventions that are conceptualised in terms of the ways in which psychosocial factors and asthma interact.

The Coping with Asthma Study: a randomised controlled trial of a home based, nurse led psychoeducational intervention for adults at risk of adverse asthma outcomes

BACKGROUND

Morbidity and mortality associated with severe asthma might be reduced by interventions that address psychosocial factors contributing to adverse outcomes. A study was undertaken to assess the effectiveness of a 6 month home based psychoeducational intervention delivered by a respiratory nurse specialist for adults at risk of adverse asthma outcomes.

METHODS

A pragmatic randomised controlled trial was performed in 92 adults registered with hospital or primary care asthma clinics. All had previous hospital admissions and/or were on British Thoracic Society step 4-5 treatment and had failed to attend clinic appointments or were considered to have poor adherence to other aspects of their agreed management. Patients were visited in their homes for assessment and, where appropriate, intervention. The main outcomes measured were symptom control, asthma specific quality of life, and generic health status.

RESULTS

At the 6 month primary time point there were no significant differences between usual care and intervention groups in mean symptom control, physical functioning, or mental health scores (differences (with 95% CI) -0.35 (-1.83 to 1.13), 3.10 (-11.42 to 17.63), 0.42 (-10.22 to 11.07), respectively). Small effects on asthma specific quality of life up to 12 months (e.g. adjusted difference at 12 months 0.13 (95% CI 0.02 to 0.25)) and short term effects on generic health status, which mirrored improvements in aspects of self-care observed at the end of the intensive phase of the intervention, were apparent only from fully adjusted analyses.

CONCLUSIONS

A home based intervention provided by a nurse receiving psychological supervision may have effects on quality of life but is overall of limited long term benefit to adults at risk of adverse asthma outcomes.

Laparoscopic retroperitoneal live donor right nephrectomy for purposes of allotransplantation and autotransplantation

PURPOSE

We report the technique of and initial experience with retroperitoneal laparoscopic live donor right nephrectomy for purposes of renal allotransplantation and autotransplantation.

MATERIALS AND METHODS

A total of 5 patients underwent retroperitoneoscopic live donor nephrectomy of the right kidney for autotransplantation in 4 and living related renal donation in 1. Indications for autotransplantation included a large proximal ureteral tumor, a long distal ureteral stricture and 2 cases of the loin pain hematuria syndrome. In all cases a 3-port retroperitoneal laparoscopic approach and a pelvic muscle splitting Gibson incision for kidney extraction were used. In patients undergoing autotransplantation the same incision was used for subsequent transplantation.

RESULTS

All procedures were successfully accomplished without technical or surgical complications. Total mean operating time was 5.8 hours and average laparoscopic donor nephrectomy time was 3.1 hours. Mean renal warm ischemia time, including endoscopic cross clamping of the renal artery to ex vivo cold perfusion, was 4 minutes. Average blood loss for the entire procedure was 400 cc. Radionuclide scan on postoperative day 1 confirmed good blood flow and function in all transplanted kidneys. Mean analgesic requirement was 58 mg. fentanyl. Mean hospital stay was 4 days (range 2 to 8), and convalescence was completed in 3 to 4 weeks.

CONCLUSIONS

In the occasional patient requiring renal autotransplantation live donor nephrectomy can be performed laparoscopically with renal extraction and subsequent transplantation through a single standard extraperitoneal Gibson incision, thus, minimizing the overall operative morbidity. Furthermore, these data demonstrate that live donor nephrectomy of the right kidney can be performed safely using a retroperitoneal approach with an adequate length of the right renal vein obtained for allotransplantation or autotransplantation.

Constitutive activation of stimulatory guanine nucleotide binding protein (G(S)alphaQL)-mediated signaling increases invasiveness and tumorigenicity of PC-3M prostate cancer cells

An abnormal stimulation of cAMP signaling cascade has been implicated in various human carcinomas. Since the agents activating G(S)alpha-mediated signaling pathways have been shown to increase in vitro proliferation of prostate cancer cells, present studies examined the G(S)alpha-mediated signaling in tumorigenicity and invasiveness of PC-3M prostate cancer cells. PC-3M cells were stably transfected with plasmids containing either wild type (G(S)alpha-WT) or constitutively active (gsp mutant of G(S)alpha or G(S)alpha-QL) cDNAs. The stable transfectants were then tested for: (1) colony formation in soft agar; (2) cell migration and penetration of basement matrix in an in vitro invasion assay; and (3) the ability to form tumors and metastases in nude mice. PC-3M cells expressing G(S)alpha-QL protein displayed 15-fold increase in their ability to migrate and penetrate the basement membrane as compared to parental PC-3M cells or those expressing G(S)alpha-WT. G(S)alpha-QL transfectants also displayed a dramatically greater rate of growth in soft agar, and greater tumorigenicity and metastasis forming ability when orthotopically implanted in nude mice. All mice receiving PC-3M cells produced primary tumors within 5 weeks after implantation. However, the cells expressing G(S)alpha-QL displayed a significantly faster tumor growth as assessed by prostate weight (greater than 20-fold as compared to PC-3M cells), and produced metastases in kidneys, lymph nodes, blood vessels, bowel mesentery and intestine. Interestingly, expression of G(S)alpha-WT reduced the ability of PC-3M cells to form tumors in nude mice. These results suggest that persistent activation of G(S)alpha-mediated signaling cascade can dramatically accelerate tumorigenesis and metastasizing ability of prostate cancer cells.

Perforating eye injuries from external rear vision mirrors

PURPOSE

To highlight external rear vision mirrors as a cause of ocular injuries in motor vehicle accidents.

METHODS

Three cases of perforating eye injuries due to shattered external rear vision mirrors in motor vehicle accidents are described. The relevant Australian design rules are reviewed.

RESULTS/CONCLUSION

External rear vision mirrors can be responsible for serious ocular injuries in motor vehicle accidents. Further investigation of the incidence of such injuries is required to determine whether vehicle manufacturing methods and the design rules covering their production warrant revision.

Muscarinic cholinergic receptors promote growth of human prostate cancer cells

BACKGROUND

Recent evidence suggests that muscarinic receptors induce mitogenesis in cells capable of undergoing cell proliferation. Human prostate gland is innervated by the autonomic nervous system and muscarinic receptors have been localized in the prostate gland.

METHODS

Effects of carbachol (a stable analog of acetyl choline) on DNA synthesis of LNCaP cells (a human prostate cancer cell line) and primary prostate cells was examined. The DNA synthesis in the cultured cells was assessed using techniques of 3H-thymidine incorporation and bromodeoxyuridine (BrdU) incorporation immunocytochemistry.

RESULTS

Carbachol induced a significant increase in BrdU- and 3H-thymidine incorporation of LNCaP cells. The effect of carbachol was completely reversed by atropine, a selective muscarinic antagonist. Subtypes of muscarinic receptors mediating carbachol-induced DNA synthesis were identified using selective receptor subtype antagonists. Pirenzepamine and gallamine did not affect carbachol action on LNCaP cells but diphenylpyralamine, an M3 receptor antagonist, completely blocked carbachol-induced DNA synthesis. Carbachol also stimulated DNA synthesis in primary prostate cells. Prostate carcinoma (PC)-derived primary prostate cells displayed a dramatically greater response to carbachol (a ten-fold increase in DNA synthesis) as compared to benign prostate hypertrophy (BPH)-derived cells (a two-fold increase in DNA synthesis).

CONCLUSIONS

M3 receptors stimulate the proliferation of LNCaP cells, BPH-derived and PC-derived primary prostate cells. A dramatically higher response to carbachol by PC-derived prostate cells suggests that M3 receptors may be up-regulated in PC. M3 receptors may play a significant role in PC tumors growth and androgen-independent tumor progression.

Penetrating eye injuries in rural New South Wales

PURPOSE

To determine the epidemiology and outcomes of penetrating eye injuries in a rural Australian setting.

METHODS

A retrospective study of an 11 year period to identify 77 cases of penetrating eye injury in Lismore, New South Wales.

RESULTS

The commonest cause of penetrating eye injury was fencing wire followed by hammering metal. The average age was 32.6 years, and males were involved in 88% of cases. A final visual acuity of 6/12 or better was achieved in 61% of cases. Enucleation was performed in 14%. Visual outcome was best for wounds involving the cornea only.

CONCLUSIONS

Penetrating eye injuries are potentially devastating to vision, but with modern surgical techniques patients are likely to achieve reasonable vision. Prevention requires education to ensure adequate protective measures are taken in potentially hazardous settings.

Calcitonin stimulates growth of human prostate cancer cells through receptor-mediated increase in cyclic adenosine 3',5'-monophosphates and cytoplasmic Ca2+ transients

Our recent study has shown that a calcitonin (CT)-like immunoreactive substance(s) is secreted by cultured prostate cells, and secretion of this material is significantly higher in malignant than in benign prostate cells. To test the hypothesis that prostatic CT may serve as a paracrine/neuroendocrine factor, the present study investigated for the presence of CT receptors in the prostate gland. Signal transduction mechanisms activated by CT were examined, and the study also tested its effects on prostate cell proliferation, as assessed by [3H]thymidine incorporation. The results show that high affinity binding sites for [125I]salmon CT were present in plasma membrane fractions of human prostate tissue specimens and the prostate cancer LnCaP cell line. The maximal binding for CT receptors was 564 +/- 163 fmol/mg protein, and the apparent dissociation constant (Kd) was 2.89 +/- 0.58 nM. CT induced a dose-dependent increase in cAMP generation in LnCaP cells. The effect of CT on cytoplasmic Ca2+ transients of LnCaP cells was examined by videofluoromicroscopy. CT (100 nM) induced a rapid and sharp increase in cytoplasmic Ca2+ concentrations in LnCaP cells. The CT-induced increase in cytoplasmic Ca2+ transients appeared to be biphasic (spike and plateau), and this increase was 4- to 10-fold during the initial phase. The profile of this response is characteristic of the activated Ca2+/phospholipid second messenger system. CT also caused a dose-dependent increase in [3H]thymidine incorporation by LnCaP cells. These results suggest that a locally secreted CT-like peptide(s) induces mitogenic responses in prostate cancer cells. This action seems to be mediated through activation of signaling mechanisms, leading to the accumulation of two different second messengers, cAMP and calcium. Activation of dual second messenger systems by CT receptors suggests that the peptide hormone may play an important role in rapidly growing cell populations during the process of tumor formation.

Comparison of patient-controlled analgesia versus intramuscular narcotics in resolution of postoperative ileus after radical retropubic prostatectomy

Patient-controlled analgesia has become standard practice after major abdominal operations. The benefits of patient-controlled analgesia have been well documented. However, its possible effect of prolonging postoperative ileus has not been well examined. To determine if patient-controlled analgesia prolongs postoperative ileus when compared to conventional intramuscular narcotics, a retrospective review of length of postoperative ileus in 98 consecutive patients (62 using patient-controlled analgesia and 36 using intramuscular narcotics) undergoing bilateral pelvic lymphadenectomy and radical retropubic prostatectomy was done. The patients receiving patient-controlled analgesia resolved the postoperative ileus an average of 1.0 day later than the intramuscular injection group (5.2 days versus 4.2 days p < 0.0001). Overall hospital stay was not significantly affected. Our results show that patient-controlled analgesia use prolongs postoperative ileus.

Management of abdominal aortic aneurysm and invasive transitional cell carcinoma of bladder

Between January 1980 and June 1990 we treated 21 patients with invasive carcinoma of the bladder and abdominal aortic aneurysm. Three distinct groups of patients were identified. Group 1 comprised 8 patients who were initially diagnosed with invasive bladder cancer and during cancer staging a concomitant abdominal aortic aneurysm was found. Group 2 consisted of 10 patients previously treated for invasive bladder cancer who had aneurysmal disease at a later date. Group 3 included 3 patients who underwent a previous aneurysm repair and subsequently had invasive carcinoma of the bladder. Total survival was 9 of 21 patients (43%) with a mean of 84 months of followup after initial diagnosis. This finding is comparable to long-term (greater than 5 years) survival in patients with invasive carcinoma of the bladder alone. In fact, none of the 21 patients studied experienced rupture of the aneurysm and/or died of aneurysmal disease. We found that patients with abdominal aortic aneurysm and invasive bladder cancer have a poor overall prognosis. Although aneurysm repair presents technical challenges, mortality is dependent upon the carcinoma and other vascular or medical diseases, and does not bear direct relationship to abdominal aortic aneurysm.

Combined cholecystectomy and radical genitourinary cancer surgery

We have routinely performed simultaneous cholecystectomy in patients with cholelithiasis undergoing selected radical genitourinary cancer surgery. A total of 31 patients have undergone cholecystectomy at the time of radical nephrectomy (25), radical cystectomy (5), and radical prostatectomy (1). Operative time was increased twenty-five to forty-five minutes. There was no significant increase in blood loss, postoperative total bilirubin, or number of complications. No complications were directly attributable to the cholecystectomy except for 1 patient who had prolonged drainage from a closed suction drain in the gallbladder fossa. We conclude that concomitant cholecystectomy at the time of radical genitourinary cancer surgery does not significantly increase morbidity and recommend that it be performed in the presence of cholelithiasis.

Simplified urinary diversion in patients with preexisting or imminent colostomy

The indications for urinary and fecal diversion often mirror each other and at times overlap. Between 1980 and 1990 we encountered 14 patients with preexisting or newly diagnosed rectosigmoid disease who required diverting colostomy and urinary diversion. We describe a simple method for managing urinary diversion in these patients, which avoids a bowel anastomosis. The preexisting or newly created colostomy is used as the urinary stoma for a colon conduit, while a proximal colostomy is created for fecal diversion. This technique has proved to be beneficial and should be considered for high risk patients who require urinary and fecal diversion, and for whom an abbreviated operation would be desired.

Initial experience with combined interferon-alpha 2B and carbon dioxide laser for the treatment of condylomata acuminata

The incidence of condylomata acuminata, a common sexually transmitted disease caused by certain types of human papillomaviruses, is increasing rapidly and treatment regimens presently are not consistently effective. One of the more popular and effective modes of treatment has been laser therapy. Because of the relatively high recurrence rate of condylomata acuminata with laser treatment alone and because laser treatment in some patients with confluent acetowhite lesions would render cosmetically unacceptable results in the entire area were treated, we believed that it was reasonable to use intralesional pretreatment. We present our preliminary data on 14 consecutive patients with the clinical diagnosis of condylomata acuminata who were treated with the combination of carbon dioxide laser and intralesional interferon-alpha 2B. We found the treatment regimen to be effective in decreasing the recurrence rate compared to laser treatment alone and it was well tolerated with only transient side effects in a minority of patients. We are encouraged by our result and have recently begun a randomized double-blind prospective study to provide more conclusive information regarding this treatment combination.

Presence of calcitonin-like immunoreactivity (iCT) in human prostate gland: evidence for iCT secretion by cultured prostate cells

Immunoreactive calcitonin (iCT) has been detected in human prostate tissue extracts as well as seminal plasma. The present studies were undertaken to examine whether iSCT (immunoreactive salmon CT-like human peptide) co-exists with iHCT (thyroid CT-like substance) in human prostate tissue extracts, and whether these substances are secreted by primary prostate cells in culture. Since the local secretion of these substances seems to increase in some neoplasms, a second objective of the study was to examine whether basal secretion of iCTs from primary prostate cells is increased in carcinoma. The present results have shown that both iHCT and iSCT were present in prostate tissue extracts. The mean iHCT levels in extracts of benign hyperplastic prostates (BPH) were 0.59 ng/g prostate, and these were significantly lower than iHCT concentrations in prostatic carcinoma (PC) (2.53 ng/g). No significant differences in their iSCT contents were observed. However, the results from culture of over 90 individual prostate tissue specimens from BPH or PC indicate that primary prostate cells secreted detectable quantities of iSCT and the basal release of this material from PC prostate cultures was almost four-fold higher than that from BPH prostate cultures. These results suggest that a CT-like immunoreactive material is secreted by primary prostate cells in culture, and the basal secretion of this material is significantly higher in PC cells as compared to BPH cells. Endogenous secretion of prostatic CT, and the elevation of its expression in PC suggest that it may serve as a regulatory factor in the pathophysiology of the prostate gland.

Correlation of ultrasound guided and digitally directed transrectal biopsies of palpable prostatic abnormalities

The authors evaluated 51 patients with palpable prostatic abnormalities detected during digital rectal examination. These findings consisted of a nodule or an area of induration. Each palpable abnormality was confined to 1 prostatic lobe and there was no suggestion of extracapsular extension of neoplasm or systemic metastatic disease. All patients underwent 7.0 MHz. sagittal ultrasound guided transrectal biopsy followed by digitally directed transrectal biopsy. Biopsies were obtained only from the area of interest. The procedure was performed in the outpatient clinic without use of sedation or anesthesia. Digitally directed biopsies were positive for adenocarcinoma in 9 lesions. Ultrasound guided biopsies detected adenocarcinoma in 23 lesions, including all those detected by the blind digitally directed technique. This study demonstrates greater diagnostic accuracy using 7.0 MHz. ultrasound guided techniques and its routine use is warranted in the evaluation of palpable prostatic abnormalities.

Use of the Collings knife electrode for percutaneous access in difficult endourology cases

Percutaneous endourological techniques for the removal of upper urinary tract calculi and for the closed treatment of ureteropelvic junction obstruction are well described. These techniques are dependent on satisfactory percutaneous access and nephrostomy tract dilation. We used the Collings knife electrode for the creation of a nephrostomy tract in 17 patients (19 renal units) with difficult percutaneous access due to scarification, or the inability to advance a guide wire sufficiently for stabilization and dilation by conventional means. A nephrostomy tract was established successfully in all 19 procedures requiring an average of 12 minutes. Two major complications occurred that required blood transfusion and an open operation. Endourological treatment was successful in the remaining 17 cases. We believe that this technique provides an alternative to an open operation when standard access and dilation methods for endourological procedures are unsuccessful.

Analysis of bladder carcinoma by subsite. Cystoscopic location may have prognostic value

Nine hundred fourteen cases of carcinoma of the urinary bladder registered from 1977 to 1988 with the Kansas state tumor registry were evaluated by subsite for differences in grade, histology, sex, age at diagnosis, and survival. Only initial occurrences of carcinoma were included. Carcinoma of the lateral walls accounted for 37.1%; the posterior wall, 17.9%; the trigone, 12.6%; the neck, 11.1%; the ureteric orifices, 9.8%; the dome, 7.7%; and the anterior wall, 3.8%. Malignant neoplasms occurring in the neck of the bladder had a significantly poorer prognosis by survival analysis (P less than 0.05). Malignancies of the dome were found to present as higher grade lesions (P = 0.00003), and carcinoma of the ureteric orifices and lateral walls tended to be of lower grade (P = 0.02 and P = 0.05, respectively). Carcinomas of the anterior wall and dome occurred in a more elderly population (mean ages, 75.6 and 73.9 years, respectively), and carcinomas of the trigone and ureteric orifices occurred in a younger group (mean ages, 68.3 and 67.5 years, respectively). On histologic evaluation the trigone gave rise to more squamous cell carcinoma than expected (P = 0.001, 325% of expected). No distribution difference was noted among subsites with respect to sex. These data show significant differences among subsites of the urinary bladder with regard to survival, grade, histology, and age at diagnosis.

Penetration of topically applied betamethasone sodium phosphate into human aqueous humour

Gas Chromatography combined with Negative Chemical Ionisation Mass Spectrometry (GCMS) was used to determine the absorption of topically applied beta-methasone sodium phosphate into the aqueous humour of human subjects undergoing routine intraocular surgery. The Betamethasone concentration was greatest in the interval 91-120 minutes following topical administration (mean peak concentration = 7.7 ng/ml). At twelve hours post instillation the mean concentration of Betamethasone was 2.5 ng/ml and detectable levels were recorded in the aqueous humour 24 hours after application (mean concentration 0.4 ng/ml).

Analysis and management of chronic testicular pain

A total of 45 patients was seen in consultation between May 1980 and April 1989 for chronic unilateral or bilateral orchialgia, defined as intermittent or constant testicular pain 3 months or longer in duration that significantly interferes with the daily activities of the patient so as to prompt him to seek medical attention. We analyzed 34 patients available for followup in terms of socioeconomic parameters, etiology and duration of pain, associated urological symptomatology, specific treatment and results of therapy. Of the patients 31 underwent surgical treatment after failing medical management (24 orchiectomies, 10 epididymectomies, 5 orchiopexies and 1 hydrocelectomy). Of 10 patients who underwent epididymectomy 9 underwent subsequent orchiectomy as definitive treatment. Of 15 patients who underwent inguinal orchiectomy 11 (73%) reported complete relief of pain, while 4 had partial relief. Of the 9 patients who underwent scrotal orchiectomy 5 (55%) reported complete relief of pain, 3 had partial relief and 1 denied improvement. On the basis of these results we recommend inguinal orchiectomy as the procedure of choice for the management of chronic testicular pain when conservative measures are unsuccessful.

Penetration of synthetic corticosteroids into human aqueous humour

The penetration of prednisolone acetate (1%) and fluorometholone alcohol (0.1%) into human aqueous humour following topical application was determined using the very sensitive and specific technique of Gas Chromatography with Mass Spectrometry (GCMS). Prednisolone acetate afforded peak mean concentrations of 669.9 ng/ml within two hours and levels of 28.6 ng/ml in aqueous humour were detected almost 24 hours post application. The peak aqueous humour level of fluorometholone was 5.1 ng/ml. The results are compared and contrasted with the absorption of dexamethasone alcohol (0.1%), betamethasone sodium phosphate (0.1%) and prednisolone sodium phosphate (0.5%) into human aqueous humour.

Penetration of topically applied prednisolone sodium phosphate into human aqueous humour

Gas Chromatography with Mass Spectrometry (GCMS) was utilised to determine the penetration of prednisolone sodium phosphate into the aqueous humour of human volunteers undergoing routine cataract extraction. Detectable levels of prednisolone were measured in the aqueous humour within 15 minutes. Peak concentrations occurred between 90 and 240 minutes, and the steroid could not be detected in samples taken 10 hours or more after topical administration.

Penetration of topically applied dexamethasone alcohol into human aqueous humor

Gas chromatography combined with mass spectrometry was used to determine the absorption of topically applied dexamethasone alcohol into the aqueous humor of human subjects undergoing routine intraocular surgery. The dexamethasone concentration in aqueous humor was greatest in the interval between 91 and 120 minutes following instillation (mean concentration, 31 ng/mL). Dexamethasone was still detectable in the aqueous 12 hours after instillation.

Combined occlusion of the central retinal artery and central retinal vein following blunt ocular trauma: a case report

A healthy young woman suffered complete loss of the vision of one eye following a blunt ocular injury. She sustained a combined occlusion of the central retinal artery and central retinal vein of the affected eye. Initially few retinal haemorrhages were present, but they increased considerably in number and size during the day following injury.

Papaverine-induced priapism: 2 case reports

Intracorporeal papaverine injection therapy for impotence has been reported recently as a therapeutic option with low morbidity. We report 2 cases of papaverine-induced priapism that required surgical intervention.

Precision of cell density estimates and endothelial cell loss with age

The precision of estimating endothelial cell density of the cornea, using a noncontact method of specular microscopy, was assessed by asking eight individuals with known densities in one operated-on and one unoperated-on eye to have photography on two occasions in the same day. Three photographs of each eye were assessed by two individuals using masking procedures. Interobserver differences were negligible and estimates were similar except for one eye with low density values. The method was applied to a natural history study in which 103 eyes had cell-density estimates at zero and two years, and mean cell loss was found to be 2%. A collateral study using only good photographs that were available at both zero and two years showed a similar loss of 1.86% and reduced the number of counts showing unexpectedly high gains and losses.

A comparison of end versus loop stomas for ileal conduit urinary diversion

We compared the loop and end stoma techniques for ileal conduit urinary diversion in 54 and 27 adults, respectively, with serious bladder disease during a 3-year interval. Followup by trained enterostomal therapists averaged nearly 2 years for all patients. Stenosis occurred in 12 end stomas (44 per cent) but not in any loop stomas. We believe that this result reflects the inherently better blood supply of the loop stoma, which we recommend over the end ileostomy for patients undergoing ileal diversion.

Treatment of renal cell carcinoma with renal infarction, delayed nephrectomy, medroxyprogesterone, and xenogeneic immune RNA

The authors have used xenogeneic immune ribonucleic acid (RNA) in the treatment of patients with renal cell carcinoma. This has been used in conjunction with renal artery embolization, delayed nephrectomy, and progestational therapy, using immune RNA derived from sheep cell lymphocytes immunized with patient's tumor. Four of 5 patients with Stage I disease had extremely large primary tumors. This group is alive with no evidence of disease at twelve to twenty-four months. There are no Stage II tumors in this group. One patient with Stage III tumor is alive at twenty-two months without evidence of disease. Three patients with metastases are stable at five to twenty-two months. Two patients have progressive disease at three and six months. This treatment has not been effective in patients with massive tumor burden. The results in the other groups are encouraging.

Inferior vena caval replacement after resection of left renal tumor in canine model

An animal model simulating the necessity of replacing the inferior vena cava (IVC) with a prosthetic graft is described. Six dogs underwent replacement of the IVC with an expanded polytetrafluoroethylene (E-PTFE) graft using an interrupted-suture technique. Three dogs served as controls, undergoing resection and autograft of the native IVC. Distal side-to-side femoral arteriovenous fistulas were constructed in each case and allowed to remain for six weeks. Subcutaneous heparin and prophylactic antibiotics were administered in the early postoperative period. All grafts were patent at six months, indicating a potentially successful technique for reconstruction of the IVC involved in disease or trauma.

Oral fluorescein and cystoid macular oedema: detection in aphakic and pseudophakic eyes

The ingestion of oral fluorescein in 38 consecutive cases 6 to 7 weeks after cataract surgery with and without iris clip lens implantation permitted satisfactory fluorography to detect all cases of clinical cystoid macular oedema. There were no adverse reactions from any test subject.

Myelolipoma: an unusual surgical lesion of the adrenal gland

The clinical and pathologic features of three cases of surgically removed myelolipoma of the adrenal gland are presented. As with 18 previously reported cases, the lesions were found in obese, middle-aged persons; two of three had chronic, systemic disease (vasculitis and lymphoma, sustained hypertension). The only symptom possibly attributable to the neoplasm was nonspecific abdominal pain, and each lesion was identified by inferior renal displacement on intravenous urography. As computed tomography becomes widely available, the authors expect more myelolipomas to be detected that require surgical exploration, since there are no satisfactory, specific radiographic criteria to differentiate adrenal myelolipoma from adrenocortical carcinoma.

Renal subcapsular hematoma: a diagnostic and therapeutic dilemma

Subcapsular renal hematomas have been found in 14 hypertensive patients between 17 and 66 years old. In 11 patients with chronic lesions hypertension improved more often with nephrectomy (7 of 7 cases) than with a conservative operation (2 of 4 cases). Non-operative management of acute hematoma resulted in radiographic resolution and improvement of hypertension in 3 of 3 patients. Awareness of the clinical features and judicious use of diagnostic modalities enable proper management of subcapsular renal hematomas in most cases.

Screening excretory urography in patients with cryptorchidism or hypospadias: a survey and review of the literature

Hypospadias and cryptorchidism constitute common problems in urology for which the use of routine screening urography has been challenged recently. To assess better current thinking 233 urologists who devote a significant part of their practice to children were surveyed as to the number of procedures performed as well as to the instances when excretory urography was obtained. Of 163 physicians who responded 70 per cent do not favor routine screening urography in cryptorchid patients, while approximately 50 per cent believe that it is worthwhile in hypospadias. In the cryptorchid responses there was a definite decrease in the percentage of physicians obtaining x-rays as the yearly volume of cases increased (50 per cent with less than 10 cases per year and 18 per cent with greater than 20 cases per year), while this relationship was not maintained for hypospadias. A review of the literature correlates well with this survey in that excretory urography is not necessary in cases of cryptorchidism but its value is still debated in cases of hypospadias.

Preservation of ischemically damaged canine kidneys. Cold storage versus perfusion

Dog kidneys subjected to a period of warm ischemia followed by either simple cold storage or hypothermic pulsatile perfusion were autotransplanted 24 hr after harvesting, and a contralateral nephrectomy was performed at the same time. Renal function was comparable with both techniques, and all dogs survived. When kidneys were subjected to 30 min of warm ischemia followed by one of the two preservation methods, renal function was again comparable and 50 per cent of the animals in each group survived. We conclude, therefore, that for 24 hr of canine renal preservation, cold storage is as effective as pulsatile perfusion even when the kidney has been initially subjected to 30 min of warm ischemia.

Aortorenal reimplantation in treatment of renovascular hypertension

From 1964 to 1977, 33 patients underwent aortorenal reimplantation as surgical treatment for renovascular hypertension. Over-all results were 13 patients cured (39 per cent), 15 patients improved (46 per cent), and there were 5 failures (15 per cent). The results were equally satisfactory in patients with atherosclerotic or fibrous renal artery disease. Postoperative arterial stenosis or occlusion occurred in 5 patients (15 per cent). Aortorenal reimplantation is an effective method of renal revascularization in properly selected patients, and long-term results are comparable with those of aortorenal bypass.