The enhanced paper grip test can substantially improve community screening for the risk of falling

BACKGROUND

Lower-limb strength measures can enhance falls risk assessment but due to the lack of clinically applicable methods, such measures are not included in current screening. The enhanced paper grip test (EPGT) is a simple-to-use and cost-effective test that could fill this gap. However, its outcome measure (EPGT force) has not yet been directly linked to the risk of falling.

RESEARCH QUESTION

Is the EPGT a good candidate for falls risk screening in older people in the community?

METHODS

Seventy-one older people living independently in the community were recruited for this prospective observational study (median age 69 y, range 65y-79y). Lower-limb and whole-body strength were assessed at baseline using the EPGT and a standardised hand-grip method respectively. Incident falls were recorded monthly for a year through follow-up telephone conversations. The capacity of individual strength measures to predict falls and to enhance an established falls risk assessment tool (FRAT) commonly used by UK's national health service (NHS) was assessed using binomial logistic regression. The analysis was repeated for the subset of participants without history of falling at baseline (prediction of first-ever falls).

RESULTS

Increased EPGT force and increased symmetry in strength between limbs were significantly associated with reduced risk of falling. Compared to the NHS-FRAT, the EPGT correctly classified more people (73% vs 69%), it achieved higher sensitivity (56% vs 26%) and higher negative predictive value (76% vs 68%). Complementing the NHS-FRAT with the EPGT produced a more comprehensive model that correctly classified 91% of participants and achieved 98% specificity, 81% sensitivity, 89% negative and 96% positive predictive value. Replacing the EPGT with hand-grip strength consistently undermined prediction accuracy. The EPGT remained highly accurate when focused on the prediction of first-ever falls.

SIGNIFICANCE

The EPGT can substantially enhance falls screening in the community. These results can also inform effective personalised strength exercise interventions.

An exploration of the mechanistic link between the enhanced paper grip test and the risk of falling

The enhanced paper grip test (EPGT) offers an easy-to-use measure of hallux plantar-flexion strength that does not need expensive specialised equipment. Literature suggests that it could be a useful screening tool to assess the risk of falling in older people. However, research on a specific mechanistic link to the risk of falling is lacking. It is hypothesised here that muscle weakening (assessed by the EPGT) is indicative of impaired ability to recover balance after a slip or a trip. To get an initial assessment of validity of the above hypothesis, the EPGT is compared against an established lab-based measure of lower-limb strength that is capable of assessing a person's ability to recover balance after a slip or a trip: maximum isometric leg press push-off force (leg press force). A gender-balanced sample of twenty people (median age=34 y) was recruited. Two different but equaly valid techniques of administering the EPGT were included regarding whether the participants' ankle was supported by the examiner or not. Results for the two EPGT techniques differed susbtantialy but they were both significantly associated with leg press force and therefore linked to better ability to maintain balance after a slip or a trip. The "ankle not held" EPGT technique was more strongly correlated to leg press force (r(18) = 0.652, p = 0.002) than the "ankle held" (r(18) = 0.623, p = 0.003) and appears to be the more favourable technique to administer the EPGT. These findings offer new insight on a potential mechanistic link between the EPGT and the risk of falling and support its optimal use in future research involving older people.

The 'Wing' versus the 'Vapor Cut' electrodes in transurethral electrovaporization-resection of the prostate: comparative changes in safety parameters

We compared the early safety features of two-band resection devices used in transurethral vaporization-resection of the prostate (TUVRP). Ninety patients with prostatic outflow obstruction were prospectively evaluated in two open studies for the treatment using the 'Wing' cutting electrode in group 1 (Richard Wolf, Germany) and the 'Vapor Cut' electrode in group 2 (Karl Storz, Germany). Patients in both groups were comparable in age, presentation, prostate size and blood parameters. Safety features evaluated included changes in serum hemoglobin, hematocrit, sodium concentration and incidence of side effects. The mean drop in hemoglobin, hematocrit and serum sodium 1 h postoperatively for the Wing group were 0.54 g/dl, 2.04 ml/dl and 0.084 mEq/l respectively compared to a mean drop of 1.1 g/dl, 3.07 ml/dl and 3.1 mEq/l in the Vapor Cut group. These differences were statistically significant (p = 0.004, 0.03 and <0.0001 respectively). The mean resection weight was 24.78 +/- 10.4 and 24.46 +/- 14.79 g in groups 1 and 2, respectively; however, the mean operation time was significantly longer in the Wing group (47.7 vs. 37.1 min, p = 0.003). We conclude that both loops were safe and efficacious in the treatment of patients with prostatic outflow obstruction. Safety features that are related to the vaporization effect are influenced by the speed of resection.

Continent urinary undiversion to modified ureterosigmoidostomy in bladder extrophy patients

The objectives of urinary diversion are expanding from merely preserving kidney functions to enabling the patient to have a good quality of life while maintaining an acceptable certain body image. During the new era of continent urinary diversion the psychological drawbacks of noncontinent skin stoma in young adolescents cannot be overlooked. Ureterosigmoidostomy has been the technique of choice for continent urinary diversion in bladder extrophy patients when bladder reconstruction is not feasible or has failed. Although it provides a good daytime continence it is associated with a high rate of nighttime incontinence and delayed complications of pyelonephritis and hyperchloremic acidosis. We managed five male bladder extrophy patients with noncontinent skin stoma (sigmoid colon conduit in three and ileal conduit in two) including two patients who had previously had complicated classic ureterosigmoidostomy. They underwent urinary undiversion to the valved and augmented rectum (three patients) and the valved S-shaped rectosigmoid pouch (two patients) with some modifications. The conduit was used in the construction, and the ureters were implanted behind an isolated intussusception ileal nipple valve. Tube cecostomy and total parenteral nutrition was used for 7 to 10 days instead of a temporary defunctioning transverse colostomy. With a mean follow-up of 19.8 months (range 9-36 months) all the patients are fully continent during the day and night, with an emptying intervals of 3 to 6 hours. Follow-up intravenous pyelography and renal scans revealed improvement or stabilization of the function and configuration of the upper tracts in all renal units. No prophylactic alkali therapy was given. No clinical evidence of acidosis or symptomatic urinary tract infection was observed. Modified ureterosigmoidostomy is a good alternative for continent urinary undiversion even in those who have previously had complicated classic ureterosigmoidostomy. Our modification of using tube cecostomy and parenteral nutrition instead of a temporary transverse colostomy warrants attention; it made the technique simpler and more attractive.

Rehabilitation of long-term defunctionalized bladder for renal transplantation

Some kidney transplant candidates have urinary diversion due to lower urinary tract dysfunction. Careful assessment of the native defunctionalized bladder before kidney transplantation may reveal a usable bladder in a substantial number of these patients. However, most of these bladders need some kind of rehabilitation. An assessment of the continence mechanism is also crucial. We report on successful kidney transplantation into a native bladder, defunctionalized for 9 years, after it had been carefully evaluated and rehabilitated.

Treatment of erectile dysfunction after kidney transplantation with intracavernosal self-injection of prostaglandin E1

PURPOSE

We evaluate the results of treatment of erectile dysfunction in kidney transplant patients with intracavernosal self-injection of vasoactive drugs.

MATERIALS AND METHODS

We evaluated and treated 26 male kidney transplant patients for erectile dysfunction. All patients had stable kidney function 6 to 75 months (mean 26.6 +/- 9) after transplantation. Each patient received an intracavernosal injection of 20 microg. prostaglandin E1 (PGE1), and after 20 to 30 minutes the response was assessed. Nonresponders received 40 microg. PGE1 at another visit, and those who showed no response were reinjected with 40 microg. PGE1 plus 30 mg. papaverine hydrochloride. A total of 21 patients were enrolled in a self-injection program and have been followed between 3 and 21 months (mean 11.6 +/- 2.7).

RESULTS

Hormonal alterations were seen in 7 patients with serum testosterone as low as 16.6 ng./ml. (normal 33 to 100), and testosterone injections gave only marginal response in 2. Intracavernosal injection of 20 microg. PGE1 provided good response in 15 patients (57.7%), while 40 microg. PGE1 alone or in combination with 30 mg. papaverine resulted in good response in another 6 and 2 patients, respectively. Among the 21 patients who were enrolled in the self-injection program 19 (90.5%) reported complete satisfaction with no adverse local or systemic complications except for local pain at the injection site in 4. There has been no change in serum creatinine, cyclosporine level or doses of immunosuppression medications during the observation period.

CONCLUSIONS

Intracavernosal self-injection of PGE1 is well accepted and tolerated by kidney transplant patients. It poses no apparent risks to the transplanted kidney and could be a good modality to treat erectile dysfunction in kidney transplant recipients.

Conservative management with percutaneous intervention of major blunt renal injuries

This retrospective study assessed the results of treatment of patients with renal trauma to determine the optimal management (conservative or surgical) for patients with grade III renal injuries. During the past 12 years 108 patients (including 43 children) with renal injuries were managed: 43 had grade I injuries (renal contusion), 33 had grade II (minor laceration), 31 had grade III (major laceration), and 1 had grade IV (pedicle injury). All patients with grades I and II injuries were successfully managed conservatively. The patient with renal pedicle injury underwent uneventful nephrectomy. Nineteen patients with grade III injuries (including 5 patients with shattered kidneys and 3 patients with polar avulsion) were managed conservatively, and 2 developed progressively enlarging urinomas that required percutaneous drainage with complete resolution. No patient in this group developed perinephric abscess or urinary fistulae, and no delayed nephrectomy was necessary. Long-term follow-up of 7 patients in this group, including 3 with shattered kidneys and 2 with polar avulsion, showed that none have developed hypertension. Twelve patients with grade III injuries were managed surgically. Six (50%) patients underwent total (4 patients) or partial (2 patients) nephrectomy. In 6 patients, the surgical intervention was only open drainage of the perinephric collection and/or parenchymal suturing. It was concluded that conservative management with timely percutaneous or endoscopic intervention in patients with major renal injuries results in minimal loss of renal tissue without significant late complications.

An unusual cause of recurrent bacteriuria in a kidney transplant recipient

A 17-year old Saudi male presented to the transplant clinic of the King Fahad National Guard Hospital, Riyadh two weeks after undergoing a living unrelated kidney transplant in India. Graft function was normal and routine urine culture grew Pseudomonas aeruginosa for which he was treated; a follow-up urine culture was negative. Five months later, routine urine culture again documented the presence of Pseudomonas while the patient continued to be asymptomatic with normal graft function. Abdominal ultrasound showed shrunken native kidneys and a normal graft. A slightly echogenic mass was detected in the bladder. Cystocopy showed a retained non-absorbable suture at the area of the uretero-vesical anastomosis. Cystoscopic removal of the suture was carried out following which urine cultures have remained persistently negative.

Scrotal exploration in 123 azoospermic patients: The results of surgery for obstructive azoospermia

During the last eight years, scrotal exploration for attempted vasoepididymostomy was performed in 123 azoospermic patients at the King Faisal Specialist Hospital and Research Centre. All patients had normal or slightly elevated serum FSH, and normal-size testes (at least on one side). Testicular biopsy was not recommended but had already been done before referral in 73 patients and was reported to show normal spermatogenesis or mild hypospermatogenesis. Vasoepididymostomy could be performed in only 83 (67.5%) patients using the conventional fistula technique in 34 patients and microsurgical single tubule anastomosis in 49 patients. Sixty-seven patients were followed between six and 30 months (mean 17.8 months). Among these patients, 25 produced sperm in the ejaculate with a patency rate of 37.3 percent and seven patients impregnated their wives, for a pregnancy rate of 10.4%. These preganancies resulted in four living children. The patency rate with the conventional fistula technique was (7/26) 26.9%,a nd with microsurgical technique (18/41) 43.9%; the difference is statistically significant. Microsurgical single tubule vasoepididymostomy is strongly recommended for the treatment of obstructive azoospermic patients, as it gives a higher percentage of successful anastomosis.

The valved S-shaped rectosigmoid pouch for continent urinary diversion

Continent urinary diversion to the valved S-shaped rectosigmoid pouch was performed in 9 female and 6 male patients 12 to 65 years old (mean age 51 years). The pouch was constructed by detubularization and S-shaped reconfiguration of 30 cm. of the intact rectum and sigmoid colon. The ureters were reimplanted into the pouch using antireflux techniques. Reflux of urine from the pouch to the proximal colon was prevented by fashioning an intussusception valve. The construction was protected by a transverse colostomy for 6 to 8 weeks. With a followup of 3 to 24 months (mean 11 months), all patients are continent during the day and also at night with evacuation intervals of 3 to 6 hours. There have been no cases of symptomatic urinary tract infection. Only 1 patient had mild hyperchloremic acidosis. No patient complained of abdominal distention or constipation. Contrast study via the anus (radiography of the pouch) showed that the intussusception valve was competent in all but 1 patient in whom reflux to the proximal colon was noted due to sliding of the nipple valve, which was revised successfully. Urodynamic studies (cystometry of the pouch) showed a capacity of 400 to 900 ml. (mean 600) with an intraluminal pressure of 22 cm. water (range 10 to 34) at maximal filling. The valved S-shaped rectosigmoid pouch is a faster and simpler surgical procedure compared with the modified rectal bladder (valved rectum augmented with ileum). It also results in a smooth postoperative course, since an intestinal anastomosis proximal to the colostomy is avoided.

Experience with penile fractures in Egypt: long-term results of immediate surgical repair

We present our experience in the management of 14 patients with fracture of the penis. The time between the injury and hospital arrival ranged from 2 to 12 hours. All the patients were managed by emergency surgical repair. Surgery consisted of complete evacuation of the hematoma and repair of the tear in the tunica albuginea. Urethral injury associated with penile fracture was not seen in this series. Follow-up time ranged from 12 to 78 months (average, 42.3 +/- 18.3). The results were excellent, with complete early recovery of erectile function. Slight penile curvature during erection was observed in two patients, but this did not affect their sexual activity. Because of these encouraging results and the reported high complication rate of conservative treatment, the need for immediate surgical repair is emphasized.

Spontaneous bladder rupture after colocystoplasty. Case report

An 18-year-old girl had bladder extrophy managed by sigmoid cystoplasty with clean intermittent catheterization. Spontaneous bladder rupture occurred 12 months after reconstructive surgery. The diagnosis was made by ultrasound with abdominal tapping and cystography under fluoroscopy. Management included intravenous antibiotics, laparotomy and closure of the perforation. The diagnosis was delayed and postoperative intraperitoneal abscess formation occurred.