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Clark L, Fitzgerald B, Noble S, MacNeill S, Paramasivan S, Cotterill N, Hashim H, Jha S, Toozs-Hobson P, Greenwell T, Thiruchelvam N, Agur W, White A, Garner V, Cobos-Arrivabene M, Clement C, Cochrane M, Liu Y, Lewis AL, Taylor J, Lane JA, Drake MJ, Pope C. Proper understanding of recurrent stress urinary incontinence treatment in women (PURSUIT): a randomised controlled trial of endoscopic and surgical treatment. Trials 2022; 23:628. [PMID: 35922823 PMCID: PMC9347071 DOI: 10.1186/s13063-022-06546-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 07/13/2022] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- L Clark
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - B Fitzgerald
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - S Noble
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - S MacNeill
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - S Paramasivan
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - N Cotterill
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - H Hashim
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - S Jha
- Department of Urogynaecology, Sheffield Teaching Hospitals NHS Foundation Trust, Jessop Wing, Tree Root Walk, Sheffield, UK
| | - P Toozs-Hobson
- Department of Urogynaecology, Birmingham Women's & Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - T Greenwell
- Department of Urology, University College London Hospital, London, UK
| | - N Thiruchelvam
- Department of Urology, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - W Agur
- Department of Obstetrics and Gynaecology, NHS Ayrshire and Arran, University Hospital Crosshouse, Kilmarnock, UK
| | - A White
- Patient and Public Involvement (PPI) Representative, Bristol, UK
| | - V Garner
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - M Cobos-Arrivabene
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - C Clement
- Bristol Trials Centre (BTC), University of Bristol, Bristol, UK
| | - M Cochrane
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Y Liu
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - A L Lewis
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,Bristol Trials Centre (BTC), University of Bristol, Bristol, UK
| | - J Taylor
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,Bristol Trials Centre (BTC), University of Bristol, Bristol, UK
| | - J A Lane
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,Bristol Trials Centre (BTC), University of Bristol, Bristol, UK
| | - M J Drake
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK. .,Department of Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - C Pope
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,Bristol Trials Centre (BTC), University of Bristol, Bristol, UK
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Abdel-Fattah M, Chapple C, Guerrero K, Dixon S, Cotterill N, Ward K, Hashim H, Monga A, Brown K, Drake MJ, Gammie A, Mostafa A, Bladder Health UK, Breeman S, Cooper D, MacLennan G, Norrie J. 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. Trials 2021; 22:745. [PMID: 34702331 PMCID: PMC8546752 DOI: 10.1186/s13063-021-05661-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 09/24/2021] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- M Abdel-Fattah
- Aberdeen Centre for Women's Health Research, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK.
| | - C Chapple
- Department of Urology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - K Guerrero
- Department of Urogynaecology, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - S Dixon
- Health Economics and Decision Science, University of Sheffield, Sheffield, UK
| | - N Cotterill
- Bristol Urological Institute, North Bristol NHS Trust, Bristol, UK
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - K Ward
- Warrell Unit, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - H Hashim
- Bristol Urological Institute, North Bristol NHS Trust, Bristol, UK
- Bristol Urological Institute, University of Bristol, Bristol, UK
| | - A Monga
- Department of Gynaecology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - K Brown
- Department of Gynaecology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - M J Drake
- Bristol Urological Institute, North Bristol NHS Trust, Bristol, UK
- Bristol Urological Institute, University of Bristol, Bristol, UK
| | - A Gammie
- Bristol Urological Institute, North Bristol NHS Trust, Bristol, UK
| | - A Mostafa
- Aberdeen Centre for Women's Health Research, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | | | - S Breeman
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - D Cooper
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - G MacLennan
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - J Norrie
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
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Williams MP, Modgil V, Drake MJ, Keeley F. The effect of consultant outcome publication on surgeon behaviour: a systematic review and narrative synthesis. Ann R Coll Surg Engl 2018; 100:428-435. [PMID: 29962298 PMCID: PMC6111901 DOI: 10.1308/rcsann.2018.0052] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2018] [Indexed: 02/02/2023] Open
Abstract
Introduction Surgeon-specific outcome data, or consultant outcome publication, refers to public access to named surgeon procedural outcomes. Consultant outcome publication originates from cardiothoracic surgery, having been introduced to US and UK surgery in 1991 and 2005, respectively. It has been associated with an improvement in patient outcomes. However, there is concern that it may also have led to changes in surgeon behaviour. This review assesses the literature for evidence of risk-averse behaviour, upgrading of patient risk factors and cessation of low-volume or poorly performing surgeons. Materials and methods A systematic literature review of Embase and Medline databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Original studies including data on consultant outcome publication and its potential effect on surgeon behaviour were included. Results Twenty-five studies were identified from the literature search. Studies suggesting the presence of risk-averse behaviour and upgrading of risk factors tended to be survey based, with studies contrary to these findings using recognised regional and national databases. Discussion and conclusion Our review includes instances of consultant outcome publication leading to risk-averse behaviour, upgrading of risk factors and cessation of low-volume or poorly performing surgeons. As UK data on consultant outcome publication matures, further research is essential to ensure that high-risk patients are not inappropriately turned down for surgery.
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Affiliation(s)
- MP Williams
- University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - V Modgil
- Heart of England NHS Foundation Trust, Birmingham, UK
| | - MJ Drake
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
- Translational Health Sciences, University of Bristol, Bristol, UK
| | - F Keeley
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
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4
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Delgado D, Canham L, Cotterill N, Cottrell D, Drake MJ, Inglis K, Owen D, White P. Protocol for a randomized, double blind, placebo controlled, crossover trial of Melatonin for treatment of Nocturia in adults with Multiple Sclerosis (MeNiMS). BMC Neurol 2017; 17:63. [PMID: 28347292 PMCID: PMC5368919 DOI: 10.1186/s12883-017-0845-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 03/21/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nocturia (the symptom of needing to wake up to pass urine) is common in progressive Multiple Sclerosis (MS) patients. Moderate-to-severe nocturia affects quality of life, can exacerbate fatigue and may affect capacity to carry out daily activities. Melatonin is a natural hormone regulating circadian cycles, released by the pineal gland at night-time, and secretion is impaired in MS. Melatonin levels can be supplemented by administration in tablet form at bedtime. The aim of this study is to evaluate the effect of melatonin on mean number of nocturia episodes per night in MS patients. Secondary outcome measures will assess impact upon quality of life, urinated volumes, lower urinary tract symptoms (LUTS), cognition, sleep quality and sleep disturbance of partners. METHODS A randomized, double blind, placebo controlled, crossover trial consisting of two, six week treatment phases (active drug melatonin 2 mg or placebo), with a 1 month wash-out period in between. The primary outcome (change in nocturia episodes per night) in this two arm, two treatment, two period crossover design, will be objectively measured using frequency volume charts (FVC) at baseline and following both treatment phases. Questionnaires will be used to assess quality of life, sleep quality, safety and urinary tract symptoms. Qualitative interviews of participants and partners will explore issues including quality of life, mechanisms of sleep disturbance and impact of nocturia on partners. DISCUSSION This study will evaluate whether melatonin reduces the frequency of nocturia episodes in MS patients, and therefore whether 'Circadin' has the potential to reduce LUTS and fatigue, and improve cognition and overall quality of life. TRIAL REGISTRATION (EudraCT reference) 2012-00418321 registered: 25/01/13. ISRCTN Registry: ISRCTN38687869.
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Affiliation(s)
- D Delgado
- Bristol Urological Institute, North Bristol NHS Trust, Southmead Hospital, Bristol, BS10 5NB, UK
| | - L Canham
- Department of Neurology, North Bristol NHS Trust, Southmead Hospital, Bristol, UK.,School of Clinical Sciences, University of Bristol, Bristol, UK
| | - N Cotterill
- Bristol Urological Institute, North Bristol NHS Trust, Southmead Hospital, Bristol, BS10 5NB, UK
| | - D Cottrell
- Department of Neurology, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - M J Drake
- Bristol Urological Institute, North Bristol NHS Trust, Southmead Hospital, Bristol, BS10 5NB, UK. .,School of Clinical Sciences, University of Bristol, Bristol, UK.
| | - K Inglis
- Bristol Urological Institute, North Bristol NHS Trust, Southmead Hospital, Bristol, BS10 5NB, UK
| | - D Owen
- Bristol Urological Institute, North Bristol NHS Trust, Southmead Hospital, Bristol, BS10 5NB, UK
| | - P White
- University of West of England, Bristol, UK
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5
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Sherman E, Nobles C, Berry CC, Six E, Wu Y, Dryga A, Malani N, Male F, Reddy S, Bailey A, Bittinger K, Everett JK, Caccavelli L, Drake MJ, Bates P, Hacein-Bey-Abina S, Cavazzana M, Bushman FD. INSPIIRED: A Pipeline for Quantitative Analysis of Sites of New DNA Integration in Cellular Genomes. Mol Ther Methods Clin Dev 2016; 4:39-49. [PMID: 28344990 PMCID: PMC5363316 DOI: 10.1016/j.omtm.2016.11.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 11/15/2016] [Indexed: 01/24/2023]
Abstract
Integration of new DNA into cellular genomes mediates replication of retroviruses and transposons; integration reactions have also been adapted for use in human gene therapy. Tracking the distributions of integration sites is important to characterize populations of transduced cells and to monitor potential outgrow of pathogenic cell clones. Here, we describe a pipeline for quantitative analysis of integration site distributions named INSPIIRED (integration site pipeline for paired-end reads). We describe optimized biochemical steps for site isolation using Illumina paired-end sequencing, including new technology for suppressing recovery of unwanted contaminants, then software for alignment, quality control, and management of integration site sequences. During library preparation, DNAs are broken by sonication, so that after ligation-mediated PCR the number of ligation junction sites can be used to infer abundance of gene-modified cells. We generated integration sites of known positions in silico, and we describe optimization of sample processing parameters refined by comparison to truth. We also present a novel graph-theory-based method for quantifying integration sites in repeated sequences, and we characterize the consequences using synthetic and experimental data. In an accompanying paper, we describe an additional set of statistical tools for data analysis and visualization. Software is available at https://github.com/BushmanLab/INSPIIRED.
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Affiliation(s)
- Eric Sherman
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104-6076, USA
| | - Christopher Nobles
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104-6076, USA
| | - Charles C Berry
- Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, CA 92093, USA
| | - Emmanuelle Six
- Imagine Institute, Paris Descartes-Sorbonne Paris Cité University, 75014 Paris, France; Laboratory of Human Lymphohematopoiesis, INSERM 24, 75014 Paris, France
| | - Yinghua Wu
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104-6076, USA
| | - Anatoly Dryga
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104-6076, USA
| | - Nirav Malani
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104-6076, USA
| | - Frances Male
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104-6076, USA
| | - Shantan Reddy
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104-6076, USA
| | - Aubrey Bailey
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104-6076, USA
| | - Kyle Bittinger
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104-6076, USA
| | - John K Everett
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104-6076, USA
| | - Laure Caccavelli
- Biotherapy Department, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France; Biotherapy Clinical Investigation Center, Groupe Hospitalier Universitaire Ouest, Assistance Publique-Hôpitaux de Paris, INSERM, 75014 Paris, France
| | - Mary J Drake
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104-6076, USA
| | - Paul Bates
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104-6076, USA
| | - Salima Hacein-Bey-Abina
- Biotherapy Department, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France; Biotherapy Clinical Investigation Center, Groupe Hospitalier Universitaire Ouest, Assistance Publique-Hôpitaux de Paris, INSERM, 75014 Paris, France
| | - Marina Cavazzana
- Biotherapy Department, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France; Biotherapy Clinical Investigation Center, Groupe Hospitalier Universitaire Ouest, Assistance Publique-Hôpitaux de Paris, INSERM, 75014 Paris, France
| | - Frederic D Bushman
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104-6076, USA
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6
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Berry CC, Nobles C, Six E, Wu Y, Malani N, Sherman E, Dryga A, Everett JK, Male F, Bailey A, Bittinger K, Drake MJ, Caccavelli L, Bates P, Hacein-Bey-Abina S, Cavazzana M, Bushman FD. INSPIIRED: Quantification and Visualization Tools for Analyzing Integration Site Distributions. Mol Ther Methods Clin Dev 2016; 4:17-26. [PMID: 28344988 PMCID: PMC5363318 DOI: 10.1016/j.omtm.2016.11.003] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Accepted: 11/15/2016] [Indexed: 01/08/2023]
Abstract
Analysis of sites of newly integrated DNA in cellular genomes is important to several fields, but methods for analyzing and visualizing these datasets are still under development. Here, we describe tools for data analysis and visualization that take as input integration site data from our INSPIIRED pipeline. Paired-end sequencing allows inference of the numbers of transduced cells as well as the distributions of integration sites in target genomes. We present interactive heatmaps that allow comparison of distributions of integration sites to genomic features and that support numerous user-defined statistical tests. To summarize integration site data from human gene therapy samples, we developed a reproducible report format that catalogs sample population structure, longitudinal dynamics, and integration frequency near cancer-associated genes. We also introduce a novel summary statistic, the UC50 (unique cell progenitors contributing the most expanded 50% of progeny cell clones), which provides a single number summarizing possible clonal expansion. Using these tools, we characterize ongoing longitudinal characterization of a patient from the first trial to treat severe combined immunodeficiency-X1 (SCID-X1), showing successful reconstitution for 15 years accompanied by persistence of a cell clone with an integration site near the cancer-associated gene CCND2. Software is available at https://github.com/BushmanLab/INSPIIRED.
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Affiliation(s)
- Charles C Berry
- Department of Family Medicine and Public Health, UC San Diego, La Jolla, CA 92093, USA
| | - Christopher Nobles
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104-6076, USA
| | - Emmanuelle Six
- Paris Descartes-Sorbonne Paris Cité University, Imagine Institute, 75015 Paris, France; INSERM 24, Laboratory of Human Lymphohematopoiesis, 75015 Paris, France
| | - Yinghua Wu
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104-6076, USA
| | - Nirav Malani
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104-6076, USA
| | - Eric Sherman
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104-6076, USA
| | - Anatoly Dryga
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104-6076, USA
| | - John K Everett
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104-6076, USA
| | - Frances Male
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104-6076, USA
| | - Aubrey Bailey
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104-6076, USA
| | - Kyle Bittinger
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104-6076, USA
| | - Mary J Drake
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104-6076, USA
| | - Laure Caccavelli
- Biotherapy Department, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France; Biotherapy Clinical Investigation Center, Groupe Hospitalier Universitaire Ouest, Assistance Publique-Hôpitaux de Paris, INSERM, 75014 Paris, France
| | - Paul Bates
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104-6076, USA
| | - Salima Hacein-Bey-Abina
- Biotherapy Department, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France; Biotherapy Clinical Investigation Center, Groupe Hospitalier Universitaire Ouest, Assistance Publique-Hôpitaux de Paris, INSERM, 75014 Paris, France
| | - Marina Cavazzana
- Biotherapy Department, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France; Biotherapy Clinical Investigation Center, Groupe Hospitalier Universitaire Ouest, Assistance Publique-Hôpitaux de Paris, INSERM, 75014 Paris, France
| | - Frederic D Bushman
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104-6076, USA
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7
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Bailey K, Abrams P, Blair PS, Chapple C, Glazener C, Horwood J, Lane JA, McGrath J, Noble S, Pickard R, Taylor G, Young GJ, Drake MJ, Lewis AL. Urodynamics for Prostate Surgery Trial; Randomised Evaluation of Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men: study protocol for a randomised controlled trial. Trials 2015; 16:567. [PMID: 26651344 PMCID: PMC4676182 DOI: 10.1186/s13063-015-1087-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 11/26/2015] [Indexed: 11/17/2022] Open
Abstract
Background Lower urinary tract symptoms (LUTS) comprise storage symptoms, voiding symptoms and post-voiding symptoms. Prevalence and severity of LUTS increase with age and the progressive increase in the aged population group has emphasised the importance to our society of appropriate and effective management of male LUTS. Identification of causal mechanisms is needed to optimise treatment and uroflowmetry is the simplest non-invasive test of voiding function. Invasive urodynamics can evaluate storage function and voiding function; however, there is currently insufficient evidence to support urodynamics becoming part of routine practice in the clinical evaluation of male LUTS. Design A 2-arm trial, set in urology departments of at least 26 National Health Service (NHS) hospitals in the United Kingdom (UK), randomising men with bothersome LUTS for whom surgeons would consider offering surgery, between a care pathway based on urodynamic tests with invasive multichannel cystometry and a care pathway based on non-invasive routine tests. The aim of the trial is to determine whether a care pathway not including invasive urodynamics is no worse for men in terms of symptom outcome than one in which it is included, at 18 months after randomisation. This primary clinical outcome will be measured with the International Prostate Symptom Score (IPSS). We will also establish whether inclusion of invasive urodynamics reduces rates of bladder outlet surgery as a main secondary outcome. Discussion The general population has an increased life-expectancy and, as men get older, their prostates enlarge and potentially cause benign prostatic obstruction (BPO) which often requires surgery. Furthermore, voiding symptoms become increasingly prevalent, some of which may not be due to BPO. Therefore, as the population ages, more operations will be considered to relieve BPO, some of which may not actually be appropriate. Hence, there is sustained interest in the diagnostic pathway and this trial could improve the chances of an accurate diagnosis and reduce overall numbers of surgical interventions for BPO in the NHS. The morbidity, and therapy costs, of testing must be weighed against the cost saving of surgery reduction. Trial registration Controlled-trials.com - ISRCTN56164274 (confirmed registration: 8 April 2014). Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-1087-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- K Bailey
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK. .,Bristol Randomised Trials Collaboration (BRTC), University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - P Abrams
- North Bristol NHS Trust, Bristol Urological Institute, Level 3, Learning and Research Building, Southmead Hospital, Bristol, BS10 5N, UK.
| | - P S Blair
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK. .,Bristol Randomised Trials Collaboration (BRTC), University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK. .,Bristol Randomised Trials Collaboration, University of Bristol, St. Michael's Hospital, Level D, Southwell Street, Bristol, UK.
| | - C Chapple
- Sheffield Teaching Hospitals NHS Trust, Room H26, H-Floor, Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2JF, UK.
| | - C Glazener
- Health Services Research Unit, University of Aberdeen, 3rd Floor, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, Scotland.
| | - J Horwood
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK. .,Bristol Randomised Trials Collaboration (BRTC), University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - J A Lane
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK. .,Bristol Randomised Trials Collaboration (BRTC), University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - J McGrath
- Exeter Surgical Health Services Research Unit - Urology, Royal Devon and Exeter Hospital, Barrack Road, Exeter, Devon, EX2 5DW, UK.
| | - S Noble
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK. .,Bristol Randomised Trials Collaboration (BRTC), University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - R Pickard
- Institute of Cellular Medicine, University of Newcastle, 3rd Floor, William Leech Building, Newcastle upon Tyne, NE2 4HH, UK.
| | - G Taylor
- University of Plymouth, Plymouth, Devon, PL4 8AA, UK.
| | - G J Young
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK. .,Bristol Randomised Trials Collaboration (BRTC), University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - M J Drake
- North Bristol NHS Trust, Bristol Urological Institute, Level 3, Learning and Research Building, Southmead Hospital, Bristol, BS10 5N, UK. .,School of Clinical Sciences, University of Bristol, 69 St Michael's Hill, BS2 8DZ, Bristol, UK.
| | - A L Lewis
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK. .,Bristol Randomised Trials Collaboration (BRTC), University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
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8
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Thiruchelvam N, Drake MJ, Venn S, Morley R. A 2014 snapshot audit of the role of urodynamics in the UK for benign prostatic enlargement surgery. Neurourol Urodyn 2014; 35:271-2. [PMID: 25451958 DOI: 10.1002/nau.22704] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2014] [Accepted: 10/13/2014] [Indexed: 11/11/2022]
Affiliation(s)
- N Thiruchelvam
- Addenbrookes Hospital, Cambridge University Hospitals NHS Trust, Cambridge, United Kingdom
| | - M J Drake
- School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - S Venn
- St Richard's Hospital Chichester, Chichester
| | - R Morley
- Kingstion, Hospital, London, United Kingdom
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Carugo D, Elmahdy M, Zhao X, Drake MJ, Zhang X, Clavica F. An artificial model for studying fluid dynamics in the obstructed and stented ureter. Annu Int Conf IEEE Eng Med Biol Soc 2013; 2013:5335-8. [PMID: 24110941 DOI: 10.1109/embc.2013.6610754] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Fluid dynamics in the obstructed and stented ureter represents a non-trivial subject of investigation since, after stent placement, the urine can flow either through the stent lumen or in the extra-luminal space located between the stent wall and the ureteric inner wall. Fluid dynamic investigations can help understanding the phenomena behind stent failure (e.g. stent occlusions due to bacterial colonization and encrustations), which may cause kidney damage due to the associated high pressures generated in the renal pelvis. In this work a microfluidic-based transparent device (ureter model, UM) has been developed to simulate the fluid dynamic environment in a stented ureter. UM geometry has been designed from measurements on pig ureters. Pressure in the renal pelvis compartment has been measured against three variables: fluid viscosity (μ), volumetric flow rate (Q) and level of obstruction (OB%). The measurements allowed a quantification of the critical combination of μ, Q and OB% values which may lead to critical pressure levels in the kidney. Moreover, an example showing the possibility of applying particle image velocimetry (PIV) technology to the developed microfluidic device is provided.
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Asaduzzaman AM, Laref S, Deymier PA, Runge K, Cheng HP, Muralidharan K, Drake MJ. A first-principles characterization of water adsorption on forsterite grains. Philos Trans A Math Phys Eng Sci 2013; 371:20110582. [PMID: 23734049 DOI: 10.1098/rsta.2011.0582] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Numerical simulations examining chemical interactions of water molecules with forsterite grains have demonstrated the efficacy of nebular gas adsorption as a viable mechanism for water delivery to the terrestrial planets. Nevertheless, a comprehensive picture detailing the water-adsorption mechanisms on forsterite is not yet available. Towards this end, using accurate first-principles density functional theory, we examine the adsorption mechanisms of water on the (001), (100), (010) and (110) surfaces of forsterite. While dissociative adsorption is found to be the most energetically favourable process, two stable associative adsorption configurations are also identified. In dual-site adsorption, the water molecule interacts strongly with surface magnesium and oxygen atoms, whereas single-site adsorption occurs only through the interaction with a surface Mg atom. This results in dual-site adsorption being more stable than single-site adsorption.
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Affiliation(s)
- Abu Md Asaduzzaman
- Lunar and Planetary Laboratory, University of Arizona, Tucson, AZ 85721, USA
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11
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Thüroff JW, Abrams P, Andersson KE, Artibani W, Chapple CR, Drake MJ, Hampel C, Neisius A, Schröder A, Tubaro A. [EAU Guidelines on Urinary Incontinence]. Actas Urol Esp 2011; 35:373-88. [PMID: 21600674 DOI: 10.1016/j.acuro.2011.03.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Accepted: 03/31/2011] [Indexed: 11/19/2022]
Abstract
CONTEXT The first European Association of Urology (EAU) guidelines on incontinence were published in 2001. These guidelines were periodically updated in past years. OBJECTIVE The aim of this paper is to present a summary of the 2009 update of the EAU guidelines on urinary incontinence (UI). EVIDENCE ACQUISITION The EAU working panel was part of the 4th International Consultation on Incontinence (ICI) and, with permission of the ICI, extracted the relevant data. The methodology of the 4th ICI was a comprehensive literature review by international experts and consensus formation. In addition, level of evidence was rated according to a modified Oxford system and grades of recommendation were given accordingly. EVIDENCE SUMMARY A full version of the EAU guidelines on urinary incontinence is available as a printed document (extended and short form) and as a CD-ROM from the EAU office or online from the EAU Web site (http://www.uroweb.org/guidelines/online-guidelines/). The extent and invasiveness of assessment of UI depends on severity and/or complexity of symptoms and clinical signs and is different for men, women, frail older persons, children, and patients with neuropathy. At the level of initial management, basic diagnostic tests are applied to exclude an underlying disease or condition such as urinary tract infection. Treatment is mostly conservative (lifestyle interventions, physiotherapy, physical therapy, pharmacotherapy) and is of an empirical nature. At the level of specialised management (when primary therapy failed, diagnosis is unclear, or symptoms and/or signs are complex/severe),more elaborate assessment is generally required, including imaging, endoscopy, and urodynamics. Treatment options include invasive interventions and surgery. CONCLUSIONS Treatment options for UI are rapidly expanding. These EAU guidelines provide ratings of the evidence (guided by evidence-based medicine) and graded recommendations for the appropriate assessment and according treatment options and put them into clinical perspective.
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Affiliation(s)
- J W Thüroff
- Departamento de Urología, Johannes Gutenberg University, Mainz, Alemania.
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12
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Drake MJ, Fowler CJ, Griffiths D, Mayer E, Paton JFR, Birder L. Neural control of the lower urinary and gastrointestinal tracts: supraspinal CNS mechanisms. Neurourol Urodyn 2010; 29:119-27. [PMID: 20025025 DOI: 10.1002/nau.20841] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Normal urinary function is contingent upon a complex hierarchy of CNS regulation. Lower urinary tract afferents synapse in the dorsal horn of the spinal cord and ascend to the midbrain periaqueductal gray (PAG), with a separate nociception path to the thalamus. A spino-thalamo-cortical sensory pathway is present in some primates, including humans. In the brainstem, the pontine micturition center (PMC) is a convergence point of multiple influences, representing a co-ordinating center for voiding. Many PMC neurones have characteristics necessary to categorize the center as a pre-motor micturition nucleus. In the lateral pontine brainstem, a separate region has some characteristics to suggest a "continence center." Cerebral control determines that voiding is permitted if necessary, socially acceptable and in a safe setting. The frontal cortex is crucial for decision making in an emotional and social context. The anterior cingulate gyrus and insula co-ordinate processes of autonomic arousal and visceral sensation. The influence of these centers on the PMC is primarily mediated via the PAG, which also integrates bladder sensory information, thereby moderating voiding and storage of urine, and the transition between the two phases. The parabrachial nucleus in the pons is also important in behavioral motivation of waste evacuation. Lower urinary tract afferents can be modulated at multiple levels by corticolimbic centers, determining the interoception of physiological condition and the consequent emotional motor responses. Alterations in cognitive modulation, descending modulation, and hypervigilance are important in functional (symptom-based) clinical disorders.
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Affiliation(s)
- M J Drake
- Bristol Urological Institute, Southmead Hospital, Bristol, UK.
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13
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Lagou M, Gillespie J, Kirkwood T, Harvey I, Drake MJ. Muscarinic stimulation of the mouse isolated whole bladder: physiological responses in young and ageing mice. ACTA ACUST UNITED AC 2006; 26:253-60. [PMID: 16879490 DOI: 10.1111/j.1474-8673.2006.00364.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
1 Peripheral autonomous bladder activity is an incompletely understood property that may be important both in normal bladder function and in functional problems of the lower urinary tract. We describe how a muscarinic agonist, arecaidine, influences intravesical pressure and intramural bladder contractions in the isolated mouse and how response varies in ageing mice. 2 A group of 12 mice aged 3-4 months was compared with an 'ageing' group of 12 mice age 28-34 months. Bladders were microsurgically removed and mounted in whole organ tissue baths. The effects of the muscarinic agonist arecaidine on intravesical pressure and intramural contractions were performed at different bladder volumes. 3 In normal mice, arecaidine elicited tonic and phasic contractions, the latter showing a more substantial increase in amplitude with bladder distension. Localized 'micromotion' contractions were seen in the bladder wall, with regional differences arising after exposure to arecaidine. A background release of acetylcholine was inferred from the pressure increase induced by the cholinesterase inhibitor physostigmine. 4 Both micromotion activity and the phasic component of the arecaidine response were substantially reduced in ageing mice; the tonic component was preserved in the same specimens. 5 We conclude that the enhanced pressure fluctuations seen at high bladder volumes may act as a peripheral determinant of bladder capacity, and that changes in such activity may contribute to altered functional capacity and lower urinary tract symptoms in ageing individuals.
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Affiliation(s)
- M Lagou
- Urophysiology Research Group, School of Surgical Sciences, University of Newcastle, Newcastle-upon-Tyne, UK
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Drake MJ, Cortina-Borja M, Savic G, Charlifue SW, Gardner BP. Prospective evaluation of urological effects of aging in chronic spinal cord injury by method of bladder management. Neurourol Urodyn 2005; 24:111-6. [PMID: 15605371 DOI: 10.1002/nau.20091] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AIMS Risk of treatment-related problems in spinal cord injury (SCI) mandates assessment of complication rates of different bladder management methods (BMMs). The current study evaluated aging-related complications of various BMMs over a 6-year period in a population with spinal cord injury for at least 20 years. MATERIALS AND METHODS Clinical parameters were compared using a linear mixed effects model, controlling for various confounding variables, to establish complication trends with aging and their association with BMM. Results for people whose BMM was changed during the study were evaluated separately as well as in combination with the whole population. RESULTS One hundred and ninety six people (mean age 57.4 and years post injury (YPI) 33) were evaluated on three occasions. Both age and YPI were significantly associated with rising complication rates regardless of BMM. The BMMs assessed differed in terms of complication rates. In comparison with balanced reflex voiding, straining was significantly better for renal structural abnormality. Intermittent catheterization was associated with significantly worse renal function, possibly for demographic reasons. Overall, 28.8% changed BMM during the study period, particularly, those using straining or balanced reflex voiding. The probability of change increased with age and YPI. Reasons for change of BMM were varied and there was no specific association between reason for change and BMM. CONCLUSIONS Aging and duration of injury substantially influence urological complication rates, and BMM options differ in respect of prevalence and incidence of complications. At a late stage post injury there remains a high probability of change in BMM. The findings indicate the importance of long-term planning from the time of injury to minimize late complications.
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Affiliation(s)
- M J Drake
- School of Surgical Sciences, University of Newcastle, United Kingdom.
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Gillespie JI, Drake MJ. The actions of sodium nitroprusside and the phosphodiesterase inhibitor dipyridamole on phasic activity in the isolated guinea-pig bladder. BJU Int 2004; 93:851-8. [PMID: 15050004 DOI: 10.1111/j.1464-410x.2003.04727.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To investigate the actions of the nitric oxide (NO) donor sodium nitroprusside (SNP) and phosphodiesterase (PDE) inhibitors, which purport to affect intracellular cGMP levels, on the phasic activity generated by agonist stimulation of the isolated whole bladder of the guinea pig. MATERIALS AND METHODS Isolated whole bladders from female guinea pigs (270-300 g) were used in all experiments. Each bladder was cannulated via the urethra and suspended in a chamber containing oxygenated solution at 33-35 degrees C. Bladder pressure was recorded and pharmacological agents added to the solution bathing the abluminal surface of the bladder. RESULTS In the unstimulated bladder, SNP at up to 300 micromol/L caused only small (<2 cmH(2)O) rises in intravesical pressure. In the presence of phasic activity induced by either muscarinic or nicotinic stimulation, SNP at > 30 micromol/L, produced a dose-dependent increase in the frequency of the transients. The cells responding to SNP with an increase in intracellular cGMP were identified by immunofluorescence, and were in the suburothelial layer and within the muscle bundles. Smooth muscle cells of the detrusor body did not show a rise in cGMP. Exposure to the cGMP/PDE inhibitor zaprinast had no effect on phasic activity, but exposure to dipyridamole produced a transient rise in frequency, followed by an inhibition. Dipyridamole also significantly increased the amplitude of the phasic activity. CONCLUSION These data show an excitatory role for NO/cGMP in the integrated regulation of phasic bladder activity. One population of cells which may be involved may be in the suburothelial layer and within the muscles. The differential sensitivity to PDE inhibitors affecting cGMP suggests that the cells responsible express specific isoforms of these regulatory enzymes. The importance of these observations, their possible role in the integrated physiology of the bladder and origins of bladder pathology, are discussed.
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Affiliation(s)
- J I Gillespie
- The Urophysiology Research Group, School of Surgical and Reproductive Sciences, The Medical School, The University, Newcastle upon Tyne NE2 4HH, UK.
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16
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Abstract
PURPOSE Nocturia is a common condition often attributed in aging men to benign prostatic enlargement. Older adults are prone to nocturnal sleep disturbance, of which disturbed circadian rhythm may be a component since it improves with nighttime administration of melatonin. This study was designed to investigate melatonin as a potential treatment for nocturia associated with bladder outflow obstruction in older men. MATERIALS AND METHODS A total of 20 men with urodynamically confirmed bladder outflow obstruction and nocturia were entered into a randomized, double blind, placebo controlled crossover study assessing the effect of 2 mg controlled release melatonin at night on nocturia. Symptoms were assessed at baseline and after each 4-week treatment period using a frequency volume chart, the International Prostate Symptom Score and symptom problem index. Maximum urinary flow rate and post-void residual urine volume were also assessed. RESULTS Baseline frequency of nocturia was 3.1 episodes per night. There were 7 men (35%) with detrusor overactivity and 10 (50%) had nocturnal polyuria. Melatonin and placebo caused a decrease in nocturia of 0.32 and 0.05 episodes per night (p = 0.07) and a decrease in the nocturia bother score of 0.51 and 0.05, respectively (p = 0.008). Nocturia responder rates (a reduction from baseline of at least -0.5 episodes per night) differed between the active medication and placebo groups (p = 0.04). Daytime urinary frequency, International Prostate Symptom Score, relative nocturnal urine volume, maximum urinary flow rate and post-void residual were unaffected by melatonin treatment. CONCLUSIONS Melatonin treatment is associated with a significant nocturia response rate, improvement in nocturia related bother and a good adverse effect profile. However, it is uncertain whether the observed changes in this study are clinically significant.
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Affiliation(s)
- M J Drake
- Department of Urological Sciences, University of Newcastle upon Tyne, Newcastle upon Tyne, United Kingdom.
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17
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Abstract
OBJECTIVE To evaluate the peripheral anatomical distribution of innervation within muscle bundles of the detrusor and the changes arising in neurogenic detrusor overactivity (DO). PATIENTS AND METHODS Full-thickness samples from the bladder dome of three cadaveric transplant organ donors and four people with neurogenic DO caused by spinal cord injury were compared. Systematic serial cryostat sections were stained using Masson trichrome and elastin techniques, and vimentin immunohistochemistry. A coherent image stack was generated for three-dimensional image reconstructions, which were displayed using mixed rendering (i.e. differing graphics for separate tissue components) to show peri- and intra-bundle innervation against the muscle fascicle framework. RESULTS Control specimens had a dense nerve supply. Muscle bundle innervation was derived by dichotomous branching from peri-bundle nerve trunks in the inter-bundle connective tissue. Transverse interfascicular branches entered bundles perpendicular to the long axis at the midpoint of the bundle. They gave rise to axial interfascicular branches, which distributed to the pre-terminal and terminal nerve fibres. All samples from patients with neurogenic DO had patchy denervation. The primary deficit was predominantly at the level of the terminal axial innervation and was cross-sectionally consistent along the longitudinal axis of the muscle bundle. CONCLUSION Patchy denervation may reflect a deficit at the level of the peripheral ganglia. Any contraction in the areas of denervation either occurs out of co-ordination with the rest of the bladder, or is co-ordinated by means of non-neural structures. The observation of fine muscle strands running between fascicles, and connective tissue anchoring structures, represent two hypothetical mechanisms by which such co-ordination might be effected.
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Affiliation(s)
- M J Drake
- Tyne Micturition Research Group, School of Surgical Sciences, University of Newcastle, Newcastle upon Tyne, UK.
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Gillespie JI, Harvey IJ, Drake MJ. Agonist- and nerve-induced phasic activity in the isolated whole bladder of the guinea pig: evidence for two types of bladder activity. Exp Physiol 2003; 88:343-57. [PMID: 12719759 DOI: 10.1113/eph8802536] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Spontaneous localised propagating waves of contraction and localised stretches have been reported to occur in the isolated whole bladder of the guinea pig. The physiological role and the cellular processes underlying these events are unknown. In order to gain insight into the mechanisms generating this complex activity, experiments were performed to examine and compare the responses of the whole bladder preparation to (i) the muscarinic agonists carbachol and arecaidine, (ii) the nicotinic ligand lobeline and (iii) nerve stimulation. High concentrations of the muscarinic agonists (>3 micro M) induced a slow rise in intra-vesical pressure upon which were superimposed pressure transients, while low concentrations (< 300 nM) induced only phasic rises in pressure. One interpretation of these data is that there are two separate mechanisms activated by muscarinic agonists: one generating contracture and the other phasic activity. Immunocytochemical staining revealed M(3) muscarinic receptors on smooth muscle cells within trabeculae and a second population of positive cells in the sub-urothelial layer. This observation raises the possibility that the actions of muscarinic agonists are a consequence of activating different cell types. Lobeline (1-60 micro M) activated phasic contractions but did not cause a rise in basal pressure. Atropine did not inhibit the lobeline-induced responses but abolished the muscarinic responses. Also, hexamethonium or tetrodotoxin did not affect the lobeline-induced responses. These observations suggest that the mechanism generating phasic activity is activated by a nicotinic stimulus that does not involve ganglia, nerves or the neuromuscular junction. Stimulation of the bladder nerve at frequencies between 20 and 30 Hz for 5 s resulted in a rapid rise in intra-vesical pressure. Prolonged nerve stimulation (10-200 s) at frequencies between 1 and 10 Hz activated phasic rises in pressure. Low frequency nerve stimulation increased the frequency of agonist-induced phasic activity. Thus, nerve stimulation can also produce two forms of activity and low frequency stimulation can augment the processes generating phasic activity. These observations suggest that there are two distinct types of bladder activity: global contractions involving most of the bladder wall and phasic contractions comprising propagating waves of contraction. The mechanisms generating these contractile events appear to be different and they may involve cells located in different regions of the bladder. The nature of these mechanisms and their possible physiological significance is discussed.
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Affiliation(s)
- J I Gillespie
- The Urophysiology Research Group, School of Surgical and Reproductive Sciences, The Medical School, University of Newcastle, Newcastle upon Tyne NE2 4HH, UK.
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19
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Abstract
The antiangiogenic effects of thalidomide have been assessed in clinical trials in patients with various solid and haematological malignancies. Thalidomide blocks the activity of angiogenic agents including bFGF, VEGF and IL-6. We undertook an open-label study using thalidomide 100 mg once daily for up to 6 months in 20 men with androgen-independent prostate cancer. The mean time of study was 109 days (median 107, range 4-184 days). Patients underwent regular measurement of prostate-specific antigen (PSA), urea and electrolytes, serum bFGF and VEGF. Three men (15%) showed a decline in serum PSA of at least 50%, sustained throughout treatment. Of 16 men treated for at least 2 months, six (37.5%) showed a fall in absolute PSA by a median of 48%. Increasing levels of serum bFGF and VEGF were associated with progressive disease; five of six men who demonstrated a fall in PSA also showed a decline in bFGF and VEGF levels, and three of four men with a rising PSA showed an increase in both growth factors. Adverse effects included constipation, morning drowsiness, dizziness and rash, and resulted in withdrawal from the study by three men. Evidence of peripheral sensory neuropathy was found in nine of 13 men before treatment. In the seven men who completed six months on thalidomide, subclinical evidence of peripheral neuropathy was found in four before treatment, but in all seven at repeat testing. The findings indicate that thalidomide may be an option for patients who have failed other forms of therapy, provided close follow-up is maintained for development of peripheral neuropathy.
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Affiliation(s)
- M J Drake
- Department of Surgery, School of Surgical Sciences, The Medical School, University of Newcastle upon Tyne, UK.
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20
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Abstract
Phasic changes in pressure have been reported to occur in the bladder which are not associated with micturition. Spontaneous intravesical pressure changes can be recorded from bladders in vitro or bladders in vivo isolated from the central nervous system suggesting that the bladder itself is capable of autonomous activity. Experiments using isolated cells and muscle strips indicate that the smooth muscle can generate spontaneous activity. Whether this is the origin of phasic changes in the intact organ remains unknown. The present study set out to establish the presence and characteristics of autonomous activity in the isolated guinea pig bladder. Multiple-point motion analysis and concurrent intravesical pressure recording were used to identify and quantify spontaneous and evoked activity. Highly complex autonomous activity was observed in unstimulated bladders. This activity comprised localised micro-contractions in single or multiple discrete regions, waves of activity and micro-stretches. Low-amplitude phasic 'micro-transients' were seen in the intravesical pressure trace in association with micro-contractions. Incremental increases in the intravesical volume recruited additional areas of activity. Atropine and tetrodotoxin had no effect on the micro-transients or micro-contractions. Exposure to the muscarinic agonist arecaidine (10-300 nM) initially increased the incidence of micro-contractions which subsequently became co-ordinated into phasic pressure rises and contraction waves, interspersed with periods of total quiescence. The findings describe the generation and co-ordination of autonomous activity in the bladder wall and also demonstrate complex phasic activity. This approach has shown the importance of assessing the integrative properties of the entire organ in studies of the physiology and patho-physiology of the bladder.
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Affiliation(s)
- M J Drake
- School of Surgical and Reproductive Sciences, 3rd floor Leech building, The Medical School, University of Newcastle, NE2 4HH, UK
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21
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Drake MJ, Cowan NC. Fluoroscopy guided retrograde ureteral stent insertion in patients with a ureteroileal urinary conduit: method and results. J Urol 2002; 167:2049-51. [PMID: 11956436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
PURPOSE We evaluated retrograde double pigtail stent placement in patients with ureteroileal anastomosis. MATERIALS AND METHODS Procedures were performed under digital C-arm fluoroscopic guidance and the patient under sedation analgesia. Radiography of the conduit was done to delineate urinary diversion anatomy and identify ureteral reflux. A purpose designed, angled tip catheter was used to direct a straight glide wire across the ureteroileal anastomosis. The glide wire was exchanged for a stiff guide wire for stent placement. We retrospectively evaluated the clinical records of 7 men and 5 women with a mean age of 54.3 years in a 7-year period. In 11 patients a new stent was placed because of ureteroileal stricture in 5, anastomotic leakage in 3, ureterolithiasis in 2 and recurrent malignancy in 1. RESULTS New stent placement was successful in 10 of the 11 patients (90.9%, 13 of 16 ureters or 81.3%). Stent placement was successful in the 8 ureters in which reflux was noted on radiography of the conduit and in 5 of the 9 (55.6%) in which no reflux was noted. Stent replacement was accomplished in all 22 ureters (6 patients) in which it was attempted. Mean radiological screening time for new stent placement was 13.3 minutes (range 4.7 to 19.7), while for exchange it was 6.4 minutes (range 0.8 to 15.1). There were no immediate complications. CONCLUSIONS This technique represents a useful approach to the ureter and should be considered an alternative to percutaneous nephrostomy and surgical revision. The approach is also useful for other ureteral procedures, including stone or migrated stent retrieval.
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Affiliation(s)
- M J Drake
- Departments of Urology and Radiology, Churchill Hospital, Oxford, United Kingdom
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22
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Abstract
Considerable evidence points to a martian origin of the SNC meteorites. Noble gas isotopic compositions have been measured in most SNC meteorites. The 129Xe/132Xe vs, 84Kr/132Xe ratios in Chassigny, most shergottites, and lithology C of EETA 79001 define a linear array. This array is thought to be a mixing line between martian mantle and martian atmosphere. One of the SNC meteorites, Nakhla, contains a leachable component that has an elevated 129Xe/132Xe ratio relative to its 84Kr/132Xe ratio when compared to this approximately linear array. The leachable component probably consists in part of iddingsite, an alteration product produced by interaction of olivine with aqueous fluid at temperatures lower than 150 degrees C. The elevated Xe isotopic ratio may represent a distinct reservoir in the martian crust or mantle. More plausibly, it is elementally fractionated martian atmosphere. Formation of sediments fractionates the noble gases in the correct direction. The range of sediment/atmosphere fractionation factors is consistent with the elevated 129Xe/132Xe component in Nakhla being contained in iddingsite, a low temperature weathering product. The crystallization age of Nakhla is 1.3 Ga. Its low-shock state suggests that it was ejected from near the surface of Mars. As liquid water is required for the formation of iddingsite, these observations provide further evidence for the near surface existence of aqueous fluids on Mars more recently than 1.3 Ga.
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Affiliation(s)
- M J Drake
- Lunar and Planetary Laboratory, University of Arizona, Tucson 85721, USA
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23
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Abstract
Normal bladder function is controlled by the central nervous system (CNS) and any peripheral contribution to bladder control is believed to be small. Nevertheless, anatomically and functionally, such a contribution might exist. Taking account of this evidence, we propose that the detrusor muscle is arranged into modules, which are circumscribed areas of muscle active during the filling phase of the micturition cycle. These modules might be controlled by a peripheral myovesical plexus, consisting of intramural ganglia and interstitial cells. Detrusor overactivity is the occurrence of abnormal increases in pressure during bladder filling, which the patient cannot inhibit. This disorder is thought to be a consequence of abnormal expression of the micturition reflex or changes in the properties of the smooth muscle. We propose that detrusor overactivity results from exaggerated symptomatic expression of peripheral autonomous activity, resulting from a shift in the balance of excitation and inhibition in smooth muscle modules. These structures responsible for origin and spread of peripheral autonomous activity could be targeted to help develop new therapeutic strategies.
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Affiliation(s)
- M J Drake
- Tyne Micturition Research Group, School of Surgical Sciences, Medical School, University of Newcastle upon Tyne NE2 4HH, UK.
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Drake MJ, Hedlund P, Mills IW, McCoy R, McMurray G, Gardner BP, Andersson KE, Brading AF. Structural and functional denervation of human detrusor after spinal cord injury. J Transl Med 2000; 80:1491-9. [PMID: 11045565 DOI: 10.1038/labinvest.3780158] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
The bladder receives an extensive nerve supply that is predominantly cholinergic, but several putative transmitters are present, some of which are colocalized. Previous studies have shown increased levels of sensory nerves, reduced inhibitory transmitters, and structural and functional changes in the excitatory input in unstable bladder conditions. The present study compared the end-organ nerve supply to the bladder in spinal cord injury (SCI) with uninjured controls. Acetylcholinesterase histochemistry and double-label immunofluorescence were used to investigate neurotransmitter content, with confocal laser scanning microscopy to assess colocalization. Organ bath studies provided functional correlates for the structural changes in the excitatory innervation. Control samples had dense innervation of the detrusor containing a diverse range of transmitters. Hyperreflexic SCI samples showed patchy denervation, and areflexic SCI samples were diffusely denervated. Vasoactive intestinal polypeptide-, neuropeptide Y-, neuronal nitric oxide synthase-, and galanin-immunoreactive nerve fibers were reduced from frequent or moderately frequent to infrequent or very infrequent in SCI. Calcitonin gene-related peptide-immunoreactive fibers were infrequent in controls and SCI samples. Patterns of colocalization were unchanged, but significantly fewer fibers expressed more than one transmitter. The subepithelial plexus was markedly reduced and several of the smaller coarse nerve trunks showed no immunoreactivity to the transmitters assessed. There was no reduction in sensitivity to electrical field stimulation of intrinsic nerves in SCI, but the maximum force generated by each milligram of bladder tissue and the peak force as a proportion of the maximum carbachol contraction were significantly reduced and the responses were protracted. There was no significant functional atropine-resistant neuromuscular transmission in controls or SCI. The reported findings have clinical implications in the management of chronic SCI and development of new treatments.
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Affiliation(s)
- M J Drake
- University Department of Pharmacology, Oxford, United Kingdom.
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Abstract
OBJECTIVE To investigate the role of cholinergic excitation in mediating changes in detrusor compliance (manifested on conventional cystometry as an incremental rise in detrusor pressure as bladder volume increases) under conditions of propofol-sedation in the pig. Materials and methods Consecutive cystometrograms (CMGs) were obtained from eight female Large White pigs at a bladder filling rate of 50 mL/min. The first CMG was obtained while the pig was awake and unsedated. Two subsequent CMGs were obtained after light to moderate sedation with propofol (2-8 mg/kg/h) before and after the administration of intravenous atropine (0.02 mg/kg). RESULTS All bladders were highly compliant over the volumes instilled (before sedation) with a maximum pressure during the filling phase of 0.9 cmH2O and a compliance of 943 mL/cmH2O. After sedation with propofol, the maximum pressure during the filling phase increased to 14 cmH2O with a compliance of 69 mL/cmH2O. Atropine antagonized this change in compliance; after sedation and atropine, the maximum pressure during the filling phase decreased to 4 cmH2O (P < 0.05) and the compliance increased to 337 mL/cmH2O (P < 0.05). CONCLUSION The decrease in compliance seen in the pig bladder after sedation with propofol is mediated via muscarinic excitation. This probably occurs as a result of low-level tonic release of acetylcholine by the efferent parasympathetic nerves. The existence of such efferent excitatory activity during the storage phase in the overactive human bladder might explain the efficacy of bladder-selective muscarinic antagonists in a proportion of patients with detrusor hyper-reflexia and instability.
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Affiliation(s)
- I W Mills
- Oxford Continence Group, University Department of Pharmacology, Mansfield Road, Oxford, UK
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Mills IW, Drake MJ, Brading AF, McCoy R, Noble JG. Carbachol-induced sustained tonic contraction of rat detrusor muscle. BJU Int 2000; 85:381-2. [PMID: 10744455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
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Affiliation(s)
- M J Drake
- Department of Urology, Churchill Hospital, Oxford, UK
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Abstract
Nearly all gynecological procedures have been reported to cause ureteric injury, with an incidence of 0.4%-2.5% for non-malignant conditions. The incidence is rising as more ambitious operations are undertaken laparoscopically. Risk factors for ureteric injury include cancer, hemorrhage, endometriosis, adhesions and an enlarged uterus. Types of injury include ligation, crush, laceration, avulsion, stretch and devascularization. The diagnosis may be obvious intraoperatively, but postoperative presentation with loin pain, pyrexia, fistula or non-specific signs is more common. A significant number are asymptomatic. Early diagnosis is vital, and urological investigation should be considered in any patient who is not recovering as expected. Injuries recognized intraoperatively should be repaired during the same operation. Delayed recognized injuries are being managed conservatively with increasing success in selected cases. Early operative repair achieves good results unless the injury is severe. Litigation is less likely if the diagnosis is prompt, repair is successful and the patient is treated with consideration.
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Affiliation(s)
- M J Drake
- Churchill Hospital, Headington, Oxford, UK
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Abstract
The bladder is vulnerable to the adverse effects of drugs because of its complex control and the frequent excretion of drug metabolites in the urine. Incontinence results when bladder pressure exceeds sphincter resistance. Stress incontinence because of sphincter weakness occurs with antipsychotics and alpha-blockers, especially in women. Urge incontinence and irritative symptoms may be caused by drugs. Anticholinergics, anaesthetics and analgesics cause urinary retention because of failure of bladder contraction. They are more likely to cause retention in men because of prostatic enlargement. Cyclophosphamide and tiaprofenic acid can cause chemical cystitis, and should be withdrawn if a patient develops irritative symptoms or haematuria. Cyclophosphamide may also induce bladder tumours. Adverse effects of cyclophosphamide can be reduced with prophylactic administration of mesna and adequate hydration. Mitomycin, doxorubicin or bacillus Calmette-Guerin (BCG) instilled locally to treat bladder tumours can cause cystitis, contracture and calcification. Their administration should be limited to 1 hour per week for a maximum of 8 weeks. Retroperitoneal fibrosis and urine discolouration may be caused by drugs. Ureteric calculi may result from any drug causing nephrolithiasis.
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Affiliation(s)
- M J Drake
- Department of Urology, Churchill Hospital, Oxford, England
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Drake MJ, Quinn FM. Absent vas deferens and ipsilateral multicystic dysplastic kidney in a child. Br J Urol 1996; 77:756-7. [PMID: 8689131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- M J Drake
- Department of Urology, Addenbrooke's NHS Trust, Cambridge, UK
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Abstract
The abundances of siderophile elements in the Earth's silicate mantle are too high for the mantle to have been in equilibrium with iron in the core if equilibrium occurred at low pressures and temperatures. It has been proposed that this problem may be solved if equilibrium occurred at high pressures and temperatures. Experimental determination of the distribution of siderophile elements between liquid metal and liquid silicate at 100 kilobar and 2000 degrees C demonstrates that it is unlikely that siderophile element abundances were established by simple metal-silicate equilibrium, which indicates that the segregation of the core from the mantle was a complex process.
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Abstract
Infrared reflectance spectra have been obtained for the meteorites Shergotty and Allan Hills (ALHA) 77005, a unique achondrite apparently related to the shergottites. Comparisons with the reflectance spectra of eucrites and asteroid 4 Vesta indicate that the surface of Vesta is covered with eucrite-like basalts and that, if shergottite-like basalts are present on the surface of Vesta, they must be a minor rock type. The paradox that both the eucrite and shergottite parent bodies should presently exist is examined. The preferred solution is that both eucrites and shergottites are derived from Vesta, and that this asteroid is compositionally and isotopically heterogeneous; however, other possible solutions cannot be ruled out.
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Abstract
The partition of europium between plagioclase feldspar and magmatic liquid is considered in terms of the distribution coefficients for divalent and trivalent europium. A model equation is derived giving the europium anomaly in plagioclase as a function of temperature and oxygen fugacity. The model explains europium anomalies in plagioclase synthesized under controlled laboratory conditions as well as the variations of the anomaly observed in natural terrestrial and extraterrestrial igneous rocks.
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Abstract
All phases in a thin section of sample 10022 have been analyzed by electron microprobe. Augite grains show strong iron enrichment in the outer 15 to 20 microns. Pigeonite cores occur within augite grains. The plagioclase has an anorthite content of between 73 and 81 mole percent and is high in Si and low in Al compared to stoichiometric feldspar. Residual phases include microcrystalline Fe-rich "pyroxene," plagioclase, K-rich alkali feldspar, silica, and rare areas rich in P and Zr with concentrations of Ba, Y, and rare earth elements. The density, viscosity, and crystallization history of the lava of sample 10022 are discussed.
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