The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline

This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.

Reconciling artificial intelligence and non-Bayesian models for pterygomaxillary morphometrics

BACKGROUND

The base of the skull, particularly the pterygomaxillary region, has a sophisticated topography, the morphometry of which interests pathologists, maxillofacial and plastic surgeons. The aim of the study was to conduct pterygomaxillary morphometrics and test relevant hypotheses on sexual and laterality-based dimorphism, and causality relationships.

MATERIALS AND METHODS

We handled 60 dry skulls of adult Asian males (36.7%) and females (63.3%). We calculated the prime distance D [prime] for the imaginary line from the maxillary tuberosity to the midpoint of the pterygoid process between the upper and the lower part of the pterygomaxillary fissure, as well as the parasagittal D [x-y inclin.] and coronal inclination of D [x-z inclin.] of the same line. We also took other morphometrics concerning the reference point, the maxillary tuberosity.

RESULTS

Significant sexual as well as laterality-based dimorphism and bivariate correlations existed. The univariate models could not detect any significant effect of the predictors. On the contrary, summative multivariate tests in congruence with neural networks, detected a significant effect of laterality on D [x-y inclin.] (p-value = 0.066, partial eta squared = 0.030), and the interaction of laterality and sex on D [x-z inclin.] (p-value = 0.050, partial eta squared = 0.034). K-means clustering generated three clusters highlighting the significant classifier effect of D [prime] and its three-dimensional inclination.

CONCLUSIONS

Although the predictors in our analytics had weak-to-moderate effect size underlining the existence of unknown explanatory factors, it provided novel results on the spatial inclination of the pterygoid process, and reconciled machine learning with non-Bayesian models, the application of which belongs to the realm of oral-maxillofacial surgery.

Simultaneous pelvic exenteration and liver resection for primary rectal cancer with synchronous liver metastases: results from the PelvEx Collaborative

AIM

At presentation, 15-20% of patients with rectal cancer already have synchronous liver metastases. The aim of this study was to determine the surgical and survival outcomes in patients with advanced rectal cancer who underwent combined pelvic exenteration and liver (oligometastatic) resection.

METHOD

Data from 20 international institutions that performed simultaneous pelvic exenteration and liver resection between 2007 and 2017 were accumulated. Primarily, we examined perioperative outcomes, morbidity and mortality. We also assessed the impact that margin status had on survival.

RESULTS

Of 128 patients, 72 (56.2%) were men with a median age of 60 years [interquartile range (IQR) 15 years]. The median size of the liver oligometastatic deposits was 2 cm (IQR 1.8 cm). The median duration of surgery was 406 min (IQR 240 min), with a median blood loss of 1090 ml (IQR 2010 ml). A negative resection margin (R0 resection) was achieved in 73.5% of pelvic exenterations and 66.4% of liver resections. The 30-day mortality rate was 1.6%, and 32% of patients had a major postoperative complication. The 5-year overall survival for patients in whom an R0 resection of both primary and metastatic disease was achieved was 54.6% compared with 20% for those with an R1/R2 resection (P = 0.006).

CONCLUSION

Simultaneous pelvic exenteration and liver resection is feasible, with acceptable morbidity and mortality. Simultaneous resection should only be performed where an R0 resection of both pelvic and hepatic disease is anticipated.

A279 EUS-GUIDED BILIARY DRAINAGE IN MALIGNANT DISTAL BILIARY OBSTRUCTION: AN INTERNATIONAL SURVEY TO IDENTIFY BARRIERS OF TECHNOLOGY IMPLEMENTATION

Background

Endoscopic ultrasound-guided biliary drainage (EUS-BD) is a promising alternative to endoscopic retrograde cholangiopancreatography (ERCP) in malignant distal biliary obstruction (MDBO). Recent small randomized controlled trials comparing EUS-BD with ERCP suggest that EUS-BD achieves a similar technical success rate and safety profile while potentially being associated with lower rates of stent dysfunction However, its application in clinical practice has been impeded by various undefined barriers.

Aims

To evaluate the current practice of EUS-BD and the determinants for its clinical implementation in MDBO.

Methods

An online survey was generated using Google Forms. Five endoscopy societies have distributed the survey as of October 10th, 2019. Survey questions measured participant characteristics, EUS-BD in different clinical scenarios, and potential barriers to implementation. Descriptive statistics were calculated using frequencies, chi-square statistics were used for inferential analysis, and a standard step-wise multivariable analysis was performed to identify independent variables for and against the use of EUS-BD.

Results

To date, 102 physicians have participated in the survey (response rate 7.97%). The majority of participants are from North America (39.2%), Asia (31.4%), and Europe (19.6%). Most participants are gastroenterologists with formal therapeutic endoscopy training (66.7%), though only 28.4% have received EUS-BD training. In unresectable cancer, 85.1% of respondents favoured EUS-BD over percutaneous biliary drainage following ERCP failure (p<0.0001), while in borderline resectable disease, 72.3% preferred EUS-BD. On multivariable analysis, male gender, formal training in EUS-BD, and unresectable cancer were independent variables for the use of EUS-BD. Conversely, independent discouraging factors for EUS-BD included fear of adverse events, limited high-quality data, lack of local expertise, and inadequate access to EUS technology.

Conclusions

In this international survey, it appears that EUS-BD is gaining traction, especially in the setting of unresectable disease following ERCP failure. However, barriers to implementation include the lack of high-quality data, fear for adverse events, limited experts in the field, and inadequate access to EUS technology. This suggest the need for high-quality clinical trials, increased endoscopist training in this field, and further technology development in EUS-BD in order to increase its uptake in clinical practice.

Funding Agencies

None

Evaluation of community-based HIV self-testing delivery strategies on reducing undiagnosed HIV infection, and improving linkage to prevention and treatment services, among men who have sex with men in Kenya: a programme science study protocol

BACKGROUND

HIV prevalence among men having sex with men (MSM) in Kenya is 18.2%. Despite scale-up of HIV testing services, many MSM remain unaware of their HIV status and thus do not benefit from accessing HIV treatment or prevention services. HIV self-testing (HIVST) may help address this gap. However, evidence is limited on how, when, and in what contexts the delivery of HIVST to MSM could increase awareness of HIV status and lead to early linkage to HIV treatment and prevention.

METHODS

The study will be embedded within existing MSM-focused community-based HIV prevention and treatment programmes in 3 counties in Kenya (Kisumu, Mombasa, Kiambu). The study is designed to assess three HIV testing outcomes among MSM, namely a) coverage b) frequency of testing and c) early uptake of testing. The study will adopt a mixed methods programme science approach to the implementation and evaluation of HIVST strategies via: (i) a baseline and endline bio-behavioural survey with 1400 MSM; (ii) a socio-sexual network study with 351 MSM; (iii) a longitudinal qualitative cohort study with 72 MSM; (iv) routine programme monitoring in three sites; (v) a programme-specific costing exercise; and (vi) mathematical modelling. This protocol evaluates the impact of community-based implementation of HIV self-testing delivery strategies among MSM in Kenya on reducing the undiagnosed MSM population, and time for linkage to prevention, treatment and care following HIV self-testing. Baseline data collection started in April 2019 and the endline data collection will start in July 2020.

DISCUSSION

This study is one of the first programme science studies in Sub-Saharan Africa exploring the effectiveness of integrating HIVST interventions within already existing HIV prevention and treatment programmes for MSM in Kenya at scale. Findings from this study will inform national best approaches to scale up HIVST among MSM in Kenya.

Adaptive coarse graining method for energy transfer and dissociation kinetics of polyatomic species

A novel reduced-order method is presented for modeling reacting flows characterized by strong non-equilibrium of the internal energy level distribution of chemical species in the gas. The approach seeks for a reduced-order representation of the distribution function by grouping individual energy states into macroscopic bins, and then reconstructing state population using the maximum entropy principle. This work introduces an adaptive grouping methodology to identify and lump together groups of states that are likely to equilibrate faster with respect to each other. To this aim, two algorithms have been considered: the modified island algorithm and the spectral clustering method. Both methods require a measure of dissimilarity between internal energy states. This is achieved by defining "metrics" based on the strength of the elementary rate coefficients included in the state-specific kinetic mechanism. Penalty terms are used to avoid grouping together states characterized by distinctively different energies. The two methods are used to investigate excitation and dissociation of N₂ (Σg+1) molecules due to interaction with N(Su4) atoms in an ideal chemical reactor. The results are compared with a direct numerical simulation of the state-specific kinetics obtained by solving the master equations for the complete set of energy levels. It is found that adaptive grouping techniques outperform the more conventional uniform energy grouping algorithm by providing a more accurate description of the distribution function, mole fraction and energy profiles during non-equilibrium relaxation.

Mixed urinary incontinence- what should we treat first?

Mixed urinary incontinence (MUI) is defined as ‘the involuntary loss of urine associated with urgency and also with effort or physical exertion, or on sneezing or coughing’. It is highly prevalent, increases with age and affects women more than men. It has a significant negative impact on health-related quality of life (HRQL). Additionally, treatment of mixed urinary incontinence places a large financial burden on both individuals and the NHS. Optimal management of this common condition is contested – should we treat the urge urinary incontinence (UUI), stress urinary incontinence (SUI) or predominant symptom first? At the 2015 BAUS Section of Female, Neurological and Urodynamic Urology this subject was debated. Based on a common scenario, the authors of the debate present the arguments for treating the urge urinary incontinence component, stress urinary incontinence component or the predominant symptom of mixed urinary incontinence first, before making recommendations for current practice.

Integrative review on the non-invasive management of lower urinary tract symptoms in men following treatments for pelvic malignancies

AIM

To develop a non-invasive management strategy for men with lower urinary tract symptoms (LUTS) after treatment for pelvic cancer, that is suitable for use in a primary healthcare context.

METHODS

PubMed literature searches of LUTS management in this patient group were carried out, together with obtaining a consensus of management strategies from a panel of authors for the management of LUTS from across the UK.

RESULTS

Data from 41 articles were investigated and collated. Clinical experience was sought from authors where there was no clinical evidence. The findings discussed in this paper confirm that LUTS after the cancer treatment can significantly impair men's quality of life. While many men recover from LUTS spontaneously over time, a significant proportion require long-term management. Despite the prevalence of LUTS, there is a lack of consensus on best management. This article offers a comprehensive treatment algorithm to manage patients with LUTS following pelvic cancer treatment.

CONCLUSION

Based on published research literature and clinical experience, recommendations are proposed for the standardisation of management strategies employed for men with LUTS after the pelvic cancer treatment. In addition to implementing the algorithm, understanding the rationale for the type and timing of LUTS management strategies is crucial for clinicians and patients.

Efficacy of flexible ureteroscopy and laser lithotripsy for lower pole renal calculi

Objective:

Our aim was to determine whether flexible ureterorenoscopy and laser lithotripsy is efficacious and safe in treating lower pole renal calculi.

Materials and methods:

Patient, procedure and stone data of patients who underwent flexible ureterorenoscopy and laser lithotripsy at our referral centre were collected prospectively between November 2005 and November 2011 and entered into a designated database. In all, 242 procedures were performed in 198 patients.

Results:

The mean age was 51.2 years. The mean calculi size was 10.51 mm (range 4–27 mm). Thirty seven patients had more than one stone in the lower pole. An access sheath was used in 19 patients (9.6%), 171 (86.4%) had a ureteric stent inserted after the procedure, and 165 patients had a single procedure. Re-operation rate was 16.7%. Stone-free rates after one procedure were 89%, 80% and 41%, respectively, for calculi measuring 4–10 mm ( n=107), 11–20 mm ( n=76) and > 20 mm ( n=15). The overall stone-free rate was 83%, 91% and 95% after one, two and three procedures, respectively.

Conclusion:

Flexible ureterorenoscopy and laser lithotripsy is a safe and effective minimally invasive treatment option for patients with 4–20 mm lower pole calculi. Staged procedures, however, become necessary as the size of the stone increases greater than 20 mm, and this should be mentioned when counselling patients for their primary procedure.

Botulinum toxin-A for the treatment of overactive bladder: UK contributions

Background:

Botulinum toxin-A (BoNT/A) is now established second-line management for refractory overactive bladder (OAB) and recognised in many incontinence guidelines and pathways. For those with neurogenic detrusor overactivity secondary to spinal cord injury or multiple sclerosis, the toxin is currently licensed in certain parts of the world, including the UK. It is an effective treatment in those in whom antimuscarinics and conservative measures have failed who have symptoms of OAB and or detrusor overactivity (DO).

Methods:

Treatment can be given in an outpatient setting and can be administered under local anaesthesia. Its efficacy lasts for between six and 12 months.

Results:

It has an acceptable safety profile with the biggest risk being urinary tract infection and difficulty emptying the bladder, necessitating clean intermittent self-catheterisation (CISC). Medium-term follow-up suggests repeated injections are also safe and efficacious.

Conclusions:

The mechanism of action of the toxin is more complicated than originally thought, and it seems likely that it affects motor and sensory nerves of the bladder. In the last 10 years much of the progress of this treatment from early experimental trials to mainstream clinical use, and a better understanding of how it works in the bladder, are as a result of research conducted in the UK. This review summarises the significant and substantial evidence for BoNT/A to treat refractory OAB from UK centres.

The safety and efficacy of botulinum toxin-A in the management of bladder oversensitivity: a randomised double-blind placebo-controlled trial

OBJECTIVE

To assess the safety and efficacy of botulinum toxin-A (botn-A) in the management of patients with bladder oversensitivity (BO).

PATIENTS AND METHODS

Twenty-three consecutive patients with a diagnosis of BO refractory to anticholinergics were enrolled in this randomised, double blind, placebo-controlled trial. Patients were randomly allocated to receive intradetrusor injections of either botn-A (100 U Botox) or saline (placebo) via a flexible cystoscopic approach. The study was designed to have 90% power to detect a change in the maximum cystometric capacity (MCC) of 30%. It was calculated that a total cohort of 58 patients would be required. Urodynamic assessment (UDS), voiding diaries (VD) and quality of life (QoL) were assessed at baseline and at 4 and 12 weeks following intervention.

RESULTS

An interim analysis was performed and the trial halted after recruitment of 23 patients as a result of poorly perceived patient benefit. Data were analysed for 21 patients (10 botn-A; 11 placebo). In the treatment arm, there was a significant increase in MCC (mean rise 105 ml; p = 0.009). However, storage symptoms remained statistically unchanged following botn-A. Three patients in the treatment arm were required to perform clean intermittent self-catheterisation with no clinical improvement. The limitations of this trial include the small sample size and the unplanned interim analysis.

CONCLUSIONS

This is the first randomised, double blind, placebo-controlled trial examining the effects of botn-A exclusively in patients with BO. A significant increase in MCC was observed but this did not translate to clinical benefit with no change observed in the symptoms and quality of life for the majority of patients.

Knowledge, attitude and practice of emergency contraceptive pills among tertiary level students in Trinidad: a cross-sectional survey

OBJECTIVE

The objective of this study was to estimate the general knowledge, attitude and practice of Emergency Contraceptive pills (ECs) among tertiary level students in Trinidad.

METHOD

A 32-item questionnaire was constructed to assess knowledge, attitudes and practice of EC. There were 76 medical and 160 non-medical students who volunteered to fill-up the questionnaire. This survey was conducted by graduate students under supervision of the Department of Mathematics and Computer Science, UWI, St Augustine.

RESULTS

Eighty-four per cent of the students were less than 25 years of age, 64% were Christians and 92% were single. Sixty-three per cent were female and there were more females in the non-medical group than the medical students group but the numbers were not significant. Eighty-one per cent used condoms as the main type of contraception. Only 63% had heard of ECs before and only 9% had heard of ECs from medical sources. Among the factors that related to attitude towards EC, only two factors were significant. Sixty-two per cent of students felt that increased EC use would increase promiscuity (p = 0.013) but 59% also felt that ECs should be made more easily available (p = 0.014).

CONCLUSION

The general level of their knowledge about ECs was poor. The general attitude of students towards ECs was positive. This study will help policy-makers by providing evidence-based knowledge to promote EC use among university students.

Community-based Randomized Controlled Trial of Non-pharmacological Interventions in Prevention and Control of Hypertension among Young Adults

CONTEXT

Hypertension is a major chronic lifestyle disease. Several non-pharmacological interventions are effective in bringing down the blood pressure (BP). This study focuses on the effectiveness of such interventions among young adults.

AIMS

To measure the efficacy of physical exercise, reduction in salt intake, and yoga, in lowering BP among young (20-25) pre-hypertensives and hypertensives, and to compare their relative efficacies.

SETTINGS AND DESIGN

The study was done in the urban service area of JIPMER. Pre-hypertensives and hypertensives, identified from previous studies, constituted the universe. The participants were randomized into one control and three interventional groups.

MATERIALS AND METHODS

A total of 113 subjects: 30, 28, 28 and 27 in four groups respectively participated for eight weeks: control (I), physical exercise (II) - brisk walking for 50-60 minutes, four days/week, salt intake reduction (III) - to at least half of their previous intake, and practice of yoga (IV) - for 30-45 minutes/day on at least five days/week.

STATISTICAL ANALYSIS USED

Efficacy was assessed using paired t test and ANOVA with Games Howell post hoc test. An intention to treat analysis was also performed.

RESULTS

A total of 102 participants (29, 27, 25 and 21 in groups I, II, III and IV) completed the study. All three intervention groups showed a significant reduction in BP (SBP/DBP: 5.3/6.0 in group II, 2.6/3.7 in III, and 2.0/2.6 mm Hg in IV respectively). There was no significant change (SBP/DBP: 0.2/0.5 mmHg) of BP in control group (I). Physical exercise was most effective (considered individually); salt intake reduction and yoga were also effective.

CONCLUSIONS

Physical exercise, salt intake reduction, and yoga are effective non-pharmacological interventions in significantly reducing BP among young hypertensives and pre-hypertensives. These can therefore be positively recommended for hypertensives. There is also a case to deploy these interventions in the general population.

Evolution of transdermal oxybutynin in the treatment of overactive bladder

Overactive bladder (OAB) syndrome affects millions of people worldwide. In addition to adversely affecting quality of life, the direct and indirect costs in managing patients with OAB incur a substantial financial burden on health services. Among the approved anticholinergics for treating OAB, oxybutynin is the most extensively studied drug in clinical trials. The principle metabolite of oxybutynin has a higher affinity for muscarinic receptors in salivary glands which lead to significantly high dry mouth rates. This prompted the development of alternative formulations of oxybutynin aiming to achieve better tolerability whilst sustaining efficacy. This editorial examines the efficacy and tolerability of transdermal oxybutynin (OXY-TD) in treating OAB. Articles were retrieved from PubMed between 2000 to the present day relating to OXY-TD. Data is presented from phase I-IV trials. The results from placebo-controlled trials indicate that OXY-TD is efficacious in treating patients with OAB associated with urge urinary or mixed incontinence. Systemic side effects most notably dry mouth, appear to be less with this formulation compared with oral anticholinergics. However, further study is required in different OAB populations. The main limitation appears to be related to application site adverse events such as pruritus and erythema. OXY-TD is likely to find its place as first-line pharmacotherapy in the clinicians' armamentarium in treating OAB.

Laparoscopic upper urinary tract surgery for benign and malignant conditions. Does aetiology have an effect on health-related quality of life?

INTRODUCTION

We present health-related quality of life (HRQoL) data on a cohort of patients undergoing upper urinary tract laparoscopy for a variety of benign and malignant conditions.

PATIENTS AND METHODS

The Short Form 8 (SF-8) Health Survey is a validated HRQoL questionnaire that calculates scores for physical (PCS8) and mental (MCS8) components of health. It was administered prospectively to 58 patients. Radical nephrectomy or nephroureterectomy was carried out for upper tract malignancy (n = 21). Laparoscopy for benign disease (n = 37) included simple nephrectomy for giant hydronephrosis and small non-functioning kidneys, de-roofing of renal cysts and pyeloplasty. Data were collected before and 6 weeks after surgery.

RESULTS

The mean pre- and postsurgery scores were 45.99; 47.43 and 43.93; 51.54 for PCS8 and MCS8 respectively. With regard to the PCS8 score, there was no significant difference before or after surgery (p = 0.585) or when analysing the benign (p = 0.343) or malignant (p = 0.509) groups individually. The MCS8 score, however, showed a significant increase after surgery (p < 0.0001). This remained significant when analysing just the benign (p < 0.0009) or the malignant (p < 0.0003) groups but neither group was more significant than the other (p = 0.750).

CONCLUSIONS

Laparoscopic upper urinary tract surgery significantly improves mental and does not appear to reduce physical HRQoL in patients regardless of aetiology, 4 weeks following surgery. Interestingly, those operated on for malignant conditions do not have a greater improvement in mental health when compared with benign disease.

Day-case and short-stay surgery: the future for thyroidectomy?

Day-case and short-stay thyroid surgery is carried out routinely around the world. In the UK longer postoperative stay is usually advocated to circumvent/identify potentially catastrophic complications following thyroidectomy. In the current climate of the National Health Service with focus on patient-centred service, reduced hospital stay and cost cutting, we conducted a review to provide a comprehensive assessment of day-case and short-stay thyroidectomy. A systematic electronic literature search using MEDLINE, Ovid, Embase, PubMed and Cochrane databases revealed 22 original studies that met our inclusion criteria. Generally studies demonstrated encouraging results regarding the feasibility of these approaches. Complication rates appeared equivocal to traditional longer stay thyroidectomy and only one patient died. The majority of life-threatening complications occurred in the immediate postoperative period. Of concern, some late haemorrhage has been documented at 5 days postsurgery. Complication rates following day-case/short-stay thyroid surgery appears comparable with inpatient thyroidectomy. Further study is required to determine whether this approach is truly safe.

Synchronous colectomy and caesarean section for fulminant ulcerative colitis: case report and review of the literature

Ulcerative colitis (UC) affects women of all ages, with a peak incidence in the third and fourth decades, at the prime of their reproductive years [Baiocco PJ, Korelitz BI (1984) The influence of inflammatory bowel disease and its treatment on pregnancy and fetal outcome. J Clin Gastroenterol 6(3):211-216]. We describe a case of fulminating UC at 28 weeks' gestation treated by combined emergency subtotal colectomy and caesarean section with excellent foetal and maternal outcome. A treatment algorithm is suggested, and the literature surrounding inflammatory bowel disease in pregnancy is reviewed.

Laparoscopic pyeloplasty and pyelopyelostomy for ureteropelvic junction obstruction in a duplicated collecting system

Ureteropelvic junction obstruction can be associated with renal anomalies. We present a case of symptomatic ureteropelvic junction obstruction associated with a duplicated collecting system that was successfully treated by laparoscopic pyeloplasty and concomitant pyelopyelostomy. The operative time was 210 minutes, and the blood loss was 20 mL. The inpatient stay was 4.5 days, and the patient returned to work after 28 days. Subsequent renograms confirmed improvement in renal function and resolution of obstruction. After 1 year, the patient remained asymptomatic. This is a feasible minimally invasive procedure for this condition that requires advanced reconstructive and intracorporeal suturing skills.

Laparoscopic Management of Cryptorchidism in Adults

OBJECTIVES

Little is reported on the management of impalpable testis in adults. We present the impact of laparoscopy in this patient group.

PATIENTS AND METHODS

Twelve adult patients have been referred to our centre over the last year, with impalpable testis. Pre-operative assessment was by either ultrasound or magnetic resonance imaging (MRI) or both. Quality of life and patient satisfaction were assessed by validated SF8 and client satisfaction (CSQ-8) questionnaires. Patients were also administered a self constructed questionnaire specifically looking at the impact of a laparoscopic service on their condition.

RESULTS

The mean age was 29 yrs (range: 19-36). Two patients declined treatment. Of ten patients undergoing transperitoneal laparoscopy, five had intra-abdominal testes treated by laparoscopic orchidectomy (none malignant), two had the vas going into the deep ring and needed inguinal orchidectomy for an impalpable nubbin while in three cases there were blind ending vessels and vas. SF8 scores for physical HRQoL were unchanged but mental scores were significantly improved (p < 0.03). All patients were completely satisfied with a mean CSQ-8 score of 30.6 out of a possible 32. The majority of patients indicated that the availability of a laparoscopic service had prompted them to seek medical advice.

CONCLUSIONS

Laparoscopic examination and orchidectomy is a safe and reliable procedure. Excellent patient satisfaction and quality of life are achievable. In particular mental health scores improve as previous uncertainty is removed. The advent of laparoscopy has encouraged adult patients to seek advice regarding a condition that has been present since childhood. We advocate the use of laparoscopy in evaluating and treating adult patients with maldescended testes.

Laparoscopic ureteroneocystostomy for benign lower ureteric stricture: case study and literature review

The surgical treatment of distal ureteric strictures depends on their length and aetiology. Laparoscopic procedures in this setting are uncommon. We describe a laparoscopic non-refluxing ureteroneocystostomy for a symptomatic distal ureteric stricture performed on a 26-year-old man. The operation was carried out successfully without complication. Blood loss was 100 ml with an operating time of 250 min. He was discharged on the fourth day and returned to work after 11 days. Retrograde ureterography and cystography after 1 month showed no evidence of obstruction or reflux. At 3 months, an intravenous urogram showed excellent drainage and at 6 months the patient remained asymptomatic. We advocate the use of laparoscopic ureteroneocystostomy for benign distal ureteric stricture refractory to endoscopic procedures. In symptomatic patients, it is a feasible, safe, minimally invasive procedure with all the added benefits of laparoscopy compared with open repair. A non-refluxing anastomosis is preferable. Reconstructive and intracorporeal suturing skills are needed to carry out this procedure.

Eosinophilic cystitis and its management

Eosinophilic cystitis (EC) is a rare clinicopathological condition characterized by transmural inflammation of the bladder predominantly with eosinophils, associated with fibrosis with or without muscle necrosis. The cause of EC remains unclear, although it has been associated with various aetiological factors, such as allergy, bladder tumour, bladder trauma, parasitic infections and chemotherapeutic agents. EC is, probably, caused by the antigen-antibody reaction. This leads to the production of various immunoglobulins, which, in turn, cause the activation of eosinophils and initiates the inflammatory process. The most common symptom complex consists of frequency, haematuria, dysuria and suprapubic pain. Cystoscopy and biopsy are the gold standard for diagnosis. Additional laboratory evidence supporting the diagnosis includes proteinuria, microscopic haematuria and peripheral eosinophilia, the last one occurring in few patients. There is no curative treatment for this condition. Current treatment modalities include transurethral resection of the bladder lesion along with non-specific medical therapy, such as non-steroidal anti-inflammatory agents or steroids. Because the lesion tends to recur in spite of the above therapy, long-term follow-up is mandatory.

Botulinum toxin for the treatment of lower urinary tract symptoms: A review

AIMS

To review the available literature on the application of botulinum toxin in the urinary tract, with particular reference to its use in treating detrusor overactivity (DO).

METHODS

Botulinum toxin, overactive bladder (OAB), detrusor instability, DO, detrusor sphincter dyssynergia (DSD), and lower urinary tract dysfunction were used on Medline Services as a source of articles for the review process.

RESULTS

DO poses a significant burden on patients and their quality of life. Traditionally patients have been treated with anti-cholinergic drugs if symptomatic, however, a significant number find this treatment either ineffective or intolerable due to side effects. Recent developments in this field have instigated new treatment options, including botulinum toxin, for patients' refractory to first line medication. Botulinum toxin, one of the most poisonous substances known to man, is a neurotoxin produced by the bacterium Clostridium botulinum. Botulinum toxin injections into the external urethral sphincter to treat detrusor sphincter dyssynergia has been successfully used for some years but recently its use has expanded to include voiding dysfunction. Intradetrusal injections of botulinum toxin into patients with detrusor overactivity and symptoms of the overactive bladder have resulted in significant increases in mean maximum cystometric capacity and detrusor compliance with a reduction in mean maximum detrusor pressures. Subjective and objective assessments in these patients has shown significant improvements that last for 9-12 months. Repeated injections have had the same sustained benefits.

CONCLUSIONS

Application of botulinum toxin in the lower urinary tract has produced promising results in treating lower urinary tract dysfunction, which needs further evaluation with randomised, placebo-controlled trials.

Short-stay thyroid surgery

Achieved in 104 consecutive procedures

Rational use of anti-snake venom (ASV): trial of various regimens in hemotoxic snake envenomation

BACKGROUND

Viperine snake bites cause hemotoxicity in the form of coagulation dysfunction. Optimal dose requirement of anti-snake venom (ASV) and duration of therapy in such situation have not yet been fully explored. Our aim in this study was to compare two low-dose continuous infusion regimes with the standard high dose intermittent bolus regime in treating systemic envenomation and preventing its recurrence.

METHODS

A prospective interventional study was conducted on 90 adult patients with snake bite with hemotoxicity. Patents were allocated into three treatment regimes, each regime being tried on 30 patients. Regimen I (standard high dose regimen) consisted of conventional, intermittent bolus dosage of 100 ml of ASV as a loading dose followed by 50 ml every six hours till whole blood coagulation time (CT) became normal. Regimen II consisted of 30 ml of ASV as a loading dose followed by 30 ml continuous infusion every six hours till two CTs at an interval of six hours were normal and a further dose of 30ml over 24 hours. Regimen III was similar to Regimen II in all aspects except that loading dose was 70 ml (instead of 30 ml).

RESULTS

In patients with mild envenomation, even though the average requirement of ASV was only marginally lower in Regimen II (128.6 ml) as compared to in Regimen I (137.5 ml), one patient on Regimen I had relapse of coagulation dysfunction. In patients with moderate envenomation, average requirement of ASV was 221.3 ml and 179 ml in Regimens II and III respectively, which was much less than in Regimen I (343.8 ml) (p values 0.05 and 0.01 respectively). Further, no patient receiving Regimen III had relapse of coagulation dysfunction. In severe envenomation, average dose of ASV required was almost similar in Regimens II and III, i.e., 213.7 ml and 233.7 ml respectively, as compared to 433.3 ml required in Regimen I (p values 0.02 and 0.001 respectively). However, time lapse for CT normalization was only 18 hours in Regimen III as compared to 23.6 hours and 24 hours in Regimens I and II respectively.

CONCLUSION

Regimens consisting of continuous intravenous infusion of ASV i.e., Regimen II in mild envenomation and Regimen III in moderate and severe envenomation are likely to make significant saving of ASV and reduction of recurrence of coagulation dysfunction.

A comparison of sonourethrography and retrograde urethrography in evaluation of anterior urethral strictures

AIM

This prospective study was undertaken to evaluate the abnormalities of the male anterior urethra using high-resolution ultrasound (sonourethrography) and to compare the efficacy with that of retrograde urethrography (RGU) using operative findings as the gold standard.

MATERIALS AND METHODS

Seventy patients with symptoms of lower urinary tract obstruction underwent RGU followed by sonourethrography. The sonologist was blinded to the findings of RGU. The parameters studied were compared with the intra-operative findings as gold standard, and the sensitivity, specificity and overall accuracy for the procedures were calculated. Chi-square test and kappa statistics were used where appropriate.

RESULTS

All patients found to have urethral stricture disease by RGU were also detected by sonourethrography and confirmed intra-operatively. In the estimation of stricture length, RGU showed a lower sensitivity (60-80%) for lengths 1-4 cm, compared with sonourethrography (73.3-100%). Spongiofibrosis was detected by sonourethrography with a sensitivity of 77.3-83.3%. All the false tracts and calculi detected at sonourethrography were confirmed at surgery, whereas RGU showed a low sensitivity in their detection. The complications encountered during the procedures were pain, urethral bleeding and contrast intravasation. The frequency of pain during RGU was greater (p < 0.001); however, the difference in frequency of bleeding after the two procedures was not significant (p < 0.5).

CONCLUSION

RGU and sonourethrography are equally efficacious in detection of anterior urethral strictures. Further characterization of strictures in terms of length, diameter and periurethral pathologies, like spongiofibrosis and false tracts, is done with greater sensitivity using sonourethrography as compared with RGU, with the added benefit of lower incidence of complications.

Handgrip strength and endurance as a predictor of postoperative morbidity in surgical patients: can it serve as a simple bedside test?

Postoperative morbidity is related to preoperative nutritional status. Current methods of assessing this are cumbersome, lack sufficient accuracy to completely separate all those at risk from others, and require a laboratory backup. This study was done to evaluate handgrip manometry, a simple bedside test as an indicator of preoperative nutritional status to predict risk of postoperative complications. Normal values for maximal grip strength and endurance times were established in 496 controls. Similar values were recorded in 100 patients undergoing elective surgery preoperatively. Postoperative variables studied included complication rate and hospital stay. The efficacy of four parameters, serum albumin, clinical nutritional score based on subjective global assessment, maximal grip strength (MGS), and grip endurance time, in predicting complications were studied. It was found that age and presence of co-morbidity increased risk of complications. Of the four predictive parameters studied, it was found that MGS is better than serum albumin. Clinical scoring was superior to MGS in predicting risk of complications. MGS is a simple bedside test, which can be easily performed. It can be used as a complimentary test to clinical scoring in identifying patients at risk of complications after surgery. Patients with abnormal MGS require urgent preoperative correction to reduce the risk of complications.

Attitudes of medical and dental students to dissection

Guy's, King's, and St. Thomas's School of Medicine encourages students to learn anatomy from human dissection. Today, there is a worldwide move of anatomy-based teaching away from dissection to prosection. This study investigates how attitudes toward dissection vary with gender and ethnicity. We assessed students' reactions and concerns regarding the dissecting room, any coping strategies they use to combat them, and analyzed effective methods of teaching anatomy to medical and dental students. Three questionnaires were distributed amongst 474 first-year medical and dental students before dissection and 1 week and 12 weeks after exposure to the dissecting room. Over the 3 months we found significant changes in the concerns of students about dissection. There were also significant differences (P < 0.05) between medical and dental students, males and females, and students of differing ethnic backgrounds, which persisted over 12 weeks. Both medical and dental students found tutorials and textbooks of most value in learning anatomy. Dental students found prosection more useful than medical students (P < 0.001) though neither group demonstrated a significant preference for prosection over dissection. Of concern, 7% reported recurring images of cadavers and 2% insomnia after commencing dissection. Interest in the subject matter and discussion were the commonest methods used to combat stress. This study contributes to the ongoing debate about the value of the dissecting room in the medical school curriculum.

Acute polymorphic psychotic disorder: diagnostic stability over 3 years

OBJECTIVE

Acute polymorphic psychotic disorder without symptoms of schizophrenia (APPD) in ICD-10 is unique in many characteristics. This study aimed at investigating the diagnostic stability of APPD over 3 years.

METHOD

Forty-five patients with first episode APPD were followed up and assessed at regular intervals over a period of 3 years.

RESULTS

Thirty-two patients were females. Average age of the sample was 26.9 years. Thirty-three cases retained their index diagnosis of APPD, while 12 cases required diagnostic revision: 10 to bipolar affective disorder and the rest to unspecified non-organic psychosis. Shorter duration of illness (<1 month) and abrupt onset (<48 h) predicted a stable diagnosis of APPD.

CONCLUSION

APPD is a relatively stable diagnosis and argues for a distinct diagnostic entity.

Effects of intrapartum zidovudine therapy on fetal heart rate parameters in women with human immunodeficiency virus infection

OBJECTIVE

To determine the effects of intrapartum maternal administration of zidovudine on fetal heart rate (FHR) parameters in women infected with the human immunodeficiency virus (HIV).

METHODS

Term HIV-infected women who delivered at our institution (1995-1998) were identified by medical records coding. Sixty minutes of FHR tracing prior to zidovudine administration and 60 min of FHR tracing 2 h after initiation of therapy were reviewed by 3 perinatologists blinded to patient status. Data were compared with paired t tests; p < 0.05 was considered significant. Inter- and intra-observer FHR interpretation variation were calculated.

RESULTS

Ten patients met study criteria. Their demographic data included: Maternal age 26.5 +/- 6.5 years, gestational age 38.9 +/- 1.3 weeks, median parity 2 (range 0-3). Eighty percent were African American. There were no significant differences in FHR parameters after intravenous zidovudine therapy (pretreatment versus 2 h after treatment) with respect to FHR baseline (p = 0.2), FHR variability (p = 0.3), or the number of accelerations (p = 0.1). There was also no difference in the number of variable (moderate or severe), early, or prolonged decelerations following zidovudine infusion.

CONCLUSION

Two hours of continuous intrapartum intravenous infusion of zidovudine does not alter any parameter of the FHR in the laboring HIV-infected gravida.

Hypoxia stimulates osteopontin expression and proliferation of cultured vascular smooth muscle cells: potentiation by high glucose

We examined the effect of hypoxia on proliferation and osteopontin (OPN) expression in cultured rat aortic vascular smooth muscle (VSM) cells. In addition, we determined whether hypoxia-induced increases in OPN and cell proliferation are altered under hyperglycemic conditions. Quiescent cultures of VSM cells were exposed to hypoxia (3% O(2)) or normoxia (18% O(2)) in a serum-free medium, and cell proliferation as well as the expression of OPN was assessed. Cells exposed to hypoxia for 24 h exhibited a significant increase in [(3)H]thymidine incorporation followed by a significant increase in cell number at 48 h in comparison with respective normoxic controls. Exposure to hypoxia produced significant increases in OPN protein and mRNA expression at 2 h followed by a gradual decline at 6 and 12 h, with subsequent significant increases at 24 h. Neutralizing antibodies to either OPN or its receptor beta3 integrin but not neutralizing antibodies to beta5 integrin prevented the hypoxia-induced increase in [(3)H]thymidine incorporation. Inhibitors of protein kinase C (PKC) and p38 mitogen-activated protein (MAP) kinase also reduced the hypoxia-induced stimulation of proliferation and OPN synthesis. Exposure to high-glucose (HG) (25 mmol/l) medium under normoxic conditions also resulted in significant increases in OPN protein and mRNA levels as well as the proliferation of VSM cells. Under hypoxic conditions, HG further stimulated OPN synthesis and cell proliferation in an additive fashion. In conclusion, hypoxia-induced proliferation of cultured VSM cells is mediated by the stimulation of OPN synthesis involving PKC and p38 MAP kinase. In addition, hypoxia also enhances the effect of HG conditions on both OPN and proliferation of cultured VSM cells, which may have important implications in the development of diabetic atherosclerosis associated with arterial wall hypoxia.

Acute pancreatitis and bacterial translocation

Infectious complications are the most frequent and severe complications of acute narcotizing pancreatitis (AP) with a mortality rate up to 80%. Although experimental and clinical studies suggest that the microbiologic source of pancreatic infection could be enteric, information in this regard is scant. This study evaluated bacterial translocation (BT) using mild and severe models of AP. Mild AP was induced by 6-hr continuous intravenous infusion of cerulein, while severe AP was induced by additional infusion of glycodeoxycholic acid into the biliopancreatic duct. BT was evaluated with organ cultures performed when animals were killed (24 hr). To confirm the gastrointestinal origin of the translocating microorganisms, fluorescent microspheres were also given to the animals in drinking water 24 hr before induction of AP. At the time of death beads were counted with a (fluorescence-activated cell sorter) (FACS) in peritoneal lavages and with fluorescent microscopy in frozen sections of the pancreata. Morphology of the distal small bowel showed significant changes in the animals with AP compared to controls, such as reduction of villus high and altered microvasculature. Mild AP induced BT to the pancreas in 100% of the animals, compared to pancreata from control groups. Severe AP induced increased BT to the pancreas. BT to liver and spleen was also significantly increased with AP. The presence of fluorescent microspheres confirmed their enteric derivation. This study provides evidence for the enteric origin of microorganisms responsible for pancreatic infectious complications during AP. The evidence of BT after laparotomy suggests an increased risk of infections with the association of these conditions. This could provide an explanation for the high mortality associated with laparotomy in course of AP.