Oestriol in the treatment of postmenopausal urgency: a multicentre study

Oestrogen deficiency in postmenopausal women is thought to be important in the genesis of lower urinary tract symptoms, in particular the 'urge syndrome'. Evidence to support the use of oestrogen therapy in symptomatic postmenopausal women is, however, limited. Oestriol is a weak, naturally occurring oestrogen that may be beneficial to the urogenital tissues without stimulating the endometrium. We have investigated the use of oestriol in the treatment of postmenopausal sensory and motor urge incontinence.

MATERIALS AND METHODS

A double-blind, placebo-controlled, randomised, multicentre study of 3 mg oral oestriol/day for 3 months in the treatment of women with urge incontinence was undertaken.

RESULTS AND CONCLUSIONS

Sixty-four women were recruited into the study. Although oestriol produced both subjective and objective improvement in lower urinary tract function, it was not significantly better than placebo. Some of the difficulties of running a multicentre study were encountered.

Organising a continence advisory service

Modern surgical techniques have greatly improved the treatment of incontinence, but there remains a large number of patients for whom conservative management will be necessary. This paper reports the appointment of a continence adviser 10 years ago, and describes the subsequent development of a District Continence Advisory Service. Experience has shown that this appointment is essential, not only in terms of facilitating the service, but also as a means of ensuring cost efficiency.

Effects of norepinephrine infused in the paraventricular hypothalamus on energy expenditure in the rat

The metabolic effects of norepinephrine (NE), when infused into the paraventricular nucleus of the hypothalamus (PVN), were examined using indirect calorimetry. In two separate experiments, it was found that NE infused into the PVN reduced energy expenditure in freely moving rats. While NE also reduced motor activity, these reductions were not statistically significant. Reductions in voluntary motor activity were not necessary for a reduction in energy expenditure, as NE still reduced energy expenditure in rats that were lightly sedated. Clonidine, but not L-phenylephrine, mimicked the hypometabolic effect of NE, suggesting an action at alpha 2 receptors. Infusions of NE were also found to increase blood glucose shortly after infusion, although the specificity of this effect is questionable. Taken together, these data suggest that activation of noradrenergic neurons within the PVN results in a metabolic shift towards energy conservation.

Effect of beta blockade on singing performance

The symptoms associated with performance anxiety, or the so-called stage fright syndrome, are similar to those of alpha and beta adrenergic stimulation. Suppression of symptoms and improvement in instrumentalist's performance after beta blockade suggest that this modality would be of benefit for singers as well. To evaluate the dose-effect relationship of beta blockade upon singing performance and the possible effect of these agents upon performance maturation, we studied 34 singing students during end of semester juries, using a double-blind crossover paradigm. Students performed once with either placebo, 20, 40, or 80 mg of nadolol, and again 48 hours later, with placebo. There was a significant dose-related, limiting effect upon intraperformance cardiac rate. A small, but statistically significant, dichotomous effect upon performance rating was noted: low-dose nadolol tended to enhance performance, whereas larger doses impaired performance. We conclude that the effects of low dose beta blockade upon singing are minimally helpful and high doses may detract from performance ability.

Clean intermittent self-catheterisation in the management of adult lower urinary tract dysfunction

The results of clean intermittent self-catheterisation in a group of 57 patients (2 male, 55 female) followed for up to 5 years are reported. The benefits in patient management are discussed and particular note is made of this technique for female patients with chronic urinary retention and overflow incontinence.

Effect of dehydroepiandrosterone on growth in lean and obese Zucker rats

Several studies were undertaken to determine the effect of dehydroepiandrosterone (DHEA) on growth in Zucker rats. In experiment 1, 3 weeks of DHEA treatment in lean rats resulted in decreased body weight gain in comparison to control rats. In experiment 2, both lean and obese rats were treated with DHEA from 6 to 21 weeks of age. Significant decreases in body weight were found for both lean and obese DHEA-treated rats. The food efficiency ratio (FER) was significantly decreased in both DHEA-treated groups. Significant decreases in parametrial and retroperitoneal fat pads were found in both lean and obese DHEA-treated rats. This was primarily attributed to a decrease in fat cell number in lean rats and to decreases in both number and size of fat cells in obese rats. In experiment 3 obese female rats were treated with DHEA from 6 to 21 weeks of age followed by 15 weeks with DHEA removed from the diet. Significantly more weight was gained by the rats previously treated than by the control rats, but body weight remained significantly lower than in the control groups. These data indicate DHEA has an effect on altering body weight and body fat in lean and obese Zucker rats.

Metabolic alterations after dehydroepiandrosterone treatment in Zucker rats

Dehydroepiandrosterone (DHEA) is a known noncompetitive inhibitor of glucose-6-phosphate dehydrogenase (G6PD). In the present investigation, the effects of chronic DHEA treatment on G6PD and several other enzymes involved in lipid metabolism were examined in lean and obese Zucker rats. Significant decreases in body weight were found in DHEA-treated rats in comparison with nontreated rats. In lean rats, DHEA treatment did not decrease either liver or adipose tissue G6PD and fatty acid synthetase activity, but malic enzyme activity was increased. In obese rats, decreased liver and adipose tissue G6PD and fatty acid synthetase activities were found. Malic enzyme activity in liver of obese DHEA rats was increased but not in adipose tissue. Adipose tissue lipoprotein lipase activity was decreased in both lean and obese DHEA rats. Serum insulin in obese DHEA rats was also decreased compared with control obese rats. These results indicate that the inhibition of G6PD may not be the mechanism of action of the antiobesity effect of DHEA. However, the metabolic effects of DHEA seen in obese rats may contribute to its antiobesity action.

Simple practical techniques in the management of urinary incontinence

Surgery for incontinence should be reserved for specific indications where its value as a primary treatment has been proven. Otherwise surgery should not be employed until a wide range of conservative treatments have been tried and have failed. The conservative methods of management outlined below include "bladder training' using frequency/volume charts to monitor, and alter, the pattern of micturition and number of episodes of incontinence, re-education of the pelvic floor muscles, intermittent self-catheterization, hormone replacement therapy, regulation of fluid intake and bowel habit, discriminate use of diuretics and hypnotics and adjustments to domestic conditions.

Determinants of response to intravenous hydralazine in hypertension

There is marked interindividual variation in hypotensive response to intravenous hydralazine (H). We examined the determinants of response in patients with hypertension. After a single intravenous dose of 0.3 mg/kg H, response was correlated independently (r = 0.8364) with both predrug blood pressure and acetylator index (AI). Intravenous dose ranging studies showed that response also depended on the amount of H in the systemic circulation. Although plasma H levels depend on AI after oral doses, this is not so after intravenous administration. AI must therefore affect response to H by an alternative, presumably nonmetabolic mechanism which, not related to AI, perhaps indicating specificity of this effect for H. These data reinforce the potential usefulness of determining AI before giving H to a patient.

Acute duodenal ulceration in children

Seven cases of acute duodenal ulcer in Papua New Guinea children have been treated personally over a period of 14 years. All had bled, six seriously enough to threaten life, while in five cases laparotomy revealed unsuspected perforation. Aspirin and antimalarials may have been causal in two children. In three others there was an associated illness, but no common cause could be found to explain all cases. Operative treatment recommended is suture control of bleeding, plus vagotomy and pyloroplasty as for an adult with similar presentation.

Phaeochromocytomas in 72 patients: clinical and diagnostic features, treatment and long term results

Phaeochromocytomas were diagnosed in 72 patients in Hammersmith, Belfast and Newcastle between 1955 and 1976. Fourteen were found unexpectedly at autopsy while 58 were diagnosed in life. Associated lesions included neurofibromatosis (7 patients), medullary carcinoma of the thyroid (3), renal artery stenosis (2) and cerebellar haemangioblastoma (1). The clinical features were similar to those reported by others. Hypertension was found in all but one of the patients and was sustained only in 17 per cent, paroxysmal only in 48 per cent and sustained with superadded paroxysms in 33 per cent. Hypertension was significantly greater in the women than in the men.

Diagnosis was confirmed chemically in all patients and urinary vanylmandelic acid (VMA) was elevated in all but one. Tumours were localized correctly by various radiographic techniques and by selective venous sampling in over 80 per cent of patients. The tumours were in adrenals in 59 patients (bilateral in 6) and at extra-adrenal, intra-abdominal sites in 13.

The tumours were removed surgically from those in whom they were diagnosed in life. Before 1967 3 of 17 patients died after operation (18 per cent). Since then patients have been prepared with alpha blockade and have received infusions of plasma, blood or dextran after removal of the tumours. One of 41 patients so treated has died after operation (2 per cent). Phaeochromocytomas were diagnosed and treated in pregnancy in 4 patients, all of whom survived. Two of the fetuses died.

Five tumours diagnosed in life were malignant and 2 recurred (40 per cent). Fifty-three were benign and 2 of these recurred locally (4 per cent).

All but 2 patients (who could not be traced) were followed completely from 1 to 20 years after operation and 3 died during this period. Two-thirds of the patients were alive after 10 years.

Paroxysmal hypertension was abolished by operation, but sustained hypertension often persisted and required drug therapy.

It is concluded that at least one-third of phaeochromocytomas are not diagnosed in life and that a high index of suspicion is required to bring them to light. If they are diagnosed and treated by present methods, the prognosis is good.

Clostridium welchii type C antitoxin in the treatment of "pig bel" (enteritis necroticans): a controlled trial in Papua New Guinea

Enteritis necroticans remains a serious problem in the Highlands of Papua New Guinea. Earlier claims that Clostridium Welchii Type C antitoxin is effective in lowering mortality rates were subjected to a prospective controlled trial in 1972-73. Use of the antitoxin was found to be of no benefit in treatment of this disease.

Studies on the maternal immune response to placental antigens: absence of a blocking factor from the blood of abortion-prone women

The leucocyte migration-inhibition assay was employed to assess the reactivity of cells from postpartum women to placental antigen preparations. Leucocytes from normal primigravidae responded to their own placental antigens and displayed a limited degree of cross-reactivity with allogeneic preparations. Autologous plasma suppressed this antigen recognition and the factor responsible was shown to be an IgG antibody. Leucocytes from five women with spontaneous abortions also responded to autologous placental preparations but no immunosuppressive factor could be detected in their blood. It is suggested that target antigens for maternal lymphocytes are present on the placenta, a structure critical to the continuance of pregnancy, and that the presence of the blocking antibody is necessary for fetal well-being.

A Simulator and Training Technique for Diagnosing Plant Failures from Control Panels

The paper describes (1) the development of a simulator and (2) the first results of a training technique for the identification of plant failures from control panel indications. Input or signal features of the task present more simulation fidelity problems than its response or output features. Current, techniques for identifying effective signals, e.g. ' blanking-off ' information, or protocol analysis, bias any description of problem solving since they require serial reporting, if not serial collection, of information by the operator. They also require inferences as to what is an effective item of information. It is therefore argued that simulation should preserve all those features which may in principle provide, or influence acquisition of, diagnostic information, specifically panel layout, instrument design and display size. Further fidelity problems are the stress from operating in a dangerous environment; stress from hazards or sanctions following mistaken diagnosis; and the stress of diagnosing in a short time interval. The simulator uses bock-projection to life size of slides of control panel mock-ups by a random access projector. Under an adaptive cumulative part regime, trainees saw on average 89 failure arrays in 30 min, an obvious advantage over the operational situation. In a test 24 hr after training, consisting of the eight faults each presented four times in random order, 4 out of 17 trainees made only one error in 32 diagnosos; the other trainees performed perfectly. Subjects' reports indicate very different solution strategies, e.g., recognition of alarm patterns; serial instrument checking determined by heuristics of plant functioning. Several features of performance arc consistent with the view that trainees use a minimal number of dimensions for correct discrimination and that these change as the number of different fault arrays increases. It is argued that this training regime should reduce stress. In particular it is argued that, according to current theories of stress, the fewer dimensions needed for diagnosis, the more robust will be diagnostic performance in dangerous environments.