The late symptomatic and functional results of enterocystoplasty

A symptomatic and, where possible, urodynamic assessment has been made in 19 patients undergoing enterocystoplasty over a 16-year period. It is suggested that this operation should be considered in those cases of interstitial cystitis and irritable bladder syndrome in which all recognised medical and surgical treatment has failed.

Endoscopic examination in children

Cystourethroscopy is an uncomfortable and often painful investigation for children. It is distressing to the parents, and even when it is done on a day case basis it can cause considerable disruption to the family. It should therefore only be considered when it is felt that the examination will contribute to the management of the urinary problem in the child, and then only after routine assessment including physical examination, urine culture, renal function studies, excretion urography and, where indicated, micturating cystogram. In a study of 242 children who had cystourethroscopy, it was found to be of only limited value in children with enuresis, incontinence, haematuria, recurrent urinary infection and painful micturition. In some children it provided an opportunity for either indirect (from instrumentation) or formal urethral dilatation and this seemed to be associated with post-operative symptom relief in some children. Endoscopy appeared to be of most value in the management of vesicoureteric reflux, upper tract duplication and specific urethral abnormalities. In these situations the examination provided essential information which was helpful with further management of the children.

Late results of skin inlay urethroplasty

Sixty-two patients undergoing either one-stage or two-stage skin inlay urethroplasty for stricture of the urethra have been reviewed. The success rate and incidence of complications are discussed. The technique of skin inlay urethroplasty requires a considerable degree of surgical expertise and a similar skill in clinical evaluation is required in the selection of patients for this procedure.

Urodynamic findings in chronic retention of urine and their relevance to results of surgery

Fifty-five consecutive male patients aged 18-77 with chronic retention of urine were investigated urodynamically. All were shown to have obstructed micturition. Inflow cystometry defined two groups, one with high-pressure and one with low-pressure filling. Recent-onset enuresis and upper-tract dilatation as seen on radiography were significantly associated with high-pressure bladder filling. Postoperative studies showed that patients with high-pressure filling on preoperative cystometryhad a better response to outflow-tract surgery. The poor response of the patients with low-pressure filling was due to a high incidence of inadequate detrusor contraction leading to persistent residual urine. Thus urodynamic studies may be used to indicate which patients are likely to benefit from prostatectomy and, after the operation, whether the obstruction has been relieved.

Coagulum pyelolithotomy

In 25 patients undergoing pyelolithotomy a supplementary coagulum technique has been used. Initial difficulties were found in the preparation, instillation and extraction of the coagulum, but with experience a satisfactory technique has been developed. The type of stone situation most likely to benefit from coagulum pyelolithotomy would seem to be where there is a small, mobile stone or stone fragment lying in a calix or in a wide renal pelvis.

Ureteric reimplantation for vesico-ureteric reflux in the adult

A retrospective study of 32 adult patients undergoing ureteric reimplantation for reflux has been carried out. Reflux and reimplantation in relation to urolithiasis, pregnancy, renal failure, hypertension and bladder neck obstruction have been discussed. Eighty-four per cent of patients with primary reflux had pyelonephritic scarring compared with only 34% of patients where reflux was secondary. Reimplantation has been technically successful in preventing reflux in every patient in this series, with 18 patients (65%) becoming symptom free. Pyelonephritis, hypertension and renal failure were not significantly improved but no progressive changes were observed in the follow-up period after reimplantation.

Carcinoma of the penis

Sixty-three patients with squamous cell carcinoma of the penis have been reviewed. The 3 year survival was 77%, and the 5 year survival was 59%. Prognosis was related to both clinical staging and histological grading. Stage I and II carcinomas were best treated by surgery alone. Stage III and IV carcinomas were best treated by local amputation of the penis combined with radiotherapy to the inguinal nodes. Surgery as a primary treatment for clinically positive nodes was successful in less than half the cases treated, and in this series was always followed by wound infection and lymphoedema. Tender, enlarged inguinal lymph nodes should be observed for up to 3 months following primary treatment, as a large percentage of these nodes are inflammatory and subside spontaneously.

Mechanism of electrical alternans in patients with pericardial effusion

Electrical alternans concomitant with pericardial effusion has been considered a pathognomonic sign suggestive of a large effusion with cardiac tamponade, particularly if there is P wave alternans as well as QRS alternans. However, the mechanism of this phenomonon remains controversial. A patient with pericardial effusion secondary to adenocarcinoma of the lung with metastases, pericardial effusion, electrical alternans, and cardiac tamponade was studied by echocardiography, right and left heart catheterization, and pericardiocentesis. Hemodynamic data were consistent with cadiac tamponade. The echocardiogram demonstrated a large anterior and posterior pericardial effusion. Noncongruous motion of the septum and posterior wall was pericardial effusion. Noncongruous motion of the septum and posterior wall was recorded at a rate equal to the heart rate. In addition, congruous motion of the septum and posterior wall was recorded at a rate that was half the heart rate and corresponded to the electrical alternans. The congruous movement disappeared after pericardiocentesis, as did the electrical alternans. The electrical alternans is synchronous with and due to the pendulous movement of the heart within the pericardial sac, as demonstrated by echocardiogram and cineangiograms.

Interstitial cystitis, treated by prolonged bladder distension

25 patients with interstitial cystitis were treated by prolonged bladder distension. 16 patients are symptom-free, but 5 of these have had 1 or more previous prolonged bladder distensions. 6 patients are improved, whilst 3 remain symptomatically unchanged. Prolonged bladder distension can be repeated successfully when symptoms return. These results suggest that prolonged bladder distension has a place in the treatment of interstitial cystitis.

Specific glucocorticoid receptor in the iris--ciliary body of the rabbit

The cytoplasm of the iris--ciliary body of the rabbit contains a receptor capable of specifically binding dexamethasone. This binding protein has a high affinity for dexamethasone (average KD = 2.0 X 10(-8) M), a low capacity (average 4.8 X 10(-13) mol of steroid bound per milligram of protein), and extreme heat sensitivity; it exhibits a pattern of competition virtually identical to that obtained with glucocorticoid receptors from other tissues and shows characteristic physicochemical behavior in various salt concentrations. The demonstration of a specific dexamethasone receptor in the iris--ciliary body provides the first direct biochemical evidence that these tissues may function as a target organ for glucocorticoids.

Retinoblastoma-like neoplasm induced in C3H/BifB/Ki strain mice by human adenovirus serotype 12

Eighty newborn C3H/BifB/Ki strain mice received a single intraocular inoculation of 0.002--0.003 ml of 10(8.0) TCID 50/0.1 ml human adenovirus 12 (AD 12), within 24 h after birth. Forty mice survived and in seven of these (17.5%) a solid retinoblastomalike neoplasm developed between 64 and 236 days. The tumors have been successfully cultured and also transplanted subcutaneously into syngeneic hosts. Morphologically, all tumors revealed characteristic features of retinoblastoma associated with the Homer Wright type of rosettes. Bizarre giant cells were commonly detectable. Ad 12-specific T-antigens were demonstrated in both the primary and cultured tumor cells using immunofluorescent techniques. Some giant cells also showed numerous T-positive filaments. Electron microscopy disclosed poorly differentiated unipolar cells possessing a large ovoid nucleus. Many tumor cells appeared to contain a well organized solitary cilium consisting of a typical ring of nine doublets with no axial (9 + 0) in close association with a pair of centrioles. Some multinucleated giant tumor cells also contained multiple cilia-centriole complexes within their broad syncytial cytoplasm. Occasional endogenous C particle-like virions unique to murine neuroblastomas were observed for the first time in virus-induced retinal tumors. This unprecedented tumor model in a pure strain mouse adds to the range of known animals sensitive to Ad 12 oncogenesis.

Clinical significance of the V wave in the main pulmonary artery

Among 68 patients with mitral insufficiency who had right and left cardiac catheterization and left ventriculography, 6 had retrograde transmission of the left atrial V wave into the main pulmonary artery. All of these patients had mitral insufficiency of acute onset. The remaining 62 patients had chronic mitral insufficiency that was considered severe in 17. Pulmonary vascular resistance was lower in the group with acute insufficiency (mean 139 dynes sec cm-5) than in the group with chronic severe insufficiency (mean 631 dynes cm-5) (P less than 0.005). Nondistensibility of the left atrium and low pulmonary vascular resistance were the two factors favoring retrograde transmission of V waves. Because both factors are present in acute mitral regurgitation, this finding is helpful in differentiating patients with acute mitral insufficiency.

Social discomfort in the patient with spinal cord injury

A 20-item inventory of social situations which might create anxiety and/or lead to aviodance in patients with spinal cord injury was administered to 40 male inpatients. The respondents rated each item on the basis of the amount of social discomfort they would feel in the situation. The results were analyzed by dividing the subjects into eight groups based on age, type of injury and length of time since injury. On the total score of the items rated as producing the most discomfort, older patients, regardless of type or duration of injury, perceived themselves as having more social discomfort in these situations than younger patients. Implications for social skills training programs and further assessment procedures are discussed.

Effect of intermittent left bundle branch block on left ventricular performance in the normal heart

The effect of left bundle branch block on left ventricular performance was studied in a patient with rate-dependent left bundle branch block and an otherwise normal heart. The timing of left heart events, hemodynamic pressures and indexes of left ventricular contractility were determined during normal intraventricular conduction and during left bundle branch block. The results indicate that in the normal heart left bundle branch block has no significant effect on left ventricular performance.

The structure of the rabbit urinary bladder after experimental distension

The effect of prolonged bladder distension produced by elevating intravesial pressures under controlled conditions has been examined in rabits. Bladders were distended in vivo for 3 hr and studied at selected intervals during the postoperative period using light and electron microscopic techniques. In the acute phase, the continuity of the epithelium was partially destroyed and submucosal hemorrhages and edema were evident. However, these changes rapidly resolved and speciments obtained 7 days after distension were similar to controls. Using electron microscopy, smooth muscle cells were structrually unaffected by the experimental procedure and "junction" regions between adjacent cells were of normal appearance throughout the postoperative period. The arrangement and fine structure of autonomic nerves amongst detrusor smooth muscle were similar to those of control samples. These findings are discussed with reference to the findings of other workers and in relation to the use of bladder distension in the treatment of human detrusor instability.

Transient unifascicular, bifasicular and trifascicular block: electrophysiologic correlations in a patient with rate-dependent left bundle branch block and transient right bundle branch block

Correlations of the His to ventricular (H-V) conduction time were made with the surface electrocardiogram during normal intraventricular conduction, unifascicular block (right bundle branch block), bifascicular block (left bundle branch block) and trifascicular block (right and left bundle branch block) in a patient with rate-dependent left bundle branch block who had transient right bundle branch block during recording of the His bundle electrogram. The results provide a functional confirmation of the theory that a prolonged H-V time is a manifestation of trifascicular disease.

Urgency and urge incontinence of urine treated by prolonged bladder dystension: interim results

Prolonged bladder distension has been used to treat patients with urgency and urge incontinence of urine. At follow-up varying from 14 to 24 months 17 out of 33 patients were symptom-free, 13 symptomatically improved and 3 unchanged. These results, as anticipated, are not so good as the initial early reported results, but are sufficiently encouraging for us to recommend prolonged bladder distension for the treatment of severe urgency and urge incontinence of urine.

Distension therapy for the unstable bladder: later results including an assessment of repeat distensions

51 patients with urgency and urge incontinence of urine and enuresis have been treated by prolonged bladder distension. At recent follow-up, 16 patients were symptom free, 25 substantially improved and 10 symptomatically unchanged, at a mean of 13 months after distension. 13 patients whose symptoms relapsed after a previous distension or who failed to obtain a satisfactory improvement have had a further distension for a more prolonged period. The early results in this group are not as good as for patients having first distensions, although 2 patients have become symptom free, and 6 have shown a substantial symptomatic improvement.

A nurse clinician's role in the management of hypertension

The nurse has assumed more responsibility for patients with hypertension, not only in their education, but also in their follow-up. In this study the physician was aware of each patient's progress through conference with the nurse clinician. In addition, the nurse clinician consulted the physician about any problems or questions that arose. The nurse also served an educational role by informing patients about their disease and the side effects of the medications being used in their therapy. Since the physician was aware of the progress of these patients, his time was freed for other purposes. The nurse clinician's role in the management of hypertension was beneficial not only to the patient, but also to the physician.

Left ventricular function and coronary obstruction as predictors of survival following aorta-coronary bypass

A retrospective analysis was undertaken of clinical data and catheterization studies of 151 consecutive unselected patients who underwent aorta-coronary bypass at the University of Kansas Medical Center between 1971 and 1973. The purpose was to determine the effect of preoperative left ventricular function and extent and severity of coronary artery obstruction on operative mortality rate and long-term survival. The postoperative follow-up period ranged from 10 to 49 months and averaged 26 months. Left ventricular function was assessed by qualitative analysis of left ventricular angiograms. Severity of coronary obstruction was quantified by scoring coronary arteriograms according to the system of Friesinger and associates. Patients with normal or near normal ventriculograms were considered to have good left ventricular function. Patients showing moderate or severe impairment of contraction were considered to have poor left ventricular function. Obstruction scores ranging from 2 to 7 points were classified as low scores, and scores from 8 to 15 points were classified as high scores. Four groups of patients were identified based upon preoperative left ventricular function and obstruction severity: Group I, 29 patients with good left ventricular function and low scores; Group II, 22 patients with poor left ventricular function and low scores. Group III, 28 patients with good left ventricular function and high scores. Elective aorta-coronary bypass in these three groups was accompanied by no operative or late deaths. Group IV comprised 72 patients with poor left ventricular function and high scores. In this group there was a 10 per cent operative mortality rate (7 of 72 patients) and a 5 per cent year late mortality rate. Relief of angina occurred equally in all groups. Thus operative risk can be prospectively determined by analysis of left ventricular function and severity of coronary obstruction. Surgical treatment resulted in negligible operative and late mortality rates (0 per cent) in all patients except those in whom poor ventricular function was accompanied by severe and diffuse coronary artery obstruction. Operation should be offered to this latter group (Group IV) despite the higher operative and postoperative risk because of salutary postoperative results.