The treatment of interstitial cystitis with supratrigonal cystectomy and ileocystoplasty: difference in outcome between classic and nonulcer disease

PURPOSE

Interstitial cystitis is a chronic debilitating condition that mainly affects women. Accumulated evidence indicates that interstitial cystitis is a heterogeneous syndrome. The nonulcer type seems to respond less favorably to various conservative treatments than the classic type. Supratrigonal cystectomy with ileocystoplasty is established treatment for interstitial cystitis refractory to conservative treatment. We evaluate whether classic interstitial cystitis responds differently than nonulcer disease to subtotal bladder resection and ileocystoplasty.

MATERIALS AND METHODS

We evaluated 13 patients 27 to 79 years old with interstitial cystitis who underwent supratrigonal cystectomy and ileocystoplasty due to failure to respond to conservative treatment.

RESULTS

In all 10 patients with classic interstitial cystitis symptoms were relieved after ileocystoplasty. In the 3 patients with nonulcer interstitial cystitis pain remained, while the frequency of voiding somewhat decreased. In these patients trigonal resection and urinary diversion with a Kock pouch resolved the symptoms.

CONCLUSIONS

Our study confirms that supratrigonal cystectomy with ileocystoplasty results in a good outcome in classic interstitial cystitis. However, this method seems to be unsuitable for nonulcer disease. Identification of the relevant subtype of interstitial cystitis is of crucial importance for selecting the appropriate method of lower urinary tract reconstruction.

[Impact of antimalarial drug accessibility on malarial morbidity and chloroquine resistance. A study carried out in Touba (Senegal)]

In Touba, more important accessibility to antimalarial drugs and their uncontrolled use let to assure that the rate of malarial morbidity would be lower there than in other place in Senegal whereas the rate of chloroquine resistance would be higher. A checking survey of these assumptions has been carried out from october 15 to november 10, 1995 in Touba's health center. Among 227 feverish subjects investigated, 111 were Plasmodium falciparum carriers. Malarial bouts accounted for 48.9% of the feverish fits observed and for the major cause of consultation during the rainy season. These figures are higher than those usually observed in urban environment. Conversely, the rate of chloroquine resistance is lower than those observed in urban zones, since the therapeutic efficacy of chloroquine on Plasmodium falciparum was 100% in that survey.

Efficacy and safety of tolterodine in patients with detrusor instability: a dose-ranging study

OBJECTIVE

To investigate the efficacy and safety of tolterodine, a new antimuscarinic agent, and define the optimum dosage in patients with symptoms of detrusor instability (urgency, increased frequency of micturition and/or urge incontinence).

PATIENTS AND METHODS

A double-blind, placebo-controlled, multicentre study was carried out; after a 1-week run-in period to establish baseline values, 81 patients were randomized to receive placebo or tolterodine 0.5, 1, 2 or 4 mg twice daily for 2 weeks. Micturition (diary) variables, urodynamics and subjective urinary symptoms were assessed after 2 weeks' treatment.

RESULTS

A per-protocol analysis of efficacy in 64 patients showed dose-related improvements in recorded micturition and urodynamic variables, e.g. at a dosage of 2 mg twice daily, the frequency of micturition, episodes of incontinence and pad use were reduced by 20%, 46% and 29%, respectively, while the volume at first contraction increased by 89 mL. The 4 mg dosage was associated with a large increase in residual urinary volume and an increased incidence of dry mouth. The incidence of adverse events (mainly mild or moderate antimuscarinic effects) was comparable with placebo at tolterodine dosages of < or = 2 mg. No serious adverse events were observed and tolterodine had no clinically significant impact on electrocardiographic or laboratory findings.

CONCLUSION

The results indicate that tolterodine offers an effective treatment for the symptoms of detrusor instability. The optimum dosage appears to be 1-2 mg twice daily.

An evaluation of a nurse-led ear care service in primary care: benefits and costs

BACKGROUND

Nurses trained in ear care provide a new model for the provision of services in general practice, with the aim of cost-effective treatment of minor ear and hearing problems that affect well-being and quality of life.

AIM

To compare a prospective observational cohort study measuring health outcomes and resource use for patients with ear or hearing problems treated by nurses trained in ear care with similar patients treated by standard practice.

METHOD

A total of 438 Rotherham and 196 Barnsley patients aged 16 years or over received two self-completion questionnaires: questionnaire 1 (Q1) on the day of consultation and questionnaire 2 (Q2) after three weeks. Primary measured outcomes were changes in discomfort and pain; secondary outcomes included the effect on normal life, health status, patient satisfaction, and resources used.

RESULTS

After adjusting for differences at Q1, by Q2 there was no statistical evidence of a difference in discomfort and pain reduction, or differential change in health status between areas. Satisfaction with treatment was significantly higher (P = 0.0001) in Rotherham (91%) than in Barnsley (82%). Average total general practitioner (GP) consultations were lower in Rotherham at 0.4 per patient with an average cost of 6.28 Pounds compared with Barnsley at 1.4 per patient and an average cost of 22.53 Pounds (P = 0.04). Barnsley GPs prescribed more drugs per case (6% of total costs compared with 1.5%) and used more systemic antibiotics (P = 0.001).

CONCLUSIONS

Nurses trained in ear care reduce costs, GP workload, and the use of systemic antibiotics, while increasing patient satisfaction with care. With understanding and support from GPs, such nurses are an example of how expanded nursing roles bring benefits to general practice. Nurses trained in ear care reduce treatment costs, reduce the use of antibiotics, educate patients in ear care, increase patient satisfaction, and raise ear awareness.

Nephrogenic adenoma--a study with special reference to clinical presentation

OBJECTIVE

To obtain information on the presenting symptoms, location, sex distribution, age, endoscopic appearance, histopathology, suitable treatment and recurrence of nephrogenic adenoma, a rare, benign lesion of the urinary tract mucosa.

PATIENTS AND METHODS

The records of 31 patients with nephrogenic adenoma diagnosed at the Sahlgrenska University Hospital between 1980 and 1996 were reviewed to determine the symptomatology, imaging investigations, endoscopic presentation, clinical outcome after resection and the frequency of recurrence.

RESULTS

The lesions were found in the urinary bladder, bulbar urethra, urethral diverticula and the prostatic urethra. Eight patients presented with haematuria, 13 complained of urinary frequency and bladder pain and in 12 patients without subjective symptoms from the urinary tract, the lesion was found accidentally. Twenty-seven of the patients had a history of previous urothelial trauma, either by instrumentation or inflammation. Seventeen of the lesions were polypoid at endoscopy, the remainder being flat except for two cases, in which they were not noted because they were concealed in another lesion to be resected. Seven patients had one or more recurrences. All patients with symptoms responded well to transurethral resection.

CONCLUSION

Nephrogenic adenoma mimics tumour or chronic cystitis and it is rarely suspected on clinical grounds; instead, the diagnosis is almost always histological. This study supports the view that nephrogenic adenoma may represent a metaplastic response to trauma of the urothelium and that transurethral resection provides a good method of relieving the symptoms in symptomatic nephrogenic adenoma.

Positive ice-water test: a predictor of neurological disease?

The urinary bladder is equipped with a reflex system including cold receptors of the bladder wall and having reflex pathways partly separate from the normal micturition reflex. The ice-water test involves cooling of the bladder wall with ice-cold saline solution. In the neurologically intact adult the test is negative. A positive test indicates overt or occult neuropathy. In this report, examples are given of patients presenting with bladder symptoms and a positive test but initially lacking signs of a neurological condition. During follow-up, various neurogenic diseases appeared. It is suggested that a positive ice-water test may represent a negative prognostic urodynamic sign along with a potential risk for neurogenic disease to come.

Comparative assessment of pelvic floor function using vaginal cones, vaginal digital palpation and vaginal pressure measurements

A group-comparative study to assess pelvic floor muscle function using vaginal cones, vaginal digital palpation, and vaginal pressure measurements in 30 women suffering from genuine stress urinary incontinence and in an age-matched group of continent women was undertaken. Vaginal digital palpation score and vaginal pressure during active contraction were greater (p < 0.001) in continent women (1.9 +/- 0.1 and 8.6 +/- 0.7 cm H2O, respectively) as compared with incontinent women (1.0 +/- 0.1 and 4.1 +/- 0.4 cm H2O, respectively). Continent women were able to retain a vaginal cone of greater weight (6.3 +/- 0.4; n = 9, weight ranging from 10 to 90 g) than women suffering from stress incontinence (4.7 +/- 0.5; p < 0.001). There was a better correlation between all three techniques of assessing pelvic floor function in continent as compared with incontinent women, especially in the comparisons involving vaginal cones. (Vaginal pressure measurement-vaginal digital palpation, r = 0.86/0.75; vaginal pressure measurement-vaginal cones. r = 0.57/0.10; vaginal digital palpation-vaginal cones, r = 0.60/0.18.) In some women, especially those with incontinence, heavy cones were retained in spite of a weak pelvic floor due to the transverse position of the cone in the vagina which was verified radiographically.

The ice-water test in the diagnosis of detrusor-external sphincter dyssynergia

The ice-water test (IWT) implies rapid intravesical infusion of 100 ml of sterile ice-water during continuous pressure measurement and registration of fluid leakage. In a typical positive test, there is fluid leakage around the catheter(s) during the peak of detrusor contraction elicited by cold stimulation. Seventy-six patients, the majority with different forms of spinal disorders and a clinical and urodynamically suspected detrusor-external sphincter dyssynergia, were subjected to cystometry, needle electromyography (EMG) and an ice-water test. Detrusor-external sphincter dyssynergia was found in 44 (59%) patients and 41 of them had a positive IWT. A positive test with a high detrusor pressure indicates detrusor-external sphincter dyssynergia whereas the contrary applies to the negative test. Eighteen patients who responded to cold stimulation with detrusor contraction but without fluid leakage, called positive non-leakage IWT, all presented detrusor-external sphincter dyssynergia according to EMG. In this situation, the cheap, non-invasive and simple IWT can replace a needle EMG study.

Clinical and urodynamic effects of intravesical capsaicin treatment in patients with chronic traumatic spinal detrusor hyperreflexia

PURPOSE

We administered capsaicin, a neurotoxic substance causing a reversible suppression of C fiber afferent neuronal activity, in an attempt to decrease bladder hyperreflexia.

MATERIALS AND METHODS

Capsaicin solution (2 mM.) dissolved in 30% alcohol was instilled into the bladders of 10 men with traumatic chronic spinal lesions and left in place for 30 minutes. Effects on bladder function, including response to cold stimulation, were recorded during treatment, immediately after instillation and at followup.

RESULTS

Bladder function improved in all but 1 patient, which was expressed as an increase in cystometric capacity and/or a decrease in maximal detrusor pressure. The effects lasted for 2 to 7 months. Immediately after capsaicin administration the ice water test was negative in half of the patients.

CONCLUSIONS

The positive effects on bladder function of capsaicin treatment can be explained by the blocking of C fiber afferents. The optimum dose and treatment interval are presently not established. The ice water test might possibly be used as an instrument to monitor the ideal dosage.

[Care charges and direct costs related to hospitalization of Senegalese children with cerebral malaria. Study of 76 cases in the Albert-Royer Hospital in Dakar in 1991-1992]

To optimize the funds devoted to health care, and to objectively assess the tools used in monitoring patients with cerebral malaria, we determined two parameters, care charges and direct costs due to hospitalization. During this longitudinal study conducted at the Albert Royer Pediatric Hospital in Dakar from October 15, 1991 to October 15, 1992 with 76 cases, malaria represented 5.2% of the febrile cases and 3.4% of the hospitalized cases. The lethality rate was 3.4%. Clinical features were not correlated with care charges and thus were not good indicators of worker's labor. The average cost of a cerebral malaria hospitalization was estimated at 35,710 F CFA (In October 1992, 1 F CFA = 0.02 FF). This cost is very high depending the limited resources of the region. Rapid and proper treatment of malaria cases may lead to a significant reduction of costs.

Vaginal wall bipedicled flap and other techniques in complicated urethral diverticulum and urethrovaginal fistula

BACKGROUND

Repair of a urethral diverticulum in females may be a rather simple operation or it may represent an operative challenge, depending on the site of the lesion and previous treatment. Thirty women operated upon during a 15-year-period and with a variety of complicating factors, such as proximal location of diverticula or the presence of a urethrovaginal fistula, were reviewed. A new procedure using a transverse bipedicled vaginal flap to cover the urethral repair was used routinely.

STUDY DESIGN

The long-term results were evaluated by clinical, endoscopic, and urodynamic methods. A follow-up postal survey was obtained reporting the presence of urethral pain, incontinence, frequency of micturition, postoperative sexual complaints, and subsequent operations.

RESULTS

Repeated operations were rather common. The end result of operative repair was satisfactory in all but three patients, two of whom underwent multiple operations (four and seven times, respectively). These patients were left with residual symptoms of incontinence and recurrent urethral syndrome. However, the majority of patients who were operated upon repeatedly were cured. One patient who had impaired detrusor contractility had a relative urethral stricture.

CONCLUSIONS

The successful treatment of complicated diverticula and fistula requires some basic technical steps during repair. When recurrence develops, it is important to interpret carefully urethral pressure profiles, cystometry, and other functional tests.

Toward a new classification of overactive bladders

Based on a large retrospective series, this study compares the International Continence Society's (ICS) classification of overactive bladders and a functional subtyping of our own, founded on clinical and urodynamic parameters. Functionally identical symptoms and urodynamic patterns were found within the Detrusor Hyperreflexia as well as the Unstable Detrusor categories. There are strong arguments for a revision of the current ICS classification system.

Quality of minor surgery by general practitioners in 1990 and 1991

BACKGROUND

The 1990 contract for general practitioners encouraged them to undertake minor surgical procedures in their practices.

AIM

A study was undertaken to determine whether the subsequent expansion of general practitioner minor surgery activity was accompanied by changes in quality of care.

METHOD

Data were analysed relating to minor operations conducted in 22 practices during April-June 1990 and April-June 1991.

RESULTS

The volume of general practitioner minor surgery increased by 41% between the two study periods. Waiting time, accuracy of diagnosis, use of histology, adequacy of excision, complications and the need for corrective treatment in hospital did not change significantly between the two periods.

CONCLUSION

The findings do not support suggestions that the expansion of general practitioner minor surgery activity following the 1990 contract has been associated with an erosion of quality of care.

Pressure, volume and infusion speed criteria for the ice-water test

OBJECTIVE

To define pressure, volume and infusion speed criteria for the ice-water test (IWT).

PATIENTS AND METHODS

In this prospective clinical study, cystometry and IWTs were performed in 115 patients.

RESULTS

The critical response for a positive IWT was found to be a peak detrusor pressure above 30 cm H2O, with or without fluid leakage. Neither the infusion speed nor the infused volume was critical for the outcome of the test provided that the bladder wall was sufficiently cooled.

CONCLUSION

The IWT is a rapid, simple and robust test, whose results are easy to interpret. The test increases the precision of urodynamic diagnosis, especially in patients with an overactive detrusor dysfunction, at a small cost.

Positive bladder cooling test in neurologically normal young children

The bladder cooling test, which consists of rapid infusion of 0 to 8C saline into the bladder with simultaneous pressure measurement, was performed in 50 neurologically intact infants and children 6 months to 13 years old. The patients were referred for urodynamic investigation because of various disorders of the lower urinary tract. A positive bladder cooling test was defined as a sustained reflex detrusor contraction of about the same magnitude as the micturition contraction. The test was positive during the first 4 years of life but typically negative in children older than 5 years. These findings indicate that a positive bladder cooling test is an infant reflex response that, with the maturation of the central nervous system, becomes suppressed by descending signals from higher centers.

Pathology of interstitial cystitis

Morphologic changes, including light microscopy and ultrastructural, immunologic, and immunohistochemical findings in interstitial cystitis are described. The results indicate that biopsies are useful as an aid in the diagnosis of interstitial cystitis.

Transcutaneous electrical nerve stimulation in classic and nonulcer interstitial cystitis

Long-term treatment of interstitial cystitis by transcutaneous electrical stimulation provides a conservative means of bringing the disease to remission. The overall results are better in the classic than in the nonulcer subtype of interstitial cystitis. These findings are considered in relation to the role of neutral factors in the disease.

Long-term results of pelvic floor training in female stress urinary incontinence

One hundred and seventy women with genuine stress urinary incontinence participated in a pelvic floor exercise (PFE) programme (duration 4.7 +/- 0.2 months, range 1-18). Twenty-seven women awaiting surgery for genuine stress urinary incontinence constituted the control group. The women were evaluated using a provocation test, vaginal palpation and subjective assessment before and after treatment. After the PFE programme, 23% of the women considered themselves cured, 48% were improved and 29% unchanged. According to the provocation test used in this study 64% were cured or improved following PFE. The long-term results of PFE were assessed by means of a postal questionnaire 2 to 7 years after completion of the supervised training period (response rate 152/170; 89%). During this time 38 women (25%) had undergone operative treatment. Of the remaining patients, 13 (11%) reported that they were still cured, 50 (44%) continued to be improved, 35 (31%) were unchanged and 16 (14%) had deteriorated. However, the frequency of PFE training during the follow-up period was unsatisfactory, as only 15% were training several times a day. This indicates that continued guidance from a physiotherapist could improve the long-term efficacy of PFE training.

Minor surgery by general practitioners under the 1990 contract: effects on hospital workload

OBJECTIVE

To determine the extent to which minor surgery undertaken by general practitioners after the introduction of the 1990 contract substituted for hospital outpatient workload.

DESIGN

Before and after observational study.

SETTING

Four English family health services authorities.

SUBJECTS

Patients in 22 practice populations who were operated on by their general practitioner or referred to hospital for minor surgery during April to June 1990 or April to June 1991.

MAIN OUTCOME MEASURES

Numbers of minor surgical procedures undertaken in general practice and in hospital, numbers of referrals to hospitals for conditions treatable by a minor surgical procedure, and the mix of diagnoses and procedures undertaken in each setting.

RESULTS

General practitioners claimed reimbursement for 600 minor surgical procedures during April to June 1990 and for 847 during April to June 1991, an increase of 41%. Referrals to hospital for comparable conditions showed no compensatory decrease (385 during April to June 1990 and 388 during April to June 1991, 95% confidence interval for change in referrals -51 to 57), and the number of hospital procedures resulting from those referrals also remained constant (187 in the first period, 189 in the second, 95% confidence interval for change in procedures -36 to 40). The mix of procedures did not change significantly from one study period to the next in either setting.

CONCLUSIONS

Many or all of the additional patients receiving minor surgery under the terms of the 1990 contract may not have previously been referred to hospital. General practitioners seem not to have systematically shifted towards treating the more trivial cases. The overall increase in minor surgical activity may reflect an improvement in accessibility of care or changes in patients' perceptions and attitudes.

Case against targeting long term non-attenders in general practice for a health check

A study was undertaken to describe the consequences of implementing that part of the 1990 contract for general practitioners which requires them to offer health checks to all patients aged 16-74 years not seen within the previous three years. A random sample of 679 patients who had not attended for three years and 379 patients who had attended in this period were identified from 30 practice lists (including eight inner city practices) in five family health services authority areas. All patients were sent an invitation to a health check by their own practice and an attempt was made by the research team to conduct a home interview. The results showed that a considerable proportion of non-attenders were not in a position to take advantage of such an invitation; 17% of those at inner city practices were known to have received the invitation, 68% in practices elsewhere. Interviewed non-attenders (76% of those known to have received their invitation) had sociodemographic characteristics similar to the comparison group of interviewed attenders, although women aged 55-74 years were over-represented. At interview, non-attenders reported relatively less use of accident and emergency services and preventive health care and scored significantly better on all six dimensions of the perceived health status measure. Overall, 3% of all identified non-attenders in the inner city practices and 13% elsewhere accepted the invitation to a health check. Low levels of morbidity were found at health checks for those who had and who had not attended their general practitioners in the previous three years.(ABSTRACT TRUNCATED AT 250 WORDS)

The bladder cooling reflex in man--characteristics and sensitivity to temperature

The ice-water test is a simple supplementary urodynamic test that increases the precision of the diagnosis of overactive bladder subtypes. A similar bladder cooling reflex has recently been characterised in the cat and was found to originate from specific cold receptors in the bladder wall. In the present study, the threshold temperature of the human bladder cooling reflex was determined in patients with positive ice-water tests. Estimated threshold values were somewhat lower than those of the cat but still well above the temperatures required for cold stimulation of nociceptors. As in the cat, the strength of the cooling reflex varied inversely with the bladder temperature. These findings indicate that the human bladder cooling reflex is in principle organised in the same way as that of laboratory animals. The human bladder thus seems to be endowed with cold receptors with excitatory reflex connections to the detrusor.

The ice-water test--a simple and valuable supplement to routine cystometry

The results of cystometrograms and ice-water tests (IWTs) were retrospectively evaluated in 557 patients with overactive bladders, lower motor neuron lesions or pure stress incontinence. The IWT was considered positive when, following ice-water instillation, the fluid was expelled from the bladder within 1 min. The test was considered false negative when no fluid escaped despite a sustained detrusor contraction of the same magnitude as the micturition contraction. Ninety-seven percent of patients with complete and 91% of those with incomplete upper motor neuron lesions had a positive or a false negative IWT. About 75% of the patients with multiple sclerosis, Parkinson's disease or previous cerebrovascular accident had a positive IWT. All patients with lower motor neuron lesions or pure stress incontinence had a negative IWT. There was a significant correlation between a positive IWT and an abnormal sensation of bladder filling and inability to inhibit micturition voluntarily, as well as between a negative IWT and the occurrence of phasic detrusor contractions during cystometry. The study shows that the IWT is a sensitive test for differentiating upper from lower motor neuron lesions. It is also a useful parameter for functional subdivision of overactive bladders. In patients with voiding dysfunction in the absence of lower urinary tract inflammation, a positive test is an indicator of a silent or overt neurological disorder.

Subtypes of overactive bladder in old age

The prevalence of urinary incontinence increases dramatically with age and is mainly related to urge incontinence and bladder overactivity. It is a reasonable hypothesis that bladder overactivity primarily results from a disturbed central neuronal control of the lower urinary tract. Different sites and extents of neurogenic lesions or dysfunctions should result in different functional and urodynamic characteristics. We have recently identified three distinct urodynamic subtypes of bladder overactivity, and we report a retrospective study of the distribution of these subtypes in elderly patients. Eight hundred and fourteen patients aged 65 years or older with symptoms of urgency and/or urge incontinence underwent cystometry and the ice-water test. Two hundred and sixty-seven of them (33%) presented an overactive bladder. The prevalence of overactive bladder was constant up to the age of 65. A marked increase above this age was almost entirely ascribed to an increase of the so-called uninhibited overactive bladder subtype. This dysfunction occurred in 70% of the older patients. Patients with this condition have a coordinated reflex micturition at normal bladder volumes, but an abnormal perception of bladder fullness and lack of voluntary inhibitory control. This constellation of symptoms and signs indicates a suprapontine dysfunction.

Traditional acupuncture and electrical stimulation of the posterior tibial nerve. A trial in chronic interstitial cystitis

A prospective study on the symptomatic effect of traditional Chinese acupuncture treatment and transcutaneous nerve stimulation (TENS) of the tibial nerve in patients with interstitial cystitis is presented. There was no difference in voiding frequency, mean voided volume, maximal voided volume or visual analogue scale symptom scores before or after treatment with either TENS or acupuncture. Only one patient became improved both subjectively and objectively after acupuncture for a short period of time. Even though the present material involves a small group of patients, it seems that the two methods, as applied in this study, have a very limited effect in patients with interstitial cystitis.

Transurethral microwave thermotherapy versus transurethral resection for benign prostatic hyperplasia: preliminary results of a randomized study

The results of transurethral microwave thermotherapy (TUMT) were compared in a prospective randomized study with those of transurethral resection (TURP) in patients with benign prostatic obstruction. In this preliminary report, 39 and 40 patients treated with TUMT and TURP, respectively, were followed between 2 and 12 months. Statistically significant improvements in symptom score, maximum flow rate, residual urine and maximum bladder capacity at cystometry were observed in both groups. The improvements were more pronounced in the TURP group, but major complications were more frequent in this group. Results are compared to other published studies.

Cost effectiveness of minor surgery in general practice: a prospective comparison with hospital practice

The cost effectiveness of general practitioners undertaking minor surgery in their practices was determined in a prospective comparison of patients having minor surgery undertaken in five general practices over a 12 week period in 1989, and in the departments of dermatology and general surgery in Rotherham District General Hospital over a contemporaneous eight week period. There were no differences between the settings in the reported rates of wound infection or other complications and only one general practice patient was subsequently referred to hospital for specialist treatment. General practitioners sent a smaller proportion of specimens to a histopathology laboratory than hospital doctors (61% versus 90%, P less than 0.001); incorrectly diagnosed a larger proportion of malignant conditions as benign (10% versus 1%, P less than 0.05) and inadequately excised 5% of lesions where this never happened in hospital (difference not significant). General practice patients had shorter waiting times between referral and treatment, spent less time and money attending for treatment and more of them were satisfied with their treatment. The cost of a procedure undertaken in general practice was less than in hospital--pounds 33.53 versus pounds 45.54 for the excision of a lesion and pounds 3.00 versus pounds 3.22 for cryotherapy of a wart (1989-90 prices). Performing minor surgery in general practice would seem cost effective compared with a hospital setting. However, the risk of general practitioners inadequately excising a malignancy and not sending it to a histopathology laboratory must be addressed and the conclusion regarding cost effectiveness only applies where general practice is a substitute for the hospital setting and not an additional activity.

Apolipoprotein A1 as an early index of protein-energy malnutrition

Protein-energy malnutrition (PEM) is, together with infectious and parasitic diseases, a major cause of childhood illness in Africa. Diagnosis and treatment of PEM requires an accurate, simple and reliable method of assessing nutritional status from a blood sample. Plasma apolipoprotein (apo A1), prealbumin and albumin were measured in a group of Senegalese children suffering from PEM who had been hospitalized for refeeding, and in a group of control children. Statistical analysis of the results indicated that: (1) Plasma apo A1 was significantly correlated with prealbumin in assessing nutritional status (P less than 0.005 on day 8 of refeeding); (2) plasma apo A1 alone was sufficient for diagnosing and monitoring the dietary treatment of PEM; it was capable of detecting subclinical forms; (3) apo A1 could be used for differential diagnosis of forms of PEM; (4) plasma apo A1 concentration began to increase earlier (94% of control values at day 8) than did prealbumin (73% on day 8). We therefore propose apo A1 as an index of nutritional status in children living in areas where infectious and parasitic diseases are endemic.

Electrical stimulation. A physiologic approach to the treatment of urinary incontinence

Appropriate management of patients with urinary incontinence requires access to a variety of methods. Electrical stimulation, although so far proportionally small in the armamentarium of methods, is founded on physiologic principles and has the advantage of being curative without significant side effects.

Prevalence of malnutrition and vitamin A deficiency in the Diourbel, Fatick, and Kaolack regions of Senegal: a controlled study

Two hundred and six Senegalese preschool children included in an epidemiological study were selected by their results from impression cytology with transfer (ICT) for assessment of their nutritional state by means of biological variables and for assessment of the diagnostic values of the ICT. A problem of protein-calorie malnutrition existed (transthyretin and retinol-binding protein concentrations were low) associated with vitamin A deficiency (retinol concentrations were low). The sensitivity and specificity of the ICT defined with respect to retinol (threshold fixed at 0.35 mumol/L) varied with the classification criteria of ICT and seemed to be fairly insensitive but specific.

Prevalence of malnutrition and vitamin A deficiency in the Diourbel, Fatick, and Kaolack regions of Senegal: epidemiological study

The purpose of our study was to determine the prevalence of protein-calorie malnutrition (PCM), ocular diseases, and vitamin A deficiency in preschool children selected at random in a rural zone of the groundnut belt of Senegal. The prevalence of PCM was 37.1% (95% CI 33.8-40.2%) according to the Waterlow classification, with a majority of stunting, and prevalence of hypovitaminosis A was estimated to be 11.4% (95% CI 9.3-13.5%) by using impression cytology. Furthermore, 19.4% (95% CI 15.8-22.0%) of the children might be defined at risk of deficiency. The prevalence of Bitot's spots was equal to 0.2% (95% CI 0.03-0.9%). A problem of PCM associated with a health-endangering vitamin A deficiency existed.

Prevalence of malnutrition and vitamin A deficiency in the Diourbel, Fatick, and Kaolack regions of Senegal: feasibility of the method of impression cytology with transfer

The evaluation of the prevalence of ophthalmological diseases and vitamin A deficiency in Senegalese preschool-aged children enabled us to confirm the method of impression cytology with transfer (ICT) and to assess the impact of ophthalmological diseases on the cytological appearance of conjunctival cells. A simplification of the ICT method consisted of transferring cells present on a strip of paper to a glass slide by finger pressure. Harris-Schorr staining of the sample papers confirmed the results obtained by the transfer. Inflammatory trachoma influenced the results of the test. This simple method will prove very helpful for detection of vitamin A deficiency in children in underdeveloped areas.

Interstitial cystitis: bladder mucosa lymphocyte immunophenotyping and peripheral blood flow cytometry analysis

Interstitial cystitis is a chronic bladder disorder of unknown etiology that primarily afflicts women and is characterized by urgency and pain. Although immune mechanisms have been implicated in the disease process, little is known about the local or peripheral blood immune responses. Cryostat sections of snap-frozen bladder biopsies obtained by transurethral resection from 43 patients (24 with classical and 9 with nonulcerative or early interstitial cystitis, and 10 controls) were analyzed using a panel of monoclonal antibodies with an avidin-biotin immunoperoxidase technique to characterize the local immune response of bladder mucosa. Simultaneously obtained heparinized peripheral blood (10 cc) was analyzed by flow cytometry in 24 patients (9 with classical and 5 with nonulcerative early interstitial cystitis, and 10 controls) using the same panel of antibodies. The control group biopsies (median age 44 years, range 27 to 52 years) had no ulcers, few lymphoid cells (predominately T-helper cells), rare T cell nodules and no B cells. The nonulcer group (median age 39 years, range 29 to 44 years) had rare mucosal ruptures but no ulcers, slightly increased lymphoid cells (predominately T-helper), occasional T cell aggregates, no B cell nodules and rare plasma cells. No statistically significant difference between control and nonulcerative interstitial cystitis patients was identified. In contrast, the classical interstitial cystitis group (median age 68 years, range 47 to 73 years) had ulcers, intense inflammation with focal sheets of plasma cells, aggregates of T cells, B cell nodules including germinal centers, a decreased or normal helper-to-suppressor cell ratio and suppressor cytotoxic cells in germinal centers. Flow cytometry analysis of peripheral blood lymphocyte subsets showed normal patterns in controls, increased numbers of secretory Ig positive B cells and activated lymphocytes in the nonulcerative group, and increased numbers of secretory Ig positive B cells with mildly abnormal kappa-to-lambda ratios and activated lymphocytes in the classical group. We conclude that an immune mechanism has at least a partial role in the pathophysiology of interstitial cystitis. A parallel between interstitial cystitis and inflammatory bowel disease is evident. Further studies are indicated.

A bladder-to-bladder cooling reflex in the cat

1. Reflex effects of cold stimulation of the lower urinary tract were studied in cats anaesthetized with alpha-chloralose. The bladder and the urethra were catheterized for separate fluid instillations and the bladder pressure was monitored together with the evoked efferent nerve responses in pelvic nerve filaments. 2. A bladder cooling reflex could be evoked from both the bladder and the urethra. The response was an efferent discharge in preganglionic pelvic motor fibres to the bladder. 3. Bladder mechanoreceptors that drive the normal micturition reflex were not directly involved in the cooling reflex. Their tension sensitivity was decreased by cooling and the efferent reflex response typically occurred before any activation of these receptors. The efferent activity of the cooling reflex also survived an intentional unloading of the mechanoreceptors, a manipulation that abolishes the normal micturition reflex. 4. The dynamic threshold temperature of the cooling reflex was about 30-32 degrees C, which was at the thermal neutral point of the bladder in our experimental situation. 5. The bladder-evoked component of the reflex was greatly reduced or abolished by an intravesical infusion of the local anaesthetic Xylocaine. It was also abolished by total bladder denervation. 6. The vesical component of the reflex was unchanged by bilateral transections of the hypogastric nerves but abolished by pelvic nerve transection. The cooling reflex from the distal urethra was abolished by transection of the pudendal nerves. 7. It was proposed that the cooling reflex originates from cold receptors in the bladder and urethral walls and that the responsible afferent fibres are unmyelinated C fibres. The function of the reflex may be to rid the body of a thermal ballast when under cooling stress.

Clinical features and spectrum of light microscopic changes in interstitial cystitis

Transurethral resection material from a series of 64 patients with classical (ulcer) interstitial cystitis (60 women and 4 men, with a mean age of 64 years), 44 with nonulcer interstitial cystitis (40 women and 4 men, with a mean age of 39 years) and 20 control women (mean age 49 years) were studied by light microscopy. Patients with classical disease had mucosal ulceration and hemorrhage, granulation tissue, intense inflammatory infiltrate, elevated mast cell counts and perineural infiltrates. Patients with nonulcer disease, despite the same severe symptoms, had a relatively unaltered mucosa with a sparse inflammatory response, the main feature being multiple, small, mucosal ruptures and suburothelial hemorrhages that were noted in a high proportion of the patients. It is suggested that these features are characteristic, specific and prevalent enough to allow for morphological differentiation of the 2 clinical subtypes of interstitial cystitis.