ABC of Urology. Urological emergencies in general practice

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ABC of urology. Bladder outflow obstruction

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ABC of urology. Urological evaluation

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ABC of urology. Introduction to urology

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Diarrhea associated with nasogastric feedings

PURPOSE/OBJECTIVES

To determine the difference in the incidence of diarrhea among subjects given one of three formulas with varying fiber concentrations administered by nasogastric (NG) tube, variables affecting incidence of diarrhea, discomforts other than diarrhea associated with NG tube feedings, and effects of changing from continuous to interval feedings on incidence of diarrhea and discomforts.

DESIGN

Prospective, double-blind, randomized study.

SETTING

Midwestern tertiary care center otolaryngology nursing unit.

SAMPLE

Eighty randomized subjects who were 18 years or older, English-speaking, and undergoing head and neck cancer surgery that required an NG tube postoperatively and who had no gastrointestinal (GI) illness within two weeks prior to surgery.

METHODS

Subjects received continuous administration of formula containing no fiber, 7 gms/L of fiber, or 14 gms/L of fiber until they reached the caloric intake goal and then were advanced to interval feedings. Patients' medical records provided past medical history and information on medication administration. A bedside flow sheet was used for documenting incidence of diarrhea and other GI discomforts.

MAIN RESEARCH VARIABLES

Amount of fiber in the formula administered, patient's genders and prior food aversions, and antibiotics' effect on diarrhea and other GI discomforts.

FINDINGS

Multiple logistic regression showed significant odds ratios (ORs) for developing diarrhea in female subjects (OR = 7.96), subjects who had prior food aversions (OR = 2.67), and subjects receiving broad spectrum antibiotics (OR = 3.22). Diarrhea was four times more likely to occur in males who received fiber-free formula. Of all subjects, 70% experienced GI discomforts with continuous feedings, and 50% experienced discomforts when advanced to interval feedings.

CONCLUSIONS

Fiber formulas reduced the incidence of diarrhea in male subjects but not in female subjects. Antibiotics' effect on diarrhea paralleled the findings of other studies.

IMPLICATIONS FOR NURSING PRACTICE

Use formulas with fiber for males. Liquid stools do not require interruption of tube feeding; GI discomforts warrant interruption. Interval feeding schedules require monitoring similar to continuous feeding schedules.

Cytochemical localization of glycogen in Chlamydia trachomatis inclusions

The origin and distribution of glycogen in inclusions of Chlamydia trachomatis were demonstrated with silver proteinate stain for electron microscopy. Glycogen particles were detected in all developmental stages of C. trachomatis, as well as free in the inclusions. Intrachlamydial glycogen was most common in elementary bodies but was also detected in intermediate forms and reticulate bodies (RBs). Abnormal divisions and breakdown of cytoplasmic membranes were common in RBs. Cytoplasmic contents, including glycogen particles, were released into the inclusions after rupture of the outer membranes of abnormal RBs and intermediate forms. From these observations, we conclude that glycogen in inclusions of C. trachomatis originates in the organisms themselves.

In vivo cellular tropism of human T-lymphotropic virus type II is not restricted to CD8+ cells

We have examined the in vivo and in vitro susceptibility of lymphocyte subpopulations to human T-lymphotropic virus type II (HTLV-II) to determine the cellular tropism for this virus. Monoclonal antibodies to T-cell subsets were used to separate highly purified CD4+ and CD8+ cells from peripheral blood lymphocytes of 35 individuals previously shown to be infected with HTLV-II. The purified T-cell subsets were analyzed for HTLV-II provirus (pol and tax gene sequences) by polymerase chain reaction (PCR) and cultured to determine virus expression by p24gag antigen detection. On the basis of PCR amplification in the pol and tax gene regions, both CD8+ subsets (89 to 91%) and CD4+ subsets (54 to 80%) from most infected subjects demonstrated HTLV-II provirus, irrespective of the viral genotype. Analysis of cultured lymphocytes demonstrated a higher spontaneous lymphocyte proliferation (17,986 +/- 4675 cpm) and p24gag antigen production (median 115 pg/ml; range 14-1360 pg/ml) in CD8+ cells compared to CD4+ cells (2333 +/- 826 cpm; p24gag antigen; 9 pg/ml; 2-250 pg/ml), suggesting a higher proviral load in CD8 cells. Limiting cell-dilution PCR analysis indicated that the CD8+ subset carried a higher HTLV-II provirus burden than the CD4+ subset. In vitro infection of purified CD4+ and CD8+ lymphocytes with irradiated HTLV-II cell lines resulted in productive infection of both subsets. Cell sorting and PCR analysis of lymphocyte subsets from 4 HTLV-II-infected subjects further demonstrated that in addition to CD4+ and CD8+ subsets, both CD45RO+ and CD45RO- and non-T-cells (CD14, CD16, and CD19) carried HTLV-II provirus. Taken together, these data suggest that HTLV-II possesses a broad tropism for peripheral blood mononuclear cells.

Choosing the correct pain relief for extracorporeal lithotripsy

OBJECTIVES

To determine the best choice of analgesic for patients undergoing lithotripsy, and to attempt to identify factors which might predict which patients are most likely to find the procedure painful.

PATIENTS AND METHODS

Sixty patients with stones in the pelvicalyceal system of the kidney were randomized prospectively to undergo lithotripsy with the Dornier MPL9000 lithotripter (Dormier Medical Systems, Marietta, GA, USA) after receiving either diclofenac 100 mg per rectum (n = 30) or pethidine 50 mg intravenously (n = 30) for analgesia. The patients completed a detailed questionnaire prior to treatment, and the level of pain perceived during lithotripsy was monitored using visual analogue scales (VASs). Arterial oxygen saturation (SaO2) was monitored before analgesia was given, throughout the treatment and for 30 min after cessation of treatment.

RESULTS

The VASs were available for 56 patients and the results of pulse oximetry for 51 patients. Although a higher kilovoltage was recorded in the group who received pethidine this difference was not significant. Patients who received diclofenac or pethidine alone, showed a non-significant fall of SaO2 30 minutes after the end of treatment, although the largest fall in SaO2 observed with pethidine was 10%. Patients who received diclofenac and pethidine similarly showed a non-significant fall in SaO2. Four patients received intravenous benzodiazepines in addition to pethidine, and in this group there was a dramatic fall in SaO2 which persisted more than 30 min after the end of treatment (P < 0.0027). Diclofenac provided effective analgesia for most of the patients who underwent lithotripsy. Overall 11 patients (18%) required additional analgesia. Diclofenac or pethidine alone, in the doses used in this study, did not cause a significant drop in SaO2 during ESWL. The only response found to be of value in predicting a painful experience was fear of the dentist.

CONCLUSIONS

This study shows that modern lithotripsy, in addition to being safe and effective, can be performed as an out-patient procedure using simple non-opiate analgesics. The need for stronger analgesia and/or sedation should be tailored to the needs of the individual patient, although it remains difficult to predict which patients will require such measures.

Does lithotripsy cause hearing loss?

OBJECTIVE

To determine whether lithotripsy with the Dornier MPL9000 has any significant effect on the hearing of either patients or operators, as determined by pure tone audiometry.

PATIENTS AND METHODS

Twenty patients had audiometry prior to a single exposure to lithotripsy and one hour after treatment. Staff were monitored on a 3 monthly basis.

RESULTS

No evidence was found to suggest that single or repeated exposure to the noise emitted by this Dornier lithotripter was associated with any hearing loss.

CONCLUSIONS

These results suggest that the risk to the hearing of patients exposed to lithotripter noise is negligible. Cochlear damage resulting from excessive noise depends on both the intensity of the sound and the duration of exposure. The acoustic properties of the building housing the machine may also be important and can significantly influence the intensity of the sound at the ear. At marginal levels it may be years before the deficit reaches a level that can be detected by subjective audiometry. In addition, susceptibility to noise induced hearing loss is difficult to predict. Although these results suggest that there is minimal risk to the hearing of staff members exposed to lithotripter noise, the authors recommend that staff exposed to repeated lithotripter noise over long periods undergo regular audiometric assessment (including a preemployment baseline assessment) to identify evidence of noise induced auditory trauma, and that protective equipment be worn by staff members to reduce the possibility of long-term damage.

Pharmacokinetics and pharmacodynamics in copper deficiency. I. Antiinflammatory activity of aspirin

The effect of nutritional copper (Cu) deficiency on the antiinflammatory activity and pharmacokinetics of aspirin (ASA) was investigated in rats. Male, weanling Sprague-Dawley rats were fed either a Cu-deficient (CuD) or Cu-sufficient (CuS) diet for 49-50 d. The antiinflammatory activity of ASA was studied using the carrageenan-induced paw edema (CPE) test. ANOVA analyses of edema volumes at 2, 3, 4, 5, and 21 h postcarrageenan indicated significant differences between groups. The percent inhibition of edema due to ASA treatment in CuS was lower than that in CuD rats at 5 h, AUC5h, and AUC21h. ASA was found to be significantly more effective in inhibiting the CPE in CuD rats when compared to the CuS rats. Thus, we hypothesized that the increase in ASA's antiinflammatory activity in CuD rats was a result of a decrement in its elimination during nutritional Cu deficiency. The elimination of ASA in CuD and CuS rats was studied using an iv dose of 200 mg/kg. Concentrations of ASA and salicylic acid (SA) were determined in blood; whereas the concentrations of SA, salicylic phenol-glucuronide (SPG), and salicyluric acid (SUA) were determined in urine by HPLC. The results of the pharmacokinetic analyses from blood and urinary data indicated no significant differences in the disposition of ASA between CuD and CuS rats. For instance, the total body clearance for ASA (mean +/- SD, mL/min/kg) was 37.9 +/- 9.4 and 38.5 +/- 13.9 (p > 0.05); and the volume of distribution (Vd) for ASA (mean +/- SD, mL/kg) was 385.5 +/- 110.3 and 397.1.1 +/- 137.9 (p > 0.05) for CuD and CuS groups, respectively. Thus, contrary to our hypothesis, the enhanced antiinflammatory activity of ASA in CuD rats does not appear to be mediated via a decrement in the elimination of the drug. In addition, plasma ASA-esterase activity was found to be independent of Cu nutritional status.

Magnetic resonance imaging of urinary calculi

Accurate prediction of the response of an individual patient to lithotripsy remains impossible. Certain factors such as the chemical composition, size, and position of the calculus are known to be important in determining the success rate. This paper reports the use of magnetic resonance imaging (MRI) to evaluate 141 urinary calculi in vitro. A wide range of signals for each chemical type of calculus was found on each of the three imaging sequences used (T1-weighted, T2-weighted, and proton density). None of the chemical groups examined showed a typical MRI profile allowing it to be distinguished from the other groups. Analysis of variance showed a statistical difference between signals for apatite and struvite on the T1-weighted sequence, and between struvite and uric acid on the proton density sequence (both, P < 0.05). These results show for the first time that MRI is capable of distinguishing between different chemical types of stones. This is particularly important for the comparison of struvite and apatite which appear to be similar in conventional investigations but have quite different hardness values. Further work is in progress correlating the results of this study with stone microhardness and extracorporeal shockwave lithotripsy fragility tests to determine whether MRI accurately predicts the success of lithotripsy.

Epstein-Barr virus-coded BHRF1 protein, a viral homologue of Bcl-2, protects human B cells from programmed cell death

Epstein-Barr virus, a human herpesvirus that persists within the B-lymphoid system, can enhance the survival potential of latently infected B cells in vitro through up-regulation of the cellular survival protein Bcl-2. The possibility that an analogous effect is operative in lytically infected cells was suggested by the observation of distant sequence homology between an Epstein-Barr virus-coded early lytic cycle protein, BHRF1, and Bcl-2. Here we show by gene transfer that BHRF1 resembles Bcl-2 both in its subcellular localization and in its capacity to enhance B-cell survival. Thus confocal microscopic analysis of cells acutely cotransfected with BHRF1 and Bcl-2 expression vectors revealed substantial colocalization of the two proteins in the cytoplasm. In subsequent experiments, stable BHRF1 gene transfectants of Burkitt lymphoma cells paralleled Bcl-2 transfectants in their enhanced survival under conditions that induce cell death by apoptosis. Despite their limited sequence conservation, therefore, the two proteins appear to be functionally homologous. We suggest that BHRF1 provides an alternative, Bcl-2-independent, means of enhancing B-cell survival that may operate during the virus lytic cycle.

Breast disease and the general surgeon. II. Effect of audit on the referral of patients with breast problems

OBJECTIVES

To determine the number of patients with breast problems referred to general surgical clinics in a district general hospital and to assess the effect of changes implemented following the previous study on waiting time, investigations performed, and management of the patients.

DESIGN

Two prospective outpatient audits with patient details recorded on questionnaires by the medical staff.

SETTING

The general surgical outpatient clinics of a single general surgical firm at Newbury District Hospital, Berkshire.

PATIENTS

Those patients attending the above clinics during two 3-month periods, 1 October to 31 December 1989 (Study 1), and 16 April to 19 July 1990 (Study 2).

RESULTS

Of new referrals, 25% were for a breast problem. The waiting time fell from a median of 22 days in Study 1 to 10 days in Study 2. There was no significant difference between the studies for the proportion of each type of investigation performed. Between 80% and 85% of new patients did not need admission for an operation; however, of those operations performed, 65% were for carcinoma. The number of patients diagnosed as having carcinoma was the same in the two studies.

CONCLUSIONS

That 25% of new, and up to 40% of follow-up patients seen in a general surgical clinic have breast problems. Many patients do not regard their symptoms as worrying and will not attend early clinic appointments even if these are offered. Writing to patients and general practitioners with the results of investigations ensures quicker receipt of the diagnosis and treatment plan, and reduces follow-up attendance. Only 15-20% of new patients need admission for an operation, and carcinoma is found in only 13-17%. Open access to the clinics does not result in general practitioners referring patients unnecessarily with breast problems.

Breast disease and the general surgeon. I. Referral of patients with breast problems

OBJECTIVES

To determine the proportion of all new and follow-up patients referred to general surgical outpatient clinics with breast problems. To ascertain how long these patients wait for an appointment and how many require investigation or admission for operation. To review our management of patients with breast problems in the clinic and to determine the ratio of benign breast disease to malignancy.

DESIGN

A 3-month prospective outpatient survey with patient details recorded on questionnaires completed by the medical staff.

SETTING

The general surgical outpatient clinics of this firm at Battle Hospital, Reading, and Newbury District Hospital, Berkshire.

PATIENTS

Those patients attending the above clinics during the 3-month period 1 October to 31 December 1989.

RESULTS

In all, 693 new patients and 554 follow-up patients were seen. Of the new patients, 119, and of the follow-up patients 140 were seen for a breast complaint. At Battle Hospital 16% of all new patients presented with a breast problem, while at Newbury Hospital the figure was 24%. Of the follow-up patients at Battle Hospital, 23% were seen for a breast problem, and 41% at Newbury. The overall median waiting time for a new outpatient appointment was 21 days. No investigations were needed in 22% of the patients. The remaining 93 patients had investigations and a total of 70 mammograms and 53 fine needle aspirations for cytology were performed. The mean cost of investigations per patient investigated was estimated at 27 pounds. Of new patients, 58% were discharged from the clinic after a single consultation, and investigations as necessary. In 79% of the patients admitted for an operation, the decision to admit was made on the basis of the initial history and examination alone. Of new patients, 84% did not need admission and were managed in the clinic. In all, 14 breast carcinomas were diagnosed--12% of new patients with breast problems.

CONCLUSIONS

The figures suggest that 24% of new patients and 41% of follow-up patients attending a general surgical clinic are seen for a breast problem. The waiting time for new appointments is unacceptably long. Most new patients do not require admission for an operation. Only 12% of new patients referred with a breast problem were found to have a carcinoma.

Use of calcium alginate to pack abscess cavities: a controlled clinical trial

Many conventional dressings are painful when removed, and may be detrimental to healing. In a pilot study ten consecutive abscesses, requiring incision and drainage, were packed with a calcium alginate dressing: this was well tolerated, its removal causing minimal pain. No adverse effects were attributable to its use. A controlled trial was therefore carried out to compare calcium alginate with the more traditional saline-soaked gauze for packing abscess cavities, following incision and drainage. Patients were randomized to receive either calcium alginate (16 patients) or gauze dressing (18 patients). At the first dressing change the patient marked on a linear analogue scale the pain experienced; the nurse noted similarly the ease of removal of the dressing. Calcium alginate was significantly less painful to remove after operation (P less than 0.01), and also easier to remove (P less than 0.01) than gauze dressings. If abscess cavities are packed after incision and drainage, calcium alginate appears to be an improvement on conventional dressings.

Memory and attention in patients with senile dementia of the Alzheimer type and in normal elderly subjects

Previous studies have shown that cholinergic blockade in normal subjects induces impairment of vigilance as well as memory deficits. In the present investigation we have examined the validity of this pharmacological model of dementia by administering a battery of cognitive tasks to patients with mild and moderate senile dementia of the Alzheimer type and to age-matched controls. In contrast to volunteers receiving scopolamine all the mildly demented patients, and half of those moderately affected, performed normally on tests of vigilance whilst exhibiting the expected memory deficits. These data suggest that the mechanism of memory loss in Alzheimer's disease may differ from that found in scopolamine-induced amnesia.

HIV-1 binding to CD4 T cells does not induce a Ca2+ influx or lead to activation of protein kinases

The penetration of CD4+ cells by human immunodeficiency virus (HIV) involves a high affinity interaction between the viral attachment protein, gp120, and the cellular receptor, CD4. The mechanism by which the virus penetrates the host cell subsequent to viral binding is unknown. We have investigated the possibility that HIV penetration induces changes in the metabolic state of the infected cell similar to those seen with the perturbation of CD4 cells by monoclonal antibodies (MAb) directed against the CD4 molecule, or with specific antigen-mediated activation. The activation of cellular protein kinases was examined. The basal level of activity was not altered in the presence of HIV. Kinase activity was markedly increased in cells stimulated with phytohemagglutinin (PHA), and was qualitatively and quantitatively changed by a brief exposure to the phorbol ester TPA (12-o-tetradecanoyl phorbol-13-acetate). The phosphorylation state of the CD4 molecule was examined by radioimmunoprecipitation and found to be unaltered by the binding of HIV under conditions in which TPA induced rapid CD4 phosphorylation. The activity of the CD4-associated protein tyrosine kinase p56lck was measured by in vitro assays of 32PO4 incorporation in CD4 immunoprecipitates from HIV-incubated cells. TPA incubation resulted in a rapid loss of CD4-associated p56lck activity, presumably due to dissociation of the enzyme from CD4. Concanavalin A stimulation resulted in a similar change but with a slower time course. However, no change in CD4-associated activity was detected in HIV-incubated cells. We found that Ca2+ influx was not induced by the binding of HIV to CD4+ cells.(ABSTRACT TRUNCATED AT 250 WORDS)