Peripapillary retinal nerve fibre layer thickness and macular ganglion cell layer volume in association with motor and cognitive outcomes in 11-year-old children born very preterm

PURPOSE

The purpose of the study was to study the association between retinal parameters and motor and cognitive outcomes in children born very preterm.

METHODS

This study is part of a prospective cohort study of very preterm infants (birth weight ≤ 1500 grams/gestational age < 32 weeks). At 11 years of age, the ophthalmological assessment included a retinal optical coherence tomography (OCT) examination of the peripapillary retinal nerve fibre layer (PRNFL) and the macular ganglion cell layer (GCL). The motor performance was assessed with the Movement Assessment Battery for Children-Second Edition (Movement ABC-2), and the cognitive outcome with the Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV).

RESULTS

A total of 141 children were included. The mean (SD) average PRNFL was 95 μm (10.2 μm). The mean (SD) macular GCL volume was 0.34 mm³ (0.03 mm³ ). Higher PRNFL thickness associated with higher percentiles for total scores in the motor assessment (b = 0.5, 95% CI 0.1-0.8, p = 0.01) and higher macular GCL volume with higher scores in the cognitive assessment (b = 1.4, 95% CI 0.5-2.3, p = 0.002), also when adjusted for gender, birth weight z-score (birth weight in relation to gestational age) and major brain pathology at term.

CONCLUSION

The associations between higher average PRNFL thickness and better motor performance as well as higher macular GCL volume and better cognitive performance refer to more generalized changes in the brain of 11-year-old children born very preterm. Retinal OCT examinations might provide a deeper insight than mere eyesight in long-term neurodevelopmental follow-up of children born very preterm.

Hammersmith Infant Neurological Examination and long-term cognitive outcome in children born very preterm

AIM

To study the association between the Hammersmith Infant Neurological Examination (HINE) at age 2 years and neurocognition at age 11 years in children born very preterm. We hypothesized that the HINE at 2 years would be associated with neurocognition, that is, neurological, motor, and cognitive outcomes at 11 years.

METHOD

A total of 174 children (mean gestational age 29.0wks, SD 2.7; minimum 23.0, maximum 35.9; 95 [55%] males, 79 [45%] females) born very preterm (birthweight ≤1500g/gestational age <32wks), were included in a prospective cohort recruited from 2001 to 2006 in Turku, Finland. The HINE was performed at 2 years' corrected age. Neurocognition at 11 years was assessed with the Touwen neurological examination, Movement Assessment Battery for Children, Second Edition (MABC-2), and full-scale IQ (Wechsler Intelligence Scale for Children, Fourth Edition).

RESULTS

The HINE global score was associated with the results of the Touwen neurological examination (odds ratio [OR]=0.9, 95% confidence interval [CI] 0.8-0.9, p=0.001), MABC-2 (β=1.4, 95% CI 0.7-2.2, p<0.001), and full-scale IQ (β=1.2, 95% CI 0.8-1.7, p<0.001), even when adjusted. When children with cerebral palsy (CP) were excluded, the HINE was still associated with full-scale IQ (unadjusted β=1.2, 95% CI 0.3-2.1, p=0.01).

INTERPRETATION

A higher HINE global score at 2 years was associated with better general intelligence at 11 years even in children without CP. The HINE may be a useful tool to detect children at risk for later cognitive impairment. What this paper adds A Hammersmith Infant Neurological Examination (HINE) global score at 2 years was associated with long-term neurocognitive function. Severe cognitive impairment was significantly more common in 11-year-old children with complex minor neurological dysfunction compared to typically developing children. The HINE performed at 2 years detects risks of cognitive impairment at 11 years in children born very preterm. A higher HINE score at 2 years was associated with better general intelligence at 11 years.

Declarative Algorithms and Complexity Results for Assumption-Based Argumentation

The study of computational models for argumentation is a vibrant area of artificial intelligence and, in particular, knowledge representation and reasoning research. Arguments most often have an intrinsic structure made explicit through derivations from more basic structures. Computational models for structured argumentation enable making the internal structure of arguments explicit. Assumption-based argumentation (ABA) is a central structured formalism for argumentation in AI. In this article, we make both algorithmic and complexity-theoretic advances in the study of ABA. In terms of algorithms, we propose a new approach to reasoning in a commonly studied fragment of ABA (namely the logic programming fragment) with and without preferences. While previous approaches to reasoning over ABA frameworks apply either specialized algorithms or translate ABA reasoning to reasoning over abstract argumentation frameworks, we develop a direct declarative approach to ABA reasoning by encoding ABA reasoning tasks in answer set programming. We show via an extensive empirical evaluation that our approach significantly improves on the empirical performance of current ABA reasoning systems. In terms of computational complexity, while the complexity of reasoning over ABA frameworks is well-understood, the complexity of reasoning in the ABA+ formalism integrating preferences into ABA is currently not fully established. Towards bridging this gap, our results suggest that the integration of preferential information into ABA via so-called reverse attacks results in increased problem complexity for several central argumentation semantics.

Mechanical and oral antibiotic bowel preparation versus no bowel preparation in right and left colectomy: subgroup analysis of MOBILE trial

BACKGROUND

In retrospective series, mechanical and oral antibiotic bowel preparation (MOABP) has been reported to reduce surgical-site infections (SSIs) after colectomy compared with no bowel preparation (NBP).

METHOD

This was a subgroup analysis of a multicentre randomized trial that included patients scheduled for elective colectomy. The MOABP group underwent mechanical bowel preparation, and took 2 g neomycin and 2 g metronidazole orally during the day before surgery. The NBP group did not undergo bowel preparation. Patients were categorized according to the side of resection (right versus left colectomy), and these subgroups compared for postoperative outcomes.

RESULTS

Among 217 patients undergoing right colectomy (106 in MOABP and 111 in NBP group), SSI was detected in seven (7 per cent) and 10 (9 per cent) patients (odds ratio (OR) 0.71, 95 per cent c.i. 0.26 to 1.95; P = 0.510), anastomotic dehiscence in two (2 per cent) and two (2 per cent) patients (OR 1.05, 0.15 to 7.58; P = 1.000), and the mean(s.d.) Comprehensive Complication Index (CCI) score was 9.4(12.9) and 10.5(18.0) (mean difference -1.09; 95 per cent c.i. -5.29 to 3.11; P = 0.608) in the MOABP and NBP groups respectively. Among 164 patients undergoing left colectomy (84 in MOABP and 80 in NBP group), SSI was detected in five (6 per cent) and eight (10 per cent) patients (OR 0.57, 0.18 to 1.82; P = 0.338), anastomotic dehiscence in four (5 per cent) and five (6 per cent) patients (OR 0.75, 0.19 to 2.90; P = 0.742), and the CCI score was 10.2(13.1) and 6.5(11.0) (mean difference 3.68, -0.06 to 7.42; P = 0.053) in the MOABP and NBP groups respectively.

CONCLUSIONS

MOABP did not decrease the rate of SSI or complications in patients undergoing either right or left colectomy compared with NBP.

FRI0082 SLEEP PROBLEMS IN EARLY RHEUMATOID ARTHRITIS

Background:

It is well known that patients with established RA suffer from problems with sleep quality[1]. There are however few, if any, studies on sleep quality among newly diagnosed patients.

Objectives:

To investigate the sleep quality among patients newly diagnosed with RA.

Methods:

We used the Swedish study Epidemiological Investigation of RA (EIRA) including patients at the time of diagnosis, based on the 1987 ACR criteria during 2008-2016. At 1 and 3 years after diagnosis, the patients were sent a questionnaire in which they were asked to rate their sleep quality on 10 different questions. We then calculated 6 different sleep components consisting of insomnia, non-restorative sleep, sleep problems, general quality of sleep, if poor sleep affected the health and if they were getting enough sleep[2].

Sleep problems were defined as mostly or always having problems with either of the following: falling asleep, many awakenings with difficulties to go back to sleep, waking up early or having disturbed/restless sleep. Insomnia was defined as answering mostly or always on either problem with falling asleep, many awakenings with difficulties to go back to sleep or waking up early, in combination with mostly or always being tired during the day.

Having problems with non-restorative sleep was defined as mostly or always having trouble waking up or not feeling well rested when waking up. We defined having problem with not getting enough sleep, sleep quality affecting the health and poor sleep quality as reporting any of the two highest scores on the corresponding questions.

We then calculated the proportion of people experiencing no problems at 1 or 3 years after RA diagnosis, developing problems, improving or always having problems with their sleep.

Results:

We identified 1483 patients with data at either one or both time points. The mean age was 59 years (IQR 19), and 1063 (72%) were women. At 1 year, 36% of the patients reported having at least one type of sleep problem, after 3 years, this figure was 29%. Over 20% of the patients reported having “Rather big” or “Very big” problems with sleep after one year (Table 1) and 31% had problems at one or both time points (Table 2). Disturbed sleep was a problem for their health in 20% of the patients and 11% reported having “poor” or “very poor” sleep quality at both times. Insomnia was experienced by 118 (10%) patients at 1 year and 112 (11%) at 3 years.

Table 1.

Sleep problems at 1 and 3 years after diagnosis of RA.

1 year3 yearsInsomnia118 (9%)112 (11%)Not getting enough sleep102 (8%)113 (11%)Problems with sleep in general270 (22%)231 (22%)Sleep quality affecting health238 (19%)197 (19%)Poor sleep quality218 (17%)209 (20%)Problem with non-restorative sleep218 (17%)154 (14%)Table 2.

Individuals experiencing no problems, developing problems, improving or always having problems with their sleep at 1 and 3 years after diagnosis of RA.

No problems at any time pointImprovedDeveloped problemsProblems at both 1 and 3 yearsInsomnia702 (85%)43 (5%)46 (6%)39 (5%)Not getting enough sleep719 (86%)36 (4%)47 (6%)34 (4%)Problems with sleep in general576 (69%)81 (10%)78 (9%)103 (12%)Sleep quality affecting health616 (74%)65 (8%)70 (8%)85 (10%)Poor sleep quality623 (74%)57 (7%)66 (8%)91 (11%)Problem with non-restorative sleep654 (78%)71 (8%)46 (5%)67 (8%)

Conclusion:

In a population-based early RA cohort receiving today’s standard care, 30% of the patients reported some type of sleep problem during the first 3 years. Although this is a lower rate than has been reported in established RA, this is a significant proportion of RA patients, and these findings warrant further studies to closer identify the course of sleep problems and the factors influencing it such as pain.

References:

[1]Bourguignon C et al PMID 14596374

[2]Akerstedt T et al PMID 18484368

Acknowledgments:

The authors wish to acknowledge the EIRA study group and the EIRA data collectors.

Disclosure of Interests:

Tiina Lehtonen: None declared, Torbjörn Åkerstedr: None declared, Lauren Lyne: None declared, Lars Klareskog: None declared, Saedis Saevarsdottir Employee of: Part-time at deCODE Genetics/Amgen Inc, working on genetic research unrelated to this project, Lars Alfredsson: None declared, Helga Westerlind: None declared

Diffusion tensor imaging is associated with motor outcomes of very preterm born children at 11 years of age

AIM

Very preterm children born <32 weeks of gestation are at risk for motor difficulties such as cerebral palsy and developmental coordination disorder. This study explores the association between diffusion tensor imaging metrics at term and motor outcomes at 11 years of age.

METHODS

A cohort of 37 very preterm infants (mean gestational age 29 4/7, SD 2 0/7) born in 2004-2006 in Turku University Hospital underwent diffusion tensor imaging at term. A region of interest analysis of fractional anisotropy and mean diffusivity was performed. Motor outcomes at 11 years of age were measured with the Movement Assessment Battery for Children - Second Edition.

RESULTS

The diffusion metrics of the corpus callosum (genu P = .005, splenium P = .049), the left corona radiata (P = .035) and the right optic radiation (P = .017) were related to later motor performance. Mean diffusivity decreased and fractional anisotropy increased in proportion to the improving performance.

CONCLUSION

The diffusion metrics of the genu and splenium of the corpus callosum, the left corona radiata and the right optic radiation at term were associated with motor skills at 11 years of age. Diffusion tensor imaging should be further studied as a potential tool in recognising children at risk for motor impairment.

School performance is age appropriate with support services in very preterm children at 11 years of age

Aim

This Finnish regional birth‐cohort study compared the school performance of very preterm and full‐term children when they reached 11 years of age.

Methods

Teachers rated the educational abilities of 123 preterm children and 133 full‐term controls at the age of 11 years as well as the support services they received. The children were all born in the Turku University Hospital between 2001 and 2005. In the preterm group, neurosensory impairments were confirmed at two years of corrected age, and full‐scale intelligence quotient (IQ) was assessed at 11 years of age using the Wechsler Intelligence Scale, Fourth Edition.

Results

Educational abilities, including academic skills and classroom functioning, did not differ between the two groups after excluding the children with a full‐scale IQ < 70. However, 40% of the preterm group and 26% of the controls had received at least one support service (p <0.02). The 13 preterm children with a full‐scale IQ <70 and the 10 with neurosensory impairment received more support services. Boys in both groups displayed more classroom‐functioning problems than girls.

Conclusion

A full‐scale IQ ≥ 70 and age‐appropriate educational abilities do not exclude a significant need for support services in very preterm children at the age of 11 years.

Oncological outcomes before and after the extralevator abdominoperineal excision era in rectal cancer patients treated with abdominoperineal excision in a single centre, high volume unit

AIM

The extralevator abdominoperineal excision (ELAPE) has been expected to reduce the risk of positive circumferential resection margins (CRMs) and local recurrence in locally advanced distal rectal cancer. The aim was to determine whether there is any difference in local recurrence rates between patients who were operated on for distal rectal cancer before and after the introduction of ELAPE in our unit.

PATIENTS AND METHODS

In all, 206 patients with distal rectal cancer without distant metastases (T1-4N0-2M0) were treated with curative intent. The patients were divided into two cohorts operated in 2000-2007 (A) and 2008-2014 (B). The ELAPE procedure was introduced in 2008. Since then, it has been used in cases of T4 and T3 tumours with threatened margins. In T1-T3 tumours without threatened margins a conventional abdominal perineal excision has been performed.

RESULTS

There was no significant difference in overall survival or cancer-specific survival between the two time periods. The local recurrence rate was 15.5% in group A and 6.7% in group B (P = 0.048), although there was no significant difference in the cumulative local recurrence rate. Intra-operative tumour perforation occurred significantly more often during the earlier period when ELAPE was not in use: group A 15/71 (21.1%) vs group B 11/135 (8.1%), P = 0.01. CRM was positive more often in group A (16.4%) vs group B (7.4%), P = 0.054.

CONCLUSION

The local recurrence rate, intra-operative tumour perforation and positive CRM rate were significantly lower during the later period when more extensive surgery (ELAPE) was performed for locally advanced T3-T4 rectal cancer with threatened margins.

The effect of cataract surgery and IOL implantation on the magnification of a fundus photograph: a pilot study

PURPOSE

The goal was to determine the effect of cataract surgery-induced change in ametropia and anterior chamber depth on the magnification of a fundus photograph.

METHODS

Fundus photographs were taken from 11 subjects undergoing cataract surgery and intraocular lens (IOL) implantation before and after surgery with a telecentric Zeiss and Topcon fundus cameras. The distance between two distinct fundus landmarks, i.e. two crossings of retinal vessels, was measured before and after surgery, and the results were compared to axial length and surgery-induced change in ametropia and anterior chamber depth. In addition, the change in the conversion factor of Topcon fundus camera was calculated and its correlation to axial length, change in ametropia and anterior chamber depth was analysed. Further, the change in the mathematical location of P', i.e. the second principal point of the eye in the formula of Bennett et al. (1994), was calculated.

RESULTS

Cataract surgery and IOL implantation did not significantly influence the magnification of a fundus photograph taken with a telecentric Zeiss or Topcon fundus camera even when ametropia changed markedly. Axial length and anterior chamber depth did not correlate with change in the magnification of a fundus photograph. The average change in the mathematical location P' due to surgery was -39.4%, SD 0.33.

CONCLUSION

Fundus photographs taken with a telecentric Zeiss or Topcon fundus camera can be reliably used to follow the size of fundus landmarks even if ametropia and anterior chamber depth are changed after cataract surgery and IOL implantation.

Simulating level-crossing probabilities by importance sampling

Let X1, X2, · ·· be independent and identically distributed random variables such that ΕΧ1 < 0 and P(X1 ≥ 0) ≥ 0. Fix M ≥ 0 and let T = inf {n: X1 + X2 + · ·· + Xn ≥ M} (T = +∞, if for every n = 1,2, ···). In this paper we consider the estimation of the level-crossing probabilities P(T <∞) and , by using Monte Carlo simulation and especially importance sampling techniques. When using importance sampling, precision and efficiency of the estimation depend crucially on the choice of the simulation distribution. For this choice we introduce a new criterion which is of the type of large deviations theory; consequently, the basic large deviations theory is the main mathematical tool of this paper. We allow a wide class of possible simulation distributions and, considering the case that M →∞, we prove asymptotic optimality results for the simulation of the probabilities P(T <∞) and . The paper ends with an example.

Determining the size of retinal features in prematurely born children by fundus photography

PURPOSE

The purpose was to study the effect of prematurity on the macula-disc centre distance and whether it could be used as a reference tool for determining the size of retinal features in prematurely born children by fundus photography.

METHODS

The macula-disc centre distance of the left eye was measured in pixels from digital fundus photographs taken from 27 prematurely born children aged 10-11 years with Topcon fundus camera. A conversion factor for Topcon fundus camera (194.98 pixel/mm for a 50° lens) was used to convert the results in pixels into metric units.

RESULTS

The macula-disc centre distance was 4.74 mm, SD 0.29. No correlation between ametropia and the macula-disc centre distance was found (r = -0.07, p > 0.05). One child (subject 20) had high myopia and retinopathy of prematurity (ROP), and the macula-disc centre distance was longer than average (6.35 mm).

DISCUSSION

The macula-disc centre distance in prematurely born children at the age of 10-11 years provides an easy-to-use reference tool for evaluating the size of retinal features on fundus photographs. However, if complications of ROP, for example temporal macular dragging or high ametropia, are present, the macula-disc centre distance is potentially altered and a personal macula-disc centre distance should be determined and used as a refined reference tool.

Genomic analysis of the 55 kDa subunit of DNA polymerase epsilon in human intracranial neoplasms

BACKGROUND

Defects of some DNA polymerases have shown cancer associations, but there are only limited data on DNA polymerase (Pol) epsilon.

MATERIALS AND METHODS

We examined 26 human brain neoplasm DNA samples and 8 control blood samples (from Poland) for possible mutations in the entire coding region of the 55 kDa small subunit of human DNA Pol epsilon gene using polymerase chain reaction-single-strand conformation polymorphism (PCR-SSCP) analysis, and sequence analysis of DNA.

RESULTS

One single base intronic transition in intron 14 was found. The AATT deletion previously found in some breast and colorectal tumors was not found in samples from brain neoplasms or controls, but it was found in 1/100 normal blood samples from South-West Finland.

CONCLUSION

We found no evidence that potential mutations in the 55 kDa subunit of DNA Pol epsilon are a contributing factor in the development of the tested cases of human intracranial tumors.

Finasteride following balloon dilatation of the prostate. A double-blind, placebo-controlled, multicenter study

BACKGROUND AND AIMS

To evaluate the efficacy, safety and tolerability of finasteride administered for 24 months following successful balloon dilatation in patients with benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

75 patients with moderate to severe symptoms of benign prostatic hyperplasia were first treated with balloon dilatation. After a 4-week placebo runin period, 64 patients with successful dilatation and over 50 % reduction in symptoms were randomized to receive either finasteride (33 pts.) at 5 mg/day or placebo (31 pts.) for 24 months. Altogether 12 patients dropped out at some stage, and the final analysis hence included 27 patients in the finasteride group and 25 patients in the placebo group.

RESULTS

The symptom scores increased by an average of 3.2 points in the finasteride group and 4.4 points in the placebo group during two years. The mean maximum flow in the finasteride group remained constant: 13.7 ml/s at baseline and 13.9 ml/s at 24 months. In the placebo group the mean maximum flow decreased from 13.3 ml/sec to 11.2 ml/s. During the two-year study period, neither of the groups displayed any changes in residual urine. The above mentioned changes were not statistically significant, however. Prostate volume and serum PSA were significantly lower in the finasteride group (p < 0.001). The groups did not differ with regard to side-effects.

CONCLUSIONS

On the basis of the findings, BPH patients with moderate to severe symptoms can be treated with balloon dilatation. The effect of balloon dilatation is quick, and it alleviates the patients' symptoms immediately. Finasteride treatment maintains the positive effect of balloon dilatation. This combination of treatment is tolerated well and side-effects are rare. The favourable effect of balloon dilatation was maintained for at least two years. Finasteride treatment diminished significantly both prostate volume and serum prostate-specific antigen after balloon dilatation compared to placebo treatment.

Prospective randomized trial of interferon alfa-2a plus vinblastine versus vinblastine alone in patients with advanced renal cell cancer

PURPOSE

The combination of interferon alfa-2a (IFNalpha2a) plus vinblastine (VLB) induces objective tumor responses in patients with advanced renal cell cancer. However, no prospective randomized trial has shown that this treatment prolongs overall survival. We compared overall survival after treatment with IFNalpha2a plus VLB versus VLB alone in patients with advanced renal cell cancer.

PATIENTS AND METHODS

We prospectively randomized 160 patients with locally advanced or metastatic renal cell cancer to receive either VLB alone or IFNalpha2a plus VLB for 12 months or until progression of disease. In both groups, VLB was administered intravenously at 0.1 mg/kg every 3 weeks, and in the combination group IFNalpha2a was administered subcutaneously at 3 million units three times a week for 1 week, and 18 million units three times a week thereafter for the second and subsequent weeks. For patients unable totolerate IFNalpha2a at 18 million units per injection, the dose was reduced to 9 million units.

RESULTS

Median survival was 67.6 weeks for the 79 patients receiving IFNalpha2a plus VLB and 37.8 weeks for the 81 patients treated with VLB (P =.0049). Overall response rates were 16. 5% for patients treated with IFNalpha2a plus VLB and 2.5% for patients treated with VLB alone (P =.0025). Treatment with the combination was associated with constitutional symptoms and abnormalities in laboratory parameters, but no toxic deaths were reported.

CONCLUSION

The combination of IFNalpha2a plus VLB is superior to VLB alone in the treatment of patients with locally advanced or metastatic renal cell carcinoma. This is the first study to demonstrate that survival can be prolonged by using IFNalpha2a for these patients.

MRI and CT in blunt renal trauma: an update

In our experience, MRI is as effective as CT in correctly staging renal injury. The coronal and sagittal slice orientations of MRI are particularly helpful in determining the extent of the renal parenchymal damage. Both methods are accurate in finding perirenal hematomas, assessing the viability of renal fragments, and detecting preexisting renal abnormalities but are relatively inaccurate in visualizing urinary extravasation. Although CT remains the method of choice in radiological staging of renal injury, MRI can complement CT in patients with severe renal injury, preexisting renal abnormality, equivocal CT findings, or when repeated radiological follow-up is required. MRI could replace CT in patients with iodine allergy and be used for initial staging if CT is not available.

[Can finasteride reverse the progress of benign prostatic hyperplasia? A two-year placebo-controlled study.]

OBJECTIVE

To study if placebo-induced improvement in men with symptomatic benign prostatic hyperplasia (BPH) is maintained over two years, and to study the efficacy and safety from intervention with finasteride 5 mg for 24 months.

METHODS

This was a multicenter, double-blind, placeba-controlled study involving 707 patients with moderate symptoms of BPH enrolled at 59 centers in five Scandinavian countries. Following enrollment and a four-week single-blind placebo run-in period, patients were randomized to receive finasteride 5 mg once daily or placebo for 24 months. Urinary symptoms, urinary flow rate, prostate volume, postvoiding residual urinary volume, and serum concentrations of prostate-specific antigen together with laboratory safety parameters were measured at entry and at months 12 and 24. Interim physical and laboratory examinations were performed when indicated clinically.

RESULTS

In finasteride-treated patients the total symptom score improved throughout the study, with a significant difference between the two groups at 24 months (p<0.01) whereas in placebo-treated patients, there was an initial improvement in the symptom score but no change from baseline at 24 months. The maximum urinary flow rate decreased in the placebo group, but improved in the finasteride group, resulting in a between-group difference of 1.8 mL/s at 24 months (p<0.01). The mean change in prostate volume was +12% in the placebo group versus -19% in the finasteride-treated group (p%lt;0.01). Finasteride was generally well tolerated throughout the two-year study period.

CONCLUSIONS

The efficacy of therapy with finasteride 5 mg in improving both symptoms and maximum urinary flow rate and reducing prostate volume has been shown to be maintained during 24 months while patients receiving placebo experienced a return to baseline or deterioration of these parameters during the study. These results demonstrate that finasteride can reverse the natural progression of BPH.

[Treatment of benign prostatic hyperplasia with Proscar (finasteride). Results of a 10-year Scandinavian study]

707 patients with moderate prostatic hyperplasia were recruited to a two-year Scandinavian multicenter study. The study was randomized, prospective and double-blind. Half of the patients were treated with finasteride (5 mg daily) and the controls were given placebo. The patients were monitored with regard to symptoms, urinary flow rate and prostate volume. In addition, various laboratory examinations were performed. A statistically significant difference was found between the groups with regard to symptom improvement and increase in urinary flow rate in favour of finasteride. Finasteride reduced prostate volume and stopped further growth, leading to a difference of 30% in prostate volume between the two groups after two years of treatment. Thus, finasteride was able to stop the continuous growth of the prostate in the elderly male. The proportion of patients with adverse clinical experiences was similar in both treatment groups. However, the finasteride-treated group contained more patients with sexual dysfunction. We conclude that finasteride is an alternative to vigilant waiting for patients with moderate symptoms of benign prostatic hyperplasia.

[Finanseride in symtomatic benign prostatic hyeprtrophy. A 2-year placebo-controlled study]

The efficacy and safety of treatment with finasteride 5 mg daily for 24 months was assessed in this multicentre double blind placebo-controlled study including 707 patients with moderately symptomatic benign prostatic hyperplasia. Efficacy parameters were changes in voiding- and bladder storage symptoms assessed by a validated symptom score, changes in maximum urinary flow rate and changes in the prostate volume. In the finasteride patients, symptom score improved during the whole study with a significant difference between active treatment and placebo after 24 months (p < 0.01). Maximum flow rate increased in finasteride treated patients resulting in a difference between these and the placebo treated patients of 1.8 ml/s after 24 months (p < 0.01). Prostate volume was reduced by 19% in the finasteride treated patients versus an increase of 12% in the placebo treated patient group (p < 0.01). Finasteride was well tolerated. Patients receiving placebo progressed in symptoms after 16 months. Finasteride can halt the natural progression of moderately symptomatic BPH over a 24 month period.

Results of treatment in testicular nonseminoma

Seventy-one testicular nonseminomatous germ cell tumours were treated in the Helsinki University Central Hospital between 1980 and 1990. Thirty-five (49%) were stage I, 16 (23%) stage II and 20 (28%) stage III tumours. The 5-year survival rates were 91%, 94% and 70%, respectively. Five of the eight patients relapsing in stage I had adverse histopathological risk factors in their tumours. In the retrospective evaluation two stage I patients had actually a higher stage. The good results in stage II were achieved with a routine combination of chemotherapy and retroperitoneal lymph node dissection. All five patients lost for stage III nonseminoma had risk factors for unfavourable prognosis: liver metastases or very high serum markers at diagnosis. The results presented here are considerably better than in the 1970s in this country and well comparable to results from countries where this malignancy is more common. Still some patients were lost. Co-operation in different fields of medicine is essential to find and treat optimally those with more aggressive disease and those who are cured with less strenuous treatment modalities.

Can finasteride reverse the progress of benign prostatic hyperplasia? A two-year placebo-controlled study. The Scandinavian BPH Study Group

OBJECTIVES

To study if placebo-induced improvement in men with symptomatic benign prostatic hyperplasia (BPH) is maintained over 2 years, and to study the efficacy and safety from intervention with finasteride 5 mg for 24 months.

METHODS

This was a multicenter, double-blind, placebo-controlled study involving 707 patients with moderate symptoms of BPH enrolled at 59 centers in five Scandinavian countries. Following enrollment and a 4-week single-blind placebo run-in period, patients were randomized to receive finasteride 5 mg once daily or placebo for 24 months. Urinary symptoms, urinary flow rate, prostate volume, postvoiding residual urinary volume, and serum concentrations of prostate-specific antigen together with laboratory safety parameters were measured at entry and at months 12 and 24. Interim physical and laboratory examinations were performed when indicated clinically.

RESULTS

In finasteride-treated patients the total symptom score improved throughout the study, with a significant difference between the two groups at 24 months (P < or = 0.01), whereas in placebo-treated patients, there was an initial improvement in the symptom score but no change from baseline at 24 months. The maximum urinary flow rate decreased in the placebo group, but improved in the finasteride group, resulting in a between-group difference of 1.8 mL/s at 24 months (P < or = 0.01). The mean change in prostate volume was +12% in the placebo group versus -19% in the finasteride-treated group (P < 0.01). Finasteride was generally well tolerated throughout the 2-year study period.

CONCLUSIONS

The efficacy of therapy with finasteride 5 mg in improving both symptoms and maximum urinary flow rate and reducing prostate volume has been shown to be maintained during 24 months while patients receiving placebo experienced a return to baseline or deterioration of these parameters during the study. These results demonstrate that finasteride can reverse the natural progression of BPH.

Comparison of high-field magnetic resonance imaging with computed tomography in the evaluation of blunt renal trauma

OBJECTIVE

To compare magnetic resonance (MR) imaging and computed tomography (CT) in radiographic staging of blunt renal trauma.

DESIGN

A prospective study.

MATERIALS AND METHODS

Fourteen patients with blunt renal trauma not requiring early surgical treatment underwent CT, and high-field (1.0 T) MR imaging.

MEASUREMENTS AND MAIN RESULTS

MR imaging equaled CT in correctly grading the renal injury. The coronal and sagittal projections of MR imaging were helpful in determining the extent of the renal parenchymal lesion. Both methods were accurate in finding perirenal hematomas, assessing the viability of renal fragments, and detecting pre-existing renal abnormalities, but failed to visualize urinary extravasation on initial examination.

CONCLUSIONS

Although CT remains the method of choice in radiographic staging of renal injury, MR imaging can complement CT in patients with severe renal injury, pre-existing renal abnormality, equivocal CT findings, or when repeated radiographic follow-up is required. MR imaging could replace CT in patients with iodine allergy and be used for initial staging if CT is not available.

Aetiology of priapism in 207 patients

Two hundred and seven patients were treated for priapism in Finnish hospitals in 1973-1990. In order to analyse the aetiology of priapism, the original data on these and on 163 age- and time-matched controls, who underwent appendicectomy, were collected from the hospitals. The information was completed by collecting extra data from other hospitals and health centres or by personal contacts. In 43 of the 207 cases (21%), the cause of priapism was an intracavernous injection of a vaso-active drug. These patients were excluded from the logistic regression analysis used to evaluate the most essential factors associated with priapism. They were found to abuse alcohol (p < 0.001), use psychopharmaceuticals (p < 0.001), antihypertensive drugs (p = 0.003), anticoagulants (p = 0.005), as well as to have lumbar disc pain (p = 0.002) and chronic prostatitis (p = 0.01). Smoking was also significantly more common in the patients affected by priapism (56%) than in the controls (33%), being significantly associated with heavy alcohol drinking and use of psychopharmaceuticals. A disease or trauma was a possible causative factor in one third of the patients. The present study confirms the suggestion of a multifactorial aetiology for the initiation of priapism.

The effect of prostatic capsule perforation on the absorption of irrigating fluid during transurethral resection

Thirty patients undergoing transurethral resection of the prostate using ethanol-tagged irrigating fluid were investigated in order to study the effects of a breach in the prostatic capsule. Measurements were made of end-tidal ethanol (ET-ethanol) in the expired air, serum glycine and sodium, haemoglobin, blood loss and volumetric determination of irrigating fluid absorption. Perforation of the prostatic capsule occurred in 13 patients (Group P), with 17 judged to have no perforation (Group NP). In all Group NP patients the ET-ethanol remained below 0.05/1000, serum sodium decreased by < or = 3 mmol/l and serum glycine remained < 1.5 mmol/l. ET-ethanol was significantly increased in Group P, rising to between 0.1 and 0.45/1000 in 5 patients, 3 of whom showed a reduction in serum sodium > 5 mmol/l. Five patients in Group P demonstrated significantly raised serum glycine concentrations up to 15 mmol/l. These findings suggest that perforation of the prostatic capsule may lead to rapid absorption of irrigating fluid, and that ET-ethanol monitoring is a useful method of detecting this quickly.

Scandinavian clinical study of finasteride in the treatment of benign prostatic hyperplasia

The effects of finasteride, a potent 5 alpha-reductase inhibitor, were assessed in patients with benign prostatic hyperplasia. Patients were treated with finasteride or placebo for 24 weeks in a double-blind multicenter study followed by a 12-month open-extension period. After 24 weeks, finasteride-treated patients, when compared to placebo-treated patients, showed a significant reduction in prostate volume (22.5% median decrease) and prostate significant antigen (32.4% median decrease), a significant increase in maximum urinary flow (1.6 ml/s mean increase from baseline) and a significant improvement in their obstructive symptom scores (two-point decrease from baseline). Finasteride was well tolerated, and the improvements in prostate volume, maximum urinary flow rate and obstructive symptom scores observed in the controlled study were maintained throughout the extension study.

Localized amyloidosis of the urinary bladder

Localized amyloidosis of the urinary bladder is a rare condition. Five patients, 1 with localized secondary amyloidosis, are described. The symptoms, macroscopic hematuria and tumor-like appearance in cystoscopy, may mimic bladder cancer. Diagnosis is based on histopathological examinations with Congo red staining. In most instances, the treatment of choice is transurethral resection and electrocoagulation. Because of the risk of recurrences, a close follow-up is recommended.

Diagnostic problems associated with cystinuria

To elucidate the role of the urinary cystine concentration for the formation of urinary stones, 190 stone-formers were evaluated in this prospective study. Seven patients (3.8%) were heterozygous and one patient (0.5%) was homozygous for cystinuria; only two (1%) of them were cystine stone-formers. Two patients with calcium stones were heterozygous for cystinuria. This study confirms the observation that elevated concentrations of urine cystine are relatively infrequent among patients with urinary stones.

Morphology of testicular germ cell tumours in treated and untreated cryptorchidism

The histology of 75 testicular germ cell tumours in 73 patients with treated or untreated cryptorchidism was investigated in a group of 503 patients with testicular germ cell tumour and evaluated according to the WHO classification. The proportion of pure seminoma was associated with the height of the testis, being 87% in abdominal. 78% in inguinal and 50% in normally positioned testes. In patients operated upon for cryptorchidism, the current site of the testis seemed to be a more important determinant of this proportion than the original site. The proportion of pure seminoma which developed in testes after successful orchiopexy was equal to that in normally-descended testes (50%) and lower (39%) if orchiopexy had been performed before the age of 16 years. Similarly, among non-seminomas, a higher proportion of tumours containing teratoma tissue was found in cryptorchidism was successfully treated in childhood. It was concluded that a successful orchiopexy in childhood decreases especially the risk of seminoma.

Trends in incidence and results of treatment of testicular germ cell tumours in Finland 1972-1983

A nationwide series of 422 patients with testicular germ cell cancer diagnosed in Finland in 1972-1983 was analysed. The age-adjusted incidence rate, although very low (1.6 per 10(5) male population per year), has increased compared to that in previous decades. The 3-year survival rate has improved markedly and was during the last part of the period high in patients with local (stage I) and regional (stages IIA-B) disease (100% for seminoma and over 90% for non-seminoma patients) but still fairly poor in advanced stages (stages IIC-IV) (58% for seminoma and 26% for non-seminoma patients). The improvement of the survival rate was most marked in non-seminoma patients below the median age (28.5 years). Cisplatin based chemotherapy was one of the major reasons for the improved prognosis, not only in non-seminoma patients but also in those with seminoma. There was no trend with time concerning the stage distribution of the disease. On the basis of relapse rates in stage I non-seminoma and seminoma patients staged surgically and clinically respectively, accuracy of clinical staging but not of surgical staging seemed to have improved. During the early period surgically staged stage I-II non-seminoma patients had a slightly better prognosis than clinical stage I-II patients but a similar difference was not observed during the cisplatin era.

Illness behavior and personality changes in patients with chronic prostatitis during a two-year follow-up period

Illness behavior and personality changes during a 2-year follow-up period were studied in 40 patients with chronic prostatitis. In the first study, the existence of psychic problems among the subjects was high. Sexual problems were striking. During the follow-up period the personality of the patients did not change, but subjective well-being, both psychosocial and somatic, was impaired. Sexual problems and homosexual behavior also increased. In addition, the cooperation of the patients markedly decreased and their illness behavior became problematic. The results indicate a strong need for psychic support of these patients.

Pheochromocytoma of the urinary bladder. Report of 2 cases with ultrastructural and immunohistochemical analyses

Two cases of primary pheochromocytoma of the urinary bladder are reported. Ultrastructural demonstration of neuroendocrine granules and immunoreactivity for neuron-specific enolase and synoptophysin, and the absence of cytokeratin, an epithelial marker, are useful features for distinguishing pheochromocytomas from carcinomas of the bladder.

Comparison of magnetic resonance imaging with computed tomography and intravesical ultrasound in staging bladder cancer

Magnetic resonance imaging (MRI), computed tomography (CT), and intravesical ultrasound (US) scanning were performed on 11 patients in whom infiltrative bladder cancer was suspected at cystoscopy. Equipment with magnetic field 0.02 T was used for the MRI. Tumors larger than 2 cm could be identified in all cases by MRI. In 3 of 4 cases in which the tumor was smaller than 2 cm, it could not be properly visualized and the degree of infiltration could not be assessed. When the tumor was visualized on MRI, tumor staging by MRI was correct in 7 of 8 cases (88%). Infiltration of the deep muscle layer of the bladder wall could be detected by MRI but not by CT. Intravesical US staging was correct in 7 of 9 cases (78%). As a noninvasive method, MRI is promising for the preoperative evaluation of bladder cancer and offers the advantage of imaging the bladder in different planes.

Psychological factors related to interstitial cystitis

Psychological factors related to interstitial cystitis were studied in 31 women. The control group consisted of 24 women with acute bacterial cystitis. The subjects were tested with psychological methods. Results showed that traditional signs of psychic pathology were not related to the symptoms of interstitial cystitis but psychic helplessness and inadequacy in coping with problems was found in the patients. Sexual problems were prominent. Results do not refer to the psychological origin of interstitial cystitis but stress that psychological factors have to be taken into consideration in the treatment of these patients.

Epidermoid cyst of the testis. Case report with a review of the literature

Epidermoid cysts of the testis are rare, benign testicular tumors. Only 188 cases have been reported in the world literature until July 1986. There is controversy in the literature regarding whether local excision or enucleation of the cyst and sparing the testicle or orchiectomy is the preferred treatment approach of these lesions. A case with epidermoid cyst of testis, diagnosed correctly by ultrasound and frozen section and treated successfully by an excisional operation, is presented.

Prostatic cancer protruding into the bladder imaged by transurethral and transrectal ultrasound

A case is described in which the nature of the tumour mass found in the bladder could be evaluated by combining transurethral and transrectal ultrasound.

Computerized tomography and transrectal ultrasound in the assessment of local extension of prostatic cancer before radical retropubic prostatectomy

The value of computerized tomography and transrectal ultrasound in the demonstration of local extension of prostatic cancer was evaluated in 38 patients undergoing radical retropubic prostatectomy. Transrectal ultrasound proved to be reliable for the demonstration of local extension of cancer beyond the prostatic capsule (sensitivity 86 per cent, specificity 94 per cent and accuracy 90 per cent). Invasion of the seminal vesicles was demonstrated by ultrasound, with a sensitivity of 29 per cent, specificity 100 per cent and accuracy 77 per cent. The addition of transrectal ultrasound scanning to clinical evaluation increased sensitivity in relation to detection of extraprostatic involvement from 15 to 92 per cent. When computerized tomography scanning was added to clinical examination, the sensitivity increased from 15 to only 46 per cent. Transrectal ultrasound is valuable for the preoperative evaluation of patients in whom radical prostatectomy is being considered as treatment for clinically localized prostatic cancer.

Echogenic structure of prostatic cancer imaged on radical prostatectomy specimens

Twenty radical prostatectomy specimens were scanned ultrasonically in vitro using a transrectal ultrasonic probe to evaluate the ultrasonic pattern of prostatic cancer. Histological and ultrasonic findings of the same areas were compared. No ultrasonic pattern specific for intracapsular prostatic cancer was found. Most often (in 40% of cases) the areas of prostatic cancer appeared hypoechoic on the ultrasonograms. In 30% of cases the carcinoma had a hyperechoic or mixed ultrasonic pattern, and in 30% the echo structure of the prostate was fairly uniform; intracapsular cancer could not be detected ultrasonically in these latter cases. The lack of a specific ultrasonic pattern for intracapsular prostatic carcinoma reduces the value of transrectal ultrasonography in detecting early intracapsular cancers. The main value of ultrasonography in patients with prostatic cancer is in the preoperative staging of the disease and in the follow-up of patients.

Free tunica vaginalis patch in urethroplasty. An experimental study

The management of urethral strictures is a challenge for surgery. In the present study the value of tunica vaginalis tissue for urethroplasty was investigated. 30 male rabbits were divided into two groups. In group I (11 animals) a urethral defect was covered with a tunica vaginalis patch (n = 6) or was left uncovered (n = 5). In group II (19 animals) a preoperative urethral stricture was induced by electrocoagulation through a urethroscope. The strictured urethra was plastied with tunica vaginalis (n = 9) or preputial (n = 10) patches. The results were analyzed after a period of 2 weeks to 5 months with radiographic, macroscopic and microscopic methods. The tunica vaginalis graft showed its superiority over the preputial graft: only 1 postoperative short stricture from 15 plasties (6 normal and 9 strictured urethrae) was found in the plastied group, whereas 2 strictures from 10 plasties were seen in the preputial patch group. In the urethral defect group, strictures were seen in 2 of 5 animals. The mesenchymal tunica vaginalis epithelium was covered with thin transitiocellular-like epithelium resembling transitiocellular layers. The present study supports the earlier findings on the use of tunica vaginalis tissue in urethroplasty.

Ureteroscopy in the treatment of ureteral obstruction caused by papillary necrosis

We report a case where renal papillary necrosis caused ureteral obstruction. Sloughed papillary bodies could be successfully removed from the ureter using a rigid ureteroscope.

99mTc-DTPA and 99mTc-DMSA renal gamma imaging in the surveillance of patients with conduit urinary diversion

We studied renal anatomy and function using 99mTc-2-3 dimercaptosuccinic acid (DMSA) and 99mTc-diethylenetriaminepentaacetic acid (DTPA) in 27 patients with conduit urinary diversion. In this condition, free ureteral reflux is often associated with bacteriuria, and these factors are thought to precipitate progressive renal deterioration. Gamma-camera images provided valuable information concerning the structure of the renal parenchyma, the function of individual kidneys and possible ureteral obstruction, thus helping us to decide whether or not to instigate further treatment. The information gained using renal gamma imaging with 99mTc-DTPA and 99mTc-DMSA was complementary and partly overlapping. We preferred the use of 99mTc-DTPA because of its ability to visualise the ureters and the region of ureteroconduit anastomosis. Using diuretic medication, we were able to differentiate true ureteral obstruction from atony in 9 patients using 99mTc-DTPA.

Mucosal morphology of ileal conduits with particular reference to urinary infections

Mucosal biopsies were obtained for histological and electron microscopical studies from 20 patients with ileal urinary conduits. Special interest was focused on problems of urinary tract infections and their possible role in the pathogenesis of these changes. Chronic inflammation with mild to total villous atrophy was found as well as reduction in the amount of mucosal glands. Ultrastructurally the main cellular elements of the ileal epithelium and mucosa were preserved. The age of the conduit did not seem to be decisive in the histological findings. Also recurrent infections could not be shown to be responsible for the changes in the conduit mucosa. In irradiated patients, fibrotic changes in the lamina propria of the conduit mucosa were apparent and the microvilli especially short and scanty.

The value of CT in detecting pelvic lymph node metastases in cases of bladder and prostate carcinoma

Fifty-one patients, 15 with bladder cancer and 36 with prostatic cancer, were examined by preoperative pelvic CT scanning in order to determine its sensitivity, specificity and accuracy in detecting pelvic lymph node metastases. The poor sensitivity of CT (40%) in detecting lymph node metastases reduces its value for staging lymph nodes. The reason for the low sensitivity is that metastases in nodes which are of normal size cannot be detected by CT. Pelvic lymphadenectomy remains the only accurate method for evaluating the state of pelvic lymph nodes.

CT in determining the depth of infiltration of bladder tumors

The findings from 141 CT investigations of bladder tumors are compared with histopathological staging (103 cases) and clinical staging (36 cases). Twenty-five tumors could not be seen on CT and 2 tumors could not be staged because of artifacts caused by hip prosthesis. When the tumor was visible at CT and there was histological confirmation of the depth of the infiltration, we were able to differentiate extravesical tumor stages T3b and T4 from each other and from all the other stages in 49 of 59 cases (83%). However, CT failed to differentiate superficial from intramural tumor stages. The greatest value of CT in staging bladder tumors is in cases of deeply infiltrating tumors; examination should be made before biopsy or any therapeutic procedures are begun.

Renal cell adenocarcinoma and retrovirus p30-related antigen excreted to urine

The authors have previously demonstrated in syncytiotrophoblastic cells of human placenta, hydatidiform and destructive moles, and choriocarcinoma antigens reacting with antibodies to the endogenous feline retrovirus RD114 p30 and human T cell leukemia-lymphoma virus p19 proteins. The authors now report that a monoclonal IgG1 antibody (HPS-1), recognizing both syncytiotrophoblasts and RD114 p30, also reacts with an antigen in the tumor cell cytoplasm of all 27 renal cell adenocarcinomas studied. Positively stained antigenic material was also seen in the lumen of normal tubuli of tumor kidneys, suggesting its excretion into urine. None of 10 normal kidneys, 17 Wilms' tumors, 5 transitional cell carcinomas of the renal pelvis, 5 similar tumors of the urinary bladder, 20 adenocarcinomas of the cervix uteri, 20 adenocarcinomas of the corpus uteri, or 20 adenocarcinomas of the colon showed any positive staining. All 3 renal oncocytomas studied gave a positive staining reaction. In RD114 p30 radioimmunoassay antigenic activity was detected in the urine of renal cell adenocarcinoma patients in amounts up to 1.93 ng/mg protein, but not in the serum. After nephrectomy, a decline of the excreted antigen was observed, the preoperative values being 0.16 to 1.93 ng/mg protein and the postoperative ones ranging from immeasurable to 0.58 ng/mg protein. The patients with measurable postoperative urine values had clinically detectable distant metastases. The p30-related antigen may provide a marker for renal cell adenocarcinoma.

Mr 75,000 protein, a tumor marker in renal adenocarcinoma, reacting with antibodies to a synthetic peptide based on a cloned human endogenous retroviral nucleotide sequence

Using a rabbit antiserum to a synthetic undecapeptide deduced from a cloned human retroviral gag-gene-related DNA sequence, we found a specific immunohistochemical reaction in all of 42 tested renal cell adenocarcinomas (RCC), while none of 17 similarly tested Wilms' tumors and 65 carcinomas at other sites were positive. The RCC included two cases that presented with distant metastases. It had not been possible to establish the origin of these until immunohistochemical staining revealed this typical reaction. Subsequent renal angiography disclosed the primary. In immunoblotting the antiserum detected an Mr 75,000 protein in RCC tissue, and this reaction was blocked by the undecapeptide. The usefulness of this protein as a tumor marker for RCC is discussed.

Active specific immunotherapy with supportive measures in the treatment of palliatively nephrectomized, renal adenocarcinoma patients. A thirteen-year follow-up study

The results of a 13-year (1971-1984) follow-up of specific active immunotherapy using polymerized autologous tumor tissue with adjuvants and supportive measures, following palliative nephrectomy in 71 patients suffering from advanced renal adenocarcinoma, are presented. The control patient group comprised 56 patients who received the best possible conservative treatment available. The statistically calculated life expectancy in the immunotherapy group is 44.5 months (SE 5.7) and in the control group 19.0 months (SE 3.3). The difference is statistically highly significant (generalized Wilcoxon [Breslow], t = 14.9, p less than 0.0001). There were no serious side effects from the immunization. The supportive measures entailing the administration of factors involved in cell regulatory functions mediated by the central nervous system, amino acids, trace elements, hormones and vitamins has still to be optimized.

The value of urethrocystography in the investigation of patients with spinal cord injury

In a review of 127 urethrocystograms carried out on 92 males with spinal cord injury the following conclusions were drawn. (1) In the presence of vesico-ureteric reflux or urethral reflux into the male adnexa, bladder outlet obstruction should be suspected. (2) Lesions of the anterior urethra develop easily as the result of indwelling catheterisation in patients lacking sensation. A retrograde urethrogram is necessary to demonstrate these lesions. (3) Severe trabeculation of the bladder wall can be a sign of high-pressure outlet obstruction. (4) Dilatation of the bladder neck in patients with detrusor sphincter dyssynergia may lead to total urinary incontinence after sphincterotomy. (5) Urethrocystography is not a valid investigation to detect bladder stones.

Upper urinary tract changes in patients with spinal cord injury

Two hundred and six intravenous urograms on 119 patients with spinal cord injury were reviewed and the findings correlated with the clinical data. Fifty (42%) of 119 patients had pathological changes in their upper urinary tracts. The most common feature was impaired renal emptying. Patients with normal and pathological upper tracts had similar findings according to the number of positive urine cultures during the first post-injury year, but in the follow-up those with pathological urograms showed bacteriuria significantly more often. Febrile urinary tract infections at least once a year were encountered in the follow-up of 40% of the patients with pathological urograms, as compared with 8% with normal urograms. All patients with severe renal changes had impaired emptying from the kidneys. This supports the view that the basic patho-physiological mechanism leading to upper tract deterioration in patients with spinal cord injury is a functional or mechanical obstruction of the lower urinary tract. This should be treated actively before irreversible renal changes develop.