Impact of COVID-19 pandemic on functional urology procedures in France: a prospective study

Purpose

To evaluate the impact of COVID-19 pandemic on functional urology procedures in France.

Methods

A prospective study was conducted within 11 secondary and tertiary referral centers in France. Patients aged > 18 years who were diagnosed with a functional urology disease before the national lockdown (March 17th, 2020) and who required a surgery were included. Study period went from March 17th to September 30th 2020. The included interventions were listed according to the guidelines for functional urology enacted by the French Association of Urology and delay of reoperation was compared to the guidelines’ delay. The primary outcome was the number of procedures left unscheduled at the end of the study period. Descriptive statistics were performed.

Results

From March 17th 2020 to September 3 rd 2020, 1246 patients with a previous diagnosis of a functional urological disease requiring a surgery were included. The mean follow-up was 140.4 days (± 53.4). Overall, 316 interventions (25.4%) were maintained whereas 74 (5.9%) were canceled, 848 (68.1%) postponed and 8 patients (0.6%) died. At the end of the follow-up, 184 patients (21.7%) were still not rescheduled. If the intervention was postponed, the mean delay between the initial and final date was 85.7 days (± 64.4).

Conclusion

Overall, more than two thirds of interventions had to be postponed and the mean delay between the initial and final date was about three months.

Impact of Anemia on the Risk of Bleeding Following Percutaneous Coronary Interventions in Patients ≥75 Years of Age

Bleeding risk stratification is an unresolved issue in older adults. Anemia may reflect subclinical blood losses that can be exacerbated after percutaneous coronary intervention . We sought to prospectively determine the contribution of anemia to the risk of bleeding in 448 consecutive patients aged 75 or more years, treated by percutaneous coronary interventions without concomitant indication for oral anticoagulation. We evaluated the effect of WHO-defined anemia on the incidence of 1-year nonaccess site-related major bleeding. The prevalence of anemia was 39%, and 13.1% of anemic and 5.2% of nonanemic patients suffered a bleeding event (hazard ratio 2.75, 95% confidence interval 1.37 to 5.54, p = 0.004). Neither PRECISE-DAPT nor CRUSADE scores were superior to hemoglobin for the prediction of bleeding. In conclusion, anemia is a powerful predictor of bleeding with potential utility for simplifying tailoring therapies.

Clinical significance of urinary obstruction in critically ill patients with urinary tract infections

Urinary obstruction may be a complicating factor in critically ill patients with urinary tract infections (UTIs) and requires efforts for identifying and controlling the infection source. However, its significance in clinical practice is uncertain. This retrospective study investigated the overall hospital courses of patients in the intensive care unit (ICU) with UTIs from the emergency department.Baseline severity was assessed by the sequential organ failure assessment (SOFA) score; outcomes included probability and inotropic-, ventilator-, renal replacement therapy (RRT)-, and ICU-free days and 28-day mortality.Of 122 patients with UTIs, 99 had abdominal computed tomography scans. Patients without computed tomography scans more frequently had quadriplegia and a urinary catheter than those without scans (P = .001 and .01). Urinary obstruction was identified in 40 patients who had higher SOFA scores and lactate levels (P = .01 and P < .001). The use and free days of inotropic drugs and ventilator did not differ between the groups. However, patients with obstruction were more likely to require RRT and had shorter durations of RRT-free days (odds ratio 3.8; P = .06 and estimate -3.0; P = .04). Durations of ICU-free days were shorter, but it disappeared after adjustment for initial SOFA scores (estimate -2.3; P = .15). Impact of the timing of urinary drainage on outcomes was evaluated, demonstrating that an intervention within 72 hours lengthened the duration of RRT-free days compared with that after 72 hours (estimate -6.0 days; P = .03). On the other hand, the study did not find the association between other outcomes including 28-day mortality and the timing of urinary drainage.Urinary obstruction can be a complicating factor, resulting in a higher probability of RRT implementation and shorter durations of RRT- and ICU-free days in critically ill patients with UTIs. Furthermore, delayed intervention for urinary drainage may result in longer durations of RRT. Efforts should be warranted to find the presence of urinary obstruction and to control infection source in critically ill patients with UTIs.

Prognostic performance of preoperative cardiac troponin and perioperative changes in cardiac troponin for the prediction of major adverse cardiac events and mortality in noncardiac surgery: A systematic review and meta-analysis

Background

Increased postoperative cardiac troponin (cTn) independently predicts short-term mortality. Previous studies suggest that preoperative cTn also predicts major adverse cardiovascular events (MACE) and mortality after noncardiac surgery. The value of preoperative and perioperative changes in cTn as a prognostic tool for adverse outcomes has been sparsely investigated.

Methods and findings

A systematic review and meta-analysis of the prognostic value of cTns for adverse outcome was conducted. Adverse outcome was defined as short-term (in-hospital or <30 days) and long-term (>30 days) MACE and/or all-cause mortality, in adult patients undergoing noncardiac surgery. The study protocol (CRD42018094773) was registered with an international prospective register of systematic reviews (PROSPERO). Preoperative cTn was a predictor of short- (OR 4.3, 95% CI 2.9–6.5, p<0.001, adjusted OR 5.87, 95% CI 3.24–10.65, p<0.001) and long-term adverse outcome (OR 4.2, 95% CI 1.0–17.3, p = 0.05, adjusted HR 2.0, 95% CI 1.4–3.0, p<0.001). Perioperative change in cTn was a predictor of short-term adverse outcome (OR 10.1, 95% CI 3.2–32.3, p<0.001). It was not possible to conduct pooled analyses for adjusted estimates of perioperative change in cTn as predictor of short- (a single study identified) and long-term (no studies identified) adverse outcome. Further, it was not possible to conduct pooled analyses for unadjusted estimates of perioperative change in cTn as predictor of long-term adverse outcome, since only one study was identified. Bivariate analysis of sensitivities and specificities were performed, and overall prognostic performance was summarized using summary receiver operating characteristic (SROC) curves. The pooled sensitivity and specificity for preoperative cTn and short-term adverse outcome was 0.43 and 0.86 respectively (area under the SROC curve of 0.68). There were insufficient studies to construct SROCs for perioperative changes in cTn and for long-term adverse outcome.

Conclusion

Our study indicates that although preoperative cTn and perioperative change in cTn might be valuable predictors of MACE and/or all-cause mortality in adult noncardiac surgical patients, its overall prognostic performance remains uncertain. Future large, representative, high-quality studies are needed to establish the potential role of cTns in perioperative cardiac risk stratification.

Nefro-urological mortality causes in Jerez de los Caballeros (Badajoz) in the nineteenth century

The causes of mortality from nefro-urologic diseases in Jerez de los Caballeros (Badajoz) during the nineteenth century will be our object of study. We have analyzed the death registry books of the parishes in Jerez. The percentage of deaths from nefro-urologic diseases compared to other pathologies is 0.8%, being most affected males in age ranges from 25-34 and 65-75 years of age. The months with the highest mortality were July, December and January. Due to the deficient death registrations in the first decades of the century, the results should be taken with caution.

Surgical complications in pediatric and adolescent renal transplantation

To report the surgical complications among our pediatric and adolescent renal transplants and to compare these results with other reported series in the literature. A total of 50 pediatric and adolescent renal transplants were included in this study. There were 30 boys and 20 girls with a mean age of 13 years (range 6 - 18 years). 70% of patients received their kidneys from living donors. Two patients underwent renal re-transplantation. Among the 52 transplantations, 17 surgical complications were encountered in 15(30%) patients. The incidence of urological and vascular complications was respectively 13.2% and 18.9%. These complications included vesico-ureteral reflux (9.4%), urinary leakage (3.8%), lymphocele (5.8%), peri-renal hematoma (1.9%), renal artery stenosis (3.7%), and thrombosis of the allograft (7.5%). The patients with vesico-ureteral reflux were treated by antibiotic prophylaxis. In four recipients, thrombosis of the allo-graft with subsequent graft loss occurred. The graft survival rate was 90% in 1 year, 77% in 5 years and 40% in 10 years follow-up. The patient survival rate was 94.4% in 1 year and 84% after 8 years follow-up. We conclude that surgical complications can be minimized if basic principles of careful transplant techniques are used. Prompt identification and treatment of any complication are critical for graft and patient survival.

Cholesterol, cholesterol-lowering agents/statins, and urologic disease: Part V--Statins versus aspirin for primary prevention, and the winner is...?

There are no national guidelines when comparing an aspirin daily to a statin drug in individuals with no history of a cardiovascular event (primary prevention). However, recent reviews of the medical clinical research on statins and aspirin for preventing a first coronary heart disease (CHD) event concluded that compared to no treatment, aspirin is cheaper and has more of an impact in middle-aged men whose 10-year risk for CHD is 7.5% or higher, and adding a statin to aspirin therapy is better in terms of cost effectiveness when a patient's 10-year CHD risk before any treatment is greater than 10%. However, when scrutinizing these data it seems that statins beat aspirin in every single risk-reduction category, and has equal to perhaps less side effects, but a statin costs more. In addition, patients should be informed about the recent observational data suggesting that statins may reduce mortality from other causes such as prostate cancer.

Presentation and outcome of emphysematous renal tract disease in patients with diabetes mellitus

BACKGROUND

Emphysematous renal tract disease (ERTD) is a rare necrotizing infection of the renal parenchyma and urinary tract caused by gas-producing organisms. ERTD deserves special attention because of its life-threatening potential.

OBJECTIVES

To study the clinical features, radiological classification and prognostic factors of ERTD; and to compare the modalities of management and the outcome among the various radiological classes of ERTD.

PATIENTS AND METHODS

Twenty consecutive patients with diabetes and ERTD, seen over last 3 years in a tertiary care institute of north India, were included in the study. All patients were subjected to computerized tomography (CT) after initial diagnosis by ultrasonography. They were classified into 5 classes as previously described. All patients included in the study were conservatively managed with appropriate antibiotics and/or percutaneous drainage or surgery if required.

RESULT

Mean age (+/- SD) of these subjects was 54.4 +/- 20.6 years; duration of diabetes mellitus 8.6 +/- 5.8 years, and duration of symptoms related with ERTD ranged from 3 days to 3 months. Two patients had isolated emphysematous cystitis, 13 patients had emphysematous pyelonephritis (EPN), 3 had both EPN and cystitis, and 1 patient had EPN with cholecystitis, and 1 patient had EPN with pyomyositis. Only 7 (35%) patients had a history of pneumaturia. Escherichia coli was the commonest microorganism. The radiological distribution in 18 (2 had isolated cystitis) patients with EPN was: 2 patients had class 1; 1 had class 2; 2 had class 3A; 11 had class 3B, and 2 had class 4. Of 20 patients 11 (55%) survived. However, those patients who died had severe EPN based on radiological class (6 had class 3B and 1 had class 4). There was no significant difference between the survivor and non-survivor groups with respect to age, gender, duration of diabetes mellitus, duration of symptoms, serum creatinine level, total leukocyte count, hemoglobin, platelet count and culture positivity.

CONCLUSION

Computerized tomographic class 3B or 4 is the most reliable predictor of outcome in patients with ERTD.

Fetale Nephro-/Uropathien: Retrospektive Analyse von 124 Fällen, erfasst im Zeitraum von 1996 bis 2002

BACKGROUND

The embryological development of the kidneys and the urinary tract follows a complex choreography. Disorders are quite common. The incidence of disorders amounts to 0.3 - 0.8 % of live-born infants. In addition, several chromosomal anomalies are combined with renal malformations. The poor prognosis of some of these diseases is reflected in a perinatal mortality of 6.3 %.

PATIENTS AND METHODS

Retrospectively 124 cases with fetal nephro-/uropathy detected by prenatal ultrasonography between 1996 and 2002 were analyzed. Features of hypo-dysplastic kidneys (uni- or bilateral) were seen in 21 cases. Multicystic kidney disease (uni- or bilateral) existed in 40 fetuses. In some cases of multicystic or dysplastic kidney diseases, extrarenal malformations were combined. 21 fetuses suffered from autosomal recessive polycystic kidney disease. 18 male unborns showed the typical picture of intravesical obstruction due to posterior uretheral valves. The prune belly syndrome was seen 4 times. Hydronephrotic kidneys with more than 5 mm pelvic dilatation were detected in 13 cases. Renal agenesis led to a lethal outcome perinatally in 5 cases. One child died of bilateral thrombosis of renal artery and venous system.

RESULTS

The high incidence of diseases with a poor prognosis accounts for the high mortality of 50.8 % (intrauterine or postnatal death, induced abortion). Such a fatal outcome was observed in autosomal recessive polycystic kidney disease, bilateral multicystic dysplastic kidney disease, bilateral renal dysplasia combined with severe extrarenal malformations, intravesical obstruction, renal agenesis and bilateral thrombosis of the renal vessels. Only 60 children survived. Of these 26 needed urological surgery. 15 suffered from progressive renal insufficiency. During a follow-up of 8 - 58 months only 44 exhibited a normal renal function.

CONCLUSIONS

Such complex renal and urological diseases in the fetus require an interdisciplinary management of the pregnancy.

Fetal obstructive uropathy: is urine sampling useful for prenatal counselling?

OBJECTIVES

To evaluate whether fetal urinary sodium and chloride provide clinically useful information in addition to ultrasound in bilateral obstructive uropathy.

METHODS

Sonographic features and urinary concentrations of sodium and chloride were evaluated in fetuses with bilateral obstructive uropathy. After a minimum of 12 months of postnatal follow-up, cases that developed increased serum creatinine (greater than 50 micromol/L) were compared with those that did not.

RESULTS

Of the cases studied, 16/35 died perinatally, all showing anamnios and markedly elevated urinary electrolytes. Of the survivors, ten maintained normal postnatal serum creatinine, whereas nine did not. The frequency of reduced amniotic fluid/olygohydramnios was higher in cases that developed increased serum creatinine (four out of nine) than in those that did not (nil). Sodium above the 95th percentile was 100% specific and 44% sensitive to predict an increased serum creatinine during early infancy, while chloride above the 95th percentile was 70% specific and 56% sensitive. All seven cases in which urinary sodium was elevated and/or amniotic fluid volume was reduced developed renal failure.

CONCLUSION

Urine sampling slightly improved renal function prediction, but this must be balanced against its fetal risks.

Parkinsonism in Ontario: Comorbidity associated with hospitalization in a large cohort

To study comorbidity in patients with Parkinsonism (PKM), relative hospitalization rates from 1994 to 1999 for 15,304 cases were compared with 30,608 controls. After correction for differential survival, the rates were higher for cases compared to controls for aspiration pneumonia (6.34; 95% confidence interval [CI], 5.23, 7.93), affective psychosis (2.71; 95% CI, 2.13, 3.32), hip fractures (2.56; 95% CI, 2.35, 2.76), other urinary tract disorders including infections (2.5; 95% CI, 2.17, 2.86), septicemia (2.39; 95% CI, 2.02, 2.85) and fluid and electrolyte disorders (2.27; 95% CI, 1.93,2.66). The rates for cardiac, cerebrovascular, and peripheral vascular disease were similar. Preventive measures and aggressive management of these conditions as outpatients may reduce the rates of hospitalization and improve the morbidity and mortality of PKM.

Unexpected out-of-hospital deaths in persons aged 85 years or older: an autopsy study of 1886 patients

PURPOSE

The aim of this study was to determine the causes of death in the very elderly.

METHODS

We reviewed 24,081 consecutive autopsies performed over 10 years (1989 to 1998) at the Institute of Forensic Medicine, Vienna, Austria. We focused on autopsies of people aged 85 years or older who died unexpectedly out of hospital.

RESULTS

The mean age of the 1886 patients (561 men and 1325 women) at the time of death was 88 +/- 3 years (range, 85 to 108 years). Thirty-one percent (n = 588) of those who died were described as having been previously healthy. Cardiovascular disease was the most common cause of death (n = 1465 [77%]). Thirteen percent (n = 246) died of respiratory illness, 5% (n = 94) of gastrointestinal disorders, and 3% (n = 53) of diseases of the central nervous system. Genitourinary and metabolic diseases were uncommon.

CONCLUSION

Although this out-of-hospital sample is not representative of the entire elderly population, postmortem examinations emphasize the importance of cardiovascular diseases in causing unexpected deaths in older persons.

[Advances in the treatment of newborns with congenital malformations]

Authors analyzed the type and the number of treated congenital malformations in 544 newborns operated between 1992-2001 in the Department of Paediatric Surgery in the Institute of Mother and Child. The patients were divided in the following groups: digestive tract defects, abdominal wall and diaphragm defects, neural tube defects, urinary track defects, craniofacial and brain defects and others anomalies occurring rarely. Most of the operations were preformed in the first 48 hours of life. Since 1995 special newborn transport, early cardiac surgery and neonatal intensive care have been introduced. Total mortality of operated newborns and death in particular groups were analyzed. The implemented elements caused a decrease in mortality from 36 to 13 percent. In the authors' opinion improvement in treatment results is due to earlier diagnosis and better understanding of pathophysiology of the defects, introduction of noninvasive pre- and postnatal diagnostics and establishment of centres specialized in neonatal surgery and intensive care.

Lifestyle risks for three disease outcomes in spinal cord injury

OBJECT

The majority of research focusing on lifestyle risks in the spinal cord-injured population to date has mainly been descriptive in nature. Limited research has examined the relationships between lifestyle risks and morbidity. This study was undertaken to quantify the associations between selected lifestyle risks and morbidity associated with three top causes of mortality in adults with spinal cord injury (SCI).

METHOD

Ninety-seven adults who had incurred a spinal cord injury between 1972 and 1992 were interviewed over the telephone to assess morbidity and lifestyle exposure history. Logistic regression modelling was used to assess the association between lifestyle risks and cardiovascular, respiratory and urinary tract disorders.

RESULTS

Risk of cardiovascular morbidity was found to be positively associated with age and duration of cigarette use. Risk of respiratory morbidity was found to be positively associated with quadriplegia, number of cigarettes smoked per day, and the interaction between cigarettes smoked per day and excessive alcohol consumption. Risk of urinary tract morbidity was found to be positively associated with a complete lesion, number of cigarettes smoked per day and, surprisingly, physical activity. Risk of urinary tract morbidity was negatively associated with monthly alcohol consumption, a traumatic injury and the interaction between monthly alcohol consumption and a complete lesion.

CONCLUSION

With respect to the three morbidity outcomes in this study, cigarette smoking is the most damaging lifestyle behaviour in the spinal cord-injured population. Attention and resources should be directed towards SCI-specific smoking prevention and cessation programmes to prevent the development and exacerbation of chronic diseases in this unique population. Further research is needed to fully understand the associations between lifestyle and chronic diseases in the SCI population.

Coordinated genetic control of neoplastic and nonneoplastic diseases in mice

Some models of aging imply that late-life diseases, though roughly synchronous, are the result of distinct pathophysiological processes, each in turn influenced by polymorphisms at multiple loci. Other models suggest that the dramatic increase in later life of multiple forms of illness might reflect the outcome of a unitary process, of so-far unknown biochemical nature, that proceeds at a species-specific rate to increase the risk of many forms of disease and disability in parallel. We have previously reported the results of genetic linkage analyses documenting the ability of alleles at D9Mit110, D10Mit15, and D12Mit167, and an allele pair at D2Mit58 and D16Mit182 to predict longevity in mice bred as the progeny of (BALB/cJ x C57BL/6J)F1 mothers and (C3H/HeJ x DBA/2J)F1 fathers (the UM-HET3 stock). Here we report the results of post hoc analyses to test the hypothesis that the genes that extend the life span of mice dying of neoplastic diseases also extend the life span of mice that die of nonneoplastic causes. In all four cases we find that the genotype associated with increased survival in mice dying of cancer is also associated for a similar degree of life span extension in mice dying of other causes. For D9Mit110 and the combination of D2Mit58 and D16Mit182, the difference is statistically significant in both the neoplastic and nonneoplastic mouse groups. The data support the hypothesis that many forms of late-life disease may be influenced by shared pathophysiologic mechanisms that are under coordinated genetic control.

The urological complications of renal transplantation: an 11-year-experience at Ramathibodi Hospital

From February 1986 to December 1996, renal transplantation was performed on 344 patients at Ramathibodi Hospital. The urological complications were retrospectively analyzed in 335 patients (338 renal transplants), 9 patients were lost to follow-up. There were 227 males and 108 females with age ranging from 15 to 62 years (mean age 40.28 years). There were 207 cadaveric and 131 living-related graft donors. The ureteroneocystostomy was performed either by modified Politano-Leadbetter (93 cases) or extravesical technique (245 cases). There were 23 cases of urological complications: ureterovesical anastomotic leakage 6, ureteric obstruction 6, vesicoureteric reflux 4, significant bleeding from ureterovesical anastomosis 3, renal infarction with fistulas 2, hydronephrosis due to blood clot retention and swelling of the anastomosis, requiring temporary double J stenting 2. The analysis was done by dividing the patients into 3 groups, the first and second groups consisted of 100 cases each and the third group consisted of 138 cases. The urological complications in the groups were 10 per cent, 9 per cent and 2.89 per cent respectively. There was a statistically significant difference between the first two groups combined and the third group in terms of complications (p < 0.025). The urological complications of living-related cases were 9 (6.87%), and of cadaveric cases were 14 (6.76%). There was no significant difference of the complications between living-related and cadaveric transplants (p < 0.05). The comparative results of the ureteric complications of the extravesical technique were significantly less than the modified Politano-Leadbetter technique (4.49% vs 10.75%), (p < 0.05). In conclusion, the extravesical technique of ureterovesical anastomosis was superior than the modified Leadbetter-Politano technique in terms of post-operative ureteral complications.

[Urologic complications after kidney transplantation (II)]

Urological complications after renal transplantation are often responsible for postoperative morbidity and mortality in spite of a decrease in incidence and severity of such complications in the last decades. It is of particular interest to detect this complications early and to treat them in an adequate manner especially in regard to the increasing lack of human organs for transplantation. The number of transplanted patients in the population is still increasing and they are treated not only in transplant centers but also by general practitioners, nephrologists and urologists in private consultings. This necessitates a survey about the most important complications including diagnostics and therapeutic options. Measures of prevention and early detection are taken into account. Questions concerning impotence and incontinence are discussed in detail. Attention must be paid to the fact of immunosuppression and its peculiarities in transplanted patients. In this way the outcome of patients and transplants can be prolonged.

Clinical experience with the detubularized ileocecal reservoir and continent appendicoumbilical stoma in urinary diversion

OBJECTIVE

To obtain clinical experience of a reservoir using a detubularized ileocecal segment (Mainz pouch) and continent appendiceal stoma connected to the umbilicus.

METHODS

The operation was performed in 23 patients. The submucosally placed in situ appendix was connected to the umbilicus acting as the continence mechanism and route for self-catheterization. The follow-up period was 8-62 months.

RESULTS

No operative mortality occurred. In 2 patients the postoperative period was complicated by catheter perforation of the appendix. In 4 patients stomal stenosis required excision of the stricture and reanastomosis. All patients are completely continent and catheterization is easy.

CONCLUSION

Both functional and cosmetic results are very satisfactory.

[Prognosis in gynecologic diseases]

Besides early diagnosis, the prognosis of gynecological disease is dependent on the state of the urinary tract. Mainly tumours and site anomalies of the female genital system as well as endometriosis and chronic-inflammatory masses of the appendages lead to malfunction of urinary bladder, ureter and kidneys. Ureteric changes are seen in 3 to 55% of genital tumours and in 20 to 40% of cases of endometriosis. Ureteric and kidney dysfunction can occur even more often in longstanding site anomalies. Typical renal complications of gynecological diseases are pyelonephritis, pyelectasy and hydronephrosis. Their frequency lies between 8 and 40% depending on kind and duration of the underlying disease. The figures shown, indicate that renal and ureteric changes sometimes are more serious than the genital disease. Improvement of prognosis can only be achieved by early recognition of the underlying gynecological disease together with the timely proof of renal and ureteric dysfunction.

Causes of mortality among sows in Danish pig herds

The likely causes of sow mortality in Danish pig herds were investigated in a sample of 598 of the breeding animals delivered to a large rendering plant in the winter seasons of 1992 and 1993. In 263 cases information about the circumstances of the death or euthanasia and the herd characteristics were available, including the size of the herd, its health status, the age at weaning, the method of feeding and the use of straw for bedding. For these animals the distribution of likely causes of death or euthanasia was: leg weakness, 28.5 per cent; problems related to farrowing and late pregnancy, 20.9 per cent; disorders of the digestive system, 17.1 per cent; disorders of the urinary system, 13.1 per cent; physical injuries, 10.7 per cent; and other disorders, 9.5 per cent. For the other 335 sows the distribution of likely causes of death was: leg weakness, 16.1 per cent; problems related to farrowing and late pregnancy, 10.7 per cent; disorders of the digestive system, 21.2 per cent; disorders of the urinary system, 15.2 per cent; other disorders, 15.0 per cent; and unknown causes of death, 21.8 per cent. According to the official statistics from Danish rendering plants, more than 60,000 carcases of breeding pigs were processed during 1992, corresponding to a mortality rate of 5 to 6 per cent in the sow herds. The mortality rate appeared to increase with increasing herd size, and in herds with more than 100 sows the mortality rate was three times the mortality in herds with fewer than 50 sows. Compared with previous reports, the proportion of disorders involving the gastrointestinal system has increased during the past 20 years. Gastric dilation is particularly common, probably as a result of the intensification of pig production and the associated changes in management practises. The use of straw bedding was marginally significant (P = 0.06) and associated with a low frequency of gastrointestinal disorders.

[Urologic complications after kidney transplantation. Experiences in a center with 539 recipients]

A total of 539 renal transplantations were performed at the Department of Urology of the University Hospital of Hamburg between 1984 and 1991. 132 (24.5%) patients developed urological complications (by definition, complications occurring as a result of the operative procedure). In 31 cases the transplants had to be removed secondary to urological complications, and 4 patients died of such complications (mortality 0.7%, lethality 3.0%). Urinary tract infections occurred in 13.2% of all patients during the first postoperative year and were by far the most frequent complication, followed by haematomas, which occurred in 9.6%. The incidence of urinary tract and wound infections was significantly reduced during the 8-year period studied by improving antibiotic prophylaxis and adopting a strategy of early removal of indwelling catheters (P < 0.05). Stenting the ureteroneocystostomy with a double-J stent instead of an external ureteral catheter resulted in a definite decrease in the incidence of ureteral leaks (P < 0.05). Continuous control of operative results and efforts to improve operative and perioperative strategies make it possible to reduce the incidence of urological complications in renal transplantation and thus result in an improved graft function and patient survival.

Prenatal diagnosis of urinary tract anomalies. The value of two ultrasound examinations

OBJECTIVE

To determine when fetal urinary tract anomalies were detected by ultrasound screening during pregnancy and to discuss the possible consequences if only one early ultrasound examination is performed.

DESIGN

A retrospective study of 47 cases where fetal urinary tract malformations were diagnosed in a two-stage screening program (17th and 32nd week of gestation) covering 22,310 women over ten years, 1982-91.

SETTING

Ullevål University Hospital in Oslo which serves as a referral center for obstetric and neonatal diseases.

RESULTS

Urinary tract anomalies were diagnosed in 0.18% of the pregnancies. Of these, 61.7% were found at the second routine ultrasound screening. The most difficult differential diagnoses were those of hydronephrosis without megaureter and a multicystic kidney. Hydronephrosis was found in 51% and a multicystic kidney in 21% of the cases. The tentative prenatal diagnoses were confirmed postnatally in 83% of the cases. Six of the fetuses had anomalies regarded as incompatible with postnatal life. These pregnancies were terminated, and the diagnoses verified by autopsy. Two other infants died perinatally, one of them as a result of the urinary tract anomalies.

CONCLUSION

If only one ultrasound scanning had been performed in the 17th week, approximately two-thirds of the cases would not have been detected. Early intervention and follow-up after delivery would only have been performed if the infants had developed symptoms or complications related to the urinary tract anomalies.

A prospective study of sow mortality in breeding herds

This investigation was conducted to study the incidence and the causes of sow mortality in breeding herds. Data were obtained from 24 swine breeding herds with an average inventory of 3755 sows and served gilts for the total sample. Producers were involved for 12 consecutive months and agreed to submit to the diagnostic laboratory every dead or moribund sow and served gilt. The average herd death rate was 3.3% +/- 0.5 (SEM), but varied considerably among herds, ranging from 0% to 9.2%. A total of 137 sows and mated gilts died during the year, and these females had produced an average of 4.2 litters +/- 0.2 (SEM). The number of deaths was significantly higher during the months of July, August and October. The peripartum period appeared to be when sows were most at risk, with 42% of all deaths occurring during this short period of the reproductive cycle. The three major causes of death were heart failure (31.4%), torsions and accidents of abdominal organs (15.3%) and cystitis-pyelonephritis (8.0%). Other causes included endometritis (6.6%), uterine prolapses (6.6%), pneumonia (3.6%), gastric ulcers (3.6%), downer sow syndrome (2.2%), miscellaneous (8.0%) and unknown (14.6%).

An epidemiologic study of abuse of analgesic drugs. Effects of phenacetin and salicylate on mortality and cardiovascular morbidity (1968 to 1987)

BACKGROUND

Phenacetin abuse is known to produce kidney disease; salicylate use is supposed to prevent cardiovascular disease. We conducted a prospective, longitudinal epidemiologic study to examine the effects of these drugs on cause-specific mortality and on cardiovascular morbidity.

METHODS

In 1968 we evaluated a study group of 623 healthy women 30 to 49 years old who had evidence of a regular intake of phenacetin, as measured by urinary excretion of its metabolites, and a matched control group of 621 women. Salicylate excretion was also measured. All subjects were examined over a period of 20 years.

RESULTS

Life-table analyses of mortality during the 20 years, with adjustment for the year of birth, cigarette smoking, and length of follow-up, revealed significant differences between the groups in overall mortality (study group vs. control group, 74 vs. 27 deaths; relative risk, 2.2; 95 percent confidence interval, 1.5 to 3.3), deaths due to urologic or renal disease (relative risk, 16.1; 95 percent confidence interval, 3.9 to 66.1), deaths due to cancer (relative risk, 1.9; 95 percent confidence interval, 1.1 to 3.3), and deaths due to cardiovascular disease (relative risk, 2.9; 95 percent confidence interval, 1.5 to 5.5). The relative risk of cardiovascular disease (fatal or nonfatal myocardial infarction, heart failure, or stroke) was 1.8, and the 95 percent confidence interval 1.3 to 2.6. The odds ratio for the incidence of hypertension was 1.6, and the 95 percent confidence interval 1.2 to 2.1. The effects of phenacetin on morbidity and mortality, with adjustment for base-line salicylate excretion, were similar. In contrast, salicylate use had no effect on either mortality or morbidity.

CONCLUSIONS

Regular use of analgesic drugs containing phenacetin is associated with an increased risk of hypertension and mortality and morbidity due to cardiovascular disease, as well as an increased risk of mortality due to cancer and urologic or renal disease. The use of salicylates carries no such risk.

Economies of scale, physician volume for urology patients, and DRG prospective hospital payment system

Diagnosis Related Group (DRG) hospital payment has begun to squeeze hospitals financially and is likely to do so in the future. This study analyzed the relationship between the volume of urologic procedures by an individual urologist, hospital costs per patient, and outcome. We used a three-year DRG database of urology patients (N = 2,980) at an academic medical center to analyze these. Low-volume urologists (arbitrarily defined by us) had higher hospital costs per patient, financial losses versus profits under DRGs, and a poorer outcome when compared with high-volume urologists. Pearson correlation showed a positive relationship between cost per patient and physician volume for nonemergency patients (-0.129, p less than 0.0001) and emergency patients (-0.368, p less than 0.0001). This may have been explained (in part) by a greater severity of illness for patients of low-volume urologists. These findings suggest, however, that the volume of urologic procedures per urologist may be related to hospital resource consumption. The health care financing environment of the future should provide substantial interest in this finding for those involved in the consumption of urologic services.

[Midterm evolution in the uropathy patient receiving a kidney transplant]

The outcome of renal transplantation was examined in 17 pediatric patients, whose primary renal disease was uropathy. The results indicate that the outcome of renal transplantation in patients with posterior urethral valves, reflux nephropathy, neurogenic bladder or bilateral ureterocele is similar to that the other transplant recipients. Urologic complications will not occur with increased frequency. Allograft survival rate during a period of four years is comparable to that of our entire transplant population.

Bilateral fetal uropathy: what is the outlook?

OBJECTIVE

To assess the morbidity and mortality associated with a prenatal diagnosis of bilateral fetal uropathy.

DESIGN

Retrospective study.

SETTING

Departments of radiology, paediatric surgery, obstetrics, and pathology in two teaching hospitals that serve as referral centres for the Yorkshire region.

PATIENTS

126 Cases of fetal uropathy were referred either prenatally or postnatally from hospitals in Yorkshire between August 1982 and December 1987. The disease was bilateral in 54 cases and unilateral in 72 cases. In 14 cases bilateral fetal uropathy was associated with coexistent disease.

INTERVENTIONS

All cases were managed individually by an obstetrician after discussion with the radiologists and paediatric surgeons. Babies who survived were treated prophylactically with antibiotics after delivery and were operated on if appropriate.

END POINT

Assessment of prognosis for long term renal function for each baby referred between August 1982 and December 1987: follow up ranged from six months to five years.

MEASUREMENTS AND MAIN RESULTS

Of the 54 fetuses with bilateral fetal uropathy, 13 were terminated as the prenatal findings of ultrasonography were considered to be incompatible with long term survival. Ten of the liveborn babies died, five of renal or pulmonary insufficiency, or both, and five of associated congenital anomalies. Thirty one infants survived to follow up; four of these had serious coexistent disease and two had impaired renal function. Thus the overall mortality was 43% and the morbidity rate 19%. The renal anomaly was associated with other serious disease in 14 cases (26%) compared with two (3%) of the 72 cases of unilateral fetal uropathy. All but two of the 27 infants with isolated bilateral urinary tract disease had excellent prospects for survival.

CONCLUSION

Although bilateral fetal uropathy is associated with a high morbidity rate and mortality, careful prenatal assessment can help to identify fetuses with a poor prognosis. The outlook for a fetus with isolated renal disease if treated promptly after delivery is excellent and compares favourably with that reported after prenatal surgical intervention.

Non-invasive management of fetal obstructive uropathy

Fetal outcome was studied in 43 consecutive cases of fetal obstructive uropathy in which no prenatal treatment was undertaken: 12 babies survived. In the 31 who did not survive, oligohydramnios was present in 24 and urethral atresia was the most common cause of obstruction (in 27). At necropsy, bilateral renal dysplasia was found in 23 and pulmonary hypoplasia in 13; 16 had structural or chromosomal anomalies, less than half of which were detected by prenatal ultrasound. In the survivors, 8 had posterior urethral valves, 1 had oligohydramnios, and 2 had associated anomalies. Obstructive uropathy is often associated with other anomalies which may escape prenatal ultrasound detection, and studies to determine the efficacy of intrauterine decompression techniques must allow for this observation.

Major morbidity after pelvic exenteration: a seven-year experience

Thirty-eight patients underwent pelvic exenteration at the University of South Florida during the last seven years. The majority of the operations were performed for recurrent carcinoma of the cervix, and the operative mortality was 5.3%. Twenty-one patients developed major morbidity in the postoperative period, and 11 with complications involving the gastrointestinal or urinary tract required reoperation. Multivariate logistic regression analysis demonstrated a correlation between the amount of pelvic radiation, type of pelvic floor, type of pelvic drain, amount of blood loss, race, and the occurrence of serious postoperative morbidity. Strategies to avoid serious postoperative morbidity are discussed.

Postmarketing surveillance of the safety of cimetidine: mortality during second, third, and fourth years of follow up

A previous report analysed the pattern of mortality during the first year of follow up among 9928 patients taking cimetidine who were recruited to a postmarketing drug surveillance study in Glasgow, Nottingham, Oxford, and Portsmouth. A further analysis has now been conducted extending the period of follow up to four years. The 12 month report noted that cimetidine was being given, knowingly or unknowingly, in the late stages of many diseases and also to counter the adverse gastric effects of other drugs used in the treatment of serious disorders. This finding was underlined by a steady fall in the excess death rate among cimetidine users with increasing length of follow up, such that by the fourth year the pattern of observed deaths was not much different from that expected on the basis of national rates. Some excess of observed over expected deaths from gastric cancer, lung cancer, and urinary disorders was still apparent after four years of follow up, but there was no evidence that cimetidine was responsible. Indeed, no fatal disorder emerged as being associated with cimetidine during the follow up period. Deaths from the complications of disease related to gastric acid occurred in only 38 of the 9928 subjects over the four years. These findings provide further evidence of the safety of cimetidine.

Changes in mortality among the elderly Finnish population 1951-1979

Morbidity and mortality cannot be explained by biological factors alone; socio-economic factors, environment, life-style and health care delivery system also affect mortality rates. Many changes have taken place in socio-economic factors and environment among the elderly, and the health care system has expanded over the last few decades in Finland. However, the social changes have not only been for the better; and the changes in different causes of death among the elderly may have been different. Overall mortality among elderly Finnish males and females decreased in the 1950s, but increased at the beginning of the 1960s. From the later half of the 1960s overall mortality decreased. The decrease in female death rates began earlier and was more rapid than among males. Over one-half of the decrease from 1960-1969 to 1970-1979 among elderly males was due to the decrease in cardiovascular and cerebrovascular mortality; one-fifth was due to the decrease in genitourinary mortality. The male death rates in neoplasms and in violent causes increased during the period under study. Over one-half of the decrease from 1960-1969 to 1970-1979 among elderly females was attributable to the decrease in cardiovascular and cerebrovascular mortality. Lessening genitourinary mortality, gastrointestinal mortality, respiratory mortality, mortality from neoplasms and from violent causes accounted for less than 5% decrease in overall mortality.

Cause of death in rheumatoid arthritis

A series of 489 consecutive patients with definite or classical rheumatoid arthritis was followed for a mean of 11.2 years. Cohort-analysis of the series showed a three-fold increase in mortality overall in comparison with age- and sex-specific rates in the general population. In patients first seen in hospital early in the course of the disease (less than 5 years from onset), the excess of deaths from circulatory, respiratory and musculoskeletal disorders was highly significant. Malignant disease and digestive system disorders accounted for a small excess of borderline significance. Patients who were referred later (greater than 5 years from onset) experienced, in addition, a highly significant excess of deaths from infections and disorders of the digestive and genito-urinary system but not from malignant neoplasms.

[Causes of death and disease in cats based on 1969-1982 autopsy statistics]

The post mortem investigation of 4561 cats during 14 years is analysed according to the diagnosis. The age of the cats necropsied ranged from 1 day to 22 years, with an average of 3,3 years. The sex distribution was about 1:1. The most common disease is feline panleucopenia (16,6%) followed by traumata (11,5%), disorders of the urinary tract (7,0%), feline infectious peritonitis (6,0%), disorders of the circulatory system (5,8%), and diseases of the digestive tract (5,3%). The majority of kittens died of virus diseases, mainly feline panleucopenia. Feline leucosis is found among all groups of age. In middle aged animals (5-10 years) feline leucosis and diseases of the urinary tract are the main causes of death. Cats older than eight years show a high rate of tumor incidence, especially those of non lymphatic origin. Among siamese cats congestive cardiomyopathy is very common. A sexual disposition is notable for the feline urologic syndrome, occurring predominantly in male individuals.

A proportionate mortality analysis of California agricultural workers, 1978-1979

There are few published reports of epidemiologic studies of the risks of agricultural work. Members of this occupational group have been of special concern because of their exposure to pesticides, some of which are mutagens and animal carcinogens. A previous proportionate mortality study of California agricultural workers was based on deaths recorded among white males of this occupational group during 1959-1961. We have conducted a proportionate mortality analysis of all deaths recorded during 1978-1979 among California farm workers and farm owner/managers. In general, the findings of our study are consistent with those of the previous study. For farm workers, we found proportionate mortality ratios (PMRs) which were consistently elevated for all race and sex categories (in which there were 6 or more decedents) for deaths due to motor vehicle accidents, all respiratory disease, and all infective and parasitic diseases. The PMRs for the former three causes of death were also found to be elevated across several race and sex categories for farm owner/managers. We also found a significant and consistent deficit of deaths among farm workers and farm owner/managers due to arteriosclerotic heart disease. The proportionate cancer mortality ratios (PCMRs) for cancer of the stomach and cancer of other lymphatic tissue were elevated, although not necessarily statistically significantly, for several race and sex categories among farm workers and farm owner/managers. The PCMR for cancer of the cervix was statistically significant for white female farmworkers.

[Clinical statistics on patients admitted at the Department of Urology, Kyoto University Hospital, 1977-1982]

A statistic survey was carried out on the patients, diseases, and operations experienced at the urological ward of Kyoto University Hospital during the years of 1977 to 1982.

Analysis of mortality from nephritis and nephrosis among nickel-cadmium battery workers

Mortality from nephritis and nephrosis (and other diseases of the genitourinary system) experienced by a study cohort of 3,025 nickel-cadmium battery workers was investigated. Observed (O) numbers of deaths from these diseases for the period 1946 through 1981 were compared with those that might be expected (E) to occur on the basis of rates of mortality for the general population of England and Wales (nephritis and nephrosis, International Classification of Diseases, eighth revision [ICD 8th] Code No. 580-584; E = 5.49, O = 10: all disease of the genitourinary system (noncancers), ICD 8th 580-629; E = 11.50, O = 17). These differences were not statistically significant at the 5% level. When the estimated cadmium exposures of those who died from these causes were compared with those of all matching survivors using the method of regression models in life-tables, no statistically significant association was found between occupational exposure to cadmium and mortality from these diseases. A separate analysis was made of the mortality experience of 39 workers with cadmium nephropathy.

Increasing survival and changing causes of death in myelopathy patients

Survival, mortality rates, and causes of death were determined for 132 myelopathy patients during the 9-year period between April 1973 and March 1982. The average age was 54; 81% were paralyzed by trauma. Average survival was 15 years. Myelopathy mortality was eight times that of the general population for the third decade of life but comparable by the seventh decade. The major causes of death were pulmonary (41 patients- 71% with pneumonia or bronchitis), vascular (37 patients - 54% with ischemic heart disease), gastrointestinal (19 patients - 42% with carcinoma, 32% with peritonitis), and urinary (16 patients - 50% with renal failure and 44% with carcinoma). As survival of myelopathy patients has improved, deaths due to pneumonia, ischemic heart disease, carcinoma, and renal failure have become the major causes of death.

Mortality of Shipham residents: 40-year follow-up

The 1939 populations of Shipham, a village in Somerset with high soil-cadmium levels, and a nearby control village have been followed for 40 years. Death certificates were obtained for those who had died, and the mortality rates were compared with those for England and Wales. Small excesses of hypertensive, cerebrovascular, and genitourinary disease were noted in Shipman but not in the control village. These conditions have been associated wih cadmium toxicity, and so it is possible that cadmium had some influence on the disease pattern in Shipham; but if so, the effect was slight. By contrast, fewer deaths than expected from respiratory disease and cancers were observed in both villages. This gave rise to all-cause mortality rates in Shipham and the control village which were similar and well below the national average.

Survival from spinal cord injury

Mean survival of 110.5 months (9 yr. 2.5 months) for spinal cord-injured persons who died between 1963 to 1976 compared favorable with the figure of 52.8 months (4 yr, 4.8 months) calculated in 1955 by Dietrick and Russi [1]. If suicides were not considered, then mean longevity for the deceased patients would be 126 months (10 yr, 6 months). The leading causes of death were related to the cardiovascular system, respiratory system, suicide and the urinary tract.

Mortality and autopsy rate from urogenital diseases in Finland in 1955-1973

Mortality from various urogenital diseases including the malignant neoplasms of the genito-urinary system and the breast in Finland in 1955-1973 was studied. Only minor changes were found in the total death rate of all these diseases between 1955 and 1973. However, the age-specific death rates of the nephritis-nephrosis group decreased both among males and females. Also mortality from all other urogenital diseases than malignant neoplasms decreased among elderly and middle-aged people. Mortality from malignant neoplasms of the breast increased slightly among elderly women and that of the prostate among elderly men. The autopsy rate of the deaths due to all other urogenital diseases (33.5% in 1973) than malignant neoplasms (27.4%) was of the same order as that recorded for all natural deaths (33.2%) in Finland between 1963 and 1973. Many types of malignant urogenital neoplasms remained significantly under-autopsied. The highest autopsy rates of the single urogenital diseases were recorded for acute nephritis and unqualified nephritis; the respective national rates were 90 and 71%, in 1973. These rates exceeded highly significantly the mean national autopsy rate of all deaths which was 38.2%.

[Frequency of diabetes mellitus and nature of treatment in urologic diseases]

In a comparative period of 20 years is reported on the frequency of diabetes mellitus in urological diseases. It was found that 0.87% of the patients suffer from a concomitant diabetes. The peak of the disease is between the 60th and 70th year. As to the distribution of sex was established that the concomitant diabetes is to be found more frequently in males (ratio 2.4: 1). The lethality in diabetics with a urological disease is with 9.4% more than twice as high as in the other urological patients (4.3%). At the top of the immediate causes of death is the cardiovascular failure (30.7%), followed by the pulmonary blood clot embolism and the uraemic coma with 15.4% each. A diabetic coma never appeared. In the analysis of the urological diseases with concomitant diabetes the lithiasis (34.4%) is in the first place; then follow the adenoma of the vesical cervix (32.4%), the chronic relapsing pyelonephritis (12.9%), and the malignant tumours (7.1%). Many urological forms of diseases appeared combined. In the investigation of the complications without lethal exitus which appeared in 25.1% of all cases with concomitant diabetes the cardiovascular failure is again in the first place, then follow thrombotic diseases, urea-nitrogen disturbances. Peculiarities in conduction and treatment of the diabetes mellitus are shown and a close collaboration between several specialities is considered necessary.

Follow-up 15 years after a geronto-psychiatric prevalence study. Conditions concerning death, cause of death, and life expectancy in relation to psychiatric diagnosis

In relation to a follow-up 15 years after a geronto-psychiatric prevalence investigation of the population aged 65+ in a rural population, analysis has been made of the type of death certificate, residence at time of death, place of death, cause of death and life-expectancy in relation to psychiatric diagnoses prevalent in 1961.