Using novel methodologies to support burden of disease estimates

A challenge to estimating burden of diarrheal diseases, particularly in LMICs, where laboratory capacity and surveillance systems are limited, is obtaining valid estimates of etiology proportions of cases. A commonly used method is systematic review of studies reporting pathogen isolation in diarrhea cases. However, studies often differ in design, source population, timeframe, and pathogens included, hampering extrapolation to the target population. In a study co-funded by the Bill and Melinda Gates Foundation and the UK Department for International Development, we explore a novel approach for estimating diarrhea etiology proportions in urban and rural populations in four African countries. We analyse sewage samples using short-read next-generation sequencing (NGS) to determine abundance of genes that can be mapped to specific bacterial genera, providing an estimate of the relative abundance of specific pathogens in each sample. In parallel to collecting sewage samples, a questionnaire-based population survey will estimate diarrheal incidence. By combining results, pathogen-specific incidence will be estimated and compared with incidence estimates from the traditional approach. The application NGS to human sewage has great potential for surveillance of foodborne infections, particularly in resource-poor settings where laboratory capacity for bacterial isolation is limited. First, NGS is a one method takes all approach, as it is based on detection of RNA/DNA, a language common across pathogens. Second, it is culture independent, allowing for real-time data generation and standardized sharing. Finally, few samples are needed to survey large populations for several pathogens at the same time. Thus, surveillance based on NGS of sewage may prove to be an indirect measure of incidence. Although it will not provide an estimate for the true incidence in the population, it will increase our understanding of the burden and as such be a proxy and novel way of ranking diseases.

Artificial Urinary Sphincters

A small selected group of patients with urinary incontinence can be treated effectively with an artificial urinary sphincter. Since the fluid in the hydraulic system of this device is radiopaque, radiography is useful in its evaluation. An immediate postoperative radiogram should be performed to control the position and integrity of the system. It also serves as a useful baseline study in case of later complications. It should include radiograms both in the deactivated and activated state. A few cases of tube kinking may be overlooked when exposures in only one projection are used. Experience with 110 implanted sphincters is presented.

Evaluation of a Performance-Based Expert Elicitation: WHO Global Attribution of Foodborne Diseases

For many societally important science-based decisions, data are inadequate, unreliable or non-existent, and expert advice is sought. In such cases, procedures for eliciting structured expert judgments (SEJ) are increasingly used. This raises questions regarding validity and reproducibility. This paper presents new findings from a large-scale international SEJ study intended to estimate the global burden of foodborne disease on behalf of WHO. The study involved 72 experts distributed over 134 expert panels, with panels comprising thirteen experts on average. Elicitations were conducted in five languages. Performance-based weighted solutions for target questions of interest were formed for each panel. These weights were based on individual expert's statistical accuracy and informativeness, determined using between ten and fifteen calibration variables from the experts' field with known values. Equal weights combinations were also calculated. The main conclusions on expert performance are: (1) SEJ does provide a science-based method for attribution of the global burden of foodborne diseases; (2) equal weighting of experts per panel increased statistical accuracy to acceptable levels, but at the cost of informativeness; (3) performance-based weighting increased informativeness, while retaining accuracy; (4) due to study constraints individual experts' accuracies were generally lower than in other SEJ studies, and (5) there was a negative correlation between experts' informativeness and statistical accuracy which attenuated as accuracy improved, revealing that the least accurate experts drive the negative correlation. It is shown, however, that performance-based weighting has the ability to yield statistically accurate and informative combinations of experts' judgments, thereby offsetting this contrary influence. The present findings suggest that application of SEJ on a large scale is feasible, and motivate the development of enhanced training and tools for remote elicitation of multiple, internationally-dispersed panels.

Risk ranking of pathogens in ready-to-eat unprocessed foods of non-animal origin (FoNAO) in the EU: initial evaluation using outbreak data (2007-2011)

Foods of non-animal origin (FoNAO) are consumed in a variety of forms, being a major component of almost all meals. These food types have the potential to be associated with large outbreaks as seen in 2011 associated with VTEC O104. In order to identify and rank specific food/pathogen combinations most often linked to human cases originating from FoNAO in the EU, a semi-quantitative model was developed using seven criteria: strength of associations between food and pathogen based on the foodborne outbreak data from EU Zoonoses Monitoring (2007-2011), incidence of illness, burden of disease, dose-response relationship, consumption, prevalence of contamination and pathogen growth potential during shelf life. The top ranking food/pathogen combination was Salmonella spp. and leafy greens eaten raw followed by (in equal rank) Salmonella spp. and bulb and stem vegetables, Salmonella spp. and tomatoes, Salmonella spp. and melons, and pathogenic Escherichia coli and fresh pods, legumes or grains. Despite the inherent assumptions and limitations, this risk model is considered a tool for risk managers, as it allows ranking of food/pathogen combinations most often linked to foodborne human cases originating from FoNAO in the EU. Efforts to collect additional data even in the absence of reported outbreaks as well as to enhance the quality of the EU-specific data, which was used as input for all the model criteria, will allow the improvement of the model outputs. Furthermore, it is recommended that harmonised terminology be applied to the categorisation of foods collected for different reasons, e.g. monitoring, surveillance, outbreak investigation and consumption. In addition, to assist future microbiological risk assessments, consideration should be given to the collection of additional information on how food has been processed, stored and prepared as part of the above data collection exercises.

Towards an Integrated Approach in Supporting Microbiological Food Safety Decisions

Decisions on food safety involve consideration of a wide range of concerns including the public health impact of foodborne illness, the economic importance of the agricultural sector and the food industry, and the effectiveness and efficiency of interventions. To support such decisions, we propose an integrated scientific approach combining veterinary and medical epidemiology, risk assessment for the farm-to-fork food chain as well as agricultural and health economy. Scientific advice is relevant in all stages of the policy cycle: to assess the magnitude of the food safety problem, to define the priorities for action, to establish the causes for the problem, to choose between different control options, to define targets along the food chain and to measure success.

The occurrence and epidemiology of Salmonella in European pig slaughterhouses

This study was part of an international research project entitled SALINPORK (FAIR CT-950400) initiated in 1996. The objectives were to investigate the occurrence of Salmonella in pig slaughterhouses and to identify risk factors associated with the contamination of pig carcasses. Data was collected from 12 slaughterhouses in five European countries. Isolates were characterized by serotyping, phage typing and antimicrobial susceptibility. In one country, no Salmonella was found. Salmonella was isolated from 5.3% of 3485 samples of pork and from 13.8% of 3573 environmental samples from the seven slaughterhouses in the four remaining countries. The statistical analyses (multi-level logistic regression) indicated that the prevalence was significantly higher during the warmer months and that the environmental contamination increased during the day of slaughter. The polishing (OR 3.74, 95% CI 1.43-9.78) and pluck removal (OR 3.63, 95% CI 1.66-7.96) processes were found to contribute significantly to the total carcass contamination, the latter especially if the scalding water also was contaminated. To reduce carcass contamination, it is recommended to ensure sufficiently high temperatures of scalding water (62 degrees C) and appropriate cleaning and disinfection of the polishing equipment at least once a day in order to reduce the level of carcass contamination and consequently the prevalence of Salmonella in pork.

The cysteinyl leukotriene D4 receptor antagonist montelukast for the treatment of interstitial cystitis

PURPOSE

The presence of leukotriene D4 receptors in human detrusor myocytes and increased urinary leukotriene E4 in patients with interstitial cystitis and detrusor mastocytosis imply a role for cysteinyl containing leukotrienes as proinflammatory mediators in this disease. We examined the efficacy of the cysteinyl leukotriene 1 receptor antagonist montelukast for treating patients with interstitial cystitis and detrusor mastocytosis.

MATERIALS AND METHODS

Ten women in whom interstitial cystitis was diagnosed according to National Institute of Diabetes and Digestive and Kidney Diseases criteria and who also had detrusor mastocytosis with a minimum of 28 mast cells per mm.2 muscle tissue were included in this study. Patients received a single dose of montelukast daily for 3 months. The efficacy of treatment was determined by 24-hour urinary frequency, nocturia and pain using visual analog scales.

RESULTS

After 1 month of montelukast treatment there was a statistically significant decrease in 24-hour urinary frequency, nocturia and pain which persisted during the 3 months of treatment. After 3 months 24-hour urinary frequency had decreased from 17.4 to 12 voidings (p = 0.009), nocturia had decreased from 4.5 to 2.8 (p = 0.019) and pain had decreased from 46.8 to 19.6 mm. on a visual analog scale (p = 0.006). No side effects were observed during treatment.

CONCLUSIONS

Montelukast treatment resulted in significant improvement in urinary frequency and pain. Its efficacy for decreasing urinary frequency and pain imply a role of leukotriene receptor antagonists for managing interstitial cystitis but further placebo controlled clinical studies are needed.

Trends and seasonal variations in the occurrence of Salmonella in pigs, pork and humans in Denmark, 1995-2000

A mandatory programme monitoring the occurrence of Salmonella in pork at slaughterhouses and a serological monitoring of slaughter-pig herds has been implemented in Denmark since 1993 and 1995, respectively. All results are stored in a central database. From this, aggregated weekly results of serological and bacteriological samples collected in the period between January 1995 and July 2000 were extracted. In addition, the reported weekly incidence of human infections with S. Typhimurium covering the same time period was obtained. The times series were analysed for trends and cyclic variations by seasonal decomposition. The association between the incidence in humans and the prevalence of Salmonella in pigs and pork, and prevailing weather conditions, were analysed by using a general linear (glm) and a general additive model (gam). Explanatory variables were lagged to account for time elapsed between sampling, consumption, incubation period and case registration. The results of the seasonal decomposition showed an overall declining trend in all three time series. All time series exhibited a double peaked annual cycle. The seasonal variation of the prevalence in pork and the human incidence had a very similar course. The variables that were both biologically meaningful and statistically significant in both regression models were the prevalence in pork sampled 4 to 5 weeks before case registration, the seroprevalence, measured as the average prevalence of week 15 to 35 before case registration, and the air temperature lagged at 2 and 3 weeks. Limitations on inferences from overall surveillance data are discussed.

The action of cysteinyl-leukotrienes on intracellular calcium mobilization in human detrusor myocytes

OBJECTIVE

To investigate the presence of leukotriene D4 receptors in fura-2-loaded human detrusor smooth muscle cells (DSMCs) by examining the ability of leukotriene D4 to raise intracellular-free Ca2+ concentration ([Ca2+]i), to determine the origin of the leukotriene D4-mediated rise in [Ca2+]i and to investigate whether the specific leukotriene D4 receptor antagonist montelukast inhibits the Ca2+ response induced by leukotriene D4.

MATERIALS AND METHODS

Detrusor muscle biopsies were obtained from patients with benign noninvasive bladder diseases undergoing cystoscopy. DSMCs were isolated using an explant technique and maintained in culture. Only primary cultures or cells passaged up to three times were used for experiments. DSMCs were characterized with immunohistochemical staining and their identity confirmed by transmission electron microscopy. [Ca2+]i was measured in single DSMCs using the Ca2+ probe fura-2 and fluorescence-ratio microscopy.

RESULTS

Immunohistochemical staining showed that 80-99% of the cells were positive for smooth muscle alpha-actin. The ultrastructural features of the cultured cells were those of smooth muscle cells and showed no differentiation in a fibroblastic or myofibroblastic direction. Leukotriene D4 increased the level of [Ca2+]i in a dose-dependent manner. Calcium was mobilized almost exclusively from intracellular Ca2+ stores. There was a dose-dependent inhibition of the increase in [Ca2+]i by montelukast.

CONCLUSION

The present study is the first to show the presence of specific leukotriene D4 receptors in human detrusor myocytes. This may have implications for a potential pathophysiological role of leukotriene D4 in patients with interstitial cystitis and other functional or inflammatory bladder disorders.

Continued improvement in pressure-flow parameters in men receiving finasteride for 2 years. Finasteride Urodynamics Study Group

OBJECTIVES

To assess the long-term effects of finasteride on pressure-flow parameters in men with urodynamically documented bladder outflow obstruction (BOO).

METHODS

One hundred twenty-one men with benign prostatic enlargement (BPE) and lower urinary tract symptoms (LUTS) underwent a pressure-flow study (PFS) at 1 of 11 clinical centers. The PFS technique was standardized, and all tracings were read by a single reader unaware of the treatment group. Patients who were obstructed according to a modified Abrams-Griffiths nomogram were randomized to 5 mg finasteride (n = 81) or placebo (n = 40) for 12 months; all patients continuing into an open extension received finasteride during the second 12 months of therapy. Results of the initial 12-month study demonstrated the benefit of finasteride treatment on PFS parameters. To examine the continuing effects over time, an analysis of the data from 54 patients who completed 24 months of treatment with finasteride is provided.

RESULTS

Detrusor pressure at maximum flow (PdetQmax) continued to decrease during the second 12 months of therapy (decreases of 5.3 and 11.7 cm H2O at months 12 and 24, respectively). The percentage of patients obstructed by Abrams-Griffiths classification decreased from 76.2% at baseline to 66.7% at month 12 and 59.6% at month 24. An intention-to-treat analysis yielded similar results.

CONCLUSIONS

Finasteride improves urodynamic measures of obstruction in men with BPE and LUTS, with continued improvement during the second 12 months of therapy.

Improvement of pressure flow parameters with finasteride is greater in men with large prostates. Finasteride Urodynamics Study Group

PURPOSE

We assess the effect of finasteride, a 5alpha-reductase inhibitor, on objective voiding parameters in men with lower urinary tract symptoms and benign prostatic enlargement on digital rectal examination (known as clinical benign prostatic enlargement) in a double-blind placebo controlled multicenter study using strict standard pressure flow study techniques.

MATERIALS AND METHODS

A modification of the Abrams-Griffiths nomogram was used by 1 reader to ensure that all patients met objective criteria for bladder outlet obstruction at baseline. After performing a pressure flow study patients with obstruction were randomized 2:1 to receive 5 mg. finasteride (81) or placebo (40) daily. A second pressure flow study was performed at month 12. At baseline and month 12 free urinary flow studies and transrectal ultrasound were performed, and International Prostate Symptom Score questionnaires were completed. Patients were treated between May 1994 and July 1996.

RESULTS

Finasteride caused a significant decrease (-8.1 cm. water) in detrusor pressure at maximum flow (p <0.05 versus placebo p = 0.02), increase (+1.1 ml. per second) in maximum flow rate (p <0.05 versus placebo p = 0.02) and decrease (-22.8%) in prostate volume (p <0.05 versus placebo p <0.001). Men with prostates larger than 40 cc had greater improvement in detrusor pressure at maximum flow (between group difference -14.5 cm. water, 95% confidence interval -26.2 to -2.6, p = 0.02) and maximum flow rate (mean treatment effect +1.6 ml. per second, 95% confidence interval -0.2 to 3.0, p = 0.02) compared to those with prostates 40 cc or less (between group differences not significant).

CONCLUSIONS

Finasteride treatment resulted in improvements in urodynamic parameters, which were greater in men with large prostates.

Interstitial cystitis. Ultrastructural observations on detrusor smooth muscle cells

Ultrastructural investigation of detrusor muscle cells in biopsies from 13 patients (8 interstitial cystitis (IC) and 5 controls) was performed. In all IC-patients and in one control a varying number of smooth muscle cells revealed a characteristic oak leaf pattern with protrusions of the sarcolemma. The alterations may express degeneration of smooth muscle cells. Although most probably non-specific yet highly characteristic, the ultrastructural detrusor changes may be important in diagnosing IC.

Comparison of the Danish Prostatic Symptom Score with the International Prostatic Symptom Score, the Madsen-Iversen and Boyarsky symptom indexes. ALFECH Study Group

OBJECTIVE

To compare the Danish Prostatic Symptom Score (DAN-PSS) with the International Prostatic Symptom Score (IPSS). Madsen-Iversen and Boyarsky symptom indexes in a clinical setting, and to evaluate the potential significance of any differences in information obtained from these questionnaires.

PATIENTS AND METHODS

The study comprised two substudies: in the first, 205 patients with lower urinary tract symptoms (LUTS) suggestive of bladder outlet obstruction (BOO), a Madsen-Iversen score > 6 and a maximum flow rate of < 10 mL/s were randomized to receive either placebo or alfuzosin in a double-blind study of 16 weeks. The symptoms were assessed using the Madsen-Iversen, DAN-PSS and the IPSS questionnaires. In the second, 138 patients with LUTS suggestive of BOO were selected for treatment with transurethral microwave thermotherapy (TUMT, 52 degrees C for 60 min, microwave energy 200 kJ) and their symptoms assessed using the Boyarsky and the DAN-PSS questionnaires. Patients were then followed for one year. Rank correlation coefficients and regression lines were calculated using Spearman's non-parametric test. The relative changes, i.e. responsiveness, calculated for the DAN-PSS, IPSS and Boyarsky indexes were compared pairwise using the Wilcoxon-Pratt test.

RESULTS

The DAN-PSS, IPSS and Madsen-Iversen indexes were correlated on a pairwise basis. The DAN-PSS and IPSS indexes have significant construct validity in terms of correlation with the Madsen-Iversen system (Spearman's correlation coefficient, rs = 0.51 and rs = 0.45, respectively). The DAN-PSS and the IPSS indexes were correlated (rs = 0.61). The DAN-PSS was more sensitive than the IPSS to changes after pharmacological treatment, with scores decreasing 70% and 29% (P < 0.05), respectively, after treatment with an alpha-blocker for 4 months, and 50% and 29% (P < 0.05), respectively, after 4 months on placebo treatment. Finally, the responsiveness of the Boyarsky and DAN-PSS indexes to TUMT showed that the DAN-PSS system was significantly more responsive than the Boyarsky index, with scores decreasing 57% and 15% (P < 0.05), respectively, after one year.

CONCLUSIONS

The DAN-PSS index is more sensitive than the IPSS, Madsen-Iversen and Boyarsky symptom indexes, incorporates important outcome events, includes a patient-weighting of each symptom, thereby reflecting better the patients' global assessment of outcome.

[Validation of the patient-administered Danish Prostate Symptom Score Schedule]

The DAN-PSS-1 system, a self-administered quality-of-life questionnaire comprising 12 questions related to voiding problems and the perceived bother of each individual symptom, was compared to other extensively used score systems and furthermore included in different clinical situations so as to validate the system. The system was internally consistent (alpha cr = 0.73), the median test-retest reliability of answers to each question was 83.5% (range 0-99.7%). A high degree of construct validity demonstrated in the correlation with the Madsen-Iversen score system (rs = 0.51) and with the patients' answers to questions about how bothersome their symptoms were (rs = 0.71). The discriminant validity of the DAN-PSS-1 was excellent with an area under the ROC curve of 0.94. Finally, the DAN-PSS-1 was sensitive to changes following intervention, with scores decreasing 100% after transurethral prostatectomy and 65% after four months of treatment with an alpha-blocker. The DAN-PSS-1 is reliable, valid and responsive, and therefore can be recommended for assessing the severity of symptoms among patients presenting with lower urinary tract complaints suggestive of BPH and during follow-up.

Benign prostatic hyperplasia. Does a correlation exist between prostatic morphology and irritative symptoms?

Fifty-two consecutive patients with prostatism who underwent a prostatectomy were investigated with regard to irritative symptom score, age, prostate volume, urine culture results, degree of detrusor instability, inflammation in the prostate, and stromal, glandular or mixed prostatic histopathology. We did not find any statistical correlations between irritative symptom score and the mentioned parameters. This indicates that irritative symptoms should rather be attributed to extraprostatic factors such as e.g. bladder reaction.

Prostatic specific antigen and benign prostatic hyperplasia

The aim of this study on patients (n = 51) with urodynamically proven obstruction was to search for correlations between serological levels of prostatic specific antigen (PSA) and age of patients, volume of prostate and prostatic morphology as evaluated on transurethral resection specimens. No correlations could be found between PSA levels and morphological parameters such as degree of inflammation and relative degree of stromal or epithelial hyperplasia. Significant correlations were demonstrated between PSA levels and age of patients and prostatic volume.

[Evaluation of symptoms in patients with benign prostatic hyperplasia]

Benign prostatic hyperplasia (BPH) is the most common cause of voiding dysfunction in elderly men. With the age related demographic changes in the western world, the epidemiological and economical burden of BPH is anticipated to increase. BPH is clinically diagnosed on a variety of more or less well defined symptomatic, macroscopical, and physiological criteria, whereas the histological diagnosis is straightforward. Yet, no symptom is specific for BPH and numerous other diseases have to be considered when a patient presents with symptoms of bladder outlet obstruction. A BPH questionnaire is useful when weighing the pros and cons for intervention. Furthermore, a symptom index represents a valuable indicator for the quality of care provided. Through the last decades a number of BPH questionnaires have been introduced. This article scrutinizes various BPH indices and provides an introduction to the prerequisites of clinical questionnaires.

Validation of the self-administered Danish Prostatic Symptom Score (DAN-PSS-1) system for use in benign prostatic hyperplasia

OBJECTIVE

To validate the Danish Prostatic Symptom Score (DAN-PSS-1), a self-administered quality-of-life questionnaire comprising 12 questions related to voiding problems and the perceived bother of each individual symptom.

METHODS

Using published results from several comparisons of other symptom scoring systems with DAN-PSS-1, the test-retest reliability, internal consistency, construct and content validity, and responsiveness of the DAN-PSS-1 system were assessed.

RESULTS

The system was internally consistent (Cronbach's alpha = 0.73), the median test-retest reliability of answers to each question was 83.5% (range 0-99.7%) and the questionnaire was well understood by the patients. The DAN-PSS-1 system demonstrated a high degree of construct validity, correlating with the extensively used Madsen-Iversen score system (Spearman's correlation coefficient, rs = 0.51) and with the patients' answers to questions about how bothersome their symptoms were (rs = 0.71). The DAN-PSS-1 system discriminated clearly between patients with benign prostatic hyperplasia (BPH) and control subjects (an area under the receiver operating characteristic curve of 0.94). Finally, the DAN-PSS-1 was sensitive to changes following intervention, with scores decreasing from a median of 20 to zero 4 months after patients underwent transurethral prostatectomy and from a median of 11.5 to 7.5 (65%) after patients had received 4 months treatment with an alpha-blocker.

CONCLUSIONS

The DAN-PSS-1 system is reliable, valid and responsive, and therefore can be recommended for assessing the severity of symptoms among patients presenting with lower urinary tract complaints suggestive of BPH and in the follow-up after intervention.

Detrusor in ageing and obstruction

It is disputed whether fibrosis of the detrusor is a consequence of obstruction or ageing. In the present study, bladder wall morphology was analyzed semiquantitatively in biopsies from "normal" young persons, infravesically obstructed and non-obstructed elderly persons. Fibrosis occurring around and inside muscle fascicles was demonstrated to the same degree with obstruction as well as ageing. Our results give rise to the question whether "prostatism" is related to obstruction per se or to ageing or both.

Review of current treatment of benign prostatic hyperplasia

The treatment of benign prostatic hyperplasia is changing, with many new modalities being tested: Some are already used routinely, others are still investigational. Surgery, however, is still the principal treatment, producing an 85-90% improvement in symptoms and urodynamics. Stents are being used more frequently, particularly in patients with a high operative risk. Balloon dilation can be performed in small glands; however, the durability of results remains in doubt. Thermotherapy has been found to produce histologic changes in the prostate and may change the urodynamics as well. Finally, drug treatment, which is currently limited to a-blocking agents and 5 a-reductase inhibitors, has proven to be effective symptomatically, with small, but significant changes in urodynamics.

[Pharmacological treatment of benign prostatic hyperplasia]

Over the last five to ten years, new treatment modalities have appeared at an increasing pace. The emerging pharmacological treatment modalities have all been used on a large scale. The exact indications and limitations of these methods have not yet been definitely established. Careful analysis of the symptomatology is crucial in counseling the patient. The Danish Prostatic Symptom Score model (DAN-PSS) is proposed. However, treatment benefits should exceed harm and there must be a reasonable cost-effectiveness. Pharmacological agents that reduce prostatic size and/or the tone in the prostate are effective in treatment of benign prostatic hyperplasia. Selective alpha-1 blockers seem to be useful in patients with uncomplicated benign prostatic hyperplasia and mild to moderate symptoms. The side effects of hormone therapy are prohibitive for use in patients with a benign disease. Data currently available indicate a yet to be defined role for 5-alpha-reductase inhibitors.

A new patient weighted symptom score system (DAN-PSS-1). Clinical assessment of indications and outcomes of transurethral prostatectomy for uncomplicated benign prostatic hyperplasia

A patient weighted symptom score system, the Danish Prostatic Symptom Score (DAN-PSS-1), including a disease specific self administered quality of life questionnaire, is presented. The model was evaluated pre- and postoperatively in 29 patients apparently suffering from uncomplicated benign prostatic hyperplasia. The score system is based on the severity of 12 symptoms related to bladder storage and voiding function, and three questions related to sexual function (symptom score). For each of these parameters the patient must also evaluate its influence on his daily life (bother score). In the 29 patients with uncomplicated benign prostatic hyperplasia (BPH) bother scores exceeded symptom scores for the irritative symptoms but not for the obstructive symptoms, and surprisingly the symptom score was less improved than the bother score 6 months after transurethral resection of the prostate (TUR-P). Furthermore the postvoiding dribble was worsened after the operation. We find that this model, DAN-PSS-1, assists in creating a solid base for the indication for and the evaluation of treatment of uncomplicated BPH.

Extraperitoneal pelvioscopy in staging of bladder carcinoma and detection of pelvic lymph node metastasis

This study was carried out to examine the efficacy of extraperitoneal pelvioscopy in detecting pelvic metastasis in patients scheduled to undergo radical cystectomy without preoperative chemo- or radiotherapy. The results of pelvioscopy were compared with those obtained by laparotomy. 54 consecutive patients underwent pelvioscopy without complications. Three were technically insufficient. Lymphatic tissue was biopsied in 29 (54%). Pelvioscopy demonstrated tumor dissemination in 5 patients (9.3%): 2 had pT4b tumor, 2 pelvic nodal metastases and 1 both. The remaining 49 patients with benign pelvioscopy were scheduled for laparotomy but 7 patients did not undergo the procedure: 3 had extrapelvic metastasis, 1 bronchial carcinoma, 1 aortic aneurysm, 1 refused surgery and 1 had pulmonary insufficiency. Accordingly, 42 patients underwent open exploration which demonstrated pelvic metastasis in 11: 9 had nodal metastasis, 1 a pT4b tumor and 1 both. Consequently the sensitivity of pelvioscopy in detecting pelvic metastasis was calculated at only 31%. This result indicates that extraperitoneal pelvioscopy should be considered a screening procedure rather than an accurate staging procedure for pelvic metastasis.

Review of current medical treatment of benign prostatic hyperplasia

Over the last 5-10 years new treatment modalities have appeared at an increasing pace. The emerging pharmacological treatment modalities have all been used on a large scale. The exact indications and limitations of these methods have not yet been definitely established. Careful analysis of the symptomatology is crucial in counselling the patient. The Danish prostatic symptom score model is proposed. However, treatment benefits should exceed harm and there must be a reasonable cost-effectiveness. The established clinical experience with pharmacological agents that reduce prostatic size and/or the tone in the prostate are effective in the treatment of benign prostatic hyperplasia. Selective alpha 1 blockers seem to be useful in patients with uncomplicated benign prostatic hyperplasia and mild to moderate symptoms. The side effects of hormone therapy are inhibitive for use in patients with a benign disease. Data currently available indicate a role for 5 alpha-reductase inhibitors yet to be defined.

Nonsurgical, nonpharmacologic treatment of benign prostatic hyperplasia

New treatment modalities are becoming available for benign prostatic hyperplasia. Permanent or temporary stenting of the prostatic urethra, balloon dilatation of the prostate, and hyperthermia and thermotherapy are in the forefront. None of the methods has found a definite place in the spectrum of indications. Prospective trials are needed to ascertain the safety, efficacy, and durability of results.

Recombinant interleukin-2 and lymphokine-activated killer cell treatment of advanced bladder cancer: clinical results and immunological effects

The purpose of this study was to evaluate the efficacy of treatment with recombinant interleukin-2 (rIL-2) and lymphokine-activated killer cells in patients with advanced bladder cancer and to study the induced changes in the distribution of leukocyte subsets in blood and tumor. Nine patients with metastatic transitional cell cancer of the bladder were treated with a continuous infusion of rIL-2 combined with lymphocytes stimulated in vitro with rIL-2. None of the patients responded to the therapy despite substantial changes observed in the immunological cells, both in tumor and blood. The rIL-2 infusion induced migration of leukocytes to the tumors, which was related to increased expression of the adhesion molecule VLA-1 on both peripheral blood mononuclear cells and the endothelial cells of small tumor vessels. Only T-cells, predominately expressing IL-2 receptors, and macrophages infiltrated the tumors. Natural killer cells remained few or absent in the tumors, even though the natural killer cells in peripheral blood were activated by the treatment. This study shows that the present technique of rIL-2 and lymphokine-activated killer cell therapy is able to induce substantial changes in the immune system of patients with metastatic bladder cancer. However, this treatment did not induce tumor regression, which may be due to the advanced stage of disease.

World Health Organization Consensus Committee recommendations concerning the diagnosis of BPH

The expert committees, which met in Paris in June 1991 under the patronage of WHO to establish a consensus concerning BPH, adopted the recommendations summarised in this report. Despite certain criticisms which can be made, these recommendations offer the advantage of simplicity and uniformity, thereby constituting a "universal language". This will facilitate comparison of patients and therapeutic results, both in everyday practice and in the course of clinical trials. These recommendations will be periodically re-evaluated in the light of clinical experience and technological progress.

Failure of combined supratrigonal cystectomy and Mainz ileocecocystoplasty in intractable interstitial cystitis: is histology and mast cell count a reliable predictor for the outcome of surgery?

Eight women with severe intractable interstitial cystitis were treated with supratrigonal cystectomy and Mainz ileocecocystoplasty. The preoperative evaluation consisted of symptom analysis, cystometry, cystoscopy and bladder pathological findings. Seven patients had increased mast cell density. Median followup was 10 months. The symptoms resolved in 2 patients but recurred in 6 shortly after the operation. Voiding could not be established in 4 patients. Self-catheterization was difficult and painful. Ultimately, cystectomy and urinary diversion were performed in 5 patients and is scheduled in 1. The 2 cured patients had a small contracted bladder preoperatively while they were under anesthesia, while all 6 failed cases had a large bladder capacity. Postoperative biopsies from the trigone showed no difference in the amount of fibrosis, the degree of degenerative changes in the muscle and mast cell density between the 2 cured patients and the 6 who failed to improve. The mast cell density and the histological status of the trigone cannot be used as predictors of the outcome of supratrigonal cystectomy. The role of the mast cells in interstitial cystitis is reviewed. Combination of supratrigonal cystectomy and a Mainz augmentation cystoplasty cannot be recommended in patients with intractable interstitial cystitis and a large bladder capacity.

[Urinary incontinence. Experiences with the artificial urethral sphincter AS 800]

Since 1983, 62 patients with incontinence of urine (43 men and 19 women) were treated with an artificial sphincter model AS 800. During the period of observation, the artificial sphincters were removed in five patients on account of complications and six patients had died. In 22 patients, a total of 34 operations were required on account of complications. Out of 51 patients with artificial sphincters at the time of this review, 43 (84%) had experienced improvement: 15 (29%) were completely continent and 18 (35%) had only slight stress incotinence. It is concluded that the technical improvement which has taken place has improved the therapeutic results and approximately halved the number of complications requiring treatment.

Upper urinary tract deterioration after implantation of artificial urinary sphincter

The preoperative urodynamic evaluations of twenty patients with myelomeningocele who had had artificial sphincter implantation because of urinary incontinence were reviewed. Four patients developed hydronephrosis and severe impairment of renal function between two and six years after implantation of the artificial sphincter. The condition was partly reversible after removal of the artificial sphincter. The urodynamic evaluation prior to implantation revealed in the four mentioned patients compared to the 16 patients with normal upper urinary tract, a tendency to lower bladder compliance, lower bladder capacity and more severe detrusor hyperreflexia, but it was not possible to make a clear discrimination between the two groups. Attention is drawn to this unfortunate combination of effects after artificial sphincter implantation. Periodic control of the upper urinary tract by urography is recommended.

Polyamines and other accessory sex gland secretions in human seminal plasma 8 years after vasectomy

In 56 males, vasectomized 8 years previously, and in 56 age-matched non-vasectomized controls, a number of secretory products of prostatic, seminal vesicular and epididymal/testicular origin were used to monitor post-operative changes in accessory sex gland function. Significant reductions were observed in seminal plasma volume (3.0 vs 4.9 ml, P less than 0.01), and the total ejaculate contents of zinc (5.1 vs 9.7 mumol, P less than 0.01), magnesium (10.6 vs 26.5 mumol, P less than 0.01), PAP (371 vs 1260 IU, P less than 0.005) and citric acid (76.7 vs 127.9 mumol, P less than 0.05), indicating a major impact on secretions of prostatic origin. Unaltered PGE-1 (54.3 vs 53.2 micrograms, P less than 0.95) and fructose (3.9 vs 4.5 mumol, P greater than 0.1) indicated no effects on the secretory function of the seminal vesicles. A marked reduction was demonstrated in the ejaculatory contents of the polyamines, spermidine (366 vs 650 nmol, P less than 0.005) and spermine (5435 vs 11 804 nmol, P less than 0.05) but not their acknowledged precursor, putrescine, which is also of prostatic origin.

Standardized evaluation of erectile dysfunction in 95 consecutive patients

We investigated 95 patients referred for erectile dysfunction by penile blood pressure measurement, the intracavernous papaverine test and Doppler investigation of the penile arteries. Furthermore, penile cutaneous perception threshold, bulbocavernosus reflex latency and somatosensory cortical evoked potentials of the pudendal nerve were measured. In selected cases cavernosometry, cavernosography and corpus cavernosum electromyography were performed. Doppler investigation of the cavernous arteries after papaverine injection was more reliable than penile blood pressure measurement in the diagnosis of arteriogenic erectile dysfunction. Decreased sensibility of the penis may be the sole factor responsible for inability to sustain an erection. Erectile dysfunction may be provoked by impaired function of the pudendal nerve. Penile cutaneous perception threshold measurement and corpus cavernosum electromyography are mandatory in the evaluation of neurogenic etiology. Cavernosometry and cavernosography are reliable methods in the determination of abnormal drainage from the corpus cavernosum.