Non-catheter simple noninvasive bladder draining method with no costs.

OBJECTIVES: To develop a simple, rapid (8 min) non-invasive non-catheter method for draining urine from the bladder, with no introduction of infection. This is of interest to men with incomplete or no bladder emptying, and also to those with a large diverticulum. There are no running costs. It could also be cautiously explored for use by neo-bladder patients and for use in various conditions of poor detrusor function. MATERIALS AND METHODS: This method is based on postural drainage used in physiotherapy. A carefully graded application of pressure, kneeling, with torso horizontal, facing downwards, supported by a 12-inch square stool-top, gave passive low-pressure voiding. If the abdominal contents approximate to a non-elastic viscous fluid, such pressure is transmitted uniformly everywhere (isostatic) and so will be equal both outside and inside the bladder, and, both outside and inside the ureters connected to it. Even if this assumption is not made, calculations show that the pressure is normally less than would cause upper tract damage. Starting with a low force was important for avoiding any upper tract damage (ureter dilation, and possible refluxing back into the kidney). Initially, a partial pre-emptying by normal urination was done (if feasible). A final stage employed a simple plastic crescent shape. Website:www.ebbflow.org.uk/Page_12x.htm. RESULTS: Average residual bladder volumes were 43 mL. CONCLUSIONS: The method was tested for four years on one patient with low-pressure chronic retention and found successful: no complications, infections, or adverse effects.

Metastatic non-small-cell lung cancer and the use of gemcitabine during pregnancy.

We present a case of metastatic non-small-cell lung malignancy diagnosed in the mother in her 24th week of pregnancy and illustrate the obstetric, oncology, neonatal and ethical issues involved. This is the second reported case on the use of gemcitabine for lung cancer in human pregnancy.

Comparison of gemcitabine and carboplatin versus cisplatin and etoposide for patients with poor-prognosis small cell lung cancer.

BACKGROUND: The combination of cisplatin and etoposide (PE) has been a standard treatment for patients with poor-prognosis small cell lung cancer (SCLC). This non-inferiority design trial aimed to determine whether the combination of gemcitabine and carboplatin (GC) results in similar survival but is less toxic with better quality of life. METHODS: Previously untreated patients with SCLC with extensive disease or limited stage with poor prognostic factors were randomly assigned to six 3-weekly cycles of GC or PE. RESULTS: 241 patients (121 GC, 120 PE) were recruited, of which 216 (90%) had died. There was no difference in overall survival (HR 1.01, 95% CI 0.77 to 1.32). Median survival with GC and PE was 8.0 and 8.1 months, respectively. Median progression-free survival was 5.9 months with GC and 6.3 months with PE. Grade 3 or 4 myelosuppressions were more frequent with GC (anaemia: 14% GC vs 2% PE; leucopenia: 32% GC vs 13% PE; thrombocytopenia: 22% GC vs 4% PE), but these were not associated with increased hospital admissions, infections or fatalities. Grade 2-3 alopecia (68% PE vs 17% GC) and nausea (43% PE vs 26% GC) were more frequent with PE. Patients given GC received more chemotherapy as outpatients (89% GC vs 66% PE of treatment cycles). In QoL questionnaires, more patients receiving PE reported being upset by hair loss (p = 0.004) and impaired cognitive functioning (p = 0.04). CONCLUSIONS: GC is as effective as PE in terms of overall survival and progression-free survival and has a toxicity profile more acceptable to patients. TRIAL REGISTRATION NUMBER: ISRCTN 39679215.

Radioiodide (131I) therapy for the treatment of canine thyroid carcinoma.

OBJECTIVE: To assess the efficacy of radioactive iodine treatment (131I) for canine thyroid carcinoma, as both the sole therapeutic modality and as an adjunct to surgery. DESIGN: Retrospective analysis of case records from the Gladesville Veterinary Hospital Nuclear Medicine Service, Sydney, between August 1988 and December 2001. CASE DETAILS: The records of 65 dogs with thyroid carcinoma were analysed according to therapy and outcome. Forty-three dogs received radioiodide therapy, either as the sole therapeutic modality (32) or as an adjunct to surgery (11). Radioisotope therapy consisted of one to three doses of 131I with a dose range of 555 to 1850 MBq. For analysis, dogs were divided into groups according to therapy: no treatment, surgery alone, surgery with radioiodide therapy or radioiodide therapy alone. Mode of therapy, dosage of 131I, clinical staging and age were all independently analysed according to survival to compare efficacy or predictive value respectively. RESULTS: When radioiodide therapy was used as an adjunct to surgery, median survival was 34 months. Censored median survival time for dogs that received radioiodide alone was 30 months. Dogs that did not receive treatment had a median survival of only 3 months. Log rank statistical analysis indicated that mode of therapy was significantly correlated with survival but that clinical stage of disease was not. CONCLUSION: The authors conclude that 131I therapy is effective at extending survival time, both as a sole therapeutic modality and as an adjunct to surgery, in dogs with invasive canine thyroid carcinoma. Incomplete surgical resection may not prolong survival in dogs also receiving 131I therapy, however surgical resection with curative intent should be recommended as the first line of therapy for mobile thyroid carcinomas. Radioisotope therapy can be recommended for cases where surgery alone is considered unlikely to be curative because of metastatic disease or local invasion, or for cases where surgery has been attempted but complete surgical removal has not been achieved.

Nitrogen uptake in riparian plant communities across a sharp ecological boundary of salmon density.

BACKGROUND: Recent studies of anadromous salmon (Oncorhynchus spp.) on the Pacific Coast of North America indicate an important and previously unrecognized role of salmonid nutrients to terrestrial biota. However, the extent of this uptake by primary producers and consumers and the influences on community structure remain poorly described. We examine here the contribution of salmon nutrients to multiple taxa of riparian vegetation (Blechnum spicant, Menziesii ferruginea, Oplopanax horridus, Rubus spectabilis, Vaccinium alaskaense, V. parvifolium, Tsuga heterophylla) and measure foliar delta15N, total %N and plant community structure at two geographically separated watersheds in coastal British Columbia. To reduce potentially confounding effects of precipitation, substrate and other abiotic variables, we made comparisons across a sharp ecological boundary of salmon density that resulted from a waterfall barrier to salmon migration. RESULTS: delta15N and %N in foliage, and %cover of soil nitrogen indicators differed across the waterfall barrier to salmon at each watershed. delta15N values were enriched by 1.4 per thousand to 9.0 per thousand below the falls depending on species and watershed, providing a relative contribution of marine-derived nitrogen (MDN) to vegetation of 10% to 60%. %N in foliar tissues was slightly higher below the falls, with the majority of variance occurring between vegetation species. Community structure also differed with higher incidence of nitrogen-rich soil indicator species below the waterfalls. CONCLUSIONS: Measures of delta15N, %N and vegetation cover indicate a consistent difference in the riparian community across a sharp ecological boundary of salmon density. The additional N source that salmon provide to nitrogen-limited habitats appears to have significant impacts on the N budget of riparian vegetation, which may increase primary productivity, and result in community shifts between sites with and without salmon access. This, in turn, may have cascading ecosystem effects in forests adjacent to salmon streams.

Long-term response to subtotal colectomy in colonic inertia.

The purpose of this study was to determine the long-term outcome of patients who had previously undergone subtotal colectomy for severe idiopathic constipation at the University of Florida between 1983 and 1987. In addition, we aimed to determine whether preoperative motility abnormalities of the upper gastrointestinal tract are more common among those patients who have significant postoperative complications after subtotal colectomy. We evaluated 13 patients who underwent subtotal colectomy for refractory constipation between 1983 and 1987 at the University of Florida. Preoperatively, all patients exhibited a pattern consistent with colonic inertia as demonstrated by means of radiopaque markers. Each patient was asked to quantitate the pain intensity and frequency of their bowel movements before and after surgery. In seven patients an ileosigmoid anastomosis was performed, whereas in six patients an ileorectal anastomosis was used. Abdominal pain decreased after subtotal colectomy. Patients with abnormal upper gastrointestinal motility preoperatively experienced greater postoperative pain than those with normal motility regardless of the type of anastomosis. In addition, the number of postoperative surgeries was similar in those patients with abnormal upper motility compared to those with normal motility. Overall, the total number of bowel movements per week increased from 0.5 +/- 0.03 preoperatively to 15 +/- 4.5 (P < 0.007) postoperatively. The results of our study suggest that patients with isolated colonic inertia have a better long-term outcome from subtotal colectomy than patients with additional upper gastrointestinal motility abnormalities associated with their colonic inertia.

Changes in the profile of paediatric intensive care associated with centralisation.

OBJECTIVES: To compare intensive care admissions from a defined population of children in 1991 and 1999, during a period of organisational change and centralisation of paediatric intensive care. DESIGN: Two 12-month population-based audits were compared. Data were collected from hospitals in Birmingham and the surrounding districts. Denominator data were obtained from the Office for National Statistics. The place and rate of intensive care admission, the use of mechanical ventilation at admission, mortality and length of stay were compared. SETTING: Hospitals in the West Midlands. PARTICIPANTS: All children (<15 yrs) living in Birmingham who received intensive care during the study periods. MEASUREMENTS AND RESULTS: The number of Birmingham resident children admitted for intensive care increased from 277 to 510 (p<0.0001) i.e. from 1.3 to 2.3 admissions per 1,000 children per year. The proportion of admissions to the principal paediatric intensive care unit increased from 60% to 90% (p<0.0001) in association with its expansion from 6 to 18 beds. Length of ICU stay decreased from 103 to 74 h (difference 29 h, 95%CI, 4.78-54.2 h, p=0.0117). Child mortality fell over this period by 34 deaths per 100,000 children (95%CI 16-51, p<0.0001). The proportion of children requiring mechanical ventilation at admission to intensive care was unchanged. CONCLUSIONS: Centralisation by expansion of the lead centre was associated with a large increase in the numbers of children receiving intensive care consistent with an unmet need for paediatric intensive care in 1991, which may still exist. Centralisation of paediatric intensive care may have contributed to the fall in child mortality over this time period.

Assessment of gastric emptying using a low fat meal: establishment of international control values.

OBJECTIVE: The diagnosis of gastroparesis implies delayed gastric emptying. The diagnostic gold standard is scintigraphy, but techniques and measured endpoints vary widely among institutions. In this study, a simplified scintigraphic measurement of gastric emptying was compared to conventional gastric scintigraphic techniques and normal gastric emptying values defined in healthy subjects. METHODS: In 123 volunteers (aged 19-73 yr, 60 women and 63 men) from 11 centers, scintigraphy was used to assess gastric emptying of a 99Tc-labeled low fat meal (egg substitute) and percent intragastric residual contents 60, 120, and 240 min after completion of the meal. In 42 subjects, additional measurements were taken every 10 min for 1 h. In 20 subjects, gastric emptying of a 99Tc-labeled liver meal was compared with that of the 99Tc-labeled low fat meal. RESULTS: Median values (95th percentile) for percent gastric retention at 60, 120, and 240 min were 69% (90%), 24% (60%) and 1.2% (10%) respectively. A power exponential model yielded similar emptying curves and estimated T50 when using images only taken at 1, 2 and 4 h, or with imaging taken every 10 min. Gastric emptying was initially more rapid in men but was comparable in men and women at 4 h; it was faster in older subjects (p < 0.05) but was independent of body mass index. CONCLUSIONS: This multicenter study provides gastric emptying values in healthy subjects based on data obtained using a large sample size and consistent meal and methodology. Gastric retention of >10% at 4 h is indicative of delayed emptying, a value comparable to those provided by more intensive scanning approaches. Gastric emptying of a low fat meal is initially faster in men but is comparable in women at 4 h; it is also faster in older individuals but is independent of body mass.

Passenger aircraft cabin air quality: trends, effects, societal costs, proposals.

As aircraft operators have sought to substantially reduce propulsion fuel cost by flying at higher altitudes, the energy cost of providing adequate outside air for ventilation has increased. This has lead to a significant decrease in the amount of outside air provided to the passenger cabin, partly compensated for by recirculation of filtered cabin air. The purpose of this review paper is to assemble the available measured air quality data and some calculated estimates of the air quality for aircraft passenger cabins to highlight the trend of the last 25 years. The influence of filter efficiencies on air quality, and a few medically documented and anecdotal cases of illness transmission aboard aircraft are discussed. Cost information has been collected from the perspective of both the airlines and passengers. Suggestions for air quality improvement are given which should help to result in a net, multistakeholder savings and improved passenger comfort.

Role of alpha- and beta-calcitonin gene-related peptide in postoperative small bowel ileus.

Ablation of a-calcitonin gene-related polypeptide (CGRP) containing neurons with the afferent neurotoxin capsaicin improves postoperative foregut transit in a rodent model. Similarly, administration of a selective alpha-CGRP antibody or hCGRP((8-37)), a CGRP receptor antagonist, improves postoperative gastric emptying. Unlike the stomach, which contains only alpha-CGRP, the small bowel additionally contains beta-CGRP. The role of the latter in postoperative small bowel transit is unknown. The purpose of this study was to evaluate the effect of an alpha-CGRP antibody and hCGRP((8-37)) on postoperative small bowel transit. Male Sprague-Dawley rats underwent placement of duodenal catheters and were randomly assigned to 1 of 11 groups. Four groups were pretreated with 1% capsaicin. One week later, all animals underwent standardized laparotomy following administration of a control antibody or the alpha-CGRP mono-clonal antibody, or during infusion of hCGRP((8-37)) at varying doses. Small bowel transit was measured 25 minutes postoperatively. The alpha-CGRP antibody sped postoperative transit when given alone or in combination with capsaicin. In contrast, animals treated with hCGRP((8-37)) showed no significant improvement in postoperative transit, and the beneficial effect of capsaicin was blocked. Unlike their similar effects on postoperative gastric emptying, we found that hCGRP((8-37)) and the alpha-CGRP antibody had differing effects on postoperative small bowel transit. The reason for this is unknown but may be related to their differing specificities for alpha- and beta-CGRP.

Products of cyclooxygenase-2 catalysis regulate postoperative bowel motility.

Laparotomy involving manipulation of the small intestine causes injury, initiating an inflammatory cascade in the small bowel wall, which generates eicosanoids and proinflammatory cytokines. We have shown that ketorolac and salsalate, nonselective cyclooxygenase (COX) inhibitors, ameliorate postoperative small bowel ileus in a rodent model. Others have shown that interleukin-1 receptor antagonism improves postoperative gastric emptying. We examined whether inhibition of the proinflammatory cytokines, tumor necrosis factor alpha (TNFalpha) and interleukin-1 (IL-1), or selective blockade of cyclooxygenase-2 (COX-2), the COX isoform induced during inflammation, would accelerate postoperative small bowel transit in our model. Duodenostomy tubes were inserted into male Sprague-Dawley rats. One week later, animals were randomized to receive TNF-binding protein (TNF-bp), IL-1 receptor antagonist (IL-1ra), or saline (NS) prior to standardized laparotomy. Additional rats were gavaged preoperatively with a selective COX-2 inhibitor (NS-398) or NS. Small intestinal transit was measured as the geometric center (GC) of distribution of (51)CrO(4) at 30 min, 3 h, or 6 h (n = 5-9 rats/group) following laparotomy. Selective inhibition of COX-2 significantly increased postoperative small bowel transit compared to controls (GC 2.9 +/- 0.3 vs 2.2 +/- 0.1 at 30 min, GC 2.9 +/- 0.3 vs 2.5 +/- 0.2 at 3 h, and GC 3.3 +/- 0.3 vs 2.8 +/- 0.2 at 6 h, P < 0.05). In contrast, neither TNF-bp nor IL-1ra altered postoperative small intestinal transit in this model. Use of selective COX-2 inhibitors may accelerate recovery of postoperative bowel dysmotility without the undesirable effects (e.g., gastrointestinal irritation and anti-platelet effect) of nonselective COX inhibitors.

An outbreak of Bacillus cereus respiratory tract infections on a neonatal unit due to contaminated ventilator circuits.

An outbreak of Bacillus cereus respiratory tract infections affecting six ventilated preterm neonates over a two-week period is described. Reusable ventilator circuits were identified as the cause of the outbreak. Ordinarily these were reprocessed on the Neonatal Unit (NNU), first through a washing machine and then through a low-temperature steam (LTS) disinfector. The onset of the outbreak coincided with a breakdown of the LTS facility, which necessitated sending the washed circuits off site for LTS disinfection. The washing machine was shown to be contaminated with the same serovars of B. cereus as those isolated from patients. Two critical steps in the off site LTS disinfection process allowed exsporulation and multiplication of B. cereus: the circuits were inadequately dried after processing, whilst return of the moist circuits to the NNU was often delayed. The outbreak was terminated by withdrawal of the heat-disinfected ventilator circuits. This outbreak emphasizes the need for high standards where medical equipment is reprocessed, especially for use in vulnerable patients.

Unusual presentation of hemoptysis in a 78-year-old with previous Nissen fundoplication.

A 78-year-old individual, who had a previous transthoracic Nissen fundoplication 20 years earlier, presented to our institution with hemoptysis. Initial workup included chest roentgenogram, upper gastrointestinal series, and upper endoscopy, all of which were nondiagnostic. A repeat upper endoscopy diagnosed a gastrobronchial fistula by revealing a large gastric ulcer that penetrated into the lung parenchyma. The patient underwent surgery for takedown of the fistula. One of the most common symptoms associated with gastrobronchial fistula is hemoptysis, although insidious cough, recurrent pneumonia, or gastrointestinal bleeding are also observed. The most useful diagnostic study is an upper gastrointestinal series, which must be read with a high index of suspicion. Gastrobronchial fistula is most commonly a long-term complication from hiatal hernia repair. The most frequently used procedure for repair of this disorder is the Nissen fundoplication. This can be done from either an abdominal or transthoracic approach. When the procedure is done such that the gastric wrap is left above the diaphragm, serious complications can occur. These include gastric ulceration, gastric herniation with gastric outlet obstruction, slippage or perforation of the wrap, and gastrobronchial fistula. Because of these serious complications, the Nissen fundoplication with the wrap left above the diaphragm should only be used in certain situations, such as obesity and shortened esophagus.

Long-term consequences after jejunoileal bypass for morbid obesity.

This study assesses the long-term results of jejunoileal bypass (JIB) in 43 prospectively followed patients whose surgical bypass remained intact. Follow-up was 12.6+/-0.25 years from JIB. Weight loss and improved lipid levels, glucose tolerance, cardiac function, and pulmonary function were maintained. Adverse effects such as hypokalemia, cholelithiasis, and B12 or folate deficiency decreased over time. The incidence of diarrhea remained constant (63% vs 64% at five years), while the occurrence of hypomagnesemia increased (67% vs 43% at five years, P < 0.05). Nephrolithiasis occurred in 33% of patients. Hepatic fibrosis developed in 38% of patients and was progressive. Overall, after more than 10 years, 35% of patients appeared to benefit from JIB as defined by alleviation of preoperative symptoms and the development of only mild complications (vs 47% at five years). On the other hand, irreversible complications appeared to outweigh any benefit derived from the JIB in 19% (vs no patients at five years; P < 0.01). In summary, patients with JIB remain at risk for complications, particularly hepatic fibrosis, even into the late postoperative period.

Fetal thyrotrophin: the best indicator of long term thyroid function after in utero exposure to iodine-131?

A woman treated with radioiodine for thyrotoxicosis was subsequently found to be 19 weeks pregnant at the time of treatment. Fetal thyroid hormone levels in utero were normal or mildly elevated but fetal thyrotrophin (TSH) levels were very high. The baby remained euthyroid after birth, but required treatment with thyroid hormone replacement to normalise the TSH level. Neurodevelopment was normal at age 36 months.