Extracorporeal shock wave lithotripsy for obstructing pancreatic duct calculi.

PURPOSE: A review was done to determine the effectiveness of extracorporeal shock wave lithotripsy (ESWL) in the treatment of impacted pancreatic duct calculi. MATERIALS AND METHODS: A total of 19 patients, who were potential candidates for radical pancreatic surgery after unsuccessful endoscopic retrograde cholangiopancreatography, sphincterotomy and attempted stone extraction from the pancreatic ducts, underwent ESWL of the calculi. Followup ranged from 6 months to 6 years. RESULTS: Of the 19 patients 14 avoided a major operation and 6 have remained pain-free for the long term. Two patients died of causes not related to ESWL or endoscopic retrograde cholangiopancreatography. Five patients eventually underwent a Whipple or Puestow procedure for relief of symptoms or persistent obstruction. Complications were minimal. CONCLUSIONS: ESWL is a valuable adjunct in patients with impacted pancreatic duct calculi unretrievable by primary endoscopic retrograde cholangiopancreatography.

The costs of mergers and acquisitions in the U.S. health care sector.

Important trends are emerging from evidence of health care industry concentration in the United States. Some of these are the durable consumer concerns--cost, choice, and access--which have received attention throughout the introduction of managed care. But with the intensified industry concentration, these have been joined by concerns about pricing power, control and quality, integrity of health system and health policy-making, and clashing institutional mandates. Such trends are particularly evident in the hospital and pharmaceutical industries.

Pubovaginal slings using fascia lata for the treatment of intrinsic sphincter deficiency.

PURPOSE: Various materials and techniques have been used to construct a pubovaginal sling. We believe that fascia lata has several advantages and report our experience. MATERIALS AND METHODS: A total of 32 female patients with urodynamically proved intrinsic sphincter deficiency underwent a pubovaginal sling procedure using fascia lata. An unscarred fascial strip 24 to 28 x 2 cm. was attached to itself over a 3 to 4 cm. bridge of abdominal wall fascia. Results were tabulated by chart review and an independent patient survey. RESULTS: Chart review revealed that 28 of 32 patients (87%) required no pads, and 3 improved and 1 did not. An independent patient survey revealed that 70% of patients (21 of 30) required no pads, 20% required 1 to 3 small pads and 10% required more than 3 small pads per day. Of the patients 80% would undergo the procedure again. CONCLUSIONS: Excellent results can be obtained with fascia lata for the treatment of intrinsic sphincter deficiency. A long, wide strip of fascia attached to itself allows for precise tensioning and good urethral closure, and minimizes the risk of obstruction.

Back-pressure testing to prevent autoinflation of penile prosthetic devices.

Autoinflation of a penile prosthetic device can be a frustrating experience for the patient and surgeon alike. Although there are many causes of autoinflation, elevated reservoir pressure at the time of surgical placement is one of the more common etiologies. We describe a simple, quick technique to quantitate reservoir pressures and volume, preventing pressures that could lead to autoinflation.

Combining operant-baseline-derived conditioned excitors and inhibitors from the same and different incentive classes: an investigation of appetitive-aversive interactions.

The dynamics of appetitive-aversive interaction theory were assayed in an experiment where excitors and inhibitors from the same and different incentive classes were compounded. Excitatory and inhibitory incentive properties acquired by the discriminative stimuli resulted from the reinforcement differences between components of four-component multiple training schedules, with the influence of competing peripheral responses factored into the design. Rats' barpressing was maintained in tone and in click by food or free-operant shock avoidance; extinction was programmed in click-plus-light and in the simultaneous absence of tone, click, and light. In Test 1, an excitor that occasioned operant responding and an inhibitor that occasioned response cessation were compounded. Here, compounding an inhibitor with an excitor from the same incentive class reduced responding significantly more than did compounding an inhibitor with an excitor from the other incentive class. In Test 2, the compounds consisted of elements that individually occasioned operant responding. Here, compounding stimuli that were excitors from different incentive classes appeared to create reciprocal inhibition that counteracted the additive effects produced when these stimuli were excitors from the same incentive class. Predictions from appetitive-aversive interaction theory and Weiss' two-factor model of stimulus control were confirmed within this experimental design, where all conditioning was a by-product of the behavioural contingencies programmed on the operant baselines.

Timing of penile color flow duplex ultrasonography using a triple drug mixture.

Duplex ultrasonography is an accepted method to assess noninvasively arterial inflow to the penis. Optimal pharmacological agents as well as timing of the scan and stimulation during the scan continue to be debated. In an effort to achieve a more complete smooth muscle relaxation and capture what we perceived was a wide variation in interval to maximum arterial velocity, we revised our duplex protocol in January 1991. We report on 280 consecutive patients evaluated in this manner. Patients received 0.25 or 0.5 cc of a triple drug mixture containing 22.5 mg./cc papaverine, 0.83 mg./cc phentolamine and 8.33 micrograms/cc prostaglandin E1. Scans were performed at 0, 5, 15 and 30 minutes after injection in all patients. Any patient not having a full erection at 15 minutes performed private self-stimulation while in the standing position for at least 5 minutes before the 30-minute scan. If we conservatively define normal arterial inflow as a peak Doppler velocity of 25 cm. per second or greater in the best artery, only 35% of our patients achieved this velocity at 5 minutes. Of the remainder 26% and 22% did not reach normal velocity values until 15 and 30 minutes, respectively, after the injection. By delaying initial measurements of velocity until 5 minutes, could the highest inflow velocity be missed and patients diagnosed incorrectly? The group at risk would be those who had good tumescence at 5 minutes and who had presumably already decreased the inflow velocities. Of the 280 patients 74 (26%) had greater than 10% tumescence at 5 minutes. Only 6 of these 74 patients did not reach velocities of 25 cm. per second or more in the best artery at some time during their study. In conclusion, our study clearly supports delaying the initial scan until 5 minutes, since only 6 of our 280 patients (2.1%) may have been incorrectly diagnosed. The study also strongly argues for additional scans until 30 minutes and self-stimulation when necessary.

Intravenous versus epidural administration of hydromorphone. Effects on analgesia and recovery after radical retropubic prostatectomy.

BACKGROUND: It remains unclear whether epidural administration of hydromorphone results in spinal analgesia or clinical benefit when compared with intravenous administration. Therefore, we undertook this study to determine whether epidural administration of hydromorphone resulted in decreased opioid requirement, improved analgesia, reduced side effects, more rapid return of gastrointestinal function, or shorter duration of hospital stay than intravenous administration. METHODS: Sixteen patients undergoing radical retropubic prostatectomy were randomized in a double-blind manner to receive either intravenous or epidural hydromorphone via patient-controlled analgesia (PCA) for postoperative analgesia. All patients underwent a standardized combined epidural and general anesthetic and all received ketorolac for 72 h postoperatively. To decrease variability, patients were cared for according to a standardized protocol and were deemed ready for discharge according to prospectively defined criteria. RESULTS: Patients in the intravenous PCA group required approximately twice as much opioid than the epidural PCA group (P < 0.008), but there were no differences between groups in pain scores or patient satisfaction. Epidural administration resulted in a greater incidence of pruritus (P = 0.02). Gastrointestinal function recovered quickly in all patients with little variation, and there were no differences between groups. All patients were deemed ready for discharge by the third postoperative day, and removal of surgical drains was the last discharge criterion reached in all patients. CONCLUSIONS: Our results indicate that epidural administration of hydromorphone results in spinally mediated analgesia. However, epidural administration did not provide significant benefits in terms of postoperative analgesia, recovery of gastrointestinal function, or duration of hospitalization. Furthermore, we suggest that radical retropubic prostatectomy no longer be used as a model to assess the effects of analgesic technique on postoperative recovery, because control of discharge criteria revealed that hospital discharge was primarily dependent on removal of surgical drains.

Experience with triple-drug therapy in a pharmacological erection program.

A group of 170 impotent men achieved usable erections during a 26-month period with a combination of papaverine, phentolamine and prostaglandin E1 (triple-drug therapy) injected intracorporeally. Of the patients 146 elected to enter a pharmacological erection program using this combination. Patient age ranged from 24 to 85 years and the average duration on the program was 11.2 months. Average injection volume was 0.36 cc per injection (range 0.1 to 1). Among those patients managed by our nurse clinician, only 3 episodes of priapism were encountered (1.7%). Scarring was documented in 7 of 170 patients (4.2%) 1 week to 21 months after starting the injections. Pain was encountered in 6 of 170 patients (3.5%). A superior dose response coupled with a low incidence of priapism, pain and scarring have led us to use triple-drug therapy as our agent of choice in the pharmacological management of erectile dysfunction.

Hyperbaric oxygen therapy for radiation-induced hemorrhagic cystitis.

From May 1988 through May 1991, 14 patients with radiation-induced hemorrhagic cystitis confirmed by cystoscopy and biopsy, who had failed all other attempts at management and who had no evidence of infection or recurrent malignancy, were treated with hyperbaric oxygen therapy. During followup ranging from 10 to 42 months 8 patients (57%) had complete resolution of symptoms and 2 (14%) had marked improvement, for a total of 10 patients (71%) with a positive outcome. Of 4 patients (29%) with a poor outcome 3 had limited improvement and were later diagnosed as having recurrent malignancy that was not present on biopsy before hyperbaric treatment. One patient was withdrawn from hyperbaric treatment due to illness. The average cost per patient was $10,000 to $15,000, comparing favorably to the cost of multiple conservative treatments to control symptoms. Hyperbaric oxygen therapy for radiation-induced hemorrhagic cystitis appears to be an efficacious treatment modality for patients who have failed other forms of management.

Generalization peak shift for autoshaped and operant key pecks.

Pigeons acquired discriminated key pecking between 528- and 540-nm stimuli by either a response-reinforcer (operant group) or a stimulus-reinforcer (autoshaped group) contingency, with other training-schedule parameters comparable over groups. For the birds in the operant group, key pecks intermittently produced grain in the presence of one hue on the key (positive stimulus) but not in the other (negative stimulus). For the birds in the autoshaped group, pecking emerged when grain was intermittently presented independently of key pecking during one key color but was not presented during the other key color. Two independent contingency assays, peck-location comparisons and elimination of differences in reinforcement rate, confirmed the effectiveness of the two training procedures in establishing operant or respondent control of key pecking. After reaching a 10:1, or better, discrimination ratio between key pecks during the two key colors, the birds received a wavelength generalization test. Criterion baseline key-peck rates were comparable for operant and autoshaped groups prior to testing. On the generalization test, performed in extinction, all birds pecked most at a stimulus removed from the positive training stimulus in the direction away from the negative stimulus. In testing, autoshaped "peak" rates (24.5 to 64.9 pecks per minute) were from 33% to 80% higher than rates in the presence of the training stimuli. Respondent peak shift rarely has been reported heretofore, and never this consistently and robustly. These results further confirm the similarity of perceptual processing in classical and operant learning. They are discussed in terms of Spence's gradient-interaction theory and Weiss' (1978) two-process model of stimulus control.

Pulsed dye laser fragmentation of ureteral calculi: a review of the first 50 cases performed at Virginia Mason Medical Center.

During the preceding 2 1/2 years 50 patients have undergone laser fragmentation of ureteral calculi at our medical center. Of these 50 patients 48 (96%) became free of stones without the need for an open operation: 44 (88%) were managed in 1 setting and 4 required adjunctive extracorporeal shock wave or ultrasonic lithotripsy, or a repeat session with the laser. Two patients (4%) eventually required an open operation: 1 required ureterolithotomy for a large impacted stone overlying the bony pelvis after a ureteroscope could not be advanced to this level and 1 had a good initial result with the laser but a persistent ureteral stricture developed and he required ureteroureterostomy 4 months later. Both open procedures were necessitated by mid ureteral stones, and the ureteral stricture was believed to be related to ureteroscopy and the impacted nature of the stone, rather than any damage by the laser probe.

Total prostatectomy for clinically localized prostatic cancer: long-term results.

The fate of the first 52 patients with clinically localized prostate cancer who underwent total perineal prostatectomy at our clinic and have been followed for a minimum of 15 years is reviewed to evaluate the long-term impact of this operation on the disease. None of these patients received any adjuvant therapy. Nine patients (17 per cent) had recurrence and 5 (10 per cent) died of disease during this interval. The actual observed over-all survival at 15 years was 64 per cent, the actuarial survival was 67 per cent and the cause-specific survival was 90 per cent.

The epithelial origin of a stromal cell population in adenocarcinoma of the rat prostate.

Dunning R3327-H rat prostate adenocarcinoma cells, when grown in syngeneic (Copenhagen) rats or nude mice, produce tumors with prominent hypercellular stroma. The authors have previously demonstrated the presence of anomalous steroid-sensitive cells in both the epithelium and stromal compartments of this model system. In order to better understand the histogenesis of these cells, the authors studied samples of the tumor which were radiolabeled overnight with tritiated dihydrotestosterone (3H-DHT). Frozen sections of the tissues were thaw-mounted onto autoradiographic emulsion-coated slides to permit silver grain identification in association with nuclei of androgen-sensitive cells. Surprisingly, numerous silver grains were found to be associated with nuclei of large cells within the stroma. Therefore, these cells were termed "epithelioid" pending confirmation of their origin. To further define these cells and their relationship to the surrounding matrix, autoradiograms have now been examined immunohistochemically with antibodies directed against the basement membrane glycoprotein, laminin, as well as antibodies specific for intermediate cytoskeletal filaments. Following identification of acinar basement membranes, epithelioid cells were identifiable both in the stroma and in the acinar epithelial cell layer. Histochemical staining with acid phosphatase, a marker for prostatic epithelium, was performed and shown to be present in acinar epithelial cells as well as in epithelioid cells. Additionally, fluorescence-activated cell sorting was employed to characterize the DNA content of cell types within the H tumor. Epithelioid cells were found to be in highest concentration in an aneuploid peak with a ploidy of approximately 6N. The autoradiographic, immunohistochemical, cytometric, and ultramicroscopic studies suggest that 1) epithelioid cells are epithelial derived stromal cells; 2) these epithelioid cells arise by pathologic division of aneuploid neoplastic precursor cells of approximately 3N ploidy, which are found within the prostatic epithelium; and 3) the resulting 6N cells degrade the basement membrane locally, invade the stroma, and populate it. Here, they can be distinguished from fibroblasts by their size, acid phosphatase activity, and hormone receptor content. Thus, the term "epithelioid" is inappropriate; and these cells should be regarded simply as large neoplastic epithelial (LNE) cells. The presence of this cell type suggests that this tumor subline represents a useful naturally occurring model for the study of the initial stages of neoplastic transformation.

Actin filament organization of the Dunning R3327 rat prostatic adenocarcinoma system: correlation with metastatic potential.

Recently, Volk, Geiger, and Raz (Cancer Res., 44: 811-824, 1984) addressed the question of whether variations in actin organization in clones of the murine K-1735 melanoma tumor correlated with their metastatic capability. Using immunofluorescence techniques, they found that clones which had a more ordered actin network were less metastatic, whereas clones having a diffuse actin staining pattern were more metastatic. Similarly, we have found that in the Dunning rat R3327 prostatic adenocarcinoma tumor system, the non-metastatic (less than 0.1%) H-prostatic tumor cell line has a prominent network of actin filament bundles, whereas the highly metastatic (greater than 90%) MatLyLu cell line has a diffuse actin staining pattern. In the low-metastatic (less than 10%) AT1 cell line an intermediate actin organization between H and MatLyLu was observed. Analysis of cell extracts from H- and MatLyLu-cells revealed differences in the level of activity of cellular proteins which affect actin filament assembly and structure in a manner similar to that of the cytochalasins, fungal metabolites which bind with high affinity to the fast-growing end of actin filaments. Extracts of MatLyLu were significantly more effective than those of H-cells in decreasing the extent of actin filament network formation and in inhibiting the rate of filament assembly by blocking monomer addition onto the fast-growing end. Measurements of spin-lattice nuclear magnetic resonance water proton relaxation times (T1) were made in surgically removed tumor tissue from four sublines (H, AT1, MatLyLu, and MatLu) of the Dunning R3327 tumor system. The highly metastatic cell lines had significantly longer water proton T1 relaxation times than did the lines with low metastatic potential. These differences in T1 may reflect the observed alterations in organization of actin filaments within these various sublines of the Dunning R3327 prostatic adenocarcinoma tumor system.

Photodynamic therapy of prostate cancer: an in vitro study.

The photo-induced toxicity of hematoporphyrin derivative on Dunning R3327 rat prostate cancer cells was studied. Dunning R3327 cells in culture were incubated for two hours in hematoporphyrin derivative and then exposed to red light at 630 nanometers wavelength from an argon pumped dye laser. Cell survival was measured for varying laser power densities, variable concentrations of hematoporphyrin derivative and variable light exposure times. AT1 cells not incubated with hematoporphyrin derivative were directly killed by laser light exposure at power densities greater than 500 mw./cm.2, probably due to hyperthermia. Cells that retained hematoporphyrin derivative were effectively killed using non-thermal levels of red light exposure due to a photochemical effect. Decreasing cell survival of cells that retained hematoporphyrin was related to increasing time of exposure to red light. This form of therapy may be applicable to the treatment of locally invasive prostatic carcinoma in man.

Left bundle branch block: a predictor of poor left ventricular function in coronary artery disease.

Clinical, coronary arteriographic, and hemodynamic studies were performed in 55 patients with left bundle branch block (LBBB) and coronary artery disease and were compared with 110 patients consecutively matched for age and sex with ischemic heart disease but without LBBB. No significant differences were found in duration of symptoms or frequency of prior myocardial infarction, hypertension, or diabetes mellitus; however, the LBBB patients had a significantly (p less than 0.001) higher frequency of congestive heart failure (38.2% vs 11.8%) and cardiomegaly (63.6% vs 25.5%). An evaluation of severity of the coronary disease on the basis of subtotal vs total obstructive lesions, number of vessels involved, total coronary score, and individual coronary arteries involved revealed no significant differences between the groups. The LBBB patients had significantly (p less than 0.001) greater impairment of left ventricular function as reflected by the end-diastolic volume (107 +/- 43 vs 79 +/- 30 ml/m2), ejection fraction (0.35 +/- 0.19 vs 0.59 +/- 0.18), and frequency of an abnormal contractile pattern (91% vs 61%). Evaluating the LBBB patients on the basis of the QRS width and axis revealed no significant intragroup differences in clinical profile, severity of coronary disease, or left ventricular dysfunction. A prolonged PR interval (greater than or equal to 0.20 second) was associated with more severe coronary artery disease and an enlarged heart. This study indicates that coronary artery disease associated with LBBB identifies patients with severe left ventricular dysfunction.

Sexuality and the life-style of home dialysis patients.

This study was designed to assess the impact of chronic illness on the sexuality and life-style of a group of veterans with end stage renal disease. Thirty-two married home dialysis patients and 14 of their wives were interviewed by a sex therapist. An Index of Sexual Function (ISF) was developed to quantify 5 aspects of male genital function. The Index was correlated with the following: other major areas of sexuality including masculine self-concept, sex drive, sexual activity, sexual relationship, and sexual satisfaction; quality of life factors such as work, marital adjustment, and sociability; several demographic factors; and 15 medical variables. There were significant correlations between genital function and sexual satisfaction, the patient's attitude toward the importance of sex, sex drive, and positive feelings about the self. Better sexual function occurred in the patients with the least neuropathy; there was no correlation with other medical factors. Of the patients studies, 9 (28%) had full sexual function, 7 (22%) had moderate dysfunction, and 16 (50%) had severe dysfunction. Despite the genital dysfunction, marital and social adjustment of our patients compared favorably with studies of couples in the general population. After this study a sex counseling program was developed.