Outcomes of an enhanced recovery after radical cystectomy program in a prospective multicenter study: compliance and key components for success.

OBJECTIVE: To investigate the effect of an Enhanced Recovery After Surgery (ERAS) program on complications and length of stay (LOS) after radical cystectomy (RC) and to assess if the number and type of components of ERAS play a key role on the decrease of surgical morbidity. MATERIALS AND METHODS: We analyzed the data of 277 patients prospectively recruited in 11 hospitals undergoing RC initially managed according to local practice (Group I) and later within an ERAS program (Group II). Two main outcomes were defined: 90-day complications rate and LOS. As secondary variables we studied 90-day mortality, 30-day readmission and transfusion rate. RESULTS: Patients in Group II had a higher use of ERAS measures (98.6%) than those in Group I (78.2%) (p < 0.05). Patients in Groups I and II experienced similar complications (70.5% vs. 66%, p = 0.42). LOS was not different between Groups I and II (12.5 and 14 days, respectively, p = 0.59). The risk of having any complication decreases for patients having more than 15 ERAS measures adopted [RR = 0.815; 95% confidence interval (CI) 0.667-0.996; p = 0.045]. Avoidance of transfusion and nasogastric tube, prevention of ileus, early ambulation and a fast uptake of a regular diet are independently associated with the absence of complications. CONCLUSIONS: Complications and LOS after RC were not modified by the introduction of an ERAS program. We hypothesize that at least 15 measures should be applied to maximize the benefit of ERAS.

Progressive alterations in circular smooth muscle contractility in TNBS-induced colitis in rats.

The present study was designed to investigate inflammation-induced changes in smooth muscle responses to acetylcholine and the tachykinins that may contribute to the abnormal motility associated with inflammatory bowel disease. Colitis was induced in male Sprague-Dawley rats by intrarectal administration of trinitrobenzenesulphonic acid in ethanol. After either 4 h (acute) or 7 days (chronic) the distal colon was taken for in vitro measurement of smooth muscle tension and histological assessment. Acute colitis featured injury and neutrophilic infiltration confined to the mucosa while chronic inflammation showed marked injury, lymphocytic infiltration and muscle thickening. Acute inflammation increased responses to substance P and acetylcholine but decreased responses to neurokinin A. The enhanced response to substance P was dependent on nerves, while the decreased response to neurokinin A reflected a reduction in activity at the level of the smooth muscle. In the saline group, there was evidence of cholinergic interaction with substance P, but not neurokinin A. Substance P modulation of cholinergic nerves was absent in acute inflammation. Responses to all neurotransmitters were decreased in the chronic stage. These data demonstrate progressive changes in the smooth muscle function during acute and chronic colitis that may contribute to the abnormal motility associated with inflammatory bowel disease.

Etiology and treatment of achalasia in the pediatric age group.

Achalasia in children bears many similarities to the disorder in adults, both in terms of clinical features and in terms of the approach to therapy. Pharmacologic management is of limited temporary benefit until more definitive therapy is undertaken. Intrasphincteric injections of botulinum toxin provides safe but short-term relief from symptoms. Based on our review of the safety and effectiveness of pneumatic dilation, we advocate this procedure as the primary form of definitive therapy for achalasia in children. In patients who do not achieve satisfactory results from a series of graduated pneumatic dilations, Heller myotomy provides safe and effective surgical treatment.

Online chat rooms: virtual spaces of interaction for socially oriented people.

The internet has opened a new social space for communication. The present work studies interpersonal relationships in cyberspace using the chat channel as an interaction medium. Data obtained have outlined the sociodemographic and personality profile of internet users who engage in online chats as well as group self-perception, chatters' use habits, motivations to interact online, and the chatters' network of virtual and face-to-face relationships. Results suggests that relationships developed online are healthy and a complement to face-to-face relationships. These data are confirmed by personality studies. The theoretical and methodological implications of data are discussed.

[Extrinsic stenosis of the ureter. Our caseload and review of the literature]. / Estenosis extrínseca de uréter. Nuestra casuística y revisión de la literatura.

Obstructive uropathy is the common presentation course for various processes with an origin either intraluminar, parietal or extraluminar. A retrospective analysis of 41 cases of extrinsically originated obstructive uropathy seen in our Urology Unit from 1976 to 1991 was carried out. The cases were divided in three groups following an exclusively etiological criterion: 21.9% (9 patients) corresponded to primary retroperitoneal fibrosis; 51.2% (21 patients) to tumoral ureteral obstruction; and 26.8% (11 patients) to non-tumoral processes. For each division established, the features of clinical presentation, performance of the various diagnostic procedures used, and different therapy approaches are described also including a review on the current literature.

[Therapeutic options in metastatic renal carcinoma]. / Opciones terapéuticas en el carcinoma renal metastásico.

Within the scope of urogenital tract tumoral diseases, renal adenocarcinoma is the third most frequent neoplasia diagnosed in the adult population. The limited clinical presentations in early analysis and their anarchical behaviour are the cause for 50% to 60% of patients having already developed distant disease at the time of diagnosis. The only curative procedure so far is radical surgery, which is possible when there is a single metastatic site and sometimes even, depending on various factors which will be analyzed, several sites. In these occasions, the traditional therapeutic choices (Hormonotherapy, Chemotherapy, Radiotherapy) have proven to have limited or no efficacy in managing the disease. This fact, together with the successful results obtained in other tumoral processes, have allowed the clinical development of different modalities of Immunotherapy for the management of metastatic renal carcinoma, with results clearly hopeful. This work is a review of the results reported for each of the mentioned therapeutic choices, basically analyzing the role currently played by surgery and immunotherapy in the management of advanced renal carcinoma.

[Complications of varicocele embolization: adhesion of the intravascular catheter during infusion of bucrylate]. / Complicaciones de la embolización del varicocele: adhesión del catéter intravascular durante la infusion de bucrilato.

The introduction of percutaneous occlusion techniques to manage a varicocele has made possible the control of the process with success rates similar to those obtained with conventional surgery. Its efficacy and minimal invasive nature, although not entirely risk-free, are responsible for its expansion. Contribution of one case of adhesion of the intravascular catheter to the underlying spermatic vein wall during infusion with isobutyl cyanoacrylate (bucrylate) as embolization material, an event which forced immediate surgical removal.

[Tuberculous prostatic abscess in a patient with AIDS]. / Absceso prostático tuberculoso en paciente con SIDA.

Despite of prostate abscesses having become an uncommon disease, a number of cases has been described lately specially in immunodepressed patients caused by infrequent agents, such as Mycobacterium tuberculosis. This paper describes the case of one HIV-positive patient, diagnosed with a prostate abscess within a tuberculous dissemination. The best diagnostic method is considered to be the transrectal ultrasound (TRU), the choice therapy being drainage by ultrasound-guided transperineal percutaneous puncture.

Morbidity and mortality in children with pyogenic liver abscess.

Review of our experience from 1975 to 1986 and a literature survey disclosed 109 children with pyogenic liver abscess. During this time, newer imaging techniques, especially ultrasonography and computed tomography, facilitated the prompt diagnosis of cystic lesions within the liver parenchyma. The incidence of pyogenic liver abscess at our institution (25 per 100,000 pediatric hospital admissions) was higher than previously reported. Since the majority of abscesses were located in the right lobe of the liver, patients were most effectively treated with percutaneous drainage of the abscess cavity. Staphylococcus aureus was the most common bacterial agent responsible for pyogenic liver abscess; however, anaerobic organisms were noted as a major group of pathogens and represented 27% of our patients. Furthermore, one patient was discovered to have multiple microabscesses of the liver associated with cat-scratch disease; pleomorphic gram-negative bacilli were not cultured. Among the 109 patients, the overall mortality of 15% was considerably better than that for children with PLA before 1975. The improved survival may be related to more prompt diagnosis of pyogenic liver abscess followed by evacuation of the liver abscess and antibiotic therapy.

[Use of a water jet for synovectomy: in vitro study of feasibility]. / Der Druckwasserstrahl zum selektiven Abtrag der Synovialis--In-vitro-Studie zur Machbarkeit eines neuen Synovektomieverfahrens.

AIM: The selectivity of a water jet (WJ) is already used with clinical advantage in the surgery of liver, brain, kidney and herniated lumbar discs. The aim of the present study was to determine whether a WJ can be used for synovectomy without damaging the joint capsule and the cartilage. METHOD: 60 human cadaver knee specimens (67 +/- 14 years) were dissected into synovial and cartilage samples. They were randomly assessed to four pressure groups (pW = 3; 6; 9; 12 MPa) and three jet surface angles (beta = 30; 60; 90 degrees) The nozzle diameter was dD = 0.12 mm, the stand off distance of the jet was s = 10 mm with a feed rate of vV = 2 mm/s. The acquired parameters were depth of the cuts, histological layer, and change of the samples thickness. RESULT: There was a correlation of the cutting depth and the pressure (pW), whereas the jet-surface angle (beta) showed no correlation. The synovial layer of the cut likewise correlated with the pressure. At pW = 6 MPa the stratum subsynoviale could be cut selectively without damaging the fibrous capsule or the cartilage. The increase of the samples thickness was caused by an interstitial oedema. CONCLUSION: The different mechanical properties of the joint capsule and the stratum subsynoviale lead to the selective cutting of the water jet. Since the joint capsule was not damaged, the feasibility of WJ synovectomy has been proven. The device can be used for synovectomy in parts of the joint that are not visible as well as in very small joints.

Lack of efficacy of thickened feeding as treatment for gastroesophageal reflux.

The efficacy of thickened feedings for the treatment of gastroesophageal reflux in infancy was evaluated. Fifty-two infants were examined with prolonged pH monitoring of the distal esophagus after feedings of apple juice or apple juice thickened with rice cereal. All infants had a minimum of three feedings of both thickened and unthickened juice. The recordings of distal esophageal pH were analyzed for the percent of time the pH was less than 4 in the first 2 hours after each feeding. The infants were maintained in the following positions after feeding: prone (n = 29), prone-board with the head elevated 30 degrees from horizontal (n = 29), supine (n = 7), and unrestricted (n = 21). We found no significant difference in the percent of time with reflux with thickened versus unthickened feedings except in those infants maintained in the 30-degree prone position. In the first 2 hours after eating thickened juice, infants maintained in this position had increased esophageal reflux time (P less than 0.006). Further analysis revealed that 33% of the infants had a greater than 30% increase in esophageal reflux time after thickened feedings. Our study suggests that the immediate effect of thickened feedings on gastroesophageal reflux in infants is unpredictable.

Abnormal gastroduodenal motility in children and adolescents with recurrent functional abdominal pain.

To determine whether motor activity of the stomach and proximal small intestine is a factor in recurrent abdominal pain in adolescents, we prospectively investigated eight patients with recurrent abdominal pain and compared them with seven normal adolescents. All patients underwent a detailed examination to exclude other known organic causes of the pain. The gastroduodenal motor activity during fasting was studied with a semiconductor recording probe. The recordings were analyzed for periodicity, duration, and propagation velocity of the activity front of the migrating motor complex. The amplitude of the antral and duodenal contractions was also determined. The patients with recurrent abdominal pain had more frequent migrating motor complexes, but these were shorter in duration and moved more slowly down the intestine (slower propagation velocities). The patients also had high-pressure duodenal contractions that were associated with abdominal pain during the study period. These studies suggest that altered intestinal motility may be the underlying mechanism of recurrent abdominal pain in some children.

Tachykinergic neurotransmission is enhanced in small intestinal circular muscle in a rabbit model of inflammation.

Previous electrophysiological studies have shown that tachykinin-mediated excitatory junction potentials are enhanced in a ricin model of inflammatory bowel disease. The present study extends these findings by investigating the contractile response to stimulation of noncholinergic nerves and tachykinin agonists. According to rank order potencies, the rabbit ileal circular muscle was neurokinin (NK)1 preferring, and the response to these agonists was down-regulated by acetylcholine and up-regulated by nitric oxide. In ricin-treated tissue, cholinergic and nitridergic modulation was lost; in the presence of atropine and N-nitro-L-arginine methyl ester, or tetrodotoxin, the response to NK1 and NK2 agonists was enhanced. The noncholinergic response to nerve stimulation was predominantly mediated by NK1 receptors, and the enhanced response of ricin-treated tissue to NK1 agonists probably contributes to the increased response to electrical field stimulation observed under these conditions. Increased tachykinin response and loss of control of this response by acetylcholine and nitric oxide are likely to have profound effects on intestinal motility and could contribute to some of the symptomology of inflammatory bowel disease.

Colonic leiomyoma--an unusual cause of gastrointestinal hemorrhage in childhood. Report of a case.

Leiomyomas of the intestine are rarely found in the pediatric population. The authors' review of the literature revealed only three colonic leiomyomas previously described. The authors present the first reported case of a child with lower gastrointestinal hemorrhage secondary to a colonic leiomyoma. Pathologic aspects of intestinal leiomyomas are discussed along with the difficulty in histologic differentiation from leiomyosarcomas. Wide resection is recommended for spindle cell neoplasms of the intestine owing to difficulty in differentiating benign from malignant tumors.

Alterations in spontaneous contractions in vitro after repeated inflammation of rat distal colon.

In inflammatory bowel disease, smooth muscle function reportedly varies with disease duration. The aim of these studies was to determine changes in the control of spontaneous contractions in a model of experimental colitis that included reinflammation of the healed area. The amplitude and frequency of spontaneous contractions in circular smooth muscle were determined after intrarectal administration of trinitrobenzenesulfonic acid in rat distal colon. With the use of a novel paradigm, rats were studied 4 h (acute) or 28 days (healed) after the initial inflammation. At 28 days, rats were studied 4 h after a second inflammation (reinflamed) of the colon. Colitis induced transient increases in the amplitude of spontaneous contractions coincident with a loss of nitric oxide synthase activity. The frequency of contractions was controlled by constitutive nitric oxide in controls. Frequency was increased in healed and reinflamed colon and was associated with a shift in the dominance of neural constitutive nitric oxide synthase control to that of inducible nitric oxide synthase (iNOS). The initial colitis induced a remodeling of the neural control of spontaneous contractions reflecting changes in their regulation by constitutive nitric oxide synthase and iNOS.

Migrating myoelectric complex demonstrated in four avian species.

The migrating myoelectric complex (MMC) is demonstrated in four avian species: three gallinaceous birds (Gallus, Phasianus, Coturnix) and an owl (Strix). The complex in birds is strikingly similar to the MMC that is known in mammalian species. It has the same basic pattern of quiescence, followed by a period of irregular spike activity, then a period of intense regular spike activity, and finally a return to quiescence. The frequency and duration of avian MMCs are similar to those of mammals, but the propagation velocity and slow-wave frequency are slower. Granivorous birds (Gallus, Phasianus) and carnivores (Strix) exhibit the same basic motility patterns whether in the fed or fasted states. Interspecific differences occur, however, in the details of frequency, propagation velocity, duration, and slow-wave frequency. The closely related galliforms (chickens, pheasants) are more similar to each other in MMC characteristics than either is to the more distantly related owls.

Colitis-induced alterations in adrenergic control of circular smooth muscle in vitro in rats.

The present study investigated inflammation-induced changes in adrenergic regulation of smooth muscle. Colitis was induced in rats by intrarectal administration of trinitrobenzenesulfonic acid in ethanol. After 4 h (acute) or 7 days (chronic), in vitro isometric tension was measured in strips of circular smooth muscle taken from the distal colon. In controls, the major inhibitory control of smooth muscle responses to nerve stimulation was mediated by nitric oxide and beta adrenergic receptors. There was less evidence of alpha adrenergic control. Studies with the beta3 receptor antagonist cyanopindolol and the beta3 receptor agonist BRL37344 revealed that beta adrenergic regulation of spontaneous contractions and responses to nerve stimulation were mediated primarily by the beta3 adrenoreceptor. Both acute and chronic colitis significantly increased responses to electrical field stimulation. This effect was attributed to a loss of inhibitory nitrergic regulation as well as to selective changes in the beta adrenergic control of colonic circular smooth muscle. Inflammation did not alter alpha adrenergic control. Chronic colitis also decreased the sensitivity to nerve stimulation and pharmacological contractile agents. Acute and chronic inflammation reduced the ability of BRL37344 to inhibit contractions in response to nerve stimulation. In addition, in inflamed colon, BRL37344 was less effective in relaxing carbachol-induced precontractions. Finally, inflammation resulted in a loss of the ability of the cyanopindolol to increase the amplitude of both spontaneous contractions and contractions in response to nerve stimulation. These effects indicated that colitis induced a down-regulation of inhibitory beta3 adrenergic control of colonic smooth muscle function. This loss of adrenergic regulation may contribute to the diarrhea in inflammatory bowel disease.

Role of sensory afferents in the myoelectric response to acute enteric inflammation in the rabbit.

The role of sensory afferents in inflammation-induced alterations in myoelectric activity in vivo was investigated in the rabbit small intestine. Isolated ileal loops were implanted with serosal electrodes and exposed to ricin or vehicle after pretreatment with 125 mg/kg of subcutaneous (125 mg over 3 days) or intraluminal (640 microM) capsaicin. After 5 h of myoelectric recording, the loops were prepared for histology and for ex vivo generation of eicosanoids. Capsaicin exacerbated mucosal damage after exposure to ricin but did not alter neutrophil infiltration. Subcutaneous capsaicin alone elevated slow-wave frequency and spike events and transiently suppressed the myoelectric response to ricin. In contrast, intraluminal capsaicin alone did not alter myoelectric activity but produced a sustained inhibition of the response to ricin. Eicosanoid production was unchanged by capsaicin alone. Intraluminal capsaicin blocked increases in leukotriene C4 and prostaglandin E2 during inflammation, an effect that paralleled its inhibition of myoelectric activity. Thus the contribution of sensory afferents to altered motility during acute ileitis involves the release of mucosal inflammatory mediators that influence neural control of smooth muscle.

Migrating action potential complex: unmasked by 6-hydroxydopamine.

We have previously described the myoelectric characteristics of a single moving ring contraction, the migrating action potential complex (MAPC), in rabbit ileal loops exposed to certain bacteria or their enterotoxins. The MAPC is thought to act as a defense mechanism of the host, clearing unwanted substances from the lumen. In the present study, 6-hydroxydopamine, a substance that selectively destroys adrenergic varicosities containing the neurotransmitter norepinephrine, unmasked the MAPC from the activity front of the migrating motor complex in an unanesthetized rat model. The animals developed diarrhea and lost weight. The study suggests that the MAPC may also be a physiological complex and under the modulation of the enteric nervous system. The MAPC may not be seen under normal control conditions because the complex migrates with the activity front and is under inhibitory control. Destroying the inhibitory mechanisms unmasked the MAPC from the activity front of the migrating motor complex and allowed neural transmission of the ring contraction.