Diagnostic options for early identification and management of interstitial cystitis/painful bladder syndrome.

AIMS: The aims of this article were to discuss options for diagnosing interstitial cystitis (IC), to compare approaches and to encourage early diagnosis of this disorder in the primary care setting. METHODS: Experts discussed the tools available to diagnose IC and the advantages and disadvantages of each approach. Treatment options, both pharmacological and non-pharmacological, were also discussed. The importance of patient follow-up was emphasised. RESULTS: Diagnostic options for IC include a thorough history and physical examination, laboratory evaluations, symptom screening tools, cystoscopy with hydrodistention, bladder biopsy, potassium sensitivity testing, intravesical anaesthetic challenges, urodynamics and urinary markers. Treatment options include oral and intravesical medications, dietary modification and physical therapy. Patient follow-up can be an opportunity to educate and empower patients to participate in their treatment. DISCUSSION: A thorough patient history, physical examination and laboratory evaluations are keys to the diagnosis of IC. Optional diagnostic approaches may help increase physician confidence in prescribing therapy for this disorder. Multimodal therapy with an emphasis on patient education can help ensure success in treating IC. CONCLUSION: Understanding the options available to diagnose IC may result in earlier identification and treatment for some patients.

The dyskinetic cilia syndrome. Ciliary motility in immotile cilia syndrome.

Ciliary motility was studied in three patients with Kartagener syndrome who had previously been found to have absent nasal and pulmonary mucociliary transport and missing dynein arms in nasal cilia. A video system was used to record movement of cilia obtained by nasal brushings for analysis of wave form and beat frequency. Two patterns of abnormal ciliary beat were observed; an oscillating and a rotating type of motion. There was no evidence of planar coordination of metachronicity. This abnormal motion was present in up to 40 percent of cells and the remainder were totally immotile. Thus, in Kartagener syndrome many ciliated cells are motile, but the motion is abnormal. We suggest that "immotile cilia syndrome" is a misnomer, and recommended it be renamed "dyskinetic cilia syndrome."

Ketorolac for postoperative pain management in children.

Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) with potent analgesic effects and a relatively low incidence of adverse effects. Numerous clinical trials of postoperative pain treatment in children have shown that ketorolac is as effective as the major opioid analgesics, such as morphine, and more effective than codeine. The pharmacokinetics of ketorolac differ in children compared with adult patients after surgery. In children, the volume of distribution (Vd) of ketorolac is increased by as much as 2-fold relative to that in adults. The plasma clearance (CL) of ketorolac is also higher in children, probably because of lower binding to plasma proteins. However, the elimination half-life (t 1/2 beta) of ketorolac is similar in children and adults because t 1/2 beta is directly proportional to Vd but inversely proportional to CL. These pharmacokinetic differences indicate that a higher relative dosage is required in children, but the dosage interval is similar in children and adults. Ketorolac can be administered intravenously, intramuscularly or orally. The intravenous route is preferred during the immediate postoperative period, until the patient can tolerate oral medication. Intramuscular injections are not recommended in children, unless the intravenous route is unavailable. The recommended intravenous dosage of ketorolac in children is 0.5 mg/kg, followed either by bolus injections of 1.0 mg/kg every 6 hours or an intravenous infusion of 0.17 mg/kg/h. The maximum daily dosage is 90mg, and the maximum duration of treatment is 48 hours. The recommended oral dosage is 0.25 mg/kg to a maximum of 1.0 mg/kg/day, with a maximum duration of 7 days. Older children may require somewhat lower dosages, while infants and young children may require slightly higher dosages to achieve the same level of pain relief. Ketorolac is not recommended for use in infants aged < 1 year. Unlike opioid analgesics ketorolac does not depress ventilation, and is not associated with nausea and vomiting, urinary retention or sedation. When combined with an opioid, ketorolac exhibits marked opioid-sparing effects, allowing a lower dosage of opioid to be used. Clinical studies in children and adults show that the synergistic action of ketorolac and opioids improves the degree and quality of pain relief, and reduces the incidence of opioid-related adverse effects such as respiratory depression, nausea/vomiting and ileus. Recovery of bowel function after abdominal surgery occurs sooner in ketorolac-compared with opioid-treated patients. Ketorolac reversibly inhibits cyclo-oxygenase, and decreases the hypersensitisation of tissue nociceptors that occurs with surgery. It also has reversible antiplatelet effects, which are attributable to the inhibition of thromboxane synthesis. Bleeding time is usually slightly increased, but in most patients it remains within normal values. There is conflicting evidence of the potential for increased surgical-site bleeding after tonsillectomy but, for other types of paediatric surgery, numerous clinical studies have confirmed that ketorolac is not associated with increased bleeding. Thus, ketorolac is well suited for the treatment of postoperative pain in children, either alone or in combination with opioids or local anaesthetics, because of its analgesic potency and relatively low incidence of adverse effects.

The involvement of prostaglandins and thromboxanes in the response to pulmonary embolism in anaesthetized rabbits and isolated perfused lungs.

Embolisation of blood clots produced an increased pulmonary artery pressure in vitro and systemic hypotension in vivo. In control anaesthetized animals, systemic blood pressure fell by 44.9 +/- 28.0 mm Hg following embolisation and 40% of the animals died within 5 minutes of embolisation. Plasma concentrations of thromboxane B2 (TXB222222 2) and 6-keto-prostaglandin F 1 alpha (6-keto-PGF 1 alpha) were increased by 0.54 +/- 0.13 ng/ml and 0.41 +/- 0.25 ng/ml, respectively. Pretreatment of animals with aspirin (ASA), 5 mg/kg or 250 mg/kg, reduced the hypotensive response and the TXB 2 and 6-keto-PGF 1 alpha release. Embolisation of isolated lungs perfused with blood-free medium induced an increase in pulmonary artery pressure of 32.7 +/- 21.0 mm Hg and significantly increased the content of TXB 2 and 6-keto-PGF 1 alpha in the perfusate. Pretreatment of lungs with indomethacin, 10 micrograms/ml, reduced the mean pulmonary pressure response to embolisation to 10.6 +/- 4.9 mm Hg and blocked the appearance of TXB 2 in the perfusate. Embolisation with an agarose clot induced only a 2.58 +/- 0.8 mm Hg increase in pressure and no detectable TXB 2 release. These results indicate that embolisation of lungs with a blood clot induces the release of TXB 2 and 6-keto-PGF 1 alpha. The release of these mediators, the hemodynamic responses and mortality were blocked by ASA pretreatment.

Comparative pulmonary mechanics in the horse and the cow.

Pulmonary mechanics and lung volumes were measured in horses and cows to determine if differences in breathing pattern between the two species were due to differences in the mechanical properties of the lungs. Tidal volume (VT) was larger in the horses, while the respiratory rate (fR) and minute ventilation (VE) were higher in the cows. The horses often had a double peak in airflow during inspiration and, or, expiration, while the cows had a single peak during expiration. Measured lung volumes were larger in the horses and they had a higher dynamic lung compliance (Cdyn,L), although the static compliance of the lung, chest wall and respiratory system (Cst,L,Cst,w and Cst,rs respectively) did not appear to differ between the two species. The cows had a greater change in maximum transpulmonary pressure (delta PLmax) and an increased nonelastic work of breathing (Wb). However, the pulmonary resistance (RL) did not differ between the two species, thus the higher delta PLmax and Wb in the cows were most likely a function of their higher flow rates. Calculations of the rate of work of breathing (W) indicate that both species breathed at an fR above the minimum W. The fR in the horses was close to the fR predicted for the average minimum muscle force, but the fR in the cows was higher. As the differences in the mechanical properties of the lung do not explain the differences in flow pattern, nor adequately account for the higher fR in the cows, it is suggested that the differences in breathing pattern between the two species is due to differences in the chest wall, particularly the size and shape of the abdomen.

Comparative ventilation and gas exchange in the horse and the cow.

Ventilation and gas exchange were studied in healthy, adult horses and cows, two large species with different lung structures and different breathing patterns. The oxygen uptake (VO2), carbon dioxide output (VCO2), respiratory rate (fR), minute ventilation (VE), alveolar ventilation (VA), alveolar oxygen pressure (PAO2), and VE/VO2 ratio were higher in the cows, while the tidal volume (VT) and physiological dead space (VD) were larger in the horses. The arterial blood gases, alveolar-arterial oxygen pressure difference (PAO2-PaO2) and VD/VT ratio did not differ between the two species. The higher VO2 in the cows was most likely due to the energy cost of standing, and possibly to a higher cost of digestion. The higher VE, VA, VE/VO2 and PAO2 were most likely secondary to the increased VO2 and the slightly higher respiratory exchange ratio (R) in the cows. In contrast to hypotheses based on allometric equations, the PAO2 of horses and cows did not appear to differ from that of smaller mammals. The VD was larger than that predicted from allometric equations, and even though the VD/VT ratio (0.50) was lower than the previously reported values for horses and cows, it was significantly larger than the predicted weight-independent value of 0.36. Re-examination of the data used to derive the equation for VD raised questions as to the validity of this equation, and it is suggested that caution be exercised in the use of allometric equations for prediction.

Case report: scrotal cellulitis secondary to hot tub exposure.

Inflammatory disorders of the scrotum vary in their presentation and etiology. This may range from relatively minor cutaneous infections to scrotal gangrene. Herein presented is a case of scrotal cellulitis secondary to cutaneous inoculation from a hot tub.

Abdominal pain secondary to a lymphangiomatous cyst of the adrenal: case report and review of literature.

An adrenal cyst is a rare clinical finding with an incidence of approximately 0.06% in the general population. As the majority are clinically silent, adrenal cysts are usually discovered incidentally at autopsy or during surgery for an unrelated disease process. We report a case of a lymph-angiomatous adrenal cyst diagnosed in a 27-year-old female presenting with abdominal pain.

The response to epidural steroid injections in chronic dorsal root pain.

Thirty-seven patients with long-standing post-herpetic neuralgia and 27 with post-traumatic neuralgia (PTN) were treated with three epidural injections each of methylprednisolone acetate (Depo Medrol) given at weekly intervals. Differential subarachnoid or epidural block was done in all patients and placebo responders were excluded from the study. Mean age, duration of symptoms, and pain intensity measured by visual analogue scale were similar in both groups. Visual analogue scale ratings were reduced one month after treatments from both groups. Visual analogue scale ratings were reduced one month after treatments from pretreatment values of 84.4 and 78.7 to 9.6 and 15.2 in the post-herpetic and post-traumatic groups respectively, and were further reduced to 4.6 and 11.6 respectively after one year when 89 per cent of patients in the post-herpetic group and 59 per cent of patients in the post-traumatic group were completely pain free. Side effects were minor in all cases. It is suggested that this is the treatment of choice in post-herpetic and post-traumatic neuralgia where steroid administration is not contraindicated.

Structural aspects of gas exchange.

The lung is composed of several million small air spaces, lined by a delicate tissue membrane separating air from capillary blood. The design features of the gas exchange region in the lung are optimal for gaseous diffusion, by having a very extensive contact surface but with a minimal tissue barrier composed of an epithelial and endothelial layer separating an interstitial layer. The extent of the gas exchange surface in adult lungs is determined by general maturation which in turn is influenced by metabolic requirements of the organism. Environmental factors can modulate the pattern of ultimate lung development. Lung inflation causes air spaces to expand mainly by a process of tissue unfolding beneath an extremely thin layer of alveolar surfactant. This ensures cellular integrity during extreme deformations while at the same time providing a reserve of gas exchange surface so that functional diffusion capacity at all lung volumes is less than the structural maximum.

An unusual complication after stellate ganglion block by the paratracheal approach: a case report.

A case is presented of repeated stellate ganglion block using the paratracheal approach at the level of C6 and using the low dose method. Subarachnoid spread of local anaesthetic resulted in total spinal block below the level of C4. The potential hazards of this techinque of stellate ganglion block and methods of avoiding them are discussed, together with the possible mechanism in this case.

Lung tissue plasticity: morphometric analysis of anisotropic strain in liquid filled lungs.

Lungs of rats were fixed at different inflation pressures (Ptp) during liquid filling with the pulmonary vessels tied to prevent vascular volume change after fixation had begun. Morphometric analysis showed that alveolar surface varied as a alveolar volume (Va) to the power 0.82, while the arithmetic mean tissue thickness varied as Va-0.2. This is interpreted as evidence for anisotropic expansion. Capillary volume (Vc) was found to increase from zero Ptp to a maximum at Ptp = 2 cm H2O then decrease as Va increased. Morphometric diffusion capacity of the membrane component increased as Va0.59 while that for whole lung (DL)paralleled the change in Vc. Alveolar capillary tissue unfolding is described as the main factor accounting for anistropic expansion of alveolar surface and for capillary configuration. The absolute values of Vc and DL were lower by 60% and 50%, respectively, compared with values obtained by standard instillation fixation methods and this is suggested could account for previous discrepancres between morphometric and physiologic estimates of DL.

The effect of changes in lung volume on the size and shape of alveoli.

1. A technique is described by which living anaesthetized guinea-pigs were artificially ventilated with a positive and negative pressure cycle, and rapidly frozen at the instant of cessation of ventilation at a preselected point on the respiratory cycle.2. The dimensions of alveoli and alveolar ducts were measured by histological morphometric methods, and related to the degree of lung inflation at the instant of freezing.3. The alveolar volume fraction increased from 0.52 at low lung volumes, up to 0.62 at lung volumes in the mid-inflation range, then decreased to 0.51 at high lung volumes. The alveolar duct volumetric fraction remained constant at all lung volumes.4. The total volume of alveoli increased linearly with increase in lung volume. The total alveolar duct volume increased little until the lungs were 40% inflated, above which it increased steeply.5. The total number of alveoli was linearly related to the body weight.6. The total alveolar surface area increased steeply between lungs of low lung volume and those which were up to 50% inflated, above which the increase levelled off. The absolute values of total alveolar surface depended on the body weight as well as the degree of lung inflation.7. The mean alveolar duct diameter was 40% greater, and the mean alveolar mouth diameter 35% greater in lungs which were fully inflated than in lungs which were nearly collapsed. The average geometrical shape of alveoli was not related to the degree of lung inflation.8. The harmonic mean thickness of the air-blood barrier was 33% less in lungs which were fully inflated than in lungs which were nearly collapsed. The alveolar surface membrane was smooth whether the lungs were fully inflated or collapsed.

Management of chronic dorsal root pain with epidural steroid.

Twenty-eight patients presenting with typical dorsal root pain of more than six months' duration were given a series of three epidural injections of methylprednisolone acetate. The patients were grouped according to known aetiologic factors. Improvement in symptoms was most marked in the post-herpetic group where 86% were free of pain after six months. In the post-trauma/surgical group, 50% of patients were free of pain after six months, while in the idiopathic group only minimal improvement occurred. The side-effects of steroid administration into the epidural space were in all cases minor.