Feasibility of outpatient daycase local anaesthestic Rezum™ without sedation.

BACKGROUND: Rezum™ is a relatively new bladder outflow obstruction (BOO) procedure that uses thermal energy through water vapour to cause necrosis of prostatic tissue. The standard delivery of this treatment is in an operating theatre under a general or spinal anaesthetic, or under local anaesthetic with sedation that requires patient monitoring. METHODS: We propose an outpatient daycase method of delivering Rezum™ under local anaesthetic without sedation, using a prostatic local anaesthetic block and cold local anaesthetic gel instillation into the urethra. RESULTS: Preliminary results of our first thirteen patients demonstrate the feasibility of this new technique, with a mean pain score of 2.1 out of 10 on a visual analogue scale, a successful trial without catheter in all 13 patients (one patient voided successfully on second trial), a reduction in mean International Prostate Symptom Score (IPSS) from 20.6 to 5.4, and improvement in maximum flow from 8.8 ml/s to 14.4 ml/s. The complications were minor (Clavien-Dindo less than III) and included a UTI, minor bleeding not requiring admission, and retrograde ejaculation. CONCLUSIONS: We demonstrate that an outpatient local anaesthetic daycase service without sedation is feasible. This can be delivered in a clinic setting, reduce waiting times for BOO surgery, and increase availability of operating theatre for other general anaesthetic urological procedures.

Low-level lead exposure and behavior in early childhood.

OBJECTIVE: To assess whether small elevations in blood lead level were associated with measurable behavioral changes in a group of poor children between 1 and 3 years old. METHODS: The study population consisted of children presenting for routine well-child care to the pediatric clinic at Bellevue Hospital Center, a large urban public hospital. The following inclusion criteria were used for entry into the study: age 12 to 36 months; capillary lead screening result <1.21 micromol/L (25 microg/dL); no known prior history either of blood lead level >1.21 micromol/L (25 microg/dL) or lead exposure requiring chelation therapy; Latino or African-American; English or Spanish spoken in the home; biological mother as primary caretaker; child not presently attending day care; full-term, singleton gestation; birth weight at least 2500 g; no known neurologic or developmental disorder; and no severe chronic disease, including human immunodeficiency virus infection. Study enrollment was simultaneously stratified by capillary lead level and age. All children between 12 and 36 months attending the pediatric clinic during the study period received screening capillary blood measures of lead level following the recommendations of the Centers for Disease Control and Prevention and the American Academy of Pediatrics as part of routine primary care. During periods of enrollment, consecutive lead measurements performed in the pediatric clinic were reviewed by one of the researchers. For those children meeting entry criteria based on lead level and age, further eligibility based on the remainder of the inclusion criteria was determined through parental interview and review of the medical record. Lead exposure was assessed with a single capillary blood specimen, using atomic absorption spectrophotometry. Subjects were considered to be lead-exposed if their lead level was between 0.48 and 1.20 micromol/L (10 and 24.9 microg/dL) and nonexposed if their lead level was between 0 and 0.48 micromol/L (0 and 9.9 microg/dL). Behavior was assessed using the Behavior Rating Scale (BRS) of the Bayley Scales of Infant Development, second edition. The BRS in this age group consists of three components: an Emotional Regulation Factor that measures hyperactive/distractible/easy-frustration behaviors; an Orientation-Engagement Factor that measures fear/withdrawal/disinterest behaviors; and a Motor Quality Factor that assesses the appropriateness of movement and tone. The BRS is scored as a percentile; lower scores reflect more problematic behaviors. Researchers performing the BRS were blinded to capillary lead results. Information was collected concerning factors that might confound the relationship between lead and behavior. Demographic factors were collected, including: child's age, gender, and country of origin; mother's age, marital status, parity, country of origin, and primary language spoken; parental education, and occupation and receipt of public assistance. Socioeconomic status was determined using the Hollingshead Two-Factor Index of Social Position. Maternal verbal IQ was assessed using the Peabody Picture Vocabulary Test-Revised. Maternal depression was assessed using the Center for Epidemiologic Studies-Depression Scale. Cognitive stimulation provided in the home was assessed using a new office-based instrument, the StimQ, which measures the quantity and quality of play materials and parent-toddler activities in the child's home. To assess the child for iron deficiency, we performed a hematocrit and mean corpuscular volume at the time of the capillary lead evaluation. A presumptive diagnosis of iron deficiency was made if the child was either anemic (defined as a hematocrit <32) or had a mean corpuscular volume <72. RESULTS: The study sample consisted of 72 children. Children in the lead-exposed group (n = 41) had a mean BRS behavior score that was 15.8 points lower than that of children in the nonexposed group (n = 31), which was significant by the Stu

Elevated production rate of 1,25-dihydroxyvitamin D in patients with absorptive hypercalciuria.

Previous studies of 1,25-dihydroxyvitamin D [1,25-(OH)2D] kinetics in normal subjects using the pulse injection technique have led to conflicting results, and only limited data are available concerning 1,25-(OH)2D kinetics in hypercalciuric patients. We developed an infusion equilibrium technique that measures the metabolic clearance and production rates of 1,25-(OH)2D and applied this technique in 13 normal subjects and 9 well characterized patients with absorptive hypercalciuria; all subjects were studied after 10 days on a 400-mg calcium intake. All subjects received a constant infusion of [3H]1,25-(OH)2D3 (20,000 dpm/min). Purified plasma radioactivity reached steady state levels after 15 h, and between 15 and 19 h, serial measurements of purified plasma radioactivity and endogenous 1,25-(OH)2D were made for calculation of metabolic clearance and production rates. In the 13 normal subjects, the MCR values were within a narrow range, with a mean +/- SD value of 37 +/- 6 ml/min, which, when combined with the mean steady state concentration of endogenous 1,25-(OH)2D (42 +/- 6 pg/ml), yielded a mean production rate of 2.2 +/- 0.5 micrograms/day. In the 9 patients with absorptive hypercalciuria, MCR values also were tightly clustered, with a mean of 35 +/- 4 ml/min. However, the mean endogenous steady state 1,25-(OH)2D level was significantly elevated in these patients, such that the calculated mean 1,25-(OH)2D production rate was significantly elevated at 3.4 +/- 0.5 micrograms/day. In 7 of the 9 patients with absorptive hypercalciuria, production rates exceeded the highest values found in the normal subjects. These data demonstrate disordered 1,25-(OH)2D production as opposed to metabolic clearance in the syndrome of absorptive hypercalciuria.