An adaptable computer interface for radioimmunoassay.

To assist data handling of results derived from radioimmunoassay the RIACalc Multigamma counter package was interfaced to a laboratory information system. The interface was bidirectional and allowed transfer of worklists and results. A suite of programs was written for the laboratory information system that enabled flexible data processing to meet a range of laboratory requirements. One utility within the suite contained a simple user definable rule based routine for automatically requesting additional tests. Use of the interface and new software improved laboratory efficiency and illustrated the potential benefits of decision making systems.

Industrial dermatitis.

Dermatitis is a common problem in industrial workers, resulting in disability varying from discomfort to permanent incapacity. Authorities concerned with skin disease and industrial health should cooperate to give more attention to understanding and management of this problem.

Assessment of the malignant potential of cystoplasty.

The study group comprised 34 patients with either an ileal augmentation cystoplasty or a colonic substitution cystoplasty. The histological appearance of the intestinal segment, suture line, bladder remnant and bacterial colonisation of the urine and urinary nitrosamine levels were recorded. There was a high incidence of histological abnormalities, the more significant of which correlated with heavy mixed bacterial growth on urine culture and with high levels of urinary N-nitrosamines. This group of compounds is thought to act as carcinogens in both bladder and bowel under certain circumstances. It was concluded that patients undergoing lower urinary tract reconstruction using intestinal segments should be considered at risk of developing malignant change either in the intestinal segment or in the bladder remnant. Close long-term follow-up of these patients is essential.

One hundred artificial sphincters.

One hundred patients with urinary incontinence of various aetiologies underwent implantation of an artificial urinary sphincter (AUS). In 40 patients various reconstructive procedures of the lower urinary tract were carried out at the same time. In 93 patients the results were successful and they are continent. Six are incontinent and 4 of these await AUS replacement. One patient has had a urinary diversion with the sphincter still in situ and functioning. The complication rate was 45% (of which 29% were designated "sphincter-related"). Half of these were accounted for by two complications: one was a change in bladder behaviour in patients with neuropathic bladders and the other was stress incontinence as a direct result of implanting low pressure devices. If these two factors and the "sphincter-unrelated" problems are discounted, the complication rate was 13%. The AUS is a satisfactory and successful method of treatment for sphincter weakness incontinence regardless of aetiology and the results suggest no contraindication to implantation at the same time as reconstructive surgery of the lower urinary tract.

Calcium balance, growth and skeletal mineralisation in patients with cystoplasties.

Twelve adult female patients and 16 children who had undergone augmentation cystoplasty at least 2 years previously were studied to assess calcium balance and skeletal mineralisation. The serum and 24-h urinary calcium levels were measured and arterial blood gas analysis was performed in all patients. In children, skeletal mineralisation was assessed by serial study of their growth charts, comparing their growth centiles before and after cystoplasty. In adults, skeletal mineralisation was assessed by dual photon absorptiometry (DPA). As previously reported, all patients had a metabolic acidosis, usually with respiratory compensation. Serum and 24-h urinary calcium levels were all within the normal range. Growth charts of the 6 children with colocystoplasties showed an average of 20% reduction in growth potential in 3 of them. Growth charts in the 10 children with ileocystoplasties did not show any change in growth pattern. DPA bone scans in adults were all normal. These results suggest that if calcium is mobilised from bone in patients with a cystoplasty as a result of the metabolic acidosis, then it is reabsorbed from the bladder by the gut segment after an ileocystoplasty; colonic segments are less efficient than ileal segments, however, so that after a colocystoplasty skeletal demineralisation or a reduction in growth potential is more likely.

Metabolic complications of cystoplasty.

A series of 48 patients with intestinal segments incorporated into the urinary tract underwent assessment of acid-base and electrolyte balance. All patients had abnormal blood gas analyses, usually a metabolic acidosis with respiratory compensation; 33% had hyperchloraemia. Radioisotope studies using sodium, potassium and bromine showed that all were absorbed and that absorption was unaffected by renal function. The results suggest that all such patients, but particularly women and children, may be at risk of the secondary effects of chronic acidosis, especially skeletal demineralisation, unless some compensatory mechanism is working to offset the effects of the acidosis.

Construction of a virtual EPR and automated contextual linkage to multiple sources of support information on the Oxford Clinical Intranet.

We have used internet-standard tools to provide access for clinicians to the components of the electronic patient record held on multiple remote disparate systems. Through the same interface we have provided access to multiple knowledgebases, some written locally and others published elsewhere. We have developed linkage between these two types of information which removes the need for the user to drill down into each knowledgebase to search for relevant information. This approach may help in the implementation of evidence-based practice. The major problems appear to be semantic rather than technological. The intranet was developed at low cost and is now in routine use. This approach appears to be transferable across systems and organisations.

Secreto-motor function of intestinal segments used in lower urinary tract reconstruction.

Mucus excretion, sialic acid excretion and secretory IgA (sIgA) production from patients with a substitution caecocystoplasty (20), augmentation "clam" ileocystoplasty (20) or ileal conduit (10) were measured. Significant amounts of all of these substances were present in the urine of reconstructed patients and showed no evidence of diminution with time. Motility was studied by videocystourethrography. In patients with a neuropathic aetiology the amplitude of contractions was significantly increased and produced incontinence. The results demonstrate that intestinal secreto-motor function in gut segments incorporated into the lower urinary tract continues normally and must be taken into account when considering the long-term management of these patients.

Detrusor behaviour following implantation of the Brantley Scott artificial urinary sphincter for neuropathic incontinence.

During a 3-year period, 102 Brantley Scott artificial urinary sphincters were implanted to control urinary incontinence. Nineteen patients underwent endoscopic sphincterotomy and artificial sphincter implantation for the control of sphincter weakness incontinence due to congenital neuropathic bladder dysfunction. None had previous augmentation or substitution procedures. Nine patients (47%) subsequently showed a deterioration in detrusor function, resulting in either recurrent incontinence or upper tract dilatation. Eight of these (89%) had previously been shown to have an intermediate pattern of neuropathic bladder abnormality. All patients implanted with an AUS require long-term surveillance including videourodynamic studies, and patients with intermediate neuropathic bladders should be considered for augmentation or substitution at the time of implantation.

Role of the artificial urinary sphincter in the treatment of stress incontinence in women.

The artificial urinary sphincter (AUS) is rarely indicated in the treatment of women with stress incontinence because most of these women have deficient urethral support rather than pure sphincter weakness and the AUS is a treatment specifically for pure sphincter weakness. The procedure is contraindicated after pelvic radiotherapy and after previous sling surgery because of the high incidence of cuff erosion. Otherwise the artificial sphincter gives excellent results comparable to those seen in men with post-prostatectomy incontinence and much better than in neuropathic bladder dysfunction.

The "congenital" wide bladder neck anomaly: a common cause of incontinence in children.

In a study of 251 children (108 boys, 143 girls) undergoing videourodynamic studies for the assessment of non-neuropathic bladder dysfunction, 45 (19%) were found to have a wide bladder neck as their primary abnormality. Based on these studies there is evidence that the wide bladder neck anomaly is congenital in origin. In addition to producing significant urinary symptoms in childhood, this anomaly may provide a basis for stress incontinence in later life.

The effect of cromakalim on the normal and hyper-reflexic human detrusor muscle.

Cromakalim is a benzopyran derivative which relaxes smooth muscle, probably by opening membrane potassium channels. This study tested the effect of cromakalim on spontaneous, electrically induced and pharmacologically induced contractile activity of normal and hyper-reflexic human detrusor muscle samples. All 3 types of contractile activity were reduced in the presence of cromakalim. A preliminary clinical trial of cromakalim was conducted, the results of which also suggest that this type of drug may have a significant role in the treatment of detrusor instability and hyper-reflexia.

Problems in the surgical treatment of interstitial cystitis.

Two series of patients with histologically proven interstitial cystitis that was unresponsive to hydrostatic bladder distension and intravesical chemotherapy with dimethyl sulfoxide have been studied. In the first series 24 patients were treated by subtotal cystectomy and substitution cystoplasty without further consideration; 8 of these 24 patients had persistent frequency due to active disease in the remaining trigone and/or urethra and in 2 cases this was severe. Because of this experience the second group of patients had routine biopsy of the trigone and assessment of urethral sensation as part of the initial assessment. In those in whom the trigone was unaffected, treatment was unchanged. If the trigone was affected, total cystourethrectomy was performed with substitution cystourethroplasty unless the patient chose or was advised to avoid surgery altogether or to have a simpler option such as conduit or continent urinary diversion. Trigonal biopsies should be part of the routine assessment of all patients being considered for surgery, since residual active disease is a major cause of dissatisfaction after subtotal cystectomy and substitution cystoplasty.

Lower urinary tract reconstruction in patients with bladder exstrophy after failed primary treatment in early childhood.

The results of neonatal surgery for bladder exstrophy are not very satisfactory. A significant percentage of patients present in later childhood or adolescence for correction of their residual deformities. We have reconstructed 26 patients, correcting their entire urogenital and cosmetic deformity in a one-stage procedure. The results show that one-stage total reconstruction is possible and is preferable to serial correction of the various individual abnormalities. The principles of surgical reoperation in adolescence are the same as those now established for the primary correction in neonatal life.

Malignant change in enterocystoplasty: a histochemical assessment.

Increasing numbers of cases of malignant tumours occurring in enterocystoplasties are being reported. Material from five cases of adenocarcinoma arising in such patients were studied using standard mucin and carbohydrate lectin staining methods. Sections from the tumour and adjacent and distant mucosa were stained to determine the pattern of histochemical changes. The abnormal staining patterns seen suggest that the adenocarcinomata arising at the enterovesical anastomosis are of intestinal origin. A hypothesis is advanced to explain the pathogenesis of these tumours.

Relative indications for orthotopic lower urinary tract reconstruction, continent urinary diversion and conduit urinary diversion.

Continent urinary diversion has become increasingly popular in the last few years and there are now several situations in which ileal conduit diversion, continent diversion and orthotopic reconstruction of the lower urinary tract are equally valid options. This review was intended to determine specific indications for each. Of 513 patients treated for severe lower urinary tract problems in the last 10 years, 399 underwent orthotopic reconstruction, 68 underwent continent diversion and 46 had an ileal conduit. Problems occurred 2 to 3 times more commonly in the continent diversion group than in either of the other groups. Given a free choice, most patients would choose an orthotopic reconstruction and this should probably be regarded as the gold standard. Continent diversion is specifically indicated in male patients who require a total cystourethrectomy for bladder cancer, in severe post-radiotherapy problems, and in patients with neuropathic bladder dysfunction in whom, for various reasons, self-catheterisation is impossible. Ileal conduit diversion remains the simplest and safest technique in high-risk patients and does not preclude a subsequent continent diversion or orthotopic reconstruction.

Clam enterocystoplasty in the neuropathic bladder.

Clam enterocystoplasty has proved to be the most effective treatment for severe detrusor instability resistant to conservative treatment (Bramble, 1982; Mundy and Stephenson, 1985). More recently it has become the procedure of choice in patients with neuropathic bladders with hyper-reflexia or severely impaired compliance, provided that the bladder is of reasonable size and that gross fibrosis and/or diverticular formation of the bladder wall has not occurred. Fifty-nine patients have undergone the clam procedure as part or all of their reconstruction in the past 4 years. Although uncontrolled incontinence was the commonest indication, impaired renal function was the indication in 14 patients and need for undiversion in seven. Currently all but four are voiding satisfactorily or are on intermittent self-catheterisation, though six have significant stress incontinence. The clam procedure is easier, quicker and as satisfactory as substitution cystoplasty in selected cases.