Recent changes in high-mountain plant community functional composition in contrasting climate regimes.

High-mountain plant communities are strongly determined by abiotic conditions, especially low temperature, and are therefore susceptible to effects of climate warming. Rising temperatures, however, also lead to increased evapotranspiration, which, together with projected shifts in seasonal precipitation patterns, could lead to prolonged, detrimental water deficiencies. The current study aims at comparing alpine plant communities along elevation and water availability gradients from humid conditions (north-eastern Alps) to a moderate (Central Apennines) and a pronounced dry period during summer (Lefka Ori, Crete) in the Mediterranean area. We do this in order to (1) detect relationships between community-based indices (plant functional leaf and growth traits, thermic vegetation indicator, plant life forms, vegetation cover and diversity) and soil temperature and snow duration and (2) assess if climatic changes have already affected the vegetation, by determining directional changes over time (14-year period; 2001-2015) in these indices in the three regions. Plant community indices responded to decreasing temperatures along the elevation gradient in the NE-Alps and the Apennines, but this elevation effect almost disappeared in the summer-dry mountains of Crete. This suggests a shift from low-temperature to drought-dominated ecological filters. Leaf trait (Leaf Dry Matter Content and Specific Leaf Area) responses changed in direction from the Alps to the Apennines, indicating that drought effects already become discernible at the northern margin of the Mediterranean. Over time, a slight increase in vegetation cover was found in all regions, but thermophilisation occurred only in the NE-Alps and Apennines, accompanied by a decline of cold-adapted cushion plants in the Alps. On Crete, xeromorphic shrubs were increasing in abundance. Although critical biodiversity losses have not yet been observed, an intensified monitoring of combined warming-drought impacts will be required in view of threatened alpine plants that are either locally restricted in the south or weakly adapted to drought in the north.

Using a model based fourth-corner analysis to explain vegetation change following an extraordinary fire disturbance.

In ecosystems where large-scale disturbances are infrequent, the mode of succession may be difficult to discern and floristic surveys alone cannot be used determine the underlying processes causing vegetation change. To determine the causes of vegetation change in response to a large-scale fire event, we combined traditional floristic survey data, plant functional traits and environmental variables in a model-based solution to the fourth-corner problem. This approach allowed us to describe the trait-environment relationship and provides an intuitive matrix of environment by trait interaction coefficients. We could then quantify the strength and direction of associations between plant traits, species life-forms and environmental factors in two alpine plant communities over nine years post-fire. Initially, the fire drastically reduced vegetation cover and species density to very low levels. The fourth-corner analysis interaction coefficients indicated that over the course of the nine-year study a high abundance of graminoids, a low abundance of shrubs, tall species and those with high leaf dry matter content had the strongest associations with the two plant communities. We also found evidence for functional homogenisation between these two communities using this novel technique. Analysing plant traits and species responses post-fire in this manner can be used to infer the ecological processes driving shifts in vegetation.

The Charlson comorbidity score: a superior comorbidity assessment tool for the prostate cancer multidisciplinary meeting.

INTRODUCTION: Multidisciplinary team (MDT) meetings use precise prognostic factors to select treatment options for patients with prostate cancer. Comorbidity is judged subjectively. Recent publications favour the Charlson comorbidity score (CS) for the use in the management of prostate cancer. We assess the feasibility of using the CS by our MDT in planning the treatment of patients with prostate cancer. PATIENTS AND METHODS: Patients from the histopathology database aged less than 75 years and with a diagnosis of localized prostate cancer between 1993 and 1995 were included in a notes audit. A second group consisted of patients recommended for curative treatment for localized prostate cancer by the local MDT in 2004. Data on comorbidity, prostatic malignancy and survival up to 10 years was collected. The prognostic accuracy of the CS was assessed for those patients offered radical treatment between 1993 and 1995. RESULTS: Of 1043 patients initially assessed, 37 patients with localized prostate cancer were identified. Using Cox regression, we found the CS to be a statistically significant predictor of survival, following radical treatment for localized prostate cancer (P=0.005). Current practice in 2004 (56 patients) shows a mean (range) Charlson probability of 10-year survival for radical prostatectomy of 0.823 (0.592-0.923) and for radical radiotherapy of 0.653 (0.07-0.936). CONCLUSIONS: Our results support the findings of recent research. We also found the CS easy to calculate and therefore feasible to use in our MDT setting. We propose the introduction of the Charlson score by prostate cancer MDTs to assess age and comorbidity.

Investigating couples' sleep: an evaluation of actigraphic analysis techniques.

'Blip' analysis, fast wavelet transformations (FWT) and correlation analysis have all been used to actigraphically assess the impact one person is having on another's sleep, yet no review exists as to the differences between, and applicability of, these methods for investigating couples' sleep. Using actigraphy data and audio sleep diaries collected from 18 couples, this paper provides such a review. This paper constructs and assesses two novel, analytical methods: Lotjonen's sleep/wake algorithm, and the partner impact on sleep wake analysis (PISWA). Both 'blip' analysis and correlation suggest that the strongest relationship between bed partners occurs on an epoch-to-epoch basis. However, 'blips' deal strictly with onset of movement and fail to incorporate strength and duration of movement. Conversely, correlation analysis incorporates some elements of strength and duration of movement but makes identification of onset problematic. FWT offer useful 'relativistic' pattern recognition, identifying onset, strength and duration of movement, but are difficult to quantify. Although audio diary data support the potential of Lotjonen's sleep/wake algorithm to identify sleep non-movement, sleep movement, wake non-movement (or quiet wakefulness) and wake movement, the problem remains that this method also relies on visualization. Of most promise, we argue, is the PISWA, which examines 'impact' of bed partners through incorporating elements of 'blip' analysis and the sleep/wake algorithm.

Pregnancy after lower urinary tract reconstruction for congenital abnormalities.

OBJECTIVE: To evaluate the effect of pregnancy on renal function, and the effect of congenital urinary tract abnormality and reconstruction on pregnancy and delivery. PATIENTS AND METHODS: The case notes were reviewed of 20 women (median age 32.5 years) who had had 29 live babies. Data collected included patient demographics, congenital urological abnormality, urological reconstructive procedure(s) and any subsequent urological complications. Pregnancy details, including urological and obstetric complications, presentation and mode of delivery, were obtained via a postal questionnaire from the relevant obstetrician. RESULTS: Seven patients had exstrophy-epispadias, seven spinal dysraphism, two sacral agenesis, and one each cerebral palsy, epispadias, imperforate anus and small bladder with vesico-ureteric reflux and congenital incontinence. They had had a mean (range) of 5.7 (1-12) urological reconstructive procedures each. Patients with exstrophy-epispadias had significantly more operations (mean 7.8) than those with spinal dysraphism (mean 4.14) or other diagnoses (mean 2.6) (P < 0.01). At the last follow-up 13 patients had an enterocystoplasty, six a neobladder and one an ileal conduit. Pregnancy-related urological complications were urinary tract infection in 15, upper tract obstruction requiring nephrostomy and stent in three, Mitrofanoff difficulties in two and pyelonephritis in one. There was no significant deterioration in glomerular filtration rate or serum creatinine after pregnancy. Only 10 of the births were normal or assisted vaginal deliveries. Seven patients had emergency and 12 had elective Caesarean sections for obstetric indications, including four breech births in the seven patients with vesical exstrophy. CONCLUSIONS: Pregnancy has no long-term effect on renal function and does not compromise reconstruction. Although there is a substantial complication rate and an increased need for Caesarean section, pregnancy in women with lower urinary tract reconstruction for congenital urological abnormalities is ultimately safe for both mother and baby. Interdisciplinary co-operation is desirable for a successful outcome.

Outcome of the artificial urinary sphincter in female patients.

PURPOSE: We reviewed the outcome in female patients at our unit in whom an artificial urinary sphincter was inserted. MATERIALS AND METHODS: We reviewed notes on 68 patients and mailed a questionnaire to those without recent followup. RESULTS: Median time since insertion was 12 years. Overall 25 patients (37%) had the original artificial urinary sphincter in situ and were dry at a median followup of 7 years. The artificial urinary sphincter was replaced for loss of function in 12 patients, of whom 11 were dry with the replaced device. The device was removed for erosion or infection in 31 patients, of whom 19 underwent successful replacement or were continent after removal. Overall 55 of 68 patients (81%) were continent. Those with neuropathic bladder dysfunction achieved a continence rate of greater than 90%, although half required sphincter removal initially. When the indication for insertion was stress incontinence, 70% of the patients had the original or a replaced artificial urinary sphincter in situ and 82% were continent. All patients with previous pelvic irradiation had the sphincter removed and urinary diversion was done. CONCLUSIONS: The overall continence rate in female patients after insertion of an artificial urinary sphincter is satisfactory. A satisfactory outcome was achieved in terms of stress incontinence and we would recommend an artificial urinary sphincter after an adequate anti-stress incontinence operation fails. Continence in patients with neuropathic bladder dysfunction is excellent and the artificial urinary sphincter should be considered first line treatment in this group, although the risk of revision surgery is high. Pelvic irradiation is a contraindication to the artificial urinary sphincter in female patients.

Cryptosporidium meleagridis from humans: molecular analysis and description of affected patients.

OBJECTIVES: To genetically characterize an unusual genotype of Cryptosporidium from the stools of humans with diarrhoea and to identify risk factors in the affected patients. METHODS: DNA was extracted from human faeces where Cryptosporidium oocysts were detected by light microscopy. Cryptosporidial gene fragments from six different loci were analysed by PCR alone, PCR/RFLP and by DNA sequencing. Oocysts were characterized by light and immunofluorescence microscopy and epidemiological data was collected from the affected patients. RESULTS: Analysis of the Cryptosporidium oocyst wall protein (COWP) gene amplified from > 2000 human faecal samples identified 19 patients all of which produced an unusual RFLP profile. Subsequent DNA sequence analysis of this and an additional four genetic loci (including 18S rRNA sequences) confirmed these as a homogeneous group which was genetically distinct from Cryptosporidium parvum. The isolates were identified as Cryptosporidium meleagridis since the gene sequences were identical to those from this species recovered from birds. Conventional microscopy showed oocysts indistinguishable from C. parvum and reacted strongly with two different commercially available anti-oocyst monoclonal antibodies. None of the patients showed risk factors unusual for cryptosporidiosis; however, ten of the cases occurred during the summer/autumn, six had a history of foreign travel, four were co-infected with Giardia, two were HIV positive, and six were without identifiable immunocompromising factors. CONCLUSIONS: This study further confirms that C. meleagridis, in addition to C. parvum, is involved in human disease. The study also highlights the lack of basic information on the host range of this genus of parasites, the complexity of the transmission routes involved in human cryptosporidiosis, and the value of molecular techniques in identify hitherto unrecognised differences in Cryptosporidium from human faeces.

'Nerve-sparing' cystectomy in women.

Although the indications for cystectomy other than for cancer are few, it is occasionally necessary for severe interstitial cystitis or hemorrhage due to radiation cystitis. The use of substitution cystoplasty after cystectomy has increased in men in the last decade, and this has resulted in the development of 'nerve-sparing' approach to cystectomy to improve continence and potency. The use of substitution cystoplasty in women after cystectomy has lagged behind that in men because it was considered necessary to remove the entire urethra, making orthotopic substitution impossible. Recently the need to remove the entire urethra has been questioned, with the finding that if the bladder neck is free of tumour, recurrence of disease in the urethra has not so far been found to occur. In addition, it appears possible to substitute on to the urethra without incontinence. This has led to the development of a 'nerve-sparing' technique of cystectomy, and renewed interest in the anatomy of the urethra. This paper reviews the current literature on 'nerve-sparing' cystectomy and describes our technique.

The long-term outcome of artificial urinary sphincters.

PURPOSE: We reviewed the outcome of artificial urinary sphincters inserted more than 10 years ago. MATERIALS AND METHODS: We analyzed the records of 100 patients and mailed a questionnaire to those without recent followup. RESULTS: Overall 84 patients were continent, including 36 with the original artificial urinary sphincter in place who were dry at a median followup of 11 years and 27 in whom the device was successfully replaced due to mechanical failure who were previously continent for a median of 7 years. In 21 patients it was removed due to infection or erosion and reimplantation was successful 3 to 6 months later or they remained dry without another artificial urinary sphincter. Of the male patients with a bulbar and bladder neck sphincter 92% and 84%, respectively, were continent at 10 years as well as 73% of the females. Device survival was 66% at 10 years. Overall 37% of the prostheses were removed due to infection or erosion in the 10-year period with the highest risk in females (56%) and lowest in males with a bulbar sphincter (23%). CONCLUSIONS: The artificial urinary sphincter is effective long-term treatment for incontinence in male patients. In female patients the risk of erosion is high, although overall long-term continence is satisfactory.

Continent urinary diversion using the Mainz-type ureterosigmoidostomy--a valuable salvage procedure.

OBJECTIVES: To review the indications and outcome of patients undergoing a Mainz-type ureterosigmoidostomy. PATIENTS AND METHODS: Fourteen patients who had lost or were about to lose their urethra and sphincter mechanism underwent this operation to provide a continent urinary diversion. Patients had a minimum follow-up of 2 years. RESULTS: There were no significant postoperative complications. Three patients have died from recurrent malignant disease. All patients were continent. CONCLUSION: The Mainz-type ureterosigmoidostomy is a useful technique in situations where orthotopic reconstruction is not possible. Incontinence and reflux do not occur with this detubularized pouch.

Pelvic fracture injuries of the female urethra.

OBJECTIVE: To review pelvic fracture urethral injuries in women, generally regarded as rare and thus discussed infrequently. PATIENTS AND METHODS: Twelve patients (age range 7-51 years) with such injuries were reviewed; most had associated injuries, generally more severe than seen in males with urethral injuries. RESULTS: Patients with milder injuries, perhaps damaging just the innervation of the urethra, presented with incontinence; more severe injuries seemed to cause a longitudinal tear in the urethra but again patients presented mainly with incontinence problems. The most severe injuries were associated with complete rupture of the urethra and a distraction defect suggesting an avulsion injury. These problems were difficult to treat both reconstructively and in providing continence. CONCLUSIONS: Pelvic fracture urethral injuries occur in females, but less often than in males. The female urethra seems relatively resistant to injury; differing degrees of severity of pelvic trauma cause different types of urethral injury but in general, a more severe injury is needed to damage it than is necessary in males.

Changing practice in anterior urethroplasty.

OBJECTIVE: To describe our experience of penile urethral repair and reconstruction, cataloguing the change in practice from one-stage flap to two-stage free graft procedures for anterior urethroplasty. PATIENTS AND METHODS: Between January 1992 and December 1996, 79 patients underwent anterior urethroplasty. Of the 45 one-stage bulbar patch urethroplasties, 37 (76%) used buccal mucosal free grafts rather than flaps. Of the 34 penile urethroplasties, 26 (82%) (including all of the circumferential reconstructions) were two-stage procedures. RESULTS: Buccal mucosal free grafts were at least as good as local skin flaps for patch urethroplasty and two-stage repairs gave much better results than one-stage repairs for total circumferential reconstruction of the penile urethra. CONCLUSIONS: For a patch urethroplasty of an uncomplicated stricture in the bulbar urethra, buccal mucosal free grafts are now the material of choice. For a patch urethroplasty of an uncomplicated stricture in the penile urethra the Orandi procedure remains the 'gold standard'. For a circumferential repair of the urethra, particularly the penile urethra, a two-stage repair using a free graft gives better results than a one-stage repair using a flap.

'Nerve-sparing' cystectomy and substitution cystoplasty in patients of either sex: limitations and techniques.

OBJECTIVES: To determine the limitations of cystectomy and orthotopic substitution cystoplasty in men and women with bladder cancer. PATIENTS AND METHODS: Cystectomy and orthotopic substitution cystoplasty were carried out in 79 patients (mean age 60 years, range 31-74, including eight women) who were followed for a mean of 7 years (range 1-13) to evaluate continence, potency and survival. RESULTS: Overall, 80% of the patients were continent without further treatment and 55% of the men who were potent before surgery remained so afterward. The best results were obtained with retrograde cystectomy in both sexes and are only achievable in women in this way. Continence was achieved more easily in women than in men, although pathological delineation of the tumour preoperatively and technical considerations per-operatively make both the selection and the procedure more demanding in women than in men. CONCLUSIONS: Cystectomy and orthotopic substitution cystoplasty is possible in patients of either sex and should be offered to all patients as an alternative to ileal conduit urinary diversion, unless preoperative assessment suggests that the urethra must be removed with the bladder, which is rare in men and uncommon in women. In such patients, a continent diversion may be the preferred option.

Long-term results of augmentation cystoplasty.

OBJECTIVES: To present the long-term results and complications of augmentation cystoplasty. METHODS: 267 patients underwent augmentation cystoplasty with a minimum follow-up of 3 years. RESULTS: Patients with neuropathic bladders had a 78% continence rate with cystoplasty alone increasing to 90% with the addition of an artificial urinary sphincter. Patients undergoing cystoplasty for detrusor instability had a 93% continence rate. The complications of this procedure include bacteriuria, absorption disorders, stones and the potential risk of malignancy. DISCUSSION: The overall results of continence with augmentation cystoplasty are excellent. Long-term follow-up is required to ensure prompt treatment of the complications.

Urethroplasty for balanitis xerotica obliterans.

OBJECTIVE: To review the results of different methods of urethroplasty for anterior urethral strictures caused by balanitis xerotica obliterans (BXO). PATIENTS AND METHODS: Twenty-eight patients underwent urethroplasty for BXO; 12 had a one-stage pedicled penile skin-flap urethroplasty and 16 excision and a two-stage free-graft urethroplasty using nongenital skin. RESULTS: The treatment failed in all patients undergoing a one-stage pedicle penile skin urethroplasty because the disease recurred with BXO, whereas the treatment failed in only one patient using a two-stage free graft procedure. CONCLUSION: A two-stage free-graft urethroplasty using nongenital skin is recommended for anterior urethral strictures caused by BXO.

Early experience with the use of buccal mucosa for substitution urethroplasty.

OBJECTIVE: To evaluate the early results of anterior urethroplasty using a one-stage free graft with buccal mucosa. PATIENTS AND METHOD: Thirty-nine patients (aged 23-59 years) underwent a one-stage urethroplasty using buccal mucosa, 28 as a patch and 11 as tube grafts. All patients were evaluated by post-operative urethrography at 6 months and were followed using urinary flow rates and symptoms for 2-5 years. RESULT: There was one recurrent stricture (3%) in the group with a patch urethroplasty but five of the 11 patients with tube grafts had a recurrent stricture. CONCLUSION: The early results using buccal mucosa for patch urethroplasty are encouraging. Although the results from tube grafts are poor, they are similar to those from other methods of single-stage urethroplasty.

Heating characteristics of a 434 MHz transurethral system for the treatment of BPH and interstitial thermometry.

A system is described for delivering transurethral hyperthermia to the prostate. The system used a helical coil antennae powered by a 434 MHz generator. The antennae was housed in a disposable 22 Ch Foley catheter with water passed down the centre of the winding of the antennae and returned between the antennae and inner wall of the catheter. The flow rate of the circulating water could be varied. The position of the antennae was adjustable with respect to the balloon, essentially altering the length of the antennae. Urethral wall temperature was measured with a thermocouple passed down a small tube moulded into the outer wall of the catheter. Rectal temperature was measured using thermocouples placed in grooves machined into a custom made perspex rectal applicator. A computer program displayed the temperature and controlled the power to the generator. The SAR around the catheter was measured in a polyacrylamide gel phantom. However this does not take into account the effects blood flow and thermal conduction which may have important clinical implications. In order to investigate the actual temperature within the prostate during treatment, a group of patients underwent intraprostatic thermometry.