Nationwide standardisation and evaluation of scintigraphic gastric emptying: reference values and comparisons between subgroups in a multicentre trial.

By means of a standardised procedure, reference values for scintigraphic gastric emptying were established. The influence of gender, age, menstrual cycle, body mass index (BMI) and smoking habits was also evaluated. Eight centres recruited 20 healthy subjects each. The meal consisted of a technetium-99m labelled omelet (1,300 kJ) and of 150 ml unlabelled soft drink. Geometric means of frontal and dorsal acquisitions were utilised in a linear fit model for determination of the linear emptying rate, and by using the intercepts of the regression line with the 90% and 50% levels, the lag phase and half-emptying time, respectively, were defined. All individuals showed an initial lag phase and subsequent linear emptying. Because of a longer lag phase and a slower linear emptying rate, premenopausal women had a slower gastric emptying than postmenopausal women and men of all ages. The gastric emptying rate increased with age in the women, mainly due to a shortened lag phase, while the emptying rate remained almost unchanged with age in the males. There were no significant differences in results between the centres. The menstrual cycle, BMI and smoking habits did not affect emptying. In conclusion, the fact that the results showed a slower gastric emptying rate in younger women compared with older women and men indicates that it is necessary to use separate reference values for fertile females.

[Examination of gastric emptying with gamma camera. Clinically useful, uniform method now established]. / Undersökning av ventrikeltömning med gammakamera. Kliniskt användbar, enhetlig metod nu fastställd.

Although more than 30 years have passed since the introduction of scintigraphic testing of gastric emptying there has been no well-defined standard. Eight Swedish hospitals have established a nationally standardized method for scintigraphic testing of gastric emptying of solids. 160 healthy subjects participated. The meal consisted of a 99mTc-labeled omelet (1300 kJ) and 150 ml unlabeled soft drink (290 kJ). There were no differences in calculated variables between the centers. Premenopausal women showed slower emptying than postmenopausals and men of any age, making separate reference values for younger women necessary.

Urodynamic pattern in asymptomatic infants: siblings of children with vesicoureteral reflux.

PURPOSE: We studied the urodynamic pattern in asymptomatic infants who are siblings of children with vesicoureteral reflux. MATERIALS AND METHODS: Cystometry and perineal electromyography were performed with voiding cystourethrography in 16 male and 21 female infant siblings screened for reflux at age 0.2 to 7.3 months (median 1.1). RESULTS: Vesicoureteral reflux was present in 25% of the male and 10% of the female infants. In those without vesicoureteral reflux unstable bladder contractions were noted in 8% of the male and 16% of the female subjects. In these infants median maximum voiding detrusor pressure was 127 (range 84 to 211) and 72 cm. water (range 42 to 240), respectively, and median bladder capacity was 20 ml. (range 10 to 49 and 10 to 120, respectively). Maximum voiding detrusor pressure was significantly higher in male than in female infants (p <0.01). Perineal electromyography was interpretable in 13 of the 16 male and 16 of the 21 female infants overall. All but 1 female subject had increased activity during voiding, which was also present intermittently in all subjects. CONCLUSIONS: Our study of asymptomatic siblings of children with vesicoureteral reflux has provided results that may be used as reference data for normal urodynamics in early infancy. Instability was rare. Bladder capacity was lower than expected with a predicted capacity at birth of approximately 20 ml. Maximum voiding pressure was high, especially in male subjects. The urodynamic voiding pattern suggests physiological dyscoordination, probably due to immature detrusor-sphincter function.

Bladder dysfunction: an integral part of the ectopic ureterocele complex.

PURPOSE: We evaluate whether bladder dysfunction is common in patients with ectopic ureterocele and, if so, whether it is an integral part of the ectopic ureterocele complex or a result of surgery. MATERIALS AND METHODS: From 1986 to 1995, 34 patients with a mean age of 10 months were treated for large or medium ectopic ureteroceles at our institution and 32 participated in postoperative followup. Bladder function was investigated by a careful history and repeat uroflowmetry, and residual urine estimation was assessed by ultrasound and cystometry. RESULTS: Of the 32 patients 19 had infrequent voiding and 3 had incontinence. Cystometric bladder capacity was increased to greater than 150% of the normal value for age in 15 of 27 patients (55%). Uroflowmetry revealed greater than 5 ml. residual urine in 15 patients (56%). Postoperatively no radiological signs of bladder neck obstruction were found. Increased bladder capacity and residual urine did not correlate with ureterocele size or location, or surgical procedure. There was no progression of bladder dysfunction with age. CONCLUSIONS: Children with ectopic ureterocele are at high risk for a high capacity bladder with incomplete emptying. This bladder dysfunction associated with ectopic ureterocele does not seem to be the result of surgery but an integral part of the disorder.

Urodynamic pattern in infants with urinary tract infection.

PURPOSE: We studied the urodynamic pattern in infants with urinary tract infection and evaluated the influence of the infection. MATERIALS AND METHODS: Cystometry was combined with voiding cystourethrography (video cystometry) in 90 male and 68 female infants admitted to the hospital with first time urinary tract infection. Evaluation was performed 1 to 30 days (mean 11) and 32 to 78 days (mean 46) after diagnosis in 93 and 65 infants, respectively. RESULTS: Bladder instability was found in two-thirds of male and female infants. Compared to older children male infants had high voiding detrusor pressure and low bladder capacity (hypercontractility). Female infants also had increased voiding pressure levels but they were significantly lower than those in male infants. The voiding detrusor pressure was even higher in both sexes when evaluation was delayed after the infection. CONCLUSIONS: Infants with urinary tract infection have bladder instability and hypercontractility compared to older children. Bladder hypercontractility was less pronounced early after infection, suggesting that the infectious agents inhibit detrusor muscle contractility. Whether hypercontractility is a normal urodynamic pattern in infancy or represents bladder dysfunction can only be addressed by urodynamic studies of healthy infants.

Natural filling cystometry in small boys with posterior urethral valves: unstable valve bladders become stable during sleep.

PURPOSE: Our aim was to demonstrate the voiding pattern in small boys with posterior urethral valves during the day and night. MATERIALS AND METHODS: Long-term natural filling and standard cystometry was performed in 16 boys 1.4 to 6 years old (mean age 3.4) in whom posterior urethral valves were diagnosed in infancy. The boys were divided into 2 groups according to whether they had day incontinence. RESULTS: All boys had instability in the daytime but at night bladders were mainly stable. Voiding frequency during the day was high at a mean of 1.7 and 0.5 voidings per hour in the day incontinent and day continent groups, respectively, compared to 0.1 voiding per hour at night in both groups. Voiding detrusor pressure was higher and functional bladder capacity was lower during the day than at night in both groups. CONCLUSIONS: Natural filling cystometry revealed pronounced instability during the day and stable bladders at night. This difference between day and night is an important factor contributing to frequent small voidings during the day, dry nights and high bladder volume in the morning.

Gender-related differences in gastric emptying rate of solid meals.

Controversy exists about the occurrence of a gender-related difference in gastric emptying in humans. In this paper, a strictly standardized scintigraphic method, in which pancakes were labeled with technetium-99m-macroaggregated albumin, was used to follow gastric emptying in 16 male and 14 female healthy young subjects. The resulting mean gastric emptying curves described biphasic patterns. There was a similar lag period (30.6 +/- 4.2 vs 33.6 +/- 3.8 min; means +/- SEM) but a faster linear gastric emptying rate (32.9 +/- 1.4 vs 22.0 +/- 1.3%/hr), a shorter half-emptying time (111.2 +/- 8.6 vs 158.2 +/- 6.4 min) and lower residual radioactivity after 2 hr (43.0 +/- 3.5 vs 62.8 +/- 1.7%) in the male subgroup as compared with the female subgroup. The differences were highly statistically significant. As a result, separate reference values are recommended for young male and fertile female subjects.

Development of the urodynamic pattern in infants with myelomeningocele.

OBJECTIVE: To study changes in the urodynamic pattern during the first year of life in patients with myelomeningocele (MMC) and to correlate these to deleterious effects on the upper urinary tract. PATIENTS: methods Thirty-four infants with MMC were investigated using cystometry, micturating cystourethrography and urography at 1, 4 and 10 months of age. RESULTS: Detrusor contractility was characterized by an increase in activity, with hyper-reflexia in 45% initially, increasing to 65% at the 4-month investigation. During the same period, the number of infants with areflexia decreased from 25% to 12%. Between 4 and 10 months, there were only minor changes in detrusor contractility. The number of patients with poorly compliant bladders also increased between the first and fourth month. The number of patients with elevated outlet resistance increased only slightly during the first year, from 32% of all infants at the initial investigation to 40% at the 10-month follow-up. Vesico-ureteric reflux was detected in 12 of the patients during the year, with five already diagnosed at the first investigation. Almost all refluxes were cured with clean intermittent catheterization, with additional pharmacological therapy in two patients; one patient required a vesicostomy. CONCLUSIONS: This study indicates that detrusor activity, and to some extent outlet resistance, change during the first year of life in infants with MMC. The changes were mainly increases in activity and occurred mostly between the first and fourth months of age. There was a strong correlation between the occurrence of reflux and poor compliance, hypercontractility and outlet obstruction.

Video cystometric recording of dilating reflux in infancy.

PURPOSE: Bladder hypercontractility has previously been suggested to occur in male infants with gross bilateral reflux, and the causal relationship between hypercontractility and reflux has been questioned. MATERIALS AND METHODS: In this video urodynamic study of dilating reflux the association between reflux and bladder pressure was evaluated in 16 infants. RESULTS: In our 11 male patients hypercontractility was noted often, usually with reflux that occurred simultaneously with an increase in detrusor pressure. In the 5 female patients no hypercontractility was noted and reflux occurred without an increase in detrusor pressure. CONCLUSIONS: Our results further confirm the association between bladder dysfunction and dilating reflux in infants but with different patterns in male and female infants.

Bladder dysfunction in boys with posterior urethral valves before and after puberty.

PURPOSE: We characterized bladder dysfunction in boys with posterior urethral valves during childhood and adolescence. MATERIALS AND METHODS: A total of 12 prepubertal boys with posterior urethral valves presenting before age 1 year was followed from ages 4 to 14 years and compared to 6 postpubertal boys with posterior urethral valves. Urodynamic evaluations and renal function studies were performed repeatedly. RESULTS: Patients had a changing urodynamic pattern with instability decreasing with time, increasing bladder capacity and commonly an unsustained voiding contraction causing emptying difficulties. Postpubertal boys had high capacity bladders with low contractility. CONCLUSIONS: We suggest that previously described urodynamic patterns of the valve bladder (unstable, poorly compliant and over distended bladders) are variations of the same basic pattern that changes with time toward decompensation.

The changing urodynamic pattern in valve bladders during infancy.

Bladder dysfunction in boys with posterior urethral valves is well documented in studies of long-term followup. These reports suggest that dysfunctional bladders can be divided into 3 main types, including unstable, low compliant and over distended. To our knowledge urodynamic findings at presentation during infancy have not been described previously. We report on 16 male patients born between 1989 and 1993 who presented with symptoms of posterior urethral valves between birth and age 5 months, and who were followed with repeated urodynamic evaluations for a mean of 19 months. At presentation the bladder was hypercontractile with low capacity. During the first 3 years of life, the urodynamic pattern changed with vanishing hypercontractility and increasing bladder capacity, although instability remained unchanged with emptying difficulties. Thus, the 3 patterns of bladder dysfunction reported in older boys after resection of posterior urethral valves could not be found in infants and small children.

Positive bladder cooling test in neurologically normal young children.

The bladder cooling test, which consists of rapid infusion of 0 to 8C saline into the bladder with simultaneous pressure measurement, was performed in 50 neurologically intact infants and children 6 months to 13 years old. The patients were referred for urodynamic investigation because of various disorders of the lower urinary tract. A positive bladder cooling test was defined as a sustained reflex detrusor contraction of about the same magnitude as the micturition contraction. The test was positive during the first 4 years of life but typically negative in children older than 5 years. These findings indicate that a positive bladder cooling test is an infant reflex response that, with the maturation of the central nervous system, becomes suppressed by descending signals from higher centers.

Declining incidence of nephropathy in insulin-dependent diabetes mellitus.

BACKGROUND: The high relative mortality among patients with insulin-dependent diabetes mellitus results mainly from diabetic nephropathy. The cumulative incidence of nephropathy of 25 to 30 percent among patients who had had diabetes for 25 years remained stable from 1950 to the early 1980s. In a population study, we assessed recent trends in the incidence of diabetic nephropathy. METHODS: We studied all 213 patients in whom insulin-dependent diabetes mellitus was diagnosed before the age of 15 years between 1961 and 1980 in a district in southeastern Sweden. Ninety-two percent of the patients were followed from the onset of diabetes to 1991 or to death. Patients with persistent albuminuria (positive Albustix test) were considered to have diabetic nephropathy. Glycosylated hemoglobin was measured periodically in all patients, beginning in 1980. RESULTS: The cumulative incidence of persistent albuminuria after 25 years of diabetes decreased from 30.0 percent among the patients in whom diabetes developed in the period 1961 to 1965 to 8.9 percent among those in whom it developed from 1966 to 1970 (P = 0.01). After 20 years of diabetes, the cumulative incidence decreased from 28.0 percent among the patients in whom diabetes developed from 1961 to 1965 to 5.8 percent among those in whom it developed from 1971 to 1975 (P = 0.01). Persistent albuminuria has not yet developed in any patient in whom diabetes was diagnosed in the period 1976 to 1980. The average glycosylated hemoglobin value decreased from 7.4 percent in the period 1980 to 1985 to 7.0 percent from 1986 to 1991 (P < 0.001). The mean glycosylated hemoglobin value was higher in the patients with persistent albuminuria than the patients with no albuminuria (8.1 percent vs. 7.1 percent, P < 0.001). CONCLUSIONS: During the past decade the cumulative incidence of diabetic nephropathy, as manifested by persistent albuminuria, among patients who have had diabetes for 25 years has decreased substantially, probably as a result of improved glycemic control.

Gastroplasty for obesity: long-term weight loss improved by vagotomy.

Sixty-nine (13M, 56F), severely obese patients (body mass index 47 kg/m2) have had vertical banded gastroplasty (GP) with 5-cm polypropylene mesh (n = 39) or fascia (n = 30) bands since 1981. Of these 69 patients, 30 also had truncal vagotomy (TVG) without drainage. Total office follow-up rate is 94%. During follow-up of 1 year or more (mean 60 months), 25 patients with vagotomy plus gastroplasty lost 33 +/- 3 kg, corresponding to 51% of excess weight, compared to 21 +/- 3 kg (34% excess weight) in the 34 patients having gastroplasty alone (p < 0.01). In patients followed > or = 5 years (mean 83 months) 10 patients with TVG lost 40 +/- 5 kg (61% of excess) compared to 17 +/- 4 kg (28% of excess) in 22 patients with GP alone (p < 0.001). Frequency and severity of complications were similar in both groups, but there were seven reoperations after GP and three after TVG (p < 0.05). Studies of gastric emptying of a solid meal in 14 of the patients with GP and 14 with TVG demonstrated greater weight loss in those with prolonged emptying and gastroesophageal pooling, though the emptying rates of patients with GP and those with TVG showed no statistically significant difference. Our earlier studies, which showed reduced liquid consumption after vagotomy, imply that this mechanism (rather than delayed emptying) explains why vagotomy potentiates weight loss after gastroplasty.

Tc-labelled pancake for studies of gastric emptying of solids.

To achieve a stable isotope marker of solid food, different variants of isotope-labelled Swedish pancake were tested. The marker stability was investigated by a new method assumed to test both the affinity of the isotope complex to the test meal and the mechanical stability. The test procedure included use of a gamma camera and human gastric juice. Pancakes labelled with either pertechnetate, 99TcmO4 (Tc-pert), or 99Tcm-macroalbumin aggregates (Tc-MAA) were compared. The results showed a significant difference (P less than 0.01), with 91.4 +/- 2.1% (mean +/- 1 S.D.) of activity remaining in the Tc-MAA pancake (n = 5) and only 81.1 +/- 5.8% in the Tc-pert pancake (n = 6) after 3 h. Pancakes labelled with Tc-MAA were also compared with chicken liver labelled in vivo with 99Tcm-sulphur colloid (Tc-SC). The results revealed significantly better marker stability (P less than 0.05) of pancakes compared to chicken liver, with 83.0 +/- 9.1% remaining in the Tc-MAA pancake (n = 8) and 74.9 +/- 6.7% in the Tc-SC chicken liver (n = 8) after 180 min.

Late ischaemic sequelae after umbilical artery catheterization.

The acute complications of umbilical artery catheterization are well recognized but very little is known about long-term consequences. Two cases are presented which indicate that umbilical artery catheterization during the neonatal period may give rise to late ischaemic complications.

Home blood glucose monitoring in diabetic children and adolescents. A 3-year feasibility study.

In order to elucidate the question whether blood glucose monitoring should replace glucosuria testing in childhood diabetes 160 diabetic children and adolescents were invited to participate in a feasibility study on home blood glucose testing. Seventeen girls and 15 boys with an age of 4-21 years and duration of diabetes for 0.3-18.7 years accepted, thus a selection of motivated patients. They performed 20-22 diurnal blood glucose profiles, each consisting of 7 blood samples, during a 3 month period. Thereafter, all patients were encouraged to continue blood glucose self-control and the actual performance of the 32 patients was evaluated 3 years later. Daily glucosuria tests were also made and HbA1 was analysed. Patients' attitudes were evaluated through 2 questionnaires. The study shows that blood glucose monitoring is feasible in the actual age groups. Most patients were positive towards blood tests, particularly because it gave an immediate answer to an actual problem, but its introduction did not change the metabolic control. However, pain restricted its daily use and only 6.4% of the patients preferred blood testing to urinalysis for long term use. Furthermore, the correlation between home glucosuria and HbA1 was as good as between home blood glucose and HbA1. It is concluded, that blood glucose self-monitoring is a valuable tool in the management of childhood diabetes, but that it should be regarded as a complement to and not a substitute for daily home urinalysis.