[Addictions]. / Addictions.

This article describes a new form of administration of inhaled prescribed heroin currently under investigation. It underlines the particularity of opioid agonist prescription in jail and presents new perspectives in using psilocybin in addiction medicine treatment. A brief literature review about vaping confirms its interest in quitting cigarette, with a cost of addiction to vaping and recent worrisome reports of chemical pneumonia. Finally, the withdrawal of WHO guidelines on opiates use in pain management, in the context of a suspicion of conflict of interest, underlines the sensible balance between over- and under- prescription of opiates in analgesic treatment.

Cet article montre l'intérêt d'une nouvelle forme d'administration inhalée d'héroïne pharmaceutique actuellement à l'étude. Il sensibilise aux conditions particulières de la prescription d'agonistes opioïdes en milieu carcéral et ressuscite des souvenirs des seventies en reprenant l'exploration scientifique des vertus thérapeutiques de la psilocybine. Même si le vapotage semble être un bon moyen de lâcher la cigarette, les anciens fumeurs ont tendance à s'y accrocher et un risque de pneumonie chimique parfois mortelle vient d'être mis en évidence. Finalement, le retrait de l'OMS de deux directives relatives à l'usage d'opioïdes dans le traitement de la douleur, sur fond de suspicion de conflit d'intérêts, montre l'équilibre délicat entre sur- et sous-prescription des antalgiques opioïdes.

Cannabis use among a sample of 16 to 18 year-old students in Switzerland.

BACKGROUND: The aim of this study was to estimate the prevalence of cannabis use among Swiss students and to assess their attitudes regarding health and safety issues associated with drug use. SUBJECTS AND METHODS: After a workshop, 173 students (23.1% male, 75.7% female; 44.4% age 16, 43.8% age 17 and 11.8% age 18) from a Swiss school were surveyed by questionnaire. RESULTS: 59.3% (n=103) of all participants had tried cannabis, and 30.1% of those who reported cannabis use had consumed more than 100 joints. Of those 103 students with cannabis experience, 6.8% rated the risk of cannabis-related psychic effects as low, and 9.8% were not concerned about driving under the influence of cannabis. In cases of heavy cannabis use, the chance of increased tobacco, alcohol or other drug use is higher than for those with less or no cannabis use at all (odds ratios of 4.33-10.86). CONCLUSIONS: This paper deals primarily with cannabis prevalence data in adolescents from previous studies and sources, and shows that our findings deviate significantly - and surprisingly - from past research. Our data from a school survey indicates higher cannabis use than data from official drug policy studies. Additionally, our data shows that the students' self-reported attitudes towards health and safety issues were mostly realistic. The examination of methodological issues that might impact prevalence estimates should be added to the cannabis literature.

Can autologous myoblasts be used as a potential bulking agent?

OBJECTIVE: To investigate the behaviour of donor myoblasts at the vesico-ureteric junction (VUJ) and to evaluate their potential as an autologous bulking agent, as myoblast transplantation has been shown to regenerate damaged or degenerated tissue, and it was postulated that they could be used to treat vesico-ureteric reflux. MATERIALS AND METHODS: Muscle biopsies were obtained from the lower limb muscles of 10 pigs. The quality of the cells was evaluated by electrophysiological and immunohistochemical tests. The cell membranes of myoblasts were labelled with PKH26, a fluorescent dye. Six weeks after taking of the muscle biopsies all pigs underwent cell transplantation; 30 x 10(6) cells suspended in transplantation medium (in 1-mL syringes) were injected at the VUJ, into the proximal urethra and the rhabdosphincter. At the VUJ volumes of 1 mL were injected, whereas in the urethra and rhabdosphincter small cell depots (0.1 mL) were injected. All the pigs were killed 8 weeks later, and the myoblasts and newly formed myofibres were identified using fluorescence microscopy, with a histological evaluation and investigation of potential local inflammatory reaction. RESULTS: Two to three intact layers of autologous myoblasts were found in the outer aspects of the large cell depots in the VUJ. Immunohistochemistry further showed that the myoblasts were only viable at these outermost borders of the large bulking areas, whereas necrosis with red fluorescent cell detritus was visible in the remaining central aspects of the large bulk of cells. By contrast, cells survived and formed myotubes in the wall of the proximal urethra and the rhabdosphincter where the small cell depots had been injected. CONCLUSIONS: In small depots, transplanted autologous myoblasts can survive and differentiate into myofibres, while in a large bulk of cells the vast majority of cells become necrotic. The present results show that myoblasts cannot be used for augmentation of large volumes of tissue or as a bulking agent.

Chronic pelvic pain in women: still a challenge.

Chronic pelvic pain (CPP), a common condition particularly in reproductive-aged women, causes disability and distress, and significantly compromises quality of life and affects healthcare costs. The pathogenesis of CPP is still poorly understood and consequently poorly managed. Furthermore, the lack of a consensus on the definition of CPP greatly hinders epidemiological studies. Patients present with various associated problems, including bladder or bowel dysfunction, gynaecological pathologies or sexual dysfunction, and other systemic or constitutional symptoms. Other conditions, e.g. depression, anxiety and drug addiction, can also coexist. Effective management presupposes an integrated knowledge of all pelvic organs and other systems, including musculoskeletal, neurological and psychiatric systems. The key to treating CPP is to treat it as the complex disease it is. Treatment options range from conservative medical therapy to surgical intervention, and are primarily directed towards symptom relief. Unsatisfactory results of treatment render this condition a frustrating problem for both patients and physicians.

Anatomical approach for surgery of the male posterior urethra.

OBJECTIVE: To investigate, in a morphological study, the anatomy of the male rhabdosphincter and the relation between the membranous urethra, the rhabdosphincter and the neurovascular bundles (NVBs) to provide the anatomical basis for surgical approach of the posterior urethra as successful outcomes in urethral reconstructive surgery still remain a challenging issue. MATERIALS AND METHODS: In all, 11 complete pelves and four tissue blocks of prostate, rectum, membranous urethra and the rhabdosphincter were studied. Besides anatomical preparations, the posterior urethra and their relationship were studied by means of serial histological sections. RESULTS: In the histological cross-sections, the rhabdosphincter forms an omega-shaped loop around the anterior and lateral aspects of the membranous urethra. Ventrally and laterally, it is separated from the membranous urethra by a delicate sheath of connective tissue. Through a midline approach displacing the nerves and vessels laterally, injuries to the NVBs can be avoided. With meticulous dissection of the delicate ventral connective tissue sheath between the ventral wall of the membranous urethra and the rhabdosphincter, the two structures can be separated without damage to either of them. This anatomical approach can be used for dissection of the anterior urethral wall in urethral surgery. CONCLUSIONS: Based on precise anatomical knowledge, the ventral wall of the posterior urethra can be dissected and exposed without injuring the rhabdosphincter and the NVBs. This approach provides the basis for sparing of the rhabdosphincter and for successful outcomes in urethral surgery for the treatment of bulbo-membranous urethral strictures.

Association of lower urinary tract symptoms and chronic ischaemia of the lower urinary tract in elderly women and men: assessment using colour Doppler ultrasonography.

OBJECTIVES: To investigate, using transrectal colour Doppler ultrasonography, (TRCDUS) whether perfusion of the bladder and prostate is reduced in elderly patients with lower urinary tract symptoms (LUTS), common in later life, as experimental data suggest that chronic ischaemia has a key role in the development of LUTS. PATIENTS, SUBJECTS AND METHODS: In 32 elderly patients with LUTS (12 women, mean age 82.3 years, group 1; and 20 men, 79.4 years, group 2) perfusion of the bladder neck (in women) and of the bladder neck and prostate (in men) was measured using TRCDUS and the resistive index (RI) and colour pixel density (CPD) determined, assessed by a TRUS unit and special software. To assess the age-related effect two control groups of 10 young healthy women (mean age 42.3 years, group 3) and 10 age-matched healthy men (mean age 41.5 years, group 4) were also enrolled. RESULTS: Irrespective of gender, there was markedly lower bladder perfusion in elderly patients with LUTS than in the younger subjects. The mean (SD) RI of the bladder neck in group 1, of 0.88 (0.06), and group 2, of 0.80 (0.08), was higher than in control groups 3, of 0.62 (0.05), and group 4, of 0.64 (0.09). The results were similar for the CPD measurements. The frequency of daily and nightly micturition showed a strong negative correlation with perfusion in the urinary bladder. CONCLUSION: In elderly patients with LUTS there was decreased perfusion of the bladder neck and prostate when assessed using TRCDUS. Therefore, decreased perfusion in the urinary bladder might be responsible for the development of LUTS with advancing age.

Real-time virtual ultrasonographic radiofrequency ablation of renal cell carcinoma.

OBJECTIVE: To evaluate the usefulness of real-time virtual ultrasonography (RVS) as a new navigational tool for percutaneous radiofrequency ablation (RFA) of solid renal cell carcinoma (RCC). PATIENTS AND METHODS: Ten patients with 13 RCCs were treated with percutaneous RFA using RVS, which displays ultrasonograms and corresponding multiplanar reconstruction images of computed tomography in parallel. RESULTS: RVS allowed excellent anatomical visualization and precise navigation of RFA for RCC. All patients were treated successfully in one session with percutaneous RVS RFA. There were no significant complications, and none of the patients had a local tumour recurrence during the follow-up. CONCLUSION: RVS for RFA of solid RCC is a new and promising alternative imaging method.

Do mountain bikers have a higher risk of scrotal disorders than on-road cyclists?

OBJECTIVE: To sonographically investigate whether mountain bikers have a higher prevalence of scrotal abnormalities compared with on-road cyclists. DESIGN: We studied 85 male mountain bikers (mean age: 25 years; range 17-45 years) and 50 male on-road cyclists (mean age: 23 years, range 15-46 years) with regard to scrotal findings on ultrasound (US). SETTING: Medical University Innsbruck, Austria. PARTICIPANTS: Only males who gave a history of extensive mountain biking or on-road bicycling (2 hours or more per day on 6 days a week with a covered distance of more than 5,000 km/year) were entered in our study. INTERVENTIONS: In addition to clinical evaluation, a standard ultrasonographic examination of the scrotum was performed using a linear array transducer operating at a frequency of 8.0 MHz (Acuson Sequoia 512). MAIN OUTCOME MEASUREMENTS: The sonographic findings obtained in mountain bikers were compared with those obtained in on-road cyclists. RESULTS: Eighty of 85 mountain bikers (94%) and 24 of 50 on-road cyclists (48%) presented with abnormal findings on scrotal US. Abnormal US findings in mountain bikers included scrotoliths in 69 bikers (81%), spermatoceles in 39 bikers (46%), and epididymal calcifications in 34 bikers (40%). US findings in on-road cyclists were scrotoliths in 8 cyclists (16%), spermatoceles in 13 cyclists (26%), and epididymal calcifications in 6 cyclists (12%). The overall number of scrotal abnormalities was significantly greater in mountain bikers than in on-road cyclists (P < 0.001). CONCLUSIONS: Mountain bikers compared with on-road cyclists have shown to be at a higher risk for scrotal disorders on US examination. Not only protective measures but also the awareness of the bikers are required to reduce the potential risk. Further studies should be undertaken to determine the clinical significance of the sonographic changes.

Female sexual dysfunction: a new urogynaecological research field.

OBJECTIVE: To critically review published data on the urogynaecological aspects of female sexual dysfunction (FSD), as FSD is a developing multidisciplinary issue associated with several biological, medical and psychological factors. METHODS: The reported prevalence of FSD is 19-50% and women with lower urinary tract symptoms or urinary incontinence (UI) not only complain of a deteriorating of quality of life but also of sexual life with an incidence as high as 26-47%. Furthermore, urogynaecological surgery represents an important but underestimated cause of FSD. Different databases (Pub Medical, Medline, serial titles, the Cochrane library and the NLM gateway database) were searched for the keywords 'sexuality; sexual function; urinary incontinence; pelvic organ prolapse; questionnaire; symptom severity; epidemiology; quality of life; instruments; sexual health; vagina; vaginal surgery; pelvic surgery'. RESULTS: There is a lack of a standardized instrument for assessing FSD. Recent studies investigate the impact of UI on sexual function, but the pathophysiology has not been elucidated. Vaginal or pelvic surgery does not affect overall sexual satisfaction. CONCLUSIONS: Our investigation highlights the need for studies to assess the anatomical, physiological and sensory mechanisms related to FSD. Specific questionnaire are needed to quantify the problem. In the definition, symptoms assessment and preoperative counselling is important, to make a distinction between overall sexual function and individual parameters, such as psychosocial context. Only in this way, will it be possible to identify new therapeutic targets. A definition of success in urogyneacological terms should include aspects of quality of life and quality of sexual life. Immediate research in this field is needed.

Assessment of the intratesticular resistive index by colour Doppler ultrasonography measurements as a predictor of spermatogenesis.

OBJECTIVE: To investigate the value of the resistive index (RI) of intratesticular arteries, and to establish diagnostic criteria for normal and pathological sperm counts on the basis of quantitative colour Doppler ultrasonography (CDUS), as the assessment of the testicular RI is widely used to measure intratesticular blood flow. PATIENTS AND METHODS: In all, 160 men (aged 22-43 years, 320 testicles) were prospectively investigated; 80 had a normal and 80 a pathological sperm count, the latter having mild oligoasthenozoospermia. The RI was measured using a high-frequency Doppler ultrasound probe (14 MHz), three times on each testicle at an intratesticular artery in the upper, middle and lower testicular pole. The testicular volume was also measured by US. The RI values were compared between patients with normal and pathological sperm counts, and were compared statistically with testicular volumes. In addition, blood samples were obtained for DNA extraction, chromosome analysis and hormonal evaluations. RESULTS: Patients with normal sperm counts had a mean (sd) RI of 0.54 (0.05) and a mean testicular volume of 18.7 (5.2) mL, the respective values in those with pathological sperm counts were 0.68 (0.06) and 16.8 (6.0) mL, with a significantly greater RI in the latter (P < 0.001), but with no statistically significant difference in testicular volume between the groups (P > 0.05). CONCLUSION: These preliminary data suggest that an RI of >0.6 might be suggestive of a pathological sperm count in andrological patients. The intratesticular RI as measured by CDUS seems to be a reliable indicator for routine clinical use to identify subfertile men.

Dutasteride prior to contrast-enhanced colour Doppler ultrasound prostate biopsy increases prostate cancer detection.

OBJECTIVES: This study assessed the effect of premedication with dutasteride, a dual 5alpha-reductase inhibitor, on prostatic blood flow prior to prostate biopsy and its impact on prostate cancer detection. METHODS: Thirty-six patients, aged 52-74 yr, with elevated prostate-specific antigen (PSA) levels (>or=1.25 ng/ml and free-to-total ratio of <18%) were treated with dutasteride 14 d prior to prostate biopsy. Contrast-enhanced colour Doppler (CECD) ultrasound was performed before and 7 and 14 d after dutasteride treatment. Contrast-enhanced targeted biopsies (

Adult stem cell therapy of female stress urinary incontinence.

OBJECTIVES: To investigate the efficacy of transurethral ultrasound (TUUS)-guided injections of autologous myoblasts and fibroblasts in women with incontinence. METHODS: Between January and June 2005, 20 female patients suffering from stress urinary incontinence (SUI) were included. Skeletal muscle biopsies were taken from the left arm to obtain cultures from autologous fibroblasts and myoblasts. By TUUS guidance the fibroblasts were injected into the urethral submucosa and the myoblasts were injected into the rhabdosphincter. A defined incontinence score, quality-of-life score and urodynamic, electromyographic, and laboratory parameters, as well as morphology and function of urethra and rhabdosphincter were evaluated before and up to 2 yr after therapy. RESULTS: Eighteen of 20 patients were cured 1 yr after injection of autologous stem cells and in 2 patients SUI was improved. Two years after therapy 16 of the 18 patients presented as cured, 2 others were improved, and 2 were lost to follow-up. Incontinence and quality-of-life scores were significantly improved postoperatively. The thickness of urethra and rhabdosphincter as well as activity and contractility of the rhabdosphincter were also statistically significantly increased after therapy. CONCLUSIONS: Clinical results demonstrate that SUI can be treated effectively with autologous stem cells. The present data support the conclusion that this therapeutic concept represents an elegant and minimally invasive treatment modality to treat SUI.

Comparison of the precision of transurethral endoscopic versus ultrasound-guided application of injectables.

OBJECTIVE: To compare the precision of transurethral endoscopic- vs ultrasound (US)-guided injections, as transurethral application of various injectables under endoscopic view are widely used to treat urinary incontinence. MATERIAL AND METHODS: Bovine collagen was injected into the lower urinary tract in 20 dead female pigs. In each pig five depots of collagen were injected and there were five pigs in each group. In group I collagen was injected into the urethral wall under endoscopic control. In group II collagen depots were injected periurethrally under endosocopic guidance. In group III collagen was injected into the urethral wall under US control. In group IV collagen depots were injected periurethrally under US guidance. A transurethral US probe (6 F, 15 MHz) and injection device were used for transurethral US-guided injections. In all pigs the urethra and the periurethral tissue were removed after injection and investigated using anatomical preparations and histological sections. RESULTS: In group I only two collagen depots were actually located in the urethral wall in two pigs (two of 25 depots, 8%). In group II five depots in two pigs were located in the urethral wall (five of 25 depots, 20%). The periurethral collagen depots were found to spread out in the loose connective and fat tissue around the urethra. In group III all US-guided injections of collagen were situated in the urethral wall and in group IV they were all located periurethrally. CONCLUSIONS: The present study shows that endoscopic application of injectables is an inaccurate technique, while US-guided injections are precise. US-guided injection enables excellent control of the therapeutic procedure.

Comparison of contrast-enhanced color Doppler imaging (CDI), computed tomography (CT), and magnetic resonance imaging (MRI) for the detection of crossing vessels in patients with ureteropelvic junction obstruction (UPJO).

OBJECTIVE: To assess the use of contrast-enhanced color Doppler imaging (CDI), computed tomography (CT), and magnetic resonance imaging (MRI) for the detection of crossing vessels at the ureteropelvic junction (UPJ) in patients with ureteropelvic junction obstruction (UPJO). MATERIALS AND METHODS: Forty-eight patients aged 18-69 yr (mean age, 52) who had been diagnosed with an UPJO on intravenous pyelography and diuretic renography were included. Contrast-enhanced CDI was performed by using both color Doppler frequency and color Doppler amplitude ("Power") modes. Spiral CT was performed by using a three-phase CT (arterial, venous, and excretory phases) allowing for CT angiography. MRI technique included dual-phase magnetic resonance angiography (arterial, venous) for the assessment of respective arteries and veins. The type (ie, arterial or venous) and position of the vessel relative to the UPJ (ie, anterior or posterior) were assessed. The CDI, CT, and MRI findings were correlated with the surgical findings at laparoscopic pyeloplasty. RESULTS: Forty-four of 48 patients (92%) demonstrated crossing vessels at subsequent laparoscopy. Altogether a total of 60 vessels were detected. Contrast-enhanced CDI and MRI correctly detected all crossing vessels (accuracy, 100%), whereas CT missed four posterior crossing veins (accuracy, 93%). CONCLUSION: Contrast-enhanced CDI is recommended as first-line imaging modality for the detection of crossing vessels in patients with UPJO.

alpha-Blockers improve chronic ischaemia of the lower urinary tract in patients with lower urinary tract symptoms.

OBJECTIVE: To investigate whether a mechanism of action of alpha-blockers on lower urinary tract symptoms (LUTS) involves improved perfusion of the LUT. PATIENTS, SUBJECTS AND METHODS: The accuracy of perfusion measurements using transrectal colour Doppler ultrasound (TRCDUS) and colour pixel density (CPD) was initially confirmed in a porcine model. Following this confirmation, measurements were taken from four healthy male volunteers and 19 patients with LUTS. The urinary bladder was filled slowly (50 mL/min) with 0.2 m KCl, which resembles the osmolarity of concentrated urine, and evaluated by cystometry. In parallel, TRCDUS and measurement of the CPD of the LUT were performed. The patients with LUTS were then treated with daily alpha-blocker (0.4 mg tamsulosin) for 5 weeks and urodynamic variables as well as perfusion were evaluated again. RESULTS: In the healthy men, perfusion of the LUT increased considerably (157%) during filling of the bladder to a mean (sd) maximum cystometric capacity (C(max)) of 481 (28.9) mL. All the patients with LUTS had a reduced mean C(max) during filling with KCl at 322.4 (58.5) mL. The mean CPD in the urinary bladder and the prostate were only increased by 58.4% during filling with KCl. After alpha-blocker therapy the mean C(max) during filling with KCl rose to 382.5 (42.9) mL; furthermore, perfusion of the LUT measured by CPD was significantly increased (132.8%). CONCLUSIONS: The present data strongly suggest that LUTS are associated with chronic ischaemia of the prostate and urinary bladder. alpha-blockers increase perfusion in the LUT and C(max). These results might explain the therapeutic effects of alpha-blockers on LUTS.

Ultrasound of prostate cancer: recent advances.

Prostate cancer is the most common cancer in men. In the future, a significant further increase in the incidence of prostate cancer is expected. Therefore, improvement of prostate cancer diagnosis is a main topic of diagnostic imaging. The systematic prostate biopsy ("ten-core biopsy") is now the "gold standard" of prostate cancer diagnosis but may miss prostate cancer. Contrast-enhanced colour Doppler ultrasound (US) and elastography are evolving methods that may dramatically change the role of US for prostate cancer diagnosis. Contrast-enhanced colour Doppler US allows for investigations of the prostate blood flow and consequently for prostate cancer visualization and therefore for targeted biopsies. Comparisons between systematic and contrast-enhanced targeted biopsies have shown that the targeted approach detects more cancers and cancers with higher Gleason scores with a reduced number of biopsy cores. Furthermore, elastography, a new US technique for the assessment of tissue elasticity has been demonstrated to be useful for the detection of prostate cancer, and may further improve prostate cancer staging. Therefore, contrast-enhanced colour Doppler US and elastography may have the potential to improve prostate cancer detection, grading and staging. However, further clinical trials will be needed to determine the promise of these new US advances.

Acute pyelonephritis: comparison of diagnosis with computed tomography and contrast-enhanced ultrasonography.

OBJECTIVE: To assess the value of contrast-enhanced ultrasonography (US) with the contrast pulse-sequence (CPS) technique for detecting renal parenchymal changes in acute pyelonephritis (APN), compared with contrast-enhanced computed tomography (CT) as the reference standard. PATIENTS AND METHODS: We examined 100 patients (82 women, 18 men; mean age 30.2 years, range 18-67); children (those aged <18 years) were excluded from the study. All patients had clinical symptoms suggestive of APN. For the US a Sequoia 512 (Acuson, Mountain View, CA, USA) unit including Cadence CPS technology, with a 6C2 probe, was used. A bolus of a 2.4-mL US contrast agent SonoVue (Bracco, Milan, Italy) was injected. For CT a multislice 16-row unit was used (Sensation 16, Siemens, Erlangen, Germany), at a table speed of 2.5 mm/s and a slice thickness of 3 mm; 100 mL of intravenous iodinated contrast agent (flow 3 mL/s) was injected. RESULTS: On contrast CT, 84 patients (84%) had renal parenchymal changes suggestive of APN; on contrast US, 82 of the 84 (98%) showed renal parenchymal changes, and APN was correctly diagnosed. Seventy-six patients (90%) had unilateral and eight (10%) had bilateral APN, and in two (2%) with APN the diagnosis could not be confirmed by US/CPS (false-negative). No false-positive findings were detected on US/CPS, which had a sensitivity of 98%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 89%. CONCLUSION: CPS/US is accurate for detecting parenchymal changes in APN; it is very sensitive and specific, and allows small renal parenchymal changes to be detected with no radiation exposure.