A Systematic Review of Surgical interventions for the Treatment of Bladder Pain Syndrome/Interstitial Cystitis.

CONTEXT: Bladder pain syndrome/interstitial cystitis (BPS/IC) is a poorly understood chronic debilitating condition. Surgery is reserved for severe refractory cases; however, there is no consensus on patient selection or optimal approach. OBJECTIVE: To evaluate the evidence relating to the safety and efficacy of surgical interventions for treating BPS/IC. EVIDENCE ACQUISITION: PubMed and Scopus databases were searched for original studies, using keywords "cystectomy", "interstitial cystitis", and "bladder pain syndrome". Articles were reviewed and screened by three independent reviewers. EVIDENCE SYNTHESIS: A total of 450 patients were identified from 20 eligible studies: mean age was 54.5 yr and 90.2% were female. The median duration of symptoms preoperatively was 60 mo (range 9-84), with a mean follow-up of 45.5 mo. A total of 448 patients underwent surgery: subtotal cystectomy with cystoplasty (48.6%), cystectomy and orthotopic neobladder (21.9%), cystectomy and ileal conduit (11.2%), and urinary diversion only (18.3%). Symptomatic improvement occurred in 77.2%, with higher rates in the total cystectomy and orthotopic neobladder group. Thirty-one patients (6.9%) required secondary total cystectomy and/or ileal conduit diversion; 48.4% subsequently improved. Seventeen studies reported 102 complications overall (26.5%). Overall mortality was 1.3%. CONCLUSIONS: Overall surgical intervention is associated with a 23% risk of failure to improve symptoms. Higher rates of improvement were reported in patients with total cystectomy. Interpretation should be guarded given the small patient number, multiple centres, and variable outcome measurements. There is a need for prospective randomised studies to answer questions regarding patient selection and optimal surgical approach. PATIENT SUMMARY: In this review, we looked at the outcomes of surgery for treatment-refractory bladder pain syndrome/interstitial cystitis. We found overall symptom improvement in 77.2% of patients with a complication rate of 26.5%. However, there remains a need for further studies of higher quality to identify patients who will have symptom improvement and the best surgical option.

Loss of function of parathyroid hormone receptor 1 induces Notch-dependent aortic defects during zebrafish vascular development.

OBJECTIVE: Coarctation of the aorta is rarely associated with known gene defects. Blomstrand chondrodysplasia, caused by mutations in the parathyroid hormone receptor 1 (PTHR1) is associated with coarctation of the aorta in some cases, although it is unclear whether PTHR1 deficiency causes coarctation of the aorta directly. The zebrafish allows the study of vascular development using approaches not possible in other models. We therefore examined the effect of loss of function of PTHR1 or its ligand parathyroid hormone-related peptide (PTHrP) on aortic formation in zebrafish. APPROACH AND RESULTS: Morpholino antisense oligonucleotide knockdown of either PTHR1 or PTHrP led to a localized occlusion of the mid-aorta in developing zebrafish. Confocal imaging of transgenic embryos showed that these defects were caused by loss of endothelium, rather than failure to lumenize. Using a Notch reporter transgenic ([CSL:Venus]qmc61), we found both PTHR1 and PTHrP knockdown-induced defective Notch signaling in the hypochord at the site of the aortic defect before onset of circulation, and the aortic occlusion was rescued by inducible Notch upregulation. CONCLUSIONS: Loss of function of either PTHR1 or PTHrP leads to a localized aortic defect that is Notch dependent. These findings may underlie the aortic defect seen in Blomstrand chondrodysplasia, and reveal a link between parathyroid hormone and Notch signaling during aortic development.

Molecular control of vascular development in the zebrafish.

The zebrafish is emerging as a novel model for the study of embryonic vascular development. In this review we summarize the advantages of this intriguing experimental system and the advances in our understanding of the molecular control of vascular development it has allowed.

How kids develop

Children really want to become adults. It's what they're set up for. Despite being born with an impressive number of physiological adaptations that help survive, e.g. extra water in their cells at birth so they can survive a short period of starvation, the ability to cling on to fingers so strongly that you can lift them up, and an amazing cry which has been called one of the most stimulating calls to action that any adult human will ever hear, babies are still quite helpless. Innate in a healthy baby is the ability to develop her brain as long as she is given the opportunity to do so. like dogs, which adapted very successfully to humans 15,000 years ago, babies are the keenest observers of human behaviour and body language. That's why they observe us so closely. That's why they imitate us so much. They are trying to learn new skills. That's called development and it is related to those amazing connections between brain cells that develop as soon as the baby is born and is exposed to increasing variety of sounds, sights, smells, tastes and emotions. Most children learn these skills in an orderly, progressive fashion - one following an building on the other. First the child learns to say 'Da Da', then she learns 'Bye Bye' and after some time she learns to say 'Bye Bye, Da Da'. These skills are called developmental milestones and they are points of progress that we can observe and measure on the child's route to adulthood. When a child does not attain one of these milestones at the proper time, there is a possibility that the child has some form of disability, some of which can be very subtle.

Can primary care patients be identified within an emergency department workload?

AIM: To quantify the proportion of emergency department (ED) discharges that could have been managed in primary care, and to determine the consistency with which healthcare professionals assess cases as 'primary care appropriate'. METHOD: 1200 case notes from 30,493 Wellington Hospital ED discharges over a 12-month period were randomly selected. 180 were assessed by an expert panel of 12 healthcare professionals comprising GPs, ED specialists, and nurses. Level of agreement was measured between professional groups. The panel adapted an international clinical protocol on ED appropriateness. The remaining 1020 cases were assessed according to these adapted criteria. RESULTS: The panel considered 37% of all ED presentations (49.7% of those not admitted) 'primary care appropriate,' and 50% of all ED presentations (68.1% of those not admitted) 'primary care appropriate' if laboratory and radiological facilities were immediately available. These figures were similar when the full 1200 cases were reviewed by researchers. There was poor to moderate agreement between individuals and professional groups about which were appropriate (Kappas 0.35-0.45). In 15% of cases, professionals gave a different response to the same case on different occasions. CONCLUSIONS: Our study has shown retrospectively that a significant number of ED presentations may have been managed in primary care. However this was determined with knowledge of investigation results and final diagnosis, by clinicians who had poor agreement about individual cases. In reality, triage nurses in ED have only the presenting complaint. This study shows how variable clinicians can be in determining primary care appropriateness even with full clinical details.

Breast feeding in developing countries

Human milk has recently been reappraised with respect to its nutritional content, and anti-effective properties. Concerns with global food supply, economics of infant feeding, contraception and prevention of infections are specially relevant to developing countries. The benefits of breast feeding for the Third World is highlighted, reviewing the special advantages over adapted cow's milk(AU)

Maternal and foetal iron and folate activities at parturition - abstract

This study was undertaken to determine the extent to which anaemia in the mother is reflected in the neonate and to what extent iron and folate deficiency might contribute to maternal anaemia. Haemoglobin (Hb), serum iron, transferrin saturation, serum folate and red cell (RBC) folate were measured in blood samples taken from 85 mothers and from the umbilical cords at delivery. Forty-two per cent of the mothers were anaemic by WHO standards (Hb <110 g/l) and 27 per cent were anaemic using a cut-off point of 106 g/l. Twenty-eight per cent of the neonates were considered anaemic (cord Hb <136 g/l). Serum iron and folate and RBC folate were significantly higher (p<0.01) in cord than maternal blood. Only 3.5 per cent of the mothers had serum iron defiency(<8.1 æmol/l) while 35 per cent had serum folate deficiency (<6.8 æmol/l). At low (<106 g/l) compared to adequate (>110 g/l) maternal Hb, maternal mean serum iron and folate and RBC folate were all significantly lower (p<0.05). No significant differences were found in cord mean serum iron and folate and mean RBC folate between cord bloods with low Hb compared to those with adequate Hb. At deficient (<6.8 æmol/l) compared to adequate (>13.6 æmol/l) maternal serum folate, maternal mean Hb and mean RBC folate were significantly lower (p<0.001) and p<0.0001, respectively); similarly, both cord mean serum folate and mean RBC folate were significantly lower (p<0.0001 and p <0.001, respectively). These results suggest that mothers who are anaemic at parturition do not necessarily have anaemic babies except when the maternal anaemia is extremely severe. Folate deficiency appears to be a bigger contributor than iron deficiency to anaemia in pregnancy (AU)

Bothrops atrox snake bite in a six-year-old child

A rare case of snake bite poisoning presenting as disseminated intravascular coagulation is presented. It is important to consider this entity in the differential diagnosis of children presenting with acute bleeding disorders in the West Indian islands where Bothrops atrox is present, namely, in Trinidad, St. Lucia and Martinique. (AU)

A family with homozygous haemoglobin E in Trinidad and Tobago

We report the first case of homozygous E in the West Indies, and describe the family, whose ancestors came to Trinidad from India approximately 100 years ago (AU)

Paediatric acquired immunodeficiency syndrome (PAIDS) in Trinidad and Tobago

The first twenty-one cases of Paediatric Acquired Immunodeficiency Syndrome (PAIDS) in Trinidad and Tobago were studied. An overwhelming majority of patients were of African descent. Most of the children presented within the first year of life, the average time between presentation and death was one and a half months, and the majority presented with either diarrhoea or pneumonia or failure to thrive, common conditions in the West Indies. Fever lasting longer than two weeks as well as hepatomegaly were clues which led to a definite diagnosis (AU)

Variations of the prevalence of IgG and IgM antibodies to Toxocara in Trinidadian school children - abstract

Toxocara involvement in ocular lesions was suspected following the high frequency of IgG antibodies in serum samples of patients attending the Eye Clinic at the General Hospital, Port-of-Spain. Also, a high prevalence of IgG antibodies to Toxocara was found in 5-9 year-old children in certain Caribbean islands. Fifty children, aged 6-15 years with equal numbers of boys and girls, were randomly selected from 5 schools in rural South and Central Trinidad. A stool sample (examined for parasites) and a 5ml blood sample were obtained from each student. Serum from 17 patients with ocular symptoms and from 39 patients with other symptoms were also examined. Serum IgG and IgM antibodies (to Toxocara) were determined by ELISA method. Fifty children from one school were given a thorough eye examination. The prevalence of antibodies seemed to increase with age, from 54 per cent in 5-7 year olds to 87 per cent in 12-13 year olds for IgG, and from 56 per cent to 61-63 per cent for IgM antibodies. IgG antibodies to Toxocara were more prevalent in males than females, but there was no positive correlation with reported geophagia or association with domestic pets. There was a higher prevalence of IgGs (88 per cent) in sera from patients with ocular lesions than in those without such lesions (39 per cent, p<0.01). Results suggest the need for a comprehensive study of toxocariasis in childhood in Trinidad and Tobago (AU)

Blastocystis hominis in two children of one family

Two apparently healthy children from the same family were found to have moderate to heavy Blastocytis hominis in their stools samples whilst being investigated for intestinal symptoms: sporadic, painless, rectal bleeding in one and persistant diarrhoea in the other. After treatment with metronidazole, they had no further signs and stool samples became negative. Eighteen months later, both were asymptomic, and stool samples continued to be negative for the parasite (AU)

Paediatric excretory urography at the Port-of-Spain General Hospital, 1985-1987 - abstract

In developing countries where ultrasonography and nuclear medicine scanning are not widely available, the intravenous pyelogram (IVP) is the principal method of visualizing the urinary tract. As a result, there exists a real potential for over requesting this relatively expensive study which is unpleasant and not without risk, especially in children. To assess the appropriate use of paediatric IVPs at the Port-of-Spain General Hospital, a retrospective study was done of all IVPs (n=373) performed on children at this institution during the 3-year period, 1985-1987. Radiological abnormalities were reported in 29 percent of cases. The most common abnormal findings were consistent with infection (29 percent) and hydronephrosis (26 percent). The most common indications for radiological study were urinary tract infection (23 percent) and haematuria (17 percent). Problems in making the diagnosis of a urinary tract infection in children were identified as the improper collection and handling of the urine specimen. Based on this survey, almost one-third of children who have IVPs at this institution do not have any indication for doing this potentially dangerous and certainly expensive procedure (AU)

Childhood asthma education project - abstract

An educational programme, consisting of a booklet explained by a nurse in four sessions and the showing of a videotaped dramatization of the same informaton, was administered to 16 parents of asthmatic children. Fifteen comparable parents were followed and used as a control group. This preliminary report shows that the parents of both groups had similar levels of knowledge of asthma at the initial test. On retesting at the six-month follow-up, the parents in both groups did significantly better than on the initial test. However, the experimental group's improvement was statistically better than that of the controls (p=0.003). More important are the changes in attitude and behaviour implied by the higher rate of casualty visits, and the higher rate of attacks identified in cases as compared with controls. The fall in admissions among cases, while controls had a steady rate of admissions in both the year of the study and in the preceeding year, has positive economic implications that are especially exciting in a developing country such as ours (AU)

Socio-economic, dietary, and cultural factors associated with diarrhoeal disease in Trinidad and Tobago

A survey was conducted in County Victoria South Trinidad, among mothers of children hospitalized with diarrhoea and matched controls (n=30 for each group). Socio-economic, dietary, and knowledge attitude-practice factors relating to diarrhoea were investigated and anthropometric measurements were taken. Ten per cent of children of both groups were found to be below normal limits for weight for length (or height). Consistent trends were seen of lower birth weight, earlier introduction of the bottle, and fewer house-pipes among cases. The most significant finding to emerge that over half the mothers withheld some or all food from the child during an episode of diarrhoea, and one-third also reduced fluid intake. Both practices need to be strongly discouraged. Until socio-economic conditions in Trinidad and Tobago improve to the point where infectious illnesses decline spontaneously, as happened in Europe and North America, immediate measures are essential to protect the young child at risk of diarrhoeal disease. It is suggested that priority be given to the following health education practices to both the public and medical profession. 1. Protection: by strongly encouraging breast feeding and discouraging bottle feeding. 2. Early treatment: provision of oral fluid-salt replacement therapy in the Community to prevent serious dehydration and quickly restore the child's appetite. (AU)

The Caribbean and New York: the heart connection - abstract

An association between North Shore University Hospital, New York and the Caribbean region started in 1982, whereby Caribbean children needing cardiac surgery were operated on at North Shore at no, or nominal, cost to the patient. During the last 6 years, 239 patients were referred for cardiac surgery 107 from Trinidad, 69 from Barbados, 19 from Jamaica, 18 from Saint Vincent, 17 from Saint Lucia, 4 from Dominica, 2 from Antigua and one each from Anguilla, Grenada and Nevis. Fifty of the patients were catheterised in Barbados between 1982 and 1985, and 55 were catheterised at Brookdale Hospital, New York, in 1986 - 1987. The other patients were catheterise at North Shore. Two hundred and sixteen (216) patients have had surgery - 180 open and 36 closed heart. Four had pacemaker implantations, 3 balloon valvuloplasties and 2 balloon atrial septostomies. There were 7 operative deaths (3.2 percent mortality) and 4 late deaths. An analysis of the programme points overwhelmingly to its high degree of success. Over the last 2 years, the programme has expanded to include 4 other major hospitals in New York. The programme is critically dependent on a system of co-operation and co-ordination between the referring and accepting physicians. Well-developed links have also been developed wihtin the wider New York based West Indian community. These links provide crucial logistic support to both patients and their families, thus increasing the economic viability of the programme while decreasing the trauma associated with the physical dislocation of extra-regional surgery. While the success of the programme is noted, it should in no way detract from the need to accelerate plans aimed at the development of an active open-heart surgical programme in the region (AU)

A radio and television campaign to educate Trinidadians and Tobagonians about diarrhoea, dehydration and oral rehydration - abstract

A radio and television campaign to educate people of Trinidad and Tobago about diarrhoea, dehydration and oral rehydration was conducted in 1985. Two radio and two television advertisements were developed which addressed the prevention and treatment of gastroenteritis. Sanitation, nutrition and oral rehydration therapy (ORT) were emphasised. Breast feeding was an essential component of both advertisements. The advertisements and a questionnaire were pre-tested at the Port-of-Spain General Hospital in January, 1985. From March 11 to 22, five hundred mothers, who had just given birth, were questioned by two trained interviewers at the three major hospitals in Trinidad. From April 1 to 22, 1985, the television advertisements were shown once a day during the major news programme; from July 1 to September 8, both radio and television advertising were given daily. The radio advertisements had no fixed time of delivery. Three hundred and sixty of the mothers were located and re-questioned by the same interviewers from November 15 to December 1, 1985. There was no change in the mothers' knowledge of the causes of gastroenteritis, which remained high. The campaign doubled the percentage of mothers who knew the signs of dehydration. The percentage of mothers who would use ORT increased from 55 to 84, but only 25 percent understood why. There was no recriprocal fall in the alternative fluids the mothers thought could be usefully given or in the use of foods or when to restart feeding. There was a small reduction in the number who thought that drugs were useful (AU)