Lingual metastasis from renal cell carcinoma management and review of the literature.

A case of anterior lingual swelling, which on excision biopsy was diagnosed as a secondary from renal cell carcinoma, is presented. We reviewed the indexed literature and present a review of the literature and current management of this uncommon problem.

Dynamic rectus abdominis tendon colposuspension for female stress urinary incontinence: a new procedure and its follow-up.

AIMS AND OBJECTIVE: To describe the technique, results and follow-up of dynamic rectus abdominis tendon colposuspension (DRTC) in the management of female stress urinary incontinence (SUI). PATIENTS AND METHODS: Eighteen patients with SUI were studied prospectively from 1998 to 1999 who underwent DRTC. Type I and type II SUI patients with or without mild to moderate cystocoele were included in the study. A complete preoperative work-up was done as described in detail in this article. Follow-up assessment was done at 6 weeks, 3 and 6 months and then annually involving a SEAPI quality-of-life score, a satisfaction questionnaire, urge symptoms and assessment of dryness. RESULTS: Mean follow-up of these 18 patients was 20 +/- 6 months. Cure of symptoms and dryness was achieved in 16/18 (89%) of the patients. Four of 9 patients had residual urge symptoms and 2 developed de novo urge, which settled by 3 months; no patient required long-term anticholinergics. Three patients required clean self-intermittent catheterization (CSIC) immediately postoperatively but only 1 patient continued to perform CSIC after 3 months. Mean operating time was 41 +/- 10 min and mean hospital stay was 3.5 +/- 1 days. There were two failures, one in a patient with a neurogenic bladder and one in a patient with multiple previous pelvic operations. One so-called failure uses <2 pads/day postoperatively with an improvement in both symptom and dryness score. Postoperative complications include blood transfusion in 1, urinary tract infection in 1 and wound infection in 1 patient. All the patients with initial good results showed persistent results over follow-up. CONCLUSIONS: DRTC is a simple procedure with minimal morbidity showing good results, which are consistent on follow-up.

Percutaneous management of renal pelvic urothelial tumors: long-term followup.

PURPOSE: We present the long-term outcome of percutaneous resection of renal urothelial tumor. MATERIALS AND METHODS: A total of 24 patients underwent primary percutaneous resection of renal urothelial tumor. Patients with low stage pT0-1 disease were treated primarily with percutaneous surgery. All pelvicaliceal tumors were taken for biopsy and treated with percutaneous resection. Patients with multi-segmental pelvicaliceal system involvement, stage greater than pT1, high grade histology or additional ureteral tumors were considered for nephroureterectomy. Topical chemotherapy (mitomycin C or epirubicin) was administered via nephrostomy tube or intravesical instillation after Double-J stent (Medical Engineering Corp., New York, New York) insertion. Surveillance included upper tract cytology, nephroscopy or fiberoptic ureterorenoscopy. Long-term followup was correlated with histopathology. RESULTS: Of the 24 cases 2 had squamous cell carcinoma, 5 had grade III transitional cell carcinoma, 15 had grade I to II transitional cell carcinoma and 2 had no tumor. Control was established with initial percutaneous resection in 18 (75%) cases and second look nephroscopy in 4. Early recurrences were detected by excretory urography (IVP) in 3 cases, small pelvic recurrences by IVP in 2, fiberoptic ureterorenoscopy in 2 and bladder tumors by flexible cystoscopy in 3 after 1 year. A total of 10 nephroscopies were performed in 5 cases, 24 flexible uretereorenoscopies in 9 and IVP in 6. Three synchronous, grade I bladder tumors were managed conventionally. All patients with high grade disease died of malignancy except one (with no further treatment) and 6 of the 15 patients with low grade noninvasive transitional cell carcinoma underwent nephroureterectomy during followup either due to progression of disease, concomitant tumor or complications. Two patients with solitary kidneys died of renal failure unrelated to malignancy. High grade tumors or tumors greater than T1 were treated with nephroureterectomy early during management. There was no perioperative mortality and 9 (60%) of the low grade cases the kidneys were preserved at a mean followup +/- SD of 64 +/- 15 months. All excised tracks from patients who underwent nephroureterectomy and the renal fossae were free of tumor on histopathological examination. CONCLUSIONS: Percutaneous resection of transitional cell tumor should be considered primarily in patients with early stage disease excluding tumors crossing caliceal infundibula, ureteropelvic junction tumor, tumor extending over multiple calices and synchronous ureteral tumors. The long-term outcome of low grade tumors is good and they should be managed by either form of minimally invasive surgery. Nephron sparing is possible in a large percentage of low grade disease but high grade tumors should be treated with nephroureterectomy.

Understanding newborn infant readmission: findings of the Ontario Mother and Infant Survey.

The Ontario Mother and Infant Survey examined health and social service utilization of postpartum women and newborn infants from five hospital sites. A cross-sectional multilanguage survey design with longitudinal follow-up was used: 1,250 eligible, consenting women completed a self-report questionnaire in hospital and 875 women participated in a structured telephone interview at four weeks post-discharge. Rates of newborn infant readmission ranged from 2.4% to 6.7%. The best predictors of readmission were: main source of household income was other than employment; maternal self-rating of health was poor; mother anticipated inadequate help and support at home following discharge; mother received help from friends/neighbours following discharge; and mother had concern about infant care and behaviour. Readmission was not associated with length of postpartum hospital stay. The study findings suggest that there is a complex relationship between infant health care needs, family resources and provider practices that produces clinically important, site-specific readmission patterns.

Percutaneous resection of renal transitional carcinoma: venous injury and its conservative management.

An interesting observation encountered at percutaneous resection of a renal transitional cell carcinoma and its conservative management is described. During resection of the tumour sudden heavy haematuria was encountered. Nephroscopic inspection revealed the blood to be coming from behind a loop-generated flap, the raising of which allowed entry of the endoscope into a sizeable vein and thence upwards into the renal vein and inferior vena cava (IVC). On table nephrostogram confirmed contrast outlining the renal vein and IVC. Placement and clamping of a nephrostomy tube was followed by stabilization of the patient and the bleeding stopped. The urine became clear within 24 h. Later on repeat nephrostogram showed an intact pelvicalyceal system with an acceptable tumour clearance. This case highlights the importance of a trial of conservative management in the treatment of bleeding complications during nephroscopy.

The Patient Care Travelling Record in palliative care: effectiveness and efficiency.

The Patient Care Travelling Record (PCTR) is a passport-like health-care summary that, in previous research by the authors, has been found to be a feasible and acceptable tool to convey important clinical information about the palliative care patient. This randomized controlled trial was conducted to determine the effectiveness and efficiency of this Record in improving patient mood, decreasing uncertainty, improving satisfaction with health care, reducing use of health-care services, and maximizing pain control. Eligible patients were randomized to receive or not receive the PCTR (completed by nurse or physician and reviewed jointly with the patient). As baseline entry into the study and then at 1 and 2 months, patients completed measures on level of certainty, mood states, satisfaction with care, levels of pain, and health-care services utilization. During the 2-year study period, only 20% (N = 61) of the patients enrolled in a palliative care program in Southern Ontario were eligible for the trial. Of these patients, 18 died, 15 declined to participate, and 7 were emotionally unable to complete the questionnaires. Thus 21 patients completed the trial. With the exception of those age 65 years and over, the patients using the Record reported decreased levels of uncertainty on follow-up. There was no additional use of health-care services, no differences in mood states, pain relief, or satisfaction with health care. It is significant that 80% of palliative patients were not eligible because their physical and psychological status rendered them insufficiently stable to participate in a research study. Because of their vulnerable status, these patients may be ideal for the utilization of the Record in clinical care. Although research in this palliative care population is challenging due to difficulties with recruitment and high dropout rates due to death, the PCTR, which was previously shown to be acceptable and feasible, has now been shown to be effective in reducing patient uncertainty, specifically for adults under 65 years. Indications for future research are described.

Critical appraisal of the health research literature: prevalence or incidence of a health problem.

This article identifies and discusses criteria that can be used by health professionals to critically appraise research articles that estimate the prevalence or incidence of a disease or health problem. These guidelines will help determine the validity and usefulness of such community assessment studies. The criteria relate to the validity of the study methods (design, sampling frame, sample size, outcome measures, measurement and response rate), interpretation of the results and applicability of the findings. The research question "What is the prevalence of dementia in Canada?" is used as an example for this paper.

Occult filum terminale syndrome.

Thirty-two pediatric patients presenting with symptoms of urinary dysfunction, stool incontinence and/or severe back and/or leg pain are described. In patients with urological dysfunction, urodynamic testing was consistent with a neurogenic etiology. Imaging studies demonstrated the tip of the conus medullaris to lie above the L2 vertebral body, and the filum terminale to be of normal diameter ( < 2 mm) in all patients. A diagnosis of an occult filum terminale syndrome was made based on clinical presentation in the absence of associated imaging abnormalities and section of the filum terminale was performed. Postoperatively, the majority of patients (97%) experienced significant ( > 50%) relief of their symptoms. The management of these patients is discussed.

Effects of 2 years of hormone replacement upon bone mass, serum lipids and lipoproteins.

The objective of this study was to measure the effects on postmenopausal women of 2 years of either a low dose or a moderate dose regimen of hormone replacement upon bone mass and serum cardiovascular risk factors. After 6 months of calcium supplementation, 75 women chose to add hormone replacement or to remain on calcium. Those choosing hormones were randomised to either 0.3 mg/day equine estrogen and 2.5 mg/day medroxyprogesterone or 0.625 mg/day equine estrogen, days 1-25, and 5 mg/day medroxyprogesterone, days 16-25. On calcium only, lumbar spine bone mineral content and radius bone mass fell. Serum concentrations of cholesterol and triglycerides increased while HDL concentration fell. The low dose continuous regime reduced whole body bone turnover and prevented the age related reductions in bone mass and serum cardiovascular risk profile. The moderate dose regimen reduced whole body bone turnover and increased lumbar spine bone mass. Total serum cholesterol was unchanged while HDL levels increased, LDL levels fell and triglyceride concentration increased.

Evaluation of five small turbine-type respirometers used in adult anesthesia.

OBJECTIVE: The purpose of this study was to determine the accuracy of five rotating vane or turbine-type respirometers--fdE Magtrak Respiratory Monitor, fdE Haloscale Standard Wright Respirometer, Micro-Medical Pocket Monitor II, and Ohmeda 5400 and 5410 Volume Monitors--which are marketed as suitable for measuring expired gas volume in anesthetized adult patients. METHODS: The devices were tested for accuracy at simulated minute ventilations ranging from 2.4 to 15 L/min with three gas mixtures: air, air saturated with water vapor, and N2O/O2 (70:30). RESULTS: In the usual range for adult minute ventilation during general anesthesia with intermittent positive-pressure ventilation (5-12 L/min), all devices were on average accurate to within 12%. At the lowest minute volume readings (2.4 L/min) all devices except the Pocket Monitor tended to have low readings. No significant differences in readings were introduced by either saturation with water vapor or introduction of 70% N2O, except with ventilation below 4 L/min with both Ohmeda respirometers. CONCLUSIONS: All monitors showed reasonable clinical accuracy in the usual adult minute ventilation range during general anesthesia with intermittent positive-pressure ventilation (> 5 L/min) when used to measure air, water vapor-saturated air, or N2O/O2 mixtures.

A patient care travelling record for palliative care: a feasibility study.

The provision of palliative care can be a complex process. Patients are treated in a variety of settings, by multiple persons, thus risking loss of continuity of care. These patients take numerous medications and require many complex treatment decisions in the course of their illness, making the ready availability of current and accurate information a vital component of effective care. The use of a patient care travelling health record, while requiring time and commitment from all parties to be effective, has been shown to be both feasible and helpful to patients, families, and health professionals. Considerable education and commitment is necessary to ensure compliance by all involved parties.