Child drawings and salivary cortisol in children undergoing preoperative procedures associated with day surgery.

BACKGROUND: Perioperative procedures in children can impair their emotional status negatively with stress and/or anxiety. Cortisol concentrations and drawings could be helpful in gaining information about a child's levels of stress and/or anxiety when attending the hospital for surgery. PURPOSE: The purpose of this study was to determine the degree of anxiety and stress as well as to explore the association between objective measures of stress (cortisol concentration in saliva) and subjective assessment of hospital anxiety (children's drawings) as interpreted by the Swedish version of the Child Drawing: Hospital manual. METHODS: A total of 93 children scheduled for day surgery were included. Salivary cortisol was sampled preoperatively on the day of surgery at which time the children were also requested to make a drawing of a person at the hospital. RESULTS: Results showed no association between salivary cortisol concentration and the CD:H score. CONCLUSION: The drawings and salivary cortisol concentration preoperatively on the day of surgery reflect different components of the conditions of fear, anxiety, or stress emerging in the situation.

The chronic prostatitis/chronic pelvic pain syndrome and pain catastrophizing: a vicious combination.

OBJECTIVE: This study aimed to evaluate the presence and importance of pain catastrophizing among men diagnosed with chronic abacterial prostatitis/chronic pelvic pain syndrome (CP/CPPS) in a routine clinical setting. MATERIAL AND METHODS: 61 men, mean age 46 ± 11 years, with a mean CP/CPPS history of 11 ± 11 years, completed the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI), Short-Form McGill Pain Questionnaire (SF-MPQ) and Coping Strategies Questionnaire (CSQ) to evaluate pain catastrophizing, and the International Index of Erectile Function (IIEF-5). They were also scored according to the UPOINT system. RESULTS: The patients' mean scores were: IEEF-5 17.6 ± 7.3, NIH-CPSI pain subscale 11.1 ± 4.4, quality of life question 2.7 ± 1.6, quality of life impact subscale 6.9 ± 2.7 and CSQ catastrophizing score 15.3 ± 9.1. Patients with a high tendency for catastrophizing (CSQ score ≥20) (28%) had higher UPOINT and pain scores, worse quality of life and quality of life impact, but did not stand out regarding voiding dysfunction and ejaculatory pain. CONCLUSIONS: Two distinctly different cohorts could be identified: a smaller cohort with a high degree of catastrophizing, severe pain and poor quality of life, and a larger one with a low degree of catastrophizing, less severe pain and moderately reduced quality of life. It is important in clinical practice to distinguish between the two groups since they require different therapeutic approaches.

Pain associated with the chronic pelvic pain syndrome is strongly related to the ambient temperature.

OBJECTIVE: There are indications suggesting that the pain associated with the chronic pelvic pain syndrome (CPPS) may be related to cold. The purpose of the present study was to evaluate how the symptom intensity reported by the patient relates to the time of the year in a temperate climate, i.e. to the ambient temperature and to weather changes. MATERIAL AND METHODS: Thirty-one patients, mean age 51 years (range 35-66 years), with CPPS for 17 ± 10 years (3-42 years) were asked to complete a set of questionnaires including questions concerning how they experienced their symptom intensity during the different seasons using the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) questionnaire. RESULTS: The total NIH-CPSI score was 22.2 ± 8.2. There was a highly marked relationship between season and pain intensity as reported by the informants: it was experienced to be three times more intense during the winter months. All subjects reported that a temperature drop was associated with deterioration. CONCLUSION: The strong relationship between the ambient temperature, a drop in temperature and the pain experienced by men with CPPS confirms the association between cold and symptom intensity in the Scandinavian countries, where the seasonal temperature variation spans a long range and the winters are long. The cause of this relationship is still to be established. Muscular spasm/stiffness is a possibility that remains to be explored.

Urine cultures from indwelling bladder catheters in nursing home patients: a point prevalence study in a Swedish county.

OBJECTIVES: To survey the bacterial flora and antibiotic resistance in urinary strains from patients with indwelling bladder catheters residing in nursing homes within a geographically defined region. MATERIAL AND METHODS: Urine was sampled for culture from 163 catheter patients (126 men and 37 women) during a 2 week period in March 2010. Susceptibility testing of the isolated bacteria was compared with all urinary strains (n = 9994) from hospitals and primary healthcare in the same geographical area cultured during the first 6 months of 2010 (control group). RESULTS: Bacteriuria was found in 159 of 163 urine samples (98%). Enterococcus faecalis and Escherichia coli were the most common species, one or both being detected in 72% of the urine samples, while Proteus species were found in10% and a single isolate of Providentia species was seen.Strains in the study patients were more resistant to antibiotics than in the control group. Particularly large differences were noted for ciprofloxacinin in E. coli (16.9% vs 7.9%) and for trimethoprim-sulfamethoxazole in E. faecalis (39.1% vs 24.8%). One extended spectrum ß-lactamase (ESBL)-producing E. coli was cultured (1.3%), compared with 1.6% in the control group. No vancomycin-resistant enterococci (VRE) or methicillin-resistant Staphylococcus aureus (MRSA) were detected. CONCLUSIONS: Proteus mirabilis and Providentia species were rarely isolated, in sharp contrast to previous studies from geriatric hospital wards where they have often been in the majority. The limited incidence of ESBL and the absence of VRE and MRSA is gratifying, but the high resistance to antibiotics needs to be assessed on a continuous basis.

Febrile reactions after transrectal ultrasound-guided prostatic biopsy: a retrospective study.

OBJECTIVE: The aim of this study was to evaluate the incidence and clinical presentation in patients with hospital admission owing to febrile infections after transrectal ultrasound-guided prostate biopsies. MATERIAL AND METHODS: The case histories of the 57 patients (3.5%) who, between January 2006 and December 2009, were admitted owing to a febrile infection secondary to the 1633 transrectal prostate biopsies performed during the period were retrospectively analysed. Norfloxacin 400 mg ? 2 was given for 3 days as prophylaxis starting just before or within 10 min of biopsy. RESULTS: Quinolone-resistant Escherichia coli was isolated from blood cultures in 43% of the patients (n = 15) presenting with fever between 24 and 48 h postbiopsy. The urine culture was positive in 13% and no patient had symptoms suggestive of a urinary tract infection (UTI). In patients presenting after 48 h (n = 42), quinolone-resistant E. coli was never isolated from blood; E. coli was cultured from urine in 45% of the patients and in 48% it was associated with UTI symptoms. CONCLUSIONS: The finding that early postbiopsy fever was often associated with a quinolone-resistant E. coli bacteraemia and never with UTI symptoms, as opposed to late-onset fever, where such symptoms were common and quinolone-resistant E. coli was rarely detected, suggests divergent pathogenic mechanisms underpinning early- and late-onset febrile reactions. These findings have implications for how antibiotic prophylaxis should be given.

A prospective registration of catheter life and catheter interventions in patients with long-term indwelling urinary catheters.

OBJECTIVE: The aims of this study were to register the incidence of scheduled and acute urinary catheter changes and rinses (acute interventions) among nursing home patients, to relate the incidence of acute interventions to catheter material and time of catheterization, and to register the use of antibiotics for catheter-associated urinary tract infections. MATERIAL AND METHODS: Catheter life and catheter-related interventions were followed prospectively for 1 year in all patients with long-term indwelling catheters in all 78 nursing homes in a county in western Sweden. RESULTS: Altogether, 366 patients were followed: 117 (32%) women and 249 (68%) men. Acute changes (n = 718) were more common than scheduled ones (n = 519). The rate of acute interventions was not related to catheter material and was significantly lower in patients with a catheter for over 2 years. In 25% of the patients, acute interventions were virtually never necessary, in contrast to 10% where acute interventions were registered nearly every month. Antibiotic treatment for reasons assumed to be related to the urinary tract was instituted on 170 occasions among 85 men (34%) and 20 women (17%), a significant difference between the genders (p < 0.01). CONCLUSIONS; No catheter material appeared to be superior. The surprising finding that acute interventions were less common after 2 years' catheterization needs further study to be verified and explained. Only 10-25% had a more frequent need for acute interventions and are candidates for future interventional studies.

The perioperative dialogue reduces postoperative stress in children undergoing day surgery as confirmed by salivary cortisol.

AIM: To evaluate the efficacy of 'the perioperative dialogue (PD)' by analyzing salivary cortisol, in 5- to 11-year-old children undergoing day surgery. BACKGROUND: To deal with anxiety prior to investigations and/or procedures, children need to be confident and informed about what is going to happen. Therefore, intervention strategies should be initiated before admission to hospital. METHODS AND MATERIALS: Children (n = 93), 79 boys and 14 girls, scheduled for elective day surgery requiring general anesthesia were randomly recruited into three groups: (i) standard perioperative care (n = 31), (ii) standard perioperative care including preoperative information (n = 31), and (iii) the PD (n = 31). Saliva was sampled for cortisol analysis at specific time points during the pre- and perioperative procedures. RESULTS: The children who received the PD had significantly lower (P = 0.003) salivary cortisol concentrations postoperatively. Moreover, it continuously decreased during the day of surgery compared with the other two groups (P < 0.01). Among the children who received analgesics, the PD group received significantly less morphine (P = 0.014) related to bodyweight: the mean dose was 0.1 mg·kg(-1) (n = 9) in the control group vs 0.04 mg·kg(-1) (n = 6) in the PD group. Irrespective of group, there was a positive correlation between the children's morphine consumption and salivary cortisol concentration (r = 0.56; P = 0.038). The W-B scale score was higher in the group that received morphine (median = 3 vs median=1; P = 0.001). CONCLUSIONS: The PD's caring, continuity, and on-going dialogues were associated with low concentrations of salivary cortisol postoperatively and reduced morphine consumption and thus appears to be a valuable complement to standard perioperative care in children undergoing day surgery.

Evaluation of the Swedish version of the Child Drawing: Hospital Manual.

AIM: This paper is a report of psychometric testing of the Swedish version of the Child Drawing: Hospital Manual. BACKGROUND: Drawings have shown to be useful in assessing emotional status and anxiety in children because they generally speak to us more clearly and openly through their drawings than they are willing or able to verbally. METHOD: The Child Drawing: Hospital Manual was translated into Swedish according to World Health Organization guidelines (a routine procedure for translation of English instruments) in order to assess anxiety by analysing the drawings of 59 children (5-11 years), of whom nine were girls and 50 boys undergoing day surgery during 2007-2009. RESULTS: Inter-rater reliability (five independent scorers) was high and internal consistency reliability was good (coefficient alpha =0·77). Parts A and C, as well as the total scale score of the Child Drawing: Hospital Manual, discriminated anxiety significantly between the group of children undergoing day surgery and a comparison group of school children, indicating adequate construct validity. CONCLUSION: For the Swedish version of the Child Drawing: Hospital Manual, our study demonstrates evidence for adequate construct validity in Parts A and C (and total scale score), high inter-rater reliability and acceptable internal consistency reliability. However, some improvements are needed before the instrument will be a clinically useful assessment of anxiety in children undergoing day surgery.

Urine bladder catheters in nursing home patients: a one-day point prevalence study in a Swedish county.

OBJECTIVE: The aim of this study was to register the use of long-term indwelling catheters in nursing homes in a defined geographical region, and present the indications for and duration of catheterization, catheter material and size, the time between the regular catheter changes and the number of patients with regular catheter rinses. MATERIAL AND METHODS: On 16 February 2009, the 78 nursing homes in a county in western Sweden with 260 000 inhabitants reported the required information to the study centre. RESULTS: Of the 2625 nursing home patients (1781 women and 844 men), 50 (3%) of the women (mean age 88 years) and 135 (16%) of the men (mean age 85 years) had indwelling catheters. Urine retention and high residual urine were the most common indications (79%). Incontinence (6%) was rarely the reason. The men had been catheterized much longer (mean ± SD 32 ± 29 months) than the women (20 ± 19 months). Regular bladder catheter rinses were used in 51 patients (28%). CONCLUSION: Seven per cent of nursing home patients in the region had an indwelling catheter, the men five times more often than the women. The main indication for both genders was insufficient bladder emptying, and rarely incontinence. The men had been catheterized for much longer periods than the women and more often arrived at the nursing home with a long-term indwelling catheter.

Evaluation of a modification of the UPOINT clinical phenotype system for the chronic pelvic pain syndrome.

OBJECTIVE: . To evaluate the recently presented six-domain UPOINT phenotype system for the chronic abacterial prostatitis/chronic pelvic pain syndrome (CPPS) and to correlate it with clinically relevant parameters such as ejaculatory pain, pain localization, erectile dysfunction, cold sensitivity and the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI). MATERIAL AND METHODS: Fifty men with CPPS were classified in each of the six UPOINT domains. A CPPS focused history was obtained and the men were asked to complete the NIH-CPSI, the International Index of Erectile Function (IIEF-5) and the Coping Strategies Questionnaire (CSQ). RESULTS: The mean age was 46 years (range 26-71 years). The percentage positive for each domain was 26 (52%) for urinary, 18 (36%) for psychosocial, 19 (38%) for organ specific, 19 (38%) for infection, 18 (36%) for neurological/systemic and 16 (32%) for pelvic muscle tenderness. Mean NIH-CPSI was 23+/-7. The number of positive domains and the NIH-CPSI [correlation coefficient (r) = 0.478, p=0.002] and its quality of life section (r=0.432, p=0.003) were linked; there was, however, no correlation between the number of positive domains and IIEF-5, ejaculatory pain, painful micturition, cold sensitivity or pain localization (except for scrotal pain). The link between catastrophizing and NIH-CPSI was marked (r=0.61, p<0.001). CONCLUSIONS: The correlation between the UPOINT score and NIH-CPSI was verified. A weak or lacking correlation with the studied clinical parameters suggests that further development is required before UPOINT can be considered an optimal phenotyping instrument.

The morbidity associated with a TURP procedure in routine clinical practice, as graded by the modified Clavien-Dindo system.

Background: Transurethral resection of the prostate (TURP) is considered the reference surgical method of treating benign prostatic enlargement (BPE) causing obstruction. The procedure still carries a significant risk of perioperative morbidity according to previous reports. The aim of the present study was to disclose complications after TURP undertaken in routine clinical practice at a non-academic center.Methods: All patients with BPE submitted to TURP from January 2010 to December 2012 were evaluated for complications occurring during hospital stay, after discharge up to the end of the third post-operative month and finally for any late endourological re-interventions undertaken up to five years after TURP. All complications were graded according to the Clavien-Dindo system.Results: In total, 354 men underwent a TURP during the study period. In total, 47% had pre-operative urinary retention. Significant co-morbidity was seen in 17% of men (ASA III-IV). Spinal anaesthesia was applied to 312 men (88%). During hospital stay, major complications, graded as Clavien-Dindo ≥ III, was seen in only eight men (2.3%). Minor complications occurred in 91 men (26%). Between hospital discharge and follow-up visit major complications were noted in 12 men (3.4%). Minor complications occurred in 79 men (22%). The only factor that was associated with an increased risk of a major complication was general anaesthesia. Late complications, requiring an endourological re-intervention, occurred in 30 men (9.7%).Conclusion: TUR-P in routine clinical practice was associated with a low incidence of severe complications. TUR syndrome was very rare. Within five years a small proportion of men require the transurethral intervention to be redone.

Urinary cytology and nuclear matrix protein 22 in the detection of bladder cancer recurrence other than transitional cell carcinoma.

OBJECTIVE: To assess the value of nuclear matrix protein-22 (NMP22), compared with urinary cytology, in predicting the recurrence of bladder cancer that is not transitional cell carcinoma (non-TCC). PATIENTS AND METHODS: We tested the sensitivity, specificity and the predictive accuracy of NMP22 in the context of non-TCC bladder cancer recurrence, and compared it to the performance of urinary cytology. The study group comprised 2687 patients with history of non-muscle-invasive bladder cancer from 10 centres across four continents. RESULTS: The mean patient age was 64.8 years and 75.4% were men; of all patients, 513 (19.1%) had positive urinary cytology, 906 (33.7%) had a positive NMP22 test (>or=10 units/mL) and 80 (3.0%) had non-TCC recurrence. Most of these, i.e. 60 (75%), were stage >or=T2. The sensitivity and specificity of urinary cytology were, respectively, 20.0% and 94.8%, vs 77.5% and 81.8% for NMP22 of >or=10 units/mL. The predictive accuracy of urinary cytology was 57.5%, vs 87.1% for NMP22 >or= 10 units/mL. A combined model that included dichotomized NMP22 and urinary cytology was 85.3% accurate. CONCLUSION: The ability of a NMP22 level of >or=10 units/mL to predict non-TCC recurrence was better than that of urinary cytology, suggesting that NMP22 might have a role in the surveillance of patients at risk of non-TCC recurrence.

Giving patients with erectile dysfunction the opportunity to try all three available phosphodiesterase type 5 inhibitors contributes to better long-term treatment compliance.

INTRODUCTION: There are three phosphodiesterase type 5 (PDE5) inhibitors marketed, sildenafil, Vardenafil, and tadalafil for oral treatment of erectile dysfunction (ED). Although the treatment is simple and mostly effective, around 50% has ceased to use the medication within 2 years. One recently described way to improve the compliance is to let the patient try all the three PDE5 inhibitors and to prescribe the drug(s) he and his partner desires. AIM: To study long-term compliance among patients who were treated according to this "three-drug regime." MAIN OUTCOME MEASURES: Compliance and reasons for discontinuation after >2 years. METHODS: The men who, during 2003, were enrolled in a treatment regime, where they had the opportunity to test all the three drugs and to chose the one(s) they preferred, were interviewed in 2006 by telephone concerning their ongoing ED treatment and the reason for discontinuation. RESULTS: Of the 138 men, mean age 60 years (36-79 years), who had been enrolled and successfully treated with the three-drug regime, 127 (92%) could be reached. The mean follow-up time was 27 months (23-34 months). Of the 127 men, as many as 109 (86%) were still using PDE5 inhibitors. A few (8%) used more than two tablets per week. The majority (44%) used one to two tablets per week or one to two per month (43%), the others (5%) less often. The causes for discontinuation were varying. The most common reason (N = 7) was return of a satisfactory non-assisted erection. Seventy-five percent of the men used only one drug; the others switched between a short- and long-acting drug depending on the situation. It was not uncommon (25%) that the preference had changed during the 3 years of PDE5 inhibitor use. CONCLUSION: To let patients with ED test the three available PDE5 inhibitors results in an unusually high compliance even under an extended period of time (>2 years).

Defining and discriminating responders from non-responders following transurethral resection of the prostate.

BACKGROUND: Transurethral resection of the prostate (TURP) is the reference standard surgical treatment for lower urinary tract symptoms (LUTS) related to benign prostatic enlargement. The aim of this study was to investigate the response rate following TURP in two distinctly different patient categories; men with bothersome LUTS and men in urinary retention (UR) requiring catheterisation. METHODS: In total, 355 men underwent TURP due to LUTS or UR. Responders in the LUTS group were defined as having an International Prostate Symptom Score ≤7 or >50% loss compared to baseline, a Qmax ≥ 15 mL/s or >50% gain compared to baseline, a post-void residual ≤100 mL or a bother score ≤2. Patients fulfilling at least one out of the four criteria were defined as responders. In the UR group, responders were defined as being catheter-free at follow-up. RESULTS: In total, 337 men remained for final analysis. The proportion operated on due to UR was 46%. In men with LUTS, the response rate was 95%. One in four were classified as excellent responders, fulfilling all four outcome criteria. Men with UR had a successful removal of the catheter after TURP prior to discharge in 77% of the cases and an additional 6% within 3 months, yielding a total response rate of 83%. CONCLUSION: TURP is a successful procedure in men with bothersome LUTS and in men with UR. Considering the difference regarding voiding outcomes in men operated on due to LUTS or UR, these groups should be analysed separately in future studies comparing TURP against newer treatment modalities.

Treatment for erectile dysfunction based on patient-reported outcomes: to every man the PDE5 inhibitor that he finds superior.

Erectile dysfunction (ED) is a common medical condition linked both to aging and to many medical conditions such as diabetes mellitus and cardiovascular disease. Although a common condition, treatment for ED has in the past been conducted by a few specialists, mostly urologists and sex therapists. The revolutionary introduction of oral therapy, and the massive amount of research into sexual dysfunction that followed, has led to paradigm shift in the treatment of ED. This is no longer something done by a few for a few; it involves all disciplines of medicine and more patients are being treated by a greater number of physicians. Several medications administered by different routes are available for treating ED but oral pharmacotherapy represents the first-line option. Phosphodiesterase (PDE) type 5 inhibitors are the most widely prescribed oral agents and they have a satisfactory efficacy-safety profile in patients of all categories. An alternative for men who do not respond to PDE5 inhibitors is intracavernosal injection therapy with alprostadil, a prostaglandin analogue. Other alternatives include sublingual apomorphine and intraurethral alprostadil. Both agents have a less satisfactory efficacy profile than PDE5 inhibitors and a low compliance rate. The aim of ED treatment is to restore an erection satisfactory for the sexual needs of the patient. Thus, the patient-reported outcome is the gold standard in efficacy evaluation. There are now three PDE inhibitors available, all with satisfactory efficacy-safety profiles, but with different pharmacokinetic properties. The availability of three different agents has initiated studies aiming to evaluate them regarding patient preference. However, the results are rather conflicting with some studies suggesting that tadalafil has the best patient preference, while others fail to demonstrate a clinically significant difference between the three agents. However, there is a tendency for younger men to choose tadalafil because it gives them a broader window of opportunity, while older men tend to prefer vardenafil or sildenafil. These data could be used when making a decision on which PDE5 inhibitor to prescribe, although another option is to let the patient try all three available agents and make his own choice.

[One man of five aged 50 years and over referred to a urologist is diagnosed with cancer. PSA analysis is important for correct prioritization of the referrals]. / Var femte man över 50 år som remitteras till urolog har cancer. PSA viktigt för att remisserna ska kunna prioriteras rätt.

In 20% of the men 50 years of age and older referred to a urological specialist clinic, a cancer, mostly a prostate cancer, was diagnosed. No symptom mentioned in the referral form was correlated to the diagnosis of a cancer. S-PSA density did not have a better predictive value than S-PSA alone. S-PSA 3.0 microg/L as a borderline for prostate biopsy or not had a 99.5% negative predictive value and only a slightly lower specificity then 4.0 microg/L. In clinical practice, for patients where curative treatment is feasible, S-PSA 3.0 microg/L appears to be a more appropriate borderline for prostate biopsy than 4 microg/L.

[Testicular torsion--a diagnostic dilemma. Diagnosis confirmed by exploration in only 9 per cent of cases, color ultrasound more accurate]. / Testistorsion--ett diagnostiskt dilemma. Exploration bekräftar diagnos hos 9 procent, färgdopplerultraljud säkrare.

The diagnosis was confirmed in only 9% of 170 patients surgically explored for suspected testicular torsion over a period of 2 years at four Swedish hospitals. In only every second case of testicular torsion was it considered meaningful to leave the testicle in situ. The high number of explorations, where the preoperative suspicion could not be verified, suggests that the preoperative diagnostic work-up should be improved. The use of power or colour ultrasound is suggested as a way of achieving this.