A cost-effectiveness analysis of long-term intermittent catheterisation with hydrophilic and uncoated catheters.

STUDY DESIGN: Cost-effectiveness analysisObjective:To establish a model to investigate the cost effectiveness for people with spinal cord injury (SCI), from a lifetime perspective, for the usage of two different single-use catheter designs: hydrophilic-coated (HC) and uncoated (UC). The model includes the long-term sequelae of impaired renal function and urinary tract infection (UTI). SETTING: Analysis based on a UK perspective. METHODS: A probabilistic Markov decision model was constructed, to compare lifetime costs and quality-adjusted life years, taking renal and UTI health states into consideration, as well as other catheter-related events. UTI event rates for the primary data set were based on data from hospital settings to ensure controlled and accurate reporting. A sensitivity analysis was applied to evaluate best- and worst-case scenarios. RESULTS: The model predicts that a 36-year-old SCI patient with chronic urinary retention will live an additional 1.4 years if using HC catheters compared with UC catheters, at an incremental cost of £2100. Moreover, the lifetime number of UTI events will be reduced by 16%. All best- and worst-case estimates were within the UK threshold of being cost effective. CONCLUSION: The use of HC catheters for intermittent catheterisation in SCI patients is highly cost effective. The outcome is consistent irrespective of whether UTI data are collected in hospital or community settings.

Increased complications in geriatric patients with a fracture of the hip whose postoperative weight-bearing is restricted: an analysis of 4918 patients.

AIMS: The aims of this study were to evaluate the incidence of postoperatively restricted weight-bearing and its association with outcome in patients who undergo surgery for a fracture of the hip. PATIENTS AND METHODS: Patient aged > 60 years undergoing surgery for a hip fracture were identified in the 2016 National Surgical Quality Improvement Program (NSQIP) Hip Fracture Targeted Procedure Dataset. Analysis of the effect of restricted weight-bearing on adverse events, delirium, infection, transfusion, length of stay, return to the operating theatre, readmission and mortality within 30 days postoperatively were assessed. Multivariate regression analysis was used to adjust for confounding demographic, comorbid and procedural characteristics. RESULTS: Of the 4918 patients who met inclusion criteria, 3668 (63.53%) were allowed to weight-bear as tolerated postoperatively. Controlling for patient and procedural factors, multivariate odds of any adverse event, major adverse event, delirium, infection, transfusion, length of stay ≥ 75th percentile (six days) and mortality within 30 days were all higher in patients with weight-bearing restrictions. Notably, there were no differences for thromboembolic events, return to the operating theatre or readmission within 30 days between the groups. CONCLUSION: Elderly patients with a fracture of the hip with postoperative weight-bearing restrictions have a significantly greater risk of developing most adverse events compared with those who are encouraged to weight-bear as tolerated. These findings emphasize the importance of immediate weight-bearing as tolerated to optimize the outcome in these frail patients; however nearly 25% of surgeons fail to meet this evidence-based guideline. Cite this article: Bone Joint J 2018;100-B:1377-84.

Renal inflammatory myofibroblastic tumor: a rare tumor indistinguishable from renal cell carcinoma­report of two cases.

Renal inflammatory myofibroblastic tumor (IMT) is a rare soft-tissue tumor of controversial etiology with a potential for local recurrence after incomplete surgical resection. The radiological findings in renal IMT are not well described. We report two cases in adults with a renal mass treated with nephrectomy on suspicion of malignancy.

The effect of penile vibratory stimulation on male fertility potential, spasticity and neurogenic detrusor overactivity in spinal cord lesioned individuals.

PURPOSE: Present the possibility for treatment of male infertility, spasticity, and neurogenic detrusor overactivity in spinal cord lesioned (SCL) individuals with penile vibratory stimulation (PVS). METHOD: Obtaining reflex-ejaculation by PVS, by using a vibrator developed for this purpose. The stimulation was performed with a vibrating disc of hard plastic placed against the frenulum of the penis (amplitude > or = 2.5 mm). The vibration continued until antegrade ejaculation or for a maximum of 3 minutes followed by a pause of 1 minute before the cycle was repeated, maximally 4 times. RESULTS: >80% SCL men are able to obtain ejaculation with PVS. Pregnancy rates obtained with home PVS and intra-vaginal insemination was 22-62% (4 studies), and with PVS or electroejaculation and intrauterine insemination/in-vitro fertilization/intracytoplasmatic sperm injection 39-64% (9 studies). PVS was demonstrated to decrease spasticity significantly when measured by the modified Ashworth scale. In addition, a decrease of the number of spontaneous EMG events which probably indicate spasms was observed. Increase in bladder capacity at leakpoint following 4 weeks of frequent ejaculation with PVS treatment was likewise demonstrated. CONCLUSION: PVS has proved its importance for SCL male fertility, in the years to come its place in treatment of spasticity and neurogenic detrusor overactivity has to be established.

Urinary tract infections in patients with spinal cord lesions: treatment and prevention.

Even though the mortality due to urinary tract complications has decreased dramatically during the last decades in individuals with spinal cord lesions (SCL), urinary tract infections (UTI) still cause significant morbidity in this population. Complicated UTI are caused by a much wider variety of organisms in individuals with SCL than in the general population and are often polymicrobial. Escherichia coli, Pseudomonas spp., Klebsiella spp., Proteus spp., Serratia spp., Providencia spp., enterococci, and staphylococci are the most frequently isolated bacteria in urine specimens taken from individuals with SCL. There is no doubt that the greatest risk for complicated UTI in these individuals is the use of an indwelling catheter. Intermittent catheterisation during the rehabilitation phase has been shown to lower the rate of UTI, and virtually eliminate many of the complications associated with indwelling catheters. Persons with SCL should only be treated for bacteriuria if they have symptoms. Generally, it is advisable to use antibacterial agents with little or no impact on the normal flora. Single agent therapy - in accordance with antimicrobial susceptibility test - is preferred. We advise extending treatment to at least 5 days, and in those with reinfection or relapsing UTI, at least 7 to 14 days, depending on the severity of the infection. The diagnosis of structural and/or functional risk factors is essential in order to plan an optimal treatment for UTI in individuals with SCL, which should include treatment of simultaneously occurring predisposing factors. The treatment of structural risk factors follows general urological principles, aiming for sufficient outlet from the bladder with minimal residual urine and low pressure voiding. For prevention of UTI, general cleanliness and local hygiene should be encouraged. If the patient has a reinfection or relapsing symptomatic UTI, it is important to check for inadequately treated infection and complications, which need special attention, in particular residual urine and urinary stones. No reliable evidence exists of the effectiveness of cranberry juice and other cranberry products. Prophylactic antibacterials should only be used in patients with recurrent UTI where no underlying cause can be found and managed, and in particular if the upper urinary tract is dilated. Antibacterials should not be used for the prevention of UTI in individuals with SCL and indwelling catheters. However, the use of prophylactic antibacterials for individuals with SCL using intermittent catheterisation or other methods of bladder emptying is controversial.

Nonoperative management of the ultrasonically evaluated appendiceal mass.

Forty patients with an ultrasonically evaluated appendiceal mass were studied. Abscesses were diagnosed in 31 patients (78%). Seventeen patients had an ultrasonically guided percutaneous drainage performed, and all but one patient had resolution of symptoms without further treatment or complications. Fourteen patients were treated conservatively without drainage, and 12 had resolution of symptoms without interference. Ultrasonograms in the remaining nine patients (22%) revealed phlegmonous inflammation only, and all recovered without treatment. The three patients considered failures had surgery because of intestinal obstruction or suspected but unverified perforation. Three patients (8.5%) had recurrent appendicitis within 5 months after the initial attack. Diagnostic errors delayed proper therapy for 1 month in a patient with a cecal carcinoma and for 5 months in a patient with Crohn's disease. Late sequelae were observed in four patients, three of whom had surgery. Nonoperative treatment and if possible ultrasonically guided percutaneous drainage of verified abscesses are safe procedures with few complications and late sequelae. However, diligent in-hospital observation and close follow-up are mandatory.

In vivo evaluation of visco-elasticity in a biological tube. Part 1. Stress relaxation in the female urethra studied by cross-sectional area and pressure measurements.

The urethral response to a sudden forced dilatation was studied by a mathematical analysis of the pressure response in ten healthy women. A total of 60 dilatations, using various sizes and velocities of deformation, were performed in the high-pressure zone. The decay in pressure during relaxation proved to follow an exponential equation of the following form: Y = Z + C alpha e-t/tau alpha + C beta e-t/tau beta, where Z is the equilibrium pressure, C alpha and C beta are pressure decay, and T alpha and T beta are time constants. The time constants were unaffected by the circumstances of dilatation, whereas all the other parameters were correlated to size or velocity of dilatation, or both. The time constants showed a fairly high reproducibility when repeated after one weak. The method is presumed to characterise the tissue composition of the periluminal tissue layers and may prove useful in the evaluation of the normal urethral sphincter function. Furthermore, it may prove of value in the elucidation of the pathophysiology of stress urinary incontinence.

In vivo evaluation of visco-elasticity in a biological tube. Part 2. Application of a mechanical model.

Based on a theoretical model, the urethral stress-relaxation response following a sudden forced dilatation was studied in ten healthy female volunteers. The energy dissipation following a sudden urethral dilatation proved to follow the function Y = Z + C alpha e-t/tau alpha + C beta e-t/tau beta. Hence, a mechanical model was chosen, consisting of two Maxwell elements and one Hooke element coupled in parallel. The decay in force following deformation may be described as F = F(o) exp (-t.E/eta) for each Maxwell element. Thus, it was possible to determine the elastic E and viscous eta coefficients for the participating mechanical equivalents in the model, and thereby quantitatively describe the visco-elastic properties in the urethra. The reproducibility of the elastic and the viscous coefficients proved to be fairly high, and they seemed to be unaffected by the size of dilatation. On the other hand, the rate of dilatation clearly influenced the computed parameters. However, this phenomenon was easily explained by the duration of the deformation, which allowed the viscous elements to move before any measurements were performed. The present method permits in vivo evaluation of the elastic and viscous properties of the urethra, as well as other accessible biological tubes, and may be of value in the description of normal physiological and pathophysiological behaviour of the structures studied.

[Early complications of enterostomy. Importance of the type of suture]. / Tidlige komplikationer ved anlaeggelse af enterostomi. Betydning af den anvendte suturtype.

The frequency and character of early complications following creation of enterostomies, and their relation to the type of suture material used were studied in 50 consecutive patients. The stomas were matured by muco-cutaneous eversion, and were fixated with Maxon 4-0 and Vicryl 3-0 sutures. Half the stoma circumference was sutured with the one suture type, and the other half with the other. No statistically significant correlation was found between enterostomy type or surgical procedure and complications. The incidence of muco-cutaneous complications was significantly higher following fixation with Vicryl as compared to Maxon sutures. The cause of this difference is uncertain, however, the physical configuration of the sutures seems important, Maxin being monofile versus Vicryl being braided. Whether the chemical structure is significant as well remains undetermined at present.

[Delayed diagnosis of bronchial foreign body]. / Sen diagnostik af bronkialt fremmedlegeme.

An open safety pin was found in the middle lobe bronchus in a 3-year old girl with pneumonia. The point was directed downwards, and the pin could be removed during bronchoscopy. The lock was found to be partly corroded following months in the bronchial tree. The safety pin had thus most probably been closed when aspirated, and had thereafter remained silent until its spontaneous opening.

[Waiting lists for men with benign urinary disorders]. / Ventelisteprojekt for maend med benigne vandladningsforstyrrelser.

This paper reflects the problems in having a large non-specific waiting-list. One hundred and twenty-eight patients were on a waiting-list under the main diagnosis of prostatism. This diagnosis revealed seven patients with cancer in the urinary tract system. Only two-thirds of the patients on the waiting-list were interested in further examination and treatment. This paper emphasizes the need for a more specific referral, when dealing with symptoms from the lower urinary tract system.