How to avoid clean intermittent catheterization in men with ileal bladder substitution

PURPOSE: In male patients with ileal bladder substitute we ascertained the likelihood of spontaneous voiding failure, the corrective procedures required and the eventual outcomes. MATERIALS AND METHODS: Following cystectomy and ileal bladder substitution for urothelial cancer between April 1985 and September 2002 male patients were identified and analyzed from the prospective departmental database. Four patients underwent ileum conduit conversion following urethral recurrence or pouch necrosis and were excluded from study. Funnel-shaped outlets were avoided during bladder substitute surgery after the first 4 patients with this configuration experienced voiding failure and required corrective procedures. Only patients with a minimum 5-year followup were assessed for voiding failure, corrective procedures and final outcomes. RESULTS: Of 354 patients with a median age of 65 years (range 36 to 84) treated with bladder substitute 180 (51%) were alive at 5 years. All 180 of these patients spontaneously voided within 3 months of surgery. During this 5-year observation period 22 (12%) patients experienced voiding problems requiring de-obstructive procedures. Following intervention 177 (98%) patients were spontaneously voiding by 5 years. Of 237 patients 77 (32%) were alive at 10 years. Of these 77 patients followed for another 5 years 10 (13%) had similar voiding problems requiring de-obstructive procedures. Subsequently 74 (96%) were voiding spontaneously by 10 years. CONCLUSIONS: Patients often fail to void spontaneously after ileal bladder substitution. However, if a funnel-shaped outlet is avoided and de-obstructive surgery is appropriately implemented, excellent long-term results are seen with spontaneous voiding and clean intermittent catheterization can be avoided.

To stent or not to stent perioperatively the ureteroileal anastomosis of ileal orthotopic bladder substitutes and ileal conduits? Results of a prospective randomized trial

PURPOSE: We evaluated the impact of stenting the ureteroileal anastomosis on its competence, upper urinary tract dilatation, gastrointestinal recovery, metabolic parameters and patency rate after cystectomy with ileal bladder substitution or ileal conduit. MATERIALS AND METHODS: A total of 54 patients (37 with an ileal bladder substitute and 17 with an ileal conduit) were prospectively randomized into 2 groups, with (29) or without (25) perioperative stenting of the ureteroileal anastomosis. In all cases an end-to-side ureteroileal refluxing anastomosis was performed. The stents were removed after 5 to 10 days. The parameters assessed postoperative days 1, 3 and 7 were creatinine concentration from the wound drains, upper urinary tract dilatation, time to bowel function recovery, serum creatinine, as well as urea and incidence of metabolic acidosis. RESULTS: Median patient age was 68 years (range 45 to 85). Urine leak on postoperative day 1 was more frequent in those anastomoses without stents, and on postoperative days 3 and 7 the values were comparable. Stenting of the ureteroileal anastomosis resulted in significantly decreased early postoperative upper urinary tract dilatation, improved recovery of bowel function and decreased metabolic acidosis. In either group no patient had clinical evidence of ureteroileal anastomotic stricture during the early postoperative period. Three patients with perioperative stenting required surgical or endoscopic treatment for a stricture of the ureteroileal anastomosis during the 12-month followup. CONCLUSIONS: Stenting of the ureteroileal anastomosis allows for significantly less frequent incidence of early postoperative dilatation of the pelvicaliceal system, bowel activity resumes significantly earlier and metabolic acidosis is significantly less frequent.

Prevalence of nephrolithiasis in patients with ileal bladder substitutes

OBJECTIVES: To assess the effect of ileal bladder substitutes with preservation of the ileocecal valve and distal 25 cm of ileum on nephrolithiasis. METHODS: We reviewed a consecutive series of 518 patients (44 women and 474 men) with ileal orthotopic bladder substitution in whom 55 to 65 cm of ileum was resected but with preservation of the ileocecal valve and distal 25 cm of ileum, to determine prevalence of nephrolithiasis as well as bicarbonate, base excess, creatinine levels, and urinary pH at time of stone diagnosis and 2 years before it. RESULTS: Four male patients with a median age of 66 years (range, 50 to 70 years) developed nephrolithiasis after ileal bladder substitute, for a total of five calculi. The prevalence of nephrolithiasis in this retrospective cohort is thus 1% (5 of 518). They developed the calculi after a median follow-up of 8 years (range, 4 to 17 years). The four patients were diagnosed with calculi at 2.3, 3, 10, 10.3, and 14 years after bladder substitute. Two of the stones were uric acid calculi; the remaining three were calcium oxalate. None of our patients were acidotic or had elevated serum creatinines at time of stone formation. Urinary pH determined once in spontaneously voided urine at the time of stone diagnosis was pH 6.0 for the two uric acid calculi and pH 7.0 for the remaining calculi. CONCLUSIONS: The present study demonstrates a low prevalence of calculi in our cohort.

Dimensional ridge alterations following immediate implant placement in molar extraction sites: a six-month prospective cohort study with surgical re-entry

AIM: To assess dimensional ridge alterations following immediate implant placement in molar extraction sites. MATERIAL AND METHODS: Twelve subjects received 12 immediate transmucosal implants in molar extraction sites. Peri-implant defects were treated according to the principles of Guided Bone Regeneration by means of a deproteinized bone substitute and a bioresorbable collagen membrane. Changes in vertical (IS-BD, CREST-BD) and horizontal distances (EC-I, IC-I) of alveolar bony walls to the bottom of the defects (BD) and to the implant surfaces (I) were compared between implant placement and surgical re-entry at 6 months. RESULTS: The implant survival rate at 6 months was 100%. Statistically significant differences (P<0.01) were observed in the mean changes in vertical distances IS-BD and CREST-BD between baseline and re-entry. At re-entry, all peri-implant marginal defects assessed from the internal socket wall to the implant surface (IC-I) were healed. The residual combined thickness of the buccal wall with the newly formed peri-implant bone at sites with an initial thickness of 1 mm was statistically significantly smaller (P<0.05) compared with that of sites with an initial buccal thickness of 2 mm (2.50 +/- 0.76 vs. 4+/-0 mm). CONCLUSIONS: The marginal defects around immediate implants placed in molar extraction sites were completely filled after 6 months of healing through de novo bone formation. Bone resorption was observed from the external aspects of the buccal and oral socket walls. Dimensional changes of the external socket walls were mostly pronounced at the buccal aspects.

Graft remodeling during growth following anterior cruciate ligament reconstruction in skeletally immature sheep

INTRODUCTION: Ruptures of the anterior cruciate ligament are being diagnosed with increasing frequency in skeletally immature individuals. It was our aim to investigate the graft remodelling process following an autologous, transphyseal reconstruction of the anterior cruciate ligament (ACL) in skeletally immature sheep. We hypothesized that the ligamentisation process in immature sheep is quicker and more complete when compared to adult sheep. MATERIALS AND METHODS: Skeletally immature sheep with an age of 4 months underwent a fully transphyseal ACL reconstruction using an autologous tendon. The animals were subsequently sacrificed at 3, 6, 12 and 24 weeks following surgery. Each group was characterised histomorphometrically, by immunostaining (VEGF, SMA), by transmission electron microscopy (TEM) and biomechanically (UFS Roboter). RESULTS: The histomorphometric analysis and presence of VEGF and SMA positive cells demonstrated a rapid return to a ligament like structure. The biomechanical analysis revealed an anteroposterior translation that was still increased even 6 months following surgery. CONCLUSION: As in adult sheep models, the remodeling of a soft tissue graft used for ACL reconstruction results in a biomechanically inferior substitute. However, the immature tissue seems to remodel faster and more complete when compared to adults.

Influence of Particle Size of Deproteinized Bovine Bone Mineral on New Bone Formation and Implant Stability after Simultaneous Sinus Floor Elevation: A Histomorphometric Study in Minipigs

BACKGROUND Deproteinized bovine bone mineral (DBBM) is one of the best-documented bone substitute materials for sinus floor elevation (SFE). PURPOSE DBBM is available in two particle sizes. Large particles are believed to facilitate improved neoangiogenesis compared with small ones. However, their impact on the rate of new bone formation, osteoconduction, and DBBM degradation has never been reported. In addition, the implant stability quotient (ISQ) has never been correlated to bone-to-implant contact (BIC) after SFE with simultaneous implant placement. MATERIALS AND METHODS Bilateral SFE with simultaneous implant placement was performed in 10 Göttingen minipigs. The two sides were randomized to receive large or small particle size DBBM. Two groups of 5 minipigs healed for 6 and 12 weeks, respectively. ISQ was recorded immediately after implant placement and at sacrifice. Qualitative histological differences were described and bone formation, DBBM degradation, BIC and bone-to-DBBM contact (osteoconduction) were quantified histomorphometrically. RESULTS DBBM particle size had no qualitative or quantitative impact on the amount of newly formed bone, DBBM degradation, or BIC for either of the healing periods (p > 0.05). Small-size DBBM showed higher osteoconduction after 6 weeks than large-size DBBM (p < 0.001). After 12 weeks this difference was compensated. There was no significant correlation between BIC and ISQ. CONCLUSION Small and large particle sizes were equally predictable when DBBM was used for SFE with simultaneous implant placement.

Osteocyte lacunar density and area in newly formed bone of the augmented sinus

OBJECTIVES Osteocytes, the most common cells of the bone, are buried in lacunae. Density and area of the osteocyte lacunae change with increasing maturation of the newly formed bone. Evaluation of osteocyte lacunae can therefore provide insights into the process of graft consolidation. MATERIALS AND METHODS Here, we determined the osteocyte lacunar density (number of osteocyte lacunae per bone area; N.Ot/BAr) and the osteocyte lacunar area in μm(2) (Lac.Ar) in histological specimens 6 and 12 weeks after the sinuses of 10 minipigs were augmented with Bio-Oss(®) , a deproteinized bovine bone mineral, and Ostim(®) , an aqueous paste of synthetic nanoparticular hydroxyapatite. The region of interest was defined by the following criteria: (i) >1 mm from the host bone, (ii) >0.5 mm from the sinus mucosa, (iii) minimum area of 0.2 mm(2) , and (iv) bone tissue spanning at least two bone substitute particles. RESULTS The overall osteocyte lacunar density was significantly higher in the Bio-Oss(®) group than in the Ostim(®) group and decreased during the observation period at a similar range in both groups. The osteocyte lacunar area was smaller in the Bio-Oss(®) group than the Ostim(®) group but there was no significant change within the groups over time. CONCLUSIONS These results suggest that bone substitutes affect the osteocyte lacunar density and the osteocyte lacunar area in the newly formed bone within the augmented sinus in this particular model situation. These measures can provide insights into the maturation of newly formed bone in the augmented sinus.

Stricture of the Afferent Isoperistaltic Tubular Segment: A Late and Rare Cause of Bilateral Dilation of the Upper Urinary Tract After Ileal Bladder Substitution

OBJECTIVE To evaluate the etiology and treatment of bilateral hydronephrosis not responding to bladder substitute drainage after ileal bladder substitution using an afferent isoperistaltic tubular segment. MATERIALS AND METHODS A retrospective analysis was performed of a consecutive series of 739 patients who had undergone bladder substitution from April 1985 to August 2012. RESULTS Of the 739 ileal bladder substitute patients, 10 (1.4%) developed bilateral hydronephrosis unresponsive to complete bladder substitute drainage. The etiology was stenosis of the afferent isoperistaltic tubular segment. The median interval to presentation was 131 months (range 45-192). The incidence of afferent tubular segment stenosis was significantly higher in the 61 ileal bladder substitute patients with recurrent urinary tract infection (9 [15%]) than in the 678 without recurrent urinary tract infection (1 [0.15%]; P <.001). Urine cultures revealed mixed infections (34%), Escherichia coli (18%), Staphylococcus aureus (13%), enterococci (11%), Candida (8%), Klebsiella (8%), and others (8%). Seven patients underwent 10 endourologic interventions, only 1 of which was successful (10%). After failed endourologic treatment, 7 open surgical revisions with resection of the stricture were performed, with all 7 (100%) successful. CONCLUSION Bilateral dilation of the upper urinary tract after ileal orthotopic bladder substitution unresponsive to complete bladder substitute drainage is likely to be caused by stenosis of the afferent isoperistaltic tubular segment. The stenosis occurs almost exclusively in patients with long-lasting, recurrent urinary tract infection and can develop many years after the ileal bladder substitution. Minimally invasive endourologic treatment is usually unsuccessful; however, open surgical revision offers excellent results.

Determination of the molecular subtypes of diffuse large B-cell lymphomas using immunohistochemistry: a case series from the Inselspital, Bern, and a critical appraisal of this determination in Switzerland

The two major subtypes of diffuse large B-cell lymphoma (DLBCL) (germinal centre B-cell - like (GCB-DLBCL) and activated B-cell - like (ABC-DLBCL)) are defined by means of gene expression profiling (GEP). Patients with GCB-DLBCL survive longer with the current standard regimen R-CHOP than patients with ABC-DLBCL. As GEP is not part of the current routine diagnostic work-up, efforts have been made to find a substitute than involves immunohistochemistry (IHC). Various algorithms achieved this with 80-90% accuracy. However, conflicting results on the appropriateness of IHC have been reported. Because it is likely that the molecular subtypes will play a role in future clinical practice, we assessed the determination of the molecular DLBCL subtypes by means of IHC at our University Hospital, and some aspects of this determination elsewhere in Switzerland. The most frequently used Hans algorithm includes three antibodies (against CD10, bcl-6 and MUM1). From records of the routine diagnostic work-up, we identified 51 of 172 (29.7%) newly diagnosed and treated DLBCL cases from 2005 until 2010 with an assigned DLBCL subtype. DLBCL subtype information was expanded by means of tissue microarray analysis. The outcome for patients with the GCB subtype was significantly better compared with those with the non-GC subtype, independent of the age-adjusted International Prognostic Index. We found a lack of standardisation in the subtype determination by means of IHC in Switzerland and significant problems of reproducibility. We conclude that the Hans algorithm performs well in our hands and that awareness of this important matter is increasing. However, outside clinical trials, vigorous efforts to standardise IHC determination are needed as DLBCL subtype-specific therapies emerge.

The Great Silk Alternative Multiple Co-Evolution of Web Loss and Sticky Hairs in Spiders

Spiders are the most important terrestrial predators among arthropods. Their ecological success is reflected by a high biodiversity and the conquest of nearly every terrestrial habitat. Spiders are closely associated with silk, a material, often seen to be responsible for their great ecological success and gaining high attention in life sciences. However, it is often overlooked that more than half of all Recent spider species have abandoned web building or never developed such an adaptation. These species must have found other, more economic solutions for prey capture and retention, compensating the higher energy costs of increased locomotion activity. Here we show that hairy adhesive pads (scopulae) are closely associated with the convergent evolution of a vagrant life style, resulting in highly diversified lineages of at least, equal importance as the derived web building taxa. Previous studies often highlighted the idea that scopulae have the primary function of assisting locomotion, neglecting the fact that only the distal most pads (claw tufts) are suitable for those purposes. The former observations, that scopulae are used in prey capture, are largely overlooked. Our results suggest the scopulae evolved as a substitute for silk in controlling prey and that the claw tufts are, in most cases, a secondary development. Evolutionary trends towards specialized claw tufts and their composition from a low number of enlarged setae to a dense array of slender ones, as well as the secondary loss of those pads are discussed further. Hypotheses about the origin of the adhesive setae and their diversification throughout evolution are provided.

Evaluation of a novel photography-based home assessment protocol for identification of environmental risk factors for falls in elderly persons

PRINCIPLES To evaluate the validity and feasibility of a novel photography-based home assessment (PhoHA) protocol, as a possible substitute for on-site home assessment (OsHA). METHODS A total of 20 patients aged ≥65 years who were hospitalised in a rehabilitation centre for musculoskeletal disorders affecting mobility participated in this prospective validation study. For PhoHA, occupational therapists rated photographs and measurements of patients' homes provided by patients' confidants. For OsHA, occupational therapists conducted a conventional home visit. RESULTS Information obtained by PhoHA was 79.1% complete (1,120 environmental factors identified by PhoHA vs 1416 by OsHA). Of the 1,120 factors, 749 had dichotomous (potential hazards) and 371 continuous scores (measurements with tape measure). Validity of PhoHA to potential hazards was good (sensitivity 78.9%, specificity 84.9%), except for two subdomains (pathways, slippery surfaces). Pearson's correlation coefficient for the validity of measurements was 0.87 (95% confidence interval [CI 0.80-0.92, p <0.001). Agreement between methods was 0.52 (95%CI 0.34-0.67, p <0.001, Cohen's kappa coefficient) for dichotomous and 0.86 (95%CI 0.79-0.91, p <0.001, intraclass correlation coefficient) for continuous scores. Costs of PhoHA were 53.0% lower than those of OsHA (p <0.001). CONCLUSIONS PhoHA has good concurrent validity for environmental assessment if instructions for confidants are improved. PhoHA is potentially a cost-effective method for environmental assessment.

An overview of positive and negative effects of gender-fair language use

The basic principle of gender-fair language is symmetric linguistic treatment of women and men. Depending on the structure of the respective language, two principle strategies can be deployed to make a language gender-fair. In languages with few gender-differentiating forms, such as English, there is a tendency towards neutralization. Here, gender-unmarked forms such as police officer or chairperson are used to substitute the male-biased policeman or chairman. The second strategy, feminization, implies that feminine forms of human nouns are used more frequently and systematically to make female referents visible.Since the 1970s, gender-fair language has been suggested, if not prescribed, for both scientific and official texts and its positive effects are widely documented. The use of gender-fair language increases the cognitive availability of feminine exemplars. Also in an applied context women responding to job advertisements formulated in gender-fair language feel more motivated to apply for the position. However, "side effects" of gender-fair language have also been observed: For instance, women referred to with a gender-fair title (e.g. chairperson) were evaluated as lower in status than women referred to with a masculine generic (e.g. chairman). Similarily, social initiatives framed with the use of gender-fair language were evaluated less-favourably than initiatives using traditional language. This presentation presents the gender-fair language use in the framework of a social dilemma. In order to protect themselves (or initiatives they stand for) from being ascribed incompetence or a lower status, women may avoid feminine forms and thus contribute to the perpetuation of gender-unfair language, which may be detrimental for women in general. Raising awareness for this social concern, and framing it both in terms of group and individual interest can direct the discussion about gender-fair language into a broader perspective of gender equality.

Can jatropha improve the energy supply of rural households in Africa?

There is still discussion regarding whether liquid biofuels can contribute to rural energy security in the global South. We argue that transitioning to a village energy supply based on jatropha hedges around smallholder plots is possible, but requires collective effort for the acquisition and maintenance of processing equipment and for the running of village generators. The use of jatropha oil for lighting in rural households is affordable and technically possible, but not ideal if more efficient electric solutions exist. Cooking with jatropha oil or press cake is also possible, but quantities produced in hedges can only substitute a small part of the firewood used by rural households.

A Comparison of Complications in 400 Patients After Native Nail Versus Silicone Nail Splints for Fingernail Splinting After Injuries

BACKGROUND The fingertip is the most commonly injured part of the hand and is an important aesthetic part of the hand. METHODS In this retrospective study we analyzed data from 700 patients operated on between 1997 and 2008 for complications after nail splinting with native nail or silicone nail. Inclusion criteria were patients living in Bern/Berner Land, complete documentation, same surgical team, standard antibiotics, acute trauma, no nail bed transplantation, and no systemic diseases. Groups were analyzed for differences in age, gender, cause and extension of trauma, bony injury and extent, infection, infectious agent, and nail deformities. Statistical analysis was done using the χ (2) test, Fisher's exact test, and Pearson correlation coefficients. RESULTS A total of 401 patients, with a median age of 39.5 years, were included. There were more men with injured nails. Two hundred forty native nails and 161 silicone splints were used. There were 344 compression injuries, 44 amputations, and 13 avulsion injuries. Forty-three patients had an infection, with gram-positive bacteria (Staphylococcus aureus) causing most infections. A total of 157 nail dystrophies were observed, split nails most often. The native nail splint group showed significantly (p < 0.015) fewer nail deformities than the silicone nail splint group; otherwise, there were no statistical differences. However, there were twice as many infections in the silicone nail group. CONCLUSION It seems to be advantageous to use the native nail for splinting after trauma, when possible. In case of a destroyed and unusable nail plate, a nail substitute has to be used.

Tools & Techniques - Statistics: Propensity score techniques.

Propensity score (PS) techniques are useful if the number of potential confounding pretreatment variables is large and the number of analysed outcome events is rather small so that conventional multivariable adjustment is hardly feasible. Only pretreatment characteristics should be chosen to derive PS, and only when they are probably associated with outcome. A careful visual inspection of PS will help to identify areas of no or minimal overlap, which suggests residual confounding, and trimming of the data according to the distribution of PS will help to minimise residual confounding. Standardised differences in pretreatment characteristics provide a useful check of the success of the PS technique employed. As with conventional multivariable adjustment, PS techniques cannot account for confounding variables that are not or are only imperfectly measured, and no PS technique is a substitute for an adequately designed randomised trial.