The ice-water test in the diagnosis and treatment of the neurogenic bladder

OBJECTIVE: To determine the usefulness of the ice-water test (IWT) in the diagnosis and treatment of neurological bladder disease. PATIENTS AND METHODS: The IWT was carried out in 148 patients with neuropathic bladder dysfunction resulting from a traumatic lesion, to assist in their diagnosis and treatment, and in 130 patients with neuropathic bladder dysfunction and multiple pathogenic disorders; the results of the IWT were used to classify those patients with hyperactive bladders. RESULTS: The IWT was positive in 95% of patients affected by complete and in 86% of patients with incomplete medullary lesions. The IWT in patients with lower motor neuron medullary lesions was always negative. The test was used diagnostically in all patients with lower and in 43% of those with upper motor neuron lesions. In the latter, it was used in 48% of patients as a rehabilitation method during the medullary-shock phase to accelerate the appearance of the micturition reflex. In 9% of patients it was used to induce micturition during cystography. CONCLUSION: Because it is simple to perform, the IWT is a useful complement to urodynamic examinations in patients with neurological bladder disease and in patients with micturitional disorders that are otherwise difficult to interpret.     

Interphase cytogenetic diagnosis of bladder cancer on cells from urine and bladder washing

In order to determine the value of fluorescence in situ hybridization (FISH) in the diagnosis and follow-up of bladder cancer interphase cytogenetics was performed on cells from urine and bladder washings. 50 ml of urine or bladder washings were collected. FISH was carried out using centromere probes for chromosomes 7, 8, 9 and 12 according to standard protocols. In each case 100 cell nuclei were analysed. Fifty-four samples from urine and 67 samples from bladder washing were analysed by FISH in comparison with results obtained by conventional cytology. Sensitivity of detection of tumor cells by FISH was 68.5% in urine and 63% in bladder washings regardless of tumor stage and grade. Sensitivity obtained by conventional cytology was 50% in urine and 77.3% in bladder washings. FISH on cells from urine samples is an effective complement to the standard urine cytology. Using centromere probes this approach is characterized by high specificity and sensitivity in tumors with T-category higher than pTa and grade higher than G1.     

The results of the surgical treatment of bladder cancer patients

A new method for accommodation training making use of a computer is proposed. A specially generated dynamic grid of concentric rings serves the stimulus. Changes of the accommodation parameters (the nearest and farthest points of clear vision) were examined in 11 display users aged 30 to 50 during a training session and in the course of 15 sessions. The training improved the accommodation volume by an average of 0.9 diopters at the expense of approximating the nearest and withdrawing the farthest clear vision points. In 4 subjects anisoaccommodation disappeared almost completely. The proposed method may be used to normalize the accommodation of display users.     

Selective bladder preservation by combination treatment of invasive bladder cancer

BACKGROUND: For patients with invasive bladder cancer the usual recommended treatment is radical cystectomy, although transurethral resection of the tumor, systemic chemotherapy, and radiotherapy are each effective in some patients. We sought to determine whether these treatments in combination might be as effective as radical cystectomy and thus might allow the bladder to be preserved and the cancer cured. METHODS: We enrolled 53 consecutive patients with muscle-invading bladder cancer (stages T2 through T4, NXM0) in a trial of transurethral surgery, combination chemotherapy, and irradiation (4000 cGy) with concurrent cisplatin administration. Urologic evaluation of the tumor response directed further therapy: radical cystectomy in the 8 patients who had incomplete responses, additional chemotherapy and radiotherapy (6480 cGy) in the 34 patients who had complete responses or who were unsuited for cystectomy, and alternative care in the 11 patients who could not tolerate either irradiation or chemotherapy. RESULTS: After a median follow-up of 48 months, 24 of the 53 patients (45 percent) were alive and free of detectable tumor. In 31 patients (58 percent) the bladder was free of invasive tumor and functioning well, even though in 9 (17 percent) a superficial tumor recurred and required further transurethral surgery and intravesical drug therapy. Of the 28 patients who had complete responses after initial treatment, 89 percent had functioning tumor-free bladders. CONCLUSIONS: Conservative combination treatment may be an acceptable alternative to immediate cystectomy in selected patients with bladder cancer, although a randomized clinical trial that included a group for simultaneous comparison would be required to produce definitive results.     

Recent aspects in the diagnosis and prognosis of bladder cancer

Phenylephrine and (+/-)N-[5-(4,5-dihydro-1-H-imidazol-2yl)-2-hydroxy-5,6,7,8-tetr ahydronaphthalen-1-yl] methanesulphonamide hydrobromide (A 61603) evoked concentration-dependent contractions of the rabbit spleen. These contractions were antagonized by prazosin (10(-8)-10(-7) M) with pA2 values of 8.34+/-0.11 and 8.15+/-0.10 against phenylephrine and A 61603, respectively. In both cases, the slopes of the Schild plots were not significantly (P>0.05) different from 1.0, indicating competitive antagonism. The effects of subtype-selective antagonists WB 4101 [2-(2-6-dimethoxyphenoxyethyl)aminomethyl-1,4-benzodioxane hydrochloride] and 5-methylurapidil on agonist-induced contractions were also examined. WB 4101 competitively antagonized agonist-induced contractions; pA2 values were 8.13+/-0.10 and 8.10+/-0.03 against phenylephrine and A 61603, respectively. Corresponding values for 5-methylurapidil were 8.28+/-0.17 and 7.93+/-0.02 against phenylephrine and A 61603, respectively. Tamsulosin and Rec 15/2739 [(8-3-[4-(2-methoxyphenyl)-1-piperazinyl]-propylcarbamoyl)-3-methy l-4-oxo-2-phenyl-4H-1-benzopyran dihydrochloride] also antagonized phenylephrine- and A 61603-induced contractions with pA2 values of 9.38+/-0.13 and 9.18+/-0.06 (tamsulosin) and 8.41+/-0.12 and 8.34+/-0.11 (Rec 15/2739) against phenylephrine and A 61603, respectively. HV 723 (alpha-ethyl-3,4,5-trimethoxy-alpha-(3-((2-(2-methoxyphenoxyethyl) -amino)-propyl)benzene-aceto-nitrile) fumarate) competitively antagonized phenylephrine-induced contractions with a pA2 value of 8.57+/-0.06. Chloroethylclonidine (CEC; 10(-4) M) shifted phenylephrine and A 61603 concentration-response curves to the right, reducing their potencies approximately two- to threefold, while the maximum response was reduced by 8% in both cases. It was therefore concluded that contractions of the rabbit spleen induced by alpha1-adrenergic agonists were mediated predominantly by a relatively CEC-insensitive alpha1-adrenoceptor subtype, possibly the alpha1L-subtype.     

The effect of cancer diagnosis and treatment on hand function

Cancer diagnosis and treatment can have a profound effect upon hand function, presenting a challenge to the occupational therapist. The therapist who specializes in oncology or hand therapy must have knowledge of the medical treatment model in regard to cancer conditions and must be able to set realistic goals that consider the patient's medical prognosis as well as the effect the disease or medical treatment has on the patient's physical and emotional functioning. The challenge to therapists in this area of practice will be to conduct research to verify or validate the effectiveness of the occupational therapy interventions currently provided. As cancer is diagnosed at earlier stages of the disease and survival improves after cancer treatment, hand therapy may improve the functional outcomes of persons with cancer. This judgment of rehabilitation oncology practice will need to be confirmed by research.     

The pathogenesis of bladder cancer

Carcinoma of the urinary bladder appears to arise, in at least some cases, from carcinoma in situ developing in a field of atypical epithelial proliferation. There is both a spatial and temporal relationship between invasive and in situ bladder cancer, although the exact relationship between the noninvasive flat and papillary types of tumors is not known. Prenoeplastic bladder lesions are defined as irreversible, although not necessarily progressive, and an experimental animal model of the disease has been developed. The appearance of pleomorphic microvilli on the luminal surface of epithelial cells of the urinary bladders of Fischer rats is correlated with the irreversibility of hyperplastic epithelial lesions induced by feeding N-[4-(5-nitro-2-furyl)-2-thiazolyl] formamide (FANFT) to the test animals. This alteration can be visualized by scanning electron microscopy of cytologic and histologic preparations.     

The current role of radiotherapy in the treatment of invasive bladder cancer

Invasive bladder cancer remains a therapeutic challenge. Approximately 50% of patients treated with radical cystectomy die of metastatic disease. External beam radiation therapy when given alone has results inferior to that of surgery, and although it has shown some benefit when given in the preoperative setting, this was not verified by randomized trials. Altered fractionation radiation schemes and combined modality using a cisplatin-based combination chemotherapy with radiation have resulted in up to 60% bladder preservation.     

The surgical treatment of thoracolumbar metastases

Intrathecal implants of adrenal chromaffin cells are known to release analgesic substances such as catecholamines and opioid peptides. In the present study, bovine chromaffin cells were encapsulated in a permselective polymer membrane which protects the cells from the host immune system and allows grafting of xenogeneic cells without immunosuppression. The effects of such implants were evaluated on the pain behavior resulting from a chronic constrictive injury (CCI) of the rat sciatic nerve. Sprague-Dawley rats with a unilateral lesion were implanted in the lumbar subarachnoid space and tested for mechanical/thermal allodynia and hyperalgesia. A significant reduction in pain was observed after mechanical non-nociceptive stimulation in animals implanted with chromaffin cells. Furthermore, these animals showed decreased signs of spontaneous pain. However, response to thermal non-noxious stimuli or to painful mechanical stimuli was not significantly decreased. Abundant clusters of viable chromaffin cells intensely labeled with the anti-tyrosine hydroxylase antibodies were observed in the retrieved implants. These results establish the analgesic efficacy of intrathecal encapsulated chromaffin cells in a chronic pain model of nerve injury. Immunoprotected allo- or xenogeneic chromaffin cells acting as 'mini pumps' continuously delivering neuroactive substances could be a useful therapy for patients suffering from neuropathic pain.     

An overview of bladder cancer: treatment and nursing implications

PURPOSE/OBJECTIVES: To review the incidence, pathophysiologic mechanisms, treatment options, and nursing care of patients with bladder cancer. DATA SOURCES: Published articles, book chapters, American Cancer Society materials, and a computerized data base. DATA SYNTHESIS: Nearly 53,000 cases of bladder cancer will be diagnosed this year. Recent studies link mutations on the p53 gene and abnormalities on chromosome 9 to bladder cancer. Seventy percent of patients present with local tumors within the bladder. Surgery and intravesical chemotherapy are the most common treatments for superficial bladder cancer. Deeply invasive disease sometimes can be cured by surgery, irradiation, or a combination of treatment modalities. Early stage detection has a 91% survival rate. Prevention strategies include smoking cessation and reduction of the risk of occupational exposure to toxic chemicals. CONCLUSIONS: Bladder cancer is a prevalent disease with significant morbidity. IMPLICATIONS FOR NURSING PRACTICE: Knowledge about bladder cancer will help nurses prevent and manage the disease and its treatment complications and meet patients' psychological needs.     

Endoscopic diagnosis and treatment of early colorectal cancer

Colorectal adenomas and early cancers are grossly classified into three groups: protruded, flush or slightly elevated (so-called flat adenomas), and depressed. Protruded lesions and flat adenomas are not invasive until they are rather large, whereas depressed lesions can invade the submucosa even when very small. It is not difficult to detect protruded and flat adenomas, but depressed carcinomas are often overlooked. Keys to the detection of depressed carcinomas are a slight color change, bleeding spots, interruptions of the capillary network pattern, slight deformation of the colonic wall, shape change of the lesion with insufflation and deflation of air, and interruption of the innominate grooves by the lesion. Spraying of indigo carmine dye helps to clarify the lesions. Pit pattern analysis with magnifying colonoscopy is useful for diagnosis of early colorectal cancer. Pit pattern analysis and histologic examination suggest that depressed carcinomas probably have arisen de novo, without going through an adenomatous step. Some adenomas appear at first to have a depression, but such cancer-mimicking adenomas with pseudodepression must be distinguished from depressed carcinomas because they are quite different in nature. Protruded and flat adenomas can usually be removed with polypectomy or hot biopsy techniques. Depressed carcinomas are treated with an endoscopic mucosal resection (EMR) technique; but when they massively invade the submucosa, surgical resection is indicated. Some neoplastic lesions, which we call laterally spreading tumors, extensively and circumferentially spread along the colonic wall, although they are short in height. They tend to have a rather benign nature despite their large size; therefore EMR or a piecemeal EMR method is indicated.     

Radiotherapy of bladder cancer: relevance of bladder volume changes in planning boost treatment

PURPOSE: This study aims to evaluate tumor motion with controlled changes of the bladder volume, and to assess the reproducibility of bladder (and tumor) position using a urinary catheter balloon as an immobilization device. METHODS AND MATERIALS: First, three patients with tumor growths in three different bladder regions (trigone, left lateral wall, anterior wall) were evaluated. Three-dimensional CT-based reconstructed images were used to measure the displacement of the tumors when 100 cc were removed from a bladder originally filled with 170 cc of contrast. The 3D calculated boost beam arrangements and field sizes for the three tumors in the partially emptied bladders were used to simulate treatment of the same tumors in the maximally filled bladders. Dose-volume histograms were obtained. Second, verification of an ellipsoid model for bladder volume changes was undertaken in 41 patients. Third, in eight additional patients a urinary catheter balloon filled with 80-cc sterile saline solution was used in an attempt to reproduce the shape and spatial coordinates of the bladder during the boost treatment. A pair of orthogonal films with the 80-cc balloon filled with contrast material were taken at simulation and repeated twice at weekly intervals during radiotherapy. The reproducibility was quantified by sequentially calculating the common surface of the bladder images in each orthogonal view. RESULTS: Target motion, especially in the craniocaudal axis, appeared to be more relevant for tumors arising in the bladder walls (15 mm) than in the trigone (5 mm). Underdosage (<95% of the prescribed dose to the target volume) was observed in 20, 20, and 50% (with 1 cm margins around the tumor) and in 10, 10, and 15% (with 1.5 cm margins around the tumor) of the tumors arising in the trigone, left lateral wall, and anterior wall, respectively. The ellipsoidal model was validated with a strong correlation coefficient allowing to establish a predictive model for bladder wall displacements as a function of bladder volume. In the balloon reproducibility study, mean reproducibility factors of 0.84 (+/-0.06) and 0.82 (+/-0.07) were obtained for both anteroposterior and lateral views, respectively. CONCLUSIONS: Changes in bladder volume and shape related to bladder filling can result in clinically significant displacements of the target volume. A minimum of 2-cm margins around the target may compensate for extreme bladder volume changes during boost treatment. An ellipsoidal model for the bladder is consistent with these observations. Although an 80-cc urinary catheter balloon helped to immobilize the bladder, reproducibility was less than perfect.     

The optimal diagnosis of recurrence and metastases in female genital cancer by needle biopsy (author's transl)

The "true-cut" disposable biopsy needle was used for 95 needle biopsies in 42 patients who were suspected to have a recurrence or metastases of low lying gynaecological cancer. Up to 3 biopsies per patient were obtained. In 21 patients the clinical suspicion of malignant was verified by microscopic examination. The needle biopsies were done as often by the vaginal as by the rectal route. Because of the low incidence of complications the needle biopsy was recommended for the definite diagnosis and follow-up examination of suspicious low lying gynaecological tumors.     

Orbital metastases: diagnosis and course

AIMS: Three issues were investigated in adult outpatients with orbital metastases. One, how accurate are current diagnostic methods? Two, what is the survival associated with orbital metastases? Three, did any clinical factors correlate with prognosis in this patient cohort? METHODS: Retrospective analysis of patients with orbital metastases managed in an ocular oncology unit. RESULTS: 11 of 31 (35%) patients had no known primary malignancy at the time of orbital diagnosis. In eight of 31 (26%) computed tomography and/or magnetic resonance imaging data did not yield the diagnosis of metastases. In 15 of 17 (88%) cases a fine needle aspiration biopsy was diagnostic. Several types of therapy were used. The median survival was 1.3 years. CONCLUSION: Orbital metastases, even with newer diagnostic techniques can be difficult to diagnose. Management was based on location and extent of both orbital and systemic disease as well as vision. In most cases, orbital symptoms were palliated; however, survival was dismal. No clinical factor correlated with prognosis.     

Successful treatment of solitary extracranial metastases from non-small cell lung cancer

BACKGROUND: Recurrence after resection of non-small cell lung carcinoma is generally associated with a poor outcome and is treated with either systemic agents or palliative irradiation. Recently, long-term survival has been reported after resection of isolated brain metastases from non-small cell lung carcinoma, but resection of other metastatic sites has not been explored fully. METHODS: We have identified 14 patients who had solitary extracranial metastases treated aggressively after curative treatment of their non-small cell lung carcinoma. The histology was squamous carcinoma in 5, adenocarcinoma in 8, and large cell carcinoma in 1. Initially, 3 patients had stage I, 5 stage II, and 6 stage IIIa disease. RESULTS: The sites of metastases included extrathoracic lymph nodes (six), skeletal muscle (four), bone (three), and small bowel (one). The median disease-free interval before metastases was 19.5 months (range, 5 to 71 months). Complete surgical resection of the metastatic site was the treatment in 12 of 14 patients. Two patients received only curative irradiation to the metastatic site, with complete response. The overall 10-year actuarial survival (Kaplan-Meier) was 86%. To date, 11 patients are alive and well after treatment of their metastases (17 months to 13 years), 1 has recurrent disease, 1 died of recurrent widespread metastases, and 2 died of unrelated causes. CONCLUSION: Long-term survival is possible after treatment of isolated metastases to various sites from non-small cell lung carcinoma, but patient selection is critical.     

Successful treatment of brain metastases from ovarian cancer using gamma-knife radiosurgery

We report two cases of fully intruded tooth after facial fracture in adults. In the first case, the lateral incisor was intruded into the nasal cavity and slipped into the pyriform sinus during operation. The second case involved full intrusion of a molar into the maxillary sinus, resulting in infection. The importance of a thorough intraoral examination for patients with facial trauma is emphasized. All missing teeth should be accounted for to ensure that they have not dislodged inside the body. When full intrusion of a tooth is suspected, facial computed tomography scan may provide assistance with definite diagnosis. If an incisor is completely intruded into the nasal cavity, removal through the floor of the nostril should be considered.     

Update on the diagnosis and treatment of prostate cancer

Our understanding of the causes of prostate cancer and improvements in screening methodologies and risk assessment prior to definitive local therapy continue to be refined. The utility of hormone therapy has been further evaluated, both as adjuvant and neoadjuvant therapy with radiation therapy or radical prostatectomy, as well as for patients with more advanced disease. Finally, modest inroads continue to be made in the treatment and understanding of hormone-refractory prostate cancer.