Biomedical subjects
I Richards
Publications and source records attributed to I Richards.
Does attendance at a general practice asthma clinic reduce asthma morbidity more than does standard medical treatment?
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Subclinical changes in bladder function in children presenting with nonurological symptoms of the tethered cord syndrome.
PURPOSE: We evaluated the urodynamic findings in myelodysplastic children with the tethered cord syndrome without urological symptoms to determine if occult bladder changes occur or if routine preoperative urodynamic evaluation is not indicated for this select population. MATERIALS AND METHODS: Preoperative and postoperative urodynamic studies were performed on children with myelodysplasia and the tethered cord syndrome between 1988 and 1994. Inclusion criteria were neurological or musculoskeletal surgical indications only, without urological status changes, radiographic confirmation of the tethered cord syndrome, and water cystometry performed preoperatively within 1 week and again postoperatively within 6 months. The parameters of interest included total bladder capacity and pressure, leak point pressure, compliance, uninhibited contractions, electromyelogram activity and sensation. RESULTS: A total of 20 children, 11 girls and 9 boys, 2.3 to 17.3 years old were included in the study. Worsening scoliosis and lower extremity weakness were the most common presentations. Urodynamic studies were conducted 1.8 days preoperatively (mean) and 104.3 days postoperatively (mean). Results were analyzed with regard to improvement or deterioration between preoperative and postoperative urodynamic studies. Of the 20 children 15 (75%) demonstrated improvement between the 2 urodynamic studies, including 10 who improved in 1 parameter (most often with resolution of uninhibited contractions), 3 in 2, 1 in 3 and 1 in 4. There were no significant postoperative changes for any of the specific parameters. Urodynamic studies identified 7 children with preoperative leak point pressures above 40 cm. water, of whom only 2 had decreased pressures below 40 cm. water, 2 had postoperative deterioration of compliance and 1 had preoperative detrusor-sphincter dyssynergia. CONCLUSIONS: Routine preoperative and postoperative urodynamic evaluations in children with the tethered cord syndrome without clinical changes to urological status may be important. The majority of clinically asymptomatic children will demonstrate preoperative urodynamic findings that improve postoperatively, which serves as another marker of progress after spinal cord untethering. Moreover, some asymptomatic children will demonstrate changes to the urinary tract that merit management changes, such as detrusor-sphincter dyssynergia, elevated bladder storage pressures and poor compliance, which may have otherwise been delayed in recognition.
The spectrum of irritant-induced asthma: sudden and not-so-sudden onset and the role of allergy.
A retrospective investigation of 86 asthmatic subjects defined clinical features of irritant-induced asthma and assessed the contributory role of an allergic predisposition. Three categories of asthma were evaluated: (1) occupational asthma due to a sensitizer (11 subjects, 13%); (2) irritant-induced asthma (54 persons, 63%); and (3) not occupational/environmental exposure-related asthma (21 subjects, 24%). Two distinct clinical presentations of irritant-induced asthma emerged: the first was sudden onset (29 subjects) and the second was not so sudden in onset (25 subjects). Sudden-onset, irritant-induced asthma was analogous to the reactive airways dysfunction syndrome. Clinical manifestations began immediately or within a few hours (always within 24 h) following an accidental, brief, and massive exposure. In contrast, for the not-so-sudden-onset asthma subjects, the causative irritant exposure was not brief, usually not massive, continued for > 24 h, and the initiation of asthma took longer to evolve. Eighty-eight percent of individuals with not-so-sudden irritant-induced asthma displayed an atopy/allergy status (p < 0.01). Some of the atopy/allergy subjects with presumed new-onset asthma were found to have suffered preexisting asthma that had been clinically quiescent for at least 1 year before the triggering exposure (16 persons). We conclude that preexisting allergic/atopy and/or preexisting asthma were significant contributors to the pathogenesis of not-so-sudden, irritant-induced asthma and emphasizes a critical interaction between environmental and host factors in the pathogenesis of asthma.
Asthma clinics in general practice: the educator's perspective.
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Age related bladder capacity and bladder capacity growth in children with myelomeningocele.
PURPOSE: Currently the relationship between bladder capacity and age in children with myelomeningocele is inadequately understood, such that nomograms derived from neurologically normal children are inappropriately applied to the myelodysplastic population. The aim of the present study was to evaluate age related bladder capacity and bladder capacity growth in children with myelomeningocele, and compare them to those of age matched, neurologically intact children. MATERIALS AND METHODS: Bladder capacity was determined by cystometrography in children with myelodysplasia. Regression analysis was used to derive a relationship between bladder capacity and patient age. Data were stratified by sphincter activity, bladder sensation and uninhibited contractions, and regression analysis was repeated. To evaluate serial growth change in bladder capacity divided by time yielded a yearly bladder capacity growth rate in patients who underwent 2 cystometrograms done at least 3 months apart before age 9 years. RESULTS: A total of 506 children satisfied study inclusion criteria. Bladder capacity (BC) was related to age for the first 9 years by the linear equation, BC = 24.5 (age) + 62. This equation is approximately 25% less steep than published age related bladder capacity in neurologically intact children using the formula, 32 (age) + 73. After data stratification bladder capacity in children with sphincter activity, bladder sensation or no uninhibited contractions approached that of neurologically intact children. In contrast, children without sphincter activity or bladder sensation, or with uninhibited contractions had markedly smaller age related bladder capacity. Bladder capacity growth in the subgroup of 55 children in whom 2 cystometrograms were performed at least 3 months apart before age 9 years confirmed a mean gain in capacity of 24 cc per year. CONCLUSIONS: Normal bladder capacity in children with myelodysplasia is approximately 25% less than in age matched, neurologically intact children. The bladder grows approximately 24 cc per year until age 9 years. When there is failure to store urine, bladder capacity is much smaller, while children with good storage features may attain the bladder capacity expected of age matched, neurologically intact children.
Clinical evaluation of a rapid diagnostic screen (URISCREEN) for bacteriuria in children.
PURPOSE: We assessed clinical use of the URISCREEN test for detecting significant bacteriuria in children and compared it to standard quantitative culture. MATERIALS AND METHODS: URISCREEN detects catalase in urine samples, reflecting the presence of at least 50,000 colony-forming units per ml. or 10 somatic cell per high power field. Catheterized urine specimens from 200 consecutive children scheduled to undergo urodynamic evaluation were tested by URISCREEN and quantitative culture methods. Sensitivity, specificity, positive and negative predictive values, and accuracy were determined. RESULTS: Of these specimens there were 22 false-positive and 16 false-negative URISCREEN results. Sensitivity was 65.2%, specificity 85.7%, positive predictive value 57.7%, negative predictive value 89.2% and overall accuracy 81%. CONCLUSIONS: URISCREEN is a rapid screen for bacteriuria. However, the high false-negative rate limits clinical use in the pediatric urological patient for whom detecting infection is essential.
Transrectal electrostimulation therapy for neuropathic bowel dysfunction in children with myelomeningocele.
PURPOSE: We attempted to evaluate the efficacy of transrectal bowel stimulation for neurogenic bowel dysfunction in children with myelodysplasia. MATERIALS AND METHODS: Daily sessions of transrectal electrostimulation were performed on an outpatient basis for 2 to 3 weeks on children with myelodysplasia and stool incontinence. If benefits were noted, 5 to 10 additional daily sessions were performed. Complete success was defined as improvement in all parameters of interest, including decrease in the frequency of daily bowel movements, increased sensation, increased ability to hold stool and a significant subjective change in bowel habits. Moderate success implied improvement in 1 to 3 parameters and treatment failure was defined as lack of improvement in any parameter. RESULTS: A total of 55 children 2 to 14 years old (mean age 6.7) completed a mean of 18 daily sessions per patient of bowel electrostimulation. Followup ranged from 1 to 6 years. Diapers are no longer required due to defecation problems in 14 children older than 3 years. Complete success was achieved in 20 cases (36.3%) and moderate success in an additional 30 (54.5%, overall success rate 90.8%). Specifically, 89% of the patients reported elimination of stooling accidents, 82% reported increased sensation and 71% were able to hold the bowel movement. Overall 68% of the patients noticed significantly improved bowel function. Complete/moderate success of transrectal electro-stimulation was statistically significant for all 4 parameters (p < 0.05), and complete success was significant for increased sensation, ability to hold and episodes of accidents. Therapy failed in 5 children (9%). There were no untoward effects. CONCLUSIONS: Transrectal electrostimulation is a well tolerated and minimally invasive modality that provides sustainable improvement in stool continence in children with myelomeningocele and neuropathic bowel dysfunction.
Psychotherapy for delinquents?
The results of a psychotherapy consultation service for delinquents are presented. Based on the clinical material obtained from this programme, and a review of relevant delinquency and psychotherapy literature, a working model of individual psychotherapy related to attachment theory as it applies to this population is discussed. Developmental and existential difficulties that warrant resolution are included, as are issues with resistance and counter transference.
Use of bladder stimulation in high risk patients.
PURPOSE: We evaluated whether intravesical bladder stimulation therapy is effective in improving bladder compliance in patients with myelomeningocele, neurogenic bladder and high risk urodynamic parameters. MATERIALS AND METHODS: We reviewed the charts of all patients treated with bladder stimulation therapy at our institution since 1984, and identified 7 with pretreatment high risk urodynamic findings (percent expected bladder capacity 60% or less and bladder capacity pressure 50 cm. water or greater). Urodynamic and clinical data were reviewed before and after therapy. RESULTS: Following bladder stimulation in 4 of the 7 patients percent expected bladder capacity substantially increased and bladder capacity pressure decreased to safe levels. Two patients had minimal increases in percent expected bladder capacity but bladder capacity pressure decreased to 50 cm. water or less. Overall percent expected bladder capacity increased from an average pretreatment value of 44% before to 65% after bladder stimulation (p < 0.05). Average bladder capacity pressure improved from 63.9 cm. water before to 32.3 cm. water after treatment (p < 0.05). Also, bladder compliance improved in all 7 patients to the point that bladder augmentation was not performed. CONCLUSIONS: Bladder stimulation is effective in improving bladder compliance in high risk patients and it may be a viable alternative to enterocystoplasty. Further long-term followup will be necessary to establish the longevity of this response.
Psychiatric disorder among adolescents in custody.
OBJECTIVE: To determine the diagnostic breakdown and comorbid patterns of 100 consecutive cases referred for psychiatric consultation at juvenile detention centres, and to compare diagnoses according to gender and legal status. METHOD: Diagnoses were made at the time of an initial semi-structured clinical interview, and reviewed after follow-up. RESULTS: There was an appreciable minority of young offenders with non-behaviour disordered diagnoses as well as a large number with conduct disorder and substance abuse. Conduct disorder and affective disorder were most influential on adjustment in the community. CONCLUSION: Psychiatric initiatives are essential in the management of serious young offenders.
Bladder stimulation therapy improves bladder compliance: results from a multi-institutional trial.
PURPOSE: We examined data from multiple institutions to determine whether intravesical bladder stimulation therapy is effective in improving bladder compliance by increasing bladder capacity and lowering bladder storage pressures. MATERIALS AND METHODS: The charts of 568 patients from 11 institutions were evaluated. Of the 568 patients 335 had adequate and accurate pretreatment and posttreatment urodynamic studies, and were included in this study. A total of 155 patients was from Children's Memorial Hospital, while the remaining 180 were from 10 other institutions. Bladder capacity and bladder capacity pressure were determined for each patient before and after therapy. RESULTS: Overall, 53% of patients had increased bladder capacity of 20% or greater after treatment (average increase 105 cc), which represents a 63% increase from pretreatment values. This increase occurred in an average of 1.9 years. Further analysis of this subset of patients revealed that in 90% intravesical storage pressures were decreased or maintained within a safe range (less than 40 cm. water). Evaluation of patients who did not respond to bladder stimulation with a 20% or greater increase in bladder capacity revealed that they had nearly normal bladder capacity before therapy. When the data on bladder capacity and bladder capacity pressure from Children's Memorial Hospital were compared to results from the 10 other institutions, there were no appreciable differences. CONCLUSIONS: Bladder stimulation is effective in increasing bladder capacity without significantly elevating storage pressure in a majority of patients. We conclude that this technique is safe and effective in improving bladder compliance, and that it is reproducible elsewhere.
Selective sacral rhizotomy in children with high pressure neurogenic bladders: preliminary results.
Recent successful introduction of selective rhizotomy in the management of lower extremity spasticity in patients with myelodysplasia has prompted us to use it as a means of managing high pressure neurogenic bladders occasionally encountered in myelodysplastic patients. During the last 1 1/2 years 8 children have undergone selective sacral rhizotomy in an attempt to avert urinary diversion or bladder augmentation. Patient age ranged from 6.5 to 18.5 years. The level of the respective lesions was evenly distributed throughout the spine. At spinal surgery each patient had an electrode placed in the detrusor of the bladder via a suprapubic approach, electromyography electrodes were placed in the perineum and slow fill water cystometry was performed throughout the procedure. Standard electrophysiological stimulation of the nerve roots was performed to identify the rootlets that would only affect the detrusor and spare the external sphincter. Postoperative followup has been obtained on all patients. Of the patients 4 have exhibited significant improvement and they have not required augmentation, 2 have not shown any further deterioration in bladder function, 1 has demonstrated deterioration and 1 still lacks urodynamic followup. Postoperative cystometric studies have revealed a bladder capacity increase of 69% for the group. Uninhibited bladder contractions were abated in all but 1 patient. No patient has been rendered incontinent of urine from the procedure and no patient has had a problem with stool continence as a result of the rhizotomy. It appears that selective rhizotomy of the sacral roots has been able to increase bladder capacity as well as compliance in patients who normally would have been relegated to either bladder augmentation or urinary diversion. While these are encouraging results, some further followup is required to ascertain if the early improvements will be long-lasting.
Dose, time and route dependency of the induction of rat hepatic ornithine decarboxylase by 12-tetradecanoylphorbol 13-acetate.
Ornithine decarboxylase (ODC) activity, the rate limiting enzyme in polyamine biosynthesis, was determined after 12-O-tetradecanoylphorbol 13-acetate (TPA) administration to female Sprague-Dawley rats. The extent of induction depended on the dose, exposure, time and route of administration. The most effective dose for ODC induction by the intraperitoneal route was 40 ug TPA/kg which caused 3-5 fold ODC induction. Maximal ODC induction occurred in a narrow time band 5 hours after TPA administration. TPA had no adverse effects on hepatic DNA (measured by alkaline elution), cytochrome P-450 content and reduced glutathione content or serum alanine aminotransferase (SGPT) activity.
Hydrogen peroxide: a potent activator of dioxygenase activity of soybean lipoxygenase.
Hydrogen peroxide, an ubiquitous biologically occurring peroxide, was found to stimulate the dioxygenase activity of soybean lipoxygenase at the physiologically attainable concentration. The increase in enzyme specific activity was directly proportional to hydrogen peroxide concentration up to 0.5 nM. A decrease in the stimulation of dioxygenase activity was observed at higher concentrations. At low enzyme concentration up to 28-fold stimulation was noted when the formation of lipid hydroperoxide was monitored spectrophotometrically. The stimulation was further confirmed by increased oxygen uptake. It is proposed that the mechanism for in vivo activation involves hydrogen peroxide.
Mirex induces ornithine decarboxylase in female rat liver.
Ornithine decarboxylase, the rate-limiting enzyme in polyamine synthesis, was significantly induced in female rat liver following oral administration of the pesticide mirex. After dual oral exposure (120 mg/kg of mirex; 21 and 4 hr prior to sacrifice), ornithine decarboxylase activity in rat liver cytosol was 70-fold higher than control values. A single oral dose of mirex (180 mg/kg) induced hepatic ornithine decarboxylase activity 55-fold over controls. After a single oral dose of mirex the maximal induction of ODC activity occurred at 36 hr. Mirex is an unusually potent and long-lasting inducer of rat hepatic ornithine decarboxylase activity.
Intravesical transurethral bladder stimulation to increase bladder capacity.
Intravesical transurethral bladder stimulation is a diagnostic rehabilitative procedure that has been successful in initiating sensory-induced detrusor contractions. However, of greater significance has been the recognition that the process also will increase bladder capacity while maintaining low filling and leak pressures. Data are available on 88 patients. In 80 per cent of the children treated a greater than 50 per cent increase in bladder capacity was noted. We evaluated 46 patients who underwent long-term treatment. The beneficial effects on bladder capacity have been maintained. Exploration into whether this technique could be used, rather than augmentation procedures, is for future examination.
Intravesical bladder stimulation in myelodysplasia.
Intravesical transurethral bladder stimulation has been used as a diagnostic and rehabilitative technique in children with a neurogenic bladder for 3 years. The program has expanded from 10 to 42 patients undergoing a significant number of therapy sessions. The technique presently is done on an outpatient basis. The child is catheterized for 90 minutes and undergoes electrotherapy for 60 minutes, ideally 3 to 5 days per week. An individual series consists of 15 to 30 daily sessions. Presently, 62 patients have been evaluated and 42 have had a least 1 complete series. This ongoing program has provided more data to classify better patients who can expect success with the program. Of the patients who presented initially with detrusor contractions and areflexia 80 and 33 per cent, respectively, can expect to void to completion or have full sensation so as to perform timely clean intermittent catheterization. A total of 21 patients underwent at least 3 series, and 38 per cent void with low pressure and total continence.