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Biomedical subjects

P J Shah

Publications and source records attributed to P J Shah.

At least 19 recordsLinked to original sources
PubMed2002

Chronic, treatment-resistant depression and right fronto-striatal atrophy.

BACKGROUND: Treatment-resistant depression (TRD) is relatively common but its neurobiological basis is poorly understood. Fronto-striatal structural brain changes have been reported in patients with depression but their association with treatment resistance and chronicity has not been established. METHOD: Magnetic resonance images of 20 patients with TRD were compared with images of 20 recovered patients and 20 healthy controls. Images were compared using a voxel-based analysis (VBA) method; the results were validated by conventional volumetric analysis. The clinical associations of magnetic resonance imaging (MRI) changes with illness duration and severity were examined by VBA. RESULTS: Only the TRD group exhibited right fronto-striatal atrophy, and subtle MRI changes in the left hippocampus on VBA. Atrophy was confirmed on volumetric analysis, the degree correlating with the cumulative number of electroconvulsive therapy (ECT) treatments received, suggesting an acquired deficit. CONCLUSIONS: This is the first study to demonstrate fronto-striatal atrophy in patients with depression with poor outcome; the atrophy is more marked in those with more severe illness.

Adult↗
PubMed2002

Bladder and renal stones: management and treatment.

The prevalence of renal tract calculi in the population is such that patients may present acutely not only to urologists, but in the setting of any medical specialty. This article aims to enable all practitioners to be able to recognize the condition and instigate early investigation and management before referring to the urologist for definitive treatment.

Drinking↗
PubMed2001

Vesico-ureteric reflux in adults with neuropathic bladders treated with Polydimethylsiloxane (Macroplastique).

OBJECTIVE: To establish the efficacy of Macroplastique in treating vesico-ureteric reflux (VUR) in adults with neuropathic bladder dysfunction. PATIENTS AND METHODS: Fifteen patients (12 male and three female), age range 19 to 80 years (mean age 38) were included in this study. Diagnosis was confirmed by videourodynamics. In seven patients reflux was present bilaterally. Twenty-two refluxing ureters were treated. Twelve patients had detrusor hyper-reflexia, two had areflexic bladders and one had loss of bladder wall compliance. According to the International Grading System, 10 ureters had grade IV reflux, five had grade III reflux, five had grade II reflux, and two had grade I reflux. Macroplastique (0.5-1.5 ml) was injected submucosally under each ureteric orifice to convert the opening to a slit like shape. The patients were followed up from 9 to 68 months. RESULTS: VUR was completely resolved in 72.7% (16) ureters following a single injection and in a further 4.5% (1) ureter following a second injection. 9.1% (2) ureters were improved and treatment failed in 13.7% (3) ureters. Two patients showed a recurrence of reflux 1 and 4 years after primary injection and subsequently had a curative second injection. Most of the patients in whom VUR was cured or improved showed a reduction in laboratory proven urinary infection rates. CONCLUSION: Macroplastique produced an excellent result (86% with complete resolution or improvement of reflux) in treating VUR in adult neuropathic bladders. This is comparable to larger studies carried out on the paediatric population. This is an easy procedure, which avoids major surgery and can be performed as a day case. In cases of failure or recurrence, repeat injection or open surgery can be undertaken without any added complications.

Adult↗
PubMed2001

The acute effects of continuous and conditional neuromodulation on the bladder in spinal cord injury.

STUDY DESIGN: Laboratory investigation using serial slow-fill cystometrograms. OBJECTIVES: To examine the acute effects of different modes of dorsal penile nerve stimulation on detrusor hyperreflexia, bladder capacity and bladder compliance in spinal cord injury (SCI). SETTING: Spinal Injuries Unit, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK. METHODS: Fourteen SCI patients were examined. Microtip transducer catheters enabled continuous measurement of anal sphincter, urethral sphincter and intravesical pressures. Control cystometrograms were followed by stimulation of the dorsal penile nerve at 15 Hz, 200 micros pulse width and amplitude equal to twice that which produced a pudendo-anal reflex. Stimulation was either continuous or in bursts of one minute triggered by a rise in detrusor pressure of 10 cm water (conditional). Further control cystometrograms were then performed to examine the residual effects of stimulation. RESULTS: Bladder capacity increased significantly during three initial control fills. Continuous stimulation (n=6) significantly increased bladder capacity by a mean of 110% (+/-Standard Deviation 85%) or 173 ml (+/-146 ml), and bladder compliance by a mean of 53% (+/-31%). Conditional stimulation in a different group of patients (n=6) significantly increased bladder capacity, by 144% (+/-127%) or 230 ml (+/-143 ml). In the conditional neuromodulation experiments, the gap between suppressed contractions fell reliably as bladder volume increased, and the time from start of stimulation to peak of intravesical pressure and 50% decline in intravesical pressure rise was 2.8 s (+/-0.9 s) and 7.6 s (+/-1.0s) respectively. The two methods of stimulation were compared in six patients; in four out of six conditional neuromodulation resulted in a higher mean bladder capacity than continuous, but the difference was not significant. CONCLUSIONS: Both conditional and continuous stimulation significantly increase bladder capacity. The conditional mode is probably at least as effective as the continuous, suggesting that it could be used in an implanted device for bladder suppression.

Adult↗
PubMed2001

Tuberculosis of the craniocervical junction.

Tuberculosis of the craniocervical junction is rare even where the condition is endemic. It poses problems in both diagnosis and management. We describe 25 cases followed over a period of 12 years, and relate the presentation, diagnosis and management. Of our 25 patients 16 were managed conservatively and nine by surgery. In order to diagnose this condition a high index of suspicion and advanced imaging techniques are necessary. Early diagnosis and adequate treatment led to good results without fatal complications.

Adolescent↗
PubMed2001

Child and adolescent forensic psychiatry survey--in Scotland.

OBJECTIVES: To review the provision of Adolescent Forensic Services, and assess the need for the development of a separate service as exists for adult mentally disordered offenders. DESIGN AND SUBJECTS: To investigate by postal survey to all child and adolescent psychiatrists in Scotland. RESULTS: There is a lack of forensic adolescent expertise in Scotland and a perceived need for it. Child and adolescent psychiatrists are required to deal with difficult forensic cases, without appropriate training. CONCLUSION: A child and adolescent forensic service for Scotland needs to be developed.

Accreditation↗
PubMed2000

An unusual case of duplex ureteropyelocystoplasty.

Ileocystoplasty is associated with electrolyte disturbances, mucus production and gastrointestinal tract disruption. An unusual case is presented of duplex ureteropyelocystoplasty with an excellent postoperative result. This technique avoids the complications associated with the use of ileum in the urinary tract.

Adult↗
PubMed1999

Abnormal response to negative feedback in depression.

BACKGROUND: Recent studies have suggested that subjects with depression suffer a diagnosis-specific motivational deficit, characterized by an abnormal response to negative feedback that endures beyond clinical recovery. Furthermore, it has been suggested that negative feedback may motivate non-depressed controls, but not depressed patients, to improve their performance in neuropsychological tests. METHODS: We describe two studies. The first compared performance on the simultaneous and delayed match to sample (SDMS) task from the CANTAB neuropsychological test battery, in 20 patients with severe depression with 20 with acute schizophrenia, 40 with chronic schizophrenia and 40 healthy controls. The second examined the performance of depressed patients with diurnal variation in symptoms and cognitive function. RESULTS: All patients groups showed impairments on the simultaneous and delayed match to sample task compared to controls. Depressed patients did not show an abnormal response to negative feedback. Controls did not show a motivational effect of negative feedback. Depressed patients with diurnal variation showed no variation in their response to perceived failure. There was no evidence of abnormal response to negative feedback in any patient group using the 'runs test' or of a motivational effect in controls. Conditional probability analysis was not independent of the total number of errors made in the SDMS task. CONCLUSIONS: Further studies are suggested to examine whether an abnormal response to negative feedback characterizes particular subgroups of patients suffering from depression.

Acute Disease↗
PubMed1999

Reduced cortical excitability in depression. Impaired post-exercise motor facilitation with transcranial magnetic stimulation.

BACKGROUND: In healthy controls, preactivation of muscles by exercise results in enhanced motor-evoked potential (MEP) responses to transcranial magnetic stimulation (TMS). AIMS: We tested the hypothesis that medicated, depressed patients would show reduced post-exercise MEP facilitation compared with controls. METHOD: Ten patients with DSM-IV depression (two male, eight female) and ten controls (three male, seven female) participated. MEPs were elicited at rest, then after exercising the contralateral abductor pollicis brevis muscle, using TMS of the primary motor cortex. RESULTS: The mean MEP amplitude recorded after exercise (expressed as a percentage of baseline) was 210% in controls and 130% in patients. There was a significant difference in post-exercise MEP between patients and controls (P = 0.03). CONCLUSIONS: Post-exercise MEP facilitation was demonstrated in controls but not in patients. This supports the hypothesis that the modulation of cortical excitability may be impaired in depression.

Adult↗
PubMed1998

Transverse retubularized ileum: early clinical experience with a new second line Mitrofanoff tube.

PURPOSE: Transverse retubularization of small ileal segments has been described as a new time and labor saving variation of the Mitrofanoff principle in a dog model with good functional results. We report our initial clinical experience with this technique. MATERIALS AND METHODS: From May 1996 through January 1997 a new technique of channel formation for intermittent catheterization was applied in 9 children (1 to 16 years old) and 7 adults (18 to 56) with various abnormalities of the lower urinary tract. The new method was used in primary reconstruction of the lower urinary tract and in revision procedures. An ileal segment 2 cm. long was excised. The bowel wall was opened longitudinally about 1 cm. from the mesentery. The resulting rectangle was retubularized over a 14F catheter in transverse direction. The longer portion of the tube was implanted submucosally into the native bladder, the augmented bladder or an intestinal reservoir. The shorter portion was used to form the stoma. In 4 patients we created a double tube. RESULTS: Of the patients 13 (81%) are completely continent day and night with easy catheterization postoperatively. In 2 cases of tunnel failure continuous leakage required reimplantation of the intact ileal tube to achieve continence. Minor leakage with bladder fullness in an 11-year-old boy could be obviated by adjusting the interval of catheterization. CONCLUSIONS: With the advantage of constant availability, minimal loss of bowel, relative simplicity (no mesentery interfering with implantation, high tube mobility), minimized risk of stone formation (no staples), reliable continence (no leak point) and easy catheterization (longitudinal folds), this straightforward technique is an excellent second choice use of the Mitrofanoff principle.

Adolescent↗
PubMed1998

Iatrogenic hypospadias--a preventable injury?

Iatrogenic hypospadias is a preventable injury to the ventral male urethra produced by the downward pressure of an indwelling urethral catheter. In spite of avoiding long-term urethral catheterisation, we have acquired 16 patients with this injury in the last 9 years either in our unit or discovered in patients referred to our unit. Although not a life endangering complication, the majority of such patients find the penile appearance so produced unacceptable. We have reconstructed any penis that has more than meatal cleavage in a total of six patients, with good results. The majority of patients have been fully investigated so that an alternative therapy to catheterisation may be provided. Where possible a catheter free state has been achieved. If not, a suprapubic catheter has been inserted. Those not reconstructed were due to reasons of ill health, and in two instances, due to patient choice.

Adult↗
PubMed1998

Long-term suprapubic catheterisation: clinical outcome and satisfaction survey.

We report on the clinical outcome and satisfaction survey of long-term suprapubic catheterisation in patients with neuropathic bladder dysfunction. Between early 1988 and later 1995, 185 suprapubic catheters were inserted under direct cystoscopic vision. Anti-cholinergic therapy was given to all patients with significant detrusor hyper-reflexia; the catheters clamped daily for two hours and changed every six weeks. Ultrasonography and assessment of the serum creatinine were used to assess the upper renal tracts, and the results of the pre- and post-catheter video-cystometrography was used to evaluate bladder morphology, cystometric capacity, maximum detrusor pressure and the presence of vesico-ureteric reflux. There were equivalent numbers of males and females. The follow-up ranges from 3-68 months. Following catheterisation, there was a 50% reduction in the average maximum detrusor pressure, bladder morphology improved in 85% of the cases; the bladder capacity and upper renal tracts remained unchanged. Vesico-ureteric reflux was abolished in 33% of the cases. Complaints were common consisting of recurrent catheter blockage, persistent urinary leakage and recurrent urinary tract infections. There was a 2.7% incidence of small bowel injury with one fatality. However, the general level of satisfaction was high. It is concluded that suprapubic catheterisation is an effective and well tolerated method of management in selected patients with neuropathic bladder dysfunction for whom only major surgery would otherwise provide a solution to incontinence. We are encouraged to find preservation of renal function with maintained bladder volumes and reduced maximum detrusor pressures thus justifying the policy of catheter clamping and anti-cholinergic therapy in the presence of significant detrusor hyper-reflexia. However, even in expert hands this procedure is not without hazards.

Adolescent↗
PubMed1998

Histological changes associated with long-term urethral stents.

OBJECTIVE: To assess the histological changes found in patients with long-term external sphincter, prostatic and urethral stents. PATIENTS AND METHODS: Eighteen patients with long-term stents (mean time since insertion 3.5 years) were investigated. Three had external sphincter stents for detrusor-sphincter dyssynergia secondary to spinal injury, eight had prostatic stents for obstruction secondary to benign prostatic hyperplasia and seven had urethral stents for recurrent strictures. Nine stents were occluded at investigation, of which seven were entirely removed. The mucosae overlying the remaining two were biopsied, as were mucosae over the nine patent stents, at urethroscopy. RESULTS: The changes observed included polypoid hyperplasia (11 of 18 patients) between and around the stent mesh wires, nonkeratinizing squamous metaplasia (two) or hyperkeratotic squamous metaplasia (seven), chronic inflammation (15) with prominent plasma cell infiltrates (11), variable foreign-body granuloma (two) and microabscess formation (five), usually associated with clefts formed around the stent wires (three of five). CONCLUSION: Stents become incorporated into the urethral wall by a process of polypoid hyperplasia through the stent mesh, with at least focal covering of the stent in most cases, and with variable inflammatory infiltrates, most of which are rich in plasma cells. The urothelial and connective tissue proliferation resulted in obstruction of the stent lumen in nine of the patients studied. Further long-term study is necessary to exclude the development of carcinoma in patients with keratinizing squamous metaplasia, although no malignancy was seen in this study.

Adult↗
PubMed1998

Surgical management of urethral damage in neurologically impaired female patients with chronic indwelling catheters.

OBJECTIVE: To evaluate the clinical outcome of female patients with spinal cord injury who underwent a variety of surgical procedures to treat urethral injury and incontinence from prolonged indwelling urethral catheterization. PATIENTS AND METHODS: The study included 18 female patients (mean age 53.6 years, range 17-75), most of whom had spinal cord injury, who had indwelling urethral catheterization for a mean of 3.5 years (range 6 months to 30 years); they presented with severe urethral injury and intractable incontinence despite catheterization. Several different surgical operations were used to correct the incontinence, including urethral reconstruction (urethrocleisis) and urethral closure both transvaginally and suprapubically, in association with permanent suprapubic catheterization. The patients were followed for a mean of 4.6 years. RESULTS: Four patients who underwent transabdominal urethral closure were dry. Four of eight patients who underwent urethral closure transvaginally developed urethral fistulae; these occurred within 3 months of their operation, two being corrected at subsequent operations. Two of six patients who underwent urethral reconstruction were incontinent and this was corrected via a transabdominal closure. Overall, the 18 patients underwent 22 procedures and 16 are dry, i.e. approximately 90% success. CONCLUSION: Where the urethra is irrecoverably damaged, closure via the transvaginal approach is the preferred approach because it has low morbidity and is tolerated by these severely disabled patients. Urethrocleisis and urethral preservation provide a better option only in a select group of patients.

Adolescent↗
PubMed1998

Cortical grey matter reductions associated with treatment-resistant chronic unipolar depression. Controlled magnetic resonance imaging study.

BACKGROUND: The aetiology of treatment-resistant major depression is little understood; its apparent intractability may reflect brain abnormality. METHOD: Magnetic resonance images of the brains of 20 subjects with major depression lasting for two years or more were compared with 20 healthy control subjects and 20 other subjects who had completely recovered from depression. Subjects were individually matched for age, gender, years of education and premorbid IQ. Grey matter was segmented from the images, and compared between groups on a voxel-by-voxel basis. RESULTS: Subjects with chronic depression showed reduced grey matter density in the left temporal cortex including the hippocampus. There was also a trend for reduction in the right hippocampus. Left hippocampal grey matter density was correlated with measures of verbal memory, supporting the functional significance of the observed magnetic resonance imaging changes. CONCLUSIONS: Our results potentially challenge the accepted view of depression as a functional and fully reversible illness, implying instead that more permanent brain changes may be associated with chronicity. Confirmatory longitudinal and prospective studies are required to determine whether these differences pre-date the onset of depression or are the result of the chronic illness process or its treatment.

Adult↗