Wim A.J.G. Lemmens

Relationship Between Lower Urinary Tract Abnormalities and Disease-Related Parameters in Multiple Sclerosis

Multiple sclerosis affects the lower urinary tract in many patients. The relationship between lower urinary tract abnormalities and disease-related parameters of multiple sclerosis is not well described. We screened urologically and neurologically 212 patients according to a standard protocol. Micturition complaints were noted in 52% of the patients and urodynamic abnormalities were found in 64%. A statistical correlation was found between detrusor hyperactivity and detrusor hypoactivity with disease-related parameters, that is disease duration, disability status, myelin basic protein concentration in the cerebrospinal fluid and neurophysiological investigations. No relationship was found between detrusor hypersensibility or detrusor hyposensibility and the aforementioned disease-related parameters. In 1 patient upper urinary tract abnormalities were noted in combination with urodynamic abnormalities. We conclude that lower urinary tract abnormalities can be found in every patient with multiple sclerosis unrelated to the state of the disease. Severe upper urinary tract abnormalities are rare.

Sexual dysfunction after renal replacement therapy.

The existence of a sexual problem as the subjective evaluation of sexual function was assessed with a simple questionnaire. Those questioned were patients undergoing dialysis treatment (n = 400) or with a functioning renal transplant (RTx; n = 300) and both men and women in the general Dutch population (n = 591). In the Dutch control population, 8.7% of the men and 14.9% of the women reported a sexual problem, showing a significant gender difference but unrelated to age. In patients, the prevalence of a sexual problem was significantly greater (hemodialysis, men, 62.9%; women, 75.0%; peritoneal dialysis, men, 69.8%; women, 66.7%; renal transplantation, men, 48.3%; women, 44.4%). In RTx recipients, sexual problems were significantly less prevalent than in patients undergoing dialysis (P < 0.001). Only in male patients was an association between prevalence of a sexual problem and age found. The results of the simple questionnaire were sufficiently validated when 102 of 104 patients confirmed their responses in a subsequent structured interview. This study shows that the prevalence of sexual problems in patients undergoing renal replacement therapy is high and clinically relevant.

Cerebrospinal fluid C3 and C4 indexes in immunological disorders of the central nervous system

Objectives– Validation of cerebrospinal fluid (CSF) indexes as a measure for intrathecal C3 and C4 production. Examination of their role in differential diagnosis of immunological disorders of the central nervous system (CNS). Material and methods– Correlative study in controls (low back pain without disk herniation) between the CSF/serum ratio (Q) for albumin, and Q C3 and Q C4. Comparative study of C3 and C4 indexes in patients with CNS dysfunction due to relapsing–remitting (RR) multiple sclerosis (MS), secondary progressive (SP) MS, systemic lupus erythematosus (SLE), and human immunodeficiency virus (HIV) infection. Results– Strong and statistically highly significant correlations between Q albumin and Q C3 (r=0.89, P=0.0001), and Q C4 (r=0.68, P=0.0001). In MS patients decreased mean values for serum (RR, SP) and CSF (RR) C3, and increased C3 index mean value (RR, SP). In CNS SLE increase of mean C3 and C4 index values. In CNS HIV increase of mean C3 and C4 index values, and CSF C3 and C4 concentrations. Most individual index values were within the reference range. Conclusion– CSF index is a valid tool to detect intrathecal C3 or C4 production. C3 or C4 index contributes little to the differential diagnosis of immunological CNS disorders. C3 might play a pathogenic role in various immunological CNS disorders.

Extracorporeal shock wave lithotripsy for large renal calculi: The role of ureteral stents. A Randomized Trial

Ureteral stents reduce complications after extracorporeal shock wave lithotripsy (ESWL*) and contribute to successful stone passage. However, some reports note complications that are attributed to indwelling ureteral stents. We randomized 64 patients with large renal calculi (stone burden more than 200 mm.2) for in situ treatment or treatment with a prophylactically inserted stent. We used a 6Ch round stent with single-coiled ends or a triangular shaped stent with double-coiled ends. Patients were treated with a Siemens Lithostar lithotriptor. After 3 months we evaluated the results of treatment and post-ESWL morbidity. Of the in situ group (23 patients) treatment complications consisted of fever in 3, pyelonephritis in 1 and steinstrasse in 3. After 3 months 8 patients (35%) were free of stones. Of the stented population (41 patients) treatment complications consisted of fever in 7, pyelonephritis in 1, steinstrasse in 6 and bladder discomfort in almost half of the patients. Stent calcification and stent migration were also seen in 7 and 10 patients, respectively. Calcified stents had been in situ longer than noncalcified stents. The round stents migrated and calcified more often than the more rigid triangular stents. After 3 months 18 of the stented patients were stone-free (44%). We conclude that ureteral stents do not reduce post-ESWL complications. They are clearly associated with morbidity and do not improve stone passage markedly. Therefore, patients with a stone burden of more than 200 mm.2 should be treated in situ without auxiliary stenting.

Evidence for Early Lower Urinary Tract Dysfunction in Clinically Silent Multiple Sclerosis

The occurrence of micturition complaints as late sequelae of multiple sclerosis is well studied and documented. However, no reports exist on urologically asymptomatic patients with a relatively short disease duration. In a prospective study of 40 patients with definite multiple sclerosis (mean disease duration 5 years), urodynamic investigations (cystometry and pressure-flow study) were combined with neuro-urophysiological measurements (cortical evoked potentials and sacral reflex latencies). Patients with (13) and without (27) micturition complaints were investigated. Neurourodynamic abnormalities were seen in 35 of 40 patients (88%). The lower urinary tract proved to be afflicted by multiple sclerosis at an early stage of the disease. Early neurourodynamic investigations had clinical implications. All of the complaining and half of the noncomplaining patients showed urodynamic abnormalities upon which the need for further followup and eventual therapeutic intervention was based. We conclude that neurourodynamic testing of a urinary functional system can be worthwhile as part of the initial diagnostic evaluation in patients with proved multiple sclerosis.

Buffering capacity of human semen

The buffering capacity of 270 semen samples derived from 196 men of infertile couples was determined from titration curves. The average buffering capacity in the physiologic range (pH 7.0 to 6.0) was 41.1 slyke (standard deviation [SD], 9.9), which is significantly higher (P less than 0.01) than that in serum (23.3 slyke; SD, 7.5; n = 42). When the buffering capacity of several semen samples of one man in the course of time was measured, the variation between these samples was larger than the determination error. No correlation was found between the buffering capacity of serum and semen of the same man, nor between the buffering capacity of semen and the fertility grade determined by physical and morphologic analysis of the samples.

Comparison of biothesiometry and neuro-urophysiological investigations for the clinical evaluation of patients with erectile dysfunction

In the literature the determination of the vibration sensitivity threshold of the penile glans by means of biothesiometry has been introduced as a cost-effective office test for the evaluation of penile neuropathy in impotent men. At our facility we have gained extensive experience with neuro-urophysiological tests for the evaluation of penile innervation. These neuro-urophysiological tests have the disadvantage of complexity, invasiveness and time consumption. In our study both methods were compared in 31 impotent patients. The results showed that penile glans biothesiometry yields consistent results when measurements are repeated during 1 session. However, no relationship was found between the outcome of penile glans biothesiometry and neuro-urophysiological tests of the dorsal penile nerve, which is probably due to the fact that vibration is not an adequate stimulus to the skin of the penile glans that contains free nerve endings (that is pain receptors) only, and hardly any vibration receptors. We conclude that biothesiometric investigation of penile glans innervation is unsuited for the evaluation of penile innervation and cannot replace neuro-urophysiological tests.

Prevalence of common “acquired” nevocytic nevi and dysplastic nevi is not related to ultraviolet exposure

The precise role of ultraviolet radiation in the induction of nevocytic nevi is unsettled. We studied mole counts in relation to the attitude toward ultraviolet exposure in 508 students 18 to 30 years of age. Moles were counted on the chest, back, and legs. Lesions measuring 2 mm or less in diameter and those measuring more than 2 mm were recorded separately. Dysplastic nevi were also recorded separately. The attitude toward sun worship was related to the average periods of sunbathing, the frequency of holidays in sunny climates, and the use of artificial ultraviolet sources. The frequency of pigmented nevi showed no correlation with sun behavior, irrespective of sex, mole size, or burning and tanning propensities. This lack of correlation between ultraviolet exposure and mole counts held true for all solar parameters: periods of sunbathing, sunny holidays, and sunlamp usage. Contrary to expectation, there was a clear, although not statistically significant, excess of dysplastic nevi in subjects with short periods of ultraviolet exposure during leisure. From these data insufficient evidence emerges to support the hypothesis of a correlation between the occurrence of common nevocytic nevi and dysplastic nevi and the degree of insolation by natural or artificial ultraviolet radiation.

Outcome of first line systemic treatment in elderly compared to younger patients with metastatic colorectal cancer: a retrospective analysis of the CAIRO and CAIRO2 studies of the Dutch Colorectal Cancer Group (DCCG)

Abstract Background. Metastatic colorectal cancer (CRC) is predominantly a disease of the elderly, therefore the current standards should be evaluated in this population. Material and methods. We evaluated in different age groups the outcome in terms of median overall and progression-free survival, response rate, disease control rate, relative dose intensity (RDI), tolerability, and global quality of life (QoL) of first-line capecitabine monotherapy (CAP) versus capecitabine + irinotecan (CAPIRI) and capecitabine + oxaliplatin + bevacizumab (CAPOX + BEV) in the CAIRO and CAIRO2 study, respectively. Patients were categorized into three age groups: age > 75, 70–75 and < 70 years. Results. Clinical outcomes were not significantly different among age groups, with the exception of a higher response rate from CAP treatment in the elderly. Elderly patients treated with CAPOX + BEV showed a trend towards a worse median overall survival compared to younger patients. Only treatment with CAP resulted in a higher incidence of grade 3–4 toxicity and a lower RDI in elderly versus younger patients. Treatment with CAP and CAPOX + BEV in elderly patients was significantly more often discontinued due to toxicity instead of progression to disease compared to younger patients. The increase in global QoL was comparable for the three age groups for each treatment regimen. Conclusion. We did not observe significant differences in survival outcomes between elderly and younger metastatic CRC patients with three different first-line systemic treatment regimens. Our data suggest that initial dose reduction of CAP monotherapy may be indicated in elderly patients.

Cerebrospinal fluid analysis differentiates between relapsing-remitting and secondary progressive multiple sclerosis

OBJECTIVES To find whether CSF analysis may differentiate between relapsing-remitting and secondary progressive multiple sclerosis. METHODS In 17 patients with relapsing-remitting and 16 patients with secondary progressive multiple sclerosis, all without current or recent relapses, albumin CSF: peripheral blood ratio, mononuclear cell number, CD4+, CD8+, and B1+ subsets, CD4+:CD8+ ratio, IgG, IgG index, IgM, IgM index, complement components C3 and C4, and C3 and C4 indices, myelin basic protein, neuron specific enolase, S100, and lactate were determined. For each measure the statistical distance measure D2 was calculated. For computation of a discriminant score variables with a P value⩽0.15 were included (two sided univariate t test). These were albumin CSF: peripheral blood ratio, mononuclear cell number, IgM, IgM index, C3, C4, neuron specific enolase, S100, and lactate. Simultaneous distributions of the variables were compared between both groups (multivariate t test) and a discriminant score was computed (linear discriminant analysis). RESULTS The discriminant score allocated all 14 relapsing-remitting patients to the relapsing-remitting group (positive score) and 12 of 13 secondary progressive patients to the secondary progressive group (negative score). One secondary progressive patient was allocated to the relapsing-remitting group. CONCLUSIONS Patients with relapsing-remitting or secondary progressive multiple sclerosis differ in CSF profile and CSF analysis may help to differentiate between relapsing-remitting and secondary progressive multiple sclerosis.