Southmead Hospital Research Articles

Life at the UK renal registry-an unforgettable experience.

On 21 June 2007, at the ERA-EDTA Conference in Barcelona, I was one of nine candidates to win a short-term fellowship to visit the UK Renal Association Renal Registry (UKRR) at the Southmead Hospital, Bristol, UK. My successful application had been designed around three aims: to gain an understanding of how the UKRR worked and explore what lessons there might be for the Hungarian Renal Registry, to obtain experience in undertaking analyses with registry data so that quality analyses of existing Hungarian Renal Registry data may be performed, and to observe how a peritoneal dialysis programme can be organized and consider how such a programme might be introduced to my renal unit in Debrecen, Hungary. The UKRR started with a pilot of seven renal units and has expanded over 10 years to cover all UK renal units. Over those 10 years, registry data have played a major role in building the ‘business cases’ for the expansion of renal units when funding has had to be sought from commissioners. The planning of renal services in Hungary would also benefit from having such epidemiological data available. Before this can happen, however, there needs to be an improvement in renal information technology (IT) systems; gaining an understanding of the IT systems already in use in renal units in Hungary will be the first step. Hopefully we too will ultimately be in a position to publish centre performance data with each centre clearly identified. Throughout my 3 months in Bristol, I worked hard to maximize my training by working closely with the PD team. PD is less common in Hungary than in the UK as doctors gain little experience with it during their training. Socioeconomic problems do not help, and there is no patient education team, psychologist or renal dieticians. Indeed the multidisciplinary team model of health care provision in the UK was one of the biggest lessons for me during my stay; the nurse-led patient education team advised patients on RRT before dialysis and the majority of dialysis lines (tunnelled and non-tunnelled) are inserted by one highly trained nurse with a noticeable improvement in infection rates. Clear guidelines in the UK have empowered nurses who do not need a doctor's approval in order to perform simple tasks—a world away from the way things happen in Hungary. All in all, my short-term fellowship was a wonderful learning experience and I have returned to Hungary full of ideas and enthusiasm. As I finish writing up the analysis commenced in Bristol, I am hopeful that our renal units can continue to build on these links into the future.

Improving Neonatal Outcome Through Practical Shoulder Dystocia Training

To compare the management of and neonatal injury associated with shoulder dystocia before and after introduction of mandatory shoulder dystocia simulation training. This was a retrospective, observational study comparing the management and neonatal outcome of births complicated by shoulder dystocia before (January 1996 to December 1999) and after (January 2001 to December 2004) the introduction of shoulder dystocia training at Southmead Hospital, Bristol, United Kingdom. The management of shoulder dystocia and associated neonatal injuries were compared pretraining and posttraining through a review of intrapartum and postpartum records of term, cephalic, singleton births in which difficulty with the shoulders was recorded during the two study periods. There were 15,908 and 13,117 eligible births pretraining and posttraining, respectively. The shoulder dystocia rates were similar: pretraining 324 (2.04%) and posttraining 262 (2.00%) (P=.813). After training was introduced, clinical management improved: McRoberts' position, pretraining 95/324 (29.3%) to 229/262 (87.4%) posttraining (P<.001); suprapubic pressure 90/324 (27.8%) to 119/262 (45.4%) (P<.001); internal rotational maneuver 22/324 (6.8%) to 29/262 (11.1%) (P=.020); delivery of posterior arm 24/324 (7.4%) to 52/262 (19.8%) (P<.001); no recognized maneuvers performed 174/324 (50.9%) to 21/262 (8.0%) (P<.001); documented excessive traction 54/324 (16.7%) to 24/262 (9.2%) (P=.010). There was a significant reduction in neonatal injury at birth after shoulder dystocia: 30/324 (9.3%) to 6/262 (2.3%) (relative risk 0.25 [confidence interval 0.11-0.57]). The introduction of shoulder dystocia training for all maternity staff was associated with improved management and neonatal outcomes of births complicated by shoulder dystocia. II.

Phantom larynx: a clinical survey

A phantom phenomenon has been reported to occur after amputation or deafferentation of a limb or another body part. A phantom phenomenon following laryngectomy has not been described before. In the search for a phantom phenomenon, we carried out a retrospective clinical study on 35 post total laryngectomy patients who attended the Head and Neck Clinic of Southmead Hospital, Bristol (a tertiary referral centre for head and neck cancer), comparing them to a control group of 57 patients who attended the same clinic but had not undergone a total laryngectomy. The main outcome measures were, charting subjective sensation of phantom larynx and eliciting phantom phenomenon by cutaneous stimulation of neck and face. In 24 (69%) patients, there was either a subjective sensation of phantom or a positive response to cutaneous stimulation. There was no response to cutaneous stimulation in the control group. In conclusion, a phantom phenomenon does appear to occur after total laryngectomy.

Survey of the Use of Nonheart-Beating Kidneys in Pediatric Practice in the United Kingdom

In the United Kingdom, the introduction of funded programs to recover organs from nonheart-beating donors (NHBDs) has increased the numbers of organs available for transplant into adult recipients. In the latest report from UK Transplant, NHBD organs now account for 12% of adult renal transplants (1). These programs do not appear to have had a significant effect on pediatric practice. Therefore, in June 2006, we distributed an online questionnaire to research leads at all 13 UK pediatric nephrology units in order to assess current practice. Replies were received from 12 units, accounting for a 92% response rate. Ten units were aware of local NHBD programs. Since the establishment of UKT-funded NHBD programs, only one unit had actually transplanted a NHBD organ into a pediatric recipient. Another unit was offering them to pediatric patients and had three children on the waiting list for them. Both of these units had local programs that had been established for 3 years or more and retrieved organs of Maastricht category 3 or 4 (2). None of the units with local programs retrieving Maastricht category 2 organs had plans to transplant them into children, but did not give the category as a reason. The main reasons for not using these organs were lack of outcome data on their use in children (n=6) and lack of outcome data on their use in adults, on which to base decisions about children (n=4) (Table 1).TABLE 1: Reasons given for not using NHB organs in pediatric recipients (more than one reason could be given)There are many published series on the use of NHBD organs in adults from around the world. The most recently published data from UKT show that outcome data is similar between transplants from non-heart beating and heart beating cadaveric donors (1). One-year graft survival for these transplants is 94% and 92%, respectively, with 5-year graft survival being 86% and 84%. A paucity of data exist regarding the use of these organs in children. The largest most recent series has been reported by The United Network for Organ Sharing (3). During a 10-year period, 26 renal transplants were performed with allografts from NHB organs into pediatric recipients. There was no statistical significantly difference in 1- and 5-year graft survival between NHB and heart- beating transplants (1 year: 82.5 and 89.6%, respectively, 5 year: 74.3 and 64.8%, respectively). Although the numbers analyzed are small, this evidence suggests that children should not be denied access to NHB organs in units in which there is a well-established adult NHBD program. We believe that although few data are available regarding the use of organs from NHBD donors in pediatric recipients there is strong evidence that, in adults, organs from NHBDs have equivalent survival to those from heart- beating donors. Therefore, they should be strongly considered as an option for pediatric patients. Anusha G. Edwards Justin D. Morgan Southmead Hospital Westbury on Trym Bristol BS10 5NB Kingdom Carol Inward Bristol Royal Hospital for Children Paul O'Gorman Building Upper Maudlin Street Bristol BS2 8BJ United Kingdom

Safety of Broncho-alveolar Lavage in Ventilated Patients With Acute Respiratory Distress Syndrome

To the Editor: Bronchoalveolar lavage (BAL) is an essential diagnostic tool in infiltrative lung disease. According to national standards,1 BAL should be well tolerated in ventilated patients provided appropriate precautions are taken, even in acute respiratory distress syndrome (ARDS).2 During BAL in a nonventilated patient, the standard 5.7-mm bronchoscope only occupies 10% to 15% of the tracheal cross-sectional area whereas in the intubated patient, it occupies 66% of a 7-mm endotracheal tube (ETT) and 40% of a 9-mm ETT.1 Therefore, transient desaturation during BAL is expected. However, there are also previous reports of acute changes in hemodynamic status, significant desaturation, and even cardiac arrest.3 One hundred forty-eight ventilated patients with ARDS in Intensive Care Unit (ICU) according to the 1994 consensus definition4 were bronchoscoped in the ICU with BAL for investigation of ventilator-associated pneumonia. Patients were preoxygenated and sedated with/without paralysis before BAL. During BAL, continuous oximetry, electrocardiogram, and hemodynamic monitoring were undertaken. The mean (SE) patient age was 60.9 years (1.31) (81 men and 67 women), with baseline PaO2/FiO2 141.6 mm Hg (6.01), APACHE2 19.7 (0.69), SAPS2 45.1 (1.26), and APACHE3 72.5 (2.3). The minimum ETT diameter was 8 mm. No deaths or major complications occurred in relation to BAL. Only 2 (bronchospasm and secretion retention) minor episodes of desaturation (fall in SpO2 of 6%) occurred both at 2 hours after BAL, a complication rate of 1.4% (P=0.49, Fisher exact). No associated significant hemodynamic alterations occurred. In conclusion, in keeping with national guidelines and many previous observational studies, bronchoscopy with BAL in ICU in ventilated ARDS patients (even with extreme hypoxemia as above) is safe provided adequate precautions are taken. These include hemodynamic stability of the patient before BAL, preoxygenation, an ETT of sufficient diameter and adequate sedation/paralysis with appropriate oxygenation and monitoring after BAL, especially in the first 2 hours. Andrew R. Medford, MD* Ann Brigid Millar, MD† *Chest Clinic, Derriford Hospital, Plymouth Devon †Department of Clinical Science at North Bristol, University of Bristol, Paul O'Gorman Lifeline Centre, Southmead Hospital, Westbury-on-Trym, Bristol Avon, England, UK

Certificate in urodynamics

FURTHER INFORMATION Bristol Urological Institute, Southmead Hospital, Bristol BS10 5NB; tel: 0117 959 5690; fax: 0117 950 2229; edu@bui.ac.uk; www.bui.ac.uk Urologists, gynaecologists, urology nurse specialists, and gynaecology nurse specialists, but really anybody who helps perform or is interested in learning more about urodynamics. The course is aimed at clinicians who have some experience, but do not consider themselves experts. As part of my current job I am expected to perform urodynamics, and in …

Short falls in epistaxis management. A Nationwide Survey in UK1

Clinical OtolaryngologyVolume 31, Issue 6 p. 560-561 Short falls in epistaxis management. A Nationwide Survey in UK1 S. Duvvi, S. Duvvi Department of Otolaryngology/Head and Neck Surgery, Southmead Hospital, Bristol, UK,E-mail: [email protected]Search for more papers by this authorA. Khattab, A. Khattab Department of Otolaryngology/Head and Neck Surgery, Southmead Hospital, Bristol, UK,E-mail: [email protected]Search for more papers by this authorH.S. Khalil, H.S. Khalil Department of Otolaryngology/Head and Neck Surgery, Southmead Hospital, Bristol, UK,E-mail: [email protected]Search for more papers by this authorD.A. Nunez, D.A. Nunez Department of Otolaryngology/Head and Neck Surgery, Southmead Hospital, Bristol, UK,E-mail: [email protected]Search for more papers by this author S. Duvvi, S. Duvvi Department of Otolaryngology/Head and Neck Surgery, Southmead Hospital, Bristol, UK,E-mail: [email protected]Search for more papers by this authorA. Khattab, A. Khattab Department of Otolaryngology/Head and Neck Surgery, Southmead Hospital, Bristol, UK,E-mail: [email protected]Search for more papers by this authorH.S. Khalil, H.S. Khalil Department of Otolaryngology/Head and Neck Surgery, Southmead Hospital, Bristol, UK,E-mail: [email protected]Search for more papers by this authorD.A. Nunez, D.A. Nunez Department of Otolaryngology/Head and Neck Surgery, Southmead Hospital, Bristol, UK,E-mail: [email protected]Search for more papers by this author First published: 06 December 2006 https://doi.org/10.1111/j.1365-2273.2006.01311.xCitations: 7 1 Presented in the British Rhinologic Society meeting, Worcester, May 2003. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article.Citing Literature Volume31, Issue6December 2006Pages 560-561 RelatedInformation

(Still) time to organise training in airway management in the UK

(Still) time to organise training in airway management in the UK

Does training in obstetric emergencies improve neonatal outcome?

To determine whether the introduction of Obstetrics Emergency Training in line with the recommendations of the Clinical Negligence Scheme for Trusts (CNST) was associated with a reduction in perinatal asphyxia and neonatal hypoxic-ischaemic encephalopathy (HIE). A retrospective cohort observational study. A tertiary referral maternity unit in a teaching hospital. Term, cephalic presenting, singleton infants born at Southmead Hospital between 1998 and 2003 were identified; those born by elective Caesarean sections were excluded. Five-minute Apgar scores were reviewed. Infants that developed HIE were prospectively identified throughout this period. The study compared the period 'pre-training' (1998-1999), with the period 'post-training' (2001-2003). Five-minute Apgar scores and HIE. Infants (19,460) were included. Infants born with 5-minute Apgar scores of <or=6 decreased from 86.6 to 44.6 per 10,000 births (P<0.001) and those with HIE decreased from 27.3 to 13.6 per 10,000 births (P=0.032) following the introduction of the training courses in 2000. Antepartum and intrapartum stillbirth at term rates remained unchanged, at about 15 and 4 per 10,000 births, respectively. The introduction of obstetric emergencies training courses was associated with a significant reduction in low 5-minute Apgar scores and HIE. This improvement has been sustained as the training has continued. This is the first time an educational intervention has been shown to be associated with a clinically important, and sustained, improvement in perinatal outcome.

A Radiological and Laboratory Assessment of Polyethylene Wear in Failed Total Hip Replacement

This study assessed the reliability of radiological assessment of polyethylene wear in loose total hip replacements (THRs) by comparing it with a laboratory assessment using the shadowgraph technique. It was performed in Avon Orthopaedic Centre, Southmead Hospital, from September 1997 to June 1998. True linear wear depth measured using the shadowgraph technique was 42% greater than that determined from the radiological femoral head eccentricity in standard non-weightbearing plain x-rays. There was an inverse statistically significant correlation between cup inclination angle and the volumetric wear rate. The linear wear rate, as determined with the shadowgraph technique, was greater in retrieved cups during the first six years postoperatively, but reduced to a lower level in cups retrieved after that time of service.

A radiological and laboratory assessment of polyethylene wear in failed total hip replacement

This study assessed the reliability of radiological assessment of polyethylene wear in loose total hip replacements (THRs) by comparing it with a laboratory assessment using the shadowgraph technique. It was performed in Avon Orthopaedic Centre, Southmead Hospital, from September 1997 to June 1998. True linear wear depth measured using the shadowgraph technique was 42% greater than that determined from the radiological femoral head eccentricity in standard non-weightbearing plain x-rays. There was an inverse statistically significant correlation between cup inclination angle and the volumetric wear rate. The linear wear rate, as determined with the shadowgraph technique, was greater in retrieved cups during the first six years postoperatively, but reduced to a lower level in cups retrieved after that time of service.

Is the Bladder a Reliable Witness for Predicting Detrusor Overactivity?

We determined how well the symptoms of OAB syndrome correlate with urodynamic DO using International Continence Society definitions. The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004. Patients were selected based on OAB syndrome symptoms (urgency, urgency urinary incontinence and frequency). The percent of patients who had symptoms alone or in combination and DO was calculated. There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women. Of men 69% and 44% of women with urgency (OAB dry) had DO, while 90% of men and 58% of women with urgency and urgency urinary incontinence (OAB wet) had DO. Stress urinary incontinence seems to have accounted for the decreased rates in women since 87% of women with urgency urinary incontinence also had the symptom of stress urinary incontinence. The ICS definition does not specify what constitutes abnormal voiding frequency. Analysis of results showed that increasing voiding frequency did not have any effect on increasing the accuracy of diagnosis of DO except in women with 10 or more daytime micturition episodes. The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO, more so in the OAB wet than in OAB dry patients.

The importance of lymph-nodes in the assessment of gastric carcinoma at operation.

Journal Article The importance of lymph-nodes in the assessment of gastric carcinoma at operation Get access E G Cantrell E G Cantrell Department of Medicine, Southmead Hospital, Bristol Search for other works by this author on: Oxford Academic Google Scholar British Journal of Surgery, Volume 58, Issue 5, May 1971, Pages 384–386, https://doi.org/10.1002/bjs.1800580518 Published: 07 December 2005

Role of Enterobius vermicularis in the aetiology of appendicitis.

An evaluation was made of the histological material obtained from all 1529 appendices removed during the last 5 years at Southmead Hospital, Bristol, in order to elucidate possible relationships between the incidence of Enterobius vermicularis and the origin of inflammation in the appendix. In total, 1419 appendices were removed as cases of clinical appendicitis and 110 in the course of another surgical procedure. E. vermicularis was identified in 2.7 per cent of patients with clinical appendicitis and was most commonly seen in appendices with either chronic inflammation or where the appendix was histologically normal. E. vermicularis was rarely associated with histological changes of acute appendicitis. No cases of E. vermicularis infestation occurred in appendices removed during the course of other surgical procedures. The results suggest that, although E. vermicularis may have a causal role in appendicular pain and chronic inflammation, it is rarely related to acute appendicitis.

Bailey and Love's short practice of surgery. Revised by A. J. Harding Rains, M.S. (Lond.), F.R.C.S. (Eng.), Professor of Surgery, University of London at Charing Cross Hospital Medical School, and W. Melville Capper, F.R.C.S. (Eng.), Consultant Surgeon, Bristol Royal Hospital and Southmead Hospital, Bristol. Fourteenth edition. 9¾ × 6⅝ in. Pp. 1270 + xii, with 1638 illustrations. 1968. London: H.

Bailey and Love's short practice of surgery. Revised by A. J. Harding Rains, M.S. (Lond.), F.R.C.S. (Eng.), Professor of Surgery, University of London at Charing Cross Hospital Medical School, and W. Melville Capper, F.R.C.S. (Eng.), Consultant Surgeon, Bristol Royal Hospital and Southmead Hospital, Bristol. Fourteenth edition. 9¾ × 6⅝ in. Pp. 1270 + xii, with 1638 illustrations. 1968. London: H.

Recurrent laryngeal nerve palsy associated with thyroiditis.

Journal Article Recurrent laryngeal nerve palsy associated with thyroiditis Get access M E Lucarotti, M E Lucarotti Department of Surgery, East Birmingham Hospital, UK Correspondence to: Miss M. E. Lucarotti, University Department of Surgery, Southmead Hospital, Bristol BS10 5NB, UK Search for other works by this author on: Oxford Academic Google Scholar R T J Holl-Allen R T J Holl-Allen Department of Surgery, East Birmingham Hospital, UK Search for other works by this author on: Oxford Academic Google Scholar British Journal of Surgery, Volume 75, Issue 10, October 1988, Pages 1041–1042, https://doi.org/10.1002/bjs.1800751030 Published: 06 December 2005 Article history Accepted: 12 May 1988 Published: 06 December 2005

Use of Skin Grafting to Demonstrate Tolerance Prior to Kidney Transplantation without Immunosuppression in the Recipient of a Previous Bone Marrow Transplant: Response

Fehr et al. state that there is an extensive published literature on solid organ transplantation after bone marrow transplantation from the same donor and that the use of skin grafting as an in vivo test of tolerance prior to solid organ transplantation imposes an additional procedure/risk with no gain of immunological knowledge. However, in all the cases referred to, the transplant recipients received some immunosuppression. This was either in the form of corticosteroids (1, 2) or ciclosporin(3). Although in comparison to standard protocols for solid organ transplantation, a reduced immunosuppressive regime was used, its use for even a short time suggests that transplant clinicians were unsure about the degree and robustness of tolerance achieved. Based on the published literature, Fehr et al.'s confidence that the risk of rejection is insignificant is not shared by other clinicians undertaking this procedure. As far as we know, ours is only the third case report where no immunosuppression has been used. The experience published by Sellers et al. (4) and referred to in our paper is almost identical to our own. Interestingly, this report was quoted in the review (5) published by Fehr and Sykes but the concerns voiced in their letter were not raised when discussing Seller's work. We acknowledge Fehr et al.'s concern regarding use of skin grafting as a test for alloreactivity against minor antigens. We recognize both the presence of tissue-specific minor antigens and the fact minor antigen mismatched grafts can reject rapidly. These points were raised in the extensive discussions we had within the team before the procedure. After careful consideration we felt that sensitization to skin specific antigens would be of no consequence and the likelihood of responses to skin specific minor antigens spreading to result in sensitization to donor HLA was negligible. Furthermore, tolerance to donor skin grafts, but rejection of third party grafts still continues to be the gold standard test of tolerance in experimental settings. A full thickness skin graft is a relatively risk free and minimally painful procedure, both to recipient and donor. We felt this was the safest and most practical way of testing donor specific responses and survival of the skin graft increased our confidence in the decision to subject the donor to nephrectomy and proceed without immunosuppression in the recipient. The safety and efficacy of this approach is demonstrated by the fact 30 months postrenal transplant, our patient remains well, leukemia free, rejection free, with a creatinine <90 mmol having never had any immunosuppression. Rommel Ravanan Paul A. Lear Christopher R.K. Dudley Richard M. Smith David J. Unsworth Christopher J. Burton Richard Bright Renal Unit and Departments of Surgery and Immunology Southmead Hospital Bristol, United Kingdom

THE EFFECT OF FLUID INTAKE ON URINARY SYMPTOMS IN WOMEN

We determined the effect of caffeine restriction and fluid manipulation in the treatment of patients with urodynamic stress incontinence and detrusor overactivity. This was a 4-week randomized, prospective, observational crossover study in 110 women with urodynamic stress incontinence (USI) or idiopathic detrusor overactivity (IDO) to determine the effect of caffeine restriction, and of increasing and decreasing fluid intake on urinary symptoms. Data were recorded in a urinary diary for the entire study period on urgency episodes, frequency, pad weight increase, wetting episodes and quality of life. A total of 69 women with a mean age of 54.8 years completed the study, including 39 with USI and 30 with IDO. In the IDO group decreasing fluid intake significantly decreased voiding frequency, urgency and wetting episodes with improved quality of life. In the USI group there was a significant decrease in wetting episodes when fluid intake was decreased. Changing from caffeine containing to decaffeinated drinks produced no improvement in symptoms. Conservative and life-style interventions are first line treatments in the management of incontinence and storage lower urinary tract symptoms. This study shows that a decrease in fluid intake improves some of these symptoms in patients with USI and IDO and, therefore, it should be considered when treating such patients.

Immunology of type 1 diabetes

The incidence of type 1 diabetes in the UK is 20 per 100 000 and increasing, particularly in the under-5-years age group.1 It comes with the burden of daily insulin injection and blood testing, as well as both short- and long-term complications, and this can include premature death. The standardized mortality ratio for type 1 diabetes has been estimated as 4-fold for females and 2.7-fold for males in the UK.2 Even with tight glucose control, there is a significant risk of neuropathy, retinopathy and nephropathy, as well as a 3-fold increase in the risk of severe hypoglycaemia.3 Understanding the pathology of type 1 diabetes may help improve management. Type 1 diabetes is characterized by an absolute loss of insulin secretion, and results from an autoimmune process that destroys insulin-producing β cells within the pancreatic islet. This review will focus on the immunology of type 1 diabetes, and how this understanding may influence the clinical management, and development of new treatments for this disease. There are over one million islets in a healthy adult pancreas. They make up 1% of the total pancreatic volume, weigh about 1 g, and contain about 1 mg of insulin.4 Histological analysis of the pancreas from patients with type 1 diabetes shows immunological activity not present in a healthy or a type 2 diabetic pancreas.5 This activity is limited to insulin-containing islets, includes infiltration by activated lymphocytes, antibodies and components of the complement system. These histological findings are consistent with type 1 diabetes being an immune-mediated disease (Figure 1). Figure 1. Insulitis. A pancreatic islet (insulin in red) being invaded by T lymphocytes (green), the currently irreversible process that leads to type 1 diabetes. Courtesy of Anne Cooke, University of Cambridge. Further evidence comes from studies showing that drugs that suppress the immune response can modulate … Address correspondence to: Dr P. Narendran, Clinical Science at North Bristol, University of Bristol, Southmead Hospital, Bristol BS10 5NB. email: parth.narendran{at}bristol.ac.uk

Trying to predict ‘dangerous’ bladders in children: The area under the curve concept

Objective Children with neurological and non-neurological lower urinary tract dysfunction normally undergo video urodynamics. One reason is to try to diagnose ‘dangerous’ bladders. Currently, bladder compliance is used to predict ‘dangerous’ bladders; however, in children there are no standardized methods of measurement and thus no ‘cut-off’ values. Compliance may also be normal even though high-pressure detrusor overactivity waves may exist during the filling phase of urodynamics. We tried to determine whether measuring the area under the detrusor pressure curve (AUC) during the filling phase of urodynamics would be a useful parameter in predicting ‘dangerous’ bladders. Patients and methods Children referred to the urodynamics unit at Southmead Hospital, a tertiary referral centre, from 2000 to 2004 were investigated. Although 130 patients were identified, only 15 patients had raw data which were analysable using the available computer software. Results There was no correlation between the AUC and predicting ‘dangerous’ bladders possibly due to limitations in the computer software. Conclusion Although the study did not reveal any correlation between the AUC and ‘dangerous’ bladders, it revealed the limitations of the available computer software in determining AUC, and highlighted the need for new standardized software and multinational, multi-centre trials to look into the concept of AUC. There is also a need for the International Continence Society to standardize methods and terminology in predicting ‘dangerous’ bladders.