Biomedical subjects
A J Costello
Publications and source records attributed to A J Costello.
Nd:YAG laser ablation of the prostate as a treatment for benign prostatic hypertrophy.
Many techniques have been used to relieve obstructive symptoms associated with benign prostatic hypertrophy. Transurethral resection of the prostate (TURP) with an electrocautery loop is the most commonly performed operation to relieve bladder neck and urethral obstruction caused by prostatic adenoma. There is increased interest in alternative therapies to reduce prostatic size for symptom relief in this condition. We describe a technique using the neodymium:YAG (Nd:YAG) laser and a 600-microns laser quartz fibre with an attached terminal gold-plated metal alloy reflector to provide reliable deep penetration into prostatic tissue for prostatic adenoma ablation. We report the first use of this technique in three patients with benign prostatic obstruction and one with localised adenocarcinoma of the prostate.
Radiotherapy as a treatment for bladder cancer.
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Corporeal penile plication for correction of erectile penile deformity.
Penile curvature causing functional impairment of sexual intercourse is uncommon but a number of patients are significantly inconvenienced by this condition. Seven patients who had marked erectile deviation were treated with surgical plication for their penile deformity. Mean follow-up was 16 months (range 3-48 months) and no postoperative complications were encountered. In six cases the penis has remained straight. In one patient recurrence of deformity occurred 12 months after corporeal plication. The simplicity of the corporeal plication technique with the low incidence of associated complications makes it an attractive surgical alternative for the treatment of penile erectile deformity.
Experience with the pulsed dye laser in management of ureteric calculi.
Pulsed dye laser lithotripsy is a recently developed technique for the management of urinary calculi. This article reports the results of treatment of a cohort of patients managed with this technology. Post-treatment bed stay was generally less than 48 h, narcotic analgesia was not regularly required, and no significant post-treatment complications were encountered. This treatment appeared to complement an existing extracorporeal shockwave lithotripsy (ESWL) service at St Vincent's Hospital and may offer a financial advantage in the treatment of patients with urinary calculi.
Laparoscopic pelvic lymph node dissection for carcinoma of the prostate and bladder.
Improvements in instruments and camera systems have allowed the development of operative techniques for laparoscopic pelvic lymph node dissection. A series of dissections in 20 patients is reported. The mean operation time was 1 h and 40 min. When the nodes appeared malignant, a node biopsy was sent for frozen section. If this was positive, the dissection went no further. In three patients it was necessary to complete the operation by open surgery. A mean number of five lymph nodes was dissected per side. After laparoscopic dissection, all patients were discharged the morning after surgery. The operation is possible without making great demands on hospital bed occupancy and the patient has a comfortable and speedy return to normal activity. Using laparoscopic techniques, node dissection becomes a more appealing option as an investigation and staging procedure.
Laser ablation of the prostate in patients with benign prostatic hypertrophy.
Seventeen patients with bladder neck obstruction due to benign prostatic hypertrophy have been treated with the Neodymium: YAG laser. We review our experience since the first patient was treated in September 1990. Using a prototype deflecting gold alloy tip on a quartz laser fibre (Lateralase TM), we ablated obstructing prostatic adenoma and constricting bladder neck tissue. Experience with this technique has enabled a patient population to be defined in whom laser therapy for prostatic obstruction may be effective. The treatment is relatively simple, speedy and attended by virtually no blood loss. Laser ablation therapy may offer some advantages over conventional transurethral resection of the prostate (TURP) in a selected subgroup of patients. The advent of new delivery systems may make laser ablation therapy a practical alternative to TURP.
Laparoscopic pelvic lymph node dissection.
The infiltration of pelvic lymph nodes by carcinoma of the prostate or carcinoma of the bladder is an important factor in disease staging. Until now, this could be accurately assessed only by means of open surgery, an undesirable option as an investigation. Recent advances in laparoscopic instruments and camera systems have allowed the performance of laparoscopic pelvic lymph node dissection. A series of dissections in 14 patients is reported.
Comparative study of the role of endo-urological manipulation in the treatment of ureteric calculi using extracorporeal shock wave lithotripsy.
The results of treatment of 115 patients with upper and mid-ureteric calculi, using endo-urological manipulation and extracorporeal shock wave lithotripsy were reviewed. The number of shocks administered, the kilovoltage used, the radiation exposure time and the degree of fragmentation achieved were evaluated. Complications occurring in the course of this treatment were also reviewed. A significantly lower number of impulses was required for fragmentation to be apparent at 24 h post-treatment, when the ureteric calculus was able to be manipulated back into the renal pelvis. However, at 6 weeks post-extracorporeal shock wave lithotripsy (ESWL) satisfactory fragmentation was apparent in approximately equal percentages of patients who had undergone successful and unsuccessful manipulation. In addition, a significantly greater mean radiation exposure was used in the treatment of mid-ureteric calculi that could not be successfully manipulated and required treatment in situ within the ureter. These results suggest that treatment of a ureteric calculus in situ within the ureter provides a satisfactory method of fragmentation, although fragmentation takes longer to become apparent than when treatment is undertaken upon a calculus within the renal pelvis. The greater radiation exposure for patients in whom ureteric calculi were treated in in situ within the ureter may reflect the operators' attempts to visualize a change in configuration of the calculus similar to that seen when treatment is given to a stone that has been successfully manipulated. However, since the absence of fragmentation at 24 h post-surgery does not indicate a failed treatment in this group, prolonged screening of the calculus with fluoroscopy may be unnecessary. The complication rate of this method of treatment was low.
A checklist of hospitalization criteria for use with children.
Each year in the U.S. more than 130,000 children are hospitalized for psychiatric reasons. The decision to hospitalize a child is based on a complex set of factors. In this study, a 12-item checklist of criteria for hospitalization adapted by the authors was tested for its ability to predict hospitalization in a cohort of 389 children between the ages of two and 12 who were evaluated for either inpatient or outpatient treatment. Eighty-seven (22 percent) of the children were subsequently hospitalized. In 95 percent of the cases, the checklist was able to correctly predict whether the patient was hospitalized. A shorter checklist of six items was also able to predict the subsequent form of treatment in 95 percent of the cases. Although such checklists cannot take the place of informed clinical decisions, they can serve as a guide to decision making, especially for inexperienced mental health workers, and as a tool for utilization review when treatment decisions are questioned.
Sutureless end-to-end bowel anastomosis using Nd:YAG and water-soluble intraluminal stent.
Sutureless end-to-end intestinal anastomoses were successfully constructed in 20 rabbits. A water-soluble intraluminal stent was used to approximate the tissue edges, and the anastomotic seam was lased with 1.06 microns neodymium:YAG (Nd:YAG) laser energy supplied through a hand-held 600-microns gas-cooled noncontact optical fiber. A continuous 5-watt wave of power was applied over periods ranging from 46 to 92 seconds to produce the tissue blanching and shrinkage that indicated a satisfactory tissue weld. Integrity, degree of tissue reaction, and bursting pressures of the anastomoses were compared to those of anastomoses constructed using standard sutured techniques. The results of the two methods were equivalent at 1 to 3 days, but the laser-fused enteric anastomoses showed less inflammatory reaction and greater bursting pressures at 7 and 14 days. Application of a variety of proteinaceous solutions including extracellular matrix materials and epidermal growth factors prior to lasing failed to augment wound healing. We conclude that lasers show promise as reconstructive, in addition to ablative, surgical instruments.
The pediatrician as gatekeeper to mental health care for children: do parents' concerns open the gate?
Data from a study of children seen for pediatric care in a Health Maintenance Organization are used to examine factors which influence the likelihood that a pediatrician will identify a psychiatric problem and refer an identified child to a mental health specialist for further evaluation and treatment. Parental level of distress, family psychiatric history, and discussion of parental concerns with the pediatrician were found to be important. Characteristics of the service delivery system which may impede appropriate identification and referral are discussed. Implications for participation of child and adolescent psychiatrists in the training of pediatricians are presented.
Prognostic indicators for failure of surveillance management of stage I non-seminomatous germ cell tumours.
Fifty-three patients presenting with non-seminomatous germ cell tumours (NSGCT) of the testis were examined. Particular interest was directed towards the association of several morphological features of the primary tumour with metastatic disease, either at presentation or later in the course of the tumour. It is apparent from this study that the presence of vascular invasion in the primary tumour, high T stage (advanced local disease) and the presence of choriocarcinoma are poor prognostic signs in NSGCT. In such tumours presenting as clinical stage I, surveillance management may not be appropriate because of the high rate of relapse.
Psychiatric disorders in pediatric primary care. Prevalence and risk factors.
Children aged 7 to 11 years visiting their primary care pediatrician for a wide range of reasons were studied to determine the one-year prevalence of DSM-III disorders and the risk factors associated with them. Parents completing the Child Behavior Checklist about their children identified problems that placed 24.7% of 789 children in the clinical range. Detailed psychiatric interviews with 300 parents and children, using the Diagnostic Interview Schedule for Children, yielded a one-year weighted prevalence of one or more DSM-III disorders of 22.0% +/- 3.4%, combining diagnoses based on either the child or the parent interview.
Convergence between statistically derived behavior problem syndromes and child psychiatric diagnoses.
The relations between scores on statistically derived behavior problem syndromes and DSM-III diagnoses were examined for 270 clinically referred children aged 6 through 16. Each child's parent completed the Child Behavior Checklist (CBCL) and was administered the NIMH Diagnostic Interview Schedule for Children (DISC)--a structured interview covering DSM-III diagnostic criteria. Numerous behavior problems scales scored from the CBCL were significantly related to one or more diagnoses. The strongest relations were between scores on the Hyperactive, Delinquent, and Depressed scales and diagnoses of Attention Deficit Disorder, Conduct Disorder, and Depression/Dysthymia, respectively. This convergence supports the validity of some syndromal constructs common to both assessment paradigms.
Psychopathology in pediatric primary care: the new hidden morbidity.
In a study of emotional and behavioral problems seen in children attending pediatric primary care clinics in a health maintenance organization, parents of 789 children 7 to 11 years of age completed a behavior screening questionnaire, the Child Behavior Checklist. Of the 195 (24.7%) children identified by the checklist as disturbed, 126 were given a detailed psychiatric assessment using the Diagnostic Interview Schedule for Children, a structured psychiatric interview of known validity and reliability. A randomly selected group of 174 nondisturbed children was also assessed. The pediatricians' judgment about the presence of emotional and behavioral problems, made at the index clinic visit, was compared with diagnoses made from the computer-scored interviews. Pediatricians diagnosed one or more such problems in 5.6% of the children (weighted estimate: 95% confidence limits 3.8% to 7.6%), compared with 11.8% (95% confidence interval 9.3% to 13.5%) based on the interview with the parent. Pediatricians were highly specific, ie, 84% of children assessed as nondisturbed had no psychiatric disorder, but they showed low sensitivity, ie, they only identified 17% of the children with behavioral or emotional problems, giving a "hidden morbidity rate" of 83% (ie, 83% of cases were not identified). The role of primary care pediatricians in the identification, prevention and treatment of what has been called "the new morbidity" is discussed. We suggest that, on the basis of these findings, emotional and behavioral problems in children have to be seen as "the new hidden morbidity."
Service utilization and psychiatric diagnosis in pediatric primary care: the role of the gatekeeper.
Levels of morbidity in 789 children 7 to 11 years of age attending two primary care pediatric clinics in a health maintenance organization were examined in relation to psychiatric disturbance. Physical morbidity was measured as mean number of illness episodes per year enrolled, based on the child's medical record. Two measures of psychiatric disturbance were compared: the pediatricians' judgment and a detailed assessment using standard psychiatric interviews with parent and child. Children identified by pediatricians as disturbed had more than twice as many physical illness episodes as nonidentified children. Children identified by the standard psychiatric assessment had the same number of physical illness episodes as nondisturbed children. Pediatricians showed high specificity but low sensitivity to mental illness. Their sensitivity in the high user group was double that in the low user group. These results suggest that (1) the association between mental illness and high use may be, in part, the result of the confounding factor of physicians' judgment; (2) in settings where primary care practitioners serve as "gatekeepers" to mental health services, the offset effect of lower medical service use following psychiatric treatment may be partially explained by this; (3) the source of referral must be taken into account when assessing the offset effect in other settings.