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Ecological diversity and community ecology in the Fayum sequence (Egypt).

The Jebel Qatrani sequence found in the Fayum region of Egypt samples the richest Paleogene mammalian fauna of Africa, including some of the earliest anthropoid primates. The paleoecology of the Fayum has been interpreted as either a woodland bushland or a lowland evergreen tropical forest, although the issue of changing ecological conditions through time has never been investigated. The Fayum fossils can be grouped into four successive and stratigraphically distinct faunal assemblages. Each of these mammalian assemblages is compared with modern mammal communities. Six communities from modern African forest habitats and six communities from woodland bushland habitats are used to produce typical models of ecological diversity. An ecological spectrum for each modern community is generated by assigning mammal species to categories of taxonomic, diet, and body size diversity. Modern forest communities have a higher diversity of rodents and primates, a high diversity of frugivores, low diversity of grazers, and show a steep gradient in body size distribution from a high diversity of small species towards a low diversity of large species. Woodland-bushland communities have a higher diversity of ungulates and carnivores, a low diversity of frugivores but a high diversity of grazers, and a more even body size distribution. Diversity spectra from the four successive Fayum fossil assemblages are compared with the models derived from the modern mammal communities. The Fayum assemblages show similarities to modern forest habitats in patterns of diet diversity and to modern woodland bushland habitats in body size diversity. More detailed analyses of taxonomic diversity suggest that the lowermost assemblages were different in ecological structure from modern habitats, while the uppermost assemblage shows strong resemblances to modern humid tropical forests.

Animals↗

Incidence of urolithiasis in cystectomy patients after intestinal conduit or continent urinary diversion.

The purpose of this study was to determine the incidence of nephrolithiasis in radical cystectomy patients treated with either intestinal conduit or continent urinary diversion. The charts from 94 patients who had undergone radical cystectomy with urinary diversion at our institution from 1988 to 1998 were reviewed retrospectively for this study. Charts and radiographs from all patients were examined for renal function and evidence or urinary tract calculi. Two groups were compared: group I patients had undergone diversion with an intestinal conduit, and group II patients had received a continent diversion (primarily involving an Indiana pouch). Conduit diversions were typically done with a freely refluxing anastomosis (Bricker), whereas continent diversions were done with a nonrefluxing ureteral-intestinal anastomosis. Group I consisted of 54 patients who had undergone ileal conduit (50) or colon conduit (4) diversion with a mean follow-up of 2.5 years (range 0.6-7.0 years). Group II consisted of 40 patients who had undergone continent diversion (33 Indiana pouches, 7 orthotopic diversions) with a mean follow-up of 3.1 years (range 0.5-10.5 years). Laboratory studies of serum blood urea nitrogen, creatinine, and CO(2) were similar between the two groups. Six patients in group I developed urolithiasis, all in the upper tract. Stones developed at a mean of 3.1 years after urinary diversion. Three patients required operative intervention, whereas the others were managed expectantly. One patient in group II had an upper tract stone at the time of presentation for his bladder cancer, but no patient developed new upper tract stones during the present study period. Two patients in group II developed pouch calculi at a mean of 5 years after diversion; both required surgical intervention. In our study the risk for upper tract urolithiasis seemed higher in the intestinal conduit group (group I), with 11% of the patients developing stones. In the continent diversion group, no patient developed upper tract stones, although two patients (5%) developed pouch stones. Refluxing urine may contribute to an increased risk for stone formation after urinary diversion, whereas pouch stasis may contribute to stone formation in the continent diversion group.

Aged↗

Ambulance diversion reduction: the Sacramento solution.

PURPOSE: The diversion of ambulances away from their intended emergency departments (EDs) in the United States has become commonplace and may compromise patient care. Although ambulance diversion resulting from ED overcrowding has been well described in the literature, little is known about how to reduce the incidence of ambulance diversion on a regional level. We describe the development, implementation, and impact of a region-wide program to reduce ambulance diversion. BASIC PROCEDURES: This study was undertaken in the greater Sacramento, California region from January 2001 to December 2003. This comprehensive ambulance diversion reduction program was implemented May 15, 2002, with analysis of data for this 3-year time frame. The data for this study were obtained from 17 hospitals with ambulance diversion hours being the main outcome measure for this study. FINDINGS: The greater Sacramento region had 23785 hours of ambulance diversion in 2001. In 2003, there were 7143 ambulance diversion hours. Comparing the 17-month period before implementation of this program with the 19-month period after implementation, the difference in the means of these two groups was -1428 hours per month (95% confidence interval, -1252 to -1597), a 74% decrease in ambulance diversion hours. Notably, this reduction occurred despite overall increases in ED census (6.5%), hospital admissions from the ED (8.8%), EMS arrivals to the ED (17.1%), inpatient hospital census (7.4%), and overall Sacramento population (5.7%). CONCLUSIONS: Our results demonstrate a sizeable reduction of ambulance diversion in a large urban region after the successful implementation of a comprehensive ambulance diversion reduction program. The description of this effort may serve as a model for other regions across the country that do not have an organized approach in place for ambulance diversion, although boarding of admitted patients will still be a major hurdle to effective reduction of ambulance diversion.

Ambulances↗

Diversity in medical school: perceptions of first-year students at four southeastern U.S. medical schools.

PURPOSE: To assess students' perceptions of the extent of diversity in their classes, the role of diversity in their first-year curriculum, and their predictions of the amount of diversity in their future patient populations. METHOD: In 1998, students at four southeastern U.S. medical schools that had distinct demographics and differing institutional missions completed a questionnaire on diversity at the end of the first year. In the instrument, diversity was defined according to nine population characteristics: age, sex, race, ethnic background, physical disability, religious affiliation, sexual orientation, socioeconomic status, and rural background (growing up in a community of less than 5,000). Responses were compared according to students' institution, sex, and race. RESULTS: Questionnaires were returned by 349 of 474 students (74%). Students at the school with the most diverse first-year class placed the greatest value on the contributions of diversity to the learning environment. Women students placed more value on the inclusion of diversity issues in the curriculum than did men students, and they placed greater value on understanding diversity issues in their future medical practices than did men. Compared with Asian American, Hispanic, and white students, African American students were the least likely to think that the curriculum contained adequate information about diversity. CONCLUSIONS: The results indicate that perceptions of diversity were influenced by the students' own demographic characteristics and those of their medical school. The more diverse the class, the more comfortable the students were with diversity and the more they valued its contribution to their medical education.

Curriculum↗

Functional diversity: back to basics and looking forward.

Functional diversity is a component of biodiversity that generally concerns the range of things that organisms do in communities and ecosystems. Here, we review how functional diversity can explain and predict the impact of organisms on ecosystems and thereby provide a mechanistic link between the two. Critical points in developing predictive measures of functional diversity are the choice of functional traits with which organisms are distinguished, how the diversity of that trait information is summarized into a measure of functional diversity, and that the measures of functional diversity are validated through quantitative analyses and experimental tests. There is a vast amount of trait information available for plant species and a substantial amount for animals. Choosing which traits to include in a particular measure of functional diversity will depend on the specific aims of a particular study. Quantitative methods for choosing traits and for assigning weighting to traits are being developed, but need much more work before we can be confident about trait choice. The number of ways of measuring functional diversity is growing rapidly. We divide them into four main groups. The first, the number of functional groups or types, has significant problems and researchers are more frequently using measures that do not require species to be grouped. Of these, some measure diversity by summarizing distances between species in trait space, some by estimating the size of the dendrogram required to describe the difference, and some include information about species' abundances. We show some new and important differences between these, as well as what they indicate about the responses of assemblages to loss of individuals. There is good experimental and analytical evidence that functional diversity can provide a link between organisms and ecosystems but greater validation of measures is required. We suggest that non-significant results have a range of alternate explanations that do not necessarily contradict positive effects of functional diversity. Finally, we suggest areas for development of techniques used to measure functional diversity, highlight some exciting questions that are being addressed using ideas about functional diversity, and suggest some directions for novel research.

Adaptation, Physiological↗

Effects of hospital closures and hospital characteristics on emergency department ambulance diversion, Los Angeles County, 1998 to 2004.

STUDY OBJECTIVE: We assess the effects of nearby hospital closures and other hospital characteristics on emergency department (ED) ambulance diversion. METHODS: The study design was a retrospective, multiple interrupted time series with control group. We studied all ambulance-receiving hospitals with EDs in Los Angeles County from 1998 to 2004. The main outcome measure was monthly ambulance diversion hours because of ED saturation. RESULTS: Our sample included 80 hospitals, of which 9 closed during the study period. There were increasing monthly diversion hours over time, from an average of 57 hours (95% confidence interval [CI] 51 to 63 hours) in 1998 to 190 hours (95% CI 180 to 200 hours) in 2004. In multivariate modeling, hospital closure increased ambulance monthly diversion hours by an average of 56 hours (95% CI 28 to 84 hours) for 4 months at the nearest ED. County-operated hospitals had 150 hours (95% CI 90 to 200 hours) and trauma centers had 48 hours (95% CI 9 to 87 hours) more diversion than other hospitals. Diversion hours for a given facility were positively correlated with diversion hours of the nearest ED (0.3; 95% CI 0.28 to 0.32). There was a significant and positive interaction between diversion hours of the nearest ED and time, suggesting that the effects of an adjacent facility's diversion hours increased during the study period. CONCLUSION: Hospital closure was associated with a significant but transient increase in ambulance diversion for the nearest ED. The temporal trend toward more diversion hours, as well as increasing effects of the nearest facility's diversion hours over time, implies that the capacity to absorb future hospital closures is declining.

Adolescent↗

Novel algorithms for the optimization of molecular diversity of combinatorial libraries.

Various approaches to measuring and optimizing molecular diversity of combinatorial libraries are presented. The need for different diversity metrics for libraries consisting of discrete molecules ("cherry picking") vs libraries formed from combinatorial R-group enumeration (array-based selection) is discussed. Ideal requirements for diversity metrics applied to array-based selection are proposed, focusing, in particular, on the concept of incremental diversity, i.e., the change in diversity as redundant or nonredundant molecules are added to a compound collection or combinatorial library. Several distance and cell-based diversity functions are presented and analyzed in terms of their ability to satisfy these requirements. These diversity functions are applied to designing diverse libraries for two test cases, and the performance of the diversity functions is assessed. Issues associated with redundant molecules in the virtual library are discussed and analyzed using one of the test examples. The results are compared to reagent-based diversity optimizations, and it is shown that a product-based diversity protocol can result in significant improvements over a reagent-based scheme based on the diversity obtained for the resulting libraries.

Algorithms↗

Alpha, beta, or gamma: where does all the diversity go?

Global taxonomic richness is affected by variation in three components: within-community, or alpha, diversity, between-community, or beta, diversity; and between-region, or gamma, diversity. A data set consisting of 505 faunal lists distributed among 40 stratigraphic intervals and six environmental zones was used to investigate how variation of alpha and beta diversity influenced global diversity through the Paleozoic, and especially during the Ordovician radiations. As first shown by Bambach (1977), alpha diversity increased by 50 to 70 percent in offshore marine environments during the Ordovician and then remained essentially constant of the remainder of the Paleozoic. The increase is insufficient, however, to account for the 300 percent rise observed in global generic diversity. It is shown that beta diversity among level, soft-bottom communities also increased significantly during the early Paleozoic. This change is related to enhanced habitat selection, and presumably increased overall specialization, among diversifying taxa during the Ordovician radiations. Combined with alpha diversity, the measured change in beta diversity still accounts for only about half of the increase in global diversity. Other sources of increase are probably not related to variation in gamma diversity but rather to appearance and/or expansion of organic reefs, hardground communities, bryozoan thickets, and crinoid gardens during the Ordovician.

Animals↗

Spatial components of bird diversity in the Andes of Colombia: implications for designing a regional reserve system.

Beta diversity, or the turnover in species composition among sampling sites in a region, is an important criterion for obtaining adequate representation of regional biodiversity in systems of protected areas. Recently, the additive model for partitioning regional (gamma) diversity (in opposition to the multiplicative model) has been proposed because it allows a direct measure of the contribution of beta diversity to gamma diversity. We determined avian beta diversity along latitudinal (among neighboring river drainages) and elevational axes in a 1347-km2 region on the western slope of the Central Cordillera of the Colombian Andes, where a regional system of protected areas is being designed. We then compared avian beta diversity between sites based on rapid versus long-term (>1 year) inventories and between fragmented sites versus continuous forest. Overall, beta diversity represented 63.1% of gamma diversity among 16 sites. Elevational differences in species composition accounted for 43.3% of regional diversity, whereas differences among drainages accounted for 19.8%. A complementary cluster analysis showed that sites grouped by elevational zones. Rapid inventories overestimated beta diversity because of sampling effects, but the effect was biologically small. Estimators of species richness derived from species accumulation curves provided a useful alternative to compensate for undersampling in short-term surveys. Forest fragmentation increased beta diversity because of differential local extinction of populations. Nevertheless, in our region, forest fragments contributed to gamma diversity because they contained complementary sets of species. More importantly, they contained populations of special-interest species. Although the region is relatively small, our analyses indicate that spatial differentiation of the biota is an important factor for deciding number and location of protected areas in the Andean region.

Animals↗

Genetic relationship and diversity in a sesame (Sesamum indicum L.) germplasm collection using amplified fragment length polymorphism (AFLP).

BACKGROUND: Sesame is an important oil crop in tropical and subtropical areas. Despite its nutritional value and historic and cultural importance, the research on sesame has been scarce, particularly as far as its genetic diversity is concerned. The aims of the present study were to clarify genetic relationships among 32 sesame accessions from the Venezuelan Germplasm Collection, which represents genotypes from five diversity centres (India, Africa, China-Korea-Japan, Central Asia and Western Asia), and to determine the association between geographical origin and genetic diversity using amplified fragment length polymorphism (AFLP). RESULTS: Large genetic variability was found within the germplasm collection. A total of 457 AFLP markers were recorded, 93 % of them being polymorphic. The Jaccard similarity coefficient ranged from 0.38 to 0.85 between pairs of accessions. The UPGMA dendrogram grouped 25 of 32 accessions in two robust clusters, but it has not revealed any association between genotype and geographical origin. Indian, African and Chinese-Korean-Japanese accessions were distributed throughout the dendrogram. A similar pattern was obtained using principal coordinates analysis. Genetic diversity studies considering five groups of accessions according to the geographic origin detected that only 20 % of the total diversity was due to diversity among groups using Nei's coefficient of population differentiation. Similarly, only 5% of the total diversity was attributed to differences among groups by the analysis of molecular variance (AMOVA). This small but significant difference was explained by the fact that the Central Asia group had a lower genetic variation than the other diversity centres studied. CONCLUSION: We found that our sesame collection was genetically very variable and did not show an association between geographical origin and AFLP patterns. This result suggests that there was considerable gene flow among diversity centres. Future germplasm collection strategies should focus on sampling a large number of plants. Covering many diversity centres is less important because each centre represents a major part of the total diversity in sesame, Central Asia centre being the only exception. The same recommendation holds for the choice of parents for segregant populations used in breeding projects. The traditional assumption that selecting genotypes of different geographical origin will maximize the diversity available to a breeding project does not hold in sesame.

Gene Flow↗

[Effects of disturbances on plant species diversity of secondary forest in montane regions of eastern Liaoning Province].

According to the distance from forest stands to residential area and the first and second grade roads, as well as the canopy density and the percentage of damaged trees, this paper defined the disturbances, anthropogenic and natural, as low, medium and high levels. On the basis of this, the effects of different level disturbances on the plant species diversity of secondary forest in montane regions of eastern Liaoning Province were analyzed, and the differences between the effects of anthropogenic and natural disturbances were discussed. The results showed that without considering forest types, the overall plant species diversity of secondary forest under medium level anthropogenic disturbance was higher than that under low and high level anthropogenic disturbances, with the Simpson indexes being 0.96, 0.95 and 0.92, and Shannon-Wiener indexes being 3.77, 3.60 and 3.36, respectively. The diversities of shrub and herb layers were also the highest under medium level anthropogenic disturbance, while the highest diversity of arbor layer was appeared under the high level one. Among different forest types, there existed differences in the plant species diversity under anthropogenic disturbances, e. g. , the diversity under medium level anthropogenic disturbance was the lowest in hard broad-leaved forests, but the highest in other forest types. In all test forest types, no consistent tendency was observed in the changes of three layers' diversities with anthropogenic disturbance levels, but the diversities of shrub and herb layers were greatly affected by the disturbances. After 3 years of snow/wind damage, there was no distinct difference in the diversities among the birch forests under low, medium and high level natural disturbances, with the Simpson indexes being 0.91, 0.91 and 0.92, and the Shannon-Wiener indexes being 2.30, 2.93 and 2.89, respectively. The diversities of arbor and shrub layers were both increased with the enhancement of natural disturbances, but there was no great difference in the diversity of herb layer among the three levels of natural disturbances. At present, anthropogenic disturbance mostly occurred in understory, while snow/wind damage occurred in canopy. Such dissimilarity could make the effects of environmental factors on plant species diversity differed greatly.

Biodiversity↗

Cultural diversity in central America and Panama: its relationship to conservation and planning.

The most frequently overlooked aspect of conservation of natural resources and economic development is human cultural diversity. However, conservation and development of natural resources are basically human-oriented endeavors and all conservation and developmental efforts ought to start with a clear understanding of the varied needs of the people. In addition, cultural diversity is a natural resource that ought to be protected along with all the more commonly recognized resources of the ecosystems of which humans form an integral part. Cultural diversity in a large measure is an ecological phenomenon because such diversity includes variations in the ways different people perceive and utilize the environments in which they live. Thus, cultural diversity, in large measure, equates with ecological diversity. It has been well established that a high degree of ecological diversity (including taxonomic, niche, biogeochemical and other measures of diversity) is a necessary attribute of humid tropical ecosystems if such ecosystems are to remain viable over long periods of time. The current land-use trends in Central America and Panama are leading toward ever larger areas being devoted to monocultural use with sharply reduced ecological diversity that poses great dangers for the near and long terms. In addition, the resultant removal of people from rural areas results in growing social, economic and political problems, that are not being successfully met by developing nations. Not only is there a growing wastage of human resources, a weakening of the social structures, and an increasing and dangerous dependence upon monocultures oriented toward export markets, but the ecological diversity of the previous existing land-use systems are being lost. This kind of diversity is probably no less valuable to the ecological health of a nation's agriculture, forestry, and general resource utilization than is the genetic diversity of "primitive" crop plant varieties which biologists now recognize and increasingly seek to preserve as "modern" crop plant varieties become ever more simple genetically and hence ever more vulnerable to disease and other perturbations.

Agriculture↗

Ileal conduit urinary diversion in patients with previous history of abdominal/pelvic irradiation.

Urinary diversion among patients receiving prior radiation is common. Herein, we present our experience with ileal conduit (IC) diversion in patients with a history of prior abdominal and/or pelvic radiation therapy. We analyzed the charts of 177 patients who underwent IC urinary diversion between 1/1994 and 6/2000, and 36 patients were identified who had previously undergone radiation therapy. Decisions to proceed were based on surgeon preference as determined by intraoperative appearance and viability of the selected bowel segment. Chart review included serum studies, upper tract imaging studies, and complications related to diversion. Durability of diversion was determined by examining the interval between urinary diversion and the need for additional procedures. A total of 30 patients with at least 3 months follow-up were identified. Renal function remained stable in 86% (26/30) with a median follow-up of 21.5 months (range 3-63 months). Hydronephrosis was noted preoperatively in 4 patients (13%) who demonstrated stable upper tracts and serum creatinine in the post-operative period. Three patients (10%) developed unilateral hydronephrosis related to tumor recurrence, with one patient demonstrating a rise in baseline serum creatinine. Hydronephrosis was noted in 5 patients (16%) secondary to development of ureteroenteric stricture. Serum creatinine remained stable in 2 patients without intervention with 2 years follow-up. Intervention for obstruction was necessary in 3 patients at 22, 31, and 61 months following diversion. In one patient, an intraoperative decision to use the colon for urinary diversion was made secondary to appearance of small bowel. Minor complications were noted in 9 patients (30%), while 3 patients (10%) experienced major complications in the immediate post-operative period. Five patients (17%) experienced complications potentially related to the use of ileum for urinary diversion. The use of ileum for urinary diversion among patients with a history of radiation appears technically feasible and a viable treatment alternative. Our data support the use of ileum in the majority of patients as evidence by a low complication rate and a high rate of upper tract preservation. In addition, these data imply that a prior history of abdominal and/or pelvic radiation should not serve as the sole determining factor in the selection of bowel segment utilized during urinary diversion.

Abdominal Neoplasms↗

Assessing urinary diversion experience in urologic residency programs-are we adequately training the next generation?

PURPOSE: Operative experience is important in developing surgical skills and technical competency. There is also emerging evidence directly linking increased surgical volume to patient outcomes. Accordingly, resident training should provide the framework for mastery of complex operations. We evaluated the current urological residency experience in performing adult urinary diversion. MATERIALS AND METHODS: The Accreditation Council for Graduate Medical Education-Residency Review for Urology Operative Log Reports were reviewed from 2000 to 2004 with an emphasis on urinary diversion experience. Resident logs were analyzed specifically for all procedures that included CPT codes for continent and incontinent diversions. The logs were compared by year of training and type of urinary diversion. RESULTS: Overall, the total number of urinary diversions performed by graduating residents from 4-year programs has increased from 2,259 (2000 to 2001) to 4,017 (2003 to 2004). In addition, the mean and median number of urinary diversion cases among residents completing training have remained relatively constant. For graduating urology residents in 2003 to 2004, the mean (median) number of continent urinary diversion and incontinent urinary diversion cases were only 6.7 (3.0) and 9.5 (4), respectively. CONCLUSIONS: Current Accreditation Council for Graduate Medical Education data suggest the average urology resident has limited exposure to urinary diversion in general, and even less experience with more complex continent urinary diversion. These results suggest that many urology residency programs may not have sufficient volume to provide residents with a broad experience in urinary diversion, and alternative strategies to ensure proper training should be explored.

Internship and Residency↗

Quality of life survey of urinary diversion patients: comparison of ileal conduits versus continent Kock ileal reservoirs.

There has been a recent marked increase in interest in continent urinary diversions. While considerable time has been spent on the technical aspects of these diversions the psychological impact has not yet been fully explored. We describe an extensive survey that was conducted among 100 consecutive adults (87 respondents) who had undergone urinary diversion via an ileal conduit and 100 consecutive adults (85 respondents) in whom a continent Kock ileal reservoir was created during the last 3 to 5 years at our university by the same surgeons. The Kock pouch patients were stratified further into 63 with primary diversion and 22 who underwent conversion from previous conduit diversions. The survey consisted of a questionnaire that included a social and sexual survey, the Beck Depressive Inventory, the Profile of Mood States and a physical impact study. The results revealed that all patients surveyed generally were satisfied with the diversions and they had adapted reasonably socially, physically and psychologically. The key to adaptation seemed to be a detailed, realistic preoperative education about the type of diversion used. Patients with ileal conduit diversions had the lowest expectations of the form of diversion as defined by the preoperative awareness of the need to wear an external ostomy appliance with its associated inconveniences and change in the external body image. Postoperatively, ileal conduit patients also had the poorest self images as defined by a decrease in sexual desire and in all forms of physical contact (sexual and nonsexual). The subset of patients who underwent conversion from conduit diversions to Kock pouches, however, were statistically the most satisfied, and they were the most physically and sexually active. We conclude that the Kock continent urostomy offers an important alternative to noncontinent forms of diversion.

Adaptation, Psychological↗

Temporary high diversion for posterior urethral valves.

PURPOSE: Temporary high diversion for posterior urethral valves remains controversial. Even in the most severe cases some physicians deny the efficacy of this treatment. They assert that high diversion does not change the outcome of kidney function and has an iatrogenic, deleterious effect on the bladder. We believe that these 2 assertions may be inaccurate. MATERIALS AND METHODS: We evaluated 17 of 120 boys with posterior urethral valves who underwent temporary high diversion via Sober-en-T ureterostomy. This procedure immediately decompresses the upper urinary tract and leaves the bladder functional. Mean duration of diversion was 13 months. Bladder function results were good and diversion clearly had no deleterious effect. However, our series was too small to conclude with certainty that renal function improved due to diversion and not to valve resection only. Rapid improvement in creatinine was noted in all cases after diversion. RESULTS: In this study we reviewed opposing opinions. It appears clearly evident that physicians who believe that ureterostomy creates a valve bladder are considering only loop diversion, which temporarily defunctionalizes the bladder. On the contrary, Sober-en-T diversion preserves bladder cycling. In addition, those who report poor kidney function after high diversion fail to mention that this procedure is usually performed only in the most severe cases. CONCLUSIONS: For severe cases of posterior urethral valves one should not hesitate to create temporary high diversion, which may possibly improve renal function. Sober-en-T ureterostomy does not damage the bladder.

Child↗

[From urostoma to bladder replacement: current possibilities in urinary diversion].

OBJECTIVE: To analyse 48 urinary diversions in an oncological patient population. DESIGN: Retrospective study. SETTING: The Dutch cancer institute 'Nederlands Kanker Instituut/Antoni van Leeuwenhoek Ziekenhuis' in Amsterdam, the Netherlands. METHOD: The medical records of all patients who had a urinary diversion in the period 1989-1993 were analysed for type of diversion, indication for this specific type and postoperative complications. RESULTS: In 48 patients (24 women and 24 men with a mean age of 62.1 years) a urinary diversion was constructed because of cystectomy for bladder cancer (n = 27), cystectomy in total pelvic exenteration (13), total urinary incontinence following radiotherapy (5), urethral cancer (1) or local palliation (2). Twenty-one diversions according to Bricker, 25 continent reservoirs according to Rowland and (or) neo-bladders, I ureterosigmoidostomy and I continent access to the bladder (Mitrofanoff procedure) were done. The standard diversion according to Bricker was preferred in the following circumstances: extensive intestinal resections (also previous ones), older age, fear of incontinence or no need for continent diversion. Specific problems of the new diversion techniques were difficulties of patients with catheterising the reservoir and folic acid deficiency. All other postoperative problems were related to the extensiveness of the primary oncological procedure rather than to the diversion technique. CONCLUSION: Apart from a few contraindications such as shortage of intestine, tumour growth into the urethra and patients' inability or unwillingness to catheterize themselves, there are no objections to the new diversion techniques (continent reservoir/neo-bladder). Patients being considered for urinary diversion ought to be informed about these new techniques.

Adult↗

Open pelvic fracture and fecal diversion.

BACKGROUND: Mandatory fecal diversion has been advocated as an appropriate measure to prevent infection in the clinical setting of an open pelvic fracture. However, the efficacy of this practice has not been verified by prospective investigation and has received only inconsistent support from retrospective analyses. OBJECTIVE: To determine whether fecal diversion is associated with a substantially lower incidence of abdominopelvic infectious complications in patients with open pelvic fractures. DESIGN: Case-control study. SETTING: University-based tertiary care, level I trauma center. METHODS: The current study reviews our experience with 60 cases admitted from 1987 to 1993 to Harborview Medical Center, a regional level I trauma center. Data collected on each patient included age, sex, Injury Severity Score, Glasgow Coma Scale, initial heart rate and systolic blood pressure, location and severity of wound, fracture pattern, pelvic stability, time to open reduction internal fixation or external fixation, mortality, use of fecal diversion, and incidence and location of infection. Review of the literature produced an additional 186 patients amenable to analysis. RESULTS: Fecal diversion was performed in 19 patients, 5 (26%) of whom experienced subsequent abdominopelvic infectious morbidity. Of the remaining 41 patients, 7 patients (17%) experienced infectious complications. The 2 groups (diversion vs no diversion) were comparable with regard to relevant demographic and clinical characteristics of injury severity. Combining the present series with those reported by others gave a composite series of 246 patients. For the composite series, diversion was performed in 70% of patients. Infection developed in 27% of patients who underwent diversion vs 29% in patients who did not. In the present series, only mechanical instability was determined by stepwise logistic regression to be significantly associated with pelvic infection. This association was not altered by diversion status. CONCLUSIONS: Diversion of the fecal stream to protect open pelvic fractures is not associated with a lower incidence of abdominopelvic infectious complications. Diversion may offer protection to a select group of patients with extensive soft tissue injury or posterior wounds. Mechanical instability was independently associated with infection.

Abdominal Abscess↗