Psychiatric patients and their response to experimental stress

Serum levels of Epinephrine (E), norepinephrine (NE), heart rate (HR), skin conductance reaction (SCR) and skin conductance level (SCL) were measured in schizophrenic, endogenous depressed and anxiety patients as well as in normal controls. Conditions were rest, noise and a mental arithmetic (MA) task. Schizophrenic and depressed patients had an attenuated HR response to MA. Moreover, Schizophrenic patients also had higher NE base level and the highest NE secretion during noise. Anxiety and depressed patients showed significantly lower phasic electrodermal activity (SCR) throughout the whole trial, exclusively anxiety patients had significantly higher tonic electrodermal activity (SCL). These findings indicate that autonomous reactions discriminate between patient groups and controls as well as between each other.     

Five‐Year Follow‐up After Sacral Neuromodulation: Single Center Experience

Objective. We studied long‐term clinical efficacy of sacral neuromodulation (SNM) therapy in patients with refractory urgency incontinence (UI), urgency/frequency (UF) and voiding difficulty (VD), together with urodynamic data at baseline and six   months postimplant. Materials and Methods. Twenty‐two patients were implanted with a neurostimulator after a positive response to a percutaneous nerve evaluation test defined as a greater than 50% improvement in symptoms. Results. At five‐year follow‐up, the number of incontinent episodes and pad usage per day decreased significantly in 10 out of 15 UI patients. Two of five UF patients were successfully treated with SNM; the number of daily voids for all UF patients decreased from 25 to 19 and average voided volume increased from 98 to 212 mL. One of the two VD patients was able to void to completion. Mean first sensation of filling at the six‐month urodynamic investigation for the UI and UF patients increased from 78 to 241 mL and 141 to 232 mL, respectively, and the maximum bladder capacity increased from 292 to 352 mL and 223 to 318 mL, respectively. Five of 22 patients underwent device explant and one patient still has an inactive stimulator implanted. Conclusion. SNM is an effective treatment modality that offers sustained clinical benefit in the majority of patients with refractory UI, UF, and VD that do not respond to other, more conservative therapies.     

Pharmacology of the internal anal sphincter and its relevance to faecal incontinence

1 The internal anal sphincter (IAS) has a spontaneous tone and is the main contributor to the maintenance of faecal continence. The spontaneous resting tone exhibited by the sphincter can be modified by neurotransmitters from the autonomic and enteric nervous systems. 2 In this review, the influence of the sympathetic and parasympathetic nervous systems on IAS tone are discussed and the putative roles of nitric oxide, carbon monoxide, vasoactive intestinal peptide and adenosine triphosphate in non‐adrenergic non‐cholinergic transmission are considered. 3 Faecal incontinence is a common condition that places a heavy financial burden on the health service and severely affects patients’ quality of life. Resting anal pressure is reduced in patients with faecal incontinence and agents that increase sphincter tone tend to relieve symptoms. The results of clinical studies of the use of phenylephrine to treat faecal incontinence are reviewed. 4 It is concluded that the IAS is a potential target for drug development for the treatment of faecal incontinence.     

Chewing gum,stress and health

Hollingworth described chewing gum as ‘a technique of relaxation’. Recent research has examined this issue and there is evidence that chewing gum can prevent the adverse effects of acute stress. There are also plausible biological mechanisms that could explain such effects. It is now important to examine chewing gum and chronic stress and the present study involved a survey of this topic. The survey covered the ‘stress process’, collecting data on exposure to stressful events, levels of perceived stress and health outcomes. Frequency of chewing gum was also recorded. Potential confounding factors (demographics, personality and health-related behaviours) were also recorded. The web-based survey was completed by a community sample of 2,248 full-time workers (68% female. Mean age: 35 years, range 18–74 years). Sixty-one per cent of the sample were gum chewers. The results showed that chewing gum was associated with lower levels of perceived stress (both at work and life in general). Gum chewers were also less likely to be depressed and to have seen their doctor for high blood pressure or high cholesterol. Chewing gum was associated with lower levels of alcohol consumption and with cigarette smoking. Gum chewers were also more likely to be neurotic extraverts. Those who chewed gum were also more likely to be exposed to negative factors at work. Logistic regression analyses showed that the effects of chewing gum on stress and health remained significant when these confounding factors were controlled for. These results suggest that chewing gum may be a simple way of preventing stress and the negative health outcomes that are often associated with it. Intervention studies are now required and the mechanisms underlying the effects reported here need further investigation. Copyright © 2009 John Wiley & Sons, Ltd.     

Early results of immediate repair of obstetric third-degree tears: 65% are completely asymptomatic despite persistent sphincter defects in 61%

OBJECTIVE: The outcome of immediate repair of obstetric third-degree tears is poorly documented. Immediate repair may give better functional results than delayed repair because scarring is reduced. This aim of this prospective study was to examine the early outcome of immediate repair of third-degree tears. METHOD: A total of 121 women who had immediate repair of obstetric third-degree tears underwent interview, anal ultrasonography and anorectal physiology. RESULTS: At review, 79 (65%) were completely asymptomatic (score = 0), 23 (19%), had minor flatus incontinence or mild urgency causing no compromise to their quality of life (score 1-4), and 19 (16%) had clinically embarrassing faecal incontinence (score 5-24). Thirty-nine (32%) had an intact internal anal sphincter (IAS) and external anal sphincter (EAS) (i.e. a successful repair), eight (7%) had a defect in the IAS alone but the EAS was intact (i.e. a successful repair but a residual IAS defect), 43 (35%) had a residual defect in the EAS alone (IAS intact) and 31 (26%) had a persistent defect in the IAS and EAS. Residual defects in either or both of the sphincters were associated with a significantly higher incidence of abnormal resting and squeeze anal pressures. Anal manometry had no correlation with symptoms. The highest proportion of severe incontinence was in those with an IAS defect alone (37%) and when there was a residual IAS and EAS defect (24%). Only 2 of 39 (5%) with an intact IAS and EAS had severe incontinence and only 8 of 43 (18%) with a residual EAS defect alone had severe faecal incontinence. CONCLUSION: These results indicate a good outcome following immediate repair of third-degree obstetric tears and emphasize the role of the IAS in providing continence.     

Prospective multicenter clinical trial of Uretex Sup for surgical treatment of stress urinary incontinence

AIM: To evaluate in a prospective multicenter study the efficacy and safety of the suburethral support Uretex (Sofradim, Trevoux, France) delivered by a suprapubic approach in the treatment of female stress urinary incontinence. METHODS: Between March 2002 and March 2003, 57 patients were treated for stress urinary incontinence with Uretex. Preoperative evaluation included urodynamic examination and questionnaires (symptoms and quality of life, Contilife). Forty patients had pure stress urinary incontinence and 17 mixed urinary incontinence. No associated procedure was performed. The objective cure rate was evaluated by clinical examination and pad-test, and the subjective cure rate was assessed through questionnaires at 1, 3 and 12 months. RESULTS: The mean follow-up was 13 months (range 11-24 months). During follow up, chronic urinary retention requiring a tape section occurred in one patient, and in another patient a delay of vaginal healing was followed by a sling exposure and resection at 4 months. No infection or urethral erosion was reported. The objective cure rate was 96.2%, and the subjective cure rate was 79.2%; four patients reported low leakage on stress and nine patients complained of urge incontinence (four de novo and five persistent). CONCLUSION: The suprapubic Uretex Sup procedure is a safe and effective treatment for women with stress urinary incontinence.     

Head-to-head comparison of retropubic, perineal and laparoscopic radical prostatectomy

OBJECTIVE: As more patients are diagnosed with prostate cancer at an early stage, it is becoming increasingly important to refine the technique of surgical excision. For this purpose we have generated objective data comparing three different surgical approaches used by three experienced surgeons. METHODS: We prospectively compared three contemporary personal series of 50 consecutive radical prostatectomy (RP) patients. The health-related quality of life was evaluated preoperatively and in months 1, 3, 6, 12 and 24. RESULTS: Considering in turn the patients undergoing retropubic, perineal and laparoscopic RP, the median procedure time was 2 h and 27 min, 1 h and 50 min and 4 h, with a transfusion rate of 2, 0 and 8%, respectively. In the perineal group there were more wound infections. Median catheter drainage was 7, 10 and 7 days and zero, 13 and one patients needed reinsertion of a catheter. Early continence varied considerably, with 57.4, 11.4 and 6.3% of patients pad-free after 1 month, but there were no differences in social continence (zero or one pad) with 97.8, 97.8 and 91.9% after 2 years. The Litwin score for incontinence (preoperative minus postoperative) was -24, -41 and -63% after 1 month and -13, +3 and -29% after 2 years. Twenty-nine, five and 15 patients had a preoperative five-item version of International Index of Erectile Function (IIEF-5) score of > or = 17 points and a nerve-sparing procedure. After 2 years, 48.1, 0 and 0% had an IIEF-5 score of > or = 17 points without the use of phosphodiesterase type 5 (PDE-5) inhibitors, but when including patients using inhibitors there were no significant differences. CONCLUSIONS: A comparison of morbidity, short-term convalescence and long-term side-effects of different surgical techniques is strongly biased by both the preoperative status of patients and the skill of the surgeons. Overall, we found some differences in the short-term results (e.g. early continence) and comparable long-term results.     

Complex urethral disruptions: In pursuit of a successful reconstruction

OBJECTIVES: We analyzed the methods and outcomes of urethroplasty in men with complex urethral disruptions. METHODS: The medical records of 40 men with complex urethral disruptions were analyzed. Surgical methods were individualized according to stricture location, severity and length of the stricture, bladder neck characteristics and presence of complicating factors. Patients were divided into four groups based on the above characteristics. RESULTS: End-to-end urethroplasty performed in six patients with short bulbar strictures (<3 cm) was successful in all. Elaborated perineal repair was performed in 10 patients with intermediate (3-6 cm) strictures with or without complicating factors. Elaborated perineal repair with urethral substitution was performed in nine patients with long segment stricture (>6 cm). Abdominal transpubic repair was successfully applied to patients with rectourethral fistula or lacerated bladder neck. Success rate of anastomotic urethroplasty was 95% while over all success rate was 85%. CONCLUSION: Guidelines for urethral reconstruction of complex urethral disruptions are predicated on stricture length, location, bladder neck characteristics and associated complicating factors. End-to-end urethroplasty with stricture excision is highly reliable for short strictures for which previous operative repair have failed. Elaborated perineal repair is extremely versatile for intermediate and longer strictures with associated complicating factors. Abdominal transpubic urethroplasty is effective for patients with rectourethral fistula or lacerated bladder neck.     

Pharmacologic management of overactive bladder

Overactive bladder (OAB) is a prevalent and costly condition that can affect any age group. Typical symptoms include urinary urgency, frequency, incontinence and nocturia. OAB occurs as a result of abnormal contractions of the bladder detrusor muscle caused by the stimulation of certain muscarinic receptors. Therefore, antimuscarinic agents have long been considered the mainstay of pharmacologic treatment for OAB. Currently, there are five such agents approved for the management of OAB in the United States: oxybutynin, tolterodine, trospium, solifenacin and darifenacin. This article summarizes the efficacy, contraindications, precautions, dosing and common side effects of these agents. All available clinical trials on trospium, solifenacin and darifenacin were reviewed to determine its place in therapy.     

铰链式冠外附着体的结构强度分析

目的探讨铰链式冠外附着体设计的合理性.方法采用有限元应力分析的实验方法,分析铰链式冠外附着体阳性结构L形球体的应力分布情况,对其结构强度进行测试.结果在附着体阳性结构L形球体的转角处应力最大,应力值为321.847MPa.结论该铰链式附着体的结构强度符合临床设计要求.