Levator avulsion and grading of pelvic floor muscle strength

In a retrospective study investigating the relationship between levator avulsion and clinical grading of levator ani muscle strength, we analyzed the 3D/4D translabial ultrasound and digital assessment data of 1,112 women seen in a tertiary Urogynecological clinic. Levator avulsion was diagnosed whenever the examiner was unable to palpate the insertion of the pubovisceral muscle on the inferior pubic ramus and/or whenever a discontinuity between bone and muscle was detected on ultrasound. For clinical grading of levator muscle strength, we used the modified Oxford grading. Avulsion defects were found in 252 women (23%), and this was associated with a highly significant reduction in the overall Oxford grading (2.07 vs 2.81, P < 0.001). The prevalence of avulsion increased depending on the side differences in the modified Oxford grading: from 16% when there was no difference to 76% when the side difference was 1.5 or higher (P < 0.001). Avulsion of the puborectalis muscle seems to have a marked effect on pelvic floor muscle strength, which may help in diagnosing trauma.     

New imaging method for assessing pelvic floor biomechanics.

OBJECTIVES: The investigation of female pelvic floor biomechanics is attracting attention due to its importance in pelvic floor dysfunction and childbirth. To date, there are no established means of assessing pelvic floor elasticity. We propose the use of translabial ultrasound to estimate strain, one element of pubovisceral muscle elasticity. METHODS: Ultrasound datasets of 98 women seen at a tertiary urogynecology clinic were reviewed using proprietary software. Data were processed to estimate muscle fiber strain during Valsalva and contraction by measuring hiatal circumference and deducting bony arc length. Clinical assessment included levator palpation during maximal contraction (modified Oxford grading scale) and at rest, with tone recorded on a new six-point scale. Analysis of imaging data was performed without knowledge of clinical data. RESULTS: Mean age was 52.2 (range, 19-87) years and mean parity was 2.4 (range, 0-8). Mean (SD) hiatal area during contraction, rest and Valsalva was 15.4 (3.8) cm(2), 18.9 (5.0) cm(2) and 27.3 (8.9) cm(2), respectively. There was a moderate association between strain during contraction and Oxford grade (r = 0.439, P < 0.0001), and a weak but significant association between strain during Valsalva and resting tone (r = - 0.224, P = 0.033). CONCLUSIONS: Translabial ultrasound can be used to measure strain, a component of pubovisceral muscle elasticity, and we have validated the technique against clinical assessment. Pubovisceral strain during contraction correlates positively with Oxford grade. Pubovisceral strain during Valsalva correlates negatively with resting tone grade. This new non-invasive ultrasound technique may be of value for assessing patients with pelvic floor dysfunction.     

Reliability and factorial structure of the Chinese version of the Beck Depression Inventory

The Chinese version of the Beck Depression Inventory (C-BDI) was administered to 2,150 Chinese secondary school students. The BDI was found to have high internal consistency as a scale and high item-total correlations for most of the items. Factor analysis with a two-factor solution showed that two factors were abstracted from the scale, namely, general depression and somatic disturbances. By randomly splitting the total sample into two subsamples, these two factors could be reproduced reliably, and high coefficients of congruence were found. These findings generally suggest that the Chinese version of the BDI possesses acceptable psychometric properties, and the factor analytic data tend to support Beck's multi-dimensional view of depression as a construct.     

Chondromyxoid fibroma of skull base: a tumour prone to local recurrence.

Chondromyxoid fibroma of the skull base is extremely uncommon. Sometimes involvement of the nasal cavity may occur and the patients may present with nasal symptoms. The biological behaviour of this tumour has not been well studied, primarily because of the limited number of reported cases and the short duration of follow-up. We report a histologically confirmed case of chondromyxoid fibroma of the skull base that recurred repeatedly over a 10-year period after the initial operation. Histologically it showed identical morphology to the original tumour with no evidence of histological progression or dedifferentiation. Ultrastructurally, the spindle tumour cells in the fibromyxoid area showed dual chondroblastic and fibroblastic differentiation, suggesting that these spindle fibroblastic cells and the better differentiated chondroid cells were of the same cell type with different histological morphology.     

The quantification of levator muscle resting tone by digital assessment

The biomechanical properties of the puborectalis muscle are likely to be important for pelvic organ support. However, neither elasticity nor its clinical correlate, muscle resting tone, have received much attention to date. We therefore conducted a prospective study to test a newly developed resting tone scale for validity and reproducibility. Ninety-eight patients underwent a physical examination including prolapse staging and palpation of the levator ani. They were also assessed by 4D translabial ultrasound for levator hiatal dimensions and prolapse assessment. Resting tone was negatively associated with anterior and posterior compartment prolapse. An independent test–retest series yielded a weighted kappa of 0.55 (CI 0.44–0.66), implying “moderate” repeatability. Resting tone of the puborectalis muscle can be determined by digital palpation. It is moderately repeatable and associated with pelvic organ prolapse. Palpation of resting tone may be a useful new tool for assessing women with pelvic floor dysfunction.     

Warfarin-acetaminophen drug interaction revisited.

Physicians and pharmacists routinely advise patients receiving warfarin to take acetaminophen for pain or fever because of its relative safety; however, a recent study questioned the safety of such practice. A comprehensive search of MEDLINE and IPA for human studies and case reports from 1966-1999 revealed evidence that acetaminophen may potentiate the effect of warfarin by a mechanism that has yet to be elucidated. Due to lack of a safer alternative, acetaminophen still should be the analgesic and antipyretic of choice in patients taking warfarin, as long as excessive amounts and prolonged administration (> 1.3 g acetaminophen/day for > 2 wks) are avoided. With the high degree of interpatient variability and the unpredictability of various drug-drug interactions with warfarin, close and frequent monitoring of international normalized ratios is the key for safe oral anticoagulation therapy.     

Intravenous digital subtraction renal angiography: use in screening for renovascular hypertension

Intravenous digital subtraction renal angiography (DSRA) has been compared with conventional angiography only in small, selected series of hypertensive patients. The authors prospectively examined with intravenous DSRA 94 patients at increased risk for renovascular hypertension and compared these studies with conventional angiography. A stenosis of at least one main renal artery was identified with intravenous DSRA in 22 patients and confirmed in 20 patients. No significant stenoses were seen with conventional angiography in any of the 64 patients in whom lesions were not seen with intravenous DSRA. Since inadequate DSRA studies were considered positive for renal artery stenosis, the sensitivity of intravenous DSRA was 100% (25 of 25); specificity, 93% (64 of 69); positive predictive value, 83% (25 of 30); and negative predictive value, 100% (64 of 64). The authors conclude that intravenous DSRA is a sensitive test for identifying stenosis of the main renal arteries and is appropriate to use as a screening test among patients at increased risk for renovascular hypertension.     

Incidence, causes and mechanism of hypercalcaemia in a hospital population in Hong Kong

To determine the incidence and causes of hypercalcaemia in a hospital population in Hong Kong, all 29,107 samples received in the laboratory in one year were analysed for plasma calcium and albumin, and samples with a plasma calcium concentration adjusted for albumin greater than 2.55 mmol/l were investigated. Plasma calcium greater than 2.55 mmol/l was found in 462 patients. Repeat samples were received from 302 of these and hypercalcaemia was confirmed in 183. The main causes of hypercalcaemia were malignancy (72.1 per cent), tuberculosis (6.0 per cent), and primary hyperparathyroidism (5.5 per cent). In the malignant hypercalcaemia group, carcinoma of lung was the most common (31.8 per cent) and carcinoma of breast was uncommon (3.0 per cent). Secondary deposits in bone were detected in 35 of the 122 solid tumours. In order to identify the mechanism of hypercalcaemia the contributions of renal tubular reabsorption and increased bone resorption to the plasma calcium concentration were calculated. Increased tubular reabsorption was the main contributor to hypercalcaemia in primary hyperparathyroidism and carcinoma of liver (none of whom had bony metastases) and it contributed significantly to hypercalcaemia in carcinoma of lung without bony metastases and carcinoma of oesophagus. We conclude that in Hong Kong (a) primary hyperparathyroidism is uncommon, (b) tuberculosis is an important cause and (c) humoral factors may be responsible for a relatively high proportion of cases of malignant hypercalcaemia.     

Improved anticonvulsant activity of phenytoin by a redox brain delivery system I: Synthesis and some properties of the dihydropyridine derivatives

Nine chemical delivery systems (CDSs) were synthesized for the efficient transport of phenytoin (DPH) across the blood-brain barrier. The CDSs were based on a dihydropyridine in equilibrium quaternary pyridinium ion redox system which relies on chemistry similar to the NADH in equilibrium NAD interconversion for activity. The chemical carriers, derivatives of trigonelline, 1-alkylcarboxynicotinamide, 3-pyridylacetic acid, and N-methylpicolinic acid, were esterified with 3-(hydroxymethyl)phenytoin. The CDSs proved to be more lipophilic (5-23 times) than DPH. The 1-alkylcarboxydihydronicotinamide CDSs, excluding the sterically hindered one (11e), were quite unstable in rat tissue homogenates and hydrolyzed to release DPH. In human blood, however, they were found to be much more stable (75 times) toward hydrolysis. All other CDSs were oxidized quantitatively to the corresponding pyridinium ion in rat brain homogenates. These compounds were found to possess the required physicochemical characteristics for delivering DPH into rat brain.