The Integral Theory System Questionnaire: an anatomically directed questionnaire to determine pelvic floor dysfunctions in women

Purpose

Anatomical damage to pelvic floor structures may cause multiple symptoms. The Integral Theory System Questionnaire (ITSQ) is a holistic questionnaire that uses symptoms to help locate damage in specific connective tissue structures as a guide to reconstructive surgery. It is based on the integral theory, which states that pelvic floor symptoms and prolapse are both caused by lax suspensory ligaments. The aim of the present study was to psychometrically validate the ITSQ.

Materials and methods

Established psychometric properties including validity, reliability, and responsiveness were considered for evaluation. Criterion validity was assessed in a cohort of 110 women with pelvic floor dysfunctions by analyzing the correlation of questionnaire responses with objective clinical data. Test–retest was performed with questionnaires from 47 patients. Cronbach’s alpha and “split-half” reliability coefficients were calculated for inner consistency analysis.

Results

Psychometric properties of ITSQ were comparable to the ones of previously validated Pelvic Floor Questionnaires. Face validity and content validity were approved by an expert group of the International Collaboration of Pelvic Floor surgeons. Convergent validity assessed using Bayesian method was at least as accurate as the expert assessment of anatomical defects. Objective data measurement in patients demonstrated significant correlations with ITSQ domains fulfilling criterion validity. Internal consistency values ranked from 0.85 to 0.89 in different scenarios.

Conclusions

The ITSQ proofed accurate and is able to serve as a holistic Pelvic Floor Questionnaire directing symptoms to site-specific pelvic floor reconstructive surgery.     

The influence of anesthesia-controlled time on operating room scheduling in Dutch university medical centres

Background

Predicting total procedure time (TPT) entails several elements subject to variability, including the two main components: surgeon-controlled time (SCT) and anesthesia-controlled time (ACT). This study explores the effect of ACT on TPT as a proportion of TPT as opposed to a fixed number of minutes. The goal is to enhance the prediction of TPT and improve operating room scheduling.

Methods

Data from six university medical centres (UMCs) over seven consecutive years (2005-2011) were included, comprising 330,258 inpatient elective surgical cases. Based on the actual ACT and SCT, the revised prediction of TPT was determined as SCT × 1.33. Differences between actual and predicted total procedure times were calculated for the two methods of prediction.

Results

The predictability of TPT improved when the scheduling of procedures was based on predicting ACT as a proportion of SCT.

Conclusions

Efficient operating room (OR) management demands the accurate prediction of the times needed for all components of care, including SCT and ACT, for each surgical procedure. Supported by an extensive dataset from six UMCs, we advise grossing up the SCT by 33% to account for ACT (revised prediction of TPT = SCT × 1.33), rather than employing a methodology for predicting ACT based on a fixed number of minutes. This recommendation will improve OR scheduling, which could result in reducing overutilized OR time and the number of case cancellations and could lead to more efficient use of limited OR resources.     

Pancreaticoduodenectomy After Bariatric Surgery: Challenges and Available Techniques for Reconstruction

Introduction

Obesity is an epidemic in the USA, with approximately 7 % of the population considered morbidly obese (BMI?>?40 or >35 with significant comorbidities).

Discussion

Weight loss surgery is recognized as a durable solution to both obesity and obesity-associated morbidities. With an increasing number of pancreatic lesions being discovered on cross-sectional imaging, the pancreatic surgeon is increasingly likely to encounter patients with prior bariatric surgery who are in need of pancreaticoduodenectomy. As such, surgeons need to be familiar with the various bariatric operations, as well as the manner in which to handle prior bariatric reconstructions at the time of pancreatic surgery. Literature on this topic, however, is scarce with only a handful of small case series.

Conclusion

We herein review the different operations performed for weight loss, as well as provide an overview of the available operative approaches for reconstruction after pancreaticoduodenectomy in postbariatric surgical patients.     

Resection of Isolated Renal Cell Carcinoma Metastases of the Pancreas: Outcomes from the Johns Hopkins Hospital

Purpose

This study aims to assess outcomes and characteristics associated with resection of metastatic renal cell carcinoma (mRCC) to the pancreas.

Materials and Methods

From April 1989 to July 2012, a total of 42 patients underwent resection of pancreatic mRCC at our institution. We retrospectively reviewed records from a prospectively managed database and analyzed patient demographics, comorbidities, perioperative outcomes, and overall survival. Cox proportional hazards models were used to evaluate the association between patient-specific factors and overall survival.

Results

The mean time from resection of the primary tumor to reoperation for pancreatic mRCC was 11.2 years (range, 0–28.0 years). In total, 17 patients underwent pancreaticoduodenectomy, 16 underwent distal pancreatectomy, and 9 underwent total pancreatectomy. Perioperative complications occurred in 18 (42.9 %) patients; there were two (4.8 %) perioperative mortalities. After pancreatic resection, the median follow-up was 7.0 years (0.1–23.2 years), and median survival was 5.5 years (range, 0.4–21.9). The overall 5-year survival was 51.8 %. On univariate analysis, vascular invasion (hazard ratio, 5.15; p?=?0.005) was significantly associated with increased risk of death.

Conclusions

Pancreatic resection of mRCC can be safely achieved in the majority of cases and is associated with long-term survival. Specific pathological factors may predict which patients will benefit most from resection.     

Randomized clinical evaluation of a light-cured base material for complete dentures

Objectives

The purpose of this study was to compare plaque adhesion, tissue reaction, and technical complications for complete dentures based on visible light-cured resin (VLCR) or on conventional poly(methyl methacrylate) (PMMA).

Materials and methods

A stratified randomized cohort study was designed with 52 patients treated with a complete denture in the maxilla (n?=?28), the mandible (n?=?2), or both (n?=?22). Seventy-four dentures were manufactured, 38 of PMMA and 36 of VLCR. Investigators and patients were unaware of the nature of the denture base material. Plaque adhesion, tissue reaction, and technical complications were investigated 4 weeks after denture insertion (baseline). Recall investigations were performed after 6, 12, and 24 months.

Results

After 6, 12, and 24 months, plaque adhesion was significantly higher for VLCR dentures than for PMMA dentures. Tissue reaction was comparable for both groups, however. After 6, 12, and 24 months, need for repair was significantly greater for VLCR prostheses. The mean number of additional aftercare sessions per patient after 24 months was 50 % higher for VLCR than for PMMA.

Conclusions

Good oral hygiene must be established by patients treated with VLCR dentures, to remove biofilm from these dentures. Increased aftercare must also be taken into account when this material is used.

Clinical relevance

VLCR might be a viable alternative to PMMA for patients with allergic reactions to residual monomer or benzoyl peroxide.     

Validity of the 3D VECTRA photogrammetric surface imaging system for cranio-maxillofacial anthropometric measurements

Purpose

The use of three-dimensional (3D) photography for anthropometric measurements is of increasing interest, especially in the cranio-maxillofacial field. Before standard implementation, accurate determination of the precision and accuracy of each system is mandatory.

Methods

A mannequin head was labelled with 52 landmarks, and 28 three-dimensional images were taken using a commercially available five-pod 3D photosystem (3D VECTRA; Canfield, Fairfield, NJ) in different head positions. Distances between the landmarks were measured manually using a conventional calliper and compared with the digitally calculated distances acquired from labelling by two independent observers. The experimental set-up accounted for clinical circumstances by varying the positioning (vertical, horizontal, sagittal) of the phantom.

Results

In the entire calliper measurement data set (n?=?410), a significant difference (p?=?0.02) between the directly measured and corresponding virtually calculated distances was found. The mean aberration between both modalities covering all data was 7.96 mm. No differences (p?=?0.94) between the two groups were found using a cut-off of 10 % (leaving n?=?369 distances) due to considerable errors in direct measurements and the necessary manual data translation. The mean diversity of both measurement modalities after cut-off was 1.33 mm (maximum, 6.70 mm). Inter-observer analysis of all 1,326 distances showed no difference (p?=?0.99; maximal difference, 0.58 mm) in the digital measurements.

Conclusion

The precision and accuracy of this five-pod 3D photosystem suggests its suitability for clinical applications, particularly anthropometric studies. Three-hundred-and-sixty degree surface-contour mapping of the craniofacial region within milliseconds is particularly useful in paediatric patients. Proper patient positioning is essential for high-quality imaging.     

Charge separation and charge delocalization identified in long-living states of photoexcited DNA

Base stacking in DNA is related to long-living excited states whose molecular nature is still under debate. To elucidate the molecular background we study well-defined oligonucleotides with natural bases, which allow selective UV excitation of one single base in the strand. IR probing in the picosecond regime enables us to dissect the contribution of different single bases to the excited state. All investigated oligonucleotides show long-living states on the 100-ps time scale, which are not observable in a mixture of single bases. The fraction of these states is well correlated with the stacking probabilities and reaches values up to 0.4. The long-living states show characteristic absorbance bands that can be assigned to charge-transfer states by comparing them to marker bands of radical cation and anion spectra. The charge separation is directed by the redox potential of the involved bases and thus controlled by the sequence. The spatial dimension of this charge separation was investigated in longer oligonucleotides, where bridging sequences separate the excited base from a sensor base with a characteristic marker band. After excitation we observe a bleach of all involved bases. The contribution of the sensor base is observable even if the bridge is composed of several bases. This result can be explained by a charge delocalization along a well-stacked domain in the strand. The presence of charged radicals in DNA strands after light absorption may cause reactions—oxidative or reductive damage—currently not considered in DNA photochemistry.DNA photophysics is crucial for the understanding of light-induced damage of the genetic code (1). The excited state of single DNA bases is known to decay extremely fast on the subpicosecond time scale, predominantly via internal conversion (2, 3). This ultrafast decay is assumed to suppress destructive decay channels, thereby protecting the DNA from photodamage and avoiding disintegration of the genetic information. In contrast to this ultrafast deactivation of single nucleobases, the biological relevant DNA strands show further long-living states (4, 5). Several explanations for these long-living states and the size of their spatial extent have been discussed in the literature (5–9). Delocalized excitons (9); excitons that decay to charge-separated states or neutral excimer states (10, 11); exciplexes located on two neighboring bases (5, 8, 12, 13); or even excited single bases, where steric interactions in the DNA strand impedes the ultrafast decay (14), have been proposed. Further computations suggest a decay of an initially populated delocalized exciton to localized neutral or charged excimer states (15–17). However, to our knowledge, a final understanding of the nature of these long-living states has not been reached. Related experiments were performed in the last decade to investigate charge transport processes in DNA, motivated by DNA electronics and oxidative damage (18, 19). Charge transport was initiated by photoexcitation of modified DNA bases or chromophores and followed by transient absorption (20–23). The transport mechanism was described by charge-hopping, superexchange, or transfer of charge along delocalized domains in DNA (18).Until now, most experimental investigations of the long-living state were performed with transient absorption spectroscopy in the UV-visible (UV/Vis) regime (5, 9, 12) or with time-resolved fluorescence (10, 24, 25). Due to the broad, featureless, and overlapping absorption bands of the different DNA bases in this spectral region, it is difficult to investigate the molecular origin of the long-living states using these methods. A further drawback is the unselective and simultaneous excitation of several bases used in most experiments. To circumvent these problems, we used for the present study well-defined oligonucleotides, which enable selective excitation of one single base. Observation of the long-living excited states was performed via time-resolved IR spectroscopy, which can profit from the many “fingerprint” vibrational bands (26, 27). IR spectroscopy is able to distinguish between different DNA bases and their molecular states. It can also reveal changes in the electronic structure and identify charge-separated states.In this study we used single-stranded DNA, in which π stacking between neighboring bases leads to structured domains, similar to the structure in a double helix (28). This interaction is known to be crucial for the long-living states (5). The investigation of single-stranded DNA enables us to construct special sequences, where only one base can be selectively excited. We used the natural bases 2′-deoxyuridine (U), 2′-deoxyadenosine (A), 5-methyl-2′-deoxycytidine (mC), and 2′-deoxyguanosine (G). The nucleobase U occurs naturally in RNA and is similar to the DNA base thymine but shows a blue-shifted absorbance spectrum. mC occurs with a frequency of 4–5% in mammalian DNA (29) and plays an important role as an epigenetic marker (30). The UV/Vis absorbance of mC and G are red-shifted in comparison with A and U, which allows selective excitation at 295 nm in oligonucleotides consisting of mC, A, and U (Fig. 1 A and B) or G and A. This selectivity can only be obtained in single-stranded DNA because G and its complementary base mC have overlapping absorbance bands in the UV range (Fig. S1). Selectivity in probing is based on the significant differences in the IR-absorption spectra of these bases, which display distinct marker bands for each base (Fig. 1 A and E).Open in a separate windowFig. 1.Selective excitation of mC in mCUA and probing of characteristic A, U, and mC marker bands in the IR. (A, B, and E) Picosecond UV light pulses at 295 nm allow selective excitation of mC (shown in bold) in mixed DNA sequences consisting of mC, U, and A. (B) Absorbance spectra of 2′-deoxyadenosine monophosphate (A), 2′-deoxy-5-methylcytidine (mC), and uridine monophosphate (U). (C) Time-resolved absorption difference (color-coded) plotted vs. wavenumber and delay time for mCUA and (D) for a mixture of the corresponding monomers. (E) Probing the individual contribution of each base is possible in the IR at 1,625 cm⁻¹ (A), 1,655 cm⁻¹ (U), and 1,667 cm⁻¹ (mC) (marked by dashed lines). (F) Transients at 1,667 cm⁻¹ for mCUA and the mixture of monomers.With the combination of selective excitation and selective probing we are able to elucidate the nature of the long-living states in DNA strands. Investigation of dinucleotides clearly shows that light absorption in DNA leads to charge separation between stacked neighboring bases, which recombine on the 100-ps time scale. In longer oligonucleotides we observe simultaneous bleach of several bases, which points to a delocalization of the charges along the strand. Our results show that charge transfer in DNA is a natural process, induced by UV-light absorption of DNA.