Laparoscopic hysteropexy: 1- to 4-year follow-up of women postoperatively

Introduction and hypothesis

Uterine conserving re-suspension surgery has become more popular in recent years. Such surgery may allow preservation of fertility in younger women, but may also have the added benefit of augmenting weak connective tissue and possibly providing stronger apical support than the conventional hysterectomy. Our goal was to evaluate the 1- to 4-year outcome of laparoscopic hysteropexy for the surgical management of uterine prolapse.

Methods

This study was a prospective observational study of 182 consecutive women who underwent laparoscopic hysteropexy, with or without additional vaginal repair, from the beginning of 2007 until the end of 2010. Women were invited to attend a dedicated clinic for interview and their prolapse was assessed using the Patient Global Impression of Improvement (PGI-I), the International Consultation on Incontinence Questionnaire for Vaginal Symptoms (ICIQ-VS) and the pelvic organ prolapse quantification (POP-Q) scale. Wilcoxon signed-rank test was used to compare pre-operative with postoperative data. Complications and women’s satisfaction were also noted.

Results

One hundred and forty women agreed to participate; the mean interval from operation was 2.1 years (range 1–4.4). Eighty-nine percent of women felt that their prolapse is “very much” or “much” better using PGI-I subjective outcome measure. There was significant improvement for all parameters of ICIQ-VS and POP-Q scoring post-surgery (p?<?0.001). Six women (4 %) had further apical prolapse; of these, 3 underwent further prolapse surgery. None of the participants had any mesh exposure. Ninety two percent of participants would recommend the operation.

Conclusions

Laparoscopic hysteropexy is a safe and effective treatment. The 1- to 4-year outcome suggests high patient satisfaction and low rates of apical prolapse recurrence. Longer term follow-up and randomized controlled studies are required.     

Too Fit To Fracture: exercise recommendations for individuals with osteoporosis or osteoporotic vertebral fracture

Summary

A consensus process was conducted to develop exercise recommendations for individuals with osteoporosis or vertebral fractures. A multicomponent exercise program that includes balance and resistance training is recommended.

Introduction

The aim was to develop consensus on exercise recommendations for older adults: (1) with osteoporosis and (2) with osteoporotic vertebral fracture(s).

Methods

The Grading of Recommendations Assessment, Development, and Evaluation method was used to evaluate the quality of evidence and develop recommendations. Outcomes important for decision making were nominated by an expert panel and patient advocates. They included falls, fractures, bone mineral density (BMD), and adverse events for individuals with osteoporosis/vertebral fractures, and pain, quality of life, and function for those with vertebral fracture. Meta-analyses evaluating the effects of exercise on the outcomes were reviewed. Observational studies or clinical trials were reviewed when meta-analyses were not available. Quality ratings were generated, and informed the recommendations.

Results

The outcome for which evidence is strongest is falls. Point estimates of the effects of exercise on falls, fractures, and BMD vary according to exercise type. There is not enough evidence to quantify the risks of exercise in those with osteoporosis or vertebral fracture. Few trials of exercise exist in those with vertebral fracture. The exercise recommendations for exercise in individuals with osteoporosis or osteoporotic vertebral fracture are conditional. The panel strongly recommends a multicomponent exercise program including resistance and balance training for individuals with osteoporosis or osteoporotic vertebral fracture. The panel recommends that older adults with osteoporosis or vertebral fracture do not engage in aerobic training to the exclusion of resistance or balance training.

Conclusions

The consensus of our international panel is that exercise is recommended for older adults with osteoporosis or vertebral fracture, but our recommendations are conditional.     

Longitudinal changes and seasonal variations in serum 25-hydroxyvitamin D levels in different age groups: results of the Longitudinal Aging Study Amsterdam

Summary

Vitamin D levels remained fairly stable during ageing with increasing levels in persons aged 55–65 years old and decreasing levels in persons aged 65–88 years old. The seasonal variation was larger than the longitudinal change. Our findings implicate that vitamin D supplementation becomes more important in older age groups and during wintertime.

Introduction

Longitudinal changes in serum 25-hydroxyvitamin D (25-OHD) levels during aging have not been studied extensively. Two studies showed increasing serum 25-OHD levels. One of these studies suggested that there might be decreasing levels in persons aged 65 years and older. The objectives of the current study are the following: (1) to examine longitudinal changes in serum 25-OHD levels in different age groups and (2) to describe the seasonal variation in different age groups.

Methods

Data of the Longitudinal Aging Study Amsterdam (LASA), an ongoing cohort study, were used. Two different cohorts were included: (1) younger cohort: aged 55–65 years old at baseline, n?=?738, follow-up of 6 years and (2) older cohort: aged 65–88 years old at baseline, n?=?1,320, follow-up of 13 years.

Results

At baseline, average levels were 56.5 nmol/L in the younger cohort and 51.1 nmol/L in the older cohort. In the younger cohort, a longitudinal increase in the mean serum 25-OHD levels of 4 nmol/L in 6 years was observed; in the older cohort, a longitudinal decrease in the mean serum 25-OHD levels of 4 nmol/L in 13 years was observed. The seasonal variation was ±12 nmol/L in the younger cohort and ±7 nmol/L in the older cohort.

Conclusions

Long-term serum 25-OHD levels remained fairly stable during aging with slightly increasing levels in persons aged 55–65 years old and slightly decreasing levels in persons aged 65–88 years old. On average, the seasonal variation was larger than the longitudinal change. Our findings implicate that vitamin D supplementation becomes more important in older age groups and during wintertime.     

Accuracy of sentinel node biopsy in esophageal carcinoma: a systematic review and meta-analysis of the pertinent literature

The use of sentinel node surgery for esophageal carcinoma is still under investigation. We evaluated the data available in the literature on this topic, and herein present the results in a systematic review format. PUBMED, SCOPUS, the ISI web of knowledge and the information from the annual meetings of the Japan Esophageal Society were searched using the search terms: “(esophagus OR esophageal) AND sentinel”. The outcomes of interest were the detection rate and sensitivity. Overall, 18 studies were included. The pooled detection rate was 89.2 % [82.6–93.5]. Patients with T1 and two tumors had a 17 % higher detection rate compared to those with T3 and four tumors. The pooled sensitivity was 84 % [78–88 %]. The sensitivity was higher for adenocarcinoma compared to squamous cell carcinoma (SCC) (91 vs. 81 %). In the SCC patients, there was a trend toward decreased sensitivity associated with an increasing tumor depth (T1:88 %, T2:76 %, T3:50 %). Our analysis indicated that sentinel node biopsy is useful in adenocarcinoma patients. For SCC patients, including only cN0 patients (preferably T1 and 2) would increase the detection rate and sensitivity. Due to the limited number of high-quality studies, drawing any more definite conclusions is impossible. Large cohort studies with a standardized and consistent design will be needed in the future.     

Proteolysis of the endothelial cell protein C receptor by neutrophil proteinase 3

BACKGROUND: The endothelial cell protein C receptor (EPCR) presents protein C to the thrombin:thrombomodulin complex on the endothelium of large vessels, and enhances the generation of activated protein C (APC) and activation of protease-activated receptor-1. A previous report has demonstrated binding of soluble (s) EPCR to activated neutrophils via surface proteinase 3 (PR3). METHODS: We now report further characterization of this interaction. Activated neutrophils and purified PR3 both decrease endothelial cell (EC) surface EPCR, suggestive of its proteolysis. RESULTS: When added to purified recombinant sEPCR, PR3 produced multiple cleavages, with early products including 20 kDa N-terminal and C-terminal (after Lys(176)) fragments. The binding of active site blocked PR3 to sEPCR was studied by surface plasmon resonance. Estimates of the K(D) of 18.5-102 nM were obtained with heterogeneous binding, suggestive of more than a single interaction site. CONCLUSIONS: This work demonstrates PR3 binding to and proteolysis of EPCR and suggests a mechanism by which anticoagulant and cell protective pathways can be down-regulated during inflammation.     

Induction of IgG antibodies against GD3 ganglioside in rabbits by an anti-idiotypic monoclonal antibody.

Anti-idiotypic MAb were raised in syngeneic mice against a mouse MAb recognizing GD3 ganglioside (MAb R24). Two anti-idiotypic MAb, designated BEC2 and BEC3, recognized distinct determinants on MAb R24 that mapped near or within the GD3-binding site. New Zealand white rabbits, which express GD3 on normal tissues, were immunized with either BEC2, BEC3, or control MAb FLOPC-21. All rabbits developed high and equivalent titers of antibodies against mouse immunoglobulins. Immunization with BEC2 and BEC3 induced rabbit antibodies expressing R24 idiotype as demonstrated by their ability to inhibit BEC2 binding to R24. Antibodies (IgG and IgM) reacting with GD3 developed in five of eight rabbits immunized with BEC2 but not in rabbits immunized with BEC3 or with control MAb. Serum antibodies against GD3 did not cross-react with other gangliosides. These results show that MAb BEC2 can mimic GD3 ganglioside and can induce antibodies against GD3 ganglioside despite expression of GD3 on normal rabbit tissue.     

Metabolic clearance and secretion rates of subunits of human thyrotropin.

Metabolic clearance rates (MCR) of the alpha and beta subunits of human thyrotropin (hTSH-alpha and hTSH-beta) were determined by a constant infusion to equilibrium method. In 15 normal individuals (six men, six premenopausal women, and three post-menopausal women), the mean MCR of hTSH-alpha (68 ml/min per m2) was significantly faster than that of hTSH-beta (48 ml/min per m2) was significantly faster than that of hTSH-beta (48 ml/min per m2); both were two to three times more rapid than the previously determined MCR of hTSH. In patients with primary hypothyroidism, MCR were significantly slower with a mean value of 55 ml/min per m2 for hTSH-alpha and 37 ml/min per m2 for hTSH-beta. However, MCR of subunits were not significantly faster than normal in hyperthyroid patients. Serum concentrations of alpha subunits and hTSH-beta were measured by radioimmunoassay, and secretion rates of alpha and hTSH-beta from the pituitary were calculated using hTSH-alpha and hTSH-beta MCR, respectively. In the normal individuals, alpha secretion rates averaged 91 mug/day per m2, greater than those previously determined for hTSH and human follicle-stimulating hormone. Alpha secretion rates were significantly elevated in the normal postmenopausal women (211 mug/day per m2) and in the premenopausal hypothyroid women (202 mug/day per m2); they were also elevated in the postmenopausal hypothyroid women (277 mug/day per m2). Alpha secretion rates were significantly decreased in the premenopausal hyperthyroid women (66 mug/day per m2). Usually, the secretion rates of hTSH-beta could not be calculated in normal individuals, and the rates in hyperthyroid patients could never be calculated because serum hTSH-beta was not detected. Six normals had detectable hTSH-beta secretion rates (17 mug/day per m2); hTSH-beta secretion rates were significantly increased in patients with primary hypothyroidism (28 mug/day per m2). Although we had previously demonstrated a 50-fold increase in hTSH secretion rates in primary hypothyroidism, there was only a 2-fold increase in alpha and hTSH-beta secretion rates. Thus, increased subunit synthesis appears to be utilized predominantly for production of complete hTSH.     

A new method for cerclage wire fixation to maximal pre-tension with minimal elongation to failure

Objective. To develop and test a new cerclage wire tightening technique, yielding reproducibly maximal pre-tension, load to failure and minimal elongation to failure of the wire junction.

Design. Laboratory bench study.

Background. Cerclage wire fixation is difficult to perform by hand with reproducible quality and tightening tension, which are required for optimal performance.

Methods. With the new technique, 1, 1.25 and 1.5 mm steel wires were passed through a 9 × 18 mm steel tube, grasped using a modified ASIF wire-tightener and tightened by twisting until spontaneous failure of the wires in the tube. These fixations were compared to wires pre-tightened by hand to controlled high or low pre-tension using the simple twist, the knot twist and twist secured against untwisting, loaded to failure on a testing machine. The tests assessed pre-tension, ultimate failure load and elongation to failure.

Results. Wire twists performed with the new technique were always perfectly symmetrical and may be tightened to maximal pre-tension without weakening of the wire. The twist secured against untwisting combined high stiffness with high failure load.

The knot twist elongates to an unacceptable degree, unlike the secured twist. The simple twist untwists under little tension.

Conclusions. The new technique allows to obtain maximal pre-tension and thus minimal elongation to failure of simple wire twists, without having to worry about breaking the wire at the base of the twist due to over-tightening.Relevance

Cerclage wire fixation is an effective and cheap method to perform osteosynthesis. For adequate performance, maximal pre-tension, symmetrical twisting and high load to failure are necessary. The here presented technique combines all of these pre-requisites in a simple fashion.     

Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests

Previous research indicates that physical examination cannot diagnose sacroiliac joint (SIJ) pathology. Earlier studies have not reported sensitivities and specificities of composites of provocation tests known to have acceptable inter-examiner reliability. This study examined the diagnostic power of pain provocation SIJ tests singly and in various combinations, in relation to an accepted criterion standard. In a blinded criterion-related validity design, 48 patients were examined by physiotherapists using pain provocation SIJ tests and received an injection of local anaesthetic into the SIJ. The tests were evaluated singly and in various combinations (composites) for diagnostic power. All patients with a positive response to diagnostic injection reported pain with at least one SIJ test. Sensitivity and specificity for three or more of six positive SIJ tests were 94% and 78%, respectively. Receiver operator characteristic curves and areas under the curve were constructed for various composites. The greatest area under the curve for any two of the best four tests was 0.842. In conclusion, composites of provocation SIJ tests are of value in clinical diagnosis of symptomatic SIJ. Three or more out of six tests or any two of four selected tests have the best predictive power in relation to results of intra-articular anaesthetic block injections. When all six provocation tests do not provoke familiar pain, the SIJ can be ruled out as a source of current LBP.