Repeat versus primary slings in patients with intrinsic sphincter deficiency

Introduction and hypothesis

Our goal was to compare outcomes of repeat vs. primary synthetic slings in patients with stress urinary incontinence (SUI) with intrinsic sphincter deficiency (ISD).

Materials and methods

We reviewed patients who underwent a sling for SUI with ISD from 2003 to 2010. The patients were divided into two groups according to whether they underwent primary or repeat sling. Surgical success was defined as no incontinence and no reintervention (i.e., urethral bulking) during follow-up. Statistical analysis included the unpaired t test, Wilcoxon rank sums test, chi-squared/Fisher’s exact tests, and logistic regression to identify risk factors associated with failure.

Results

Six hundred and thirty-seven patients with ISD underwent a sling procedure at our institution; 557 (87 %) a primary sling and 80 (13 %) a repeat sling. Patient demographics were similar. Preoperatively, patients with recurrent SUI reported more subjective bother. Mean follow-up was 66.5 weeks (24–374). Success was achieved in 81 % of primary compared with 55 % of repeat slings (p?<?0.0001). Repeat patients were 3.4 times more likely to fail surgery [odds ratio (OR)?=?3.43, 95 % confidence interval (CI) 2.1–5.6]. Additionally 30 % of the repeat group underwent urethral bulking postoperatively compared with 8.6 % in the primary group (OR?=?4.4, 95 % CI 2.5–7.7). Prior incontinence procedures, a positive supine stress test, and transobturator sling were independent risk factors for failure. Among the types of slings placed (transobturator, retropubic, tensioned pubovaginal), pubovaginal slings were most successful (OR?=?2.7, 95 % CI 1.4–5.2).

Conclusion

In women with ISD, repeat slings are associated with lower success rates compared with primary slings. Pubovaginal slings resulted in the highest success rate compared with both transobturator and retropubic slings.     

Overt use of a tactile/kinaesthetic strategy shifts to covert processing in rehabilitation of letter-by-letter reading

Background: Letter-by-letter readers identify each letter of the word they are reading serially in left to right order before recognising the word. When their letter naming is also impaired, letter-by-letter reading is inaccurate and can render even single word reading very poor. Tactile and/or kinaesthetic strategies have been reported to improve reading in these patients, but only under certain conditions or for a limited set of stimuli.

Aims: The primary aim of the current study was to determine whether a tactile/kinaesthetic treatment could significantly improve reading specifically under normal reading conditions, i.e., reading untrained words presented in free vision and read without overt use of the strategy.

Methods & Procedures: Three chronic letter-by-letter readers participated in a tactile/kinaesthetic treatment aimed at first improving letter-naming accuracy (phase 1) and then letter-by-letter reading speed (phase 2). In a multiple case series design, accuracy and speed of reading untrained words without overt use of the trained tactile/kinaesthetic strategy was assessed before phase 1, after phase 1, and again after phase 2.

Outcomes & Results: All three patients significantly improved both their speed and accuracy in reading untrained words without overt use of the trained tactile/kinaesthetic strategy. All three patients required the additional practice in phase 2 to achieve significant improvement. Treatment did not target sentence-level reading, yet two of the three patients became so adept that they could read entire sentences.

Conclusions: This study replicates previous findings on the efficacy of tactile/kinaesthetic treatment for letter-by-letter readers with poor letter naming. It further demonstrates that this treatment can alter cognitive processing such that words never specifically trained can be read in free vision without overtly using the trained strategy. The data suggest that an important element in achieving this level of generalisation is continuing training beyond the point of initial mastery (i.e., accurate letter naming).     

Yohimbine administration and cue-reactivity in cocaine-dependent individuals

Rationale

Preclinical studies suggest that stress potentiates cue-induced cocaine seeking and that this effect is more pronounced in females. These findings have not been characterized in clinical populations.

Objectives

The objectives of this study were to examine the impact a pharmacological stressor, alpha-2 adrenergic receptor antagonist yohimbine, on the subjective, endocrine, and physiologic responses to drug-paired cues cocaine-dependent men and women.

Methods

In a double-blind placebo-controlled cross-over study, cocaine-dependent men (n?=?32), cocaine-dependent women (n?=?30), control men (n?=?32), and control women (n?=?25) received either yohimbine or placebo prior to two cocaine cue exposure sessions.

Results

Yohimbine increased ratings of anxiety both before (p?p?=?0.035) cues, and the post-cue increase in anxiety was more pronounced in women (p?=?0.001). Yohimbine also significantly increased craving, compared with placebo (p?p?=?0.006). Yohimbine also increased salivary cortisol (p?p?=?0.003) levels, regardless of diagnostic group. Women had a significantly greater heart rate response following yohimbine as compared with men (p?Conclusions Stress may increase the salience of cocaine cues for cocaine-dependent women as compared with men. This suggests gender differences in vulnerability to craving and relapse under stressful conditions.     

Health care costs and costs associated with changes in work productivity among persons with systemic lupus erythematosus

Objective

To estimate health care costs and costs associated with changes in work productivity among persons with systemic lupus erythematosus (SLE) in the US.

Methods

Data were derived from the University of California, San Francisco Lupus Outcomes Study. Participants provided information on their health care resource use and employment. Cost estimates were derived for both direct health care costs and costs related to changes in work productivity. Direct health care costs included costs for hospitalizations, emergency department services, physician visits, outpatient surgical procedures, dialysis, and medications. Productivity costs were estimated by measuring changes in hours of work productivity since diagnosis of SLE; these estimates were also compared with normal US population data.

Results

For the total population of participants, the mean annual direct cost was $12,643 (2004 US dollars). The mean annual productivity cost for subjects of employment age (≥18 and <65 years) was $8,659. The mean annual total cost (direct and productivity) for subjects of employment age was $20,924. Regression results showed that greater disease activity, longer disease duration, and worse physical and mental health were significant predictors of higher direct costs; older age predicted lower direct costs. Older age, greater disease activity, and worse physical and mental health status were significant predictors of higher costs due to changes in work productivity.

Conclusion

Both direct health care costs and costs associated with changes in work productivity are substantial and both represent important contributors to the total costs associated with SLE.