Prevalence of unrepaired third- and fourth-degree tears among women taken to the operating room for repair of presumed obstetric fistula during two fistula camps in Kenya

Introduction and hypothesis

More than 2 million women on earth today are said to be suffering from obstetric fistula (OF), a communication between the vagina and either the urinary tract or rectum. Since unrepaired third- and fourth-degree perineal tears often manifest with symptoms identical to OF, we hypothesized that the global burden of OF is in part due to these unrepaired deep obstetric tears.

Methods

Four consultant gynecologists retrospectively reviewed the medical and operative records of all obstetric fistula cases that underwent surgical repair during the July and August, 2014, Kenyatta National Hospital and Embu Provincial Hospital Fistula Camps in Kenya.

Results

One hundred and eighty charts were reviewed. All 180 women had fecal incontinence (FI), urinary incontinence (UI), or both as their primary complaint. Sixty of the 180 (33 %) women had isolated FI as their presenting symptom, and at operation, 57 of these 60 (95 %) were found to have unrepaired third- and fourth-degree obstetric tears. Ninety-two of the 180 (51 %) women with OF symptoms ultimately had true OF confirmed at operation.

Conclusion

These findings suggest that many women with OF symptoms in Kenya may harbor unrepaired third- and fourth-degree tears. Additionally, women with isolated FI may be more likely to suffer from third- and fourth-degree tears than from true OF. Immediate postpartum diagnosis and repair of third- and fourth-degree perineal tears could significantly reduce the overall burden of women with symptoms of OF.

     

Reaping benefits from intellectual capital

The wealth and value of organizations are increasingly based on intellectual capital. Although acquiring talented individuals and investing in employee learning adds value to the organization, reaping the benefits of intellectual capital involves translating the wisdom of employees into reusable and sustained actions. This requires a culture that creates employee commitment, encourages learning, fosters sharing, and involves employees in decision making. An infrastructure to recognize and embed promising and best practices through social networks, evidence-based practice, customization of innovations, and use of information technology results in increased productivity, stronger financial performance, better patient outcomes, and greater employee and customer satisfaction.     

Facial nerve injury during temporal artery biopsy

Temporal artery biopsy is considered the gold standard investigation of giant cell arteritis and is recommended in suspected cases despite a sensitivity of 81–91%. This review highlights the potential risk of facial nerve injury during temporal artery biopsy and introduces recent advances in the emerging role of imaging modalities. When these non-invasive techniques are used in conjunction with American College of Rheumatology scoring, which includes clinical features and biochemical test results, temporal artery biopsy may be avoided in selected cases.     

Role of preoperative carbohydrate loading: a systematic review

INTRODUCTION

Surgical stress in the presence of fasting worsens the catabolic state, causes insulin resistance and may delay recovery. Carbohydrate rich drinks given preoperatively may ameliorate these deleterious effects. A systematic review was undertaken to analyse the effect of preoperative carbohydrate loading on insulin resistance, gastric emptying, gastric acidity, patient wellbeing, immunity and nutrition following surgery.

METHODS

All studies identified through PubMed until September 2011 were included. References were cross-checked to ensure capture of cited pertinent articles.

RESULTS

Overall, 17 randomised controlled trials with a total of 1,445 patients who met the inclusion criteria were identified. Preoperative carbohydrate drinks significantly improved insulin resistance and indices of patient comfort following surgery, especially hunger, thirst, malaise, anxiety and nausea. No definite conclusions could be made regarding preservation of muscle mass. Following ingestion of carbohydrate drinks, no adverse events such as apparent or proven aspiration during or after surgery were reported.

CONCLUSIONS

Administration of oral carbohydrate drinks before surgery is probably safe and may have a positive influence on a wide range of perioperative markers of clinical outcome. Further studies are required to determine its cost effectiveness.     

Serology and ultrasound for diagnosis of choledocholithiasis

Introduction

Magnetic resonance cholangiopancreatography (MRCP) is not a routine investigation to exclude choledocholithiasis unless there is clinical or biochemical suspicion of common bile duct (CBD) stones. This study attempted to determine which radiological or serological parameters best predicted CBD stones.

Methods

All patients undergoing MRCP from 2005 to 2011 were selected. Patients with pancreatitis were excluded. Liver function tests (LFTs) at admission and prior to MRCP were recorded, as was abdominal ultrasonography and MRCP results. Parameters measured routinely on LFTs included alkaline phosphatase (ALP), alanine transaminase (ALT) and bilirubin. Receiver operating characteristic curve area analysis (area under the curve [AUC]) and chi-squared analysis were undertaken.

Results

Overall, 195 patients were identified, 71 of whom had CBD stones on MRCP. Raised ALP levels on admission demonstrated a correlation with CBD stones (AUC: 0.619, odds ratio [OR]: 3.16, p=0.06). At ultrasonography, a dilated CBD (OR: 3.76, p<0.001) and intrahepatic duct dilation (OR: 5.56, p<0.001) were highly significant predictors. However, only 37% of patients had a dilated CBD on ultrasonography. Ongoing elevation of LFT parameters, particularly ALP (AUC: 0.707, OR: 4.64, p<0.001) and ALT (AUC: 0.646, OR: 5.40, p<0.001), displayed a significant correlation with CBD stones.

Conclusions

Ongoing (even if minor) elevations of liver function test parameters should prompt the need to exclude CBD stones even in the presence of a normal CBD diameter on ultrasonography.     

Factors associated with receipt of residential rehabilitation by opiate users indicate that these clients are more amenable to drug treatment

Aims: Residential rehabilitation (RR) is relatively expensive and is received by a minority of drug users seeking treatment. It is perceived to be particularly effective, but those entering RR may be more amenable to treatment than those treated in other modalities. The objective of this study was to explore ways in which opiate users treated in a residential setting differ, at treatment entry, from those treated in a community setting. Methods: Opiate users (N?=?406) who received either RR or community substitute prescribing (CSP) were sampled from the UK Drug Treatment Outcomes Research Study (DTORS). A logistic regression analysis, controlling for Drug Action Team, was used to predict the occurrence of RR versus CSP for the treatment of opiate dependence. Measures included self-reported levels of drug use, offending, social measures and health. Findings: RR clients were different to CSP clients in a number of respects that may positively influence treatment outcome; most importantly, their reasons for seeking treatment were different and they were better motivated. Conclusions: Higher treatment motivation may be one factor that explains why RR is a more effective treatment for clients with complex drug-related problems.     

College student motivational determinants for combining alcohol and energy drinks: Early identification could be the key

Aims: Strategic energy drink marketing continues to target college students despite this group already being identified as high-risk for experiencing negative consequences. To better understand and predict drinking behaviors and to develop more effective prevention programs, this study examined students alcohol-only and combined-use positive drinking motives within subjects.

Methods: A convenience sample of college students (n?=?540) from a university in the Southwest United States voluntarily completed an online version of the Drinking Motives Questionnaire-Revised (α?=?0.96) to explore motives for consuming alcohol only and alcohol combined with energy drinks.

Findings: Results indicate college students who combine alcohol and energy drinks have more positive drinking motives than those who consume alcohol-only.

Conclusions: Positive drinking motivational determinants can be used to improve existing prevention programs and to help practitioners work more effectively with students to address alternative ways to achieve the desired social and cognitive effects of drinking.     

Thrombin causes subsecond changes in protein phosphorylation of platelets

We have developed a general quenched-flow approach to study platelet function as early as 0.3 seconds after stimulation. Phosphorylation of 20- and 40-kd proteins has been analyzed during the first five seconds of platelet response to thrombin from 0.1 to 5.0 U/mL and compared with the progress of aggregation and serotonin secretion. The onset time for aggregation and phosphorylation of both proteins was less than one second, although with lowest (less than 0.5 U/mL) thrombin levels, a lag of up to 0.6 seconds occurred before 40K phosphorylation increased. The thrombin sensitivity of aggregation and 20K phosphorylation was approximately twice that of 40K phosphorylation, with Ka values of 0.51 and 0.53 v 1.10 U/mL, respectively. External calcium was necessary for maximal 20K phosphorylation, since EDTA inhibited this by 30%. The 40K phosphorylation was not affected by EDTA. Platelet activation by thrombin thus induced biochemical changes well before one second. The quenched-flow approach may help to reveal relationships between phospholipase activation, calcium fluxes, and protein phosphorylation during these early periods of platelet function.     

Terminal ileal mucosal mast cells in irritable bowel syndrome

Terminal ileal biopsies were prospectively obtained and stained specifically for mast cells in 20 patients with irritable bowel syndrome (IBS) and 15 controls. The number of terminal ileal mast cells per high powered field (MC/HPF) (mean ±SEM) was 23.3±3.1 for, IBS and 6.8±1.1 for controls (P=0.0001). The diarrhea IBS subgroup had the greatest number of MC/HPF. No correlation was found between terminal ileal mucosal mast cell counts (MMCC) and the number of Manning criteria present or the functional bowel disease score (r=0.06 andr=?0.31, respectively). We conclude that terminal ileal MMCC are significantly elevated in a majority of patients with IBS. The mast cell may be responsible for the altered visceral perception found in the gastrointestinal tract in patients with IBS. The poor correlation of the MMCC to the clinical features of IBS may be the result of the dynamic state of the mast cell.