Sacral neuromodulation for refractory detrusor overactivity in women with an artificial urinary sphincter

PURPOSE: We assessed the efficacy of sacral neuromodulation as an alternative therapeutic option in women with an artificial urinary sphincter (AUS) who had de novo irritative urinary symptoms (urgency/frequency) refractory to conventional treatment. MATERIALS AND METHODS: Between 1984 and 2002 we implanted an AUS in 350 women and detrusor overactivity developed in 14. Six of the 14 patients responding positively to a percutaneous nerve evaluation test (greater than 50% subjective/objective improvement) were implanted with an S3 neuromodulator within 42.8 weeks (range 21 to 106) of AUS implantation. Followup included analysis of the voiding diary, a pad test and urodynamic assessment. RESULTS: After 30.5 months followup (range 14 to 40) 1 patient was dry, 4 were improved and treatment failed in 1. At 12 months mean voiding frequency daily had decreased from 17 (range 12 to 23) to 8 (range 4 to 12) and the mean number of leakages episodes daily had decreased from 14.7 (range 8.5 to 17) to 6 (range 4 to 10). Mean voided volume had increased from 121.7 (range 90 to 170) to 180 ml (range 120 to 225), mean first desire to void volume had increased from 117 (range 88 to 190) to 183 ml (range 130 to 275) and mean functional bladder capacity had increased from 325 (range 200 to 530) to 372 ml (range 250 to 580). Uninhibited bladder contractions had resolved in 4 of 5 patients. CONCLUSIONS: In women who already have an AUS with urge incontinence sacral neuromodulation can help resolve symptoms. Because this therapy does not compromise the potential for future treatment, it appears to be an alternative option in these patients. It can postpone or avoid more mutilating surgery and self-catheterization.     

Are there race/ethnicity differences in outpatient congestive heart failure management, hospital use, and mortality among an insured population?

OBJECTIVE: The objective of this study was to assess the quality of outpatient care received by patients with congestive heart failure (CHF) and whether differences in care and outcomes exist by race/ethnicity. BACKGROUND: Appropriate outpatient CHF management can improve patient well-being and reduce the need for costly inpatient care. Yet, little is known regarding outpatient CHF management or whether differences in this care exist by race/ethnicity. METHODS: Using automated data sources, we identified a cohort of insured patients seen in an outpatient setting for CHF between September 1992 and August 1993. Medical record abstraction was used to confirm diagnosis of CHF. Patients (N = 566) were followed until September 1998. Race/ethnicity differences in outpatient management and medical care utilization were assessed using generalized estimating equations. Differences in mortality and hospitalization for CHF, controlling for patient characteristics and outpatient management, were assessed using Cox and Andersen-Gill models, respectively. RESULTS: With the exception of beta blocker use and primary care visit frequency, few differences by race/ethnicity in patient characteristics and CHF management were found. However, older black patients had more hospital use both at baseline and during follow up. These differences persisted after adjusting for patient characteristics and clinical management. No race/ethnicity differences were found in mortality. CONCLUSIONS: In an insured population, older black patients with CHF have substantially more hospital use than older white patients. This increased use was not explained by differences in CHF outpatient management. Further research is needed to understand why race/ethnicity differences in hospital use are observed among older patients with CHF.     

Endocarditis caused by Tropheryma whippelii

Cardiac involvement in Whipple's discase is frequent. However, its clinical occurrence without gastrointestinal symptoms is rarely described. Whipple's endocarditis occurs ollen in patients wilh native valves, without underlying, disease. It affects frequently more than one valve h, the same patient. Its clhlical presentation is generally subacute or chronic. Fever and congestive heart failure are fickle. Histological findings on the valves suggest the diagnosis, that con be confirmed by PCR technique. Treatment must be prolonged. We report a case of Whipple's endocarditis revealed by arterial embolisms and fever appeured 3 weeks after the onset.     

Spontaneous abortions in couples declining multifetal pregnancy reduction

Multifetal pregnancy reduction (MFPR) has clearly improved the outcomes of multifetal gestations. Several recent reports have also suggested improved outcomes in nonreduced cases, but there have been methodologic concerns about the denominators, i.e. have all cases been included and is there a 'hidden mortality' of unknown lost cases. Here we assessed the outcome of patients telephoning to discuss MFPR, but who chose not to have the procedure. Over a 3-year period, 446 patients had MFPR by one operator. Nineteen patients chose not to have the procedure. There were 11 preterm births, 1 term delivery, and 5 spontaneous losses (7 of 17) prior to 24 weeks, a loss rate of 35%. Two patients delivering triplets had a loss of 1 fetus/neonate. These data suggest that the loss rates of nonreduced pregnancies may be higher than generally thought, making the improvements with MFPR even bigger than generally realized.     

Advancing the tracheal tube over a flexible fiberoptic bronchoscope by a sleeve mounted on the insertion cord

The advancement of an endotracheal tube (ETT) over a flexible fiberoptic bronchoscope (FOB) is often impeded at the glottis. This is attributed to the creation of a cleft by the difference in the outer diameter of the fiberscope and the internal diameter of the tube. We designed a conical-shaped polyvinyl chloride sleeve to fit the insertion cord. This report compares the ease of advancement of the tube over a sleeved versus a nonsleeved bronchoscope. General anesthesia was induced, and one anesthesiologist introduced the FOB (a 3.8-mm Olympus LF2). Patients were randomly assigned to undergo tracheal intubation with the regular bronchoscope (25 patients) or the sleeved bronchoscope (25 patients). The FOB was advanced to approximately 1 cm above the carina. A blinded operator advanced the tube over the bronchoscope. The ETT was successfully advanced over the nonsleeved bronchoscope into the trachea on the first attempt in 64% of the patients, whereas tracheal intubation succeeded from the first attempt in 96% of patients when the sleeved FOB was used (P < 0.05). Advancement of the ETT over the fiberscope can be facilitated by using a conically shaped sleeve mounted on the insertion cord. IMPLICATIONS: This report shows that a conical sleeve mounted on the insertion cord of a fiberoptic bronchoscope will facilitate advancing the endotracheal tube into the trachea.     

Improvement in outcomes of multifetal pregnancy reduction with increased experience

OBJECTIVE: This study was undertaken to evaluate a decade of data on multifetal pregnancy reductions at centers with extensive experiences. STUDY DESIGN: A total of 3513 completed cases from 11 centers in 5 countries were analyzed according to year (before 1990, 1991-1994, and 1995-1998), starting and finishing numbers of embryos or fetuses, and outcomes. RESULTS: With increasing experience there has been a considerable improvement in outcomes, with decreases in rates of both pregnancy loss and prematurity. Overall loss rates in the last few years were correlated strongly with starting and finishing numbers (starting number > or =6, 15.4%; starting number 5, 11.4%; starting number 4, 7.3%; starting number 3, 4.5%; starting number 2, 6.2%: finishing number 3, 18.4%; finishing number 2, 6.0%; finishing number 1, 6.7%). Birth weight discordance between surviving twins was increased with greater starting number. The proportion of cases with starting number > or =5 diminished from 23.4% to 15.9% to 12.2%. The proportion of patients >40 years old increased in the last 6 years to 9.3%. Gestational age at delivery did not vary with increasing maternal age but was inversely correlated with starting number. CONCLUSION: Multifetal pregnancy reduction outcomes at our centers for both losses and early prematurity have improved considerably with experience. Reductions from triplets to twins and now from quadruplets to twins carry outcomes as good as those of unreduced twin gestations. Patient demographic characteristics continues to change as more older women use assisted reproductive technologies. In terms of losses, prematurity, and growth, higher starting numbers carry worse outcomes.