Bladder neck mobility in continent nulliparous women

Objective To evaluate the mobility of the vesical neck during coughing and valsalva in healthy nulliparous volunteers and to test the reliability of the technique applied.
Design Clinical observational study.
Setting Department of Obstetrics and Gynaecology, Cantonal Hospital Lucerne, Switzerland.
Population Thirty-nine nulliparous volunteers.
Methods Vesical neck motion was assessed with perineal ultrasound. Intra–abdominal pressure was controlled for with an intrarectal probe. Intra-rater reliability was evaluated.
Results Vesical neck mobility was significantly lower during coughing (8 mm, SD 4 mm) than during valsalva (15 mm, SD 10 mm) (   P < 0.005  ). Between individuals mobility varied from 4 mm to 32 mm during coughing and from 2 mm to 31 mm during valsalva. Test-retest-studies showed a maximum difference between to tests during coughing of 4 mm and during valsalva of 5 mm.
Conclusion The bladder neck is mobile in normal continent women and bladder neck mobility is lower during coughing than during Valsalva.     

The prognostic impact of a prolonged second stage of labor on maternal and fetal outcome

OBJECTIVE: While obstetrical management has changed significantly over years, the optimal duration of the second stage of labor still remains to be defined. The purpose of this study was to evaluate the effect of the duration of labor on fetal distress and maternal perinatal morbidity. METHODS: There were 1457 consecutive patients delivered of a singleton fetus in cephalic presentation beyond the 34th week of gestation at the I. Frauenklinik, Ludwig-Maximilians University, Munich between May 1999 and June 2000. The 257 patients (17.6%), who underwent cesarean section prior to or during labor, were excluded from the study. Of the 1200 vaginal deliveries, 1017 (84.8%) were normal spontaneous deliveries, while 183 (15.2%) were instrumentally assisted. Data were contemporaneously collected and analyzed for the presence of severe pelvic floor damage, maternal hemorrhage, maternal fever, delayed involution of the uterus, fetal acidosis and APGAR score, and the necessity for admitting the newborn to the intensive care unit (NICU). A second stage duration of > 2 hr was considered to be prolonged. RESULTS: The mean duration of the second stage of labor was 70 min (range 2-387, SD 73 min). For 952 patients (79.3%), the second stage was less than 2 h. For 47 patients (3.9%), it exceeded 4 h. A prolonged duration of the second stage was not associated with low Apgar scores 5 and 10 min postpartum (P = 0.76 and P = 0.38, respectively), a higher incidence of umbilical artery pH levels of < 7.20 (P = 0.60), nor with an increased rate of admission to the NICU (P = 0.24). A significant increase in the rate of maternal blood loss was noted after long second stages (1.84 g/dl median difference between the intrapartum and postpartum hemoglobin level) in comparison to patients with normal duration of second stage (0.79 g/dl), both by univariate (P < 0.0001) and multivariate (P < 0.001) analysis. The incidence of third degree anal sphincter tears was significantly correlated with a prolonged duration of second stage in univariate analysis (7.7%, P = 0.001), but not in multivariate analysis after allowing for duration of the second stage, maternal age, birth weight, episiotomy, and mode of delivery (P = 0.26). CONCLUSION: There is no evidence that prolonged second stage of labor is a serious disadvantage to the fetus, if adequate monitoring is provided. Because the increase of maternal morbidity in patients with prolonged labor may be partially attributed to a higher rate of operative procedures in these patients, interventions should not be solely based on the elapsed time after full cervical dilatation.     

Functional development of the visual system in normal and protein-deprived rats. VII. Lamination of oxidative enzyme activity in the visual cortex during post-natal development

Lamination of activity of two mitochondrial enzymes - succinate dehydrogenase (SDH) and menadione-dependent a-glycerophosphate dehydrogenase (M-GPDH) - was examined in the visual cortex of control (C) and protein-deprived (PD) rats from 10 days old to adult. In C rats, lamination of enzyme activity was evident from 10 days by a band of higher activity in lamina IV. A band of higher SDH activity was seen in superficial lamina VI from 15 days. Lamination of M-GPDH activity became less pronounced with increasing age, whereas distinct bands of high SDH activity in lamina IV and VI remained also in adult rats. PD rats showed a developmental delay of approximately 5 days with regard to the general increase in neuropile activity. A band of higher enzyme activity in lamina IV was present from 10 days, but it was markedly less distinct in the PD rats compared to the C rats between 15 and 25 days. A band of higher SDH activity in superficial lamina VI was not seen until 25 days in PD rats. No apparent differences were seen between adult C and PD rats. The observed developmental alterations are discussed in relation to other delays, distortions and deficits found in the visual system of PD rats.     

Allogeneic bone marrow transplantation in children: single institution experience from 1974 to 1992

At the Children's Hospital, University of Helsinki, Finland, bone marrow transplantations have been performed since 1974. Between 1974 and 1992, 62 children received allogeneic bone marrow grafts. Median patient age was 9.3 years. Thirty-two patients had ALL, 13 AML and 11 had severe aplastic anemia (SAA). Graft failure occurred in 4 of the 62 patients. The overall long-term survival rate was 47%. Relapse of leukemia was the most common cause of death, especially in patients with ALL transplanted in second or later remission. Deaths during the first 2 months after transplant have decreased with time. In a small country such as Finland, it is important to centralize the experience of allogeneic BMTs, particularly for pediatric patients.     

Evaluation of anti-activated protein C antibody development in patients with severe sepsis from four clinical studies with drotrecogin alfa (activated)

Summary.  Background : Drotrecogin alfa (activated) (DAA) is a recombinant human activated protein C (APC), which is an antithrombotic protein. Objectives : To evaluate the development of anti-APC antibodies in severe sepsis patients in DAA clinical studies. Patients and methods : Serum and plasma samples were collected in placebo-controlled studies (PROWESS, ADDRESS) and studies where all patients were DAA-treated (ENHANCE, XPRESS). An enzyme-linked immunosorbent assay detecting anti-APC IgA/IgG/IgM antibodies was used. IgG isolated from plasma of positive samples was tested for neutralizing activity against DAA-induced prolongation of activated partial thromboplastin time. Results : The proportions of patients with negative baseline but positive postbaseline anti-APC antibodies were 1.5% (27/1855) and 1.6% (24/1493) in the DAA and placebo cohorts, respectively ( P  = 0.72 for the difference). Of the 27 DAA and 24 placebo patients with positive anti-APC antibodies, all but one (DAA) were alive at day 28, and all but seven (four DAA and three placebo) were alive at hospital discharge, including eight (five DAA and three placebo) patients who tested positive for anti-APC neutralizing antibodies. Two of the 51 patients who tested positive for the development of anti-APC antibodies experienced a thrombotic event (one DAA, one placebo). In ADDRESS, no anti-APC antibody was detected in the six DAA-treated patients who had received a previous course of DAA therapy. Conclusions : The proportion of patients with anti-APC antibodies was low and was similar between DAA-treated and placebo-treated patients. No relationship between anti-APC antibody development and adverse reactions was observed. There was no evidence that the anti-APC antibodies detected represented a specific immune response to DAA therapy.     

Urogynecological training, testing and treatment among gynecologists in Germany

OBJECTIVE: A survey was conducted to evaluate the urogynecology training of German gynecologists and the diagnostic tests and therapeutic options offered to women with incontinence or prolapse in hospital departments and private practices. STUDY DESIGN: Questionnaires were mailed to 3000 gynecologists in private practice and to 500 consultants in gynecology departments. The questionnaire included items on urogynecological training, diagnostic workup as well as conservative and surgical treatment options. RESULTS: The response rate was 16.8% with 589 of the 3500 questionnaires being returned. Less than one third of the respondents (28.6%) regard their training in urogynecology as good, 41% rate their training as moderate and 30.4% state that their urogynecology training during residency was inadequate. Male physicians significantly more often consider themselves well trained than women (p=.00006). The majority of gynecologists in private practice (74.7%) refer patients to a gynecological clinic for assessment of urogynecologic symptoms, 37.7% refer their patients to urologists in private practice, 10.4% to other gynecologists in private practice, and 10.4% to a urological clinic (percentages add up to more than 100% because multiple answers were allowed). Among the gynecologists who offer surgery, 81.2% perform retropubic TVT-operation and 80.1% colposuspension. Seventy-seven percentage of the gynecologists in private practice who do operations on an inpatient basis still perform anterior colporrhaphy to treat stress urinary incontinence compared to 62% of consultants in gynecological clinics (p<.05). CONCLUSION: One third of German gynecologists consider themselves inadequately trained in urogynecology. The results of our survey show that there is a need for improved general training during residency and for subspecialist training.     

IMRT using simultaneously integrated boost (SIB) in head and neck cancer patients

Background

Preliminary very encouraging clinical results of intensity modulated radiation therapy (IMRT) in Head Neck Cancer (HNC) are available from several large centers. Tumor control rates seem to be kept at least at the level of conventional three-dimensional radiation therapy; the benefit of normal tissue preservation with IMRT is proven for salivary function. There is still only limited experience with IMRT using simultaneously integrated boost (SIB-IMRT) in the head and neck region in terms of normal tissue response. The aim of this work was (1) to establish tumor response in HNC patients treated with SIB-IMRT, and (2) to assess tissue tolerance following different SIB-IMRT schedules.

Results

Between 1/2002 and 12/2004, 115 HNC patients have been curatively treated with IMRT. 70% received definitive IMRT (dIMRT), 30% were postoperatively irradiated. In 78% concomitant chemotherapy was given. SIB radiation schedules with 5–6 × 2 Gy/week to 60–70 Gy, 5 × 2.2 Gy/week to 66–68.2 Gy (according to the RTOG protocol H-0022), or 5 × 2.11 Gy/week to 69.6 Gy were used. After mean 18 months (10–44), 77% of patients were alive with no disease. Actuarial 2-year local, nodal, and distant disease free survival was 77%, 87%, and 78%, respectively. 10% were alive with disease, 10% died of disease. 20/21 locoregional failures occurred inside the high dose area. Mean tumor volume was significantly larger in locally failed (63 cc) vs controlled tumors (32 cc, p <0.01), and in definitive (43 cc) vs postoperative IMRT (25 cc, p <0.05); the locoregional failure rate was twofold higher in definitively irradiated patients. Acute reactions were mild to moderate and limited to the boost area, the persisting grade 3/4 late toxicity rate was low with 6%. The two grade 4 reactions (dysphagia, laryngeal fibrosis) were observed following the SIB schedule with 2.2 Gy per session.

Conclusion

SIB-IMRT in HNC using 2.0, 2.11 or 2.2 Gy per session is highly effective and safe with respect to tumor response and tolerance. SIB with 2.2 Gy is not recommended for large tumors involving laryngeal structures.     

Sexualit?t nach Beckenbodenchirurgie

Female sexual function can be affected by pelvic disorders such as incontinence and prolapse or their treatment. Surgery can improve sexuality but also result in functional impairment, all the way to precluding intercourse. For that reason sexual function should be evaluated before surgery, and the patient thoroughly advised on possible results before any surgery for prolapse or incontinence. There is a need for larger studies assessing both classic and newer surgical methods in respect to effects on sexual activity.     

Retropubic vs. transobturator tension-free vaginal tape for female stress urinary incontinence: 3-month results of a randomized controlled trial

Background

We conducted a prospective randomized controlled noninferiority trial to compare objective and subjective outcomes of retropubic tension-free vaginal tape (TVT) with those of transobturator tape (TVT-O) as primary treatment for stress urinary incontinence (SUI) in women.

Study design

The study was conducted at 25 gynecology units in Austria and Germany; regional and academic hospitals participated. A total of 569 patients were randomly assigned to undergo TVT or TVT-O.

Results

A total of 480 patients (85 %) were examined at 3 months. A negative cough stress test with stable cystometry to 300 ml was seen in 87 % of patients after TVT and in 84 % after TVT-O; 64 % and 59 % of patients, respectively, reported no pad use, and 88 % of patients in both groups considered themselves much or very much better on the Patient Global Impression of Improvement (PGI-I) scale. Quality of life (QoL) as assessed with the SF-12 Health Survey, Kings’ Health Questionnaire, (KHQ), and EuroQol-5D (EQ-5D) was significantly improved in both arms, with no differences between arms. There were no significant differences in postoperative pain or complications.

Conclusions

Results of this trial demonstrate noninferiority between TVT and TVT-O with regard to postoperative continence and QoL and suggest little difference in perioperative problems (ClinicalTrials.gov NCT 00441454).