The pathophysiology of an enterocele and its management.

This paper describes 130 patients with enteroceles and their treatment. It includes analysis of all cases with enterocele over a 17-month period in a pelvic floor dysfunction database. Procedures performed included the Moschcowitz procedure with suspension of the vaginal vault to the sacrum in 13 patients (10%), colposacrosuspension (CSS) (mesh from the upper posterior half of the vagina to the sacrum with mobilisation and fixation of the rectum to the mesh) in 39 patients (30%), perineocolposacrosuspension (PCSS) (similar to CSS, but the mesh is inserted further down to the perineum) in 48 patients (37%) and perineopubo-colposacrosuspension (PPCSS) (as PCSS, but with a second mesh between the bladder and vagina extending to the sacrum) in 30 patients (23%). An additional modified Burch colposuspension was performed in 87 patients (67%). A failure was defined as a recurrent vaginal prolapse of Grade II or more, or urinary incontinence requiring surgical correction. The patients' mean age was 60.5 years, their mean parity 3.3 and 92.3% were white. Preoperatively, 33.8% of the patients complained of constipation, 33.1% of difficulty in defaecation and 77% had bladder symptoms, suggesting urinary stress incontinence or detrusor instability. In 74.6% of the patients part of the vagina protruded through the vaginal introitus. The mean period of follow-up was 7.4 months (range 1-26) with only 13 patients (10%) not followed. Only two patients (1.5%) developed Grade II vaginal prolapse (both cystoceles and both from the PCSS group). Urinary stress incontinence in need of further treatment developed in 13 patients (10%). The failure rate, therefore, was 11.5%. In six patients (4.6%) the mesh had to be removed due to mesh reaction. In all cases the mesh was unabsorbable. Vaginal suspension procedures with mobilisation of the rectum provided satisfactory results for severe enterocele over the short term.     

A smoking cessation intervention among tuberculosis patients in rural China

Objective: To assess the integration of a smoking cessation intervention into routine tuberculosis (TB) services.Method: Consecutive TB patients registered from 1 March to 31 August 2010 were enrolled in an intervention for self-reported smoking to promote tobacco cessation during treatment for TB. Information on the harmful health effects of tobacco smoke and smoking and TB were provided to TB patients who self-reported as current smokers. Smoking status was reassessed at every follow-up visit during anti-tuberculosis treatment with reinforced health messages and advice to quit.Results: Of 800 TB patients enrolled, 572 (71.5%) were male and 244 (30.5%) were current smokers. Females were more likely to be non-smokers (100% vs. 35.8%, P < 0.001). Of the 244 current smokers, 144 (59.0%) started smoking at <20 years, 197 (80.7%) consumed ⩾20 cigarettes per day, 211 (86.5%) had perceived smoking dependence and 199 (81.6%) had made no attempt to quit before the diagnosis of TB. Of the 244 current smokers, 234 (95.9%) were willing to quit, and 156 (66.7%) reported abstinence at month 6. Challenges to implementing smoking cessation intervention were identified.Conclusion: The majority of current smokers among TB patients were willing to quit and remained abstinent at the end of anti-tuberculosis treatment. This intervention should be scaled up nationwide.     

Aggressive or expectant management for patients with severe preeclampsia between 28-34 weeks' gestation: a randomized controlled trial

Fifty-eight women with severe preeclampsia between 28-34 weeks' gestation qualified for a randomized controlled trial to establish whether elective delivery 48 hours after administration of betamethasone (aggressive-management group) or delivery later as indicated by maternal or fetal condition (expectant-management group) was more beneficial to maternal and fetal outcome. Twenty women who qualified were not randomized because they developed maternal or fetal indications necessitating delivery within 48 hours; these newborns developed most of the complications. Expectant management was not associated with an increase in maternal complications, but it significantly prolonged the gestational age (mean 7.1 days; P less than .05), reduced the number of neonates requiring ventilation (P less than .05), and reduced the number of neonatal complications (P less than .05).     

Professional freedom and Act 101 of 1965

Act 101 of 1965 replaced Act 13 of 1928 because the latter had become obsolete. Act 101 makes many new demands on and restricts certain privileges of the medical profession. New ideas, particularly if they restrict previous privileges, are resented. Also, new ideas do not necessarily denote progress. I am of the opinion that these curtailments are detrimental to public benefit. However, to provide positive suggestions to ease the situation is extremely difficult. All those concerned with public welfare should once again review public requirements. Ultimately, Act 101 prescribes for the whole population--is it then unreasonable to curtail medical professional freedom? Under the present circumstances this does not seem to be the case. However, sections of the Act may hamper doctors in the performance of their duties.     

Role of Bruton's tyrosine kinase in myeloma cell migration and induction of bone disease

Myeloma cells typically grow in bone, recruit osteoclast precursors and induce their differentiation and activity in areas adjacent to tumor foci. Bruton's tyrosine kinase (BTK), of the TEC family, is expressed in hematopoietic cells and is particularly involved in B‐lymphocyte function and osteoclastogenesis. We demonstrated BTK expression in clinical myeloma plasma cells, interleukin (IL)?6– or stroma–dependent cell lines and osteoclasts. SDF‐1 induced BTK activation in myeloma cells and BTK inhibition by small hairpin RNA or the small molecule inhibitor, LFM‐A13, reduced their migration toward stromal cell‐derived factor‐1 (SDF‐1). Pretreatment with LFM‐A13 also reduced in vivo homing of myeloma cells to bone using bioluminescence imaging in the SCID‐rab model. Enforced expression of BTK in myeloma cell line enhanced cell migration toward SDF‐1 but had no effect on short‐term growth. BTK expression was correlated with cell‐surface CXCR4 expression in myeloma cells (n = 33, r = 0.81, P < 0.0001), and BTK gene and protein expression was more profound in cell‐surface CXCR4‐expressing myeloma cells. BTK was not upregulated by IL‐6 while its inhibition had no effect on IL‐6 signaling in myeloma cells. Human osteoclast precursors also expressed BTK and cell‐surface CXCR4 and migrated toward SDF‐1. LFM‐A13 suppressed migration and differentiation of osteoclast precursors as well as bone‐resorbing activity of mature osteoclasts. In primary myeloma‐bearing SCID‐rab mice, LFM‐A13 inhibited osteoclast activity, prevented myeloma‐induced bone resorption and moderately suppressed myeloma growth. These data demonstrate BTK and cell‐surface CXCR4 association in myeloma cells and that BTK plays a role in myeloma cell homing to bone and myeloma‐induced bone disease. Am. J. Hematol. 88:463–471, 2013. © 2013 Wiley Periodicals, Inc.