The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction

This article presents a standard system of terminology recently approved by the International Continence Society, the American Urogynecologic Society, and the Society of Gynecologic Surgeons for the description of female pelvic organ prolapse and pelvic floor dysfunction. An objective site-specific system for describing, quantitating, and staging pelvic support in women is included. It has been developed to enhance both clinical and academic communication regarding individual patients and populations of patients. Clinicians and researchers caring for women with pelvic organ prolapse and pelvic floor dysfunction are encouraged to learn and use the system.

Pelvic floor damage

Birth attendants must keep up to date with the recommendations made in good clinical studies, and incorporate these into their practice. There is no justification for routine, liberal use of episiotomy, and when performed it must be a mediolateral incision, not midline. The indications for episiotomy are fetal distress, prolonged active second stage of labour and if severe perineal damage is thought to be imminent. Further study of the effect of overstretching tissues is required, to establish if episiotomy would protect against prolapse. Perineal trauma should be repaired by an experienced member of staff, with a polyglycolic acid suture, preferably using a continuous subcuticular technique. It is possible that women who are particularly at risk of pelvic floor damage, such as those who have already experienced postpartum anorectal incontinence, should be offered an elective caesarean section.

Treatment planning for carcinoma of the cervix: a patterns of care study report

PURPOSE

The Patterns of Care Study (PCS) of patients treated in 1988-89 included "patterns of treatment planning" for radiotherapy of carcinoma of the uterine cervix. A Consensus Committee of radiation physicists and oncologists established current guidelines and developed questionnaires to assess the treatment planning process (i.e., the general structure, methodology, and tools) of institutions involved in the Patterns of Care Study. This paper reports the findings of the assessment.

METHODS AND MATERIALS

The PCS surveyed 73 radiotherapy facilities, of which 21 are academic institutions (AC), 26 hospital-based facilities (HB), and 26 free-standing centers (FS). In total, 242 cases were assessed with 39% from academic centers, 33% from hospital-based centers, and 28% from free-standing centers. The survey collected treatment planning information such as the use of computed tomography (CT), simulation procedure, contouring of patient outline, tumor or target delineation, identification of critical structures, method of dose prescription (point or isodose), etc. Data was also obtained concerning implant boosts, e.g., radioisotope used, use of midline block for external beam treatment, availability of remote afterloader, practice of interstitial implants, combination with hyperthermia, etc.

RESULTS

There is a high degree of compliance relative to the basic treatment planning standards. For example, 171 cases (out of 173) from AC and HB institutions included simulation and 169 used port film; for cases from FS centers, 61 out of 69 involved simulation and 66 out of 69 included port film. Most institutions used linacs (231 out of 242); in five cases, Co-60 units and in six cases betatron was used. In terms of treatment planning, 53% used skin contours, but only 14% had target volume delineation, with AC and HB being slightly more conscientious in these efforts. Critical organs did not appear to be explicitly considered in external beam treatment planning, with only 3% outlining the bladder, 5% the rectum, and less than 1% the small bowel. Only 11% of the centers used CT in treatment planning, and none reported the use of magnetic resonance imaging (MRI). For patients receiving implants, about 40% had midline blocking during external beam treatment, of which one out of three were shielded by standard blocks and two out of three with customized ones. About 11% of the patients receiving implants were treated with remote afterloading devices, 5% received interstitial implants, and none were treated in combination with hyperthermia.

CONCLUSION

The treatment planning aspects of radiotherapy of carcinoma of the cervix have been established by this Patterns of Care Study Survey. There is a high level of uniformity in the approach. Some variations exist among centers in the different strata.

Nursing diagnoses for hospitalized patients with AIDS

This study examined the reliability of nursing diagnoses identified from the medical records of 100 patients hospitalized for HIV disease on a 22-bed designated unit at a large metropolitan teaching hospital in Los Angeles. The diagnoses were identified in two ways: (a) staff nurses identified 16 different nursing diagnoses using preprinted care plans found in the medical records, with 2 to 9 problems per patient (M = 4.8, SD = 1.6) and (b) the nurse researcher-identified 45 different nursing diagnoses derived from defining characteristics documented in the medical records, with 1 to 9 identified problems per patient (M = 3.3, SD = 1.8). The most frequent problems identified were the same as those addressed in the clinical literature: pain, respiratory problems, nutritional deficits, and psychosocial concerns. The results of this study raise concerns about the limitations of nursing diagnosis research using existent data bases and the use of preprinted care plans.

Laparoscopic and needle colposuspension

Laparoscopic colposuspension can produce a similar anatomical result to open colposuspension. The procedure does, however, require additional laparoscopic surgical skills which take time to learn. Whether it is worth investing this time will only be known when a longer-term follow-up is reported by surgeons who have considerable experience with the technique.

Patterns of care survey results: treatment planning for carcinoma of the prostate

PURPOSE

Treatment planning has been defined differently at various institutions to encompass tasks ranging from the initial evaluation of the patient to the delivery of the treatment as well as a more narrow view, focused primarily on isodose computation. To evaluate the impact of much of the new treatment-planning technology that has become available, it is necessary to define and develop recommended guidelines for the treatment-planning process.

METHODS AND MATERIALS

The 1989 Patterns of Care Study (PCS) included questionnaires to access treatment planning practices currently in use for the entire census of oncology facilities in the United States. These questionnaires were developed by a consensus committee consisting of both physicists and radiation oncologists whose charge was to formulate a description of current treatment-planning practices. The description was based on the committee's experience and knowledge of the treatment-planning process considered to be widely available and in general use, as well as a review of the literature. From the description of the treatment-planning process, a set of guidelines for treatment planning was developed for prostate as well as each of the other disease sites included in the PCS. Data from the study defined the general structure, methodology, process, and tools used by each institution involved in the Patterns of Care Survey Study. National averages for all of the variables were calculated with weighted averages, with the weights reflecting the sample design and number of patients in the different types of facilities. The data were stratified according to academic, hospital, or free-standing facility and were compared with the Consensus Guidelines for Treatment Planning of the Prostate.

DISCUSSION

Based on the consensus statement, the treatment-planning process was separated into the following categories: (a) Treatment-Planning Workup, (b) Treatment Plan Implementation, (c) Treatment Delivery, (d) Treatment Verification, and (e) Quality Assurance. The results from the survey were summarized for each category and compared with the consensus statement.

CONCLUSIONS

Although there is an increasing trend toward using computed tomography (CT) information to acquire individualized patient data, volume definition and localization are often completed in the simulator without the direct use of CT information (47%). As more sophisticated beam arrangements and blocking are used, one needs to look at the full three-dimensional (3D) volume to ensure that there are no marginal misses due to blocking and beam arrangement. Improved and more widespread use of immobilization devices is also required with conformal treatments and reduced margins. The results of the survey helped to identify and establish the standard of practice for treatment planning of the prostate as well as to provide documentation for better defining a complete description of the treatment planning process. Well-documented guidelines will provide more consistent treatment of patients, which should have an impact on outcome.

Laparoscopic surgery for incontinence and genitourinary prolapse

Surgery with the aid of a laparoscope has enabled the surgeon to visualize the pelvic viscera and supports with new clarity. This has also enabled procedures normally performed through a laparotomy incision to be performed without a large incision. Generally, this results in a reduction in postoperative pain and a reduced convalescence time. The first reports for bladder neck surgery are encouraging, but longer-term follow up is required before a full appraisal of these new techniques can be made.

Treatment planning for Hodgkin's disease: a patterns of care study

PURPOSE

To conduct a survey of the process of treatment planning for the radiation treatment of Hodgkin's Disease in the United States, and to compare survey results with consensus guidelines as determined by recognized experts.

METHODS AND MATERIALS

A consensus committee developed guidelines for the radiotherapeutic management of Hodgkin's Disease. A series of survey forms were designed to evaluate the standards of practice and compare these with the consensus guidelines. A total of 61 facilities divided evenly into the strata of academic, hospital based, and free standing had eligible Hodgkin's Disease cases. There were 275 eligible cases of Hodgkin's Disease evaluated. Data collected from the radiation oncology records included treatment-specific parameters such as energy, dose, blocking, and calculations, as well as treatment planning practices. Statistical analysis was performed on each data element and for all institution strata.

RESULTS

For a number of treatment parameters, there were some discrepancies note between the current United States practice and the consensus guidelines. Some significant differences were found in practice between the stratified institution types. A representative sample of results are: the majority of Hodgkin's Disease patients are treated with x-ray energies in the recommended range, between 4 and 10 MV. Standard mantle (for upper extended field treatment) and modified spade (for lower extended field treatments) are the fields of choice for all types of facilities. The consensus guidelines recommended that dose calculations at multiple points be obtained; however, 15% of patients in the survey received only a single point calculation. Current irregular field dosimetry calculation software does not take account of inhomogeneities. Thirty percent of Hodgkin's Disease patients do not receive a gap calculation for the abutment of upper and lower extended fields. In 70% of treatment fields, no compensation is used. Very few patients receive any kind of in vivo dosimetry check.

CONCLUSION

The survey served to verify that, in general, Hodgkin's Disease treatment planning at all strata of institution has kept pace with recommended practice as delineated in current literature and texts. Small pockets of practice still need improvement in technique and equipment. Changes in practice were identified that can contribute to improved dose uniformity and accuracy.

Reagent strip testing urine for significant bacteriuria in a urodynamic clinic

OBJECTIVES

To determine the effectiveness of two reagent strips in detecting significant bacteriuria amongst patients attending for urodynamic assessment.

PATIENTS AND METHODS

Four hundred patients undergoing urodynamic assessment were recruited for the study. Routine diagnostic catheter specimens of urine were tested for nitrite, leucocytes and protein.

RESULTS

The leucocytes and nitrite strips had a high specificity rate of 99.5%. The frequency of significant bacteriuria in our population was 7% (n = 28).

CONCLUSION

Culturing samples which test negative for these strips is unnecessary. Reagent strip testing of urine provides a cheap, rapid method of screening for infection.

Cellular fatty acid analysis of Bacillus thuringiensis ssp. israelensis (ONR-60A)

The cellular fatty acid composition of Bacillus thuringiensis ssp. israelensis (B.t.i.) ONR-60A was determined by gas-liquid chromatography (GLC). Isolates of ONR-60A were obtained from the Bacillus Genetic Stock Center, Pasteur Institute, and USDA culture collections. These isolates were compared to one another and the culture collections differed in the strains that they contained. Eleven separate strains of ONR-60A were identified, based on fatty acid composition of the cell envelope. The current Pasteur Institute international standard for B.t.i., IPS 82, was also analyzed and it consisted of 3 strains using these same criteria. Profiles were created for each strain found in ONR-60A and IPS 82, and validated against profiles of commercially produced B.t.i. from 2 time periods, 1983-84, and 1990-94. Approximately 84% of the commercially produced B.t.i. (134 out of 160 agar plates) was identified as belonging to the strains found in ONR-60A and in IPS 82. The most prevalent strain found in IPS 82 is also the most prevalent strain in the recently produced commercial material, 40.8% of the commercial plates analyzed, but commercially produced B.t.i. also retained a strong ONR-60A ancestry (35% of the plates analyzed).

Treatment planning structure and process in the United States: a "Patterns of Care" study

PURPOSE

To conduct a study of the structure and process of treatment planning in the United States.

METHODS AND MATERIALS

A Patterns of Care treatment planning consensus committee developed a survey form that was used to gather data for 106 items relating to the structure and process of treatment planning. These questions were general in nature and not specific to any particular disease site. Seventy-three facilities were randomly selected for site visits from the 1321 radiation therapy facilities in the United States: 21 academic, 26 hospital, and 26 free-standing. During the site visit the facility physicist, assisted by the site-visit physicist, completed the form.

RESULTS

Twenty-nine percent of facilities have cobalt-60 machines; 25% have 4 MV linacs; 75% have photon energies in the range of 5-8 MV; and less than 10% have energies greater than 20 MV. Academic facilities led hospital and free-standing facilities by about 30 percentage points in the availability of all electron energies (88 vs. 58%, approximately, in the range 4-13 MeV and scaling downward to about 60 vs. 30% at the highest energies). The national averages for the availability of Cs-137, Ir-192, and I-125 were 87, 73, and 44%, respectively. Computerized tomography (CT) scanning is not available or not used in 15% of hospital and free-standing facilities. Ninety-six percent of facilities have treatment planning computers; at 10% of facilities physicians do not participate in treatment planning. The estimated national averages of facilities having formal quality assurance (QA) programs for treatment planning systems, simulators, film processors, and blocking systems are 44, 79, 62, and 55%, respectively. Sixty-three percent of facilities obtain independent machine calibrations.

CONCLUSION

This is the first patterns of treatment planning study carried out in the United States and the results reported here will establish a baseline for future studies. The present study has identified some elements that were unexpected, such as the percentage of facilities lacking formal QA programs for treatment planning systems; however, it has not established any impact of such findings. It is recommended that future studies include the availability of new technologies such as multileaf collimation, dynamic wedges, digital portal imaging, and CT simulation. With the increasing nationwide concern with the cost of health care, we must continue to monitor the implementation, use, and impact on treatment outcome of new and expensive technologies.

6-Thioguanine-induced growth arrest in 6-mercaptopurine-resistant human leukemia cells

The thiopurines 6-thioguanine (6TG) and 6-mercaptopurine (6MP) are cytotoxic to proliferating cells by a mechanism involving incorporation into DNA via the purine salvage pathway, and resistance to these agents can be conferred by lack of the salvage pathway enzyme hypoxanthine-guanine phosphoribosyltransferase. However, human and murine hypoxanthine-guanine phosphoribosyltransferase-deficient leukemia cell lines have been shown to respond to 6TG by growth arrest and differentiation by a mechanism apparently not involving incorporation of 6TG into DNA. If so, leukemia cells resistant to 6MP should still respond to 6TG by growth arrest via an undescribed epigenetic mechanism. To test this, polyclonal 6MP-resistant variants were produced from three human leukemia cell lines, HL-60, U937, and CCRF-CEM. Treatment of both sensitive and resistant cells with 6TG induced growth arrest. The effect of 6TG in the 6MP-sensitive HL-60 and U937 cells was associated with significant loss of viability and DNA fragmentation. In contrast, the 6TG-treated 6MP-resistant cells exhibited a slower decline in viability and no DNA fragmentation. To identify the mechanism by which 6TG may induce growth arrest, tRNA was isolated from 6MP-resistant cells cultured for 48 h with 6TG. 6TG was found to be incorporated into tRNAs normally containing queuine in the anticodon wobble position. These studies may provide a basis for the development of new therapeutic regimens for the treatment of leukemia.

Role of connective tissue and muscle in pelvic floor dysfunction

This paper covers the role and anatomy of connective tissue and muscle in the normal pelvic floor of women. Current understanding of the changes in these components of pelvic floor dysfunction is discussed. Areas of ignorance in need of further research are highlighted.

Effect on lipopolysaccharide structure of aeration during growth of a plum isolate of Pseudomonas syringae pv. morsprunorum

The composition of lipopolysaccharide (LPS) extracted with aqueous phenol from a virulent English plum isolate of Pseudomonas syringae pv. morsprunorum varied according to the partial pressure of oxygen (pO2) in the culture medium at the time of harvest. When pO2 was low, the organism grew slowly and produced smooth LPS bearing rhamnan sidechains. As pO2 was raised, the rate of growth increased and smooth LPS was replaced by a rough species deficient in rhamnose, which co-extracted with a D-glucan. Organization of rhamnose and glucose into separate polymers was shown by the selective susceptibility of the rhamnose-containing polymer to hydrolysis by rhamnanase of the phage A7. By methylation analysis, GC-MS, and 1H- and 13C-NMR spectroscopy, the glucan was shown to consist of alpha (1-->4)-linked residues with alpha (1-->4,6)-branch points and non-reducing terminal residues in the approximate ratio 4:1:1, resembling glycogen in composition. A glucan which co-extracted with LPS using phenol/water from an avirulent plum isolate that was resistant to lysis by phages A1 and A7 was shown by methylation analysis to have a similar structure. Whether the effect on LPS composition was due directly to pO2, or was dependent on the rate of growth, has not been established. It is suggested that, because epiphytic growth would entail exposure to high pO2, English plum isolates growing on the surfaces of host plants might be unable to produce smooth LPS. Since cell surface composition affects virulence in plant-pathogenic pseudomonads, this effect could account for the observed failure of the English plum isolates to enter the host via leaf scars.

Laparoscopic hysterectomy

Laparoscopic hysterectomy, an alternative to abdominal hysterectomy, is associated with a faster recovery rate than conventional surgery, but training in the new surgical techniques is needed and complications can occur.

Application of airborne gamma spectrometric survey data to estimating terrestrial gamma-ray dose rates: an example in California

We examined the applicability of radioelement data from the National Aerial Radiometric Reconnaissance, an element of the National Uranium Resource Evaluation, to estimate terrestrial gamma-ray absorbed dose rates, by comparing dose rates calculated from aeroradiometric surveys of uranium, thorium, and potassium concentrations with dose rates calculated from a radiogeologic data base and the distribution of lithologies in California. Gamma-ray dose rates increase generally from north to south following lithological trends, with low values of 25-30 nGy h-1 in the northernmost 1 x 2 degrees quadrangles between 41 and 42 degrees N to high values of 75-100 nGy h-1 in southeastern California. Lithologic-based estimates of mean dose rates in the quadrangles generally match those from aeroradiometric data, with statewide means of 63 and 60 nGy h-1, respectively. These are intermediate between a population-weighted global average of 51 nGy h-1 reported in 1982 by UNSCEAR and a weighted continental average of 70 nGy h-1, based on the global distribution of rock types. The concurrence of lithologically and aeroradiometrically determined dose rates in California, with its varied geology and topography encompassing settings representative of the continents, indicates that the National Aerial Radiometric Reconnaissance data are applicable to estimates of terrestrial absorbed dose rates from natural gamma emitters.

Use of cellular fatty acid analysis to characterize commercial brands of Bacillus thuringiensis var. israelensis

The cellular fatty acid composition of Bacillus thuringiensis var. israelensis (B.t.i.) from 5 commercial brands (Vectobac, Acrobe, Skeetal, Bactimos and Teknar), as well as of the current International Standard for B.t.i. (IPS 82), was determined using a Hewlett-Packard Microbial Identification System. The original strain of B.t.i., B.t. var. kurstaki, B.t. var. thuringiensis, B.t. var. morrisoni and Bacillus sphaericus strain 2362 were used as outgroups. Acrobe, Bactimos, Teknar, Vectobac and IPS 82 consisted of the same strain. Skeetal represented a different strain than the other commercially produced B.t.i. Our results indicate that cellular fatty acid analysis can be used to distinguish among the forms of B.t.i. produced by various manufacturers.

Purification and preliminary characterization of permethrinase from a pyrethroid-transforming strain of Bacillus cereus

Bacillus cereus SM3 was isolated on a mineral salts medium with Tween 80 as the primary carbon source. It was able to hydrolyze second- and third-generation pyrethroids, thereby generating noninsecticidal products. The enzyme responsible for this hydrolytic reaction was named permethrinase for this study. This is the first instance in which pyrethroid detoxification has been achieved with a cell-free microbial enzyme system. Permethrinase was purified by ion-exchange chromatography and gel filtration chromatography. The molecular mass of native permethrinase was 61 +/- 3 kDa, as estimated by Sephadex G-100 gel filtration. This novel microbial esterase seems to be a carboxylesterase. Permethrinase activity had an optimum pH of 7.5 and a temperature optimum of 37 degrees C. No cofactors or coenzymes were required for permethrinase activity. The enzyme may be a serine esterase, as it seems to be sensitive to the organophosphorus compound tetraethylpyrophosphate at concentrations in the micromolar range. Addition of dithiothreitol afforded permethrinase protection against the inhibitory effects of the sulfydryl agents p-chloromercuribenzoate and N-ethylmaleimide. The enzyme was stable over a range of temperatures. Cell extracts of strain SM3 also contained another esterase, which was active towards beta-naphthylacetate, but this enzyme was distinct from permethrinase.

Parental perceptions of information about medication prescribed for their children

AIMS

The study aimed to examine parents' perceptions of the information provided to them on prescribed medication; how it might be improved and; parental level of knowledge of medication administration.

METHODS

245 parents completed a questionnaire at a preschool health day. The questionnaire covered parental opinion on whether the doctor provided enough information about illness and medication, recall of pharmacist's instructions on medication, parental general knowledge of medication and what parents wanted to know about medication for their children.

RESULTS

The findings indicated there was an overall lack of information from the doctor on side effects and what to do if problems occurred with medication. Furthermore, half (49%) of the parents did not recall receiving any information from the pharmacist. Parents appeared to understand the basics of medication administration.

CONCLUSIONS

It is suggested that improvements should be made regarding the information given to parents on prescribed medication. This may improve satisfaction with the service received from health professionals, such as doctors and pharmacists, and increase patient compliance with treatment regimes.

Behavioral effects of prenatally administered smokeless tobacco on rat offspring

Two dosages of Smokeless Tobacco (ST) extract were given to gravid Sprague-Dawley rats by oral gavage on gestational days (GD) 6-20. The low dosage contained ST extract equivalent to 1.33 mg/kg nicotine (STD-1), and the high dosage contained ST extract equivalent to 4.0 mg/kg nicotine (STD-2). Dams were dosed three times daily at 8 a.m., 11 a.m., and 2 p.m., thus providing total daily nicotine equivalent dosages of 4 mg/kg/day and 12 mg/kg/day. Controls received equivalent amounts of distilled water by gavage. Dams were allowed to deliver and all experimental pups were fostered to control mothers. On postnatal day 1 (PND 1) litters were culled to 4 +/- 1 females and 4 +/- 1 males. Weights, physical landmark development, and behavioral performance of pups were monitored during pre- and post-weaning periods. Behavioral tests included: surface righting, negative geotaxis, swimming development, open-field activity, active avoidance in shuttle box, and Cincinnati swimming maze. Our results show that the STD-2 dose resulted in reduced maternal weight gain. Offspring weights were reduced in a dose-related manner, with the most consistent weight deficits seen in the STD-2 group until PND29. Consistent STD-1 weight deficits were seen up to PND 8. The incidence of deaths was increased in the STD-2 dosage group. No significant treatment-related differences were observed in development of physical landmarks. Male STD-2 pups righted faster than controls, and significant differences were noted in swimming development with the STD-1 group of pups performing less effectively than controls. Activity levels, assessed during both pre- and post-weaning periods were not affected. No treatment-related differences were seen in the active avoidance shuttle box or Cincinnati swimming maze tests, which assessed learning. Female brain weights were reduced in the STD-1 treatment group.