Preliminary study of a new online and equipment-free vision screening alternative for remote and isolated community

INTRODUCTION

Vision screening has been initiated to detect potential vision problems, paving referral pathways towards a full eye examination. Time-cost-labour practicality challenges of equipment-based vision screening have lingered for decades. Going for the highest sensitivity and specificity or opting for a pragmatic and affordable vision screening program remains a dilemma in public eye health. We aimed to report the development of a new online and equipment-free vision screening called Eye: Questionnairebased Vision Screening (EyeQVS). We also analysed the visual profile of Orang Bateq resided in a remote locality, using findings from EyeQVS, single test vision screening and full eye examination.

MATERIALS AND METHODS

Multi-perspective development strategies were employed in designing EyeQVS. The questionnaire items were constructed using the working backward technique, compiling common vision disorders from the literature and face validation using expert panels. Face validation and usability assessment were performed on EyeQVS. The vision screening was carried out using EyeQVS and single test visual acuity screening method. The full eye examination included visual acuity, refraction, binocular vision and ocular health assessment. The visual profile of indigenous people (Orang Bateq) at Kampung Bengoi and Kampung Atok, Jerantut, Pahang was analysed using EyeQVS, single test visual acuity screening method and full eye examination.

RESULTS

The performance of EyeQVS was affirmative in both face validation and usability. About 95% of Orang Bateq failed full eye examination, while 55% failed EyeQVS screening. None of them failed single test vision screening. Binocular disorders and dry eye problems were commonly found in Orang Bateq. EyeQVS unearthed more various vision problems compared to the single test vision screening (visual acuity alone) as a screening tool in a remote location.

CONCLUSION

EyeQVS can screen for binocular disorders and dry eyes problem commonly found among indigenous people, which might be missed using a single-test visual acuity screening approach. EyeQVS is a practical alternative for vision screening in places where financial or location hinders eye healthcare access.

Use of prophylactic ureteral stents in gynecologic surgery

BACKGROUND

The aim of this study was to evaluate rate of complications with the use of prophylactic ureteral localization stents (PULSe) in gynecologic surgery. To compare the occurrence of complications according to the indication of surgery.

METHODS

This retrospective study included 1248 women who underwent 1275 different gynecologic surgeries with PULSe between 2007 and 2020. Data was collected regarding patient characteristics (age, sex, race, ethnicity, parity, previous pelvic surgery, creatinine), operative characteristics (trainee, guidewire use, indication) and complications in the first 30 days (ureteral injury, urinary tract complication, re-stenting, hydronephrosis, urinary tract infection (UTI), pyelonephritis, emergency room visit, re-admission).

RESULTS

Median age was 57 years (range: 18-96 years), most women were Caucasian (88.9%), and had previous pelvic surgery (77.7%). Indication of surgery was benign for 459 (36.0%), female pelvic medicine and reconstructive surgery (FPMRS) for 545 (42.7%), and gynecologic oncology (gyn-onc) for 271 (21.3%). Disabling complications occurred rarely with 8 patients (0.6%) having a ≥III Clavien Dindo Grade (CDG), and only 1 (0.08%) ≥IV CDG. Statistically significant differences between benign, FPMRS, and gyn-onc groups were noted for re-stenting (0.9% vs. 0.0% vs. 1.1%, P=0.020), hydronephrosis (0.9% vs. 0.2% vs. 2.2%, P=0.014), UTI (4.6% vs. 9.4% vs. 7.0%, P=0.016), and re-admission (2.4% vs. 1.1% vs. 4.4%, P=0.014).

CONCLUSIONS

The incidence of 30-day CDG III and IV complications after PULSe placement is low. FPMRS patients had a higher rate of complicated UTI, however gyn- onc patients appear to be at overall higher risk of stent related complications when compared to surgeries for FPMRS or benign indications.

Trigger point injections followed by immediate myofascial release in the treatment of pelvic floor tension myalgia

PURPOSE

Pelvic floor physical therapy (PFPT) is first-line therapy for treatment of pelvic floor tension myalgia (PFTM). Pelvic floor trigger point injections (PFTPI) are added if symptoms are refractive to conservative therapy or if patients experience a flare. The primary objective was to determine if a session of physical therapy with myofascial release immediately following PFTPI provides improved pain relief compared to trigger point injection alone.

METHODS

This was a retrospective cohort analysis of 87 female patients with PFTM who underwent PFTPI alone or PFTPI immediately followed by PFPT. Visual analog scale (VAS) pain scores were recorded pre-treatment and 2 weeks post-treatment. The primary outcome was the change in VAS between patients who received PFTPI alone and those who received PFTPI followed by myofascial release.

RESULTS

Of the 87 patients in this study, 22 received PFTPI alone and 65 patients received PFTPI followed by PFPT. The median pre-treatment VAS score was 8 for both groups. The median post-treatment score was 6 for the PFTPI only group and 4 for the PFTPI followed by PFPT group, showing a median change in VAS score of 2 and 4, respectively (p = 0.042). Seventy-seven percent of patients in the PFTPI followed by PFPT group had a VAS score improvement of 3 or more, while 45% of patients in the PFTPI only group had a VAS score improvement greater than 3 (p = 0.008).

CONCLUSION

PFTPI immediately followed by PFPT offered more improvement in pain for patients with PFTM. This may be due to greater tolerance of myofascial release immediately following injections.

OnabotulinumtoxinA Injections for the Treatment of Myofascial Pelvic Pain: 12-year Experience at a Tertiary Care Academic Center

OBJECTIVE

The aim of this study was to highlight the safety of OnabotulinumtoxinA (BTA) injections, with or without concurrent pudendal nerve block, in treating women with myofascial pelvic pain (MFPP).

DESIGN

This was a retrospective cohort study.

SETTING

Tertiary care academic center PARTICIPANTS/MATERIALS: We conducted a chart review of patients who were diagnosed with MFPP and treated with BTA with or without pudendal nerve block between January 2010 and February 2022.

METHODS

BTA was injected transvaginally into the pelvic floor muscle group. The primary outcomes were adverse events after BTA injections, and the secondary outcome was the effect of concomitant pudendal nerve block at the time of BTA injections.

RESULTS

The cohort included 182 patients; 103 (56.6%) received BTA injections with pudendal nerve block, and 79 (43.4%) received BTA alone. There were no significant demographic differences between the two groups. Post-treatment complications of BTA administration included worsening of pelvic pain (11.5%), constipation (6.6%), urinary tract infection (2.7%), urinary retention (3.8%) and fecal incontinence (2.7%). No statistical difference was noted in the number of phone calls, patient-initiated electronic messages, emergency room visits, or clinic visits for both groups within 30 days post-treatment. The mean number of total injections was 1.6 in the BTA-only group and 1.7 in the BTA with pudendal block group (p=0.421). Median time to re-intervention with a second BTA injection was 6.0 months; 5.6 months in the BTA with pudendal block group and 6.8 months in the BTA-only group; p=0.46. There were 63 re-intervention events after BTA injections.

LIMITATIONS

Limitations of our study include the retrospective design making it vulnerable to missing or incomplete data available for review CONCLUSION: OnabotulinumtoxinA is beneficial in treating women with MFPP; with a duration of therapeutic effect of approximately 6 months. The use of a concurrent pudendal nerve block did not impact clinical outcomes.

Association of coccygodynia with pelvic floor symptoms in women with pelvic pain

BACKGROUND

Coccygodynia is a painful condition of the tailbone that occurs more commonly in females. The association of coccyx pain with pelvic floor symptoms and the prevalence of coccyx pain in women with pelvic pain has not previously been reported.

OBJECTIVE

To identify the prevalence of coccygodynia in women with pelvic pain and to describe the association of coccygodynia with pelvic floor examination findings and symptoms.

DESIGN

Retrospective cohort analysis.

SETTING

Tertiary medical institution.

PARTICIPANTS

One hundred twenty-seven women presenting for outpatient pelvic floor physical therapy treatment who underwent vaginal and rectal pelvic floor examination.

MAIN OUTCOME MEASURES

Prevalence of coccygodynia, pain scores, association of coccygodynia with other comorbidities and diagnoses, and association of coccygodynia with physical examination findings.

RESULTS

Sixty-three (49.6%) of 127 women with pelvic pain presented with coccygodynia and 64 (50.4%) did not. Women with coccygodynia had significantly higher rates of muscle spasm (50.8% vs. 31.2%, p = .025) higher visual analog scale pain scores (median 5 vs. 3, p = .014), higher rates of outlet dysfunction constipation (31.7% vs. 10.0%, p = .032), and higher rates of fibromyalgia (15.9% vs. 3.1%, p = .014). On pelvic examination, women with coccygodynia were significantly more likely to have sacrococcygeal joint hypomobility (65.1% vs. 14.1%, p < .001), coccygeus muscle spasm (77.8% vs. 17.2%, p < .001), anococcygeal ligament pain (63.5% vs. 9.4%, p < .001), external anal sphincter pain/spasm (33.3% vs. 13.1%, p < .001), and impaired pelvic floor muscle coordination (77.8% vs. 57.8%, p = .016).

CONCLUSIONS

Almost 50% of women seeking pelvic floor physical therapy for pelvic pain had coexisting coccygodynia. These women had higher pain scores, increased pelvic floor dysfunction, and significantly greater abnormal physical exam findings. This study demonstrates a strong link between coccygodynia, pelvic floor symptoms, and pelvic pain and highlights the importance of screening for and identifying coccyx pain when evaluating women with pelvic pain.

Surgical Science - Simbionix Robotic Hysterectomy Simulator: Validating a New Tool

STUDY OBJECTIVE

To gather validity evidence for and determine acceptability of Surgical Science - Simbionix Hysterectomy Modules for the DaVinci Xi console simulation system and evaluate performance benchmarks between novice and experienced or expert surgeons.

DESIGN

Prospective education study (Messick validity framework) SETTING: Multi-center, academic medical institutions PARTICIPANTS: Residents, fellows, and faculty in Obstetrics and Gynecology were invited to participate at 3 institutions. Participants were categorized by experience level: less than 10 hysterectomies (novice), 10 to 50 hysterectomies (experienced), and greater than 50 hysterectomies (expert). A total of 10 novice, 10 experienced, and 14 expert surgeons were included.

INTERVENTIONS

Participants completed 4 simulator modules (ureter identification, bladder flap development, colpotomy, complete hysterectomy) and a qualitative survey. Simulator recordings were reviewed in duplicate by educators in minimally invasive gynecologic surgery using the Modified Global Evaluative Assessment of Robotic Skills (GEARS) rating scale.

MEASUREMENTS AND MAIN RESULTS

Most participants felt the simulator realistically simulated robotic hysterectomy (64.7%) and that feedback provided by the simulator was as or more helpful than feedback from previous simulators (88.2%) but less helpful than feedback provided in the OR (73.5%). Participants felt this simulator would be helpful for teaching junior residents. Simulator-generated metrics correlated with GEARS performance for bladder flap and ureter identification modules in multiple domains including total movements and total time for completion. GEARS performance for the bladder flap module correlated with experience level (novice vs experienced/expert) in domains of interest and total score but did not consistently correlate for the other procedural modules. Performance benchmarks were evaluated for the bladder flap module for each GEARS domain and total score.

CONCLUSION

The modules were well received by participants of all experience levels. Individual simulation modules appear to better discriminate between novice and experienced/expert users than overall simulator performance. Based on these data and participant feedback, use of individual modules in early residency education may be helpful for providing feedback and may ultimately serve as one component of determining readiness to perform robotic hysterectomy.

New options for managing fecal incontinence in women

Fecal incontinence often is underreported and can be associated with both social embarrassment and isolation. As patients often do not proactively discuss their symptoms, healthcare providers should screen for this distressing condition. The cause of fecal incontinence often is multifactorial, so no single therapy can guarantee perfect, risk-free outcomes. This article reviews the limited therapies for managing fecal incontinence, including a minimally invasive vaginal control device that may offer hope for managing fecal incontinence in women.

Association of uterine dimensions and route of contained morcellation following laparoscopic hysterectomy

BACKGROUND

The aim of this study was to determine if uterine dimensions on preoperative imaging are associated with route of contained morcellation during laparoscopic hysterectomy.

METHODS

This is a prospective cohort study of patients undergoing laparoscopic hysterectomy and requiring morcellation for specimen extraction from March 2017 through August 2019. A contained extraction system was inserted and manual morcellation was performed vaginally, abdominally, or via a combination of both methods in cases of failed vaginal extraction.

RESULTS

A total of 47 patients were treated. Median age was 47 (range 38-70). Morcellation was performed vaginally for 29 patients (61.7%), abdominally for 13 patients (27.7%), and via combined approach for 5 patients (10.6%). The combined group had the highest frequency of patients who were black (vaginal: 24%, abdominal: 31%, combined: 100%; P=0.005), the longest median total operating time (vaginal: 167 minutes, abdominal: 183 minutes, combined: 268 minutes; P=0.006) and the longest median time of uterine morcellation (vaginal: 14 minutes, abdominal: 37 minutes, combined: 85 minutes; P<0.001). There was strong evidence of a positive correlation with time of uterine morcellation for both largest uterine diameter (Spearman's r: 0.62, P<0.001) and uterine volume (Spearman's r: 0.70, P<0.001). These associations remained consistent after multivariable linear regression models that were adjusted for route of morcellation, hysterectomy type, and BMI (both P<0.001).

CONCLUSIONS

Larger uterine dimensions are associated with increased total operating and morcellation times. Uterine size and volume on preoperative imaging were not associated with route of morcellation, but there was a trend towards failed vaginal extraction when uterine dimensions exceeded 16 centimeters.

[Multicenter study of human adenovirus infection in pediatric community-acquired pneumonia in China]

Objective: To investigate the predominant genotypes and epidemiological characteristics of human adenovirus (HAdV) in pediatric community-acquired pneumonia (CAP) in China. Methods: This was a repeated cross sectional study. Between November 2014 and November 2016, nasopharyngeal aspirates (NPAs) or throat swabs from each hospitalized pediatric patients diagnosed as CAP in 12 hospitals in Northern and Southern China were collected. Respiratory specimens were screened for 18 respiratory viruses including HAdV by using Luminex xTAG RVP Fast V2 multiplex Assay. Typing of HAdV and analysis for the epidemiological characteristic of HAdV were performed. Results: (1) A total of 2 723 hospitalized pediatric patients with CAP were enrolled in this study and 156 (5.7%, 156/2 723) respiratory specimens were positive for HAdV, and 74 (6.6%, 74/1 128) and 82 (5.1%, 82/1 595) were in Northern and Southern China, respectively. There was no significant difference in the positive detection rate between the Northern and Southern China. (2) In Northern China, the HAdV positive rate of children at the age of <6 months, 6 months-<1 years, 1-<3 years, 3-<5 years and ≥5 years was 5.9%(6/101), 6.7%(7/104), 10.3%(34/331), 4.1%(11/266) and 4.9%(16/326), respectively, and the incidence of HAdV infection peaked in children aged 1-3 years (χ(2)=11.511, P=0.021). While in Southern China the HAdV positive rate of children at the age of <6 months, 6 months-<1 years, 1-<3 years, 3-<5 years and ≥5 years was 2.2% (7/312), 4.6% (12/259), 6.3% (31/494), 7.3% (18/245) and 4.9%(14/285), respectively. There was no significant difference in the positive detection rate among age groups. (3) In 2015, the highest detection rate of HAdV in northern China was 12.5% (25/200) in winter, and in Southern China was 6.7% (35/525) in spring and 5.3% (19/357) in summer. (4) In 108 cases of HAdV positive specimens typing was done and 80 in cases classification was successfully performed.Totally 7 genotypes of HAdV, including HAdV-3 (n=32), HAdV-7 (n=9), HAdV-1 (n=12), HAdV-2 (n=15), HAdV-5 (n=10), HAdV-6 (n=1) and HAdV-4 (n=1), were detected. The predominant HAdV genotypes were HAdV-3 (30.8%, 8/26) and HAdV-7 (26.9%, 7/26) in Northern China, while HAdV-3 (44.4%, 24/54) and HAdV-2 (22.2%, 12/54) were the most prevalent genotypes in Southern China. Conclusions: HAdV is an important viral pathogen in pediatric CAP. The predominant HAdV genotypes and peak seasons of HAdV infections were different between Northern and Southern China. The predominant HAdV genotypes were HAdV-3 and HAdV-7 in Northern China, while HAdV-3 and HAdV-2 in Southern China. The peak season of HAdV infections was winter in Northern China. However, HAdV infections are more common in spring and summer in Southern China.

Robotic Placement of the FENIX Continence Restoration System in a Patient with Previous Radiation to the Pelvis: A Case Report

Fecal incontinence (FI) is a disabling problem affecting women. Conservative treatment includes dietary modification, antimotility agents, and pelvic floor physical therapy. If conservative medical management is unsuccessful, surgical intervention may be required. Surgical options include rectal sphincteroplasty, bulking agent injection, radiofrequency anal sphincter remodeling, and sacral nerve stimulation therapy. Recently, a new therapy for FI, the FENIX Continence Restoration System (Torax Medical, Inc., Shoreview, MN), has become available. The FENIX device is placed through a perineal incision; however, pelvic radiation and previous anal carcinoma are both contraindications. We report the case of a 62-year-old woman with FI after anal carcinoma. Treatment included surgery, chemotherapy, and pelvic radiation. Initially, she was treated with conservative therapy and sacral nerve stimulation, which were only partially effective. A physical examination showed perineal skin changes consistent with previous radiation, which increased the patient's risk of infection and a nonhealing wound. Therefore, a robotic approach was used to place the FENIX device and improve the patient's quality of life. Our case sets a precedent for expanding the treatment options of FI in patients with previous pelvic radiation and using a robotic approach for the placement of the FENIX device.

The Fenix System for Fecal Incontinence: An Overview and Surgical Demonstration

STUDY OBJECTIVE

This video shows a new technique for the surgical management of fecal incontinence using the Fenix Continence Restoration System (TORAX Medical Inc, Shoreview, MN) in 2 patients.

DESIGN

A step-by-step explanation of the video using videos and pictures (educational video) for surgeons (Canadian Task Force classification III).

SETTING

The use of the Fenix System received United States Food and Drug Administration approval under a humanitarian device exemption and can be used with institutional review board approval in patients who have failed previous medical and surgical management of fecal incontinence. The device is a small, flexible band of interlinked titanium, magnetic beads on a titanium string that is placed using a perineal approach around the anal canal. Increased intra-abdominal pressure opens the beads to allow for the passage of stool.

INTERVENTIONS

Placement of the device was performed in 2 patients. Case 1 is a 63-year-old woman with a long-standing history of fecal incontinence who failed sphincteroplasty, sacral neuromodulation, and an artificial sphincter cuff and pump. Case 2 is a 60-year-old woman with a long-standing history of fecal incontinence secondary to radiation therapy for rectal cancer who failed physical therapy and sacral neuromodulation.

CONCLUSION

Both Fenix Continence Restoration Systems were placed successfully. Long-term postoperative effectiveness is currently being evaluated.

Interaction of six candidate genes in essential hypertension

We explored the interaction of 6 candidate genetic mutations in essential hypertension (EH). The mutations AGT M235T, ACE I/D, eNOS Glu298Asp, ET-2 A985G, ANP T2238C, and NPRC A-55C were detected using a genechip microarray in 100 patients with EH and 97 controls from the Han population living in the Yunnan Province of China. Risks of EH were evaluated with respect to a combination of these genotypes. Interactions were analyzed using multifactor dimensionality reduction (MDR). P values were corrected using Bonferroni's adjustment. Results showed that CC genotype frequencies for NPRC A-55C (0.540) in EH were significantly higher than those in controls (0.237, Pc < 0.01; odds ratio (OR) = 3.777; 95% confidence interval (CI) = 2.050-6.960). The OR for NPRC A-55C CC combined with ET-2 A985G GG increased to 4.673 and to 5.529 when the MT genotype of AGT M235T, the EE genotype of eNOS Glu298Asp, the GG genotype of ET-2 A985G, and the CC genotype of NPRC A-55C were combined. MDR showed that ET-2/NPRC is the best model (OR = 4.002; 95%CI = 2.1597-7.4159). The CC genotype for NPRC A-55C and the G allele for ET-2 A985G were associated with susceptibility to EH. Although the contributions of the candidate genes differ, they may have cooperative effects on conferring risk for EH. Moreover, potential gene-gene interactions were found between ET-2 A985G and NPRC A-55C in EH.

Factors associated with poor academic achievement among urban primary school children in Malaysia

INTRODUCTION

The aim of this study was to identify factors associated with poor academic achievement during the early school years.

METHODS

This was a cross-sectional study of urban Primary Two children. Sociodemographic and medical data were obtained from questionnaires and interviews. Achievement was based on marks obtained in the core subjects of the Primary One examination. All students underwent the Raven's Standard Progressive Matrices test as a general measure of cognitive ability, audiometry and visual tests, and standardised measurements of weight and height.

RESULTS

Out of 1,470 eligible children, 206 (14 percent) had poor academic achievement. Of the 919 children who participated in the study, 111 (12.1 percent) had poor achievement compared with 95 (17.2 percent) of the 551 non-participants. Using logistic regression analysis, the factors that were found to be independently associated with poor academic achievement were lower mean Raven scores (p-value is less than 0.001), lower mean socioeconomic status scores (p-value is less than 0.001), larger sibship size (p-value is 0.031), male gender (odds ratio [OR] 1.7; 95 percent confidence interval [CI] 1.1-2.65) and a history of prematurity (OR 14; 95 percent CI 2-97.8).

CONCLUSION

Cognitive ability, gender, prematurity and social factors contribute to poor academic achievement during the early school years. The higher proportion of poor achievers among non-participants warrants further attention.

Orientobilharzia species: neglected parasitic zoonotic agents

Parasites of the genus Orientobilharzia belong to Platyhelminthes, Trematoda, Digenea, Schistosomatidae, and the type species is Orientobilharzia turkestanicum. O. turkestanicum was first described by Skrjabin from cattle in Russian Turkestan in 1913. Adult worms of Orientobilharzia species live in the portal veins or intestinal veins of cattle, sheep and other mammals, and often cause orientobilharziasis in China, India, Mongolia, Pakistan, Iraq, Iran in Asia, and Russia and Turkey in Europe. More importantly, the cercariae of Orientobilharzia species can infect humans and often cause cercarial dermatitis. Though Orientobilharzia species have been confirmed as zoonotic agents, they have been largely neglected, compared with other pathogens causing cercarial dermatitis, such as Trichobilharzia spp., Schistosoma spindale and Bilharziella sp., which have attracted considerable attention. Here we review the current status of knowledge on the taxonomy of Orientobilharzia spp., human and animal infections with Orientobilharzia spp., and address some considerations for further work on the systematics and pathogenesis of these organisms.

Robotic-assisted sacrocolpopexy: technique and learning curve

BACKGROUND

Laparoscopic sacrocolpopexy (LSCP) offers a minimally invasive approach for treating vaginal vault prolapse. The Da Vinci robotic surgical system may decrease the difficulty of the procedure. The objective of this study was to describe the surgical technique of robotic-assisted sacrocolpopexy (RASCP) and evaluate its feasibility, safety, learning curve, and perioperative complications.

METHODS

Eighty patients underwent RASCP between November 2004 and June 2007. Robotic dissection of the planes between the bladder and vagina anteriorly and between the vagina and rectum posteriorly was performed. A peritoneal incision was made to expose the sacral promontory and extended down to the vaginal apex. A Y-shaped mesh was sutured to the anterior and posterior surfaces of the vagina. The tail end of the mesh was sutured to the sacral promontory. Intracorporeal knot tying was used in all sutures. The peritoneal incision was closed to cover the mesh using a running suture.

RESULTS

Mean operative time was 197.9 [standard deviation (SD) 66.8] min. After completion of the first ten cases, mean operative time decreased by 25.4% [64.3 min, 95% confidence interval (CI) 16.1-112.4 min, p < 0.01]. Two (2.5%) patients had injury to the bladder, one (1.2%) patient had a small bowel injury, and one (1.2%) patient had a ureteric injury. Postoperatively, five (6%) patients developed vaginal mesh erosion, one (1.2%) patient developed a pelvic abscess, and one (1.2%) patient had postoperative ileus. Four (5%) cases were converted to laparotomy. Mean follow-up period was 4.8 months (range 1-24 months).

CONCLUSIONS

RASCP is a feasible procedure with acceptable complication rates and short learning curve.

The role of traditional Chinese medicine in colorectal cancer treatment

Surgery, chemotherapy and radiotherapy have been the mainstay of colorectal cancer treatment. There is however current intense research on traditional Chinese medicine (TCM) as novel or additional treatment methods for colorectal cancer. This article reviews the current use of TCM in colorectal cancer so as to increase the awareness of colorectal surgeons. The pathogenesis of colorectal cancer according to TCM is discussed. TCM has been used successfully during the perioperative period to relieve intestinal obstruction, reduce postoperative ileus and reduce urinary retention after rectal surgery. Good results have been reported in the treatment of the complications of chemotherapy and radiation enterocolitis. Favourable results have also been shown in the use of TCM either alone or in combination with chemotherapy to treat advanced colorectal cancer. Molecular studies have shown some TCM compounds to reduce tumour cell proliferation and induce apoptosis. Although the reported results of TCM have been exciting thus far, problems of lack of consensus on treatment regimes and questions on the reliability, validity and applicability of published studies prevent its widespread use. There is now an urgent need for colorectal surgeons to work with TCM physicians in the continuing research on this 6,000-year-old art so as to realize its full potential for our patients.

Incidence of occult rectal prolapse in patients with clinical rectoceles and defecatory dysfunction

OBJECTIVE

The purpose of this study was to determine the incidence of occult rectal prolapse (rectal intussusception) by defecating proctography in patients with clinical rectoceles and defecatory dysfunction.

STUDY DESIGN

Patients who were seen from September 2000 through August 2001 with defecatory dysfunction and clinical rectoceles underwent single contrast defecating proctography. Radiologists who specialized in gastrointestinal fluoroscopy interpreted the results, which were retrieved from a computerized database. Study Design: Sixty patients who met the inclusion criteria were evaluated. Twenty patients (33%) had intussusception; 58 patients (97%) had rectocele; 1 patient (1.7%) had sigmoidocele, and 6 patients (10%) had anismus (paradoxic contraction of the puborectalis).

RESULTS

All but 1 case of intussusception was associated with a rectocele radiographically. Anismus was associated with rectoceles radiographically, except in 1 patient for whom it was the sole finding.

CONCLUSION

The data suggest a 33% incidence of occult rectal prolapse in patients with clinical rectoceles and defecatory dysfunction. This is highly clinically significant because one third of patients who are examined for defecatory dysfunction and rectocele may require sigmoid resection rectopexy along with other reconstructive procedures to restore pelvic floor function and prevent symptomatic recurrence.

Sacral neuromodulation: new applications in the treatment of female pelvic floor dysfunction

PURPOSE OF REVIEW

The first sacral nerve stimulators implanted by Tanagho and Schmidt (1981) were performed for the indications of urinary urge incontinence, urgency-frequency, and nonobstructive urinary retention. Since that time, observations have been made for benefits beyond voiding disorders. These additional benefits have included re-establishment of pelvic floor muscle awareness, resolution of pelvic floor muscle tension and pain, decrease in vestibulitis and vulvadynia, decrease in bladder pain (interstitial cystitis), and normalization of bowel function.

RECENT FINDINGS

Therapy for fecal incontinence in patients with a structurally intact sphincter mechanism appears to be very promising. Investigators agree that there is a role for sacral nerve stimulation in patients with urge fecal incontinence that have failed conservative efforts. Objective manovolumetric testing shows an increase in resting pressure, an increase in voluntary contraction pressure, a decrease in rectal volumes which cause first urge, a decrease in rectal volume to initiate first urge to defecate, and an increase in duration of maximum squeeze pressure. Intractable interstitial cystitis is defined as patients that have failed conventional therapy. Historically, the only option remaining was extirpative surgery or diversion. Maher et al. reported on patients with intractable interstitial cystitis who had undergone sacral nerve stimulation. They found that 73% of these patients had a reduction in pelvic pain, daytime frequency, nocturnal urgency and an increase in average voided volumes. The final area of interest concerns refractory pelvic pain. Siegal et al. reported a decrease in severity, number of hours of pain, and improved quality of life measures in patients who underwent transforamenal sacral nerve stimulations. These patients had all failed conventional pain therapy.

SUMMARY

While the data are encouraging in these new arenas of pelvic floor disorders, investigators acknowledge the need for multicenter, statistically powered studies to evaluate the validity of these findings.

The integrin-mediated cyclic strain-induced signaling pathway in vascular endothelial cells

The irregular distribution of plaque in the vasculature results from the interaction of local hemodynamic forces with the vessel wall. One well-characterized force is cyclic circumferential strain, the repetitive pulsatile pressure distention on the arterial wall. This review summarizes current research, which has aimed to elicit the signal transduction pathway by which cyclic strain elicits functional and structural responses in endothelial cells; specifically, it summarizes the signaling pathway that begins with the reorganization of integrins. One method by which these extracellular matrix receptors affect signal transduction is through their ability to initiate the process of phosphorylation on tyrosine residues of cytoplasmic protein kinases, including focal adhesion kinase. The strain-induced pathway appears to also involve ras and the mitogen-activated protein kinase family of enzymes, and preliminary data suggests a role for src as well. Ultimately, it is the regulation of gene expression through the modulation of transcription factors that allows endothelial cells to respond to changes in local hemodynamics.

A prospective analysis of the relationship between walking and mood in sedentary ethnic minority women

Walking for exercise is becoming widely recognized for bestowing health benefits. This study examined the association of walking for exercise and mood in sedentary, ethnic minority women over a five-month period. Ethnic minority women (N = 102) participated in a randomized, controlled trial of a 7-week behaviorally based telephone and mail intervention that promoted the adoption of walking for exercise compared to a non-behavioral minimal intervention. At 2-month post-test and 5-month follow-up, participants reported significant decreases in depressive mood and increases in vigor. Increase in walking over the course of the study was associated with change in vigor. Limited evidence was found to support a relationship between walking for exercise and mood improvement in ethnic-minority women.

Cyclic strain activates the pro-survival Akt protein kinase in bovine aortic smooth muscle cells

BACKGROUND

Pulsatile pressure induced by the beating heart causes cyclic strain on arterial endothelial cells and smooth muscle cells (SMCs). This study examined whether Akt, a serine/threonine protein kinase known to promote cell survival by inhibiting apoptosis, is activated by cyclic strain in bovine aortic SMCs.

METHODS

Bovine aortic SMCs were cultured on flexible-bottomed membranes and then serum-starved for 24 to 36 hours. The cells were then exposed to 150-mm Hg repetitive deformations, which created an average of 10% strain on the monolayer SMCs at a frequency of 60 cycles/minute for 0 (negative control) and 30 minutes. Platelet-derived growth factor (PDGF)--stimulated SMCs were used as positive controls. Phosphorylation of Akt was determined by means of Western blot analysis. An apoptosis assay (TUNEL) was also performed on SMCs exposed to cyclic strain.

RESULTS

Akt phosphorylation was significantly increased over that of the negative control after 30 minutes of cyclic strain and in the PDGF group. Cyclic strain did not increase the prevalence of apoptosis in SMCs over the control.

CONCLUSIONS

Cyclic strain activated the pro-survival Akt kinase. The pro-survival function was supported by the fact that cyclic strain did not increase apoptosis in bovine aortic SMCs. This experiment suggests that cyclic strain may induce arterial wall thickening by tipping the balance toward arterial SMC proliferation through the inhibition of apoptosis.

MYO1F as a candidate gene for nonsyndromic deafness, DFNB15

BACKGROUND

Earlier studies have mapped the autosomal recessive nonsyndromic deafness locus, DFNB15, to chromosomes 3q21.3-q25.2 and 19p13.3-13.1, identifying one of these chromosomal regions (or possibly both) as the site of a deafness-causing gene. Mutations in unconventional myosins cause deafness in mice and humans. One unconventional myosin, myosin 1F (MYO1F), is expressed in the cochlea and maps to chromosome 19p13.3-13.2.

OBJECTIVE

To evaluate MYO1F as a candidate gene for deafness at the DFNB15 locus by determining its genomic structure and screening each exon for deafness-causing mutations to identify possible allele variants of MYO1F segregating in the DFNB15 family.

METHODS

We used radiation hybrid mapping to localize MYO1F on chromosome arm 19p. We next determined its genomic structure using multiple long-range polymerase chain reaction experiments. Using these data, we completed mutation screening using single-stranded conformational polymorphism analysis and direct sequencing of affected and nonaffected persons in the original DFNB15 family.

RESULTS

Radiation hybrid mapping placed MYO1F in the DFNB15 interval, establishing it as a positional candidate gene. Its genomic structure consists of 24 coding exons. No mutations or genomic rearrangements were found in the original DFNB15 family, making it unlikely that MYO1F is the disease-causing gene in this kindred.

CONCLUSIONS

Although we did not find MYO1F allele variants in one family with autosomal recessive nonsyndromic hearing loss, the gene remains an excellent candidate for hereditary hearing impairment. Given its wide tissue expression, MYO1F might cause syndromic deafness.

Intermittent Pneumatic Compression Devices – Physiological Mechanisms of Action

There are many reports of how IPC is used effectively in the clinical setting; including the prevention of deep venous thrombosis, improvement of circulation in patients with lower extremity arterial diseases, reduction of lymphoedema, and the healing of venous ulcers. However, despite the widely accepted use of IPC, it is still unclear how IPC actually exerts its beneficial effects. The exact physiological mechanisms of action are unknown. The clinical utility of IPC and the putative mechanisms by which IPC could exert its therapeutic effect will be reviewed. The paper will examine the mechanical effects of IPC exerted on the lower extremity, and the subsequent biochemical changes in the circulation. In vitro studies of the effects of mechanical stress such as compressive strain and shear on cultured endothelial cells, and their clinical relevance to IPC will also be reviewed.

Free-space accommodative response and minus lens-induced accommodative response in pre-school children

PURPOSE

The purpose of this study was to investigate and compare the accommodative accuracy of pre-school children between free-space accommodative stimulus and minus lens-induced accommodative stimulus.

METHODS

The accommodative responses of 59 pre-school children, ages 2 to 5 years, were measured objectively with a Canon Autoref R-1 under two different conditions, giving an optical accommodative stimulus of 1 D; first, viewing a target placed 100 cm away (free-space stimulus), and second, viewing a distant target through a -1.00 D lens.

RESULTS

The mean lag of the accommodative response for the free-space accommodative stimulus is 0.24 D, while the mean lag of the accommodative response with the minus lens-induced accommodative stimulus is 0.69 D. The lag of accommodative response for free-space accommodative stimulus is significantly lower than the lag of accommodative response for minus lenses.

CONCLUSIONS

Pre-school children can accommodate more accurately toward a free-space accommodative stimulus, as compared with minus lens-induced accommodative stimulus.

2E4/Kaptin (KPTN)--a candidate gene for the hearing loss locus, DFNA4

Stereocilia of the inner ear play an integral role in the mechanotransduction of sound. Their structural support is derived from actin filaments and actin-binding proteins. We have identified a novel actin-binding protein, 2E4-kaptin (KPTN), which appears to be involved in this structural network. Using double label immunofluorescence, we now show that KPTN extends beyond the barbed ends of actin filaments at the tips of stereocilia, and using cloned human cDNA, we mapped KPTN to chromosome 19q13.4. A combination of FISH, radiation hybrid mapping and YAC screening localized KPTN between markers D19S412 and NIB1805, making this gene an excellent functional and positional candidate for DFNA4, a form of autosomal dominant non-syndromic hearing loss. We identified a second family with inherited deafness that also maps to the DFNA4 region. To screen KPTN for deafness-causing mutations, we first determined its genomic structure and then completed a mutational analysis by direct sequencing and SSCP in affected family members. Although no deafness-causing mutations were identified in the coding region, KPTN remains an excellent candidate gene for hearing loss; by synteny, its murine orthologue also remains a candidate gene for the Nijmegan waltzer (nv) mouse mutant, which has vestibular defects and a variable sensorineural hearing loss.

Laryngeal cancer cost analysis: association of case-mix and treatment characteristics with medical charges

OBJECTIVES

To examine the relationship of various pretreatment case-mix characteristics and treatment modalities with medical charges incurred during diagnosis, treatment, and 2-year follow-up for patients with laryngeal cancer.

DESIGN

Retrospective chart review and billing record analysis.

METHODS

The charts and billing records of patients diagnosed with laryngeal cancer at the University of Iowa Hospitals and Clinics (UIHC) between January 1, 1991 and December 31, 1994 were reviewed. The independent variables included various pretreatment patient-mix and tumor characteristics (age, AJCC TNM clinical stage, smoking history, ASA class, and comorbidity as defined by Kaplan-Feinstein grade) as well as type of treatment. The dependent variables included total physician, office, and university hospital-based charges incurred during the pretreatment evaluation and 0- to 3-, 3- to 12, and 12- to 24-month billing periods after the initiation of cancer-directed therapy. Total 1-year and 2-year charges were also evaluated. Univariate and multivariate analyses were used to investigate the relationships between dependent and independent variables and to develop models predictive of management charges during the individual and total billing periods.

RESULTS

Pretreatment charges showed no significant associations (P < .05) with any of the independent variables. Multiple regression analyses indicated that comorbidity, stage, and initial treatment modality were significant variables in one or more of the models predicting charges incurred during the 0- to 3-month, 3- to 12-month, total 1-year, and total 2-year billing periods. The models yielded R2 values for the total 1- and 2-year billing periods of 0.5246 and 0.5055, respectively.

CONCLUSIONS

This work supports continued study of measures that may result in earlier detection of laryngeal cancer as a potential means of reducing management charges. These results also indicate that a more accurate method of stratifying the disease severity of laryngeal cancer patients for reimbursement purposes would include measurements of the severity of the index disease as well as comorbid diseases.

Oral transmucosal fentanyl pretreatment for outpatient general anesthesia

The oral transmucosal formulation of fentanyl citrate (OTFC) has been reported to be an effective sedative, providing convenient and atraumatic sedation for children prior to general anesthesia or painful diagnostic procedures. Thirty-three young children (24-60 months of age) scheduled for outpatient general anesthesia for treatment of dental caries were enrolled in this randomized placebo-controlled clinical trial. To determine the effectiveness of the OTFC premedication, patient behavior was evaluated using three distinct outcome ratings. A sedation score rated behavior in the waiting room prior to OTFC as well as 10 minutes and 20 minutes after OTFC. A separation score rated the child's response to being separated from his/her parent or guardian for transport to the dental operatory. Finally, a cooperation score rated the child's acceptance of the mask induction. The OTFC formulation was well tolerated by most of the children in this study. Compared with the placebo oralet, the active OTFC improved behavior for separation from the parent (P < .05) and cooperation with the mask induction (P < .05). The duration of surgery and the time of recovery did not differ between placebo and active premedication. Side effects including respiratory and cardiovascular complications were reported more frequently in the active fentanyl group. Continuous monitoring of respiratory function is essential when using this unique and effective formulation of fentanyl for pediatric preanesthetic sedation.

Epithelial ovarian carcinoma in the reproductive age group

BACKGROUND

A retrospective review of women age < or = 40 years with epithelial ovarian carcinoma was undertaken to determine whether patient age and tumor grade are independent prognostic factors for survival, to investigate the survival rate for young women with ovarian carcinoma, and to characterize these young women in terms of reproductive capability.

METHODS

The tumor registry of the Massachusetts General Hospital was used to identify cases of ovarian carcinoma diagnosed between January 1980 and July 1996. Patient records and pathology were reviewed. Survival rates were calculated by the Kaplan-Meier method and Cox proportional hazards models were used to determine the independent effect of each variable on survival.

RESULTS

Ninety-two tumors epithelial tumors were identified with 46 (50%) classified as borderline. In the univariate analysis, stage (P < 0.001), grade (P < 0.001), residual disease (< or = 2 cm vs. > 2 cm, P < 0.001), and age (< 30 years vs. 31-40 years; P = 0.019) were found to be significant prognostic factors for survival. However, in the multivariate analysis only tumor grade (with borderline tumors assigned a grade of 0) and stage were significant predictors of survival (P < 0.01 for both). The 5-year survival rate for carcinoma patients with advanced disease was 22.9%. Patients with borderline tumors were more likely be diagnosed during an evaluation for infertility and were more likely to have successful live births after carcinoma treatment.

CONCLUSIONS

Young women with advanced epithelial carcinoma have a 5-year survival rate similar to that quoted in the literature, despite the use of more aggressive chemotherapeutic regimens. Patients with borderline tumors of any stage have an excellent prognosis for preserving fertility options.

Efficacy of media enriched with nonlactate-generating substrate for organ preservation: in vitro and clinical studies using the cornea model

BACKGROUND

Using a rabbit cornea model, our recent study demonstrated that Chen Medium (CM), an isotonic media enriched with nonlactate-generating high-energy substrates, is very effective for organ preservation. In the present study, the efficacy of CM is further evaluated with human corneas

METHODS

The effectiveness of CM and Optisol for preserving the endothelial integrity of human corneas in vitro was evaluated by scanning electron microscopy. Clinical efficacy was evaluated in a total of 83 patients: 10 patients with keratoconus grafted randomly with either CM- or Optisol-stored cornea of the same donor, and 73 patients with various conditions grafted with CM-stored corneas. After surgery, visual acuity and quality of the graft were monitored for up to 4.6 years.

RESULTS

The scanning electron microscopic study revealed that after 11-day storage at 4 degrees C, the CM-stored cornea had only marginal disruptive changes, 9.4+/-1.1%, in endothelial cells, as opposed to 42.4+/-4.6% of the Optisol-stored cornea. All 78 CM-stored corneas, including 67 with 12.2- to 17.7-hr death-to-storage time, 3-7.6 days of storage time, and initial marginal quality before storage, were successfully transplanted. These grafts were thin and clear, with an excellent epithelial integrity and without significant changes in endothelial cell density. Five Optisol-stored corneas were also successfully grafted; one of them, however, was edematous for about 4 weeks, and all the grafts were slightly thicker with substantial endothelial cell loss.

CONCLUSION

Using a cornea model, present and recent studies show that CM is very effective for preserving tissue viability and endothelial integrity. Previous study revealed that CM-stored tissues maintained high levels of ATP and metabolic function, with suppression of lactate formation and accumulation. Thus, these findings support the concept that preservation of tissue viability is closely associated with the ability of the tissues to retain metabolic activity, to generate ATP efficiently, and to prevent acidosis effectively during storage.

Toxicity and allergy to local anesthesia

Considering the amount of local anesthetic administered on a daily basis, dental professionals must be familiar with the factors that influence the dose and type of local anesthetic that induces a toxic or allergic reaction. In addition to the route and rate of administration, the patient's physical condition and health may also influence the dose of local anesthetic that could be safely administered. This article reviews the different causes of local anesthesia toxicity and allergy. With prevention and early recognition of the warning signs, poor prognosis can be avoided.

Active vs. passive methods of recruiting ethnic minority women to a health promotion program

Ethnic minority women have been underrepresented in health promotion research. There is a need to develop effective methods of recruiting ethnic minority women to health promotion programs and research studies. This article evaluates several methods for recruiting ethnic minority women to a study of a telephone and mail intervention encouraging participation in a home-based walking program. One hundred twenty-six sedentary ethnic minority women between the ages of 25 and 55 were recruited using two types of approaches. Number of participants screened, number enrolled, and recruitment efficiency (ratio of number recruited/number screened) were assessed. "Active" recruitment, contacting targeted individuals in person, by phone, or by mail, yielded 236 screened and 29 recruited with a recruitment efficiency of 11%. "Passive" recruitment, informing the community through public notices and waiting for volunteers to call, yielded 151 screened and 97 recruited with a recruitment efficiency of 64%. Those recruited by active or passive methods did not differ by demographic characteristics, baseline psychosocial variables, or dropout rates. Passive recruits walked significantly more at five-month follow-up than active recruits. Passive recruitment may be more economical at the cost of potentially biased samples.

Localization of a novel gene for nonsyndromic hearing loss (DFNB17) to chromosome region 7q31

Autosomal recessive nonsyndromic hearing loss (ARNSHL) is the most common form of hereditary hearing impairment (HHI). To date, 16 different loci have been reported, making ARNSHL an extremely heterogeneous disorder. One of these loci, DFNB4, was mapped to a 5-cM interval of 7q31 in a large Middle-Eastern Druze family. This interval also includes the gene for Pendred syndrome. We report on three new families with HHI from the Madras region of southern India that demonstrate linkage to 7q. Their pedigrees are compatible with autosomal recessive inheritance. Furthermore, the largest family identifies a novel locus (DFNB17) telomeric to the DFNB4 and Pendred intervals. A 3-cM region of homozygosity by descent between markers D7S486 and D7S2529 is present in all affected individuals in this family and generates a multipoint LOD score of 4.24. The two other families map to the previously reported DFNB4 region but have insufficient power to attain significant LOD scores. However, mutations in the Pendred syndrome gene are present in one of these families.

A home-based behavioral intervention to promote walking in sedentary ethnic minority women: project WALK

A home-based telephone and mail intervention was evaluated for its effectiveness in promoting walking in a sample of sedentary, ethnic minority women. One hundred twenty-five women (ages 23-54) were randomly assigned to behavioral or brief educational interventions. Women in the 8-week behavioral condition received behavior change materials through the mail and 6 structured telephone counseling sessions. Educational condition participants received a single 5-min telephone call and educational information. Both groups reported significantly increased walking at a 2-month posttest (M change = 86 and 81 min per week for behavioral and educational groups, respectively) and 5-month follow-up (M change = 40 and 52 min per week). A 30-month follow-up of 50 participants indicated both groups continued to report more walking than at baseline. The behavioral intervention was not superior to the educational condition at any assessment point. The findings may be explained as (a) both interventions were equally effective, so extensive telephone counseling is unnecessary; (b) changes over time reflected secular trends; or (c) increases in self-reported walking may be due to socially desirable reporting. Other strategies need to be evaluated for promoting walking that are tailored to the needs of ethnic minority women.

Presymptomatic diagnosis of nonsyndromic hearing loss by genotyping

BACKGROUND

Nonsyndromic hearing loss (NSHL) is the most common type of hereditary hearing impairment (HHI). It is genetically heterogeneous, and although the exact number of genes is not known, 38 loci have been identified. By cloning the relevant genes and studying the function of the encoded proteins at the molecular level, it may be possible to impact the habitation of persons at risk for HHI. Currently, for select families, presymptomatic diagnosis of NSHL by genotyping is possible.

OBJECTIVE

To provide presymptomatic diagnosis of HHI to individuals in select families who have participated in linkage studies.

DESIGN

In 2 large families with autosomal dominant HHI, genes for NSHL were mapped to chromosomes 6 (DFNA10) and 19 (DFNA4). In each family, the phenotype is one of progressive sensorineural hearing loss that begins in the individual's mid-30s and progresses to a severe-to-profound loss requiring amplification. Presymptomatic diagnosis was requested by, and provided to, 19 at-risk persons in these kindreds.

RESULTS

By reconstructing haplotypes through the use of short tandem repeat polymorphisms tightly linked to the disease gene, risk calculations and genetic counseling were provided to these persons.

CONCLUSIONS

By simple Mendelian genetics, the risk of inheriting a fully penetrant autosomal dominant NSHL gene from a single affected parent is 50% for each offspring. However, by reconstructing haplotypes in families in which an HHI gene has been localized, this risk can be changed substantially.

Labor induction with intravaginal misoprostol in term premature rupture of membranes: a randomized study

OBJECTIVE

To evaluate the safety and clinical effectiveness of intravaginal misoprostol, a synthetic prostaglandin E1 analogue, for labor induction in gravidas with premature rupture of membranes (PROM) at term.

METHODS

One hundred forty-one pregnant women with term PROM were assigned randomly to one of two induction groups: 1) intravaginal misoprostol or 2) intravenous oxytocin by continuous infusion.

RESULTS

Seventy subjects were allocated to the misoprostol group and 71 to the oxytocin group. The mean (+/- standard deviation) interval from induction to delivery was significantly shorter in the misoprostol group (416 +/- 276 compared with 539 +/- 372 minutes; P = .04). In 85.7% of patients in the misoprostol group, only one dose was required. Intrapartum complication rates, mode of delivery, and neonatal or maternal adverse event rates were similar in the two treatment groups. Uterine tachysystole occurred more frequently with misoprostol than with oxytocin (28.6% compared with 14.0%; P < .04).

CONCLUSION

Intravaginal administration of misoprostol induces labor safely and effectively in patients with PROM at term.