Comparison between porcine dermal implant (Permacol) and silicone injection (Macroplastique) for urodynamic stress incontinence

The objective of this study was to compare the efficacy of porcine dermal implant injection (Permacol) and silicone injection (Macroplastique) in the treatment of female urodynamic stress incontinence (USI) in a prospective randomized trial. Fifty women with urodynamically proven stress incontinence were recruited and randomised to receive either Permacol or Macroplastique injection. Twenty-five patients were enrolled in each case. An International Continence Society (ICS) standard 1-h pad test was carried out prior to the injection and a subjective analysis of incontinence made using a Stamey scoring system. In addition, a Kings College Hospital Quality of Health Questionnaire (KCQ) was completed. The women were followed up at 6 weeks and 6 months and the same methods used to gauge the success or failure of the operation. Preoperatively there were no significant differences in pad losses, Stamey score or King's score between the two groups. The mean age of the women was 61 years (range 28-80 years). At 6 weeks there were significant reductions in the mean and median values in pad losses, Stamey score and King's score in both Permacol and Macroplastique patients but the effects were more pronounced in Permacol patients than Macroplastique patients. Of the Permacol patients, 64% were improved on quantified pad losses out of which 60% were dry whereas 54% of Macroplastique patients were improved on pad losses of which 41.6% were dry. Of the Permacol patients, 64% and 60% had reduction in Stamey and KCQ score, respectively, whereas Macroplastique patients had 46% reduction in one or more grades of Stamey scores and 42% reduction in KCQ scores. At 6 months the results in the Permacol patients appeared to be sustained but not for Macroplastique patients. This study has shown that Permacol injection when used as a urethral bulking agent appears to have a higher cure rate for urodynamic stress incontinence than Macroplastique and these results persist until the follow-up period of 6 months. The use of Permacol injection is an attractive alternative in the treatment of urodynamic stress incontinence.

Differentiation of Autoimmune Pancreatitis from Pancreatic Cancer Remains Challenging

BACKGROUND

Autoimmune pancreatitis (AIP) is an uncommon form of chronic pancreatitis. Whilst being corticosteroid responsive, AIP often masquerades radiologically as pancreatic neoplasia. Our aim is to appraise demographic, radiological and histological features in our cohort in order to differentiate AIP from pancreatic malignancy.

METHODS

Clinical, biochemical, histological and radiological details of all AIP patients 1997-2016 were analysed. The initial imaging was re-reviewed according to international guidelines by three blinded independent radiologists to evaluate features associated with autoimmune pancreatitis and pancreatic cancer.

RESULTS

There were a total of 45 patients: 25 in type 1 (55.5%), 14 type 2 (31.1%) and 6 AIP otherwise not specified (13.3%). The median (IQR) age was 57 (51-70) years. Thirty patients (66.6%) were male. Twenty-six patients (57.8%) had resection for suspected malignancy and one for symptomatic chronic pancreatitis. Three had histologically proven malignancy with concurrent AIP. Two patients died from recurrent pancreatic cancer following resection. Multidisciplinary team review based on radiology and clinical history dictated management. Resected patients (vs. non-resected group) were older (64 vs. 53, p = 0.003) and more frequently had co-existing autoimmune pathologies (22.2 vs. 55.6%, p = 0.022). Resected patients also presented with less classical radiological features of AIP, which are halo sign (0/25 vs. 3/17, p = 0.029) and loss of pancreatic clefts (18/25 vs. 17/17, p = 0.017). There were no differences in demographic features other than age.

CONCLUSION

Despite international guidelines for diagnosing AIP, differentiation from pancreatic cancer remains challenging. Resection remains an important treatment option in suspected cancer or where conservative treatment fails.

Are dyspepsia management guidelines coherent with primary care practice?

BACKGROUND

Spontaneous physician behaviour can affect guideline applicability, implementation strategies and application costs, particularly in relation to widespread pathologies chiefly managed by general practitioners (GPs). Of the array of dyspepsia management guidelines, the closest to general practice, partly owing to proposing committee composition, are the European Society for Primary Care Gastroenterology (ESPCG) guidelines.

METHODS

To evaluate variability in dyspepsia management among GPs in Padua and divergence in spontaneous prescriptive behaviour from the ESPCG dyspepsia guideline, we prospectively studied the behaviour of 39 GPs over a 3-month period of outpatient activity, through questionnaires on each consultation. Test-group representativeness was preliminarily defined in terms of antisecretory drug expenditure.

RESULTS

1790 forms on dyspepsia-related consultations were studied in a population of 51,193 registered patients; 1264 patients with a history of dyspeptic pathology consulted their GP (19% duodenal ulcer (DU), 9% gastric ulcer (GU), 54% gastro-oesophageal reflux disease (GERD), 32% non-ulcer dyspepsia (NUD), 1% cholelithiasis), while 526 patients presented with symptoms of dyspepsia with no previous gastroscopy (EGDS) (42% were aged <45 years), of whom 42% had twice consulted their GP. Empirical management by prescription of symptomatic drugs was the most common procedure in DU (33%), GU (73%) and NUD (74%) relapses. Helicobacter pylori eradication therapy was prescribed in only 2% of patients with a history of organic or functional dyspepsia. 145 patients with uninvestigated dyspepsia were referred for second-level endoscopy and 43 for H. pylori testing. Forty-four percent of endoscopies prescribed for uninvestigated patients did not comply with the ESPCG guideline; full compliance would have determined a 105% rise in endoscopies. Prescriptive variability between GPs was high (based on the Goodman-Kruskal (0.41, P < 0.001) and Cramer tests (V = 0.51, P < 0.005)) and agreement between observed and expected prescriptions according to ESPCG criteria was as low as V = 0.11. On the basis of the most frequently observed behaviours, we developed three options of the ESPCG guideline and compared them to spontaneous prescriptions.

CONCLUSIONS

Highest compliance emerged where the clinical approach for all patients with uninvestigated dyspepsia was symptomatic therapy at first presentation followed by a different attitude at second presentation, setting a higher cut-off age than in the guideline (which in our case proved, on mathematical calculation, to be 55 years).

Bladder augmentation using PelvicolTM implant for intractable overactive bladder syndrome

The objective of the study was to evaluate the effectiveness of an implant of porcine dermis to augment the bladder in women with refractory overactive bladder syndrome (OAB). Twelve women underwent a Pelvicol bladder augmentation. A visual analogue score for severity of incontinence and a quality of life questionnaire was carried out pre-operatively and at 12 months post-operatively. Follow up cystoscopy was carried out in three women in addition. Three women were dry and cured; five women were significantly improved; two women were slightly improved and the procedure was unsuccessful in the remaining two women. There were no significant complications and voiding was spontaneous in every case. A bladder augmentation using porcine dermis may have a role in the surgical management of non-neuropathic women with OAB that has failed to respond to conservative therapy.

Prevalence of anorectal dysfunction in women attending health care services

The aim of this study was to assess the prevalence of different bowel symptoms (constipation, faecal incontinence and faecal evacuation dysfunction) and associated urinary symptoms in women attending health care services. All women attending colposcopy clinics and general gynaecology clinics in a district general hospital in the southwest of England were invited to participate in the study. In addition, women attending the local family planning clinic were also recruited. Women attending these clinics routinely completed a history sheet and were asked to complete the Birmingham Bowel and Urinary Symptoms Questionnaire. Two hundred women participated in the study: 116 (64.4%) had at least one bowel symptom from the list in the questionnaire and 57 (31.6%) of women thought they had a bowel problem but only 26 (14.4%) consulted their family doctor regarding the problem while four (2.2%) were referred for specialist opinion. Six were unsure about their bowel symptoms. There were 46 (25.5%) of women who had constipation, 99 (55%) had faecal incontinence and 97 (53.8%) complained of faecal evacuation dysfunction. Only 48 (26.6%) of women were free of any bowel complaint. One patient with faecal incontinence discussed her problem with her midwife but no further action was taken as she was too embarrassed to discuss it with her doctor. Seventy-eight (43.3%) of patients had urinary symptoms. Fifty-five (30.5%) thought they had a urinary problem but only 29 (16.1%) consulted their doctor and 17 (9.4%) were referred for specialist opinion. Sixty-one (33.8%) of those who admitted to have urinary incontinence also had faecal incontinence. Forty-nine (27.2%) of the patients were free of all symptoms. The mode of delivery as well as previous surgery did not have any influence on urinary incontinence nor on anal incontinence. This study has demonstrated a high prevalence of bowel symptoms in women attending health care services.

Membrane-containing virus particles exhibit the mechanics of a composite material for genome protection

The protection of the viral genome during extracellular transport is an absolute requirement for virus survival and replication. In addition to the almost universal proteinaceous capsids, certain viruses add a membrane layer that encloses their double-stranded (ds) DNA genome within the protein shell. Using the membrane-containing enterobacterial virus PRD1 as a prototype, and a combination of nanoindentation assays by atomic force microscopy and finite element modelling, we show that PRD1 provides a greater stability against mechanical stress than that achieved by the majority of dsDNA icosahedral viruses that lack a membrane. We propose that the combination of a stiff and brittle proteinaceous shell coupled with a soft and compliant membrane vesicle yields a tough composite nanomaterial well-suited to protect the viral DNA during extracellular transport.

IRMER regulations: compliance rate of radiograph reporting by non-radiology clinicians

AIM

To assess compliance with regulation 7(8) of Ionizing Radiation Medical Exposure Regulations (IRMER) 2000 legislation amongst non-radiologists reporting radiographs in a large district general hospital.

MATERIALS AND METHODS

A prospective review of 100 consecutive radiography request cards from five different departments undertaking their specialty radiograph reporting were collected over 4 weeks. The requests were then traced to their respective case notes to assess documentation of radiographs. The five departments included chest, maxillo-facial, rheumatology, orthopaedics, and inpatients. Twenty-two case notes were gathered from chest clinics, 21 from maxillo-facial, 15 from rheumatology, 23 from orthopaedics fracture clinics, and 19 were taken from inpatients.

RESULTS

Only 53% of radiographs undertaken by non-radiologists had a documented report. The specialty most compliant with IRMER was orthopaedics 17/23 (74%) and the specialty least compliant was maxilla-facial 8/21 (38%). Of the documented radiographs, the consultant grade was the largest group of doctors [36% (19/53)] that undertook documentation, and for the undocumented radiographs, they were also the largest group of clinicians that did not document radiographs [77% (36/47)]. All radiographs that were documented in the notes also had documented interpretation of the radiograph.

CONCLUSION

Only 53% of plain radiographs were documented and reported by non-radiology clinicians even though IRMER legislation applies to all clinicians undertaking radiograph interpretation. All clinicians undertaking interpretation of radiographs should be made aware of this legislation and the responsibility to document their findings.

Effect of IUCD on human uterine fluid protein concentration throughout the menstrual cycle

Uterine fluid of 96 Women implanted with IUCD was collected and processed for protein estimation. The results obtained in women having IUCD were compared with those of parous/normal women. The trend of fluctuation in protein concentration was the same in both parous and women with IUCD. But comparatively the protein concentration in it was so much higher in women having IUCD throughout the menstrual cycle. The increased concentration may be responsible for making the fluid environment unfavourable for blastocyst as well as sperm metabolism.

Unilateral Atraumatic Expulsion of an Ectopic Pregnancy in a Case of Bilateral Ectopic Pregnancy

Ectopic pregnancy occurs in 1-2% of pregnancies. The fallopian tube is the most common site; however, bilateral tubal ectopic pregnancy is an extremely rare phenomenon, seen in approximately 1/200,000 pregnancies. It is usually the result of assisted reproductive techniques (ART). Ultrasound (USS) and serial beta-hCG levels have shown poor efficacy for accurate diagnosis. Laparoscopy is the diagnostic gold standard. The majority of cases are managed surgically with bilateral salpingectomy. A 26-year-old female presented to our early pregnancy unit with pain and vaginal bleeding at 5-week gestation after IVF. USS was inconclusive and her b-hCG levels rose with worsening pain; therefore, a decision was made for diagnostic laparoscopy. Although there was a clear right sided ectopic pregnancy, the left tube was swollen and therefore a methylene blue dye test was carried out to confirm blockage. Atraumatic milking, to expose the dye, expelled necrotic tissue which histology confirmed to be a second ectopic pregnancy. She made a good recovery with falling beta-hCG levels and left tubal preservation. As the use of ART increases, bilateral ectopic pregnancies will become more common. Novel and established techniques should be used to help confirm the diagnosis and assist in tubal preservation.

[Interferon-alpha. Results of a pharmaco-epidemiologic study]

In the present study we evaluated the use of alpha-IFN in the ULSS 21 of Veneto Region. All outpatients treated with interferon during the period June-July 1992 (114 subjects) were interviewed using a standard questionnaire which was meant to collect information about therapy, side effects and quality of life. Alpha-IFN was mostly prescribed for chronic non-A non-B hepatitis (as approved by the FDA in the USA and by the Ministero della Sanità in Italy), while 35% of the patients were suffering from diseases for which interferon use is approved by Ministero della Sanità but not by FDA. In most cases, independently of the specific disease, a standard dose of 9 MU/week was used, which often resulted to be below the recommended doses reported in the literature. Adverse effects were frequently reported. The most common include fever, chills, headache, fatigue, myalgia. Mild mental disturbances (irritability and/or depression) and thyroid dysfunction were also reported but were less frequent. Finally, a negative influence of alpha-IFN therapy on the quality of life was reported by about half of the interviewed patients.

Serum calcium and magnesium levels in women with detrusor overactivity

The aim of this study was to determine whether abnormal serum levels of magnesium and calcium occur in women with detrusor overactivity. These were compared with the serum level of magnesium and calcium ions in women with urodynamic stress incontinence as controls to see whether alteration of these levels offer a further therapeutic option. The study included 20 women with urodynamically proven detrusor overactivity compared with 20 women with urodynamic stress incontinence as controls. A blood test was taken to determine serum levels of total magnesium phosphate together with free and corrected calcium. In addition, the calcium and magnesium ratio (Ca:Mg) and calcium corrected and magnesium ratio (Ca Corr:Mg) were calculated. Both parametric and non-parametric tests were used to compare the two groups with respect to these variables. The mean, median and standard deviation of the two groups are very similar for each of the variables. There is no evidence to suggest that there is any difference between detrusor overactivity and urodynamic stress incontinence with respect to these variables. This study has shown that there is no abnormal correlation between serum calcium and magnesium ions in women with detrusor overactivity. There appears to be no therapeutic benefit in calcium and/or magnesium supplements for detrusor overactivity.