Defects on endoanal ultrasound and anal incontinence after primary repair of fourth-degree anal sphincter rupture: a study of the anal sphincter complex and puborectal muscle

OBJECTIVES

To perform three-dimensional endoanal ultrasound (EAUS) after primary repair of fourth-degree anal sphincter rupture (ASR) and correlate the sonographic defects with anal incontinence (AI); to measure the axial and sagittal thickness and angle of the puborectal muscle (PRM) as well as the length of the anal canal, and then correlate these measures with AI; and to assess the interobserver measurement agreement between an inexperienced and an experienced sonologist.

METHODS

EAUS was offered to 84 consecutive women, who were asked to answer a validated questionnaire after fourth-degree ASR. AI was graded according to the Wexner score and EAUS defects were graded according to the Starck score.

RESULTS

Sixty-one women (73%) answered the questionnaire. The median (range) follow-up time was 5.1 (1.3-8.7) years. Thirty-three (54%) of these women underwent EAUS and were included in the study. There was no difference in the incontinence scores between women who underwent EAUS and those who did not. Eleven of the women who underwent EAUS (33%) were continent, 22 women (67%) had flatus incontinence at least once a month, of whom 12 also had incontinence for liquid stool and two had incontinence for solid stool. The median Wexner score was 2 (range, 0-12). Five of the patients (15%) had no ultrasound defects. All of the patients with Wexner scores > or = 4 had a Starck score of > or = 10. No association between ultrasound defects and AI was demonstrated, however, the angle of the PRM and parity were associated with Starck score. No clear association between the measurements of the PRM and AI was shown. The experienced observer detected more of the small defects than did the inexperienced observer.

CONCLUSION

In a 1-9-year follow-up period after primary suture of fourth-degree ASR, the frequency of AI was high, at 67%. No clear association was seen between AI and sphincter defects detected on ultrasonography. There was an association between the angle of the PRM and the extent of ultrasound defects.

[Convalescence recommendations after hysterectomy. A study of opinions among Danish physicians]

INTRODUCTION

The aim of this study was to describe advice and restrictions given by Danish general practitioners (GPs) and gynaecologists to patients after uncomplicated hysterectomy.

MATERIALS AND METHODS

Four hundred and ninety-one randomly selected GPs and 433 gynaecologists received a postal questionnaire in 1998/1999. The questions concerned the length of recommended sick leave, lifting restrictions, and time to resumption of seven defined common activities after hysterectomy. In addition, the gynaecologists were asked about the use of vaginal packaging, bladder catheters, and expected length of hospital stay.

RESULTS

The total response rate was 72%. GPs and gynaecologists recommended a median of 4 weeks (1-8 weeks) of convalescence after hysterectomy to patients, whose work did not involve heavy lifting, and a median of six weeks (2-12 weeks) to women, whose work did. Responses concerning the resumption of common activities showed considerable variation, for instance patients were advised to postpone sexual intercourse for a median of four weeks postoperatively (0-12 weeks). Lifting restrictions varied from lifting a maximum of 15 kg for two weeks to a maximum of 2 kg for 12 weeks.

CONCLUSION

A considerable variation was found in recommendations and regimens for hysterectomised patients. Evidence-based guidelines do not exist, and until these are available, the national and local boards of physicians need to agree on what restrictions should be given to patients.

Substantial variability in postoperative treatment, and convalescence recommendations following vaginal repair. A nationwide questionnaire study

BACKGROUND

Postoperative care and convalescence recommendations following vaginal surgery are generally not evidence based. The aim of this study was to describe pre and postoperative treatment, and advice and restrictions for the convalescence period, given by Danish hospital-employed gynecologists, and gynecologists in private practice, to patients undergoing vaginal repair.

METHOD

In 1999 all Danish gynecologists (n=433) received a tested questionnaire about postoperative treatment and convalescence recommendations following vaginal repair. Non-responders received one reminder.

OUTCOME MEASURES

Pre and postoperative treatment, and expected hospital stay. Furthermore, lifting restrictions, sick leave, and convalescence before resumption of defined activities.

RESULTS

The overall response rate was 82%. The expected postoperative hospital stay was median 3 days (range, 1-7) following anterior repair, and 2 days (range, 1-7) following posterior repair. The recommended sick leave was median 6 weeks (range, 2-12) for patients with work with heavy lifts. There were substantial differences in recommendations. Recommended lifting restrictions were median 3 kg (range, 0-20) for median 4 weeks (range, 1-12), and the recommended time till recommencement of sexual intercourse was median 4 weeks (range, 0-12). The recommended convalescence was median 4-5 weeks for strenuous activities, and median 1-2 weeks for non-strenuous activities, with ranges from 0-24 weeks. The overall, great variance could not be explained by demographic differences between gynecologists.

CONCLUSION

Postoperative treatment, and convalescence recommendations given by Danish gynecologists following vaginal repair, show substantial variability and are based on individual viewpoints. Evidence based guidelines and consensus are desirable.

[Placenta accreta. Bleeding and disseminated intravascular coagulation following Cesarean section]

A case of placenta accreta in a 30-year old woman with one prior caesarean section is presented. The operative course of her second caesarean section was complicated by mild atonia. The postoperative course was complicated by mild atonia, which was followed by excessive vaginal and intraabdominal bleeding due to atonia and disseminated intravascular coagulation. An abdominal hysterectomy was performed. Risk factors, antenatal diagnostic methods, complications and different treatment aspects are discussed.

Influence of age on the prognostic importance of left ventricular dysfunction and congestive heart failure on long-term survival after acute myocardial infarction. TRACE Study Group

The aim of this study was to assess the importance of congestive heart failure and left ventricular (LV) systolic dysfunction after an acute myocardial infarction (AIM) on long-term mortality in different age groups. A total of 7,001 consecutive enzyme-confirmed AMIs (6,676 patients) were screened for entry into the TRAndolapril Cardiac Evaluation (TRACE) study. Medical history, echocardiographic estimation of LV systolic function determined as wall motion index, infarct complications, and survival were documented for all patients. To study the importance of congestive heart failure and wall motion index independent of age, we performed Cox proportional-hazard models in 4 different age strata (< or = 55 years, 56 to 65 years, 66 to 75 years, and > 75 years). Patients in these strata had 1-year mortality rates of 5%, 11%, 21%, and 32%, respectively. Three-year mortality rates were 11%, 20%, 34%, and 55%, respectively. The risk ratios (and 95% confidence limits) associated with congestive heart failure in the same 4 age strata were 1.9 (1.3 to 2.9), 2.8 (2.1 to 3.7), 1.8 (1.5 to 2.2) and 1.8 (1.5 to 2.2), respectively. The risk ratios associated with decreasing wall motion index were 6.5 (3.6 to 11.4), 3.3 (2.3 to 4.6), 2.7 (2.2 to 3.4), and 2.1 (1.7 to 2.6), respectively. In absolute percentages, there was an excess 3-year mortality associated with congestive heart failure in the 4 age strata of 14%, 24%, 25%, and 28% respectively. The absolute excess in 3-year mortality associated with LV systolic dysfunction in the 4 age strata was 15%, 19%, 25%, and 21%, respectively. Thus, the relative importance of LV systolic dysfunction and congestive heart failure diminished with increasing age. However, the absolute excess mortality associated with congestive heart failure and LV systolic dysfunction was more pronounced in the elderly than in the young.

Influence of gender on short- and long-term mortality after acute myocardial infarction. TRACE study group

The aim of this study was to assess differences in short- and long-term mortality between male and female patients with acute myocardial infarction (AMI). The study population consisted of 6,676 consecutive patients admitted alive with an enzyme-confirmed AMI to 27 Danish hospitals from 1990 to 1992. Five patients were excluded because of missing information. Female patients (n = 2,170) were on average 5 years older than male patients (n = 4,501, p <0.001), had lower body mass index, and more often had diabetes, hypertension, and congestive heart failure. Left ventricular systolic function was the same for men and women. Women received thrombolytic therapy less often. The 1-year mortality for female patients was 28 +/- 1% and for men 21 +/- 1% (p <0.001). The unadjusted risk ratio associated with male gender in a proportional-hazards model was 0.76 (95% confidence intervals [CI] 0.70 to 0.83). Adjustment for age removed the importance of gender, and the risk ratio associated with male gender was 1.06 (95% CI 0.97 to 1.2, p = 0.2). An introduction of further variables in the model did not change this. Subdividing mortality into 6-day, 30-day, and late mortality demonstrated a significantly increased mortality in women in the short-term (6 and 30 days), with a risk ratio in men of 0.58 (95% CI 0.42 to 0.81) and 0.80 (95% CI 0.65 to 0.99), respectively. From day 30 onward there was an increased mortality in men with a risk ratio of 1.16 (95% CI 1.03 to 1.31, p = 0.01). Thus, women admitted alive to the hospital with an AMI have an increased long-term mortality that is explained by their older age. However, short-term mortality in women seems to increase independently of other risk factors, but is later followed by an increase in mortality in men.

[Chlamydia trachomatis in pregnant women in the county of Vestsjaelland. Prevalence, prevention of perinatal transmission and cost-effectiveness of screening]

The prevalence of genital Chlamydia trachomatis (CT) in pregnant women and the perinatal transmission after treatment was investigated. An analysis of the cost-effectiveness of introducing a screening program among women at risk of having CT was made. Out of 339 pregnant women 2.9% had cervical CT. CT-positive women were treated with erythromycin. CT-positive women were significantly younger than CT-negative women and the odds ratio (OR) of having CT if nulliparous was 3.35. The CT-prevalence was 6.6% among women younger than 25 years and 1.6% among women 25 years or older (p = 0.0163). OR of having CT if younger than 25 years was 4.3. The young women were significantly younger at sexual début. None of the children of women treated for CT during pregnancy developed neonatal CT-conjunctivitis. The screening of women younger than 25 years was considered to be cost-effective. It is concluded that women younger than 25 years are at risk of having CT. Treatment of CT-positive women with erythromycin during pregnancy seems to be effective in eradicating this microorganism and thus preventing perinatal transmission and neonatal CT-conjunctivitis. It therefore seems rational to screen all pregnant women under the age of 25 years for cervical CT, especially in high risk areas.

[Chlamydia trachomatis]

Almost 11,000 cases of Chlamydia trachomatis (CT) are diagnosed every year in Denmark. The most important epidemiologic factor is age under 25 years. The prevalence of CT among women applying for legal abortion is five to eight percent and in a recent study the prevalence of CT among second trimester pregnant women was found to be 2.9 percent. The consequences of CT-caused infections are many, including risk of infertility, ectopic pregnancies, perinatal transmission etc. The perinatal transmission rate is high in untreated cases of CT during pregnancy, but it can be prevented by treatment of the expecting woman with erythromycin. The Danish National Board of Health do recommend screening for CT before transcervical interventions, but there are no such recommendations concerning pregnancy health care. A recent Danish study as well as many other studies have shown that it is cost-effective to screen high risk women i.e. women younger than 25 years. An introduction of such screening of Danish pregnant women younger than 25 years should therefore be considered.

Thyroid function and autoimmunity in pernicious anemia before and during cyanocobalamin treatment

Out of 35 consecutive patients with decreased plasma-cobalamin 22 had newly diagnosed overt pernicious anemia (PA) six of which had a known history of thyroid disease. At referral, 5 of these 6 were thyroid peroxidase antibody (TPOAb)-positive and 2 were thyroglobulin antibody (TgAb)-positive, while none were thyroid stimulating antibody (TSAb)-positive (an overall autoantibody appearance of 83.3%). Fifty percent of the 22 patients had TPOAb and 13.6% had TgAb compared to 18.2% and 4.5%, respectively in sex and age matched healthy controls. Six PA-patients without a history of thyroid disease had thyroid autoantibodies and another patient seroconverted within the first year during treatment with cyanocobalamin. Measurements of serum concentrations of thyroid hormones and thyroid stimulating hormone were performed during the first year of treatment with cyanocobalamin. Two cases of subclinical myxoedema were found among PA-patients and another case was found among patients with latent PA. The female:male ratio of thyroid disease among PA-patients and among thyroid autoantibody-positive PA-patients was interestingly found to be 1:1. Treatment with cyanocobalamin did not have any systematic effect on thyroid function. Routine screening for thyroid function and thyroid autoantibodies in patients with latent or overt PA is recommended.

Prognosis after nephrectomy for renal cell carcinoma

During the period 1977-1988 177 males and 81 females (age 28-87 years) had nephrectomy performed for renal cell carcinoma. The most frequent symptoms were flank pain (54%) and hematuria (53%). Few patients (6%) had the classical triad of symptoms. Overall survival at 2 and 5 years were 0.55 and 0.41. Renal cell carcinoma specific survival were 0.59 and 0.49. Univariate analyses showed that increasing T stage, positive N or M stage, increasing stage according to Robson, hypersedimentation, anaemia and perioperative blood transfusion had a significant detrimental influence on survival. Multivariate analysis showed that simple Robson stage gave a simpler and equally good description as did the TNM stage. In the Cox multiple regression analysis Robson stage and ESR were the only statistically significant variables.

Giant ovarian tumor masked by obesity

Giant ovarian tumors are rare, but comprise both a clinical as well as a surgical challenge. During the past two decades only 20 cases of ovarian tumors weighing 20 kg or more have been reported. We present a new case, where a giant benign ovarian cystadenoma weighing 28 kg, masked by obesity, was removed. Pathology, complications and treatment of such tumors is discussed. Intact removal and pre-/intra operative drainage of such tumors are equally good as treatment of choice and each case must, therefore, be considered individually. The overall mortality rate in treating such tumors has decreased markedly during the past century. We recommend abdominal ultrasound scan for diagnosis, which should be kept in mind in severe obesity, especially when disproportionate.

Perioperative blood transfusion does not affect survival after operation for renal cell cancer

We retrospectively studied the effect of perioperative blood transfusion in 208 transfused and 50 nontransfused patients operated on during a 12-year period for renal cell cancer. The 5-year renal cell cancer specific survival rate was 0.46 in the transfused patients versus 0.62 in the nontransfused patients. However, when differences in risk factors were accounted for by Cox regression analysis, perioperative blood transfusion was not a significant risk factor. The study does not support the hypothesis that blood transfusion promotes death after operation for renal cell cancer.

Abdominal ultrasound combined with histological and cytological fine needle biopsy of suspected ovarian tumors

To investigate, in a population of women suspected of an ovarian mass, whether pelvic ultrasound (US) and US combined with US-guided fine needle biopsy (FNB) increased the detection rate and whether tumor specific diagnoses could be obtained, a cohort of 307 patients suspected of an ovarian mass underwent US examination as part of routine gynecologic work-up. In cases of solid or solid/cystic lesions a US guided FNB for histology as well as cytology was proposed. All 35 primary ovarian cancers, 6 of 7 secondary ovarian cancers, and 3 of 4 non-ovarian cancers were demonstrated on US. Among 17 cases with normal palpation and an ovarian mass on US, operation disclosed 3 ovarian cancers. FNB identified 24 of 27 primary ovarian cancers and 7 of 7 cancers of extra-ovarian origin. The use of US, in this study, increased the detection of masses in the pelvis and FNB provided a reliable verification.

[Spontaneous bladder perforation--a rare complication of neurogenic bladder dysfunction]

Spontaneous rupture of the urinary bladder which is not associated with trauma is uncommon. A case of spontaneous bladder perforation (triggered by an episode of urinary retention) and peritonitis in a 69-year old male patient with neurogenic bladder dysfunction is reported. The latter was due to disseminated sclerosis and was complicated by recurrent urinary tract infection and two bladder calculi. The etiology, diagnosis and treatment of spontaneous bladder perforation is briefly discussed. The diagnosis spontaneous bladder perforation should be considered in patients with non-characteristic acute abdominal conditions and voiding symptoms, especially if they have neurogenic bladder dysfunction and a history of recurrent lower urinary tract infections and/or bladder calculi. We recommend that bladder stones should be removed--also in asymptomatic cases.

Preoperative investigations for suspected pelvic masses

Ultrasound examination was performed on 307 patients admitted to Herlev Hospital, Copenhagen, for suspicion of a pelvic tumor. Of these, 194 were operated on, 38 (19.6%) having a malignant tumor and 156 with benign conditions. A solid tumor was suspected in 72 patients on whom intravenous pyelography, barium enema, cystoscopy and rectoscopy were performed, although 11 did not undergo an intravenous pyelography and 12 did not undergo a barium enema. Intravenous pyelography, barium enema, rectoscopy and cystoscopy very seldom gave unsuspected information and never changed the indications for operation. Ultrasound examination of the kidneys, urinary tract, bowel system, liver and retroperitoneum as a complementary investigation to the gynecologic examination of the pelvic tumor gave the same information as did the barium enema, intravenous pyelography, rectoscopy and cystoscopy. Therefore, we conclude that these investigations should be carried out only in patients with symptoms from the urinary tract or the bowel system. Instead, we suggest that ultrasound examination of a pelvic mass also include an examination of the kidneys, urinary tract, bowel system, liver and retroperitoneum.

[Pernicious anemia. A study of initial forms of the disease and diagnostic significance of determination of the intrinsic factor antibody and parietal cell antibody]

In a prospective study of thirty five consecutive patients with decreased plasma cobalamine (P-Cbl), twenty-two (63%) were diagnosed as having pernicious anaemia (PA) (no age or sex differences) on basis of the B12-absorption test and/or megaloblastic changes in the bone marrow. In this group ten patients were anaemic (six of whom were characterized as macrocytic), sixteen of nineteen examined had megaloblastic changes in the bone marrow, and all of thirteen examined had achlorhydria with positive correlation to Parietal Cell Antibodies (PCA). Two patients with PA had normal Cbl-absorption and two had malabsorption at the time of diagnosis. Twenty-one patients (95%) had PCA and thirteen (59%) were Intrinsic Factor Antibody (IFAb) positive. Three patients IFAb-seroconverted within a year. Among the remaining thirteen patients (37%), one had PCA but not IFAb and three were IFAb-positive all of whom had normal Cbl-absorption. Of the three patients with IFAb one had also PCA, one IFAb-seroconverted within three months, and one had microcytic anaemia with iron depleted bone marrow due to coecal cancer. Among twenty two healthy adult controls four (18%) had PCA while none had IFAb. This investigation shows that at the debut half of PA patients (55%) do not have anaemia, some have normal Cbl-absorption and some have malabsorption. 95% have PCA and 59% have IFAb. So, IFAb-negative PA is often seen (41%) and seroconversion can take place. Diagnosis is even more reliable, when achlorhydria is present in PCA-positive persons. Healthy PCA-positive persons are probably predisposed to develop PA. Patients with cbl-deficiency, IFAb and/or PCA must be considered as having latent PA even if they have normal haemoglobin and normal Cbl-absorption. These patients should be followed and, in case of anaemia or signs of neuropathia, treated.(ABSTRACT TRUNCATED AT 250 WORDS)

Irradiation of pigmented melanoma cells with high intensity pulsed radiation generates acoustic waves and kills cells

Photokilling of pigmented mouse melanoma cells (B-16) was investigated using pulsed high intensity visible radiation. Melanin acts as an endogenous chromophore, and 694 nm radiation with 40 nsec pulse duration and 0.5-3 X 10(7)w/cm2 intensity causes cell death. Irradiation of non-pigmented human melanoma cells (U1) or human squamous carcinoma cells (FaDu) under similar conditions did not kill the cells. Also, irradiation of B-16 cells with 300 microsec laser pulses (10(3)W/cm2) or with continuous wave (CW) radiation (10(-3)W/cm2) did not kill the cells. These data indicate that pigmented cell killing is due to absorption of radiation by melanin and that the pulsewidth and intensity of radiation play important roles in cell killing. The generation of acoustic waves due to absorption of the pulsed radiation by pigmented cells and by isolated melanosomes was demonstrated at 532 and 625 nm and 8.5 nsec pulse duration (10(7)-10(8) W/cm2); the amplitudes of the acoustic signals were approximately 2.5-3.0-fold higher at 532 nm compared with 625 nm, and they increased with increasing fluence. In contrast, irradiation of U1 or FaDu cells with comparable fluences and intensities did not generate acoustic waves. A possible correlation between the generation of photoacoustic waves and pigment cell death is proposed. Since the thermal relaxation time of melanosomes is 0.5-1.0 microsec, the mechanism proposed is that thermal confinement of high intensity, short-pulse visible radiation generates acoustic waves by thermal expansion, leading to mechanical damage to the cells.

Complete amino acid sequence of alpha-acetolactate decarboxylase from Bacillus brevis

The complete amino acid sequence of acetolactate decarboxylase (EC 4.1.1.5) from Bacillus brevis has been determined by sequencing of the intact enzyme and of peptides obtained by cleavage with cyanogen bromide, Staphylococcus aureus V8 protease and trypsin, respectively. Determination of the C-terminal part was made by treatment with carboxypeptidases Y and M II. The enzyme has a molecular weight of 29,093 and consists of 260 amino acid residues arranged in a single peptide chain without disulphide bonds.

Enzymes immobilized as crystals. Hydrogen isotope exchange of crystalline lysozyme

Immobilization of enzymes by crystallization and subsequent cross-linking provide structures characterized by a regular three-dimensional molecular arrangement and a high packing density. Compared to randomly immobilized enzymes, such structures permit more detailed analysis of the variations in kinetic properties arising from the three-dimensional network or perturbations of the molecular conformations. To obtain information on the effect of crystallization on the dynamic properties of the folded peptide chain in an enzyme molecule, hydrogen exchange rates were measured for both dissolved and crystalline lysozyme over a wide range of pH. Using this method, which reflects molecular oscillations between closely related conformations, no differences were detected between lysozyme in crystalline and dissolved state.