Changes in incontinence after hysterectomy

PURPOSE

Information about the perioperative incontinence following hysterectomy is limited. To advance the postoperative rehabilitation further we need more information about qualitative changes in incontinence, fatigue and physical function of patients undergoing hysterectomy.

METHODS

108 patients undergoing planned hysterectomy were compared pre- and postoperatively. In a sub-study of the prospective follow-up study the changes in incontinence, postoperative fatigue, quality of life, physical function, and body composition were evaluated preoperatively, 13 and 30 days postoperatively. Sample size calculation indicated that 102 women had to be included. The incontinence status was estimated by a Danish version of the ICIG questionnaire; further, visual analogue scale, dynamometer for hand grip, knee extension strength and balance were applied. Work capacity was measured ergometer cycle together with lean body mass by impedance. Quality of life was assessed using the SF-36 questionnaire. Patients were examined preoperatively and twice postoperatively.

RESULTS

In total 41 women improved their incontinence after hysterectomy and 10 women reported deterioration. Preoperative stress incontinence correlated with BMI (r = 0.25, p < 0.01) and urge incontinence with age (r = 0.24, p < 0.02). Further, improvement after hysterectomy in stress incontinence was associated with younger age (r = 0.20, p < 0.04). Improvement in urge incontinence was positively associated with BMI (r = 0.22, p = 0.02). A slight but significant loss was seen in lean body mass 13 and 30 days postoperatively.

CONCLUSIONS

Hysterectomy was not significantly associated with the risk of incontinence; in particular, when no further vaginal surgery is performed. Hysterectomy may even have a slightly positive effect on incontinence and de-novo cure.

Non-operative treatment of ruptured ectopic pregnancy

Ruptured ectopic pregnancy often causes abdominal pain, vaginal bleeding and internal haemorrhage; it is a very serious condition and can be life-threatening. Patients with a ruptured ectopic pregnancy are normally treated by surgical intervention. We describe a case of a 20-year-old woman who presented with abdominal pain and vaginal bleeding. Urine human chorionic gonadotropin was positive and on examination she had localised tenderness of the abdomen. Transvaginal ultrasonography revealed a ruptured tubal pregnancy along with blood in the abdomen. The patient was closely monitored and treated conservatively, with a successful outcome. She recovered uneventfully. Our case shows that non-operative treatment of a ruptured ectopic pregnancy may be a possible non-invasive treatment option in highly selected patients.

Appendicitis during pregnancy in a Greenlandic Inuit woman; antibiotic treatment as a bridge-to-surgery in a remote area

Appendicitis during pregnancy causes severe diagnostic problems, and is associated with an increase in perforation rate and morbidity compared to that in the normal population. In addition, it may cause preterm birth and fetal loss. In remote areas, appendicitis during pregnancy, besides presenting diagnostic problems, also creates treatment difficulties. In Northern Greenland, geographical distances are vast, and weather conditions can be extreme. We report a case of a Greenlandic Inuit woman who presented with appendicitis during pregnancy. The nearest hospital with surgical and anaesthetic care was located nearly 1200 km away, and, due to extreme weather conditions, she could not be transferred immediately. She was treated with intravenous antibiotic treatment, and after weather conditions had improved, she was transferred by aeroplane and underwent appendicectomy. She recovered without complications. Our case suggests that appendicitis during pregnancy may be treated with antibiotics in remote areas until surgical treatment is available.

Gestational trophoblastic disease in a Greenlandic Inuit: diagnosis and treatment in a remote area

We report on a 21-year-old pregnant Greenlandic Inuit woman, who presented at a small local hospital in Northern Greenland. The patient suffered from lower abdominal pain, irregular bleeding and vomiting. urine-human chorionic gonadotropin (U-hCG) was positive. Ultrasonography showed the typical 'snow-storm' images of a mole pregnancy. Owing to the fact that local physicians were able to perform an ultrasound, proper diagnosis could be established, and the patient was transferred to the regional hospital, located nearly 1200 km away. At the regional hospital, uterine evacuation was performed under general anaesthesia. Blood analysis showed that serum hCG returned to undetectable levels, and the patient recovered uneventfully. Our case shows that ultrasonography is a valuable diagnostic tool also in remote areas. In Greenland, geographical distances are large and weather conditions can be extreme, and in this report, we discuss how healthcare can be optimised in remote areas.

Genetic diversity of the attachment (H) protein gene of current field isolates of canine distemper virus

To characterize the variability of recent field isolates of canine distemper virus (CDV) from different hosts and geographical areas, we conducted nucleotide sequence analysis of the gene encoding the haemagglutinin (H), the attachment protein of this virus. Pronounced differences between field isolates were revealed in comparison to the Convac and Onderstepoort vaccine strains. The diversity of CDV appeared to exceed that determined for measles virus. Phylogenetic analysis also separated the field isolates of CDV from the vaccine strains and provided evidence for the existence of different contemporary genotypes of CDV. Isolates from a Greenlandic sledge dog and a Siberian seal formed a distinct lineage. The remaining isolates formed a group. This group contained two European isolates from mink and ferret, a single lineage comprising three European dog isolates, and another separate lineage of North American isolates from dog, javelina, raccoon and captive leopards.

Comparative analysis of the attachment protein gene (H) of dolphin morbillivirus

DMV, dolphin morbillivirus, a paramyxovirus of uncertain origin recently emerged in Mediterranean dolphins. This study presents the complete nucleotide sequence of the hemagglutinin (H) gene including the gene boundaries. The single open reading frame of the DMV H gene encodes a protein of 604 residues which exhibits overall sequence characteristics similar to the H genes of other morbilliviruses. When compared to its closest homologues, measles virus (MV) and rinderpest virus (RPV), DMV has, respectively, 44 and 46% of amino acid residues in identical positions. The primary sequence of the DMV H protein is markedly less conserved than that of the fusion protein. The comparative data at the genomic level correspond with cross-neutralization studies with different morbilliviruses. Retrospective serogical studies dating back to 1983 indicate DMV-like infections in whales of the eastern Atlantic. The presented data support and extend previous studies suggesting that this novel morbillivirus is one of the phylogenetically oldest morbilliviruses known to circulate today. The relationship of DMV and established morbilliviruses to the newly emerged candidate morbillivirus infecting horse and man is discussed.

Secretion of pancreastatins from the porcine digestive tract

Pancreastatin, a 49-amino acid peptide with a COOH-terminal glycine amide, was originally isolated from porcine pancreas, but pancreastatin immunoreactivity has been found in several neuroendocrine tissues. There are strong indications that pancreastatin is derived from chromogranin A, since the amino acid sequence 240-288 in porcine chromogranin A corresponds to pancreastatin flanked by typical signals for proteolytic processing. We have studied the effect of electric stimulation of the nervous supply to perfused porcine pancreas, antrum, nonantral stomach, and small intestine on the release of immunoreactive pancreastatin, and we characterized the molecular nature of the secreted immunoreactivity by using a radioimmunoassay specific for the COOH-terminal glycine amide of porcine pancreastatin in combination with chromatography. In all tissues nerve stimulation significantly increased the release of immunoreactive pancreastatin. The secreted immunoreactive pancreastatin was heterogeneous, consisting of pancreastatin itself, a COOH-terminal pancreastatin fragment, and NH2-terminally extended pancreastatin forms. Pancreastatin predominated in the perfusate from pancreas and antrum, whereas mainly NH2-terminally extended molecular forms were secreted from the antrectomized stomach and small intestine. The different molecular forms of pancreastatin were secreted from the perfused organs in the same molar ratio as they occur in extracts of the corresponding tissues. Thus, pancreastatin and other chromogranin A-derived peptides in organ-specific proportions regularly accompany the secretion of the peptide hormones from the gastrointestinal tissues on appropriate stimulation.

Secretion of pancreastatins from isolated, perfused, porcine adrenal glands

Pancreastatin is a 49 amino acid peptide with a C-terminal glycine amide originally isolated from porcine pancreas. There are strong indications that pancreastatin is derived from chromogranin A, since the amino acid sequence 240-288 in porcine chromogranin A contains pancreastatin flanked by typical signals for proteolytic processing. Several molecular forms of immunoreactive pancreastatin have been reported to be present in porcine adrenal medulla, but no information on the secretion of the peptides is available. We studied stimuli for the release of immunoreactive pancreastatin from adrenal glands as well as the molecular nature of the released immunoreactivity using isolated, perfused, porcine adrenal glands with intact splanchnic nerve supply and a radioimmunoassay specific for the C-terminal glycine amide of porcine pancreastatin in combination with chromatography. Stimulation of the splanchnic nerves greatly enhanced the release of immunoreactive pancreastatin by a mechanism that seems to involve cholinergic nicotinic transmission. The pancreastatin immunoreactivity was due to large amounts of a N-terminally extended pancreastatin form, possibly corresponding to the chromogranin A(1-288) fragment and small amounts of pancreastatin and a C-terminal pancreastatin fragment. Adrenal extracts also contained unprocessed chromogranin A. We conclude that in the porcine adrenals at least 25% of chromogranin A is processed to smaller molecular forms with the pancreastatin sequence forming their C-terminus. These forms appear to be released in parallel with the catecholamines.

Binding of C-reactive protein to Aspergillus fumigatus fractions

Calcium-dependent binding of C-reactive protein (CRP) to Aspergillus fumigatus was determined by enzyme-linked immunosorbent assay. A homogenate of young hyphae was fractionated by hydrophobic interaction chromatography followed by gel filtration. High CRP-binding activity was found in a fraction of mol. wt c. 500,000 which was characterised by strong binding to the hydrophobic column. Three fractions of less conspicuous CRP-binding activity were identified (c. 500 000, 150 000 and 150 000-50 000 mol. wt respectively). In these four fractions, phosphorylcholine was detected by an anti-phosphorylcholine mouse hybridoma antibody. Some CRP-binding activity in fractions with low affinity for the hydrophobic column did not correspond closely with the presence of phosphorylcholine. It is suggested that C-reactive substance in A. fumigatus is heterogeneous. The C-reactive substances did not correspond with fractions containing major antigens (470 000 and 250 000 mol. wt respectively) which elicit a strong immune response in man.