Urethral atrophy after artificial urinary sphincter placement:Is cuff downsizing effective?

Purpose: We reviewed the outcome of cuff downsizing with an artificial urinary sphincter for treating recurrent incontinence due to urethral atrophy.

Materials and Methods: We analyzed the records of 17 patients in a 7-year period in whom clinical, radiological and urodynamic evidence of urethral atrophy was treated with cuff downsizing. Cuff downsizing was accomplished by removing the existing cuff and replacing it with a 4 cm. cuff within the established false capsule. Incontinence and satisfaction parameters before and after the procedure were assessed by a validated questionnaire.

Results: Mean patient age was 70 years (range 62 to 79). Average time to urethral atrophy was 31 months (range 5 to 96) after primary sphincter implantation. Mean followup after downsizing was 22 months (range 1 to 64). Cuff downsizing caused a mean decrease of 3.9 to 0.5 pads daily. The number of severe leakage episodes decreased from a mean of 5.4 to 2.1 The mean SEAPI (stress leakage, emptying, anatomy, protection, inhibition) score decreased from 8.2 to 2.4. Patient satisfaction increased from 15% to 80% after cuff downsizing. In 1 patient an infected cuff required complete removal of the device.

Conclusions: Patient satisfaction and continence parameters improved after cuff downsizing. We believe that this technique is a simple and effective method of restoring continence after urethral atrophy.

Cadaveric fascia lata pubovaginal slings:early results on safety, efficacy and patient satisfaction

Objective To prospectively evaluate and quantify the efficacy of cadaveric fascia lata (CFL) as an allograft material in pubovaginal sling placement to treat stress urinary incontinence (SUI).

Patients and methods Thirty-one women with SUI (25 type II and six type III; mean age 63 years, range 40-75) had a CFL pubovaginal sling placed transvaginally. The operative time, blood loss, surgical complications and mean hospital stay were all documented. Before and at 4 months and 1 year after surgery each patient completed a 3-day voiding diary and validated voiding questionnaires (functional inquiry into voiding habits, Urogenital Distress Inventory and Incontinence Impact Questionnaire, including visual analogue scales).

Results The mean (range) operative time was 71 (50-120) min, blood loss 78.7 (20-250) mL and hospital stay 1.2 (1-2) days; there were no surgical complications. Over the mean follow-up of 13.5 months, complete resolution of SUI was reported by 29 (93%) patients. Overactive bladder symptoms were present in 23 (74%) patients before surgery, 21 (68%) at 4 months and two (6%) at 1 year; 80% of patients with low (<15 cmH (2) O) voiding pressures before surgery required self-catheterization afterward, as did 36% at 4 months, but only one (3%) at 1 year. Twenty-four (77%) patients needed to adopt specific postures to facilitate voiding. After surgery there was a significant reduction in daytime frequency, leakage episodes and pad use (P <0.05). The severity of leak and storage symptoms was also significantly less (P <0.002), whilst the severity of obstructive symptoms remained unchanged. Mean subjective levels of improvement were 69% at 4 months and 85% at 1 year, with corresponding objective satisfaction levels of 61% and 69%, respectively. At 1 year, approximate to 80% of the patients said they would undergo the procedure again and/or recommend it to a friend.

Conclusion Placing a pubovaginal sling of CFL allograft is a highly effective, safe surgical approach for resolving SUI, with a short operative time and rapid recovery. Storage symptoms are significantly improved, and subjective improvement and satisfaction rates are high.

Artificial urinary sphincter implantation in the irradiated patient:safety, efficacy and satisfaction

Objective To compare the long-term outcome of artificial urinary sphincter (AUS) implantation in patients after prostatectomy, with and with no history of previous irradiation.

Patients and methods The study included 98 men (mean age 68 years) with urinary incontinence after prostatectomy for prostate cancer (85 radical, 13 transurethral resection) who had an AUS implanted. Twenty-two of the patients had received adjuvant external beam irradiation before AUS implantation. Over a mean (range) follow-up of 46 (5-118) months, the complication and surgical revision rates were recorded and compared between irradiated and unirradiated patients. The two groups were also compared for the resolution of incontinence and satisfaction, assessed using a questionnaire.

Results Overall, surgical revision was equally common in irradiated (36%) and unirradiated (24%) patients. After activating the AUS, urethral atrophy, infection and erosion requiring surgical revision were more common in irradiated patients (41% vs 11%; P <0.05); 70% of patients reported a significant improvement in continence, regardless of previous irradiation. Patient satisfaction remained high, with >80% of patients stating that they would undergo surgery again and/or recommend it to others, despite previous Irradiation and/or the need for surgical revision.

Conclusions Despite higher complication and surgical revision rates in patients who have an AUS implanted and have a history of previous Irradiation, the long-term continence and patient satisfaction appear not to be adversely affected.

Non-invasive antidromic neurostimulation:A simple effective method for improving bladder storage

Patients with intractably diminished bladder storage function are encountered frequently by neurourologists, occasionally requiring reconstructive surgery for appropriate resolution. Although sacral neuromodulation is a recognized effective therapeutic modality, present techniques are technically demanding, invasive, and expensive. This study investigated the effect of non-invasive third sacral nerve (S3) stimulation on bladder activity during filling cystometry. One hundred forty-six patients underwent standard urodynamic filling cystometry that was then immediately repeated. Patients in the study group (n = 74) received antidromic transcutaneous sacral neurostimulation during the second fill and the control group (n = 72) underwent a second fill without neurostimulation. A statistically significant increase in bladder storage capacity without a corresponding rise in detrusor pressure was observed in the neurostimulated patients. This improvement in functional capacity is an encouraging finding that further supports the use of this non-invasive treatment modality in clinical practice. Neurourol. Urodynam. 20:73-84. 2001. (C) 2001 Wiley-Liss, Inc.

Post-Conflict Performance, Film and Visual Arts:Cities of Memory

This book examines how contemporary theatre, performance, film and the visual arts respond to the post-conflict condition. The contents of the volume focus on a range of post-conflict cities, encouraging interdisciplinary discussion on the role of the arts and its relation to issues of testimony, witnessing, forgetting, representation, healing, reconciliation, agency, and metaphor. Contributors include: Thomas Elsaesser, Jane Taylor, Marvin Carlson, Rob Stone, Laurel Borisenko, Katarzyna Puzon, Miriam Paeslack, Emma Grey, Paula Blair, Zoran Poposki, Marija Todorova, Elena Carduro, and Paul Devlin.

Exercise rehabilitation following intensive care unit discharge for recovery from critical illness

Background: Skeletal muscle wasting and weakness are significant complications of critical illness, associated with the degree of illness severity and periods of reduced mobility during mechanical ventilation. They contribute to the profound physical and functional deficits observed in survivors. These impairments may persist for many years following discharge from the intensive care unit (ICU) and may markedly influence health-related quality of life. Rehabilitation is a key strategy in the recovery of patients following critical illness. Exercise based interventions are aimed at targeting this muscle wasting and weakness. Physical rehabilitation delivered during ICU admission has been systematically evaluated and shown to be beneficial. However its effectiveness when initiated after ICU discharge has yet to be established. Objectives: To assess the effectiveness of exercise rehabilitation programmes, initiated after ICU discharge, on functional exercise capacity and health-related quality of life in adult ICU survivors who have been mechanically ventilated for more than 24 hours. Search methods:We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), OvidSP MEDLINE, Ovid SP EMBASE, and CINAHL via EBSCO host to 15th May 2014. We used a specific search strategy for each database. This included synonyms for ICU and critical illness, exercise training and rehabilitation. We searched the reference lists of included studies and contacted primary authors to obtain further information regarding potentially eligible studies. We also searched major clinical trials registries (Clinical Trials and Current Controlled Trials) and the personal libraries of the review authors. We applied no language or publication restriction. We reran the search in February 2015. We will deal with any studies of interest when we update the review.  Selection criteria:We included randomized controlled trials (RCTs), quasi-RCTs, and controlled clinical trials (CCTs) that compared an exercise interventioninitiated after ICU discharge to any other intervention or a control or ‘usual care’ programme in adult (≥18years) survivors ofcritical illness. Data collection and analysis:We used standard methodological procedures expected by The Cochrane Collaboration. Main results:We included six trials (483 adult ICU participants). Exercise-based interventions were delivered on the ward in two studies; both onthe ward and in the community in one study; and in the community in three studies. The duration of the intervention varied according to the length of stay in hospital following ICU discharge (up to a fixed duration of 12 weeks).Risk of bias was variable for all domains across all trials. High risk of bias was evident in all studies for performance bias, although blinding of participants and personnel in therapeutic rehabilitation trials can be pragmatically challenging. Low risk of bias was at least 50% for all other domains across all trials, although high risk of bias was present in one study for random sequence generation (selection bias), incomplete outcome data (attrition bias) and other sources. Risk of bias was unclear for remaining studies across the domains.All six studies measured effect on the primary outcome of functional exercise capacity, although there was wide variability in natureof intervention, outcome measures and associated metrics, and data reporting. Overall quality of the evidence was very low. Only two studies using the same outcome measure for functional exercise capacity, had the potential for pooling of data and assessment of heterogeneity. On statistical advice, this was considered inappropriate to perform this analysis and study findings were therefore qualitatively described. Individually, three studies reported positive results in favour of the intervention. A small benefit (versus. control)was evident in anaerobic threshold in one study (mean difference, MD (95% confidence interval, CI), 1.8 mlO2/kg/min (0.4 to 3.2),P value = 0.02), although this effect was short-term, and in a second study, both incremental (MD 4.7 (95% CI 1.69 to 7.75) Watts, P value = 0.003) and endurance (MD 4.12 (95% CI 0.68 to 7.56) minutes, P value = 0.021) exercise testing demonstrated improvement.Finally self-reported physical function increased significantly following a rehabilitation manual (P value = 0.006). Remaining studies found no effect of the intervention.Similar variability in with regard findings for the primary outcome of health-related quality of life were also evident. Only two studies evaluated this outcome. Following statistical advice, these data again were considered inappropriate for pooling to determine overall effect and assessment of heterogeneity. Qualitative description of findings was therefore undertaken. Individually, neither study reported differences between intervention and control groups for health-related quality of life as a result of the intervention. Overall quality of the evidence was very low.Mortality was reported by all studies, ranging from 0% to 18.8%. Only one non-mortality adverse event was reported across all patients in all studies (a minor musculoskeletal injury). Withdrawals, reported in four studies, ranged from 0% to 26.5% in control groups,and 8.2% to 27.6% in intervention groups. Loss to follow-up, reported in all studies, ranged from 0% to 14% in control groups, and 0% to 12.5% in intervention groups. Authors’ conclusions:We are unable, at this time, to determine an overall effect on functional exercise capacity, or health-related quality of life, of an exercise based intervention initiated after ICU discharge in survivors of critical illness. Meta-analysis of findings was not appropriate. This was due to insufficient study number and data. Individual study findings were inconsistent. Some studies reported a beneficial effect of the intervention on functional exercise capacity, and others not. No effect was reported on health-related quality of life. Methodological rigour was lacking across a number of domains influencing quality of the evidence. There was also wide variability in the characteristics of interventions, outcome measures and associated metrics, and data reporting.If further trials are identified, we may be able to determine the effect of exercise-based interventions following ICU discharge, on functional exercise capacity and health-related quality of life in survivors of critical illness.

Development of a biocidal treatment regime to inhibit biological growths on cultural heritage: BIODAM

Existing chemical treatments to prevent biological damage to monuments often involve considerable amounts of potentially dangerous and even poisonous biocides. The scientific approach described in this paper aims at a drastic reduction in the concentration of biocide applications by a polyphasic approach of biocides combined with cell permeabilisers, polysaccharide and pigment inhibitors and a photodynamic treatment. A variety of potential agents were screened to determine the most effective combination. Promising compounds were tested under laboratory conditions with cultures of rock deteriorating bacteria, algae, cyanobacteria and fungi. A subsequent field trial involved two sandstone types with natural biofilms. These were treated with multiple combinations of chemicals and exposed to three different climatic conditions. Although treatments proved successful in the laboratory, field trials were inconclusive and further testing will be required to determine the most effective treatment regime. While the most effective combination of chemicals and their application methodology is still being optimised, results to date indicate that this is a promising and effective treatment for the control of a wide variety of potentially damaging organisms colonising stone substrates

Control of biofilm growth through photodynamic treatments combined with chemical inhibitors: in vitro evaluation methods

The rock/atmosphere interface is inhabited by a complex microbial community including bacteria, algae and fungi. These communities are prominent biodeterioration agents and remarkably influence the status of stone monuments and buildings. Deeper comprehension of natural biodeterioration processes on stone surfaces has brought about a concept of complex microbial communities referred to as "subaerial biofilms". The practical implications of biofilm formation are that control strategies must be devised both for testing the susceptibility of the organisms within the biofilm and treating the established biofilm. Model multi-species biofilms associated with mineral surfaces that are frequently refractory to conventional treatment have been used as test targets. A combination of scanning microscopy with image analysis was applied along with traditional cultivation methods and fluorescent activity stains. Such a polyphasic approach allowed a comprehensive quantitative evaluation of the biofilm status and development. Effective treatment strategies incorporating chemical and physical agents have been demonstrated to prevent biofilm growth in vitro. Model biofilm growth on inorganic support was significantly reduced by a combination of PDT and biocides

Photo-dynamic biocidal action of methylene blue and hydrogen peroxide on the cyanobacterium Synechococcus leopoliensis under visible light irradiation

Biofilm growth on stone surfaces is a significant contributing factor to stone biodeterioration. Current market based biocides are hazardous to the environment and to public health. We have investigated the photo-dynamic effect of methylene blue (MB) in the presence of hydrogen peroxide (H₂O₂) on the destruction of the cyanobacterium Synechococcus leopoliensis (S. leopoliensis) under irradiation with visible light. Data presented in this paper illustrate that illumination of S. leopoliensis in the presence of a photosensitiser (MB) and H₂O₂ results in the decomposition of both the cyanobacterium and the photosensitiser. The presence of MB and H₂O₂ affects the viability of the photosensitiser and the cyanobacterium with the fluorescence of both decreasing by 80% over the irradiation time investigated. The photo-dynamic effect was observed under aerobic and anaerobic conditions indicating that oxygen was not necessary for the process. This novel combination could be effective for the remediation of biofilm colonised stone surfaces

Photosensitized destruction of Chlorella vulgaris by methylene blue or nuclear fast red combined with hydrogen peroxide under visible light irradiation

A considerable number of investigations have started to elucidate the essential roles biological agents play in the biodeterioration of stone. Chemical biocides are becoming increasingly banned because of the environmental and health hazards associated with these toxic substances. The present study reports the photodynamic effect of Methylene Blue (MB) and Nuclear Fast Red (NFR) in the presence of hydrogen peroxide (H₂O₂) on the destruction of the algae Chlorella vulgaris (C. vulgaris) under irradiation with visible light. Illumination of C. vulgaris in the presence of MB or NFR combined with H₂O₂ results in the decomposition of both the algal species and the photosensitizer. The photodynamic effect was investigated under aerobic and anaerobic conditions. Differences in mechanism type are reported and are dependent on both the presence and the absence of oxygen. The behavior of each photosensitizer leads to a Type II mechanism and a Type I/Type II combination for MB and NFR, respectively, being concluded. This novel combination could be effective for the remediation of biofilm-colonized stone surfaces.

The Cyrenaican Prehistory Project 2012: the sixth season of excavations in the Haua Fteah cave

The paper reports on the sixth season of fieldwork of the Cyrenaican Prehistory Project (CPP) undertaken in September 2012. As in the spring 2012 season, work focussed on the Haua Fteah cave and on studies of materials excavated in previous seasons, with no fieldwork undertaken elsewhere in the Gebel Akhdar. An important discovery, in a sounding excavated below the base of McBurney's 1955 Deep Sounding (Trench S), is of a rockfall or roof collapse conceivably dating to the cold climatic regime of Marine Isotope Stage (MIS) 6 (globally dated to c. 190-130 ka) but more likely the result of a seismic event within MIS 5 (globally dated to c. 130-80 ka). The sediments and associated molluscan fauna in Trench S and in Trench D, a trench being cut down the side of the Deep Sounding, indicate that this part of the cave was at least seasonally waterlogged during the accumulation, probably during MIS 5, of the -6.5 rn of sediment cut through by the Deep Sounding. Evidence for human fréquentation of the cave in this period is more or less visible depending on how close the trench area was to standing water as it fluctuated through time. Trench M, the trench being cut down the side of McBurney's Middle Trench, has now reached the depth of the latest Middle Stone Age or Middle Palaeolithic (Levalloiso-Mousterian) industries. The preliminary indications from its excavation are that the transition from the Levalloiso-Mousterian to the blade-based Upper Palaeolithic or Late Stone Age Dabban industry was complex and perhaps protracted, at a time when the climate was oscillating between warmstage stable environmental conditions and colder and more arid environments. The estimated age of the sediments, c. 50-40 ka, places these oscillations within the earlier part of MIS 3 (globally dated to 60-24 ka), when global climates experienced rapid fluctuations as part of an overall trend to increasing aridity and cold.

The Science of a Lost Medieval Graveyard: The Ballyhanna Research Project

he Science of Lost Medieval Gaelic Graveyard tells the story of the discovery in 2003 of a graveyard and the foundations of a small forgotten stone church at Ballyhanna, in Ballyshannon, Co. Donegal, as part of the N15 Bundoran–Ballyshannon Bypass archaeological works. This led to the excavation of one of the largest collections of medieval burials ever undertaken on this island. Over 1,200 individuals were excavated from the site at Ballyhanna during the winter of 2003–4, representing 1,000 years of burial through the entire Irish medieval period. The discovery led to the establishment of a cross-border research collaboration—the Ballyhanna Research Project—between Queen’s University Belfast and the Institute of Technology, Sligo, which has brought to life this lost Gaelic graveyard.

This book shows how cutting-edge scientific research may aid our understanding and interpretation of archaeology and reveal new insights into past societies. For example, the use of ancient DNA analysis represented the first biomolecular archaeological evaluation of a medieval population to date and provided evidence that cystic fibrosis was much less prevalent in the medieval period than today. The Science of Lost Medieval Gaelic Graveyard is about a community who lived in Gaelic Ireland, about their lifestyles, health and diet. It tells us of their deaths and of their burial traditions, and through examining all of these aspects, it reveals the ebb and flow of their lives.

The book is accompanied by a CD-ROM which includes supplementary information from the Ballyhanna Research Project and the original excavation and survey reports for all of the archaeological sites on the N15 Bundoran–Ballyshannon Bypass.