The use of transvaginal synthetic mesh for anterior vaginal wall prolapse repair: a randomized controlled trial

The aim of the study was to compare the efficacy and safety of transvaginal trocar-guided polypropylene mesh insertion with traditional colporrhaphy for treatment of anterior vaginal wall prolapse.This is a randomized controlled trial in which women with advanced anterior vaginal wall prolapse, at least stage II with Ba a parts per thousand yenaEuro parts per thousand+1 cm according to the Pelvic Organ Prolapse Quantification (POP-Q) classification, were randomly assigned to have either anterior colporrhaphy (n = 39) or repair using trocar-guided transvaginal mesh (n = 40). the primary outcome was objective cure rate of the anterior compartment (point Ba) assessed at the 12-month follow-up visit, with stages 0 and I defined as anatomical success. Secondary outcomes included quantification of other vaginal compartments (POP-Q points), comparison of quality of life by the prolapse quality of life (P-QOL) questionnaire, and complication rate between the groups after 1 year. Study power was fixed as 80 % with 5 % cutoff point (p < 0.05) for statistical significance.The groups were similar regarding demographic and clinical preoperative parameters. Anatomical success rates for colporrhaphy and repair with mesh placement groups were 56.4 vs 82.5 % (95 % confidence interval 0.068-0.54), respectively, and the difference between the groups was statistically significant (p = 0.018). Similar total complication rates were observed in both groups, with tape exposure observed in 5 % of the patients. There was a significant improvement in all P-QOL domains as a result of both procedures (p < 0.001), but they were not distinct between groups (p > 0.05).Trocar-guided transvaginal synthetic mesh for advanced anterior POP repair is associated with a higher anatomical success rate for the anterior compartment compared with traditional colporrhaphy. Quality of life equally improved after both techniques. However, the trial failed to detect differences in P-QOL scores and complication rates between the groups.

Rapid detection of health-care-associated bloodstream infection in critical care using multipathogen real-time polymerase chain reaction technology: a diagnostic accuracy study and systematic review

Background: There is growing interest in the potential utility of real-time polymerase chain reaction (PCR) in diagnosing bloodstream infection by detecting pathogen deoxyribonucleic acid (DNA) in blood samples within a few hours. SeptiFast (Roche Diagnostics GmBH, Mannheim, Germany) is a multipathogen probe-based system targeting ribosomal DNA sequences of bacteria and fungi. It detects and identifies the commonest pathogens causing bloodstream infection. As background to this study, we report a systematic review of Phase III diagnostic accuracy studies of SeptiFast, which reveals uncertainty about its likely clinical utility based on widespread evidence of deficiencies in study design and reporting with a high risk of bias. 

Objective: Determine the accuracy of SeptiFast real-time PCR for the detection of health-care-associated bloodstream infection, against standard microbiological culture. 

Design: Prospective multicentre Phase III clinical diagnostic accuracy study using the standards for the reporting of diagnostic accuracy studies criteria. 

Setting: Critical care departments within NHS hospitals in the north-west of England. 

Participants: Adult patients requiring blood culture (BC) when developing new signs of systemic inflammation. 

Main outcome measures: SeptiFast real-time PCR results at species/genus level compared with microbiological culture in association with independent adjudication of infection. Metrics of diagnostic accuracy were derived including sensitivity, specificity, likelihood ratios and predictive values, with their 95% confidence intervals (CIs). Latent class analysis was used to explore the diagnostic performance of culture as a reference standard. 

Results: Of 1006 new patient episodes of systemic inflammation in 853 patients, 922 (92%) met the inclusion criteria and provided sufficient information for analysis. Index test assay failure occurred on 69 (7%) occasions. Adult patients had been exposed to a median of 8 days (interquartile range 4–16 days) of hospital care, had high levels of organ support activities and recent antibiotic exposure. SeptiFast real-time PCR, when compared with culture-proven bloodstream infection at species/genus level, had better specificity (85.8%, 95% CI 83.3% to 88.1%) than sensitivity (50%, 95% CI 39.1% to 60.8%). When compared with pooled diagnostic metrics derived from our systematic review, our clinical study revealed lower test accuracy of SeptiFast real-time PCR, mainly as a result of low diagnostic sensitivity. There was a low prevalence of BC-proven pathogens in these patients (9.2%, 95% CI 7.4% to 11.2%) such that the post-test probabilities of both a positive (26.3%, 95% CI 19.8% to 33.7%) and a negative SeptiFast test (5.6%, 95% CI 4.1% to 7.4%) indicate the potential limitations of this technology in the diagnosis of bloodstream infection. However, latent class analysis indicates that BC has a low sensitivity, questioning its relevance as a reference test in this setting. Using this analysis approach, the sensitivity of the SeptiFast test was low but also appeared significantly better than BC. Blood samples identified as positive by either culture or SeptiFast real-time PCR were associated with a high probability (> 95%) of infection, indicating higher diagnostic rule-in utility than was apparent using conventional analyses of diagnostic accuracy. 

Conclusion: SeptiFast real-time PCR on blood samples may have rapid rule-in utility for the diagnosis of health-care-associated bloodstream infection but the lack of sensitivity is a significant limiting factor. Innovations aimed at improved diagnostic sensitivity of real-time PCR in this setting are urgently required. Future work recommendations include technology developments to improve the efficiency of pathogen DNA extraction and the capacity to detect a much broader range of pathogens and drug resistance genes and the application of new statistical approaches able to more reliably assess test performance in situation where the reference standard (e.g. blood culture in the setting of high antimicrobial use) is prone to error.

Evaluación de la disfunción sexual en mujeres con incontinencia urinaria antes y después de la cinta suburetral

Objetivo: Evaluar prospectivamente el grado de disfunción sexual en pacientes con incontinencia urinaria de esfuerzo antes y después de la cinta suburetral libre de tensión mediante el cuestionario PISQ-12 validado en español. Materiales y Métodos: Estudio observacional longitudinal de antes y después. Se seleccionaron 60 mujeres sexualmente activas con algún grado de disfunción sexual, entre abril del 2014 hasta marzo del 2015, diagnosticadas con incontinencia urinaria, programadas para colocación de cinta suburetral transobturadora en el Hospital Universitario Mayor Méderi. La mayoría de las pacientes presentaron algún grado de prolapso genital y requirieron corrección quirúrgica asociada a la cinta. Todas las pacientes respondieron el cuestionario PISQ-12 antes y 6 meses después del procedimiento. Resultados: La edad promedio fue 48 ± 4.58 años. El grado de prolapso con mayor frecuencia fue el estadío II del POP-Q 55% (n=33). El 96.7% (n=50) de las pacientes requirieron además de la colocación de la cinta suburetral corrección quirúrgica del prolapso genital. En la evaluación preoperatoria la disfunción sexual se distribuyó así: Severa: 70%, Moderada 18.3% y Leve 11.7%, después de 6 meses postoperatorios se encontró una diferencia estadísticamente significativa del cambio en el grado de disfunción sexual así: Moderada 41.5% y Leve 58.2% donde ninguna paciente quedó clasificada con disfunción severa. Discusión y Conclusión: Las pacientes que presentaron disfunción sexual severa obtuvieron mayor cambio en el grado de disfunción, luego de la colocación de la cinta suburetral.

VIP expression in vessels of the vaginal wall: relationship with estrogen status

Objective Vasoactive intestinal peptide (VIP) is a neuropeptide with elevated expression in regions that control urogenital functions. Estrogen appears to modulate VIP expression in various organs, but this effect has not been demonstrated in the vaginal wall. The aim of this study was to evaluate the influence of estrogen status on VIP expression in vessels of the vaginal wall. Methods Surgical specimens were removed from the vaginal walls of 18 premenopausal women and 12 postmenopausal women who were given surgery for genital prolapse grade I or II. Vaginal specimens were stained with estrogen receptor-alpha (ER-alpha) and VIP antibodies. Levels of follicle stimulating hormone (FSH), estradiol, prolactin, fasting glucose and serum thyroxine stimulating hormone were also measured. Estrogen status was assessed on the basis of FSH and ER-alpha scores. Results The vaginal walls of premenopausal women had significantly higher ER-alpha scores than those of menopausal women (premenopausal group, 3.6 +/- 2.2; menopausal group, 1.4 +/- 1.8; p = 0.01). Premenopausal women also had significantly higher levels of VIP in the vaginal wall than menopausal women (p = 0.02). Increasing age was associated with lower level of VIP staining (odds ratio 0.88; 95% confidence interval 0.78-0.99). Conclusion Levels of ER-alpha and VIP expression in the posterior vaginal wall were higher in premenopausal than in menopausal women, but VIP expression was not associated with estrogen status. Age was an independent predictor of VIP staining in vaginal wall biopsies.

Sexual function after sacrocolpopexy

Pelvic organ prolapse affects approximately 50% of parous women over 50 years of age and has a lifetime risk of 30-50%. Vault descent or prolapse occurs in about 20% after hysterectomy and can have a negative effect on sexual function. Sacrocolpopexy is the gold standard of surgical treatment for apical prolapse in fit, sexually active patients. Few data exist which determine sexual function after sacrocolpopexy.

Sexual function after rectocele repair

Pelvic organ prolapse is a common condition among women with a prevalence of 11% and may affect the anterior, posterior, or apical compartment with a negative impact on sexual function.

How do we apply video-assisted retroperitoneal necrosectomy with minimal access?

The conservative treatment of acute necrotizing pancreatitis has greatly improved due to broad antibiotic treatment and improved organ support in intensive care units. Nevertheless, infected necrosis or persistent multi-organ dysfunction are predictors of poor outcome. In these patients, there is still a need to perform necrosectomy. Open surgery results in extensive operative trauma and is associated with high morbidity and mortality. Therefore, several minimally invasive techniques have been developed recently. Retroperitoneal necrosectomy has been shown to be safe and to reduce morbidity and mortality compared to the open procedure.

Gynaecological operations: do they improve sexual life?

Aim of the study was to determine if gynaecological operations have an effect on sexual function using the current medlined literature. We performed a Medline search using the terms "sexual life/function after operative gynaecological treatment", "sexual life/function after operations for gynaecological problems", "sexual life/function after hysterectomy", "sexual life/function, incontinence" and "sexual life/function, pelvic organ prolapse". Reviews were excluded. We divided the operations into four groups of (1) combined prolapse and incontinence operations, (2) prolapse operations only, (3) incontinence operations only and (4) hysterectomy and compared pre-to postoperative sexual outcome. Thirty-six articles including 4534 patients were identified. Only 13 studies used a validated questionnaire. The other authors used self-designed and non-validated questionnaires or orally posed questions by the examiner to determine sexual function. Prolapse operations particularly posterior repair using levator plication seem to deteriorate sexual function, incontinence procedure have some worsening effect on sexual function and hysterectomy seems to improve sexual function with no differences between subtotal or total hysterectomy. Gynaecological operations do influence sexual function. However, little validated data are available to come to this conclusion.

The feasibility, efficacy and functional outcome of local anaesthetic repair of anterior and posterior vaginal wall prolapse

INTRODUCTION: Urogenital prolapse is a very common condition in women with a prevalence of 30%. If conservative therapy fails or is not desired by the patient, prolapse repair is usually performed under general or regional anaesthetic. The aim of the study was to evaluate feasibility, efficacy and functional outcome after fascial prolapse repairs under local anaesthetic (LA). PATIENTS AND METHODS: Between November 1999 and December 2000, 130 consecutive patients presenting with anterior or posterior prolapse or both were invited to have their procedure performed under LA. All patients with a symptomatic minimum stage II prolapse were included. Prior to surgery all women completed a standardized questionnaire examining the specific and non-specific symptoms of prolapse and their situation was classified using the ICS Pelvic Organ Prolapse (POP-Q) system. Follow up was 30 months. Objective success was defined as a stage 1 or less and no symptoms of bulge, subjective success was defined as lack of specific or non-specific symptoms of prolapse. RESULTS: There were 128 patients who agreed to have their operations performed under LA: 68 in the anterior group, 52 in the posterior group and 8 with a combined anterior and posterior repair. Objective cure rate was 88% for posterior repair, 87% for anterior repair and 63% for combined repair. Success rates were no different in primary from recurrent cases. There were no intraoperative complications and operating time was 21 min (anterior repair) or 23 min (posterior repair). There was no de novo postoperative urinary or stool incontinence and all patients but two would have the operation performed again under the same circumstances. The two remaining refused due to embarrassment but for no other reason. CONCLUSION: Local anaesthetic prolapse repair is feasible and effective in middle term results. It is well accepted by the patients who benefit from less side effects and short hospital stay.

Sexual function after suburethral sling removal for dyspareunia

INTRODUCTION: Impact on sexual function has received little attention in the medical literature for a long time. Because of the site of insertion of permanent tension free vaginal tape (TVT) the G spot might be affected or the tape might interfere with arousal and sensory stimulation. Recent studies have reported varying degrees of sexual impairment after TVT insertion ranging from 0% to 15% including dyspareunia. AIM: The aim of this study was to evaluate sexual function before and after suburethral sling removal due to postoperative female de novo dyspareunia. As a secondary outcome, general patients' satisfaction with their overall continence situation was assessed. PATIENTS AND METHODS: Between December 2005 and December 2007, we included 18 female patients who complained of de novo dyspareunia after suburethral sling insertion for urinary stress incontinence. All patients filled in an FSFI questionnaire prior to sling removal and at 3 months postoperatively. Additionally, all women were asked to estimate their general satisfaction regarding their continence situation using a Visual Analogue Scale (VAS) from 0 to 10, with 0 being the least satisfying situation and 10 being the most satisfying situation. All patients underwent gynaecological examination including ICS-pelvic organ prolapse staging (ICS-POP score). RESULTS: Of the 18 slings, ten were transobturator tapes (6 x TVT-O, 2 x Monarch, 2 x unknown) and eight were retropubic tapes (7 x TVT, 1 x SPARC). Desire, arousal, lubrication, satisfaction, and pain improved statistically significant. Orgasm scores were low with median scoring of 1.5 scores before and 1.0 scores after sling removal, and they did not change significantly after sling removal. The satisfaction rate deteriorated from a median of 7 (95% confidence interval [CI] 6.3-7.7) to a median of 4 (95% CI 3.7-5.1; p=0.99) but not statistically significant. CONCLUSIONS: Sexual function in patients with de novo dyspareunia is likely to improve after sling removal but not in all domains. Bladder function may deteriorate.

Midline rectovaginal fascial plication for repair of rectocele and obstructed defecation

OBJECTIVE: To estimate the efficacy of midline fascial plication of the posterior vaginal wall in women with rectoceles and obstructed defecation. METHODS: Prospective evaluation of 38 consecutive women with symptomatic rectoceles (stage II or greater) and obstructed defecation included pre- and postoperative standardized pelvic floor questions, pelvic organ prolapse quantification measurements, validated bowel function questionnaires, defecating proctogram, and patient satisfaction. Reviews were conducted by nonsurgical coauthors. RESULTS: The median follow-up was 12.5 months (range 2.5-26 months). The subjective success rates were 97% (95% confidence interval [CI] 0.83-1.00%) at 12 months and 89% (95% CI 0.55-0.98%) at 24 months. The objective success rates were 87% (95% CI 0.64-0.96%) at 12 months and 79% (95% CI 0.51-0.92%) at 24 months. The average points, Ap and Bp, were significantly reduced from -0.1 (range -2 to 3) and 1.1 (range -1 to 8), preoperatively, to -2.6 (range -3 to -1) and -2.5 (range -3 to 0), postoperatively, respectively (P

Epidemiology of invasive aspergillosis in critically ill patients: clinical presentation, underlying conditions, and outcomes

INTRODUCTION: Invasive aspergillosis (IA) is a fungal infection that particularly affects immunocompromised hosts. Recently, several studies have indicated a high incidence of IA in intensive care unit (ICU) patients. However, few data are available on the epidemiology and outcome of patients with IA in this setting.

The effect of lumbar support on the trunk muscle activity and pelvic tilt in a passenger vehicle car seat

In order to gain a competitive edge in the market, automotive manufacturers and automotive seat suppliers have identified seat ergonomics for further development to improve overall vehicle comfort. Adjustable lumbar support devices have been offered since long as comfort systems in either a 2-way or 4-way adjustable configuration, although their effect on lumbar strain is not well documented. The effect of a lumbar support on posture and muscular strain, and therefore the relationship between discomfort and comfort device parameter settings, requires clarification. The aim of this paper is to study the effect of a 4-way lumbar support on lower trunk and pelvis muscle activity, pelvic tilt and spine curvature during a car seating activity. 10 healthy subjects (5 m/f; age 19-39) performed a seating activity in a passenger vehicle with seven different static lumbar support positions. The lumbar support was tested in 3 different height positions in relation to the seatback surface centreline (high, centre, low), each having 2 depths positions (lumbar prominence). An extra depth position was added for the centre position. Posture data were collected using a VICON MX motion capture system and NORAXON DTS goniometers and inclinometer. A rigid-body model of an adjustable car seat with four-way adjustable lumbar support was constructed in UGS Siemens NX and connected to a musculoskeletal model of a seated-human, modelled in AnyBody. Wireless electromyography (EMG) was used to calibrate the musculoskeletal model and assess the relationship between (a) muscular strain and lumbar prominence (normal to seatback surface) respective to the lumbar height (alongside seatback surface), (b) hip joint moment and lumbar prominence (normal to seatback surface) respective to lumbar height (alongside seatback surface) and (c) pelvic tilt and lumbar prominence (normal to seatback surface) respective to the lumbar height (alongside seatback surface). This study was based on the assumption that the musculoskeletal human model was seated at the correct R-Point (SgRP), determined via the occupant packaging toolkit in the JACK digital human model. The effect of the interaction between the driver/car-seat has been investigated for factors resulting from the presence and adjustment of a 4-way lumbar support. The results obtained show that various seat adjustments, and driver’s lumbar supports can have complex influence on the muscle activation, joint forces and moments, all of which can affect the comfort perception of the driver. This study enables the automotive industry to optimise passenger vehicle seat development and design. It further more supports the evaluation of static postural and dynamic seat comfort in normal everyday driving tasks and can be applied for future car design to reduce investment and improve comfort.