Structured reporting in fetal magnetic resonance imaging with congenital diaphragmatic hernia.

OBJECTIVE: We aim to provide a template structured report of fetal Magnetic Resonance Imaging in congenital diaphragmatic hernia (CDH) that was locally validated by the CDH study group in Mannheim. METHODS: A selection of 50 fetal MRIs of patients with an isolated diaphragmatic hernia and associated radiology reports from five different senior radiologists from a single center resulted in a primary structured report, which was put into practice by using dedicated software. A questionnaire survey of the interdisciplinary CDH study group Mannheim was used to adapt the report to the clinical requirements. RESULTS: There was a huge variability in how deep the free text reports go into detail. The side of the hernia was named in 94% of cases. In 58%, both the lung volume and the total lung volume were reported. A comparison with the expected lung volume was reported in 66% of cases. Additional findings, such as herniated organs, were reported in 96% of cases. Overall satisfaction with the newly established structured report was high within the CDH study group with a mean of 4.7. CONCLUSIONS: The use of the structured report of this study can optimize the interdisciplinary dialog, the standardization of report content, increase report completeness and improve quality.

Weak Polyampholytes at the Interface of Magnetic Nanocarriers: A Facile Catch-and-Release Platform for Dyes.

We present a platform of charge-invertible core-shell hybrid particles for the selective and reversible adsorption of small charged molecules as model systems. The herein employed carrier systems consist of an iron oxide core coated with different pH-responsive polyampholytes which exhibit varying surface charge depending on the surrounding pH value. The resulting materials were used for electrostatically mediated catch-and-release experiments of either cationic or anionic dyes with the perspective to allow the pH-dependent magnetically guided transport of suitable cargo. The use of three different polyampholyte coatings (poly(2-(imidazol-1-yl)acrylic acid) (PImAA), poly(dehydroalanine) (PDha), and poly(N,N-diallylglutamate) (PDAGA)) enables a deeper understanding about how the surface net charge in combination with the charge and charge density of any cargo influences such processes. The size, surface charge, and aggregation behavior of the herein described particles were investigated via dynamic light scattering (DLS), transmission electron microscopy (TEM), and pH-dependent ζ-potential measurements, whereas adsorption and release studies were investigated via UV-vis.

Preparation of Core-Shell Hybrid Materials by Producing a Protein Corona Around Magnetic Nanoparticles.

Nanoparticles experience increasing interest for a variety of medical and pharmaceutical applications. When exposing nanomaterials, e.g., magnetic iron oxide nanoparticles (MNP), to human blood, a protein corona consisting of various components is formed immediately. The composition of the corona as well as its amount bound to the particle surface is dependent on different factors, e.g., particle size and surface charge. The actual composition of the formed protein corona might be of major importance for cellular uptake of magnetic nanoparticles. The aim of the present study was to analyze the formation of the protein corona during in vitro serum incubation in dependency of incubation time and temperature. For this, MNP with different shells were incubated in fetal calf serum (FCS, serving as protein source) within a water bath for a defined time and at a defined temperature. Before and after incubation the particles were characterized by a variety of methods. It was found that immediately (seconds) after contact of MNP and FCS, a protein corona is formed on the surface of MNP. This formation led to an increase of particle size and a slight agglomeration of the particles, which was relatively constant during the first minutes of incubation. A longer incubation (from hours to days) resulted in a stronger agglomeration of the FCS incubated MNP. Quantitative analysis (gel electrophoresis) of serum-incubated particles revealed a relatively constant amount of bound proteins during the first minutes of serum incubation. After a longer incubation (>20 min), a considerably higher amount of surface proteins was determined for incubation temperatures below 40 °C. For incubation temperatures above 50 °C, the influence of time was less significant which might be attributed to denaturation of proteins during incubation. Overall, analysis of the molecular weight distribution of proteins found in the corona revealed a clear influence of incubation time and temperature on corona composition.

Application of in situ thermography for evaluating the high-cycle and very high-cycle fatigue behaviour of cast aluminium alloy AlSi7Mg (T6).

The present paper illustrates the application of infrared thermal measurements for the investigation of crack initiation point and crack propagation in the high-cycle and the very high-cycle fatigue range of cast AlSi7Mg alloy (A356). The influence of casting defects, their location, size and amount was studied both by fractography and thermography. Besides internal and surface fatigue crack initiation as a further crack initiation type multiple fatigue crack initiation was observed via in situ thermography which can be well correlated with the results from fractography obtained by SEM investigations. In addition, crack propagation was studied by the development of the temperature measured via thermography. Moreover, the frequency influence on high-cycle fatigue behaviour was investigated. The presented results demonstrate well that the combination of fractography and thermography can give a significant contribution to the knowledge of crack initiation and propagation in the VHCF regime.

Jones birefringence in twisted single-mode optical fibers.

In this work we analyze the birefringence matrix developed for a twisted fiber in order to identify the basic optical effects that define its birefringence. The study was performed using differential Jones calculus. The resultant differential matrix showed three independent types of birefringence: circular, linear at 0 degrees and linear at 45 degrees (Jones birefringence). We applied this birefringence matrix to the description of the output state of polarization measured for three commercial fibers that due to its higher rigidity present stronger birefringence changes when twisted. The torsion applied to the erbium-doped fiber samples varied from 0 to 1440 degrees.

[Multiparametric prostate MRI for follow-up monitoring after radiation therapy]. / Multiparametrische MRT der Prostata zum Therapiemonitoring nach Strahlentherapie.

CLINICAL/METHODICAL ISSUE: Radiation therapy is a therapeutic option with curative intent for patients with prostate cancer. Monitoring of prostate-specific antigen (PSA) values is the current standard of care in the follow-up. Imaging is recommended only for symptomatic patients and/or for further therapeutic options. STANDARD RADIOLOGICAL METHODS: For detection of local recurrence magnetic resonance imaging (MRI) of the prostate is acknowledged as the method of choice. PERFORMANCE: Good results for primary diagnosis were found especially in combination with functional techniques, whereas in recurrent prostate cancer only few studies with heterogeneous study design are available for prostate MRI. Furthermore, changes in different MRI modalities due to radiation therapy have been insufficiently investigated to date. PRACTICAL RECOMMENDATIONS: As the initial results were promising prostate MRI and available therapeutic options for detection of local recurrence should be considered in patients with increased PSA.

[Imaging diagnostics of the prostate]. / Bildgebung der Prostata.

Prostate cancer is the most common malignancy of men with approximately 32,000 new cases of prostate cancer in Germany and approximately 11,000 men who would die of the disease each year. For early diagnosis of prostate cancer PSA testing is used, whereas at present screening cannot be recommended due to the lack of confirmed medical and economic benefits. Regarding the imaging modalities, ultrasound of the prostate, currently performed in combination with elastography and histoscanning, magnetic resonance imaging of the prostate in combination with endorectal coils and positron emission tomography combined with computed tomography (PET-CT) are the methods of choice. Using these methods benign prostatitis can be differentiated from prostate cancer and staging of the tumor can be accomplished. On the other hand using these imaging methods it is possible to define the dominant intraprostatic lesion with different sensitivities and specificities, which is important for minimally invasive therapeutic strategies.

[Imaging of prostate cancer by diagnostic radiology and nuclear medicine]. / Radiologisch-nuklearmedizinische Bildgebung des Prostatakarzinoms.

The diagnostic methods in radiology and nuclear medicine for the imaging of prostate cancer as well as for the detection of locoregional recurrent disease and positive lymph nodes have progressed dramatically over the past years. Regarding technical advances in magnetic resonance imaging (MRI) and the new tracers used in nuclear medicine, an increase in sensitivity up to 85-90% and in specificity up to 75-90% has been achieved. Especially in MRI, efforts had been made to implement multiparametric imaging using the diagnostic methods of spectroscopy and diffusion-weighted sequences and by including dynamic contrast enhancement studies. In addition, by the use of dedicated, lymph-node specific contrast media, "ultrasmall paramagnetic iron particles" (USPIO), up to 100% of all pathological lymph nodes were detected in the published studies. Also in the field of nuclear medicine there have been relevant advances such as the development of specific tracer substances, which can be coupled to 18fluorine, a nuclide that is characterised by a longer half-life time than 11C and is therefore usable even in sites without an in-house cyclotron. Using this nuclide, the sensitivity and specificity rates in the detection of primary prostate cancer as well as in locoregional recurrences have been increased to values between 85 and 95%.

Current epidemiological aspects of human parvovirus B19 infection during pregnancy and childhood in the western part of Germany.

This investigation was undertaken to provide detailed information on the epidemiology of human parvovirus B19 (B19) infection during pregnancy and childhood in the western part of Germany. Between 1997 and 2004, 40,517 sera from pregnant women aged 17-45 years and 6060 sera from children and young adults were tested for B19 IgG and IgM in our laboratory. In pregnant women, both the history of a 'specific' (OR 7.7, 95% CI 5.2-11.4) and a 'non-specific' rash (OR 3.3, 95% CI 1.5-7.1) was predictive for B19 IgM positivity. The B19 IgG prevalence was 69.2% (4097/5924) in a subgroup of asymptomatic pregnant women screened for B19 antibodies. In children, the age-specific IgG-positivity rate increased from 12.2% (66/541) at 2 years of age to 71.9% (396/551) in those older than 10 years. In conclusion, the prevalence of B19 IgG in pregnant women from the western part of Germany is higher then previously reported. Contact with children aged 3-10 years is a major risk factor for exposure to B19. Pregnant women with the history of a 'non-specific' rash should also be evaluated for acute B19 infection.

Neuropathic injury to the levator ani occurs in 1 in 4 primiparous women.

OBJECTIVE: We measured levator ani neuromuscular function before and after first delivery to identify the location, timing, and mechanism of injury. STUDY DESIGN: Fifty-eight primiparous women underwent electromyographic examination of the levator ani antepartum at 6 weeks and 6 months after the delivery. Antepartum turns/amplitude data were pooled to create a normal range. We calculated each woman's percentage of outliers from this range and assessed relationships between delivery and extent of injury. RESULTS: At 6 weeks, 14 of 58 women (24.1%) had neuropathy, with 9 of those 14 women recovering by 6 months. At 6 months, 17 of 58 women (29.3%) were neuropathic, which included 12 new injuries. Women who had elective cesarean delivery had virtually no injury, but all other modes of delivery had similar injury rates. CONCLUSION: Obstetric delivery is associated frequently with electromyographic evidence of neuropathic injury to the levator ani. The entire levator complex is at risk, and cesarean delivery while in labor is not protective.

Repression of the prolactin promoter: a functional consequence of the heterodimerization between Pit-1 and Pit-1 beta.

The POU-homeodomain transcription factor Pit-1 is required for the differentiation of the anterior pituitary cells and the expression of their hormone products. Pit-1beta, an alternate splicing isoform, has diametrically different outcomes when it is expressed in different cell types. Pit-1beta acts as a transcriptional repressor of prolactin (PRL) and growth hormone genes in pituitary cells, and as a transcriptional activator in non-pituitary cells. In order to explore these differences, we: (1) identified the transcriptional cofactors necessary for reconstitution of repression in non-pituitary cells; (2) tested the effect of the beta-domain on heterodimerization with Pit-1 and physical interaction with the co-activator CREB binding protein (CBP); and (3) determined the beta-domain sidechain chemistry requirements for repression. Co-expression of both Pit-1 isoforms reconstituted the repression of the PRL promoter in non-pituitary cells. The beta-domain allowed heterodimerization with Pit-1 but blocked physical interaction with CBP, and specific chemical properties of the beta-domain beyond hydrophobicity were dispensable. These data strongly suggest that Pit-1beta represses hormone gene expression by heterodimerizing with Pit-1 and interfering with the assembly of the Pit-1-CBP complex required for PRL promoter activity in pituitary cells.

Brevetoxin Depuration in Shellfish via Production of Non-toxic Metabolites: Consequences for Seafood Safety and the Environmental Fate of Biotoxins.

During blooms of the dinoflagellate Karenia brevis, filter-feeders such as oysters and clams bioaccumulate brevetoxins, often to levels that are toxic to humans. In controlled aquarium experiments, we exposed live oysters to bloom levels of toxic K. brevis, followed by 10 weeks of exposure to non-toxic microalgae. Oysters were harvested weekly and analyzed for brevetoxins and brevetoxin metabolites to quantify toxin bioaccumulation and depuration. All of the PbTx-2 concentrated by oysters was immediately converted to a mixture of polar metabolites that were then slowly eliminated from the oysters. However, 90% of measured PbTx-3 was eliminated within two weeks of toxic exposure but without apparent biotransformation. Extracts of oysters containing high levels of PbTx-3 were toxic to mice by intraperitoneal (IP) injection. Extracts of oysters harvested after PbTx-3 had been eliminated were non-toxic despite high concentrations of PbTx-2 metabolites. Oysters collected in Florida during and after a bloom of K. brevis contained polar metabolites of PbTx-2 as well as PbTx-3, but no PbTx-2. Again, PbTx-3 concentration was a good predictor of mouse toxicity. One hundred percent conversion of PbTx-2 to polar metabolites was also accomplished in vitro by spiking oyster or clam homogenate with PbTx-2, followed by a brief incubation at room temperature. These PbTx-2 metabolites did not kill mice, either orally or by intraperitoneal injection, even at concentrations 30 times greater than toxic PbTx-3 levels.

[Diagnostic and therapy of a severe fetal parvovirus-B19-infection with persistence of viral DNA in the mothers blood but inconspicuous serological tests. Case report]. / Diagnostik und Therapie einer schweren fetalen Parvovirus-B19-Infektion bei mütterlicher Viruspersistenz, aber unauffälliger Serologie. Fallbericht.

In the 24th week of gestation we diagnosed a severe hydrops fetalis in a 25 year old VI gravid III para, who had contact to parvovirus B19 in the 14th week of gestation. Because of the severe anaemia of the fetus and the massively increased bilirubinoides in the amniotic fluid we decided at the same day to apply the first of four intrauterine transfusions. The serological patterns of maternal blood with highly positive parvovirus-B19-IgG and negative IgM suggested that an infection had occurred. Parvoviral DNA was found in maternal and fetal blood confirming the diagnosis of an acute intrauterine parvovirus-B19 infection. No viral DNA was detected in fetal ascites. IgM in fetal blood was negative. By means of four transfusions, the pregnancy could be prolonged until the 32 + 5th week of gestation while the ascites was declining. When rupture of membranes occurred, a cesarean section had to be performed due to contractions and presentation of the feet. The newborn's blood count exhibited a thrombocytopenia with normal haemoglobin and haematocrit. Five days after delivery, a blood exchange had to be done because of a hyperbilirubinaemia. After seven weeks, the child could be dismissed from hospital in good general status, with decreasing ascites, normal liver function and normal neurological status. The blood of the newborn was tested to be positive for IgG, while IgM-antibodies and parvovirus-B19-DNA were negative. The diagnosis of a parvovirus-B19 infection of a fetus with severe hydrops and anaemia could be verified by a positive proof for DNA in maternal blood, with negative IgM and highly positive parvovirus-B19-IgG and on the other hand highly positive viral DNA in fetal blood and in the amniotic fluid. 10 weeks after contact to parvovirus B19, i. e. in the 24th week of gestation, positive IgG- and negative IgM-antibodies were found in the mother's blood, whereas fetal complications were noticed. These data demonstrate that following an acute parvovirus-B19-infection of the mother IgM-antibodies can be proofed for 6 - 8 (- 10) weeks. On the other side parvovirus-B19-DNA in the mothers blood is detectable by means of PCR for 8 - 10 weeks and in some cases even more than 15 weeks.

The standardization of terminology for researchers in female pelvic floor disorders.

The lack of standardized terminology in pelvic floor disorders (pelvic organ prolapse, urinary incontinence, and fecal incontinence) is a major obstacle to performing and interpreting research. The National Institutes of Health convened the Terminology Workshop for Researchers in Female Pelvic Floor Disorders to: (1) agree on standard terms for defining conditions and outcomes; (2) make recommendations for minimum data collection for research; and (3) identify high priority issues for future research. Pelvic organ prolapse was defined by physical examination staging using the International Continence Society system. Stress urinary incontinence was defined by symptoms and testing; 'cure' was defined as no stress incontinence symptoms, negative testing, and no new problems due to intervention. Overactive bladder was defined as urinary frequency and urgency, with and without urge incontinence. Detrusor instability was defined by cystometry. For all urinary symptoms, defining 'improvement' after intervention was identified as a high priority. For fecal incontinence, more research is needed before recommendations can be made. A standard terminology for research on pelvic floor disorders is presented and areas of high priority for future research are identified.

Cost-effectiveness of universal cystoscopy to identify ureteral injury at hysterectomy.

OBJECTIVE: To evaluate the cost-effectiveness of routine cystoscopy at the time of abdominal, vaginal, and laparoscopically assisted vaginal hysterectomy in terms of cost per ureteral injury identified and treated. METHODS: Using a hospital-based perspective, a decision-analysis model was constructed to estimate the outcomes and costs of cystoscopy or no cystoscopy at the time of abdominal hysterectomy. A similar model was constructed for vaginal and laparoscopically assisted vaginal hysterectomy to account for the cost of conversion to laparotomy. Cost estimates were based on estimated costs of Duke University Medical Center and from average Medicare reimbursements for similar Diagnostic Related Groups from the Health Care Financing Administration. The incidence of ureteral injury was obtained from a review of the literature. Sensitivity analyses were performed for the following variables: ureteral injury rate, silent ureteral injury rate, cost of cystoscopy, and cost of therapeutic interventions. We assumed a silent renal death rate of 0%. RESULTS: Routine cystoscopy at abdominal hysterectomy was cost-saving above a threshold ureteral injury rate of 1.5%. At a ureteral injury rate of 0.2%, the marginal increase in the cost of routine intraoperative cystoscopy was $108 per abdominal hysterectomy, with an associated cost of $54,000 per ureteral injury identified. In comparison, at a ureteral injury rate of 2%, routine cystoscopy gave a marginal cost savings of $44 per hysterectomy, with a cost savings of $2200 per ureteral injury identified intraoperatively. At the baseline ureteral injury rate of 0.5%, routine cystoscopy had a marginally increased cost of $83 per hysterectomy, with an incremental cost-effectiveness of $16,600 spent per ureteral injury identified. The model constructed for vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy yielded a threshold ureteral injury rate of 2%, above which routine cystoscopy was cost-saving. In both models, the incidence of ureteral injury and the cost of readmission were the two variables with the greatest influence on cost-effectiveness. CONCLUSION: The cost-effectiveness of routine intraoperative cystoscopy depends on the rate of ureteral injury independent of the route of hysterectomy. If that rate exceeds 1.5% for abdominal hysterectomy and 2% for vaginal or laparoscopically assisted vaginal hysterectomy, then routine cystoscopy is cost-effective.

Effectiveness of laparoscopic cadaveric dissection in enhancing resident comprehension of pelvic anatomy.

BACKGROUND: Anatomic instruction during preclinical years of medical school has been in decline recently. There is evidence that residents already lose a considerable portion of basic anatomic knowledge in the transition from student to clinician, and this deficit is even more dramatic in residents who start their training with a decreased understanding of anatomy. We questioned whether anatomy could be adequately retaught to new residents as surgical anatomy. In an effort to address this deficiency, we developed a program to teach pelvic anatomy in fresh cadavers using a laparoscopic approach. The purpose of this investigation is to determine if such a program is effective in enhancing residents' pelvic anatomy comprehension. STUDY DESIGN: An obstetrics and gynecology residency was divided into intervention (n = 15) and control (n = 13) groups. The intervention was a 4-hour laparoscopic dissection in a fresh cadaver. Outcomes measures included a multiple-choice test, practical exam, faculty evaluation, and satisfaction assessment. The faculty evaluation and satisfaction assessment used a visual analog scale. Univarate and nonparametric analysis were used when appropriate. RESULTS: Initial test scores (p = 0.32), faculty evaluations (p = 0.25), and satisfaction scores (p = 0.17) were similar. Both groups improved their anatomic knowledge based on test scores (p = 0.004) and faculty evaluations (p < 0.001), and final test scores were not significantly different (p = 0.19). Data measured on a 10-cm visual analog scale suggested higher faculty evaluations in the intervention group (14mm versus 10.3mm, (p = 0.23). Similarly there were higher scores on the cadaver test in the intervention group (65% versus 50%), (p = 0.13). The intervention group was significantly more satisfied with their anatomic training (16.1 mm versus-10.1 mm, p = 0.001). CONCLUSIONS: This study did not have sufficient power to demonstrate that a single laparoscopic cadaveric dissection improves cognitive measures of anatomic perception, but suggested that it improves spatial perception of anatomy and is perceived by residents to be a valuable educational approach.

Vaginal mesh erosion after abdominal sacral colpopexy.

OBJECTIVE: Our goal was to compare the prevalence of vaginal mesh erosion between abdominal sacral colpopexy and various sacral colpoperineopexy procedures. STUDY DESIGN: We undertook a retrospective analysis of all sacral colpopexies and colpoperineopexies performed between March 1, 1992, and February 28, 1999. The patients were divided into the following 4 groups: abdominal sacral colpopexy, abdominal sacral colpoperineopexy, and 2 combined vaginal and abdominal colpoperineopexy groups, one with vaginal suture passage and the other with vaginal mesh placement. Survival analysis and Cox proportional hazards models were developed to examine erosion rates and time to erosion between groups. RESULTS: A total of 273 abdominal sacral vault suspensions were performed with the use of permanent synthetic mesh. There were 155 abdominal sacral colpopexies and 88 abdominal sacral colpoperineopexies. Among the 30 combined abdominal-vaginal procedures, 25 had sutures attached to the perineal body and brought into the abdominal field and 5 had mesh placed vaginally and brought into the abdominal field. Overall, mesh erosion was observed in 5.5% (15/273). The prevalence of mesh erosion was 3.2% (5/155) in the abdominal sacral colpopexy group and 4.5% (5/88) in the abdominal sacral colpoperineopexy group (P not significant). The rates of erosion when sutures or mesh was placed vaginally were 16% (4/25) and 40% (2/5), respectively, and were significantly increased in comparison with the rates for abdominal sacral colpopexy (hazard ratio, 5.4; 95% confidence interval, 1.6-18.0; P = .005; vs hazard ratio, 19.7; 95% confidence interval, 3.8-101.5; P < .001). These variables retained their significance after we controlled for other independent variables, including age, concomitant hysterectomy, concomitant posterior repair, and estrogen status. The median time to mesh erosion was 15.6 months for abdominal sacral colpopexy, 12.4 months for abdominal sacral colpoperineopexy, 9.0 months in the suture-only group (P < .005), and 4.1 months in the vaginal mesh group (P < .0001). CONCLUSIONS: The rate of mesh erosion is higher and the time to mesh erosion is shorter with combined vaginal-abdominal sacral colpoperineopexy with vaginal suture and vaginal mesh placement in comparison with abdominal sacral colpopexy.

Which women with stress incontinence require urodynamic evaluation?

OBJECTIVE: This study was undertaken to determine the predictive value of the symptom of stress urinary incontinence and to evaluate the ability of other factors suggested by a published Agency for Health Care Policy and Research guideline for the discrimination of patients unlikely to require urodynamic testing before surgical management. STUDY DESIGN: We evaluated 950 consecutive women without advanced (stage III or IV) pelvic organ prolapse who were referred with symptoms of incontinence. Incontinence was recorded by means of standard forms and was characterized as "any stress loss" (76.4%), "primarily stress loss" (58.9%), "stress loss only" (29.8%), "stress and urge loss" (52.2%), "urge loss only" (13.8%), "constant and stress loss" (1.9%), or "constant loss" (2.3%). Other variables were assessed by means of a standardized history, physical examination (including urethral axis determination and stress test), 1-week urinary diary, and postvoid residual volume measurement. A urodynamic diagnosis of pure genuine stress incontinence was used as the criterion standard. Sensitivity, specificity, and positive and negative predictive values were calculated. Logistic regression models incorporating various combinations of stress loss only, previous prolapse or incontinence surgery, nocturia, voiding frequency, urethral hypermobility, and postvoid residual volume <100 mL (the factors recommended by the Agency for Health Care Policy and Research guidelines), along with age and race as predictors of genuine stress incontinence, were constructed to evaluate the predictive ability of the guideline in a subset of 447 patients for whom data on all variables were available. RESULTS: Of the entire population 480 (50.5%) had pure genuine stress incontinence, 134 (14.1%) had both genuine stress incontinence and detrusor instability, 180 (18.9%) had pure detrusor instability, and 40 (4.2%) had intrinsic sphincter deficiency. Fifty-four (5.7%) had normal study results, and 62 (6.5%) had other nonincontinence diagnoses. Among the subjects with symptoms of stress loss only, 10.8% did not have genuine stress incontinence confirmed on urodynamic examination. Agency for Health Care Policy and Research guideline criteria had excellent discrimination (C statistic of 0.807) compared with the sole criterion of stress urinary incontinence only (C statistic of 0.574), with a positive predictive value of 85.7%. Only 7.8% of subjects met all the criteria, however, and 5.7% of these ultimately had a urodynamic diagnosis of either detrusor instability or normal study result. CONCLUSION: The predictive value of stress symptoms alone was not high enough to serve as the basis for surgical management. Agency for Health Care Policy and Research guidelines improved the predictive value but were applicable to only a small subset of patients referred with urinary incontinence.

Pelvic muscle electromyography of levator ani and external anal sphincter in nulliparous women and women with pelvic floor dysfunction.

OBJECTIVE: The purpose of this study was to compare results of electromyographic assessment of muscular recruitment between nulliparous control subjects without pelvic floor dysfunction and parous subjects with genuine stress urinary incontinence and with pelvic organ prolapse. Interference pattern analysis is an electromyographic technique that reproducibly measures muscular recruitment by detecting both "turns" in the electromyographic signal produced by positive and negative peaks of the motor unit potentials and motor unit potential amplitude. Fewer turns can indicate loss of motor units or failure of central activation of contraction, whereas greater amplitude can indicate reinnervation after nerve damage. STUDY DESIGN: We performed concentric needle electrode electromyographic examinations of the levator ani and external anal sphincter in 15 nulliparous control subjects and 20 parous subjects with abnormalities (n = 9 with genuine stress urinary incontinence, n = 11 with stage III or IV pelvic organ prolapse). We made digital recordings at multiple sites at rest and with moderate and maximal contraction. Interference pattern analysis yielded the number of turns per second and the mean signal amplitude (in microvolts) for each site at each contraction level. We compared individual patient data with data from the healthy population by means of cloud analysis. Mean values of number of turns per second and mean amplitude in each group were then compared with nonparametric methods and regression models. RESULTS: Mean ages were 28.7 years (range, 20-49 years) for the control group, 54.3 years (range, 35-75 years) for subjects with genuine stress urinary incontinence, and 65 years (range, 41-77 years) for subjects with pelvic organ prolapse. Median clinical levator ani strengths were 9 (range, 5-9) in the control group, 5 (range, 2-7) in the genuine stress urinary incontinence group, and 5 (range, 2-8) in the pelvic organ prolapse group. Median external anal sphincter strengths were 9 (range, 7-9) in the control group, 5 (range, 3-9) in the genuine stress urinary incontinence group, and 8 (range, 4-9) in the pelvic organ prolapse group. The external anal sphincters of subjects with pelvic organ prolapse had the highest percentage of abnormal study results according to cloud analysis. Mean number of turns per second in levators was greater in control subjects than in subjects with abnormalities (P =.034). We found similar differences in number of turns per second for the external anal sphincter (P =.004). In contrast, we did not find differences between groups in mean amplitude in either the levator ani or the external anal sphincter. Comparison of patients with genuine stress urinary incontinence versus subjects with pelvic organ prolapse showed no significant difference in the number of turns per second in either muscle. Mean amplitude was greater in the pelvic organ prolapse group than in the genuine stress urinary incontinence group for both muscles (levator ani, P =.028; external anal sphincter, P =.048). Neither mean amplitude nor the number of turns per second could be predicted by clinically estimated levator ani strength, age, or fecal incontinence. CONCLUSION: Compared with nulliparous control subjects, patients with genuine stress urinary incontinence and pelvic organ prolapse had changes in the levator ani and external anal sphincter consistent with either motor unit loss or failure of central activation, or both. Subjects with pelvic organ prolapse had findings consistent with greater recovery than was found in those with genuine stress urinary incontinence. Measures of recruitment by interference pattern analysis correlated better with clinical external anal sphincter strength than with levator ani strength and were independent of age.

Bilateral uterosacral ligament vaginal vault suspension with site-specific endopelvic fascia defect repair for treatment of pelvic organ prolapse.

OBJECTIVE: The anatomic and functional success of suspension of the vaginal cuff to the proximal uterosacral ligaments is described. STUDY DESIGN: Forty-six women underwent vaginal site-specific repair of endopelvic fascia defects with suspension of the vaginal cuff to the proximal uterosacral ligaments for pelvic organ prolapse. Outcome measures included operative complications, pelvic organ prolapse quantitation, and assessment of pelvic floor symptoms. RESULTS: After a median follow-up of 15.5 months (range, 3.5 months-3.4 years), 90% of patients had both resolution of vaginal bulging or prolapse symptoms and improvement of the stage of prolapse. There were improvements in all pelvic organ prolapse quantitation measurements except for total vaginal length, for which the median decrease was 0.75 cm. Intraoperatively, ureteral occlusion was noted in 11% (5/46) of patients with universal cystoscopy. In 3 patients the uterosacral suspension sutures were removed and replaced with resolution of the occlusion and in 2 patients ureteral reimplantation was required. Symptomatic prolapse (2 apical segment, 1 anterior, and 1 posterior) developed in 4 patients (10%), and 3 of them underwent reoperation. There were significant improvements in symptoms of bulging and pressure, voiding dysfunction, and vaginal and perineal splinting. CONCLUSION: Suspension of the vaginal vault to the proximal uterosacral ligaments combined with site-specific repair of endopelvic fascia defects provides excellent anatomic and functional correction of pelvic organ prolapse in most women. The risk of ureteral injury with this technique makes intraoperative cystoscopy essential.