Evaluation of the fascial technique for surgical repair of isolated posterior vaginal wall prolapse.

OBJECTIVE: To study the anatomic and functional efficacy and assess long-term success of the fascial technique in the repair of rectocele. METHODS: Forty-two women with symptomatic posterior vaginal wall prolapse of at least stage II underwent a surgical repair using the technique of reconstruction of the rectovaginal septum. These women were evaluated at 6 weeks and 18 months postoperatively for anatomic improvement in the grade of their rectocele and a functional improvement in their vaginal, bowel, and sexual symptoms. RESULTS: Ninety-five percent (40 of 42) were assessed at 6 weeks and 78.5% (33 of 42) attended follow-up at 18 months. Preoperative symptoms included 1) vaginal protrusion (78%); 2) defecation symptoms (76%), which included fecal incontinence alone in 9.5%, evacuation difficulties in 57%, and both fecal incontinence and evacuation difficulties in 9.5%; and 3) sexual dysfunction (33%). At 6-week follow-up there was resolution of vaginal protrusion in 87.5%, and bowel symptoms in 87%. At 18 months there was anatomic cure in 92%, improvement in defecation in 81%, and improvement of sexual dysfunction in 35%. No major complications were seen. CONCLUSION: This technique is effective in providing relatively long anatomic cure of the rectocele and resolution of its symptoms.

Magnetic resonance imaging of normal levator ani anatomy and function.

OBJECTIVE: To evaluate the anatomy and function of the levator ani in normal women by dynamic magnetic resonance imaging. METHODS: Twelve asymptomatic, nulliparous, premenopausal women with no previous pelvic surgery underwent a dynamic magnetic resonance imaging scan of their pelvis. The origin, orientation, thickness, and function of the two components of the levator ani were studied. RESULTS: The ileococcygeus is a thin muscle with an upward convexity. It slopes forward and medially. It is of variable thickness (mean thickness 2.9 mm, standard deviation 0.8 mm). There are apparent gaps in the muscle diaphragm and at its site of origin from the obturator fascia. The puborectalis is a thicker muscle. It is shaped like a belt encasing the pelvic organs. It is taller posteriorly than anteriorly. It is not attached to the bladder neck, but the midurethra and lower urethra lie in close proximity to it. The puborectalis moves dorsoventrally, whereas the ileococcygeus moves craniocaudally. CONCLUSION: The levator ani is not a single muscle but has two functional components that vary in thickness, origin, and function. The ileococcygeus has a mainly supportive function, whereas the puborectalis has a sphincteric function. Gaps in the diaphragmatic portion of the ileococcygeus are a normal finding. Individual components of the levator ani may be prone to different types of childbirth trauma and should therefore be assessed separately when planning rehabilitation.

Assurance opportunities for local health departments.

CONTEXT: Widespread changes in health care in the United States, especially the growth in the number and membership of health maintenance organizations (HMOs), provide increasing opportunities for collaboration, especially through contracts, between local health departments (LHDs) and HMOs to achieve public health goals. OBJECTIVES: (1) To identify, through a review of the literature, the areas in which HMOs and LHDs can collaborate to their mutual benefit and (2) for the leadership of an LHD in Florida to engage HMOs in its county in Florida in collaboration. DESIGN: University faculty reviewed the relevant literature; the Director of Medical Services for the Duval County Health Department developed the relationships with Duval County HMOs. SETTING: The setting for the study was Duval County. PARTICIPANTS: The participants in the study included faculty from the College of Public Health at the University of South Florida, State and county public health officials, and representatives of 10 HMOs. MAIN OUTCOME MEASURES: The main outcome measures were a literature review to identify feasible areas for collaboration and successful collaboration with HMOs in areas of mutual interest. RESULTS: The director of medical services for the county health department initiated a variety of collaborative activities with 10 HMOs. These led to agreements, participation on committees and task forces, provision of services, and improved communication. CONCLUSIONS: Collaboration between LHDs and HMOs to achieve public health assurance goals is feasible. Other organizations can encourage such collaboration through public and private policies.

Relative value of oocyst counts in evaluating anticoccidial activity.

Birds medicated with roxarsone and in another experiment with zoalene in the feed produced higher oocysts counts than unmedicated control birds receiving the same oocyst dose of Eimeria tenella or a mixture of six species (E. tenella, E. necatrix, E. brunetti, E. maxima, E. acervulina, and E. mitvati). These experiments confirm the conclusion that oocyst counts constitute an unsatisfactory and unreliable parameter for judging effectiveness of an anticoccidial even though such increases are a relatively rare occurrence in anticoccidial evaluation experiments.

Development of immunity to coccidiosis in chickens administered anticoccidials in feed.

New combinations of techniques were employed for comparing the development of immunity of Eimeria tenella in chickens being medicated with 12 different anticoccidials. Broiler-type birds in batteries received a daily measured dose of E. tenella oocysts for 15 consecutive days while the drug was administered at the manufacturer's recommended level. Two or more tests of each drug gave the following ratings: strong suppression, monensin (121 ppm), salinomycin (80 ppm), lasalocid (75 ppm); moderate suppression, monensin (100 ppm), decoquinate (30 ppm), clopidol (125 ppm), and narasin (80 ppm); slight suppression, arprinocid (70 ppm), nicarbazin (125 ppm), and amprolium (125 ppm + ethopabate (4 ppm); no effect, robenidine (33 ppm), zoalene (125 ppm), and aklomide (250 ppm).

Coccidiosis and intestinal pH in chickens.

The intestinal contents of white Leghorn cockerels were significantly lower in pH in birds infected with Eimeria mivati, E. maxima, or E. necatrix than in uninoculated control birds. The particular Eimeria species used affected the region of the intestine involved, the days (5-9 postinoculation) on which pH decreased, and the magnitude of the decrease. The effects on the magnitude and frequency of pH decrease were as follows: E. mivati, marked in the duodenum and jejunum, variable in the ileum; E. maxima, slight in the duodenum, variable in the jejunum and ileum; E. necatrix, no change in the duodenum, variable in the jejunum and ileum. Infection with E. tenella did not change the intestinal pH. The pH of the gizzard was occasionally higher in birds infected with E. mivati or E. necatrix than in uninoculated control birds. With all four species, on some days the pH in the ceca was higher than in the ceca of controls. These results and previous reports indicate that infection with one of the above four species or with E. acervulina or E. brunetti produces the greatest and most consistent decrease in pH in the region of the intestine where the particular species characteristically produces the severest infection.

Interaction of infectious bursal disease and coccidiosis in layer replacement chickens.

During a floor-pen study on anticoccidial programs for layer-replacement pullets, there was a natural outbreak of infectious bursal disease (IBD). The interaction of coccidiosis and IBD was characterized by: excessive deaths from coccidiosis; and apparent failure of some anticoccidial drug treatments. Immunity to coccidiosis was not blocked by the IBD infection, although immunity was less in some treatments than would be expected with the degree of coccidiosis exposure.

Anticoccidial activity of Lasalocid in control of moderate and severe coccidiosis.

The fermentation product lasalocid ("Antibiotic X-537A," Hoffmann-LaRoche) showed good anticoccidial activity when administered via feed at 50 or 75 ppm in a replicated floor-pen experiment. Lasalocid was compared with monensin (121 ppm) ("positive control") and also with unmedicated ("negative") controls in pens heavily seeded or indirectly seeded with eight species of coccidia (Eimeria acervulina, E. brunetti, E. hagani, E. maxima, E. mitati, E. necatrix, E. praecox, and E. tenella). Under severe coccidiosis exposure (litter seeded by infected birds) both anticoccidials permitted significantly increased weights, improved feed conversions, and reduced lesion scores. Shank depigmentation was numerically less in anticoccidial-treated birds than in unmedicated controls, though not significantly. Coccidiosis mortality (lesions or parasites demonstrated) was 10% in unmedicated controls. Lasaloic reduced this mortality significantly to 0.8% at 50 ppm and 0.4% at 75 ppm. No coccidiosis mortality occurred with monensin-fed birds. With moderate exposure (indirect seeding) both anticoccidials permitted significantly greater weight gains and less shank depigmentation than in unmedicated controls. In unmedicated pens severity of coccidiosis was significantly greater in the intentionally seeded pens than in indirectly seeded pens with all parameters except depigmentation. This design provided a practical procedure for testing anticoccidials in a single experiment against severe and moderate exposures to coccidiosis as are normal in broiler production.

Efficacy of monensin against turkey coccidiosis in laboratory and floor-pen experiments.

Monensin at 60, 80, or 100 ppm in feed reduced mortality and lesion scores while protecting against weight loss of turkeys infected with the major pathogenic species: Eimeria adenoides, E. meleagrimitis, and E. gallopavonis. With single and mixed infections in battery-cage experiments, the death rate of unmedicated turkey poults was 33-75%. Weight gains were significantly (P is less than or equal to 0.05) better with 100 ppm monensin than 60 ppm, as were also lesion scores. Under floor-pen conditions there were no significant differences among monensin treatments. Moisture content of the litter was significantly lower in all monensin-medicated pens (40%, compared with 52% moisture in pens of unmedicated controls).

Efficacy of arprinocid against coccidiosis of broilers in battery and floor-pen trials.

Medication of broilers with arprinocid [9-(2-chloro-6-fluorophenylmethyl)-9H-purine-6-amine] gave protection against the effects of coccidiosis in both battery and floor-pen trials. In battery trials, efficacy was tested on single-species inoculations of Eimeria acervulina, E. mivati, E. necatrix, E. maxima, E. Brunetti, and E. tenella. Two strains of each species recently recovered from the field, were tested separately. In floor-pen trials, all six species, both field and laboratory strains, were used as a mixed infection. In batteries, 60 and 70 ppm essentially eliminated coccidiosis-induced mortality and weight depression. Effects of 50 ppm on weight gain were variable. The effectiveness of different medication levels varied between strains within a species. In floor-pen trials, 40, 60, or 80 ppm was effective in controlling mortality and weight depression, and increasing feel-conversion ratios. All levels were significantly as effective as monensin in protecting against coccidiosis. With severe exposure to coccidia, 60 and 80 ppm gave significantly lower lesion socres than did 40 ppm of arprinocid or 120 ppm monensin.

Demonstration of Eimeria tenella in bursa of Fabricius of chickens.

Coccidial life-cytle stages were detected in the bursa of Fabricius of broiler chickens inoculated with Eimeria tenella, whether or not the chickens had previously been infected with infectious bursal disease virus (IBDV). Chickens infected only with E. tenella had developing parasites in the lining epithelium, whereas chickens with both infections had gametocytes also in the epithelial cells surrounding numerous degenerating bursal cysts.

Influence of infectious bursal disease on the development of immunity to Eimeria tenella.

Specific-pathogen-free (SPF) chicks infected with infectious bursal disease (IBDV) virus at one day of age or midway (7 days) through a two-week immunization program for Eimeria tenella showed significantly less (P less than or equal to 0.05) protection against coccidal challenge as measured by lesion scores than chicks given IBDV after 14 days of coccidial immunization. The chicks showed complete protection to later coccidial challenge administered on Day 21. Bursae were markedly smaller from IBDV-infected chicks than from uninfected controls, and pathological changes were extensive. Virus-neutralization tests demonstrated that titers to IBD were higher in chicks exposed to the virus than in unexposed controls.

Effect of the anticoccidial arprinocid on production, sporulation, and infectivity of Eimeria oocysts.

Medication of broilers with arprinocid [MK-302, 9-(2-chloro-6-fluorbenzyl adenine)] had 3 distinct effects on oocysts; (1) the number of oocysts produced was decreased, (2) fewer of the oocysts sporulated, and (3) those oocysts which did sporulate were less infective than those from unmedicated birds. The drug level necessary to prevent passage of oocysts depended on the species and strain of coccidia. To essentially eliminate oocyst production (less than 5% of controls) required medication with the following levels of arprinocid: 70 ppm with Eimeria maxima; 60 ppm with E. mivati, E. E. necatrix, and E. brunetti; and 50 ppm with E. tenella. With E. acervulina, oocysts were completely eliminated by 60 ppm of arprinocid with one field strain but were still numerous at 70 ppm with a second field strain. Oocysts recovered from birds on medication often failed to sporulate. No sporulation was seen at drug levels of 30 ppm or above with E. maxima and E. mivati. The level of arpinocid required to prevent sporulation with other species depended on the strain being studied, but varied from 30 ppm to 70 ppm. The oocysts of E. acervulina, E. mivati, E. tenella, and E. brunetti recovered from medicated birds that subsequently sporulated, were less infective when inoculated into susceptible birds, than oocysts from unmedicated birds. Oocysts from low medication level with E. necatrix (30 ppm) and E. maxima (10 ppm), once sporulated, were as infective as oocysts from unmedicated control birds, even though the numbers produced were less. No differences were detected in the time oocysts were produced between medicated and unmedicated birds infected with E. acervulina, E. maxima, E. brunetti, and E. tenella.

Role of angiogenesis in benign, premalignant and malignant vulvar lesions.

OBJECTIVE: To investigate the presence of angiogenic factors in benign, premalignant and malignant vulvar lesions. STUDY DESIGN: Immunohistochemical demonstration of vascular endothelial growth factor (VEGF) and platelet-derived endothelial cell growth factor (PD-ECGF) in normal vulvar skin, lichen sclerosus, vulvar intraepithelial neoplasia (VIN) and vulvar cancer. RESULTS: VEGF was found in the majority of vulvar cancers but only a minority of VIN lesions. PD-ECGF was found in the majority of lesions. CONCLUSION: Demonstration of angiogenesis may suggest which preinvasive lesions will progress to invasive cancer.

Is there a link between vulval cancer and blood group?

Risk factors for squamous cell vulval cancer (SCC) remain unclear though there have been associations with lichen sclerosis, smoking, and vulval intraepithelial neoplasia (VIN). We studied 191 patients who had been referred to the vulval clinic at the Royal Free Hospital and who had both blood group and histopathology results available. Seventy-two percent of patients with SCC and non-neoplastic epithelial disorders of the vulva (NNEDV) were found to be in blood group A with only 17% in blood group O. Those with SCC associated with VIN had only 30% in blood group A with 50% in blood group O. The control population showed that 38% of the population were in blood group A and 43% were in blood group O. Our results suggest that blood group A is prevalent in patients with SCC associated with NNEDV but not in those women with squamous vulval cancer and associated VIN.

Progress in the control of coccidiosis with anticoccidials and planned immunization.

New anticoccidials continue to be introduced to the poultry industry on an average of about one every 2 years. Revised requirements have increased costs of discovery, development, and approval by the Food and Drug Administration to several million dollars for each product. Gross sales of anticoccidials are now estimated to be in excess of $30,000,000 annually. Anticoccidials are almost universally used in starter rations for meat-type birds being raised under floor-pen management. Protection is more important with these fast-growing birds than with egg-producing types where immunity and cage layer management modify demands for anticoccidials. Coccidiosis mortality has generally been eliminated by all 25 approved anticoccidials if properly used. Selection of specific anticoccidials is based on the ability of the anticoccidial to: (1) improve weights and (2) feed conversion, and (3) to suppress development of lesions. Costs of the product may influence decisions on which one to use. With some anticoccidials the rapid emergence of drug resistant strains has been the biggest problem. "Switching" among the 13 classes of anticoccidials and the so-called "shuttle program" are common methods used to avoid development of resistance. Preventive medication will probably continue to constitute the major method of coccidiosis control with meat-type poultry if attempts to develop economic cage-type management do not supplant current litter and floor-pen management. Immunity acquired through incidental or planned immunization is more important in control of coccidiosis with layer and breeder flocks raised in floor-pens. Some progress in development of avirulent immunogenic strains of different species of coccidia has been reported and further research efforts in this direction should be encouraged.

Efficacy of different feeding levels of monensin in the control of coccidiosis in broilers.

The feed level of monensin which gave maximal protection from coccidial infection in broilers reared in floor pens depended on the severity of the coccidial exposure and the criteria of infection studied. With indirect seeding of pens with coccidia (light coccidial exposure), 40 ppm was as efficacious as 100 ppm in improving weight gain, lesion score, and feed conversion. Statistical analysis with direct seeding (seeder birds; severe coccidial exposure) showed that feed levels of 84 and 102 ppm gave maximal improvement of weight gain and 4-week feed conversion, respectively. Further increasing the monensin level from 100 to 121 ppm did not improve weight gain and feed conversion at 8 weeks. Conversely, the relationship of plasma pigmentation and total lesion scores to monensin feed levels indicated that increasing the dosage of monensin from 100 to 121 ppm improved the performance of the broilers on the basis of these 2 infection indicators.

Monensin, Eimeria tenella infection, and effects on the bacterial populations in the ceca of gnotobiotic chickens.

Bacteria-free chicks in separate plastic film isolators were inoculated orally with single species of bacteria. Within an isolator, half the birds were fed unmedicated feed and half received feed containing 100 ppm monensin. With clostridium perfringens as the established species of monoflora, bacterial counts from the duodenum were 10(4) times lower and counts from the ceca were three times lower in monensin-fed birds compared to unmedicated birds. Infection with Eimeria tenella stimulated an eight-fold increase in the numbers of C. perfringens in the ceca of unmedicated birds but no increase in monensin-fed birds. With Bacteroides sp. or Streptococcus faecalis as monoflora, there was no difference in the cecal or duodenal populations between medicated and unmedicated birds uninfected with coccidia. In contrast to C. perfringens, populations of Bacteroides sp. and S. faecalis in the ceca decreased five to 100-fold in both medicated and unmedicated chicks after infection with E. tenella. Duodenal populations of C. perfringens, Bacteroides sp., and S. faecalis were unaffected by the coccidial infection.

Effects of anaerobic bacteria on Eimeria tenella infection in bacteria-free, monofloral, and conventional chickens.

Bacteria-free, monofloral, and conventional chicks were infected with Eimeria tenella. Monofloral chicks were established by inoculating birds in several gnotobiotic isolators with a single species of Escherichia coli or with one of three Bacteroides sp. isolates (No. 157, No. 202, or No. 366). Daily weights of individual birds were recorded for six days post-infection (PI). On Day 6 PI all birds were sacrificed and cecal lesions were scored. Conventional, infected birds lost weight on days 5 and 6 PI and showed severe lesions. Birds maintained as monofloral groups with isolates of Bacteroides sp. No. 157, No. 202 or E. coli showed equally severe lesions, but lost weight only on day 6 PI. Conventional, uninfected birds with no lesions, birds infected with Bacteroides sp. isolate No. 366 with mild lesions, and bacteria-free birds with mild to severe coccidial lesions all continued to gain weight on each day post-infection.

Effects of roxarsone on pigmentation and coccidiosis in broilers.

Roxarsone (0.005%) medicated chickens inoculated at seven weeks of age with Eimeria maxima oocysts had significantly higher pigment levels in blood plasma than did unmedicated controls. Unmedicated E. maxima infected birds had significantly lower pigment levels compared to uninoculated controls. Uninoculated roxarsone medicated controls showed no increase in pigment levels over uninoculated unmedicated birds. This experimental design demonstrates that the beneficial effect of roxarsone medication is due to anticoccidial action rather than an increase in pigmentation after feeding the yellow-colored roxarsone. Since uninoculated birds gained more rapidly if roxarsone (0.025%) was added to the diet, the drug also appears to stimulate growth as well as to protect against coccidial infection. In two floor-pen experiments roxarsone demonstrated anticoccidial activity as measured by higher pigment scores than unmedicated infected controls. The coccidial infection was induced after seeding the litter with oocysts from birds infected with E. acervulina, E. brunetti, E. hagani, E. maxima, E. mivati, E. necatrix, E. praecox, and E. tenella. Pigmentation levels were significantly higher in plasma and skin of roxarsone medicated chickens in two experiments and in shanks in one experiment. Similar protection against depigmentation was demonstrated by adding roxarsone to feed medicated with nequinate. These results involving addition of roxarsone may explain some equivocal reports on pigmentation, weight gains or feed conversion. Some previous investigators appear to have used an inadequate experimental design by omitting use of unmedicated uninoculated controls or to have made no attempt to monitor for presence or absence of coccidiosis.