Conservative management of intravesical erosion of a synthetic mid-urethral sling for the treatment of stress urinary incontinence, based on patient preference: A case report.

BACKGROUND: Intravesical mesh erosion is an uncommon late complication of placement of a synthetic mid-urethral sling (MUS) for the treatment of stress urinary incontinence, and only a few cases have been reported. Optimal management remains controversial, though there is a tendency toward surgical removal through a variety of routes. However, surgical removal comes with its own risks and is not necessarily associated with an improvement in symptoms. We, herein present the first case of a conservatively managed intravesical mesh erosion following MUS placement. CASE: Nine years after insertion of a tension-free vaginal tape (TVT), a patient presented with persistent lower abdominal pain and dysuria. Flexible cystoscopy demonstrated an erosion of the tape through the bladder wall. The patient declined surgical intervention at the time. Therefore, she was commenced on regular methenamine hippurate and vaginal oestrogen, and kept under surveillance with regular cystoscopies. Her symptoms responded to this treatment and 6 years later remained well controlled on this regime. CONCLUSION: This case demonstrates that conservative management may be a safe and appropriate option for patients who decline surgical excision of mesh erosion.

Proceedings of resources for optimal care of acute care and emergency surgery consensus summit Donegal Ireland.

BACKGROUND: Opportunities to improve emergency surgery outcomes exist through guided better practice and reduced variability. Few attempts have been made to define optimal care in emergency surgery, and few clinically derived key performance indicators (KPIs) have been published. A summit was therefore convened to look at resources for optimal care of emergency surgery. The aim of the Donegal Summit was to set a platform in place to develop guidelines and KPIs in emergency surgery. METHODS: The project had multidisciplinary global involvement in producing consensus statements regarding emergency surgery care in key areas, and to assess feasibility of producing KPIs that could be used to monitor process and outcome of care in the future. RESULTS: Forty-four key opinion leaders in emergency surgery, across 7 disciplines from 17 countries, composed evidence-based position papers on 14 key areas of emergency surgery and 112 KPIs in 20 acute conditions or emergency systems. CONCLUSIONS: The summit was successful in achieving position papers and KPIs in emergency surgery. While position papers were limited by non-graded evidence and non-validated KPIs, the process set a foundation for the future advancement of emergency surgery.

Beneficial metabolic actions of a stable GIP agonist following pre-treatment with a SGLT2 inhibitor in high fat fed diabetic mice.

The purpose of the present study was to examine if a stable glucose-dependent insulinotropic polypeptide (GIP) agonist could exert beneficial metabolic control in diabetic mice which had been pre-treated with sodium-glucose-cotransporter-2 (SGLT2) inhibitor dapagliflozin (DAPA). High fat fed mice administered low dose streptozotocin (STZ) received vehicle, DAPA once-daily over 28 days, or DAPA once-daily for 14 days followed by (DAla(2))GIP once-daily for 14 days. Energy intake, body weight, glucose and insulin concentrations were measured at regular intervals. Glucose tolerance, insulin tolerance test, dual-energy X-ray absorptiometry (DEXA) and pancreatic histology were examined. Once-daily administration of (DAla(2))GIP for 14 days in high fat fed diabetic mice pre-treated with DAPA demonstrated significant decrease in body weight, blood glucose and increased insulin concentrations which were independent of changes in energy intake. Similarly, glucose tolerance, glucose-stimulated insulin secretion, insulin sensitivity and HOMA-ß were significantly enhanced in (DAla(2))GIP-treated mice. DEXA analysis revealed sustained percentage body fat loss with no changes in lean mass, bone mineral content and density. Pancreatic immunohistochemical analysis revealed decreased islet number and increases in islet area, beta cell area and pancreatic insulin content. The DAPA-induced increase in alpha cell area was also reversed. Additional acute in vitro and in vivo experiments confirmed that the impaired action of (DAla(2))GIP under hyperglycaemic-induced conditions was significantly reversed by DAPA treatment. These data demonstrate that (DAla(2))GIP can exert beneficial metabolic control in high fat fed diabetic mice pre-treated with DAPA. The results highlight possibility of a targeted and personalized approach using a GIP agonist and SGLT2 inhibitor for the treatment of type 2 diabetes.

Linear IgA disease associated with ulcerative colitis: the role of surgery.

The association of linear IgA disease (LAD) with ulcerative colitis (UC) is well documented. One hypothesis for the association proposes immune exposure to autoantigens present in the colon, and subsequent targeting of these autoantigens in the skin. There are variable reports on the effect of bowel surgery on skin disease in such patients. We report a patient with LAD and UC who required colectomy to control her UC, but whose skin disease failed to resolve following surgery. A literature review revealed that in reported cases of this association, proctocolectomy has resulted in remission of skin disease in all cases where it has been performed, in contrast to variable results seen in cases where colectomy alone was performed.

Mutation screening and genotype:phenotype correlation in familial hypercholesterolaemia.

The aim of this study was to develop a mutation screening protocol for familial hypercholesterolaemia (FH) patients and to assess genotype/phenotype effects in terms of pre-treatment lipid profiles and presentation of tendon xanthomata (TX). A total of 158 families with clinical definitions of possible (120) or definite (38) FH were studied using a tiered screening protocol. Mutations were identified in 52 families, 44 families showing 23 different LDLR gene defects and eight families showing the common Apo B100 gene defect R3500Q. LDLR defects were detected in various regions of the gene with 56% in the LDL binding domain (exons 2-6) and 37% in the EGF precursor homology domain (exons 7-14). The most common mutations were D461N(7), C210X(5), 932delA(5), and C163Y(4). Frameshift mutations accounted for 20% with nonsense 13%, mis-sense 35%, splice 3%, Apo B 13% and 2% large deletion, 13% of clinically definite FH remained undefined. In conclusion, DNA based diagnosis is possible in 79% (30/38) of clinically definite FH families and of the 120 possible FH families at the start of the screening program, 18% (22/120) now have defined mutations. Overall 60 families from the original 158 meet the clinical and/or genetic criteria for definite FH. Tendon xanthomata were present in only 58% (30/52) of genetically defined FH families, thus limiting its use as a strict diagnostic criteria. Families with low density lipoprotein receptor (LDLR) defects present with higher total and LDL cholesterol levels and a higher incidence of TX than do those with the common Apo B variant, and frameshift mutations appear to have the most severe presentation.

A novel single base deletion in the LDLR gene (211delG): Effect on serum lipid profiles and the influence of other genetic polymorphisms in the ACE, APOE and APOB genes.

A single base deletion (211delG) in the low density lipoprotein receptor (LDLR) gene was shown to cause familial hypercholesterolaemia (FH) in a large family from Northern Ireland. Twenty-four of 52 family members tested had this mutation, 13 of which were newly diagnosed. Mutation-positive individuals had significantly higher mean total-cholesterol (TC) and LDL-cholesterol (LDL-C) than those without 211delG. LDL-C was a more accurate indicator of disease status than TC. When TC levels alone were considered, in individuals over 16 years, a false negative rate (TC < 7.5 mmol/l) of 40% was found; however this fell to 13% based on inclusion of LDL-C levels. Individuals with coronary artery disease (CAD) had significantly higher TC levels than those without CAD and tended to have tendinous xanthomas (TX) and corneal arcus (CA). Generic polymorphisms in the angiotensin converting enzyme (ACE) and apolipoprotein (apo) B genes did not appear to be associated with lipid levels or with the clinical severity of the disease; however, the apo E epsilon4 allele did show a lipid-raising effect in individuals with the mutation.

Diffuse plane xanthomatosis associated with a monoclonal band displaying anti-smooth muscle antibody activity.

We report a patient with diffuse planar xanthomatous lesions associated with a benign monoclonal gammopathy. This patient has a very high titre of anti-smooth muscle antibody (1:10,240), but normal liver function tests and a normal liver biopsy. The paraprotein band displays anti-smooth muscle antibody activity. There is no evidence of any other underlying disease process. The findings are consistent with a diagnosis of diffuse plane xanthomatosis, but the mechanism of xanthoma formation remains unclear.

Inhibition of fibrin monomer polymerisation by myeloma immunoglobulin.

Myelomatosis was diagnosed in a 64 year old man on the basis of a serum paraprotein band (type IgG lambda, 42 g/l), plasma cell infiltration of bone marrow, and multiple lytic lesions evident on skull x ray picture. Blood specimens taken into plain glass tubes showed bulky gelatinous clot formation with minimal clot retraction. Coagulation tests were significantly abnormal with an increase in thrombin time, prothrombin time, and reptilase time. The possibility that the paraprotein was interfering with fibrin production was investigated. The rate of fibrin monomer polymerisation (measured turbidometrically) was reduced in patient plasma compared with control plasma. Although purified fibrin monomer prepared from the patient's fibrinogen polymerised normally, the addition of purified paraprotein caused a dose dependent reduction in the rate of polymerisation. These results suggest that the paraprotein was impairing fibrin formation by inhibiting fibrin monomer polymerisation. After chemotherapy the paraprotein concentration decreased and the coagulation results returned to normal.

Physico-chemical conditions necessary for the in vitro excystment of Zygocotyle lunata (Trematoda:Paramphistomatidae).

Various physico-chemical factors associated with the in vitro excystment of metacercariae of Zygocotyle lunata were studied. Metacercariae could excyst with or without the presence of trypsin or bile salts, although the rate of excystation was slower in the absence of both. Crude ox-bile extract promoted faster excystment than did more refined sodium taurocholate. Pretreatment of cysts with pepsin also resulted in faster excystment rates. Optimal excystation occurred at 40 degrees C and between pH 5.5 and 7.5. The broad pH and temperature ranges and the non-specific enzyme/bile salt requirements for excystation were correlated with the wide range of vertebrate hosts used by this trematode.

Button wires in the treatment of mandibular fractures.

Button wiring has been used as an alternative to eyelet wiring in the Department of Oral and Dental Surgery of Birmingham General Hospital since 1977. This clinical update reviews 65 patients with mandibular fractures in which button wires were utilised in their treatment.

A radio-isotope study of the healing of mandibular bone grafts in patients.

Radionucleotide scanning is now accepted as a reliable method of visualising the metabolic activity of the skeletal system. Its application to the maxillo-facial region is reviewed, and its possible role in monitoring the healing of bone grafts is discussed. The radio-isotope 99m technetium-methylene diphosphonate was used to study the revascularisation and healing of large autogenous bone grafts to the mandible in eight patients. The scans demonstrated the dynamic activity in the grafts and showed varying patterns in different types of grafts.