Foundation for an evidence-informed algorithm for treating pelvic floor mesh complications: a review.

To address evidence gaps on the management of complications related to mesh in pelvic floor surgery, we created an evidence-based algorithm that includes defining evidence gaps. We utilized the Delphi method within a panel of surgeons treating mesh complications to define a treatment strategy. The first round provided a list of clinically based postulates that informed a review expanding postulates to recommendations and included grading of the quality of evidence. A second round informed the final algorithm. While the quality of the available evidence is low, it provides a framework for planning diagnosis and management of mesh-related complications. TWEETABLE ABSTRACT: Removal of mesh must balance resolution of complications with the risk of removal and recurrence of pelvic floor symptoms.

Association between asymptomatic deep vein thrombosis detected by venography and symptomatic venous thromboembolism in patients undergoing elective hip or knee surgery.

BACKGROUND: Venography is commonly used to compare the efficacy of different thromboprophylaxis strategies for preventing deep vein thrombosis (DVT) in patients undergoing total hip replacement (THR) or total knee replacement (TKR). METHODS: We explored the relation between asymptomatic DVT and symptomatic venous thromboembolism (VTE) in patients undergoing THR or TKR treated with standard doses of enoxaparin (30 mg b.i.d. or 40 mg o.d.) by comparing the incidence of asymptomatic DVT in venographic studies with the incidence of symptomatic VTE in studies where venography was not performed. RESULTS: In 10 venographic studies involving 5796 patients, the incidence of asymptomatic DVT after THR was 13.2% [95% CI, 12.2-14.2%] and after TKR was 38.1% (95% CI, 35.5-40.8%). In two studies involving 3500 patients who did not undergo venography, the 90-day incidence of symptomatic VTE after THR was 2.7% (95% CI, 2.1-3.4%) and after TKR was 1.8% (95% CI, 0.9-2.7%). For every symptomatic VTE in THR studies where venography was not performed there were five asymptomatic DVTs in the venographic studies; for TKR, the ratio was 1:21. The incidence of asymptomatic DVT and the symptomatic VTE/asymptomatic DVT ratio was influenced by the venogram reading committee (Gothenburg vs. Hamilton: total DVT after THR, 19.5% vs. 8.7%, P < 0.0001; for TKR, 42.7% vs. 27.2%, P < 0.0001). CONCLUSIONS: Comparisons across trials show a consistent relation between asymptomatic venographic DVT in patients undergoing elective THR or TKR surgery and symptomatic VTE in patients not undergoing venography. Differences exist in the strength of the relation depending on the type of surgery and the venogram reading committee.

Direct comparisons of hand and mouth kinematics during grasping, feeding and fork-feeding actions.

While a plethora of studies have examined the kinematics of human reach-to-grasp actions, few have investigated feeding, another ethologically important real-world action. Two seminal studies concluded that the kinematics of the mouth during feeding are comparable to those of the hand during grasping (Castiello, 1997; Churchill et al., 1999); however, feeding was done with a fork or spoon, not with the hand itself. Here, we directly compared grasping and feeding kinematics under equivalent conditions. Participants were presented with differently sized cubes of cheese (10-, 20- or 30-mm on each side) and asked to use the hand to grasp them or to use a fork to spear them and then bring them to the mouth to bite. We measured the apertures of the hand during grasping and the teeth during feeding, as well as reaching kinematics of the arm in both tasks. As in many past studies, we found that the hand oversized considerably larger (~11-27 mm) than the food item during grasping; moreover, the amount of oversizing scaled with food size. Surprisingly, regardless of whether the hand or fork was used to transport the food, the mouth oversized only slightly larger (~4-11 mm) than the food item during biting and the oversizing did not increase with food size. Total movement times were longer when using the fork compared to the hand, particularly when using the fork to bring food to the mouth. While reach velocity always peaked approximately halfway through the movement, relative to the reach the mouth opened more slowly than the hand, perhaps because less time was required for the smaller oversizing. Taken together, our results show that while many aspects of kinematics share some similarity between grasping and feeding, oversizing may reflect strategies unique to the hand vs. mouth (such as the need to have the digits approach the target surface perpendicularly for grip stability during lifting) and differences in the neural substrates of grasping and feeding.

A critical appraisal of bleeding events reported in venous thromboembolism prevention trials of patients undergoing hip and knee arthroplasty.

BACKGROUND: Anticoagulants are effective for the prevention of venous thromboembolism (VTE) but cause bleeding. Interpretation of the risks and benefits of new anticoagulant regimens for VTE prevention is complicated by a lack of standardized definitions and reporting of bleeding. We reviewed the reporting of bleeding in randomized controlled trials of new anticoagulants compared with standard doses of enoxaparin in hip and knee arthroplasty, and examined the possible impact of differences in the definition of major bleeding on interpretation of the trial results. METHODS: Electronic searches identified 16 phase III trials published between 2001 and 2010 involving 41,265 patients comparing one of five new anticoagulants with a common comparator, enoxaparin. RESULTS: Major bleeding rates in patients treated with enoxaparin ranged from 0.1% to 3.1% in hip arthroplasty trials and from 0.2% to 1.4% in knee arthroplasty trials. In studies that excluded surgical-site bleeding from the definition, major bleeding rates were about 10-fold lower than in those which included surgical-site bleeding. Within the individual trials, the choice of bleeding definition and the methods of assessment of bleeding influenced the conclusions regarding the risk of bleeding with new anticoagulant regimens relative to enoxaparin. Eight of the 16 studies demonstrated a ≥ 40% relative risk differences in major bleeding between treatment groups but the difference was statistically significant in only two of these trials. CONCLUSION: Randomized VTE prevention trials report markedly different rates of major bleeding despite similar patient populations and doses and durations of anticoagulant prophylaxis and were underpowered to detect modest differences in patient-important bleeding events. Standardization of bleeding definitions and reporting seems desirable.

The human dorsal stream adapts to real actions and 3D shape processing: a functional magnetic resonance imaging study.

We tested whether the control of real actions in an ever-changing environment would show any dependence on prior actions elicited by instructional cues a few seconds before. To this end, adaptation of the functional magnetic resonance imaging signal was measured while human participants sequentially grasped three-dimensional objects in an event-related design, using grasps oriented along the same or a different axis of either the same or a different object shape. We found that the bilateral anterior intraparietal sulcus, an area previously linked to the control of visually guided grasping, along with other areas of the intraparietal sulcus, the left supramarginal gyrus, and the right mid superior parietal lobe showed clear adaptation following both repeated grasps and repeated objects. In contrast, the left ventral premotor cortex and the bilateral dorsal premotor cortex, the two premotor areas often linked to response selection, action planning, and execution, showed only grasp-selective adaptation. These results suggest that, even in real action guidance, parietofrontal areas demonstrate differential involvement in visuomotor processing dependent on whether the action or the object has been previously experienced.

fMRI reveals a preference for near viewing in the human parieto-occipital cortex.

Posterior parietal cortex in primates contains several functional areas associated with visual control of body effectors (e.g., arm, hand and head) which contain neurons tuned to specific depth ranges appropriate for the effector. For example, the macaque ventral intraparietal area (VIP) is involved in head movements and is selective for motion in near-space around the head. We used functional magnetic resonance imaging to examine activation in the putative human VIP homologue (pVIP), as well as parietal and occipital cortex, as a function of viewing distance when multiple cues to target depth were available (Expt 1) and when only oculomotor cues were available (Expt 2). In Experiment 1, subjects viewed stationary or moving disks presented at three distances (with equal retinal sizes). Although activation in pVIP showed no preference for any particular spatial range, the dorsal parieto-occipital sulcus (dPOS) demonstrated a near-space preference, with activation highest for near viewing, moderate for arm's length viewing, and lowest for far viewing. In Experiment 2, we investigated whether the near response alone (convergence of the eyes, accommodation of the lens and pupillary constriction) was sufficient to elicit this same activation pattern. Subjects fixated lights presented at three distances which were illuminated singly (with luminance and visual angle equated across distances). dPOS displayed the same gradient of activation (Near>Medium>Far) as that seen in Experiment 1, even with reduced cues to depth. dPOS seems to reflect the status of the near response (perhaps driven largely by vergence angle) and may provide areas in the dorsal visual stream with spatial information useful for guiding actions toward targets in depth.

Lower limb contrast venography: a modified technique for use in thromboprophylaxis clinical trials for the accurate evaluation of deep vein thrombosis.

Lower limb venography remains the imaging modality of choice for detection of asymptomatic deep vein thrombosis (DVT) in clinical trials of anticoagulant agents. A variety of techniques of venography have been described. Here, we describe a modified technique (the "King's" technique) developed to increase the overall adequacy of identification of lower limb veins and detection of small asymptomatic DVT. Essential elements include proper preparation of patients prior to their arrival in the radiology department, intermittent use of tourniquets to ensure complete and adequate deep vein filling, use of a consistent image acquisition sequence and visualization of all veins in at least two different planes. Use of this technique minimizes technical difficulties, provides improved patient through-put in "busy" fluoroscopy units and, ultimately, improves "off-site" levels of adjudication.

Are ureteral catheters in gynecologic surgery beneficial or hazardous?

STUDY OBJECTIVE: To evaluate the use of ureteral catheters in gynecologic surgery. DESIGN: A prospective study. SETTING: A university-affiliated private hospital. PATIENTS: A series of 317 women undergoing a variety of gynecologic surgeries who were at high risk for ureteral injury. INTERVENTIONS: The procedures ranged from radical oncologic surgery to difficult operations for benign disease. In 273 patients the ureteral catheters were inserted prophylactically, and in 44 they were inserted postoperatively to confirm ureteral patency. Nineteen were lighted catheters used during laparoscopic surgery. MEASUREMENTS AND MAIN RESULTS: Only 3 of 546 ureters could not be catheterized preoperatively. The average time to insert the catheters was 6 minutes (range 2-21 min). All ureters were easily identified, and their dissection was facilitated by the catheters. Two asymptomatic cases of transitional cell cancer of the bladder were diagnosed. One case of ureteral obstruction was identified at postoperative ureteral catheter insertion. No immediate or delayed problems were identified. The frequency of urinary tract infection was 3.2%. CONCLUSION: Ureteral catheters are safe and are simple to insert. They enhance identification of ureters and facilitate ureteral dissection.

Transvaginal repair of bladder lacerations during LAVH.

Eight bladder lacerations occurred during laparoscopic-assisted vaginal hysterectomy (LAVH) at a university-affiliated private hospital. All were exposed vaginally. Six were repaired with a standard two-layer closure by the vaginal route. One patient had a combined vaginal and laparoscopic repair. Another had a partial ureteric avulsion that was repaired vaginally, and a double-J ureteric catheter was left in situ for 6 weeks. All patients underwent cystoscopy to confirm adequate closure and confirmation of ureteric patency. All repairs were successful. The planned procedure (LAVH) was completed without further complications and the hospital stay was not prolonged as a result of the injury. The patient with partial ureteric avulsion had a normal intravenous pyelogram, and the ureteric catheter was removed in the office by transurethral cystoscopy. We conclude that bladder injuries during LAVH can be readily identified intraoperatively. Excellent results can be achieved with transvaginal repair, and the planned procedure can be completed by the intended route. Cystoscopy to confirm ureteric patency is essential after all repairs.

Safe and cost-effective laparoscopic removal of adnexal masses.

STUDY OBJECTIVE: To evaluate laparoscopic removal of adnexal masses using a plastic bag to avoid peritoneal spillage. DESIGN: An observational study. SETTING: A university-affiliated private hospital. PATIENTS: Thirty-one women (mean age 48.7 yrs) with adnexal masses. INTERVENTIONS: Laparoscopic removal of adnexal masses ranging from 3 to 12 cm (18 complex, 5 septated cystic masses, 8 persistent simple cysts). The masses were placed in plastic sandwich bag and removed through the umbilical incision. Hospital costs, length of stay and operating times were compared with those of 24 patients undergoing the removal of similar masses by laparotomy. MEASUREMENTS AND MAIN RESULTS: Three masses were functional cysts, 4 were tubal cysts, 4 were endometriomas, and 20 were benign ovarian neoplasms. There were no malignancies. Peritoneal spillage occurred during one ovarian cystectomy. The only complication was bleeding from the cannula site. Comparing laparoscopy and laparotomy, average operating time was 73.45 minutes (range 34-148 min) and 81 minutes, average length of hospital stay was 17.4 hours (range 6-73 hrs) and 2.92 days, and average hospital cost was $2401 and $3539, respectively. CONCLUSION: Laparoscopic access provides a cost-effective method of removing adnexal masses with a very small risk of peritoneal spillage. When managed in this manner, rather than laparotomy, the cost reduction was significant.

Extended-duration prophylaxis against venous thromboembolism after total hip or knee replacement: a meta-analysis of the randomised trials.

BACKGROUND: The optimum duration of prophylaxis against venous thromboembolism after total hip or knee replacement is uncertain. Our primary objective was to establish the efficacy of extended-duration prophylaxis on symptomatic venous thromboembolic events. METHODS: We identified randomised trials comparing extended-duration prophylaxis using heparin or warfarin with placebo or untreated control in patients undergoing elective total hip or knee replacement by searching electronic databases (MEDLINE, EMBASE), references from retrieved articles, and abstracts from conference proceedings, and by contact with pharmaceutical companies and investigators. Two reviewers independently extracted data on study design, symptomatic and symptomless venographic venous thromboembolism, death, and bleeding outcomes. Results from individual trials were combined with the Mantel-Haenszel method. FINDINGS: Nine studies met our inclusion criteria (3999 patients), eight with low molecular weight heparin, and one with unfractionated heparin. Extended-duration prophylaxis for 30-42 days significantly reduced the frequency of symptomatic venous thromboembolism (1.3% vs 3.3%, OR 0.38; 95% CI 0.24-0.61, numbers needed to treat [NNT]=50), with no statistical evidence of heterogeneity (x(2) test, p=0.69). There was a greater risk reduction in patients undergoing hip replacement (1.4% vs 4.3%, 0.33; 0.19-0.56, 34) compared with knee replacement (1.0% vs 1.4%, 0.74; 0.26-2.15, 250). A significant reduction in symptomless venographic deep vein thrombosis was also observed (9.6% vs 19.6%, 0.48; 0.36-0.63, 10). There was no increase in major bleeding but extended-duration prophylaxis was associated with excess minor bleeding (3.7% vs 2.5%, 1.56; 1.08-2.26, numbers needed to harm [NNH]=83). INTERPRETATION: Among patients undergoing total hip or knee replacement, extended-duration prophylaxis significantly reduces the frequency of symptomatic venous thromboembolism. The reduction in risk is equivalent to about 20 symptomatic events per 1000 patients treated.

Guillain-Barré syndrome in pregnancy. A case report.

Severe Guillain-Barré syndrome in a patient 33 weeks pregnant, who went into premature labour 48 hours after requiring mechanical ventilation, is described. The labour required augmentation with oxytocin and a healthy 2,100 g baby was delivered using forceps. Obstetrically, the patient had an uncomplicated puerperium. She required ventilation for 20 days and after extensive physiotherapy was discharged with no disability. It is our opinion that the management of the gravid patient with Guillain-Barré syndrome does not differ much from that of non-pregnant patients with the disease. Supportive care in an intensive care unit remains the cornerstone of treatment and unnecessary obstetric intervention must be strongly resisted.

Sexually transmitted pathogens in acute pelvic inflammatory disease.

The prevalence of sexually transmitted pathogens in two groups of women was studied: 50 women with clinical diagnoses of acute pelvic inflammatory disease (PID) and 50 asymptomatic women attending a family planning clinic (FPC). Genital specimens, collected by non-invasive procedures, were examined. Endocervical Neisseria gonorrhoeae was present in 62% of the PID group and 10% of the FPC group (P less than 0.0001). One-third of N. gonorrhoeae isolates were penicillinase-producing strains. Chlamydia trachomatis was isolated from the endocervix in 30% of the PID group and 26% of the FPC group (P = 0.8240 NS). Mycoplasma hominis was more prevalent in the vaginas and endocervices of the PID group than the FPC group (84% and 72% v. 50% and 42%; P = 0.0006 and 0.0047 respectively). Trichomonas vaginalis was present in 56% of the PID group and 20% of the FPC group (P = 0.0004). Syphilis serology was positive in 34% of the PID group and 10% of the FPC group (P = 0.0026). In the PID group of patients, 8% were positive for HBsAg. Antibody to the human immunodeficiency virus was not detected in any of the 100 women. The high prevalence of recognised sexually transmitted pathogens underlines the need for appropriate antimicrobial agent(s) active against N. gonorrhoeae, C. trachomatis and M. hominis in patients with PID. In view of the high prevalence of penicillinase-producing strains of N. gonorrhoeae, routine use of an antibiotic active against such strains is desirable.