Characteristics, risk factors and outcomes of critically ill patients with active TB.

BACKGROUND: TB continues to impose a significant healthcare burden despite advancement in diagnostics and increased availability of effective antimicrobials. Recent years have seen a resurgence of the disease in association with increasing life expectancy and use of immunosuppressive therapy. Mortality remains high in TB patients requiring admission to critical care units.METHODS: We conducted a retrospective study in two public hospitals to determine factors associated with mortality in patients with TB requiring critical care admission. All patients aged ≥21 years with a diagnosis of active TB involving any organ system at the time of a critical care admission were eligible. The primary outcome measure was 30-day mortality.RESULTS: Over the study period of 4 years, 148 patients were identified. Overall 30-day mortality was 36.5%. Based on multivariate analysis, factors which independently correlated with 30-day mortality include higher APACHE II (Acute Physiology and Chronic Health Evaluation II) score, acid-fast bacilli smear positivity, initiation of anti-TB treatment prior to critical care admission and need for renal replacement therapy.CONCLUSION: TB in critically ill patients continues to be associated with significant mortality. The factors identified to be associated with poor survival outcomes in our study were largely related to greater disease burden and potential for suboptimal treatment.

The impact of surgical treatment on the mental health of women with obstetric fistula.

Obstetric fistula is estimated to affect 2 million women worldwide and has considerable social and psychological effects on affected individuals. In this prospective study, 51 consecutive women with obstetric fistula admitted to the Barhirdar Hamlin Fistula Centre in the north of Ethiopia were screened using the General Health Questionnaire (GHQ-28) for potential mental health disorder before and 2 weeks after fistula surgery. Prior to surgery, all women screened positive. By 2 weeks after, this had dropped to 36% (P = 0.005). 27% of the 45 women who were cured of their incontinence screened positive, while all 6 of those with severe residual incontinence continued to screen positive. We conclude that surgical treatment of obstetric fistula results in marked improvements in mental heath.

Laparoscopic versus open Burch colposuspension: a randomised controlled trial.

OBJECTIVE: To compare perioperative characteristics, short-term, and long-term outcomes for laparoscopic Burch colposuspension (LBC) and open Burch colposuspension (OBC) for the treatment of urinary stress incontinence. DESIGN: Randomised surgical trial with single blinding. SETTING: Three tertiary level teaching hospitals involving seven surgeons of varying skill levels. POPULATION: Two hundred women with urodynamic stress incontinence (USI). METHODS: The two groups were treated in identical fashion, except for the laparoscopic or open approach to surgery. Attempts were made to blind the subjects and the observers obtaining outcome data to treatment group. Analyses were adjusted for surgeon experience. MAIN OUTCOME MEASURES: Absence of USI 6 months following surgery, postoperative pain, time spent in hospital, and time to return to activities of normal daily living. RESULTS: There were no significant differences in objective and subjective measures of cure and in patient satisfaction at 6 months, 24 months, or 3-5 years of follow up between laparoscopic and open colposuspension groups. Laparoscopic colposuspension took longer time to perform (87 versus 42 minutes, P< 0.0001) but was associated with less blood loss (P = 0.03), less pain (P = 0.02), and quicker return to normal activities (P = 0.01). CONCLUSION: LBC has significant advantages over traditional OBC, without any apparent compromise in short-term and long-term outcomes. To compare perioperative characteristics, short-term, and long-term outcomes for laparoscopic Burch colposuspension (LBC) and open Burch colposuspension (OBC) for the treatment of urinary stress incontinence. Randomised surgical trial with single blinding. Three tertiary level teaching hospitals involving seven surgeons of varying skill levels. Two hundred women with urodynamic stress incontinence (USI). The two groups were treated in identical fashion, except for the laparoscopic or open approach to surgery. Attempts were made to blind the subjects and the observers obtaining outcome data to treatment group. Analyses were adjusted for surgeon experience. Absence of USI 6 months following surgery, postoperative pain, time spent in hospital, and time to return to activities of normal daily living. There were no significant differences in objective and subjective measures of cure and in patient satisfaction at 6 months, 24 months, or 3-5 years of follow up between laparoscopic and open colposuspension groups. Laparoscopic colposuspension took longer time to perform (87 versus 42 minutes, P < 0.0001) but was associated with less blood loss (P= 0.03), less pain (P= 0.02), and quicker return to normal activities (P= 0.01). LBC has significant advantages over traditional OBC, without any apparent compromise in short-term and long-term outcomes.

Biomechanical properties of prolapsed vaginal tissue in pre- and postmenopausal women.

The aim of this study was to biomechanically assess vaginal tissue from pre- and postmenopausal women with symptomatic prolapse. Vaginal tissue was collected at the time of surgery in women with symptomatic prolapse. Tissue specimens were biomechanically assessed by a purpose-built tissue puller system and stress-strain curves were digitally recorded. Tissue was stretched at a constant rate of 0.8 mm/s to an elongation of 8 mm. A force-stiffness relationship was obtained. All data were normalized for length and cross-sectional area of the specimens. Tissues from the anterior vaginal wall were analyzed in 10 postmenopausal and 8 premenopausal women. The mean age of the postmenopausal women was 69 years, compared to 41 years for premenopausal women. Pre- and postmenopausal groups show very little or no difference regarding elongation or long-term tissue deformation. A significantly higher elastic modulus was observed in postmenopausal vaginal tissue. This is most likely an age-related phenomenon. Apart from this, pre- and postmenopausal vaginal tissue showed few differences in biomechanical assessment.

A new method to measure elastic properties of plastic-viscoelastic connective tissue.

An experimental protocol was tested to measure elastic properties of connective tissue displaying viscoelastic as well as plastic properties. The protocol consisted of a slow rate, linear elongation (0.88 mms(-1), 8 mm) in combination with a superimposed sinusoidal vibration of small amplitude (50 Hz, 0.1 mm). Using digital filters and mathematical algorithms, the force responses to linear elongation and to vibration were obtained. The method was tested on excised fibromuscular tissue of the vaginal wall obtained from women who suffered a vaginal prolapse. The force-stiffness and force-elongation relationships based on the vibration response were unaffected by any long-term deformation of the specimens. The directly measured force-elongation curves were strongly affected by these deformations. It was therefore concluded that with the new method, it is possible to determine the elastic properties accurately. Furthermore, this method seems more sensitive to small changes in elastic properties than the classic tensile test.

Genital tract fistula repair on 116 women.

A personal series of 130 genital tract fistula repairs in 116 women is presented. All fistulas were repaired vaginally. The majority of the fistulas were due to obstetric injuries, especially prolonged obstructed labour. Obstetric fistula continue to be a cause of personal and social morbidity to sufferers.

Positive Kleihauer result following an ectopic pregnancy.

The case presented highlights the risk of fetomaternal haemorrhage in ectopic pregnancy. With the current shortages of anti-D, it may be necessary to reduce administration of anti-D, but this may result in an increase in rhesus isoimmunization. As Kleihauer testing may be of limited value (1), recommendations by deCrespigny and Davison (2) for the use of a reduced dose of 30 mcg anti-D in all rhesus negative women with early pregnancy complications including ectopic pregnancy, would seem appropriate.

Transcervical endometrial resection.

STUDY OBJECTIVES: To determine the safety and efficacy of endometrial resection, and to provide an indicator of the operative problems and treatment outcomes. DESIGN: Prospective study. SETTING: Academic practice tertiary care setting. PATIENTS: One hundred twenty-six consecutive women undergoing endometrial resection because of menorrhagia, who wished to retain their uterus. INTERVENTION: Hysteroscopic endometrial resection performed as a day procedure. MEASUREMENTS AND MAIN RESULTS: In 126 women, 2 cases of uterine perforation were readily identified on the operating monitor screen; they had no serious sequelae. Three patients had heavy uterine bleeding, which was controlled by intrauterine tamponade. No women had other serious complications. CONCLUSION: Hysteroscopic endometrial resection is a safe, successful, and cost-effective treatment of menorrhagia.

Female circumcision.

Three cases of female circumcision are presented together with a literature review. Unfortunately, this procedure frequently results in genital mutilation. Treatment with deinfibulation enables restoration of the external genitalia and vagina. Obstetric and gynaecological complications have been documented, but emotional and psychological effects may be difficult to assess. These women should be treated without bias and with sensitivity.

A new laparoscopic aspiration technique for ovarian dermoid cysts.

A new method for aspirating benign dermoid cysts enables removal of the collapsed cyst wall without the need for extending laparoscopic incisions or opening the pouch of Douglas. The technique has been used by one of the authors in 10 patients with good effect and minimal or no spillage of dermoid cyst contents into the peritoneal cavity.

External cephalic version at term.

The case notes of women with singleton term (37 weeks' gestation and beyond) breech presentation and delivery were retrospectively reviewed. Thirty-two of the 72 women in the study group had attempted external cephalic version at term, with a success rate of 53% (17 women). The Caesarean section rate was significantly lower in the group which had attempted ECV compared to the group which did not.