Investigation of predictive factors for the presence of voiding dysfunction after transvaginal mesh surgery-Can the flow curve shape on uroflowmetry be a predictor?

PURPOSE: This study established the prognostic significance of the uroflowmetry flow curve shape in the presence of voiding dysfunction following transvaginal mesh surgery. METHODS: This is a retrospective study of 439 symptomatic cystocele patients who underwent anterior wall repair with transvaginal mesh surgery. Uroflowmetry and postvoid residual were used to evaluate voiding function both preoperatively and 12 months postoperatively. The patients were divided into two groups: those with and without postoperative voiding dysfunction, and the predictors of postoperative voiding dysfunction were analyzed. The shape of the urine flow curve was analyzed for its influence on the presence of postoperative voiding dysfunction. RESULTS: Thirty-five participants were in the voiding dysfunction group, while 404 were in the nonvoiding dysfunction group. Multivariate analysis was conducted by adding an interrupted-shaped curve to age, Qmax, and postvoid residual, which showed significant differences in univariate analysis, found that age 68 years or older (odds ratio [OR]: 7.68, 95%CI 1.02-58, p = 0.048), postvoid residual ≥110 mL (OR: 2.8, 95%CI 1.25-6.29, p = 0.013) and interrupted-shaped curve (OR: 2.47, 95%CI 1.07-5.69, p = 0.034) were discovered to be independent risk factors for the presence of voiding dysfunction after transvaginal mesh surgery. CONCLUSIONS: Following transvaginal mesh surgery for cystocele, three variables were found to be predictive of voiding dysfunction: the old age, excessive postvoid residual, and an interrupted-shaped flow curve. The uroflowmetry flow curve shape has the potential to be a new predictor of postoperative voiding dysfunction.

Transvaginal repair of enterocele following robot-assisted radical cystectomy using a mesh for abdominal wall hernia repair.

Introduction: This report aims to describe our experience in the pelvic floor reconstruction of anterior enterocele following radical cystectomy by transvaginal surgery using a mesh for abdominal wall hernia repair. Case presentation: An 84-years-old woman developed pelvic organ prolapse 4 months after undergoing robot-assisted radical cystectomy. After examination, she was diagnosed with a midline anterior enterocele. Considering the thinness of the vaginal wall and the large defect of the vaginal wall muscle layer, we performed transvaginal repair using a mesh for abdominal wall hernia repair designed to reduce the adhesion to the intestinal tract. Conclusion: At the 1-year follow-up, neither recurrence nor complications were observed. This showed that transvaginal mesh surgery for abdominal wall hernia repair could be a treatment option for pelvic organ prolapse with a vaginal wall muscle layer defect after radical cystectomy.

Are anterior mesh arms necessary in Japanese-style transvaginal mesh surgery for cystocele?

AIM: In this study, we retrospectively analyzed the medium-term efficacy and safety of surgery with transobturator two-arm transvaginal mesh for cystocele and to verify whether the anterior arms are necessary for Japanese-style transvaginal mesh surgery. METHODS: The study included 203 patients with cystocele who underwent transobturator two-arm transvaginal mesh at our hospital between August 2015 and June 2017 and received appropriate follow-up care for at least 48 months after surgery. RESULTS: The Pelvic Organ Prolapse Quantification stage was III in all the patients. Intraoperative complications included two cases of bladder injury and one case of more than 200 mL of blood loss. The mean observation period was 51.9 months, and prolapse recurred in the operated compartment in nine patients (4.4%). No cases of mesh exposure were observed. In comparing the preoperative characteristics of the 9 patients with prolapse recurrence at the surgical site with those of the other 194 patients, we found that the recurrence rate was significantly higher among patients in whom point Ba being 3.5 cm or more and among patients younger than 66 years. CONCLUSIONS: Transobturator two-arm transvaginal mesh for cystocele was as good and safe as the procedure previously reported with four-arm mesh; thus, it was possible to omit the anterior mesh arms in Japanese-style transvaginal mesh surgery. Patients should be informed preoperatively that prolapse recurs at a significantly higher rate among younger patients and in those whose point Ba being 3.5 cm or more.

Is transvaginal mesh procedure a potential measure for pelvic organ prolapse repair when performed by expert surgeons?

OBJECTIVES: The aim of this study was to verify the safety and efficacy of transvaginal mesh by analyzing the 2-year follow-up data of patients performed by a surgeon with a high volume of procedures. METHODS: A total of 617 patients with pelvic organ prolapse underwent transvaginal mesh by a single surgeon. Complications and anatomical status of each patient were examined up to 24 months after surgery. Risk factors for the recurrence were also analyzed. RESULTS: Regarding complications, we experienced 10 patients (3.8%) of bladder injuries in anterior transvaginal mesh and eight (3.4%) in anterior and posterior transvaginal mesh. Massive blood loss was observed in four patients, but there was no case of blood transfusion. Mesh exposures were seen in seven patients (1.2%). A total of 100 patients (16.2%) had prolapse recurrence, defined as the Pelvic Organ Prolapse Quantification System stage ≥II. As to recurrences on the operated compartments, we observed five patients (2.0%) for anterior transvaginal mesh, three (6.5%) for posterior transvaginal mesh, five (7.4%) for combined transvaginal mesh, and 31 (14.2%) in anterior and posterior transvaginal mesh. Regarding Point C before operation in the anterior and posterior transvaginal mesh, the recurrence rates were more than 23% in patients with a Point C of 4 or more. Binominal regression analyses showed that higher body mass index, younger age, and higher stage of uterine prolapse were significant risk factors. CONCLUSIONS: The transvaginal mesh surgery is safe when conducted by experts. However, the recurrence rate may exceed 20% for high-stage uterine prolapse even when conducted by experts.

Patient's age and D-dimer levels predict the prognosis in patients with TAFRO syndrome.

OBJECTIVES: To identify prognostic factors for TAFRO syndrome, a rare inflammatory disorder of unknown etiology characterized by thrombocytopenia, anasarca, fever, reticulin myelofibrosis, renal dysfunction, and organomegaly. METHODS: Data of patients with TAFRO syndrome were extracted from a Japanese patient registry. Patients were divided into groups according to the clinical and laboratory parameters at initial presentation. Cut-off values for the laboratory parameters were determined using receiver operating characteristic curve analysis and by clinical relevance. Patient survival was analyzed by the Kaplan-Meier method. Univariable analysis was performed using log-rank tests. Multivariable analyses were performed with the logistic regression model and the Cox proportional hazards model. RESULTS: We extracted the data of 83 patients with TAFRO syndrome from the registry. Univariable analysis identified several potential prognostic factors. Of these factors, age ≥60 years and D-dimer ≥18 µg/dL remained significant predictors of poor overall survival in the multivariable Cox proportional hazards model. Based on these results, we developed a simple prognostic scoring system for TAFRO syndrome (TS-PSS). CONCLUSION: Patients in our cohort were stratified into low, intermediate, and high-risk groups by the TS-PSS. This system should be verified with independent patient cohorts in future studies.

The effect of simulated gestational weight gain on balance, gait, and fear of falling.

The effects of pregnancy on balance with the eyes closed and maximum walking speed remain unclarified. The present study aimed to examine the effect of simulated gestational weight gain on balance, gait, and fear of falling in nulligravid women to enhance understanding of the impact of gestational weight gain. We prospectively evaluated the following outcomes in 24 healthy nulligravid women with and without a maternity-simulation jacket that simulated third-trimester pregnancy. To measure balance, we used the single-leg-stance test with eyes open and closed, and the functional reach test. We evaluated gait function by measuring walking speed, step length, and cadence at self-selected and maximum speeds. We used the timed-up-and-go test as a comprehensive measure of gait and balance, and the modified falls efficacy scale to evaluate fear of falling. Differences in these parameters between a simulated gestational weight gain condition and a "nonpregnant" condition were assessed. Simulated gestational weight gain caused significantly worse performances in the single-leg-stance test with eyes open and closed, functional reach test, walking speed, step length at self-selected and maximum speeds, and timed-up-and-go test. The effect size was larger for the single-leg-stance test with eyes closed than with eyes open. The average score for each modified falls efficacy scale item ranged from 4.7-8.5. In conclusion, balance decreased with simulated gestational weight gain, and balance may be more affected without visual feedback. Simulated gestational weight gain resulted in worse gait function at both self-selected and maximum speeds.

[Factors related to the life space of daycare center users].

PURPOSE: We examined the factors related to life space and changes in the care level after one year in daycare center users. METHODS: The participants were 83 older adults (age, > 65 years; mean age, 79.5±6.8 years) with MMSE scores of ≥20, who could walk independently, who needed support (1-2) or care (1), and who underwent rehabilitation at a daycare center. The life space was evaluated by the Life Space Assessment (LSA). The subjects' basic information (i.e., age, medical history.) was collected, and their physical function (i.e., grip strength, timed up and go test [TUG]), mental function (i.e., vitality, fear of falls), and social function (i.e., friends, hobbies, public transportation) were assessed to investigate the factors associated with their LSA scores. In addition, a follow-up survey was conducted on the care level at approximately one year later. RESULTS: A multiple regression analysis indicated that TUG scores (ß=-0.33), hobbies (ß=0.30), friends (ß=0.29), public transportation (ß=0.26), and grip strength (ß=0.24) were related to the life space. Next, the participants were divided into LSA-high and LSA-low groups, and changes in the care level (improvement, maintenance, deterioration) at approximately one year after the initial assessment were examined using a chi-squared test. A significant difference was observed in the distribution of the groups (p=0.03). CONCLUSIONS: Multiple factors were related to the life space. Moreover, it is possible that improvements in the level of care may be achieved by improving the life space.

[Participant characteristics and intervention effects of a program to improve the physical function in community-dwelling frail elderly subjects].

AIM: To examine the intervention effects of a physical function improvement program for community-dwelling frail elderly subjects. METHODS: The subjects included 309 participants (108 males, 224 females) who took part in "Iki Iki Health Classes," an exercise training program for frail elderly individuals conducted over three years from April 2008 to March 2011. The average participant age was 75.4±5.8 years in the males and 74.6±5.6 years in the females. RESULTS: Many participants had bone and joint disease with hypertension. The proportion of those with a history of falls (49.0%) was high. Significant improvements from the program were seen in the motor function and in the total scores for the Kihon checklist, grip strength, standing on one leg, timed up-and-go test (TUG), 5-m walking time and 5-m walking maximum time, fear of falling (77.5→70.1%) and subjective health ("good/well good/usually," increased from 73.6% to 89.1%). A new care-needs certification was issued in 21.6% of the subjects during the period spanning to March 31, 2013. A logistic regression analysis revealed that the deterioration of subjective health was significantly related to the presence of risk factors for new care-needs certification (odds ratio and 95% confidence interval: 4.99 (1.04-23.9), p=0.04). CONCLUSIONS: These results suggest that the interventions used in the program to improve the physical function contributed to improving the subjects' mental and physical functions. We speculate that whether improvements in subjective health are linked to roles in normal life and/or social activity participation is important for care prevention.

[Information tools utilized by outpatients presenting to a female urological clinic and their temporal trend: analysis of 3,480 patients].

OBJECTIVES: Female urological diseases, including pelvic organ prolapse and urinary incontinence, are common in elderly people, but public knowledge about these diseases is limited. We analyzed information tools that patients with female urological disease utilized to acquire information about their diseases. MATERIALS AND METHODS: This study included 3,480 patients who presented to our female urological clinic between January 2005 and December 2008. We conducted a questionnaire survey on what information tools were used for information gathering. RESULTS: The newspaper was the leading information tool (39.9%), followed by referral from another clinic (17.8%), internet (15.7%), TV (14.8%), recommendation by family or friends (5.5%), books or magazines (3.2%), and informative sessions for the public (0.6%). The temporal trend in the rate of information tool use over the 4 years showed that internet use increased significantly every year (p trend = 0.041) and was the most utilized tool in 2008, along with referral from other clinics. The rate of newspaper or TV use depended on their volumes of the female urological diseases. Additionally, no change over the study period was observed for the rate of internet utilization for patients in their 40s or under; however, it increased in patients in their 50s or over, and patients in their 50s and 60s utilized the internet as often as patients in their 40s or under in 2008. CONCLUSIONS: The newspaper was the most utilized information tool for patients with female urological diseases. However, internet use for gathering disease information is increasing, and the internet may be the most important information tool in the near future.

[Tension-free vaginal mesh repair for recurrence of pelvic organ prolapse after vaginal mesh procedures: a case report].

A 61-year-old woman presented with the chief complaint of a vaginal bulge for 2 years. She had undergone two operations for pelvic organ prolapse. The initial procedure was the Manchester procedure and posterior colporrhaphy, and the second was a vaginal repair with mesh for recurrent rectocele 3 years after the initial surgery. She noticed the vaginal bulge shortly after the second surgery. A gynecological examination revealed a stage III rectocele associated with a 2 cm, firm mass at the posterior vaginal wall. T2-weighted magnetic resonance imaging showed a 2 × 3 cm high-intensity mass located between the vaginal wall and rectum. The recurrent rectocele might have been caused by incomplete support from the mesh, which was not fixed in the vaginal wall, resulting in formation of a mass. The patient underwent complete mesh removal and tension-free vaginal mesh-posterior surgery for the rectocele. The excised mesh had shrunk from a 7 × 5 cm rectangle mesh preoperatively into a firm 2 × 2 × 3 cm mass. No recurrence has been seen for 18 months postoperatively.

[Influence of high fall-related self-efficacy on falls due to dissociation with ADL among elderly women in nursing homes].

AIM: We examined the influence of high fall-related self-efficacy on falls due to dissociation with activities of daily living (ADL) among elderly women in nursing homes. METHODS: We enrolled 72 female nursing home residents who were 70 years old or over and who scored 18 or higher on the Mini-Mental State Examination (MMSE). Subjects were classified into three groups based on the relationship between ADL and fall-related self-efficacy derived from a scattergram of the Functional Independence Measure (FIM) motor items and Falls Efficacy Scale (FES). The three groups were: group I which had low ADL and high fall-related self-efficacy (n=25); group II which had high ADL and low fall-related self-efficacy (n=30); and group III which had a correlation of ADL and fall-related self-efficacy in the 95% confidence interval (n=17). Then, we investigated the incidence of falls and the number of falls after 6 months in the three groups. The risk factor of falls was also investigated using multiple logistic regression analysis. RESULTS: The incidence and number of falls were significantly different in the three groups after 6 months. Moreover, the incidence of those falling was significantly different between group I and group III. The occurrence of falls was also significantly related with a past history of falls, FES, and group I which had low ADL and high fall-related self-efficacy. CONCLUSION: These findings suggest that the risk of falling increases in the presence of excessive fall-related self-efficacy dissociated from ADL.

Relation of falls efficacy scale (FES) to quality of life among nursing home female residents with comparatively intact cognitive function in Japan.

The purpose of this study was to investigate the relation of the Falls Efficacy Scale (FES) to quality of life (QOL) among nursing home residents. The subjects were 133 institutionalized women aged 70 years or older. They had comparatively intact cognitive function, with a Mini-Mental State Examination (MMSE) score of 15 or more, and could provide sufficient informed consent for a questionnaire survey. We evaluated their age, height, weight, body-mass index, history of hip fracture, history of fall(s) within the past year, complicating conditions, MMSE, Medical Outcomes Study 8-Item Short-Form Health Survey (SF-8), FES, and their subscores for Functional Independence Measure (FIM) motor items (self care, sphincter control, transfer, locomotion). There was a significant relationship between the Physical Component Summary (PCS) of SF-8 and FES. In each subscale, FES showed significant relations that were especially close in physical functioning (PF) and role physical (RP), with those relations proving stronger than those of the subscores of transfer and locomotion. In conclusion, the present results suggested that taking account of mental confidence is important for physical QOL, and that falls self-efficacy, including not only physical activity per se but also mental confidence, should be given prominence in the physical QOL of the institutionalized elderly.

Dynamic monitoring of brain activation under visual stimulation using fMRI--the advantage of real-time fMRI with sliding window GLM analysis.

An fMRI technique based on real-time analysis was applied to evaluate the advantages of dynamic monitoring of the t-statistics based on a general linear model. The temporal change of the t-statistics in V1 and V4 under four conditions of visual stimuli covering different visual fields with or without coloring was estimated using an incremental analysis and a sliding window analysis (SWA). The SWA not only visualized the dynamic change of the activation in response to the task conditions and switching, but also enabled us to evaluate the temporal correlation of the t-statistics among the four visual areas. It was suggested that the activity in the V4 was bilaterally organized, and the altering color stimuli gave stronger stimulation to the V1 than did the black and white stimuli. Although the activation map at each time point represents the brain activity during several task and rest blocks, a SWA will be useful to evaluate the transition of neuronal activation in response to several sequential task conditions. An incremental analysis will be useful to monitor the ongoing activation in real-time during the scan, since it gives a higher t-value according to the accumulation of volume data. These two methods will be complementary.

An FMRI study to investigate auditory attention: a model of the cocktail party phenomenon.

In human life, discrimination of a target voice from other voices or sounds is indispensable, and inability for such discrimination results in sensory aphasia. To investigate the neuronal basis of the attentional system for human voices, we evaluated brain activity during listening comprehension tasks using functional magnetic resonance imaging (fMRI) at 3T. Diotic listening comprehension tasks, in which a narration was superimposed by another given by the same speaker (SV experiment) or by a different speaker (DV experiment), were presented to normal volunteers. The story indicated in the baseline task blocks, in which only one narration was presented, was intensively followed during the superimposed task blocks. In each experiment, 6 task blocks, 3 blocks for each condition, and 7 rest blocks were alternatively repeated, and the contrast of the superimposed condition to the baseline condition in each session was obtained. In the DV experiment, compared with the control condition, activation in Wernicke's area (BA22) was increased. In the SV experiment, activation in the frontal association cortex (BA6, BA9/ 46, BA32, BA13/47) was additionally increased. These results suggested that difficulty in phonological processing to discriminate human voices calls for further semantic, syntactic, and prosodic processing, as well as augmented selective attention.

Temporal relationship between action and visual outcome modulates brain activation: an fMRI study.

Monitoring the visual outcome of our actions is critical to our visuo-motor behavior. To investigate the neural basis of monitoring visual change produced by self-movement, we examined the temporal relationship between manual depression of a button and visual feedback on activation of the brain. Six neurologically normal subjects participated in 3 experiments (synchronous, delayed, and visual [control]). Magnetic resonance (MR) images of their brains were acquired during the experiments using a scanner operating at 3T. In the synchronous experiment, subjects pressed a button at self-paced intervals and received synchronous visual stimuli in response. In the delayed experiment, visual stimuli were presented with a delay after subjects pressed a button at self-paced intervals. In the control experiment (visual experiment), subjects did not press the button, but viewed visual stimuli generated by a computer at random intervals. In the synchronous experiment, activation in the cerebellum and right parietal lobe was stronger than in the delayed experiment, whereas activation in the primary visual cortex was weaker than in the delayed and visual experiments. These results suggest that visual outcomes produced synchronously with action are processed in the cerebellum and the parietal area for the organization of optimal motor behavior, rather than in the primary visual area that is known to process the visual properties of external objects. The cerebellar signal related to visuo-motor contingency may modulate the cortical processing of visual input that is synchronous with action.

An fMRI study of temporal sequencing of motor regulation guided by an auditory cue--a comparison with visual guidance.

The neuronal system to process and transfer auditory information to the higher motor areas was investigated using fMRI. Two different types of internal modulation of auditory pacing (1 Hz) were combined to design a 2x2 condition experiment, and the activation was compared with that under a visual guidance. The bilateral anterior portion of the BA22 (ant-BA22) and the left BA41/42 were more extensively activated by the combined modulation condition under the auditory cue than that under the visual cue. Among the four auditory conditions with or without the two types of internal modulation, the activation in the ant-BA22 was augmented only on the left side by the combined modulation condition. The left ant-BA22 may be especially involved in integrating the external auditory cue with internal modulation, while the activation on the right side did not depend on the complexity. The role of the left BA41/42 in motor regulation may be more specific to the processing of an auditory cue than that on the right side. These two areas in the left temporal lobe may be organized as a subsystem to handle the timing of complex movements under auditory cues, while the higher motor areas in the frontal lobe support both sensory modalities for the cue. This architecture may be considered as 'audio-motor control', which is similar to the visuo-motor control of the front-parietal network.

Quantitative analysis of cellular fetal hemoglobin gamma chain messenger RNA (HbF-gamma mRNA) in maternal peripheral blood.

OBJECTIVE: Fetal cells cross the feto-maternal barrier and circulate in maternal peripheral blood; thus, this study aimed to show the relationship between clinical evidence in pregnancy and qualitative feto-maternal barrier changes. METHODS: The expression of fetal hemoglobin gamma chain messenger RNA (HbF-gamma mRNA) was measured by quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) in maternal peripheral blood. RESULTS: HbF-gamma mRNA was detected in all pregnant women after 5 weeks of gestation. In normal pregnancy, there were two peaks at 10 and 40 weeks, and a significant increase 4 weeks prior to the onset of labor. In intrauterine growth restriction (IUGR), preterm delivery and placenta previa, the HbF-gamma mRNA expression was significantly higher than in normal pregnancies. CONCLUSION: The expression of HbF-gamma mRNA relative to that of beta-actin mRNA is thought to reflect the real-time leakage of fetal cells into maternal blood.

MFB-1, an F-box-type ubiquitin ligase, regulates TGF-beta signalling.

TGF-beta signalling regulates cell growth, differentiation, morphogenesis and apoptosis. MAFbx/Atrogin-1 has been identified as a regulator for skeletal muscle atrophy and encodes an F-box-type E3 ubiquitin ligase. However, little is known about how MAFbx/Atrogin-1 regulates cellular signalling. Here, we identify and genetically characterize MFB-1, a MAFbx/Atrogin-1 homologue from Caenorhabditis elegans. The mfb-1 deletion mutant significantly enhanced the dauer constitutive (Daf-c) phenotype caused by mutations in the DAF-7/TGF-beta-like signalling pathway, but not the DAF-2/insulin receptor-like signalling pathway. Conversely, the Daf-c phenotypes of DAF-7 pathway mutants were partially suppressed by mfb-1 cDNA transgenes. Therefore, MFB-1 acts genetically downstream in the DAF-7 pathway. A mfb-1::GFP fusion was found to be expressed in the nervous system, hypodermis and intestine and overlapped expression of many DAF-7 pathway genes. We propose that MFB-1 is a novel F-box protein that negatively regulates dauer formation in concert with the DAF-7 signalling pathway in C. elegans.