Computational and Experimental Study of Thermodynamics of the Reaction of Titania and Water at High Temperatures.

Gaseous titanium hydroxide and oxyhydroxide species were studied with quantum chemical methods. The results are used in conjunction with an experimental transpiration study of titanium dioxide (TiO2) in water vapor-containing environments at elevated temperatures to provide a thermodynamic description of the Ti(OH)4(g) and TiO(OH)2(g) species. The geometry and harmonic vibrational frequencies of these species were computed using the coupled-cluster singles and doubles method with a perturbative correction for connected triple substitutions [CCSD(T)]. For the OH bending and rotation, the B3LYP density functional theory was used to compute corrections to the harmonic approximations. These results were combined to determine the enthalpy of formation. Experimentally, the transpiration method was used with water contents from 0 to 76 mol % in oxygen or argon carrier gases for 20-250 h exposure times at 1473-1673 K. Results indicate that oxygen is not a key contributor to volatilization, and the primary reaction for volatilization in this temperature range is TiO2(s) + H2O(g) = TiO(OH)2(g). Data were analyzed with both the second and third law methods using the thermal functions derived from the theoretical calculations. The third law enthalpy of formation at 298.15 K for TiO(OH)2(g) at 298 K was -838.9 ± 6.5 kJ/mol, which compares favorably to the theoretical calculation of -838.7 ± 25 kJ/mol. We recommend the experimentally derived third law enthalpy of formation at 298.15 K for TiO(OH)2, the computed entropy of 320.67 J/mol·K, and the computed heat capacity [149.192 + (-0.02539)T + (8.28697 × 10-6)T2 + (-15614.05)/T + (-5.2182 × 10-11)/T2] J/mol-K, where T is the temperature in K.

Urinary symptoms and impact on quality of life in women after treatment for endometrial cancer.

The primary objective of our study is to describe urinary symptoms in women treated for endometrial cancer. We performed a cross-sectional survey of women who had undergone surgical treatment for endometrial cancer. Three validated questionnaires were utilized: the Sandvik Severity Index, the Urinary Distress Inventory-6 (UDI-6), and Incontinence Impact Questionaire-7 (IIQ-7). Our study included 70 women treated for endometrial cancer; 35.7% (25/70) of women reported adjuvant radiation therapy after surgical staging. Urinary incontinence was reported in over 80% of women. Mean UDI-6 and IIQ-7 scores for women treated with adjuvant radiation therapy were higher compared to women with no adjuvant radiation therapy [47(+/-26.8) vs. 35.6(+/-21.7; p = 0.05)] and [24.4(+/-28.5) vs. 8.1(+/-16.4; p = 0.004)], respectively. Treatment with adjuvant radiation therapy was associated with more severe incontinence symptoms and impact on quality of life.

Urethral resistance measurement: a new method for evaluation of stress urinary incontinence in women.

The aim of this study was to evaluate a new method to measure urethral resistance among 66 women with urinary incontinence. A stainless steel sphere attached to a guide wire was developed. The sphere is inserted into the bladder and withdrawn through the urethra at a steady rate. Serial measurements with spheres of 5, 6 and 7 mm were performed. The mean urethral resistance as measured by the largest sphere (0.07+/-0.03) was significantly greater than that measured by the medium sphere (0.06+/-0.02, p<0.0001), which was significantly larger than that measured by the smallest sphere (0.04+/-0.01, p<0.0001). There was good correlation of urethral resistance with maximum urethral closure pressure (MUCP) by this technique, but no correlation with Valsalva leak point pressure (VLPP).

Risk of new-onset urinary incontinence after forceps and vacuum delivery in primiparous women.

OBJECTIVE: We sought to determine the incidence of new-onset urinary incontinence after forceps and vacuum delivery compared with spontaneous vaginal delivery. STUDY DESIGN: We performed a prospective study in primiparous women delivered by forceps (n = 90), vacuum (n = 75), or spontaneous vaginal delivery (n = 150). Follow-up for urinary incontinence was at 2 weeks, 3 months, and 1 year after delivery. RESULTS: The incidence of urinary incontinence was similar in the 3 groups at 2 weeks after delivery. The proportion of women developing new-onset urinary incontinence decreased significantly over time in the spontaneous vaginal (P =.003) and vacuum delivery groups (P =.009) but not in the forceps group (P =.2). No relationship of urinary incontinence with vaginal lacerations, epidural anesthesia, length of second stage of labor, or infant birth weight was seen. CONCLUSIONS: In primiparous women, urinary incontinence after forceps delivery is more likely to persist compared with spontaneous vaginal or vacuum delivery.

Office screening test for intrinsic urethral sphincter deficiency: pediatric Foley catheter test.

OBJECTIVE: To evaluate an office-based test as a screening method for intrinsic sphincter deficiency. METHODS: One hundred seventy-three women with urinary incontinence were evaluated prospectively by complete urodynamic studies. After catheterization, the pediatric Foley catheter test was performed on an empty bladder by withdrawing the inflated bulb of an 8-French Foley catheter through the urethra. The test was considered positive if the inflated catheter bulb could be withdrawn completely through the urethra. Women with grade 3 genital prolapse or higher were excluded. Intrinsic sphincter deficiency was defined as the presence of genuine stress incontinence and low maximum urethral closure pressure (at most 20 cm H(2)O). RESULTS: Seventy-six of 173 women (44%) had positive tests and 97 (56%) had negative tests. Seventy-six percent of those with positive tests were diagnosed with intrinsic sphincter deficiency, compared with 19% in women with negative tests (P <.001). All women with positive tests and negative cotton swab tests had intrinsic sphincter deficiency. The sensitivity, specificity, and positive and negative predictive values for diagnosing intrinsic sphincter deficiency were 76, 81, 76, and 81%, respectively. CONCLUSION: A positive pediatric Foley catheter test in the absence of urethral mobility strongly suggests intrinsic sphincter deficiency. The pediatric Foley catheter test may be useful in screening for intrinsic sphincter deficiency.

Development and utilization of paperless medical records: a unique approach.

The purpose of this article is to describe the development and utilization of a unique paperless medical record system in a large multispeciality group practice setting. The Scott and White integrated health care delivery system provides care over a 34-county area in Central Texas. Since 1988, clinicians at Scott and White have developed a text-based, content-searchable electronic medical record system known as EMRx. This system provides a single clinical data repository that allows patient care activities and aggregate data analyses to occur by using the same set of data on a daily basis. Use of this approach has led to the aggregation of over 9.8 million clinical documents since 1994. Over 1,845 health care providers used the system during May 2000 for direct patient care; 866,114 patient records have been accessed since January 1, 1999 to answer questions related to patient care, quality assurance, outcomes research, and accreditation.

Pelvic anatomy for obstetrics and gynecology residents: an experimental study using clay models.

OBJECTIVE: To determine whether clay modeling with lecture is more effective than lecture alone in teaching female pelvic anatomy. METHODS: A pretest preceded a lecture on female pelvic anatomy in the following five groups of obstetrics and gynecology residents: postgraduate year 1 (PGY-1) residents at Women and Infants Hospital of Rhode Island (RI), PGY-1 residents at University of Connecticut (CT), and PGY-2, -3, and -4 residents at RI. The study group (PGY-1 RI) also participated in a clay modeling session. Both groups of PGY-1 residents were tested immediately (posttest 1) and then 8 weeks later (posttest 2). The PGY-2, -3, and -4 residents had only posttest 2. Data were analyzed with parametric, nonparametric, and repeated measures analyses. RESULTS: There was no significant difference between the mean pretest scores of the five groups. The study group showed significant improvement in mean scores at posttest 1 (29.7 +/- 0.9, P <.001) and at posttest 2 (24.1 +/- 4.6, P =.03) compared with the mean pretest score (17.4 +/- 3.7). The CT residents demonstrated significant improvement in mean scores at posttest 1 (25.2 +/- 4.4, P =.02) but not at posttest 2 (19 +/- 3.7, P =.2) compared with their mean pretest score (15.2 +/- 2.9). There was no significant improvement in the mean scores at posttest 2 for PGY-2, -3, and -4 resident groups compared with their pretest scores. CONCLUSION: Clay modeling with lecture was more effective than lecture alone for teaching pelvic anatomy.

The sensitivity of auditory brainstem response testing for the diagnosis of acoustic neuromas.

OBJECTIVES: To determine the sensitivity of auditory brainstem response (ABR) testing for detecting acoustic neuromas and to determine whether the test is less sensitive for detecting small tumors. DESIGN: Retrospective review of the medical charts of 58 patients with acoustic neuroma who had all of the data necessary for inclusion in the study. SETTING: University-affiliated referral practice of one neurotologist. PATIENTS: Patients with acoustic neuromas who had both ABR tracings and magnetic resonance imaging films available for review. MAIN OUTCOME MEASURES: Positive ABR and negative ABR results correlated with tumor size. RESULTS: Tumor size ranged from 0.4 to 7 cm. The overall sensitivity of ABR in diagnosing acoustic neuromas was 90%. However, ABR was progressively less sensitive with decreasing tumor size. Only 7 (58%) of the 12 tumors 1 cm or smaller were detected by ABR. CONCLUSION: Auditory brainstem response testing cannot be relied on for detection of small acoustic neuromas and should not be used as a criterion to determine whether magnetic resonance imaging should be performed when an acoustic neuroma is suspected clinically.

Patient satisfaction with laparoscopic Burch retropubic urethropexy.

OBJECTIVE: To assess six-month and three- to four-year patient-oriented outcomes after laparoscopic Burch retropubic urethropexy. STUDY DESIGN: Twenty-two women with urodynamically proven genuine stress incontinence with urethral hypermobility underwent laparoscopic Burch retropubic urethropexy. Preoperatively, all 22 women completed a questionnaire concerning their incontinence. Postoperative measures of symptoms of incontinence, impact of incontinence on daily activities and patient satisfaction were assessed at six months and three to four years postoperatively. In those women who were followed, the questionnaire data at the three-time points (preoperative, six months and three to four years) were compared. RESULTS: Thirteen women (59%) completed postoperative questionnaires at six months and three to four years. When compared to preoperative data, there was a significant improvement in symptoms of stress incontinence at six months (P = .0005) and at three to four years (P = .002). There was also a significant reduction in limitations on daily activities at six months (P = .0005) and at three to four years (P = .0005) as compared to preoperative data. Twelve of the 13 women considered their surgery successful at six months and at three to four years. CONCLUSION: After laparoscopic Burch retropubic urethropexy, there was a significant improvement in patient-oriented outcomes, including complaints of incontinence and functional status.

An integrated data warehouse system: development, implementation, and early outcomes.

This paper describes a generic vision of global information flow and the development of an integrated data warehouse system, using clinical data on all patient encounters and administrative data on all operating transactions as part of an integrated health care system. This new integrated data warehouse system has been successfully used for multiple purposes, including patient care, health services research, resource utilization and feasibility studies. During 1999, core analyses included the electronic abstraction, aggregation, and analysis of data on over 400,000 patients. This approach to building a centralized data system comprised of multiple repositories efficiently meets a variety of individual and aggregate information needs, while reducing the need to create duplicate databases.

Rapid bioanalytical determination of dextromethorphan in canine plasma by dilute-and-shoot preparation combined with one minute per sample LC-MS/MS analysis to optimize formulations for drug delivery.

The determination of dextromethorphan in canine plasma is used to demonstrate the high throughput bioanalytical approach of automated dilute-and-shoot (DAS) sample preparation followed by a 1 min isocratic liquid chromatography tandem mass spectrometry (LC-MS/MS) analysis. Dilute-and-shoot preparation is commonly used for the determination of drugs in several biological matrices such as urine and saliva, but is not typically used with plasma samples because the amount of protein present in plasma can lead to a variety of problems including column failure. As a result, plasma sample preparation usually removes protein by precipitation, extraction or filtration; however, the dilute-and-shoot approach solubilizes proteins throughout the chromatographic portion of the assay. The attributes of this approach are compared with a previously validated liquid/liquid extraction procedure for determination of dextromethorphan in plasma. Accuracy and precision of both methods are similar. The lower limit of quantitation (LLOQ) of the dilute-and-shoot approach is much higher at 2 ng/ml versus 5 pg/ml with the liquid/liquid extraction; however, the sample throughput of the preparation portion of the dilute-and-shoot approach is more than 50-fold greater. The ruggedness of the dilute-and-shoot method was thoroughly investigated because of the problems traditionally associated with the direct injection of diluted plasma onto an LC-MS/MS instrument. With the optimal conditions, greater than 1,000 injections of diluted plasma have been successfully performed on a single column in less than 19 h making this technique an excellent approach for the rapid preparation and high throughput of plasma samples containing drug levels in the ng/ml range or higher. Application of this methodology to measure the levels of dextromethorphan in canine plasma to evaluate drug delivery from various formulations is also presented.

Dietary caffeine intake and the risk for detrusor instability: a case-control study.

OBJECTIVE: To determine whether there is an association in women between caffeine intake and risk for detrusor instability. METHODS: Women were included if they had symptoms of urinary incontinence, completed a 48-hour voiding diary detailing fluid and caffeine intake, and had undergone standardized multichannel urodynamics. The study group had 131 women with detrusor instability on provocative cystometry and maximum urethral closure pressure greater than 20 cm of water. The control group had 128 women without detrusor instability on provocative cystometry and maximum urethral closure pressure greater than 20 cm of water. For statistical comparison, women were divided into the following three groups on the basis of caffeine intake: minimal (< 100 mg/day), moderate (100-400 mg/day), and high (> 400 mg/day). RESULTS: The mean caffeine intake of women with detrusor instability (484 +/- 123 mg/day) was significantly higher than that of controls (194 +/- 84 mg/day, P =.002). On univariate analysis, significant risk factors for detrusor instability were age, smoking status, and caffeine intake. On multivariate analysis, the statistically significant association between high caffeine intake and detrusor instability persisted after controlling for age and smoking (odds ratio [OR] 2.4, 95% confidence interval [CI] 1.1, 6.5, P =.018). When women with moderate caffeine intake were compared with those with minimal caffeine intake, the risk for detrusor instability was lower and did not reach significant levels (OR 1.5, 95% CI 0.1, 7.2, P =.093). CONCLUSION: An association between high caffeine intake and detrusor instability was seen in this population. Larger studies are required to determine whether the association is causal.

Otogenic cerebrospinal fluid rhinorrhea: a new technique for closure of cerebrospinal fluid leak.

OBJECTIVE: To describe a new technique for control of cerebrospinal fluid (CSF) rhinorrhea and to review alternative approaches. STUDY DESIGN: Five cases and literature review. SETTING: Tertiary referral center. PATIENTS: Five case study patients. INTERVENTION: Surgical. MAIN OUTCOME MEASURE: Control of CSF rhinorrhea. RESULTS: CSF rhinorrhea can be controlled through eustachian tube ligation in the nasopharynx, distal to all known pathways through which CSF leaks may occur from the temporal bone into the eustachian tube. CONCLUSION: Transoral eustachian tube ligation appears to be a safe and effective alternative to other techniques for controlling CSF rhinorrhea and should be included in the otologist's repertoire.

Use of a Web-based process model to implement security and data protection as an integral component of clinical information management.

Delivery of health care at Scott and White, a large integrated health care delivery system, is supported by an Electronic Medical Record (EMR) system repository of six million SGML-based documents. Control of document access is currently based on standard commercial security and confidentiality methodologies. Given the planned release in Fall 1999 of new federal security and confidentiality requirements, we have developed a web-based security process model that "wraps" existing EMR documents with HTML-compliant security attributes. Resulting logical documents are filtered regarding user queries by mapping the security attributes of the data to specific user role characteristics. A key virtue of our approach is that source EMR data do not undergo alteration by the imposition of the security process. It also places no additional work load or query pressure on the existing EMR system.

Is urinary incontinence different in women with Parkinson's disease?

The purpose of this study was to determine the risk of detrusor hyperreflexia in women with Parkinson's disease. Fourteen women with Parkinson's disease and urinary complaints were compared with 28 age-matched women who had urinary complaints and no neurologic disease (controls). Demographic data, symptomatology, multichannel urodynamic indices and rates of diagnoses were compared between the two groups using the Mantel-Haenszel matched odds ratio (OR) and the Kruskal-Wallis test. The mean age of the women was 73.3 years. Those with Parkinson's disease had an increased rate of detrusor hyperreflexia (92.8% vs. 50.0%, OR 13, 95% confidence interval 1.6,228, P=0.02) which occurred at lower volumes (150.0 ml vs. 225.0 ml, P=0.01), and a lower maximum cystometric capacity (240.0 ml vs. 335.0 ml, P=0.02) compared to the control group. It was concluded that women with Parkinson's disease and lower urinary tract complaints have a lower maximum cystometric capacity and a higher rate of detrusor hyperreflexia at lower bladder volumes.

Conservative surgical management of Mersilene mesh suburethral sling erosion.

OBJECTIVE: The aim of this study was to describe conservative surgical management of polyethylene terephthalate (Mersilene, Ethicon, Inc, Somerville, NJ) mesh suburethral sling erosion as an alternative to sling removal. STUDY DESIGN: Seven women who had undergone suburethral sling procedures with Mersilene mesh were found to have varying degrees of mesh visible in the vagina at 4 to 12 weeks after the operation. Three women with erosions <5 mm were treated in the office and 4 women who had 6 to 30 mm erosions underwent inpatient surgical revision, which consisted of trimming of mesh when needed, excision of granulation tissue, and re-covering of the erosion in 2 layers. RESULTS: All 7 patients have been followed up for 6 to 37 months. Only 1 woman who underwent inpatient surgical revision had a recurrence (4 mm); this was treated successfully in the office. CONCLUSION: Vaginal erosions in suburethral sling procedures with Mersilene mesh can be managed initially with our conservative surgical technique.

Double pessary use in grade 4 uterine and vaginal prolapse.

BACKGROUND: Certain situations dictate conservative management of grade 4 uterine or vaginal vault prolapse in women. The reduction of a prolapse may not be possible if the vagina cannot retain a single pessary. We have used double pessaries in the management of this condition. TECHNIQUE: With the patient in the dorsal lithotomy position, either a Donut or Inflatoball (Milex Products Inc., Chicago, IL) pessary is inserted and pushed into the vagina as far as is comfortable. A second pessary, either a flexible Gellhorn or Shaatz (Milex Products Inc.), then is placed caudad to the first. EXPERIENCE: We have used this approach in five women who have been followed for 7-15 months. There have been no erosions or vaginitis and all the women experienced symptomatic relief. CONCLUSION: In women who want or require conservative management of grade 4 prolapse and are unable to retain a single pessary, the placement of two pessaries often will be successful.

The effect of posterior wall support defects on urodynamic indices in stress urinary incontinence.

OBJECTIVE: To determine if posterior vaginal wall defects affect urodynamic indices and mask stress urinary incontinence. METHODS: Ninety women with grade 0, 1, 2, or 3 posterior wall defects were evaluated prospectively by complete urodynamics to assess their urinary complaints. None had severe anterior or apical support defects. Urethral pressure profilometry and cough stress test were performed with the posterior wall in the unretracted position and then with the posterior wall retracted using a split speculum. Analysis of covariance was used to compare adjusted mean differences in maximum urethral closure pressure, functional urethral length, and units of leakage volume during the cough stress test in the unretracted and retracted positions among the posterior wall grade groups. RESULTS: In women with grade 3 posterior wall defects, there were significant changes from the unretracted to the retracted position in maximum urethral closure pressure of -7.0 cm H20, (99% confidence interval [CI] -12.4, -1.6), functional urethral length of -0.3 cm (99% CI -0.5, -0.1), and leak volume units of +0.7 (99% CI 0.4, 1.0) during the cough stress test. There were four women with grade 3 posterior wall defects who demonstrated potential stress incontinence when their posterior wall was retracted. CONCLUSION: A grade 3 posterior wall defect may artificially raise maximum urethral closure pressure, increase functional urethral length, and mask urinary stress incontinence during a cough stress test. Women with grade 3 posterior wall defects should be tested with the posterior wall retracted during urodynamic evaluation.

Distemper: not a new disease in lions and tigers.

In light of recent canine distemper virus (CDV) epidemics, we set out to determine the historical significance of CDV infection in captive lions and tigers in Switzerland. The retrospective case material consisted of 42 lion and tiger necropsy cases from 1972 to 1992. Necropsy reports for all lions and tigers were reviewed. All existing paraffin tissues were immunohistochemically examined with a polyclonal antibody raised against CDV. The results for 19 of the 42 lions and tigers were classified as positive by immunohistochemistry; 23 results were negative or questionable. The results for four animals (three positive and one negative ) were further tested by in situ hybridization, and the results concurred with the immunohistochemistry findings. CDV infection of large cats is older and more widespread than previously thought. All large cats in captivity should be immunized even if canine distemper is not believed to be a problem for large cats in the area.

Acute urinary retention and the incarcerated, retroverted, gravid uterus. A case report.

A case of urinary retention was associated with an incarcerated, retroverted, gravid uterus. In a literature review of the English language we encountered 26 similar cases. Although no series of cases has allowed evaluation of a specific protocol for evaluation and management or analysis of outcomes, a review of the literature does outline certain diagnostic tests and treatment modalities that may be useful when one is faced with this uncommon condition.