Uterosacral ligament vaginal vault suspension using delayed absorbable monofilament suture.

INTRODUCTION AND HYPOTHESIS: We investigated the incidence of suture complications and recurrent prolapse following uterosacral ligament suspension (USLS) using delayed absorbable polyglyconate monofilament suture (Maxon). METHODS: We reviewed the medical records of subjects who underwent vaginal USLS using polyglyconate suture. Primary outcomes were suture complications and anatomic failures defined as recurrent apical prolapse stage 1 or greater. Secondary outcomes were subjective failures and reoperation rate for apical prolapse. RESULTS: Fifty-seven out of 68 subjects who underwent USLS with polyglyconate suture over the study period were included in analysis. At median follow-up of 12 months, 3.5% had suture complications. The anatomic and symptomatic failure rate was 7%. One subject underwent repeat surgery for prolapse. CONCLUSIONS: Suture complications are uncommon using polyglyconate suture for USLS, and failure rates are low. This is in comparison to a 44.6% suture erosion rate with permanent suture reported by our institution using the same surgical technique.

Effectiveness of transobturator tape in women with decreased urethral mobility.

OBJECTIVE: To determine whether preoperative urethral mobility is associated with success of the transobturator insertion of suburethral polypropylene slings. STUDY DESIGN: A cohort of women who underwent a transobturator insertion of a suburethral polypropylene sling for urodynamic stress incontinence between October 2003 and January 2005 was prospectively assessed. RESULTS: Of the 134 women in the study cohort, 107 (80%) provided postoperative data at a median followup interval of 10 months. Postoperatively, 92 (86%) reported complete resolution of stress urinary incontinence on the Urogenital Distress Inventory-6 questionnaire, and 15 (14%) reported persistent incontinence. The median preoperative urethral mobility was significantly decreased among women who were incontinent postoperatively compared to those who were continent (40 degrees [10-60] vs. 50 degrees [10-90], p=0.0049). Women with preoperative urethral mobility < 45 degrees were at least 4 times more likely to report postoperative incontinence compared with women with preoperative urethral mobility > or = 45 degrees (29.4% vs. 6.9%, RR 4.29, 95% CI 1.59-11.60, p = 0.005). In addition, women with preoperative urethral straining angles < 45 degrees from the horizontal were at least 5 times more likely to report postoperative incontinence compared with women with preoperative urethral straining angles > or = 45 degrees (41.7% vs. 8.7%, RR 5.21, 95% CI 1.88-14.42, p = 0.006). Neither patient age nor the concomitant performance of an anterior colporrhaphy affected these results. CONCLUSION: Women with preoperative urethral mobility or preoperative urethral straining angles < 45 degrees appear to be at higher risk for failure following a transobturator insertion of a suburethral polypropylene sling.

Interleukin-6 in retinal ischemia reperfusion injury in rats.

PURPOSE: To study the role of interleukin (IL)-6 after retinal ischemia-reperfusion (I/R) injury in rats. METHODS: Intraocular pressure of adult male Lewis albino rats was raised to create retinal ischemia for 1 hour. Retinal reperfusion was reestablished, and the animals were killed at various time points after the injury. Their eyes were enucleated and processed for immunohistochemistry to detect IL-6 and ED-1 (a marker of microglial/phagocytic cells), enzyme-linked immunosorbent assay (ELISA) of IL-6 protein, and semiquantitative real-time RT-PCR for IL-6 mRNA. The neuroprotective effect of IL-6 was evaluated by giving intravitreal injections of 150 or 300 ng rat recombinant IL-6 to eyes immediately after I/R injury and counting cresyl violet-stained retinal ganglion cell layer cells (RGCLCs) and fluorochrome-labeled retinal ganglion cells (RGCs) on flat preparations of retinas at 7 days. RESULTS: IL-6-positive cells appeared after I/R injury in the inner plexiform layer (IPL) and the inner nuclear layer (INL). Their numbers were significantly higher 18 hours after the injury, and most of these cells were also ED-1 positive. ELISA showed noticeable increases in endogenous retinal IL-6 protein levels 8 hours after I/R injury. Semiquantitative real-time RT-PCR showed significant increases in endogenous retinal IL-6 mRNA levels between 2 and 18 hours. Exogenously added IL-6 prevented between 50% and 70% of RGC loss after I/R injury. CONCLUSIONS: IL-6 is upregulated after retinal I/R injury, and its expression by microglia/phagocytic cells may protect RGC layer neurons from I/R injury. Exogenously added IL-6 protects the inner retina after I/R injury.

Agreement between self-reported and routinely collected health-care utilization data among seniors.

OBJECTIVE: To examine the agreement between self-reported and routinely collected administrative health-care utilization data, and the factors associated with agreement between these two data sources. DATA SOURCES/STUDY SETTING: A representative sample of seniors living in an Ontario county within Canada was identified using the Ontario Ministry of Health's Registered Persons Data Base in 1992. Health professional billing information and hospitalization data were obtained from the Ontario Ministry of Health and Long-Term Care (OMH) and the Ontario Health Insurance Plan (OHIP). STUDY DESIGN: A cross-sectional survey was carried out to assess any contact and frequency of contacts with health professionals and hospital admissions. Similar information was obtained from routinely collected administrative data. The level of agreement was assessed using the proportion of absolute agreement, Cohen's kappa statistic (kappa), and the intraclass correlation coefficient (ICC). Logistic and linear regressions were used to identify factors that were associated with the magnitude and direction of disagreement respectively. DATA COLLECTION/EXTRACTION METHODS: Telephone interviews were conducted on 1,054 seniors, and complete data were available for 1,038 seniors. Each respondent's personal health number was used to electronically link survey data with health professional billing and hospitalization databases. PRINCIPAL FINDINGS: Substantial to almost perfect agreement was found for the contact utilization measures, while agreement on volume utilization measures varied from poor to almost perfect. In surveys, seniors overreported contact with general practitioners and physiotherapists or chiropractors, and underreported contact with other medical specialists. Seniors also underreported the number of contacts with general practitioners and other medical specialists. The odds of agreement decreased if respondents were male, aged 75 years and older, had incomes of less than $25,000, had poor/fair/good self-assessed health status, or had two or more chronic conditions. CONCLUSION: The findings of this study indicate that there are substantial discrepancies between self-reported and administrative data among older adults. Researchers seeking to examine health-care use among older adults need to consider these discrepancies in the interpretation of their results. Failure to recognize these discrepancies between survey and administrative data among older adults may lead to the establishment of inappropriate health-care policies.

The relationship between sensory impairment and functional independence among elderly.

BACKGROUND: It has been well established that increasing age is associated with decreasing functional ability in older adults. It is important to understand the specific factors that affect instrumental activities of daily living (IADL) and functional independence among older adults with sensory disabilities. METHODS: Nationally representative sample of adults aged 55 years and older with seeing or hearing disabilities were categorised into three sensory classifications: "Seeing Disabled but Hearing Abled" (SD-HA), "Hearing Disabled but Seeing Abled" (HD-SA), and both "Seeing and Hearing Disabled" (SD-HD). The additional category of "Seeing Disabled and/or Hearing Disabled" (SD and/or HD) was created to calculate the total of all individuals from the above categories who either had a seeing or hearing disability or both sensory disabilities. Respondents were asked to indicate whether they received assistance in performing seven IADL and their level of functional independence. RESULTS: The most common factors that affect IADL were heavy chores, grocery shopping and housework. Individuals with both seeing and hearing disabilities (SD-HD) reported having the most IADL restrictions, followed by individuals with only seeing disabilities (SD-HA) and only hearing disabilities (HD-SA). Individuals with severe sensory disabilities were generally more likely to report IADL restrictions and less likely to have decision-making control and be happy with their lives. In each sensory classification, females aged 55-64 years and 65 years and older reported more IADL restrictions than males. CONCLUSION: Both seeing and hearing disabilities have a significant impact on restricting an individual's IADL.

Caregiving process and caregiver burden: conceptual models to guide research and practice.

BACKGROUND: Parental care for a child with a developmental disability is an enormous responsibility, one that can far exceed that of typical parental care. While most parents adapt well to the situation of caring for a child with a disability, some do not. To understand parents' adaptations to their children's disabilities, the complex nature of stress processes must be accounted for and the constructs and factors that play a role in the caregiving must be considered. DISCUSSION: Evidence suggests that there is considerable variation in how caregivers adapt to their caregiving demands. Many studies have sought to qualify the association between caregiving and health outcomes of the caregivers. Contextual factors such as SES, child factors such as child behaviour problems and severity of disability, intra-psychic factors such as mastery and self-esteem, coping strategies and social supports have all been associated with psychological and/or physical outcome or parents or primary caregivers. In reviewing these issues, the literature appears to be limited by the use of traditional analytic approaches which examine the relationship between a factor and an outcome. It is clear, however, that changes to single factors, as represented in these studies, occur very rarely even in the experimental context. The literature has also been limited by lack of reliance on specific theoretical frameworks. SUMMARY: This conceptual paper documents the state of current knowledge and explores the current theoretical frameworks that have been used to describe the caregiving process from two diverse fields, pediatrics and geriatrics. Integration of these models into one comprehensive model suitable for this population of children with disabilities and their caregivers is proposed. This model may guide future research in this area.

Urogenital fistula.

This review summarizes the available evidence in the literature on the etiology, diagnosis, management, and prevention of vesicovaginal, urethrovaginal, ureterovaginal, vesicocervical, and vesicouterine fistulae. Urogenital fistula is divided by origin: obstetric fistula occurring predominantly in developing countries and iatrogenic fistula, the most common cause in developed countries.

Improving resident screening and workup of urinary incontinence in an OB/GYN residency program: a randomized controlled study.

OBJECTIVES: : With an aging US population, an increased prevalence of urinary incontinence, rising health care costs, and a disease that remains largely unidentified, there is an immediate need to train physicians to screen for and treat incontinence. We aim to evaluate resident physician screening of urinary incontinence with a chart-based review. METHODS: : This study entailed 2 parts: a retrospective chart review (part 1) and a prospective randomized trial (part 2). Charts of 200 patients were retrospectively evaluated for documentation of bladder symptoms and incontinence for part 1. In part 2, patients' charts were prospectively randomized to receive a chart-alert sticker ("Do you leak urine?") that reminded resident physicians to ask about urinary incontinence in their general gynecology clinics. The primary outcome was documentation of urinary incontinence. Secondary outcomes were initiation of workup, diagnoses made, and treatment plans. Overall, 200 charts were needed for the prospective study to provide 80% power. RESULTS: : Residents documented any type of bladder symptom (incontinence, urgency, frequency, dysuria, nocturia) in 32 (16.3%) of 196 charts in part 1 and 45 (23.7%) of the 190 randomized charts in part 2 (P = 0.154). In the prospective study, 88 included charts were randomized to receive the "Do you leak urine?" chart-alert sticker and 102 were randomized to no sticker. Residents documented that they asked about incontinence in 30 (34.1%) of the charts with stickers versus 4 (3.9%) of the charts without (P = 0.001). CONCLUSIONS: Overall, the rate that resident physicians inquired about incontinence increased with the alert-sticker from 4% to 34%. Directed education will likely further this improvement.