The impact of a nationwide hands-on workshop on the diagnostic rates and management of obstetrical anal sphincter Injuries in Israel.

AIM: The aim was to evaluate the influence of a half day, hands-on, workshop on the detection and repair of obstetric anal sphincter injuries (OASIs). METHOD: Starting in February 2011, hands-on workshops for the diagnosis and repair of OASIs were delivered by trained urogynaecologists in departments of tertiary medical centres in Israel. The structure of the hands-on workshop resembles the workshop organized at the International Urogynecological Association annual conferences. Participants included medical staff, midwives and surgical residents from each medical centre. We collected data regarding the rate of OASIs, 1 year before and 1 year following the workshop, in 11 medical centres. The study population was composed of parturients with the following inclusion criteria: singleton pregnancy, vertex presentation and vaginal delivery. Pre-viable preterm gestations (< 24 weeks), birth weight < 500 g, stillborn, and those with major congenital anomalies, multifoetal pregnancies, breech presentations and caesarean deliveries were excluded from the analysis. RESULTS: In the reviewed centres, 70 663 (49.3%) women delivered prior to the workshop (pre-workshop group) and 72 616 (50.7%) women delivered following the workshop (post-workshop group). Third- or fourth-degree perineal tears occurred in 248 women (0.35%) before the workshop, and in 328 (0.45%) following the workshop, a significant increase of 28.7% (P = 0.002). The increase in diagnosis was significant also in women with third-degree tears alone, 226 women (0.32%) before the workshop and 298 (0.41%) following the workshop, an increase of 28.3% (P = 0.005). CONCLUSION: The detection rate of OASIs has significantly increased following the hands-on workshop. The implementation of such programmes is crucial for increasing awareness and detection rates of OASI following vaginal deliveries.

Long-term follow-up of sacrocolpopexy mesh implants at two time intervals at least 1 year apart using 4D transperineal ultrasound.

OBJECTIVE: To determine, using four-dimensional (4D) transperineal ultrasound, whether the appearance, position or dimensions of sacrocolpopexy mesh implants or the degree of tissue support change in the long term. METHODS: Women who had undergone minimally invasive abdominal sacrocolpopexy for pelvic organ prolapse were invited for follow-up assessment at two consecutive visits at least 1 year apart. All participants completed a Pelvic Floor Distress Inventory questionnaire (PFDI-20) and underwent a pelvic examination by one examiner and had 4D ultrasound volumes obtained by a different examiner. Volumes were analyzed offline for mesh position with the woman at rest and on maximal Valsalva maneuver, and for mesh dimensions and characteristics on three-dimensional orthogonal planes and rendered views, with the operator blinded to the clinical data. Findings were compared between the two examinations. RESULTS: Thirty women attended follow-up assessment at two time points, a median of 22 (range, 12-37) months apart. The median age at the latter visit was 60 (range, 46-72) years, median body mass index was 25.9 (range, 20.8-31.9) kg/m2 , median parity was 3 (range, 1-7) and median time from surgery to first and second visit, respectively, was 11.2 (range, 6-26) months and 33.5 (range, 14-56) months. There were no significant differences between the two time points in symptom scores, reported satisfaction from surgery, pelvic examination findings or pelvic organ descent in any compartment according to ultrasound. While mesh dimensions of anterior and posterior arms did not change significantly over time, both arms descended less on Valsalva at the second follow-up compared with at the first (13.2 ± 6.7 mm vs 21.9 ± 10.0 mm and 9.1 ± 5.3 mm vs 16.1 ± 8.1 mm, respectively, both P < 0.001). There were no mesh erosions, but folding remained a consistent finding, occurring in 80% of women in each assessment. CONCLUSIONS: Characteristics of tissue support and dimensions of sacrocolpopexy mesh implants remained constant over long-term follow-up, with no mesh shrinkage or erosion. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Three-dimensional transperineal ultrasound for imaging mesh implants following sacrocolpopexy.

OBJECTIVE: To characterize, using three-dimensional (3D) transperineal ultrasound, the appearance, position and dimensions of mesh implants following minimally invasive abdominal sacrocolpopexy. METHODS: In women who underwent sacrocolpopexy, mesh was evaluated at rest and on maximal Valsalva, on all 3D orthogonal planes and rendered views. Mesh dimensions were obtained by 3D processing in the midsagittal and coronal planes (anterior, posterior and sacral arm) and were analyzed offline, the operator blinded to clinical data. RESULTS: Overall, 62 women, mean age 58.4 (range, 42-79) years were evaluated at a median of 9 (range, 1-26) months following surgery. The anterior arm of the mesh was caudal to the lowermost point of descent of the anterior compartment in 56 (90.3%) women, was equally positioned in five (8.1%) and was cranial in one. The posterior arm was caudal in 44 (71%) women, was equally positioned in 16 (25.8%) and was cranial in two (3.2%). The Y connection and the sacral arm of the mesh could not be adequately seen because of physical limitations of ultrasound (lower resolution at greater depth), large recurrent rectoceles, echogenic stools or folding of mesh remnants. Folding of the mesh was seen in 46 (74.2%) women, folding of the anterior arm in five (8.1%) and folding of the posterior arm in 23 (37.1%). Folding occurred caudally in 26 (41.9%) women, proximally in 11 (17.7%) and in both areas in nine (14.5%). There were no erosions. CONCLUSION: Mesh visualization following minimally invasive abdominal sacrocolpopexy procedures using transperineal 3D/four-dimensional (4D) ultrasound is feasible. Studies are needed to evaluate the correlation between ultrasound measures and prolapse recurrence or mesh erosion.

Urethral sensation following reconstructive pelvic surgery.

INTRODUCTION AND HYPOTHESIS: Most urethral neuromuscular function data focus on efferent rather than afferent innervation. We aimed to determine if changes exist in urethral afferent nerve function before and after reconstructive pelvic surgery (RPS). Secondarily, we compared afferent urethral innervation in women with and without stress urinary incontinence undergoing RPS. METHODS: Participants underwent current perception threshold (CPT) and urethral anal reflex (UAR) testing prior to surgery and again post-operatively. Wilcoxon signed ranked test and Spearman's correlations were used and all tests were two-sided. p = 0.05 was considered to indicate statistical significance. RESULTS: Urethral CPT thresholds increased significantly after RPS, consistent with decreased urethral afferent function. Pre-operative urethral CPT thresholds at 5 and 250 Hz were lower in SUI women (10 [IQR 5-29], 40 [32-750]) compared with continent women (63 [14-99], 73 [51-109]; p = 0.45, p = 0.020), signifying increased urethral sensation or easier activation of urethral afferents in SUI women. CONCLUSIONS: Reconstructive pelvic surgery is associated with a short-term deleterious impact on urethral afferent function, as demonstrated by the higher levels of stimuli required to activate urethral afferent nerves (decreased urethral sensation) immediately after RPS. Women with SUI required lower levels of stimuli to activate urethral afferent nerves prior to RPS, although UAR latencies were similar regardless of concomitant SUI.

Use of ultrasound in the clinical evaluation of women following colpocleisis.

OBJECTIVE: To assess the role of transperineal ultrasound in the postoperative evaluation of patients undergoing colpocleisis. METHODS: Patients who underwent colpocleisis between July 2009 and January 2011 completed the pelvic floor distress inventory questionnaire (PFDI-20) and underwent pelvic organ prolapse quantification (POP-Q) examination and four-dimensional (4D) transperineal ultrasound. Volumes were analyzed offline for assessment of pelvic organ descent, levator hiatal dimensions, levator avulsion trauma and the location of the colpocleisis scar. RESULTS: The study included 16 women, of mean ± SD age 75.7 ± 2.9 years, median body mass index 28 (range, 21-32) kg/m2 and median parity 2 (range, 0-5); one woman was nulliparous. Nine (56.2%) women were posthysterectomy. The median interval from surgery to ultrasound examination was 6.5 (range, 2-19) months. Most patients did not have symptoms of prolapse. The median pelvic organ prolapse distress inventory (POPDI-6) score was 37.5 (range, 0-75) and the median postoperative clinical POP-Q stage was 1 (range, 0-2). Ultrasound demonstrated clear visualization in all patients. Ten had avulsion defects (six were bilateral). Ultrasound estimated greater prolapse descent for all compartments when compared with the clinical examination. However, this difference was significant for anterior and posterior descent, but not for apical descent. In two women urethral diverticulum was detected on ultrasound; it was neither symptomatic nor clinically apparent. CONCLUSIONS: 4D transperineal ultrasound seems to be a potentially effective tool for the evaluation of vaginal anatomic and functional changes following colpocleisis surgery. Future investigation of the association between ultrasound findings and patients' subjective symptoms in a larger cohort is warranted.

Consensus on safe implementation of vaginal natural orifice transluminal endoscopic surgery (vNOTES).

STUDY OBJECTIVE: The first ever report of vaginal natural orifice transluminal endoscopic surgery (vNOTES) for benign gynaecological was reported in 2012. There has been an exponential uptake of the number of surgeons performing such procedures worldwide with no official guidance to ensure the safe implementation of this technique into gynaecological practice due its recency. The objective of this study is to report an international consensus-based statement to help guide a basis for adopting vNOTES into clinical practice. STUDY DESIGN: The consensus-based statement was developed amongst 39 international experts using the Delphi methodology over three successive rounds. Consensus was pre-defined as an agreement of 80% or more by the experts. Consensus sought over eight key concepts pertaining to vNOTES including patient selection, perioperative management, surgical technique, instruments, anatomy, training, registries and trials and definition of the surgical technique. Recommendations from an expert anaesthetist and urogynaecologist were also sought to give a broader perspective with respect to the implementation of vNOTES. RESULTS: Fifty nine international surgeons were invited to participate and 39 (66%) agreed to participate based on being involved in a minimum of 20 vNOTES procedures. They were from 13 countries across 5 continents (Europe, North America, South America, Australia and Asia). Participation was 100% on all three rounds. Overall, consensus was reached in 50 of the 56 questions (89%) with the remaining 6 questions where consensus was not reached pertaining to the domain of patient selection. CONCLUSION: An international expert based vNOTES statement is presented here to help guide adoption of vNOTES based on the experience of early adopters. Consensus was achieved on most components of this consensus statement. Given the recency of this technique, until high-level evidence becomes available, this statement provides an appropriate guidance to the safe implementation of vNOTES into gynaecological practice.

Female sexual function and gynecological disorders.

Female sexual dysfunction is a common problem among the general population. Indifferent from males is not dependent solely on the physiological function of the genital organs. Partnership, body image perception and other physiological factors play a crucial role in the evaluation and treatment of female sexual dysfunction (FSD). The following article revise the most current literature regarding common gynecological disease and its association with sexual function.

Choline pathways during normal and stimulated renal growth in rats.

Cellular membrane synthesis occurs during normal and stimulated renal growth. Choline in the kidney is utilized as a precursor for membrane synthesis via the choline kinase reaction. We investigated choline phosphorylation during normal and stimulated renal growth. Rapidly growing neonatal rat kidneys contained relatively high levels of choline kinase activity (61 pmol phosphorylcholine/min per mg protein). Choline kinase activity and phosphorylcholine production then fell gradually over the 1st mo of life; by 1 mo phosphorylcholine production was 34 pmol phosphorylcholine/min per mg protein. Choline kinase activity increased by 27% (P less than 0.001) in 28-day-old rats when renal growth was stimulated by contralateral nephrectomy; the increase occurred within 2 h after surgery. Thus, changes in the activity of this important enzyme in the initiation of membrane synthesis is associated both with normal renal development and with adaptation to nephron loss. The findings further suggest that the cell membrane may be involved in the initiation of compensatory renal growth.

The purine nucleotide cycle. A pathway for ammonia production in the rat kidney.

Particle-free extracts prepared from kidney cortex of rat catalyze the formation of ammonia via the purine nucleotide cycle. The cycle generates ammonia and fumarate from aspartate, using catalytic amounts of inosine monophosphate, adenylosuccinate, and adenosine monophosphate. The specific activities of the enzymes of the cycle are 1.27+/-0.27 nmol/mg protein per min (SE) for adenoylosuccinate synthetase, 1.38+/-0.16 for adenylosuccinase, and 44.0+/-3.3 for AMP deaminase. Compared with controls, extracts prepared from kidneys of rats fed ammonium chloride for 2 days show a 60% increase in adenylosuccinate synthetase and a threefold increase in adenylosuccinase activity, and a greater and more rapid synthesis of ammonia and adenine nucleotide from aspartate and inosine monophosphate. Extracts prepared from kidneys of rats fed a potassium-deficient diet show a twofold increase in adenylosuccinate synthetase and a threefold increase in adenylosuccinase activity. In such extracts the rate of synthesis of ammonia and adenine nucleotide from aspartate and inosine monophosphate is also increased. These results show that the reactions of the purine nucleotide cycle are present and can operate in extracts of kidney cortex. The operational capacity of the cycle is accelerated by ammonium chloride feeding and potassium depletion, conditions known to increase renal ammonia excretion. Extracts of kidney cortex convert inosine monophosphate to uric acid. This is prevented by addition of allopurinol of 1-pyrophosphoryl ribose 5-phosphate to the reaction mixture.

Phospholipid metabolism in the initiation of renal compensatory growth after acute reduction of renal mass.

Membrane metabolism was studied during the initiation of compensatory growth after acute reduction in renal mass. The rate of [(14)C]choline incorporation into phospholipid in renal cortical slices was increased by 37% at 5 min of compensatory growth in mice. The rate increased to the maximal value of 68% by 20 min and remained there for 3 h. The rate then remained increased at 28-34% above normal for 2 days and returned to normal by the 6th day. The increase in rate of choline incorporation into renal phospholipid was independent of choline uptake. [(14)C]Choline was found to be a specific precursor of the three renal phospholipids, phosphatidylcholine, lysophosphatidylcholine, and sphingomyelin, which comprise over half the amount of the phospholipids. The relative distribution of the label in each of the three phospholipid classes did not change with compensatory growth. An increased rate of choline incorporation was also observed in kidneys of rats during compensatory growth and in the compensating kidneys of mice treated with indomethacin before uninephrectomy. The rate was increased 24% at 3 h after uninephrectomy in vivo. The increase appeared to be specific for the kidney, since it did not occur in the livers of these mice. The results indicate that the onset of renal compensatory growth is associated with a specific enhancement of the synthesis of renal choline-containing phospholipids. Since the phospholipids largely occur in the cell membrane, early alterations in cell membrane metabolism may thus play a role in the initiation of cell growth.

Experimental glomerulonephritis in the isolated perfused rat kidney.

The development of immune deposits on the subepithelial surface of the glomerular capillary wall was studied in isolated rat kidneys perfused at controlled perfusion pressure, pH, temperature, and flow rates with recirculating oxygenated perfusate containing bovine serum albumin (BSA) in buffer and sheep antibody to rat proximal tubular epithelial cell brush border antigen (Fx1A). Control kidney were perfused with equal concentrations of non-antibody immunoglobulin (Ig)G. Renal function was monitored by measuring inulin clearance, sodium reabsorption, and urine flow as well as BSA excretion and fractional clearance. Perfused kidneys were studied by light, immunofluorescence, and electron microscopy. All kidneys perfused with anti-Fx1A developed diffuse, finely granular deposits of IgG along the glomerular capillary wall by immunofluorescence. Electron microscopy revealed these deposits to be localized exclusively in the subepithelial space and slit pores. Similar deposits were produced in a nonrecirculating perfusion system, thereby excluding the formation of immune complexes in the perfusate caused by renal release of tubular antigen. Control kidneys perfused with nonantibody IgG did not develop glomerular immune deposits. Renal function and BSA excretion were the same in experimental and control kidneys. Glomerular deposits in antibody perfused kidneys were indistinguishable from deposits in rats injected with anti-Fx1A or immunized with Fx1A to produce autologous immune complex nephropathy. These studies demonstrate that subepithelial immune deposits can be produced in the isolated rat kidney by perfusion with specific antibody to Fx1A in the absence of circulating immune complexes. In this model deposits result from in situ complex formation rather than circulating immune complex deposition.

Physicians' attitudes towards androgen replacement therapy for male and female sexual dysfunction.

Androgen deficiency syndrome is a commonly diagnosed condition. The aim of this study was to investigate common clinical practices of specialists in the field of sexual medicine regarding androgen replacement treatment for men and women. Attendees of the 16th Annual Congress of the European Society of Sexual Medicine held in January 2014 in Istanbul, Turkey, were asked to participate in a survey during the congress days. A 24-item self-report, closed-question questionnaire was distributed. Three sections were accessed: sociodemographic data, professional background and personal practice patterns regarding androgen substitution in men and women. A total of 133 physicians (mean age 47 years; range 25-79) completed the survey. Responses were inconsistent regarding the lab tests used for primary evaluation of male androgen deficiency. The majority of participants (62%) recommended testosterone replacement therapy for symptomatic men with testosterone levels <8 nmol l(-1) (231 ng dl(-1)). Similarly, most physicians (88%) recognized a correlation between libido and testosterone levels in women. Only 42% and 53% reported they would prescribe testosterone to women with low libido, premenopausal and postmenopausal, respectively. This survey showed discrepancies among physicians regarding testosterone replacement therapy for men and women.

Effect of acidosis and uninephrectomy on isozymes of adenylosuccinate synthetase in rat kidney.

Normal rat kidney contains primarily the L isozyme of adenylosuccinate synthetase. The increase in total adenylosuccinate synthetase activity that occurs in response to NH4Cl-feeding or a low potassium diet is mainly due to increase in the L isozyme, rather than to an increase in the M isozyme. 1 day after uninephrectomy there is little change in total adenylosuccinate synthetase activity or isozyme distribution in the remaining kidney. These results do not support extension to kidney of the theory proposed for liver that the L isozyme is involved in purine biosynthesis while the M isozyme is involved in ammonia production from amino acids via the purine nucleotide cycle.

Evolution of polypyrimidines in Drosophila.

We surveyed 101 different Drosophila species for the presence of a particular highly repetitive DNA sequence containing long tracts of polypyrimidine/polypurine DNA, first found in D. melanogaster. Out of 55 tested species in the melanogaster group, only the sibling species D. simulans and D. mauritiana, as well as one distant relative in the ananassae subgroup, D. varians, contained the same sequence. All four of these species have long pyrimidine tracts as shown by acid hydrolysis of labelled DNA. All four species have the same sequence, bu the amount of this polypyrimidine/polypurine DNA varies greatly. Four other species in the hydei subgroup were found to contain a polypyrimidine/polpurine sequence, with an oligonucleotide composition different from that of D. melanogaster. This polypyrimidine DNA varies from as much as 10% of the total DNA in D. nigrohydei, to as little as 0.4% in D. neohydei. The long pyrimidine tracts in the hydei subgroup are often more than a thousand nucleotides in length, representing exceedingly homogeneous repetitious sequences.--These results show a rapid but discontinuous pattern of evolution for polypyrimidine/polypurine DNA . These sequences are not species specific, yet closely related species have greatly different amounts of polypyrimidines. Drastic changes occur in the amounts of these satellite type DNA sequences, as if the sequence had no continuous selective advantage in evolution. The implications of these results with regard to the general function and evolution of satellite DNA are discussed.

Acid treatment of Drosophila deoxyribonucleic acid.

In cytologic preparations of chromosomes, acid-treated deoxyribonucleic acid (DNA) is found largely in the native state. However, acid treatments widely used for chromosome preparations produce significant amounts of depurination in DNA. DNA is similarly sensitive to depurination in intact cells or as purified DNA. If treated with alkali, these apurinic gaps can be converted to single strand breaks. Acid treatment has widely different effects on specific fractions of DNA. In Drosophila melanogaster 3% of the DNA is composed of very long tracts of pyrimidines (polypyrimidines) which are resistant to acid hydrolysis. The implications of these results for molecular cytogenetics are discussed.

Rapid estimation of the accuracy of automatic blood pressure measuring devices (READ).

We propose a rapid method for the evaluation of automatic blood pressure measurement devices (READ) in response to the claim to simplify the validation of those devices. The READ is based on numerous blood pressure (BP) measurements at rest and during a standardised postural challenge in a small number of subjects who exhibit a wide range of BPs. Automatic (AU) and mercury sphygmomanometric (MS) brachial BP were measured simultaneously in a blinded manner. An average of 30 measurements per patient were done in 10-min while in a supine position, followed by 30 min in head-up tilt and again supine for 10 min. Two Collin-8800 automated oscillometric devices were tested with the aid of the READ in 15 adults. The consistency of the MS standard was demonstrated by duplicate MS measurements showing minimal inter-observer differences consistent with class A of the British Hypertension Society (BHS) grading system. AU-to-MS differences of 447 measurements were mean systolic deltaBP = 1.1 +/- 11.4 mm Hg and mean diastolic deltaBP = -13.36 +/- 8.9 mm Hg, classifying into category D of the BHS. Both tested instruments, each subject, each phase of the tilt test (supine I, tilt, supine II) and each mode of measurement (at 5-min intervals or continuously) equally qualified as 'D'. We conclude that the READ permitted us to identify quickly and at low expense a grossly inaccurate automatic BP measuring device. Further studies will show whether the READ can be efficient as a pre-validation test, post-validation test, and for assessment of ambulatory BP measuring devices.

Regional differences in nitric oxide-dependent vascular responses to somatostatin.

The mechanisms of the vascular effects of somatostatin (ST) are not well known. This study compares the direct effect of ST in different vascular regions and species. Isolated perfused segments of the cat superior mesenteric artery in vitro did not exhibit a vascular response in the resting state, however, ST-induced vasodilatation was observed with norepinephrine preconstriction. In contrast, ST only slightly dilated superior mesenteric vein segments. In the artery, NG-nitro-L-arginine inhibited both ST and endothelium-dependent nitric oxide (NO) mediated response. No regular dose-response curves were found when ST was applied on the large mesenteric artery in the cat, but rings of small mesenteric artery from both cats and dogs exhibited dose-dependent relaxations. These effects were also NO-dependent. Local application of ST on the rat saphenous artery in situ elicited NO-mediated dose-dependent vasodilatation. However, ST constricted rat saphenous veins in the case of either adventitial or intraluminal application. It is concluded that ST exerts different actions on the arterial and the venous vessel wall. The major response in arteries is endothelium-mediated vasodilatation seen in various species and vascular beds. Large and small arteries respond differently to ST but these differences require further elucidation.

Follow-up of maladjusted academically underachieving children treated in a therapeutic community.

Follow-up studies present many difficulties and variables of which the researcher must be aware. They include finding the subjects--in this case children--who are being followed-up and seeking their cooperation in participating in a follow-up scheme. They also include considering the population that one is treating and most especially the duration and severity of the disturbance and how this could well affect the outcome of treatment in a therapeutic community and, eventually, the success or failure after such youngsters leave the therapeutic community. The skill and dedication of treatment being given in the therapeutic community and how this affects outcome once the child leaves the community is also important. The fact that some individuals who leave are withdrawn before it is felt they are ready may mean that incomplete treatment leads to poor outcomes anyway. Also the events that occur after leaving the treatment centre are of particular importance. These may be beneficial or harmful to the individual, increasing or decreasing the chances of rehabilitation. This is the most difficult aspect to control and hence the child who has done well during treatment in a therapeutic community may encounter extreme stresses after leaving. This may result in a poor outcome that is not attributable to what was done in the therapeutic community. This study showed that those children or adolescents with severe problems who were not rejected by the therapeutic community and who received the support of the Local Authority, parents etc. were likely to be more effective in adjusting to life outside the therapeutic community in due course. Those who were able to manipulate the system by turning one professional against another, however, were more likely to experience failure subsequently in late adolescence and as young adults.

The resolution scrapbook as an aid in the treatment of traumatized children.

The resolution scrapbook is a therapeutic technique in which traumatized children complete treatment activities and compile them in the form of a scrapbook. Scrapbook activities facilitate children's resolution of traumatization impacts. Their progress through the phases of treatment becomes a lasting record for the children after treatment is terminated.