Effects of fluoxetine and PCPA on isolation-induced morphine self-administration and startle reactivity

The present study investigated the effects of the SSRI fluoxetine and the serotonin synthesis blocker--parachlorophenylalanine (PCPA) on morphine self-administration and startle reactivity in rats subjected to social isolation during adulthood. Adult Wistar rats were housed individually or in pairs for 21days. They were treated with fluoxetine, PCPA, or vehicle and tested for their startle response and intake of a morphine solution (0.5mg/ml). Socially restricted rats consumed significantly more morphine solution (but not water) than rats living in pairs, in both one-bottle and in two-bottle tests. They also showed significantly higher startle response amplitude. Daily fluoxetine treatment (5mg/kg i.p.) counteracted these behavioral alterations induced by isolation housing while PCPA treatment (200mg/kg for 3 consecutive days) further exacerbated it. Social isolation may increase morphine self-administration and emotional reactivity in the startle box by affecting serotonin. Antidepressants (such as fluoxetine) may normalize or stabilize serotonin function and restore the behavioral changes produced by isolation.

A Novel Phospholipid Derivative of Indomethacin, DP-155 [Mixture of 1-Steroyl and 1-Palmitoyl-2-{6-[1-(p-chlorobenzoyl)-5-methoxy-2-methyl-3-indolyl acetamido]hexanoyl}-sn-glycero-3-phosophatidyl Choline], Shows Superior Safety and Similar Efficacy in Reducing Brain Amyloid β in an Alzheimer's Disease Model

Indomethacin has been suggested for the treatment of Alzheimer's disease (AD), but its use is limited by gastrointestinal and renal toxicity. To overcome this limitation, D-Pharm Ltd. (Rehovot, Israel) developed DP-155 (mixture of 1-steroyl and 1-palmitoyl-2-{6-[1-(p-chlorobenzoyl)-5-methoxy-2-methyl-3-indolyl acetamido] hexanoyl}-Sn-glycero-3-phosophatidyl [corrected] choline), a lecithin derivative of indomethacin. Safety was tested by daily oral administration of DP-155 or indomethacin to rats in a dose range of 0.007 to 0.28 mmol/kg. The prevalence of gastrointestinal ulceration was significantly lower (10-fold) for DP-155 than for indomethacin, and the ulcerations were delayed. Signs of renal toxicity, namely reduced urine output and increased urine N-acetyl glycosaminidase to creatinine ratio, were 5-fold lower for DP-155. Indomethacin, but not an equimolar dose of DP-155, reduced urine bicyclo-prostaglandin E(2). An equimolar oral dose of DP-155 or indomethacin, administered every 4 h for 3 days, was equally efficacious in reducing the levels of Abeta42 in the brains of Tg2576 mice. Indomethacin was the principal metabolite of DP-155 in the serum. After DP-155 oral administration, indomethacin's half-life in the serum and the brain was 22 and 93 h, respectively, compared with 10 and 24 h following indomethacin oral administration. The brain to serum ratio was 3.5 times higher for DP-155 than indomethacin. This finding explains the efficacy of DP-155 in reducing Abeta42 brain levels, despite the low systemic blood concentrations of indomethacin derived from DP-155. In conclusion, compared with indomethacin, DP-155 has significantly lower toxicity in the gut and kidney while maintaining similar efficacy to indomethacin in lowering Abeta42 in the brains of Tg2576 mice. This superior safety profile highlights DP-155's potential as an improved indomethacin-based therapy for AD.

Polypropylene sling for the treatment of stress urinary incontinence

INTRODUCTION

Sling procedures have been used successfully for the treatment of stress urinary incontinence. Using similar surgical principles to the cadaveric fascia sling, we describe the placement of a thinly woven Prolene mesh under the mid to distal urethra. We describe our technique and report our initial early results. Technical Considerations. A total of 98 consecutive patients were evaluated. All patients had clinical evidence of stress urinary incontinence. The patients underwent a preoperative evaluation with video- urodynamic studies, symptom questionnaire, and cystoscopy. A 1 x 10-cm Prolene mesh was placed under the mid to distal urethra. Postoperatively, the patients were evaluated at 3-month intervals with a symptom questionnaire, physical examination, and postvoid residual volume determination.

CONCLUSIONS

We describe a new, simple, quick, inexpensive, and effective method to correct stress urinary incontinence by placing a Prolene mesh under the distal urethra.

New millennium, new slings

The etiology of stress incontinence is not completely understood. In the past, bladder neck suspensions were performed to correct anatomic abnormalities of the bladder neck and urethral hypermobility. This procedure was attractive because of its simplicity, low morbidity, and excellent early success rate. With time, the successes seen with bladder neck suspensions have not proven to be durable, and alternative surgical procedures have been developed. Until recently, the indications for bladder neck suspension were types I and II stress incontinence; slings were reserved for type III incontinence. However, slings have been shown to be as effective as and more durable than bladder neck suspensions for treatment of all types of stress incontinence; therefore, their popularity has spread. The success of distal urethral slings suggests that it is not necessary to correct anatomic hypermobility to correct stress incontinence. A plethora of new procedures and materials has emerged, leading to an increased need for well-controlled, objective outcome studies in order to understand the impact of these surgeries on our patients.

Fixed and dynamic urethral compression for the treatment of post-prostatectomy urinary incontinence: is history repeating itself?

PURPOSE

We reviewed the evolution of appliances and devices used for treating post-prostatectomy urinary incontinence.

MATERIALS AND METHODS

We used the MEDLINE to search the literature from 1966 to March 2000 and then manually searched bibliographies to identify studies that our initial search may have missed.

RESULTS

The evolution of treatment for post-prostatectomy urinary incontinence may be traced back to the 18th century. Two main schools of thoughts simultaneously evolved. The first fixed urethral compression devices were constructed to enable urethral obstruction by fixed resistance. This outlet resistance allows voiding after intra-abdominal and intravesical pressure is elevated but it is sufficient to prevent leakage between urinations. The other school of thought preferred creation of dynamic urethral compression in which outlet resistance is not fixed but may be decreased when voiding is desired or elevated between urinations. Therapeutic fixed and dynamic urethral compression interventions may be further divided into external or internal compressive devices or procedures. External fixed compression devices may be traced back to antiquity. A penile clamp, similar to the later Cunningham clamp, and a truss designed to compress the urethra by external perineal compression were presented in the Heister textbook of surgery, Institutiones Chirurgicae, as early as 1750. Dynamic compressive devices applied externally were developed much later, such as the first artificial urinary sphincter, described by Foley, in 1947 and the Vincent apparatus, described in 1960. The modern era of fixed urethral compression began in 1961 with Berry. Acrylic prostheses impregnated with bismuth to allow radiographic visualization were produced in various shapes and sizes, and used to compress the urethra against the urogenital diaphragm. In 1968 the University of California-Los Angeles group under the direction of Kaufman began to use cavernous crural crossover to compress the bulbous urethra (Kaufman I). Later 2 other modifications were described, including approximation of the crura in the midline using a polytetrafluoroethylene mesh tape (Kaufman II) and an implantable silicone gel prosthesis (Kaufman III). With the advent of the artificial urinary sphincter pioneered by Scott in 1973 interest in passive urethral compression disappeared in favor of the implantation of an inflatable circumferential prosthetic sphincter. Recently there has been a trend back to passive urethral compression. Synthetic bolsters have been described that passively compress the bulbar urethra to achieve urinary incontinence after radical prostatectomy.

CONCLUSIONS

Much creativity has been dedicated to solve the complex and challenging problem of post-prostatectomy urinary incontinence. Devices used for treating this condition may be grouped according to the mechanism of action and how they are applied. Passive urethral compression, long abandoned in favor of dynamic implantable sphincters, has reemerged. Further research in this field may determine which school of thought may provide the best solution for treating post-prostatectomy urinary incontinence.

Neonatal hypoxic risk in preterm birth infants: the influence of sex and severity of respiratory distress on cognitive recovery

The authors examined the differential effects of neonatal respiratory distress syndrome (RDS)--a condition associated with elevated risk for neonatal hypoxia-ischemia--on the cognitive development of the two sexes. The authors also attempted to establish whether the severity of respiratory distress is linked to cognitive outcome. Findings revealed an appreciable female advantage in cognitive recovery from RDS, yet the association between severity of RDS and outcome did not reach conventional statistical significance level. The sex effect on intelligence test performance was significantly greater for nonverbal subtests than for verbal ones. These results augment earlier findings of sex differences in cognitive recovery from perinatal intracranial hemorrhage. The current investigation also extends these results to a population of children at neonatal hypoxic risk for whom early brain injury was excluded on the basis of neonatal cranial ultrasound findings.

Diagnostic imaging of pelvic floor dysfunction

Pelvic floor dysfunction encompasses a variety of fascial and anatomic defects that can include a combination of cystocele, rectocele, uterine prolapse, enterocele and vault prolapse. Accurate diagnosis of the coexisting abnormalities is essential in planning reconstructive procedures so that the risks of recurrence and reoperation can be minimized. At this time, dynamic magnetic resonance imaging is the study of choice to evaluate the female pelvis and delineate the possible components of pelvic floor dysfunction.

Polypropylene sling for treatment of stress urinary incontinence: an alternative to tension-free vaginal tape

PURPOSE

Sling procedures have been used successfully to treat stress urinary incontinence (SUI). We report our initial experience with the use of a synthetic polypropylene mesh for treatment of SUI. Based on similar surgical principles of cadaveric fascia sling, we describe placement of a thinly woven polypropylene mesh under the distal urethra. We describe our technique and report our initial results.

MATERIALS AND METHODS

There were 146 consecutive patients evaluated. All patients had clinical evidence of SUI. Patients underwent preoperative evaluation with video urodynamics, symptom questionnaire, and cystoscopy. Postoperatively the patients were evaluated at 3-month intervals by symptom questionnaire, physical examination, and postvoid residuals (PVR). One year after the procedure, all patients were asked to fill out a voiding dysfunction and incontinence symptom questionnaire and a validated quality-of-life questionnaire. A flow and PVR also were obtained.

RESULTS

Average intraoperative time was 27 minutes for the sling procedure. There were no intraoperative complications and one major postoperative complication. There was no permanent retention and no erosions. Ninety-two percent of patients had either no or rare stress incontinence. Postoperatively, 7% of patients developed de novo urge incontinence.

CONCLUSION

We describe excellent results with a new simple, quick, and inexpensive method to correct SUI by placing a polypropylene mesh under the distal urethra.

Pubovaginal sling using cadaveric fascia and bone anchors: disappointing early results

PURPOSE

Pubovaginal sling procedures offer highly effective treatment for patients with female stress urinary incontinence. A recent modification of this technique is the use of cadaveric fascia lata as a sling material supported with titanium anchors placed bilaterally in the pubic bone. We reviewed our experience with this procedure and assessed our outcome.

MATERIALS AND METHODS

A total of 154 consecutive patients underwent a bone anchored, cadaveric fascia pubovaginal sling procedure by a single surgeon from July 1998 to June 1999. All patients were evaluated preoperatively with a detailed history, pelvic examination and radiographic or multichannel video urodynamic studies to diagnose stress urinary incontinence. Our technique begins with the nonincision placement of titanium bone anchors transvaginally into the pubic bone bilaterally. A 2 cm. wide tunnel is created bluntly beneath the vaginal epithelium between the 2 puncture sites with a right angle clamp. A 2 x 7 cm. strip of cadaveric fascia is then passed through the tunnel, into the retropubic space and secured to 2-0 polypropylene sutures attached to the anchors. After securing the sling, the transvaginal puncture sites are closed with 2-0 polyglactin sutures. Patients were seen postoperatively at 6 weeks, and 3 and 6-month followup. Patient age averaged 60 years (range 38 to 85), with an overall average length of followup from surgery of 10.6 months (range 6 to 16). All patients were mailed a self-administered questionnaire and participated in a telephone interview with an office nurse to retrospectively assess outcome and evaluate for recurrent stress urinary incontinence. Recurrent stress urinary incontinence was graded as 0-none, 1-rare, 2-moderate and 3-severe. Repeat pubovaginal sling procedure that was performed in patients with grades 2 to 3 stress urinary incontinence was considered a failure for the purpose of our study.

RESULTS

Of all 154 patients 58 (37.6%) had recurrent moderate to severe (grades 2 to 3) stress urinary incontinence at followup. A total of 26 patients underwent a second pubovaginal sling procedure for a reoperation rate of 16.9%. Intraoperative findings at reoperation revealed the titanium anchors to be in position, the polypropylene sutures to be intact, and retropubic fibrosis and scarring of the urethropelvic ligament suggesting appropriate retropubic placement of the sling in all cases. Uniformly all allogenic cadaveric fascia used for sling material appeared to be fragmented, attenuated or simply absent. Average time to reoperation was 9 months (range 3 to 15).

CONCLUSIONS

Early results using a bone anchored cadaveric fascia pubovaginal sling procedure were discouraging. Based on findings at reoperation, we attribute this result to the failure of our sling material and have abandoned the use of cadaveric fascia allografts in all pubovaginal slings at our institution.

Magnetic resonance imaging of the perineum and pelvic floor

The aim of this article is to review the magnetic resonance (MR) findings of pelvic floor descent and pelvic organ prolapse in women. In addition, a detailed grading system of pelvic organ prolapse and pelvic floor relaxation based on dynamic MR imaging is presented. The technique described here uses very fast MR sequences, is reproducible and easily learned by radiologists and technologists, is well accepted by patients, and provides as much information as traditional projectional X-ray imaging. Reference points are the pubococcygeal line and puborectalis muscle sling. The grading system is based on degree of organ prolapse through the hiatus and the degree of puborectalis descent and hiatal enlargement.

Dynamic half Fourier acquisition, single shot turbo spin-echo magnetic resonance imaging for evaluating the female pelvis

PURPOSE

We assessed the merit of dynamic half Fourier acquisition, single shot turbo spin-echo sequence T2-weighted magnetic resonance imaging (MRI) for evaluating pelvic organ prolapse and all other female pelvic pathology by prospectively correlating clinical with imaging findings.

MATERIALS AND METHODS

From September 1997 to April 1998, 100 consecutive women 23 to 88 years old with (65) and without (35) pelvic organ prolapse underwent half Fourier acquisition, single shot turbo spin-echo sequence dynamic pelvic T2-weighted MRI at our institution using a 1.5 Tesla magnet with phased array coils. Mid sagittal and parasagittal views with the patient supine, relaxed and straining were obtained using no pre-examination preparation or instrumentation. We evaluated the anterior vaginal wall, bladder, urethra, posterior vaginal wall, rectum, pelvic floor musculature, perineum, uterus, vaginal cuff, ovaries, ureters and intraperitoneal organs for all pathological conditions, including pelvic prolapse. Patients underwent a prospective physical examination performed by a female urologist, and an experienced radiologist blinded to pre-imaging clinical findings interpreted all studies. Physical examination, MRI and intraoperative findings were statistically correlated.

RESULTS

Total image acquisition time was 2.5 minutes, room time 10 minutes and cost American $540. Half Fourier acquisition, single shot turbo spin-echo T2-weighted MRI revealed pathological entities other than pelvic prolapse in 55 cases, including uterine fibroids in 11, ovarian cysts in 9, bilateral ureteronephrosis in 3, nabothian cyst in 7, Bartholin's gland cyst in 4, urethral diverticulum in 3, polytetrafluoroethylene graft abscess in 3, bladder diverticulum in 2, sacral spinal abnormalities in 2, bladder tumor in 1, sigmoid diverticulosis in 1 and other in 9. Intraoperative findings were considered the gold standard against which physical examination and MRI were compared. Using these criteria the sensitivity, specificity and positive predictive value of MRI were 100%, 83% and 97% for cystocele; 100%, 75% and 94% for urethrocele; 100%, 54% and 33% for vaginal vault prolapse; 83%, 100% and 100% for uterine prolapse; 87%, 80% and 91% for enterocele; and 76%, 50% and 96% for rectocele.

CONCLUSIONS

Dynamic half Fourier acquisition, single shot turbo spin-echo MRI appears to be an important adjunct in the comprehensive evaluation of the female pelvis. Except for rectocele, pelvic floor prolapse is accurately staged and pelvic organ pathology reliably detected. The technique is rapid, noninvasive and cost-effective, and it allows the clinician to visualize the whole pelvis using a single dynamic study that provides superb anatomical detail.

Continence mechanism based on a modified ileocecal valve

PURPOSE

We describe the technique and results of a simply constructed continence mechanism for continent urinary diversion to the skin based on the ileocecal valve.

MATERIALS AND METHODS

During a 3-year period 28 patients underwent construction of a continent stoma using the ileocecal valve; 23 patients were available for evaluation. The various indications for lower urinary tract reconstruction in this patient population included malignancy (4), neurogenic bladder (11), and urethral dysfunction (8). The continence mechanism is provided by the ileocecal valve, with tapering of the distal ileal segment with an absorable stapling device and then securing the catheterizable ileal segment to the serosa of the cecum along an opened taenia to provide an additional level of continence to the ileocecal valve.

RESULTS

Continence was achieved in 83% (19 of 23) of patients. Two patients required revision and are now dry, and two patients have not undergone revision and remain wet. No patients have had problems with difficult or traumatic catheterization of the limb or peristomal hernia. One case of stomal stenosis was identified and treated with an outpatient revision.

CONCLUSIONS

This technique for construction of a continence mechanism for a continent cutaneous urinary reservoir is simple to create, reliable, and without excess morbidity.

Life-threatening anaphylactoid reaction associated with indigo carmine intravenous injection

Indigo carmine (sodium indigotindisulfonate), a blue dye, has been widely used by surgeons to identify and to examine the urinary tract and is considered biologically inert and extremely safe. We present a case of severe life-threatening anaphylactoid reaction followed by cardiac arrest associated with intravenous indigo carmine injection.

Cytoscopic light test to aid in the differentiation of high-grade pelvic organ prolapse

It remains quite difficult to distinguish a high-grade cystocele from an enterocele or high rectocele on the basis of physical examination findings alone. We have employed the use of a cystoscopic light test during preoperative or intraoperative endoscopy to assist in differentiating these entities.

Peripartum hypoxic risk and cognitive outcome: a study of term and preterm birth children at early school age

The authors examined the relationships between gestational maturity, perinatal hypoxic risk, and intellectual outcome in early school-age children. The sample was composed of 48 children whose arterial pH obtained within 3 hr after delivery was between 7.3 (the lower end of the normal range) and 7.1 (the lower end of the moderately acidotic range). Gestational maturity did not account for a significant proportion of variance in outcome, whereas arterial pH was found to be significantly related to subsequent intellectual performance. The observed relationship between peripartum arterial pH and cognitive performance is especially noteworthy because the arterial pH range was restricted. The authors conclude that a "dose-response" relationship can be observed between arterial pH and intellectual outcome at early school age, even when the lower end of the acidotic range is truncated above the pH level that is thought to reflect severe asphyxia neonatorum.

Transvaginal culdosuspension: technique and results

OBJECTIVES

Numerous techniques have been described for supporting the vaginal vault after enterocele repair and hysterectomy. We describe a transvaginal culdosuspension that obliterates the cul-de-sac and supports the vaginal cuff high on the levator plate. The normal vaginal axis is restored, and adequate vaginal depth is provided for normal sexual activity.

METHODS

One hundred four patients, aged 48 to 90 years (mean age 71), underwent transvaginal culdosuspension in conjunction with enterocele repair (62 patients), vaginal hysterectomy (20 patients), or both (22 patients). Two culdosuspension sutures support the vaginal vault to the origin of the sacrouterine and cardinal ligaments, and the cul-de-sac is obliterated with two pursestring sutures. Concomitant prolapse was repaired in 82 patients, bladder neck suspension in 50, cystocele repair in 45, and rectocele repair in 76.

RESULTS

One hundred patients were followed up at a mean of 17.3 months (range 6.5 to 35). Recurrence of enterocele or vault prolapse occurred in 4 patients. All patients who had preoperative stress incontinence were cured of leakage. Complications were rare, and there were no instances of vaginal foreshortening, urinary retention, vaginal skin necrosis, bladder perforation, or rectovaginal fistula.

CONCLUSIONS

Transvaginal culdosuspension is a safe and effective procedure for treating and preventing enterocele and vaginal vault prolapse. This technique restores the normal vaginal depth and axis, resulting in a sexually functional vagina.

Peripartum hypoxic risk and cognitive outcome: a study of term and preterm birth children at early school age

The authors examined the relationships between gestational maturity, perinatal hypoxic risk, and intellectual outcome in early school-age children. The sample was composed of 48 children whose arterial pH obtained within 3 hr after delivery was between 7.3 (the lower end of the normal range) and 7.1 (the lower end of the moderately acidotic range). Gestational maturity did not account for a significant proportion of variance in outcome, whereas arterial pH was found to be significantly related to subsequent intellectual performance. The observed relationship between peripartum arterial pH and cognitive performance is especially noteworthy because the arterial pH range was restricted. The authors conclude that a "dose-response" relationship can be observed between arterial pH and intellectual outcome at early school age, even when the lower end of the acidotic range is truncated above the pH level that is thought to reflect severe asphyxia neonatorum.

Grading pelvic prolapse and pelvic floor relaxation using dynamic magnetic resonance imaging

OBJECTIVES

With significant vaginal prolapse, it is often difficult to differentiate among cystocele, enterocele, and high rectocele by physical examination alone. Our group has previously demonstrated the utility of magnetic resonance imaging (MRI) for evaluating pelvic prolapse. We describe a simple objective grading system for quantifying pelvic floor relaxation and prolapse.

METHODS

One hundred sixty-four consecutive women presenting with pelvic pain (n = 39) or organ prolapse (n = 125) underwent dynamic MRI. The "H-line" (levator hiatus) measures the distance from the pubis to the posterior anal canal. The "M-line" (muscular pelvic floor relaxation) measures the descent of the levator plate from the pubococcygeal line. The "O" classification (organ prolapse) characterizes the degree of visceral prolapse beyond the H-line.

RESULTS

The image acquisition time was 2.5 minutes per study. Each study cost $540. In the pain group, the H-line averaged 5.2 +/- 1.1 cm versus 7.5 +/- 1.5 cm in the prolapse group (P <0.001). The M-line averaged 1.9 +/- 1.2 cm in the pain group versus 4.1 +/- 1.5 cm in the prolapse group (P <0.001). Incidental pelvic pathologic features were commonly noted, including uterine fibroids, ovarian cysts, hydroureter, urethral diverticula, and foreign body.

CONCLUSIONS

The HMO classification provides a straightforward and reproducible method for staging and quantifying pelvic floor relaxation and visceral prolapse. Dynamic MRI requires no patient preparation and is ideal for the objective evaluation and follow-up of patients with pelvic prolapse and pelvic floor relaxation. MRI obviates the need for cystourethrography, pelvic ultrasound, or intravenous urography and has become the study of choice at our institution for evaluating the female pelvis.

4-Defect repair of grade 4 cystocele

PURPOSE

The 4-defect repair of grade 4 cystocele corrects discrete and severe deficiencies of vesicourethral support. We describe this technique used during pelvic reconstruction in 130 women.

MATERIALS AND METHODS

During a 3-year period 130 patients (age range 35 to 96 years) underwent repair of grade 4 cystocele using the 4-defect repair technique. Cystocele repair had been performed in 60 patients (46%) and hysterectomy had been performed in 85 (65%). A "goalpost incision" is used in the vaginal wall to facilitate separation of the wall from underlying perivesical fascia, entry into the retropubic space, and exposure of the urethropelvic ligament, cardinal ligament and perivesical fascia. The 4 polypropylene sutures are used to provide an anterior vaginal wall sling which is modified to incorporate perivesical fascia and cardinal ligaments. Central defect repair is achieved by approximation of the cardinal ligaments and midline plication of the perivesical fascia over absorbable mesh.

RESULTS

A total of 112 patients were available for followup which ranged from 6 to 42 months (mean 21). Repair of grade 4 cystocele was accompanied by other transvaginal repairs in 94 patients (83%), including rectocele repair in 81, hysterectomy in 22 and enterocele repair in 31. Of the patients 92% had excellent objective and subjective results for anatomical cystocele repair. Of the patients with preoperative stress urinary incontinence 90% had excellent or good subjective results. De novo urge incontinence was seen in 7% of patients.

CONCLUSIONS

The 4-defect repair technique relies on anatomical restoration of 4 distinct deficiencies of pelvic support and is highly effective for relief of symptoms of grade 4 cystocele.