Cutting off the fuel supply to calcium pumps in pancreatic cancer cells: role of pyruvate kinase-M2 (PKM2)

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) has poor survival and treatment options. PDAC cells shift their metabolism towards glycolysis, which fuels the plasma membrane calcium pump (PMCA), thereby preventing Ca2+-dependent cell death. The ATP-generating pyruvate kinase-M2 (PKM2) is oncogenic and overexpressed in PDAC. This study investigated the PKM2-derived ATP supply to the PMCA as a potential therapeutic locus.

METHODS

PDAC cell growth, migration and death were assessed by using sulforhodamine-B/tetrazolium-based assays, gap closure assay and poly-ADP ribose polymerase (PARP1) cleavage, respectively. Cellular ATP and metabolism were assessed using luciferase/fluorescent-based assays and the Seahorse XFe96 analyzer, respectively. Cell surface biotinylation identified membrane-associated proteins. Fura-2 imaging was used to assess cytosolic Ca2+ overload and in situ Ca2+ clearance. PKM2 knockdown was achieved using siRNA.

RESULTS

The PKM2 inhibitor (shikonin) reduced PDAC cell proliferation, cell migration and induced cell death. This was due to inhibition of glycolysis, ATP depletion, inhibition of PMCA and cytotoxic Ca2+ overload. PKM2 associates with plasma membrane proteins providing a privileged ATP supply to the PMCA. PKM2 knockdown reduced PMCA activity and reduced the sensitivity of shikonin-induced cell death.

CONCLUSIONS

Cutting off the PKM2-derived ATP supply to the PMCA represents a novel therapeutic strategy for the treatment of PDAC.

How reproducible is the cardioinhibitory response to carotid sinus massage in fallers?

AIMS

To ascertain the reproducibility of the cardioinhibitory subtype of carotid sinus hypersensitivity (CICSH) in fallers.

METHODS AND RESULTS

One hundred and seventy-five subjects with CICSH and unexplained or recurrent falls were randomized to pacemaker implantation or control. Sixty-four control subjects (61% female, mean age 71.8 years, median 2 falls in the previous year) completed one-year follow-up and had carotid sinus massage (CSM) performed on 4 occasions (twice before randomization, at 6 months and 1 year following randomization). CSM was performed sequentially on the right and then left sides, initially supine and then upright at 70 degrees head-up tilt by the same investigator. On each occasion CSM was discontinued once CICSH was demonstrated. CICSH was demonstrated on 82% of occasions, 75% on right CSM and 77% whilst the subject was supine. Before randomization, and at 6 months and 1 year, 91%, 67%, and 70% of subjects had reproducible CICSH respectively. Half had CICSH on all 4 occasions. Only 17% had a consistent response on the same side in the same position.

CONCLUSIONS

In the majority of subjects CICSH is reproducible and this is more likely shortly after the initial response. However the cardioinhibitory response to CSM is inconsistent both in side elicited and subject position.

Prevalence of hypotensive disorders in older patients with a pacemaker in situ who attend the Accident and Emergency Department because of falls or syncope

AIMS

To ascertain the proportion of adults with a pacemaker in situ attending the Accident and Emergency Department because of syncope or unexplained falls and the cause of index symptoms in these patients, including the prevalence of hypotensive syndromes.

METHODS AND RESULTS

Patients presenting to the Accident and Emergency Department with unexplained syncope or non-accidental falls, who had a pacemaker in situ, were studied. Eligible patients had cardiovascular assessment (morning orthostatic blood pressure measurement, heart rate and BP measurements during carotid sinus stimulation (supine and upright), head-up tilt at 70 degrees for 40 min), assessment of haemodynamics during fixed mode pacing and gait and balance assessment. Of 5863 patients screened, 13.5% had unexplained syncope or a non-accidental fall; of these only 3% (26 patients) had pacemakers in situ. Of 18 study patients (82 +/- 8 years), 10 were female. Sixteen had a hypotensive diagnosis. Seven had more than one attributable hypotensive diagnosis. Five of 13 with vasodepressor carotid sinus syndrome had no previous diagnosis of carotid sinus hypersensitivity. No patients had vasovagal syncope induced during passive head-up tilt testing.

CONCLUSION

It is rare for patients who attend the Accident and Emergency Department because of syncope or unexplained falls to have a pacemaker in situ. In those who do, hypotensive disorders are a common finding.

Carotid sinus syndrome: a modifiable risk factor for nonaccidental falls in older adults (SAFE PACE)

OBJECTIVES

The aim of the study was to determine whether cardiac pacing reduces falls in older adults with cardioinhibitory carotid sinus hypersensitivity (CSH).

BACKGROUND

Cardioinhibitory carotid sinus syndrome causes syncope, and symptoms respond to cardiac pacing. There is circumstantial evidence for an association between falls and the syndrome.

METHODS

A randomized controlled trial was done of consecutive older patients (>50 years) attending an accident and emergency facility because of a non-accidental fall. Patients were randomized to dual-chamber pacemaker implant (paced patients) or standard treatment (controls). The primary outcome was the number of falls during one year of follow-up.

RESULTS

One hundred seventy-five eligible patients (mean age 73 +/- 10 years; 60% women) were randomized to the trial: pacemaker 87; controls 88. Falls (without loss of consciousness) were reduced by two-thirds: controls reported 669 falls (mean 9.3; range 0 to 89), and paced patients 216 falls (mean 4.1; range 0 to 29). Thus, paced patients were significantly less likely to fall (odds ratio 0.42; 95% confidence interval: 0.23, 0.75) than were controls. Syncopal events were also reduced during the follow-up period, but there were much fewer syncopal events than falls-28 episodes in paced patients and 47 in controls. Injurious events were reduced by 70% (202 in controls compared to 61 in paced patients).

CONCLUSIONS

There is a strong association between non-accidental falls and cardioinhibitory CSH. These patients would not usually be referred for cardiovascular assessment. Carotid sinus hypersensitivity should be considered in all older adults who have non-accidental falls.

ATR/ATM-mediated phosphorylation of human Rad17 is required for genotoxic stress responses

Genotoxic stress triggers the activation of checkpoints that delay cell-cycle progression to allow for DNA repair. Studies in fission yeast implicate members of the Rad family of checkpoint proteins, which includes Rad17, Rad1, Rad9 and Hus1, as key early-response elements during the activation of both the DNA damage and replication checkpoints. Here we demonstrate a direct regulatory linkage between the human Rad17 homologue (hRad17) and the checkpoint kinases, ATM and ATR. Treatment of human cells with genotoxic agents induced ATM/ATR-dependent phosphorylation of hRad17 at Ser 635 and Ser 645. Overexpression of a hRad17 mutant (hRad17AA) bearing Ala substitutions at both phosphorylation sites abrogated the DNA-damage-induced G2 checkpoint, and sensitized human fibroblasts to genotoxic stress. In contrast to wild-type hRad17, the hRad17AA mutant showed no ionizing-radiation-inducible association with hRad1, a component of the hRad1-hRad9-hHus1 checkpoint complex. These findings demonstrate that ATR/ATM-dependent phosphorylation of hRad17 is a critical early event during checkpoint signalling in DNA-damaged cells.

Carotid sinus syndrome and falls in older adults

Retrospective and circumstantial evidence supports an overlap between symptoms of falls and syncope in older adults. Because of this overlap, we undertook a prospective, explanatory, single-center study of cardiac pacing for falls in patients with carotid sinus syndrome in a consecutive series of over 56,000 adult visitors to an emergency department. One third attended because of a fall; one in five fallers had unexplained falls, and one third of these had carotid sinus hypersensitivity, of whom one half had a cardioinhibitory or mixed response that may be expected to respond to cardiac pacing. In a randomized, controlled trial of a subset of these patients, cardiac pacing was shown to significantly reduce subsequent fall rates by two thirds and syncopal rates during 1-year follow-up. The current pacing rate for carotid sinus syndrome is much higher in our practice than in other series because our facility is dedicated to falls and syncope in older subjects who have direct access to referring physicians and family practitioners. Of the implants in our region, 24% are for carotid sinus syndrome, compared with 43% for atrioventricular block, 20% for sick sinus syndrome, and 12% for atrial fibrillation. These rates do not include pacing in patients who fall, but rather reflect pacing rates consistent with American College of Cardiology guidelines for carotid sinus syndrome, such as recurrent syncope. These preliminary results from a local explanatory study are now being tested in a multicenter study entitled Syncope and Falls in the Elderly: Pacing and Carotid Sinus Evaluation (SAFE-PACE II).

Complications of carotid sinus massage--a prospective series of older patients

BACKGROUND

there is a causal association between carotid sinus hypersensitivity, falls and syncope in elderly subjects. Neurological complications during carotid sinus massage have been reported in case studies and two retrospective series. Our aim was prospectively to ascertain the incidence of complications occurring after carotid sinus massage performed for diagnostic purposes in a consecutive series of patients.

METHODS

1000 consecutive subjects aged 50 years or over who attended the accident and emergency department with syncope or 'unexplained' falls had carotid sinus massage. Carotid sinus massage was performed for 5 s on the right and then left sides both supine and upright (70 degrees head-up tilt) with continuous heart rate and phasic blood pressure recording. Contraindications to carotid sinus massage were the presence of a carotid bruit, recent history of stroke or myocardial infarction or previous ventricular tachyarrhythmia.

RESULTS

complications occurred in nine patients immediately after cessation of carotid sinus massage. Eight had transient neurological complications possibly attributable to carotid sinus massage: visual disturbance, 'pins and needles' and sensation of finger numbness in two cases each, leg weakness in one and sensation of 'being drunk' in one. All transient complications resolved within 24 h. In one patient mild weakness of the right hand persisted.

CONCLUSIONS

no subjects had cardiac complications and 1% had possible neurological symptoms, which resolved in most cases. Persistent neurological complications are uncommon, occurring in 1:1000 patients (0.1%) or 1: 3805 episodes of carotid sinus massage (0.03%).

A collapsed non-native RNA folding state

At physiological Mg2+ concentrations, the catalytic core of the bI5 group I intron does not fold into its native structure. In contrast, as judged by the global size, this RNA undergoes structural collapse at Mg 2+ concentrations much lower than required to drive folding of the RNA completely to the native state. The bI5 RNA therefore exists in equilibrium between expanded and collapsed non-native states. The activation energy of RNA folding from the collapsed state to the native state is negligible and the reaction is not accelerated by the addition of urea. This collapsed state is thus distinct from the kinetic traps observed during folding of other large RNAs. The collapsed non-native state forms readily in the case of bI5 RNA and may exist generically prior to assembly of other ribonucleoprotein holoenzymes, such as the ribosome.

Diagnosis of carotid sinus hypersensitivity in older adults: carotid sinus massage in the upright position is essential

OBJECTIVE

To assess the diagnostic value of supine and upright carotid sinus massage in elderly patients.

DESIGN

Prospective controlled cohort study.

SETTING

Three inner city accident and emergency departments and a dedicated syncope facility.

PATIENTS

1375 consecutive patients aged > 55 years presenting with unexplained syncope and drop attacks; 25 healthy controls.

INTERVENTIONS

Bilateral supine carotid sinus massage, repeated in the 70 degrees head up tilt position if the initial supine test was not diagnostic of cardioinhibitory and mixed carotid sinus hypersensitivity.

MAIN OUTCOME MEASURES

Diagnosis of cardioinhibitory or mixed carotid sinus hypersensitivity; clinical characteristics of supine v upright positive groups.

RESULTS

226 patients were excluded for contraindications to carotid sinus massage. Of 1149 patients undergoing massage, 223 (19%) had cardioinhibitory or mixed carotid sinus hypersensitivity; 70 (31%) of these had a positive response to massage with head up tilt following negative supine massage (95% confidence interval, 25.3% to 37.5%). None of the healthy controls showed carotid sinus hypersensitivity on erect or supine massage. The initially positive supine test had 74% specificity and 100% sensitivity; these were both 100% for the upright positive test. The clinical characteristics of the supine v upright positive subgroups were similar.

CONCLUSIONS

The diagnosis of carotid sinus hypersensitivity amenable to treatment by pacing may be missed in one third of cases if only supine massage is performed. Massage should be done routinely in the head up tilt position if the initial supine test is negative.

Pelvic floor electrical stimulation for genuine stress incontinence: who will benefit and when?

This study sought to determine the characteristics of women in whom pelvic floor electrical stimulation will reduce stress urinary incontinence. It also evaluates how long electrical stimulation should be used before significant improvements are seen in clinical outcomes. Subjects with genuine stress incontinence were enrolled into a multicenter non-randomized trial. They used electrical stimulation for 15 minutes twice daily or every other day for 20 weeks. At the end of 20 weeks, those with a 50% reduction in leakage episodes on voiding diary ('responders') were compared with those who did not show a 50% reduction ('non-responders'). Thirty-one subjects were enrolled and 28 completed the study. After the treatment period, 19 subjects were defined as responders and 9 as non-responders. There were no significant differences between the two groups in baseline demographics (e.g. age, parity, largest birth weight etc.) other than body mass index (greater in nonresponders). Significant subjective and objective improvements were noted among responders by 10 and 14 weeks, respectively. Compliance was higher in responders during weeks 12-15 of the study (P=0.05). It was concluded that a minimum of 14 weeks of pelvic floor stimulation was necessary before significant objective improvements were seen. Body mass index and patient compliance may affect success.

Pelvic floor electrical stimulation for the treatment of urge and mixed urinary incontinence in women

OBJECTIVES

To determine the efficacy of daily or every-other-day electrical stimulation in treating detrusor instability (urge) or urge plus genuine stress (mixed) urinary incontinence in women.

METHODS

A multicenter, prospective, nonrandomized study enrolled subjects with urge and mixed urinary incontinence assigned to daily or every-other-day treatments (15 minutes twice daily) using pelvic floor stimulation. Outcome measures assessed were (1) leakage episodes, nocturnal episodes, voiding frequency, total voids, and pad count, and (2) patient subjective assessment and quality of life.

RESULTS

Seventy-two subjects were enrolled. Sixty-eight subjects completed the 20-week protocol: 33 treated daily and 35 treated every other day. The entire study group (n = 68) experienced a significant decrease in total leaks (P < 0.001), nocturnal episodes (P = 0.001), pad count (P = 0.002), and total voids (P = 0.003) and on visual analog scales. Sixty-nine percent (n = 46) of subjects with urge or mixed incontinence were cured or improved by at least 50%, with 28% (n = 19) being cured. There were no significant differences between daily and every-other-day users. Nonresponse was correlated with number of previous therapies (P < 0.001) and number of vaginal deliveries (P = 0.007). Overall, subjects were 93% compliant with device use, and 72% (n = 47) were satisfied with the therapy.

CONCLUSIONS

Twenty weeks of pelvic floor electrical stimulation therapy is effective in treating urge and mixed urinary incontinence, regardless of daily or every-other-day treatments.

Assessing medical students' perceptions of mistreatment in their second and third years

PURPOSE

To study medical students' perceptions of mistreatment in their second and third years of training.

METHOD

A questionnaire was distributed at Wayne State University School of Medicine to the class of 1993 at the end of its third year and to the class of 1994 at the end of its second and third years. The students were asked if they had been subjected to various forms of mistreatment; the third-year students were asked to rate their perceptions of each clinical department's response to them on the basis of gender and race-ethnicity, as well as their overall treatment. The students also completed demographic information about age, gender, and marital status, number of children, and race-ethnicity. Results were analyzed using chi-square statistics, multivariate statistical analyses, analyses of variance, and Duncan's post-hoc comparisons.

RESULTS

The response rate for the class of 1993 was 71.5%; response for the class of 1994 were 66.9% in their second year and 75.2% in their third year; 41.7% were women, and the racial-ethnic breakdown was 71.2% white/Caucasian, 11.7% black/African American and 16.8% other. There was a significant difference between the percentages of second-year and third-year students reporting any experience of mistreatment (37.2% vs 75.8%, p < .001). Canonical correlation analysis revealed bias in the third year based on gender (p < .0001) and race-ethnicity (p < .0002); both variates were related to sexual humor. The students' perceptions of mistreatment were lowest for family medicine and highest for obstetrics-gynecology and surgery. Perceptions of mistreatment in departments varied significantly by gender and race-ethnicity. The nonwhite males reported the least favorable treatment in most departments.

CONCLUSION

Marked variability in the students' perceptions of mistreatment within departments suggest that a variety of approaches will be required to improve the medical training environment.

Prevalence of cardioinhibitory carotid sinus hypersensitivity in patients 50 years or over presenting to the accident and emergency department with "unexplained" or "recurrent" falls

To study the prevalence of Cardioinhibitory Carotid Sinus Hypersensitivity (CICSH) in patients 50 years or over presenting to casualty with "unexplained" or "recurrent" falls. The prospective study was from October 1, 1995 to April 30, 1996 in the Inner City Accident and Emergency Departments, Newcastle Upon Tyne, U.K. Ten thousand four hundred forty-three patients 50 years and over presented, of which 4,051 (39%) were fallers. Fallers were excluded if they lived over 15 miles from the hospital (81), were registered blind (17), were unable to speak English (22), were unable to previously walk (27), if there was a history of only one accidental fall (1,659) or were cognitively impaired (776: Mini Mental State Examination < 24 [30]) or if there was a clear attributable medical diagnosis for the fall (871). Five hundred ninety-eight "unexplained" or "recurrent" fallers (defined as three or more falls in the previous 12 months) were assessed for carotid sinus massage (CSM). One hundred forty-five patients declined CSM (24%), 70 (12%) had relative contraindications to CSM and 13 already had pacemakers in situ (2%). Two hundred seventy-nine underwent CSM, of whom 65 had CICSH (23%), which might be amenable to treatment with pacemakers. The prevalence of CICSH (a potentially treatable condition) in "unexplained" or "recurrent" fallers who present to the accident and emergency department is 23%. A randomized control study to assess benefit from pacemaker intervention in these patients is underway.

Stability of orthognathic surgery: a review of rigid fixation

The use of rigid fixation with orthognathic surgery was greeted by both excitement and healthy concern when it began to find its way into the literature approximately 10 years ago. The purpose of this paper is to review the literature and make comments based on the experience of the senior author on whether one of the early premises was true. Has rigid fixation improved stability with orthognathic surgery? The authors chose to examine mandibular advancements treated with a bilateral sagittal split osteotomy and maxillary osteotomies treated with a Le Fort I osteotomy. When compared to wire osteosynthesis, rigid fixation has improved stability; however, the individual move associated with the osteotomy must be considered. In some cases, auxiliary techniques should be used to ensure stability. Condylar resorption with mandibular advancement continues to be an area of concern.

Pelvic floor electrical stimulation: a comparison of daily and every-other-day therapy for genuine stress incontinence

OBJECTIVES

To compare the effectiveness of daily and every-other-day electrical stimulation in treating genuine stress incontinence.

METHODS

Subjects with genuine stress incontinence were enrolled in a multicenter, prospective, nonrandomized study and underwent daily or every-other-day pelvic floor stimulation treatments for 15 minutes twice a day. Outcome measures assessed were (1) leakage episodes and pad count; (2) leakage amount, and (3) subject subjective assessment and quality of life. Thirteen subjects treated daily and 15 treated every other day completed the 20-week protocol. One-year follow-up data were available for 21 subjects.

RESULTS

No significant differences in primary outcome variables were found between the groups. Subjects treated every other day had significant decreases in total leakage episodes (P = 0.04), pad count (P = 0.04), total voids (P = 0.02), and visual analog scale scores, with stress incontinence cured or improved by 50% in 73% (n = 11). Subjects treated every day had significant decreases in urge episodes (P = 0.03), pad count (P = 0.05), and visual analog scale scores, with 62% (n = 8) cured or improved by 50%. Compliance was higher for subjects treated every other day (P = 0.05). Satisfaction with therapy was 75% (n = 10) for daily treatment and 77% (n = 12) for every-other-day treatment. At 1 year, 70% (n = 7) of subjects who continued device use maintained their cure or improvement status.

CONCLUSIONS

Both daily and every-other-day therapy with pelvic floor electrical stimulation are effective in treating genuine stress incontinence. Subjects who continue device use maintain a higher curve or improvement rate.

Ehlers-Danlos syndrome: relationship between joint hypermobility, urinary incontinence, and pelvic floor prolapse

OBJECTIVE

To compare the incidence of joint hypermobility and prolapse in incontinent and continent women with Ehlers-Danlos syndrome (EDS).

METHODS

Forty-six patients with EDS were evaluated by history and physical examination. The degree of joint mobility of shoulder, elbow, wrist, hip, knee, and ankle was evaluated by orthopedic surgeons and physical therapists. Joint range of motion measurements were obtained using an orthopedic goniometer.

RESULTS

The two EDS groups, incontinent (n = 28) and continent (n = 18) women, had a statistically similar mean age, weight, and parity (p = NS). In the EDS population overall joint hypermobility averaged 34.3%. Individuals with EDS type 3 had significantly more joint hypermobility than those with type 1 and 2 EDS. However, logistic regression analysis demonstrated no significant relationship between prolapse and joint hypermobility. Wrist dorsiflexion (p < 0.05) and palmar flexion (p = 0.05) were the only variables related to incontinence.

CONCLUSION

It has previously been reported that hypermobility was correlated with pelvic floor prolapse. Of 18 joint measures per patient, hypermobility of both wrist dorsiflexion and palmar flexion was associated with symptoms of incontinence. We were unable to document an association between joint hypermobility and prolapse in the EDS population.

Pelvic floor electrical stimulation in the treatment of genuine stress incontinence: a multicenter, placebo-controlled trial

OBJECTIVE

Our purpose was to determine the efficacy of transvaginal electrical stimulation in treating genuine stress incontinence.

STUDY DESIGN

This was a multicenter, prospective, randomized, double-blind, placebo-controlled 15-week trial comparing the use of an active pelvic floor stimulator with a sham device. Thirty-five women used an active unit and 17 control subjects used sham devices. Weekly and daily voiding diaries were recorded throughout the trial. Urodynamic testing, including pad test and subtracted cystometry, was done before and at the end of device use. Pelvic muscle strength was measured at baseline and at the end of the trial. Patients scored their symptoms on visual analog scales and completed quality-of-life questionnaires before and after therapy.

RESULTS

Significant improvements from baseline were found in patients using active devices but not in controls. Comparisons of changes from baseline between active-device and control patients showed that active-device patients had significantly greater improvement in weekly (p = 0.009) and daily (p = 0.04) leakage episodes, pad testing (p = 0.005), and vaginal muscle strength (p = 0.02) when compared with control subjects. Significantly greater improvement was also found for both visual analog scores of urinary incontinence (p = 0.007) and stress incontinence (p = 0.02), as well as for subjective reporting of frequency of urine loss (p = 0.002), and urine loss with sneezing, coughing, or laughing (p = 0.02), when compared with controls. Pad testing showed that stress incontinence was improved by at least 50% in 62% of patients using an active device compared with only 19% of patients using sham devices (p = 0.01). Voiding diaries showed at least 50% improvement in 48% of active-device patients compared with 13% of women using the sham device (p = 0.02). No irreversible adverse effects were noted in either group.

CONCLUSIONS

Transvaginal pelvic floor electrical stimulation was found to be a safe and effective therapy for genuine stress incontinence.

Gynecologic disorders in women with Ehlers-Danlos syndrome

OBJECTIVE

We characterized the population with Ehlers-Danlos syndrome with regard to genital prolapse, urinary incontinence, and other gynecologic disorders.

METHODS

Forty-one adult women who had registered for a first-ever Ehlers-Danlos multidisciplinary clinic participated in the study. Each had a comprehensive standardized evaluation, including gynecologic history, physical examination, urodynamic testing, and physical therapy evaluation. Qualitative and quantitative data were analyzed to determine means for various gynecologic disorders of Ehlers-Danlos syndrome.

RESULTS

The frequencies of incontinence complaints (59%), endometriosis (27%), dyspareunia (57%), and previous hysterectomy (44%) were higher than expected for a population with a mean age of 41 years. Incontinence could not be demonstrated objectively. Prolapse was diagnosed in 12 (29.3%).

CONCLUSIONS

Careful attention should be paid to women with Ehlers-Danlos syndrome because of an association with many gynecologic complaints. Women with Ehlers-Danlos syndrome should be questioned regarding incontinence, genital prolapse, endometriosis, and dyspareunia.

Obstetric and gynecologic dysfunction in the Ehlers-Danlos syndrome

Women members of the newly formed Ehlers-Danlos National Foundation (EDNF) were surveyed with a very detailed questionnaire with 50 questions concerning family history and inheritance, past medical history, and obstetric and gynecologic problems. They entailed the largest extant database on Ehlers-Danlos Syndrome (EDS) patients. The mean age of the 68 women who responded to the survey was 42 years; most had EDS types I, III, IV and unknown. Forty-three women had 138 pregnancies; 13 women never married. The stillbirth rate was 3.15% (3/95); the preterm delivery rate was 23.1% (22/95), and the spontaneous abortion rate was 28.9% (40/138). There was a cesarean delivery rate of 8.4%, with 14.7% having perinatal bleeding problems. One woman (EDS type IV) had congestive heart failure. Common gynecologic problems were recurrent anovulation (41.3%), recurrent vaginal infections (53%), abnormal cytologic smears (19%), sexual dysfunction (61%), irregular menses (28%), endometriosis (15.8%), vaginal dryness (25%) and a need for hysterectomy (19.1%). In this largest series of pregnancies with EDS, we found relatively high rates of abortion, preterm delivery, pregnancy-related bleeding and stillbirth. Women with EDS also seem to have high frequency of anovulation, vaginal infections, abnormal cytologic smears and dyspareunia.

30-minute evaluation of incontinence in the older woman

The key to successful management of urinary incontinence in the older woman is accurate diagnosis of the underlying condition. A simple 30-minute in-office evaluation answers the important questions that increase the likelihood of reaching the correct diagnosis. This core evaluation includes a history and physical exam, urinalysis and other basic lab tests, assessment of urethral angulation, and a simple cystometrogram. A patient voiding diary may also help to pinpoint the severity of incontinence. Further testing is required if symptoms fail to resolve after empiric therapy.

Ethics in gynecologic surgical innovation

J. Marion Sims' efforts in surgically curing vesicovaginal fistula are retold. The controversy surrounding his surgical innovation on black slaves is discussed in the context of the ethical principles of autonomy, beneficence, and justice. The relevance of his story to modern surgical innovation in incontinence surgery is emphasized in a discussion of the Pereyra, Gittes, and paravaginal procedures. A call is made to establish a gynecologic ethic to ensure that patients' rights are respected in all future surgical innovation.

Complications from permanent suture in surgery for stress urinary incontinence. A report of two cases

Two cases reports are used to illustrate potential complications of permanent suture in vaginal and abdominal surgical procedures for urinary incontinence. The first case used permanent suture for an abdominal retropubic urethropexy. A portion of a glove finger remained attached to the suture and was not recognized until the patient developed a retropubic abscess two years later. In the second case, permanent suture used in a vaginal retropubic urethropexy eroded through the vagina. The patient presented with lower abdominal pain 18 months after the procedure; the pain was relieved with removal of the suture. Complications of using permanent suture in abdominal retropubic urethropexy have not been reported, but the attachment of a foreign body, such as a glove finger, can create an adverse outcome. The use of permanent suture in vaginal procedures should be used with the awareness that there are potential complications.

Urethral stones in women. A case report

Urethral stones are encountered rarely in the urethra in women. We report the clinical and urodynamic findings and the management of 17 stones in a urethral diverticulum.

Pelvic floor rehabilitation in the treatment of incontinence

This study assessed the effectiveness of a pelvic floor rehabilitation program in a clinical practice. A retrospective convenience sample of 48 women was evaluated pretreatment and posttreatment with follow-up interviews from six months to three years. This group consisted of 81% with stress urinary incontinence, 6% with unstable bladder and 10% with mixed incontinence. Fecal incontinence was present as well in 35% of the subjects. The patients were taught pelvic floor muscle exercises and instruction reinforced with electromyographic biofeedback. Neuromuscular electrical stimulation was used when clinically indicated. Two women did not continue the program beyond the first visit and were excluded. Sixty-two percent of patients with two or more visits demonstrated an improvement. Thirteen percent were completely dry, and 49% demonstrated a significant improvement. Patients with genuine stress urinary incontinence, unstable bladder and mixed incontinence showed a 66%, 33% and 50% improvement rate, respectively. Fecal incontinence was improved in 63% of women trained in pelvic floor muscle exercises. A significant decrease (P < .001) was found in the frequency of self-reported leakage at the six-month to three-year follow-up. The strength and duration of a pelvic muscle contraction was significantly greater between the first and last visit in all patients, regardless of the subjective improvement. A pelvic floor rehabilitation program was an effective alternative to surgical intervention in reducing the frequency of urinary leakage. Further studies are needed to identify factors predicting success and to determine the most cost-effective method of achieving pelvic floor rehabilitation.

Reproducibility of pressure transmission ratios in stress incontinent women

Pressure transmission ratios (PTR) are obtained during cough pressure profiles (delta urethral pressure/delta bladder pressure x 100) and have been extensively used in pre and post operative evaluation of patients with stress urinary incontinence. Sixteen patients with genuine stress were studied to assess the magnitude of PTR variance in incontinent women and how changes in bladder pressure impact on PTR. A marked variation in PTR was seen in individual patients with the coefficient of variation averaging 19.8%. Using linear regression analysis, 5 patients demonstrated a statistically significant relationship between bladder pressure and PTR. Only one of the five patients showed a decrease in pressure transmission with increased cough strength. The differences seen in PTR within individual patients make comparisons of single recordings at different times difficult to interpret.

Investigative procedures in urogynecology

History and physical examination do not always correlate with final urodynamic diagnoses in incontinent women. A large number of diagnostic procedures are available to help the clinician establish the correct diagnosis. The importance of urine culture, Q-tip test, ultrasound, pessary test for potential incontinence, neurophysiologic testing, endoscopy, urethral pressure profiles, stress/pad tests, uroflowmetry, and cystometry are discussed. The physician should understand the importance and limitations of each of the different investigative procedures.

Surgical management of stress incontinence in patients with low urethral pressure

Thirty-four women with genuine stress incontinence and low urethral closure pressure were studied pre- and postoperatively. A modified Burch retropubic urethropexy was performed in 29 patients with a cure rate of 78%, improvement in 7%, and failure in 15%. The modified Stamey procedure was performed in 5 patients with significant pelvic floor relaxation with a cure rate of 40% and improvement in 60%. If urethral mobility is present, traditional anti-incontinence procedures appear to be a reasonable alternative in patients with low urethral pressure.

Dysuria and urinary tract infections

It has been estimated that up to 25% of American women may experience acute dysuria yearly. Many physicians commonly equate dysuria with urinary tract infection and will treat empirically without adequate evaluation. This therapeutic trial of antibiotics represents undertreatment for many patients and inappropriate treatment for others. It is important that physicians understand that dysuria is only a symptom that can be produced by many different clinical entities.

The discharge of elderly patients from an accident and emergency department: functional changes and risk of readmission

Four hundred and fifty patients aged 75 years or older were followed up after discharge from an accident and emergency department. Forty-three per cent of all patients experienced some loss of functional independence. A small number, 5.6%, were readmitted to hospital within 14 days. This group were significantly less able to perform certain activities of daily living than those not readmitted. Attention to functional assessment by casualty staff may help to prevent readmission to hospital of this frail elderly group of patients.

A practical approach to the painful bladder syndrome

The painful bladder syndrome (PBS) is a progressive and painful disease of the bladder that may lead to fibrosis, contracture and reduction of bladder capacity. The usual symptoms are urinary urgency, frequency, nocturia, chronic pelvic pain and lower abdominal pain upon filling of the bladder. A retrospective analysis was performed on 21 women with PBS between March 1987 and March 1988. The patients were treated weekly with a bladder pillar block, bladder distention and dimethyl sulfoxide instillation. Symptomatic relief was observed in 80% of the patients so treated. The maximum bladder volume increased from 185 to 475 mL (P less than .01). The side effects were minimal.

Cystourethroscopy in urogynecology

Cystourethroscopy has become a basic tool in the investigation of female genitourinary problems. It provides the gynecologist with essential information regarding the presence of bladder or urethral pathology and documents ureteral patency.

Surgical management of uterine prolapse in young women

A new procedure was developed for the management of uterine prolapse in young women. Transvaginal sacrospinous uterine fixation was employed successfully in five patients. The advantages of the procedure are that it avoids surgical trauma to the cervix, can be accomplished entirely vaginally, maintains the normal vaginal axis and obliterates the space for potential enterocele.

Potassium homeostasis in pregnancy

We selectively reviewed potassium (K) metabolism during human gestation, focusing on the influence of progesterone on renal K excretion. Approximately 300 mEq of K is gained during pregnancy. Two-thirds of it are in the products of conception, but little is known about renal K handling during gestation. We have suggested that progesterone may play a role in preventing the kaliuresis that normally occurs when aldosterone levels are elevated and substantial quantities of sodium are presented to distal nephron sites. In addition, we hypothesize that subtle K secretory problems, such as those known to occur in sickle cell disease, may be aggravated during gestation, probably due to elevated circulating levels of progesterone.

Value of the cough pressure profile in the evaluation of patients with stress incontinence

The cough urethral pressure profile has been used to identify patients with genuine stress urinary incontinence. One hundred forty-four patients were studied to determine the value of this test in the evaluation of patients presenting with lower urinary tract symptoms. In the sitting position with a full bladder the test has a high specificity (92%) but relatively low sensitivity (41%). The clinical ramifications of using the test "cough pressure profile" and the definition "genuine stress urinary incontinence" are discussed.

Endometrial immunofluorescence associated with endometriosis and pelvic inflammatory disease

Anti-immunoglobulin G (anti-IgG) staining in the endometrium by immunofluorescence has been associated with endometriosis. To investigate this phenomenon further, we took endometrial samples from 42 patients who underwent laparoscopy or laparotomy, which were tested for immunofluorescence. Fluorescein-labeled anti-IgG was incubated with tissue samples. Of 18 patients with documented endometriosis, 16 had positive immunofluorescence (89% sensitivity). Of 24 patients with no evidence of endometriosis, 9 had false-positive immunofluorescence and 15 had negative immunofluorescence. Of the 9 false-positive samples, 8 had evidence of old pelvic inflammatory disease. In the absence of this condition, there was only one false-positive study for immunofluorescence. The implications of these findings in terms of the pathophysiology of endometriosis-associated infertility is that it may be an immune-mediated process. With regard to diagnosis, the high predictive value of endometrial immunofluorescent IgG may be a useful tool in indicating early laparoscopic examination of the infertile period.

Reduction of urethral pressure in response to stress: relationship to urethral mobility

It has been postulated that one factor involved in the pathophysiology of stress urinary incontinence is the sustained decrease in urethral closure pressure in response to a sudden increase in intra-abdominal pressure. Twenty-one patients with stress-related pressure decrease (group 1) and seven patients with stable pressures (group 2) were studied. Although closure pressure in group 1 decreased approximately 27% in response to a single cough in a static setting, when studied dynamically with pressure profiles before and after coughing, there was no pressure decrease seen. The evidence presented suggests that the phenomenon of pressure decrease is in actuality an artifact of measurement and not a true physiologic event. The degree of urethral mobility is related to the perceived pressure decrease.

Labial adhesions secondary to postpartum vulvar edema. A report of two cases

Labial adhesions have been found commonly in children. Two patients developed thick labial adhesions secondary to massive postpartum vulvar edema.

Use of vaginal pressure measurements in urodynamic testing

A study of 50 women using vaginal pressure measurements in urodynamic testing was performed. In the majority of patients, the vaginal pressure accurately reflects events occurring in the abdominal cavity. The elimination of abdominal pressure artifacts assists the physician in identifying patients with unstable bladders and assessing the voiding mechanisms. Vaginal placement of the pressure transducer is easier than rectal placement and better tolerated by patients.

Cesarean section. Assessment of the convenience factor

To assess the potential input of physician convenience on the performance of cesarean sections (C-sections), analysis of C-sections by time of day and day of the week was undertaken at four Chicago-area hospitals. The primary C-section rate at the University of Chicago Chicago Lying-In Hospital, with a relatively high-risk patient population and a full-time salaried resident and faculty staff, was lower than at three other hospitals staffed predominantly by private practitioners. Indications for primary C-sections were classified as "acute," "semiacute" or "nonacute." Acute and semiacute C-sections were performed without demonstrated time biases in regard to the time of day or the day of the week at all four hospitals. Nonacute C-sections (70% cephalopelvic disproportion) were not performed as frequently at night (12-8 A.M.) as at other times at three of the four hospitals, but there were no differences in the individual characteristics of the outcomes of such deliveries between day and night. There was also no Friday afternoon or Monday morning frequency increase. The data failed to reveal significant variations in the performance of acute C-sections but did show day-night variability in C-sections done for non-acute indications.

Delayed reaction to the Dacron buttress used in urethropexy

Eleven patients developed a delayed reaction to the Dacron buttress used in Stamey urethropexy. The reaction was characterized by pain, dyspareunia, vaginal discharge and/or bleeding, induration of the abdominal incision, vaginal granulation tissue and draining abdominal or vaginal sinus tracts. This complication occurred in 5% of the 163 patients we treated with the Stamey procedure for stress urinary incontinence. Treatment consisted of removal of the nylon suture and Dacron buttress. None of the 11 patients developed recurrent incontinence. The subjective cure rate for stress urinary incontinence was 92% using the Stamey procedure.

Rapid assay--possible application in the diagnosis of premature rupture of the membranes

Premature rupture of the membranes frequently presents a diagnostic dilemma to the clinician. The presence of alpha-fetoprotein (AFP) in amniotic fluid suggests a possible solution. A rapid, easy-to-use latex agglutination test for AFP was evaluated on 99 amniotic fluid samples of known AFP concentration. Body fluids (maternal serum, urine, vaginal secretions, and seminal fluid) that commonly interfere with other tests were also studied. The sensitivity for amniotic fluids from gestations less than 39 weeks was 93%, and specificity was 94%. The test is most accurate under 35 weeks, when diagnosis is critical. Equivocal results may be resolved by using radioimmunoassay. The results suggest that a rapid assay for AFP may be useful in the diagnosis of ruptured membranes. It has few interfering factors, is safe, and requires no elaborate equipment or training.

The effect of uterovaginal prolapse on urethrovesical pressure dynamics

Complete urodynamic evaluations were performed on patients with severe uterovaginal prolapse with the prolapse protruding and after reduction with a pessary. These results were compared with those from patients with genuine stress incontinence without prolapse. There was a significant increase in urethral closure pressure in patients with prolapse on the assumption of a more erect posture or on Valsalva maneuver. The opposite relationship was observed in patients with genuine stress incontinence in whom the urethral closure pressure significantly decreased under similar conditions. These results strongly suggest that the mechanism of continence in patients with significant prolapse is urethral obstruction. Reduction of the prolapse with a pessary can differentiate those patients who will require urethrovesical neck suspension.

Midforceps delivery: a critical review

A survey of results of midforceps delivery in mother and fetus was carried out, reviewing the most relevant publications of the past several years. Many discrepancies have been found from definition of what is (or should be) considered midforceps delivery to methods of gathering the material for analysis and the statistical evaluations. Specific study of some of these results was done which revealed possible flaws in the conclusions reached by the authors. Clearly maternal mortality is no longer a justifiable aspect to be studied. However, maternal morbidity should be considered and compared to that associated with vaginal and/or cesarean section deliveries. Likewise perinatal mortality and morbidity should be the standard of study and, in particular, long-term follow-up of infants delivered by the various methods. Until those observations are made from reliable data of comparable populations, it is probably not justified to condemn midforceps deliveries well conducted and judiciously indicated.

Diagnosis of lower urinary tract disorders in postmenopausal patients

One hundred patients over age 60 who had lower urinary tract symptoms were evaluated in detail. The five primary diagnoses were urethral syndrome (29%), genuine stress incontinence (21%), unstable bladder (19%), hypoestrogenism (7%), and pelvic relaxation (6%). Among patients with genuine stress incontinence, 95.2% had the symptom of stress incontinence. Of 43 patients with the symptom of stress incontinence, 67.4% had the diagnosis of genuine stress incontinence confirmed on urodynamic testing. Of the patients with an unstable bladder, 88.9% had urgency and/or urge incontinence; but of 40 patients with both of these symptoms, only 40% had the diagnosis of unstable bladder. Sixty-two patients who complained of urinary incontinence had the following primary diagnoses: genuine stress incontinence (36%), unstable bladder (29%), urethral syndrome (21%), and pelvic relaxation (5%). Because of the impossibility of clinically correlating symptom with diagnosis in the individual patient, extensive evaluation of postmenopausal patients to determine the etiology of incontinence is advised prior to surgical intervention.

A proposed scoring system for the management of female urinary incontinence

The management of urinary incontinence is frequently ineffective. Inappropriate surgical intervention can convert medically treatable incontinence into a more serious and less remediable condition. To allow a more scientific approach to management, we have developed a scoring system for female incontinence based on three primary controlling factors: (1) the direction of the urethra, (2) the urethral vesical angle and (3) the urethral pressure profile. For each factor a score of 1 to 3 was assigned according to the deviation from normal anatomy or function. Scores ranged from 3 to 9. Patients scoring 6 to 9 were treated surgically, by ventral suspension of the bladder neck and urethra. Patients scoring 3 to 5 were treated medically and underwent surgery only if indicated for other pathology. Thirty-three patients were evaluated and treated with this approach, with a one- to two-year follow-up. This system appears to provide an objective method of choosing between surgical and medical therapy for urinary incontinence.