Cross-Silo, Privacy-Preserving, and Lightweight Federated Multimodal System for the Identification of Major Depressive Disorder Using Audio and Electroencephalogram

In this day and age, depression is still one of the biggest problems in the world. If left untreated, it can lead to suicidal thoughts and attempts. There is a need for proper diagnoses of Major Depressive Disorder (MDD) and evaluation of the early stages to stop the side effects. Early detection is critical to identify a variety of serious conditions. In order to provide safe and effective protection to MDD patients, it is crucial to automate diagnoses and make decision-making tools widely available. Although there are various classification systems for the diagnosis of MDD, no reliable, secure method that meets these requirements has been established to date. In this paper, a federated deep learning-based multimodal system for MDD classification using electroencephalography (EEG) and audio datasets is presented while meeting data privacy requirements. The performance of the federated learning (FL) model was tested on independent and identically distributed (IID) and non-IID data. The study began by extracting features from several pre-trained models and ultimately decided to use bidirectional short-term memory (Bi-LSTM) as the base model, as it had the highest validation accuracy of 91% compared to a convolutional neural network and LSTM with 85% and 89% validation accuracy on audio data, respectively. The Bi-LSTM model also achieved a validation accuracy of 98.9% for EEG data. The FL method was then used to perform experiments on IID and non-IID datasets. The FL-based multimodal model achieved an exceptional training and validation accuracy of 99.9% when trained and evaluated on both IID and non-IIID datasets. These results show that the FL multimodal system performs almost as well as the Bi-LSTM multimodal system and emphasize its suitability for processing IID and non-IIID data. Several clients were found to perform better than conventional pre-trained models in a multimodal framework for federated learning using EEG and audio datasets. The proposed framework stands out from other classification techniques for MDD due to its special features, such as multimodality and data privacy for edge machines with limited resources. Due to these additional features, the framework concept is the most suitable alternative approach for the early classification of MDD patients.

From slides to insights: Harnessing deep learning for prognostic survival prediction in human colorectal cancer histology

Prognostic survival prediction in colorectal cancer (CRC) plays a crucial role in guiding treatment decisions and improving patient outcomes. In this research, we explore the application of deep learning techniques to predict survival outcomes based on histopathological images of human colorectal cancer. We present a retrospective multicenter study utilizing a dataset of 100,000 nonoverlapping image patches from hematoxylin & eosin-stained histological images of CRC and normal tissue. The dataset includes diverse tissue classes such as adipose, background, debris, lymphocytes, mucus, smooth muscle, normal colon mucosa, cancer-associated stroma, and colorectal adenocarcinoma epithelium. To perform survival prediction, we employ various deep learning architectures, including convolutional neural network, DenseNet201, InceptionResNetV2, VGG16, VGG19, and Xception. These architectures are trained on the dataset using a multicenter retrospective analysis approach. Extensive preprocessing steps are undertaken, including image normalization using Macenko's method and data augmentation techniques, to optimize model performance. The experimental findings reveal promising results, demonstrating the effectiveness of deep learning models in prognostic survival prediction. Our models achieve high accuracy, precision, recall, and validation metrics, showcasing their ability to capture relevant histological patterns associated with prognosis. Visualization techniques are employed to interpret the models' decision-making process, highlighting important features and regions contributing to survival predictions. The implications of this research are manifold. The accurate prediction of survival outcomes in CRC can aid in personalized medicine and clinical decision-making, facilitating tailored treatment plans for individual patients. The identification of important histological features and biomarkers provides valuable insights into disease mechanisms and may lead to the discovery of novel prognostic indicators. The transparency and explainability of the models enhance trust and acceptance, fostering their integration into clinical practice. Research demonstrates the potential of deep learning models for prognostic survival prediction in human colorectal cancer histology. The findings contribute to the understanding of disease progression and offer practical applications in personalized medicine. By harnessing the power of deep learning and histopathological analysis, we pave the way for improved patient care, clinical decision support, and advancements in prognostic prediction in CRC.

Vocal-friend: internet of social-things framework to aid verbal communication

PURPOSE

Deficits in social verbal communication in individuals with Social Communication Disorder (SCD) is of concern and SCD in the human community is prevalent in large population throughout the globe. Deficits in verbal social communication are prevalent in a large population. This paper aimed to propose internet connected multi-system architecture which is capable to support verbal communication in a social environment for individuals with social communication deficits.

MATERIAL AND METHODS

Implementation methodology was included with corpus collection for specific communication, deep learning based machine training for intelligent communication, and implementation of the trained algorithm on internet connected electronic multiple social communication devices. The implemented system is smart enough to initiate and maintain two types of communication; the first type includes communication between multiple individuals on the remote location and the second type includes communication with the individual present in the physical listening range.

RESULTS

The system was investigated in terms of its algorithmic parameters and found 97% to 100% in terms of training and testing accuracy with negligible mean squared error. Vocal-Friend analysed results based on audio-bot simulative conditions provide more than 91% accuracy, interaction rate and fallback rate. On the basis of the satisfaction analysis, above average results were noticed.

CONCLUSION

In terms of technical implementations and satisfaction analysis, results found acceptable with above average score.IMPLICATION FOR REHABILITATIONProposed framework is easy to use by caregivers with even having little knowledge.Support individual with deficit to learn social verbal communication skill to survive in society.Aiding parents, caregivers and professionals to understand the communication needs of individuals with communication deficits.Since technology is also grooming in the domain of rehabilitation, so this system could be used in various future applications such as social robots, social virtual assistants etc.

Deep Neural Network-based Handheld Diagnosis System for Autism Spectrum Disorder

Objective

The aim of the present work was to propose and implement deep neural network (DNN)-based handheld diagnosis system for more accurate diagnosis and severity assessment of individuals with autism spectrum disorder (ASD).

Methods

Initially, the learning of the proposed system for ASD diagnosis was performed by implementing DNN algorithms such as a convolutional neural network (CNN) and long short-term memory (LSTM), and multilayer perceptron (MLP) with DSM-V based acquired dataset. The performance of the DNN algorithms was analyzed based on parameters viz. accuracy, loss, mean squared error (MSE), precision, recall, and area under the curve (AUC) during the training and validation process. Later, the optimum DNN algorithm, among the tested algorithms, was implemented on handheld diagnosis system (HDS) and the performance of HDS was analyzed. The stability of proposed DNN-based HDS was validated with the dataset group of 20 ASD and 20 typically developed (TD) individuals.

Results

It was observed during comparative analysis that LSTM resulted better in ASD diagnosis as compared to other artificial intelligence (AI) algorithms such as CNN and MLP since LSTM showed stabilized results achieving maximum accuracy in less consumption of epochs with minimum MSE and loss. Further, the LSTM based proposed HDS for ASD achieved optimum results with 100% accuracy in reference to DSM-V, which was validated statistically using a group of ASD and TD individuals.

Conclusion

The use of advanced AI algorithms could play an important role in the diagnosis of ASD in today's era. Since the proposed LSTM based HDS for ASD and determination of its severity provided accurate results with maximum accuracy with reference to DSM-V criteria, the proposed HDS could be the best alternative to the manual diagnosis system for diagnosis of ASD.

Practice patterns, techniques, and outcomes of flexible endoscopic myotomy for Zenker's diverticulum: a retrospective multicenter study

BACKGROUND

Flexible endoscopic myotomy has been increasingly performed for Zenker's diverticulum using various endoscopic techniques and devices. The main aims of this study were to assess practice patterns and compare outcomes of endoscopic myotomy for Zenker's diverticulum.

METHODS

Procedures performed at 12 tertiary endoscopy centers from 1/2012 to 12/2018 were reviewed. Patients (≥ 18 years) with Zenker's diverticulum who had dysphagia and/or regurgitation and underwent endoscopic myotomy were included. Outcomes assessed included technical success, clinical success, and adverse events.

RESULTS

161 patients were included. Traditional endoscopic septotomy was performed most frequently (137/161, 85.1 %) followed by submucosal dissection of the septum and myotomy (24/161, 14.9 %). The hook knife (43/161, 26.7 %) and needle-knife (33/161, 20.5 %) were used most frequently. Overall, technical and clinical success rates were 98.1 % (158/161) and 78.1 % (96/123), respectively. Adverse events were noted in 13 patients (8.1 %). There was no significant difference in technical and clinical success between traditional septotomy and submucosal dissection groups (97.1 % vs. 95.8 %, P = 0.56 and 75.2 % vs. 90.9 %, P  = 0.16, respectively). Clinical success was higher with the hook knife (96.7 %) compared with the needle-knife (76.6 %) and insulated tip knife (47.1 %). Outcomes were similar between centers performing > 20, 11 - 20, and ≤ 10 procedures.

CONCLUSIONS

Flexible endoscopic myotomy is an effective therapy for Zenker's diverticulum, with a low rate of adverse events. There was no significant difference in outcomes between traditional septotomy and a submucosal dissection approach, or with centers with higher volume, though clinical success was higher with the hook knife.

IoT based assistive companion for hypersensitive individuals (ACHI) with autism spectrum disorder

OBJECTIVE

Today, most of the individuals with Autism Spectrum Disorders (ASD) have atypical sensory behaviors. The main aim of this study is to propose an assistive intervention for supporting the overloaded sensory responses in hypersensitive individuals with ASD.

METHODS

The vision, auditory, smell, and physical balance related multi-sensors based hardware prototype, namely Assistive Companion for Hypersensitive Individuals (ACHI) has been designed for individuals with ASD. The proposed ACHI prototype is an assistive-technology based companion for hypersensitive individuals with ASD which is able to 'fetch/detect the sensory information using electronic sensors', 'making the decision using fuzzy logic on the basis of fetched sensory information' and then, 'transmit the generated information over the internet through the Internet of Things (IoT)', and also able for 'generating alerts to caregivers'. The proposed design is also capable of providing audio & video feedback to calm down individuals with ASD.

RESULTS

After testing, it is observed that 93% percent of the caregivers rated the proposed ACHI intervention on the scale of above average. The remarkable reduction in hyperactive states related triggering incidents in ASD has been found with the use of ACHI.

CONCLUSION

The present work and the proposed prototype can identify and control the sensory overload triggers in ASD and it can guide the caregiver or clinicians to optimize the responsible surrounding causes of explosive behavior in ASD and would help the individuals with ASD to become calm.

A Nationwide Assessment of the "July Effect" and Predictors of Post-Endoscopic Retrograde Cholangiopancreatography Sepsis at Urban Teaching Hospitals in the United States

Background/Aims

To analyze the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) sepsis in the early (July to September) and later (October to June) academic months to assess the “July effect”.

Methods

The National Inpatient Sample (2010–2014) was used to identify ERCP-related adult hospitalizations at urban teaching hospitals by applying relevant procedure codes from the International Classification of Diseases, 9th revision, Clinical Modification. Post-ERCP outcomes were compared between the early and later academic months. A multivariate analysis was performed to evaluate the odds of post-ERCP sepsis and its predictors.

Results

Of 481,193 ERCP procedures carried out at urban teaching hospitals, 124,934 were performed during the early academic months. The demographics were comparable for ERCP procedures performed during the early and later academic months. A higher incidence (9.4% vs. 8.8%, p<0.001) and odds (odds ratio [OR], 1.07) of post-ERCP sepsis were observed in ERCP performed during the early academic months. The in-hospital mortality rate (7% vs. 7.5%, p=0.072), length of stay, and total hospital charges in patients with post-ERCP sepsis were also equivalent between the 2 time points. Pre-ERCP cholangitis (OR, 3.20) and post-ERCP complications such as cholangitis (OR, 6.27), perforation (OR, 3.93), and hemorrhage (OR, 1.42) were significant predictors of higher post-ERCP sepsis in procedures performed during the early academic months.

Conclusions

The July effect was present in the incidence of post-ERCP sepsis, and academic programs should take into consideration the predictors of post-ERCP sepsis to lower health-care burden.

Survey Study on the Practice Patterns of the Evaluation and Management of Incidental Pancreatic Cysts

BACKGROUND AND AIMS

Various gastrointestinal societies have released guidelines on the evaluation of asymptomatic pancreatic cysts (PCs). These guidelines differ on several aspects, which create a conundrum for clinicians. The aim of this study was to evaluate preferences and practice patterns in the management of incidental PCs in light of these societal recommendations.

METHODS

An electronic survey distributed to members of the American Society for Gastrointestinal Endoscopy (ASGE). Main outcomes included practice setting (academic vs. community), preferences for evaluation, management, and surveillance strategies for PCs.

RESULTS

A total of 172 subjects completed the study (52% academic-based endoscopists). Eighty-six (50%) and 138 (80%) of the participants responded that they would recommend EUS surveillance of incidental PCs measuring less than 2 cm and 3 cm, respectively. Nearly half of the endosonographers (42.5% community and 44% academic; p = 1.0) would routinely perform FNA on PCs without any high-risk features. More academic-based endoscopists (57% academic vs. 32% community; p = 0.001) would continue incidental PC surveillance indefinitely.

CONCLUSIONS

There is significant variability in the approach of incidental PCs among clinicians, with practice patterns often diverging from the various GI societal guideline recommendations. Most survey respondents would routinely recommend EUS-FNA and indefinite surveillance for incidental PCs without high-risk features. The indiscriminate use of EUS-FNA and indefinite surveillance of all incidental PCs is not cost-effective, exposes the patient to unnecessary testing, and can further perpetuate diagnostic uncertainty. Well-designed studies are needed to improve our diagnostic and risk stratification accuracy in order to formulate a consensus on the management of these incidental PCs.

Acupuncture and the Treatment of Irritative Bladder Symptoms

The conventional management of irritative bladder symptoms, namely urgency, urge incontinence, frequency and nocturia, with anticholinergic medication is limited by the side effects of treatment. Acupuncture is shown to be as effective in the management of irritative bladder symptoms as conventional anticholinergic therapy, with few side effects and a high degree of patient acceptability and compliance.

Once Versus Twice-Daily Oral Proton Pump Inhibitor Therapy for Prevention of Peptic Ulcer Rebleeding: A Propensity Score-Matched Analysis

Background

After inpatient management of upper gastrointestinal bleeding (GIB) due to peptic ulcer disease (PUD), oral proton pump inhibitor (PPI) therapy is recommended at discharge to decrease rebleeding risk and improve ulcer healing. Our aim is to determine whether once-daily oral PPI dosing at hospital discharge is associated with inferior 30-day rebleeding outcomes as compared to twice-daily dosing.

Methods

We retrospectively identified 233 patients admitted with signs and symptoms of upper GIB found to be due to PUD on upper endoscopy. After inpatient management, patients discharged on once-daily oral PPI were compared to those discharged on twice-daily therapy. We utilized propensity score matching based on Rockall scores to ensure the two groups were closely matched in terms of their baseline rebleeding risk. Primary outcome was the incidence of rebleeding within 30 days. Secondary outcomes were all-cause mortality, blood transfusion requirement, requirement for interventional radiology or surgery.

Results

Overall, 49 patients were discharged on once-daily and 184 on twice-daily PPI. Recurrent bleeding occurred in 18 patients (7.7%) within 30 days. There was no statistically significant difference in recurrent bleeding rates between once-daily (n = 7, 14.3%) as compared to twice-daily PPI (n = 11, 6%) (P = 0.053). In a 1:1 propensity score matched analysis, there was no statistically significant difference in 30-day recurrent bleeding rate between groups (14% once-daily vs. 4% twice-daily, P = 0.159). There were no differences in secondary outcomes.

Conclusions

Once-daily oral PPI dosing at hospital discharge was not associated with inferior outcomes compared to twice-daily dosing in patients hospitalized for upper GIB due to PUD.

Adherence to quality indicators and surveillance guidelines in the management of Barrett's esophagus: a retrospective analysis

BACKGROUND

 Adherence to quality indicators and surveillance guidelines in the management of Barrett's esophagus (BE) promotes high-quality, cost-effective care. The aims of this study were (1) to evaluate adherence to standardized classification (Prague Criteria) and systematic (four-quadrant) biopsy protocol, (2) to identify predictors of practice patterns, and (3) to assess adherence to surveillance guidelines for non-dysplastic BE (NDBE).

METHODS

 This was a single-center retrospective study of esophagogastroduodenoscopy (EGD) performed for BE (June 2008 to December 2015). Patient demographics, procedure characteristics, and histology results were obtained from the procedure report-generating database and chart review. Adherence to Prague Criteria and systematic biopsies was based on operative report documentation. Multiple logistic regression analysis was performed to identify predictors of practice patterns. Guideline adherent surveillance EGD was defined as those performed within 6 months of the recommended 3- to 5-year interval.

RESULTS

 In total, 397 patients (66.5 % male; mean age 60.1 ± 12.5 years) had an index EGD during the study period. Adherence to Prague Criteria and systematic biopsies was 27.4 % and 24.1 %, respectively. Endoscopists who performed therapeutic interventions for BE were more likely to use the Prague Criteria (OR: 3.16; 95 %CI: 1.47 - 6.82; P  < 0.01) than those who did not. Longer time in practice was positively associated with adherence to Prague Criteria (OR 1.07; 95 %CI: 1.02 - 1.12; P  < 0.01) but with a lower likelihood of performing systematic biopsies (OR 0.91; 95 %CI: 0.85 - 0.97; P  < 0.01). More than half (55.6 %) of patients with NDBE underwent surveillance EGD sooner (range 1 - 29 months) than the recommended interval.

CONCLUSION

 Adherence to quality indicators and surveillance guidelines in BE is low. Operator characteristics, including experience with endoscopic therapy for BE and time in practice predicted practice pattern. Future efforts are needed to reduce variability in practice and promote high-value care.

Rare cause of acute hepatitis: a common energy drink

A previously healthy man aged 50 years presented with malaise, anorexia, abdominal pain, nausea, vomiting, generalised jaundice, scleral icterus and dark urine. He was not on any prescription or over-the-counter medications, but reported drinking 4–5 energy drinks daily for 3 weeks prior to presentation. Physical examination revealed jaundice and right upper quadrant abdominal tenderness. Laboratory studies were remarkable for transaminitis and evidence of chronic hepatitis C infection. Ultrasound scan demonstrated an echogenic liver and diffuse gallbladder wall thickening. Liver biopsy showed severe acute hepatitis with bridging necrosis and marked cholestasis. The patient was treated supportively with complete resolution of his symptoms and marked improvement in his laboratory abnormalities. The development of acute hepatitis in this patient was likely secondary to excessive energy drink consumption. Energy drinks as well as other herbal/over-the-counter supplements should be considered by clinicians in the workup of patients with acute hepatitis, particularly once other aetiologies have been excluded.

Hepatitis C cirrhosis: New perspectives for diagnosis and treatment

Chronic hepatitis C infection is the leading cause of chronic liver disease, cirrhosis, hepatocellular carcinoma as well as the primary indication for liver transplantation in the United States. Despite recent advances in drugs for the treatment of hepatitis C, predictive models estimate the incidence of cirrhosis due to hepatitis C infection will to continue to rise for the next two decades. There is currently an immense interest in the treatment of patients with fibrosis and early-stage cirrhosis as treatment can lead to decrease in the rates of decompensated cirrhosis, hepatocellular carcinoma and need for liver transplantation in these patients. The goal of this paper is to provide clinicians and health care professionals further information about the treatment of patients with hepatitis C infection and cirrhosis. Additionally, the paper focuses on the disease burden, epidemiology, diagnosis and the disease course from infection to treatment. We provide an overview of multiple studies for the treatment of chronic hepatitis C infection that have included patients with cirrhosis. We also discuss the advantages and disadvantages of treatment in cirrhotic patients and focus on the most up to date guidelines available for treatment.

Duodenal perforation following esophagogastroduodenoscopy (EGD) with cautery and epinephrine injection for peptic ulcer disease: An interesting case of nonoperative management in the medical intensive care unit (MICU)

INTRODUCTION

The utilization of esophagogastroduodenoscopy (EGD) and related procedures continues to rise. Due to this increase in utilization is an inevitable rise in serious complications such as hemorrhage and perforation. One understudied and dreaded complication of EGD causing significant morbidity and mortality is duodenal perforation.

PRESENTATION OF CASE

We present the case of a 63-year-old male who presented to our institution's emergency room with dyspepsia, melanic stools, tachycardia, and hypotension. Initial laboratory evaluation was significant for severe anemia, lactic acidosis, and acute kidney injury, while CT scan of the abdomen pelvis did not suggest retroperitoneal hematoma or bowel perforation. An emergent EGD was performed which showed multiple bleeding duodenal ulcers that were cauterized and injected with epinephrine. Post-procedure the patient developed worsening abdominal pain, distension, diaphoresis, and tachypnea, requiring emergent intubation. A CT scan of the abdomen and pelvis with oral contrast confirmed pneumoperitoneum and duodenal perforation.

DISCUSSION

Due to the patient's hemodynamic instability and multiple comorbidities, he was treated non-operatively with strict bowel rest and intravenous antibiotics. The patient ultimately had a 19-day hospital course complicated by renal failure requiring hemodialysis and an ischemic limb necessitating above knee amputation.

CONCLUSION

This case describes an unsuccessful attempt at nonoperative management of duodenal perforation following EGD.

Emergence of new classes of recreational drugs-synthetic cannabinoids and cathinones

Designer drugs represent an increasingly popular form of recreational substance abuse, especially amongst young adults. The two classes of designer drugs that have recently risen to prominence are the synthetic cannabinoids and synthetic cathinones. These substances are not detected by conventional drug screening methods and can often be associated with serious health consequences, including seizures, renal failure and death. Thus, clinicians should be familiar with the signs, symptoms, and toxicities associated with the use of these substances, and maintain a high level of suspicion for synthetic drugs as an alternative means of "getting high." We present a case of a 20-year-old college student who presented to the emergency department with altered mental status and severe agitation who later admitted to using bath salts. The goal of this article is to raise awareness about these new designer drugs, their clinical presentation, and management of their intoxication.

Pre-and-post transplant considerations in patients with nonalcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) is currently the third most common indication for liver transplantation in the United States. With the growing incidence of obesity, NAFLD is expected to become the most common indication for liver transplantation over the next few decades. As the number of patients who have undergone transplantation for NAFLD increases, unique challenges have emerged in the management and long-term outcomes in patients. Risk factors such as obesity, hypertension, diabetes, and hyperlipidemia continue to play an important role in the pathogenesis of the disease and its recurrence. Patients who undergo liver transplantation for NAFLD have similar long-term survival as patients who undergo liver transplantation for other indications. Research shows that post-transplantation recurrence of NAFLD is commonplace with some patients progressing to recurrent non-alcoholic steatohepatitis and cirrhosis. While treatment of comorbidities is important, there is no consensus on the management of modifiable risk factors or the role of pharmacotherapy and immunosuppression in patients who develop recurrent or de novo NAFLD post-transplant. This review provides an outline of NAFLD as indication for liver transplantation with a focus on the epidemiology, pathophysiology and risk factors associated with this disease. It also provides a brief review on the pre-transplant considerations and post-transplant factors including patient characteristics, role of obesity and metabolic syndrome, recurrence and de novo NAFLD, outcomes post-liver transplantation, choice of medications, and options for immunosuppression.

Evidence available on the use of the selective β3-adrenoceptor agonist mirabegron for the treatment of overactive bladder

CONTEXT

Mirabegron, the selective β3-adrenoceptor agonist, heralds the latest development for the treatment of overactive bladder (OAB).

OBJECTIVE

To present the evidence available on the efficacy and tolerability of mirabegron and to discuss this treatment's potential in our setting.

EVIDENCE ACQUISITION

We reviewed 11 studies conducted with mirabegron in patients with OAB (2 phase II, 9 phase III), all studies were compared to placebo with 6 studies also including tolterodine as an additional arm. Greater emphasis shall be given to the main phase III trials performed in Europe, the USA and Australia evaluating efficacy and safety after 12 weeks (NCT00662909, NCT00689104, NCT00912964) and safety after 12 months (NCT00688688). The combined analyses of these 12 week studies is also available, with emphasis on global efficacy (FAS), efficacy with regard to incontinence (FAS i) and safety (SAF). More than 50% of patients had previously discontinued anticholinergics medication for OAB, thus allowing us to obtain data on the effectiveness of mirabegron in patients already treated with anticholinergics.

EVIDENCE SYNTHESIS

Mirabegron is an efficacious drug which presents a statistically significant reduction in the number of incontinence episodes and in urinary frequency as of 4 weeks, with a higher percentage of dry patients and a higher percentage of patients with reduction ≥50% in the number of incontinence episodes than placebo. The efficacy of mirabegron 50 and 100mg in the reduction of incontinence episodes occurs in de novo patients and who have received antimuscarinics, with adjusted mean difference and improvement in urinary frequency greater in treated patients. Its tolerability is very similar to placebo particularly for the adverse effects of the antimuscarinics (dry mouth, constipation and blurred vision). A minimal, non-clinically significant change is observed in systolic and diastolic blood pressure and pulse. Its efficacy is long-term. Mirabegron at the doses of 50 and 100mg presents an improvement versus placebo in patient satisfaction, health-related quality of life (HRQoL), symptom bother and patient's perception of bladder condition (PPBC). In the 12 week Phase III European study tolterodine delivered a lesser degree of improvement than mirabegron versus placebo in patient satisfaction, HRQoL, symptom bother and PPBC.

CONCLUSIONS

Mirabegron is the first of a new class of compounds with a novel mechanism of action that is different to the antimuscarinics. It presents significant and clinically important efficacy in the treatment of the symptoms of OAB. It has advantages with regard to the results described by the patient in treatment satisfaction. Studies on its combined use with anticholinergics are ongoing.

Mirabegron for the treatment of overactive bladder: a prespecified pooled efficacy analysis and pooled safety analysis of three randomised, double-blind, placebo-controlled, phase III studies

INTRODUCTION

To examine pooled efficacy data from three, large phase III studies comparing mirabegron (50 and 100 mg) with placebo, and pooled safety data including additional mirabegron 25 mg and tolterodine extended release (ER) 4 mg results.

METHODS

This prespecified pooled analysis of three randomised, double-blind, placebo-controlled, 12-week studies, evaluated efficacy and safety of once-daily mirabegron 25 mg (safety analysis), 50 or 100 mg (efficacy and safety analyses) and tolterodine ER 4 mg (safety analysis) for the treatment of symptoms of overactive bladder (OAB). Co-primary efficacy measures were change from baseline to Final Visit in the mean number of incontinence episodes/24 h and mean number of micturitions/24 h. Key secondary efficacy end-points included mean number of urgency episodes/24 h and mean volume voided/micturitions, while other end-points included patient-reported outcomes according to the Treatment Satisfaction-Visual Analogue Scale (TS-VAS) and responder analyses [dry rate (posttreatment), ≥ 50% reduction in incontinence episodes/24 h, ≤ 8 micturitions/24 h (post hoc analysis)]. The safety analysis included adverse event (AE) reporting, laboratory assessments, ECG, postvoid residual volume and vital signs (blood pressure, pulse rate).

RESULTS

Mirabegron (50 and 100 mg once daily) demonstrated statistically significant improvements compared with placebo for the co-primary end-points, key secondary efficacy variables, TS-VAS and responder analyses (all comparisons p < 0.05). Mirabegron is well tolerated and demonstrates a good safety profile. The most common AEs (≥ 3%) included hypertension, nasopharyngitis and urinary tract infection (UTI); the incidence of hypertensive events and UTIs decreased with increasing dose. For mirabegron, the incidence of the bothersome antimuscarinic AE, dry mouth, was at placebo level and of a lesser magnitude than tolterodine.

CONCLUSION

The efficacy and safety of mirabegron are demonstrated in this large pooled clinical trial dataset in patients with OAB.

Validation study of the Self-Assessment Goal Achievement (SAGA) questionnaire for lower urinary tract symptoms

BACKGROUND

Patients' treatment goals for overactive bladder (OAB) and other lower urinary tract symptoms (LUTS) may not be aligned with their healthcare provider's goals. Successful management of OAB symptoms is improved by individualised treatment plans with attainable treatment goals. Goal attainment setting may facilitate patient-provider interaction and the development of a personalised treatment plan based on realistic, individual goals, thereby increasing patient satisfaction and therapeutic outcomes. The purpose of this study was to validate the utility of the Self-Assessment Goal Achievement (SAGA) questionnaire for LUTS in helping patients identify and achieve realistic treatment goals.

METHODS

The 2-module SAGA questionnaire consists of nine prespecified (fixed) items and five open-ended items for goal identification and ranking (baseline module) and goal achievement rating (follow-up module). Adult patients in the United States (n = 104) seeking treatment for LUTS, including symptoms of OAB, completed the SAGA baseline module, micturition diary, other patient-reported outcome measures (PROs), and discussed their urinary goals with a clinician at baseline. The SAGA follow-up module was completed 2-4 months later. SAGA was validated based on analyses of face, concurrent, known-groups, and convergent validity and item distribution.

RESULTS

Among the nine fixed goals of SAGA, four were ranked as very important by > 50% of patients (i.e. reduce night-time frequency, daytime frequency, urine leakage, urgency). Most patients did not change the importance level of their goals after discussion with their healthcare provider. Pearson correlations between SAGA, diary variables and PRO scores were generally of low to moderate strength. The global mean (SD) follow-up SAGA T-score was 32.54 (12.54), indicating that overall goal attainment was not achieved after 3 months. The goal attainment score was significantly different between groups differing in symptom severity, health-related quality of life, bladder control and continence status.

CONCLUSIONS

The results support the validity of SAGA as a measure of patients' goals and goal achievement for the treatment of LUTS, including symptoms of OAB. SAGA may improve healthcare provider-patient interactions and treatment outcomes in clinical practice.

Systematic review of the relationship between bladder and bowel function: implications for patient management

BACKGROUND

The complex relationship between bladder and bowel function has implications for treating pelvic disorders. In this systematic review, we discuss the relationship between bladder and bowel function and its implications for managing coexisting constipation and overactive bladder (OAB) symptoms.

METHODS

Multiple PubMed searches of articles published in English from January 1990 through March 2011 were conducted using combinations of terms including bladder, bowel, crosstalk, lower urinary tract symptoms, OAB, incontinence, constipation, hypermotility, pathophysiology, prevalence, management and quality of life. Articles were selected for inclusion in the review based on their relevance to the topic.

RESULTS

Animal studies and clinical data support bladder-bowel cross-sensitization, or crosstalk. In the rat, convergent neurons in the bladder and bowel as well as some superficial and deeper lumbosacral spinal neurons receive afferent signals from both bladder and bowel. On a functional level, in animals and humans, bowel distention affects bladder activity and vice versa. Clinically, the bladder-bowel relationship is evident through the presence of urinary symptoms in patients with irritable bowel syndrome and bowel symptoms in patients with acute cystitis. Functional gastrointestinal disorders, such as constipation, can contribute to the development of lower urinary tract symptoms, including OAB symptoms, and treatment of OAB with antimuscarinics can worsen constipation, a common antimuscarinic adverse effect. The initial approach to treating coexisting constipation and OAB should be to relieve constipation, which may resolve urinary symptoms.

CONCLUSIONS

The relationship between bladder and bowel function should be considered when treating patients with urinary symptoms, bowel symptoms, or both.

Changes in nerve growth factor level and symptom severity following antibiotic treatment for refractory overactive bladder

INTRODUCTION AND HYPOTHESIS

Overactive bladder (OAB) has a multifactorial aetiology, and for some women symptoms may be associated with chronic urothelial inflammation secondary to bacterial colonisation. One marker of such inflammation may be urinary nerve growth factor (NGF). We hypothesised that for women with OAB and urothelial inflammation, urinary NGF would be reduced following antibiotic therapy.

METHODS

Women with overactive bladder and urodynamic diagnosis of detrusor overactivity who were refractory to anticholinergics, and had histological evidence of urothelial inflammation were treated with a 6-week course of rotating antibiotics. Urinary NGF was measured by ELISA before and after treatment. Three-day bladder diaries, the Patients' Perception of Intensity of Urgency Scale, the King's Health Questionnaire and the Patients' Perception of Bladder Condition questionnaire were used to assess subjective and objective outcomes of therapy.

RESULTS

Thirty-nine women with refractory DO were recruited. The NGF levels decreased significantly after antibiotic therapy (Wilcoxon signed rank test; p = 0.015). There were significant improvements in daytime frequency, nocturia and urgency (p < 0.05), and 74 % of women reported improvement in perception of their bladder condition.

CONCLUSIONS

Urinary NGF is responsive to antibiotic therapy. Women with refractory overactive bladder and elevated NGF may benefit from antibiotic treatment.

A comparison study of two lower urinary tract symptoms screening tools in clinical practice: the B-SAQ and OAB-V8 questionnaires

Lower urinary tract symptoms (LUTS) have a detrimental effect on quality-of-life (QoL). However, sufferers are often reluctant to seek help. Screening for LUTS will identify patients with bothersome symptoms who may benefit from treatment and allow patients to self-assess their symptoms and the need for medical intervention, potentially saving costly medical time and reducing long-term morbidity. The aim of this study was to compare the value of two validated questionnaires: the Bladder Control Self Assessment Questionnaire (B-SAQ) and the Overactive Bladder Awareness Tool (OAB-V8) as screening questionnaires in clinical practice. A total of 223 women were recruited prospectively from three centres. Participants completed both questionnaires in the waiting area prior to assessment by a clinician, who completed a symptom evaluation sheet. Data were analysed using receiver operating characteristic curves. Both the B-SAQ and the OAB-V8 performed well in detecting symptoms of OAB and mixed urinary symptoms. The B-SAQ performed better in detecting symptoms of stress incontinence than the OAB-V8. The opportunity to screen for haematuria should never be missed and this is an important omission from the OAB-V8.

Spontaneous occlusion of the circle of Willis in a young woman with epilepsy: epileptic-type Moyamoya disease

The authors report a case of a 31-year-old woman from India with history of seizure disorder who presented with sudden onset right hemiparesis and right-sided upper motor neuron type facial palsy. No identifiable risk factors were noted on admission and all laboratory investigations were negative. MR angiography helped in arriving at the diagnosis of moyamoya disease as the aetiology of her symptoms.

Percutaneous posterior tibial nerve stimulation as an effective treatment of refractory lower urinary tract symptoms in patients with multiple sclerosis: preliminary data from a multicentre, prospective, open label trial

Background: Percutaneous tibial nerve stimulation (PTNS) has been proposed as a new, minimally invasive neuromodulation technique to treat lower urinary tract symptoms (LUTS).

Objective: To evaluate efficacy, safety and impact on quality of life (QoL) of PTNS on patients with multiple sclerosis (MS) who have LUTS.

Methods: 21 patients (5 men, 16 women) with MS and LUTS unresponsive to anticholinergics were treated with 12 sessions of PTNS. Assessment of LUTS was by validated, self-administered chart and questionnaires, testing the subjective and objective relevance of LUTS for patients and their impact on QoL before and after treatment; the mean post-micturition residual was assessed by trans-abdominal ultrasound scanning. Analysis was by intention to treat.

Results: There was a significant reduction of daytime frequency (from 9 to 6, p = 0.04), nocturia (from 3 to 1, p = 0.002) and mean post-micturition residual (from 98 ± 124 ml to 43 ± 45 ml, p = 0.02). The mean voided volume increased from 182 ± 50 ml to 225 ± 50 ml ( p = 0.003). Eighty-nine percent of patients reported a treatment satisfaction of 70%. Significant improvement in QoL was seen in most domains of the King’s Health QoL questionnaire ( p < 0.05). No adverse events were reported.

Conclusions: PTNS is an effective, safe and well-tolerated treatment for LUTS in patients with MS.

Reference intervals of gestational sac, yolk sac and embryo volumes using three-dimensional ultrasound

OBJECTIVES

To create reference intervals of gestational sac volume (GSV), yolk sac volume (YSV), embryo volume (EV), crown-rump length (CRL) and gestational sac diameter (GSD) in the first trimester of pregnancy using three-dimensional ultrasound.

METHODS

Women in the first trimester of pregnancy were invited to participate in the study. Inclusion criteria were well-established dates, and that the women were non-smokers and healthy, without any medical disorders. Three-dimensional ultrasound volumetric data (GSV, YSV, EV) were collected together with standard two-dimensional measurements of CRL and GSD. For each measurement separate regression models were fitted to estimate the mean and SD at each gestational age. The 5(th), 50(th) and 95(th) centiles were derived using a combination of these regression models.

RESULTS

One hundred and sixty-six women at between 6 and 12 weeks' gestation were scanned once. The mean ( +/- SD) maternal age was 29.4 ( +/- 5) years. There were no miscarriages and no congenital abnormalities were noted. Mean gestational age at delivery was 39.3 ( +/- 1.4) weeks and mean birth weight was 3.3 ( +/- 0.4) kg. The CRL centiles fitted a cubic model and the GSD centiles fitted a linear model. The centiles for YSV fitted a quadratic model on the modified log-transformed data. The centiles for GSV and EV were modeled using quantile regression.

CONCLUSION

Reference intervals and centile charts for first-trimester GSV, YSV and EV have been created in addition to CRL and GSD using rigorous methodology.

Pre-operative opening detrusor pressure is predictive of detrusor overactivity following TVT in patients with pre-operative mixed urinary incontinence

AIMS

To determine if specific pre-operative urodynamic parameters could predict detrusor overactivity following TVT in patients with urodynamic mixed incontinence.

METHODS

Notes of women with detrusor overactivity (DO) and urodynamic stress incontinence (USI) before undergoing tension-free vaginal tape (TVT) surgery were retrospectively reviewed. Patients underwent clinical evaluation pre-operatively including history, examination, and conventional urodynamic studies and were treated with pelvic floor exercises and anti-cholinergic medication. Those with persistent stress urinary incontinence (SUI) underwent TVT. Patients were re-assessed after at least 6 months post-operatively. Pre- and post-operative opening and closing detrusor pressure, and detrusor pressure at maximum flow were recorded retrospectively from pre-operative urodynamics traces by two clinicians independently and compared to the patients' post-operative symptoms and urodynamic diagnosis.

RESULTS

Fifty-one women were reviewed. Forty-six of the 51 attended follow-up and 35/51 agreed to conventional urodynamic studies. Seventeen of the 35 reported OAB symptoms, and 18/35 were asymptomatic. Nineteen of the 35 women had DO and 16/35 had normal urodynamic studies (NUDS). The median pre-operative opening detrusor pressure was higher in women with overactive bladder symptoms post-operatively. The median pre-operative opening detrusor pressure in women with DO post-operatively was 33.0 cmH(2)O and the median pre-operative opening detrusor pressure in those with NUDS post-operatively was 16 cmH(2)O (15.0-23.0 cmH(2)O) (P < 0.05 Mann-Whitney U-test).

CONCLUSIONS

Higher numbers of patients are required to demonstrate the value of opening detrusor pressure in predicting post-operative overactive bladder symptoms. Opening detrusor pressure is predictive of post-operative DO after TVT.

A cost-effectiveness analysis of delayed sphincteroplasty for anal sphincter injury

OBJECTIVE

Anal-sphincter injury may result in faecal incontinence. Sphincteroplasty is usually performed as a primary (immediate) procedure. Delayed sphincteroplasty (DS) can be performed if there is significant trauma or soiling, if the primary procedure has failed, and if the injury was not recognized initially. This study aimed to determine the cost to patient and health service in the event a DS is performed.

METHOD

Patients with anal-sphincter-injury who underwent primary sphincteroplasty (PS)/DS were identified from the published literature (primary, n = 103; delayed, n = 777) using Medline, Embase, Ovid and Cochrane databases for studies published between 1976 and 2006. Studies included described at least one of the measured outcomes--probability of functional success/failure and quality of life (QOL). An economic model was constructed and decision analysis performed using a decision tree based on a Markov process. Main outcomes were quality-adjusted-life-years (QALYs) gained from each strategy, costs incurred and incremental cost-effectiveness ratio (ICER) over a 10- and 15-year time horizon.

RESULTS

Over 10 years, primary sphincteroplasty (PS) produced a gain of 5.72 QALYs for an estimated 2750 pounds, giving an ICER of 487 pounds per QALY. DS produced a gain of 3.73 QALYs for a cost of 2667 pounds, giving an ICER of 719 pounds per QALY. Both procedures fell below the 10,000 pounds per QALY willingness-to-pay threshold, but PS produced the highest QALYs. Both procedures performed poorly beyond the 10-year mark.

CONCLUSION

If DS has to be performed, the resultant cost is greater with concurrently lower QALYs gained. Successful PS substantially improves QOL and reduces overall cost-of-treatment.

Direct imaging of the pelvic floor muscles using two-dimensional ultrasound: a comparison of women with urogenital prolapse versus controls

OBJECTIVE

To evaluate the anatomy of the levator ani muscle in women with urogenital prolapse versus matched controls without prolapse using real-time two-dimensional (2-D) ultrasound.

DESIGN

Prospective observational study.

SETTING

Tertiary referral urogynaecology unit.

POPULATION

Forty-three women with pelvic organ prolapse (POP) and 24 women (controls) attending a gynaecology clinic without prolapse.

METHODS

All participants completed a standardised symptom questionnaire.

MAIN OUTCOME MEASURES

The morphology of the vagina and paravaginal tissue was recorded at different levels. The thickness of the levator ani and the hiatal area were measured at rest. Reproducibility of the method was assessed by repeated measurements to assess intra-observer variability and inter-observer variability.

RESULTS

This method showed good intra-observer and inter-observer reproducibility and reliability. In controls, the pubococcygeus muscle showed more regular echogenicity with no evidence of trauma, whereas in women with prolapse the muscle had mixed echogenicity. (P = 0.002). The mean thickness of the pubococcygeus did not differ between groups. The levator hiatal area was significantly larger in women with pelvic floor prolapse versus controls (17.8 cm2 versus 13.5 cm2, P < 0.001). This increase in hiatal area positively and significantly correlated with prolapse severity (P < 0.001).

CONCLUSIONS

Morphology and hiatal area can be reliably imaged using 2-D ultrasound. Prolapse was related to changes in pelvic floor morphology and increased levator hiatal area. The use of 2-D ultrasound provides an important insight into the pathophysiology of prolapse.

Effects of Burch colposuspension on the relative positions of the bladder neck to the levator ani muscle: An observational study that used magnetic resonance imaging

OBJECTIVE

The purpose of this study was to use magnetic resonance imaging to observe the changes of the position of the levator ani muscle relative to the bladder neck after Burch colposuspension.

STUDY DESIGN

Women with urodynamic stress incontinence underwent Burch colposuspension. Magnetic resonance imaging was performed 1 week before surgery and 1 year after the operation. The levator ani muscle and the bladder neck were imaged in the parasagittal and sagittal planes, respectively; and their position was measured in relation to the pubococcygeal line. The reproducibility of these measures was investigated. Changes that occurred to levator ani muscle anatomy after the operation were correlated to surgical success. Surgical outcome was assessed objectively at 1 year with urodynamic testing.

RESULTS

Of the 73 women who were studied, only 28 women were included in the study because the medial edge of the levator ani was visible clearly on a parasagittal magnetic resonance image. At the 1-year follow-up, the objective cure rate was 86%. Measures of bladder neck and levator ani position in relation to the pubococcygeal line were found to be reproducible. Burch colposuspension produces a significant elevation of the levator ani, with a reduced distance between the bladder neck and the levator ani muscle. Surgical success was associated significantly with a shorter distance between bladder neck and levator ani muscle.

CONCLUSION

The anatomy of the levator ani muscle is changed by colposuspension. The apposition of the levator ani muscle to the bladder neck may play a role in the restoration of continence.

A randomized controlled trial comparing medical and expectant management of first trimester miscarriage

BACKGROUND

We aimed to determine whether outpatient treatment of miscarriage with vaginal misoprostol is more effective than expectant management in reducing the need for surgical evacuation of retained products of conception (ERPC).

METHODS

Of 131 eligible women with first trimester miscarriage, 104 agreed to randomization to either 600 microg misoprostol or placebo intravaginally. They were assessed the following day and administered a second dose of their allocated treatment if miscarriage was not complete. Those not successful after two doses were seen on day 7, and, if miscarriage was not complete, an ERPC was performed.

RESULTS

The success rate of medical management was 88.5% (46/52) compared with 44.2% (23/52) for expectant management. There was no significant difference in success rate (100 versus 85.7%) in women treated with an incomplete miscarriage. Women with early pregnancy failure had a success rate of 87% with misoprostol compared with 29% with expectant management [odds ratio (OR) 15.96; 95% confidence interval (CI) 5.26, 48.37]. The complete miscarriage rate was achieved quicker in the medical group than the expectant group by day 1 (32.7 versus 5.8%) and by day 2 (73.1 versus 13.5%) of treatment. There were no differences in side-effects, bleeding duration, analgesia use, pain score and satisfaction with treatment. Women in the expectant group made more outpatient visits (5.06 versus 4.44%; OR = -0.62, 95% CI -1.04, -0.19). More women in the medical group (90.4 versus 73.1%; OR 1.26, 95% CI 1.05, 1.50) would elect the same treatment in the future.

CONCLUSIONS

Medical management using 600 microg misoprostol vaginally is more effective than expectant management of early pregnancy failure. Misoprostol did not increase the side-effect profile and patient acceptability was superior to expectant management.

Morbidity after ambulatory urodynamics

AIMS

To identify urinary symptoms and morbidity after ambulatory urodynamics.

METHODS

One hundred consecutive women underwent ambulatory urodynamics for a variety of urinary complaints. Urinary symptom questionnaires were collected before investigation and again 48 hours later, reporting dysuria and haematuria. Women were screened for urinary tract infection before investigation and again 48 hours later.

RESULTS

Of the 91 women who completed the study, 1 (1.1%) had a positive urinary culture after the investigation but was asymptomatic. Seventeen women reported mild to moderate de novo dysuria.

CONCLUSIONS

Urinary symptoms and morbidity after ambulatory monitoring is low.

Pharmacological management of detrusor instability

Urinary incontinence and lower urinary tract dysfunction remain an important cause of morbidity, affecting at least 14% of women over the age of 30 years. Whilst the etiology and pathophysiology of detrusor instability remains to be elucidated drug therapy remains important in the management of women with the irritative symptoms of urgency, frequency and urge incontinence. The number of drugs which have been developed illustrates the point that none are ideal, often having systemic adverse effects limiting their therapeutic usage and affecting compliance. This review aims to assess the current pharmacological management of detrusor instability as well as examining recent progress in the development of new agents, some of which may prove to be efficacious.

Three-dimensional ultrasound: a novel technique for investigating the urethral sphincter in the third trimester of pregnancy

OBJECTIVES

To measure urethral sphincter volume by three-dimensional (3D) ultrasound. To assess the reproducibility of this measurement technique and to compare volumes obtained using 3D ultrasound with volumes calculated from a formula based on 2D ultrasound measurements.

METHODS

Women were recruited as part of an ongoing study of changes to the pelvis resulting from pregnancy and childbirth. One hundred and eleven women in the third trimester of pregnancy (between 32 and 41 completed weeks' gestation) underwent a 3D transvaginal ultrasound scan of the urethra. In 10 cases the scan was analyzed twice by different observers to assess the reproducibility of the measurements from the scans and the results were analyzed using limits of agreement.

RESULTS

The interobserver error was consistent between all the linear, 2D and 3D measurements obtained from the area scanned. There was a significant difference between volumes calculated directly by 3D ultrasound and the approximated volumes from conventional 2D measurements.

CONCLUSIONS

Three-dimensional ultrasound appears to be a useful tool in measuring urethral sphincter volume. The error is consistent with that of linear and 2D imaging. However, the increase in normal range generated by biological variation in all three planes makes 3D ultrasound a more sensitive method of evaluating change to the urethral sphincter.

A comparison of the objective and subjective outcomes of colposuspension for stress incontinence in women

OBJECTIVES

To investigate the impact of colposuspension for stress incontinence on the symptoms and quality of life of women undergoing both primary and repeat surgery for genuine stress incontinence and in addition to assess the use of a condition specific quality of life questionnaire as an outcome measure following surgery.

DESIGN

Prospective case series: videocystourethrography performed before and between six and twelve months after surgery. Validated condition specific quality of life (QoL) questionnaires completed by women before and six to twelve months after surgery.

SETTING

A tertiary referral Urogynaecology Unit in a teaching hospital.

PARTICIPANTS

A consecutive series of 83 women undergoing colposuspension between March 1995 and December 1997. Pre-operative assessment and surgery was performed by, or was under the direct supervision of, the unit director.

INTERVENTION

Modified Burch colposuspension.

MAIN OUTCOME MEASURES

Objective results of surgery assessed with videocystourethrography. Subjective results evaluated using a condition specific QoL tool, the Kings Health Questionnaire (KHQ). Symptom severity was evaluated as a component of the condition specific QoL questionnaire.

RESULTS

Objective cure was demonstrated in 92% of women undergoing primary surgery with an 8% incidence of de-novo detrusor instability and a 10% incidence of voiding difficulties. In the group of women having repeat surgery the objective cure rate was 81% with no de-novo detrusor instability and a 6% incidence of post-operative voiding difficulties. QoL scores improved in 95% of women. Improvements of over 25% were seen in 70% of women and of over 50% in 28%. However, 2.4% of women recorded a deterioration in QoL scores.

CONCLUSIONS

Colposuspension performed in this setting, assessed using both objective and standardised subjective measures, completed by women themselves, appears to produce good objective and subjective results and leads to enhanced quality of life in the great majority of women.

Evaluating ambulatory urodynamics: a prospective study in asymptomatic women

OBJECTIVE

To identify abnormal detrusor contractions in asymptomatic women undergoing ambulatory urodynamics, to standardise the investigation technique for women with urinary symptoms for clinical practice.

DESIGN

Prospective observational study.

SETTING

Two tertiary referral urogynaecology units: one in London, UK and one in Varese, Italy.

METHODS

Women without urinary symptoms were recruited into the study. Ambulatory urodynamics was performed according to the King's College Hospital protocol. All the traces were analysed in four different ways: 1. without the second bladder transducer measurements displayed on the screen and without the diary; 2. as in 1. but with the diary; 3. with the second bladder sensor displayed on the screen but without the diary; 4. as in 3. but with the diary. The diary was always interpreted at the end of the test with the woman present. For each method we reported the total number of detrusor contractions and whether the woman would have been diagnosed as having abnormal detrusor contraction. Cochran's Q test was used for statistical analysis.

RESULTS

Twenty-six women (mean age 31.7 years) were recruited. Ambulatory urodynamic testing lasted an average of 3.57 hour. The diagnosis of abnormal detrusor contraction varied by 65.4% depending on the method of analysis used. The diary and the women's symptoms during the test were the most discriminating factors. A significant difference between the diagnoses was obtained when comparing the four different ways of analysis. According to our protocol only three women (11.5%) had abnormal detrusor contractions.

CONCLUSIONS

Using our protocol almost 90% of asymptomatic women have a stable bladder on ambulatory urodynamics. This is similar to the results of labouratory urodynamic testing of asymptomatic women but is in contrast to previous reports of ambulatory urodynamics of asymptomatic women. The technique used during ambulatory urodynamics determines the tests ability to detect detrusor instability with an accurate symptom diary being the most important.