Biomedical subjects
Publications and source records attributed to R L Harris.
A woman who was treated for intrinsic urethral sphincteric deficiency with periurethral injection of glutaraldehyde cross-linked collagen had prolapse of the urethral mucosa and recurrence of incontinence. She subsequently required surgical resection and a fascia lata sling. This is the first known occurrence of this postinjection complication.
OBJECTIVE: To determine differences between vaginally parous and nulliparous women presenting with urinary incontinence and pelvic organ prolapse. METHODS: Seven hundred forty eight consecutive referrals with urinary incontinence or pelvic organ prolapse, 62 of whom were nulliparous, were included in the analysis. Five hundred thirty-seven (72%) had urinary incontinence and 235 (31%) had at least stage III pelvic organ prolapse. Each subject had standard history, physical examination, and multichannel urodynamic testing. Differences between parous and nulliparous women were compared using parametric and nonparametric analysis of variance and the chi2 test with Yates correction where appropriate. RESULTS: The only significant demographic difference between the groups was that parous women had more previous continence and prolapse surgery. There were significant differences in distribution of diagnoses according to parity, with the nulliparas much less likely to have pelvic organ prolapse. Among incontinent women without prolapse, nulliparas were significantly more likely to have pure detrusor instability. Of those with pure genuine stress incontinence, nulliparas were older, had less anterior vaginal wall descent, less bladder neck mobility, narrower genital hiatus and perineal body measurements, and lower maximum urethral closure pressures. Of those with pure detrusor instability, the only difference was that nulliparas were significantly younger. For women with stage III pelvic organ prolapse or worse, no significant difference in any measured characteristic was noted. CONCLUSION: Nulliparous women were less likely to present with pelvic organ prolapse and those with urinary incontinence differed little from incontinent parous women.
The installation of an optical outlining system on both a simulator and treatment unit has enabled patient cross-sectional outlines to be measured throughout a radical treatment period of 5 weeks. Two studies were conducted to assess the reproducibility of positioning in treatments for breast carcinoma. The first study assessed changes in outline for 23 patients treated on a home-made tilt-board. Seven patients (32%) displayed a change in shape in excess of 1 cm during the course of treatment, which could have significant dosimetric consequences. The second study focused on the reproducibility of set-up using different tilt-boards. This included a further 19 patients treated using a commercial board, which is now in routine use.
Our objective was to determine the effect of cough strength on pressure transmission ratios and establish quantitative and qualitative intra-observer test-retest reproducibility of pressure transmission ratios calculated from dynamic urethral pressure profilometry. The study included 242 consecutive urodynamic evaluations on women without pelvic organ prolapse. Dynamic urethral pressure profiles were performed in duplicate with coughs of different intensities. The analysis included pressure transmission ratios from the proximal 3 urethral quartiles (Q1 through Q3) and the mean pressure transmission ratio calculated from these quartiles. The final diagnoses were stratified into genuine stress incontinence, 135 (56%), and stress continence, 107 (44%). Correlations were strong for pressure transmission ratios from the first versus the second dynamic urethral pressure profile (K = 0.712 for mean). While the variation in cough intensity between hard and soft coughs averaged 30 cm H2O (P < 0.001), correlation's were equally strong between hard and soft cough pressure transmission ratios (K = 0.712 for mean). When mean pressure transmission ratios were stratified into below 90% and at least 90% categories, 83.5% of subjects had test-retest concordance (K = 0.671). Concordance rates were less for stress continent subjects (80.0%; K = 0.527) than for genuine stress incontinence subjects (86.4%; K = 0.679). Pressure transmission ratios appear to have reasonable quantitative and qualitative reproducibility which is unaffected by cough strength. The degree of individual variability limits the utility of pressure transmission ratios to diagnose genuine stress incontinence independent of other, equally variable clinical and urodynamic parameters, but this measure is sufficiently reproducible to be useful in characterizing stress sphincteric function in population studies.
OBJECTIVE: Our purpose was to assess a modification of abdominal sacral colpopexy in 19 patients. STUDY DESIGN: The rectovaginal space was dissected to the superior aspect of the posterior vaginal fascia still contiguous with the perineal body. Mersilene (Ethicon, Somerville, N.J.) mesh was sutured to this fascia and along the entire posterior vaginal wall. Patients with vault prolapse, perineal descent, and associated rectoceles or enteroceles are reported. Outcome measures included bowel symptoms and pelvic organ prolapse staging. Defecography was performed in three patients. Wilcoxon signed rank analysis was used for comparison of prolapse measures. RESULTS: Mean follow-up was 11 weeks. Bowel symptoms improved in 8 of 11 women. No subjects had greater than stage II prolapse postoperatively and median improvement in stage was 3 (range 2 to 4). The mean decrease in the genital hiatus measurement was 3.13 +/- 1.25 (range 2 to 6) cm. Postoperative defecography documented correction of rectoceles and enteroceles and improvement in perineal descent with straining. CONCLUSIONS: Abdominal sacral colpoperineopexy is effective surgery for vaginal vault prolapse associated with perineal descent and posterior vaginal defects.
OBJECTIVE: Our goal was to evaluate the role of intraoperative cystoscopy during surgery for pelvic organ prolapse and urinary incontinence. STUDY DESIGN: Charts of 224 consecutive patients who had intraoperative cystoscopy performed after urogynecologic surgery were reviewed. RESULTS: Nine injuries occurred that were unsuspected before cystoscopy, for an incidence of 4%. Six ureteral ligations occurred, four after Burch cystourethropexy and two after vaginal culdoplasty. Intravesical sutures were noted after two Burch procedures, and another injury occurred with passage of fascia lata through the bladder during a pubovaginal sling procedure. Eight injuries were managed by removal and replacement of the suture or sling with only one requiring ureteroneocystotomy. When patients with injuries were compared with those without, there were no statistical differences in demographic or surgical parameters. CONCLUSIONS: The potential for damage to the lower urinary tract is significant with complex urogynecologic surgery. Because of the increased and delayed morbidity associated with unrecognized injury, intraoperative surveillance cystoscopy should be considered a part of all such procedures.
OBJECTIVE: Our purpose was to characterize historic and clinical parameters in incontinent women to determine the predictive value for urodynamic diagnoses. STUDY DESIGN: The analysis includes 535 consecutive women with final diagnoses of genuine stress incontinence, detrusor instability, or both. Evaluations included a standardized history, examination, urinary diary, quantitation test, and urodynamics. The analysis used one-way analysis of variance, chi 2 analysis with Yates' correction, and Fisher's exact test. RESULTS: A total of 351 (66%) women were diagnosed with genuine stress incontinence, 102 (19%) with detrusor instability, and 82 (15%) with both. Half had symptoms of both stress incontinence and urge incontinence, of whom only 21% had both genuine stress incontinence and detrusor instability. Fewer than half of women diagnosed with genuine stress incontinence or detrusor instability had just symptoms of stress incontinence or urge incontinence, respectively. Evaluation of historic, examination, and urinary diary data for their influences on the predictive value of pure stress incontinence or urge incontinence revealed statistical differences for urethral hypermobility, estrogen deficiency, and incontinent episodes, yet they were not clinically practical predictors. CONCLUSIONS: Pure symptoms identify fewer than half of patients with pure genuine stress incontinence or detrusor instability; historic and clinical parameters do not improve the sensitivity of these symptoms.
OBJECTIVES: Our purpose was to compare three measures proposed to diagnose intrinsic sphincteric deficiency: maximum urethral closure pressure, Valsalva leak point pressure, and straining urethral axis. STUDY DESIGN: A total of 159 women with pure genuine stress incontinence had the three measures determined in a standardized fashion. Critical cutoff values for the Valsalva leak point pressure (52 cm) and urethral axis (22 degrees) were established by examining relative frequency distribution curves, using closure pressure of 20 as the arbitrary benchmark value for the prevalence of intrinsic sphincteric deficiency. The distribution of cutoff values is described and differences among the measures with respect to risk factors for intrinsic sphincteric deficiency and incontinence severity were determined. RESULTS: Half the subjects fell below at least one cutoff value, but only 10% fell below all three. Sixty-four percent of subjects with either low closure pressure or leak point pressure had low values for the other, whereas 21% had discordance between them. Only 53% of subjects with low closure pressure and 40% with low leak point pressure had an axis < or = 22 degrees. Conversely, a substantial portion (36%) of subjects with pure genuine stress incontinence without urethral hypermobility had neither low urethral or leak point pressures. All three cutoff-values were associated with risk factors for intrinsic sphincteric deficiency, but only low closure and leak point pressures had significant associations with the severity of incontinence. CONCLUSIONS: Intrinsic sphincteric deficiency should be diagnosed by a composite of historic, urodynamic, anatomic, and clinical severity criteria. We would include a maximum urethral closure pressure < or = 20, a Valsalva leak point pressure < or = 50, and a stress urethral axis < or = 20 in this composite.
OBJECTIVE: To characterize uroflowmetry parameters in women with pelvic organ prolapse (POP) and urinary incontinence (UI) and to assess the effects of clinical and urodynamic variables on these parameters. PATIENTS AND METHODS: The study comprised 655 consecutive women who presented with UI or POP and who had interpretable uroflowmetry values. Normal uroflowmetry values were defined as a maximum flow (Q(max)) > or = 15 mL/s, a mean flow (Q(mean)) > or = 10 mL/s, a post-void residual volume (PVR) < or = 100 mL and a continuous, single-peak waveform. Parametric and non-parametric analysis of variance and chi-square analysis were used to compare differences between diagnostic groups. Multiple linear regression models were developed to evaluate factors considered to influence uroflowmetry. RESULTS: Of the 655 patients, 471 (72%) had UI of whom 16% had pure detrusor instability (DI), 69% pure genuine stress incontinence (GSI) and 15% with both, and 184 (28%) had POP, 26% of whom also had DI. Of all patients, 72% had normal uroflowmetry patterns, 13% had multiple peaks and 15% had patterns with interrupted flow; 56% had completely normal uroflowmetry. There were significant differences in uroflowmetry values between the POP and UI groups, with the former having a lower Q(max) and Q(mean) (P < 0.001), larger PVRs (P < 0.001) and a lower percentage of totally normal uroflowmetry (33% and 64%, respectively, P < 0.001). Of patients with POP, 30% had a PVR > 100 mL. Because of the differences, the POP and UI groups were evaluated separately in the regression analysis. In both groups, the most important determinants of flow rate were the volume voided and pressure transmission ratio (PTR). However, when several factors (including age, voided volume, PTR and maximum detrusor pressure with flow and at Q(max)) were included in the model, they accounted for only 23-26% of the variability of flow in the patients with UI and 36-39% of the variability in patients with POP. The subsets of patients with pure DI in both the UI and POP groups had higher PVR volumes than the other subsets. CONCLUSIONS: These results show that the positive correlation between flow rate and voided volume described in normal populations is also observed in women with UI and POP. However, most of the variability in urine flow was not attributable to factors such as age, voided volume and PTR, confirming the complexity of the micturition mechanism. Women with POP had more objective evidence of emptying-phase dysfunction than women with UI, although most emptied their bladders efficiently. Finally, the results suggest that women with DI exhibit dysfunction of both inhibitory and facilitory detrusor control.
Most patients attending a hospital appointment are likely to feel at least slightly apprehensive and, therefore, unable to retain all of the information given to them. A patient visiting a department in which they had been diagnosed with cancer that required radiotherapy is perhaps one of the worst case scenarios. Both cancer and radiotherapy are words that create some of the greatest fears for the general public and, even, for members of the health profession. Due to the misconceptions about cancer and radiotherapy, patients require accurate information to help allay some of their fears. At the Department of Radiotherapy and Oncology, Freedom Fields Hospital, Plymouth, it was decided that an audit be used to determine the accuracy and consistency of information delivered within a specialized unit, before this information was disseminated to other departments within the hospital. The goals of the audit were to highlight possible weak areas of advice, to agree on the best information to furnish for a given situation, and to implement distribution of a staff handout to help achieve these aims. Staff members (n = 35) of various professions and levels were asked to complete a questionnaire relating to a patient with carcinoma of the breast undergoing a routine course of radiotherapy. Results of the audit indicated staff vagueness or conflicting responses in certain situations.
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No data currently exist to define normal bladder compliance (C) in women. This study was undertaken to establish normative data for C in neurologically intact women and to determine if detrusor instability (DI) is associated with changes in C. The multichannel urodynamic tracings of 270 patients (195 stable, 75 unstable) were reviewed according to a standard written protocol. Vesical and abdominal pressures (Pves, Pabd) were measured during retrograde filling after a stable baseline was established (< 50 ml) and just prior to cessation of infusion. If a detrusor contraction occurred, measurements were taken during a 5-sec window preceding onset of contraction. The vesical volume used to calculate C was the total bladder volume determined by completely emptying the bladder at the end of cystometry. Compliance was calculated by dividing this volume by the change in detrusor pressure (Pdet). For the purpose of some analyses, infinite C, i.e., no observed rise in Pdet, was arbitrarily assigned a value of 1,000. Overall, 47.6% of women had no increase in Pdet with filling to maximum cystometric capacity (MCC) and had infinite C. Women with instability were significantly less likely to have infinite C than those with stable bladders (32% vs. 53%; P = 0.003). In 75% of women, C was > 130 ml/cm; in 90%, C was > 60 ml/cm; and in 95%, C was > 40 ml/cm. There were significant differences between the distribution of stable and unstable bladders above and below each of these percentile cutoffs. Only 2 women, both of whom had unstable bladders, had C < 20 ml/cm water. Ninety-five percent of neurologically intact women have C > 40 ml/cm, and nearly half have no increase in Pdet during filling to MCC. Patients with DI have significantly less compliant bladders than do those with stable bladders. If C is < 40 ml/cm, a woman is 16 times more likely to have DI. Decreased C may suggest the diagnosis of DI in patients with urge incontinence whose symptoms are not reproduced in the laboratory.
OBJECTIVE: To determine the effect of increasing vesical volume on the Valsalva leak-point pressure, examine the relationship between leakage at a given volume and clinical incontinence severity, and evaluate the relationships between leakage at a given volume and other measures of urethral resistance. METHODS: One hundred twenty women with genuine stress urinary incontinence (GSI) underwent serial Valsalva leak-point pressure determinations at vesical volumes of 100, 200, and 300 mL, and at maximum cystometric capacity. Urinary diary data, quantitative pad testing, and passive and dynamic urethral profilometry were also performed. RESULTS: Thirty-three women had leakage starting at a vesical volume of 100 mL, 18 at 200 mL, and 19 at 300 mL, and 17 had leakage only at maximum cystometric capacity. The mean first positive Valsalva leak-point pressures were significantly higher than Valsalva leak-point pressures at maximum capacity in all groups: in women who began to leak at 100 mL, 57 versus 36 cm H2O (P < .001); at 200 mL, 59 versus 45 cm H2O (P < .001); and at 300mL, 61 versus 47 cm H2O (P = .01). Women who had leakage at lower vesical volumes had worse measures of clinical incontinence severity and lower maximum urethral closure pressure less than or equal to 20 cm H2O) and pure intrinsic sphincteric deficiency (low urethral pressure and the lack of urethral hypermobility), but the specificities were 63 and 50%, respectively. CONCLUSIONS: Women with GSI are more likely to leak during Valsalva with increasing vesical volume. Valsalva leak-point pressures decrease significantly with bladder filling. The volume at which leakage occurs correlates inversely with clinical severity and directly with maximum urethral closure pressure. A negative Valsalva leak-point pressure at 300 mL excludes the presence of low urethral pressure and pure intrinsic sphincteric deficiency; however, the specificity and positive predictive value are inadequate for making a clinical diagnosis of either condition.
OBJECTIVE: Our purpose was to determine the intraobserver and interobserver reliability of site-specific measurements and stages with the proposed international Continence Society, Society of Gynecologic Surgeons, and American Urogynecologic Society 1994 draft prolapse terminology document. STUDY DESIGN: Women who completed informed consent procedures underwent pelvic examinations by two investigators, each blinded to the results of the other's examination. The reproducibility of the nine site-specific measurements and the summary stage and substage were analyzed with Spearman's correlation coefficient (rs) and Kendel tau B Correlation Coefficient (tau b), respectively. Similar analyses were performed on supine and upright examinations performed at two different times by one examiner. RESULTS: Experienced examiners averaged 2.05 minutes per examination and new examiners averaged 3.73 minutes. In the study of interobserver reliability, 48, subjects, mean age 61 +/- 14 years, parity 3 +/- 2, weight 74 +/- 31 kg, comprised the study population. Correlations for each of the nine measurements were substantial and highly significant (rs 0.817, 0.895, 0.522, 0.767, 0.746, 0.747, 0.913, 0.514, and 0.488, p = 0.0008 to < 0.0001). Staging and substaging were highly reproducible (tau b 0.702 and 0.652). In no subject did the stage vary by more than one; in 69% stages were identical. In the study of intraobserver reliability, for 25 subjects correlations for each of the nine measurements were equally strong (rs 0.780, 0.934, 0.765, 0.759, 0.859, 0.826, 0.812, 0.659, 0.431). Measurements from the upright examinations reflected greater prolapse. Staging and substaging were highly reproducible (tau b 0.712 and 0.712). In no subject did the stage vary by more than one; in 64% stages were identical. All stage discrepancies represented an increase in the upright position. CONCLUSIONS: There is good reproducibility of measures with the proposed system. The data suggest that the reliability is independent of examiner experience. Patient position is likely important in maximizing the severity of the prolapse.
This work formulates a model description of moderately soluble gas and vapor uptake in the bronchial region of the lung during initial inhalation exposure. The mass transport problem is solved using an iterative-analytical approach in which inhaled chemical is partitioned to alveolar blood-gas exchange, bronchial wall absorption, and exhalation. Results of 109 simulations allowed regression analysis to provide simple algebraic equations to describe the fraction of total inhaled mass taken up by the two alternative absorption pathways. These fractions are dependent on the chemical's solubility and liquid diffusivity. The derived relationships are then used in a modified physiologically based pharmacokinetic (PBPK) model which accounts for bronchial uptake. The results are compared to identical results from a traditional (unmodified) PBPK model to draw conclusions concerning the effect of bronchial uptake on systemic chemical distribution in addition to elevated bronchial tissue concentrations.
Hantaviruses are etiologic agents of hemorrhagic fever with renal syndrome, an acute illness characterized by acute renal insufficiency, proteinuria, and hemodynamic instability. Recently, a New World form of hantavirus disease, hantavirus pulmonary syndrome (HPS), was recognized; in this form, pulmonary edema is prominent, but renal insufficiency is generally lacking. HPS cases from the southeastern United States may be exceptional in that they have exhibited both pulmonary and renal manifestations. One case in Louisiana and one case in Florida were linked to infection by the distinct but closely related Bayou and Black Creek Canal hantaviruses, respectively. We report a nonfatal case of HPS caused by Bayou hantavirus that occurred in eastern Texas. Clinical manifestations included pulmonary and renal insufficiency and myositis, which had previously been observed in the patient from Florida. The occurrence of distinctive clinical abnormalities in HPS cases from the southeastern United States supports the concept that there are clinically significant differences between western and southeastern forms of HPS.
OBJECTIVE: Our purpose was to compared the efficacy of anterior colporrhaphy and retropubic urethropexy performed for genuine stress urinary incontinence. STUDY DESIGN: A retrospective analysis was performed on women who underwent either anterior colporrhaphy or retropubic urethropexy for genuine stress urinary incontinence. Patients were identified by a computer-assisted search, and these women were contacted by telephone. The interview was used to assess current continence status. Variables reviewed included demographic data, medications, hormonal status, current smoking history, significant medical and surgical history, and time to recurrence of incontinence. Operative procedure, prior or concomitant hysterectomy, history of previous incontinence procedures, concomitant surgery for repair of other pelvic floor defects, experience level of the primary surgeon, and duration of postoperative catheterization were also documented. RESULTS: Seventy-six women who had undergone surgery for genuine stress incontinence during a 4-year period were identified and evaluated by telephone interview. Fifty-six had undergone anterior colporrhaphy and 20 retropubic urethropexy. Both groups of patients were comparable in age, social status, race, parity, and weight. The duration of follow-up (mean +/- SD) was 66.6 +/- 14.2 months (range 48 to 96 months). Concurrent surgery to repair other pelvic floor defects was more common in patients undergoing anterior colporrhaphy than in patients undergoing retropubic urethropexy (p < 0.05). Of the 56 patients treated with anterior colporrhaphy, 26 (46%) were continent at the time of interview versus 15 of 20 (75%) treated with retropubic urethropexy (p < 0.05). Times to recurrence for anterior colporrhaphy and retropubic urethropexy were not significantly different. History of previous incontinence procedures, concomitant hysterectomy, previous hysterectomy, duration of postoperative catheterization, obesity, chronic lung disease, and smoking were not correlated with success for either procedure. Experience of the primary surgeon did have a significant effect on success, with attending staff having a better cure rate than resident surgeons (p < 0.05). CONCLUSION: Retropubic urethropexy was significantly more effective than anterior colporrhaphy for long-term cure of genuine stress urinary incontinence. We believe these conclusions should be tempered because of the complex nature of genuine stress incontinence. Patients having anterior colporrhaphy may represent a high-risk group because nearly all of them had associated pelvic floor defects. Experience of the surgeon seems to enhance the likelihood of success and may reflect subtle modifications of technique.
OBJECTIVE: This study was done to determine the impact of the method of placental removal and the site of uterine repair on postcesarean infectious morbidity rates in women receiving prophylactic antibiotics at cesarean delivery. STUDY DESIGN: This prospective study included 284 women who underwent cesarean delivery and who were randomly assigned to four groups based on the method of placental removal and the site of uterine repair: group 1, spontaneous placental removal and in situ uterine repair; group 2, spontaneous placental removal and exteriorized uterine repair; group 3, manual placental removal and in situ uterine repair; and group 4, manual placental removal with exteriorized uterine repair. Exclusion criteria were repeat cesarean deliveries without labor, active infection at the time of cesarean delivery, and patient refusal to participate. RESULTS: There was no significant difference among the groups in maternal age, race, parity, weight, the length of time from rupture of membranes (ROM) or the number of vaginal examinations from ROM to cesarean delivery, or preoperative hematocrit. Intraoperatively, the type of uterine incision, anesthesia administered, incidence of meconium-stained amniotic fluid, Apgar scores, and cord gases were similar between groups. The incidence of postcesarean endometritis was greater in group 4 (32 [45 percent] of 71, p = 0.003) compared with group 1 (17 [24 percent] of 71), group 2 (12 [30 percent] of 71); and group 3 (13 [18 percent] of 71). CONCLUSIONS: Manual placental removal and exteriorization of the uterus for repair of the surgical incision increases the infectious morbidity rate in women receiving prophylactic antibiotics at the time of cesarean delivery and increases the length of hospitalization.