Surgical approach to hysterectomy: abdominal, laparoscopy-assisted, or vaginal.
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Clinical Protocols↗
Biomedical subjects
R L Harris
Publications and source records attributed to R L Harris.
Bladder compliance in neurologically intact women.
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.
Adult↗
The effect of vesical volume on Valsalva leak-point pressures in women with genuine stress urinary incontinence.
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.
Female↗
Interobserver and intraobserver reliability of the proposed International Continence Society, Society of Gynecologic Surgeons, and American Urogynecologic Society pelvic organ prolapse classification system.
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.
Adult↗
A mathematical model of bronchial absorption of vapors in the human lung and its significance in pharmacokinetic modeling.
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.
Absorption↗
Hantavirus pulmonary syndrome, renal insufficiency, and myositis associated with infection by Bayou hantavirus.
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.
Adult↗
Comparison of anterior colporrhaphy and retropubic urethropexy for patients with genuine stress urinary incontinence.
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.
Female↗
Infectious morbidity, operative blood loss, and length of the operative procedure after cesarean delivery by method of placental removal and site of uterine repair.
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.
Adult↗
Postpartum corticosteroids: accelerated recovery from the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP).
OBJECTIVE: Because most morbidity and mortality associated with atypical preeclampsia and the syndrome of hemolysis, elevated liver enzymes, and low platelets is a postpartum phenomenon, we undertook this investigation to evaluate the use of high-dose corticosteroids to minimize maternal morbidity and accelerate postpartum recovery in patients with this form of severe preeclampsia. STUDY DESIGN: Into this prospective, randomized study 40 parturients with the syndrome were recruited. The syndrome was defined by a clinical presentation consistent with a diagnosis of severe preeclampsia or eclampsia in addition to laboratory evidence of hemolysis, hepatic dysfunction, and thrombocytopenia. Immediately post partum 20 parturients assigned to the treatment group received four doses of intravenous dexamethasone at 12-hour intervals (10 mg, 10 mg, 5 mg, 5 mg) over 36 hours. Patients assigned to the control group received no corticosteroids. All study subjects were intensively monitored by mean arterial pressure and urinary output every 2 hours, hematocrit and platelet count every 6 hours and lactic dehydrogenase, aspartate aminotransferase, and alanine aminotransferase every 12 hours for the first 48 hours post partum. RESULTS: The steroid-treated group with the syndrome of hemolysis, elevated liver enzymes, and low platelets had significant changes over time in mean arterial pressure, urinary output, platelet count, lactic dehydrogenase and aspartate aminotransferase versus the control group with the syndrome. Relative to the control group, the mean arterial pressure became significantly decreased at 22 hours in the steroid-treated group (p < 0.03), urinary output increased significantly by 16 hours (p < 0.02), the platelet count increased significantly by 24 hours (p < 0.05), and both lactic dehydrogenase and aspartate aminotransferase decreased significantly by 36 hours (p < 0.04 and p < 0.05, respectively). CONCLUSIONS: In association with high-dose corticosteroid administration, parturients with the syndrome of hemolysis, elevated liver enzymes, and low platelets recovered from the disease process more rapidly than did control subjects, as measured by urinary output, mean arterial pressure, platelet count, lactic dehydrogenase, and aspartate aminotransferase. In this disease process, which has significant associated morbidity and mortality, especially in patients with advanced cases, high-dose corticosteroid therapy appears to significantly hasten recovery and lessen the severity of the disease post partum. We postulate that use of this therapeutic approach in properly selected patients could result in lessened overall maternal morbidity and mortality, shorter patient stays in recovery and intensive-care areas, and shorter overall hospitalization with reduced medical care costs.
Adolescent↗
ED management of acute congestive heart failure in renal dialysis patients.
This is a descriptive report of the management techniques used effectively in the emergency department (ED) treatment of acute congestive heart failure (CHF) in renal dialysis patients. Study design included a prospective case series of consecutive renal dialysis patients who presented to the ED of a regional dialysis center in acute CHF. Clinical presentation, ED management, and outcome were recorded. Forty-six patients (38 hemodialysis and 8 peritoneal dialysis) were included in this study. Presentation classifications for these patients were minimal distress (13 patients), moderate distress (16 patients), and severe distress (17 patients). In addition to supplemental oxygen, treatment focused on pharmacological preload and afterload reduction. Patients received sublingual nitroglycerin (NTG) (30 patients), transdermal NTG (36 patients), captopril sublingual (10 patients) nifedipine oral (nine patients), nitroprusside (four patients), morphine sulfate (one patient), NTG infusion (one patient), and clonidine (one patient). There were no deaths in the study group, and 32 of the patients were able to be dialyzed and discharged, including seven patients in the severe group. Six patients required intubation, one of whom was extubated and discharged from the ED after dialysis. Intravascular access was obtained in 29 patients but was used in only six. All patients on nitroprusside drips were weaned during the course of their dialysis. Effective ED management of acute CHF in renal dialysis patients can be accomplished through preload reduction with nitrates and afterload reduction with captopril, nifedipine, and, in severe cases, nitroprusside.
Acute Disease↗
A novel electromechanical drive for a tether-free implantable ventricular assist device.
A tether-free ventricular assist device (VAD) based on a novel electromechanical drive was prototyped and evaluated. The unit can be adapted for implantation. The device utilizes a bladder-type ventricle taken from a pneumatically driven VAD. In mock loop testing, the unit has met the design capacity of 6 L/min against a pressure head of 150 mm Hg. The efficiency of the device allows it to operate at design flow and pressure for periods of up to 8 h when powered by a single rechargeable battery pack weighing less than 5 kg. The mechanism consists of a seamless sac-type bladder situated between hinged plates actuated by a motor-driven bell-and-crank linkage. Cycle parameters are controlled by a microprocessor-based servomotor drive.
Equipment Design↗
Preoperative skin preparation and intraoperative pelvic irrigation: impact on post-cesarean endometritis and wound infection.
OBJECTIVE: To determine the impact of two skin preparation methods and two techniques of pelvic irrigation on the incidence of post-cesarean endometritis and wound infection in an indigent patient population. METHODS: A randomized study was performed in 100 cesarean patients. Subjects were assigned to one of four groups, involving either standard skin preparation (povidone-iodine [7.5%] scrub followed by povidone-iodine [10%] solution) or special skin preparation (5-minute scrub with parachlorometaxylenol followed by povidone scrub and solution), and either normal saline or antibiotic (cefazolin sodium, 1 g in 500 mL normal saline) irrigation of the pelvis and subcutaneous tissue at uterine and fascial closure. Four groups of patients were formed: standard skin preparation plus normal saline irrigation, standard preparation plus antibiotic irrigation, special preparation plus normal saline irrigation, and special preparation plus antibiotic irrigation. RESULTS: Endometritis occurred significantly more often in the combined groups that did not include antibiotic irrigation than in the combined groups involving antibiotic irrigation (P < .001). In contrast, comparison of skin preparation methods between povidone-iodine alone versus preparation including parachlorometaxylenol indicated no significant difference (P = .22). CONCLUSION: Skin preparation with an antibacterial scrub in addition to standard povidone-iodine scrub and solution does not appear to play as significant a role in the reduction of post-cesarean endometritis or wound infection as does intraoperative pelvic irrigation with antibiotic solution.
Adult↗
Prostatic abscess due to Histoplasma capsulatum in a patient with the acquired immunodeficiency syndrome.
Disseminated histoplasmosis is a systemic fungal infection that may occur in previously healthy or immunocompromised patients. The condition is being recognized with increasing frequency in persons infected with the human immunodeficiency virus. The most common organs involved include the lung, bone marrow, lymph nodes, liver, adrenals and central nervous system, with genitourinary involvement being exceedingly unusual. We describe a Histoplasma capsulatum prostatic abscess occurring after therapy for pulmonary histoplasmosis in a patient with the acquired immunodeficiency syndrome. The prostate may be a difficult focus from which to eradicate disseminated fungal infection in immunocompromised patients.
Abscess↗
Extraparenchymal neurocysticercosis: report of five cases and review of management.
Neurocysticercosis due to parenchymal cysts carries a good prognosis regardless of therapy. Extraparenchymal neurocysticercosis (including ventricular, spinal, and subarachnoid types) carries a poorer prognosis. Most extraparenchymal cases present with hydrocephalus. Medical treatment alone in doses and schedules developed for parenchymal disease is frequently unsuccessful. For ventricular disease, most cases can be managed with shunting procedures either alone or together with the administration of antiparasitic agents (e.g., praziquantel or albendazole), without extirpation of the cysts. Subarachnoid disease was formerly associated with a case fatality rate of about 50%. However, with the combination of shunting procedures for hydrocephalus, antiparasitic agents, and, in some cases, surgical extirpation of the cysts, the prognosis is much improved. Spinal cysticercosis can be either leptomeningeal (which responds like subarachnoid disease) or intramedullary. For all forms of neurocysticercosis, the role of antiparasitic agents needs to be better defined.
Adult↗
Successful medical management of a patient with multiple hepatic abscesses due to Edwardsiella tarda.
Isolation of Edwardsiella tarda in humans has been associated with an asymptomatic carrier state as well as mild, self-limited diarrheal illness. Extraintestinal manifestations have included soft-tissue infections, meningitis, osteomyelitis, cholangitis, and sepsis. Only three cases of patients who had documented hepatic abscess due to E. tarda have been reported in the English-language literature; two patients died, and the third required a laparotomy and drainage. We report what is, to our knowledge, the first autochthonous case of hepatic abscess due to E. tarda in the United States and the first case that was successfully managed with antibiotic therapy alone.
Adult↗
Cefamandole levels during thoracoabdominal aortic aneurysm surgery.
The pharmacokinetics of prophylactic antibodies may differ in cardiac and aortic aneurysm surgery for at least two reasons: aortic aneurysm surgery generally entails a greater blood volume loss and replacement, and aortic aneurysm surgery usually does not require extracorporeal cardiopulmonary bypass. We prospectively studied two different cefamandole dosing regimens in patients undergoing aortic aneurysm surgery (phase 1, 1 gm intravenously at the induction of anesthesia; phase 2, 2 gm intravenously at the induction of anesthesia followed by 1 gm intravenously every 2 hours during surgery). In phase 1 and 2 plasma levels were measured at the time of skin incision, aortic cross-clamping, aortic unclamping, and skin closure. In phase 2 cefamandole elimination in urine and cell-saver effluent was also determined. An adequate plasma level of 10 micrograms/ml was maintained in only 4 of 14 patients in phase 1, but in 10 of 10 patients in phase 2. Cefamandole loss in cell-saver effluent was 136 +/- 100 mg, which was 13% of the measured renally excreted amount. As has been previously shown in cardiac surgery, a cefamandole prophylactic antibiotic regimen of 2 gm intravenously at the induction of anesthesia followed by 1 gm every 2 hours during surgery provides a dependable and practical dosing regimen in patients undergoing aortic aneurysm surgery.
Aged↗
Hypercalcemic hyperparathyroidism and hypophosphatemic osteomalacia complicating neurofibromatosis.
Neurofibromatosis is sometimes complicated by impaired renal tubular reabsorption of phosphate, hypophosphatemia, and osteomalacia. Hyperparathyroidism has also been reported in patients with neurofibromatosis. When hypercalcemia and elevated levels of parathyroid hormone are found in osteomalacia, however, it may be difficult to determine if the hyperparathyroidism was primary or tertiary. We describe a patient with neurofibromatosis, hypercalcemic hyperparathyroidism, hypophosphatemic osteomalacia, vitamin D deficiency, and clear-cell hyperplasia of all four parathyroid glands. Serial biomechanical, bone biopsy, and densitometric studies confirmed that treatment with ergocalciferol, calcium, and phosphate supplements significantly improved the osteomalacia but caused increased parathyroid overactivity. After subtotal parathyroidectomy, the parathyroid hormone concentration became normal and the bone mineral content increased at the spine and hip, but inappropriate phosphaturia persisted. The findings indicate that hyperparathyroidism, osteomalacia, and vitamin D deficiency adversely affect each other.
Bone and Bones↗
Treatment of postoperative infection of ascending aorta and transverse aortic arch, including use of viable omentum and muscle flaps.
Postoperative infection of the ascending aorta and aortic arch in 40 patients was treated by antibiotic therapy alone (4 patients) or by operation and lifelong suppressive antibiotic therapy (36 patients). Complications of infection included antibiotic-resistant infection, infected false aneurysm, rupture of suture line, aortocutaneous fistulas, aortic-right ventricular fistulas, arterial embolus, aortic valve insufficiency, aortobronchial fistula, mediastinal abscess, and chest wall problems. These were treated by a variety of operations including composite valve-graft replacement, graft replacement, patch-graft closure of false aneurysm, simple suture of disrupted suture lines and false aneurysm, and debridement of mediastinum and chest wall. The area of reconstruction was covered, and mediastinal dead space was reduced by mobilization of viable tissue, including local tissue and distant structures such as flaps of muscle and omentum. Thirty-three patients (83%) were early survivors, and 28 patients (70%) were alive and well at last follow-up 4 months to 6.5 years after operation.
Adult↗