OBJECTIVE

To measure mean airway pressure (MAP) delivered through the RAM Cannula® when used with a ventilator in CPAP mode as a function of percent nares occlusion in a simulated nasal interface/test lung model and to compare the results to MAPs using a nasal continuous positive airway pressure (NCPAP) interface with nares fully occluded.

METHODS

An artificial airway model was connected to a spontaneous breathing lung model in which MAP was measured at set NCPAP levels between 4 and 8 cmH2 O provided by a Dräger Evita XL® ventilator and delivered through three sizes of RAM cannulae. Measurements were performed with varying leakage at the nasal interface by decreasing occlusion from 100% to 29%, half-way prong insertion, and simulated mouth leakage. Comparison measurements were made using the Dräger BabyFlow® NCPAP interface with a full nasal seal.

RESULTS

With simulated mouth closed, the Dräger interface delivered MAPs within 0.5 cmH2 O of set CPAP levels. For the RAM cannula, with 60-80% nares occlusion, overall delivered MAPs were 60 ± 17% less than set CPAP levels (P < 0.001). Further, MAP decreased progressively with decreasing percent nares occlusion. The simulated open mouth condition resulted in significantly lower MAPs to <1.7 cmH2 O. The one-half prong insertion depth condition, with closed mouth, yielded MAPs approximately 35 ± 9% less than full insertion pressures (P < 0.001).

CONCLUSIONS

In our bench tests, the RAM interface connected to a ventilator in NCPAP mode failed to deliver set CPAP levels when applied using the manufacturer recommended 60-80% nares occlusion, even with closed mouth and full nasal prong insertion conditions.

To describe our step-by-step technique for robotic intracorporeal neobladder configuration, including the stages of conception, development and exploration of this surgical innovation, according to the Idea, Development, Exploration, Assessment, Long-term follow-up (IDEAL) Collaboration guidelines.

The Florence robotic intracorporeal neobladder (FloRIN) was performed employing the following main surgical steps: isolation of 50 cm of ileum; bowel anastomosis; urethro-ileal anastomosis creating an asymmetrical 'U'-shape (30 cm distally and 20 cm proximally to anastomosis), ileum detubularisation; posterior wall reconfiguration as an 'L'; bladder neck reconstruction; anterior folding of the posterior plate to reach the 12 o'clock position; uretero-enteral 'orthotopic' bilateral anastomosis. The conception and development of the FloRIN followed the IDEAL guidelines recommended stages: Phase 1 (simulation) involved the neobladder robotic configuration using silicone models. Phase 2a (development) aimed to reproduce the configuration in an open fashion in one patient, and then in the first three robotic procedures. Phase 2b (exploration) consisted of the technique standardisation in 15 consecutive robotic approaches. Phase 2a and 2b included urodynamics and imaging assessment of the patients treated.

From February 2016 to September 2017 FloRIN was performed in 18 patients. Comparing the first three (Phase 2a) with the subsequent 15 patients (Phase 2b), the median (interquartile range [IQR]) reconstruction operating time was 260 (220-340) vs 160 (150-210) min, respectively. Postoperative surgical complications occurred in four of the 18 patients (22.1%), including one surgical Clavien-Dindo Grade III and three Grade I, postoperative medical Clavien-Dindo Grade II complications occurred in three (16.7%) patients. On urodynamic examination (available in nine [50%] patients) the median (IQR) reservoir cystometric capacity, compliance, and post-void residual were 240 (220-267) mL, 18 (12.5-19.8) mL/cmH2 O, and 0 (0-50) mL, respectively. Ultrasonography showed no Grade ≥2 vesico-ureteric reflux.

We describe the FloRIN configuration, showing its technical feasibility with acceptable time efficiency. The first cases studied had good reservoir capacity, low pressure with no reflux, and complete voiding.

Pulmonary "air leaks," typically the result of pleural injury caused by lung surgery or chest trauma, result in the accumulation of air in the pleural space (pneumothorax). Air leaks are a major source of morbidity and prolonged hospitalization after pulmonary surgery. Previous work has demonstrated structural heteropolysaccharide (pectin) binding to the mouse pleural glycocalyx. The similar lectin-binding characteristics and ultrastructural features of the human and mouse pleural glycocalyx suggested the potential application of these polymers in humans. To investigate the utility of pectin-based polymers, we developed a simulacrum using freshly obtained human pleura. Pressure-decay leak testing was performed with an inflation maneuver that involved a 3 s ramp to a 3 s plateau pressure; the inflation was completely abrogated after needle perforation of the pleura. Using nonbiologic materials, pressure-decay leak testing demonstrated an exponential decay with a plateau phase in materials with a Young's modulus less than 5. In human pleural testing, the simulacrum was used to test the sealant function of four mixtures of pectin-based polymers. A 50% high-methoxyl pectin and 50% carboxymethylcellulose mixture demonstrated no sealant failures at transpleural pressures of 60 cmH2 O. In contrast, pectin mixtures containing 50% low-methoxyl pectin, 50% amidated low-methoxyl pectins, or 100% carboxymethylcellulose demonstrated frequent sealant failures at transpleural pressures of 40-50 cmH2 O (p < 0.001). Inhibition of sealant adhesion with enzyme treatment, dessication and 4°C cooling suggested an adhesion mechanism dependent upon polysaccharide interpenetration. We conclude that pectin-based heteropolysaccharides are a promising air-tight sealant of human pleural injuries. © 2018 Wiley Periodicals, Inc. J. Biomed. Mater. Res. Part B, 2018.

This study used an airway model to compare the ability of a pediatric endotracheal tube with a taper-shaped cuff to prevent microaspiration relative to endotracheal tubes with conventional cuffs. Four different types of 5.0-mm inner diameter cuffed pediatric endotracheal tubes (taper-shaped cuff [Taper], high-volume low-pressure [Hi-Lo], middle-volume low-pressure [Intermediate], and low-volume low-profile [Lo-Pro]) were fixed within vertically placed acrylic tubes. The cuffs were maintained at 10, 20, or 30 cmH2 O pressure and 3 mL of simulated stomach contents was added to the top of the cuffs. The volume of leakage around the cuffs after 5 min and 4 h was measured. After 5 min, the volume of leakage was significantly lower with the Taper than with the Hi-Lo, Intermediate, or Lo-Pro at all pressure settings. After 4 h, leakage was significantly lower with the Taper than with the other three tubes regardless of initial cuff pressure (P < 0.05).

OBJECTIVE

This study assesses the potential of epispinal (subdural) stimulation application in the treatment of urinary and bowel neurological disorders. Acute experiments were performed on a large animal model - the domestic pig - to develop a new methodology facilitating future results and technology transfers to human.

METHODS

After rectal and bladder catheterization, four Landrace pigs (45-50 kg) underwent spinal cord surgery - that is, lumbosacral incision, laminectomy [L4-S4], dural opening and microsurgical arachnoid dissection. Three successive electrical stimulation sessions were carried out: 1) nerve roots stimulation, 2) epispinal stimulation with a matrix electrode, 3) epispinal stimulation with a small diameter needle electrode. Changes in rectal and bladder pressures were monitored throughout the various procedures to identify spinal areas inducing responses while evaluating the influence of electrode contacts size in the measured responses amplitudes.

RESULTS

An interesting area was identified in the upper portion of the spinal myelomeres (ie, spinal cord segment delimited by two successive pairs of spinal roots) directly adjoining root with best pressures (either rectal or vesical). Significant responses (up to 40 cmH2 O) were also obtained with a needle electrode. Furthermore, bowel evacuation was triggered in one of the animals. Despite the use of smaller electrode contacts, no detrusor or rectum selective responses were observed in none of the sessions.

CONCLUSIONS

This study showed, for the first time, that epispinal stimulation causes significant detrusor and rectal responses in pigs and allows considering further studies with the objective of treating urinary and rectal disorders in spinal cord injury patients.

OBJECTIVE

Mechanical in-exsufflation (MI-E) augments the weakened cough of patients with neuromuscular disease (NMD), clearing secretions and overcoming atelectasis. Little has been published on the impact of MI-E alone on rates of hospitalisation and quality of life (QOL). The aim of this study was to assess the impact of home MI-E on hospital admissions and life-style in children with NMD.

METHODS

A retrospective chart review was performed on children using MI-E, including data on the number of admissions to hospital, length of stay and hours of ventilation. A parental survey was used to gather information on the impact of MI-E on life-style for the child and family.

RESULTS

Ten children with NMD (seven spinal muscular atrophy, two Duchenne muscular dystrophy and one centronuclear myopathy) using MI-E at home were identified. MI-E use commenced at mean age of 8.5 years (range 1.1-16.9) with 1.4 years of use (range 0.3-3.8). MI-E pressures ranged from +/-30 to 40 cmH2 O with no complications reported. There was a significant reduction in hospital days at 6 (P = 0.036) and 12 (P = 0.028) months following commencement of home MI-E compared with the same period preceding MI-E use. The survey highlighted positive benefits of MI-E use, in particular the ability to treat many pulmonary exacerbations at home.

CONCLUSIONS

Home MI-E use by children with NMD can reduce hospitalisation and benefit families by maintaining their child at home.

To assess long-term subjective, objective, and urodynamic outcomes of retropubic mid-urethral slings at 13-year follow-up.

This was a prospective observational study. Consecutive women with proven urodynamic stress incontinence were treated with standard retropubic tension free vaginal tape (TVT). Patients with mixed incontinence and/or anatomic evidence of pelvic organ prolapse were excluded. All the included patients underwent preoperative clinical and urodynamic evaluations. During follow-up examinations, women were assessed for subjective satisfaction and objective cure rates. The Cox model was used in order to investigate factors predicting the risk of recurrent stress urinary incontinence (SUI), over the study period.

Overall, 55 patients were suitable for the analysis. At 13-year follow-up, 47 out of 55 (85.5%) patients declared themselves cured (p-for-trend 0.02) and 48 out of 58 (87.2%) were at least improved (p-for-trend 0.07). No significant deterioration of objective cure rates was observed over time (P = 0.29). At the time of the last evaluation, 50 out of 55 (90.9%) women were objectively cured; urodynamic evaluation confirmed this finding in 49 (89.1%) patients. Considering factors predictive of SUI recurrence, we observed that, via multivariate analysis, obesity (HR 7.2; P = 0.01) and maximum detrusor pressure during the voiding phase ≤29 cmH2 O (HR 8.0; P = 0.01) were the only independent predictors of recurrent SUI.

Our data confirmed that TVT is a highly effective and safe procedure also at 13-year follow-up. Interestingly, we observed a significant decrease of subjective satisfaction over time. Neurourol. Urodynam. 36:192-197, 2017. © 2015 Wiley Periodicals, Inc.

OBJECTIVE

We studied the influence of preoperative detrusor underactivity in patients with stress urinary incontinence on the postoperative continence rates and patient satisfaction.

METHODS

Medical records of 41 female patients who had detrusor underactivity and had undergone a midurethral sling procedure with a follow up of at least 12 months were reviewed. The preoperative evaluation included a history taking, physical examination, voiding diary for 3 days and an urodynamic study. Detrusor underactivity was defined at pressure flow study by a maximal flow rate (Qmax ) less than 15 mL/sec and a detrusor pressure at maximal flow rate (Pdet Qmax ) less than 20 cmH2 O. The postoperative evaluation included a continence state, questionnaire regarding patient satisfaction (5: very satisfied, 1: very unsatisfied), uroflowmetry and residual urine volume.

RESULTS

The mean patient age was 52.9 (range 39-68) years. Preoperatively, mean Qmax was 12.6 ± 2.1 mL/sec, mean residual urine volume was 16.1 ± 32.3 mL and mean Pdet Qmax was 13.1 ± 4.7 cmH2 O. Postoperative continence rate was 88% (36/41). Five patients experienced minimal incontinence when they coughed violently. The amount of patients satisfied with postoperative status was 71%. Postoperatively, three patients needed medication with alpha blocker because of voiding difficulty. There was significant differences between preoperative and postoperative Qmax (13.1 ± 0.9 mL/sec vs 17.1 ± 0.9 mL/sec, P < 0.05). In addition postoperative residual urine volume (26.1 ± 27.9 mL) was significantly increased compared to the preoperative residual urine volume (16.1 ± 32.3 mL) (P < 0.05).

CONCLUSIONS

Midurethral sling can be done safely for the patients with stress urinary incontinence and detrusor underactivity. However, the evaluation of preoperative detrusor function is important since the therapeutic outcome and postoperative voiding pattern may be affected by detrusor underactivity.

To determine the risk factors predicting upper urinary tract (UUT) deterioration in patients with spinal cord injury (SCI).

Medical records of 303 SCI patients who referred to the urodynamic unit of a rehabilitation hospital between 1996 and 2003 were retrospectively reviewed. The data included general patient demographics, SCI characteristics, bladder management methods, serum creatinine level, presence of urinary tract infection, indwelling catheter time, radiological findings of upper and lower urinary tract, and video-urodynamic (VUD) findings. Univariate and multivariate analyses were used to determine the risk factors predicting UUT deterioration. ROC analysis was done to determine the cut-off values of detrusor pressure and cystometric bladder capacity volume predicting UUT deterioration.

Complete data were available on 255 patients. Median patient age was 33 years (18-75). The leading causes of SCI were motor vehicle accidents (40%) and falls (29%). Upper urinary tract deterioration was determined in 63 patients (25%). Abnormal radiological LUT findings, the absence of antimuscarinic drug usage in the history, detrusor pressures greater than 75 cmH2 O and cystometric bladder capacity less than 200 ml were found to be independent risk factors in logistic regression analysis. ROC analysis revealed that values ≥75 cmH2 O for maximum detrusor pressure, <200 ml for bladder capacity, and >6 months for indwelling catheter time were cutoff values for UUT deterioration.

Abnormal radiological LUT findings, the absence of antimuscarinic drug usage, detrusor pressures ≥75 cmH2 O, and cystometric bladder capacity <200 ml were independent risk factors predicting UUT deterioration SCI patients. Neurourol. Urodynam. 36:653-658, 2017. © 2016 Wiley Periodicals, Inc.

BACKGROUND

Benign prostatic hyperplasia (BPH) is a common urologic disease in older men. Prostatic inflammation research has focused on the magnitude of inflammation; its location has received little attention. We investigated whether the anatomic location of prostatic inflammation is related to the severity of lower urinary tract symptoms (LUTS), measured subjectively and objectively.

METHODS

We retrospectively analyzed hematoxylin+eosin-stained tissue specimens from 179 BPH patients who underwent transurethral resection of the prostate (TURP) or holmium laser enucleation of the prostate (HoLEP). Chronic prostatic inflammation was assessed by the grade (lymphocyte density), extent (lymphocyte distribution), and location of inflammation. Each inflammation-finding type was evaluated in relation to these clinical parameters: age, prostate volume, prostate-specific antigen (PSA) value, body mass index (BMI), the frequency of acute urinary retention (AUR) episodes, the international prostatic symptom score (IPSS), and urodynamic study results.

RESULTS

The magnitude and extent of inflammation were not associated with any clinical parameters. We classified the BPH patients into stromal (n = 72) versus non-stromal (n = 105) groups based on their inflammation's dominant location. The stromal group's prostatic volume was significantly larger than the non-stromal group's (63.8 vs 53.8 mL; P = 0.032). AUR episodes were more significantly frequent in the stromal group (36.1% vs 11.4%; P = 0.006). Between-group differences in storage parameters (ie, maximum cystometric capacity) in the urodynamic study were not significantly different. Voiding parameters differed significantly between the stromal and non-stromal groups: maximum detrusor pressure (maxPdet) (116.8 vs 94.5 cmH2 O, P = 0.014), Pdet at the maximum flow rate (Qmax) (95.8 vs 75.4 cmH2 O, P = 0.014), and the bladder outlet obstruction index (BOOI) (78.5 vs 56.3, P = 0.014). The stromal group's Qmax was significantly lower than the non-stromal group's (7.3 vs 9.8 mL/s, P = 0.004).

CONCLUSIONS

The location of inflammation in the prostate might be an important factor affecting the severity of LUTS, especially voiding dysfunction.

Low bladder compliance means an abnormal volume and pressure relationship, and an incremental rise in bladder pressure during the bladder filling. It is well known that at the time bladder capacity decreases, intravesical pressure increases, and the risk of upper deterioration increases. Hypocompliance is usually thought to be the range from 1.0 to 20.0 mL/cmH2 O. Though the exact cause of hypocompliance is not known, it may be caused by changes in the elastic and viscoelastic properties of the bladder, changes in detrusor muscle tone, or combinations of the two. Management aims at increasing bladder capacity with low intravesical pressure. The main is a medical therapy with antimuscarinics combined with clean intermittent catheterization. The results are sometimes unsatisfactory. Various drugs or agents through the mouth or the bladder, including oxybutynin, new antimuscarinics, capsaicin and resiniferatoxin were tried. Among them botulinum toxin-A is promising. Some patients eventually required surgical intervention in spite of the aggressive medical therapy. Finally most patients undergo the surgical treatment including autoaugmentation, diversion, and augmentation cystoplasty. Among them augmentation cystoplasty still seems the only clearly verified treatment method.

OBJECTIVE

To evaluate the efficacy of clean intermittent catheterization for urinary incontinence in myelodysplastic children.

METHODS

The cohort comprised of 38 children (19 boys and 19 girls, aged between 10 months to 16 years) with neurogenic bladder secondary to myelodysplasia. Group A included 16 children who had dilated upper urinary tract or vesicoureteral reflux when clean intermittent catheterization was introduced. The remaining 22 children with normal upper urinary tract were enrolled to group B. In the present study, we defined socially acceptable continence as having completely dry or slight stress incontinence that patients can manage with several small pads.

RESULTS

Of the 16 group A patients, 9 obtained socially acceptable continence by conservative management. Of the 22 group B patients, 11 reported socially acceptable continence by conservative management. Vesical compliance was significantly higher in cases who reported socially acceptable continence than in those with incontinence persistent regarding all participants (10 ± 7.2 vs 6.8 ± 6.2 mL/cmH2 O, P = 0.0347) and group A (9.1 ± 6.7 vs 3.7 ± 1.4 mL/cmH2 O, P = 0.0350). Leak point pressure was significantly higher in patients who obtained socially acceptable continence than in those having persistent incontinence regarding all participants (50 ± 17.2 vs 25 ± 6.6 mL/cmH2 O, P = 0.0003), group A (51 ± 21.4 vs 26 ± 7.2 mL/cmH2 O, P = 0.0348) and also, group B (49 ± 12.8 vs 23.7 ± 6.3 mL/cmH2 O, P = 0.0043).

CONCLUSIONS

In our series, socially acceptable continence was obtained in only 20 patients (52%) by conservative management. The present study suggests that the limitation of conservative treatment seems to be apparent when they have urethral closure deficiency and/or intractable poor vesical compliance.

BACKGROUND

The air-Q is a new supraglottic airway device (SAD) and has been increasingly used as a primary airway device and as a conduit for tracheal intubation in children as well as in adults. This device has either performed equally or better than other SADs in children. The Ambu Aura-i is a commonly used SAD in children undergoing various short surgical procedures. However, limited literature is available evaluating the safety and efficacy of the air-Q and the Ambu Aura-i in small children. We, therefore, conducted this study to compare the clinical performance of these two airway devices in infants weighing up to 10 kg. Our hypothesis is that air-Q, due to its improved and larger cuff design will yield better airway seal pressures as compared with the Ambu Aura-i.

METHODS

Sixty-four ASA I-II infants weighing <10 kg undergoing elective ophthalmic surgery were randomly assigned to receive either an air-Q or the Ambu Aura-i. After induction of general anesthesia (GA) and muscle relaxation, we measured oropharyngeal leak pressure (OLP) as the primary outcome. The secondary end points measured were time to insert, first insertion success rate, fiberoptic grade (FO) of laryngeal view and any other airway complications like trauma, laryngospasm, and desaturation.

RESULTS

The air-Q ILA provided significantly higher OLP as compared with the Ambu Aura-i [20.2 ± 4.6 cm H2 O, CI 18.55-21.88; vs 16.2 ± 5.6 cmH2 O, CI 14.27-18.25, P = 0.003; mean difference 4 ± 1.29 cm H2 O, CI 1.41-6.58]. However, the Ambu Aura-i required significantly less time for its insertion (14.6 ± 2.8 s, CI 13.66-15.70; vs 16.3 ± 1.5 s, CI 15.75-16.86, P = 0.005; mean difference 1.625 ± 0.56 s, CI 0.48-2.76). There were no differences in first insertion success rate, FO view, and postoperative complications.

CONCLUSIONS

We conclude that air-Q may be considered superior to Ambu Aura-i in infants for controlled ventilation as it provides higher airway sealing pressures.

Previous comparisons between the Ambu(®) AuraOnce(™) and other laryngeal mask airways have revealed different results across various clinical studies. We aimed to perform a systematic review with meta-analysis on the efficacy and safety of the AuraOnce compared with other laryngeal mask airways for airway maintenance in adults undergoing general anaesthesia. Our search of PubMed, PubMed Central, Scopus and the Central Register of Clinical Trials of the Cochrane Collaboration yielded nine randomised controlled trials eligible for inclusion. Comparator laryngeal mask airways were the LMA Unique(™) (four trials), the LMA Classic(®) (five trials) and the Portex(®) Soft Seal(®) (three trials). The AuraOnce provided an oropharyngeal leak pressure higher than the LMA Unique (304 participants, mean (95% CI) difference 3.1 (1.6-4.7) cmH2 O, p < 0.0001) and equivalent to the LMA Classic. The Soft Seal provided a higher leak pressure than the AuraOnce (229 participants, mean (95% CI) difference 3.5 (0.4-6.7) cmH2 O, p = 0.03). Insertion was significantly faster with the AuraOnce than the LMA Unique (304 participants, mean (95% CI) difference 5.4 (2.1-8.71) s, p = 0.001) and Soft Seal (229 participants, mean (95% CI) difference 9.5 (3.0-15.9) s, p = 0.004), but similar to the LMA Classic. The first-insertion success rate of the AuraOnce was equivalent to the LMA Unique, LMA Classic and Soft Seal. We found a higher likelihood of bloodstaining on the cuff with the Soft Seal and a higher incidence of sore throat with the LMA Classic. We conclude that the AuraOnce is an effective alternative to the LMA Classic and LMA Unique, and easier to insert than all three other devices studied.

BACKGROUND

We conducted this study to test whether pulse-oximetry hemoglobin saturation (SpO2 ) can personalize the implementation of an open-lung approach during laparoscopy. Thirty patients with SpO2 ≥ 97% on room-air before anesthesia were studied. After anesthesia and capnoperitoneum the FIO2 was reduced to 0.21. Those patients whose SpO2 decreased below 97% - an indication of shunt related to atelectasis - completed the following phases: (1) First recruitment maneuver (RM), until reaching lung's opening pressure, defined as the inspiratory pressure level yielding a SpO2 ≥ 97%; (2) decremental positive end-expiratory (PEEP) titration trial until reaching lung's closing pressure defined as the PEEP level yielding a SpO2 < 97%; (3) second RM and, (4) ongoing ventilation with PEEP adjusted above the detected closing pressure.

RESULTS

When breathing air, in 24 of 30 patients SpO2 was < 97%, PaO2 /FIO2 ˂ 53.3 kPa and negative end-expiratory transpulmonary pressure (PTP-EE ). The mean (SD) opening pressures were found at 40 (5) and 33 (4) cmH2 O during the first and second RM, respectively (P < 0.001; 95% CI: 3.2-7.7). The closing pressure was found at 11 (5) cmH2 O. This SpO2 -guided approach increased PTP-EE (from -6.4 to 1.2 cmH2 O, P < 0.001) and PaO2 /FIO2 (from 30.3 to 58.1 kPa, P < 0.001) while decreased driving pressure (from 18 to 10 cmH2 O, P < 0.001). SpO2 discriminated the lung's opening and closing pressures with accuracy taking the reference parameter PTP-EE (area under the receiver-operating-curve of 0.89, 95% CI: 0.80-0.99).

CONCLUSIONS

The non-invasive SpO2 monitoring can help to individualize an open-lung approach, including all involved steps, from the identification of those patients who can benefit from recruitment, the identification of opening and closing pressures to the subsequent monitoring of an open-lung condition.

OBJECTIVE

To study possible associations between pelvic floor muscle contraction, levator ani muscle (LAM) trauma and/or anatomic pelvic organ prolapse (POP) in parous women recruited from a general population.

METHODS

Cross-sectional study of 608 parous women examined with POP quantification (POP-Q) and 3D/4D transperineal ultrasound for identification of LAM macrotrauma (avulsion) and microtrauma (distension >75 percentile of the levator hiatus at Valsalva). Muscle contraction was assessed with Modified Oxford Scale (MOS), vaginal perineometry and ultrasound measurements of proportional change of anteroposterior diameter and levator hiatal area at rest and contraction. Mann-Whitney U test was used to study associations between contraction, LAM trauma and POP.

RESULTS

Women with macrotrauma (n= 113) had significantly weaker median (range) muscle contraction (MOS and perineometry) than women with intact levator (n=493) with MOS 1.5 (0.0 - 5.0) vs 3.5 (0.0 - 5.0) and perineometry 15.0 cmH2 O (0.0 -78.0) vs 28.0 cmH2 O (0.0 -129.0), p < 0.001. This was also demonstrated by ultrasound measurements (proportional change in hiatal area 19.9 (4.1 - 48.0) vs 34.0 (-212.3 - 64.0) and anteroposterior diameter 16.2 (-5.7 - 42.6) vs 26.0 (-3.4 - 42.6), p < 0.001. No statistically significant difference between women with (n=65) and without microtrauma (n=378) was found after excluding women with macrotrauma. We found weaker muscle contraction in women with pelvic organ prolapse. Women with POP-Q ≥2 (n=275) had weaker contraction than women with POP-Q <2 (n=332): MOS 3.0 (0.0 - 5.0) vs 3.5 (0.0 - 5.0), perineometry 21.0 cmH2 O (0.0 - 98.0) vs 28.0 cmH2 O (3.0 - 129.0), proportional change in hiatal area 30.0 (0.0 - 60.9) vs 33.8 (0.0 - 60.9) and anteroposterior diameter 22.8 (-5.7 - 49.4) vs 25.7 (-3.4 - 49.4), p< 0.001.

CONCLUSIONS

Levator macrotrauma was associated with weaker pelvic floor muscle contraction measured with palpation, perineometry and ultrasound. Women with pelvic organ prolapse had weaker contraction than women without prolapse. This article is protected by copyright. All rights reserved.

OBJECTIVE

To investigate video-urodynamic effects of mirabegron, a β3 -adrenoceptor agonist, on low-compliance bladder.

METHODS

We retrospectively reviewed nine patients (three men, six women, age 17-68 years) who had been diagnosed with lower urinary tract dysfunction with low-compliance bladder, and who underwent video-urodynamic study before and during administration of mirabegron 50 mg once daily. Urodynamic parameters were compared before and after treatment.

RESULTS

Mirabegron treatment significantly increased first desire to void and cystometric capacity with an average increment of 80 mL (P = 0.027) and 123 mL (P = 0.005), respectively. Bladder compliance also significantly increased (mean value 8.1 mL/cmH2 O before, 18.2 mL/cmH2 O after, P = 0.024). In the six patients who had been taking anticholinergic agents at baseline video-urodynamic study and then switched to mirabegron, mean cystometric capacity and bladder compliance were also increased significantly from 208.3 to 346.8 mL (P = 0.015) and from 7.2 to 17.5 mL/cmH2 O (P = 0.047), respectively. Vesicoureteral reflux grade was improved in three of the four patients who had shown vesicoureteral reflux on cystography before treatment.

CONCLUSIONS

Mirabegron improves cystometric capacity and bladder compliance, and it lowers vesicoureteral reflux grade in patients with low-compliance bladder. Thus, mirabegron might represent a good alternative drug for low-compliance bladder refractory to anticholinergic treatment.

Disseminated Cryptococcus disease occurs in patients with defective T-cell immunity. Cryptococcal meningitis following autologous stem cell transplant (SCT) has been described previously in only 1 patient, 4 months post SCT and while off antifungal prophylaxis. We present a unique case of Cryptococcus meningitis pre-engraftment after autologous SCT, while the patient was receiving fluconazole prophylaxis. A 41-year-old man with non-Hodgkin's lymphoma underwent autologous SCT. Post-transplant prophylaxis consisted of fluconazole 400 mg daily, levofloxacin 500 mg daily, and acyclovir 800 mg twice daily. On day 9 post transplant, he developed fever and headache. Peripheral white blood cell count (WBC) was 700/μL. Magnetic resonance imaging of the brain showed lesions consistent with meningoencephalitis. Cerebrospinal fluid (CSF) analysis revealed a WBC of 39 with 77% lymphocytes, protein 63, glucose 38, CSF pressure 20.5 cmH2 O, and a positive cryptococcal antigen. CSF culture confirmed Cryptococcus neoformans. The patient was treated with liposomal amphotericin B 5 mg/kg intravenously daily, and flucytosine 37.5 mg/kg orally every 6 h. He was switched to fluconazole 400 mg daily after 3 weeks of amphotericin therapy, with sterilization of the CSF with negative CSFCryptococcus antigen and negative CSF culture. Review of the literature revealed 9 cases of cryptococcal disease in recipients of SCT. Median time of onset was 64 days post transplant. Only 3 meningitis cases were described; 2 of them after allogeneic SCT. Fungal prophylaxis with fluconazole post autologous SCT is recommended at least through engraftment, and for up to 100 days in high-risk patients. A high index of suspicion is needed to diagnose and treat opportunistic infections, especially in the face of immunosuppression and despite adequate prophylaxis. Infection is usually fatal without treatment, thus prompt diagnosis and therapy might be life saving.

OBJECTIVE

To determine the impact of vaginal pelvic reconstructive surgery (PRS) on detrusor underactivity (DU) patients having advanced pelvic organ prolapse (POP).

METHODS

A retrospective study of patients who underwent PRS for advanced POP (POP-Q ≥ 3) with DU. Data regarding preoperative evaluation, surgical procedure, and post-operative management were collated. Patients were considered to have DU when detrusor pressure at maximum flow (Pdet Qmax ) was ≤10 cmH2 0 and peak flow rate (Qmax ) of ≤12 mL/s. Post-operative values more than the cut-off were considered objectively cured. Subjective cure was defined as having a negative response to UDI-6 Question 5, "Do you experience difficulty emptying your bladder?"

RESULTS

A total of 49 patients were evaluated. Majority of the population were post-menopausal and multiparous. Preoperatively, 38 patients (75%) had stage III prolapse and 13 patients (26%) had stage IV. Subjective cure rate of DU was 76% (37/49) and objective cure rate was 47% (23/49). Post-operative DU (P < 0.001) significantly improved together with patients having normal urodynamic diagnosis (P < 0.001). Voiding function showed significant increase in Qmax (P < 0.001) and Pdet Qmax (P < 0.001) while PVR (P < 0.001) and cystometric capacity (P < 0.001) significantly decreased. These findings were observed in 89% (43/49) of patients with post-void residual urine (PVR) of <200 mL, 63% (31/49) with Qmax >> 12 mL/s, and 57% (28/49) with Pdet Qmax >10 cmH2 0.

CONCLUSIONS

Reversal of short-term or long-term obstruction through vaginal pelvic reconstructive surgery enables bladders to regain detrusor muscle function. Although objective cure of DU was at 47%, detrusor function recovered in 57% of patients provided that mechanical obstruction was the cause.

BACKGROUND

Mouthpiece ventilation represents a valuable treatment for patients needing daytime non-invasive ventilation. This modality is however underused, in part because of limitations in the available equipment.

OBJECTIVE

To develop a new flexible and moldable mouthpiece, aiming to address some of the issues of the currently available interfaces.

METHODS

We compared two commercially available and the newly developed mouthpieces in a bench test using four life-support home ventilators and three settings per ventilator.

RESULTS

The three interfaces showed marked differences in their resistive characteristics. In the volume-controlled setting (VC-CMV) with 500 mL tidal volume (VT ), the delivered VT , ranged between 459 ± 7 mL (-8%) and 501 ± 4 mL (+0.2%), according to the used ventilator. In the VC-CMV setting with VT 1000 mL, one of the ventilators did not assure the set VT with the new mouthpiece, because of the high-pressure limitation. In the pressure-controlled setting (PC-CMV at 20 cmH2 O), the effective pressure differed between the tested interfaces according to their resistance, resulting in a decrease in the delivered VT .

CONCLUSIONS

They found measurable differences in the ventilation's performances comparing the interfaces for mouthpiece ventilation, which seem to have a minor clinical relevance in the most settings, but should be systematically checked. They validated in-vitro the newly developed mouthpiece with respect to the ventilation performances; a clinical study is needed to investigate the potential advantages we expect from the new mouthpiece.

BACKGROUND

Mechanical ventilation (MV) can result in inflammation and subsequent lung injury. Toll-like receptor (TLR)4 and NF-κB are proposed to play a crucial role in the MV-induced inflammatory response. Resveratrol (RVT) exhibits anti-inflammatory effects in vitro and in vivo supposedly by interfering with TLR4 signaling and NF-κB. In the present study, we investigated the role of RVT in MV-induced inflammation in mice.

METHODS

RVT (10 mg/kg, 20 mg/kg and 40 mg/kg) or vehicle was intraperitoneally administered 1 h before start of MV (4 h, tidal volume 8 ml/kg, positive end-expiratory pressure 1,5 cmH2 O and FiO2 0.4). Blood and lungs were harvested for cytokine analysis. DNA binding activity of transcription factor NF-κB was measured in lung homogenates.

RESULTS

MV resulted in elevated pulmonary concentrations of IL-1β, IL-6, keratinocyte-derived chemokine (KC) and NF-κB DNA-binding activity. RVT at 10, 20 and 40 mg/kg reduced NF-κB's DNA-binding activity following MV compared with ventilated controls. However, no differences in cytokine release were found between RVT-treated and control ventilated mice. Similarly, in plasma, MV resulted in elevated concentrations of TNF-α, KC and IL-6, but RVT did not affect cytokine levels.

CONCLUSIONS

RVT abrogates the MV-induced increase in pulmonary NF-κB activity but does not attenuate cytokine levels. This implies a less prominent role for NF-κB in MV-induced inflammation than previously assumed.

OBJECTIVE

To compare outcomes of renal transplantation (RTx) in children with end-stage renal disease (ESRD) resulting from lower urinary tract dysfunction (LUTD) vs other causes.

METHODS

A database of children (<18 years old) who underwent RTx between May 2008 and April 2012 was reviewed. Patients were divided into those with LUTD (group A, n = 29) and those with other causes of ESRD (group B, n = 74). RTx was performed after achieving low intravesical pressure (<30 cmH2 O) with adequate bladder capacity and drainage. The groups were compared using Student's t-test, Mann-Whitney, chi-squared or exact tests. Graft survival rates (GSRs) were evaluated using Kaplan-Meier curves and the log-rank test.

RESULTS

The mean ± sd (range) age of the study cohort was 5.05 ± 12.4 (2.2-18) years. Causes of LUTD were posterior urethral valve (PUV; 41.4%), vesico-ureteric reflux (VUR; 37.9%), neurogenic bladder (10.3%), prune belly syndrome (3.4%), obstructive megaureter (3.4%) and urethral stricture disease (3.4%). There was no significant difference in age, dialysis duration or donor type. In group A, 25 of the 29 patients (86.2%) underwent ≥1 surgery to optimize the urinary tract for allograft. Pretransplant nephrectomy was performed in 15 of the 29 patients (51.7%), PUV ablation in nine patients (31%) and ileocystoplasty in four patients (13.7%). The mean ± sd follow-up was 4.52 ± 1.55 and 4.07 ± 1.27 years in groups A and B, respectively. There was no significant difference in creatinine and eGFR between the groups at different points of follow-up. The GSRs at the end of the study were 93.1 and 91.1% in groups A and B, respectively (P = 1.00). According to Kaplan-Meier survival curves, there was no significant difference in the GSR between the groups using the log-rank test (P = 0.503). No graft was lost as a result of urological complications. In group B, one child died from septicaemia. The rate of urinary tract infections was 24 and 12% in groups A and B, respectively, but was not significant. No significant difference was found between the groups with regard to the incidence of post-transplantation hydronephrosis. Of the 22 patients who had hydronephrosis after transplantation, three were complicated by UTI. Injection of bulking agents was required in two patients for treatment of grade 3 VUR. In the third patient, augmentation cystoplasty was needed.

CONCLUSIONS

Acceptable graft function, survival and UTI rates can be achieved in children with ESRD attributable to LUTD. Thorough assessment and optimization of LUT, together with close follow-up, are key for successful RTx.

Background: The Ambu Aura Gain is a newer second-generation supraglottic airway device designed for fibreoptic bronchoscopy (FOB)-guided tracheal intubation.

Methods: 57 patients between 18 months and 6 years of age were randomized to receive either the Ambu Aura-I (n:29) or the Ambu Aura Gain (n:28). Primary endpoint was the time for intubation. Secondary endpoints were the time and number of attempts for device insertion, the feasibility of FOB-guided intubation, the oropharyngeal leak pressure (OLP) the fibreoptic grade of laryngeal view and possible complications.

Results: No difference was found in the time for intubation, the time for device insertion or the fibreoptic grade of laryngeal view. First-attempt device insertion was successful in all (n= 28) patients with Aura Gain (100%) and in 27 (97%) with Aura-i. In the Aura-i group one insertion failed. A significant difference in successful intubation was seen between the Aura-i and the Aura Gain (79% vs 100%, respectively, p=0,0011). Also found was a significant difference in the mean OLP (SD) between the Ambu Aura-i and the Ambu Aura Gain (18 (3) vs 20 (3) cm H2O, respectively; mean difference [MD] - 2 cmH2 O; P = 0.005).

Conclusions: The Ambu Aura Gain served as a reliable device for FOB-guided tracheal intubation. Even if the time for intubation, when intubation was possible did not differ, the Aura-i showed only 79% intubation success, making it a doubtful device for FOB-guided tracheal intubation in cases of emergency and severe hypoxemia in small children.

Catheters that traverse the pharynx are often in place during clinical or research evaluations of upper airway function. The purpose of this study was to determine whether the presence of such catheters affects measures of upper airway collapsibility itself. To do so, pharyngeal critical closing pressure (Pcrit) and resistance upstream of the site of collapse Rus) were assessed in 24 propofol-anaesthetized subjects (14 men) with and without a multi-sensor oesophageal catheter (external diameter 2.7 mm) in place. Anaesthetic depth and posture were maintained constant throughout each study. Six subjects had polysomnography(PSG)-defined obstructive sleep apnea (OSA) and 18 either did not have or were at low risk of OSA. Airway patency was maintained with positive airway pressure. At intervals, pressure was reduced by varying amounts to induce varying degrees of inspiratory flow limitation. The slope of the pressure flow relationship for flow-limited breaths defined Rus. Pcrit was similar with the catheter in and out (-1.5 ± 5.4 cmH2 O and -2.1 ± 5.6 cmH2O, respectively, P = 0.14, n = 24). This remained the case both for those with PSG-defined OSA (3.9 ± 2.2 cmH2O and 2.6 ± 1.4 cmH2O, n = 6) and those at low risk/without OSA (-3.3 ± 4.9 cmH2O and -3.7 ± 5.6 cmH2O, respectively, n = 18). Rus was similar with the catheter in and out (20.0 ± 12.3 cmH2O mL(-1) s(-1) and 16.8 ± 10.1 cmH2O mL(-1) s(-1), P = 0.22, n = 24). In conclusion, the presence of a small catheter traversing the pharynx had no significant effect on upper airway collapsibility in these anaesthestized subjects, providing reassurance that such measures can be made reliably in their presence.