Descending perineal syndrome cure by deep transversus perinei ligament repair: surgical options.

Descending perineal syndrome (DPS) was described by Parks et al. as descent of the anus on straining, typically 3-4 cm below a line drawn from the coccyx to the lower end of the. DPS is associated with obstructed defecation, with increased bulging of the perineum with straining, although perineal descent can also be seen at rest. In their review, Chaudhry and Tarnay stated: "It is controversial whether surgical management is even an option for patients with DPS". The deep transversus perinei (DTP) ligaments are the suspensory ligaments of the perineal body (PB). DTP are approximately 4 cm long. They attach behind the upper 2/3 and lower 1/3 of the descending ramus. If, at childbirth, the PB is overstretched and displaced laterally and inferiorly, the DTP lengthens. DPS is described as descent of the anus on straining, typically 3-4 cm below a line drawn from the coccyx to the lower end of the symphysis. DPS is associated with obstructed and often, assisted defecation, with increased bulging of the perineum with straining descent of the anus on straining. The surgical methodology begins as a standard PB repair which dissects the rectum from the vagina and PB and approximates the displaced components of the PB. We added an additional step: identifying the DTPs, shortening and reinforcing them with the Tissue Fixation System (TFS) minisling or No. 2 polyester sutures. High cure rates for obstructed defecation were achieved with the TFS minisling, and initial results using No. 2 polyester sutures are favourable. The key messages from both operations is DPS is caused by stretching and elongation of DPS ligaments, and these are surgically repairable.

Wide-bore polyester sutures may create sufficient collagen for cure of prolapse/incontinence: a work in progress.

The main thrust of the Integral Theory Paradigm (ITP) is that inadequate ligament collagen causes pelvic organ prolapses (POP) and pelvic symptoms, a concept validated by multiple publications which cured POP and bladder/bowel/pain dysfunctions by collagen-creating slings. Sling surgery for surgical cure of these conditions was eliminated in the United States, Europe and other regulatory jurisdictions by banning all mesh products (including tapes) in about 2017. The aim of this work was to inform of the progress of a highly promising alternative method for collage creation for ligament repair: wide-bore polyester sutures accurately applied to weak ligaments. The scientific rationale for the wide-bore polyester plication method was a revisit and analysis of prior Instron testing data from a rejected polyester aortic graft from a doctoral thesis. The analysis indicated that the collagen produced by No. 2 polyester sutures would be sufficient to repair weakened pelvic ligaments. The surgical methodology consisted of application of wide-bore No. 2 or No. 3 polyester sutures to existing vaginal surgical techniques such as cardinal/uterosacral ligament (CL/USL) repair in the Fothergill operation, deep transversus perinei (DTP) ligamentous supports of the perineal body (PB) and uniquely, pubourethral ligament (PUL) repair for stress urinary incontinence (SUI). No vaginal tissue was excised. These operations are now being performed in several centres around the world. Because of this, the results detailed below are indicative only, and necessarily incomplete, as they are only from these units. Twelve month data (n=35) for SUI cure (83%) following PUL repair by the urethral ligament plication (ULP) operation has been submitted for publication; POP quantification (POPQ) points Ba, C, Bp, D were significantly improved at 6 weeks postoperative review following repair of CLs (cystocele) and USLs (uterine/apical prolapse) (n=56): deep transverse perinei ligament repair (descending perineal syndrome "DPS") (n=4) were cured at 6-12 months review. Though numbers are few, in the context of DPS being considered incurable, these numbers are significant. Except for the ULP operation, the techniques for cystocele, uterine prolapse, perineocele were essentially evolved versions of the Fothergill and standard PB repairs without any vaginal or ligament excisions. Though promising, more extensive and longer-term results are clearly required before this wide-bore polyester ligament repair method can become mainstream.

Does the Fast Alcohol Screening Test Accurately Distinguish Between Harmful and Severely Dependent Tiers of Alcohol Misuse?

AIMS: Primary aim: to determine the efficacy of FAST (the Fast Alcohol Screening Test) for detecting harmful and dependent levels of alcohol use. Secondary aim: to compare the performance of the FAST to two short forms of the Alcohol Use Disorder Identification Test (AUDIT): the AUDIT-C and AUDIT-3. METHODS: Data from 3336 individuals in South Wales, compiled from full AUDIT datasets, were examined. AUROC analysis, alongside measures of sensitivity and specificity of the FAST, AUDIT-C and AUDIT-3 were utilized for the identification of harmful and dependent alcohol use. RESULTS: The FAST demonstrated efficacy in the identification of harmful and dependent levels of alcohol use, with superior performance to both the AUDIT-C and AUDIT-3. CONCLUSION: The present paper demonstrates the potential of the FAST as a cost- and time-effective method for appropriate screening and signposting in the stepped care model utilized by many health care and treatment services. Further studies are needed to ensure validity, both within the general population and for specific services and populations.

Association between physical pain and alcohol treatment outcomes: The mediating role of negative affect.

OBJECTIVE: Physical pain and negative affect have been described as risk factors for alcohol use following alcohol treatment. The current study was a secondary analysis of 2 clinical trials for alcohol use disorder (AUD) to examine the associations between pain, negative affect and AUD treatment outcomes. METHOD: Participants included 1,383 individuals from the COMBINE Study (COMBINE Pharmacotherapies and Behavioral Interventions for Alcohol Dependence; COMBINE Study Research Group, 2003; 31% female, 23% ethnic minorities, average age = 44.4 [SD = 10.2]), a multisite combination pharmacotherapy and behavioral intervention study for AUD in the United States, and 742 individuals from the United Kingdom Alcohol Treatment Trial (UKATT Research Team, 2001; 25.9% female, 4.4% ethnic minorities, average age = 41.6 [SD = 10.1]) a multisite behavioral intervention study for AUD in the United Kingdom. The Form-90 was used to collect alcohol use data, the Short Form Health Survey and Quality of Life measures were used to assess pain, and negative affect was assessed using the Brief Symptom Inventory (COMBINE) and the General Health Questionnaire (UKATT). RESULTS: Pain scores were significantly associated with drinking outcomes in both datasets. Greater pain scores were associated with greater negative affect and increases in pain were associated with increases in negative affect. Negative affect significantly mediated the association between pain and drinking outcomes and this effect was moderated by social behavior network therapy (SBNT) in the UKATT study, with SBNT attenuating the association between pain and drinking. CONCLUSION: Findings suggest pain and negative affect are associated among individuals in AUD treatment and that negative affect mediated pain may be a risk factor for alcohol relapse.

Factors associated with the use and quality of antenatal care in Nepal: a population-based study using the demographic and health survey data.

BACKGROUND: Good quality antenatal care (ANC) reduces maternal and neonatal mortality and improves health outcomes, particularly in low-income countries. Quality of ANC is measured by three dimensions: number of visits, timing of initiation of care and inclusion of all recommended components of care. Although some studies report on predictors of the first two indicators, no studies on the third indicator, which measures quality of ANC received, have been conducted in Nepal. Nepal follows the World Health Organization's recommendations of initiation of ANC within the first four months of pregnancy and at least four ANC visits during the course of an uncomplicated pregnancy. This study aimed to identify factors associated with 1) attendance at four or more ANC visits and 2) receipt of good quality ANC. METHODS: Data from Nepal Demographic and Health Survey 2011 were analysed for 4,079 mothers. Good quality ANC was defined as that which included all seven recommended components: blood pressure measurement; urine tests for detecting bacteriuria and proteinuria; blood tests for syphilis and anaemia; and provision of iron supplementation, intestinal parasite drugs, tetanus toxoid injections and health education. RESULTS: Half the women had four or more ANC visits and 85% had at least one visit. Health education, iron supplementation, blood pressure measurement and tetanus toxoid were the more commonly received components of ANC. Older age, higher parity, and higher levels of education and household economic status of the women were predictors of both attendance at four or more visits and receipt of good quality ANC. Women who did not smoke, had a say in decision-making, whose husbands had higher levels of education and were involved in occupations other than agriculture were more likely to attend four or more visits. Other predictors of women's receipt of good quality ANC were receiving their ANC from a skilled provider, in a hospital, living in an urban area and being exposed to general media. CONCLUSIONS: Continued efforts at improving access to quality ANC in Nepal are required. In the short term, less educated women from socioeconomically disadvantaged households require targeting. Long-term improvements require a focus on improving female education.

What was useful about that session? Clients' and therapists' comments after sessions in the UK Alcohol Treatment Trial (UKATT).

AIM: The aim of this study was to report and contrast the aspects of two therapies considered by clients and therapists to be most and least useful. METHOD: In the UK Alcohol Treatment Trial (UKATT), 742 clients were treated by 49 therapists with up to three sessions of motivational enhancement therapy (MET) or up to eight sessions of social behaviour and network therapy (SBNT). After each treatment session, clients and therapists were asked to independently complete two sentences, one inviting a statement about the 'most useful' and the other about the 'least useful' thing that had happened during the session. RESULTS: The proportion of 'most useful' sentences completed was greater than the proportion of 'least useful' and equally so for MET and SBNT. The content of comments was significantly different for the two treatments: more comments on social aspects followed SBNT and more motivational comments followed MET, with larger numbers of comments following both treatments that were more general. Clients more often completed 'most useful' sentences than therapists and less often completed 'least useful' sentences. There were a number of differences in the content of their comments: notably more 'most useful' client comments about talking to their therapists, and more therapist comments about client engagement. CONCLUSIONS: MET and SBNT left distinct impressions on the participants immediately following treatment sessions, adding to the evidence that they are different treatments, and hence deepening the mystery about why outcomes following the two treatments were so similar [UKATT Research Team. (2005) Br Med J 331: 541-58].

To what factors do clients attribute change? Content analysis of follow-up interviews with clients of the UK Alcohol Treatment Trial.

The UK Alcohol Treatment Trial compared outcomes after a social treatment (Social Behavior and Network Therapy) and a motivational treatment (Motivational Enhancement Therapy). As part of the process element of the trial, a subsample of clients were interviewed 3 months after treatment allocation and another subsample 12 months after allocation (N = 397) to explore the factors to which clients attributed positive changes that might have occurred in their drinking. Postinterview reports were content analyzed using three types of code: social, motivational, and general. At 3 months, Social Behavior and Network Therapy clients made significantly more social attributions and Motivational Enhancement Therapy clients more motivational attributions, and the difference for motivational attributions was maintained at 12 months (with a trend for social attributions). Overall, the factors to which change was most frequently attributed were involvement of others in supporting behavior change (a social factor), awareness of the consequences of drinking (a motivational factor), and three general factors--determination, commitment, and decision; detoxification or medication; and feeling comfortable talking. Change was more frequently attributed to general factors than it was to either social or motivational ones. Some of the difficulties in eliciting and coding attribution material are referred to. The results may help understand the absence of between-treatment type outcome differences in UK Alcohol Treatment Trial and other trials.

The clients' perspective on change during treatment for an alcohol problem: qualitative analysis of follow-up interviews in the UK Alcohol Treatment Trial.

AIM: To develop a model of change during and following professional treatment for drinking problems, grounded in clients' accounts. PARTICIPANTS: Subsets of consecutively selected clients of the UK Alcohol Treatment Trial (UKATT), followed-up at 3 months (n = 211) and 12 months (n = 198) after randomization. Location Five statutory and non-statutory alcohol problems treatment agencies in three areas of England and Wales. Data Open-ended interviews conducted according to a brief interview guide, leading to 400-800-word post-interview reports used for analysis (tape-recordings used for auditing purposes). ANALYSIS: Reports analysed by a team according to grounded theory principles, involving an iterative process with successive refinement of interviewing and analysis with each successive batch of data. FINDINGS: A model of change from the clients' perspective was developed. Treatment was seen by clients as facilitating various changes in ways of thinking and/or increased support of various kinds from family and friends, along with new ways of acting in relation to drinking or more generally. For many those changes had led to an appreciation of the benefits accruing to them. Treatment was seen as part of a broader treatment system which included pretreatment assessment, forms of help additional to the trial treatment, plus an element of self-directed change during and following treatment. Taken with awareness of worsening alcohol-related harms, triggering events and external influence to seek treatment (the catalyst system), to which clients continued to refer following treatment, the change process is depicted as a complex, ongoing set of systems in which a trial treatment is embedded. CONCLUSIONS: Models of change should be broadened so that treatment is seen as a complex system of parts, facilitating a nexus of cognitive, social and behavioural changes, embedded within a broader system of events and processes catalysing change. Such a model helps explain the relative absence of between-treatments outcome differences in UKATT and in the alcohol problems treatment and more general psychotherapy research literatures.

Family interventions for alcohol problems.

A growing body of evidence demonstrates that family interventions should be towards the top of the list of effective alcohol prevention and treatment approaches. A recent conference run by the UK Alcohol Education and Research Council presented some of this evidence (go to: aerc.org.uk then 'News' for a summary).

Fast screening for alcohol misuse.

The Fast Alcohol Screening Test (FAST) has been developed from the AUDIT questionnaire. AUDIT: The Alcohol Use Disorders Identification Test: guidelines for use in primary health care. Geneva, Switzerland: World Health Organization for use in very busy medical settings. One feature of the FAST is its ease and speed of administration, especially since one question identifies over 50% of patients as either alcohol misusers or not. This study further explores the sensitivity and specificity of the FAST across ages, gender, and locations using the AUDIT as the gold standard. Two other quick tests are also compared with the AUDIT and the FAST, namely the Paddington Alcohol Test and the CAGE. All tests were quicker to administer than the AUDIT with the FAST taking just 12 s on average. All tests identified drinkers who would accept a health education booklet (over 70% of those identified) or 5 min of advice (over 40%). The FAST was consistently reliable when sensitivity and specificity were tested against AUDIT as the gold standard.

Social behaviour and network therapy basic principles and early experiences.

The present paper reports on the basic principles of a treatment approach currently being used in a National Multicentre Randomised Controlled Trial of Alcohol Treatments in the United Kingdom (UK Alcohol Treatment Trial). The treatment: Social Behaviour and Network Therapy (SBNT) is novel as a package but has been developed by integrating a number of strategies found to be effective in other treatment approaches. The intervention is based on the notion that to give the best chance of a good outcome people with serious drinking problems need to develop positive social network support for change. A brief review of the evidence supporting social treatments for alcohol problems is followed by an outline of the feasibility work and the basic principles that guided the development of SBNT. Process data from the first 33 trial cases and 2 case vignettes are described and discussed. It is concluded that SBNT is a feasible and coherent treatment approach that can be delivered by a range of therapists in the alcohol field.

The FAST Alcohol Screening Test.

Using the Alcohol Use Disorders Identification Test (AUDIT) as the gold standard, the Fast Alcohol Screening Test (FAST) was developed for use in busy medical settings. AUDIT questionnaires were completed by 666 patients in two London accident & emergency (A&E) departments. Using a principal components analysis, as well as sensitivity and specificity indices, a two-stage screening test was developed, using four of the AUDIT items. The first stage involved one item that identified >50% of patients as either hazardous or non-hazardous drinkers. The second stage made use of the other three items to categorize the rest. The performance of this four-item questionnaire was then tested across a range of settings. Opportunistic samples of 100 patients completed AUDIT questionnaires in each of the following National Health Service settings: A&E department, fracture clinic, primary health centre and a dental hospital. It was concluded that the four-item FAST questionnaire had good sensitivity and specificity, across a range of settings, when the AUDIT score was used as the gold standard. The FAST questionnaire is quick to administer, since >50% of patients are categorized using just one question.

Comment faire face aux problèmes de toxicomanie et d' alcoolisme dans la communauté : manuel de l' agent de soins de santé primaires avec des instructions pour les formateurs / publié sous la direction de Marcus Grant & Ray Hodgson / Responding to drug and alcohol problems in the community : a manual for primary health care workers, with guidelines for trainers

Ce manuel de formation a pour but d'aider les agents de soins de santé primaires à acquérir les connaissances théoriques et pratiques nécessaires pour prendre en charge les problèmes d'alcoolisme et de toxicomanie dans le cadre des soins de santé généraux. Face à la montée en flèche de l'alcoolisme et de la toxicomanie dans le monde, ce livre souligne la nécessité d'attaquer le problème au niveau communautaire, selon une approche intégrée unissant des interventions médicales, psychologiques et sociales pour traiter les patients, les soutenir, eux et leurs familles, et entraîner la communauté à prendre des mesures appropriées. Le manuel décrit pour cela un grand éventail de moyens simples et peu coûteux qui permettraient d'élargir les compétences des agents de santé de manière à couvrir la prévention et le traitement des problèmes de l'alcool et des drogues. Tout au long de l'ouvrage, des listes récapitulatives, des exemples, des questions, des conseils pratiques viennent aider le lecteur à comprendre comment il peut intégrer dans son travail quotidien des mesures de prévention simples

Respuesta a los problemas de drogas y de alcohol en la comunidad : manual para los agentes de atención primaria de salud con orientaciones para los instructores / editado por Marcus Grant y Ray Hodgson / Responding to drug and alcohol problems in the community : a manual for primary health care workers, with guidelines for trainers

Este manual de formación tiene por objeto ayudar a los agentes de atención primaria de salud a adquirir los conocimientos teóricos y prácticos necesarios para hacer frente a los problemas de la droga y del alcohol como parte de la asistencia sanitaria general. En vista de la escalada mundial en el abuso de drogas y de alcohol, en el libro se pone de relieve la necesidad de abordar el problema al nivel de la comunidad, utilizando un método integrado que combine las interven-ciones médicas, psicológicas y sociales para tratar a los distintos pacientes, darles ayuda a ellos y a sus familias y movilizar a la comunidad para que adopte las disposiciones apropiadas. Con este fin, se describe en el libro una amplia serie de cosas sencillas y baratas que pueden hacerse para ampliar la competencia de los trabajadores de atención de salud a fin de que abarque la prevención y el tratamiento de los problemas de la droga y del alcohol. A lo largo del libro se emplean numerosas listas, ejemplos, preguntas y consejos prácticos que ayudan a los lectores a comprender lo sencillas que pue-den llegar a ser las medidas preventivas como parte de su labor cotidiana. El manual, que está destinado a cursos de formación, tiene siete capítulos principales. En el primero se dan consejos acerca del uso de entrevistas para identificar los trastornos del abuso de sustancias en los pacientes y en sus familias y para formular un adecuado plan de acción. En el segundo se exponen las diferentes maneras de recoger indicios e información acerca de los problemas de la droga y del alcohol en una comunidad. En los siguientes capítulos se explica la contribución que los agentes de atención primaria de salud pueden aportar para la prevención a nivel primario, secundario y ter-ciario y se da asesoramiento sobre la forma de movilizar la acción de la comunidad y de estimular a los grupos de autoayuda. Particular utilidad práctica tiene el capítulo dedi-cado al tratamiento individual. Los lectores se enteran de cómo se puede asistir a los pacientes para que identifiquen su problema, adopten la mejor estrategia para la abstinencia, adquieran confianza en sí mismos, refuercen los apoyos sociales y afronten las situaciones que favorecen las recaídas. En los demás capítulos se explica por qué es necesaria la colaboración de los organismos de cumplimiento de la ley y cómo se puede conseguir; se describe también cierto número de instrumentos sencillos de evaluación de utilidad en la planificación y evaluación de programas. En el último capítulo, en el que se dan orientaciones generales para los instruc-tores, figura una serie de ejercicios de solución de problemas para el aprendizaje de técnicas esenciales de entrevista, asesoramiento, gestiones y acopio de información

Responding to drug and alcohol problems in the community : A manual for primary health care workers, with guidelines for trainers / Responding to drug and alcohol problems in the community : A manual for primary health care workers, with guidelines for trainers

Drug and alcohol abuse is increasing almost everywhere and constitues a serious public health and economic problem in many parts of the world. The problem needs to be tackled at the community level, using an integrated approach that combines medical, psychological, and social interventions to treat individual patients, provide support to them and their families, and mobilize the community to take appropiate action. Primary health care workers have a key role to play in such efforts and are often ideally placed to coordinate the community's response

This manual describes how members of the primary health care team can respond more effectively to drug and alcohol problems in their community, and provides simple guidance on assessing and managing substance abuse problems at individual, family and community levels. It also explains how primary health care services can best be organized and how they can be complemented by other community activities, including those involving the law enforcement sector. Finally, guidelines are given on evaluating drug and alcohol programmes, and on using the manual in training programmes for health workers