Mesh repair of vaginal wall prolapse.

BACKGROUND: Over the last decade, mesh augmented surgical repair is being increasingly used in pelvic organ prolapse. Perigee and Apogee are comprehensive, single-use needle suspension kits that provide a standardized delivery method for mesh or graft-augmented repairs. This study has been carried out to study the safety and efficacy of the Perigee and Apogee mesh repair systems. METHODS: 10 cases of posterior vaginal wall prolapse with or without Apical prolapse underwent Apogee mesh repair surgery and 10 cases of anterior vaginal wall prolapse underwent Perigee mesh repair surgery. Depending on the findings either Apogee or Perigee or both were used. Patients were followed up for complications of the surgery if any, and for the relief of the symptoms related to prolapse and associated symptoms of bowel/bladder dysfunction. Objective cure rate was prolapse < stage 1 as per the POPQ system. Data collected was statistically analyzed. RESULTS: The objective and subjective cure rates were 100%. Postoperative complications were minor. No patient developed de novo urinary urge symptoms, stress urinary incontinence or UTI postoperatively. There were no operative complications like bladder injuries, hematoma and rectal injuries. The mean blood loss was 180 ml and the mean duration of surgery during the Apogee and Perigee mesh repair was 51.5 ± 2.99 min and 60.9 ± 4.65 min respectively. CONCLUSION: In the present study there was a significant improvement in the degree of prolapse after the mesh repair surgeries and the results were consistent even at 12 months follow up.

Effect of implant support for prostheses on electromyographic activity of masseter muscle and jaw movement in patients after mandibular fibula free flap reconstruction.

PURPOSE: Dental implants are used to stabilize, support, and retain prostheses in the mandible following fibula free flap reconstruction. A previous longitudinal prospective study showed that an implant-supported prosthesis (IP) provided additional improvement in masticatory performance compared to a conventional prosthesis (CP). Therefore, in this paper, the impact of implant retention and support of mandibular prostheses on neuromuscular function is reported via a within-subject analysis. MATERIALS AND METHODS: Forty-six participants were enrolled in the study. Prosthetic treatment with a CP was completed in 33 subjects following oromandibular resection and fibula free flap reconstruction. Twenty-five subjects completed evaluation of the CP after an adaptation period. Standardized masticatory tests with peanuts were given to subjects on the defect and nondefect chewing sides. Electromyography (EMG) of masseter muscles and jaw movement was performed and recorded simultaneously in 19 of these subjects. IP treatment was then completed in 16 of these subjects, and 15 of them participated in the IP evaluation after an adaptation period. Of these 15 subjects, 13 completed EMG and jaw movement recordings for both CP and IP. RESULTS: EMG activity of the defect-side masseter muscle increased significantly from CP to IP conditions when chewing on either side, but no significant change was found for nondefect-side muscle activity. Jaw movement parameters showed no significant changes from CP to IP. CONCLUSION: In patients restored with mandibular fibula free flap reconstruction, implant support for mandibular prostheses has the benefit of permitting greater muscle effort on the defect side, irrespective of the side on which the bolus is being chewed. The impact of an IP on jaw movements is limited.

Levonorgestrel intrauterine system: Current role in management of heavy menstrual bleeding.

A review of literature was conducted to report on the effectiveness of levonorgestrel intrauterine system (LNG-IUS) in women with heavy menstrual bleeding (HMB). The relevant data were obtained by computerized searches of PubMed up to December 2012 and other references available with the authors. Information was obtained from references listed. Studies and case reports were excluded if they did not specifically provide information about LNG-IUS usage in women with HMB. After perusal, each relevant publication was summarized and appraised in terms of whether it contained information relevant to the stated objective. Available data shows that LNG-IUS therapy is effective and safe, providing significant reduction of menstrual bleeding in patients with HMB. LNG-IUS is a good strategy to reduce the number of hysterectomies in women with HMB.

Recombinant activated factor VII in post partum haemorrhage.

Post-partum haemorrhage (PPH) is a life-threatening obstetric complication and the leading cause of maternal death. Any bleeding that results in or could result in haemodynamic instability, if untreated, must be considered as PPH. There is no controversy about the need for prevention and treatment of PPH. The keystone of management of PPH entails first, non-invasive and nonsurgical methods and then invasive and surgical methods. However, mortality remains high. Therefore, new advancements in the treatment are most crucial. One such advancement has been the use of recombinant activated factor VII (rFVIIa) in PPH. First used 12 years back in PPH, this universal haemostatic agent has been effectively used in controlling PPH. The best available indicator of rFVIIa efficacy is the arrest of haemorrhage, which is judged by visual evidence and haemodynamic stabilization. It also reduces costs of therapy and the use of blood components in massive PPH. In cases of intractable PPH with no other obvious indications for hysterectomy, administration of rFVIIa should be considered before surgery. We share our experience in a series of cases of PPH, successfully managed using rFVIIa.

Value of PET-CT in avoiding multimodality therapy in operable cervical cancer.

BACKGROUND: Posttreatment morbidity of multimodality therapy is substantially higher than either radical surgery or chemoradiation alone. Preoperative prediction of positive nodes limits optimal selection of the primary treatment modality. Computed tomography (CT) and magnetic resonance imaging have been tried for nodal assessment with modest results. Positron emission tomography (PET) combined with CT seems to be promising in this regard. This clinicopathologic study assesses the value of PET-CT in predicting nodal metastasis and avoiding multimodality therapy. MATERIALS AND METHODS: Eighty patients with clinically operable cervical cancer underwent PET-CT during the preoperative evaluation followed by radical hysterectomy. Adjuvant chemoradiation was administered when indicated by histopathologic findings. The histopathologic finding of the pelvic nodes was correlated with the PET-CT findings for nodal metastasis. The chi2 test was used as the test of significance in the statistical analysis. OBSERVATIONS: Of 62 patients found PET-CT negative for nodal disease, 52 were true negative, whereas 10 were false negative on histopathologic examination. On the other hand, 14 of 18 patients found PET-CT positive for nodal disease were true positives. Specificity, sensitivity, positive predictive value, and negative predictive value of PET-CT in nodal assessment were found to be 92.8, 58.33, 77.7, and 83.8, respectively. Twenty-four patients (30%) with pelvic nodes positive for disease on histopathologic examination were administered adjuvant chemoradiation. Had we operated only on those patients who were PET-CT negative for nodal disease, 10 of 62 patients would have required adjuvant chemoradiation for positive nodes. Eighteen patients found PET-CT positive for nodal disease would be treated with primary chemoradiation. Inclusion of PET-CT in the decision-making process for primary surgery versus primary chemoradiation would allow 87.5% patients to receive a single modality of treatment (65%, only surgery; 22.5%, only chemoradiation) and the proportion of patients requiring multimodality treatment would reduce significantly from 30% to 12.5% (P < 0.01). CONCLUSION: Positron emission tomography combined with CT in the evaluation of operable cervical cancer can help in the optimal selection of patients for surgery such that multimodality treatment with its attendant increase in morbidity is avoided.

Masticatory and swallowing threshold performances with conventional and implant-supported prostheses after mandibular fibula free-flap reconstruction.

STATEMENT OF PROBLEM: Significant strides in microvascular surgical techniques allow predictable restoration of bony and soft tissue orofacial defects. In combination with prosthetic rehabilitation, varying degrees of improvement in esthetics, speech intelligibility, and swallowing have been noted; however, the relative impact of conventional and implant-supported prostheses on restoration of masticatory function are not known. PURPOSE: The purpose of this study was to determine whether conventional or implant-supported dental prostheses and current surgical reconstructive procedures restore patients' masticatory function to presurgical levels. MATERIAL AND METHODS: Of the 46 subjects enrolled in this study, 23 (7 edentulous and 16 partially dentate) completed conventional prosthesis (CP) treatment and masticatory evaluation, and of these, 15 (3 edentulous and 12 partially dentate) completed treatment and evaluation with an implant-supported prosthesis (IP). Standardized masticatory performance tests with peanuts and carrots as the test food were made on the defect and nondefect sides. Tests of swallowing threshold performance were made with carrots as the test food. Statistical analysis included repeated-measures analysis of variance (ANOVA) with post hoc Tukey HSD tests (alpha=.05). RESULTS: Masticatory function at entry was markedly compromised. Further performance declines were noted following surgery (PS) on both the defect and nondefect sides. Restoration with CP and IP produced improvements (significant for defect side only, P<.05) in performance over the PS interval and were not significantly different from performances at entry prior to surgery. In addition, the performance on the defect side with the IP was significantly greater than the performance with the CP (P<.001). CONCLUSION: Impairment in masticatory ability remains following free-flap reconstruction prior to prosthetic rehabilitation. Both CP and IP may provide improved masticatory ability, permitting patients to regain the functional level they possessed prior to surgical intervention. The IP may contribute to greater support and stability of the prosthesis, resulting in increased use for mastication and superior performance on the defect side compared to the CP.

Efficacy of conventional and implant-supported mandibular resection prostheses: study overview and treatment outcomes.

STATEMENT OF PROBLEM: While surgical restoration of mandibular resections has advanced dramatically with free-flap techniques, oral function and patient perceptions of function, as well as treatment outcomes, often indicate significant impairment. PURPOSE: This longitudinal prospective study was designed to determine whether conventional prostheses (CP) or implant-supported prostheses (IP) and current surgical reconstructive procedures restore patients' oral functions and quality of life to their status prior to segmental mandibulectomy with immediate fibula free-flap reconstruction. Study design and implementation, characteristics of the study sample, treatment completion rates, and selected presurgical and postsurgical functional and perceptual outcomes are presented. MATERIAL AND METHODS: Forty-six subjects were enrolled. Longitudinal evaluations of medical and dental histories, oromaxillofacial examinations, questionnaires, and sensory and functional tests were planned before and after surgery and after CP and IP treatment. Sample characteristics are described with descriptive statistics and comparisons of subject responses to questionnaire items at entry and postsurgical intervals were made with Fisher exact tests (alpha=.05). RESULTS: Conventional prostheses were completed in 33 of 46 subjects, and 16 of 33 CP subjects were treated with IP. Reasons for noncompletion of IP were recurrent/metastatic disease (16), refusal of implant therapy (7), lost to follow-up (4), treatment with a reconstruction plate (1), excessive radiation at implant sites (1), and death (1). All 16 recurrences/metastases occurred within 13 months of surgery. Only 3 of the 58 implants placed in 17 participants were considered failures. One failed due to lack of integration 31 weeks following placement, and 2 were buried due to unacceptable positioning for prosthetic restoration during denture fabrication. The remaining 55 implants were successful at final evaluation, ranging from 58 to 123 weeks following implant placement (mean duration=78.9 +/- 16.0 weeks). CONCLUSIONS: While 72% (33/46) of the subjects enrolled were able and willing to complete treatment with CP, only 35% (16/46) completed IP treatment. Careful consideration must be given to selection of the type of prosthetic rehabilitation and the timing of implant placement if an IP is planned.

Comparisons of chewing difficulty of consumed foods with mandibular conventional dentures and implant-supported overdentures in diabetic denture wearers.

PURPOSE: This study compared the chewing difficulty of foods in diets of denture wearers with mandibular conventional and implant-supported overdentures. MATERIALS AND METHODS: One-week dietary logs were evaluated for 58 subjects with controlled diabetes at baseline with their original dentures and with new dentures 6 months after treatment completion. Subjects received new maxillary and mandibular complete dentures, 21 with mandibular conventional dentures and 37 with implant-supported overdentures. A 10-point chewing difficulty rating scale (10 for most difficult-to-chew foods) was used to rate food items in the dietary logs. RESULTS: ANOVA showed no differences between the chewing difficulty mean scores for all foods consumed either at baseline or posttreatment for the two groups. However, the mean scores for the combined consumption frequency of difficult-to-chew foods (6 to 10) showed a significant decrease following treatment with both types of dentures. This decline did not differ significantly between the denture types. With original dentures, more than 91% of subjects consumed foods with chewing difficulty scores of 6 to 10 at least seven times per week. With study dentures, only 21% maintained this level of consumption, with the frequency decreasing to four to six times per week in 24% and one to three times per week in 43% of subjects. The declines in consumption frequency of more difficult to chew foods with study dentures were in a higher percentage of subjects in the implant than in the conventional group. CONCLUSION: After 7 months of adaptation to new dentures, patients consumed fewer difficult-to-chew foods than with their original dentures. This decline was more frequent with mandibular implant-supported overdentures than with conventional dentures. Dietary counseling should be considered as part of implant and complete denture therapy.

A randomized clinical trial comparing the efficacy of mandibular implant-supported overdentures and conventional dentures in diabetic patients. Part V: food preference comparisons.

STATEMENT OF PROBLEM: The functional benefits of replacing old dentures with new conventional mandibular dentures or implant-supported overdentures has not been fully determined. PURPOSE: This study assessed the impact of these 2 types of replacement dentures on the food choices of diabetic patients. MATERIAL AND METHODS: A total of 68 diabetic patients with original complete dentures participated in this study. Diabetes was controlled with insulin in 38 patients (IT) and without insulin in 30 patients (NIT). All subjects received conventional maxillary dentures; 25 received mandibular conventional dentures (CD), and 43 received overdentures with plastic clips and a Hader bar attached to 2 osseointegrated implants (IOD). Subjects rated their perceptions of taste acceptability, texture acceptability, and chewing ease on a 4-point nominal scale and eating frequency on a 5-point scale for 13 specific foods at baseline (with original dentures) and at 6 months post-treatment completion (PTC). Fisher exact tests were used to compare the change in percentage distributions of responses with treatment. A 2 x 2 x 2 repeated-measures analysis of variance (ANOVA) was performed to compare mean scores between the 2 denture groups, 2 diabetic groups, and 2 time intervals for each of the 13 foods and 4 questions related to food acceptability. RESULTS: At baseline, no significant differences were found between the frequency distributions of responses in the CD and IOD groups or the IT and NIT groups for all 52 comparisons. With both types of study dentures, a higher percentage of patients perceived deterioration rather than improvement in function. When percentage distributions based on actual positive or negative change (treatment effect) in patient responses were compared, significant differences were found for 3 of the 52 responses, in favor of the IOD group. ANOVA demonstrated significant mean differences for 4 of the 52 comparisons. CONCLUSION: Both types of study dentures resulted in declines in the perceived taste and texture acceptability of almost all test foods. Declines in perceived chewing ease and eating frequency were more common and greater in the CD than in the IOD group. Both types of study dentures failed to affect food choices, as evidenced by declines or limited improvement in the perceived frequency with which most foods were eaten.

FREQUENCY SPECTROGRAPHIC ANALYSIS OF BONE CONDUCTED CHEWING SOUNDS IN PERSONS WITH NATURAL AND ARTIFICIAL DENTITIONS.

Bone conducted chewing sounds picked up by a specially designed device were recorded from three different facial bony locations in two age and sex matched groups of subjects with natural and artificial dentitions. Frequency spectrographic analysis revealed that, although the sounds were louder in subjects with natural dentition, crisp and soggy textures could be equally well differentiated by their noise levels in both groups. The use of a denture adhesive restored the chewing noise of denture wearers to that observed in the natural dentition group. There was a marked degree of mechanical impedance in the transmission of sound from the site of masticatory impact to distant cranial points. Breakdown of particle size during chewing was accompanied by declines in noise levels.