The impact of balance specific physiotherapy, intensity of therapy and disability on static and dynamic balance in people with multiple sclerosis: A multi-center prospective study.

BACKGROUND: A high-quality research identifying the best physiotherapeutic approach for the improvement of balance in people with multiple sclerosis is missing. This study compared aspects of balance improvement such as therapy specificity to balance, therapy method and category, country, intensity and medical conditions. METHODS: A multicentric randomised rater-blinded controlled trial comprised three different physiotherapy programs (Czech and Italian outpatient or inpatient programs). All patients received 20 therapy sessions. Experimental group underwent balance specific physiotherapy (it was Motor Program Activating Therapy in the Czech cohort and Sensory-motor Integration Training in the Italian cohort), control group underwent non-balance specific physiotherapy (it was Vojta reflex locomotion in the Czech cohort and conventional dynamic strengthening exercises in the Italian cohort, respectively). Static balance was evaluated by Berg Balance Scale and dynamic balance was assessed by Timed Up-and-Go Test. RESULTS: A total of 149 patients entered the study. Physiotherapy significantly improved static balance (p < 0.0001, increase by mean 2.6 points (95% confidence interval 2.0-3.5) in BBS score). Balance specific approach had a higher effect than non-specific balance approach (increase in BBS by 1.9 points, 95% confidence interval 0.9-3.7 points). The intensity of the physiotherapy significantly influenced static balance (BBS by 2.7 points higher in the inpatient setting, p= 0.007). Dynamic balance was also improved (TUG decrease by -0.8 s (95% CI -1.4 - -0.1s, p = 0.011)); the balance specificity had no impact. The level of disability played the most important role (p= 0.022). CONCLUSION: Although the overall changes in static and dynamic balance were statistically significant, they were quite small in a clinical sense. A small statistically significant difference between balance specific and non-specific treatment was found. It seems that a high intensity of the therapy is critical to maximize the effectiveness.

[ACOUSTIC FEATURES OF VOCALIZATIONS, REFLECTING THE DISCOMFORT AND COMFORT STATE OF INFANTS AGED THREE AND SIX MONTHS].

The paper presented the possibility of recognition by adult the comfort and discomfort state of 3 and 6 months old infant's on the base of their vocalizations. The acoustic features of the vocalizations that are important for the recognition of the infant state of the characteristics of voice was described. It is shown that discomfort vocalizations differ from comfort ones on the basis of the average and maximum values of pitch, pitch values in the central and final part of the vocalization. A mathematical model is proposed and described a classification function signal of discomfort and comfort. Was found that the vocalizations of infants attributable adults with a probability of 0.75 and above the categories of comfort and discomfort with high reliability are recognized by the mathematical model based on a classification function.

[Correlation between stress urinary incontinence or urgency and anterior compartment defect before and after surgical treatment]. / Vztah stresové inkontinence moci ci urgence k defektu predního kompartmentu pred jeho operacním resením a po nem.

OBJECTIVE: We aimed to assess the occurrence of stress urinary incontinence (SUI) and urgency (U) before and after an operation to treat anterior compartment defect, and to ascertain whether there is a correlation between the position or mobility of the urethro-vesical junction (UVJ) and the lowest point of bladder base (N) and SUI and U before and after surgical treatment of the defect, using various procedures. DESIGN: Prospective, randomized study. SETTINGS: Department of Gynecology and Obstetrics, First Medical Faculty, Charles University and General Teaching Hospital, Prague. MATERIALS AND METHODS: 87 women were enrolled who had proven symptomatic Pelvic Organ Prolapse POP > or = II (Pelvic Organ Prolapse Quantitative--POP-Q)--specifically anterior compartment defect cystocele; they were then randomized into three group according to the type of surgical procedure planned: the BM group, treated with the traditional Barnett-Macku technique of anterior vaginal plastic surgery (BM; n=18); the Gynemesh group, treated with anterior plastic surgery with free insertion of individualized mesh (Mesh; n=33); and the Prolift group, treated with an original kit with pre-set standard-size mesh which is anchored to the lower arm of pubis (Prolift; n=36). SUI tests were carried out for the women before the operation and 3-4 months afterwards, using International Consultation on Incontinence Questionnaire - Short form (ICIQ-UI SF) and objective assessment by cough-test, while we also took into account the urge symptom. Before and after the operation patients were also examined by 4D imaging (GE Voluson 730 Expert), with emphasis on the position of UVJ and N point at rest and at maximum Valsalva. Data were processed and analysed in open computer environment, R language, version 2.9.1. RESULTS: The different groups of patients did not show statistically significant differences in demographic data. The results also show that there is no statistical difference between individual operation groups regarding occurrence of SUI: objectively this was established for 33% of patients, and according to ICIQ for 79%. Among women where SUI was not objectively proven, 74% felt SUI, while among women with objectively proved SUI, only one did not feel the urine leakage. This means that SUI is much more often subjectively felt than objectively proven. After the operation objective improvement of SUI occurred for 6% (5) patients, while it worsened for 16% (12) patients. The differences are not statistically significant. 78% (65 patients; n=83) felt incontinent before the operation compared with 66% (54 patients; n=82) after the operation, according to the ICIQ questionnaire. 18% (14) patients showed improvement and 5% (4) deterioration. In subjective assessment of the symptoms, improvement of SUI is more often recorded than worsening, to a statistically significant degree. 34% (30) patients in total suffered from urge before the operation (for three of them urge incontinence, for the others just urgency) and 8% (7) patients after the operation (of which one suffered from urge incontinence and 6 just urgency). This means that improvement occurred for 32% (25) and deterioration for just 3% (2) if patients. We have not ascertained any correlation between UVJ mobility, N point and urinary incontinence before and after the operation. CONCLUSIONS: The results of our study imply that the presence of SUI and U before an operation to treat anterior compartment defect is one of the main symptoms accompanying prolapse. While the operation may solve the SUI problem, it very often does not, as it deals mainly with eliminating the prolapse, or para-vaginal effect. We also failed to establish any correlation between mobility of the UVJ or N point and occurrence of SUI before and after the operation. We may, however, state that elevation of the N point--bladder base due to the operation results in mitigating U. Therefore, for reconstructive surgeries that do not treat SUI it is necessary that the operation is followed by a tape procedure in the second stage, ideally after the first operation has healed, i.e., 3 months at minimum.

[Changes in the length of implanted mesh after reconstructive surgery of the anterior vaginal wall]. / Zmeny délky implantované sít'ky po rekonstrukcním výkonu prední steny posevní.

OBJECTIVE: To evaluate and quantify early and late changes in mesh length after anterior vaginal repair with implants with ultrasound. TYPE OF STUDY: Prospective interventional study. METHODS: Ultrasound assessment of 35 patient randomized in two groups both with Gynemesh insertion. In one group with Gynemesh Prolift anterior kit and second group with individualized size of the Gynemesh. Ultrasound measurement of the mesh in sagittal plane was performed postoperative day 4 and after 3-4 month. Measured values were put in proportions, together with the original size of the mesh. Results are expressed as a percentage of shortening. RESULTS: In comparison of measurements from the late ultrasound scans with original size the shortening of the Prolift was 45% vs. 25% in Mesh group. When we compared the late and early ultrasound scans, there was no difference in the shrinking of the mesh in both group 16% vs 20%. CONCLUSION: Insufficient spreading and anchoring of the anterior Prolift has a major impact on the final length of the mesh. The tissue reaction expressed as shrinking of the mesh is only 16-20%.

Can the preoperative value of VLPP and MUCP predict the postoperative quality of life?

OBJECTIVE: The aim of this study was to determine whether low values of VLPP (Valsava Leak Point Pressure) and low values of MUCP (Maximal Urethral Closure Pressure) before operation can predict quality of life (QOL) after anti-incontinence surgery. METHODS: 72 stress incontinent women were included in this study. All women underwent anti-incontinent surgery. We compared the quality of life using I-QOL (Incontinence Quality of Life) assessment with parameters of urodynamic measurement VLPP and MUCP The women filled in an I-QOL questionnaire before surgery and three month afterwards. RESULTS: As in other studies, low preoperative value of the VLPP < or =60 cmH2O was not related to a statistically lower quality of life (average I-QOL for VLPP < or =60 cmH2O was 38.4 and 48.9 for VLPP > 60 cmH2O). We did not find statistically significant lower quality of life in women with MUCP < or =20 cmH2O (average I-QOL 38.2, and for MUCP > 20 39.7). The quality of life was significantly changed after successful anti-incontinent operation, but independently of the preoperative value of VLPP or MUCP, average I-QOL for VLPP < or =60 cmH2O was 81.5 and 82.8 for VLPP > 60 cmH20, for MUCP < or =20 cmH2O 79.5, and 86.4 for MUCP >20. CONCLUSIONS: Low preoperative values of MUCP and VLPP did not correlate with QOL. Preoperative VLPP and MUCP do not predict the QOL after anti-incontinent surgery.

[Long-term efficacy of TVT procedure in the treatment of stress urinary incontinence]. / Dlouhodobbá uspesnost tahuprosté vaginální pásky pri lécbe stresové inkontinence moci.

OBJECTIVE OF THE STUDY: The objective of the study was to ascertain the long-term efficacy of TVT procedure in the treatment of stress urinary incontinence. DESIGN: Prospective observational study. SETTINGS: Department of Gynecology and Obstetrics, First Faculty of Medicine, Charles University and the General University Hospital, Prague, EuroMISE centre of the Academy of Science, Prague. MATERIAL AND METHODS: 111 women with urodynamically proven stress incontinence who had undergone a TVT operation were included in the study; patients suffering with the mixed type of incontinence were included as well while a major prolapse of anterior vaginal wall (POP-Q II and more) was applied as the exclusion criterion. An overall pre-operation examination was carried out, including urodynamic and ultrasound examination, while the patients also completed an i-QOL quality of life questionnaire. The success of the operation was assessed using objective and subjective parameters. Occurrence of post-operation complications was correlated to the pre-operation mobility of the urethra, the surgeon who carried out the procedure, the post-operation position and mobility of the tape. RESULTS: Of the 111 patients, 105 appeared for the 3-month post-operation check. Another 10 failed to appear for the one year check, and yet another 10 dropped out from the subsequent monitoring. A failure of the procedure was subsequently described for 9 patients (8.1%), who had to undergo another procedure: for 7 patients a re-operation was carried out to treat recurrence of the stress urinary incontinence, and for 2 patients discision of the tape was carried out for the reason of problems with urine retention and repeated infections of urinary tract. At the beginning of the post-operation monitoring 80% of patients were objectively stress continent. At the end of the monitoring, 74% of women were fully continent and 15% subjectively improved, with objectively proved SI. We have, however, observed a relatively higher increase in de novo urgency, where at the beginning of the monitoring, 10% of patients were thus affected, and at the end of the monitoring 22.5%. At the end of the monitoring the tape is 20% narrower and 2 mm closer to the urethra; otherwise its position unchanged. We have not proved that the pre-operation mobility of the urethra or choice of surgeon would affect the results of the operation. Neither have we proved any difference in the position and mobility of the tape in relation to the result of the operation. CONCLUSIONS: In our group of patients we have proved very good long-term efficacy of the TVT operation for treatment of stress urinary incontinence. We have, nevertheless, observed a rather high increase in de novo occurrence of urgency at the end of the monitoring period - 21%. The increase of de novo urgency might be explained by the change in the position of the tape, which is closer to the urethra at the end of the monitoring.

[The solution of persistent stress urinary incontinence in women when surgery with the TVT-SECUR* is unsuccessful]. / Resení pretrvávající stresové inkontinence moci u zen po neúspesné operaci TVT-SECUR*.

OBJECTIVE: The objective of this study is to evaluate the efficacy of the procedure of shortening the tape in the treatment of persistent stress urinary incontinence when the tension-free vaginal tape (TVT) SECUR procedure proves unsuccessful. DESIGN: Retrospective study. SETTINGS: Department of Gynecology and Obstetrics, First Faculty of Medicine, Charles University and General Teaching Hospital, Prague. MATERIALS AND METHODS: Eight patients with persistent stress urinary incontinence (SUI) after the TVT-S procedure were included in our study. In order to resolve their condition, the tape was shortened. We used the overlap and the cut-off technique. Pre- and postoperative urodynamic and ultrasound (US) examinations were carried out, and the efficacy of this procedure was evaluated by cough test, pad-weighting test (PWT) and by the questionnaires Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ12) and the International Consultation on Incontinence Questionnaire--Short form (ICIQ-UI SF). All data were processed and statistical analyses performed in statistical environment R, version 2.5.1. RESULTS: In six patients the cough test and PWT were negative after reoperation, indicating no stress urinary incontinence, while in two patients mild leakage of urine persisted. The reoperation significantly increased the value of Maximum Urethral Closure Pressure (MUCP) while coughing. From the US examination we can conclude that the tape is tightened closer to the urethra and pubic bone. CONCLUSIONS: We describe a method--shortening the tape--for the treatment of persistent stress urinary incontinence when the TVT-S procedure fails. Based on our results we have established that this procedure is simple and as effective as inserting a new tape, but cheaper.

Molecular mechanisms leading to neuroprotection/ischemic tolerance: effect of preconditioning on the stress reaction of endoplasmic reticulum.

Ischemic tolerance can be developed by prior ischemic non-injurious stimulus preconditioning. The molecular mechanisms underlying ischemic tolerance are not yet fully understood. The purpose of this study is to evaluate the effect of preconditioning/preischemia on ischemic brain injury. We examined the endoplasmic reticulum stress response (unfolded protein response (UPR)) by measuring the mRNA and protein levels of specific genes such as ATF6, GRP78, and XBP1 after 15 min 4-VO ischemia and different times of reperfusion (1, 3, and 24 h). The data from the group of naïve ischemic rats were compared with data from the group of preconditioned animals. The results of the experiments showed significant changes in the gene expression at the mRNA level in the all ischemic/reperfusion phases. The influence of preischemia on protein level of XBP was significant in later ischemic times and at 3 h, the reperfusion reached 230% of the controls. The protein levels of GRP78 in preischemic animals showed a significant increase in ischemic and reperfusion times. They exceeded to 50% levels of corresponding naïve ischemic/reperfusion groups. Preconditioning also induced remarkable changes in the levels of ATF6 protein in the ischemic phase (about 170%). The levels of ATF6 remained elevated in earlier reperfusion times (37 and 62%, respectively) and persisted significantly elevated after 24 h of reperfusion. This data suggest that preconditioning paradigm (preischemia) underlies its neuroprotective effect by the attenuation of ER stress response after acute ischemic/reperfusion insult.

Alterations induced by ischemic preconditioning on secretory pathways Ca2+-ATPase (SPCA) gene expression and oxidative damage after global cerebral ischemia/reperfusion in rats.

Ischemic preconditioning (IPC) represents the phenomenon of CNC adaptation, which results in increased tolerance of CNS to lethal ischemia. Brain ischemia/reperfusion (IRI) initiates a catastrophic cascade in which many subcellular organelles play an important role. The Golgi apparatus, which is a part of secretory pathways (SP), represents the Ca(2+) store and regulates secretion of proteins for growth/reorganization of neuronal circuit by secretory Ca(2+)ATPases (SPCA1). The purpose of this study is to evaluate the effect of IRI and preconditioning on SPCA1 gene expression and oxidative damage after 4-vessel occlusion for 15 min and after being exposed to different reperfusion periods. Rats were preconditioned by 5 min of sub-lethal ischemia and 2 days later, 15 min of lethal ischemia was induced. Our experiments conclusively showed IRI-induced depression of SPCA activity and lipo- and protein oxidation in rat hippocampal membranes. IRI also activates the induction of SPCA1 gene expression in later reperfusion periods. IPC partially suppresses lipo- and protein oxidation in hippocampal membranes and leads to partiall rovery of the ischemic-induced depression of SPCA activity. In addition, IPC initiates earlier cellular response to the injury by the significant elevation of mRNA expression to 142% comparing to 1 h of corresponding reperfusion and to 11% comparing to 24 h of corresponding reperfusion, respectively. Similar patterns were observed on the translational level by Western blot analysis. Our results indicate the specific SPCA1 expression pattern in ischemic hippocampus. It also shows that the SPCA expression and the post-translational changes induced by ischemia are modulated by the IPC. This might serve to understand the molecular mechanisms involved in the structural integrity and function of the SP after ischemic challenge. It also suggests that there is a correlation of SPCA function with the role of SP in the response to pre-ischemic challenge.

Polymorphism -23HPhI in the promoter of insulin gene and pancreatic cancer: a pilot study.

Pancreatic cancer (PC) is one of the most frequent gastrointestinal malignancies with extremely poor prognosis. In spite of a relative low incidence of PC, in comparison with other cancers, PC is the fourth leading cause of cancer death in USA in both sexes. The available data clearly suggest that diabetes mellitus (DM) can be both a long-standing cause of PC and an early manifestation of the disease. Besides of DM, insulin resistance and high insulin levels are linked as well with increased cancer risk, including PC. The variable number of tandem repeats (VNTR) locus upstream of the insulin gene (INS) regulates insulin expression and has been associated with susceptibility to many diseases including DM. It is known that there is nearly complete linkage disequilibrium of the insulin variable tandem of repeats (INS-VNTR) alleles I/III with neighboring -23 HphI A/T single nucleotide polymorphism (SNP) in Caucasians. Therefore, we have studied the association between SNP of -23HphI in promoter of INS with PC, DM Type 2 (2TDM) and healthy controls. In this study we investigated 153 subjects (86 M/67 F); 51 patients with newly-diagnosed PC (31 M/20 F), 45 patients with 2TDM (29 M/16 F) and 57 healthy control subjects (26 M/31 F). The polymorphism of -23HphI (A/T) in the promoter of INS was determined by the combination of polymerase chain reaction (PCR) with the restriction fragment length polymorphism (RFLP) methods. The results obtained by the PCR-RFLP analyses of SNP -23HphI were confirmed by a direct studied locus sequencing of the genomic DNA. The frequency of abnormal glucose metabolism (both DM and impaired fasting glucose) was 88 % (45/51) in PC group. The AA genotype in SNP -23HphI was more prevalent (67 % vs. 47 %; P<0.05) among PC patients compared to controls. Additionally, statistically significant differences were found in frequencies (%) of genotypes AA/AT/TT in groups with PC (67/27/6), 2TDM (53/40/7) compared to healthy controls (37/46/17) (P<0.05). Moreover, a statistically significant effect of -23HphI A/T polymorphism on tumor staging was found (P< 0.05). Polymorphism of -23HphI (A/T) in the promoter of INS may play a role in the pathogenesis of PC and could contribute to tumor staging. Key words: pancreatic cancer; insulin gene regulation; polymorphism of -23HphI; diabetes mellitus; disorders of glucoregulation.

Molecular analysis of endoplasmic reticulum stress response after global forebrain ischemia/reperfusion in rats: effect of neuroprotectant simvastatin.

Simvastatin is a cholesterol-lowering agent whose functional significance and neuroprotective mechanism in ischemic brain injury is not yet solved. The purpose of this study is to evaluate the effect of simvastatin on ischemic brain injury. We examined the endoplasmic reticulum stress response (UPR/unfolded protein response), by measuring the mRNA and protein levels of specific genes such as ATF6, GRP78, and XBP1 after 15 min 4-VO ischemia and different times of reperfusion (1, 3, and 24 h). The results from the group of naïve ischemic rats were compared with results from the group of pre-treated animals with simvastatin. The results of the experiments showed significant increase in all genes at the mRNA level in ischemic phase (about 43% for XBP1, 58% for GRP78, and 39% for ATF6 more than control). The protein level of XBP1 was decreased in pre-treated animals at ischemic phase and first hour of reperfusion (about 15% less), and did not reach control levels. The protein levels of GRP78 were maximal at third hour of reperfusion in statin group with a small decrease at 24 h of reperfusion in both groups. The levels of ATF6 mRNA in statin-treated animals was higher in comparison to non-statin animals at the ischemic phase and the third hour of reperfusion (about 35% higher), which was also translated into the higher protein level. This could indicate that one of the main proteins targeted to enhance neuroprotective effect to ER during the first two hours of reperfusion was ATF6 protein, the levels of which were 60% higher than in non-treated animals. These data suggest that simvastatin, in addition to the proposed neuroprotective effect, exerts a neuroprotective role in the attenuation of ER stress response after acute ischemic/reperfusion insult.

[The solution of stress urinary incontinence in women by the TVT-S surgical method--correlation between the curative effect of this method and changes in ultrasound findings]. / Resení stresové inkontinence moci u zen operacní medotou TVT-S--vztah mezi lécebným efektem operacní metody a zmenami hodnot ultrazvukových parametru.

OBJECTIVE: The aims of this study were to compare ultrasonographic findings of the urethra and the tape position and mobility following the tension-free vaginal tape secure system (TVT-S) procedure and to correlate these data with clinical signs of cure and failure of this procedure in the treatment of stress urinary incontinence (SUI) in women. Another aim of our study was to determine indications for particular position of the tape (the "hammock" or "U" position) based on ultrasonographic findings of the urethra and the tape position following TVT-S. DESIGN: Prospective, randomized study. SETTINGS: Department of Gynecology and Obstetrics, First faculty of Medicine, Charles University and General Teaching Hospital, Prague. MATERIALS AND METHODS: Analyses of the position of the urethra and the tape of 85 patients were performed using perineal ultrasonography. The efficacy of the TVT-S procedure was evaluated by cough test and by the International Consultation on Incontinence Questionnaire - Short Form (ICIQ-UI SF). RESULTS: Objective assessment by cough test showed that 53 (62%) of our patients were completely dry, and in 32 (38%) patients leakage of urine persisted after the operation. From the US examination and results we can conclude that 3 months after the operation the mobility of the urethra and bladder neck are restricted. A correlation between cure effect and the restriction of the movement of the urethra was found between the position at the middle of the urethra before and after the operation. Subjective assessment of the cure effect of this operation by the ICIQ-UI SF questionnaires (n=81) showed that 39 (48%) of our patients were completely dry and 24 (30%) of patients improved, which means that in 42 (52%) patients leakage of urine persists after the operation. There are differences in the restriction of urethral mobility between the cured patients and those where leakage persisted. The middle of the urethra and UVJ are more restricted in movement in cured patients. We found no statistically significant differences between the US measurements of the position of the urethra of patients with the tape in the "hammock" and the "U" position. The only statistically significant difference found is a slightly higher tension of the "U" tape three months after the operation during the Valsalva maneuver; the median width of the tape in the "hammock" position is 10.1 mm, while in the "U" position it is 8.1 (Wilcoxon test p = 0.0056). There were six patients diagnosed with urgency de novo, without urge incontinence in this series. In seven cases we found vaginal erosion. CONCLUSIONS: From the US examination and results we can conclude that after the TVT-S operation, mobility of the urethra and bladder neck is restricted. After comparing ultrasonographic findings of the urethra and the tape position following TVT- Secure we can determine that there is no certain indication for placement of the tape in the "hammock" or the "U" position. The cure effect for different positions of the tape is similar. In some respects the slightly higher tension of the tape in the "U" position suggests that this tape position may be preferred in patients with intrinsic sphincter defect (ISD) of the urethra. A comparison of the cure effect of the TVT-S procedure with other tape procedures suggests a lower cure effect of this operation.

Weak VLPP and MUCP correlation and their relationship with objective and subjective measures of severity of urinary incontinence.

The aims of the present study were to find the correlation between Valsalva leak-point pressure (VLPP) and cough leak-point pressure (CLPP) and to determine whether the water perfusion maximum urethral closure pressure (MUCP) correlates with VLPP. Seventy-nine women with previously untreated stress urinary incontinence were recruited to participate in a clinical study. Their mean age was 56.4 years, mean BMI was 27.8, and mean parity was 1.9. The mean values of VLPP and CLPP were 50.4 and 52.9 cm H(2)O, respectively. We did not find statistically significant differences in the mean values of VLPP and CLPP. The mean value of MUCP at rest was 44.2 cm H(2)O and the mean value of MUCP during maximal Valsalva maneuver was 37.2 cm H(2)O; with 500 ml of sterile saline in the bladder the difference between them is statistically significant. In the study group (n=79), 56 patients (77%) had low VLPP (< or =60 cm H(2)O), 21 patients (30%) had low MUCP (< or =30 cm H(2)O), and 8 patients had MUCP< or =20 cm H(2)O (all at rest). Of the 56 patients with low VLPP, 16 also had a low MUCP (< or =30 cm H(2)O). This study mainly compares two parameters-the MUCP and the VLPP. Based on our results we can conclude that there is no correlation between these parameters. MUCP measures urethral resistance at rest and VLPP measures urethral resistance during increased intra-abdominal pressure (Valsalva maneuver).

[Intrapartal fetal monitoring, sensitivity and specificity of methods]. / Intrapartální fetální monitoring, senzitivita a specificita metod.

OBJECTIVE: To evaluated sensitivity and specificity of presently used methods for intrapartal monitoring (CTG, FpO2 a STAN S-21) and their mutual comparison. TYPE OF STUDY: A prospective study. SETTING: Gynecological-Obstetrical Clinic, 1st Medical Faculty, Charles University and general Teaching Hospital, Prague. METHOD: In 114 pregnant women with high-risk or pathological course of pregnancy the authors evaluated the capability of individual methods to predict intrapartal hypoxia, determined on the basis of postnatal evaluation of parameters observed (Apgar score in 1st minute, pH from umbilical artery, lactate levels in fetal blood, base excess (BE) and postpartum condition of fetus evaluated by a neonatologist). Each method was categorized according to its importance. The quality of individual methods was evaluated by means of their sensitivity and specificity as well as by the area under ROC (Receiver Operating Characteristic), i.e. AUC (Area under Curve). A similar or different prediction of the condition of the newborn by these individual methods was evaluated by the McNamara test of symmetry. In 50 deliveries performed by Cesarean section and 24 forceps deliveries the authors evaluated postnatal pH from umbilical artery and evaluation by Chi-square test. The women in childbed were infused with a tocolytic drug (hexoprenalin) before Cesarean section. All tests were performed at 5% level of significance. RESULTS: Low level of Apgar score in the 1st minute and less) always indicated CTG, but also a large proportion of normal newborns. STAN, in contrast, well indicates all newborns with a normal point evaluation. The best balanced evaluation of the newborns is provided by FpO2 and there was a significant difference between CTG and FpO2. In evaluating pH from the umbilical artery (pH < 7.20), TCG proved to be most sensitive again but displayed low specificity. STAN was the best predictor of newborns with normal pH. In evaluating high levels of lactate (> 3.7mmol/L) and BE (> -10) and related demonstration of metabolic acidosis STAN proved to be the best predictor. The condition of the newborn evaluated by a neonatologist immediately after birth (medium or heavy depression) was best predicted by FpO2. In deliveries performed by Cesarean section and after the administration of tocolysis the postnatal pH was higher then in forceps deliveries without acute tocolysis. The occurrence of emergencies in the course of a pathological delivery in individual methods is as follows: CTG, FpO2 and STAN. CONCLUSION: Even though CTG displays a very low specificity, this method should not be rejected, since it draws attention of the obstetrician very early to the possibility of developing hypoxia. FpO2 or STAN gives more precision to the situation and demarcates a correct moment for ending the delivery for the indication of fetus hypoxia intra partum. STAN is the best predictor for conditions of developing metabolic acidosis, evaluated postnatally by the level of lactate and BE in fetal blood.

Ultrasound imaging of the lower urinary tract after successful tension-free vaginal tape (TVT) procedure.

OBJECTIVES: To evaluate changes in the mobility of the whole urethra, in the proximal urethra (funneling) and in the thickness of the urinary bladder wall, after a successful tension-free vaginal tape (TVT) procedure. METHODS: This prospective longitudinal study included 52 women with urodynamically confirmed stress urinary incontinence who had undergone a successful TVT procedure. Ultrasound examination was performed before the TVT procedure and at a median of 3 (range, 3-6) months after surgery. For all women, the changes to the urethra and urinary bladder induced by surgery were examined. For three mobility groups (low, intermediate and high urethral mobility before surgery) we compared the changes induced by the operation and the typical position and mobility of the tape. RESULTS: The position of the urethra at rest was not influenced by surgery. The operation significantly decreased the mobility of all parts of the urethra during Valsalva. The absolute changes of the vector of the urethral movement differed according to the mobility group (average decrease, 6 mm; decrease for women with low, intermediate and high mobility, respectively, 2-3 mm, 4-6 mm and 9 mm). The change in relative mobility was the same in all groups. The operation decreased funneling (width and depth) during maximal Valsalva. After surgery there was an increase in the thickness of the bladder wall (by 0.64 and 0.73 mm, respectively, at the anterior part and trigone). CONCLUSIONS: A successful TVT procedure did not influence the position of the urethra at rest but significantly decreased the mobility of the urethra during Valsalva and also decreased funneling at maximal Valsalva.

[Changes in values of urethral closure pressure and its position after Burch colposuspension--predictive value of MUCP and VLPP for successful rate of this operation]. / Zmeny hodnot maximálního uzáverového uretrálního tlaku a jeho pozice po provedené kolpopexi dle Burche--prediktivní hodnota MUCP a VLPP pro úspesnost této operace.

OBJECTIVE: To ascertain how the Burch colposuspension affects the value and position of MUCP in women without any previous uro-gynaecological operation. If possible, also to determine how the values of these parameters differ between groups of women who are free from problems after the operation, women who suffer urgency, and women who continue to suffer from stress incontinence. Furthermore, to ascertain whether the pre-operation values of MUCP and VLPP have any predictive value in determining the success rate of the Burch colposuspension. In addition, to ascertain whether in ultrasound examination we can observe any differences in urethra mobility between subgroups of women with various operation results. DESIGN: Cross-sectional clinical study. SETTINGS: Gynecological and Obstetric Clinic, First School of Medicine of Charles University and General Faculty Hospital, Prague. MATERIALS AND METHODS: 69 women after Burch colposuspension were included in the study. The average age was 51.9 (SD=7.8), BMI 26.9 (SD=3.9) and parity 2.1 (SD=0.6). A urodynamic examination was performed on the patient in the supine position, the urinary bladder was filled with 300 and 500 ml of normal saline solution. The pressure profile was examined at rest, at maximal Valsalva manoeuvre and while coughing. During examination of the urethral pressure profile we ascertained MUCP, the functional length of the urethra (FUL) and the relative distance of the MUCP point from the inner urethral orifice, which was calculated as the ratio of the MUCP position with respect to FUL. To determine position and mobility of urethra, perineal ultrasound examination was performed on patients in supine position, using Acuson 128 XP 10 equipment, 5 MHz convex abdominal probe. The bladder was filled with 300 ml of saline. Polar coordinates (distance p, angle gamma) were employed when determining the position of UVJ and of the centre of urethra, defined at 17 mm distance from inner urethral orifice. Of the 69 patients who underwent the operation 62 were examined after the operation, 48 subsequently had no problems (A), 5 suffered with de novo urgency or the urgency symptoms were worse (B), and in 9 (C) mild stress incontinence still persisted. The data were summarised as means with SD and as medians. Measurements before and after the operation were compared using the paired t-test and paired Wilcoxon test where appropriate. Subgroups A, B, C were compared using Kruskal-Wallis test or Pearson chi2-test where appropriate. The level of significance was set to 0.05. Statistical software R version 2.1.1 was used throughout the analysis. RESULTS: No statistically significant changes were observed in values of MUCP before and after surgery, at rest, at Valsalva or while coughing, or with varying volumes of the urinary bladder of 300 and 500 ml before operation. Nor did we observe any difference in values of MUCP between the individual subgroups (A, B, C) of patients after surgery. We noted statistically significant differences in values of MUCP with varying volumes of the bladder of 300 and 500 ml after operation, the value of MUCP being higher with larger volume of the bladder at rest and while coughing. We observed statistically significant shortening of FUL after operation for bladder volume of 500 ml at rest only. The distance of the point of MUCP from the inner urethral orifice was significantly shorter only for bladder volume of 300 ml during Valsalva. No statistically significant differences in these parameters were observed between subgroups A, B, C. In the group of patients with MUCP before surgery < or = 30 cm H2O (10 out of 61 bladder volume 500 ml), 70% women were without problems after the operation. Among women with MUCP >30 cm H2O, 80% were without problems. This difference, however, was not statistically significant. The same is valid for women with VLPP < or = 60 cm H2O, 71% women were without problems after the operation and women with VLPP > 60 cm H2O where 91% were without problems; there was no statistically significant difference in success rate of this operation between these groups. The results of ultrasound examination imply that the operation change the position of UVJ or the middle of urethra at rest and during Valsalva manoeuvre. From the ultrasound parameters we can conclude that the operation changed the position of UVJ and the middle of the urethra forward at rest and restricted the mobility of the urethra during Valsalva manoeuvre. CONCLUSIONS: The results of our study imply that Burch colposuspension, if properly placed and not tight, does not change MUCP either at rest or at Valsalva. The distance of the point of MUCP from the inner urethral orifice was significantly shorter only for bladder volume of 300 ml during Valsalva. No statistically significant differences in these parameters were observed between subgroups A, B, C. From the ultrasound parameters we can conclude that the operation changed the position of UVJ and the middle of the urethra forward at rest and restricted the mobility of the urethra during Valsalva maneuver. There is a slight paradoxical diminishing of the gamma angle during the Valsalva maneuver in the subgroups of patients with de novo urgency or where the urgency symptoms were worse (B), implying different movement of the urethra. Pre-operation values of MUCP and VLPP cannot be used to predict the effect of the operation, though we are aware of the fact that our results were ascertained on a rather small number of patients in the groups of patients with complications.

[Changes in values of urethral closure pressure and its position after TVT operation--predictive value of MUCP and VLPP for successful rate of this operation]. / Zmeny hodnot maximálního uzáverového uretrálního tlaku a jeho pozice po TVT operaci--prediktivní hodnota MUCP a VLPP pro uspesnost této operace.

OBJECTIVE: To ascertain how the TVT (tension free vaginal tape) operation affects the value and position of MUCP in women without any previous uro-gynaecological operation. If possible, also to determine how the values of these parameters differ between groups of women who are free from problems after the operation, women who suffer urgency, and women who continue to suffer from stress incontinence. Furthermore, to ascertain whether the pre-operation values of MUCP and VLPP have any predictive value in determining the success rate of TVT operation. In addition, to ascertain whether in ultrasound examination we can observe any differences in urethra mobility between subgroups of women with various operation results. DESIGN: Cross-sectional clinical study. SETTINGS: Gynecological and Obstetric Clinic, First School of Medicine of Charles University and General Faculty Hospital, Prague. MATERIALS AND METHODS: 59 women after TVT operation were included in the study. The average age was 54.8 (SD = 10.5), BMI 27.6 (SD = 4.7) and parity L9 (SD = 0.6). A urodynamic examination was performed in the patient in the supine position, the urinary bladder was filled with 300 and 500 ml of normal saline solution. The pressure profile was examined at rest, at maximal Valsalva manoeuvre and while coughing. During examination of the urethral pressure profile we ascertained MUCP, the functional length of the urethra (FUL) and the relative distance of the MUCP point from the inner urethral orifice, which was calculated as the ratio of the MUCP position with respect to FUL. To determine the position and mobility of urethra, perineal ultrasound examination was performed in patients in supine position, using Acuson 128 XP 10 equipment, 5 MHz convex abdominal probe. The bladder was filled with 300 ml of saline. Polar coordinates (distance p, angle gamma) were employed when determining the position of UVJ and of the centre of urethra, defined at 17 mm distance from inner urethral orifice. Of the 59 patients who underwent the operation, 47 subsequently had no problems (A), 8 suffered with urgency symptoms (B), and in 4 (C) mild stress incontinence still persisted. The data were summarised as means with SD and as medians. Measurements before and after the operation were compared using the paired t-test and paired Wilcoxon test where appropriate. Groups A, B, C were compared using Kruskal-Wallis test or Pearson chi squared-test where appropriate. The level of significance was set to 0.05. Statistical software R version 2.0.1 was used throughout the analysis. RESULTS: No statistically significant changes were observed in values of MUCP before and after surgery, at rest, at Valsalva or while coughing, or with varying volumes of the urinary bladder of 300 and 500 ml. Nor did we observe any difference in values of MUCP between the individual subgroups (A, B, C) of patients after surgery. We observed mild shortening of FUL at both volumes of the bladder at rest, but no change was observed at Valsalva. The distance of the point of MUCP from the inner urethral orifice was shifted by the operation, from 44% to 57% at rest; the small shift at Valsalva was not statistically significant. No statistically significant differences in these parameters were observed between subgroups A, B, C. In the group of patients with MUCP before surgery < or = 30 cm H2O, 67% women were without problems after the operation. Among women with MUCP > 30 cm H2O, 84% were without problems. This difference, however, was not statistically significant. The same is valid for women with VLPP < or = 60 cm H2O and VLPP > 60 cm H2O; between these groups there was no statistically significant difference in success rate of this operation. The results of ultrasound examination imply that the operation does not change the position of UVJ or the middle of urethra at rest; however, it affects the position of urethra at Valsalva manoeuvre, the scope of the movement being smaller after the operation. CONCLUSIONS: The results of our study imply that the tape in TVT operation, if properly placed and not tight, does not change MUCP either at rest or at Valsalva. The operation slightly shortens the FUL at rest and causes a minor shift of the MUCP point towards the outer urethral orifice. The operation also does not change the position of the urethra at rest while restricting its movement during Valsalva manoeuver. For the group of patients who suffer urgency after the operation we observed slight change in direction of movement of UVJ during Valsalva manoeuver; UVJ being pulled lower and towards symphysis as compared to patients who are free from problems after the operation. Pre-operation values of MUCP and VLPP cannot be used to predict the effect of the operation, though we are aware of the fact that our results were ascertained on a rather small number of patients in the groups of patients with complications.

[Changes in vesicalization of urethra and bladder after TVT operation]. / Zmeny vezikalizace uretry a mocového mechýre po TVT operaci.

OBJECTIVE: The aim of our study was to asses the changes of the funnelling and the thickness of the urinary bladder after successful TVT procedure. DESIGN: Prospective pilot study. SETTING: Obstet. Gynecol Department, General Teaching hospital, Ist Medical Faculty, Charles University, Prague. EuroMISE Centre of the Charles University and Academy of Sciences, Prague, Czech Republic. METHODS: In the prospective study were evaluated 90 women after successful TVT procedure (in the study was primarily included 101 women with proven stress urinary incontinence). Ultrasound scan was performed before surgery and 3-6 months after operation as a part of the complex urogynecological examination. Together with urethral mobility was assessed the funnelling at rest and at maximal Valsalva (the width and depth of visible opening of the proximal urethra). Thickness of the bladder wall was measured after emptying of the urinary bladder at three points (anterior, trigone and dome). The changes induced by the surgery were assessed. For the statistical evaluation t-test and Wilcoxone test were used. RESULTS: The operation did not influence the proximal urethra at rest and significantly decreased funnelling during maximal Valsalva (width and depth). After the surgery there was a slight increase in the thickness of the bladder wall (anterior and trigone by 0.4 mm). CONCLUSIONS: The action of the tape is more complex that only the compression of the urethra. The tape influenced the proximal urethra at maximal Valsalva, significantly decreased the funnelling.

[What ultrasound parameter is optimal in the examination of position and mobility of urethrovesical junction?]. / Který z ultrazvukových parametru je optimální pri vysetriení ulození a mobility uretrovezikální junkce?

OBJECTIVE: The aim of our study was to asses the validity of the ultrasound measurements, effect of the operator on the measurement and to find most accurate parameters for the monitoring of the bladder neck. DESIGN: Pilot study. SETTING: Obstet. Gynecol Department, General teaching hospital, Ist Medical Faculty, Charles University, Prague. EuroMISE centre of the Charles University and Academy of Sciences, Prague, Czech Republic. METHODS: 50 women were included in the study. The coordinate system was defined as follows: the x axis is the axis of the symphysis, with 0 at lower edge of the symphysis. The y axis is perpendicular to x. In this system the rotational angle gama (gamma) and distance (p) were measured. The measurements were taken at rest and during maximal Valsalva, repeated independently twice by each observer. Reliability of measurements was statistically tested. RESULTS: The vector of movement (distance between the position of the point at rest and at maximal Valsalva) shows a typical error of 2.2 and 2.4 mm for Operator 1 and 2, respectively. For Operator 1 the shift between two measurements was 2.1 (SD 1.5 mm); for Operator 2 the value was 3.3 (SD=1.7mm), (differences between the operators are statistically significant). Differences at maximal Valsalva were similar. While the variability in measuremets is similar for both operators, this does not mean that final measurements are the same. The vector of the movement is not influenced by the variability of the measured parameters. CONCLUSIONS: Differences between the operators are probably due to different placement of the axis of the symphysis, as there are minimal differences in vector of movement. Statistical evaluation indicates that the differences between the operators are statistically significant.