[Tracheal rupture following endotracheal intubation for an emergency cesarean]. / Trachealriss nach Intubation bei Notsectio.

This is a case report of a 45-year-old patient, 39 weeks of gestation, who was intubated via rapid sequence induction (RSI) for an emergency cesarean. The indication for emergency cesarean was a pathological cardiotocography during the ejection phase following labor induction.Despite the primary use of a video laryngoscope, there was difficulty aligning the laryngeal axis. Therefore, an internal stylet was used to heavily angulate the endotracheal tube (ETT) to a hockey stick shape to enter the larynx.Postoperative dyspnea and extensive facial swelling were initially diagnosed as an allergic reaction. Only 22 h later the diagnosis of tracheal rupture was confirmed following computer tomography.We hypothesized that the mechanism of injury was due to excessive pressure transmitted to the tip of the ETT. This probably occurred due to a leverage effect caused by the withdrawal of the heavily bent stylet from the ETT, forcing an intratracheal cranial movement of the ETT.By conducting an experiment on a pig's trachea, we were able to visualize this mechanism of injury. In addition, we were able to demonstrate that bending the stylet to a similar angle as the laryngoscope blade led to minimal movement of the tip of the ETT.Therefore, when using a stylet during intubation, we recommend bending the ETT and stylet to the shape of the used laryngoscope blade and retracting the stylet at a similar angle to avoid complications, such as tracheal rupture.

[Iatrogenic anisocoria after using a scopolamine patch for PONV prophylaxis]. / Iatrogene Anisokorie nach Scopolaminpflaster zur PONV-Prophylaxe.

This is a case report of a 29-year-old female patient who developed unilateral mydriasis following the use of a scopolamine patch for the prevention of postoperative nausea and vomiting (PONV).Given a medical history showing multiple risk factors for PONV, a preauricular scopolamine patch was applied prior to the induction of anesthesia. General anesthesia was induced with 150 mg propofol and 25 µg sufentanil and maintained with total intravenous anesthesia, using propofol (5 mg/kg per h) and remifentanil (2-3 µg/kg per h).Following an uneventful surgery of 90min duration, the patient was extubated and transferred to the recovery room, where the patch was removed. During the orthopedic ward round the following day, the clinical examination revealed anisocoria of the left eye in the form of unilateral mydriasis. In order to determine the cause of this clinical presentation, further neurological and ophthalmological examinations and investigations were carried out. In addition, magnetic resonance imaging was conducted to rule out a central nervous cause. The results of the investigations were negative and no pathology was identified. In addition, the symptoms resolved within 24 h of onset without any therapeutic intervention. Therefore, a suspected diagnosis of a pharmacologically induced anisocoria from the scopolamine patch was made, whereby the substance accidentally reached the affected left eye.Previous studies showed that scopolamine patches may reduce early emetic symptoms. Case reports describing the occurrence of anisocoria following the application of scopolamine patches have been previously published. In all of these cases the patches were used to prevent PONV and each case was comprehensively investigated using various diagnostic and clinical tools. It should be noted, however, that a dysfunctional accommodation is listed as a common side effect of the drug, affecting more than 1 in 10 patients.Even though the efficacy of scopolamine patches for the prevention of PONV is proven, clinicians should be aware of the common ophthalmological side effect. Particularly with respect to various surgical disciplines, where anisocoria may indicate an underlying surgery-related complication, the application of scopolamine patches should be well- considered.

[Ultrasound-guided peripheral venous puncture in patients with a poor venous status]. / Die ultraschallgesteuerte periphere Venenpunktion bei schlechtem Venenstatus.

BACKGROUND: In the case of a poor peripheral venous status the use of conventional approaches is associated with several failed attempts, delay of treatment, increased pain and escalation to more invasive techniques. Ultrasound-guided venous access has become increasingly popular for difficult venous access; however, in German-speaking countries it has not yet become as popular as in English-speaking countries. First attempt success rates are high, but the factors contributing to the time needed for ultrasound-guided venous access are not well investigated. It is hypothesized that body mass index (BMI), vein diameter and depth contribute to the time needed for successfully establishing a peripheral vein access in patients with a difficult venous status. METHODS: This study included 68 patients with a poor venous status. After written consent was obtained patient characteristics were documented and upper extremity veins eligible for access were scanned with ultrasound with the aim of performing an ultrasound-guided venous access. The following time periods were documented: 1) first skin contact with the ultrasound probe, 2) time to identify an accessible vein, 3) time for venous access. RESULTS: Of the patients 67 were successfully punctured by ultrasound-guided venous access, 65 at the first attempt and 2 at the second attempt. In one patient conventional venous access was obtained at the same time. A higher BMI was associated with a significantly shorter total puncture time (+1 BMI point ≙ -2.25 s) and a shorter vein identification time (+1 BMI point ≙ -1.82 s). A greater vein diameter correlated with a shorter total time (-14.23 s/mm) and a greater depth correlated with an increased total time (+1.65 s/mm). CONCLUSION: A greater vein diameter and a higher BMI contribute to a shorter time period for ultrasound-guided venous access. Obese patients with difficult venous access may benefit from ultrasound-guided venous access, which could be explained by the imaging contrast with a higher proportion of subcutaneous fatty tissue.

Influence of Apnea-induced Hypoxia on Catecholamine Release and Cardiovascular Dynamics.

Prolonged breath-hold causes complex compensatory mechanisms such as increase in blood pressure, redistribution of blood flow, and bradycardia. We tested whether apnea induces an elevation of catecholamine-concentrations in well-trained apneic divers.11 apneic divers performed maximal dry apnea in a horizontal position. Parameters measured during apnea included blood pressure, ECG, and central, in addition to peripheral hemoglobin oxygenation. Peripheral arterial hemoglobin oxygenation was detected by pulse oximetry, whereas peripheral (abdominal) and central (cerebral) tissue oxygenation was measured by Near Infrared Spectroscopy (NIRS). Exhaled O2 and CO2, plasma norepinephrine and epinephrine concentrations were measured before and after apnea.Averaged apnea time was 247±76 s. Systolic blood pressure increased from 135±13 to 185±25 mmHg. End-expiratory CO2 increased from 29±4 mmHg to 49±6 mmHg. Norepinephrine increased from 623±307 to 1 826±984 pg ml-1 and epinephrine from 78±22 to 143±65 pg ml-1 during apnea. Heart rate reduction was inversely correlated with increased norepinephrine (correlation coefficient -0.844, p=0.001). Central (cerebral) O2 desaturation was time-delayed compared to peripheral O2 desaturation as measured by NIRSabdominal and SpO2.Increased norepinephrine caused by apnea may contribute to blood shift from peripheral tissues to the CNS and thus help to preserve cerebral tissue O2 saturation longer than that of peripheral tissue.

Is internal jugular vein extensibility associated with indices of fluid responsiveness in ventilated patients?

BACKGROUND: Ultrasound of the inferior vena cava provides rapid and non-invasive assessment of fluid responsiveness. We hypothesized that the extensibility of the internal jugular vein (IJV) as well reflects intravascular volume state. We assessed IJV dimensions together with pulse pressure variation (PPV) as dynamic index for fluid responsiveness in mechanically ventilated patients. METHODS: Of 50 patients after cardiac surgery were assessed. Ultrasound of IJV dimensions as well as collection of hemodynamic data were performed in 30° and horizontal (0°) position, and the ventilator- and position-induced IJV extensibilities (E-IJV) were calculated. RESULTS: Mean ventilator-induced E-IJV in 30° position was 56%, and mean PPV in 30° position was 13.7%. Changing the patient's position from 30° to 0° significantly reduced ventilator-induced E-IJV as well as PPV. Pearson's correlation test revealed significant association between ventilator-induced E-IJV and fluid responsiveness deduced from PPV in 0° position (r = 0.43, P < 0.005). An E-IJV threshold >5% identified patients with significantly elevated PPV values. CONCLUSION: Ultrasound of the IJV and PPV as a dynamic index for fluid responsiveness can be associated under certain defined conditions. Whether or not ultrasound of the IJV can be useful to predict patient intravascular volume state should be further studied using invasive cardiac output monitoring.

[Pediatric emergence agitation]. / Postoperative Agitation im Kindesalter.

BACKGROUND: The origin of emergence agitation in children remains unclear; however, an association between surgical procedure, patient age and anesthetic regimen and the incidence of postoperative agitation has been described in the literature. AIM: The aim of this survey performed between February and April 2014 was to collect data from the daily clinical practice by experienced pediatric anesthesiologists regarding documentation, premedication, anesthesia regimen and postoperative treatment with respect to children with emergence agitation. MATERIAL AND METHODS: An online questionnaire with 33 items was developed and sent to all 525 members of the scientific committee of pediatric anesthesia (WAKKA) of the German Society of Anesthesiology and Intensive Care (DGAI). Members were asked to respond within a time period of 1 month but no reminders were sent out via email or telephone. RESULTS: A total of 156 members participated in the survey and of these 143 questionnaires were fully completed and included in the final evaluation (27 %). Of the participants 77 % had more than 6 years professional experience in the field of pediatric anesthesia and for 87 % emergence agitation remains a relevant clinical problem. The estimated incidence of emergence agitation was given as 1-10 % and as high as 11-20 % by 56% and 20 % of the participants, respectively. The incidence of postoperative agitation is documented by only 11 % of the participants with a validated score, such as the pediatric anesthesia emergence delirium (PEAD) scale and 89 % of the participants use midazolam for premedication. As a preemptive intervention total intravenous anesthesia is performed by 56 % whereas clonidine is used as first line prevention by 30 %. Postoperative pharmacological treatment is performed by a bolus administration of propofol (56 %) and clonidine (26 %). Postoperative parental presence was considered beneficial by 82 %. CONCLUSION: Emergence agitation is still seen as a relevant clinical problem by experienced pediatric anesthesiologists. Propofol is first choice when it comes to pharmacological prevention and treatment of emergence agitation. Postoperative parental presence was considered beneficial by the majority of anesthesiologists.

Bilateral bispectral index monitoring during and after electroconvulsive therapy compared with magnetic seizure therapy for treatment-resistant depression.

BACKGROUND: Electroconvulsive therapy (ECT) is a highly effective and established treatment for depression. Magnetic seizure therapy (MST) has recently been developed and seems equally effective while associated with fewer side-effects. Both require general anaesthesia, which could be quantified using the bispectral index (BIS). We compared ECT and MST with respect to recovery times, left-sided BIS, and left-right differences in BIS. METHODS: In this prospective, observational study, we enrolled 10 successive patients receiving ECT and 10 patients undergoing MST. Anaesthesia was performed with propofol and monitored with a bilateral BIS sensor. The seizure was elicited when the BIS was within a range from 50 to 60. The time to eye opening was measured and bilateral BIS were recorded for 10 min after seizure induction. RESULTS: A comparable anaesthetic depth was observed in the ECT and MST groups at baseline [mean (standard deviation, sd) BIS values of 94.1 (4.1) and 95.5 (3.0), respectively] and before seizure induction [mean (sd) BIS values of 52.3 (9.6) and 55.2 (10.3), respectively]. Post-ictally, MST patients opened their eyes significantly earlier than ECT patients [3.0 (1.0) vs 6.7 (1.3) min, P<0.001]. They showed a significantly higher BIS at 2 min after seizure induction [69.2 (10.1) vs 50.9 (15.9), P=0.003], and this difference was still present at 10 min after seizure induction [BIS 81.5 (6.5) vs 68.0 (16.4), P<0.001]. Significant differences between the left and right BIS were observed in neither the ECT nor the MST group. CONCLUSIONS: At a comparable anaesthetic depth, MST is superior to ECT in terms of post-ictal recovery, which is correctly reflected by higher post-ictal BIS values. Unilateral BIS monitoring is sufficient to monitor anaesthetic depth in ECT and MST patients. TRIAL REGISTRY NUMBER: NCT 01318018.

Patient state index vs bispectral index as measures of the electroencephalographic effects of propofol.

BACKGROUND: The patient state index (PSI) and the bispectral index (BIS) quantify anaesthetic depth based on the EEG using different algorithms. We compared both indices with regard to the prediction of the depth of propofol anaesthesia. METHODS: In 17 patients, propofol was infused until burst suppression occurred and stopped thereafter until BIS recovered to values above 60. This was repeated; afterwards, patients were intubated, for subsequent surgery. Without surgical stimulus, PSI and BIS were measured simultaneously and compared with the estimated effect-site concentrations of propofol. These were derived from simultaneous pharmacokinetic and -dynamic modelling in an individual two-stage and a population-based NONMEM approach. RESULTS: A close sigmoid relationship was observed between the propofol effect-site concentration and both PSI [coefficient of determination rho(2)=0.91 (sd 0.05)] and BIS [rho(2)=0.92 (0.03)], which was significantly steeper for PSI [gamma=2.2 (0.6)] than for BIS [gamma=1.8 (0.4)], and reached significantly lower values for PSI [E(max)=0.3 (1.1)] than for BIS [E(max)=5.3 (6.7)] at maximal propofol concentrations. A significantly smaller k(e0) was obtained for PSI [0.09 (0.03) min(-1)] compared with BIS [0.10 (0.02) min(-1)]. PSI and BIS correlated significantly with each other (rho(2)=0.866) and predicted propofol effect-site concentration with a comparable probability [P(K)=0.87 (0.05) and 0.86 (0.05), respectively]. NONMEM revealed E(0)=89.3 and 92.3, E(max)=1.9 and 8.6, C(e50)=1.38 and 1.92 microg ml(-1), gamma=1.6 and 1.48, and k(e0)=0.103 and 0.131 min(-1) as typical values for PSI and BIS, respectively. CONCLUSIONS: The PSI and the BIS monitors performed equally well in predicting depth of propofol anaesthesia. However, PSI was lower than BIS by approximately 10-15 points at high propofol concentrations.

The Entropy Module and Bispectral Index as guidance for propofol-remifentanil anaesthesia in combination with regional anaesthesia compared with a standard clinical practice group.

This study was designed to investigate the impact of the Entropy Module and Bispectral Index (BIS) monitoring on drug consumption and recovery times compared with standard anaesthetic practice in patients undergoing orthopaedic surgery using a combination of regional and general anaesthesia as performed by an experienced anaesthesiologist. We hypothesised that electroencephalogram monitoring would lead to a lower drug consumption as well as shorter recovery times. With institutional review board approval and written informed consent, 90 adult patients undergoing surgery to the upper or lower extremity received regional anaesthesia for post- and intraoperative pain control and were randomised to receive general anaesthesia by propofol/remifentanil infusion controlled either solely by clinical parameters or by targeting Entropy or BIS values of 50. Recovery times and drug consumption were recorded. Data from 79 patients were analysed. Compared with standard practice, patients with Entropy or BIS monitoring showed a similar propofol consumption (standard practice 101 +/- 22 microg/kg/minute, Entropy 106 +/- 24 microg/kg/minute, BIS 104 +/- 20 microg/kg/minute) and showed similar Aldrete scores (10/10) one minute after extubation: 9.1 +/- 0.3, 9.2 +/- 0.6 and 9.3 +/- 0.5, respectively. Time points of extubation were 7.3 +/- 2.9 minutes, 9.2 +/- 3.9 minutes and 6.8 +/- 2.9 minutes, respectively, demonstrating a significant difference between Entropy and BIS (P = 0.023). Compared with standard practice, targeting an Entropy or BIS value of 50 did not result in a reduction of propofol consumption during general anaesthesia combined with regional anaesthesia as performed by an experienced anaesthesiologist in orthopaedic patients.

Outcomes of Retropubic Synthetic Midurethral Gynecare TVT Slings When Performed by Urogynecologists, Urologists, and General Gynecologists in a Private Community Hospital.

OBJECTIVES: : To compare perioperative outcomes of a retropubic synthetic midurethral Gynecare TVT slings (Gynecare Worldwide, division of Ethicon Inc, NJ) performed by urogynecologists, urologists, and general gynecologists. METHODS: : This is a retrospective, cohort study of retropubic synthetic midurethral Gynecare TVT sling outcomes performed between 2001 and 2007 at a single institution. Other synthetic and nonsynthetic slings, or slings performed with concurrent surgeries were excluded. The primary outcomes were mean sling operating room (OR) time in minutes (min) and estimated blood loss in milliliters (mL). All variables were stratified by the surgeon's specialty: urogynecology (URO-GYN), urology (URO), and general gynecology (GYN). RESULTS: : Of 279 Gynecare TVT sling procedures, 126 were performed by URO-GYN, 30 by URO, and 123 by GYN. Mean sling OR time was 38.8 ± 8.5 minutes for URO-GYN, 42.6 ± 11.2 minutes for URO, and 39.8 ± 14.3 minutes for GYN, P = 0.30. Estimated blood loss was 56.6 ± 68.3 mL for URO-GYN, 69.7 ± 82.6 mL for URO, and 68.8 ± 73.4 mL for GYN, P = 0.37. The intraoperative complications (bladder, urethral perforations, and hemorrhage) were similar among the specialties. In the postoperative period, there was no difference in subsequent need for urethrolysis (cutting or removal of the sling), return to OR, and readmission to the hospital after the procedure among all 3 specialties. CONCLUSIONS: : All 3 specialties (urogynecologist, urologists, and general gynecologists) had similar major perioperative outcomes in performing retropubic synthetic midurethral Gynecare TVT slings.

Outcomes of hysterectomies performed by supervised residents vs those performed by attendings alone.

OBJECTIVE: The objective of the study was to compare the outcomes of hysterectomies performed by residents under supervision of a teaching physician with those performed by attendings alone. STUDY DESIGN: This was a retrospective cohort analysis of hysterectomies performed at the Greater Baltimore Medical Center from 2004 to 2006. RESULTS: Of 159 nonteaching and 265 teaching cases, there was no significant difference in any of the surgical outcomes, except mean operating room time in minutes (94.8 [+/- 47.0] vs 107.4 [+/- 42.4]; P = .005), seromas (2.5% vs 0%; P = .02), and others (5% vs 0.8%; P = .007) in nonteaching vs teaching cases, respectively. The demographics and comorbidities were similar. The mean operating room time difference of 13 minutes was not clinically significant. CONCLUSION: Although teaching hysterectomies take a bit longer to perform, there were no greater adverse outcomes.

Reduction in anaesthetic drug consumption is correlated with mean titrated intra-operative Bispectral Index values.

BACKGROUND: Several studies have shown a reduction in anaesthetic drug consumption with Bispectral Index (BIS) titration compared with standard clinical practice. However, the amount of reduction varied widely between 1% and 40%. We investigated the correlation between reduction in anaesthetic drug consumption and mean titrated BIS values. METHODS: An analysis upon randomized controlled trials cited until January 2006 in MEDLINE and other databases investigating the potential reduction in anaesthetic (hypnotic) drug consumption with BIS titration was performed. Investigations with a marked difference (> 15%) in opioid drug consumption between the BIS group and the standard practice group were excluded. Correlations between amount of reduction in hypnotic drug use and the mean titrated BIS value were analysed with linear regression. RESULTS: Fourteen manuscripts covering 2582 patients were included into the analysis. The mean BIS value in the standard clinical practice group averaged over all studies was 43.6 +/- 3.2 and the mean BIS value in the BIS-titrated group was 49.9 +/- 5.4. The amount of reduction in hypnotic drug use correlated significantly with the mean BIS values in the BIS-titrated groups (r =0.68) and with the differences between the mean BIS value in the BIS-titrated group and the mean BIS value in the standard clinical practice group (r = 0.70). Every point of BIS difference between the two groups resulted in a reduced hypnotic drug use of approximately 2%. CONCLUSION: Despite differences in the study designs and in the drugs used, a linear correlation between the mean titrated BIS value and the hypnotic drug saving potential was found.

Correlation of the A-Line ARX index with acoustically evoked potential amplitude.

BACKGROUND: Automated indices derived from mid-latency auditory evoked potentials (MLAEP) have been proposed for monitoring the state of anaesthesia. The A-Line ARX index (AAI) has been implemented in the A-Line monitor (Danmeter, V1.4). Several studies have reported variable and, in awake patients, sometimes surprisingly low AAI values. The purpose of this study was to reproduce these findings under steady-state conditions and to investigate their causes. METHODS: Ten awake unmedicated volunteers were studied under steady-state conditions. For each subject, the raw EEG and the AAI were recorded with an A-Line monitor (V1.4) during three separate sessions of 45.0 (1.6) min duration each. MATLAB (Mathworks) routines were used to derive MLAEP responses from EEG data and to calculate maximal MLAEP amplitudes. RESULTS: The AAI values ranged from 15 to 99, while 11.4% fell below levels which, according to the manufacturer, indicate an anaesthetic depth suitable for surgery. Inter-individual and intra-individual variation was observed despite stable recording conditions. The amplitudes of the MLAEP varied from 0.8 to 42.0 microV. The MLAEP amplitude exceeded 2 microV in 75.3% of readings. The Spearman's rank correlation coefficient between the MLAEP amplitude and the AAI value was r=0.89 (P<0.0001). CONCLUSIONS: The version of the A-Line monitor used in this study does not exclude contaminated MLAEP signals. Previous publications involving this version of the A-Line monitor (as opposed to the newer A-Line/2 monitor series) should be reassessed in the light of these findings. Before exclusively MLAEP-based monitors can be evaluated as suitable monitors of depth of anaesthesia, it is essential to ensure that inbuilt validity tests eliminate contaminated MLAEP signals.

Comparison of long-term outcomes of autologous fascia lata slings with Suspend Tutoplast fascia lata allograft slings for stress incontinence.

OBJECTIVE: This study was undertaken to compare the objective and subjective long-term surgical outcomes in patients receiving Tutoplast fascia lata allograft slings with those receiving autograft slings for the treatment of stress urinary incontinence (SUI). STUDY DESIGN: We reviewed all patients (n = 71) undergoing suburethral sling with either autologous fascia lata (n = 39) or Tutoplast fascia lata (n = 32) for urodynamic stress incontinence (USI) from October 1, 1998, to August 1, 2001. RESULTS: Of the original 71 patients, 47 were evaluated by objective and/or subjective means at a minimum of 2 years after surgery. Subjective quality of life measures, subjective continence, maximum urethral closure pressure, and bladder neck mobility were not different between the 2 groups. USI was demonstrated in 41.7% of allograft patients compared with no autograft patients (P = .007). CONCLUSION: Although patient reported cure of SUI is high for both sling types, USI recurs at a significantly higher rate in Tutoplast slings compared with autologous slings.

A comparison of anticipatory and postprocedure pain perception in patients who undergo urodynamic procedures.

OBJECTIVE: The purpose of this study was to compare anticipatory and postprocedure pain perception in female patients who undergo multichannel urodynamic evaluation in an office setting. STUDY DESIGN: One hundred consecutive patients completed a visual analogue pain scale before and after urodynamic testing. RESULTS: The mean postprocedure pain score of 2.32 cm was significantly lower than the anticipatory pain rating of 4.35 cm (P<.05). The lower postprocedure pain score was not influenced by previous hysterectomy, body mass index, menopausal status, estrogen replacement therapy, or analgesic or psychiatric medication usage. Patients who had undergone previous anti-incontinence surgery reported significantly higher levels of pain during the procedure (mean visual analogue pain scale score, 3.10 cm vs 2.06 cm; P=.027). CONCLUSION: Patients who undergo urodynamic testing anticipate higher degrees of discomfort than they perceive during the procedure. Previous anti-incontinence surgery appears to lower the pain threshold.

Acute renal failure caused by complete bladder eversion through a vesicovaginal fistula.

We report a rare case of bladder eversion through a vesicovaginal fistula. The bladder prolapse was almost complete, resulting in ureteral kinking, bilateral hydronephrosis and acute renal failure. After reduction of the bladder eversion, bilateral ureteral stent placement, fistula repair using the Latzko technique and colpocleisis, the patient had rapid resolution of her renal compromise.

Management of obstructive voiding dysfunction.

Voiding dysfunction may be defined as difficulty in the volitional emptying of the bladder in an efficient and controlled manner that can extend from a spectrum of minor irritative symptoms to complete retention. Resolution of symptoms can be accomplished by correctly identifying the underlying pathology and directing therapy appropriately to restore function and anatomy. Causes and treatments of obstructive voiding dysfunction tend to be gender specific. In approximately one-half of women, the causes of obstructive voiding dysfunction are prior anti-incontinence surgery and pelvic organ prolapse, which will usually lead to a surgical intervention. For men, benign prostate disease is the overwhelming cause of obstructive voiding. Due to its increasing prevalence in the aging male population, a variety of treatments--pharmacological and operative--have been developed, with more on the horizon. This review addresses a wide variety of treatments for the numerous conditions causing obstructive voiding dysfunction in men and women, all of them with the goal in mind of resolve the patient's symptoms without creating de novo pathology.

A comparison of anticipated pain before and pain rating after the procedure in patients who undergo cystourethroscopy.

OBJECTIVE: The purpose of this study was to compare anticipated pain before the procedure and actual pain rating after the procedure in female patients who undergo cystourethroscopy. STUDY DESIGN: Eighty-seven consecutive female patients completed a 10-cm visual analog pain scale before and after cystourethroscopy. A 24F urethroscope was used initially to inspect the urethra and was followed by a systematic survey of the bladder with a 17F cystoscope that was lubricated with 2% lidocaine gel. The visual analog pain scale scores were evaluated for significance with the use of the Student t test and the Pearson correlation coefficient. RESULTS: Visual analog pain scale analysis demonstrated a mean anticipated pain score of 3.75 cm before the procedure versus a mean pain rating score of 2.83 cm after the procedure (P <.05). Neither a history of previous cystoscopy (visual analog pain scale score, 3.03 vs 2.30 cm; P =.18) nor talking with someone about the procedure beforehand (visual analog pain scale score, 2.74 vs 2.89 cm; P =.76) influenced the lower pain rating after the procedure. There was no significant correlation between age, parity, body mass index, or presence of pelvic organ prolapse and anticipated or realized pain perception. CONCLUSION: Patients who undergo cystourethroscopy consistently anticipate higher degrees of discomfort than they actually perceive during the procedure.

Molecular and functional changes in voltage-dependent Na(+) channels following pilocarpine-induced status epilepticus in rat dentate granule cells.

Status epilepticus (S.E.) is known to lead to a large number of changes in the expression of voltage-dependent ion channels and neurotransmitter receptors. In the present study, we examined whether an episode of S.E. induced by pilocarpine in vivo alters functional properties and expression of voltage-gated Na(+) channels in dentate granule cells (DGCs) of the rat hippocampus. Using patch-clamp recordings in isolated DGCs, we show that the voltage-dependent inactivation curve is significantly shifted toward depolarizing potentials following S.E. (half-maximal inactivation at -43.2+/-0.6 mV) when compared with control rats (-48.2+/-0.8 mV, P<0.0001). The voltage-dependent activation curve is significantly shifted to more negative potentials following S.E., with half-maximal activation at -28.6+/-0.8 mV compared with -25.8+/-0.9 mV in control animals (P<0.05). The changes in voltage dependence resulted in an augmented window current due to increased overlap between the activation and inactivation curve. In contrast to Na(+) channel voltage-dependence, S.E. caused no changes in the kinetics of fast or slow recovery from inactivation. The functional changes were accompanied by altered expression of Na(+) channel subunits measured by real-time reverse transcription-polymerase chain reaction in dentate gyrus microslices. We investigated expression of the pore-forming alpha subunits Na(v)1.1-Na(v)1.3 and Na(v)1.5-Na(v)1.6, in addition to the accessory subunits beta(1) and beta(2). The Na(v)1.2 and Na(v)1.6 subunit as well as the beta(1) subunit were persistently down-regulated up to 30 days following S.E. The beta(2) subunit was transiently down-regulated on the first and third day following S.E. These results indicate that differential changes in Na(+) channel subunit expression occur in concert with functional changes. Because coexpression of beta subunits is known to robustly shift the voltage dependence of inactivation in a hyperpolarizing direction, we speculate that a down-regulation of beta-subunit expression may contribute to the depolarizing shift in the inactivation curve following S.E.

Correlation of symptoms with location and severity of pelvic organ prolapse.

OBJECTIVE: The purpose of this study was to compare the symptoms that are related to pelvic floor dysfunction with the location and severity of the coexisting prolapse. STUDY DESIGN: Two hundred thirty-seven consecutive patients with symptomatic pelvic organ prolapse came to Johns Hopkins Medicine during a 24-month period beginning in July 1998 and completed a symptom-specific Likert scale questionnaire that included standardized questions that were compiled from commonly used validated instruments. All questionnaires were completed by the patients before they were seen by a physician. Further evaluation included a standardized physical examination that included the International Continence Society's system for grading uterovaginal prolapse. Symptoms were categorized according to both severity and associated anatomic compartment. Symptoms that were related to urinary and anal incontinence and voiding, defecatory, sexual, and pelvic floor dysfunction were analyzed with respect to location and severity of pelvic organ prolapse with the use of the nonparametric correlation coefficient, Kendall's tau-b. RESULTS: The mean age of the women was 57.2 years (range, 23-93 years); 109 of the women (46%) had undergone hysterectomy. Overall, stage II was the most common pelvic organ prolapse (51%) that was encountered. In 77 patients (33%), anterior compartment pelvic organ prolapse predominated; 46 patients (19%) demonstrated posterior compartment prolapse, whereas 26 patients (11%) had apical prolapse. In 88 patients (37%), no single location was more severe than another. Voiding dysfunction that was characterized by urinary hesitancy, prolonged or intermittent flow, and a need to change position was associated with the increasing severity of anterior and apical pelvic organ prolapse. Pelvic pressure and discomfort along with visualization of prolapse were strongly associated with worsening stages of pelvic organ prolapse in all compartments. Defecatory dysfunction characterized by incomplete evacuation and digital manipulation was associated with worsening posterior compartment pelvic organ prolapse. Impairment of sexual relations and duration of abstinence were strongly associated with worsening pelvic organ prolapse. An inverse correlation was observed between increasing severity of pelvic organ prolapse and urinary incontinence and enuresis. CONCLUSION: Women with pelvic organ prolapse experience symptoms that do not necessarily correlate with compartment-specific defects. Increasing severity of pelvic organ prolapse is weakly to moderately associated with several specific symptoms that are related to urinary incontinence and voiding, defecatory, and sexual dysfunction.