Comparison of clinical outcomes between "ideal" and "nonideal" transobturator male sling patients for treatment of postprostatectomy incontinence.

OBJECTIVE: To review the clinical outcomes of "ideal" vs "nonideal" postprostatectomy stress urinary incontinence (PPI) patients who underwent male sling placement. METHODS: The medical records of 95 consecutive patients with PPI who underwent male sling insertion (AdVance male sling, American Medical Systems, Minnetonka, MN) were reviewed. Patients were divided into "ideal" vs "nonideal" cohorts. The ideal group consisted of patients with mild to moderate incontinence (<4 pads/day or <300 g daily pad weight), ability to volitionally contract the external urinary sphincter, no history of pelvic radiation or cryotherapy, no history of previous anti-incontinence surgical procedures, the ability to generate a volitional detrusor contraction when voiding, and a postvoid residual urine volume <100 mL. Patients in the nonideal group did not satisfy all these criteria. RESULTS: Significant reductions in daily pad usage and weight were noted in both cohorts. In the ideal patient group, 66 of 72 patients (92%) would undergo the procedure again. Conversely, only 7 of 23 nonideal men (30%) would undergo the procedure again. CONCLUSION: Preoperative patient selection can influence favorable outcomes after the treatment of PPI with AdVance male slings. Attention to ideal vs nonideal patient characteristics should be used when counseling men considering male sling surgery.

The relationship between sources and functions of social support and dimensions of child- and parent-related stress.

BACKGROUND: In this longitudinal study, we examined the relationship between the sources and functions of social support and dimensions of child- and parent-related stress for mothers of young children with mild developmental delays. METHODS: Sixty-three mothers completed assessments of stress and support at two time points. RESULTS: Multiple regression analyses revealed that parenting support during the early childhood period (i.e. advice on problems specific to their child and assistance with child care responsibilities), irrespective of source, consistently predicted most dimensions of parent stress assessed during the early elementary years and contributed unique variance. General support (i.e. primarily emotional support and validation) from various sources had other, less widespread effects on parental stress. CONCLUSIONS: The multidimensional perspective of the construct of social support that emerged suggested mechanisms mediating the relationship between support and stress and provided a framework for intervention.

Review of female stress urinary incontinence.

Stress urinary incontinence (SUI) is a common problem affecting up to 35% of the female population. SUI results from a laxity of the pelvic floor anatomy, neuromuscular injury of the external urinary sphincter mechanism or both. Evaluation of the condition includes careful history, physical examination and urine analysis. Additional tests such as urodynamic studies and cystoscopic inspection are determined on a case by case basis. Treatment options range from behavior modification to medications to surgery. We present a review of the incidence, pathophysiology, evaluation and medical/surgical treatment options for SUI.

Involvement with peers: comparisons between young children with and without Down's syndrome.

BACKGROUND: It has been well established that heterogeneous groups of young children with mild intellectual disability are at considerable risk of becoming socially isolated from their peers in school, home and community settings. METHOD: Matched groups of young children with and without Down's syndrome (DS) were compared in terms of the children's involvement with peers, maternal arranging and monitoring of peer play, and maternal beliefs about inclusion. RESULTS: Despite aetiology-specific expectations for children with DS, no differences were found for a variety of measures of peer involvement focusing on the frequency of contacts and the characteristics of children's peer social networks. Maternal arranging of activities with peers was similarly related to peer involvement for both groups of children. Higher ratings of the benefits of inclusion were obtained from mothers of children with DS, but these maternal beliefs were unrelated to maternal arranging or peer involvement. CONCLUSIONS: Parental adaptations to the aetiology-specific behavioural patterns of children and the general influence of children's experiences within a developmental framework are discussed in the context of interpreting aetiology-specific findings.

The augmented anastomotic urethroplasty: indications and outcome in 29 patients.

PURPOSE: A short bulbar stricture of 1 cm. or less is best managed by stricture excision and primary anastomosis. However, a dilemma exists when the total length of the stricture is too great for excision and anastomosis. Options include stricture incision and flap-graft onlay or stricture excision with roof or floor strip anastomosis augmented by an onlay. We report our results with the latter type of augmented anastomotic urethroplasty. MATERIALS AND METHODS: We retrospectively reviewed the charts of 29 patients who underwent augmented anastomotic urethroplasty between 1990 and 1999. Retrograde urethrography was performed 3 weeks and 3 months postoperatively, and later if the patient was symptomatic. When possible, followup clinic notes and x-rays from referring physicians were obtained and patients were contacted directly to assess the long-term outcome. RESULTS: The stricture was in the bulbar urethra in all cases. Six patients had a completely obliterative stricture. Mean stricture length was 1.5 cm. on retrograde urethrography and the mean excised length was 1.2 cm. In 9 of the 29 patients a roof strip anastomosis was augmented by a ventral onlay and in 20 a floor strip anastomosis was formed with a dorsal onlay. Onlays included a pedicled skin flap in 7 cases and a graft in 22. Mean onlay length was 4.5 cm. At a mean followup of 28 months (range 3 to 126) 27 of the 29 patients (93%) were stricture-free and all those surveyed were satisfied with the procedure. Complications include new erectile dysfunction in 1 patient, post-void dribbling in 13, pseudodiverticulum formation in 2 and subjective penile shortening in 5. CONCLUSIONS: Augmented anastomotic urethroplasty is a useful technique for strictures that are too long to be managed by excision and primary anastomosis. Greater than 90% of the patients are stricture-free and the results seem durable, although longer followup is needed. Complications are few and minor.

Outcome of hypospadias repair using the tubularized, incised plate urethroplasty.

OBJECTIVE: We reviewed our results using the tubularized incised plate urethroplasty (Snodgrass procedure) for repair of penile hypospadias. MATERIALS AND METHODS: A total of 37 patients (aged 7-72 months, mean 17.5 months) underwent repair by three pediatric urologists at two institutions. The pre-op meatal position was distal in 28, mid-shaft in five, and penoscrotal in three patients. One patient, who did not have hypospadias, had a distal urethral fistula secondary to a previous circumcision. Twenty-six patients had ventral chordee and 12 required a dorsal tunica albuginea plication for correction. Urethroplasty was performed using 6-0 synthetic absorbable suture (PDS, Maxon, Dexon, or Monocryl). Urethroplasty coverage consisted of de-epithelialized dorsal preputial skin flap (32 patients), internal spermatic fascia flap (1 patient), tunica vaginalis flap (2 patients), or no coverage (2 patients). All patients were stented (8, 10 or 12 F silastic) for a mean duration of 9.8 days (range 4-12 days). Either a foam dressing (12 patients) or a Tegaderm sandwich dressing (25 patients) was used. RESULTS: Average length of hospital stay at one institution was 3.1 days (range 1-5 days). Mean follow-up was 8.8 months (range 1.5-20 months). The post-operative results were satisfactory with the meatus in a glanular position in 35 patients and a coronal position in two patients. All had a vertical orientation of the meatus. Complications included urethrocutaneous fistula in six patients, skin dehiscence in two patients, and meatal stenosis in two patients. One of the fistulas healed spontaneously. Urethral strictures have not been encountered thus far. CONCLUSIONS: The tubularized incised plate urethroplasty achieves satisfactory results with acceptable complications. It can be used for both distal and proximal hypospadias, and in the rare situation of fistula post-circumcision. Long term follow-up is needed to ensure that urethral strictures do not result from this technique.

Variations in strategy for the treatment of urethral obstruction after a pubovaginal sling procedure.

PURPOSE: We evaluated the success of several techniques for treating urethral obstruction and erosion after a pubovaginal sling procedure. MATERIALS AND METHODS: Between April 1998 and June 1999, 32 women 33 to 79 years old (average age 62) who underwent a pubovaginal sling procedure with various materials were referred for the assessment of urethral obstruction. Patients were evaluated with a urogynecologic history, physical examination, voiding diary, cystoscopy and video urodynamics. Surgical procedures to resolve urethral obstruction were performed transvaginally and the specific techniques used were based on the type of sling material, urethral erosion and concomitant stress incontinence or other urethral pathology. Outcome measures were assessed by disease specific quality of life questionnaires, voiding diary and urogynecologic questionnaire. RESULTS: Preoperatively 30 of the 32 women (93.7%) noticed urge incontinence, 20 (62.5%) performed intermittent self-catheterization, 6 (18.7%) had an indwelling catheter and 3 (9%) complained of concomitant stress urinary incontinence. After the sling takedown 29 patients (93.5%) achieved efficient voiding within week 1 postoperatively. Urge incontinence symptoms resolved in 20 cases (67%) but stress incontinence developed in 3 (9%). Of the 32 women 27 (84%) indicated that continence was much better than before the initial sling procedure. CONCLUSIONS: Managing urethral obstruction after a pubovaginal sling procedure is challenging. Using various techniques based on sling material, urethral erosion and bladder neck integrity a successful outcome is possible in the majority of cases.

Effectiveness of early intervention for vulnerable children: a developmental perspective.

An analysis of the current state of our knowledge of the effectiveness of early intervention for children at risk and for those with established disabilities was provided. A model focused on children's cognitive development was presented in which early intervention is placed firmly within a developmental framework. Both short- and long-term effects, the mechanisms through which early intervention exerts its influence, the relation between those mechanisms and the organization of existing service systems, current limits of programs, and prospects for future research were considered in this model.

Peer social networks of young boys with developmental delays.

Community-based peer social networks of young boys with developmental delays and parental arranging and monitoring of their child's peer contacts were examined. Comparisons were made to matched groups of children who were developing typically and to children with communication disorders. Results showed more limited peer social networks for both groups of children with disabilities based primarily on the frequency of contacts with peers and linkages established across school and community settings. All three groups were indistinguishable from one another on numerous measures of peer social networks, including duration and quality of individual relationships and participation in organized group activities with peers. Groups also differed on parental arranging and monitoring, which appeared to be related to children's developmental level.

What should be the focus of emotion regulation in children? A nonlinear dynamic mathematical model of children's peer interaction in groups.

This paper questions the assumption that children's social and emotional competence be placed within the developing child, rather than in the interaction of the child with the range of peer social ecologies in which the children might function. This paper presents a new nonstatistical mathematical approach to modeling children's peer social interaction in small groups using nonlinear difference equations in which both an uninfluenced and an influenced regulatory set point of positive minus negative interaction can be separately estimated. Using this model and the estimation procedure, it is possible to estimate what a focal child and the group initially brings to the group interaction and also how these regulatory set points are influenced by the interaction to determine two influenced regulatory set points. Six-person mainstreamed and specialized groups were established involving three types of unacquainted preschool boys: children with and without developmental delays and a language disordered but intellectually normally functioning group, using a methodology that ensured appropriate matching of child and family characteristics. For each 2-week play group, the social interactions of each child were observed during a designated free play period. Handicapped children were observed in either a specialized or mainstreamed setting. The application made of this modeling process in this paper is generating theory to attempt to understand influence processes. Parameters are introduced that reflect uninfluenced target child and group set points, emotional inertia, and influence functions.

The peer relations of preschool children with communication disorders.

The peer-related social interactions of preschool-age children with communication disorders were compared to those of normally developing chronological age-mates. All children were previously unacquainted with one another and participated in a series of short-term play groups. Differences between the 2 groups emerged primarily in terms of overall social activity, as children with communication disorders engaged in fewer positive social interactions and conversed with peers less often during non-play activities. Children with communication disorders also were less successful in their social bids and appeared to be less directive with their peers. However, both groups of children exhibited similar patterns of socially competent interactions including the ability to sustain play (group play), to minimize conflict, to join others in ongoing activities, and to respond appropriately to the social bids of others. Based on peer sociometric ratings, both groups of children were equally accepted. These general patterns of similarities and differences were found in settings in which play groups consisted of all children with communication disorders (specialized settings) as well as in settings in which the play groups included both children with communication disorders and normally developing children (mainstreamed settings). However, even during the relatively brief acquaintanceship process, an analysis of peer preference patterns revealed that children with communication disorders in mainstreamed settings were less socially integrated in the play groups than normally developing children. The potential for additional difficulties in peer interactions for children with communication disorders when children become more familiar with one another and play becomes more intricate was discussed in light of interaction patterns formed during the short-term play groups.

Immediate effects of mainstreamed settings on the social interactions and social integration of preschool children.

The immediate effects of mainstreamed and specialized settings on the peer interactions of preschool children with and without developmental delays were examined. Mainstreamed and specialized playgroups were established involving unacquainted peers and using a methodology that ensured appropriate matching of child and family characteristics. For each 2-week playgroup, the social and play interactions of each child were observed during a designated free-play period. Peer sociometric ratings also were obtained. Results indicated higher levels of peer interactions in mainstreamed settings for both typically developing children and children with developmental delays. The immediate impact of mainstreamed settings appeared to be attributed to the social demands and higher interaction levels of the former group. Children with developmental delays were not fully accepted nor totally socially integrated based on sociometric measures and behavioral indices of peer preferences. Implications of these findings for developing intervention programs to maximize children's peer-related social competence was discussed.

Parent perspectives of peer relationships and friendships in integrated and specialized programs.

In-depth interviews of a large community-based sample of mothers of preschool-age children with established disabilities and those classified as at-risk were conducted focusing on issues of children's peer relations and friendships. Results revealed that mothers of children enrolled in both integrated and specialized programs perceived their respective settings as valuable for the development of their child's peer relations and friendships. Mothers of children in integrated settings reported that their child played better and was more social due to the participation of children without special needs. A similar pattern was obtained for mothers of children enrolled in specialized programs in response to a hypothetical situation. Nevertheless, both groups of mothers were clearly concerned about peer rejection and noted the importance of having other children with special needs in the program available as a means of promoting tolerance and acceptance.

Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation.

OBJECTIVE: Our purpose was to compare consequences for women of receiving versus not receiving median episiotomy early and 3 months post partum on the outcomes perineal pain, urinary and pelvic floor functioning by electromyography, and sexual functioning and to analyze the relationship between episiotomy and third- and fourth-degree tears. STUDY DESIGN: A secondary cohort analysis was performed of participants within a randomized clinical trial, analyzed by type of perineal trauma and pain, pelvic floor, and sexual consequences of such trauma, while controlling for trial arm. The study was conducted in three university or community hospitals; 356 primiparous and 341 multiparous women were studied. RESULTS: Early and 3-month-postpartum perineal pain was least for women who gave birth with an intact perineum. Spontaneous perineal tears were less painful than episiotomy. Sexual functioning was best for women with an intact perineum or perineal tears. Postpartum urinary and pelvic floor symptoms were similar in all perineal groups. At 3 months post partum those delivered with an intact perineum had the strongest pelvic floor musculature, those with episiotomy the weakest. Among primiparous women third- and fourth-degree tears were associated with median episiotomy (46/47). After forceps births were removed and 21 other variables potentially associated within such tears were controlled for, episiotomy was strongly associated with third- and fourth-degree tears (odds ratio +22.08, 95% confidence interval 2.84 to 171.53). Physicians using episiotomy at high rates also used other procedures, including cesarean section, more frequently. CONCLUSION: Perineal and pelvic floor morbidity was greatest among women receiving median episiotomy versus those remaining intact or sustaining spontaneous perineal tears. Median episiotomy was causally related to third- and fourth-degree tears. Those using episiotomy at the highest rates were more likely use other interventions as well. Episiotomy use should be restricted to specified fetal-maternal indications.

Cervical cytology with the Papette sampler.

The most reliable cervical smears for the detection of cervical cancer and its precursors are those which contain cells from the transformation zone and endocervical canal. To verify that these regions have been sampled, the cytologist must recognize either endocervical cells or immature squamous metaplastic cells on the smears. We performed an open clinical trial with a new device, the Papette, which simultaneously samples both the exocervix and endocervix. The overall cytologic quality of the smears and the device's acceptability to physicians were assessed in 1,000 women seen consecutively. The smears were compared with those collected from 1,000 women immediately after the trial using the Ayre spatula-Zelsmyr Cytobrush technique. Both the Papette and the spatula-Cytobrush obtained satisfactory smears in 91.4% and 96.0% of cases, respectively. Cell transfer onto glass slides was easier and bleeding observed less frequently with the Papette than with the spatula-Cytobrush, but the latter was more suitable for patients with a retroflexed uterus and narrow external os. Overall, the Papette harvested high-quality cellular samples and may be an option for cervical cytology.

Adhesion formation and reproductive outcome after myomectomy and second-look laparoscopy.

OBJECTIVES: To evaluate adhesion formation after myomectomy and the reproductive outcome of infertile women with a large leiomyomatous uterus after myomectomy and second-look laparoscopy. METHODS: Twenty-six infertile women with a large leiomyomatous uterus underwent second-look laparoscopy 6 weeks after a myomectomy. At laparoscopy, the degree of adhesions was scored using the American Fertility Society classification of adnexal adhesions, and the adhesions were lysed. The pregnancy rates of these women were evaluated by life table analysis. RESULTS: A myomectomy incision on the posterior wall of the uterus was associated with more adnexal adhesions than that on the fundus or anterior uterine wall (93.7 versus 55.5%; P = .04). The degree of adnexal adhesions was also higher among women who underwent myomectomy with a posterior uterine incision (22.2 +/- 2.3 points) than in those with a fundal or anterior uterine incision (2.7 +/- 1.2 points) (P < .000001). The cumulative pregnancy rate was 33.4% at 6 months and 66.7% at 12 months after the procedures. CONCLUSIONS: Myomectomy incisions on the posterior uterine wall are associated with more and a higher degree of adnexal adhesions than those on the fundus and anterior wall. Conception occurs in the majority of infertile women with a large myomatous uterus who undergo myomectomy and second-look laparoscopy.

Sting morphology and frequency of sting autotomy among medically important vespids (Hymenoptera: Vespidae) and the honey bee (Hymenoptera: Apidae).

Data from clinical sting challenge investigations indicate that certain species of yellowjackets experience sting apparatus autotomy with surprisingly high frequency. However, a retrospective survey of vespid collectors strongly supports the supposition that the frequency of yellowjacket sting autotomy seen in clinical situations is not representative of the frequency experienced under field conditions. Examination by electron microscopy of the sting apparatuses of several vespid species and that of Apis mellifera L., the honey bee, revealed previously unreported structural variations between apid and vespid aculei which likely contribute to differences in sting autotomy rates observed between the honey bee and the social wasps. Specifically, when the lancets of a vespid aculeus are in a retracted position, the width of the smooth-edged stylet extends beyond the barbed edges of the lancets, forming a protective sheath. By contrast, all honey bee aculei possess stylets of insufficient width to shroud the barbs of retracted lancets, thus allowing the barbs to be completely exposed. Additionally, the dorsal surface of all vespid stylets are smooth in contrast to the dorsal surface of honey bee stylets, which support from one to three rows of paired barbs. The exposure of barbs on retracted honey bee lancets and the presence of additional barbs on the dorsal tip of the stylet would make withdrawal of a honey bee aculeus from a victim's flesh more difficult than withdrawal of a vespid aculeus, in which the barbs of retracted lancets are shielded and no dorsal barbs are present.

Effectiveness of developmental intervention in the first five years of life.

Developmental intervention in the first 5 years of life is an expanding, complex enterprise. Documenting efficacy by traditional scientific methods has proven to be elusive for a number of practical reasons, e.g., target population heterogeneity, methodology variability, inadequate outcome measures, and cost of longitudinal cohort designs. Nevertheless, despite these shortcomings, there is accumulating research information as to which types of intervention approaches are likely to be most beneficial to specific groups of infants and children and their families. It is quite clear that preventive strategies for at-risk children and families are different than ameliorative strategies for children with established disabilities. It is also clear that comprehensive evaluation of effectiveness must include consideration of both functional child gains (e.g., social, communication, mobility, and adaptive skills) and enhancement of family function. It is the pediatrician's responsibility to be adequately informed about contemporary developmental interventions in order to balance parental hopes and needs with potential benefits.

The next decade of research on the effectiveness of early intervention.

The effectiveness of early intervention programs for children with developmental disabilities and for children at biologic risk was reviewed and analyzed. A general pattern indicating important effects of early intervention programs was noted, with effect sizes averaging between one-half and three-quarters of a standard deviation. The ability of early intervention programs to minimize declines in development was identified as a significant outcome. The effects of specific program features--age of start and family involvement--were selected for more detailed examination, and the moderating influence of the levels of severity of children's disabilities was also analyzed. Future directions for improving the effectiveness of early intervention include using the emerging knowledge of biobehavioral and child development research, as well as enhancing children's social competence.

Treatment of tubal ectopic pregnancy by salpingotomy with or without tubal suturing and salpingectomy.

Thirty-four women with unruptured tubal ectopic pregnancy (EP) were randomly assigned to undergo salpingotomy without tubal suturing (n = 15) or salpingotomy with tubal suturing (n = 19). The reproductive performance of these patients was compared with 24 patients who underwent salpingectomy for their EP (historical control). Using life table analysis, the cumulative probability of intrauterine pregnancy (IUP) at 12 and 24 months was 45% and 45% after salpingotomy without tubal suturing and 21% and 47% after salpingotomy with tubal suturing, respectively. The cumulative probability of IUP after salpingectomy (21% and 26% at 12 and 24 months, respectively) was significantly lower than after salpingotomy with or without tubal suturing. There was no difference in the cumulative probability of EP after salpingotomy with or without tubal suturing, but it was significantly higher than after salpingectomy. In 18 women who subsequently underwent laparoscopy or laparotomy, no significant difference was found between the degree of adhesions after salpingotomy with or without tubal suturing. These findings suggest that IUP after conservative treatment is higher than after salpingectomy, but recurrent EP is also higher. Intrauterine pregnancy occurs earlier after salpingotomy without tubal suturing than after salpingotomy with tubal suturing. This might be because of rapid return of tubal function after healing by secondary intention.