Uncomplicated Patient Research Articles

878 - ICS educational module: Cough stress test in the evaluation of female urinary incontinence: Introducing the ICS-Uniform cough stress test

Introduction A cough stress test (CST) is recommended in the evaluation of the uncomplicated female patient with the complaint of stress urinary incontinence (SUI) to identify the sign of SUI, and is often used as an outcome measure following SUI treatment. However, there has been no standardization of the performance or reporting of CST. A working group of the International Continence Society (ICS) has developed an educational module, comprising a Powerpoint™ presentation and evidence base manuscript, to instruct on the performance, interpretation, and reporting of the CST in a standardized manner: the ICS-Uniform Cough Stress Test (ICS-UCST). Methods The working group performed a PUBMED literature search of articles (observational/experimental and reviews) published prior to 2017 that mentioned a CST. The evidence base examined various variables in performing a CST as well as sensitivity/specificity and positive/negative predictive values of CST. Results The variables involved in performing/interpreting an ICS-UCST include: patient positioning, degree of bladder filling, number, and forcefulness of coughs, and method of SUI detection. For the ICS-UCST it is recommended that the patient be in a supine/lithotomy position with 200-400 mL of fluid in the bladder. She coughs forcefully 1-4 times and the examiner directly visualizes the urethral meatus for the presence of leakage. Leakage of fluid from the urethral meatus coincident with/simultaneous to the cough(s) is considered a positive test. Conclusion This module provides instructions to educate a uniform CST (the ICS-UCST), with the aim of improving the clinical practice of cough stress testing in female patients with urinary incontinence.

Use of Ribavirin for Hepatitis C Treatment in the Modern Direct-acting Antiviral Era.

Ribavirin, once a staple of hepatitis C treatment, has significant drawbacks, including treatment-limiting side effects, the requirement for intensive laboratory monitoring, the need for frequent dose adjustments, and teratogenicity. These factors make it difficult to escalate ribavirin-based HCV treatment to most infected patients globally. Most studies have shown comparable response rates between ribavirin-inclusive and ribavirin-sparing regimens in uncomplicated patient populations. However, ribavirin is still used in the management of patients who have failed previous therapy as well as those with decompensated liver disease. In this review, we explore the evidence supporting the use of ribavirin in the current climate of hepatitis C treatment with oral combination direct-acting antiviral agents.

Blood cardioplegia benefits only patients with a long cross-clamp time.

A clear advantage of blood versus crystalloid cardioplegia has not yet been observed in smaller population studies. The purpose of this article was to further investigate the clinical outcomes of blood versus crystalloid cardioplegia in a large propensity-matched cohort of patients who underwent cardiac surgery. The study was a single-centre study. Data was withdrawn from the Western Denmark Heart Registry, which comprises a perfusion section for each procedure. A total of 4,852 patients were propensity matched into crystalloid (CC) vs blood cardioplegia (BC) groups. The primary end points were creatinine kinase-MB (CKMB) elevation, acute myocardial infarction (AMI), stroke, dialysis, coronary angiography (CAG) and mortality (30 days and 6 months). We found lower odds ratio in 30-day mortality in the BC group (OR 0.21; CI 0.06-0.68), but no difference in overall 6-month mortality. There was no difference in CKMB elevation, AMI, dialysis or stroke. Several end points were further analysed for different cross-clamp times. In the CC group, ventilation time above 600 minutes was seen more often in almost all cross-clamp time intervals (23.5 % vs 12.2 %; p<0.0001; χ2-test) and 6-month mortality was significantly higher when the cross-clamp time exceeded 210 minutes (64.3 vs 23.8; p=0.018; χ2-test). We did not find clear evidence of superiority of either type in the uncomplicated patient. When prolonged cross-clamp time or postoperative ventilation is expected, this study indicates that blood cardioplegia might be preferable.

ICS Educational Module: Cough stress test in the evaluation of female urinary incontinence: Introducing the ICS-Uniform Cough Stress Test.

A cough stress test (CST) is recommended in the evaluation of the uncomplicated female patient with the complaint of stress urinary incontinence (SUI) to identify the sign of SUI, and is often used as an outcome measure following SUI treatment. However, there has been no standardization of the performance or reporting of CST. A working group of the International Continence Society (ICS) has developed an educational module, comprising a Powerpoint™ presentation and evidence base manuscript, to instruct on the performance, interpretation, and reporting of the CST in a standardized manner: the ICS-Uniform Cough Stress Test (ICS-UCST). The working group performed a PUBMED literature search of articles (observational/experimental and reviews) published prior to 2017 that mentioned a CST. The evidence base examined various variables in performing a CST as well as sensitivity/specificity and positive/negative predictive values of CST. The variables involved in performing/interpreting an ICS-UCST include: patient positioning, degree of bladder filling, number, and forcefulness of coughs, and method of SUI detection. For the ICS-UCST it is recommended that the patient be in a supine/lithotomy position with 200-400 mL of fluid in the bladder. She coughs forcefully 1-4 times and the examiner directly visualizes the urethral meatus for the presence of leakage. Leakage of fluid from the urethral meatus coincident with/simultaneous to the cough(s) is considered a positive test. This module provides instructions to educate a uniform CST (the ICS-UCST), with the aim of improving the clinical practice of cough stress testing in female patients with urinary incontinence.

Deteksi Protein 270 kDa Plasmodium falciparum Isolat Malang pada Membran Eritrosit Penderita Malaria dengan Komplikasi

Erythrocyte which is infected by Plasmodium falciparum will have various changes on its architecture, affinity, and biomolecular. Beside that, the infected erythrocyte also forms a knob at its surface. This knob are contained with various parasite proteins, one of them is Plasmodium falciparum erythrocyte membrane protein-1 (PfEMP-1). Our previous study had been identified a protein with molecular weight 270 kDa at P. falciparum infected erythrocyte from Malang isolate that was playing a role in cytoadherence process. The aim of this study was to detect the possibility of 270 kDa protein expression at complicated malaria falciparum patient erythrocyte membrane. The method that used was immunocytochemistry with polyclonal antibody to 270 kDa protein. The results showed that two (2) erythrocyte samples from healthy people as control had negative reaction, and so did with five (5) erythrocyte samples of uncomplicated malaria patient, but there was positive reaction that shown at two (2) samples of complicated malaria patient erythrocyte. It can be concluded from the results that 270 kDa membrane protein of P. falciparum infected erythrocyte in complicated malaria patient might be a PfEMP-1. This protein can be detected by immunocytochemistry method using polyclonal antibody and can be used for the candidate of complicated malaria diagnostic &#x0D; &#x0D; Keywords: Plasmodium falciparum, 270 kDA protein, immunocytochemistry, polyclonal antibody&#x0D;

The interprofessional learning experience: Findings from a qualitative study based in an outpatient setting

ABSTRACTClinical interprofessional education has traditionally taken place in hospital wards, but much diagnosis and treatment have shifted to the outpatient setting. The logical consequence is to shift more students’ clinical placements from the “bedside” to outpatient settings. However, it is unclear how we ensure that this shift maximises learning. The purpose of this article is to understand the authentic learning experience in an interprofessional outpatient clinic setting. We performed an exploratory case study with interviews of four nursing students, 13 medical students, and six staff members who worked in an interprofessional outpatient orthopaedic clinic from March 2015 to January 2016. The interviews were transcribed and analysed using systematic text condensation. The students’ self-reported learning experience in this outpatient clinic was characterised by direct patient contact and by authentic, interprofessional, task-based learning, and a preference for indirect supervision when conducting uncomplicated patient consultations. The supervisors intended to create this interprofessional outpatient clinic experience by having a clear teaching approach based on adult learning principles in a safe and challenging learning environment. The shift to the outpatient setting was strongly and practically supported by the management. This study indicates that student learning can be shifted to the outpatient clinic setting if there is supportive management and dedicated supervisors who establish a challenging yet safe interprofessional learning environment.

Treatment Options for Sciatica: Surgery, Epidural Injections, and Osteopathic Manipulative Treatment

Understanding the etiology and optimal treatment options for sciatica is a frequently discussed medical topic. This study analyzes treatment options-specifically surgery, epidural steroid injections (ESI), and osteopathic manipulative treatment (OMT)-for sciatic radiculopathy due to lumbar disc herniation. A review of several studies comparing surgery to non-surgical intervention, surgery to ESI, ESI to conservative care, and OMT is discussed. There is no consensus on the usefulness of ESI; several studies illustrated efficacy while numerous others did not conclude statistical significance, and rather, highlighted the adverse effects. In contrast, OMT is considered a non-invasive first-line approach to achieving relief from sciatica, while surgery is a last resort in the uncomplicated patient.

Which Factors Influence Resident Physicians to Prescribe NOACs to Patients with Non-Valvular Atrial Fibrillation?

The Canadian Cardiovascular Society and the European Society of Cardiology recommend the use of non-vitamin K antagonists (NOAC) in preference to warfarin for stroke prevention in most patients with non-valvular atrial fibrillation (AF). The aim of this study was to identify factors that predict selection of a NOAC by resident physicians when faced with patients with non-valvular AF. A web-based survey was distributed to residents across Canada to learn the attitudes and behaviours regarding stroke, bleeding risk and choices of therapy in different clinical scenarios involving the same patient and one additional co-morbidity. There were a total of 1014 respondents. In an uncomplicated patient with a new diagnosis of AF, self-reported comfort level was the strongest positive predictor for selecting a NOAC (odds ratio (OR) 2.51; 95% confident interval (CI) 1.79-3.54). Residents' desire for the availability of a reversal agent was a negative predictor (OR 0.55; 95%CI 0.39-0.77). In a patient with a prior gastrointestinal bleed, each additional year of training was associated with a choosing a NOAC (OR 1.3; 95%CI 1.1-1.5). In the same patient, the desire for the availability of a reversal agent was a negative predictor of selecting a NOAC (OR 0.42; 95%CI 0.32-0.56). The most consistent predictor for prescribing a NOAC in all clinical scenarios was self-reported comfort level. Fear of adverse events, cost of agents and dosing convenience were not significant predictors. This study found that resident physicians' adherence to guideline-preferred management of AF with regards to stroke prevention is strongly associated with self-reported comfort level, training year and the desire for the presence of a reversal agent.

Multiplicity of infection and genetic diversity of Plasmodium falciparum isolates from patients with uncomplicated and severe malaria in Gezira State, Sudan.

BackgroundMultiplicity and genetic diversity of Plasmodium falciparum infection might play a role in determining the clinical outcome of malaria infection and could be a fair reflection of the disease transmission rate. This study investigated the genetic diversity of P. falciparum and multiplicity of infection in relation to the severity of malaria and age of patients in Gezira State, Sudan.MethodsA cross-sectional health facilities-based survey was conducted in Gezira State, Sudan in January 2012. A total of 140 P. falciparum malaria patients diagnosed with microscopy and confirmed using nested PCR were recruited and classified into uncomplicated malaria and severe malaria states according to the standard WHO criteria. DNA was extracted and MSP1 and MSP2 allelic families were determined using nested PCR.ResultsThe overall multiplicity of infection (MOI) was 2.25 and 2.30 and 2.15 for uncomplicated and severe malaria respectively. There were no statistically significant differences between uncomplicated and severe malaria (SM) patient groups in MOI with regard to MSP1, MSP2 and overall MOI (Mann-Whitney U-test; all P < 0.05). The predominant MSP1 allelic families were MAD20 for uncomplicated malaria and RO33 for severe malaria. The distribution of both FC27 and IC1/3D7 MSP2 allelic families were approximately the same across disease severity. One hundred and eleven P. falciparum isolates (81 %) consisted of multiple genotypes; 71/90 (78.9 %) in uncomplicated malaria and 40/50 (85.1 %) in severe malaria patient groups. Neither MSP1 nor MSP2 allelic families showed association with malaria severity. No statistically significant differences in multiplicity of infection were observed between different age groups.ConclusionIn this study the majority of P. falciparum isolates from uncomplicated and severe malaria patients consisted of multiple genotypes. Further molecular epidemiological studies delineate the link between P. falciparum genotype with the malaria phenotype in different regions are encouraged.

The anticoagulation choices of internal medicine residents for stroke prevention in non-valvular atrial fibrillation

Purpose of the studyTo explore the oral anticoagulation (OAC) prescribing choices of Canadian internal medicine residents, at different training levels, in comparison with the Canadian Cardiovascular Society (CCS) guidelines for...

EVALUATION THE RATE OF DELAYED PARASITE CLEARANCE IN UNCOMPLICATED PLASMODIUM FALCIPARUM PATIENT AFTER 3 DAYS TREATMENT WITH DIHYDROARTEMISININ PLUS PIPERAQUIN PHOSPHATE (DHA-PPQ) IN HUONG HOA DISTRICT, QUANG TRI PROVINCE

Background: Malaria is still remains a public health disease with high circulating levels, each year causes the death of about 1.5 million people worldwide, and almost all deaths are caused by falciparum malaria. The emergence of multidrug-resistant P. falciparum parasites has made these drugs useless in many areas where malaria is endemic. As with earlier antimalarial drugs,parasite resistance to artemisinin and its derivatives has emerged in Southeast Asia. Evaluate the effectiveness of antimalarial drug is an essential activity for assessing sensitivity of drug resistance are taking a positive contribution to the prevention of malaria. Research objective: To evaluate the rate of delayed parasite clearance (DPC) in uncomplicated Plasmodium falciparum patient after 3 days treatment with DHA-PPQ in Huong Hoa district, Quang Tri province. Research methods: Cross-sectional studyandempirical research. The research samples included all patients with falciparum malaria uncomplicated in Huong Hoa district, Quang Tri province agreed to participate in our study. There are 84 patients were collected smears and whole blood samples before and after 3 days of treatment with DHA-PPQ for evaluating parasitemiae by microscopy method and Real time PCR. Results: In total 84 samples of malaria patients were collected to determine the rate of delayed parasite clearance (DPC) after 3 days of treatment with DHA-PPQ, there were 22 samples (26.2%) are parasites in blood after treatment 3days determined by microscopy; Real time PCR with 33 samples (39.3%) were parasites in the blood after treatment 3 days. Conclusion: The epidemiology of malaria in our study had a rate of delayed parasite clearance (DPC)after treatment with DHA-PPQ 3 days were 26.2% (22/84 samples) determined by microscopy and 39.3% (33/84 samples) by Real time PCR. As defined by WHO, the study results contribute to the initial report suspected artemisinin resistance occurs in endemic areas of our research. Key words: Plasmodium falciparum, Artemisinin.

Treatment of carotid paraganglioma

Carotid paragangliomas, commonly known as carotid body tumors, are the most commonly reported head and neck paragangliomas. They are slow growing and always associated with the carotid arteries and adjacent nerves. They are rarely malignant. The estimates for familial transmission of this tumor range from 30%-50%. When multiple paragangliomas are present, the most common combination is 2 carotid paragangliomas. There are no absolute indications for surgical resection, but tumors expressing biochemical activity, a growth rate >1-2 mm per year or demonstrating airway or alimentary tract compression should be resected. Patients younger than 50 years should have small-to-medium sized paragangliomas resected. Patients with significant comorbidities or a contralateral cranial nerve dysfunction should not have surgery. Large carotid paragangliomas involving the skull base would likely result in multiple lower cranial nerve dysfunction after resection requiring multispecialty care afterwards. When dealing with bilateral carotid paragangliomas, resection of the smaller tumor first is recommended. Simultaneous carotid paraganglioma excision is discouraged because of acute baroreceptor failure. The second carotid paraganglioma may be observed for growth or it may be radiated depending on symptoms, size, or growth. The role and indications for angiography and embolization are covered elsewhere in this issue. If a carotid paraganglioma is biochemically active, alpha-adrenergic blockade followed by beta blockade is recommended and should be commenced 10 days before surgery. The complications associated with carotid paraganglioma excision are lower cranial nerve palsies and cerebrovascular accidents, although these are quite uncommon for small-to-medium sized tumors. Meticulous surgery and control of the carotid arteries can decrease these morbidities dramatically. Recently, a “top down” or craniocaudal approach to these tumors has gained acceptance among many surgeons. This approach controls the cephalad internal carotid artery and external carotid artery and removes the tumor down to the bifurcation. This technique has decreased the incidence of cranial neuropathy and blood loss in these patients. Following treatment, the uncomplicated patient requires yearly follow-up consisting of physical examination and magnetic resonance imaging. The familial patient should be genetically tested for succinate dehydrogenase mutations. Depending on the type of mutation yearly imaging and evaluation of siblings, parents and children is strongly advised. As metachronous lesions are possible, this follow-up is a lifetime undertaking.

Guideline of guidelines: urinary incontinence.

The objective of the article is to review key guidelines on the management of urinary incontinence (UI) to guide clinical management in a practical way. Guidelines produced by the European Association of Urology (updated in 2014), the Canadian Urological Association (updated in 2012), the International Consultation on Incontinence (updated in 2012), and the National Collaborating Centre for Women's and Children's Health (updated in 2013) were examined and their recommendations compared. In addition, specialised guidelines produced by the collaboration between the American Urological Association and the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction on overactive bladder and the use of urodynamics were reviewed. The Appraisal of Guidelines for Research and Evaluation II (AGREE) instrument was used to evaluate the quality of these guidelines. There is general agreement between the groups on the recommended initial evaluation and the use of conservative therapies for first-line treatment, with a limited role for imaging or invasive testing in the uncomplicated patient. These groups have greater variability in their recommendations for invasive procedures; however, generally the mid-urethral sling is recommended for uncomplicated stress UI, with different recommendations on the approach, as well as the comparability to other treatments, such as the autologous fascial sling. This 'Guideline of Guidelines' provides a summary of the salient similarities and differences between prominent groups on the management of UI.

Blackwater fever in an uncomplicated Plasmodium falciparum patient treated with dihydroartemisinin-piperaquine

The mechanism of massive intravascular haemolysis occurring during the treatment of malaria infection resulting in haemoglobinuria, commonly known as blackwater fever (BWF), remains unknown. BWF is most often seen in those with severe malaria treated with amino-alcohol drugs, including quinine, mefloquine and halofantrine. The potential for drugs containing artemisinins, chloroquine or piperaquine to cause oxidant haemolysis is believed to be much lower, particularly during treatment of uncomplicated malaria. Here is an unusual case of BWF, which developed on day 2 of treatment for uncomplicated Plasmodium falciparum infection with dihydroartemisinin-piperaquine (DHA-PIP) with documented evidence of concomitant seropositivity for Chikungunya infection.

Changing the Direction of Sleep Medicine: Business can Boom, but it is Not as Usual

Changing the Direction of Sleep Medicine: Business can Boom, but it is Not as Usual

First Isolation of Carbon Dioxide-Dependent Proteus mirabilis from an Uncomplicated Cystitis Patient with Sj^|^ouml;gren's Syndrome

An uncomplicated cystitis caused by CO2-dependent Proteus mirabilis was observed in a 64-year-old Japanese female patient with Sjögren's syndrome in the Aomori Kyoritsu Hospital, Aomori, Japan. The initial P. mirabilis isolate came from a midstream urine specimen containing large numbers of Gram-negative, rod-shaped organisms that failed to grow on both Drigalski agar and sheep blood agar incubated in ambient air. The organism did grow when the urine was cultured overnight on blood agar under anaerobic conditions. Hence, we believed that the organism was an anaerobe. Further investigation revealed that the isolate grew on sheep blood agar along with swarming when the atmospheric CO2 concentrations were increased to 5%. Initially, we failed to characterize or identify the P. mirabilis isolate or determine its antimicrobial susceptibilities using the MicroScan WalkAway-40 System because the isolate did not grow in the system. However, the isolate was subsequently identified as P. mirabilis based on its morphological, cultural, and biochemical properties by using the commercially available kit systems, Quick ID-GN and ID-Test EB-20. This identification of the isolate was confirmed by sequencing the 16S rRNA gene of the organism. To our knowledge, this is the first clinical isolation of capnophilic P. mirabilis.

Placental abruption occurring soon after labor combined spinal-epidural analgesia

We present a case of placental abruption necessitating emergency cesarean section in an otherwise uncomplicated patient soon after initiation of combined spinal-epidural analgesia in labor. Administration of spinal opioids has the potential to cause fetal bradycardia due to uterine hypertonicity following rapid onset of analgesia. In this case, a previously bloody show before placement of combined spinal-epidural analgesia may have been evidence of a small abruption. We hypothesize that uterine hypertonicity following administration of spinal opioids may have hastened the development of an existing placental abruption.

Evaluation of Stress Predominant Urinary Incontinence

Urodynamic studies (UDS) have been used to objectively characterize a patient’s complaint of urinary incontinence. Presumably, the clinician can utilize the UDS data to guide treatment options. It is even hoped that UDS can help predict which treatments should be utilized to produce the most effective outcomes. However, is this currently the case? The Urinary Incontinence Treatment Network (UITN) has completed four large randomized clinical trials related to treatments for urinary incontinence. Two trials compared outcomes of different surgeries for stress urinary incontinence (SUI) in which standardized UDS protocols were used. Secondary analyses of these UDS data showed that UDS were neither prognostic of treatment outcomes nor correlative with severity of UI symptoms, suggesting limited utility of UDS in the evaluation and management of the uncomplicated SUI patient. A third trial was designed to answer whether a basic office examination is not noninferior to UDS in affecting SUI surgical outcomes. The results of this study are currently in press. A fourth trial examined treatment of urgency urinary incontinence (UUI). Because UDS was not part of this trial, the utility of UDS in management and treatment of UUI could not be assessed. In summary, UDS will need to undergo further refinements to increase its clinical effectiveness in the area of urinary incontinence.

Positioning After Feedings

Nursing’s goal is to be the least invasive as the patient's condition allows. As a NICU nurse, each feeding for our patients is a priority for them to grow and develop with the idea to speed discharge to home. When infants develop reflux or have increased gastric aspirates, we are concerned that their weight will taper and their length of stay will increase. Positioning provides nurses with a noninvasive option to care for these patients. The that the right-side position is best for infants to enhance digestion stems from theories of anatomy and physics. Research strengthens this supposition for those infants needing help with decreased gastric motility. Other research supports the left lateral and prone positions for those patients with GER. In practice, a patient does not necessarily have one or the other and in fact may have both GER and slowed gastric motility at any given time. The literature supports the right lateral position for enhancing gastric emptying or motility and left lateral position for GER in the uncomplicated patient with one gastrointestinal concern. The knowledge the research provides is encouraging to provide a solution, but it does not clarify the true issues of a complex patient who can have decreased gastric motility needing the right lateral position and also suffer from symptoms of GER requiring the left lateral position (see Table). For those more complicated infants, the solution might best be choosing the prone position. The prone position should not be forgotten as the findings of many studies, although not often the first choice (best results) showed it to be consistently the second best for digestive problems. In any case, the dominant positions appear to be the right or left lateral side with the prone position considered a reasonable compromise. Further research is needed to provide a clear choice for correct positioning in the NICU population. The reality for nurses is that neonatal patients are often fed every 3 hours and their lives depend on each feeding to provide nutrients for growth. It is ideal for these patients to receive every prescribed feeding and be comfortably placed in a variety of positions. Nurses' assumption that the right lateral position is best is considered, in most cases, to be a true statement for those infants with increased gastric aspirates. For those patients with GER, the left lateral position is more highly preferred. It is important for nurses to be aware of the literature but also guide their practice based on the patient assessment and presentation of symptoms. Future knowledge may provide nurses with the data needed to perfect positioning methods for infants with feeding intolerances.

Mechanical Ventilation Following Cardiac Surgery in Children

The application of positive pressure mechanical ventilation can result in complex changes in pulmonary and cardiovascular physiology. These cardiopulmonary interactions are particularly important in pediatric patients undergoing surgery for repair or palliation of congenital cardiac defects. In this article, we review the various effects of mechanical ventilation on right and left ventricular preload, afterload and contractility. We also address specific clinical scenarios, such as mechanical ventilation of the uncomplicated patient following cardiac surgery, ventilation of patients with delayed sternal closure, the Norwood procedure, bidirectional and total cavopulmonary anastomoses and patients with right ventricular diastolic dysfunction.