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If there is concern about recurrent yeast infections prescribe oral fluconazole 150 mg weekly for suppression 20 mg levitra soft with mastercard. Bacterial vaginosis discount levitra soft uk, vulvovaginal candidiasis order online levitra soft, and trichomoniasis vaginitis are the most common causes of vaginal discharge in premenopausal women buy discount levitra soft on line. When these conditions have been excluded, other causes of vaginal discharge must be considered in the differential diagnosis of women with vaginal complaints. Most investigators believe that it is primarily an inflammatory vaginitis of noninfectious etiology, with secondary bacterial microbiota disruption [71]. Treatment is aimed at alleviating the chronic discharge with various compounded mixtures of antibiotics, steroids, and hormones applied topically to the inside of the vagina as a suppository. Currently, we use a compounded vaginal suppository of 10% hydrocortisone + 2% clindamycin + 0. Anytime a treatment regimen involves a strong steroid like hydrocortisone or clobetasol, antifungal should be used since resultant yeast infections can be common. Surgery Surgical Treatment for Neuroproliferative Vestibulodynia Surgical intervention for management of women with neuroproliferative vestibulodynia is offered to those who have failed initial conservative medical, psychological, and/or physical therapy focused treatment. Surgery is based on the hypothesis that the pathophysiology of neuroproliferative vestibulodynia is associated with inflamed, irritated, and hypersensitive vestibular glandular tissue and related increased nerve density in the vestibular mucosa. Surgical success is therefore based on excision of this abnormal glandular and nerve tissue in the vestibule. In women with neuroproliferative vestibulodynia, the procedure entitled complete vestibulectomy with vaginal advancement flap includes excision of the vestibular mucosa adjacent to the urethral meatus/Skene’s glands region anteriorly, excision of vestibular mucosa laterally, and posteriorly to the hymen with reconstruction including the posterior vaginal flap advancement (Figure 64. Copious yellow discharge, usually described by patients as “dries like glue” and “sticks to underwear. Complications include bleeding, infection, increased pain, hematoma, wound dehiscence, vaginal stenosis, scar tissue formation, and Bartholin duct cyst formation. During vestibulectomy, the vaginal advancement may cover the ostia of the Bartholin glands; however, the risk of postoperative Bartholin gland cyst formation is only 1%. As always with surgery, the risk of these complications can be reduced with appropriate surgical techniques. Various closure techniques have been described to minimize the risks of postoperative complications. Specifically, the vaginal advancement flap should be anchored by multiple interrupted horizontal mattress sutures of 3-0 Vicryl placed in an anterior–posterior direction. The remaining mucosal flap is then approximated to the perineum with interrupted stitches of 4-0 Vicryl. Intraoperative bupivacaine extended-release liposome is applied conservatively to the dissected tissue to aid in 72 hours of postoperative recovery. Postoperative care includes oral opioid pain medications for the first few weeks, including warm baths nightly. At 6 weeks postoperative follow-up, we will (1) perform vulvoscopy and a vaginal ultrasound to determine for the presence or absence of Batholin’s cysts and (2) perform a Q-tip test to see if any recurrent glands are causing pain. We have found that cysts >10 mm, when painful, are easily drained via intraoperative marsupialization. In the twenty-first century, in medicine, increasing numbers of health-care clinicians will need to be able to manage women with sexual health concerns since more and more women will expect and demand such management. In addition, those health-care clinicians who want to maximize overall women’s health-care delivery will increasingly engage in the management of women’s sexual health concerns, in addition to the traditional focus on continence and urological conditions. The need to address these issues is such that in future it will be increasingly more difficult for female urologists and urogynecologists to not provide at least first-line sexual health care to women. The basic premise of biologically focused management of women’s sexual health concerns is that the normal physiological processes regulating sexual activity can be altered by biological pathology. How each specific medical condition modulates women’s sexual health requires increased intensive basic science investigation. From the perspective of biologically focused clinicians, identification of the underlying pathophysiology of the sexual dysfunction is essential. If the biological basis of the sexual health concern can be diagnosed by history and physical examination and laboratory testing, 1029 management outcome may be successfully directed to the source pathophysiology. Of the many challenges facing health-care professionals today, the first is to improve the ability to accurately diagnose women with sexual health concerns, and the second is to ensure that women receive the best evidence-based available management options. The biologically focused clinician needs to have access to new developments in evidence-based, state-of-the-art data concerning biologically focused management strategies for women’s sexual health concerns. Interested health-care professionals should visit the organization’s website: http://www. Distressing sexual problems in United States women revisited: Prevalence after accounting for depression. Clinically relevant changes to sexual desire, satisfying sexual activity and personal distress as measured by the profile of female sexual function, sexual activity log, and personal distress scale in postmenopausal women with hypoactive sexual desire disorder. The impact of mental illness and psychotropic medications on sexual functioning: The evidence and management. Impaired sexual function in patients with borderline personality disorder is determined by history of sexual abuse. Biofeedback, electrical stimulation, pelvic floor muscle exercises, and vaginal cones: A combined rehabilitative approach for sexual dysfunction associated with urinary incontinence. The role of pelvic floor physical therapy in the treatment of pelvic and genital pain-related sexual dysfunction. Tolterodine immediate release improves sexual function in women with overactive bladder. The impact of lower urinary tract symptoms and urinary incontinence on female sexual dysfunction using a validated instrument. Improvement in sexual functioning in patients with interstitial cystitis/painful bladder syndrome. Effects of pregnancy on female sexual function and body image: A prospective study. A cross-sectional study of female sexual function and dysfunction during pregnancy. The effects of hypoestrogenism on the vaginal wall: Interference with the normal sexual response. Current management strategies of the postmenopausal patient with sexual health problems. The current outlook for testosterone in the management of hypoactive sexual desire disorder in post-menopausal women. Sexual dysfunction is frequent in premenopausal women with diabetes, obesity, and hypothyroidism, and correlates with markers of increased cardiovascular risk: A preliminary report. Assessing sexual function in well women: Validity and reliability of the Monash women’s health program female sexual satisfaction questionnaire. Validation of the female sexual distress scale- revised for assessing distress in women with hypoactive sexual desire disorder. The sexual lives of residents and fellows in graduate medical education programs: A single institution survey. Prevalence and risk factors for low sexual function in women: A study of 1,009 women in an outpatient clinic of a university hospital in Istanbul. Effect of hormone replacement therapy on clitoral artery blood flow in healthy postmenopausal women. Comparison of the effects of hormone therapy regimens, oral and vaginal estradiol, estradiol + drospirenone and tibolone, on sexual function in healthy postmenopausal women. The effect of a novel vaginal ring delivering oestradiol acetate on climacteric symptoms in postmenopausal women. Continuous low dose estradiol released from a vaginal ring versus estriol vaginal cream for urogenital atrophy. Transdermal testosterone treatment in women with impaired sexual function and oophorectomy. Bupropion sustained release for the treatment of hypoactive sexual desire disorder in premenopausal women. Sildenafil inhibits phosphodiesterase type-5 in human clitoral corpus cavernosum smooth muscle.

Surgical and nonsurgical approaches to treat voiding dysfunction following anti-incontinence surgery discount levitra soft 20mg overnight delivery. Modified Pereyra bladder neck suspension after previously failed anti-incontinence surgery purchase generic levitra soft online. The efficacy of urethrolysis without re-suspension for iatrogenic urethral obstruction order levitra soft uk. Urethrolysis with Martius labial fat pad graft for iatrogenic bladder outlet obstruction buy cheap levitra soft 20mg line. Refractory overactive bladder after urethrolysis for bladder outlet obstruction: Management with sacral neuromodulation. However, various efforts have been made to reduce the morbidity associated with these procedures. Complications may occur during and after the procedure, and it is essential to identify high-risk patients and minimize risk from surgery before the procedure. Thus, it is necessary to inform and counsel the patients concerning the operative risks commonly attributed to general anesthesia including intubation, myocardial infarction, cerebrovascular accident, and deep vein thrombosis. As may be anticipated, mortality increases with advancing age and the presence of medical comorbidities. Recent attention to the potential complications of mesh implantation from the Food and Drug Administration has certainly heightened awareness in the urologic community to reporting of complications (http://www. Recent randomized controlled studies and meta-analysis studies did not support routine use of mini-slings in clinical practice [10,11]. The significant reported complications of midsuburethral sling procedures include bladder and urethral injuries, bleeding, de novo urgency, voiding dysfunction, bladder and urethral erosion, vaginal extrusion, urinary tract infections, pain, and dyspareunia. There is some difficulty in summarizing the published complications of midsuburethral slings data due to the lack of standardization of definitions and differences in reporting methods between studies. The incidence of complications varies with operative experience, procedure, and center reporting, and there is a learning curve that requires further delineation [6]. Previous anti-incontinence surgery and surgeon experience were reported as potential risk factors for perforation [9]. The outside-in techniques seem to be more risky than the inside-out technique although the difference is not statistically significant [11]. In case of bladder perforation when recognized intraoperatively, repositioning the tape is mandatory and without any short- or long-term consequence. Most of the authors recommend a 2- or 3-day bladder catheterization with a Foley catheter [12]. But the benefit of an extended bladder catheterization in case of bladder perforation has not been demonstrated as opposed to a 24-hour bladder drainage. Failure to recognize intravesical needle passage of sling can lead to hematuria, irritative bladder symptoms, pelvic and urethral pain, fistulas, recurrent urinary tract infections, and a return to the operating room. Given the ease, speed and availability of cystoscopy, and the potential for serious complications if perforation is overlooked, cystoscopy could be recommended in all midsuburethral sling procedures [13]. If urethral injury is noted at midsuburethral sling placement, the procedure should be aborted and the urethra closed with multiple layers. This complication occurs significantly more often in outside-in procedure than in inside-out procedure [15]. In case of perforation, the vagina has to be closed immediately and the sling can be placed. Intraoperative bleeding from the vaginal dissection can usually be controlled with direct pressure on the paraurethral and retropubic areas and then followed by vaginal packing. Greatly increased bleeding that results in a retropubic hematoma usually arises from a blinded venous injury during needle passage, and up to 2. Vascular injuries involving large arteries such as the external iliac, femoral, obturator, epigastric, and inferior vesical have been reported and have been responsible for at least one mortality [17]. Accordingly, arterial injuries must be managed immediately by laparotomy or angioembolization. Patients with a history of abdominal or pelvic surgery are at a greater risk for bowel injury because of adhesions in the retropubic space and pubic symphysis. Several reasons may account for this finding including atrophic, scarred, or compromised vaginal mucosa. Potential risk factors for extrusion related to surgery include inadequate closure of vaginal tissue, infection, mesh rejection, and unrecognized vaginal injury during needle passage. Patients with vaginal extrusion may present with vaginal discharge, vaginal pain, dyspareunia, or sling palpable. Most cases occur in the first few months after surgery but they can also occur later. In the case of small vaginal extrusion, spontaneous healing can be expected in 6–12 weeks [22]. Bladder Erosion Bladder erosion occurs 4–11 months after surgery and can lead to recurrent urinary tract infections, overactive bladder symptoms, pelvic pain, and hematuria [14,21]. A resection of the sling combining an abdominal and a vaginal approach is generally performed [14,24] (Figure 80. Prevention of this complication may be done with a good training to the technique, checking during cystoscopy that the ancillary has not been inserted inside the detrusor muscle (moving it, the detrusor must not move with). In case of any doubt, the surgery must be repeated after removal of the ancillary and/or mesh. They may be caused by a poor surgical technique that could damage the integrity of the urethral tissue, excessive tension placed on the sling or local infection. Poorly estrogenized tissue, previous vaginal surgery, or a history of pelvic radiation may also contribute. Postoperative symptoms of erosion include overactive bladder symptoms, urethral or pelvic pain, recurrent urinary tract infections, urinary retention, and hematuria. Management of these symptoms includes complete excision of the eroded part of the synthetic sling and urethroplasty. De Novo Urgency The onset of de novo urgency and its possible treatment is one of the most clinically relevant and largely debatable postoperative complications of midsuburethral slings. This phenomenon is thought to result from a combination of mild obstruction and urethral irritation caused by the sling. Bladder irritability caused by undiagnosed pelvic hematoma has been proposed as well. After excluding reversible causes such as extrusion and obstruction, anticholinergic medications are the mainstay of current therapeutic interventions. In the case of urgency refractory to medical therapy and in the absence of any clinically significant obstruction, alternative therapy such as sacral neuromodulation and botulinum toxin A injections may be considered. Consequently, patients can complain of a slow or intermittent urine stream with a significant post-voiding residual volume and recurrent lower urinary tract infections. There are no significant differences in postoperative urinary retention between retropubic and transobturator approaches [10]. Moreover, urinary tract infections in case of chronic obstruction can increase from 8% during the first year after surgery to 44% during the fifth year [28]. In a patient with immediate postoperative retention or incomplete bladder emptying, indwelling or intermittent self-catheterization should be tried because resolution is commonly spontaneous [18]. If improvement is not seen within 4 weeks, early sling lysis should be considered. Urinary Tract Infections Urinary tract infection is less commonly reported than some other postoperative complications. Moreover, the definition of urinary tract infections and how it is diagnosed is often not clear. In the case of recurrent urinary tract infections, voiding dysfunction and urethral or bladder erosions should be investigated. A randomized controlled study revealed that 16% of women in the transobturator (inside-out) arm had groin pain compared to 1. Injuries to nerves such as the obturator have been reported but are rare (less than 1%) [26,31,32]. In the case of persistent pain, some authors recommended resection of the sling [33].

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OnabotulinumtoxinA for the treatment of patients with overactive bladder and urinary incontinence: 378 Results of a phase 3 discount levitra soft 20 mg, randomized effective levitra soft 20mg, placebo controlled trial purchase levitra soft once a day. Urodynamic results and clinical outcomes with intradetrusor injections of onabotulinumtoxinA in a randomized buy levitra soft with visa, placebo-controlled dose- finding study in idiopathic overactive bladder. Role of botulinum toxin-A in refractory idiopathic overactive bladder patients without detrusor overactivity. Cannabinoids and the endocannabinoid system in lower urinary tract function and dysfunction. Transient receptor potential channel modulators as pharmacological treatments for lower urinary tract symptoms: Myth or reality? According to the 2006 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, there are 8. Researchers investigating the urinary microbiome have also begun to explore the relationship between the bacterial milieu of the bladder and lower urinary tract symptoms, which may represent an alternative treatment pathway for patients with overactive bladder symptoms. Current understanding implicates both bacterial and host factors that affect pathogenesis. Type 1 pili contain FimH subunits, an adhesin that is able to mediate urothelial cell invasion via uroplakin receptors on the urothelial cell surface [7]. In animal studies, a FimH-specific antibody was able to block urothelial adhesion and thus decrease bacterial counts in the urine [8]. Integrins are also surface adhesion molecules, and certain subtypes are bound by FimH. This attachment appears to facilitate bacterial uptake into host cells by communication with and reorganization of the actin cytoskeleton, a process that may be mediated by tyrosine kinase signaling pathways [12]. The bacteria then rapidly multiply within the superficial urothelial cells, and these infected cells are eventually exfoliated via an apoptosis-like pathway (Figure 25. While this mechanism allows the host to clear large numbers of bacteria, urothelial integrity is disrupted in the process. During exfoliation, some bacteria are released from the cell and are able to invade into deeper immature urothelial layers that are exposed during the exfoliation process [15,16]. In fact, it is thought that these quiescent bacterial communities may provide a reservoir for recurrent infections [15]. In addition, some bacteria take on a filamentous morphology and are able to avoid neutrophil phagocytosis [18], which provides a survival advantage and may contribute to sustained infection. Although it is known that bacterial invasion leads to epithelial cytokine production, the exact mechanism by which the inflammatory cascade is initiated is not well understood. There are several known toxins that modulate the host inflammatory response, induce cytopathic effects, and cause tissue damage. Alpha-hemolysin promotes cell lysis, appears to attenuate the host inflammatory response, and is associated with clinical severity [25,26]. The bladder urothelium (a) is a pseudostratified transitional epithelium lined by large facet cells. Bacteria introduced into the bladder adhere to the bladder surface via type 1 pili (b). Upon attachment, bacteria are able to invade (c) and replicate (d) within the facet cell cytoplasm. Ultimately, the bacteria flux out of their intracellular niche (g), some adopting a filamentous morphology; they then adhere to other host cells and reenter the infectious cycle. During this process, infected urothelial cells are sloughed into the urine (f) and neutrophils are recruited to the site of infection. One host defense is to limit iron availability via transferrin, an iron carrier protein that can move iron stores in and out of cells. However, our understanding of “significant bacteriuria” has been challenged by recent advances in microbiology and more accurate descriptions of the type and number of bacteria present in the bladder. However, the effect of lower urinary tract bacteria on lower urinary tract symptoms is not likely isolated to what we currently term a “urinary tract infection. In a study comparing young women with acute urinary symptoms were compared to 5 asymptomatic controls, only 33% of the symptomatic women had bacterial counts >10 ; however, 70% 3 had bacterial counts >10 (compared to 7% asymptomatic controls) [36]. In addition, when a cutoff of 2 20 leukocytes/mm was used, pyuria was present in 77% of symptomatic women compared to 19. Another group of investigators considered not only pyuria and urine culture, but also the presence of intracellular bacteria in epithelial cells shed in the urine. Perhaps more striking, however, was the finding that 94% of symptomatic subjects had evidence of intracellular bacteria compared to 29% of controls (p = 0. Finally difference in bacterial community have been shown in the urine of women [40]. The investigators also observed a decreased bacterial diversity in the urine from subjects vs. In conclusion, advances in the science of bacterial pathogenesis as well as identification of host 382 factors that may predispose an individual to colonization or altered immune response are increasing our understanding of the host–pathogen relationship in the urinary tract. Epidemiology of urinary tract infections: Incidence, morbidity, and economic costs. Ambulatory care visits to physician offices, hospital outpatient departments, and emergency departments: United States, 2001–2002. Increasing prevalence of antimicrobial resistance among uropathogens causing acute uncomplicated cystitis in women. Genetic evidence supporting the fecal-perineal-urethral hypothesis in cystitis caused by Escherichia coli. In vitro binding of type 1-fimbriated Escherichia coli to uroplakins Ia and Ib: Relation to urinary tract infections. Localization of a domain in the FimH adhesin of Escherichia coli type 1 fimbriae capable of receptor recognition and use of a domain-specific antibody to confer protection against experimental urinary tract infection. Type 1 fimbrial expression enhances Escherichia coli virulence for the urinary tract. Tamm-Horsfall protein knockout mice are more prone to urinary tract infection: Rapid communication. Induction and evasion of host defenses by type 1-piliated uropathogenic Escherichia coli. Detection of intracellular bacterial communities in human urinary tract infection. Escherichia coli uropathogenesis in vitro: Invasion, cellular escape, and secondary infection analyzed in a human bladder cell infection model. Integrin-mediated host cell invasion by type 1-piliated uropathogenic Escherichia coli. Differentiation and developmental pathways of uropathogenic Escherichia coli in urinary tract pathogenesis. Development of a long-term ascending urinary tract infection mouse model for antibiotic treatment studies. Persistence of uropathogenic Escherichia coli in the face of multiple antibiotics. Toll-like receptor polymorphisms and susceptibility to urinary tract infections in adult women. Cytotoxic necrotizing factor type 1 production by uropathogenic Escherichia coli modulates polymorphonuclear leukocyte function. Lipocalin 2 mediates an innate immune response to bacterial infection by sequestrating iron. Functional genomic studies of uropathogenic Escherichia coli and host urothelial cells when intracellular bacterial communities are assembled. The pathogen-associated iroA gene cluster mediates bacterial evasion of lipocalin 2. Bacteriuria and the diagnosis of infections of the urinary tract; with observations on the use of methionine as a urinary antiseptic. A reassessment of the importance of “low-count” bacteriuria in young women with acute urinary symptoms. Associations between individual lower urinary tract symptoms and bacteriuria in random urine samples in women. Spectrum of bacterial colonization associated with urothelial cells from patients with chronic lower urinary tract symptoms. The value of grouping and interrelating concepts and facts into an organizational structure can be measured by the ability of the final product to provide a logical framework for introducing new theories, scientific findings, and clinical observations into the existing knowledge. In addition, the system should act as a useful clinical tool for diagnosing and treating disease. Rather than create new areas of contention, a classification system that is proposed for general use should ideally incorporate ideas and resolve conflicts.

Two techniques that may be used to clarify the situation are (a) recording right and left bundle branch potentials to demonstrate that their activation begins before His bundle activation and (b) His bundle pacing producing a longer H-V interval than the one noted during the tachycardia order levitra soft in united states online. Both of these are extremely difficult to do but can help define the mechanism of His bundle activation and the tachycardia origin purchase levitra soft 20 mg online. The simplest methods for verifying proper catheter position include the following: (a) the immediate appearance of His bundle deflections on termination of the tachycardia purchase levitra soft australia, or conversely generic levitra soft 20 mg amex, disappearance of the His bundle deflection on initiation of the tachycardia, without catheter manipulation; (b) spontaneously occurring or induced supraventricular capture of the His–Purkinje system (with or without ventricular capture) during the tachycardia with the sudden appearance of His bundle deflections; and (c) in the presence of supraventricular capture, H-V intervals comparable to those during sinus rhythm (Figs. We have found that the use of more closely spaced bipolar electrodes (l to 5 mm apart) facilitate identification of His bundle activity when it occurs within the ventricular electrogram. The second atrial impulse (A) conducts through the His bundle but fails to alter the tachycardia. The first and third sinus complexes block in the A-V node due to retrograde concealment. Two complexes later, another supraventricular fusion is observed, again without influencing the tachycardia. This demonstrates lack of requirement of the His bundle for perpetuation of the tachycardia. If His deflections are not spontaneously observed during the tachycardia, because of either poor position or obscuration of the His deflection by the ventricular electrogram, rapid atrial pacing can be used to clarify the issue in some cases. Thus, knowledge of A-V conduction during sinus rhythm may be necessary to define what is a “normal” H-V interval during the tachycardia. Some investigators , suggest that the site of origin of such a tachycardia is within the His–Purkinje system. As stated earlier, pre-excited tachycardia using either an A-V or nodoventricular bypass tract must be excluded (see Chapter 10). It is not rare for a tachycardia to have a V-H interval less than the antegrade H-V interval (Fig. Retrograde conduction time over the His–Purkinje system is actually much greater than the “V-H” observed during the tachycardia. Depending on the relative conduction time up the His–Purkinje system and through slowly conducting P. Atrial pacing is begun (arrow) at a cycle length of 480 msec, which is gradually reduced to 400 msec. As the atrial-paced cycle length decreases, a greater degree of ventricular activation is produced via the normal conducting system. The His deflection typically occurs before the right bundle deflection with an H-V interval approximating the H-V interval during sinus rhythm. Theoretically, if there is prolonged retrograde conduction over the His–Purkinje system, producing a markedly delayed His deflection (very long V-H), the “in parallel” activation of the His bundle would appear as a “normal” H-V interval. In this case, one must demonstrate that the His deflection is not a requisite for subsequent ventricular activation and thus is not a reflection of bundle branch reentry. Certain criteria are necessary for the diagnosis of bundle branch reentry, all of which provide P. The mechanisms of bundle branch reentry and its variants are discussed in greater detail later in this chapter. B: The schema shows that propagation of the impulse from the reentrant circuit to the His–Purkinje system is more rapid than that to the remainder of the myocardium, resulting in a short V-H interval. In this instance, conduction to the His–Purkinje was far more rapid than that to the ventricular myocardium, resulting in early His–Purkinje activation. These differences make it mandatory that these arrhythmias not be lumped together in terms of response to stimulation, effects of pharmacologic therapy, effectiveness of ablation, and clinical outcome. Anatomic Substrate The most common anatomic substrate for all these arrhythmias is chronic coronary artery disease, usually associated with prior infarction. Arrhythmias that are due to coronary artery disease are the only ones for which we have a reasonable understanding of the pathophysiologic substrate required for their genesis. Although sustained uniform monomorphic tachycardia may occur in the presence of either hypertrophic or idiopathic dilated cardiomyopathy, or even in patients with normal hearts, it is relatively uncommon. In these instances, the pathophysiologic basis for the arrhythmia is not well understood although patchy or segmental fibrosis is a common denominator. Arrhythmogenic right ventricular dysplasia has similar pathology as infarction, but it starts on the epicardium and additionally has fatty infiltration of the myocardium. This may occur because in most cases there is patchy fibrosis instead of the large areas of contiguous scar seen in infarction. Regardless of the underlying cardiac pathophysiology, sustained monomorphic tachycardia can be studied electrophysiologically such that interpretation of the mechanism and development of therapy is possible. Electrophysiologic studies are most useful in patients with coronary artery disease and prior infarction. The pathologic substrate for patients with ventricular tachyarrhythmias associated with coronary artery disease is 20 21 22 23 usually a prior myocardial infarction resulting in wall motion abnormalities. The second group of patients who present with a cardiac arrest are those who have severe coronary artery disease and relatively normal ventricular function; in this group the arrest is most likely due to acute ischemia. Our patient population is clearly selected so that we study patients with lower ejection fractions, recognizing that lower ejection fraction per se places a person at high risk for sudden death. The extent of infarction, and perhaps location involving the septum, may be the two important prognostic factors associated with these 21 24 malignant sustained ventricular arrhythmias. The cycle lengths of the tachycardias occurring early after infarction, however, tend to be faster, and the tachycardia is more poorly tolerated. This may reflect evolving scar formation, which when ultimately completed, may be related to longer tachycardia cycle lengths, owing to abnormalities of conduction with which it is 26 associated (see following discussion). Thus, some components of the anatomic substrate must be relatively fixed once infarction has 27 occurred. This is supported by inducibility at 10 and 100 days in an Ovine infarction model. Moreover the ability of programmed stimulation to predict risk of sudden cardiac arrest and survival postinfarction lead credence to 28 this hypothesis. Attempts to make these correlations are fraught with selection and/or entry bias, which is inherent in selecting patients from catheterization laboratories, coronary care units, or exercise laboratories. Similarly, patients studied following cardiac arrest are a selected group of survivors, and as such may not reflect the timing from infarction to cardiac arrest of nonsurvivors. However, this may indicate some of the characteristics of those patients likely to survive. Of more than 1,100 selected survivors of cardiac arrest associated with coronary artery disease who we have studied, the highest incidence (≈50%) of cardiac arrest occurred in the first 6 to 12 months following infarction. After the first year following infarction, the incidence of cardiac arrest decreases rapidly, such that within 3 years the incidence is low. In the thrombolytic and primary angioplasty era, the timing of these events has not changed, but, as stated above, their frequency has been significantly reduced. The pathophysiologic substrate in disease states other than coronary artery disease is less clear. Electrophysiologic Substrate The clinically measurable electrophysiologic consequences of infarction that are potentially arrhythmogenic include abnormalities of conduction and refractoriness, heterogeneity of conduction and refractoriness, enhanced automaticity, and areas of inexcitability. Unipolar (top) and bipolar (bottom) signals recorded with the Rhythmia mapping system. The bipolar signal removes the large farfield signal recorded in the two unipolar electrograms from which the bipolar signal is derived. We developed criteria for normal, abnormal, and fractionated electrograms using bipolar signals recorded with a Bard Josephson catheter (see Fig. Normal electrograms had sharp, biphasic, or triphasic spikes with amplitudes of ≥3 mV, durations of ≤70 msec, and/or an amplitude/duration ratio of ≥0. We defined fractionated electrograms as abnormal electrograms that fell outside the 95% confidence limits of amplitude and duration of all abnormal electrograms. The most common abnormalities were low voltage and increase in electrogram duration, both of which appear to be nonspecific markers of infarction or even poor contact. Multicomponent and fractionated electrograms, isolated late potentials and late electrograms were more closely related to 31 arrhythmogenic sites; but the positive predictive value was only ∼30%. Only 14% of “sites of origin” came from sites that demonstrated normal electrograms.

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The surgeon “sculptor” should create and cele- other cosmetic operations such as face lift and so on buy levitra soft, but for brate the beauty of the human body buy 20mg levitra soft visa. From this position buy generic levitra soft, it sure levitra soft 20 mg mastercard, you can always get to a surgical layer where tissue ele- was easy for me to decide to become a plastic surgeon. On the other hand, when the sur- I first observed a liposuction, over 30 years ago, this tech- geon gets too close to the dermis, scissors will encounter nique appeared to me as an “assault to holy areas. The same happens with 3D liposcu- lines, with rough instruments as those large cannulas of the lpture. Why should we limit our work to molding that the goal of this operation shoudn’t have been only suc- fat, without considering its case, i. Other points we started thinking of skin retraction as an allied force to came with time: why should I remove only the deep layer of have optimal results. With massive tissue thinning, skin fat when the deformity usually includes also the superficial retraction capacities are best utilized (Fig. Why should I limit the use of cannulas to an aspira- erative garments which support skin retraction (i. In other words, I often compare liposuction with rhi- ticularly when patients are not very young. As in rhinoplasty, we remove the bone and carti- lage until we get to our ideal shape (Fig. In this way we can remove, 6 Clinical Series step by step, what our eyes see and our hands feel without being scared by being too much superficial. Since January 1979 to January 2011, we have treated with If compared to traditional liposuction, this innovative liposculpture 9,207 patients. This is the correct plane of inner thighs (41 %), abdomen (18 %), knees (74 %), ankles superficial liposuction. Age varied from 16 to 72 years, it is hard to establish, also because this is very patient depen- including young patients, middle-aged patients with relaxed dent (skin, fat thickness, age, etc. This way of thinking evolves from Illouz’s technique and after from Fournier and Otteni. It is then possible to have satisfactory results both from an aesthetical and functional standpoint. We now think that removal of fat limited to deep areas leads to a very thick skin flap, which is prone to lower because of gravity and edema. This explains why flap thinning leads to a dynamic skin retraction, which means more support for thorough remodeling. As a matter of fact, a thin skin flap with a compressive bandage allows a more controlled retraction, so that operating middle-aged patients with suboptimal skin quality is not impossible any more. Sometimes, lipofilling can be extremely useful, acting as a biological glue to obtain fibro- sis and a perfect adherence to the underlying layers. Iannitelli sion, liposculpture is based on skin contraction and retraction and on differences in healing between flaps of different thick- ness. Similarly, the more flaccid is the skin, the more we should thin the flap, so as to have the best skin retraction. This is why, to our thinking, the skin flap should act as a case enclosing the molded fat. With superficial liposculpture, the skin is considered for the first time as an active and dynamic structure, and not only as a passive element of surgery. The face, the breast, the abdomen, the flanks, the hips and the thighs are an ensemble of concave and convex shapes which interact continuously: the tridimensional nature of our body should be respected, in order to have natural results. Even the inner thigh should not be flattened, but should be slightly concave at its base, so as to continue gradually to cre- ate a convex line at the middle third of the thigh. The abdo- men should not be totally flat, but slightly convex in its central part and concave when descending laterally and inferiorly. The basis of liposuction emphasizes three basic points: • The use of concentric circles in order to draw the areas to be treated • A focus on the volume of fat to be removed • Fat aspiration only in a deep plane Tridimensional superficial liposculpture adds further points: • The surgical marking is based on a geometrical analysis • A minor emphasis is on volumetric evaluation as a critical Fig. During rhinoplasty, a favorable profile of the nose is not determined based on the cartilage and bone to be Because of contraction, the skin becomes more tonic; the removed, but only on post-op appearance. Aspiration of deep fat allows a reduction of volume transected: the skin is now free to be moved easily and to but, at the same time, poses limits on body reshaping. We usually reach the subdermal fat only Traditional liposuction is based on deep fat removal. In when we do need to thin maximally the flap, in patients 1989 we have modified this technique, including superfi- with flaccid skin. Superficial liposculpture never damages cial fat removal in order to get benefit from tissue retrac- the vascular plexus, and at least 3–4 mm of fat should be tion even in older people. The surgeon should feel as a “sculptor” when “surgeon’s best friend” instead of being an enemy, as in performing a liposuction. The thinner the skin-fat layer, (A) and postoperative (B) appearance of a patient after a the more feedback from this anatomical structure. Figure 6 shows the preoperative (A) and Tridimensional Liposculpture 363 postoperative (B) appearance of a patient with anelastic 8 Patient Selection and Clinical skin after a 3D lipo. Tridimensional liposculpture appears as a less empiric tech- nique, when compared to conventional liposuction. Apart from patient selection criteria, the approach to the patient is utmostly important, taking inspiration from artistical princi- ples when compared to conventional criteria in classic lipo- suction. In order to have a correct and precise setting of the patient candidate, it is very important to know the classifica- tion of fat deposits in 4 distinct groups: • Type A – Mostly trochanteric (Fig. A 2-month postoperative result with a per- different subtype requires an ad hoc treatment, according to fect skin redrapement after tridimensional superficial liposculpture the aforementioned concepts, always trying to include in the Fig. In conclusion, differently from con- treat, in order to reach the far most point of the deformed ventional liposuction, where the candidate was always a area, and the maximal projection point of such deformity young patient, liposculpture does not discriminate age nor should be marked. A+or – mark should be made where more or less fat middle-aged and fair skin quality patients. Surgery should follow very precisely these markings, never tres- passing the boundaries. One should evaluate, palpating or pinching the fat depos- rate, typical of a sophisticated surgery, where details are a its to remove, the approximate amount of fat to aspirate basic point to reach the desired result. Any depression or dermic irregularity should also be One should proceed with the following sequence: right marked, so that the surgeon can recognize them and be thigh-right flank-left thigh-left flank-gluteal regions-torso- sure they are not amenable to technical errors (patients inner thighs-abdomen-knees-heels-arms. During surgery, we will discon- trochanteric region should be treated, with a pillow between the tinue suction when we will reach this point. In the lat- deformity should be treated according to artistical con- eral position, as a matter of fact, the defect to be corrected is not cepts, always trying to include the whole defect during modified from the underlying pressure from the lateral muscles surgery and get to a total 3D harmonic shape. The lateral position also guaran- tees a better vision of the surgical area, and less bleeding, 8. Two longitudinal 3 mm-long incision are done with an 11 One of the most important aspects of 3D superficial liposcu- blade. The first one is carried out on the superior part of the lpture is the G point modeling. The G point represents the drawing, whereas the second one on the lower part, where junction between the gluteus and the lateral thigh (Fig. Under general anesthesia, the The anatomical boundaries of this area are defined by the area is infiltrated with 500 ml saline solution and 1 ml of cutaneous projection of the Roser-Nelaton line (laterally, adrenaline, using a multiple hole-cannula that helps to have from the transition between the posterior and lateral part of a uniform diffusion of the anesthetic solution. In the G anesthesia, when treating minor deformities, we add to the point, liposculpture helps to achieve a slight concavity. This solution 25 ml of lidocaine 1 % and 7 ml of sodium bicar- will enhance the gluteal roundness and increase the length of bonate. Then, we apply some ice to the areas to be treated, in the lateral portion of the thigh. After 10–15 min, ates a roundness after a superficial liposculpture, which which is enough to have a good ischemia of the area, we makes a new and more desirable curve. By press- ing the fat down to simulate the gravity effect, the superficial subdermic fat is visualized along the whole treated area. Using a 3 mm cannula, some crisscross tunnels are made to aspirate this residual fat very superficially. In order to verify that harmonic curves are obtained, we position the patient in an anti-Trendelenburg position, to simulate the orthostatic position. When some minor deformities are still present, we prefer to mold fat only by hand, and not with cannulas. The thickness of the flap should differ slightly in the treated areas, to get a harmonic 3D shape of curves and volumes.

Administering protamine too rapidly may result in severe hypotension or pulmonary hypertension cheap levitra soft 20 mg otc. Persistent bleeding after bypass: Often occurs after prolonged durations of bypass (>2 hr) and usually is caused by inadequate surgical control of bleeding sites quality 20 mg levitra soft, incomplete reversal of heparin purchase 20 mg levitra soft otc, thrombocytopenia order levitra soft 20mg visa, platelet dysfunction, hypothermia-induced coagulation defects, undiagnosed preoperative hemostatic defects, newly acquired factor deficiency, or hypofibrinogenemia. Platelet, fresh-frozen plasma, or cryopre- cipitate transfusion should be considered. Accelerated fibrinolysis confirmed by elevated fibrin degradation products (>-32 mg/mL) or evidence of clot lysis should be treated with ε-aminocaproic acid or tranexamic acid. Chest tube drainage: In the first 2 hours after surgery of more than 250 to 300 mL/hr (10 mL/kg/hr)—in the absence of a hemostatic defect—is excessive and may require surgical reexploration. Intrathoracic bleed- ing at a site not adequately drained may cause cardiac tamponade, requiring immediate reopening of the chest, and is associated with severe hypotension on anesthetic induction. For asymptomatic lesions with greater than 60% stenosis, stenting is generally recommended. Neurologic deficits should be defined, and other disease states should be optimized. Most patients are elderly, have hypertension, have general- ized arteriosclerosis, and often have diabetes. Regional anesthesia with superficial cervical plexus blocks allow the patient to be awake and neuro- logically examined during surgery. Intraoperative hypertension is common and should be treated with a vasodilator like nitroglycerin, nicardipine, or nitroprusside; phenylephrine is used for hypotension. Bradycardia or complete heart block can be caused by manipulation of the carotid baroreceptor and is treated with atropine. Complications The perioperative mortality rate is 1% to 4% and is primarily attributable to cardiac complications. Damage to the recurrent laryngeal nerve can cause hoarseness, and damage to the hypoglossal nerve can cause ipsilateral deviation of the tongue. Denervation of the ipsilateral carotid baroreceptor can cause postop- erative hypertension, and denervation of the carotid body can blunt the ventilatory response to hypoxemia. Acute cardiac tamponade usually presents as sudden hypotension, tachycardia, and tachypnea. Physical examination may show jugular venous distention, narrowed arterial pulse pressure, muffled heart sounds, friction rub, or pul- sus paradoxus. Anesthetic considerations: Symptomatic cardiac tamponade requires evacuation either by pericardiocente- sis or surgically (usually for postoperative cardiac tamponade or for large recurrent pericardial effusions). Avoid cardiac depression, vasodilation, slowing of the heart, high airway pres- sures, and deep anesthesia. A left radial arterial line should be placed because clamping of the innominate may be required. One-lung ventilation with a right-sided double-lumen tube improves surgical exposure. A heparin-impregnated left ventricular apex to femoral artery shunt or partial right atrium to femoral artery bypass may be used. The aorta is cross-clamped above and below the lesion with acute hypertension above the clamp and hypotension below when not using shunt or partial bypass. After the release of the aortic cross-clamp, severe systemic hypotension may occur. Interruption of blood flow to the spinal cord, kidneys, and intestines can produce paraplegia, renal failure, or intestinal infarction. Induction: With obstructive lesions, avoid hypovolemia, bradycardia (decreases cardiac output), tachycar- dia (impairs ventricular filling), and myocardial depression. High-dose opioids may be suitable for very small and critically ill patients when postoperative ventilation is planned. Cardiopulmonary bypass: Blood used to prime the circuit for neonates and infants to prevent excessive hemodilution. High flow rates (up to 200 mL/kg/min) may be necessary to ensure adequate perfusion in very young patients. Dopamine and epinephrine are the most commonly used inotropes in pediatric patients. Complex congenital lesions may require com- plete circulatory arrest under deep hypothermia (15°C may be safe for up to 60 min). Postbypass period: Heparin reversal, fresh-frozen plasma, and platelets are usually necessary. Can be used rou- tinely even in patients with multigraft surgery, in redo operations, and in patients with compromised left ventricular function. During proximal anastomosis, the aorta is partially clamped, and a vasodila- tor is usually needed to reduce the systolic pressure to 90 to 100 mm Hg (nitroglycerin is preferred because it reduces myocardial ischemia). An intraluminal flow-through shunt may be used to maintain coronary blood flow during sewing of distal anastomosis. Contraindications: Patients with extensive coronary disease may not be good candidates, especially if they have poor target vessels. Patients are considered to have a full stomach and should receive a clear antacid, a histamine H -receptor blocker, and metoclopramide. Rapid-sequence induction can be accomplished with sufentanil 5 mcg/kg followed by succinylcholine 1. A pulmonary artery catheter is usually necessary for postbypass management but can be placed after transplantation. Transplantation: The recipient’s heart is excised, allowing the posterior wall of both atria with the caval and pulmonary vein openings and the atria of the donor heart to be anastomosed to the recipient’s atrial remnants (left side first). The preload-dependent function of the graft makes maintenance of a normal or high cardiac preload desirable. Isoproterenol or epinephrine infusions should be readily available to increase the heart rate if necessary. Echocardiogram showed ejection fraction of 35% with posterior and anterior left ven- tricular hypokinesis. The heart is directly cardioverted for atrial fibrillation but develops subsequent bradycardia in the 30s and systolic pressures of 50 mm Hg. If pressures continue to be low, often from vasoplegia, start vasopressors such as norepinephrine or epinephrine. Atrial pacing at a rate of 80 to 100 beats/min or an intraaortic balloon pump may be needed in refractory bradycardia and hypotension. Often postbypass atrial pacing and intraaortic balloon pumps can be discontinued when hypothermia and cardioplegia are completely reversed. Humidification and filtering of inspired air are functions of the upper airway (nose, mouth, and pharynx). The function of the tracheobronchial tree is to conduct gas flow to and from the alveoli. The bronchial circulation arises from the left heart and sustains the metabolic needs of the tracheobronchial tree. Dichotomous division (each branch dividing into two smaller branches), starting with the trachea and ending in alveolar sacs, is estimated to involve 23 divisions, or generations. Whereas the chest has a tendency to expand outward, the lungs have a tendency to collapse. Alveolar collapse is directly proportional to surface tension, as demonstrated by the law of Laplace: Pressure = 2 × Surface tension/Radius. The fraction of inspired gas not participating in alveolar gas exchange is known as dead space. Dead space is composed of gases in nonrespiratory airways (anatomic dead space) as well as in alveoli that are not perfused (alveolar dead space). Dependent areas of both lungs tend to be better ventilated than do the upper areas because of a gravitationally induced gradient in intrapleural pressure (and transpulmonary pressure). Pulmonary blood flow is also not uniform because dependent portions of the lung receive greater blood flow than upper (nondependent) areas regardless of body position. Pulmonary vascular tone is heavily influenced by local factors with hypoxia being a powerful stimulus for vasoconstriction. Shunting is the process whereby desaturated, mixed venous blood returns to the left heart without being resaturated with O in the lungs. Prolonged administration of high inspired O concentrations may lead to resorption atelectasis and increases in absolute 2 shunt. Anesthetic effects on gas exchange include increased dead space, hypoventilation, and increased intrapulmonary shunt- ing. Inhalation agents, including nitrous oxide, also can inhibit hypoxic pulmonary vasoconstriction in high doses.

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Ultrasound assessment of mid-urethra tape at three-year follow-up after tension-free vaginal tape procedure discount 20 mg levitra soft with mastercard. Dynamic interaction involved in the tension-free vaginal tape obturator procedure order levitra soft now. Correlation of morphological alterations and functional impairment of the tension- free vaginal tape obturator procedure levitra soft 20 mg low price. Comparison of transobturator vaginal tape and retropubic 567 tension-free vaginal tape: Clinical outcome and sonographic results of a case-control study order 20 mg levitra soft with visa. Clinical and ultrasonographic comparison of tension-free vaginal tape and transobturator tape procedure for the treatment of stress urinary incontinence. Transobturator mesh for cystocele repair: A short- to medium-term follow-up using 3D/4D ultrasound. Role of three-dimensional ultrasound in assessment of women undergoing urethral bulking agent therapy. Three-dimensional ultrasonography: An objective outcome tool to assess collagen distribution in women with stress urinary incontinence. Can we identify the limits of the puborectalis/pubovisceralis muscle on tomographic translabial ultrasound? Minimal criteria for the diagnosis of avulsion of the puborectalis muscle by tomographic ultrasound. Anterior but not posterior compartment prolapse is associated with levator hiatus area: A three- and four-dimensional transperineal ultrasound study. Moment of inertia as a means to evaluate the biomechanical impact of pelvic organ prolapse. Tomographic ultrasound imaging of the pelvic floor in nulliparous pregnant women: Limits of normality. Validation of three-dimensional perineal ultrasound and magnetic resonance imaging measurements of the pubovisceral muscle at rest. Constriction of the levator hiatus during instruction of pelvic floor or transversus abdominis contraction: A 4D ultrasound study. Morphological changes after pelvic floor muscle training measured by 3- dimensional ultrasonography: A randomized controlled trial. The assessment of voluntary pelvic floor muscle contraction by three- dimensional transperineal ultrasonography. Comparison of levator ani muscle defects and function in women with and without pelvic organ prolapse. Levator avulsion using a tomographic ultrasound and magnetic resonance-based model. Correlating signs and symptoms with pubovisceral muscle avulsions on magnetic resonance imaging. Diagnosing pubovisceral avulsions: A systematic review of the clinical relevance of a prevalent anatomical defect. Avulsion injury and levator hiatal ballooning: Two independent risk factors for prolapse? Correlation between levator ani muscle injuries on magnetic resonance imaging and fecal incontinence, pelvic organ prolapse, and urinary incontinence in primiparous women. Prevalence of major levator abnormalities in symptomatic patients with an underactive pelvic floor contraction. Levator ani defect status and lower urinary tract symptoms in women with pelvic organ prolapse. Unilateral coronal diameters of the levator hiatus: Baseline data for the automated detection of avulsion of the levator ani muscle. Three-dimensional ultrasound appearance of pelvic floor in nulliparous women and pelvic organ prolapse women. Three-dimensional ultrasound of pelvic floor: Is there a correlation with delivery mode and persisting pelvic floor disorders 18–24 months after first delivery? Vaginal birth and de novo stress incontinence: Relative contributions of urethral dysfunction and mobility. Agreement and reliability of pelvic floor measurements during contraction using three-dimensional pelvic floor ultrasound and virtual reality. Comparison of bony dimensions at the level of the pelvic floor in women with and without pelvic organ prolapse. Assessment of levator ani morphology and function in asymptomatic nulliparous women via static and dynamic magnetic resonance imaging. In vivo assessment of anterior compartment compliance and its relation to prolapse. Dynamic magnetic resonance imaging for grading pelvic organ prolapse according to the International Continence Society classification: Which line should be used? Levator co-activation is a significant confounder of pelvic organ descent on Valsalva maneuver. Levator ani subtended volume: A novel parameter to evaluate levator ani muscle laxity in pelvic organ prolapse. Study of dynamic magnetic resonance imaging in diagnosis of pelvic organ prolapse. Magnetic resonance assessment of pelvic anatomy and pelvic floor disorders after childbirth. Perineal descent and patients’ symptoms of anorectal dysfunction, pelvic organ prolapse, and urinary incontinence. Dynamic magnetic resonance imaging to quantify pelvic organ prolapse: Reliability of assessment and correlation with clinical findings and pelvic floor symptoms. Enlargement of the levator hiatus in female pelvic organ prolapse: Cause or effect? Is levator avulsion a predictor of cystocele recurrence following anterior vaginal mesh placement? Dynamic magnetic resonance imaging before and 6 months after laparoscopic sacrocolpopexy. These relationships in the asymptomatic population, and the deficiencies seen in symptomatic women, require an approach able to assess the anatomical relationships both in a static situation and also when undergoing physical stress. Cross-sectional imaging is able to achieve this and gives valuable insights from which our current knowledge-base can be developed. Such progress is invaluable for understanding female pelvic floor anatomy for populations and individuals, understanding the changes evident in symptomatic situations, identifying women potentially at risk of future problems, and understanding impact of past events, such as childbirth or surgery. Furthermore, additional post-imaging processing can focus on specific aspects of interest and potentially display the anatomy in three dimensions. This is now augmented with dynamic imaging, in which a series of scans are obtained at rest and during movement or function (e. A strong magnetic field is placed around the subject, and the scanner detects a radiofrequency signal emitted by excited hydrogen atoms. Increased magnetic strengths are commercially available, and the technological development means magnetic field strength is likely to evolve foreseeably. Stronger magnets currently require superconduction in very cold temperatures (liquid helium). Contrast between different structures is ascertained from the rate at which excited atoms return to the equilibrium state. The nature of return to the equilibrium state involves two independent processes of T1 (spin–lattice) and T2 (spin–spin) relaxation. T1 is basically representative of the different amounts of magnetization recovery, which is achieved by changing the repetition time. T2 is the difference in magnetization decay and is achieved by changing the echo time. Distinguishing T1 and T2 gives different imaging displays that may enhance detection of specific aspects, and both approaches are typically used in scanning protocols. For example, T2 is good for detecting edema and for assessing zonal anatomy, such as in the uterus. Contrast agent, comprising gadolinium and a chelating agent, can 571 also be administered intravenously. Dynamic sequences use single-slice ultrafast acquisitions during the tested activity, in coronal and axial planes (Figures 38. The T2-weighted sagittal sequences are useful to show the bladder neck and the cervix.