Standardisation of ambulatory urodynamic monitoring: Report of the Standardisation Sub-Committee of the International Continence Society for ambulatory urodynamic studies buy proventil 100 mcg amex asthma symptoms cold air. These voids before and after sleep may need to be considered in research studies order proventil 100 mcg online asthmatic bronchitis medicine, for example best purchase for proventil asthma zone chart, in nocturnal polyuria. If this definition were used, then an adapted definition of daytime frequency would need to be used with it. In scientific communications, the definition of incontinence in children would need further explanation. If the term bladder capacity is used, in any situation, it implies that this has been measured in some way, if only by abdominal ultrasound. In children, the “expected volume” may be calculated from the formula (30 + [age in years x 30] in mL). The Swedish, French, and Italian expression “effort incontinence” is preferable; however, words 1781 such as “effort” or “exertion” still do not capture some of the common precipitating factors for stress incontinence such as coughing or sneezing. The Credé maneuver is used by some spinal cord injury patients, and girls with detrusor underactivity sometimes press suprapubically to help empty the bladder. Dysuria literally means “abnormal urination” and is used correctly in some European countries. However, it is often used to describe the stinging/burning sensation characteristic of urinary infection. In the investigation of bladder pain, it may be necessary to exclude conditions such as carcinoma in situ and endometriosis. This may be done precisely by measuring the volume of each drink or crudely by asking how many drinks are taken in a 24-hour period. If the individual eats significant quantities of water-containing foods (vegetables, fruit, salads), then an appreciable effect on urine production will result. In practice, almost all investigations are performed using medium filling rates, which have a wide range. Furthermore, it may be simplistic to relate urgency just to the presence or absence of detrusor overactivity when there is usually a concomitant fall in urethral pressure. The phrase “which the patient cannot completely suppress” has been deleted from the old definition. However, in complete spinal cord injury patients, there may be no sensation whatsoever. As a compromise, they were allocated to idiopathic and neurogenic overactivity, respectively. In the absence of sensation, the cystometric capacity is the volume at which the clinician decides to terminate filling. The reason(s) for terminating filling should be defined, for example, high detrusor filling pressure, large infused volume, or pain. In the presence of sphincter incompetence, the cystometric capacity may be significantly increased by occlusion of the urethra, for example, by Foley catheter. If symptoms are seen in association with a decrease in urethral pressure, a full description should be given. Any delineation into categories such as “urethral hypermobility” and “intrinsic sphincter deficiency” may be simplistic and arbitrary and requires further research. Leak point pressures may be calculated in three ways from the three different baseline values that are in common use: zero (the true zero of intravesical pressure), the value of pves measured at zero bladder volume, or the value of pves immediately before the cough or Valsalva (usually at 200 or 300 mL bladder capacity). While it is felt that pelvic floor contractions are responsible, it is possible that the intraurethral striated muscle may be important. Although the urethral and periurethral striated muscles are usually held responsible, the smooth muscle of the bladder neck or urethra may also be responsible. In addition, there is often urodynamic stress incontinence during bladder filling. The retention volume should be significantly greater than the expected normal bladder capacity. In patients after surgery, due to bandaging of the lower abdomen or abdominal wall pain, it may be difficult to detect a painful, palpable, or percussable bladder. If used, a precise definition and any associated pathophysiology, such as reduced urethral function, or detrusor overactivity/low bladder compliance, should be stated. The term chronic retention excludes transient voiding difficulty, for example, after surgery for stress incontinence, and implies significant residual urine; a minimum figure of300 mL has been previously mentioned. The term “diagnosis” is defined as “the determination of the nature of a disease: clinical, made from a study of the symptoms and signs of a disease; and laboratory,” multiple options mentioned . Such a specific report would require a full outline of the terminology for all symptoms, signs, urodynamic investigations for female pelvic floor dysfunction, the imaging associated with those investigations, and the most common diagnoses. It may have been possible in the past to combine all the terminology for lower urinary tract function in men, women, and children into one report. The 1988 report by the Committee on the Standardization of Terminology  is one such example. With the increasing specificity and complexity of female diagnoses, a combined report may now be an anachronism. The 2002 report  still provided the traditional core terminology and some useful modifications, many of which are repeated in this document. However, it also revealed evidence that (1) a coherent and user-friendly combined report may be starting to become too difficult and (2) the terminology for women, due to the absence of specific diagnoses as well as other female- specific terminology, may not have been advantaged by this approach . The need for standardized terminology in female pelvic floor dysfunction to enable accurate communication for clinical and research purposes has been highlighted for some time . There is indeed the need for a general terminology, forming a “backbone” or “core” terminology to which more specific terminologies can be attached. As user-friendly as possible: It should be able to be understood by all clinical and research users. Clinically based: Symptoms, signs, and validated investigations should be presented for use in forming workable diagnoses. Sections 1 through 3 will address symptoms, signs, urodynamic investigations, and current associated pelvic imaging modalities routinely used in the office or urodynamic laboratory to make those diagnoses. This report does not specifically address terminology for neurogenic pelvic floor dysfunction. The terms  “urodynamic observation” and “condition” (nonmedical) have not been used in this report. The scope of the report will exclude (1) more invasive investigations requiring anesthetic and (2) evidence-based 1784 treatments for each diagnosis. Able to indicate origin and to provide explanations: Where a term’s existing definition (from one of multiple sources used) is deemed appropriate, that definition will be included and duly referenced. A large number of terms in female pelvic floor function and dysfunction, because of their longterm use, have now become generic, as apparent by their listing in medical dictionaries. Where a specific explanation is deemed appropriate to explain a change from earlier definitions or to qualify the current definition, this will be included as a note to this appendix (superscript numbers 1, 2, 3, etc. It is suggested that acknowledgment of these standards in written publications related to female pelvic floor dysfunction be indicated by a footnote to the section “Methods and Materials,” or its equivalent, to read as follows: “Methods, definitions, and units conform to the standards jointly recommended by the International Continence Society and the International Urogynecological Association, except where specifically noted. Symptoms are either volunteered by, or elicited from the individual, or may be described by the individual’s caregiver [2,3]. Stress (urinary) incontinence: Complaint of involuntary loss of urine on effort or physical exertion (e.
Assumptions of the Model The assumptions for the fixed-effects model are as follows: (a) The k sets of observed data constitute k independent random samples from the respective populations order proventil 100mcg otc asthma 6 month old baby. P (d) The tj are unknown constants and tj ¼ 0 since the sum of all deviations of the mj from their mean purchase generic proventil online asthma definition 64g, m purchase 100 mcg proventil overnight delivery asthmatic bronchitis 21, is zero. We test the null hypothesis that all population or treatment means are equal against the alternative that the members of at least one pair are not equal. If the population means are equal, each treatment effect is equal to zero, so that, alternatively, the hypotheses may be stated as H0 : tj ¼ 0; j ¼ 1; 2;... When H0 is true the population means are all equal, and the populations are centered at the same point (the common mean) on the horizontal axis. If the populations are all normally distributed with equal variances the distributions will be identical, so that in drawing their pictures each is superimposed on each of the others, and a single picture sufficiently represents them all. When H0 is false it may be false because one of the population means is different from the others, which are all equal. The test statistic for one-way analysis of variance is a computed variance ratio, which we designate by V. The methods by which they are calculated will be given in the discussion that follows. In general, the decision rule is: reject the null hypothesis if the computed value of V. We have defined analysis of variance as a process whereby the total variation present in a set of data is partitioned into components that are attributable to different sources. The term variation used in this context refers to the sum of squared deviations of observations from their mean,orsum of squares for short. Those who use a computer for calculations may wish to skip the following discussion of the computations involved in obtaining the test statistic. The Total Sum of Squares Before we can do any partitioning, we must first obtain the total sum of squares. The total sum of squares is the sum of the squares of the deviations of individual observations from the mean of all the observations taken together. The Within Groups Sum of Squares Now let us show how to compute the first of the two components of the total sum of squares. The first step in the computation calls for performing certain calculations within each group. These calculations involve computing within each group the sum of the squared deviations of the individual observations from their mean. When these calculations have been performed within each group, we obtain the sum of the individual group results. It can be shown that when the assumptions are met and the population means are all equal, both the among sum of squares and the within sum of squares, when divided by their respective degrees of freedom, yield independent and unbiased estimates of s2. The First Estimate of s2 Within any sample, Xnj ÀÁ2 xij À x:j i¼1 nj À 1 provides an unbiased estimate of the true variance of the population from which the sample came. The student will recognize this as an extension to k samples of the pooling of variances procedure encountered in Chapters 6 and 7 when the variances from two samples were pooled in order to use the t distribution. It is not necessary, however, for H0 to be true in order for the within groups mean square to be a valid estimate of s2; that is, the within groups mean square estimates s2 regardless of whether H is true or false, as long as the population variances 0 are equal. If we solve this x equation for s2, the variance of the population from which the samples were drawn, we have 2 2 s ¼ nsx (8. This sum of squares when divided by the associated degrees of freedom k À 1 is referred to as the among groups mean square. If the null hypothesis is false, that is, if all population means are not equal, we would expect the among groups mean square, which is computed by using the squared deviations of the sample means from the overall mean, to be larger than the within groups mean square. Both conditions, a true null hypothesis and equal population variances, must be met in order for the among groups mean square to be a valid estimate of s2. If, on the other hand, the among groups mean square is considerably larger than the within groups mean square, V. We know that because of the vagaries of sampling, even when the null hypothesis is true, it is unlikely that the among and within groups mean squares will be equal. We must decide, then, how big the observed difference must be before we can conclude that the difference is due to something other than sampling fluctuation. The F Test To answer the question just posed, we must consider the sampling ÀÁdistribution of the ratio of two sample variances. In Chapter 6 we learned that the quantityÀÁ s2=s2 = s2=s2 follows a distribution known as the F distribution when the sample 1 1 2 2 variances are computed from random and independently drawn samples from normal populations. Fisher in the early 1920s, has become one of the most widely used distributions in modern statistics. We have already become acquainted with its use in constructing confidence intervals for, and testing hypotheses about, population variances. In this chapter, we will see that it is the distribution fundamental to analysis of variance. It is of interest to note that the F distribution is the ratio of two Chi-square distributions. In Chapter 7 we learned that when the population variances are the same, they cancelÀÁÀÁ in the expression s2=s2 = s2=s2 , leaving s2=s2, which is itself distributed as F. The F 1 1 2 2 1 2 distribution is really a family of distributions, and the particular F distribution we use in a given situation depends on the number of degrees of freedom associated with the sample variance in the numerator (numerator degrees of freedom) and the number of degrees of freedom associated with the sample variance in the denominator (denominator degrees of freedom). Once the appropriate F distribution has been determined, the size of the observed V. The significance level chosen determines the critical value of F, the value that separates the nonrejection region from the rejection region. Explaining a Rejected Null Hypothesis There are two possible explan- ations for a rejected null hypothesis. If the null hypothesis is true, that is, if the two sample variances are estimates of a common variance, we know that the probability of getting a value of V. When we reject H0 we may, if we wish, conclude that the null hypothesis is true and assume that because of chance we got a set of data that gave rise to a rare event. Since the among groups mean square is based on the dispersion of the sample means about their mean (called the grand mean), this quantity will be large when there is a large discrepancy among the sizes of the sample means. When we fail to reject H0, we conclude that the population means are not significantly different from each other. A study by David Holben (A-1) assessed the selenium content of meat from free-roaming white-tailed deer (venison) and gray squirrel (squirrel) obtained from a low selenium region of the United States. These selenium content values were also compared to those of beef produced within and outside the same region. Such a graph highlights the main features of the data and brings into clear focus differences in selenium levels among the different meats. We assume that the four sets of data constitute indepen- dent simple random samples from the four indicated populations.
It can be seen that the more aggressive the stimulation buy proventil without prescription asthma drugs, the higher the sensitivity but the lower the specificity cheap proventil 100 mcg line asthma treatment without medicine. A protocol involving three extrastimuli at twice diastolic threshold gives the best balance of sensitivity and specificity generic 100 mcg proventil otc uncomplicated asthma definition. Importantly, the initiating stimulus is associated with marked latency, compatible with local conduction delay at the stimulus site. Thus, in patients without a prior history of sustained ventricular arrhythmias, we try to avoid using coupling intervals <180 msec. It is clear that using three right ventricular extrastimuli there is approximately a 90% sensitivity. More aggressive modes of stimulation from the right or left ventricle add little to improve the sensitivity. By Baysean analysis, this response is more likely to have clinical significance in a patient population in whom similar arrhythmias are present. Despite this, one should always be circumspect when interpreting a polymorphic tachycardia as a clinically significant arrhythmia because, as noted previously, comparable arrhythmias can be induced in patients without any history of arrhythmia. The last two coupling intervals are 160 and 140 msec, respectively, and are associated with local conduction delay (i. It should be noted that the clinical significance of the induction of any arrhythmia, P. This is a reason for using multiple stimulation sites and drive cycle lengths (see below). When cardiac arrest is the presenting syndrome, we would not deliver more than three extrastimuli, because the additional extrastimuli would be more likely to induce polymorphic tachycardias than a uniform one (10:1), which if acted on would lead to the treatment of “nonspecific responses” in some individuals. It is important that the induced arrhythmia be comparable to the spontaneous arrhythmia to ensure specificity of programmed stimulation. It is important that repetition of “critical” coupling intervals or the entire protocol is employed in order to define a true negative study. Top: Spontaneous left bundle branch block tachycardia with left inferior axis is shown. In 10% to 15%, induction can be accomplished either during sinus rhythm or ventricular pacing. B: A single extrastimulus at the same coupling interval induces a left bundle branch block tachycardia. The cycle length used can influence the number of extrastimuli required for induction. Unfortunately, one cannot predict which cycle length will facilitate induction of the clinically relevant tachycardia. In our laboratory, we routinely use drive cycle lengths of 600 and 400 msec in all patients as well P. Additional cycle lengths may be employed if stimulation at these drive cycle lengths fails to initiate tachycardia. B: During ventricular pacing, a single extrastimulus delivered at a longer coupling interval induces the same tachycardia. Refractory periods were measured at a drive cycle length of 600 msec in 107 patients in the ventricular tachycardia group and in 57 patients in the cardiac arrest group. Refractory periods were measured at a drive cycle length of 500 msec in six patients in the ventricular tachycardia group and in two patients in the cardiac arrest group. Role of triple extrastimuli during electrophysiologic study of patients with documented sustained ventricular tachyarrhythmias. Role of triple extrastimuli during electrophysiologic study of patients with documented sustained ventricular tachyarrhythmias. Multiple Sites of Stimulation Studies have demonstrated that using at least two sites of stimulation enhances the ability to initiate 1 42 140 156 tachycardias. If three extrastimuli are delivered only from the right ventricular apex, 10% to 20% of patients will require the use of a second right ventricular or left ventricular site for initiation of 156 sustained (Fig. Thus, the inducibility appears related to the relationship of the wavefront of activation from the site of stimulation and the mechanism at the tachycardia origin. To determine the influence of stimulation site on the mode of induction and to allow for the safest stimulating protocol to induce the tachycardia (least number of extrastimuli), I recommend alternating stimulation from the right ventricular apex and outflow tract at each specified cycle length and number of extrastimuli. Role of Increasing Current Several investigators have evaluated the use of increasing current (5 to 20 mA) in the induction of sustained ventricular P. Moreover, only a small increment in sensitivity of 158 initiating a uniform sustained tachycardia occurs with increased current. Even when used, the increased current may either facilitate or inhibit induction of certain 158 tachycardias. The mechanism by which increased current seems to facilitate tachycardia is by shortening the measured local refractoriness; however, the mechanism by which induction is prevented is unknown. Therefore, we recommend use of pulse widths between 1 and 2 msec at twice diastolic threshold as the standard. If this fails to induce an arrhythmia, we deliver two extrastimuli in the same manner. If this fails, we repeat the protocol using other right ventricular or left ventricular sites. In addition, we may use isoproterenol or a Type I agent, such as procainamide, to facilitate induction of the tachycardia. Tachycardias due to abnormal automaticity may also be initiated by catecholamines alone. Programmed stimulation cannot reproducibly initiate them, even in the presence of catecholamines. Following the administration of 15 mg/kg of procainamide producing a plasma level of 11. The use of procainamide or other Type I agents to facilitate induction of a tachycardia is not as well recognized. Therefore, we believe that the end point of programmed stimulation should be induction of the clinical arrhythmia or, in this instance, the assumed ventricular arrhythmia. In the case of patients presenting with a cardiac arrest, although doubt will always exist, I believe one must treat the reproducible induction of a polymorphic arrhythmia as a possible indicator of the clinical arrhythmia. The relationship of the interval from the last stimulus to the onset of the arrhythmia and the cycle length of the early beats of the arrhythmia to the coupling interval of extrastimuli and/or the drive cycle length used to induce the arrhythmia: To do this, the tachycardia must be stopped and started again so that the effect of changing basic drive cycle lengths and the number of extrastimuli on the ability to initiate the tachycardia can be determined. Only in the latter two groups of patients does the disease process influence the ability to initiate the rhythm. For example, patients in whom double and triple extrastimuli are required for initiation during day 1 may have a different mode of initiation on day 2. Therefore, although the exact number of extrastimuli or site of stimulation may vary daily, the ability to initiate the arrhythmia does not.
The Hasson tech- nique is used for the right upper quadrant port (A); the aponeurosis of the external oblique is identifed and opened purchase generic proventil on line asthma symptoms tight chest, and a balloon dissector is infated beneath the external oblique and above the internal oblique to create a working space(Fig generic proventil 100 mcg online asthma inhaler definition. A 10-mm trocar (B) in the fank is inserted into the space to allow for an electrical scissor to divide the fascia of the external oblique laparoscopically cheap 100mcg proventil with visa asthma lung pictures, just lateral to the rectus sheath going downwards towards the right lower quadrant (Fig. In order to divide the upper part of the exter- nal oblique fascia, a 5-mm trocar is inserted (C). The camera is moved from the right upper quadrant trocar to the middle 10 mm trocar, and a scissor is introduced into the 5 mm trocar to complete the division. After the component separation is fnished, it is possible to perform an incisional hernia repair using a smaller mesh, as the component separation allows the edges of the fascial defect to be brought closer together; alternatively, a full laparoscopic incisional hernia repair with a sublay mesh can be performed. The main advantage of the laparoscopic component separation technique is to avoid the risk of devascularizing the skin, which can occur with the open method. A initial introduction site for the balloon dissector, and the Hasson trocar for the camera; B trocar port for the electri- cal scissors; C additional 5 mm port for the scissor to fnish up the division of the cephalad portion of the external oblique fascia Laparoscopic Component Separation 179 Fig. This will achieve a separation of the components and a subsequent release of the tension on the closure of the defect 180 Chapter 11 Incisional and Ventral Hernia Repair Including Component Separation Selected Alvarez C (2004) Open mesh versus laparoscopic mesh hernia repair. N Engl J Med 351(14):1463–1465 Further Bingener J, Buck L, Richards M, Michalek J, Schwesinger W, Sirinek K (2007) Long-term Reading outcomes in laparoscopic vs open ventral hernia repair. Arch Surg 144(3):228–233 Malas M, Katkhouda N (2002) Herniation through the falciform ligament following lapa- roscopic surgery. Arch Surg 141(3):304–306 Splenectomy (Total and Partial) and 12 Splenopancreatectomy Preoperative Requirements and Workup Classic Laparoscopic Laparoscopic splenectomy is a diffcult procedure that should only be performed by an Splenectomy experienced laparoscopic surgeon or under the direct supervision of such a surgeon. The surgeon should check the instrument set personally to ensure that everything is available, specifcally clip appliers, atraumatic graspers, liver fan retractors, and an irrigation suction machine with the capacity for hydrodissection. An open tray with a number 10 or 20 blade should be immediately available in case there is a need for conver- sion. The anesthesiologist must make sure that there is a suitable blood and platelet supply in the operating room prior to the start of the procedure. The patient is safely secured on a bean-bag with the left side up at a 60° angle in reverse Trendelenberg and the left arm positioned as for a left lateral thoracotomy (Fig. This allows gravity to retract the abdominal organs and maximize the working space. The surgeon stands on the patient’s right side facing the left monitor, with the camera assistant on the same side sitting on a stool to his left to avoid a confict with the elbows of the surgeon. The frst assistant is on the opposite side, but the three members of the team all look at the left monitor to avoid mirror imaging and discoordination of the critical frst assistant (Fig. When the trocars are inserted, the patient is positioned in reverse Trendelenburg. First, gravity pulls the stomach and small bowel in a rostral direction out of the operative feld. Second, the spleen is kept hanging from the diaphragm by its phrenic attachments, thus placing the gastro- splenic vessels under tension, simplifying dissection and division of the vessels later in the operation (Fig. In the anterior approach, the hilar vessels are controlled frst, and the phrenic attachments are divided at the end of the operation. In contrast, with a posterior approach, the lateral attachments are divided frst, the spleen is mobilized later- ally and the hilar vessels are controlled later, as done in open surgery (Fig. Numbers depict stages of the operation 186 Chapter 12 Splenectomy (Total and Partial) and Splenopancreatectomy Port Placement Four to fve 12 mm ports are needed for this operation (Fig. Following insuffation using a Veress needle, the frst trocar is inserted in the left upper quadrant approximately fve fnger- breadths below the costal margin, moving the camera closer to the spleen. This will permit full exploration of the abdominal cavity to check for the presence of accessory spleens and other intra-abdominal lesions that might require laparoscopic management. One port is inserted on each side of the umbilical port in a triangulated manner, for the right and left hands of the surgeon. Another trocar is inserted laterally under the left costal margin for the frst assistant. An optional subxiphoid trocar can be inserted for an irrigation/suction device or for a fan retractor used by the camera assistant if needed. Knowledge of the patient’s vascular anatomy will help decide on the most appropriate dissection technique. Knowledge of the anatomy of the spleen is critical, and two special features are of interest. First, as a rule, notched spleens and those with prominences have more entering arteries than those with smooth borders (usually dis- tributed type). Second, the tail of the pancreas lies close to the hilum of the spleen and is in direct contact with the spleen in about 30% of cases, and within 1 cm of the spleen in 40%. Caution is therefore recommended before fring a linear cutter across the hilar vessels. The procedure follows these key steps: Division of the short gastric vessels and opening the lesser sac (Fig. Lateral and superior retraction of the inferior pole of the spleen and division of the inferior pole vessels. This proceeds as for a Nissen fundoplication with the exception that the dissection is carried out much closer to the spleen than to the stomach (Chap. The frst assistant gently grasps the fatty tissue surrounding the short gastric vessels and retracts it superiorly, while the surgeon gently retracts the stomach to the right. This will expose the short gastric vessels, which are subsequently controlled with the harmonic shears. The division is then continued superiorly and then inferiorly until the tail of the pancreas is completely exposed (Fig. The frst assistant retracts the spleen superiorly and laterally with a closed Babcock clamp to expose the splenic fexure of the colon. The surgeon’s left hand retracts the transverse colon inferi- orly, exposing the splenocolic ligament. The ligament is divided using the harmonic shears to allow safe dissection of the inferior pole of the spleen. Once the splenocolic ligament has been divided, lateral and superior retraction will expose the inferior pole vessels that branch from the main splenic vessels. The inferior pole vessels are divided at this point, permitting full mobilization of the inferior pole of the spleen. We do not recommend the use of the harmonic shears on these vessels, as it will not achieve effcient hemostasis. Uncontrollable bleeding from these vessels can result in an early conversion to open surgery. Division of the Hilar Vessels and Phrenic Attachments In order to expose the hilar vessels, opposing retraction by the frst assistant and the surgeon is required.