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It is a retrograde step to have divided patients with urgency and frequency symptoms into “detrusor overactivity” and the new “bladder oversensitivity” on the basis of “involuntary detrusor muscle contractions during filling cystometry order genuine slip inn online. Further threats to the validity of detrusor overactivity as a measure of urgency have come from studies demonstrating unacceptably poor interrater reliability [59 best slip inn 1pack,60] and no significant association between individual contractions and reporting of increased sensation [61 purchase generic slip inn online,62]. The consensus process for drafting the 2009 report would therefore seem to have reiterated the conventional wisdom regarding cystometry, in the face of the best evidence. In some quarters, “voiding dysfunction” has become a catchall term for lower urinary tract symptoms. This report specifies however that the term refers only to “abnormally slow and/or incomplete micturition. The new report suggests a 30 mL residual as the upper limit of normal and a 200 mL residual as representing chronic retention . Although usage of the Liverpool nomogram for average flow rate is recommended, the report recognizes that this is an area requiring further validation studies, with poorly defined relationships between symptoms and pathology [65,66]. The report specifies that the diagnosis requires both subjective symptoms and objective findings. It is not entirely clear which term is intended to represent objective voiding dysfunction but without symptoms. For the first time, it provides unifying coverage of urogynecology and female urology. It should be an invaluable reference both for researchers planning and reporting studies and for clinicians who need to map the research evidence base onto the myriad of individual complaints and symptoms reported by patients. This commentary, however, identifies some sections that would benefit from greater depth and other areas where recommendations substantially diverge from recent evidence. Future reports should consider incorporating systematic reviews of current evidence, such as those provided by the International Consultation on Incontinence , and use of a formal Delphi method to achieve better balance of coverage. Second report on the standardisation of terminology of lower urinary tract function. International Continence Society Committee on standardisation of Terminology, Copenhagen. Third report on the standardisation of terminology of lower urinary tract function. Fourth report on the standardisation of terminology of lower urinary tract function. Sixth report on the standardisation of terminology of lower urinary tract function. Procedures related to neurophysiological investigations: Electromyography, nerve conduction studies, reflex latencies, evoked potentials and sensory testing. The International Continence Society Committee on Standardisation of Terminology, New York. Seventh report on the standardisation of terminology of lower urinary tract function: Lower urinary tract rehabilitation techniques. Standardization of terminology of lower urinary tract function: Pressure- flow studies of voiding, urethra resistance, and urethral obstruction. International Continence Society Subcommittee on Standardization of Terminology of pressure flow studies. The standardisation of terminology of lower urinary tract function: Report from the Standardisation Subcommittee of the International Continence Society. The standardization of terminology of lower urinary tract function in children and adolescents: Report from the Standardisation Committee of the International Children’s Continence Society. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. The standardization of terminology for researchers in female pelvic floor disorders. Standardization of terminology of pelvic floor muscle function and dysfunction: Report from the pelvic floor clinical assessment group of the International Continence Society. Good urodynamic practices: Uroflowmetry, filling cystometry, and pressure-flow studies. Standardisation of ambulatory urodynamic monitoring: Report of the Standardisation Sub-committee of the International Continence Society for Ambulatory Urodynamic Studies. Standardisation of urethral pressure measurement: Report from the Standardisation Sub-committee of the International Continence Society. Clinical efficacy, safety, and tolerability of once-daily fesoterodine in subjects with overactive bladder. Author’s reply to editorial comment regarding “Overactive bladder and the definition of urgency. Cystometrical sensory data from a normal population: Comparison of two groups of young healthy volunteers examined with 5 years interval. Is catheter cause of subjectivity in sensations perceived during filling 1814 cystometry? Can a faked cystometry deceive patients in their perception of filling sensations? A study on the reliability of spontaneously reported cystometric filling sensations in patients with non- neurogenic lower urinary tract dysfunction. Prioritizing research: Patients, carers, and clinicians working together to identify and prioritize important clinical uncertainties in urinary incontinence. Clinical relevance of urodynamic investigation tests prior to surgical correction of genital prolapse: A literature review. A systematic review of the reliability of frequency-volume charts in urological research and its implications for the optimum chart duration. The incidence and prevalence of nocturia (increased nocturnal voiding frequency): Results from a community based cohort study in older men. A longitudinal population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in women. A randomized trial of urodynamic testing before stress-incontinence surgery N Engl J Med 2012; 366(21):1987–1997. Value of urodynamics before stress urinary incontinence surgery: A randomized controlled trial. Preoperative clinical, demographic, and urodynamic measures associated with failure to demonstrate urodynamic stress incontinence in women enrolled in two randomized clinical trials of surgery for stress urinary incontinence. Predictive value of urodynamics on outcome after midurethral sling surgery for female stress urinary incontinence. Urodynamic verification of an overactive bladder is not a prerequisite for antimuscarinic treatment response. Detrusor overactivity does not predict outcome of sacral neuromodulation test stimulation.
Special thanks Anuj Basil cheap slip inn 1pack, a budding electrophysiology fellow buy genuine slip inn line, for reviewing Chapter 12 discount 1pack slip inn overnight delivery. I am greatly indebted to David Callans, who reviewed, updated, and edited Chapter 13 on catheter ablation of arrhythmias. This was an enormous amount of work without which the chapter would have been incomplete. I am eternally grateful to Eileen Eckstein for her superb photographic skills and guardianship of my original graphics, and to Angelika Boyce and Susan Haviland, my administrative assistants during the writing of each edition, for protecting me from distractions. Finally, this book could never have been completed without the encouragement, support, and tolerance of my wife Joan. Chapter 1 Electrophysiologic Investigation: Technical Aspects Personnel The most important aspects for the performance of safe and valuable electrophysiologic studies are the presence and participation of dedicated personnel. The minimum personnel requirements for such studies include at least one physician, one or two nurses (two nurses for complex ablations requiring conscious sedation), a technician with radiation expertise, an anesthesiologist on standby, and an engineer on the premises to repair equipment. With the widespread use of catheter ablation, appropriate facilities and technical 1 2 support are even more critical. This person should have been fully trained in clinical cardiac electrophysiology in an approved electrophysiology training program. The guidelines for training in clinical cardiac electrophysiology have undergone remarkable changes as interventional electrophysiology has assumed a more important role. The current training guidelines for competency in cardiac electrophysiology have been developed by the American College of Cardiology and the American Heart Association, and the American College of Physicians-American Society of Internal Medicine in collaboration with 3 4 the Heart Rhythm Society (formerly, the North American Society for Pacing and Electrophysiology). The clinical electrophysiologist should have electrophysiology in general and arrhythmias in particular as his or her primary commitment. As such, they should have spent a minimum of 1 year, preferably 2 years, of training in an active electrophysiology laboratory and have met criteria for certification. The widespread practice of device implantation by electrophysiologists will certainly make a combined pacing and electrophysiology program mandatory for implanters. Recently, with the development of resynchronization therapy for heart failure, there has been an interest in developing a program to train heart failure physicians to implant devices in their patients. At the least this should be a program of 1 year, and in my opinion, should include training in basic electrophysiology. Sufficient training is necessary for credentialing, which will be extremely important for practice and reimbursement in the future. This is critical for safety, particularly with use of conscious sedation or anesthesia in patients in whom there is risk of life- threatening complications. These nurse–technicians must be familiar with all the equipment used in the laboratory and must be well trained and experienced in the area of cardiopulmonary resuscitation. We use two or three dedicated nurses and a technician in each of our electrophysiology laboratories. Their responsibilities range from monitoring hemodynamics and rhythms, using the defibrillator/cardioverter when necessary, and delivering antiarrhythmic medications and conscious sedation (nurses), to collecting and measuring data online during the study. They are also trained to treat any complications that could possibly arise during the study. An important but often unstressed role is the relationship of the nurse and the patient. The nurse–technician may also play an invaluable role in carrying out laboratory-based research. It is essential that the electrophysiologist and nurse–technician function as a team, with full knowledge of the purpose and potential complications of each study being ensured at the outset of the study. A radiation technologist should also be available to assure proper equipment function and monitor radiation dose received by patients and laboratory personnel. An anesthesiologist and probably a cardiac surgeon should be available on call in the event that life-threatening arrhythmias or complications requiring intubation, ventilation, thoracotomy, and potential surgery should arise. This is important in patients undergoing stimulation and mapping studies for malignant ventricular arrhythmias and, in particular, catheter ablation techniques (see Chapter 14). We use anesthesia for all our atrial fibrillation ablations, and for ablative procedures in patients with fragile hemodynamics to P. Anesthesia is also extremely useful in elderly patients because of the frequent paradoxical response to standard sedation. Although conscious sedation is usually given by laboratory staff, in the substantial minority of laboratories, anesthesia (e. A biomedical engineer and/or technician should be available to the laboratory to maintain equipment so that it is properly functioning and electrically safe. It cannot be stated too strongly that electrophysiologic studies must be done by personnel who are properly trained in and who are dedicated to the diagnosis and management of 1 2 3 4 arrhythmias. This opinion is shared by the appropriate associations of internal medicine and cardiology. Equipment The appropriate selection of tools is of major importance to the clinical electrophysiologist. Although expensive and elaborate equipment cannot substitute for an experienced and careful operator, the use of inadequate equipment may prevent the maximal amount of data from being collected, and it may be hazardous to the patient. However, a complete evaluation of most supraventricular arrhythmias, which may require activation mapping, necessarily involves the use of multiple catheters and several recording channels as well as a programmable stimulator. Thus, an appropriately equipped laboratory should provide all the equipment necessary for the most detailed study. In the most optimal of situations, a room should be dedicated for electrophysiologic studies. This is not always possible, and in many institutions, the electrophysiologic studies are carried out in the cardiac hemodynamic–angiographic catheterization laboratory. A volume of more than 100 cases per year probably requires a dedicated laboratory. This is the current practice in more than 90% of centers and is likely to be the universal practice in the future. It is important that the electrophysiology laboratory have appropriate radiographic equipment. The laboratory must have an image intensifier that is equipped for at least fluoroscopy, and, in certain instances, is capable of cine-fluoroscopy if the laboratory is also used for coronary angiography. To reduce radiation exposure, pulsed fluoroscopy or other radiation reduction adaptations are required. This has become critical in the ablation era, when radiation exposure can be prolonged and risk of malignancy increased. Currently the best systems are pulsed and digitally based, which reduces the radiation risk and allow for easy storage of acquired data. Newer systems which markedly reduce radiation exposure enable the electrophysiologist to move catheters at a distance or in the absence of the fluoroscopic system. Examples of such systems are the Stereotaxis magnetic guided catheter positioning system and Hanson robotic system.
When X is greater than or equal to the 2 tabulated value of x for some a generic 1pack slip inn with visa, the null hypothesis is rejected at the a level of significance discount slip inn 1pack with amex. Tests of independence and tests of homogeneity are also discussed in this chapter safe 1pack slip inn. Again, these tests essentially test the goodness-of-fit of observed data to expectation under hypotheses, respectively, of independence of two criteria of classifying the data and the homogeneity of proportions among two or more groups. Finally, we discussed the basic concepts of survival analysis and illustrated the computational procedures by means of two examples. Explain how the degrees of freedom are computed for the chi-square goodness-of-fit tests. How are the degrees of freedom computed when an X2 value is computed from a contingency table? Explain the rationale behind the method of computing the expected frequencies in a test of independence. Explain the rationale behind the method of computing the expected frequencies in a test of homogeneity. Define the following: (a) Observational study (b) Risk factor (c) Outcome (d) Retrospective study (e) Prospective study (f) Relative risk (g) Odds (h) Odds ratio (i) Confounding variable 13. Explain how researchers interpret the following measures: (a) Relative risk (b) Odds ratio (c) Mantel–Haenszel common odds ratio 15. Patients filled out a health history questionnaire that included a question about victimization. The following table shows the sample subjects cross-classified by gender and the type of violent victimization reported. The victimization categories are defined as no victimization, partner victimization (and not by others), victimization by a person other than a partner (friend, family member, or stranger), and those who reported multiple victimization. Gender No Victimization Partner Nonpartner Multiple Total Women 611 34 16 18 679 Men 308 10 17 10 345 Total 919 44 33 28 1024 Source: John H. Severson, and Dunia Karana, “Violent Victimization of Women and Men: Physical and Psychiatric Symptoms,” Journal of the American Board of Family Practice, 16 (2003), 32–39. Can we conclude on the basis of these data that victimization status and gender are not independent? May we conclude on the basis of these data that for women, race and victimization status are not independent? Severson, and Dunia Karana, “Violent Victimization of Women and Men: Physical and Psychiatric Symptoms,” Journal of the American Board of Family Practice, 16 (2003), 32–39. The following table shows 200 males classified according to social class and headache status: Social Class Headache Group A B C Total No headache (in previous year) 6 30 22 58 Simple headache 11 35 17 63 Unilateral headache (nonmigraine) 4 19 14 37 Migraine 5 25 12 42 Total 26 109 65 200 Do these data provide sufficient evidence to indicate that headache status and social class are related? The following is the frequency distribution of scores made on an aptitude test by 175 applicants to a physical therapy training facility x ¼ 39:71; s ¼ 12:92. A survey of children under 15 years of age residing in the inner-city area of a large city were classified according to ethnic group and hemoglobin level. Each of a sample of 250 men drawn from a population of suspected joint disease victims was asked which of three symptoms bother him most. The same question was asked of a sample of 300 suspected women joint disease victims. The results were as follows: Most Bothersome Symptom Men Women Morning stiffness 111 102 Nocturnal pain 59 73 Joint swelling 80 125 Total 250 300 Do these data provide sufficient evidence to indicate that the two populations are not homogeneous with respect to major symptoms? For each of the Exercises 24 through 34, indicate whether a null hypothesis of homogeneity or a null hypothesis of independence is appropriate. Aresearcher wishesto comparethestatus ofthree communities with respecttoimmunity againstpolio in preschool children. In a study of the relationship between smoking and respiratory illness, a random sample of adults were classified according to consumption of tobacco and extent of respiratory symptoms. A physician who wished to know more about the relationship between smoking and birth defects studies the health records of a sample of mothers and their children, including stillbirths and spontaneously aborted fetuses where possible. A health research team believes that the incidence of depression is higher among people with hypoglycemia than among people who do not suffer from this condition. In a simple random sample of 200 patients undergoing therapy at a drug abuse treatment center, 60 percent belonged to ethnic group I. In ethnic group I, 60 were being treated for alcohol abuse (A), 25 for marijuana abuse (B), and 20 for abuse of heroin, illegal methadone, or some other opioid (C). The remainder had abused barbiturates, cocaine, amphetamines, hallucinogens, or some other nonopioid besides marijuana (D). Solar keratoses are skin lesions commonly found on the scalp, face, backs of hands, forearms, ears, scalp, and neck. The criterion for effectiveness was having 75 percent or more of the lesion area cleared after 14 weeks of treatment. There were 21 successes among 29 imiquimod-treated subjects and three successes among 10 subjects using the control cream. At 30 days postprocedure, 17 subjects experienced transient/persistent neurological deficits. The researchers performed logistic regression and found that the 95 percent confidence interval for the odds ratio for aneurysm size was. Aneurysm size was dichoto- mized as less than 13 mm and greater than or equal to 13 mm. Describe the variables as to whether they are continuous, discrete, quantitative, or qualitative. Subjects were grouped by age into younger than 50 years old, between 50 and 64, and 65 and older. What statistical technique studied in this chapter would be appropriate for analyzing these data? Describe the variables involved as to whether they are continuous, discrete, quantitative, or qualitative. Kozinszky and Bartai (A-27) examined contraceptive use by teenage girls requesting abortion in Szeged, Hungary. A control group consisted of visitors to the family planning center who did not request an abortion or persons accompanying women who requested an abortion. In the control group, there were 147 women under 20 years of age and 1053 who were 20 years or older. One of the outcome variables of interest was knowledge of emergency contraception. The researchers report that, “Emergency contraception was significantly [(Mantel–Haenszel) p <. They studied 120 children in Northern Italy identified through a population-based cancer registry (cases). Four controls per case, matched by age and gender, were sampled from population files. The researchers used a diffusion model of benzene to estimate exposure to traffic exhaust. Compared to children whose homes were not exposed to road traffic emissions, the rate of childhood leukemia was significantly higher for heavily exposed children. Characterize this study as to whether it is observational, prospective, or retrospective.
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