On the Relationship between Pubovisceral Muscle Tears and Urethral Closure Pressure in Women Following Vaginal Birth

Little is known about the implications of pubovisceral muscle tear on urethral closure pressure – the focus of this dissertation. The literature on interventions for stress urinary incontinence has focused almost exclusively on pubovisceral muscle strengthening with repetitive exercise for life, but to date reports on “strength change” and on “leakage reduction” fail to convincingly relate these two outcomes, and essentially none of the studies reported take into account pubovisceral muscle tear, which renders the muscle incapable of response to volitional contraction effort. These major limitations in the literature are largely due to a long struggle to find adequate valid, cost effective, acceptable, accessible, reliable measures for the constructs of pubovisceral muscle. Recent major advances have been made in the field of pubovisceral muscle measurement, but come with a history (70+ years) of measurement difficulties that have caused fixed ideas and misunderstandings. This dissertation advances our understanding of measures of pubovisceral muscle structure (tears at the enthesis) and pubovisceral muscle function (loss of capacity for strength), suggests gold standard measures, advances the possibility of cost-effective clinical screening exams, and then for the first time examines in a sample of postpartum women known to have had obstetric high-risk factors at delivery the relationship of pubovisceral muscle tear to urethral closure pressure. The dissertation has three purposes: 1) reviewing past and current measures for assessing pubovisceral muscle strength and pubovisceral muscle tear; 2) estimating the odds of pubovisceral muscle tear (with gold standard magnetic resonance imaging) from clinical examination identifying using index finger palpatory assessment; and 3) determining predictive value of pubovisceral muscle tear on urethral closure pressure both at rest and during volitional effort of pelvic muscle contraction. The findings from the research suggest that there are gold standard measures (MRI and one-billed speculum) that are unsurpassed in meeting criteria of precise, valid, acceptable to women, but with some not broadly accessible in part due to prohibitive cost factors and lack of technology transfer from the research arena to the public. Quantified standing stress paper towel test and sagittal dynamic ultrasound for estimating pubovisceral muscle function in women with stress incontinence are suggested for adoption widely in the clinical setting, where currently implementation is nearly non-existent. The findings also suggest, for either scientific or clinical purposes, to avoid commonly used intravaginal instrument devices known to produce measures contaminated by intraabdominal pressure, making it impossible to isolate the pubovisceral muscle activities from non-pubovisceral muscle activity occurring simultaneously. The findings further suggest that index finger palpatory assessment can be used to initially identify pubovisceral muscle tear. Finally, the findings demonstrate the strong influence of the pubovisceral muscle tear (unstandardized coefficient = - 21.1; p=.001) on reducing a woman’s ability to volitionally optimize urethral closure pressure at the moment of intraabdominal pressure rise (as in cough), to prevent stress-type incontinence. These findings establish the foundation for future prospective research on estimation of pubovisceral muscle status in parous women who have vaginal birth and have risk factors for pubovisceral muscle tear, as well as identifying the role of volitional urethral closure pressure for future prevention and intervention studies on stress incontinence. This dissertation provides crucial data to inform the field focusing on testing pubovisceral muscle tear and the tear’ influences on the urethra, as well as the prevention and intervention for stress urinary incontinence.PHDNursingUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttps://deepblue.lib.umich.edu/bitstream/2027.42/143908/1/shying_1.pd

Department of Radiology - Annual Report July 1, 1987-June 30, 1988

107 page Department of Radiology Annual Executive Summary Report, July 1, 1987 to June 30, 1988, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States. Table of Contents: Name of Department and Chairman 1 Department Divisions and Directors 1 Department Faculty 2 Radiology Residents and Fellows 6 Departmental Committees and Memberships 7 Department Organization Charts 9 State of the Department 11 Teaching Programs 23 - A. Teaching Programs for Medical Students and Non-Radiology House Staff 23 - B. Residency Program for Residents in Radiology 25 - C. Training Programs for Fellows 27 Continuing Medical Education (CME) Programs 28 Radiology Grand Rounds 30 Radiology Research Conferences 32 Research Programs and Grants: 1987-1988 34 Publications 44 Scientific Presentations 60 Honors, Editorial Activities, Service for National or Regional Radiological Organizations 88 ADDENDUM: Office of Radiation Safety - 1987 Annual Report 9

Looking at the unborn: historical aspects of obstetric ultrasound

The obstetric ultrasound scanner had its major origins in a programme of research undertaken in Glasgow in the 1950s and 1960s, under the leadership of the obstetrician, Professor Ian Donald. Donald’s work was characterized by a remarkable series of collaborations between engineers and clinicians, many of whom took part in this Witness Seminar to consider the early history of ultrasound imaging, its technical development and significant clinical applications in the diagnosis of fetal abnormalities. Technical and engineering developments of the scanner were discussed and it was practical demonstrations of the early scanners that gradually convinced the majority of obstetricians to invest time and training in this new technology. Participants include: Mr Usama Abdulla, Mr Thomas Brown, Professor Dugald Cameron, Professor Stuart Campbell, Mr John Fleming, Professor John MacVicar, Professor Peter Wells and Dr James Willocks. Introduction by E M Tansey, v, 80pp. 15 illustrations, glossary, subject and name index

Looking at the Unborn: Historical aspects of obstetric ultrasound

Edited trascript of a Witness Seminar held at the Wellcome Institute for the History of Medicine,in London, on 10 March 1998. First published by the Wellcome Trust, 2000. ©The Trustee of the Wellcome Trust, London, 2000. All volumes are freely available online at: www.history.qmul.ac.uk/research/modbiomed/wellcome_witnesses/Annotated and edited transcript of a Witness Seminar held on 10 March 1998. Introduction by E M Tansey.Annotated and edited transcript of a Witness Seminar held on 10 March 1998. Introduction by E M Tansey.Annotated and edited transcript of a Witness Seminar held on 10 March 1998. Introduction by E M Tansey.Annotated and edited transcript of a Witness Seminar held on 10 March 1998. Introduction by E M Tansey.The obstetric ultrasound scanner had its major origins in a programme of research undertaken in Glasgow in the 1950s and 1960s, under the leadership of the obstetrician, Professor Ian Donald. Donald’s work was characterized by a remarkable series of collaborations between engineers and clinicians, many of whom took part in this Witness Seminar to consider the early history of ultrasound imaging, its technical development and significant clinical applications in the diagnosis of fetal abnormalities. Technical and engineering developments of the scanner were discussed and it was practical demonstrations of the early scanners that gradually convinced the majority of obstetricians to invest time and training in this new technology. Participants include: Mr Usama Abdulla, Mr Thomas Brown, Professor Dugald Cameron, Professor Stuart Campbell, Mr John Fleming, Professor John MacVicar, Professor Peter Wells and Dr James Willocks. Tansey E M, Christie D A. (eds) (2000) Looking at the unborn: Historical aspects of obstetric ultrasound, Wellcome Witnesses to Twentieth Century Medicine, vol. 5. London: The Wellcome Trust.The Wellcome Trust is a registered charity, no. 210183

Characterization of alar ligament on 3.0T MRI: a cross-sectional study in IIUM Medical Centre, Kuantan

INTRODUCTION: The main purpose of the study is to compare the normal anatomy of alar ligament on MRI between male and female. The specific objectives are to assess the prevalence of alar ligament visualized on MRI, to describe its characteristics in term of its course, shape and signal homogeneity and to find differences in alar ligament signal intensity between male and female. This study also aims to determine the association between the heights of respondents with alar ligament signal intensity and dimensions. MATERIALS & METHODS: 50 healthy volunteers were studied on 3.0T MR scanner Siemens Magnetom Spectra using 2-mm proton density, T2 and fat-suppression sequences. Alar ligament is depicted in 3 planes and the visualization and variability of the ligament courses, shapes and signal intensity characteristics were determined. The alar ligament dimensions were also measured. RESULTS: Alar ligament was best depicted in coronal plane, followed by sagittal and axial planes. The orientations were laterally ascending in most of the subjects (60%), predominantly oval in shaped (54%) and 67% showed inhomogenous signal. No significant difference of alar ligament signal intensity between male and female respondents. No significant association was found between the heights of the respondents with alar ligament signal intensity and dimensions. CONCLUSION: Employing a 3.0T MR scanner, the alar ligament is best portrayed on coronal plane, followed by sagittal and axial planes. However, tremendous variability of alar ligament as depicted in our data shows that caution needs to be exercised when evaluating alar ligament, especially during circumstances of injury

Case series of breast fillers and how things may go wrong: radiology point of view

INTRODUCTION: Breast augmentation is a procedure opted by women to overcome sagging breast due to breastfeeding or aging as well as small breast size. Recent years have shown the emergence of a variety of injectable materials on market as breast fillers. These injectable breast fillers have swiftly gained popularity among women, considering the minimal invasiveness of the procedure, nullifying the need for terrifying surgery. Little do they know that the procedure may pose detrimental complications, while visualization of breast parenchyma infiltrated by these fillers is also deemed substandard; posing diagnostic challenges. We present a case series of three patients with prior history of hyaluronic acid and collagen breast injections. REPORT: The first patient is a 37-year-old lady who presented to casualty with worsening shortness of breath, non-productive cough, central chest pain; associated with fever and chills for 2-weeks duration. The second patient is a 34-year-old lady who complained of cough, fever and haemoptysis; associated with shortness of breath for 1-week duration. CT in these cases revealed non thrombotic wedge-shaped peripheral air-space densities. The third patient is a 37‐year‐old female with right breast pain, swelling and redness for 2- weeks duration. Previous collagen breast injection performed 1 year ago had impeded sonographic visualization of the breast parenchyma. MRI breasts showed multiple non- enhancing round and oval shaped lesions exhibiting fat intensity. CONCLUSION: Radiologists should be familiar with the potential risks and hazards as well as limitations of imaging posed by breast fillers such that MRI is required as problem-solving tool

Department of Radiology-Annual Executive Summary Report-July 1, 1999 to June 30, 2000

90 page Department of Radiology Annual Executive Summary Report, July 1, 1999 to June 30, 2000, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States

Shifting and Shaping Perceptions: Towards the Characterization and Literacy of Female Pelvic Organ Support

Pelvic Organ Prolapse (POP) is a pelvic floor condition characterized by the unnatural descent of pelvic organs into the vagina. It occurs as the result of compromised connective tissues and musculature following vaginal delivery and/or changes in tissue composition due to aging. Approximately 50% of women in the United States experience some degree of POP during their lifetime, with symptoms that include altered urination and defecation, physical discomfort, depression, and anxiety. Over the last decade, POP treatments have gained public notoriety due to surgical complications and recurrence of prolapse after surgical repair. Both outcomes stem, in part, from gaps in knowledge regarding the complex interactions of pelvic viscera, tissues, and musculature, and is exacerbated by the significant time span between events surrounding vaginal birth injuries and symptomatic prolapse. Over the last century, fields such as cardiovascular medicine and orthopedics have made significant strides to improve the human condition through the application of biomechanics, diagnostic imaging techniques, and modeling. Such methods have been used to reliably differentiate normal and diseased anatomy with respect to orientation, location, and other geometric attributes. In contrast, urogynecology remains decades behind as a result of a failure to adopt new interdisciplinary methods, limiting our ability to effectively treat POP. Thus, approximately 80% of women with symptomatic POP choose to suffer in silence. This is troubling, given that POP and related disorders will become increasingly prevalent due to the advancing age of the global population. This dissertation explores the assessment and development of diagnostic tools that improve our ability to quantify the position of the vagina with respect to physiologic changes that may occur over the lifespan within the normal range. These tools provide valuable information regarding the physical changes that occur over time and the differences between populations while serving as a potential standard by which pelvic anatomy can be quantified. Furthermore, this work explores our knowledge, perceptions, and attitudes regarding female pelvic health to challenge misconceptions surrounding normal and abnormal physiological functions, foster attitudes of empathy and acceptance for disorders, and improve health literacy by illustrating the impact that it has on lives worldwide