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Objectives  Anaphylaxis is an acute, life-threatening immediate allergic reaction caused by the sudden systemic release of mediators from mast cells. This study aims to assess the current practice of emergency management of children and adults diagnosed with anaphylaxis at the Royal Hospital, Muscat, Oman, in line with the National Institute for Health and Clinical Excellence (NICE) guidelines.  Methods This is an observational retrospective study of all anaphylaxis cases seen at the emergency department (ED) from January 2013 to January 2018 and compared with the management of anaphylaxis in the ED as per the NICE guidelines. Inclusion criteria were all patients, children (age 16 and below), and adults diagnosed with anaphylaxis based on the World Allergy Organization (WAO) criteria. Exclusion criteria are all cases labeled as anaphylaxis that did not match the WAO criteria for anaphylaxis. Results Of 100 patients with a preliminary diagnosis of anaphylaxis, 49 patients (49%) were true-anaphylaxis cases based on the WAO definition 16 were children (age 16 years and below), and 33 were adults ( age 16 years and above). The other 51 patients (51%) with misdiagnosed anaphylaxis were later diagnosed with spontaneous urticaria, septic shock, vocal cord dysfunction, severe asthma, and anxiety attack. All 49 patients with true-anaphylaxis appropriately received adrenaline intramuscularly at the ED. All 16 children were admitted, seen by an allergist, and received an adrenaline auto-injector when indicated. Only 5 of the 33 adults were admitted and seen by an allergist, and 4 of those required an adrenaline auto-injector upon discharge. The remaining 28 adults were discharged from the ED, and only 3 of these were referred to the allergist. None received an adrenaline auto-injector upon discharge from the ED, and no mention in the ED notes on patient education regarding allergen avoidance. Conclusion Third of the patients who presented to ED were children (<16 years), and two third were adults. Insect venom was the main reason for anaphylaxis in both age groups. There was an underutilization of adrenaline auto-injector prescriptions for adult patients. This could be very well improved by disseminating policies and guidelines to adult physicians.

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INTRODUCTION AND HYPOTHESIS: Surgical repair options for pelvic organ prolapse (POP) include native tissue, allograft, xenograft, and synthetic grafts. Solvent-dehydrated dermal allograft (SDDG) has an improved safety profile. We evaluated the long-term safety and efficacy of SDDG use for cystocele repair. METHODS: A total of 184 patients completed a minimum follow-up of 12 months. Incontinence Impact Questionnaire (IIQ), Urogenital Distress Inventory (UDI), and Visual Analogue Scale (VAS) were used pre and post operatively. Recurrent cystocele grade ≥ II and/or repeat cystocele repair were considered objective failure. RESULTS: Preoperatively, 17 patients (10%) had grade IV cystocele, 87 (47%) grade III, 70 (38%) grade II, and 10 (5%) grade I. All patients underwent SDDG cystocele repair with/without vaginal sling and/or POP repair and/or hysterectomy. Mean hospital stay was 0.58 days (range 0-4), mean estimated blood loss (EBL) was 111 mL, and mean length of Foley catheterization was 1.85 days (range 0-28). Postoperatively, 113 patients (64%) had no recurrent cystocele, 34 (19%) had grade I, 19 (11%) grade II, and 10 (6%) grade III cystocele. None had grade IV cystocele. Nineteen patients (10.3%) underwent repeat cystocele repair. Thirty-eight patients (21.6%) had postoperative recurrence (recurrent cystocele grade ≥ II and/or repeat cystocele repair). Dermal allograft related adverse events included 1 (0.5%) allograft vaginal exposure, dyspareunia 1 (0.5%), and transient hydronephrosis in 1 (0.5%). There were no vascular, vesical, visceral or neurological injuries. CONCLUSIONS: These results indicate that SDDG augmented cystocele repair is a safe procedure, with low morbidity, and it's success is comparable to other techniques.

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BACKGROUND: Balance testing is an important part of the initial concussion assessment. There is no research on the differences in Modified Balance Error Scoring System (M-BESS) scores when tested in real world as compared to control conditions. OBJECTIVE: To assess the difference in M-BESS scores in athletes wearing their protective equipment and cleats on different surfaces as compared to control conditions. METHODS: This cross-sectional study examined university North American football and soccer athletes. Three observers independently rated athletes performing the M-BESS test in three different conditions: (1) wearing shorts and T-shirt in bare feet on firm surface (control); (2) wearing athletic equipment with cleats on FieldTurf; and (3) wearing athletic equipment with cleats on firm surface. Mean M-BESS scores were compared between conditions. RESULTS: 60 participants were recruited: 39 from football (all males) and 21 from soccer (11 males and 10 females). Average age was 21.1 years (SD=1.8). Mean M-BESS scores were significantly lower (p<0.001) for cleats on FieldTurf (mean=26.3; SD=2.0) and for cleats on firm surface (mean=26.6; SD=2.1) as compared to the control condition (mean=28.4; SD=1.5). Females had lower scores than males for cleats on FieldTurf condition (24.9 (SD=1.9) vs 27.3 (SD=1.6), p=0.005). Players who had taping or bracing on their ankles/feet had lower scores when tested with cleats on firm surface condition (24.6 (SD=1.7) vs 26.9 (SD=2.0), p=0.002). CONCLUSIONS: Total M-BESS scores for athletes wearing protective equipment and cleats standing on FieldTurf or a firm surface are around two points lower than M-BESS scores performed on the same athletes under control conditions.

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CLINICAL QUESTION: Can ultrasonography be used in lieu of chest radiography to diagnose pneumothorax? Articles chosen 1. Ding W, Shen Y, Yang J, et al. Diagnosis of pneumothorax by radiography and ultrasonography: a metaanalysis. Chest 2011;140:859-66. [Epub 2011 May 5] 2. Alrajhi K, Woo MY, Vaillancourt C. Test characteristics of ultrasonography for the detection of pneumothorax: a systematic review and meta-analysis. Chest 2012; 141:703-8

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PURPOSE OF REVIEW: This review is a summary of the most pertinent published studies in the literature in the last 18 months that address cause, diagnosis, and management of urinary retention in women. RECENT FINDINGS: Symptoms, uroflow, and pressure-flow studies have a low predictive value for and do not correlate with elevated postvoid residual urine (PVR). Anterior and posterior colporrhaphy do not cause de-novo bladder outlet obstruction in the majority of patients with elevated PVR, and the cause of elevated PVR may be other factors such as pain or anxiety causing abnormal relaxation of the pelvic floor and contributing to voiding difficulty. The risk of urinary retention in a future pregnancy after mid-urethral sling (MUS) is small. The risk of urinary tract infection and urinary retention after chemodenervation of the bladder with onabotulinumtoxin-A (100 IU) in patients with non-neurogenic urge incontinence is 33 and 5%, respectively. There is a lack of consensus among experts on the timing of sling takedown in the management of acute urinary retention following MUS procedures. SUMMARY: There has been a significant progress in the understanding of the causation of urinary retention. Important areas that need further research (basic and clinical) are post-MUS and pelvic organ prolapse repair urinary retention and obstruction, and urinary retention owing to detrusor underactivity.

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PURPOSE: We updated the 1997 American Urological Association guideline on female stress incontinence. MATERIALS AND METHODS: MEDLINE searches of English language publications from 1994 and new searches of the literature published between December 2002 and June 2005 were performed using identified MeSH terms. Articles were selected for the index patient defined as the otherwise healthy woman who elected to undergo surgery to correct stress urinary incontinence or the otherwise healthy woman with incontinence and prolapse who elected to undergo treatment for both conditions. RESULTS: A total of 436 articles were identified as suitable for inclusion in the meta-analysis, and an additional 155 articles were suitable for complications data only due to insufficient followup of efficacy outcomes in the latter reports. Surgical efficacy was defined using outcomes pre-specified in the primary evidence articles. Urgency (resolution and de novo) was included as an efficacy outcome due to its significant impact on quality of life. The primary efficacy outcome was resolution of stress incontinence measured as completely dry (cured/dry) or improved (cured/improved). Complications were analyzed similarly to the efficacy outcomes. Subjective complications (pain, sexual dysfunction and voiding dysfunction) were also included as a separate category. CONCLUSIONS: The surgical management of stress urinary incontinence with or without combined prolapse treatment continues to evolve. New technologies have emerged which have impacted surgical treatment algorithms. Cystoscopy has been added as a standard component of the procedure during surgical implantation of slings.

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Transurethral radiofrequency collagen denaturation, a nonsurgical treatment for stress urinary incontinence, reduces regional dynamic tissue compliance without causing tissue necrosis or gross tissue shrinkage, unlike transvaginal radiofrequency tissue ablation. This retrospective study evaluated long-term safety and efficacy in 21 patients from a 12-month, randomized controlled trial utilizing 3-day diaries and the Incontinence Quality of Life (I-QOL) survey. Significant increases in overall I-QOL scores 3 years or more post treatment was the primary end point. Secondary end points were reductions in frequency and severity of incontinence episodes. After 3 years, mean overall I-QOL score improvement was 12.7 (+/-26); 56% of patients achieved 50% or more reduction in frequency. No new adverse events occurred. These results indicate that radiofrequency collagen denaturation is safe and provides durable efficacy.

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A transurethral radiofrequency collagen denaturation system was recently approved by the US FDA for nonsurgical, outpatient treatment of women with stress urinary incontinence associated with urethral hypermobility. Controlled radiofrequency energy applied through a transurethral probe heats submucosal tissue to produce collagen denaturation, resulting in reduced tissue compliance without necrosis, thus distinguishing this procedure from transvaginal radiofrequency tissue ablation. Treatment can be administered in 30 min under local anesthesia, without incisions, use of cystoscopy or other visualization of the treatment site. Safety and efficacy have been demonstrated in several studies, including a 12-month, multicenter, sham-procedure-controlled clinical trial in 173 women with mild-to-moderate stress urinary incontinence. In patients receiving active treatment, two of the four groups experienced significant quality-of-life changes (p = 0.004; p = 0.02), and all women exhibited significant increases in Valsalva leak point pressure (p = 0.02 vs sham group).

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AIMS: The aim of this study is to report the functional results, patient satisfaction, and morbidity of the Transobturator tape procedure (TOT) in the treatment of stress incontinence (SUI). METHODS: One hundred and thirty patients were prospectively evaluated with history, physical examination, quality of life questionnaire including Incontinence Impact Questionnaire (IIQ), urogenital distress inventory (UDI), and analog global satisfaction scale (GSS), and urodynamic studies. RESULTS: One hundred and seventeen patients (90%) had history of SUI, and 78 (60%) had urge incontinence. Pads/day (PPD) used was 2.48 +/- 2.42, and the score of IIQ 16.13 +/- 7.86, UDI 10.95 +/- 3.4, and GSS 1.41 +/- 1.67. All patients underwent TOT using the ObTape. Hospital stay was 0.84 +/- 0.76 days and catheter duration was 1.42 +/- 2.08 days. At a follow-up of 16.85 +/- 4.68 months, 13 patients (10%) have recurrent SUI, 21 (16.15%) persistent urge incontinence, and 1 (1.92%) de novo urge incontinence. The mean PPD is 0.15 +/- 0.56, IIQ 1.47 +/- 5.14, UDI 3.28 +/- 3.09, and GSS 8.29 +/- 1.64. Two patients (1.52%) developed urethral obstruction, five (3.84%) had vaginal extrusion of the tape, and two (1.52%) had intra-operative bladder perforation. CONCLUSIONS: These results demonstrate the safety and efficacy of the TOT. The short hospitalization and catheterization, low incidence of de novo urge incontinence and obstructive voiding offers a distinct advantage over existing techniques. No significant difference in outcome between patients with VLPP < or =60 cm H2O, and patients with VLPP >60 cm H2O was observed.

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AIMS: This prospective, randomized, controlled clinical trial was performed to demonstrate the 12 months safety and efficacy of transurethral radiofrequency energy (RF) collagen micro-remodeling in women with stress urinary incontinence (SUI). MATERIALS AND METHODS: Women with SUI, bladder outlet hypermobility, and leak point pressure (LPP) > or =60 cmH(2)O were randomized to RF micro-remodeling or "sham treatment." Adverse events (AEs) were recorded. Incidence of > or =10 point incontinence quality of life (I-QOL) score improvement, a magnitude of improvement with a demonstrated responsiveness to patient satisfaction with treatment and to > or =25% reduction in both incontinence episode frequency and stress pad weight, served as a subjective outcome measurement. Change in mean LPP served as an objective outcome measurement. RESULTS: 110 women underwent RF micro-remodeling and 63 underwent virtually identical "sham treatment" (with the exception of RF delivery). The 12 months RF micro-remodeling safety profile was statistically no different than that of sham treatment (a brief bladder catheterization). Seventy-four percent of women with moderate to severe baseline SUI experienced > or =10 point I-QOL score improvement at 12 months (P = 0.04). Women who underwent RF micro-remodeling demonstrated LPP elevation at 12 months, while sham treated women demonstrated LPP reduction (P = 0.02). CONCLUSIONS: Non-surgical, transurethral RF micro-remodeling is a safe treatment for women with SUI. In women with moderate to severe SUI, this novel therapy resulted in statistically significant improvement in quality of life of a magnitude associated with patient satisfaction with the treatment. Women who underwent RF micro-remodeling demonstrated a statistically significant elevation in mean LPP at 12 months.

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