Publications by authors named "Sarah Collins"

236 Publications

Adaptations in Hippo-Yap signaling and myofibroblast fate underlie scar-free ear appendage wound healing in spiny mice.

Dev Cell 2021 Oct 4;56(19):2722-2740.e6. Epub 2021 Oct 4.

Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA 98195, USA; Department of Pediatrics, University of Washington, Seattle, WA 98195, USA; Center for Developmental Biology & Regenerative Medicine, Seattle Children's Research Institute, Seattle, WA 98101, USA. Electronic address:

Spiny mice (Acomys cahirinus) are terrestrial mammals that evolved unique scar-free regenerative wound-healing properties. Myofibroblasts (MFs) are the major scar-forming cell type in skin. We found that following traumatic injury to ear pinnae, MFs appeared rapidly in both Acomys and mouse yet persisted only in mouse. The timing of MF loss in Acomys correlated with wound closure, blastema differentiation, and nuclear localization of the Hippo pathway target protein Yap. Experiments in vitro revealed an accelerated PP2A-dependent dephosphorylation activity that maintained nuclear Yap in Acomys dermal fibroblasts (DFs) and was not detected in mouse or human DFs. Treatment of Acomys in vivo with the nuclear Yap-TEAD inhibitor verteporfin prolonged MF persistence and converted tissue regeneration to fibrosis. Forced Yap activity prevented and rescued TGF-β1-induced human MF formation in vitro. These results suggest that Acomys evolved modifications of Yap activity and MF fate important for scar-free regenerative wound healing in vivo.
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http://dx.doi.org/10.1016/j.devcel.2021.09.008DOI Listing
October 2021

Vaginal Electrical Stimulation for Postpartum Neuromuscular Recovery: A Randomized Clinical Trial.

Female Pelvic Med Reconstr Surg 2021 Sep 30. Epub 2021 Sep 30.

From the Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL Department of Obstetrics and Gynecology, University of California, Irvine, CA.

Objective: The aim of this study was to compare 3-month postpartum anal incontinence symptoms in women who sustain obstetric anal sphincter injuries and begin immediate vaginal electrical stimulation versus sham therapy.

Methods: In this double-blind randomized controlled trial, women who sustained obstetric anal sphincter injuries were randomized to receive self-administered vaginal electrical stimulation using a commercial device or sham therapy with an identical device. Anal incontinence symptom severity was assessed at 1 week (baseline) and again at 13 weeks postpartum using the Fecal Incontinence Severity Index. The primary outcome was anal incontinence symptom severity measured by the total Fecal Incontinence Severity Index score at 13 weeks postpartum.

Results: Between February 2016 and September 2018, 48 women completed a 13-week follow-up. At 13 weeks postpartum, median Fecal Incontinence Severity Index scores were higher (more severe) in the vaginal electrical stimulation group (12; interquartile range, 0-23) than in the sham group (4; interquartile range, 0-10) (P = 0.04). Unlike the vaginal electrical stimulation group, the improvement in Fecal Incontinence Severity Index scores in the sham group (vaginal electrical stimulation: 12 [interquartile range, 8-22] to 12 [interquartile range, 0-23] [P = 0.12] vs sham: 12 [interquartile range, 6-18] to 4.0 [interquartile range, 0-11] [P < 0.001]) met the threshold for clinical significance based on the minimum important difference of the Fecal Incontinence Severity Index.

Conclusion: At 13 weeks postpartum, women who underwent postpartum vaginal electrical stimulation reported more anal incontinence symptoms compared with those receiving sham therapy. Vaginal electrical stimulation after obstetric anal sphincter injury was not beneficial in reducing anal incontinence symptoms and may impede recovery.
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http://dx.doi.org/10.1097/SPV.0000000000001037DOI Listing
September 2021

Stress Reduction to Decrease Hypertension for Black Women: A Scoping Review of Trials and Interventions.

J Racial Ethn Health Disparities 2021 Oct 4. Epub 2021 Oct 4.

Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, USA.

Introduction: Chronic stress is a potential root cause of racial/ethnic disparities in cardiovascular disease. This review assesses literature surrounding effective stressreduction interventions to reduce hypertension (HTN)-a cardiovascular disease (CVD) risk factor-among an understudied population, non-Hispanic black (NHB) women.

Methods: We conducted an electronic search of PubMed and PsycINFO literature published between January 1, 2000 and February 1, 2020, employing the keywords: "blood pressure", "hypertension", and "women", "black", "African-American", "stress", "meditation", "stress-coping", "stress-management", and "faith-based". We manually searched the bibliographies for additional articles. Studies were excluded if they: were published before 2000; were not intervention-based; did not study Black women in the US; did not target stress reduction; or did not measure blood pressure as an outcome. Independent reviewers screened the articles, which were selected based on consensus. Effect sizes and statistical p values were reported as provided in the included articles.

Results: We identified 109 articles in total. Of those, six articles met inclusion criteria. Stronger evidence presented by a randomized control trial supported the efficacy of transcendental meditation with reductions in systolic and diastolic blood pressure up to 7 mmHg. Relaxation exercises, support groups, and therapeutic massage emerged as potentially beneficial in non-randomized pilot trials with reductions in systolic BP up to 9 mmHg and diastolic BP up to 5 mmHg varying by type and duration of the intervention.

Conclusions: This scoping review found that faith-based strategies and meditation can be effective stress reduction techniques to reduce BP among NHB women. However, much remains to be known about how these strategies may be leveraged to reduce blood pressure within this highly vulnerable population.
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http://dx.doi.org/10.1007/s40615-021-01160-yDOI Listing
October 2021

Vascular injury is an infrequent finding following non-fatal strangulation in two Australian trauma centres.

Emerg Med Australas 2021 Sep 9. Epub 2021 Sep 9.

Emergency and Trauma Centre and Trauma Service, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.

Objective: Non-fatal strangulation assessment is challenging for clinicians as clear guidelines for evaluation are limited. The prevalence of non-fatal strangulation events, clinical findings, frequency of injury on computed tomography angiogram (CTA) and outcomes across two trauma centres will be used to improve this assessment process.

Methods: This is a retrospective observational study of adult presentations during 2-year period to two major-trauma referral hospitals and subsequent 12 months to identify delayed vascular injury. Patients included using standardised search terms. Demographic data, clinical findings, radiological reports and outcomes were included for review.

Results: A total of 425 patients were included for analysis. Self-inflicted injury comprised 62.1%, with domestic violence (28.5%) and assault (9.4%) the remainder. Manual strangulation events 36.7% of overall presentations and 63.3% following ligature strangulation (ligature strangulation, incomplete and complete hanging). On examination soft signs present in 133 (31.2%) cases, commonly neck tenderness in isolation. No hard signs suggesting vascular damage. Vascular injury was demonstrated in three cases (0.7% of the total cohort and 1.5% of CTA scans completed), and all occurred in ligature strangulation events as a result of hanging. No patients had delayed vascular injury in the 12-month period post-initial presentation.

Conclusions: In non-fatal strangulation presentations, the majority have subtle signs of neck injury on examination with inconsistent documentation of findings. Low rate of vascular injury overall (0.7%), and entirely in hanging events. No longer-term vascular sequalae identified. Improving documentation focusing on hypoxic insult and evidence of airway trauma is warranted, rather than a reliance on computed tomography imaging to delineate a traumatic event in non-fatal strangulation.
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http://dx.doi.org/10.1111/1742-6723.13863DOI Listing
September 2021

Prospective, Multicenter, Controlled Trial of Mobile Stroke Units.

N Engl J Med 2021 09;385(11):971-981

From the Mobile Stroke Unit, Memorial Hermann Hospital-Texas Medical Center (J.C.G., J. McCarthy, T.F.), the Departments of Biostatistics and Data Science (J.-M.Y., A.P.J., M.W., N.S., M.G.) and Management, Policy, and Community Heath (S.S.R.), University of Texas School of Public Health, the Departments of Neurology (S.A.P., N.R.G., P.L.B., N.R.-G., E.L., J.S., K.P., Y.S., E.A.N., R.B.) and Emergency Medicine (D.P.), University of Texas McGovern Medical School, the Departments of Emergency Medicine (D.P.) and Neurology (C.P.V.R.), Baylor College of Medicine, the Department of Neurology, Houston Methodist Hospital (D.C., J.V., V.M.), the Department of Neurology, Harris Health-Ben Taub General Hospital (J.S.K.), and HCA Houston Healthcare (L.G.) - all in Houston; the Department of Neurology, University of Colorado, UCHealth Anschutz Medical Campus, Aurora (W.J.J., B.D.S., K.A., M.E., D.O.), and the Department of Neurology, UCHealth Memorial Hospital, Colorado Springs (J. Miller) - both in Colorado; the Department of Neurology, University of Tennessee Health Science Center, Memphis (A.W.A., A.V.A., J.P.R.); the Department of Neurology, Weill Cornell Medicine (B.B.N., M.E.F., C.S., M.L., S.M.), and the Department of Neurology, Columbia University Irving Medical Center (J.Z.W.) - both in New York; the Department of Neurology, Ronald Reagan UCLA Medical Center, Los Angeles (M.N., J.L.S., K.M.B., B.M.V.), the Department of Neurology, Mills Peninsula Medical Center, Burlingame (I.S., J.E., N. Barazangi, J.I.), Los Angeles County Emergency Medical Services, Santa Fe Springs (M.G.-H., N. Bosson), and San Mateo County Emergency Medical Services, South San Francisco (G.G.) - all in California; and the Department of Neurology, Indiana University School of Medicine, Indianapolis (J. Mackey, S.Q.C., K.S.).

Background: Mobile stroke units (MSUs) are ambulances with staff and a computed tomographic scanner that may enable faster treatment with tissue plasminogen activator (t-PA) than standard management by emergency medical services (EMS). Whether and how much MSUs alter outcomes has not been extensively studied.

Methods: In an observational, prospective, multicenter, alternating-week trial, we assessed outcomes from MSU or EMS management within 4.5 hours after onset of acute stroke symptoms. The primary outcome was the score on the utility-weighted modified Rankin scale (range, 0 to 1, with higher scores indicating better outcomes according to a patient value system, derived from scores on the modified Rankin scale of 0 to 6, with higher scores indicating more disability). The main analysis involved dichotomized scores on the utility-weighted modified Rankin scale (≥0.91 or <0.91, approximating scores on the modified Rankin scale of ≤1 or >1) at 90 days in patients eligible for t-PA. Analyses were also performed in all enrolled patients.

Results: We enrolled 1515 patients, of whom 1047 were eligible to receive t-PA; 617 received care by MSU and 430 by EMS. The median time from onset of stroke to administration of t-PA was 72 minutes in the MSU group and 108 minutes in the EMS group. Of patients eligible for t-PA, 97.1% in the MSU group received t-PA, as compared with 79.5% in the EMS group. The mean score on the utility-weighted modified Rankin scale at 90 days in patients eligible for t-PA was 0.72 in the MSU group and 0.66 in the EMS group (adjusted odds ratio for a score of ≥0.91, 2.43; 95% confidence interval [CI], 1.75 to 3.36; P<0.001). Among the patients eligible for t-PA, 55.0% in the MSU group and 44.4% in the EMS group had a score of 0 or 1 on the modified Rankin scale at 90 days. Among all enrolled patients, the mean score on the utility-weighted modified Rankin scale at discharge was 0.57 in the MSU group and 0.51 in the EMS group (adjusted odds ratio for a score of ≥0.91, 1.82; 95% CI, 1.39 to 2.37; P<0.001). Secondary clinical outcomes generally favored MSUs. Mortality at 90 days was 8.9% in the MSU group and 11.9% in the EMS group.

Conclusions: In patients with acute stroke who were eligible for t-PA, utility-weighted disability outcomes at 90 days were better with MSUs than with EMS. (Funded by the Patient-Centered Outcomes Research Institute; BEST-MSU ClinicalTrials.gov number, NCT02190500.).
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http://dx.doi.org/10.1056/NEJMoa2103879DOI Listing
September 2021

International Urogynecological Consultation: clinical definition of pelvic organ prolapse.

Int Urogynecol J 2021 08 30;32(8):2011-2019. Epub 2021 Jun 30.

Northwestern Feinberg School of Medicine, 250 E. Superior St. Suite 05-2113, Chicago, IL, 60611, USA.

Introduction And Hypothesis: This segment of Chapter 1 of the International Urogynecology Consultation (IUC) on pelvic organ prolapse (POP) reviews the literature on the clinical definition of POP with the intent of creating standard terminology.

Methods: An international group containing nine urogynecologists and one university-based medical librarian performed a search of the literature using pre-specified search terms in PubMed, Embase, and Scopus. Publications were eliminated if not relevant to the clinical definition of POP, and those articles remaining were evaluated for quality using the Specialist Unit for Review Evidence (SURE). The resulting list of articles was used to inform a comprehensive review and creation of the clinical definition of POP.

Results: The original search yielded 31,931 references, of which 167 were used by the writing group. Ultimately, 78 are referenced in the manuscript.

Conclusions: The clinical definition of POP for this review of the literature is: "anatomical prolapse with descent of at least one of the vaginal walls to or beyond the vaginal hymen with maximal Valsalva effort WITH the presence either of bothersome characteristic symptoms, most commonly the sensation of vaginal bulge, or of functional or medical compromise due to prolapse without symptom bother."
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http://dx.doi.org/10.1007/s00192-021-04875-yDOI Listing
August 2021

Surgical Management of Stress Incontinence.

Authors:
Sarah A Collins

Clin Obstet Gynecol 2021 06;64(2):297-305

Northwestern University Feinberg School of Medicine, Chicago, Illinois.

The aim was to describe contemporary surgical procedures for the treatment of stress urinary incontinence (SUI) in women. The 4 most commonly performed surgical procedures for the treatment of SUI were reviewed using standardized terminology. We addressed the history and evolution of the procedures as well as the mechanisms of action by which they work. Efficacy and safety data were also presented. Midurethral Sling, Pubovaginal Sling, Retropubic Colposuspension, and Urethral Bulking are safe and effective procedures. Midurethral Sling, Pubovaginal Sling, Retropubic Colposuspension, and Urethral Bulking are contemporary procedures for the treatment of SUI in women.
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http://dx.doi.org/10.1097/GRF.0000000000000614DOI Listing
June 2021

Foreword: An Evidenced Based Approach to Urinary Incontinence in Women: What's New?

Clin Obstet Gynecol 2021 06;64(2):257-258

Division of Female Pelvic Medicine and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.

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http://dx.doi.org/10.1097/GRF.0000000000000620DOI Listing
June 2021

Multicenter Randomized Controlled Trial of Pelvic Floor Muscle Training with a Motion-based Digital Therapeutic Device versus Pelvic Floor Muscle Training Alone for Treatment of Stress-predominant Urinary Incontinence.

Female Pelvic Med Reconstr Surg 2021 Mar 23. Epub 2021 Mar 23.

From the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA Division of Female Pelvic Medicine and Reconstructive Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences, Oklahoma City, OK Department of Urology, Cedars Sinai Medical Center, Los Angeles, CA Cleveland Clinic, Obstetrics, Gynecology, and Women's Health Institute, Cleveland, OH Department of Urology, Eastern Virginia Medical School, Norfolk, VA Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL.

Objective: To determine whether use of an intravaginal motion-based digital therapeutic device for pelvic floor muscle training (PFMT) was superior to PFMT alone in women with stress-predominant urinary incontinence (SUI).

Methods: A multicenter, randomized-controlled trial was conducted where women with SUI or SUI-predominant mixed urinary incontinence were treated with either PFMT using the device (intervention group) or PFMT alone (control group). Primary outcomes, measured at 8 weeks, included change in Urinary Distress Inventory, short-version and improvement in the Patient Global Impression of Improvement, defined as "much better" or "very much better." Participants also completed Pelvic Organ Prolapse and Colorectal-anal Distress Inventories, Pelvic-Floor-Impact Questionnaire and a 3-day bladder diary. Primary analysis used a modified intention-to-treat approach. Statistical analysis used Student t test and χ2 test. The trial was prematurely halted due to device technical considerations.

Results: Seventy-seven women were randomized, and final analysis included 61 participants: 29 in intervention and 32 in control group. There was no statistical difference in Urinary Distress Inventory, short-version scores between the intervention (-13.7 ± 18.7) and the control group (-8.7 ± 21.8; P = 0.85), or in Patient Global Impression of Improvement (intervention 51.7% and control group 40.6%; P = 0.47). Pelvic Organ Prolapse and Colorectal-anal Distress Inventories and Pelvic-Floor-Impact Questionnaire scores improved significantly more in the intervention group than the control group (all P < 0.05). Median number of SUI episodes decreased from baseline to 8 weeks by -1.7 per-day [(-3)-0] in the intervention group and -0.7[(-1)-0] in the control group, (P = 0.047).

Conclusions: In this prematurely terminated trial, there were no statistically significant differences in primary outcomes; however, PFMT with this digital therapeutic device resulted in significantly fewer SUI episodes and greater improvement in symptom-specific quality of life outcomes. A larger powered trial is underway.
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http://dx.doi.org/10.1097/SPV.0000000000001052DOI Listing
March 2021

Postpartum contraceptive uptake and fertility desires following obstetric anal sphincter injury.

Int Urogynecol J 2021 07 22;32(7):1833-1838. Epub 2021 Mar 22.

Division of Female Pelvic Medicine and Reconstructive Surgery, Northwestern University, IL, Chicago, USA.

Introduction And Hypothesis: Our primary objective was to compare rates of contraceptive use among postpartum heterosexual primiparous women with and without obstetric anal sphincter injury (OASIS). The secondary objective was to compare fertility desires among women with and without OASIS.

Methods: This was a planned secondary analysis of a prospective cohort study of postpartum sexual function among primiparous postpartum women. Women with a history of vaginal delivery with and without OASIS completed online surveys at baseline and 3 months postpartum.

Results: Sixty-nine women completed baseline and 3-month surveys. Forty-one percent of women with OASIS and 36% without OASIS were not using contraception at 3 months postpartum. One-third of women in either group reported using at least moderately effective contraception (P = 0.9), defined as using hormonal contraception or an intrauterine contraceptive device, and excluding condoms. Most women with OASIS (54%) desired to wait 1 to 2 years before attempting another pregnancy. One fifth of women with and without OASIS desired another pregnancy within the next year (P = 0.4).

Conclusions: A minority of postpartum primiparous women in the present cohort reported using moderately effective contraception 3 months postpartum, regardless of whether they sustained OASIS. The discrepancy between current contraceptive use and desired birth spacing suggests an unmet contraceptive need within our population and an opportunity for improved contraceptive counseling consistent with patients' family planning goals, as well as national and international guidelines on birth spacing. Larger prospective studies are needed to further understand the unmet contraceptive need among women with OASIS.
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http://dx.doi.org/10.1007/s00192-021-04760-8DOI Listing
July 2021

Perioperative outcomes of laparoscopic sacrocolpopexy with and without hysterectomy: a secondary analysis of the National Surgical Quality Improvement Program Database.

Int Urogynecol J 2021 Mar 1. Epub 2021 Mar 1.

Division of Female Pelvic Medicine and Reconstructive Surgery, Northwestern University, Chicago, IL, USA.

Introduction And Hypothesis: The objective was to compare 30-day perioperative complications in women undergoing minimally invasive sacrocolpopexy with and without a concomitant hysterectomy.

Methods: Using the American College of Surgeons National Surgical Quality Improvement Program database, we identified women undergoing minimally invasive sacrocolpopexy between 2014 and 2018. Women were then stratified into two groups: sacrocolpopexy only and sacrocolpopexy + hysterectomy. The primary outcome was the occurrence of any 30-day postoperative complication. Group comparisons were performed using Student's t test, Mann-Whitney U test, and Chi-squared test. Multivariate logistic regression was used to identify independent factors associated with the occurrence of any complication.

Results: A total of 8,553 women underwent laparoscopic sacrocolpopexy, 5,123 (59.9%) of whom had a concomitant hysterectomy. Median operative time was longer in women who had sacrocolpopexy + hysterectomy compared with sacrocolpopexy alone (185 [129-241] versus 172 [130-224] min, p < 0.001). The rate of any 30-day postoperative complication did not differ between groups (sacrocolpopexy + hysterectomy 5.5% versus sacrocolpopexy alone 5.8%, p = 0.34). Likewise, organ space, deep, and superficial surgical site infections did not differ between groups. There was also no difference in reoperation or readmission rates between groups. On multivariate logistic regression, sacrocolpopexy + hysterectomy were not associated with increased odds of 30-day postoperative complications relative to women who underwent sacrocolpopexy alone.

Conclusions: Complication rates during the first 30 days after minimally invasive sacrocolpopexy are low and concomitant hysterectomy is not associated with increased risks of 30-day complications after surgery.
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http://dx.doi.org/10.1007/s00192-021-04675-4DOI Listing
March 2021

The Influence of Patients' Goals on Surgical Satisfaction.

Female Pelvic Med Reconstr Surg 2021 03;27(3):170-174

From the Division of Female Pelvic Medicine and Reconstructive Surgery, Northwestern University, Chicago, IL.

Objective: The objectives of this study were to describe patients' surgical goals and determine if goal attainment is associated with postoperative satisfaction and regret.

Methods: Women undergoing surgery for pelvic floor disorders between June and December 2019 were recruited. At their initial visit, patients listed up to 4 surgical goals. Three months after surgery, patients completed the Pelvic Floor Distress Inventory, Patient Global Impression of Improvement, Satisfaction with Decision Scale, and Decision Regret Scale. They were also shown their initial goals and asked, "Did you achieve this goal by having surgery?" Women who achieved all goals were designated "goal achievers," and those who did not achieve even 1 goal were "goal nonachievers" (GNAs).

Results: Ninety-nine patients listed a median of 1 (range, 1-4) goals. Goals were categorized as follows: symptom improvement (52%), treatment achievement (23%), lifestyle improvement (17%), and information gathering (6%). Ninety-one percent of patients were goal achievers, and 9% were GNAs. Goal achievers had higher Satisfaction with Decision Scale scores (5.0 [4.7-5.0] vs 4.0 [3.8-4.8], P = 0.002), lower Decision Regret Scale scores (1.0 [1.0-1.4] vs 2.0 [1.1-2.7], P = 0.001), and better Patient Global Impression of Improvement scores (1.0 [1.0-2.0] vs 2.0 [1.0-4.0], P = 0.004). In prolapse surgery patients, postoperative Pelvic Floor Distress Inventory scores were similar; however, GNAs had higher postoperative Urinary Distress Inventory scores (17.0 ± 18.0 vs 45.8 ± 20.8, P = 0.01).

Conclusions: Ninety-one percent of women achieved their presurgical goals, the most common being symptom relief. Goal achievers have higher satisfaction and less regret; however, those with worsening or de novo urinary symptoms are more likely to be GNAs and be unsatisfied.
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http://dx.doi.org/10.1097/SPV.0000000000001028DOI Listing
March 2021

Talking about breast symmetry in the breast cancer clinic: What can we learn from an examination of clinical interaction?

Health Expect 2021 04 31;24(2):209-221. Epub 2021 Jan 31.

Division of Psychology and Mental Health, School of Health Sciences, The University of Manchester, Manchester, UK.

Background: Breast asymmetry is a common post-operative outcome for women with breast cancer. Quality of cosmetic result is viewed clinically as a critical endpoint of surgery. However, research suggests that aesthetic standards governing breast reconstruction can be unrealistic and may problematically enforce feminine appearance norms. The aim of reconstructive procedures is to help women live well with and beyond breast cancer. Therefore, understanding how patients and clinicians talk about surgical outcomes is important. However, we lack evidence about such discussions.

Objective: To examine clinical communication about breast symmetry in real-time consultations in a breast cancer clinic.

Design: Seventy-three consultations between 16 clinicians and 47 patients were video-recorded, transcribed and analysed using conversation analysis.

Results: In most cases, patients do considerable interactional work to persuade clinicians of the validity of their concerns regarding breast asymmetry, and clinicians legitimize these concerns, aligning with patients. In a significant minority of cases, patients appear more accepting of their treatment outcome, but clinicians prioritize symmetry or treat symmetry with the presence of breast tissue as normative, generating misalignment between clinician and patient.

Conclusion: Current clinical communication guidelines and practices may inadvertently reinforce culturally normative assumptions regarding the desirability of full, symmetrical breasts that are not held by all women. Clinicians and medical educators may benefit from detailed engagement with recordings of clinical communication like those analysed here, to reflect on which communicative practices may work best to attend to a patient's individual stance on breast symmetry, and optimize doctor-patient alignment.
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http://dx.doi.org/10.1111/hex.13144DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8077149PMC
April 2021

Successful conduct of an acute stroke clinical trial during COVID.

PLoS One 2021 15;16(1):e0243603. Epub 2021 Jan 15.

Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, Texas, United States of America.

Most clinical research stopped during COVID due to possible impact on data quality and personnel safety. We aimed to assess the impact of COVID on acute stroke clinical trial conduct at sites that continued to enroll patients during the pandemic. BEST-MSU is an ongoing study of Mobile Stroke Units (MSU) vs standard management of tPA-eligible acute stroke patients in the pre-hospital setting. MSU personnel include a vascular neurologist via telemedicine, and a nurse, CT technologist, paramedics and emergency medicine technicians on-board. During COVID, consent, 90-day modified Rankin Scale (mRS) and EQ5D were obtained by phone instead of in-person, but other aspects of management were similar to the pre-COVID period. We compared patient demographics, study metrics, and infection of study personnel during intra- vs pre-COVID eras. Five of 6 BEST-MSU sites continued to enroll during COVID. There were no differences in intra- (n = 57) vs pre- (n = 869) COVID enrolled tPA eligible patients' age, sex, race (38.6% vs 38.0% Black), ethnicity (15.8% vs 18.6% Hispanic), or NIHSS (median 11 vs 9). The percent of screened patients enrolled and adjudicated tPA eligible declined from 13.6% to 6.6% (p < .001); study enrollment correlated with local stay-at-home and reopening orders. There were no differences in alert to MSU arrival or arrival to tPA times, but MSU on-scene time was 5 min longer (p = .01). There were no differences in ED door to CT, tPA treatment or thrombectomy puncture times, hospital length of stay, discharge disposition, or remote vs in-person 90-day mRS or EQ5D. One MSU nurse tested positive but did not require hospitalization. Clinical research in the pre-hospital setting can be carried out accurately and safely during a pandemic. tPA eligibility rates declined, but otherwise there were no differences in patient demographics, deterioration of study processes, or serious infection of study staff. Trial registration: NCT02190500.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0243603PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7810330PMC
April 2021

Universal screening for Lynch syndrome in uterine cancer patients: A quality improvement initiative.

Gynecol Oncol 2021 01 21;160(1):169-174. Epub 2020 Oct 21.

Division of Gynecologic Oncology, Duke Cancer Institute, Duke University Health System, Durham, North Carolina, United States of America.

Objective: To determine the feasibility and effectiveness of a quality improvement initiative (QI) to adopt universal screening for Lynch syndrome in uterine cancer patients at an institution that previously employed age-based screening.

Methods: Prior to the initiative, tumors of patients with uterine cancer diagnosed at age ≤ 60 years were screened for mismatch repair deficiency (MMR) and microsatellite instability (MSI). The QI process change model adopted universal testing of all uterine cancer specimens and implemented provider training, standardized documentation, and enhanced use of the electronic medical record (EMR). We compared screening rates, results of screening, follow up of abnormal results, and final diagnoses from the pre- and post-implementation periods.

Results: Pre- and post-implementation screening rates for women age ≤ 60 years at the time of diagnosis were 45/78 (57.7%) and 64/68 (94.5%), respectively. The screening rate for all patients with uterine cancer increased from 73/190 (38.4%) to 172/182 (94.5%). The rate of abnormal screening results increased from 15/190 (7.9%) to 44/182 (24.0%) cases. Genetics referral rates among screen positives increased from 3/15 (20.0%) to 16/44 (36.4%). Germline diagnoses increased from 2/190 (1.1%) with two Lynch syndrome diagnoses to 4/182 (2.2%) including three Lynch syndrome diagnoses and one BRCA1 germline diagnosis. The number of patients errantly not screened decreased from at least 32 patients to 3 patients after the intervention.

Conclusions: Adherence to screening guidelines significantly improved after interventions involving provider education, optimal use of the EMR, and simplification of screening indications. These interventions are feasible at other institutions and translatable to other screening indications.
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http://dx.doi.org/10.1016/j.ygyno.2020.10.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7577655PMC
January 2021

Rates of Sling Procedures and Revisions-A National Surgical Quality Improvement Program Database Study.

Female Pelvic Med Reconstr Surg 2021 06;27(6):e559-e562

From the Division of Female Pelvic Medicine and Reconstructive Surgery, Departments of Obstetrics & Gynecology and Urology, Northwestern University Feinberg School of Medicine, Chicago. IL.

Objective: The aim of this study was to describe trends in sling procedures and revisions, including fascial slings and midurethral slings (MUS) using a large, national database with respect to the 2011 U.S. Food and Drug Administration (FDA) mesh-related safety communication.

Methods: This was a cross-sectional cohort study using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2010 to 2018, evaluating the prevalence of sling revision and fascial slings and their trends over time. Patients who underwent MUS, fascial slings, and sling revisions were identified by Current Procedural Terminology codes. Sling revisions and fascial slings were evaluated as a proportion of the total number of MUS performed per year. Three distinct periods were evaluated in relation to the 2011 FDA communication: 2010 to 2012, 2012 to 2015, and 2015 to 2018. Observed trends were assessed with Pearson correlation coefficients with a P value less than 0.05 considered significant.

Results: During the study period, 32,657 slings were captured: 32,389 MUS and 268 fascial slings. The rate of sling revisions was low (0.4% in 2010 to 1.2% in 2015). Between 2012 and 2015, the rate of sling revision increased significantly (R = 1, P = 0.002); following 2015, the rate of sling revisions decreased significantly over time (R = -0.96, P = 0.04). The rate of fascial slings between 2012 and 2015 increased significantly (R = 0.95, P = 0.047); however, the rate plateaued starting in 2015 (R = -0.49, -P = 0.51).

Conclusions: Our data suggest that MUS remain the preferred procedure for treatment of stress urinary incontinence despite the recent FDA communications with MUS representing 99% of sling procedures during the study period.
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June 2021

Concurrent Retropubic Midurethral Sling and OnabotulinumtoxinA for Mixed Urinary Incontinence: A Randomized Controlled Trial.

Obstet Gynecol 2021 01;137(1):12-20

Department of Obstetrics and Gynecology, the Division of Female Pelvic Medicine and Reconstructive Surgery, and the Feinberg School of Medicine, Northwestern University, Chicago, Illinois.

Objective: To evaluate whether retropubic midurethral sling combined with onabotulinumtoxinA is more effective than sling alone in improving mixed urinary incontinence symptoms.

Methods: We conducted a prospective, double-blind, randomized, controlled trial of women with mixed urinary incontinence, planning to undergo midurethral sling. Women were randomly assigned to receive 100 unites of intradetrusor onabotulinumtoxinA or placebo during surgery. Participants completed the PGI-S (Patient Global Impression of Severity), the UDI-6 (Urinary Distress Inventory, Short Form), and the PFIQ-7 (Pelvic Floor Impact Questionnaire-Short Form 7) before and 3 months after surgery, and the primary outcome, PGI-I (Patient Global Impression of Improvement), 3 months postoperatively. Primary outcome was PGI-I score at 3 months for overall incontinence. We considered women "improved" with answers of "very much better" or "much better" on the PGI-I. Assuming a PGI-I response of "improved" in 66% of placebo and 93% of onabotulinumtoxinA participants, 68 women were needed to show a significant difference with 80% power at 0.05 significance level.

Results: From March 2016 to November 2019, 78 women completed a 3-month follow-up (onabotulinumtoxinA: 41; placebo: 37). Mean age was 51 years (±10). On the PGI-I, the number who "improved" did not differ between groups at 3 months (83% vs 84%, P=1.0). The onabotulinumtoxinA group had less severe urgency symptoms as indicated by median urgency PGI-S scores (1 [interquartile range 1-2] vs 2 [interquartile range 1-3], P=.033) and greater improvement in urgency symptoms based on median urgency PGI-I score (1 [interquartile range 1-3] vs 2 [interquartile range 2-4], P=.028). At 3 months, median UDI-6, PFIQ-7, and PGI-S scores improved significantly from baseline in both groups. Similarly, UDI-6 and PFIQ-7 scores did not differ between groups. More women in the onabotulinumtoxinA arm initiated intermittent self-catheterization, (3% placebo; 12% onabotulinumtoxinA, P=.20) and experienced urinary tract infections (5% placebo; 22% onabotulinumtoxinA, P=.051), but these did not differ statistically.

Conclusion: Concurrent intradetrusor onabotulinumtoxinA injection did not improve overall incontinence symptoms at 3 months compared with placebo among women with mixed urinary incontinence undergoing midurethral sling placement. Women with mixed urinary incontinence undergoing sling report significant improvement in overall incontinence symptoms, regardless of the addition of onabotulinumtoxinA injections, but those receiving concurrent onabotulinumtoxinA injections reported less urgency severity and greater improvement in urgency symptoms at 3 months.

Clinical Trial Registration: ClinicalTrials.gov, NCT02678377.
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January 2021

Bare Versus Hair: Do Pubic Hair Grooming Preferences Dictate the Urogenital Microbiome?

Female Pelvic Med Reconstr Surg 2021 Sep;27(9):532-537

From the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Northwestern University, Evanston.

Objective: The aim of the study was to determine whether the genitourinary microbiome differs between and within women with and without pubic hair.

Methods: Premenopausal women who self-identified into 2 groups were recruited: in the "hair" group, women did not remove any pubic hair, and in the "bare" group, all pubic hair was removed routinely. Participants submitted a vaginal swab, a voided urine sample, and a catheterized urine sample, and then "crossed over." The "hair" group removed all hair for 1 month, and the "bare" group grew hair for 2 months. After crossover, participants again submitted a vaginal swab, a voided urine sample, and a catheterized urine sample. Ten participants acted as controls. DNA was extracted, and the V4 region of 16S rRNA gene was amplified and sequenced using the MiSeq platform. Paired-end sequences were imported into QIIME2-2018.6. Alpha diversity (the number and proportion of species in an individual sample) and beta diversity (differences in microbial composition between samples) were evaluated.

Results: Forty-two participants were analyzed: 16 "bare to hair" crossovers, 16 "hair-to-bare" crossovers, and 10 controls. The microbiome varied by sample type: vaginal swabs had the lowest alpha diversity and catheterized urine had the highest (P < 0.001). At baseline, there were no differences in the alpha or beta diversity of urine or vaginal microbiomes between groups. Vaginal beta diversity at visit 2 was greater within crossovers than controls (P = 0.004), suggesting that altering hair status alters the microbiome composition. Urinary beta diversity was not different at visit 2 (P = 0.40).

Conclusions: Pubic hair status does not determine one's baseline genitourinary microbiome, but women who change their hair status may alter their vaginal microbiome.
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September 2021

Impact of a Web-Based Decisional Aid on Satisfaction in Women Undergoing Prolapse Surgery.

Female Pelvic Med Reconstr Surg 2021 02;27(2):e309-e314

From the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL.

Objectives: The objective of this study was to determine whether a computerized, condition-specific Decision Analysis Tool (DAT) for the surgical treatment of pelvic organ prolapse (POP) improves patient satisfaction and alters decision making.

Methods: Together with a health care startup company, we created a computerized DAT using the best evidence available on success rates and risks associated with sacrocolpopexy, native tissue apical suspension, and colpocleisis. Consecutively scheduled women before and after implementation of the DAT in an academic practice of 4 fellowship-trained, board-certified urogynecologists were included. The primary outcome was patient satisfaction using the Satisfaction with Decision Scale (SDS). Secondary outcomes included the Decision Regret Scale (DRS) questionnaire, differences in surgical choice, patient-reported outcomes, and individual SDS and DRS items. The SDS and DRS were administered at the 3-month postoperative visit.

Results: Forty-seven women before DAT implementation and 54 women after DAT implementation were included. There were no differences in SDS or DRS total scores (4.62 ± 0.66 vs 4.52 ± 0.72, P = 0.10 and 1.48 ± 0.79 vs 1.52 ± 0.82, P = 0.77) or individual question responses between groups. Women using the DAT were more likely to choose sacrocolpopexy than those who did not (76% vs 51%, P = 0.01). All 3 procedures led to similarly improved POP symptoms (P = 0.98), but those who underwent sacrocolpopexy had higher SDS scores compared with native tissue or colpocleisis patients (P = 0.01). Several individual SDS and DRS items were more favorable after sacrocolpopexy.

Conclusions: Women choosing surgery for POP are satisfied with their decision-making experiences with and without the assistance of a DAT. More women using a DAT, however, undergo sacrocolpopexy, which is associated with improved satisfaction.
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February 2021

Early Secondary Repair of Obstetric Anal Sphincter Injury Breakdown: Contemporary Surgical Techniques and Experiences From a Peripartum Subspecialty Clinic.

Female Pelvic Med Reconstr Surg 2021 02;27(2):e333-e335

From the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Northwestern University, Feinberg School of Medicine, Chicago, IL.

Objective: To describe surgical technique and outcomes of early secondary repair of obstetric anal sphincter injury (OASIS) breakdown.

Methods: This was a case series of all women presenting to a subspecialty peripartum clinic within 2 months of an OASIS, who ultimately underwent secondary surgical repair between September 2013 and January 2018. Cases were identified using the following CPT codes: 57308 (transperineal fistula repair), 56910 (repair of the perineum), and 46750 (repair of anal sphincter). Four board-certified urogynecologists performed all surgical procedures using the same technique: demographics, delivery data, and preoperative and postoperative data were collected.

Results: Eighteen women were identified. The majority (16 [88.9%] of 18) were primiparous; 9 (50%) women underwent spontaneous vaginal delivery and 9 (50%) women underwent forceps-assisted vaginal delivery. Over 70% (13 [72.2%] of 18) suffered a 3rd-degree tear, whereas 5 (27.8%) of 18 had a 4th-degree laceration. The median time after delivery to specialty clinic presentation was 10 days (interquartile range, 5.3-52.5 days). All women were diagnosed with wound breakdown at their initial visit. Seven (38.9%) also had a concomitant rectovaginal fistula.Median time from diagnosis of wound breakdown to secondary operative revision was 19.5 days (interquartile range, 12-26.8 days). Seventeen (94.4%) of the 18 women underwent overlapping external anal sphincteroplasty with perineorrhaphy; of these, 7 (41.2%) also underwent concurrent repair of their rectovaginal fistula. One woman underwent perineorrhaphy alone. At 3 months postoperatively, no women had a wound breakdown or recurrent fistula.

Conclusions: In women with OASIS breakdown, early secondary repair is both feasible and successful with meticulous surgical technique.
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http://dx.doi.org/10.1097/SPV.0000000000000921DOI Listing
February 2021

Restricted Convalescence Following Urogynecologic Procedures: 1-Year Outcomes From a Randomized Controlled Study.

Female Pelvic Med Reconstr Surg 2021 02;27(2):e336-e341

From the Division of Female Pelvic Medicine and Reconstructive Surgery, Departments of Obstetrics and Gynecology and Urology, Northwestern University Feinberg School of Medicine.

Objective: To assess the relationship between postoperative activity recommendations and satisfaction and anatomic and functional outcomes 1 year after surgery for symptomatic prolapse.

Methods: This is a planned secondary analysis reporting 1-year functional and anatomic outcomes of a multicenter, randomized, double-masked clinical trial "ReCOUP." In the original trial, women undergoing surgery for prolapse were randomized to liberal (no limitations on physical activity) or restricted (heavy lifting and high-impact activity prohibited) postoperative activity recommendations for 3 months after surgery. At 1 year, our primary outcome was satisfaction, assessed using a 5-point Likert scale answer to the question, "How satisfied are you with the result of your prolapse surgery?" Anatomic surgical failure was met if women had prolapse beyond the hymen, apical descent greater than one third the vaginal length, OR retreatment for prolapse.

Results: Of the 95 women (n = 45 liberal, n = 50 restricted) who were randomized and completed primary 3-month outcomes, 83 (87%) completed a functional assessment, and 77 (81%) completed both functional and anatomic assessment at 1 year. Satisfaction with surgery remained high (91.5%) with no differences between groups (86.8% vs 95.6% P = 0.155) as did anatomic and functional outcomes. There were 7.8% women who met criteria for anatomic surgical failure with no difference between the restricted (7.0%) and liberal group (8.8%). Three women (2 in the restricted group, 1 in the liberal group) with recurrent prolapse and underwent surgery.

Conclusions: There were no significant differences in anatomic and functional outcomes at 12 months after surgery in women who resume postoperative activity liberally and those who restrict postoperative activity.
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February 2021

How can we relieve gastrointestinal symptoms in people with cystic fibrosis? An international qualitative survey.

BMJ Open Respir Res 2020 09;7(1)

Child Health Obstetrics and Gynaecology, University of Nottingham, Nottingham, UK.

Introduction: Relieving gastrointestinal (GI) symptoms was identified as a 'top ten' priority by our James Lind Alliance Priority Setting Partnership in cystic fibrosis (CF). We conducted an online survey to find out more about the effect of GI symptoms in CF.

Methods: We co-produced an online survey distributed to the CF community via web-based platforms. The survey consisted of open and closed questions designed to help us learn more about the effects of GI symptoms for people with CF (pwCF). We analysed the data using descriptive statistics and thematic analysis. We promoted the survey via social media and web-based platforms which allowed respondents from any country to take part. Our participants came from the CF community, including: adults and children with CF, parents and close family of pwCF and healthcare professionals (HCPs) working with pwCF.

Results: There were 276 respondents: 90 (33%) pwCF, 79 (29%) family, 107 (39%) HCPs. The most commonly reported symptoms by lay respondents were stomach cramps/pain, bloating and a 'combination of symptoms'. The top three symptoms that HCPs said were reported to them were reduced appetite, bloating and constipation. Almost all (94% (85/90)) HCPs thought medications helped to relieve GI symptoms but only 58% (82/141) of lay respondents agreed.

Conclusions: Our survey has shown that GI symptoms among our participants are prevalent and intrude on daily lives of pwCF. There is a need for well-designed clinical studies to provide better evidence for management of GI symptoms and complications.
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http://dx.doi.org/10.1136/bmjresp-2020-000614DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7478045PMC
September 2020

Patients' Perceptions on Surgical Care Suspension for Pelvic Floor Disorders During the COVID-19 Pandemic.

Female Pelvic Med Reconstr Surg 2020 08;26(8):477-482

From the Division of Female Pelvic Medicine and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL.

Objectives: The primary objective of the study was to evaluate patients' attitudes toward the postponement of their scheduled procedures for pelvic floor disorders (PFD) because of the COVID-19 pandemic. Secondary objectives were to identify patients who were upset with the postponement of their PFD procedures and to identify factors that are associated with being upset because of the delay in care.

Methods: This was a cross-sectional, survey-based study of women from a single urban, academic practice using a novel questionnaire. The study cohort included women whose PFD surgeries or office procedures were postponed between March 17 and April 30, 2020.

Results: Ninety-eight women had surgeries postponed; 68 (70%) responded to our questionnaire. Nearly half of the respondents (32/68, 47.1%) were upset about their procedures being postponed. Upset patients reported a greater impact of PFD symptoms on their mood than those who were not upset (P=0.002). Those who were upset were also more likely to report feelings of isolation (P=0.006), fear that their PFD would worsen because of delayed care (P < 0.001), and anxiety over surgery postponement (P < 0.001) than those who were not upset about the delays. When controlling for anxiety, social isolation, and impact of PFD symptom, anxiety (adjusted odds ratio = 15.7; 95% confidence interval = 3.7-66.6) and feeling of isolation (adjusted odds ratio = 9.7; 95% confidence interval = 1.5-63.7) remained associated with increased odds of being upset because of procedure delays.

Conclusions: Half of women whose pelvic reconstructive procedures were postponed because of the COVID-19 pandemic were upset because of the delay in care, especially those who are emotionally and socially vulnerable during the COVID-19 pandemic.
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August 2020

Does a Hysterectomy Hurt? Comparing Narcotic Requirements and Pain Scores in Patients Undergoing Apical Prolapse Repair With or Without Hysterectomy.

Female Pelvic Med Reconstr Surg 2021 06;27(6):356-359

From the Division of Female Pelvic Medicine and Reconstructive Surgery, Northwestern University, Chicago, IL.

Objective: The aim of the study was to compare narcotic requirements with early postoperative pain scores in women undergoing apical prolapse surgery with or without hysterectomy.

Methods: All cases of apical prolapse repair at our institution in 2016 were identified. The following was abstracted from the health record: demographics, comorbidities, procedure details, baseline and postoperative care unit (PACU) pain scores, and operating room (OR) and PACU narcotic doses. Doses were converted to morphine milligram equivalents (MME) for analysis. Correlations are reported using Pearson ρ.

Results: One hundred fifty-six cases were identified. Seventy-eight percent of participants were white and the mean ± SD age was 59 ± 11 years. One hundred seventeen patients (75%) underwent laparoscopic/robotic sacrocolpopexy, 35 (22%) native tissue vaginal repairs, and 4 (3%) open sacrocolpopexy. One hundred twenty-two patients (78%) underwent concomitant hysterectomy: 93 (76%) were laparoscopic, 25 (20%) vaginal, and 4 (4%) abdominal.The groups were similar, with the exception of younger age and longer OR time in the hysterectomy group. Hysterectomy by any route was not associated with increased OR MMEs (29 vs 22, P = 0.22), PACU MMEs (13 vs 13, P = 0.54), 4-hour PACU pain scores (2.5 vs 2.0, P = 0.22), or 6-hour PACU pain scores (2.6 vs 2.3, P = 0.54). After controlling for age and OR time, there remained no differences in these variables. Likewise, when analyzing laparoscopic or vaginal groups separately on multivariate regression, there were no differences in MMEs or postoperative pain scores in patients with and without concomitant hysterectomy.

Conclusions: Concomitant hysterectomy at the time of prolapse repair does not increase pain medication requirements or patient-reported postoperative pain scores.
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June 2021

The First Injection: Rates of Urinary Retention in Women With Urgency Incontinence Treated With Intravesical OnabotulinumtoxinA Injection.

Female Pelvic Med Reconstr Surg 2021 01;27(1):e118-e121

From the Northwestern University, Chicago, IL.

Objective: The aim of the study was to describe the rate of symptomatic and asymptomatic urinary retention and catheterization in women undergoing initial intravesical onabotulinumtoxinA (BnTA) injection for urgency urinary incontinence (UUI).

Methods: This retrospective chart review included women receiving initial 100 U of BnTA injection for UUI for 5 years. Straight-catheterized postvoid residuals (PVRs) were performed 2 weeks after the injection. Women without the sensation of incomplete bladder emptying, worsened urgency, inability to void, or suprapubic pain but with PVR of greater than 300 mL were characterized as having asymptomatic retention, whereas women with a PVR of greater than 150 and any of these symptoms were diagnosed with symptomatic retention.

Results: One hundred eighty-seven 187 patients received initial BnTA injection. The majority were postmenopausal (89%) and white (82%) with a mean age of 65 years and body mass index of 30 kg/m2. One-third of the cohort underwent baseline urodynamic studies. At 2 weeks after injection, 163 patients (87%) followed up, and 17 (10%) had either asymptomatic or symptomatic retention (2% and 8%, respectively). There were no differences in demographic or pretreatment urodynamic parameters in women with and without retention except that women who had previous anti-stress urinary incontinence procedures were more likely to experience retention (53% vs 18%, P = 0.002) despite similar baseline PVRs.

Conclusion: We demonstrated that the rate of retention requiring catheterization after 100 U BnTA may be as high as 10% although only 5% develop PVRs for 300 mL and only 2% have asymptomatic retention for 300 mL.
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January 2021

A New Method to Reconstruct Quantitative Food Webs and Nutrient Flows from Isotope Tracer Addition Experiments.

Am Nat 2020 06 1;195(6):964-985. Epub 2020 May 1.

Understanding how nutrients flow through food webs is central in ecosystem ecology. Tracer addition experiments are powerful tools to reconstruct nutrient flows by adding an isotopically enriched element into an ecosystem and tracking its fate through time. Historically, the design and analysis of tracer studies have varied widely, ranging from descriptive studies to modeling approaches of varying complexity. Increasingly, isotope tracer data are being used to compare ecosystems and analyze experimental manipulations. Currently, a formal statistical framework for analyzing such experiments is lacking, making it impossible to calculate the estimation errors associated with the model fit, the interdependence of compartments, and the uncertainty in the diet of consumers. In this article we develop a method based on Bayesian hidden Markov models and apply it to the analysis of tracer additions in two Trinidadian streams in which light was experimentally manipulated. Through this case study, we illustrate how to estimate N fluxes between ecosystem compartments, turnover rates of N within those compartments, and the associated uncertainty. We also show how the method can be used to compare alternative models of food web structure, calculate the error around derived parameters, and make statistical comparisons between sites or treatments.
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June 2020

Mind the Gap: Changes in Levator Dimensions After Sacrocolpopexy.

Female Pelvic Med Reconstr Surg 2021 01;27(1):e184-e186

From the Northwestern University.

Objective: The aim of the study was to compare levator hiatus (LH) and levator area (LA) on transvaginal 3-dimensional (3D) ultrasound (US) and genital hiatus (GH) size by Pelvic Organ Prolapse Quantification (POP-Q) examination before and after minimally invasive sacrocolpopexy.

Methods: Women with prolapse (POP) beyond the hymen undergoing minimally invasive sacrocolpopexy without concomitant POP repairs completed Pelvic Floor Distress Inventory short form (PFDI), POP-Q, and transvaginal 3D US before and 14 weeks after surgery. Data were analyzed by 2 urogynecologists, blinded to US image sequence and to corresponding POP-Q scores.

Results: Forty-three patients were enrolled; 35 with complete data are included. Patients had a mean ± SD age of 55 ± 11 years. Most were white (89%), vaginally parous (94%), postmenopausal (66%), sexually active (63%), and had stage 3 POP (86%). The majority (89%) had concomitant hysterectomy, and 60% had midurethral slings. At baseline, the mean ± SD PFDI and Prolapse subscale of the Pelvic Floor Distress Inventory scores were 98 ± 50 and 42 ± 22. The median (interquartile range) POP-Q stage decreased after surgery from 3 (3) to 0 (0-1, P < 0.001) and the mean ± SD PFDI scores decreased to 55 ± 42 (P = 0.002). At baseline, the mean ± SD GH and perineal body measurements were 3.5 ± 0.7 and 2.4 ± 0.6 cm. Although the GH size decreased by 0.5 cm after surgery, perineal body was unchanged. Levator hiatus remained unchanged between the baseline and 14-week visits (P = 0.07), whereas LA increased by 0.8 cm2 (P = 0.03). At 14 weeks, the change in LA was not correlated with the change in GH (ρ = -0.2, P = 0.2) or POP stage (ρ = -0.2, P = 0.9).

Conclusions: Restoring the apex with sacrocolpopexy alone reduces GH size on clinical examination; however, it does not impact the size of the underlying LH on US.
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January 2021

Pregnancy in Women With Prior Treatments for Pelvic Floor Disorders.

Female Pelvic Med Reconstr Surg 2020 05;26(5):299-305

Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Northwestern Medicine, Feinberg School of Medicine, Chicago, IL.

Although the peak incidence of surgery for pelvic floor disorders does not occur until after menopause, an increasing number of younger women are seeking treatment for these problems. Whereas most surgeons would recommend delaying surgery until the completion of childbearing, published cases and case series address outcomes after subsequent pregnancies in women who have been treated for urinary incontinence and pelvic organ prolapse. This document synthesizes the available evidence on the impact of pregnancy on women with prior treatment for pelvic floor disorders and on the impact of these prior treatments on subsequent pregnancy. Pregnancy after the repair of obstetrical anal sphincter laceration is also discussed. Consensus recommendations are presented based on available literature review and expert involvement.
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May 2020

Truth or Myth: Intra-abdominal Pressure Increases in the Lithotomy Position.

J Minim Invasive Gynecol 2021 01 27;28(1):26-29. Epub 2020 Mar 27.

Division of Female Pelvic Medicine and Reconstructive Surgery (Drs. Mou, Geynisman-Tan, Collins, Mueller, Lewicky-Gaupp, and Kenton, and Ms. Tavathia).

Study Objective: To determine if there were differences in intra-abdominal pressure (IAP) in the supine, low lithotomy, and high lithotomy positions.

Design: Prospective cohort study.

Setting: University medical center.

Patients: Twenty-nine women undergoing surgery for prolapse or stress incontinence.

Interventions: Relevant medical history, including the pelvic organ prolapse quantification stage, body mass index, and airway grade (Mallampati score), was abstracted from patients' medical charts. IAP was measured in centimeters of water (cmHO) on the day of their surgery before induction of general or intravenous anesthesia using a T-doc air charged urodynamic catheter (Laborie Aquarius; Ontario, Canada) placed in a patient's vagina (for patients with incontinence) or rectum (for patients with prolapse).

Measurements And Main Results: IAP was measured in 3 positions: supine (legs at 0°), low lithotomy (legs in Yellowfin stirrups at 45°; Allen Medical, Acton, MA), and high lithotomy (legs at 90°). The means ± SDs IAP for the groups were as follows: in the supine position, 18.6 cmHO ± 7.6; low lithotomy, 17.7 cmHO ± 6.6; and high lithotomy, 17.1 cmHO ± 6.3. In the same women, there was a significant decrease in IAP from the supine to high lithotomy positions, with a mean difference of 1.4 cmHO ± 3.7, p = .05. Similarly, there was a significant, though smaller, decrease in mean IAP when moving from the supine to low lithotomy positions in these same women (mean decrease of 0.9 cmHO ± 1.5, p = .004). Neither change is clinically significant based on previous research that suggests 5 cmHO is a clinically significant change.

Conclusion: Placing patients' legs in a low or high lithotomy position does not result in a clinically significant increase in IAP. Therefore, surgeons and anesthesiologists can consider positioning patients' lower extremities in stirrups while patients are awake to minimize discomfort and possibly reduce the risk of nerve injuries.
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http://dx.doi.org/10.1016/j.jmig.2020.03.005DOI Listing
January 2021

The changing epidemiology of diphtheria in the United Kingdom, 2009 to 2017.

Euro Surveill 2020 03;25(11)

Immunisation and Countermeasures Division, National Infection Service, Public Health England, London, United Kingdom.

BackgroundDiphtheria is a potentially fatal disease caused by toxigenic strains of or AimOur objective was to review the epidemiology of diphtheria in the United Kingdom (UK) and the impact of recent changes in public health management and surveillance.MethodsPutative human toxigenic diphtheria isolates in the UK are sent for species confirmation and toxigenicity testing to the National Reference Laboratory. Clinical, epidemiological and microbiological information for toxigenic cases between 2009 and 2017 are described in this population-based prospective surveillance study.ResultsThere were 33 toxigenic cases of diphtheria aged 4 to 82 years. Causative species were (n = 18) and (n = 15). Most cases were cutaneous (14/18) while more than half of cases had respiratory presentations (8/15). Two thirds (23/33) of cases were inadequately immunised. Two cases with infections died, both inadequately immunised. The major risk factor for aquisition was travel to an endemic area and for contact with a companion animal. Most confirmed or isolates (441/507; 87%) submitted for toxigenicity testing were non-toxigenic however, toxin positivity rates were higher (15/23) for than (18/469). Ten non-toxigenic toxin gene-bearing (NTTB) were also detected.ConclusionDiphtheria is a rare disease in the UK. In the last decade, milder cutaneous cases have become more frequent. Incomplete vaccination status was strongly associated with the risk of hospitalisation and death.
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http://dx.doi.org/10.2807/1560-7917.ES.2020.25.11.1900462DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7096772PMC
March 2020
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