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Introduction and hypothesisThere is little information on the impact that postoperative instructions have on physical activity to help guide physicians in providing these recommendations after surgery. Our study objective was to evaluate the impact of postoperative instructions on physical activity. We hypothesized that there would be no differential effect of instructions on activity.MethodsIn this randomized controlled trial, patients undergoing prolapse repair were randomized to receive either liberal or restricted postoperative activity instructions between February 2017 and February 2019. Physical activity was measured using the Activities Assessment Scale (AAS) and tri-axial accelerometers measured at baseline and 2 and 6 weeks after surgery. A sample size of 146 patients was planned to compare these activity measurements. AAS scores and accelerometer readings of the two groups were compared using separate variance t tests.ResultsA total of 157 women were recruited between February 2017 and February 2019, including 146 patients with completed study data (n = 72 liberal, n = 74 restricted). There was no difference in physical activity at 2 weeks between the liberal and the restricted instruction groups, as measured by AAS scores (70.47 ± 12.83, 69.54 ± 12.22, p = 0.66), total steps (4,582.20 ± 2,164.5, 5,014.47 ± 3,025.46, p = 0.32), active minutes (4.22 ± 6.17, 4.96 ± 9.65, p = 0.25), and 10-min intervals (0.76 ± 1.11, 0.77 ± 0.93, p = 0.95) respectively. Similarly, there was no difference in activity at 6 weeks between the liberal and the restricted instruction groups. as measured by AAS scores (81.86 ± 8.25, 81.31 ± 10.31, p = 0.72), total steps (6,316.25 ± 3,173.53, 6,589.94 ± 3,826.43, p = 0.64), active minutes (8.79 ± 10.5,11.36 ± 18.18, p = 0.98), and 10-min intervals (1.37 ± 1.34, 1.34 ± 1.40, p = 0.89) respectively.ConclusionPostoperative instructions do not have an impact on physical activity measures in patients who have undergone pelvic reconstructive surgery.

Introduction and hypothesisThe urogynecology subspecialty relies on appropriate referrals from their referral base. We sought to provide guidance for optimizing appropriate referrals to urogynecology by comparing pre-referral characteristics between appropriate and inappropriate referrals.MethodsThis retrospective cohort study examined predictors of appropriate urogynecology referrals. Appropriateness categorization was based upon pelvic floor disorder (PFD) symptoms and signs provided by the referring provider. Patients with both a PFD symptom and sign were considered “appropriate.” Patients with neither a PFD symptom nor sign were considered “inappropriate.” PFD symptoms were: vaginal bulge, voiding or defecatory dysfunction. PFD signs were: vaginal vault prolapse, urethral hypermobility, mesh/sling exposure, elevated post-void residual, positive standing stress test, abnormal urinalysis or urine culture-proven infection. Continuous and categorical data were analyzed with ANOVA and chi-square test, respectively. A logistic regression model to predict appropriateness was developed from variables identified from the bivariate analysis.ResultsBivariate predictors of an appropriate referral for 1716 study subjects were older age, prior overactive bladder medication use, MD/DO referrer source and OBGYN, urogynecology or urology referrer specialty. Our logistic regression model correctly classified referrals as appropriate in 93.6% of cases.ConclusionsAge, anti-cholinergic medication use, referrer source and specialty are pre-initial visit predictors of urogynecology referral appropriateness. The predictor-generated model was successful in predicting referral appropriateness. Potential bias from information transfer issues, lack of pre-referral evaluation and referring provider unfamiliarity with urogynecology are possible reasons for inappropriate referrals and potential areas for improvement.

Introduction and hypothesis To assess the differences in patient-reported, catheter-specific satisfaction and quality of life with either suprapubic or transurethral postoperative bladder drainage following reconstructive pelvic surgery. Methods This was a prospective study of all eligible women who were scheduled to undergo reconstructive surgery requiring bladder drainage during the study period November 2013 to March 2015. Women who did not undergo the planned procedure(s) or did not require bladder drainage were excluded. The primary outcome was patient-reported quality of life using catheter-specific instruments including the Catheter-related Quality of Life (CIQOL) instrument, and a modified version of the Intermittent Self-Catheterization Questionnaire (ISC-Q), designed to evaluate aspects of catheter-related quality of life and satisfaction specific to the needs of the individual. Results A total of 178 women were analyzed, 108 in the transurethral catheter group and 70 in the suprapubic group. Women with suprapubic bladder drainage had higher quality of life and satisfaction scores than women with transurethral bladder drainage as measured by the ISC-Q (68.31 ± 16.87 vs. 54.04 ± 16.95, mean difference 14.27, 95 % CI 9.15 – 19.39). There was no difference in quality of life by the CIQOL. After regression analysis, women with suprapubic bladder drainage were more satisfied with their catheter-specific needs despite longer duration of catheter use, more concurrent continence surgery, and higher trait anxiety. Conclusions Differences in catheter-specific quality of life and patient satisfaction scores favoring suprapubic bladder drainage support its continued use in appropriately selected women for treatment of temporary postoperative urinary retention after reconstructive pelvic surgery.

Objective The purpose of our study was to determine whether the anatomic threshold for pelvic organ prolapse (POP) diagnosis and surgical success remains valid when the patient sees what we see on exam. Methods Two hundred participants were assigned, by computer-generated block randomization, to see one of four videos. Each video contained the same six clips representative of various degrees of anterior vaginal wall support. Participants were asked questions immediately after each clip. They were asked: “In your opinion, does this patient have a bulge or something falling out that she can see or feel in the vaginal area?” Similarly, they were asked to give their opinion on surgical outcome on a 4-point Likert scale. Results The proportion of participants who identified the presence of a vaginal bulge increased substantially at the level of early stage 2 prolapse (1 cm above the hymen), with 67 % answering yes to the question regarding bulge. The proportion of participants who felt that surgical outcome was less desirable also increased substantially at early stage 2 prolapse (1 cm above the hymen), with 52 % describing that outcome as “not at all” or “somewhat” successful. Conclusion Early stage 2 POP (1 cm above the hymen) is the anatomic threshold at which women identify both a vaginal bulge and a less desirable surgical outcome when they see what we see on examination.

Introduction and hypothesis Dyssynergic defecation can be difficult to diagnose. Anorectal manometry and defecography are often used to make this diagnosis. However, these tests are expensive and require expertise. Balloon expulsion testing may be a simple alternative. We compared balloon expulsion to anorectal manometry and defecography for diagnosing dyssynergia in women with chronic constipation. Methods We conducted a retrospective review. All women presenting for evaluation of chronic constipation who underwent concurrent balloon testing, manometry, and defecography were included. A diagnosis of dyssynergic defecation was established by either defecography revealing prolonged/incomplete rectal evacuation and/or by manometry revealing paradoxical contraction/inadequate relaxation of the pelvic floor. Inability to expel a 50-ml balloon defined dyssynergic defecation by balloon testing. Sensitivity, specificity, and predictive values were calculated. Results A total of 61 women met inclusion criteria. Mean age was 50 years. There were 36 women (59 %) who met Rome III criteria for dyssynergic defecation on defecography and/or manometry. Only 12 of these 36 (33 %) were similarly diagnosed by balloon testing. The sensitivity and positive predictive value of balloon testing for dyssynergia were 33 and 71 %, respectively. Of the 25 (41 %) women who did not meet Rome III criteria for dyssynergia on defecography and/or manometry, 20 (80 %) also had negative balloon testing. Thus, the specificity and negative predictive value of balloon testing for diagnosing dyssynergia were 80 and 50 %, respectively. Conclusions In our population, balloon expulsion was not an ideal screening test for dyssynergic defecation in women with constipation. Multimodal testing is necessary for more accurate diagnosis.

The objective of this study was to determine if vaginal stiffness index, an in vivo vaginal biomechanical property, is correlated with pelvic floor disorder symptom distress, impact on quality of life, or sexual function as measured by disease-specific quality-of-life scales. Forty-eight women completed validated quality-of-life scales (pelvic floor distress inventory-short form, pelvic floor impact questionnaire, and pelvic organ prolapse/urinary incontinence sexual questionnaire) and underwent in vivo vaginal biomechanical testing. After bivariate relationships between vaginal stiffness index and demographic, obstetric, and gynecologic variables were explored, multiple linear regression controlling for pelvic organ prolapse quantitative (POP-Q) stage of prolapse was performed. The vaginal stiffness index was inversely correlated with pelvic organ prolapse distress severity (POPDI-6) after controlling for POP-Q stage of prolapse ( p  = 0.011, r  = 0.67, r 2  = 0.450, β  = −2.3). These findings provide initial evidence for the construct validity of in vivo vaginal biomechanical testing for pelvic organ prolapse evaluation because an increasing vaginal stiffness index is correlated with decreasing symptomatic and anatomic severity of disease.

The aim of this study was to determine the characteristics of women who meet the criteria for intrinsic sphincteric deficiency (ISD) on maximum urethral closure pressure (MUCP) but not on leak point pressure (LPP) measurement. We performed a cross-sectional chart review of every patient who underwent multichannel, microtransducer urodynamic testing in our center between 1994 and 1996 (n=423). From this population we culled a sub-population of women who fit into one of the following two groups: women with no evidence of ISD on MUCP or LPP and women with evidence of ISD on MUCP only. Logistic regression was used to identify independent predictors of group membership. Increasing age (>60.5 years) and a positive supine empty stress test were the only independent predictors of membership in the group of women with ISD on MUCP only. Knowledge of these risk factors may help clinicians in choosing appropriate pre-operative testing.[PUBLICATION ABSTRACT]

Trials examining the benefit of thrombectomy in anterior circulation proximal large vessel occlusion stroke have enrolled patients considered to have salvageable brain tissue, who were randomly assigned beyond 6 h and (depending on study protocol) up to 24 h from time last seen well. We aimed to estimate the benefit of thrombectomy overall and in prespecified subgroups through individual patient data meta-analysis. We did a systematic review and individual patient data meta-analysis between Jan 1, 2010, and March 1, 2021, of randomised controlled trials of endovascular stroke therapy. In the Analysis Of Pooled Data From Randomized Studies Of Thrombectomy More Than 6 Hours After Last Known Well (AURORA) collaboration, the primary outcome was disability on the modified Rankin Scale (mRS) at 90 days, analysed by ordinal logistic regression. Key safety outcomes were symptomatic intracerebral haemorrhage and mortality within 90 days. Patient level data from 505 individuals (n=266 intervention, n=239 control; mean age 68·6 years [SD 13·7], 259 [51·3%] women) were included from six trials that met inclusion criteria of 17 screened published randomised trials. Primary outcome analysis showed a benefit of thrombectomy with an unadjusted common odds ratio (OR) of 2·42 (95% CI 1·76–3·33; p<0·0001) and an adjusted common OR (for age, gender, baseline stroke severity, extent of infarction on baseline head CT, and time from onset to random assignment) of 2·54 (1·83–3·54; p<0·0001). Thrombectomy was associated with higher rates of independence in activities of daily living (mRS 0–2) than best medical therapy alone (122 [45·9%] of 266 vs 46 [19·3%] of 238; p<0·0001). No significant difference between intervention and control groups was found when analysing either 90-day mortality (44 [16·5%] of 266 vs 46 [19·3%] of 238) or symptomatic intracerebral haemorrhage (14 [5·3%] of 266 vs eight [3·3%] of 239). No heterogeneity of treatment effect was noted across subgroups defined by age, gender, baseline stroke severity, vessel occlusion site, baseline Alberta Stroke Program Early CT Score, and mode of presentation; treatment effect was stronger in patients randomly assigned within 12–24 h (common OR 5·86 [95% CI 3·14–10·94]) than those randomly assigned within 6–12 h (1·76 [1·18–2·62]; pinteraction=0·0087). These findings strengthen the evidence for benefit of endovascular thrombectomy in patients with evidence of reversible cerebral ischaemia across the 6–24 h time window and are relevant to clinical practice. Our findings suggest that in these patients, thrombectomy should not be withheld on the basis of mode of presentation or of the point in time of presentation within the 6–24 h time window. Stryker Neurovascular.

This article discusses the prevention of venous thromboembolism (VTE) and is part of the Seventh American College of Chest Physicians Conference on Antithrombotic and Thrombolytic Therapy: Evidence-Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S-187S). Among the key recommendations in this chapter are the following. We recommend against the use of aspirin alone as thromboprophylaxis for any patient group (Grade 1A). For moderate-risk general surgery patients, we recommend prophylaxis with low-dose unfractionated heparin (LDUH) (5,000 U bid) or low-molecular-weight heparin (LMWH) [< or = 3,400 U once daily] (both Grade 1A). For higher risk general surgery patients, we recommend thromboprophylaxis with LDUH (5,000 U tid) or LMWH (> 3,400 U daily) [both Grade 1A]. For high-risk general surgery patients with multiple risk factors, we recommend combining pharmacologic methods (LDUH three times daily or LMWH, > 3,400 U daily) with the use of graduated compression stockings and/or intermittent pneumatic compression devices (Grade 1C+). We recommend that thromboprophylaxis be used in all patients undergoing major gynecologic surgery (Grade 1A) or major, open urologic procedures, and we recommend prophylaxis with LDUH two times or three times daily (Grade 1A). For patients undergoing elective total hip or knee arthroplasty, we recommend one of the following three anticoagulant agents: LMWH, fondaparinux, or adjusted-dose vitamin K antagonist (VKA) [international normalized ratio (INR) target, 2.5; range, 2.0 to 3.0] (all Grade 1A). For patients undergoing hip fracture surgery (HFS), we recommend the routine use of fondaparinux (Grade 1A), LMWH (Grade 1C+), VKA (target INR, 2.5; range, 2.0 to 3.0) [Grade 2B], or LDUH (Grade 1B). We recommend that patients undergoing hip or knee arthroplasty, or HFS receive thromboprophylaxis for at least 10 days (Grade 1A). We recommend that all trauma patients with at least one risk factor for VTE receive thromboprophylaxis (Grade 1A). In acutely ill medical patients who have been admitted to the hospital with congestive heart failure or severe respiratory disease, or who are confined to bed and have one or more additional risk factors, we recommend prophylaxis with LDUH (Grade 1A) or LMWH (Grade 1A). We recommend, on admission to the intensive care unit, all patients be assessed for their risk of VTE. Accordingly, most patients should receive thromboprophylaxis (Grade 1A).