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The COVID-19 pandemic disrupted medical care in the US, leading to a significant drop in utilization of some types of health services. We sought to quantify how the pandemic influenced obstetrics and gynecology care at two large health care organizations. Comparing 2020 to 2019, we quantified changes to obstetrics and gynecology care at two large health care organizations in the United States, Allegheny Health Network (in western Pennsylvania) and Johns Hopkins University (in Maryland). The analysis considered the numbers of surgical encounters, in-person visits, and telemedicine visits. For each system, we quantified temporal changes in surgical volume, in-person and telemedicine visits, and financial impact related to professional fee revenues. We used segmented regression to evaluate longitudinal effects. At both institutions, the volume of care was similar in the first few months of 2020 compared to 2019 but dropped precipitously in March 2020. From April to June 2020, surgical volumes were 67% of the same period in 2019 at Allegheny Health and 48% of the same period in 2019 at Johns Hopkins. During that same interval, televisits accounted for approximately 21% of all ambulatory care at both institutions. Although surgical and ambulatory volumes recovered in the second half of 2020, annual surgical volumes in 2020 were significantly lower than 2019 at both institutions (p<0.05) and 2020 ambulatory volumes remained significantly lower at Johns Hopkins (p = .0006). Overall, revenues in 2020 were 91% of 2019 revenues for both institutions. Obstetrical and gynecologic ambulatory visits and gynecologic surgeries were sharply reduced during the COVID-19 pandemic. Although care volumes returned to 2019 levels in late 2020, we observed an overall reduction in the volume of care provided and a 9% reduction in professional revenue for both institutions.

Introduction and hypothesis Our objective was to compare complications and prolapse recurrence between laparoscopic (L-USLS) and vaginal (V-USLS) uterosacral ligament suspensions. Methods This is a retrospective study of USLS procedures performed at a large academic center from 2011 to 2014. Patient demographics, surgical data, complications, and prolapse recurrence of L-USLS and V-USLS were compared. Logistic regression identified predictors of operative time, complications, and prolapse recurrence. Results There were 54 L-USLS and 119 V-USLS procedures with median follow-up of 21.5 weeks (IQR 9.3–50.8). Women undergoing L-USLS were less likely to have medical comorbidities and had less severe prolapse, but were more likely to report prior hysterectomy. L-USLS had longer operative times (190.1 ± 46.8 vs 172.7 ± 47.3 min, p  = 0.03), but after correcting for concomitant procedures, the operative times of the two approaches were not significantly different (adjusted OR 1.00, 95%CI 0.99–1.00). There was no significant difference in complications between groups (24.1 % vs 21.8 %, p  = 0.75). However, there were nonsignificant trends toward more ureteral injuries and suture removals following V-USLS. Postoperative POP-Q points of the groups did not differ, except for total vaginal length (TVL), which was longer after L-USLS (8.3 ± 1.1 cm vs 7.4 ± 1.2 cm, p  < 0.001). 19 patients met the composite definition of prolapse recurrence, with no significant difference between groups (16.2 % vs 16 %, p  = 0.98). After adjusting for preoperative prolapse stage, route was not a significant predictor of prolapse recurrence (adjusted OR 0.39, 95 % CI 0.12–1.30). Conclusions L-USLS has comparable clinical outcomes, with similar rates of complications and prolapse recurrence to the traditional vaginal approach.

Introduction and hypothesis In 2008 and 2011, the US Food and Drug Administration (FDA) released notifications regarding vaginal mesh. In describing prolapse surgery trends over time, we predicted vaginal mesh use would decrease and native tissue repairs would increase. Methods Operative reports were reviewed for all prolapse repairs performed from 2008 to 2011 at our large regional hospital system. The number of each type of prolapse repair was determined per quarter year and expressed as a percentage of all repairs. Surgical trends were examined focusing on changes with respect to the release of two FDA notifications. We used linear regression to analyze surgical trends and chi-square for demographic comparisons. Results One thousand two hundred and eleven women underwent 1,385 prolapse procedures. Mean age was 64 ± 12, and 70 % had stage III prolapse. Vaginal mesh procedures declined over time ( p  = 0.001), comprising 27 % of repairs in early 2008, 15 % at the first FDA notification, 5 % by the second FDA notification, and 2 % at the end of 2011. The percentage of native tissue anterior/posterior repairs ( p  < 0.001) and apical suspensions ( p  = 0.007) increased, whereas colpocleisis remained constant ( p  = 0.475). Despite an overall decrease in open sacral colpopexies ( p  < 0.001), an initial increase was seen around the first FDA notification. We adopted laparoscopic/robotic techniques around this time, and the percentage of minimally invasive sacral colpopexies steadily increased thereafter ( p  < 0.001). All sacral colpopexies combined as a group declined over time ( p  = 0.011). Conclusions Surgical treatment of prolapse continues to evolve. Over a 4-year period encompassing two FDA notifications regarding vaginal mesh and the introduction of laparoscopic/robotic techniques, we performed fewer vaginal mesh procedures and more native tissue repairs and minimally invasive sacral colpopexies.

Glioblastoma (GBM) is a primary brain tumor that carries a dismal prognosis, which is primarily attributed to tumor recurrence after surgery and resistance to chemotherapy. Since the tumor recurrence appears near the site of surgical resection, a concept of immediate and local application of chemotherapeutic after initial tumor removal could lead to improved treatment outcome. With the ultimate goal of developing a locally-applied, injectable drug delivery vehicle for GBM treatment, we created elastin-like polypeptide (ELP) hydrogels. The ELP hydrogels can be engineered to release anti-cancer drugs over an extended period. The purpose of this study was to evaluate the biomechanical properties of ELP hydrogels, to characterize their ability to release doxorubicin over time, and to investigate, in vitro, the anti-proliferative effect of Dox-laden ELP hydrogels on GBM. Here, we present microstructural differences, swelling ratio measurements, drug release characteristics, and in vitro effects of different ELP hydrogel compositions. We found that manipulation of the ELP–collagen ratio allows for tunable drug release, that the released drug is taken up by cells, and that incubation with a small volume of ELP-Dox hydrogel drastically reduced survival and proliferation of GBM cells in vitro. These results underscore the potential of ELP hydrogels as a local delivery strategy to improve prognosis for GBM patients after tumor resection.

This book offers a manifesto for a radical existentialism aiming to regenerate the place of the outside that contemporary theory underestimates. Neyrat calls this outside \"atopia\": not utopia, a dreamt place out of the world where everything would be perfect, but atopia, the internal outside that is at the core of every being. Atopia is neither an object that an \"object-oriented ontology\" would be able to formalize, nor the matter that \"new materialisms\" could identify. Atopia is what constitutes the existence of any object or subject, its singularity or more precisely its \"eccentricity.\" Etymologically, to exist means \"to be outside\" and the book argues that every entity is outside, thrown in the world, wandering without any ontological anchor. In this regard, a radicalized existentialism does not privilege human beings (as Sartre and Heidegger did), but considers existence as a universal condition that concerns every being.It is important to offer a radical existentialism because the current denial of the outside is politically, and aesthetically, damaging. Only an atopian philosophy—a bizarre, extravagant, heretic philosophy—can care for our fear of the outside. For therapeutic element, a radical existentialism favors everything that challenges the compact immanence in which we are trapped, losing capacity to imagine political alternatives. To sustain these alternatives, the book identifies the atopia as a condition of the possibility to break immanence and analyze these breaks in human and animal subjectivity, language, politics and metaphysics.

Introduction and hypothesis The aim was to determine factors associated with performing concurrent apical support procedures in hysterectomies carried out for uterovaginal prolapse. Methods Hysterectomies performed for uterovaginal prolapse from 2000 to 2010 were identified by ICD-9 codes. Uterovaginal prolapse was a proxy for apical descent. Primary outcome was the rate of concurrent apical procedures. Secondary outcomes included concurrent surgeries, complications, and surgeon training. Chi-squared tests compared categorical variables. Logistic regression determined factors associated with concurrent apical support. Results A total of 2,465 hysterectomies were performed for uterovaginal prolapse. In only 1,358 cases (55.1 %) were concurrent apical support procedures carried out. Cases without apical procedures were more likely to undergo cystocele repair (23.8 % vs 9.4 %, p  < 0.001), but less likely to have rectocele (3.4 % vs 12.2 %, p  < 0.001) or combined cystocele/rectocele repair (16.4 % vs 25.6 %, p  < 0.001). Of those without apical procedures, 95.7 % were performed by generalists. Urogynecologists and minimally invasive gynecologists were more likely to perform apical procedures (97.1 % and 88.8 % vs 23.6 %, p  < 0.001). Older patients (>75 years) were more likely to undergo apical procedures (OR 5.096, 95 % CI 3.127–8.304). Surgeons practicing for 10–14 years and >20 years were less likely to perform apical procedures than those practicing <5 years ( p  < 0.001 vs. p  = 0.01). Conclusions At a tertiary hospital, a significant proportion of hysterectomies are carried out for uterovaginal prolapse without concurrent apical support procedures, with the majority performed by generalists. Urogynecologists and minimally invasive gynecologists are more likely to perform an apical suspension at the time of hysterectomy for uterovaginal prolapse than generalists. This supports the need for continued education about apical support to appropriately manage uterovaginal prolapse.

The current consumer trend away from package tourism towards more individually organized travel, including special interest travel, is likely to have an impact on the structure and organization of the travel industry, the channels of distribution, booking systems, business and destination suppliers from private sources such as the internet and published travel guidebooks. In planning their holidays, tourists are increasingly likely to demand greater destination information. If they are to be made aware of the available range of product options and to make appropriate product choices they will need information. The extent and type of the required information will depend on the type of vacation, on the consumer's destination knowledge, prior travel experience, and cultural background. The present study reports the findings of a quantitative survey administered to Japanese, Korean, Chinese and North American travellers. The researchers aimed to investigate the need for information across Western and Asian cultures. The study has focused on the need for information in travel guidebooks and examines the extent to which culture influences the type of information sought.

Introduction and hypothesis Previous studies of dipstick urinalysis (UA) in asymptomatic peri- and postmenopausal women demonstrate poor sensitivity to detect a urinary tract infection (UTI). We hypothesized that sensitivity of this test would be improved in symptomatic peri- and postmenopausal women. Methods This was a cross-sectional study of 76 women seeking urogynecology care for irritative bladder symptoms. Subjects with a positive clean-catch (CC) dipstick UA for leukocyte esterase (LE) or nitrites (NIT) were offered enrollment. Dipstick UA was performed on CC and catheterized specimens, followed by microbiologic culture. Test characteristics were calculated for CC and catheterized UA. CC culture was compared with catheterized culture (gold standard) using Spearman’s correlation coefficient. Results Data was available for analysis in 75/76 (98.7 %) enrolled subjects. Mean age was 68 ± 11 years. Most subjects were postmenopausal (98.7 %) and Caucasian (97.3 %). Dipstick sensitivity ranged from 48 % to 87 % and 35 % to 57 % in CC and catheterized specimens, respectively. Dipstick UA from a CC specimen positive for NIT had the highest sensitivity (60.9), specificity (100), negative predictive value (85.2), and positive predictive value (100) in this population. Dipstick UA from CC and catheterized specimens had similar sensitivity for detecting UTIs. When culture results of 10 3 colony-forming units were considered positive, CC and catheterized specimens were moderately correlated ( ρ  = 0.470). Conclusions Dipstick UA in this study had improved sensitivity compared with previously published results in both CC and catheterized samples. Initiation of empiric antibiotic treatment in women with irritative bladder symptoms and NIT-positive CC dipstick UA prior to obtaining urine culture results is a reasonable option.

Although doxorubicin (dox), an anthracycline antibiotic, is widely used and effective in treating cancer, its treatment efficiency is limited by low blood plasma solubility, poor pharmacokinetics, and adverse side effects, including irreversible cardiotoxicity. Moreover, cancer cells often develop drug resistance over time, which decreases the efficacy of anti-cancer drugs, including dox. In this study, we examine a macromolecular drug delivery system for its ability to specifically deliver doxorubicin to cancer cells with and without drug resistance. This drug delivery system consists of a multi-part macromolecule, which includes the following: elastin-like polypeptide (ELP), cell penetrating peptide (CPP), a cleavable linker (releasing at low pH), and a derivative of doxorubicin. ELP is thermally responsive and improves drug solubility, while the CPP mediates cellular uptake of macromolecules. We compared cytotoxicity of two doxorubicin derivatives, where one is cleavable (DOXO) and contains a pH-sensitive linker and releases dox in an acidic environment, and the other is non-cleavable (ncDox) doxorubicin. Cytotoxicity, apoptosis, cell cycle distribution and mechanism of action of these constructs were tested and compared between dox-responsive MCF-7 and dox-resistant NCI/ADR cell lines. Dox delivered by the ELP construct is comparably toxic to both sensitive and drug resistant cell lines, compared to unconjugated doxorubicin, and given the pharmacokinetic and targeting benefits conveyed by conjugation to ELP, these biopolymers have potential to overcome dox resistance in vivo.