Functional neurological disorder is a feminist issue.

Functional neurological disorder (FND) is a common and disabling disorder, often misunderstood by clinicians. Although viewed sceptically by some, FND is a diagnosis that can be made accurately, based on positive clinical signs, with clinical features that have remained stable for over 100 years. Despite some progress in the last decade, people with FND continue to suffer subtle and overt forms of discrimination by clinicians, researchers and the public. There is abundant evidence that disorders perceived as primarily affecting women are neglected in healthcare and medical research, and the course of FND mirrors this neglect. We outline the reasons why FND is a feminist issue, incorporating historical and contemporary clinical, research and social perspectives. We call for parity for FND in medical education, research and clinical service development so that people affected by FND can receive the care they need.

Impact of psychogenic nonepileptic seizures on epilepsy presurgical investigation and surgical outcomes.

INTRODUCTION: We sought to determine the percentage of patients undergoing presurgical assessment that had both psychogenic nonepileptic seizures (PNESs) and epileptic seizures (ESs) captured within our telemetry unit and how this affected progression to surgery and describe eventual outcomes in patients with a history of mixed PNESs/ESs who underwent surgery. MATERIAL AND METHODS: To determine what happened to patients who had PNESs recorded during a presurgical workup, we reviewed the records of 725 patients admitted to our telemetry unit for presurgical assessment between 2007 and 2013 and identified those with PNESs and ESs recorded. To determine outcomes postsurgery in operated patients who had mixed PNESs/ESs, we also reviewed the records of 519 patients who had had epilepsy surgery between 1999 and 2012 and identified those within this group who also had PNESs prior to surgery. RESULTS: Nineteen of the 725 patients had PNESs captured during their presurgical telemetry along with ESs captured on either this or a previous study. Four of these patients were ultimately offered surgery. Nine of the 519 patients with a history of PNESs underwent epilepsy surgery. At 1 to 5years of follow-up (mean: 4.1years) of those nine patients, five were still having ESs and three patients had worsening or new-onset PNESs. At the last follow-up, four had had a worthwhile improvement. DISCUSSION: This study suggests that recent outcomes for people with mixed PNESs/ESs are not as promising as previously described and that PNESs should remain a relative contraindication for surgery.

Assessing quality of life questionnaires in urogynaecology--tick or type?

It is recognised that urogynaecological symptoms can have a significant impact on patient quality of life (QoL). Many of the QoL questionnaires are long and provide a burden to patients. The aim of this study was to compare patients' responses to utilising equivalent QoL questionnaires in different formats. The electronic personal assessment questionnaire, ePAQ-PF, was compared to the paper-based Queensland questionnaire. ePAQ-PF appeared to be of greater value but not more burdensome. However, women were more likely to complete the sexual function section using the Queensland questionnaire.

Recognition of psychogenic non-epileptic seizures: a curable neurophobia?

BACKGROUND: Diagnosing psychogenic non-epileptic seizures (PNES) remains challenging. The majority of 'PNES status' cases are likely to be seen in the emergency department or similar non-specialised units, where patients are initially assessed and managed by physicians of varying expertise in neurology. METHODS: 216 participants including medical students and doctors of all grades from a wide range of medical disciplines were shown video recordings of six patients with PNES and six other patients with convulsive epileptic seizures (ES). Participants were asked to choose between PNES and ES as a diagnosis and to rate their confidence in each diagnosis, both before and after a 15-minute teaching presentation on PNES and ES. RESULTS: Pre-teaching sensitivity for diagnosing PNES was 0.77, specificity 0.55. The positive predictive value (PPV) of diagnosing PNES was 0.63, and was 0.7 for ES. Diagnostic accuracy increased with increasing clinical grades (p=0.022), as did clinical confidence (p<0.0005). Clinical accuracy and clinical confidence increased post-teaching (p<0.0005). Sensitivity for diagnosing PNES post-teaching improved to 0.88, specificity to 0.67. The PPV of diagnosing PNES increased to 0.72, and to 0.84 for ES. CONCLUSIONS: Diagnosing PNES can be improved by clinical experience in neurology and focussed teaching interventions.

How accurately do adult patients report their absence seizures?

We depend upon self-reporting to determine seizure frequency for epilepsy management decisions, but people often misreport their seizures. Here, we determined misreporting rates in adults with absence seizures, undergoing inpatient video-EEG telemetry (VET) or outpatient ambulatory electroencephalography (aEEG). Under-reporting rates were based on VET data, where behavior could be assessed, whilst over-reporting was assessed using both VET and aEEG. Forty-two patients (31 female and 11 males, median age 28.5 years) and 759 reported absence seizures were included in this study. Overall, only 24% of the 759 reported seizures had an associated EEG correlate, indicating a high over-reporting rate, which occurred in 57% of patients. Age, sex, time of epilepsy, VET versus aEEG, epilepsy syndrome, or medication were not significant predictors of over-reporting. In the VET group in which we could assess both over- and under-reporting (22 patients), only 2 patients correctly reported their seizures, and patients were predominantly over-reporters or under-reporters, not both. Only 26% of 423 absence seizures were reported. Use of zonisamide or valproate was associated with under-reporting, possibly through an impact on attention. These findings indicate that self-reported absence seizures are a poor measure to use for treatment decisions due to both over- and under-reporting.

Factors influencing medical students' decision to pursue a career in obstetrics and gynaecology.

INTRODUCTION: The career intentions of medical students can exert influence on service provision and medical staffing in the health services. It is vital for a specialty's development and sustainability that it has a constant stream of trainees into it annually. An appreciation of how a specialty is viewed by medical students can be used as an opportunity for early intervention in order to improve perception of the specialty and reduce future workforce problems, such as retention and attrition within obstetrics and gynaecology (O&G). We aimed to analyse positive and negative factors of the specialty of O&G as perceived by medical students in order to gain insight into changes that need to be made to improve recruitment and retention into the specialty. METHODS: A 70-item structured questionnaire consisting of demographic information and 5-point Likert scale questions relating to O&G was administered to final year medical students in the Republic of Ireland. Data were analysed with descriptive statistics, logistic regression, and odds ratios as appropriate. RESULTS: Of 195 medical students approached, 134 completed the questionnaire, a response rate of 68.7%. The majority were female (55.2%, n = 74) and 76.1% of respondents (n = 102) were Direct Entry Medicine students, with the remainder Graduate Entry Medicine students. 30.8% (n = 41) of students who responded scored 6 or more on a 10-point Likert scale when asked about their likelihood of considering a career in O&G. Students' clerkship experience factored heavily into their perception of the specialty and was more likely to be positive if they experienced direct consultant engagement and the opportunity for hands-on experience. Lifestyle factors, litigation and media were found to be deterrents to considering the specialty after graduation. CONCLUSIONS: This study demonstrates the importance of good clerkship experience in fostering an interest amongst undergraduates in O&G. Educators and those working within the specialty should showcase the strengths of the specialty during undergraduate education, and work on ameliorating deterrents to ultimately provide a structured approach to improving recruitment into O&G.

A qualitative review of challenges in recruitment and retention in obstetrics and gynecology in Ireland: The consultants' solution based perspective.

AIM: Recruitment and retention remains a concern in obstetrics and gynecology, with consultants having a unique perspective on the daily challenges. We aimed to examine these and examine their solutions to future-proofing the workforce. METHODS: Primary data were collected from consultant obstetrician-gynecologists in the Republic of Ireland. Using a qualitative methodology, semi-structured interviews were conducted with 17 participants recruited through purposive sampling. Following transcription, deductive content analysis was conducted to identify themes and categories with respect to challenges and solutions in the specialty. RESULTS: Findings revealed four superordinate themes of professional and personal factors, opinions of the specialty and the role of the consultant. Respondents expressed fear about low morale in the specialty, but also threats posed by resource availability and training limitations, in addition to medico-legal and media challenges. Solutions centered around re-evaluating training pathways and implementing improved advocacy and support structures for the specialty and for those working within it. CONCLUSIONS: This study provides a unique standpoint from which to explore an international in obstetrics and gynecology. Its solution-based outlook provides the framework to implement changes to protect and retain the current workforce as well as future-proofing recruitment to secure the specialty.

Reality is not as it seems.

The prevalent view in cognitive science is that we construct our perception of reality in real time. But could we be misinterpreting the content of our perceptual experiences? Does what we perceive with our brain and senses reflect the true nature of reality? Might evolution have shaped our perceptions to guide adaptive behavior, without enabling us to see reality as it actually is? In a discussion moderated by Steve Paulson, cognitive scientist Donald D. Hoffman and neurologist Suzanne O'Sullivan analyze these questions and their profound implications for our understanding of human consciousness.

What is to blame for postnatal pelvic floor dysfunction in primiparous women-Pre-pregnancy or intrapartum risk factors?

BACKGROUND: The aetiology of pelvic floor dysfunction (PFD) is still poorly understood. However childbearing is recognized as a major risk factor. OBJECTIVES: To elucidate the natural history of PFD by investigating the impact of the mode of delivery on postnatal pelvic floor dysfunction in primiparas, when PFD existing before the first pregnancy is taken into consideration. STUDY DESIGN: 4P-study (Prevalence and Predictors of Pelvic floor dysfunction in Primips) is a prospective cohort study, nested within the Screening for Pregnancy Endpoints (SCOPE) study set in a tertiary referral teaching hospital with 9000 deliveries annually. Established and proposed risk factors for urinary, fecal, prolapse and sexual dysfunction and the severity of symptoms for each of these outcomes were assessed using the Australian Pelvic Floor Questionnaire in 1482 nulliparous women, who each completed the questionnaire in early pregnancy. Of these, 1060 (72%) repeated the questionnaire 12 months postpartum.Outcomes were analyzed using multivariate ordinal logistic regression. RESULTS: Significant (p<0.05) risk factors for postpartum PFD were pre-pregnancy presence of similar symptoms Odds Ratio (OR) (5.0-30.0), smoking (OR 2.2-4.6), recurrent UTI (OR 2.2-17.3), high hip circumference (OR1.4-1.6), vigorous exercising (OR 3.1-17.9), induction of labor (OR 1.5-2.3), forceps delivery (OR 1.8-8.8), and 3rd degree perineal tear (OR 2.4-2.7). Cesarean section was associated with a lower risk of stress urinary incontinence (OR 0.3-0.5). Other common pre-pregnancy significant (p<0.05) risk factors for various PFD types prior to the first pregnancy were: diagnosed depression - (OR 1.6-2.1), high BMI (OR 3.1), strenuous exercising (OR 1.3-2.2), recurrent UTI (OR 1.5-2.5) and lower educational achievement (OR 1.5-1.6). CONCLUSIONS: Pre-pregnancy PFD was mainly associated with modifiable risk factors such as smoking and exercising. The main risk factor for postpartum PFD was the presence of similar symptoms prior to pregnancy, followed by anthropometric and intrapartum factors. Hip circumference seems to be a better predictor of PFD compared to BMI. When pre-pregnancy PFD was included in the analysis, Cesarean section was protective only for stress urinary incontinence, while delivery by forceps increased the risk of prolapse.

The feasibility, efficacy and functional outcome of local anaesthetic repair of anterior and posterior vaginal wall prolapse.

INTRODUCTION: Urogenital prolapse is a very common condition in women with a prevalence of 30%. If conservative therapy fails or is not desired by the patient, prolapse repair is usually performed under general or regional anaesthetic. The aim of the study was to evaluate feasibility, efficacy and functional outcome after fascial prolapse repairs under local anaesthetic (LA). PATIENTS AND METHODS: Between November 1999 and December 2000, 130 consecutive patients presenting with anterior or posterior prolapse or both were invited to have their procedure performed under LA. All patients with a symptomatic minimum stage II prolapse were included. Prior to surgery all women completed a standardized questionnaire examining the specific and non-specific symptoms of prolapse and their situation was classified using the ICS Pelvic Organ Prolapse (POP-Q) system. Follow up was 30 months. Objective success was defined as a stage 1 or less and no symptoms of bulge, subjective success was defined as lack of specific or non-specific symptoms of prolapse. RESULTS: There were 128 patients who agreed to have their operations performed under LA: 68 in the anterior group, 52 in the posterior group and 8 with a combined anterior and posterior repair. Objective cure rate was 88% for posterior repair, 87% for anterior repair and 63% for combined repair. Success rates were no different in primary from recurrent cases. There were no intraoperative complications and operating time was 21 min (anterior repair) or 23 min (posterior repair). There was no de novo postoperative urinary or stool incontinence and all patients but two would have the operation performed again under the same circumstances. The two remaining refused due to embarrassment but for no other reason. CONCLUSION: Local anaesthetic prolapse repair is feasible and effective in middle term results. It is well accepted by the patients who benefit from less side effects and short hospital stay.

The Expression of Inflammatory Mediators in Bladder Pain Syndrome.

BACKGROUND: Bladder pain syndrome (BPS) pathology is poorly understood. Treatment strategies are empirical, with limited efficacy, and affected patients have diminished quality of life. OBJECTIVE: We examined the hypothesis that inflammatory mediators within the bladder contribute to BPS pathology. DESIGN, SETTING, AND PARTICIPANTS: Fifteen women with BPS and 15 women with stress urinary incontinence without bladder pain were recruited from Cork University Maternity Hospital from October 2011 to October 2012. During cystoscopy, 5-mm bladder biopsies were taken and processed for gene expression analysis. The effect of the identified genes was tested in laboratory animals. OUTCOME MEASURES AND STATISTICAL ANALYSIS: We studied the expression of 96 inflammation-related genes in diseased and healthy bladders. We measured the correlation between genes and patient clinical profiles using the Pearson correlation coefficient. RESULTS AND LIMITATIONS: Analysis revealed 15 differentially expressed genes, confirmed in a replication study. FGF7 and CCL21 correlated significantly with clinical outcomes. Intravesical CCL21 instillation in rats caused increased bladder excitability and increased c-fos activity in spinal cord neurons. CCL21 atypical receptor knockout mice showed significantly more c-fos upon bladder stimulation with CCL21 than wild-type littermates. There was no change in FGF7-treated animals. The variability in patient samples presented as the main limitation. We used principal component analysis to identify similarities within the patient group. CONCLUSIONS: Our study identified two biologically relevant inflammatory mediators in BPS and demonstrated an increase in nociceptive signalling with CCL21. Manipulation of this ligand is a potential new therapeutic strategy for BPS. PATIENT SUMMARY: We compared gene expression in bladder biopsies of patients with bladder pain syndrome (BPS) and controls without pain and identified two genes that were increased in BPS patients and correlated with clinical profiles. We tested the effect of these genes in laboratory animals, confirming their role in bladder pain. Manipulating these genes in BPS is a potential treatment strategy.

Female voiding dysfunction.

Female voiding dysfunction is poorly understood; it lacks standard definitions, and there is no consensus on diagnostic criteria. In the majority of women who are neurologically intact the cause is idiopathic. It affects the sufferers' quality of life, but unfortunately there is a paucity of published literature on its management. This review examines the current knowledge on the management of this common problem. Diagnosis is aimed at identifying the underlying aetiological factors, which are discussed, as well as the importance of a detailed history and focused physical examination. Investigations essential to management are outlined. Developments in the medical treatment of voiding dysfunction have been disappointing. The role of surgery is even more limited except for those with postoperative voiding problems after new-generation sling procedures. Intermittent self-catheterisation, supervised and supported by a dedicated nursing specialist, remains the mainstay of management. A multidisciplinary approach is essential to success. Emerging treatment modalities such as sacral and peripheral neuromodulation and the use of alpha(1)-blockers are discussed. Botulinum toxin A injections have been useful in some cases. There are relatively few publications on the effectiveness of these interventions in clinical practice. These issues need to be addressed by quality research. Female voiding dysfunction presents a challenge to urogynaecologists and urologists alike.