Impacts of fire and prospects for recovery in a tropical peat forest ecosystem.

Uncontrolled fires place considerable burdens on forest ecosystems, compromising our ability to meet conservation and restoration goals. A poor understanding of the impacts of fire on ecosystems and their biodiversity exacerbates this challenge, particularly in tropical regions where few studies have applied consistent analytical techniques to examine a broad range of ecological impacts over multiyear time frames. We compiled 16 y of data on ecosystem properties (17 variables) and biodiversity (21 variables) from a tropical peatland in Indonesia to assess fire impacts and infer the potential for recovery. Burned forest experienced altered structural and microclimatic conditions, resulting in a proliferation of nonforest vegetation and erosion of forest ecosystem properties and biodiversity. Compared to unburned forest, habitat structure, tree density, and canopy cover deteriorated by 58 to 98%, while declines in species diversity and abundance were most pronounced for trees, damselflies, and butterflies, particularly for forest specialist species. Tracking ecosystem property and biodiversity datasets over time revealed most to be sensitive to recurrent high-intensity fires within the wider landscape. These megafires immediately compromised water quality and tree reproductive phenology, crashing commercially valuable fish populations within 3 mo and driving a gradual decline in threatened vertebrates over 9 mo. Burned forest remained structurally compromised long after a burn event, but vegetation showed some signs of recovery over a 12-y period. Our findings demonstrate that, if left uncontrolled, fire may be a pervasive threat to the ecological functioning of tropical forests, underscoring the importance of fire prevention and long-term restoration efforts, as exemplified in Indonesia.

Excluding Male Trainees in Obstetrics and Gynecology: Why We Do It and Why It's Wrong.

This article explores the current landscape of clinical education in obstetrics and gynecology for medical students, residents, and fellows who identify as male. Academic, clinical instruction should be inclusive for the betterment of the training experience for all, but most importantly, for the betterment of women's health.

Surgical Decision-Making: Who Should Be Offered Sacrocolpopexy?

INTRODUCTION AND HYPOTHESIS: Women undergoing surgery for apical pelvic organ prolapse have several medically sound options for specific surgical approaches. METHODS: We review the principles of shared decision-making as they pertain to surgery for prolapse. We review the literature supporting the superior sacrocolpopexy as a durable treatment for prolapse and the factors that may differentiate it from other repairs in risk and benefit. RESULTS: We emphasize the importance of collaboration between patients and surgeons in surgical decision-making. CONCLUSION: All medically appropriate patients who desire reconstructive surgery for prolapse should be offered sacrocolpopexy.

Ultrasound-Measured Urethral Length Does Not Change following Minimally Invasive Sacrocolpopexy for Pelvic Organ Prolapse.

OBJECTIVES: To compare urethral length (UL), as measured by three-dimenstional transvaginal ultrasound, before and after minimally invasive sacrocolpopexy (SCP). METHODS: Secondary analysis of a prospective cohort study of women undergoing SCP for prolapse beyond the hymen with or without a concomitant anti-incontinence procedure. Participants underwent ultrasound at baseline and 14 weeks postoperatively. UL was measured in a reconstructed sagittal plane from the bladder neck to the urethral meatus. All of the participants underwent multichannel urodynamics preoperatively. Data were analyzed in SPSS using independent or paired t tests as indicated for continuous variables and the McNemar test for paired dichotomous variables. Correlations including nonparametric data are reported as Spearman rho. RESULTS: A total of 28 participants, with a mean ± standard deviation age of 56 ± 10 years and median (interquartile range) preoperative prolapse stage of 3 (3-3), were analyzed. There was no change in UL between the baseline and 14-week visits (29.8 ± 11.0 mm vs 29.3 ± 10.0 mm, P = 0.83). There was no difference in baseline UL (29.4 ± 11.8 mm vs 30.9 ± 8.9 mm, P = 0.74) in those with and without preoperative stress urinary incontinence (SUI), nor was there a difference in baseline functional UL on multichannel urodynamics between these groups. In total, 21 participants (75%) had preoperative SUI and 19 (90%) underwent a concomitant anti-incontinence procedure. UL at 14 weeks was similar in those with and without SUI symptoms (26.5 ± 10.9 mm vs 31.1 ± 11.3 mm, P = 0.32) when controlling for those who underwent anti-incontinence procedures. CONCLUSION: UL does not change following suspension of the anterior vaginal wall with SCP.

International Urogynecological Consultation: clinical definition of pelvic organ prolapse.

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."

Surgical Management of Stress Incontinence.

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.

Revealing structures in narratives: A mixed-methods approach to studying interdisciplinary handoff in critical care.

OBJECTIVE: To examine a novel mixed-methods approach for studying patterns of clinical communication that could inform future informatics solutions, with a specific focus on handoff within interdisciplinary teams. MATERIALS AND METHODS: Researchers observed, recorded, and transcribed verbal handoff discussions of different members of critical care teams. The transcripts were coded qualitatively, and then analyzed quantitatively for emerging structural patterns using categorical cluster analysis, and for degree of shared mental models (SMM) using the modified Pyramid method. RESULTS: An empirical study using the proposed mixed-methods approach suggested emerging patterns of communication among clinicians. For example, the temporal focus of handoff was often determined by the role of the clinician giving the handoff; the clinical content of handoff was consistent between clinicians, but varied between patients. The SMM index ranged from 0.065 (with the maximum possible overlap score of 1) to 0.007 with a median of 0.026; the overlap was higher in statements concerned with patient presentation (23.6% of these had overlap) and referring to the past (24% overlapped). This calculated SMM index was correlated with the assessment of coherence within the participating teams by independent physicians (r=0.63, p=0.038). CONCLUSIONS: The proposed novel mixed-methods approach helped to reveal emerging patterns in content and structure of handoff communication and highlight differences due to the clinical context, and to the different priorities of clinicians on interdisciplinary patient care teams. The approach for calculating SMM is more ecologically sensitive as it relies on naturally occurring discourse and less intrusive than traditional ways of assessing SMM, and takes initial steps toward establishing empirical foundation for the design of electronic tools to support handoff in interdisciplinary teams.

Successful Use of Acellular Small Intestinal Submucosa Graft in Vaginal Reconstruction.

PURPOSE: Various techniques for neovaginal construction have been employed in the pediatric and adult populations, including the use of intestinal segments, buccal mucosal grafts, and skin grafts. Small intestinal submucosa (SIS) extracellular matrix grafts have been described as a viable alternative, though prior experience is limited. Our purpose was to assess operative characteristics and patient outcomes with neovaginal construction using SIS grafts. METHODS: Thirteen patients underwent vaginoplasty with acellular porcine SIS grafts at our institution between 2018 and 2022. Operative and clinical data, postoperative mold management, vaginal dilating length, and complications were reviewed. RESULTS: Age at time of repair ranged from 13 to 30 years (median 19 years). Patient diagnosis included cloacal anomalies (n = 4), Mayer-Rokitansky-Küster-Hauser syndrome (n = 4), isolated vaginal atresia with or without a transverse vaginal septum (n = 4), and vaginal rhabdomyosarcoma requiring partial vaginectomy (n = 1). Following dissection of the neovaginal space, a silicon mold wrapped with SIS graft was placed with retention sutures and removed on postoperative day 7. Median (IQR) operative time was 171 (118-192) minutes, estimated blood loss was 10 (5-20) mL, and length of stay was 2 (1-3) days. The follow-up period ranged from 3 to 47 months (median 9 months). Two patients developed postoperative vaginal stenosis that resolved with dilation under anesthesia. Mean vaginal length on latest follow-up was 8.97 cm. All thirteen patients had successful engraftment and progressed to performing self-dilations or initiating intercourse to maintain patency. There were no cases of graft reaction or graft extrusion. CONCLUSIONS: We conclude that acellular small intestinal submucosa grafts are effective and safe alternatives for mold coverage in neovaginal construction. Our experience demonstrates minimal perioperative morbidity, early mold removal, and progression to successful dilation with maintenance of a functional vaginal length. Future study on sexual outcomes, patient satisfaction, and comparison against alternative techniques has been initiated. LEVEL OF EVIDENCE: IV. TYPE OF STUDY: Retrospective Study.

Relationships Between Urinary and Nonurinary Symptoms in Treatment-Seeking Women in LURN.

IMPORTANCE: Physical health and psychological health represent modifiable factors in the causal pathway of lower urinary tract symptoms (LUTS). OBJECTIVES: Understand the relationship between physical and psychological factors and LUTS over time. STUDY DESIGN: Adult women enrolled in the Symptoms of Lower Urinary Tract Dysfunction Research Network observational cohort study completed the LUTS Tool and Pelvic Floor Distress Inventory, including urinary (Urinary Distress Inventory), prolapse (Pelvic Organ Prolapse Distress Inventory), and colorectal anal (Colorectal-Anal Distress Inventory) subscales at baseline, 3 months, and 12 months. Physical functioning, depression, and sleep disturbance were measured using the Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaires; relationships were assessed using multivariable linear mixed models. RESULTS: Of 545 women enrolled, 472 had follow-up. Median age was 57 years; 61% and 78% reported stress urinary incontinence and overactive bladder, respectively; and 81% reported obstructive symptoms. The PROMIS depression scores were positively associated with all urinary outcomes (range, 2.5- to 4.8-unit increase per 10-unit increase in depression score; P < 0.01 for all). Higher sleep disturbance scores were associated with higher urgency, obstruction, LUTS Total Severity, Urinary Distress Inventory, and Pelvic Floor Distress Inventory (1.9- to 3.4-point increase per 10-unit increase, all P < 0.02). Better physical functioning was associated with less severe urinary symptoms except stress urinary incontinence (2.3- to 5.2-point decrease per 10-unit increase, all P < 0.01). All symptoms decreased over time; however, no association was detected between baseline PROMIS scores and trajectories of LUTS over time. CONCLUSIONS: Nonurologic factors demonstrated small to medium cross-sectional associations with urinary symptom domains, but no significant association was detected with changes in LUTS. Further work is needed to determine whether interventions targeting nonurologic factors reduce LUTS in women.

Building Linkages between Nursing Care and Improved Patient Outcomes: The Role of Health Information Technology.

Health information technology (health IT or HIT) holds the potential to transform the quality of care and to establish linkages between nursing care and patient outcomes. This article defines eMeasurement and describes Quality of Care Definitions and Metrics for Evaluation. The authors explore the role of health IT to improve quality, barriers to eMeasurement, and health IT interventions by considering linkages between nursing care and patient outcomes for a select set of nursing sensitive indicators including patient falls, pressure ulcers, and the patient experience. We discuss specific challenges, such as barriers for routine data capture to populate nursing sensitive indicators and the use of health IT to promote positive outcomes. The conclusion addresses the implications of the current state of health IT and identifies areas for further nursing research.

Nest material preferences in wild hazel dormice Muscardinus avellanarius: testing predictions from optimal foraging theory.

Obtaining nesting material presents an optimal foraging problem, collection of materials incurs a cost in terms of risk of predation and energy spent and individuals must balance these costs with the benefits of using that material in the nest. The hazel dormouse, Muscardinus avellanarius is an endangered British mammal in which both sexes build nests. However, whether material used in their construction follows the predictions of optimal foraging theory is unknown. Here, we analyze the use of nesting materials in forty two breeding nests from six locations in Southwest England. Nests were characterized in terms of which plants were used, the relative amount of each plant, and how far away the nearest source was. We found that dormice exhibit a preference for plants closer to the nest, but that the distance they are prepared to travel depends on the plant species. Dormice traveled further to collect honeysuckle Lonicera periclymenum, oak Quercus robur, and beech Fagus sylvatica than any other plants. Distance did not affect the relative amount used, although the proportion of honeysuckle in nests was highest, and more effort was expended collecting honeysuckle, beech, bramble Rubus fruticosus and oak compared to other plants. Our results suggest that not all aspects of optimal foraging theory apply to nest material collection. However, optimal foraging theory is a useful model to examine nest material collection, providing testable predictions. As found previously honeysuckle is important as a nesting material and its presence should be taken account when assessing suitability of sites for dormice.

Effect of surgical approach on physical activity and pain control after sacral colpopexy.

OBJECTIVE: We sought to compare recovery of activity and pain control after robotic (ROB) vs abdominal (ABD) sacral colpopexy. STUDY DESIGN: Women undergoing ROB and ABD sacral colpopexy wore accelerometers for 7 days preoperatively and the first 10 days postoperatively. They completed postoperative pain diaries and Short Form-36 questionnaires before and after surgery. RESULTS: At 5 days postoperatively, none of the 14 subjects in the ABD group and 4 of 28 (14.3%) in the ROB group achieved 50% total baseline activity counts (P = .283). At 10 days, 5 of 14 (35.7%) in the ABD group and 8 of 26 (30.8%) in the ROB group (P = .972) achieved 50%. Postoperative pain was similar in both groups. Short Form-36 vitality scores were lower (P = .017) after surgery in the ABD group, but not in the ROB group. CONCLUSION: Women undergoing ROB vs ABD sacral colpopexy do not recover physical activity faster, and pain control is not improved.

In search of common ground in handoff documentation in an Intensive Care Unit.

OBJECTIVE: Handoff is an intra-disciplinary process, yet the flow of critical handoff information spans multiple disciplines. Understanding this information flow is important for the development of computer-based tools that supports the communication and coordination of patient care in a multi-disciplinary and highly specialized critical care setting. We aimed to understand the structure, functionality, and content of nurses' and physicians' handoff artifacts. DESIGN: We analyzed 22 nurses' and physicians' handoff artifacts from a Cardiothoracic Intensive Care Unit (CTICU) at a large urban medical center. We combined artifact analysis with semantic coding based on our published Interdisciplinary Handoff Information Coding (IHIC) framework for a novel two-step data analysis approach. RESULTS: We found a high degree of structure and overlap in the content of nursing and physician artifacts. Our findings demonstrated a non-technical, yet sophisticated, system with a high degree of structure for the organization and communication of patient data that functions to coordinate the work of multiple disciplines in a highly specialized unit of patient care. LIMITATIONS: This study took place in one CTICU. Further work is needed to determine the generalizability of the results. CONCLUSIONS: Our findings indicate that the development of semi-structured patient-centered interdisciplinary handoff tools with discipline specific views customized for specialty settings may effectively support handoff communication and patient safety.

Health literacy screening instruments for eHealth applications: a systematic review.

OBJECTIVE: To systematically review current health literacy (HL) instruments for use in consumer-facing and mobile health information technology screening and evaluation tools. DESIGN: The databases, PubMed, OVID, Google Scholar, Cochrane Library and Science Citation Index, were searched for health literacy assessment instruments using the terms "health", "literacy", "computer-based," and "psychometrics". All instruments identified by this method were critically appraised according to their reported psychometric properties and clinical feasibility. RESULTS: Eleven different health literacy instruments were found. Screening questions, such as asking a patient about his/her need for assistance in navigating health information, were evaluated in seven different studies and are promising for use as a valid, reliable, and feasible computer-based approach to identify patients that struggle with low health literacy. However, there was a lack of consistency in the types of screening questions proposed. There is also a lack of information regarding the psychometric properties of computer-based health literacy instruments. LIMITATIONS: Only English language health literacy assessment instruments were reviewed and analyzed. CONCLUSIONS: Current health literacy screening tools demonstrate varying benefits depending on the context of their use. In many cases, it seems that a single screening question may be a reliable, valid, and feasible means for establishing health literacy. A combination of screening questions that assess health literacy and technological literacy may enable tailoring eHealth applications to user needs. Further research should determine the best screening question(s) and the best synthesis of various instruments' content and methodologies for computer-based health literacy screening and assessment.

Correlation of POP-Q posterior compartment measures with defecatory dysfunction.

INTRODUCTION AND HYPOTHESIS: The relationships of Pelvic Organ Prolapse Quantification (POP-Q) items pb and Bp with defecatory dysfunction were evaluated with the hypothesis that increased values for both items would correlate with symptoms of stool trapping. METHODS: Pelvic Floor Distress Inventory (PFDI-20) results and POP-Q exams from 1,663 urogynecology patients were compiled in a database. Rectocele was defined as POP-Q point Bp > -0.5 and perineocele as pb >3. PFDI-20 questions were used to compare defecatory symptoms and bother in women with and without rectocele and perineocele. RESULTS: While perineocele was not associated with symptoms or bother, women with isolated rectoceles had higher rates of splinting (p < 0.001) and incomplete evacuation (p = 0.001) and higher bother scores (p < 0.001) than those with neither rectocele nor perineocele. CONCLUSIONS: The POP-Q Bp point, but not the pb measurement, correlates with symptoms of defecatory dysfunction.

Sex Differences in Commercial Patient Reviews of Women and Men Urogynecologic Surgeons.

OBJECTIVE: The objective of our study was to describe differences in commercial patient reviews of women and men urogynecologic surgeons. MATERIALS AND METHODS: Reviews of surgeons on Healthgrades.com in 4 metropolitan areas were included. Based on the qualitative assessment using qualitative content analysis of major and minor elements, we defined 4 theme categories: global experience, social interaction, technical skills, and ancillary aspects, each embedded with discrete elements. Differences in proportions of mentioned themes as well as quantitative ratings were evaluated by sex with the appropriate statistical tests. RESULTS: Three hundred sixty-four patient reviews (51% for women surgeons and 49% for men surgeons) were identified for 141 gynecologic surgeons self-identifying as "urogynecologists." The majority of the cohort (77%) held subspecialty certification in female pelvic medicine and reconstructive surgery. Reviews of women demonstrated a lower mean quantitative "likelihood to recommend" score compared with men (4.0 vs 4.3, P = 0.002) on the 5-point scale. Women received more mention in comfort (52% vs 40%, P = 0.023) and professionalism (19% vs 9%, P = 0.007) themes and less mention with respect to surgical outcomes (28% vs 53%, P < 0.001) and technical skills (5% vs 15%, P = 0.011) compared with men. CONCLUSIONS: Commercial online patient reviews for urogynecologic surgeons reveal sex bias with women receiving lower scores overall and more comments related to social interaction and fewer comments related to surgical outcomes and technical skill compared with men.

Content overlap in nurse and physician handoff artifacts and the potential role of electronic health records: a systematic review.

PURPOSE: The aims of this systematic review were: (1) to analyze the content overlap between nurse and physician hospital-based handoff documentation for the purpose of developing a list of interdisciplinary handoff information for use in the future development of shared and tailored computer-based handoff tools, and (2) to evaluate the utility of the Continuity of Care Document (CCD) standard as a framework for organizing hospital-based handoff information for use in electronic health records (EHRs). METHODS: We searched PubMed for studies published through July 2010 containing the indexed terms: handoff(s), hand-off, handover(s), shift-report, shift report, signout, and sign-out. Original, hospital-based studies of acute care nursing or physician handoff were included. Handoff information content was organized into lists of nursing, physician, and interdisciplinary handoff information elements. These information element lists were organized using CCD sections, with additional sections being added as needed. RESULTS: Analysis of 36 studies resulted in a total of 95 handoff information elements. Forty-six percent (44/95) of the information overlapped between the nurse and physician handoff lists. Thirty-six percent (34/95) were specific to the nursing list and 18% (17/95) were specific to the physician list. The CCD standard was useful for categorizing 80% of the terms in the lists and 12 category names were developed for the remaining 20%. CONCLUSION: Standardized interdisciplinary, nursing-specific, and physician-specific handoff information elements that are organized around the CCD standard and incorporated into EHRs in a structured narrative format may increase the consistency of data shared across all handoffs, facilitate the establishment of common ground, and increase interdisciplinary communication.

Multiple constraints on urban bird communication: both abiotic and biotic noise shape songs in cities.

Ambient noise can cause birds to adjust their songs to avoid masking. Most studies investigate responses to a single noise source (e.g., low-frequency traffic noise, or high-frequency insect noise). Here, we investigated the effects of both anthropogenic and insect noise on vocalizations of four common bird species in Hong Kong. Common Tailorbirds (Orthotomus sutorius) and Eurasian Tree Sparrows (Passer montanus) both sang at a higher frequency in urban areas compared to peri-urban areas. Red-whiskered Bulbuls (Pycnonotus jocosus) in urban areas shifted the only first note of their song upwards. Swinhoe's White-eye (Zosterops simplex) vocalization changes were correlated with noise level, but did not differ between the peri-urban and urban populations. Insect noise caused the Eurasian Tree Sparrow to reduce both maximum, peak frequency, and overall bandwidth of vocalizations. Insect noise also led to a reduction in maximum frequency in Red-whiskered bulbuls. The presence of both urban noise and insect noise affected the sound of the Common Tailorbirds and Eurasian Tree Sparrows; in urban areas, they no longer increased their minimum song frequency when insect sounds were also present. These results highlight the complexity of the soundscape in urban areas. The presence of both high- and low-frequency ambient noise may make it difficult for urban birds to avoid signal masking while still maintaining their fitness in noisy cities.

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

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.