Retrograde intrarenal surgery for asymptomatic incidental renal stones: a retrospective, real-world data analysis.

OBJECTIVE: To determine surgical outcomes and stone-free rates (SFRs) when offering upfront retrograde intrarenal surgery (RIRS) to patients with asymptomatic incidental renal stones (AIRS), as active surveillance, shockwave lithotripsy or upfront intervention in patients with AIRS is still a debate among urologists. PATIENTS AND METHODS: This retrospective FLEXible Ureteroscopy Outcomes Registry (FLEXOR), supported by the Team of Worldwide Endourological Researchers (TOWER), examines adult patients who underwent RIRS. We analysed a subset of asymptomatic patients with renal stones on imaging who were treated with RIRS. Data includes patient characteristics, stone specifications, anaesthesia type, perioperative details, complications, and SFR. A multivariable logistic regression analysis was performed to assess factors associated with the SFR. RESULTS: Among 679 patients with AIRS, 640 met the inclusion criteria. The median age was 55 years, with 33.4% being female. In all, 22.1% had positive urine cultures. The median stone diameter was 12 mm, commonly in lower and interpolar locations. RIRS was preferentially performed under general anaesthesia using a reusable scope in 443 cases. Prophylactic antibiotics were administered to 314 patients. The median operation time was 58 min and the median laser time was 24 min. The SFR was 68.8%. The use of holmium laser (odds ratio [OR] 0.21, 95% confidence interval [CI] 0.06-0.63; P < 0.01) and multiple stones (OR 0.38, 95% CI 0.19-0.76; P < 0.01) were factors associated with lower odds of being stone free. Overall complications were minimal, with sepsis in 1.6% of patients. Re-interventions were performed in 76 cases (11.8%), with RIRS being the most common in 67 cases (10.6%). CONCLUSION: Our multicentre real-world study is the first of its kind that highlights the pros and cons of offering RIRS to patients with AIRS and demonstrates a favourable SFR with acceptable complications. Pre-emptively discussing potential re-intervention helps patients make informed decisions, particularly in cases involving large and multiple stones.

Childhood and adulthood trauma exposure: Associations with perinatal mental health and psychotherapy response.

Trauma exposure is strongly linked to maternal posttraumatic stress disorder (PTSD) and depressive symptoms during the perinatal period; however, childhood trauma exposure is often assessed without accounting for adult exposure. This study tested the unique impacts of childhood and adulthood trauma exposure on PTSD and depressive symptoms among pregnant women (N = 107, 82.9% Latina) enrolled in a nonrandomized intervention study. Regression analyses at baseline showed positive associations between trauma exposure and PTSD symptoms irrespective of trauma timing, childhood: B = 1.62, t(91) = 2.11, p = .038; adulthood: B = 2.92, t(91) = 3.04, p = .003. However only adulthood trauma exposure, B = 1.28, t(94) = 2.94, p = .004, was positively associated with depressive symptoms. Mixed-effects analyses of variance revealed interaction effects of time and adulthood trauma exposure, indicating that women with high degrees of adulthood trauma exposure had higher baseline levels of PTSD, F(1, 76.4) = 6.45, p = .013, and depressive symptoms, F(1, 87.2) = 4.88, p = .030, but showed a more precipitous decrease posttreatment than women with lower levels of adulthood trauma exposure. These findings support the clinical relevance of assessing both childhood and adulthood trauma exposure during the perinatal period given their impacts on baseline symptoms and psychotherapy response.

Comparison Between Holmium:YAG Laser with MOSES Technology vs Thulium Fiber Laser Lithotripsy in Retrograde Intrarenal Surgery for Kidney Stones in Adults: A Propensity Score-matched Analysis From the FLEXible Ureteroscopy Outcomes Registry.

PURPOSE: We evaluated stone-free rate and complications after flexible ureteroscopy for renal stones, comparing thulium fiber laser and holmium:YAG laser with MOSES technology. MATERIALS AND METHODS: Data from adults who underwent flexible ureteroscopy in 20 centers worldwide were retrospectively reviewed (January 2018-August 2021). Patients with ureteral stones, concomitant bilateral procedures, and combined procedures were excluded. One-to-one propensity score matching for age, gender, and stone characteristics was performed. Stone-free rate was defined as absence of fragments >2 mm on imaging within 3 months after surgery. Multivariable logistic regression analysis was performed to evaluate independent predictors of being stone-free. RESULTS: Of 2,075 included patients, holmium:YAG laser with MOSES technology was used in 508 patients and thulium fiber laser in 1,567 patients. After matching, 284 patients from each group with comparable baseline characteristics were included. Pure dusting was applied in 6.0% of cases in holmium:YAG laser with MOSES technology compared with 26% in thulium fiber laser. There was a higher rate of basket extraction in holmium:YAG laser with MOSES technology (89% vs 43%, P < .001). Total operation time and lasing time were similar. Nine patients had sepsis in thulium fiber laser vs none in holmium:YAG laser with MOSES technology (P = .007). Higher stone-free rate was achieved in thulium fiber laser (85% vs 56%, P < .001). At multivariable analysis, the use of thulium fiber laser and ureteral access sheath ≥8F had significantly higher odds of being stone-free. Lasing time, multiple stones, stone diameter, and use of disposable scopes showed significantly lower odds of being stone-free. CONCLUSIONS: This real-world study favors the use of thulium fiber laser over holmium:YAG laser with MOSES technology in flexible ureteroscopy for renal stones by way of its higher single-stage stone-free rate.

The efficacy of retrograde intra-renal surgery (RIRS) for lower pole stones: results from 2946 patients.

PURPOSE: To evaluate the perioperative outcomes of retrograde intra-renal surgery (RIRS) for lower pole stones (LPS) and factors affecting stone-free rate (SFR). METHODS: Data from 20 centers were retrospectively reviewed. Inclusion criteria were adult patients, normal renal anatomy, and LPS. Exclusion criteria were bilateral surgery, concomitant surgery for ureteral stones. SFR was defined as a single residual fragment (RF) ≤ 2 mm and evaluated 3-months after surgery. A multivariable logistic regression analysis was performed to assess factors associated with RF. Statistical significance was set at p value < 0.05. RESULTS: 2946 patients were included. Mean age and stone size were 49.9 years 10.19 mm, with multiple LPS in 61.1% of cases. Total operation and laser time were 63.89 ± 37.65 and 17.34 ± 18.39 min, respectively. Mean hospital stay was 3.55 days. Hematuria requiring blood transfusion and fever/urinary infections requiring prolonged antibiotics occurred in 6.1% and 169 5.7% of cases, while sepsis with intensive-care admission in 1.1% of patients. On multivariate analysis, Multiple stones (OR 1.380), stone size (OR 1.865), and reusable ureteroscopes (OR 1.414) were significantly associated with RF, while Thulium fiber laser (TFL) (OR 0.341) and pre-stenting (OR 0.750) were less likely associated with RF. CONCLUSIONS: RIRS showed safety and efficacy for LPS with a mean diameter of 10 mm. This procedure can achieve a satisfactory SFR in pre-stented patients with a single and smaller stone, particularly with TFL use.

Do Hounsfield Units have any significance in predicting intra- and postoperative outcomes in retrograde intrarenal surgery using Holmium and Thulium fiber laser? Results from the FLEXible ureteroscopy Outcomes Registry (FLEXOR).

PURPOSE: To evaluate outcomes of flexible ureteroscopy for renal stones by comparing hard versus soft stones based on their attenuation on computed tomography (Hounsfield Units-HU). METHODS: Patients were divided into two groups according to the type of laser employed [Holmium:YAG (HL) or Thulium fiber laser (TFL)]. Residual fragments (RF) were defined as > 2 mm. Multivariable logistic regression analysis was performed to evaluate factors associated with RF and RF needing further intervention. RESULTS: 4208 patients from 20 centers were included. In whole series, age, recurrent stones, stone size, lower pole stones (LPS), and multiple stones were predictors of RF at multivariable analysis and LPS and stone size with RF requiring further treatment. HU and TFL were associated with lesser RF and RF requiring an additional treatment. In HU < 1000 stones, recurrent stones, stone size, and LPS were predictors of RF at multivariable analysis, whereas TFL was less likely associated with RF. Recurrent stones, stone size, and multiple stones were predictors of RF requiring further treatment, while LPS and TFL were associated with lesser RF requiring further treatment. In HU ≥ 1000 stones, age, stone size, multiple stones, and LPS were predictors of RF at multivariable analysis, while TFL was less likely associated with RF. Stone size and LPS were predictors of RF requiring further treatment, whereas TFL was associated with RF requiring further treatment. CONCLUSION: Stone size, LPS, and use of HL are predictors of RF after RIRS for intrarenal stones regardless of stone density. HU should be considered an important parameter in predicting SFR.

Indications, preferences, global practice patterns and outcomes in retrograde intrarenal surgery (RIRS) for renal stones in adults: results from a multicenter database of 6669 patients of the global FLEXible ureteroscopy Outcomes Registry (FLEXOR).

PURPOSE: To collect a multicentric database on behalf of TOWER research group to assess practice patterns and outcomes of retrograde intrarenal surgery (RIRS) for kidney stones. METHODS: Inclusion criteria: age ≥ 18 years, normal renal/calyceal system anatomy, calculi of any size, number, and position. STUDY PERIOD: January 2018 and August 2021. Stone-free status: absence of fragments > 2 mm, assessed post procedure according to the local protocol (KUB X-Ray and/or ultrasound or non-contrast CT scan). RESULTS: Twenty centers from fifteen countries enrolled 6669 patients. There were 4407 (66.2%) men. Mean age was 49.3 ± 15.59 years. Pain was the most frequent symptom indication for intervention (62.6%). 679 (10.2%) patients underwent RIRS for an incidental finding of stones. 2732 (41.0%) patients had multiple stones. Mean stone size was 10.04 ± 6.84 mm. A reusable flexible ureteroscope was used in 4803 (72.0%) procedures. A sheath-less RIRS was performed in 454 (6.8%) cases. Holmium:YAG laser was used in 4878 (73.1%) cases. A combination of dusting and fragmentation was the most common lithotripsy mode performed (64.3%). Mean operation time was 62.40 ± 17.76 min. 119 (1.8%) patients had an intraoperative injury of the ureter due to UAS insertion. Mean postoperative stay was 3.62 ± 3.47 days. At least one postoperative complication occurred in 535 (8.0%) patients. Sepsis requiring intensive care admission occurred in 84 (1.3%) patients. Residual fragments were detected in 1445 (21.7%) patients. Among the latter, 744 (51.5%) patients required a further intervention. CONCLUSION: Our database contributes real-world data to support to a better understanding of modern RIRS practice and outcomes.

Fabrication and analysis of tantalum pentoxide optical waveguide resonator of high thermal stability.

We fabricated waveguide resonators with high thermal stability using tantalum pentoxide thin film covered with PECVD silicon dioxide cladding. Without complex athermal design, low temperature dependence of 7.4 pm/°C and 8.15 pm/°C were measured in waveguide Bragg gratings (WBG) and Fabry-Perot resonator sandwiched by a pair of identical WBG mirrors, respectively. Suggested by semi-analytical perturbation calculations, the athermal properties of tantalum pentoxide waveguide grating are attributed not only to the low thermo-optical coefficient in tantalum pentoxide thin film but also to the strong chromatic dispersion of the guided modes. Guidelines are proposed to design waveguide-based frequency devices of low thermo-optical effect without complex athermal design.

Visible to near-infrared octave spanning supercontinuum generation in tantalum pentoxide (Ta2O5) air-cladding waveguide.

In this work, for the first time, to the best of our knowledge, an anomalous dispersion CMOS-compatible Ta2O5 waveguide was realized, and broadband on-chip supercontinuum generation (SCG) was accordingly demonstrated. When pumped at a center wavelength of 1056 nm with pulses of 100 fs duration and peak power of 396 W, a supercontinuum ranging from 585 nm to 1697 nm was generated, comprising a bandwidth of more than 1.5 octaves and leading to an efficient SCG source. The excellent performance for Ta2O5 to generate SCG benefits mainly from its high nonlinear refractive index, which enhances the efficiency of the nonlinear conversion process.

Efficient wavelength conversion with low operation power in a Ta2O5-based micro-ring resonator.

The Ta2O5-based micro-ring resonator with an unloaded quality factor of 182,000 has been demonstrated to realize efficient nonlinear wavelength generation. The propagation loss of the resonator is 0.5 cm-1, and the buildup factor of the ring resonator is estimated to be ∼50. With a high buildup factor of the ring structure, the four-wave-mixing (FWM) conversion efficiency of -30 dB is achieved in the resonator with a pump power of 6 mW. Based on power-dependent FWM results, the nonlinear refractive index of Ta2O5 is estimated to be 1.4×10-14 cm2/W at a wavelength of ∼1550 nm. The demonstration of an enhanced FWM process in the Ta2O5-based micro-ring cavity implies the possibility of realizing FWM-based optical parametric oscillation in a Ta2O5-based micro-ring resonator.

Self-phase modulation in highly confined submicron Ta2O5 channel waveguides.

Optical spectra broadening as a result self-phase modulation in a channel waveguide fabricated on a high quality tantalum pentoxide (Ta2O5) film by using RF sputtering is measured. The full-width at half maximum of the optical spectra for transverse electric (TE)/transverse magnetic (TM) polarizations of 42.5/31.7 nm is obtained using pulses of 10 nm at a wavelength of 800 nm with a peak-coupled power of 43.77 W. The nonlinear Kerr coefficients of 2.14 × 10-14 cm2/W and 1.92 × 10-14 cm2/W for TE and TM polarizations, respectively, are then extracted from the experiments using a theoretical model based on the method of moments. The obtained results on the nonlinearity further suggest that Ta2O5 is a promising material to develop nonlinear waveguide devices for integrated photonics.

Betrayal trauma and child symptoms: The role of emotion.

Both mothers' and children's exposures to interpersonal violence-including betrayal traumas-are linked with heightened risk for children developing internalizing and externalizing symptoms. Despite this association, little research has examined additional factors that may explain this risk, such as emotion skills. The current study examined the relationship between mother-child emotion understanding abilities and use of emotion language on a behavioral facial affect perception task and betrayal trauma exposure in relation to child internalizing/externalizing symptoms. The sample included 47 ethnically diverse female guardians (ages 25-51 years old; M age = 37.7) and their children (ages 7-11 years old; M age = 9.1). Results indicated that maternal provision of a spontaneous, unprompted reason for emotions during the facial affect perception task was significantly associated with lower child internalizing/externalizing symptoms when both mothers' and children's betrayal trauma histories were controlled. The results suggest that emotion skills (in particular, the way mothers talk about emotions) warrant greater attention in research on the development of child internalizing/externalizing problems.

Low-loss and high-Q Ta(2)O(5) based micro-ring resonator with inverse taper structure.

A low-loss and high-Q Ta(2)O(5) based micro-ring resonator is presented. The micro-ring resonator and channel waveguide with core area of the 700 by 400 nm(2) were fabricated on amorphous Ta(2)O(5) thin films prepared by reactive sputtering at 300°C and post annealing at 650°C for 3 hours. The Ta(2)O(5) micro-ring resonator with a diameter of 200 µm was coupled to the channel waveguide with a coupled Q up to 38,000 at a 0.9 µm coupling gap. By fitting the transmission spectrum of the resonator, the extracted loss coefficient inside the ring cavity and transmission coefficient of TE mode were 8.1dB/cm and 0.9923, leading to the estimated unloaded Q of higher than 44,000. In addition, based on the cut-back method, the propagation loss and the coupling loss of Ta(2)O(5) channel waveguide with an inverse taper were 1.5dB/cm and 3.2 dB, respectively. The proposed Ta(2)O(5) technology offers an unique alternative for fabricating high performance guided wave devices, and may well lead to novel applications in photonic integrated circuits.

Four-wave-mixing in the loss low submicrometer Ta2O5 channel waveguide.

A degenerate four-wave-mixing (FWM) operation in the Ta2O5 submicrometer channel waveguide has been successfully demonstrated. The propagation loss of 1.5 dB/cm and total insertion loss of 5.1 dB are realized in a 12.6 mm long waveguide with inverse taper structure. The wavelength and quadratic pumping power-dependent measurements on optical transmission confirm FWM performance and characterize the nonlinearity of waveguide. The conversion efficiency of -50 dB at coupled pump power of 40 mW is observed, suggesting that the nonlinear refractive index of Ta2O5 waveguide at 1550 nm is estimated to be 1×10(-14) cm2/W. Our primary results indicate that the Ta2O5 submicrometer channel waveguide has great potential in developing nonlinear waveguide applications.

Exploring revictimization risk in a community sample of sexual assault survivors.

Previous research points to links between risk detection (the ability to detect danger cues in various situations) and sexual revictimization in college women. Given important differences between college and community samples that may be relevant to revictimization risk (e.g., the complexity of trauma histories), the current study explored the link between risk detection and revictimization in a community sample of women. Community-recruited women (N = 94) reported on their trauma histories in a semistructured interview. In a laboratory session, participants listened to a dating scenario involving a woman and a man that culminated in sexual assault. Participants were instructed to press a button "when the man had gone too far." Unlike in college samples, revictimized community women (n = 47) did not differ in terms of risk detection response times from women with histories of no victimization (n = 10) or single victimization (n = 15). Data from this study point to the importance of examining revictimization in heterogeneous community samples where risk mechanisms may differ from college samples.

Scoping Review of Experimental and Clinical Evidence and Its Influence on Development of the Suction Ureteral Access Sheath.

The ureteral access sheath (UAS) has been a boon and a bane in flexible ureteroscopy (FURS), with its merits and demerits well established. Its design and dimensions were instrumental in reshaping the way flexible scopes were used and were key adjuncts to establishing retrograde intrarenal surgery (RIRS) as a standard of care in the endourological management of renal stones. With the ever-changing landscape of RIRS over the decades shaped by technological advancements in lasers and flexible scopes, the UAS has also continuously evolved. The utility of suction in endourology has recently changed the way RIRS is performed and is a game changer for FURS outcomes. With strong clinical and experimental evidence to support its use, the UAS has undergone a transformative change in the recent past, with its ability to monitor intrarenal pressure and provide a superior vacuum-cleaner effect that improves the trifecta of RIRS, namely an improved single-stage stone-free rate (SFR), minimise complications, and reduce reinterventions. Our comprehensive review outlines the key clinical and experimental evidence and traces the developments that were key to modifying the traditional UAS into a flexible and navigable suction ureteric access sheath (FANS) and highlights how the design and modifications, in turn, influence the ability to push the boundaries of RIRS.

Comparing Same-Sitting Bilateral vs Unilateral Retrograde Intrarenal Surgery in the Elderly.

OBJECTIVE: To compare same-sitting bilateral vs unilateral retrograde intrarenal surgery (RIRS) in elderly patients, focusing on postoperative complications and stone-free rates (SFR). METHODS: Data from 2 multicenter databases, FLEXible ureteroscopy Outcomes Registry (FLEXOR) (unilateral RIRS) and same sitting bilateral-retrograde intrarenal surgery (SSB-RIRS) (bilateral RIRS), were analyzed, considering only patients aged 70+ with preoperative computed tomography. Patients were categorized into Group 1 (bilateral RIRS) and Group 2 (unilateral RIRS). Follow-up included imaging assessments and secondary treatments as needed. RESULTS: Group 1 included 146 patients, while group 2 had 495. Group 1's patients were slightly older and had a higher prevalence of recurrent stone formation. Group 2 often underwent RIRS for incidental stones. Group 1 had larger and more pelvic stones. Laser lithotripsy and total operation times were significantly longer in Group 1. Group 2 had significantly higher overall stone-free rates, although there were no significant differences in ancillary procedures for residual fragments. Group 1 experienced more pelvicalyceal injuries needing stenting, postoperative fever, and post-op hematuria not requiring transfusion. CONCLUSION: In conclusion, bilateral RIRS can be carefully considered in elderly patients. Preoperative counseling is essential for both primary and repeat RIRS procedures, and further research is needed to optimize instrument and laser strategies for better outcomes in elderly RIRS patients.

Could Use of a Flexible and Navigable Suction Ureteral Access Sheath Be a Potential Game-changer in Retrograde Intrarenal Surgery? Outcomes at 30 Days from a Large, Prospective, Multicenter, Real-world Study by the European Association of Urology Urolithiasis Section.

BACKGROUND AND OBJECTIVE: The aim of this study was to evaluate the stone-free status (SFS) rate and complications after flexible ureteroscopy (fURS) for treatment of renal stones using a flexible and navigable suction (FANS) ureteral access sheath. METHODS: Data for adults undergoing fURS in 25 centers worldwide were prospectively collected (August 2023 to January 2024). Exclusion criteria were abnormal renal anatomy and ureteral stones. All patients had computed tomography scans before and within 30 d after fURS with a FANS ureteral access sheath. SFS was defined as follows: grade A, zero fragments; grade B, a single fragment ≤2 mm; grade C, a single fragment 2.1-4 mm; and grade D, single/multiple fragments >4 mm. Data for continuous variables are presented as the median and interquartile range (IQR). Multivariable logistic regression was performed to evaluate predictors of grade A SFS. KEY FINDINGS AND LIMITATIONS: The study enrolled 394 patients (59.1% male) with a median age of 49 yr (IQR 36-61). The median stone volume was 1260 mm3 (IQR 706-1800). Thulium fiber laser (TFL) was used in 45.9% of cases and holmium laser in the rest. The median lasing time was 18 min (IQR 11-28) and the median operative time was 49 min (IQR 37-70). One patient required a blood transfusion and 3.3% of patients had low-grade fever. No patient developed sepsis. Low-grade ureteral injury occurred in eight patients (2%). The grade A SFS rate was 57.4% and the grade A + B SFS rate was 97.2%, while 2.8% of patients had grade C or D SFS. Eleven patients underwent repeat fURS. Multivariable analysis revealed that a stone volume of 1501-3000 mm3 (odds ratio 0.50) and of >3000 mm3 (odds ratio 0.29) were significantly associated with lower probability of grade A SFS, while TFL use was associated with higher SFS probability (odds ratio 1.83). Limitations include the lack of a comparative group. CONCLUSIONS AND CLINICAL IMPLICATIONS: fURS using a FANS ureteral access sheath resulted in a high SFS rate with negligible serious adverse event and reintervention rates. PATIENT SUMMARY: We looked at 30-day results for patients undergoing telescopic laser treatment for kidney stones using a special type of vacuum-assisted sheath to remove stone fragments. We found a high stone-free rate with minimal complications.

Preparation of insulating SiO2 nanostructured thin films by the sol-gel process.

Organic dispersion agents can effectively decrease the surface roughness of films. Here, films containing organic dispersion agents are used to produce metal-insulator-metal structures. It was found that addition of Triton caused films to become denser, and thicker, and the leak current of devices to decrease by 10 times compared with that without Triton because of its uniform dispersion in the films. The resulting films were used as the insulator layer of thin film transistors containing a semiconductor layer of evaporated pentacene. The interface between the insulator and semiconductor layers was found to affect the arrangement of pentacene, and O2 plasma was used to improve the interface activity to increase the order of the pentacene molecules and enhance the carrier mobility of the devices.

Design of multi-porous layer for dye-sensitized solar cells by doping with TiO2 nanoparticles.

We propose a multi-layer dye-sensitized solar cell (DSSC). Conventional DSSC components use a singular TiO2 particle size and a mono-layer active layer, but we demonstrate a multi-layer and multi-scale TiO2 particle based DSSC. Doping with large TiO2 particles can produce light scattering inside the DSSC component. Light scattering effects reduce TiO2 absorption at wavelengths of 200-300 nm. The unabsorbed light zig-zags between the Pt back electrode layer and the substrate, and enhances the Ru-dye absorption. To enhance the scattering, we doped the active layer with 20 wt% of large diameter TiO2. The multi-layer DSSC increases efficiency by about 15% compared with standard DSSCs.

Cumulative violence exposure, emotional nonacceptance, and mental health symptoms in a community sample of women.

Women exposed to more types of violence (e.g., emotional, physical, or sexual violence)--referred to here as cumulative violence exposure--are at risk for more severe mental health symptoms compared to women who are exposed to a single type of violence or no violence. Women exposed to violence may also experience greater emotional nonacceptance compared to women with no exposure to violence. Emotional nonacceptance refers to an unwillingness to experience emotional states, including cognitive and behavioral attempts to avoid experiences of emotion. Given the links between cumulative violence exposure, emotional nonacceptance, and mental health symptoms among female victims of violence, the current study tested victims' emotional nonacceptance as a partial mediator between cumulative violence exposure and the severity of 3 types of symptoms central to complex trauma responses: depression, dissociation, and posttraumatic stress disorder (PTSD) symptoms. A non-treatment-seeking community sample of women (N = 89; M age = 30.70 years) completed self-report questionnaires and interviews. Bootstrap procedures were then used to test 3 mediation models for the separate predictions of depression, dissociation, and PTSD symptoms. Results supported our hypotheses that emotional nonacceptance would mediate the relationship between women's cumulative violence exposure and severity for all symptom types. The current findings highlight the role that emotional nonacceptance may play in the development of mental health symptoms for chronically victimized women and point to the need for longitudinal research in such populations.