Urinary tract infection following intradetrusor onabotulinumtoxina injection for non-neurogenic urgency incontinence: single- vs. multi-dose prophylactic antibiotic treatment regimens.

INTRODUCTION AND HYPOTHESIS: Urinary tract infection is one of the most common adverse events following onabotulinumtoxinA injection for urgency incontinence. Our hypothesis was that those undergoing injection for urgency incontinence who received more than one dose of prophylactic antibiotics have lower post-procedure urinary tract infection rates compared to those who receive a single dose. METHODS: We conducted a multi-center retrospective cohort study in females who underwent onabotulinumtoxinA injection for non-neurogenic urgency incontinence to evaluate the effect of single- vs. multi-dose prophylactic antibiotic regimens on the risk of post-procedure urinary tract infection. The primary outcome was the rate of urinary tract infection within 30 days of injection. Our sample size calculation required 136 subjects per group. RESULTS: Two hundred eighty-one patients were included from four centers. The single-dose cohort included 145 patients (51.6%), and the multi-dose cohort included 136 patients (48.4%). The mean age was 65 years, and patients were primarily Caucasian (81.4%). There was no difference in the rate of urinary tract infections diagnosed within 30 days of injection between the cohorts (single dose 13.8% vs. multi-dose 10.3%, p = 0.369). Those with a positive urine culture within 30 days of injection had a 15.2 times greater odds of having a post-procedure infection than those who did not (95% CI 3.19-72.53). There was no significant difference between the two cohorts in terms of adverse health events following injection. CONCLUSIONS: In females with non-neurogenic urgency incontinence undergoing onabotulinumtoxinA injection, multi-dose prophylactic antibiotic regimens were not associated with lower post-procedure urinary tract infection rates.

Postoperative complications and pelvic organ prolapse recurrence following combined pelvic organ prolapse and rectal prolapse surgery compared with pelvic organ prolapse only surgery.

BACKGROUND: There is a growing interest in combined pelvic organ prolapse and rectal prolapse surgery for concomitant pelvic floor prolapse despite a paucity of data regarding complications and clinical outcomes of combined repair. OBJECTIVE: The primary objective of this study was to compare the <30-day postoperative complication rate in women undergoing combined POP + RP surgery with that of women undergoing pelvic organ prolapse-only surgery. The secondary objectives were to describe the <30-day postoperative complications, compare the pelvic organ prolapse recurrence between the 2 groups, and determine the preoperative predictors of <30-day postoperative complications and predictors of pelvic organ prolapse recurrence. STUDY DESIGN: This was a multicenter, retrospective cohort study at 5 academic hospitals. Patients undergoing combined pelvic organ prolapse and rectal prolapse surgery were matched by age, pelvic organ prolapse stage by leading compartment, and pelvic organ prolapse procedure compared with those undergoing pelvic organ prolapse-only surgery from March 2003 to March 2020. The primary outcome measure was <30-day complications separated into Clavien-Dindo classes. The secondary outcome measures were (1) subsequent pelvic organ prolapse surgeries and (2) pelvic organ prolapse recurrence, defined as patients who complained of vaginal bulge symptoms postoperatively. RESULTS: Overall, 204 women underwent combined surgery for pelvic organ prolapse and rectal prolapse, and 204 women underwent surgery for pelvic organ prolapse only. The average age (59.3±1.0 vs 59.0±1.0) and mean parity (2.3±1.5 vs 2.6±1.8) were similar in each group. Of note, 109 (26.7%) patients had at least one <30-day postoperative complication. The proportion of patients who had a complication in the combined surgery group and pelvic organ prolapse-only surgery group was similar (27.5% vs 26.0%; P=.82). The Clavien-Dindo scores were similar between the groups (grade I, 10.3% vs 9.3%; grade II, 11.8% vs 12.3%; grade III, 3.9% vs 4.4%; grade IV, 1.0% vs 0%; grade V, 0.5% vs 0%). Patients undergoing combined surgery were less likely to develop postoperative urinary tract infections and urinary retention but were more likely to be treated for wound infections and pelvic abscesses than patients undergoing pelvic organ prolapse-only surgery. After adjusting for combined surgery vs pelvic organ prolapse-only surgery and parity, patients who had anti-incontinence procedures (adjusted odds ratio, 1.85; 95% confidence interval, 1.16-2.94; P=.02) and perineorrhaphies (adjusted odds ratio, 1.68; 95% confidence interval, 1.05-2.70; P=.02) were more likely to have <30-day postoperative complications. Of note, 12 patients in the combined surgery group and 15 patients in the pelvic organ prolapse-only surgery group had subsequent pelvic organ prolapse repairs (5.9% vs 7.4%; P=.26). In the combined surgery group, 10 patients (4.9%) underwent 1 repair, and 2 patients (1.0%) underwent 2 repairs. All patients who had recurrent pelvic organ prolapse surgery in the pelvic organ prolapse-only surgery group had 1 subsequent pelvic organ prolapse repair. Of note, 21 patients in the combined surgery group and 28 patients in the pelvic organ prolapse-only surgery group reported recurrent pelvic organ prolapse (10.3% vs 13.7%; P=.26). On multivariable analysis adjusted for number of previous pelvic organ prolapse repairs, combined surgery vs pelvic organ prolapse-only surgery, and perineorrhaphy at the time of surgery, patients were more likely to have a subsequent pelvic organ prolapse surgery if they had had ≥2 previous pelvic organ prolapse repairs (adjusted odds ratio, 6.06; 95% confidence interval, 2.10-17.5; P=.01). The average follow-up times were 307.2±31.5 days for the combined surgery cohort and 487.7±49.9 days for the pelvic organ prolapse-only surgery cohort. Survival curves indicated that the median time to recurrence was not statistically significant (log-rank, P=.265) between the combined surgery group (4.2±0.4 years) and the pelvic organ prolapse-only surgery group (5.6±0.4 years). CONCLUSION: In this retrospective cohort study, patients undergoing combined pelvic organ prolapse and rectal prolapse surgery had a similar risk of <30-day postoperative complications compared with patients undergoing pelvic organ prolapse-only surgery. Furthermore, patients who underwent combined surgery had a similar risk of recurrent pelvic organ prolapse and subsequent pelvic organ prolapse surgery compared with patients who underwent pelvic organ prolapse-only surgery.

Deciphering How the Viscoelastic Properties of Mussel-Inspired Metal-Coordinate Transiently Cross-Linked Gels Dictate Their Tack Behavior.

In recent years, researchers have incorporated mussel-inspired metal-coordinate cross-links into various types of gels to improve their mechanical properties, particularly toughness and self-healing. However, not much is understood about how the linear mechanical properties of these gels dictate their tack properties. In this study, we use shear rheology and tack tests to explore correlations between linear viscoelastic properties (i.e., plateau modulus, Gp, and characteristic relaxation time, τc) and tack behavior (i.e., peak stress, σmax, and energy dissipation per volume, EDV) of transiently cross-linked hydrogels comprised of histidine-functionalized 4-arm PEG coordinated with Ni2+. By using the Ni2+-histidine ratio and polymer wt % of the transient networks to control their viscoelastic properties, we demonstrate a strong dependence of σmax on Gp and τc. The observed correlation between network dynamics and mechanics under tensile load is in good quantitative agreement with a theoretical framework for σmax, which includes the linear viscoelastic properties as parameters. EDV is also influenced by Gp and τc, and the EDV after reaching σmax is additionally dependent on the polymer wt %. These findings are consistent with previously proposed molecular mechanics of reversible HisxNi2+ cross-links and provide us with new insights into the correlations between bulk mechanics and adhesive dynamics of gels with transient metal-coordinate cross-links.

Improvement Initiatives of Resuscitation Service in a Regional Rehabilitation Hospital in Hong Kong.

UNLABELLED: Limited accessibility to resuscitation equipment and non-standardized instrument layout in trolleys would cause difficulty for the team members to access appropriate emergency equipment for delivering prompt resuscitation service in Tung Wah Eastern Hospital (TWEH). Improvement initiatives were implemented in September 2012 after endorsement by the resuscitation subcommittee: (i) standardization and installation of resuscitation equipment including resuscitation trolleys, emergency drug kits, automatic emergency defibrillators, designated response team (DRT) kit; (ii) guidelines revision involves the workflow, staff deployment, and designated areas for resuscitation during different service hours and (iii) staff training by workshop and video. Periodic resuscitation drill was held to monitor staff performance after training and the debriefing provided a chance for discussion and feedback from frontline staff. The compliance audit result for this exercise and the staff performance in the drills were improved, showing that the initiatives were successful. KEY WORDS: Resuscitation, Accessibility, Standardization, Drill.

Postoperative Activity Restrictions After Slings: A Randomized Controlled Trial.

IMPORTANCE: Restricting activity after midurethral slings is an unproven practice. OBJECTIVE: The objective of this study was to evaluate the effect of postoperative activity restriction on satisfaction and outcomes after slings. STUDY DESIGN: This was a multicenter, 2-arm, noninferiority randomized controlled trial. Patients aged 18-85 years undergoing treatment with a midurethral sling were randomized 1:1 to postoperative activity restriction or liberal activity. Restrictions included avoidance of strenuous exercise and heavy lifting. The liberal group was allowed to resume activity at their discretion. Our primary outcome was satisfaction with postoperative instruction at 2 weeks. Secondary outcomes included surgical failure, mesh exposure rates, and other adverse events. RESULTS: In total, 158 patients were randomized with 80 to the liberal group and 78 to the restricted group. At 2 weeks, 54 (80.6%) of patients in the liberal group and 48 (73.9%) of patients in the restricted group were satisfied. We found statistical evidence supporting the hypothesis that postoperative liberal activity instruction is noninferior to activity restriction with regard to patient satisfaction (P = 0.0281). There was no significant difference in strenuous activity at 2 weeks (P = 0.0824). The liberal group reported significantly more moderate activity at 2 weeks (P = 0.0384) and more strenuous activity at 6 weeks and 6 months (P = 0.0171, P = 0.0118, respectively). The rate of recurrent or persistent stress incontinence for liberal versus restricted groups was 18.52% versus 23.53% (P = 0.635). There were no statistically significant differences in complication rates. CONCLUSIONS: Postoperative liberal activity was noninferior to activity restriction with regard to patients' satisfaction. There was no evidence supporting a statistically significant association between postoperative instruction and negative surgical outcomes.

Surgeon Attitudes Toward Concurrent Urogynecologic and Gynecologic Oncology Procedures: A Cross-sectional Survey.

IMPORTANCE: There is increasing overlap in the urogynecologic and gynecologic oncologic patient populations. To improve patient advocacy and access to care, a collaborative surgical approach may benefit this cohort. OBJECTIVE: The aim of the study was to evaluate surgeon attitudes toward performing concurrent urogynecologic and gynecologic oncology procedures. We hypothesized that most surgeons are amenable to collaboration. STUDY DESIGN: We conducted a cross-sectional questionnaire of members of the Society of Gynecologic Oncology and the American Urogynecologic Society from August to November 2020. A 23-item online survey was created to assess surgeon demographics, practice and screening patterns, and attitudes toward surgical collaboration. We also evaluated obstacles to performing joint procedures and assessed whether attitudes could be influenced by new information. RESULTS: A total of 338 surveys were included in the analysis, including 158 urogynecologists and 226 gynecologic oncologists (GOs). Most surgeons (77.8%) will recommend concurrent procedures with another specialty, and 97.8% of urogynecologists and 95.7% of oncologists currently perform joint surgical procedures. Male surgeons, regardless of specialty, were more likely to recommend staged procedures (44% vs 31%, P < 0.001), as were GOs (28% vs 10.1%, P < 0.001). However, oncologists were more likely than urogynecologists to initiate referrals for surgical collaboration (33.3% vs 14.4%, P < 0.001). CONCLUSIONS: A total of 22.2% of urogynecologists and oncologists prefer staging surgical procedures. The most common barrier to a combined procedure was logistics. Urogynecologists were more concerned about the effects of cancer treatments on healing, the use of mesh implants, and financial reimbursements as compared with GOs. Treatment delay was a significantly greater concern for the oncologists.

Assessment of Level of Fear in Adult Patients Undergoing Elective Urogynecologic and Gynecologic Procedures and Surgeries During the COVID-19 Pandemic Using the Validated Surgical Fear Questionnaire.

OBJECTIVE: This study aimed to assess and trend fears surrounding elective surgery and office procedures in benign gynecologic and urogynecologic patients during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: This was a multicenter, prospective, observational study. Recruitment occurred from June 23, 2020, to March 23, 2021. Females 18 years or older presenting for elective benign gynecologic or urogynecologic surgery or office procedures were eligible. Patients were excluded if non-English speaking or undergoing an emergent procedure or surgery. Fear was assessed by the Surgical Fear Questionnaire (SFQ), which was also modified to include 2-4 additional questions pertaining to COVID-19 (modified version of the Surgical Fear Questionnaire [mSFQ]). Total SFQ scores and short- and long-term fear scores were compared between procedures and surgery and to historic data. RESULTS: A total of 209 patients undergoing 107 procedures or 102 surgical procedures completed the questionnaire. Participants were separated into subgroups determined by the timing of questionnaire completion related to phases of the pandemic. The most common procedure was urodynamics (n = 59 [55%]). The most common elective surgical procedure was hysterectomy (n = 59 [57.8%]). Furthermore, 72.5% of surgical procedures were for urogynecologic indications.Fear levels were low and not different in patients undergoing procedures versus surgery (12.38 ± 12.44 vs 12.03 ± 16.01, P = 0.958). There was no difference between procedures versus surgery for short- (6.21 ± 8.38 vs 6.81 ± 8.44, P = 0.726) or long-term fear (6.18 ± 8.89 vs 5.22 ± 8.20, P = 0.683). Compared with historic data, our hysterectomy patients had less surgical fear. The mSFQ demonstrated higher fear scores for both procedures and surgery (mSFQ, 20.57 ± 20.55 for procedures; 28.78 ± 28.51 for surgery). There were no significant fluctuations in SFQ score in relation to critical COVID-19 events. CONCLUSIONS: Fear of surgery and office procedures was low and consistent throughout the COVID-19 pandemic and lower than historic data.

Ongoing barriers to immediate postpartum long-acting reversible contraception: a physician survey.

BACKGROUND: Postpartum women are at risk for unintended pregnancy. Access to immediate long-acting reversible contraception (LARC) may help decrease this risk, but it is unclear how many providers in the United States routinely offer this to their patients and what obstacles they face. Our primary objective was to determine the proportion of United States obstetric providers that offer immediate postpartum LARC to their obstetric patients. METHODS: We surveyed practicing Fellows and Junior Fellows of the American College of Obstetricians and Gynecologists (ACOG) about their use of immediate postpartum LARC. These members are demographically representative of ACOG members as a whole and represent all of the ACOG districts. Half of these Fellows were also part of the Collaborative Ambulatory Research Network (CARN), a group of ACOG members who voluntarily participate in research. We asked about their experience with and barriers to immediate placement of intrauterine devices and contraceptive implants after delivery. RESULTS: There were a total of 108 out of 600 responses (18%). Participants practiced in a total of 36 states and/or US territories and their median age was 52 years. Only 26.9% of providers surveyed offered their patients immediate postpartum LARC, and of these providers, 60.7% work in a university-based practice. There was a statistically significant association between offering immediate postpartum LARC and practice type, with the majority of providers working at a university-based practice (p < 0.001). Multiple obstacles were identified, including cost or reimbursement, device availability, and provider training on device placement in the immediate postpartum period. CONCLUSION: The majority of obstetricians surveyed do not offer immediate postpartum long-acting reversible contraception to patients in the United States. This is secondary to multiple obstacles faced by providers.

Quality of Life after Sequential Bilateral Cochlear Implantation.

Objective Assess psychometric properties of the Comprehensive Cochlear Implant Questionnaire (CCIQ) as a tool for assessing changes in health-related quality of life (HRQoL) after receiving a second cochlear implant (CI2). Study Design Prospective study. Setting Academic cochlear implant center. Subjects and Methods The CCIQ is a 29-item questionnaire assessing the physical and psychosocial benefits of a CI2 based on a 5-point Likert scale. The CCIQ was administered with the Nijmegen Cochlear Implant Questionnaire and the Short Form-12 Patient Questionnaire (SF-12) to patients with a CI2. Speech perception was tested with the consonant-nucleus-consonant (CNC) word test and AzBio test. Results Of 56 patients, 32 (57.1%) completed the instruments sent by mail. Of the 32 patients, 22 (68.8%) completed retest CCIQs 6 weeks later. CCIQ scores demonstrated significantly increased HRQoL in all domains. Internal consistency was very good overall (Cronbach's α = 0.90), with all subdomains exceeding an alpha value of 0.70. Test-retest reliability was good, with an overall intraclass correlation of 0.62. The CCIQ showed a moderate correlation with the Nijmegen Cochlear Implant Questionnaire and a low correlation with the SF-12. Average CNC and AZBio scores significantly improved by 31% ± 29% and 34% ± 33%, respectively. Audiometric data were not significantly correlated with the CCIQ. Conclusion The CCIQ shows (1) good reliability and evidence of construct validity, (2) a significant increase in HRQoL and significantly improved speech perception after CI2, and (3) greater sensitivity at detecting CI2 improvements to HRQoL. This promising measure is quick and easy to administer and provides subjective assessments of HRQoL specifically for those with a CI2.

Reporting of Postoperative Pain Management Protocols in Randomized Clinical Trials of Mandibular Fracture Repair: A Systematic Review.

IMPORTANCE: The control of pain associated with mandibular fractures is an important treatment outcome that affects function, adherence to treatment regimens, and patient comfort and satisfaction. OBJECTIVE: To explore the pain management protocols reported in studies of mandibular fractures, including the reporting of quality-of-life measures. EVIDENCE REVIEW: PubMed/MEDLINE, EMBASE, Cochrane CENTRAL, and clinicaltrials.gov were searched for randomized clinical trials published from 1970 to July 2014. We followed PRISMA reporting standards to assess study eligibility and extract data. Studies of patients older than 16 years who underwent operative mandibular fracture management were included. The primary data collected included the type of analgesic prescribed, associated adverse effects of the analgesic, method of pain assessment, and use of quality-of-life measures. A pain attentiveness score was assigned to studies based on the comprehensiveness of the information reported. Several variables were reviewed to determine the factors that predict reporting of pain-related data. Assessments of risk for bias were performed using the Cochrane Collaboration's domain-based evaluation method. FINDINGS: The initial search identified 111 articles, of which 38 met inclusion criteria. Among the 38 reviewed articles, there were 38 trials and 1808 unique patients represented. Among the 38 articles, the procedures reported included maxillomandibular fixation only in 6 (16%), open reduction with internal fixation only in 20 (53%), and both in 12 (32%). Specific analgesics prescribed were reported in only 5 of the 38 studies (13%), and 3 of these used a combination of nonsteroidal anti-inflammatory drugs and acetaminophen (paracetamol). Thirteen studies (34%) reported pain assessments and 5 (13%) included quality-of-life measures. Geographic region was the only variable that predicted pain attentiveness, with studies from Europe (3 of 11 studies [27%]) and Asia (6 of 16 studies [38%]) most likely to have a high pain attentiveness score. A low rating was least common in the United States (2 of 5 studies [40%]) (P = .047, Fisher exact test). Most of the studies had unclear (n = 27) or high (n = 6) risks for bias in the key domains assessed. CONCLUSIONS AND RELEVANCE: Pain management is a neglected outcome in randomized clinical trials of mandibular trauma; most studies did not describe the specific analgesics used. Many randomized clinical trials (13 [34%]) assessed pain levels among patients without providing information about the agents prescribed. The incorporation of validated pain measures and quality-of-life scores in future studies of mandibular trauma would focus attention on this key outcome measure.

Impact on the quality of life of patients with arteriovenous malformations during the latent interval between gamma knife radiosurgery and lesion obliteration.

OBJECT: The aim of this study was to measure the quality of life (QOL) in patients with cerebral arteriovenous malformations (AVMs) receiving gamma knife treatment before total AVM obliteration. Quality of life was assessed as it related to the knowledge of rebleeding risk during the waiting period, AVM symptoms, and previous bleeding. METHODS: Thirty-nine patients age 18 years or older without other medical problems were asked to complete a questionnaire that included demographic variables, immediate effect of gamma knife radiosurgery, symptoms of AVM, previous hemorrhage, and the Duke-University of North Carolina Health Profile (63 items). CONCLUSIONS: The QOL of patients with cerebral AVM during the waiting period after undergoing gamma knife treatment was affected by irreversible physical disabilities rather than the knowledge of hemorrhage risk and bleeding experience.

Self-assembled phases of block copolymer blend thin films.

The patterns formed by self-assembled thin films of blended cylindrical and lamellar polystyrene-b-poly(methyl methacrylate) block copolymers can be either a spatially uniform, single type of nanostructure or separate, coexisting regions of cylinders and lamellae, depending on fractional composition and molecular weight ratio of the blend constituents. In blends of block copolymers with different molecular weights, the morphology of the smaller molecular weight component more strongly dictates the resulting pattern. Although molecular scale chain mixing distorts microdomain characteristic length scales from those of the pure components, even coexisting morphologies exhibit the same domain spacing. We quantitatively account for the phase behavior of thin-film blends of cylinders and lamellae using a physical, thermodynamic model balancing the energy of chain distortions with the entropy of mixing.

Density and distribution of cutaneous sensilla on tails of leopard geckos (Eublepharis macularius) in relation to caudal autotomy.

The lizard tail is well known for its ability to autotomize and regenerate. Physical contact of the tail by a predator may induce autotomy at the location at which the tail is grasped, and upon detachment the tail may undergo violent, rapid, and unpredictable movements that appear to be, to some degree, regulated by contact with the physical environment. Neither the mechanism by which tail breakage at a particular location is determined, nor that by which environmental feedback to the tail is received, are known. It has been suggested that mechanoreceptors (sensilla) are the means of mediation of such activities, and reports indicate that the density of sensilla on the tail is high. To determine the feasibility that mechanoreceptors are involved in such phenomena, we mapped scale form and the size, density, distribution, and spacing of sensilla on the head, body, limbs, and tail of the leopard gecko. This species has a full complement of autotomy planes along the length of the tail, and the postautotomic behavior of its tail has been documented. We found that the density of sensilla is highest on the tail relative to all other body regions examined; a dorsoventral gradient of caudal sensilla density is evident on the tail; sensilla are more closely spaced on the dorsal and lateral regions of the tail than elsewhere and are carried on relatively small scales; and that the whorls of scales on the tail bear a one to one relationship with the autotomy planes. Our results are consistent with the hypotheses of sensilla being involved in determining the site at which autotomy will occur, and with them being involved in the mediation of tail behavior following autotomy. These findings open the way for experimental neurological investigations of how autotomy is induced and how the detached tail responds to external environmental input.

Compositional dependence of the stability of AuCu alloy nanoparticles.

The oxidation of AuCu nanoparticles was studied as a function of composition and temperature. Oxidation rates at 110 °C were higher for NPs with higher Cu content, showing that Au stabilized the Cu. Electrochemistry measurements show that AuCu could be a promising catalyst for lowering the over potential of CO(2) reduction.