Characteristics of persistent urinary incontinence after successful fistula closure in Ethiopian women.

INTRODUCTION AND HYPOTHESIS: Obstetric fistulas have devastating consequences for women. Although surgical repair is largely successful in closing the defect, many women with successful fistula closure report persistent urinary incontinence. Our study is aimed at characterizing incontinence after successful fistula repair and its impact on quality of life. METHODS: This cross-sectional study enrolled women with a history of successful obstetric fistula closure with (n = 51; cases) or without (n = 50; controls) persistent urinary incontinence. Data were collected in Mekelle, Ethiopia, between 2016 and 2018. All cases underwent clinical evaluation and completed questionnaires characterizing the type, severity, and impact of incontinence. RESULTS: Cases were significantly more likely to have acquired their fistula at an earlier age and with their first vaginal delivery compared with controls. Almost all cases reported both stress (98%) and urgency (94%) incontinence, and half reported constant urinary leakage (49%) despite successful fistula closure. Of cases who completed urodynamic evaluation (n = 22), all had genuine stress incontinence and none had detrusor overactivity. All cases reported moderate to severe (80.4%) or very severe (19.6%) incontinence (measured by ICIQ-SF) and this had a moderate to severe negative impact on their quality of life (as measured by ICIQ-QoL). Although history of suicidal ideation was not significantly different between the groups, among those with suicidal ideation, cases were more likely to report having made a plan and/or attempted to commit suicide. CONCLUSIONS: When urinary incontinence persists after successful fistula closure, it tends to be severe and of mixed etiology and has a significant negative impact on quality of life and mental health.

Lessons learned from the implementation of a medically enhanced residential treatment (MERT) model integrating intravenous antibiotics and residential addiction treatment.

BACKGROUND: Hospitalizations for severe infections associated with substance use disorder (SUD) are increasing. People with SUD often remain hospitalized for many weeks instead of completing intravenous antibiotics at home; often, they are denied skilled nursing facility admission. Residential SUD treatment facilities are not equipped to administer intravenous antibiotics. We developed a medically enhanced residential treatment (MERT) model integrating residential SUD treatment and long-term IV antibiotics as part of a broader hospital-based addiction medicine service. MERT had low recruitment and retention, and ended after six months. The goal of this study was to describe the feasibility and acceptability of MERT, to understand implementation factors, and explore lessons learned. METHODS: We conducted a mixed-methods evaluation. We included all potentially eligible MERT patients, defined by those needing ≥2 weeks of intravenous antibiotics discharged from February 1 to August 1, 2016. We used chart review to identify diagnoses, antibiotic treatment location, and number of recommended and actual IV antibiotic-days completed. We audio-recorded and transcribed key informant interviews with patients and staff. We conducted an ethnographic analysis of interview transcripts and implementation field notes. RESULTS: Of the 45 patients needing long-term intravenous antibiotics, 18 were ineligible and 20 declined MERT. 7 enrolled in MERT and three completed their recommended intravenous antibiotic course. MERT recruitment barriers included patient ambivalence towards residential treatment, wanting to prioritize physical health needs, and fears of untreated pain in residential. MERT retention barriers included high demands of residential treatment, restrictive practices due to PICC lines, and perceptions by staff and other residents that MERT patients "stood out" as "different." Despite the challenges, key informants felt MERT was a positive construct. CONCLUSIONS: Though MERT had many possible advantages; it proved more challenging to implement than anticipated. Our lessons may be applicable to future models integrating post-hospital intravenous antibiotics and SUD care.

Provider Perspectives on Persistent Urinary Incontinence Following Obstetric Fistula Repair in Ethiopia.

Each year an estimated 50,000 to 100,000 women worldwide are affected by obstetric fistula. This devastating but preventable maternal morbidity leaves women incontinent, stigmatized, isolated, and often with a still birth. While fistula rates in Ethiopia have declined in recent years, estimates range from 7 to 40 percent of women suffer from persistent urinary incontinence after successful closure of their fistula. Few studies have focused on the unique experiences and challenges that providers face treating fistula patients, particularly those who experience persistent urinary incontinence. The goal of this research is to characterize the fistula provider's accounts of how to manage, support, and understand their patient's experience. Semi-structured interviews were conducted with a purposive sample of fistula care providers in Mekelle and Addis Ababa, Ethiopia. The main themes that emerged were a perceived exacerbated impact on quality of life for women with persistent urinary incontinence; a "double hit" of isolation from both their community and from other recovered fistula patients; how the church both influences how patients internalize their injury and provides them with hope and support; and the need for comprehensive and compassionate fistula care. Understanding how providers perceive and relate to their patients provides valuable insight to the unique challenges of treating this population and may better inform treatment programmes to address the gap between patient needs and current fistula care models.

Folate intake and prostate cancer risk: a case-control study.

Folate deficiency has been implicated in the carcinogenesis of several tumor types. The role of folate in prostate cancer remains indeterminate. We investigated folate as a risk factor for prostate cancer among 140 biopsy-confirmed prostate cancer patients, 230 age-matched clinic controls, and 250 negative prostate biopsy controls. Dietary folate intake was inversely associated with overall risk of prostate cancer as compared to clinic controls (P for a linear trend = 0.003). When stratified by disease severity, dietary folate and folate from natural sources were associated with reduced risk of high-grade cancer as compared to both clinic controls (P for a linear trend = 0.0009 and 0.02, respectively) and biopsy negative controls (P for a linear trend = 0.03 and 0.05, respectively). There was no interaction between alcohol consumption and folate intake. These analyses support an inverse association between dietary folate intake and prostate cancer risk and primarily risk of high-grade prostate cancer.

"We've Learned It's a Medical Illness, Not a Moral Choice": Qualitative Study of the Effects of a Multicomponent Addiction Intervention on Hospital Providers' Attitudes and Experiences.

BACKGROUND: Substance use disorders (SUD) represent a national epidemic with increasing rates of SUD-related hospitalizations. However, most hospitals lack expertise or systems to directly address SUD. Healthcare professionals feel underprepared and commonly hold negative views toward patients with SUD. Little is known about how hospital interventions may affect providers' attitudes and experiences toward patients with SUD. OBJECTIVE: To explore interprofessional hospital providers' perspectives on how integrating SUD treatment and care systems affect providers' attitudes, beliefs, and experiences. DESIGN: In-depth semi-structured interviews and focus groups. The study was part of a formative evaluation of the Improving Addiction Care Team (IMPACT), an interprofessional hospital-based addiction medicine service with rapid-access pathways to post-hospital SUD treatment. SETTING: Single urban academic hospital in Portland, Oregon. PARTICIPANTS: Multidisciplinary hospital providers. MEASUREMENTS: We conducted a thematic analysis using an inductive approach at a semantic level. RESULTS: Before IMPACT, participants felt that hospitalization did not address addiction, leading to untreated withdrawal, patients leaving against medical advice, chaotic care, and staff "moral distress." Participants felt that IMPACT "completely reframes" addiction as a treatable chronic disease, improving patient engagement and communication, and humanizing care. Participants valued post-hospital SUD treatment pathways and felt having systems to address SUD reduced burnout and provided relief. Providers noted that IMPACT had limited ability to address poverty or engage highly ambivalent patients. CONCLUSIONS: Providers' distress of caring for patients with SUD is not inevitable. Hospital-based SUD interventions can reframe providers' views of addiction and may have significant implications for clinical care and providers' well-being.

The utility of animal surveillance in the detection of West Nile virus activity in Puerto Rico, 2007.

After the isolation of West Nile virus (WNV) from humans, mosquitoes, and chickens in 2007, an analysis of animal surveillance involving multiple species (horses, monkeys, sheep, dogs, and birds) used to track WNV transmission from 2006 to 2008 was performed. During this period 13.4% of all the animal samples collected were seropositive by blocking ELISA for WNV. The most complete island-wide sampling was obtained from horses of which 22% were serologically positive and 96% were confirmed as WNV infections by plaque-reduction neutralization test. Our conclusion from this 3-year study is that animal surveillance is an early indicator of WNV activity before the identification of human cases. Additionally, the results indicated that horses have a greater geographical range and should be continued to be used as sentinels for passive surveillance in the tropics.

Dengue virus seroprevalence among febrile patients in Bamako, Mali: results of a 2006 surveillance study.

BACKGROUND: Dengue viruses (DENV) are endemic in over 100 countries worldwide, and annually 50 to 100 million people are infected by one of the four DENV serotypes, whereas over 2.5 billion people are at risk for infection. West African countries lack the surveillance to determine the true incidence of dengue; hence, this disease is likely significantly underestimated. In Mali, ?14 million people are potentially at risk of acquiring a dengue infection. METHODS AND FINDINGS: A serosurvey for DENV was conducted on 95 human serum samples obtained from the Institute National de Recherche en Sante Publique in 2006. DENV-specific IgM and IgG enzyme-linked immunosorbent assays were performed on all samples, and a subset was tested using the plaque-reduction neutralization test against the DENV and yellow fever virus (YFV). Samples collected during the acute infection (0-5 days postonset of symptoms) were tested for dengue NS1 antigen and reverse-transcriptase polymerase chain reaction for Flaviviruses, Alphaviruses, and Bunyaviruses RNA. A total of 87 (93%) of samples were positive for anti-DENV IgG antibodies. Of a subset of 13 IgG positive samples, 2 samples neutralized monotypically against DENV-1 and -2, whereas 3 others neutralized broadly against YFV and multiple DENV. Although no polymerase chain reaction positives were found, DENV NS1 was detected in 1 of the 20 acute samples tested. CONCLUSIONS: Of the 93 human serum samples tested, the dengue prevalence based on dengue IgG enzyme-linked immunosorbent assay results was 93%. Three DENV specific positive samples and two YFV positives were identified by plaque-reduction neutralization test. Finally, one sample tested positive for dengue NS1, thus suggestive of an acute infection within 14 days of obtaining the sample from the patient. Based on these serological data from this study, YFV and DENV appear to be co-circulating in Mali.

Utility of a commercial nonstructural protein 1 antigen capture kit as a dengue virus diagnostic tool.

Annually, over 2.5 billion people are at risk for infection with dengue virus (DENV), while between 50 and 100 million people contract the infection. There is an urgent need for alternative diagnostic tools that can detect DENV during acute infection. Recent studies have shown that DENV nonstructural protein 1 (NS1) is detectable in the blood as early as the onset of symptoms and persists well into the convalescent phase of the infection. We evaluated the utility of the Bio-Rad Platelia DENV NS1 antigen capture kit in combination with real-time reverse transcriptase PCR (RT-PCR) and an IgM antibody capture enzyme-linked immunosorbent assay (MAC-ELISA) for refining a new algorithm for the diagnosis of acute- or convalescent-phase DENV infection with a single clinical sample. We tested the Bio-Rad kit with three panels of sera. These panels were designed to evaluate the sensitivities of the NS1 kit for (i) early-convalescent-phase samples, (ii) acute-phase samples with false-negative PCR results, and (iii) IgM-negative convalescent-phase samples from patients with confirmed secondary DENV infections. Results show that NS1 can be detected in 22% of serum samples collected more than 10 days after the onset of illness and in 22% of samples that did not elicit an IgM response. Additionally, NS1 was detected in 37% of the tested acute-phase samples with false-negative PCR results, suggesting that NS1 detection may be valuable in increasing the sensitivity of current acute-phase diagnostics. These results will improve diagnosis with a single acute-phase or early-convalescent-phase sample for disease surveillance and clinical diagnosis.