Guideline No. 445: Management of Chronic Pelvic Pain.

OBJECTIVE: To provide evidence-based recommendations for the management of chronic pelvic pain in females. TARGET POPULATION: This guideline is specific to pelvic pain in adolescent and adult females and excluded literature that looked at pelvic pain in males. It also did not address genital pain. BENEFITS, HARMS, AND COSTS: The intent is to benefit patients with chronic pelvic pain by providing an evidence-based approach to management. Access to certain interventions such as physiotherapy and psychological treatments, and to interdisciplinary care overall, may be limited by costs and service availability. EVIDENCE: Medline and the Cochrane Database from 1990 to 2020 were searched for articles in English on subjects related to chronic pelvic pain, including diagnosis, overlapping pain conditions, central sensitization, management, medications, surgery, physiotherapy, psychological therapies, alternative and complementary therapies, and multidisciplinary and interdisciplinary care. The committee reviewed the literature and available data and used a consensus approach to develop recommendations. Only articles in English and pertaining to female subjects were included. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE: Family physicians, gynaecologists, urologists, pain specialists, physiotherapists, and mental health professionals. TWEETABLE ABSTRACT: Management of chronic pelvic pain should consider multifactorial contributors, including underlying central sensitization/nociplastic pain, and employ an interdisciplinary biopsychosocial approach that includes pain education, physiotherapy, and psychological & medical treatments. SUMMARY STATEMENTS: RECOMMENDATIONS.

Outcomes of oocyte retrievals completed by reproductive endocrinology and infertility fellows versus faculty: a 7-year retrospective review.

PURPOSE: To examine outcomes of oocyte retrievals completed by Reproductive Endocrinology and Infertility (REI) fellows versus faculty physicians. METHODS: This retrospective cohort study examined patients who underwent oocyte retrievals at Mayo Clinic from July 15, 2009, to December 15, 2016. The primary outcome was the oocyte retrieval rate (ORR) calculated per retrieval as the number of oocytes retrieved per follicles aspirated. The Wilcoxon signed-rank test was used to compare follicle and oocyte counts and ORR between fellows and faculty during the same bilateral retrieval. RESULTS: The study cohort included the first bilateral retrieval from 845 unique patients completed by 11 fellows and seven faculty. The median ORR was not statistically different for fellows and faculty (0.79 versus 0.80, p = 0.46). To assess for a learning curve, the outcomes of seven fellows who completed at least 80 retrievals in their first year were examined as four chronologically ordered sets of 20. When these sets were compared to the faculty physician mean ORR, no significant differences were found (p-values of 0.69, 0.69, 0.81, and 0.81, respectively). CONCLUSION: There were no significant differences in oocyte retrieval rates between fellows versus faculty over a 7-year period, with no significant learning curve observed. These findings suggest that fellows possess the requisite skills for successful oocyte retrieval upon entering REI fellowship following their OB/GYN residency. However, this does not diminish the critical role of comprehensive fellowship training and close supervision, especially in initial and complex cases.

Something to Chew on; Plate-Waste at an Ontario Veteran's Centre.

There is paucity of data assessing levels of food/beverage waste in long-term care (LTC) facilities, especially in Ontario. Observations in the Veteran's Centre (VC) at Sunnybrook Health Sciences Centre (Sunnybrook) indicated food/beverage waste may be high, potentially impacting sustainability efforts within our institution. Before proceeding with waste reduction efforts, we conducted a comprehensive 3-day waste-audit of food/beverage items provided to VC residents with the goal of understanding the extent of food/beverage waste at VC, items wasted, and any other factors that may inform future changes. Our results indicate that 28% of items served to residents were wasted. Lunch was the meal with greatest waste at 31% and waste of solid items was 12% higher than that of liquids. We observed a large variability in waste between residents and within each resident, with 15% of residents wasting >50% of items provided. This study provides a deeper insight into the magnitude of food/beverage waste in a LTC population and highlights the importance of considering individualized strategies to address waste to avoid negative impact on residents.

Light at night disrupts trophic interactions and population growth of lady beetles and pea aphids.

Natural variation in light has historically correlated with seasonality, providing an honest cue to organisms with seasonal life history cycles. However, with the onset of widespread light at night (LAN), the reliability of light as a cue has decreased in polluted areas, making its timing or intensity potentially clash with temperature trends. These clashing cues may influence biological systems on multiple levels. Yet, a few studies have connected behavioral underpinnings and larger community-level processes, resulting in a knowledge gap bridging individual-, population-, and community-level responses to mismatched cues. We experimentally investigated impacts of cool temperature and LAN on a lady beetle-aphid-fava system to test how light and temperature influenced aphid population growth and their underlying behavioral drivers. We used Coccinella septempunctata and Coleomegilla maculata beetles to understand the interaction of the environment and predation on pea aphid (Acyrthosiphon pisum) population growth. Aphids and their predators reacted differently to variation in light and temperature, influencing the strength of aphid-driven and predator-driven dynamics in the different conditions. We observed evidence of aphid-driven dynamics in the cool, light conditions where aphids excel and exhibited strong anti-predator behavior. In contrast, we found stronger predator-driven dynamics in warm conditions where lady beetle predatory success was higher. Overall, we found that LAN has context-dependent effects on insect communities due to the varied responses each player has to its environment.

A comparison of total inward leakage measured using sodium chloride (NaCl) and corn oil aerosol methods for air-purifying respirators.

The International Organization for Standardization (ISO) standard 16900-1:2014 specifies the use of sodium chloride (NaCl) and corn oil aerosols, and sulfur hexafluoride gas for measuring total inward leakage (TIL). However, a comparison of TIL between different agents is lacking. The objective of this study was to measure and compare TIL for respirators using corn oil and NaCl aerosols. TIL was measured with 10 subjects donning two models of filtering facepiece respirators (FFRs) including FFP1, N95, P100, and elastomeric half-mask respirators (ERs) in NaCl and corn oil aerosol test chambers, using continuous sampling methods. After fit testing with a PortaCount (TSI, Inc., St. Paul, MN) using the Occupational Safety and Health Administration (OSHA) protocol, five subjects were tested in the NaCl chamber first and then in the corn oil chamber, while other subjects tested in the reverse order. TIL was measured as a ratio of mass-based aerosol concentrations in-mask to the test chamber, while the subjects performed ISO 16900-1-defined exercises. The concentration of NaCl aerosol was measured using two flame photometers, and corn oil aerosol was measured with one light scattering photometer. The same instruments were used to measure filter penetration in both chambers using a Plexiglas setup. The size distribution of aerosols was determined using a scanning mobility particle sizer and charge was measured with an electrometer. Filter efficiency was measured using an 8130 Automated Filter Tester (TSI). Results showed the geometric mean TIL for corn oil aerosol for one model each of all respirator categories, except P100, were significantly (p < 0.05) greater than for NaCl aerosol. Filter penetration in the two test chambers showed a trend similar to TIL. The count median diameter was ∼82 nm for NaCl and ∼200 nm for corn oil aerosols. The net positive charge for NaCl aerosol was relatively larger. Both fit factor and filter efficiency influence TIL measurement. Overall, TIL determination with aerosols of different size distributions and charges using different methodologies may produce dissimilar results.

Combined effects of night warming and light pollution on predator-prey interactions.

Interactions between multiple anthropogenic environmental changes can drive non-additive effects in ecological systems, and the non-additive effects can in turn be amplified or dampened by spatial covariation among environmental changes. We investigated the combined effects of night-time warming and light pollution on pea aphids and two predatory ladybeetle species. As expected, neither night-time warming nor light pollution changed the suppression of aphids by the ladybeetle species that forages effectively in darkness. However, for the more-visual predator, warming and light had non-additive effects in which together they caused much lower aphid abundances. These results are particularly relevant for agriculture near urban areas that experience both light pollution and warming from urban heat islands. Because warming and light pollution can have non-additive effects, predicting their possible combined consequences over broad spatial scales requires knowing how they co-occur. We found that night-time temperature change since 1949 covaried positively with light pollution, which has the potential to increase their non-additive effects on pea aphid control by 70% in US alfalfa. Our results highlight the importance of non-additive effects of multiple environmental factors on species and food webs, especially when these factors co-occur.

Inward Leakage Variability between Respirator Fit Test Panels - Part I. Deterministic Approach.

Inter-panel variability has never been investigated. The objective of this study was to determine the variability between different anthropometric panels used to determine the inward leakage (IL) of N95 filtering facepiece respirators (FFRs) and elastomeric half-mask respirators (EHRs). A total of 144 subjects, who were both experienced and non-experienced N95 FFR users, were recruited. Five N95 FFRs and five N95 EHRs were randomly selected from among those models tested previously in our laboratory. The PortaCount Pro+ (without N95-Companion) was used to measure IL of the ambient particles with a detectable size range of 0.02 to 1 µm. The Occupational Safety and Health Administration standard fit test exercises were used for this study. IL test were performed for each subject using each of the 10 respirators. Each respirator/subject combination was tested in duplicate, resulting in a total 20 IL tests for each subject. Three 35-member panels were randomly selected without replacement from the 144 study subjects stratified by the National Institute for Occupational Safety and Health bivariate panel cell for conducting statistical analyses. The geometric mean (GM) IL values for all 10 studied respirators were not significantly different among the three randomly selected 35-member panels. Passing rate was not significantly different among the three panels for all respirators combined or by each model. This was true for all IL pass/fail levels of 1%, 2%, and 5%. Using 26 or more subjects to pass the IL test, all three panels had consistent passing/failing results for pass/fail levels of 1% and 5%. Some disagreement was observed for the 2% pass/fail level. Inter-panel variability exists, but it is small relative to the other sources of variation in fit testing data. The concern about inter-panel variability and other types of variability can be alleviated by properly selecting: pass/fail level (IL 1-5%); panel size (e.g., 25 or 35); and minimum number of subjects required to pass (e.g., 26 of 35 or 23 of 35).

The impacts of artificial light at night on the ecology of temperate and tropical reefs.

Despite 22% of the world's coastal regions experiencing some degree of light pollution, and biologically important artificial light at night (ALAN) reaching large portions of the seafloor (greater than 75%) near coastal developments, the impacts of ALAN on temperate and tropical reefs are still relatively unknown. Because many reef species have evolved in response to low-light nocturnal environments, consistent daily, lunar, and seasonal light cycles, and distinct light spectra, these impacts are likely to be profound. Recent studies have found ALAN can decrease reproductive success of fishes, alter predation rates of invertebrates and fishes, and impact the physiology and biochemistry of reef-building corals. In this paper, we integrate knowledge of the role of natural light in temperate and tropical reefs with a synthesis of the current literature on the impacts of ALAN on reef organisms to explore potential changes at the system level in reef communities exposed to ALAN. Specifically, we identify the direct impacts of ALAN on individual organisms and flow on effects for reef communities, and present potential scenarios where ALAN could significantly alter system-level dynamics, possibly even creating novel ecosystems. Lastly, we highlight large knowledge gaps in our understanding of the overall impact of ALAN on reef systems. This article is part of the theme issue 'Light pollution in complex ecological systems'.

Light pollution in complex ecological systems.

Light pollution has emerged as a burgeoning area of scientific interest, receiving increasing attention in recent years. The resulting body of literature has revealed a diverse array of species-specific and context-dependent responses to artificial light at night (ALAN). Because predicting and generalizing community-level effects is difficult, our current comprehension of the ecological impacts of light pollution on complex ecological systems remains notably limited. It is critical to better understand ALAN's effects at higher levels of ecological organization in order to comprehend and mitigate the repercussions of ALAN on ecosystem functioning and stability amidst ongoing global change. This theme issue seeks to explore the effects of light pollution on complex ecological systems, by bridging various realms and scaling up from individual processes and functions to communities and networks. Through this integrated approach, this collection aims to shed light on the intricate interplay between light pollution, ecological dynamics and humans in a world increasingly impacted by anthropogenic lighting. This article is part of the theme issue 'Light pollution in complex ecological systems'.

Follicle Stimulating Hormone (FSH) as a Predictor of Decreased Oocyte Yield in Patients with Normal Anti-Müllerian Hormone (AMH) and Antral Follicle Count (AFC).

Background: The purpose of the current study was to determine the utility of early follicular phase follicle-stimulating hormone (FSH) testing in patients undergoing in vitro fertilization (IVF). Methods: This was a retrospective review of patients from 2012 to 2015 at Mayo Clinic in Rochester, Minnesota, USA. Included subjects had a normal anti-Müllerian hormone (AMH) of 1 to 9 ng/ml and antral follicle count (AFC) of 10 to 29. Patients were stratified by FSH level when associated estradiol was less than 50 ng/ml. In total, 225 patients were categorized into three groups: high FSH (FSH ≥10 IU/L; n= 36), normal FSH (>5 IU/L and <10 IU/L; n=170), and low FSH (FSH ≤5 IU/L; n= 19). ANOVA and multiple logistic regression were used for statistical comparisons and for evaluation of the relationships between variables; significance level was set at <0.05. Results: There were no significant differences in demographics, IVF cycle type, or peak estradiol level between the groups. Patients with a high basal FSH level had a similar clinical pregnancy rate and live birth rate compared to controls and patients with low FSH. High FSH level was associated with decreased follicular development (17 versus 22; p<0.01), oocyte yield (15 versus 18; p=0.02), and embryo yield (8 versus 10; p=0.04) despite higher total doses of gonadotropins. Conclusion: Patients with normal AMH and AFC levels could be further stratified into lower responders and starting doses of medications can be adjusted based on high basal FSH levels. Therefore, it is suggested to counsel patients on pregnancy outcomes which seem to be quite similar regardless of the FSH level.

Extensive regional variation in the phenology of insects and their response to temperature across North America.

Climate change models often assume similar responses to temperatures across the range of a species, but local adaptation or phenotypic plasticity can lead plants and animals to respond differently to temperature in different parts of their range. To date, there have been few tests of this assumption at the scale of continents, so it is unclear if this is a large-scale problem. Here, we examined the assumption that insect taxa show similar responses to temperature at 96 sites in grassy habitats across North America. We sampled insects with Malaise traps during 2019-2021 (N = 1041 samples) and examined the biomass of insects in relation to temperature and time of season. Our samples mostly contained Diptera (33%), Lepidoptera (19%), Hymenoptera (18%), and Coleoptera (10%). We found strong regional differences in the phenology of insects and their response to temperature, even within the same taxonomic group, habitat type, and time of season. For example, the biomass of nematoceran flies increased across the season in the central part of the continent, but it only showed a small increase in the Northeast and a seasonal decline in the Southeast and West. At a smaller scale, insect biomass at different traps operating on the same days was correlated up to ~75 km apart. Large-scale geographic and phenological variation in insect biomass and abundance has not been studied well, and it is a major source of controversy in previous analyses of insect declines that have aggregated studies from different locations and time periods. Our study illustrates that large-scale predictions about changes in insect populations, and their causes, will need to incorporate regional and taxonomic differences in the response to temperature.

Outcomes of embryo transfers performed by Reproductive Endocrinology and Infertility fellows vs. faculty: an 11-year retrospective review.

OBJECTIVE: To compare the clinical pregnancy rate (CPR) and live birth rate (LBR) of embryo transfer episodes (ETEs) performed by Reproductive Endocrinology and Infertility fellows vs. those of ETEs performed by faculty physicians. DESIGN: Retrospective cohort analysis. SETTING: Academic reproductive endocrinology and infertility practice. PATIENT(S): In total, 3,073 ETEs for 1,488 unique patients were performed by fellows or faculty physicians between January 2009 and January 2020. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Clinical pregnancy rate and LBR. RESULT(S): Fifteen fellows performed 1,225 (39.9%) of 3,073 ETEs after completing 30 mock transfers. On comparing outcomes among fellowship years (FY1, FY2, and FY3), CPR (44.1% vs. 43.2% vs. 45.7%, respectively, P = .83) and LBR (39.1% vs. 38.1% vs. 38.4%, respectively, P = .97) were not significantly different. Fellowship year 1 fellows' initial 30 ETEs vs. all the remaining FY1 ETEs had a significantly higher CPR (48.1% vs. 40.5%, respectively, P = .030) and LBR (45.4% vs. 34.3%, respectively, P = .001). There were no significant differences between faculty versus fellow ETEs in terms of CPR (43.0% vs. 45.0%, respectively, P = .30) or LBR (37.3% vs. 39.8%, respectively, P = .16), even after adjusting for patient age, body mass index, primary infertility diagnosis, autologous vs. donor oocyte, fresh vs. frozen embryo, number of embryos transferred, type of transfer catheter, and year of transfer (P = .32 for CPR, P = .22 for LBR). CONCLUSION(S): Appropriately trained FY1 fellows had success rates maintained throughout all FYs. There were no significant differences in clinical outcomes between fellow- and faculty-performed transfers. These data demonstrated that allowing fellows to perform live embryo transfers is not detrimental to clinical outcomes.

Outcomes of Frozen Oocyte Donor In Vitro Fertilization (IVF) Cycles Using Fresh Versus Frozen Sperm.

The ability to use frozen sperm for insemination during in vitro fertilization (IVF) is crucial for patients and for reproductive endocrinologists. However, concerns exist regarding the effects of cryopreservation on sperm quality and IVF outcomes. This study compares outcomes of frozen donor oocyte IVF cycles with intracytoplasmic sperm injection (ICSI) of good quality fresh versus frozen ejaculated sperm. Patients who underwent their first frozen donor oocyte IVF cycle between 2013 and 2019 at Mayo Clinic were identified. The primary outcome was live birth rate (LBR). Secondary outcomes included fertilization rate (FR), blastocyst development rate (BR), and clinical pregnancy rate (CPR). Twenty-six patients used fresh sperm and 19 patients utilized frozen sperm; there were no significant demographic differences between the groups. There were no significant differences noted in CPR, FR, and BR. Although the LBR was not statistically different when frozen versus fresh sperm was utilized (52.6% vs. 61.5%, p = 0.55), there was a distinct trend towards improved outcomes with fresh sperm that may be clinically significant. This data suggests that frozen sperm may be an alternative to a fresh sample, however fresh sperm may ultimately be a better option. This finding should be further explored with studies utilizing a larger sample size.

Effects of prophylactic indomethacin on intraventricular hemorrhage and adverse outcomes in neonatal intensive care unit.

OBJECTIVE: To identify the relationship between prophylactic indomethacin (PI) administration and incidence of intraventricular hemorrhage. STUDY DESIGN: A retrospective analysis of extremely premature infants <27 weeks gestational age born between January 2014 and September 2020. RESULTS: A total of 421 infants were included from three of Nationwide Children's Hospital delivery centers. Of those 255 (61%) received PI. After adjustment by inverse proportionality treatment weighting (IPTW), no differences were found in incidence of intraventricular hemorrhage (IVH) at the time of the first ultrasound, 31% vs. 33% in PI and control groups respectively (p = 0.68). The rate of rise of serum creatinine from baseline to day of life four was significantly higher in the PI group (0.14 mg/dl PI and 0.03 mg/dl control, p < 0.001). CONCLUSION: PI was not associated with any benefit in prevention of IVH, but is associated with adverse effects including acute rise in creatinine.

Platelet-derived exosomes induce cell proliferation and wound healing in human endometrial cells.

Aim: To investigate the regenerative effects of a platelet-derived purified exosome product (PEP) on human endometrial cells. Materials & methods: Endometrial adenocarcinoma cells (HEC-1A), endometrial stromal cells (T HESC) and menstrual blood-derived stem cells (MenSC) were assessed for exosome absorption and subsequent changes in cell proliferation and wound healing properties over 48 h. Results: Cell proliferation increased in PEP treated T HESC (p < 0.0001) and MenSC (p < 0.001) after 6 h and in HEC-1A (p < 0.01) after 12 h. PEP improved wound healing after 6 h in HEC-1A (p < 0.01) and MenSC (p < 0.0001) and in T HESC between 24 and 36 h (p < 0.05). Conclusion: PEP was absorbed by three different endometrial cell types. PEP treatment increased cell proliferation and wound healing capacity.

The uterus has a remarkable ability to heal itself. Every month the inside lining of the uterus grows in preparation for pregnancy and sheds if no pregnancy occurs. Unfortunately, this cycle of growth, shedding and repair can be injured and lead to menstrual changes, pain or even infertility. In this study, we looked how special cell messengers ­ called exosomes ­ could help uterine cells. Exosomes are special messengers that contain substances to help the body heal and regenerate injured cells and tissues. We obtained exosomes created from human transfusion-grade platelets. We studied the exosomes' effects in three different cell types that all are important inside the uterine lining. Specifically, we studied the ability of the exosomes to help cells proliferate and migrate into a wound. In this study, exosomes were recognized by the human endometrial cells and were absorbed. Once they were inside the cells, they increased cell proliferation as well as the ability of the cells to heal a scratch wound. Furthermore, the more exosomes we presented to the cells, the more the cells were able to proliferate and move into a wound for healing. These findings lay the groundwork for future studies in animal models of uterine injury.

Emerging oral therapies for multiple sclerosis.

Despite notable advances in the understanding of multiple sclerosis (MS) and the availability of several treatment options, there is a need for therapies that are more effective, safe, convenient, and well tolerated. Several new oral MS therapies are being investigated. Because data on these new therapies continue to emerge, nurses will play a pivotal role in educating patients regarding the benefits and risks of potential treatments and in monitoring patients for response, safety, tolerability, and adherence. This article reviews the oral MS therapies recently approved as well as those currently in development or submitted for Food and Drug Administration approval.

An integrated approach to worker self-management and health outcomes: chronic conditions, evidence-based practice, and health coaching.

Employee health, prevention, and maintenance programs are growing exponentially each year as costs continue to rise across the health care continuum. Employers and payers alike continue to be challenged by chronic health risks, effective prevention strategies, optimal health and wellness strategies, and programs that are effective for America's work force. In light of these challenges, new and exciting health management approaches are evolving. Changes in occupational health nursing practice can ultimately affect the way occupational health nurses plan, structure, and conduct education sessions. New trends, such as health coaching, embrace the incorporation of health research through evidence-based practice and standards of care to provide the science clinicians need to support interventions. Through knowledge of chronic conditions, evidence-based practice, and health coaching, occupational health nurses possess the skills and strategies that form the foundation necessary to affect and safely guide employee self-discovery and self-management and produce optimal health outcomes.

Three degrees of separation: complete uterine and cervical septa.

OBJECTIVE: To review the diagnosis and management of 3 variations of incomplete müllerian duct fusion and reabsorption. DESIGN: Narrated video delineating the surgical management of 3 müllerian anomalies; this video was deemed exempt from review by the institutional review board of the Mayo Clinic. SETTING: Tertiary care academic medical center. PATIENT(S): This video focuses on 3 müllerian anomalies: complete septate uterus with a single septate cervix (septate uterus unicollis); complete septate uterus with duplicated cervix (septate uterus bicollis); and complete duplication of the uterus and cervix (uterine didelphys). INTERVENTION(S): Magnetic resonance imaging (MRI), cervical septoplasty, operative hysteroscopy, and uterine septoplasty. MAIN OUTCOME MEASURE(S): Several variations of uterine malformations exist. In our practice, we differentiate complete septate uteri as either unicollis or bicollis via MRI and vaginal examination. The bicollis presentation can be identified on MRI by the "lambda sign," which is seen as the 2 cervices that diverge as they enter the vagina. This is in comparison with the unicollis presentation when the single septate cervix can be traced with parallel lines as it enters the vagina. The circle method is described in this video to help distinguish between a single and duplicated cervix on examination. RESULT(S): The cervical and uterine septa were resected completely in the patient with a complete septate uterus unicollis. In contrast, the uterine septum was resected completely and the 2 cervical canals were not incised in the case of the complete septate uterus bicollis. Although uterine and cervical septa resection is controversial, our practice is to avoid the incision of the 2 cervical canals in cases that are more clearly consistent with a bicollis classification. CONCLUSION(S): Müllerian anomalies represent a continuum of disorders caused by different degrees of disruption in embryogenesis. MRI with vaginal gel and vaginal examination are tools to help classify the anomaly and guide surgical management.