Robotic sacrocolpopexy with medial umbilical ligament autologous graft to treat neovaginal prolapse in a transgender woman.

Vaginoplasty is commonly performed to treat gender dysphoria in transgender women. Neovaginal prolapse is a late complication of vaginoplasty, and there is minimal literature regarding its surgical management. We report a case of robotic sacrocolpopexy using medial umbilical ligament autologous graft to treat neovaginal prolapse in a transgender woman, which is a novel technique that has not been previously described. The procedure resulted in a good postoperative outcome for the patient. The innovative use of medial umbilical ligament autologous graft enabled the patient to benefit from a fully minimally invasive procedure whilst avoiding the risks associated with synthetic mesh.

Transient expression of antinuclear RNP-A antibodies in patients with acute COVID-19 infection.

Introduction: Viral infections have been implicated in the initiation of the autoimmune diseases. Recent reports suggest that a proportion of patients with COVID-19 develop severe disease with multiple organ injuries. We evaluated the relationship between COVID-19 severity, prevalence and persistence of antinuclear and other systemic and organ specific autoantibodies as well as SARS-CoV-2 infection specific anti-nucleocapsid (N) IgG antibodies and protective neutralizing antibody (Nab) levels. Methods: Samples from 119 COVID-19 patients categorized based on their level of care and 284 healthy subjects were tested for the presence and persistence of antinuclear and other systemic and organ specific autoantibodies as well as SARS-CoV-2 and neutralizing antibody levels. Results: The data shows significantly increased levels of anti RNP-A, anti-nucleocapsid and neutralizing antibody among patients receiving ICU care compared to non-ICU care. Furthermore, subjects receiving ICU care demonstrated significantly higher nucleocapsid IgG levels among the RNP-A positive cohort compared to RNP-A negative cohort. Notably, the expression of anti RNP-A antibodies is transient that reverts to non-reactive status between 20 and 60 days post symptom onset. Conclusions: COVID-19 patients in ICU care exhibit significantly higher levels of transient RNP-A autoantibodies, anti-nucleocapsid, and SARS-CoV-2 neutralizing antibodies compared to patients in non-ICU care.

Evaluation of Neutralizing Antibodies against SARS-CoV-2 Variants after Infection and Vaccination Using a Multiplexed Surrogate Virus Neutralization Test.

BACKGROUND: The SARS-CoV-2 virus has mutated and evolved since the inception of the COVID-19 pandemic bringing into question the future effectiveness of current vaccines and antibody therapeutics. With evolution of the virus updated methods for the evaluation of the immune response in infected and vaccinated individuals are required to determine the durability of the immune response to SARS-CoV-2 variants. METHODS: We developed a multiplexed surrogate virus neutralization test (plex-sVNT) that simultaneously measures the ability of antibodies in serum to inhibit binding between angiotensin converting enzyme-2 (ACE2) and 7 SARS-CoV-2 trimeric spike protein variants, including wild type, B.1.1.7(α), B.1.351(ß), P.1(γ), B.1.617.2(δ), B.1.617.1(κ), and B.1.429(ε). The assay was validated against a plaque reduction neutralization test (PRNT).We evaluated 170 samples from 97 COVID-19 patients and 281 samples from 188 individuals that received the Pfizer-BioNTech or Moderna mRNA vaccines. RESULTS: The plex-sVNT demonstrated >96% concordance with PRNT. Antibody neutralization activity was significantly reduced for all SARS-CoV-2 variants compared to wild type in both the infected and vaccinated cohorts. There was a decline in overall antibody neutralization activity, within both cohorts, out to 5 months post infection or vaccination, with the rate of decline being more significant for the vaccinated. CONCLUSIONS: The plex-sVNT provides a correlative measure to PRNT and a convenient approach for evaluating antibody neutralization against SARS-CoV-2 variants. Neutralization of SARS-CoV-2 variants is reduced compared to wild type and declines over the ensuing months after exposure or vaccination within each cohort, however it is still unknown what degree of neutralizing capacity is protective.

Reversal of colpocleisis-A surgical technique for recurrent pelvic organ prolapse.

Given the rarity of recurrent pelvic organ prolapse after obliterative procedures and the paucity of data in the literature on this topic, optimal management is challenging. We describe a technique of reversal of colpocleisis in an 81-year-old woman with recurrent prolapse as the first step in a staged, reconstructive procedure. Basic principles underlying our approach include multidisciplinary team involvement, detailed preoperative planning, and a series of investigations including different imaging modalities and a meticulous stepwise surgical technique. The distortion of anatomical planes, anticipated scarring, and close proximity of pelvic organs specifically bladder and rectum are important considerations. In our case, the multidisciplinary surgical team included urogynecologists, a urologist, and a colorectal surgeon. Detailed preoperative planning was agreed following multiple patient and team consultations. Preoperative investigations included ultrasound and videourodynamics. Intraoperatively, cystoscopy and sigmoidoscopy were performed to identify anatomical landmarks and planes, rule out fistulae, and evaluate for anatomical distortions involving pelvic organs. Subsequently, reversal of the colpocleisis was undertaken and uneventful. Postoperative recovery was uncomplicated and a sacrospinous fixation, anterior vaginal repair, and perineorrhaphy were performed as a secondary restorative procedure for the correction of recurrent prolapse.

Intravesical onabotulinumtoxinA injections in patients on antiplatelet and anticoagulation therapy.

AIMS: To determine the bleeding risk in patients taking anticoagulants (AC) and antiplatelets (AP) before onabotulinumtoxinA (BoNT-A) injections and improve peri-operative decision making and counseling. METHODS: We performed a retrospective review of patients having intravesical BoNT-A in three teaching hospitals from January 2016 to July 2018. Demographic data, indication for intravesical BoNT-A injection, and side-effects of significant bleeding requiring intervention were recorded. RESULTS: Five hundred and thirty-two patients had intravesical BoNT-A injections during this time. Sixty-three patients of mean age 69 years (range 19-89) had a total of 114 separate rounds of BoNT-A injections whilst on treatment dose AC/AP therapy. Of the 63, there were 33 males, with 46 having idiopatic detrusor overactivity and 17 with neurogenic detrusor overactivity. Each patient had between 1 and 7 repeat injections during the studied period. AC/AP use across the 114 episodes included; aspirin 44, clopidogrel 37, warfarin 19, and NOAC (novel/non-vitamin K oral anticoagulant) 14. Patients on warfarin who had point of care testing all had international normalized ratio less than 3. BoNT-A dose varied from 100U to 300U-modal dosage was 200U.1/114(0.88%) injection episodes resulted in postinjection hematuria requiring overnight admission. This resolved spontaneously, with an overnight catheter. This patient was on rivaroxaban and had 300U of BoNT-A injected through 20 sites, on a background of previous prostate radiotherapy and self-catheterization. CONCLUSIONS: Continuation of AP/AC therapy during intravesical BoNT-A injection treatment appears to be safe-with a 0.88% rate of spontaneously resolving hematuria.

Open removal of a migrated Gellhorn pessary and repair of a vesicovaginal fistula.

This is a case of a 91-year-old woman presenting with urinary incontinence following insertion of a Gellhorn pessary 10 months previously. She had unfortunately missed her 6 months appointment for a change of pessary as she was admitted to hospital. Our patient was found to have had erosion of her Gellhorn shelf pessary into her urinary bladder. She underwent an open removal of the migrated Gellhorn pessary in the bladder and repair of the vesicovaginal fistula with omental interposition. She recovered well and has elected to keep her suprapubic catheter long-term.

A Fully Automated Multiplex Assay for Diagnosis of Lyme Disease with High Specificity and Improved Early Sensitivity.

Lyme borreliosis is a tick-borne disease caused by the Borrelia burgdorferisensu lato complex. Bio-Rad Laboratories has developed a fully automated multiplex bead-based assay for the detection of IgM and IgG antibodies to B. burgdorferi The BioPlex 2200 Lyme Total assay exhibits an improved rate of seropositivity in patients with early Lyme infection. Asymptomatic subjects from endemic and nonendemic origins demonstrated a seroreactivity rate of approximately 4% that was similar to other commercial assays evaluated in this study. Coupled to this result was the observation that the Lyme Total assay retained a high first-tier specificity of 96% while demonstrating a relatively high sensitivity of 91% among a well-characterized CDC Premarketing Lyme serum panel. The Lyme Total assay also performs well under a modified two-tier algorithm (sensitivity, 84.4 to 88.9%; specificity, 98.4 to 99.5%). Furthermore, the new assay is able to readily detect early Lyme infection in patient samples from outside North America.

The use of urethral bulking injections in post-prostatectomy stress urinary incontinence: A narrative review of the literature.

AIMS: Post-prostatectomy stress urinary incontinence (PPI) is a common condition with significant impact on patient quality of life. With rising numbers of prostatectomies performed, recognition of incontinence during survivorship care is growing. With increasing hesitance of the use of suburethral mesh in females, urethral bulking injections in this patient population as a minimally invasive alternative to surgery are evaluated. This review aims to evaluate the existing evidence base for urethral bulking therapy in PPI and provide a summary of its efficacy, durability, and side-effect profile. METHODS: A literature search of Medline/Pubmed and Cochrane databases was conducted to identify publications reporting the clinical outcomes of urethral bulking injections in patients with PPI, up to and including October 1st, 2018. Case reports, letters and reviews were excluded. RESULTS: We identified 25 studies that fit our inclusion criteria, comprised of one RCT, two large retrospective cohort studies, and 22 case series. The success rates reported varying widely from 13%-100% with reports of symptomatic control deterioration. Complication rates remain low. This review highlighted a poor performance using the more historic bulking agents (BA), and the lack of strong evidence with the more novel BA in PPI and discussed challenges regarding optimal patient selection and techniques. CONCLUSIONS: There exists poor clinical evidence base concerning the use of urethral bulking in PPI with few high-level studies and a significant lack of consistency between studies. Further study in this area is required to evaluate the role of BA in this patient population.

Clinical and Patient-reported Outcome Measures in Men Referred for Consideration of Surgery to Treat Lower Urinary Tract Symptoms: Baseline Results and Diagnostic Findings of the Urodynamics for Prostate Surgery Trial; Randomised Evaluation of Assessment Methods (UPSTREAM).

BACKGROUND: Clinical evaluation of male lower urinary tract symptoms (MLUTS) in secondary care uses a range of assessments. It is unknown how MLUTS evaluation influences outcome of therapy recommendations and choice, notably urodynamics (UDS; filling cystometry and pressure flow studies). OBJECTIVE: To report participants' sociodemographic and clinical characteristics, and initial diagnostic findings of the Urodynamics for Prostate Surgery Trial; Randomised Evaluation of Assessment Methods (UPSTREAM). UPSTREAM is a randomised controlled trial evaluating whether symptoms are noninferior and surgery rates are lower if UDS is included. DESIGN, SETTING, AND PARTICIPANTS: A total of 820 men (≥18 yr of age) seeking treatment for bothersome LUTS were recruited from 26 National Health Service hospital urology departments. INTERVENTION: Care pathway based on routine, noninvasive tests (control) or routine care plus UDS (intervention arm). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome is International Prostate Symptom Score (IPSS) and the key secondary outcome is surgery rates 18 mo after randomisation. International Consultation on Incontinence Questionnaires were captured for MLUTS, sexual function, and UDS satisfaction. Baseline clinical and patient-reported outcome measures (PROMs), and UDS findings were informally compared between arms. Trends across age groups for urinary and sexual PROMs were evaluated with a Cuzick's test, and questionnaire items were compared using Pearson's correlation coefficient. RESULTS AND LIMITATIONS: Storage LUTS, notably nocturia, and impaired sexual function are prominent in men being assessed for surgery. Sociodemographic and clinical evaluations were similar between arms. Overall mean IPSS and quality of life scores were 18.94 and 4.13, respectively. Trends were found across age groups, with older men suffering from higher rates of incontinence, nocturia, and erectile dysfunction, and younger men suffering from increased daytime frequency and voiding symptoms. Men undergoing UDS testing expressed high satisfaction with the procedure. CONCLUSIONS: Men being considered for surgery have additional clinical features that may affect treatment decision making and outcomes, notably storage LUTS and impaired sexual function. PATIENT SUMMARY: We describe initial assessment findings from a large clinical study of the treatment pathway for men suffering with bothersome urinary symptoms who were referred to hospital for further treatment, potentially including surgery. We report the patient characteristics and diagnostic test results, including symptom questionnaires, bladder diaries, flow rate tests, and urodynamics.

A novel algorithm to improve specificity in ovarian cancer detection.

BACKGROUND: Measurement of autoantibodies (AAbs) to tumor associated antigens has been proposed to aid in the early detection of ovarian cancer with high specificity. Here we describe a multiplex approach to evaluate selected peptide epitopes of p53 protein, and propose a novel approach to increase specificity and potentially sensitivity for discrimination between healthy women and women with cancerous masses. MATERIALS AND METHODS: 20-mer overlapping peptide epitopes of p53, generated by mapping the complete p53 sequence, were evaluated in a multiplex immunoassay for their detection of serum AAbs in patients with ovarian cancer, using Luminex technology. AAbs to the selected peptides and to p53 full length protein were then detected in a multiplex immunoassay evaluating 359 sera from healthy women and 285 sera from patients with early and late stage ovarian cancer. CA-125 levels were measured in all p53 AAb-positive sera. RESULTS: We considered the AAb results together to identify sera where both the full length protein and at least one selected peptide epitope were positive and chose cutoffs that reduced false positives from these AAbs to 1/359 samples, improving specificity. Using this combined approach, we could identify 7 AAb-positive patients that were negative for CA-125 (concentrations below 35 IU/mL); this represents 26% of the p53 positive patients in the total population. CONCLUSION: By detecting p53 AAbs in CA-125-negative sera, we demonstrated that combining measurement of AAbs to the full length p53 protein and one or more selected epitopes can potentially improve sensitivity and specificity for ovarian cancer detection.

Case of acute severe postpartum urinary incontinence: an extravesical subsphincteric prolapsed ureterocoele.

A 32-year-old woman presents to outpatients 10 days postpartum, with symptoms of an intermittent vaginal lump and urinary incontinence. Vaginal examination revealed no demonstrable prolapse or stress incontinence. A swelling in the bladder was noted during an antenatal scan suggesting a ureterocoele. She was referred for pelvic floor physiotherapy in the first instance. Forty-eight hours later, she represented to casualty with discomforting vaginal lump symptoms and continuous urinary incontinence. At this stage on vaginal inspection, there was an evident dusky lump emerging from the urethra with continuous incontinence. An extravesical subsphincteric prolapsed ureterocoele was evident, 5 cm beyond the external urethral meatus. The diagnosis was confirmed with an MRI scan which demonstrated the prolapsed obstructing ureterocoele causing significant left-sided hydroureteronephrosis. The ureterocoele was managed with a cystoscopy and transurethral incision of the ureterocoele under anaesthesia, which facilitated drainage and resolution. At 3-month postoperatively, the patient remains continent and satisfied.

Effects of energetic ion irradiation on WSe2/SiC heterostructures.

The remarkable electronic properties of layered semiconducting transition metal dichalcogenides (TMDs) make them promising candidates for next-generation ultrathin, low-power, high-speed electronics. It has been suggested that electronics based upon ultra-thin TMDs may be appropriate for use in high radiation environments such as space. Here, we present the effects of irradiation by protons, iron, and silver ions at MeV-level energies on a WSe2/6H-SiC vertical heterostructure studied using XPS and UV-Vis-NIR spectroscopy. It was found that with 2 MeV protons, a fluence of 1016 protons/cm2 was necessary to induce a significant charge transfer from SiC to WSe2, where a reduction of valence band offset was observed. Simultaneously, a new absorption edge appeared at 1.1 eV below the conduction band of SiC. The irradiation with heavy ions at 1016 ions/cm2 converts WSe2 into a mixture of WOx and Se-deficient WSe2. The valence band is also heavily altered due to oxidation and amorphization. However, these doses are in excess of the doses needed to damage TMD-based electronics due to defects generated in common dielectric and substrate materials. As such, the radiation stability of WSe2-based electronics is not expected to be limited by the radiation hardness of WSe2, but rather by the dielectric and substrate.

Arthroscopic Approach to Osteochondral Defects, Impingement, and Instability.

Osteochondral defects, impingement, and instability of the ankle are common injuries in athletes. In this article, we review these diagnoses and their treatment options, with a focus on arthroscopic approaches. The treatment options continue to evolve, supported by innovation and outcome studies. In this article, we describe the advantages and disadvantages of both open and arthroscopic treatments using published evidence.

Identification of anticitrullinated protein antibody reactivities in a subset of anti-CCP-negative rheumatoid arthritis: association with cigarette smoking and HLA-DRB1 'shared epitope' alleles.

INTRODUCTION: A hallmark of rheumatoid arthritis (RA) is the development of autoantibodies targeting proteins that contain citrulline. Anticitrullinated protein antibodies (ACPAs) are currently detected by the commercial cyclic citrullinated peptide (CCP) assay, which uses a mix of cyclised citrullinated peptides as an artificial mimic of the true antigen(s). To increase the sensitivity of ACPA detection and dissect ACPA specificities, we developed a multiplex assay that profiles ACPAs by measuring their reactivity to the citrullinated peptides and proteins derived from RA joint tissue. METHODS: We created a bead-based, citrullinated antigen array to profile ACPAs. This custom array contains 16 citrullinated peptides and proteins detected in RA synovial tissues. We used the array to profile ACPAs in sera from a cohort of patients with RA and other non-inflammatory arthritides, as well as sera from an independent cohort of RA patients for whom data were available on carriage of HLA-DRB1 'shared epitope' (SE) alleles and history of cigarette smoking. RESULTS: Our multiplex assay showed that at least 10% of RA patients who tested negative in the commercial CCP assay possessed ACPAs. Carriage of HLA-DRB1 SE alleles and a history of cigarette smoking were associated with an increase in ACPA reactivity-in anti-CCP(+) RA and in a subset of anti-CCP(-) RA. CONCLUSIONS: Our multiplex assay can identify ACPA-positive RA patients missed by the commercial CCP assay, thus enabling greater diagnostic sensitivity. Further, our findings suggest that cigarette smoking and possession of HLA-DRB1 SE alleles contribute to the development of ACPAs in anti-CCP(-) RA.

An investigation of prescription and over-the-counter supply of ophthalmic chloramphenicol in Wales in the 5 years following reclassification.

OBJECTIVES: The aims of the study were to (i) quantify the sales of over-the-counter (OTC) ophthalmic chloramphenicol from all community pharmacies in Wales and investigate the impact on primary care prescriptions up to 5 years after reclassification and (ii) investigate the temporal relationship between items supplied OTC and on NHS primary care prescriptions. METHODS: Primary care prescription data (2004-2010) and OTC sales data (2005-2010) for ophthalmic chloramphenicol were obtained. The quantity sold OTC was calculated from pharmacy wholesale records and sales data from a large pharmacy multiple. Spearman's rank correlation for prescription and OTC supplies of ophthalmic chloramphenicol was calculated for data from January 2008 to December 2010. KEY FINDINGS: OTC supply of chloramphenicol eye drops and ointment were both highest in 2007-2008 and represented 68% (57,708/84,304) and 48% (22,875/47,192) of the corresponding prescription volume, respectively. There was a steady year-on-year increase in the combined supply of OTC ophthalmic chloramphenicol and that dispensed on prescription from 144,367 items in 2004-2005 to 210,589 in 2007-2008 before stabilising in 2008-2009 and 2009-2010. A significant positive correlation was observed between prescription items and OTC sales of chloramphenicol eye drops and ointment combined (r=0.7, P<0.001). CONCLUSION: OTC availability increased the total quantity of ophthalmic chloramphenicol supplied in primary care compared to that seen prior to reclassification. Although growth in the sales of ophthalmic chloramphenicol OTC has stabilised and the supply pattern mirrors primary care prescribers, further work is required to investigate whether use is appropriate and whether the publication of updated practice guidance has changed this.

Prescribing and sale of ophthalmic chloramphenicol following reclassification to over-the-counter availability.

OBJECTIVES: The impact of over-the-counter (OTC) availability of chloramphenicol eye drops and eye ointment was investigated on the prescribing and overall supply of ophthalmic chloramphenicol in primary care. METHODS: Primary care prescription data for ophthalmic chloramphenicol and ophthalmic antibacterials in England and Wales were analysed from December 2003 (month 1) to September 2008 (month 58). OTC data were analysed from June 2005 when the first OTC product was launched (months 19 to 58). KEY FINDINGS: In the 40 months following reclassification more than 2.9 million packs (53.9 per 1000 population) of chloramphenicol were sold in England and 152024 (51.7 per 1000 population) in Wales. In the 12 months to September 2008 sales of the drops and ointment were 67 and 40% of their respective prescription volumes in England. In Wales sales of drops were 52% and ointment 26% of their respective prescription volumes. The number of chloramphenicol packs sold was 2.2 times greater than the calculated reduction in ophthalmic antibacterial prescription items in England and 2.9 times greater than the reduction seen in Wales. CONCLUSION: Following the reclassification of chloramphenicol there have been significant increases in the supply of the ophthalmic antibacterials in both England and Wales.

The prescribed duration algorithm: utilising 'free text' from multiple primary care electronic systems.

PURPOSE: To develop and test an algorithm that translates total dose and daily regimen, inputted as 'free text' on a prescription, into numerical values to calculate the prescribed treatment duration. METHOD: The algorithm was developed using antibiotic prescriptions (n = 711,714) from multiple primary care computer systems. For validation, the prescribed treatment duration of an independent sample of antibiotic scripts was calculated in two ways: (a) computer algorithm, (b) manually reviewed by a researcher blinded to the results of (a). The outputs of the two methods were compared and the level of agreement assessed, using confidence intervals for differences in proportions. This was repeated on sample of antidepressant scripts to test generalisability of the algorithm. RESULTS: For the antibiotic prescriptions, the algorithm processed 98.5% with an accuracy of 99.8% and the manual review processed 98.5% with 98.9% accuracy. The differences between these proportions are 0.0% (95%CI of -0.9, 0.9%) and 1.0% (95%CI of -0.1, 2.3%), respectively. For the antidepressant prescriptions, the algorithm processed 91.5% with an accuracy of 96.6% compared to the manual review with 96.4% processed and 99.8% accuracy; difference between these proportions is 4.9% (95%CI of 2.0, 8.0%) and 3.2% (95%CI of 1.6, 5.3%), respectively. CONCLUSION: The algorithm proved to be applicable and efficient for assessing prescribed duration, with sensitivity and specificity values close to the manual review, but with the added advantage that the computer can process large volume of scripts rapidly and automatically.