Health Care Professionals' Reports of Cancer Pain Cues Among Older People With Delirium: A Qualitative-Quantitative Content Analysis.

CONTEXT: Health care professionals (HCPs) currently judge pain presence and intensity in patients with delirium despite the lack of a valid, standardized assessment protocol. However, little is known about how they make these judgments. This information is essential to develop a valid and reliable assessment tool. OBJECTIVES: To identify pain cues that HCPs report to judge pain in patients with delirium and to examine whether the pain cues differed based on patient cognitive status and delirium subtype. METHODS: Mixed qualitative-quantitative design. Doctors and nurses were recruited. All participants provided written informed consent, and before the recorded interview, demographic information was collected; then participants were asked to describe their practices and beliefs regarding pain assessment and management with older patients who are cognitively intact and patients with delirium. Interviews were transcribed verbatim and coded for pain cues. Coded data were imported into SPSS software (IBM SPSS Statistics Version 24; IBM Corporation, Armonk, NY) to conduct bivariate analyses. RESULTS: The pain cue self-report was stated more often for intact than for delirium patients (χ2 [1; N = 106] = 22.56; P < 0.001). HCPs stated yelling (χ2 [2; N = 159] = 11.14; P = 0.004), when describing pain in hyperactive than in hypoactive and mixed delirium patients; and significantly more HCPs stated grimace (χ2 [2; N = 159] = 6.88; P = 0.03), when describing pain in hypoactive than hyperactive and mixed patients. CONCLUSION: This study outlines how HCPs conduct pain assessment in patients who are delirious and, also, identifies pain behavior profiles for the subtypes of delirium.

Respite needs of families receiving palliative care.

AIM: The care of a child with a life-limiting condition proves an emotional, physical and financial strain on the family that provides care for their child. Respite care is one way which allows carers to receive some relief and support in the context of this burden of care. The provision of and the requirements for respite in this context is poorly understood. This survey aims to describe the types of respite care families receive, the respite that they would ideally receive and the barriers that prevent this. METHODS: A cohort of 34 families cared for by the Paediatric Palliative Care Service in Queensland were approached to participate in a 20-question survey about their current respite preferences for future respite, with 20 surveys returned. RESULTS: Three of the families (15%) reported receiving no respite in the previous 12 months. Families who received respite received a combination of formal respite (a structured care provider) and informal respite (family or friends). Ten families (50%) reported that they would want the time of respite changed. Barriers to receiving adequate respite included complexity of care of the child, financial barriers and lack of a respite provider. CONCLUSIONS: There is disparate provision of respite care with the main perceived barrier to attaining 'ideal respite' being the lack of a provider able to meet the complex care needs of their child. The provision of respite across diversity in geography; medical condition; social and cultural needs remains a challenge.

Impact of sacral colpopexy on in vivo vaginal biomechanical properties.

OBJECTIVE: The purpose of this study was to determine if sacral colpopexy has an impact on in vivo vaginal biomechanical properties. STUDY DESIGN: Thirty-five participants who underwent sacral colpopexy were enrolled in this prospective clinical trial. In vivo vaginal biomechanical properties, including elasticity, viscoelasticity, and vaginal stiffness index, as well as symptom severity questionnaires (pelvic floor distress inventory-short form) and Pelvic Organ Prolapse Quantification (POP-Q) examination, were performed preoperatively and 6 weeks postoperatively. RESULTS: Thirty-two participants completed the study. Six weeks after sacral colpopexy participants demonstrated a decrease in prolapse related symptoms (POPDI-6 score, 39.8 vs 9.0, P < .00001) and 97% demonstrated anatomical cure of their prolapse. At 6 weeks follow-up participants demonstrated an increase in elasticity (2.26 vs 3.43, P < .00001), viscoelasticity (1.55 vs 4.08, P < .000001), and vaginal stiffness index (108.65 vs 164.50, P < .01). CONCLUSION: These findings suggest that sacral colpopexy increases in vivo vaginal biomechanical properties, as well as decreasing anatomical and symptom-related severity of pelvic organ prolapse.

Proteomic techniques identify urine proteins that differentiate patients with interstitial cystitis from asymptomatic control subjects.

OBJECTIVE: The purpose of this study was to identify differences in urine proteins between patients with interstitial cystitis (IC) and asymptomatic control (AC) subjects with the use of proteomic techniques. STUDY DESIGN: Nine patients with IC and their age-, race-, and sex-matched AC subjects volunteered a urine specimen. Urine proteins were separated with the use of 2-dimensional polyacrylamide gels. Differing proteins underwent digestion and matrix-assisted laser desorption ionization-time of flight mass spectrometry. Computer-assisted data analysis was used to identify the corresponding protein. Differences in urine protein responses between patients with IC and AC subjects were evaluated by the Mann-Whitney U test to account for the nonnormal frequency distribution of the parameter estimate or chi-square when data were bimodal. RESULTS: Four proteins differed significantly between patients with IC and AC subjects. The AC subjects had a greater concentration of a uromodulin (P = .019) and two kininogens (P = .023, .046). The patients with IC had a greater concentration of inter-alpha-trypsin inhibitor heavy chain H4 (P = .019). CONCLUSION: These urine protein isoforms may be biomarkers for IC.

Correlation between vaginal stiffness index and pelvic floor disorder quality-of-life scales.

The objective of this study was to determine if vaginal stiffness index, an in vivo vaginal biomechanical property, is correlated with pelvic floor disorder symptom distress, impact on quality of life, or sexual function as measured by disease-specific quality-of-life scales. Forty-eight women completed validated quality-of-life scales (pelvic floor distress inventory-short form, pelvic floor impact questionnaire, and pelvic organ prolapse/urinary incontinence sexual questionnaire) and underwent in vivo vaginal biomechanical testing. After bivariate relationships between vaginal stiffness index and demographic, obstetric, and gynecologic variables were explored, multiple linear regression controlling for pelvic organ prolapse quantitative (POP-Q) stage of prolapse was performed. The vaginal stiffness index was inversely correlated with pelvic organ prolapse distress severity (POPDI-6) after controlling for POP-Q stage of prolapse (p = 0.011, r = 0.67, r (2) = 0.450, beta = -2.3). These findings provide initial evidence for the construct validity of in vivo vaginal biomechanical testing for pelvic organ prolapse evaluation because an increasing vaginal stiffness index is correlated with decreasing symptomatic and anatomic severity of disease.

Systemic and vaginal biomechanical properties of women with normal vaginal support and pelvic organ prolapse.

OBJECTIVE: The objective of the study was to compare the biomechanical properties of vaginal and systemic skin in women with and without pelvic organ prolapse. STUDY DESIGN: In this cross-sectional study, 25 women with pelvic organ prolapse and 23 age-matched women with normal pelvic support were recruited from an office setting. A Cutometer MPA 580 and DermaLab skin probe were used to measure systemic biomechanical parameters and a 1.5 mm offset DermaLab skin probe was used for vaginal biomechanical measurements. RESULTS: There were no significant differences in the baseline demographic, obstetrical, or gynecologic information between the 2 groups. There were no significant differences in the systemic biomechanical parameters between the 2 groups. Women with pelvic organ prolapse had significantly more extensible vaginal skin than women with normal pelvic support (initial stiffness index 7.3 vs 10.9 kpa, final stiffness index 5.9 vs 10.7 kpa; all P values less than .01). Furthermore, vaginal extensibility was related to pelvic organ prolapse quantification stage in a linear fashion. CONCLUSION: Our findings suggest that local, rather than systemic, alterations in biomechanical skin properties are associated with pelvic organ prolapse.

Construct validity of the incontinence severity index.

AIMS: To assess the construct validity of the incontinence severity index (ISI) by testing its correlation with two health-related quality of life measures, the short forms of the Urogenital Distress Inventory (UDI-6) and the Incontinence Impact Questionnaire (IIQ-7), in women with urodynamic stress incontinence. MATERIALS AND METHODS: A cohort of 170 women with the urodynamic stress incontinence who underwent corrective surgery completed the ISI, IIQ-7, and the UDI-6 both pre- and post-treatment. We correlated the pre- and post-treatment responses between the ISI, the IIQ-7, the UDI-6 and their subscales. We also assessed the sensitivity of the ISI to change by correlating the percent change in score between the three instruments. The results were analyzed using a non-parametric test of correlation, the Spearman's rho. RESULTS: The ISI scores were generally not well correlated with the pre-treatment IIQ-7 and UDI-6 scores (r < 0.40). The post-treatment scores and percent change from pre- to post-treatment of the ISI, however, were highly correlated with that of the IIQ-7 and UDI-6 (r's > 0.70, P < 0.001). The ISI was most highly correlated with the UDI-6 stress symptoms subscale and most poorly correlated with the UDI-6 obstructive/discomfort subscale. CONCLUSIONS: This study provides valuable insight into the construct validity of the ISI. Evidence of its convergent validity is found in the high correlation with the stress symptoms subscales of the UDI-6, while the poorer correlation with the obstructive subscale provides evidence of its divergent validity. These data also suggest that the ISI is highly sensitive to change seen with treatment.

A randomized controlled trial comparing fascia lata and synthetic mesh for sacral colpopexy.

OBJECTIVE: To compare the objective anatomic outcomes after sacral colpopexy performed with cadaveric fascia lata and polypropylene mesh. METHODS: Patients undergoing a sacral colpopexy were randomized to receive either fascia lata or polypropylene mesh in a double-blinded fashion. Data were collected at 6 weeks, 3 months, 6 months, and 1 year postoperatively. The main outcome measures were pelvic organ prolapse quantification (POP-Q) system stage and individual POP-Q points over time. Objective anatomic failure was defined as POP-Q stage 2 or more at any point during the follow-up period. Proportions of patients with objective anatomic failure at 1 year in each group were compared using the chi(2) test. Mean POP-Q points and stage at 1 year were compared by using the independent samples t test. RESULTS: One hundred patients were randomized to receive either fascia (n = 46) or mesh (n = 54). Of the 89 patients returning for 1-year follow-up, 91% (41/45) of the mesh group and 68% (30/44) of the fascia group were classified as objectively cured (P = .007). We found significant differences between the mesh and fascia groups with respect to the 1-year postoperative comparisons of points Aa, C, and POP-Q stage. There were no differences between the 2 groups with respect to points TVL (total vaginal length), GH (genital hiatus), PB (perineal body), Ap or Bp (2 points along the posterior vaginal wall). CONCLUSIONS: Polypropylene mesh was superior to fascia lata in terms of POP-Q points, POP-Q stage, and objective anatomic failure rates. LEVEL OF EVIDENCE: I.

Is the cough-stress test necessary when placing the tension-free vaginal tape?

OBJECTIVE: To estimate whether the mode of anesthesia (and the resultant ability or inability to perform the cough-stress test) used during the tension-free vaginal tape (TVT) procedure affects postoperative continence. METHODS: A cohort of 170 women who underwent the TVT procedure without any other concomitant surgery completed the short form of the Urogenital Distress Inventory (UDI-6) to assess their continence status preoperatively and postoperatively. Chi-squared, t, and Mann-Whitney U tests were used to determine the association between these data and anesthesia type during univariate analysis. RESULTS: Both anesthesia groups showed significant improvement from their preoperative UDI-6 scores to their postoperative scores. However, when comparing the change from pre- to postoperative UDI-Stress Symptoms subscale scores between the 2 groups, we found a significant difference. Mean improvement in the local group was 58.3 (+/- 33.8) compared with 41.7 (+/- 39.4) in the general group (P = .02). CONCLUSION: Women who undergo TVT show significant improvements in incontinence severity regardless of anesthesia type. However, greater improvements in stress incontinence, as measured by the UDI-Stress Symptoms subscale, are seen when the TVT is placed while using the cough-stress test under local analgesia. LEVEL OF EVIDENCE: II-2.

Is the leak point pressure alone an accurate indicator of intrinsic sphincteric deficiency?

The aim of this study was to determine the characteristics of women who meet the criteria for intrinsic sphincteric deficiency (ISD) on maximum urethral closure pressure (MUCP) but not on leak point pressure (LPP) measurement. We performed a cross-sectional chart review of every patient who underwent multichannel, microtransducer urodynamic testing in our center between 1994 and 1996 (n=423). From this population we culled a sub-population of women who fit into one of the following two groups: women with no evidence of ISD on MUCP or LPP and women with evidence of ISD on MUCP only. Logistic regression was used to identify independent predictors of group membership. Increasing age (>60.5 years) and a positive supine empty stress test were the only independent predictors of membership in the group of women with ISD on MUCP only. Knowledge of these risk factors may help clinicians in choosing appropriate pre-operative testing.

Bacterial colony counts during vaginal surgery.

OBJECTIVE: To describe the bacterial types and colony counts present before and during vaginal surgery. METHODS: A descriptive study was undertaken of patients undergoing vaginal hysterectomy with or without reconstructive pelvic surgery. Aerobic and anaerobic bacterial cultures were obtained immediately before and throughout the surgical cases at preselected time intervals. Standard antimicrobial prophylaxis was administered in all cases. Mean total colony counts and mean anaerobic colony counts were determined by adding all colonies regardless of bacteria type. 'Contamination' was defined as > or = 5000 colony-forming units/ml. RESULTS: A total of 31 patients aged 26 to 82 years (mean age +/- SD, 51 +/- 15) were included. The highest total and anaerobic colony counts were found at the first intraoperative time interval. On the first set of cultures (30 minutes after the surgical scrub), 52% (16/31) of the surgical fields were contaminated, and at 90 minutes, 41% (12/29) were contaminated. A negligible number of subsequent cultures were contaminated. CONCLUSIONS: Any future interventions designed to minimize bacterial colony counts should focus on the first 30 to 90 minutes of surgery.