Complications of obliterative versus reconstructive vaginal surgery for pelvic organ prolapse in octogenarians: A retrospective cohort study.

AIMS: Women of advanced age may choose between restorative or obliterative surgery for surgical management of pelvic organ prolapse. Obliterative surgery is traditionally reserved for a subset of older women with more severe medical comorbidities, since obliterative approaches are generally considered to be less morbid and older individuals have higher rates of perioperative complications than younger cohorts. This study compared perioperative complications amongst octogenarians undergoing obliterative versus reconstructive approaches. This data will help to inform perioperative counselling as previous studies have not been powered to evaluate complications in this population. METHODS: The National Surgical Quality Improvement Program database was used to identify patients that had Pelvic organ prolapse surgery between 2012 and 2021, aged 80 years or older. Single-compartment procedures, vaginal mesh procedures, and oncologic surgery were excluded. The primary outcome was any complication within the first 30 days excluding urinary tract infection (UTI). UTI, readmission, and severe complications were secondary outcomes. RESULTS: Of the 4149 patients identified, 2514 (60.6%) underwent reconstructive surgery and 1635 (39.4%) underwent obliterative surgery. Patients undergoing reconstructive surgery were more likely to have an American Society of Anesthesiologists (ASA) class of 1 or 2 (46.1% vs. 31.3%, p = 0.002) and were less likely to be on antihypertensive medication (72.0% vs. 75.8%, p = 0.006). Further, there was an increased length of stay (1.47 ± 1.84 vs. 1.03 ± 1.31 days, p < 0.001) in hospital for reconstructive surgery which was more often performed as an inpatient (45.7% vs. 37.9%, p < 0.001). There was no difference in the primary outcome: any complication excluding UTIs. However, UTI was more common in the reconstructive group (aOR 0.48; 95% confidence interval 0.34-0.0). The rate of serious complications (Clavien-Dindo Class IV) was low overall and not different between reconstructive and obliterative approaches (1.3% vs. 1.0%, respectively). CONCLUSIONS: Both vaginal reconstructive and obliterative approaches have low complication rates in octogenarians, with only UTI rate being different between cohorts. When choosing surgical approach, we suggest a case-based, patient center discussion on the anatomic outcomes, durability and patient satisfaction.

Prevalence and risk factors for urinary incontinence up to 2 years postpartum: a cross-sectional population-based study.

INTRODUCTION AND HYPOTHESIS: Urinary incontinence (UI) is common in the postpartum period; however, most studies focus on the early postpartum period and assess prevalence at only one or two time points. We hypothesized that UI would be prevalent across the first 2 years postpartum. Our secondary objective was to evaluate risk factors for postpartum UI among a nationally representative, contemporary sample. METHODS: This cross-sectional, population-based study used National Health and Nutrition Examination Survey (2011-2018) data for parous women within 24 months following delivery. Prevalence of UI, UI subtypes, and severity were estimated. Multivariate logistic regression was used to estimate adjusted odds (aOR) of UI for exposures of interest. RESULTS: Among 560 postpartum women, prevalence of any UI was 43.5%. Stress UI was most common (28.7%), and most women (82.8%) experienced mild symptoms. There was no significant change in prevalence of UI across the 24 months following delivery (R2 = 0.004). Individuals with postpartum UI tended to be older (30.3 ± 0.5 versus 28.8 ± 0.5 years) and had higher BMI (31.1 ± 0.6 versus 28.9 ± 0.6). In multivariate analysis, odds of postpartum UI were higher for women who had had a prior vaginal delivery (aOR 2.0, 95% CI: 1.3-3.3), prior delivery of a baby weighing 9 lb (4 kg) or more (aOR 2.5, 95% CI: 1.3-4.8), or who reported current smoking (aOR 1.5, 95% CI: 1.0-2.3). CONCLUSIONS: During the first 2 years postpartum 43.5% of women report UI, with relatively stable prevalence over this period. This high prevalence supports screening for UI after delivery regardless of risk factors.

Integrated vs nonintegrated treatment for perinatal opioid use disorder: retrospective cohort study.

BACKGROUND: Pregnant women with opioid use disorder and their infants often experience worse perinatal outcomes than women without opioid use disorder, including longer hospitalizations after delivery and a higher risk for preterm delivery. Integrated treatment models, which combine addiction treatment and maternity care, represent an innovative approach that is widely endorsed, however, limited studies have compared the outcomes between integrated and standard, nonintegrated programs from real-world programs. OBJECTIVE: This study aimed to evaluate the perinatal and substance use outcomes for pregnant women with opioid use disorder receiving coordinated, colocated obstetrical care and opioid use disorder treatment (integrated treatment) and to compare it with those of women receiving obstetrical care and opioid use disorder treatment in distinct programs of care (nonintegrated treatment). STUDY DESIGN: In this observational, retrospective cohort study, we abstracted the perinatal and opioid use disorder treatment data from the records of pregnant women with opioid use disorder (n=225) who delivered at a rural, academic medical center from 2015 to 2017. The women either received integrated (n=92) or nonintegrated (n=133) opioid use disorder treatment and obstetrical care. Using inverse probability weighted regression models to adjust for a potential covariate imbalance, we evaluated the impact of the treatment model on the risk for preterm delivery and positive meconium or umbilical cord toxicology screens. We explored whether the number of obstetrical visits mediated this relationship by using a quasi-Bayesian Monte Carlo algorithm. RESULTS: Women receiving integrated treatment were less likely to deliver prematurely (11.8% vs 26.6%; P<.001) and their infants had shorter hospitalizations (6.5±4.8 vs 10.7±16.2 days). Using a robust inverse probability weighted model showed that receiving integrated treatment was associated with a 74.7% decrease in the predicted probability of preterm delivery (average treatment effect, -0.19; standard error, 0.14; P<.001). There were no differences in the risk for a positive meconium or umbilical cord toxicology screen, a marker for second and third trimester substance use, between women receiving integrated treatment and those receiving coordinated treatment (29.4% vs 34.6%; P=.41), however, integrated treatment was associated with significantly lower rates of positive maternal urine toxicology screens at the time of delivery (35.9% vs 74.4%; P<.001). CONCLUSION: Among a cohort of rural pregnant women with opioid use disorder, receiving integrated obstetrical care and opioid use disorder treatment was associated with a reduced risk for preterm birth, a lower risk for positive maternal urine toxicology screen at the time of delivery, and shorter infant hospitalization. This relationship was mediated by the number of obstetrical visits attended during pregnancy, suggesting that increased engagement with obstetrical care through integration of services may contribute to improved perinatal outcomes.

An Audio Personal Health Library of Clinic Visit Recordings for Patients and Their Caregivers (HealthPAL): User-Centered Design Approach.

BACKGROUND: Providing digital recordings of clinic visits to patients has emerged as a strategy to promote patient and family engagement in care. With advances in natural language processing, an opportunity exists to maximize the value of visit recordings for patients by automatically tagging key visit information (eg, medications, tests, and imaging) and linkages to trustworthy web-based resources curated in an audio-based personal health library. OBJECTIVE: This study aims to report on the user-centered development of HealthPAL, an audio personal health library. METHODS: Our user-centered design and usability evaluation approach incorporated iterative rounds of video-recorded sessions from 2016 to 2019. We recruited participants from a range of community settings to represent older patient and caregiver perspectives. In the first round, we used paper prototypes and focused on feature envisionment. We moved to low-fidelity and high-fidelity versions of the HealthPAL in later rounds, which focused on functionality and use; all sessions included a debriefing interview. Participants listened to a deidentified, standardized primary care visit recording before completing a series of tasks (eg, finding where a medication was discussed in the recording). In the final round, we recorded the patients' primary care clinic visits for use in the session. Findings from each round informed the agile software development process. Task completion and critical incidents were recorded in each round, and the System Usability Scale was completed by participants using the digital prototype in later rounds. RESULTS: We completed 5 rounds of usability sessions with 40 participants, of whom 25 (63%) were women with a median age of 68 years (range 23-89). Feedback from sessions resulted in color-coding and highlighting of information tags, a more prominent play button, clearer structure to move between one's own recordings and others' recordings, the ability to filter recording content by the topic discussed and descriptions, 10-second forward and rewind controls, and a help link and search bar. Perceived usability increased over the rounds, with a median System Usability Scale of 78.2 (range 20-100) in the final round. Participants were overwhelmingly positive about the concept of accessing a curated audio recording of a clinic visit. Some participants reported concerns about privacy and the computer-based skills necessary to access recordings. CONCLUSIONS: To our knowledge, HealthPAL is the first patient-centered app designed to allow patients and their caregivers to access easy-to-navigate recordings of clinic visits, with key concepts tagged and hyperlinks to further information provided. The HealthPAL user interface has been rigorously co-designed with older adult patients and their caregivers and is now ready for further field testing. The successful development and use of HealthPAL may help improve the ability of patients to manage their own care, especially older adult patients who have to navigate complex treatment plans.

Differential Influence of Ventromedial Prefrontal Cortex Lesions on Neural Representations of Schema and Semantic Category Knowledge.

Prior knowledge, such as schemas or semantic categories, influences our interpretation of stimulus information. For this to transpire, prior knowledge must first be reinstated and then instantiated by being applied to incoming stimuli. Previous neuropsychological models implicate the ventromedial prefrontal cortex (vmPFC) in mediating these functions for schemas and the anterior/lateral temporal lobes and related structures for categories. vmPFC, however, may also affect processing of semantic category information. Here, the putative differential role of the vmPFC in the reinstatement and instantiation of schemas and semantic categories was examined by probing network-level oscillatory dynamics. Patients with vmPFC damage (n = 11) and healthy controls (n = 13) were instructed to classify words according to a given schema or category, while electroencephalography was recorded. As reinstatement is a preparatory process, we focused on oscillations occurring 500 msec prior to stimulus presentation. As instantiation occurs at stimulus presentation, we focused on oscillations occurring between stimulus presentation and 1000 msec poststimulus. We found that reinstatement was associated with prestimulus, theta and alpha desynchrony between vmPFC and the posterior parietal cortex for schemas, and between lateral temporal lobe and inferotemporal cortex for categories. Damage to the vmPFC influenced both schemas and categories, but patients with damage to the subcallosal vmPFC showed schema-specific deficits. Instantiation showed similar oscillatory patterns in the poststimulus time frame, but in the alpha and beta frequency bands. Taken together, these findings highlight distinct but partially overlapping neural mechanisms implicated in schema- and category-mediated processing.

Natural language processing for automated annotation of medication mentions in primary care visit conversations.

OBJECTIVES: The objective of this study is to build and evaluate a natural language processing approach to identify medication mentions in primary care visit conversations between patients and physicians. MATERIALS AND METHODS: Eight clinicians contributed to a data set of 85 clinic visit transcripts, and 10 transcripts were randomly selected from this data set as a development set. Our approach utilizes Apache cTAKES and Unified Medical Language System controlled vocabulary to generate a list of medication candidates in the transcribed text and then performs multiple customized filters to exclude common false positives from this list while including some additional common mentions of the supplements and immunizations. RESULTS: Sixty-five transcripts with 1121 medication mentions were randomly selected as an evaluation set. Our proposed method achieved an F-score of 85.0% for identifying the medication mentions in the test set, significantly outperforming existing medication information extraction systems for medical records with F-scores ranging from 42.9% to 68.9% on the same test set. DISCUSSION: Our medication information extraction approach for primary care visit conversations showed promising results, extracting about 27% more medication mentions from our evaluation set while eliminating many false positives in comparison to existing baseline systems. We made our approach publicly available on the web as an open-source software. CONCLUSION: Integration of our annotation system with clinical recording applications has the potential to improve patients' understanding and recall of key information from their clinic visits, and, in turn, to positively impact health outcomes.

Clinical decision analysis and model-based economic evaluation studies in perinatology: A systematic review.

INTRODUCTION: Perinatology, the study of two individuals that constitute the mother-fetus dyad, poses unique challenges to the conduct of clinical decision analysis (CDA) and economic evaluation (EE) studies. Our objective was systematically to review CDA and model-based EE studies in pregnant women to better understand how these studies have been conducted and reported in perinatology. MATERIAL AND METHODS: MEDLINE, Embase, Scopus, Web of Science and clinicaltrials.gov were searched as of October 2018. The indexing terms "pregnancy", "decision trees", "Markov models" and "economic models" were used. The search was limited to human data and the English language. Two reviewers independently screened titles and abstracts. Data extraction and assessment of reporting quality were performed in duplicate for 10% of studies and reached 100% agreement. The remainder was carried out by a single reviewer. The study protocol was registered with PROSPERO (CRD 42016047206). RESULTS: Seventy-seven studies met eligibility criteria and fulfilled between 40% and 91% of relevant attributes on the checklist for critical appraisal of CDA models. There was considerable variation in study reporting. A total of 53% of studies included maternal and offspring outcomes, 14% described using weighted means, meta-analyses or health administrative databases to estimate probabilities and 13% considered outcomes over the lifetime of mother and offspring. Patient preferences (utilities) were used in 47% of the studies. Of these, 10% were elicited from healthcare providers alone and not from pregnant women or the public. Of the EE studies, 25% described a societal analytic perspective. Where relevant, 42% described discounting for costs and benefits, and 30% reported using probabilistic and deterministic sensitivity analyses. CONCLUSIONS: Despite long-term implications of perinatal decisions to mother and offspring, CDA and model-based EE studies in perinatology frequently do not consider lifetime horizons and patient-preferences for outcomes related to mother and offspring. They also often fail to adhere to guidelines regarding conduct and reporting.

Audio-/Videorecording Clinic Visits for Patient's Personal Use in the United States: Cross-Sectional Survey.

BACKGROUND: Few clinics in the United States routinely offer patients audio or video recordings of their clinic visits. While interest in this practice has increased, to date, there are no data on the prevalence of recording clinic visits in the United States. OBJECTIVE: Our objectives were to (1) determine the prevalence of audiorecording clinic visits for patients' personal use in the United States, (2) assess the attitudes of clinicians and public toward recording, and (3) identify whether policies exist to guide recording practices in 49 of the largest health systems in the United States. METHODS: We administered 2 parallel cross-sectional surveys in July 2017 to the internet panels of US-based clinicians (SERMO Panel) and the US public (Qualtrics Panel). To ensure a diverse range of perspectives, we set quotas to capture clinicians from 8 specialties. Quotas were also applied to the public survey based on US census data (gender, race, ethnicity, and language other than English spoken at home) to approximate the US adult population. We contacted 49 of the largest health systems (by clinician number) in the United States by email and telephone to determine the existence, or absence, of policies to guide audiorecordings of clinic visits for patients' personal use. Multiple logistic regression models were used to determine factors associated with recording. RESULTS: In total, 456 clinicians and 524 public respondents completed the surveys. More than one-quarter of clinicians (129/456, 28.3%) reported that they had recorded a clinic visit for patients' personal use, while 18.7% (98/524) of the public reported doing so, including 2.7% (14/524) who recorded visits without the clinician's permission. Amongst clinicians who had not recorded a clinic visit, 49.5% (162/327) would be willing to do so in the future, while 66.0% (346/524) of the public would be willing to record in the future. Clinician specialty was associated with prior recording: specifically oncology (odds ratio [OR] 5.1, 95% CI 1.9-14.9; P=.002) and physical rehabilitation (OR 3.9, 95% CI 1.4-11.6; P=.01). Public respondents who were male (OR 2.11, 95% CI 1.26-3.61; P=.005), younger (OR 0.73 for a 10-year increase in age, 95% CI 0.60-0.89; P=.002), or spoke a language other than English at home (OR 1.99; 95% CI 1.09-3.59; P=.02) were more likely to have recorded a clinic visit. None of the large health systems we contacted reported a dedicated policy; however, 2 of the 49 health systems did report an existing policy that would cover the recording of clinic visits for patient use. The perceived benefits of recording included improved patient understanding and recall. Privacy and medicolegal concerns were raised. CONCLUSIONS: Policy guidance from health systems and further examination of the impact of recordings-positive or negative-on care delivery, clinician-related outcomes, and patients' behavioral and health-related outcomes is urgently required.

Prior knowledge modulates the neural substrates of encoding and retrieving naturalistic events at short and long delays.

Congruence with prior knowledge and incongruence/novelty have long been identified as two prominent factors that, despite their opposing characteristics, can both enhance episodic memory. Using narrative film clip stimuli, this study investigated these effects in naturalistic event memories - examining behaviour and neural activation to help explain this paradox. Furthermore, we examined encoding, immediate retrieval, and one-week delayed retrieval to determine how these effects evolve over time. Behaviourally, both congruence with prior knowledge and incongruence/novelty enhanced memory for events, though incongruent events were recalled with more errors over time. During encoding, greater congruence with prior knowledge was correlated with medial prefrontal cortex (mPFC) and parietal activation, suggesting that these areas may play a key role in linking current episodic processing with prior knowledge. Encoding of increasingly incongruent events, on the other hand, was correlated with increasing activation in, and functional connectivity between, the medial temporal lobe (MTL) and posterior sensory cortices. During immediate and delayed retrieval the mPFC and MTL each demonstrated functional connectivity that varied based on the congruence of events with prior knowledge; with connectivity between the MTL and occipital regions found for incongruent events, while congruent events were associated with functional connectivity between the mPFC and the inferior parietal lobules and middle frontal gyri. These results demonstrate patterns of neural activity and connectivity that shift based on the nature of the event being experienced or remembered, and that evolve over time. Furthermore, they suggest potential mechanisms by which both congruence with prior knowledge and incongruence/novelty may enhance memory, through mPFC and MTL functional connectivity, respectively.

Blocking Synaptic Removal of GluA2-Containing AMPA Receptors Prevents the Natural Forgetting of Long-Term Memories.

The neurobiological processes underpinning the natural forgetting of long-term memories are poorly understood. Based on the critical role of GluA2-containing AMPA receptors (GluA2/AMPARs) in long-term memory persistence, we tested in rats whether their synaptic removal underpins time-dependent memory loss. We found that blocking GluA2/AMPAR removal with the interference peptides GluA23Y or G2CT in the dorsal hippocampus during a memory retention interval prevented the normal forgetting of established, long-term object location memories, but did not affect their acquisition. The same intervention also preserved associative memories of food-reward conditioned place preference that would otherwise be lost over time. We then explored whether this forgetting process could play a part in behavioral phenomena involving time-dependent memory change. We found that infusing GluA23Y into the dorsal hippocampus during a 2 week retention interval blocked generalization of contextual fear expression, whereas infusing it into the infralimbic cortex after extinction of auditory fear prevented spontaneous recovery of the conditioned response. Exploring possible physiological mechanisms that could be involved in this form of memory decay, we found that bath application of GluA23Y prevented depotentiation, but not induction of long-term potentiation, in a hippocampal slice preparation. Together, these findings suggest that a decay-like forgetting process that involves the synaptic removal of GluA2/AMPARs erases consolidated long-term memories in the hippocampus and other brain structures over time. This well regulated forgetting process may critically contribute to establishing adaptive behavior, whereas its dysregulation could promote the decline of memory and cognition in neuropathological disorders. SIGNIFICANCE STATEMENT: The neurobiological mechanisms involved in the natural forgetting of long-term memory and its possible functions are not fully understood. Based on our previous work describing the role of GluA2-containing AMPA receptors in memory maintenance, here, we tested their role in forgetting of long-term memory. We found that blocking their synaptic removal after long-term memory formation extended the natural lifetime of several forms of memory. In the hippocampus, it preserved spatial memories and inhibited contextual fear generalization; in the infralimbic cortex, it blocked the spontaneous recovery of extinguished fear. These findings suggest that a constitutive decay-like forgetting process erases long-term memories over time, which, depending on the memory removed, may critically contribute to developing adaptive behavioral responses.

Recovering and preventing loss of detailed memory: differential rates of forgetting for detail types in episodic memory.

Episodic memories undergo qualitative changes with time, but little is known about how different aspects of memory are affected. Different types of information in a memory, such as perceptual detail, and central themes, may be lost at different rates. In patients with medial temporal lobe damage, memory for perceptual details is severely impaired, while memory for central details is relatively spared. Given the sensitivity of memory to loss of details, the present study sought to investigate factors that mediate the forgetting of different types of information from naturalistic episodic memories in young healthy adults. The study investigated (1) time-dependent loss of "central" and "peripheral" details from episodic memories, (2) the effectiveness of cuing with reminders to reinstate memory details, and (3) the role of retrieval in preventing forgetting. Over the course of 7 d, memory for naturalistic events (film clips) underwent a time-dependent loss of peripheral details, while memory for central details (the core or gist of events) showed significantly less loss. Giving brief reminders of the clips just before retrieval reinstated memory for peripheral details, suggesting that loss of details is not always permanent, and may reflect both a storage and retrieval deficit. Furthermore, retrieving a memory shortly after it was encoded prevented loss of both central and peripheral details, thereby promoting retention over time. We consider the implications of these results for behavioral and neurobiological models of retention and forgetting.

Memory and navigation: Compression of space varies with route length and turns.

For memory to be efficient and useful during recall, problem-solving, and planning, retrieval must be compressed in time. Evidence from rodents suggests that neural compression during replay of spatial memories varies widely, with a range of compression ratios reported from 6:1 to 64:1. Anecdotal evidence suggests that similar compression occurs during mental navigation in humans: we recall how to get from one place to another countless times almost every day of our lives, and this recall never takes as long as physically travelling those routes would take. In this experiment we sought to determine whether this behavioural compression could be measured during mental navigation in humans (spatial memory replay), and which factors might affect the compression of such spatial memories. To this end, thirty participants mentally navigated routes between two landmarks, which varied in length and number of turns, as we measured replay times and recorded ratings of familiarity, detail, and presence. A multi-level model was used to determine which factors were associated with variation in compression. Route length and number of turns emerged from this model as significantly correlated with compression, such that longer routes were more compressed while compression was attenuated as the number of turns in a route increased. This suggests that compression during recall may be affected by specific features of a route, especially those that may act to segment the space or event being represented.