Patients' perspectives on quality and patient safety failures: lessons learned from an inquiry into transvaginal mesh in Australia.

BACKGROUND: Transvaginal mesh (TVM) surgeries emerged as an innovative treatment for stress urine incontinency and/or pelvic organ prolapse in 1996. Years after rapid adoption of these surgeries into practice, they are a key example of worldwide failure of healthcare quality and patient safety. The prevalence of TVM-associated harms eventually prompted action globally, including an Australian Commonwealth Government Senate Inquiry in 2017. METHOD: We analysed 425 submissions made by women (n = 417) and their advocates (n = 8) to the Australian Senate Inquiry, and documents from 5 public hearings, using deductive and inductive coding, categorisation and thematic analysis informed by three 'linked dilemmas' from healthcare quality and safety theory. We focused on women's accounts of: a) how harms arose from TVM procedures, and b) micro, meso and macro factors that contributed to their experience. Our aim was to explain, from a patient perspective, how these harms persisted in Australian healthcare, and to identify mechanisms at micro, meso and macro levels explaining quality and safety system failure. RESULTS: Our findings suggest three mechanisms explaining quality and safety failure: 1. Individual clinicians could ignore cases of TVM injury or define them as 'non-preventable'; 2. Women could not go beyond their treating clinicians to participate in defining and governing quality and safety; and. 3. Health services set thresholds for concern based on proportion of cases harmed, not absolute number or severity of harms. CONCLUSION: We argue that privileging clinical perspectives over patient perspectives in evaluating TVM outcomes allowed micro-level actors to dismiss women's lived experience, such that women's accounts of harms had insufficient or no weight at meso and macro levels. Establishing system-wide expectations regarding responsiveness to patients, and communication of patient reported outcomes in evaluation of healthcare delivery, may help prevent similar failures.

Transvaginal mesh in Australia: An analysis of news media reporting from 1996 to 2021.

INTRODUCTION: Transvaginal mesh (mesh) surgeries have been used to treat stress urinary incontinence (incontinence) and/or pelvic organ prolapse (prolapse). In Australia, as in many other countries, the harms caused by mesh eventually prompted individual and collective attempts to achieve redress. The rise of mesh surgery as a procedure, the experience of mesh-affected women and the formal inquiries and legal actions that followed all occurred in social, cultural and discursive contexts. One strategy to understand these contexts is to track how the mesh and key actors in the mesh stories have been portrayed in mass media sources. We conducted a media analysis of the most highly read Australian newspapers and online news media platforms, focusing on how mesh and the interaction of stakeholders in mesh stories were presented to the Australian public. METHOD: We searched systematically in the top 10 most-read print and online media outlets in Australia. We included all articles that mentioned mesh, from the date of first use of mesh in Australia to the date of our final search (1996-2021). RESULT: After early scant media reporting focusing on the benefits of mesh procedures, major Australian medicolegal processes created a hook to shift reporting about mesh. The news media then played a significant role in redressing women's experienced epistemic injustice, including by amplifying previously ignored evidence of harm. This created an opportunity for previously unreported suffering to be revealed to powerful actors, in settings beyond the immediate control and epistemic authority of healthcare stakeholders, validating women's testimony and creating new hermeneutic resources for understanding mesh. Over time, media reports show healthcare stakeholders responding sympathetically to these new understandings in public discourse, contrasting with their statements in earlier media coverage. CONCLUSION: We argue that mass media reporting, in synergy with medicolegal actions and the Australian Senate Inquiry, appears to have provided women with greater epistemic justice, giving their testimony privileged epistemic status such that it was considered by powerful actors. Although medical reporting is not recognised in the hierarchy of evidence embedded in the medical knowledge system, in this case, media reporting appears to have contributed to shaping medical knowledge in significant ways. PATIENT OR PUBLIC CONTRIBUTION: We used publicly available data, print and online media outlets, for our analysis. Therefore, this manuscript does not contain the direct contribution of patients, service users, caregivers, people with lived experience or members of the public.

Evaluation of scale development and its regeneration potency in the desert killifish under laboratory conditions.

Scale development and its regeneration potency were evaluated in a desert killifish Aphaniops hormuzensis (family Aphaniidae) in laboratory conditions by using light and scanning electron microscopy. Scale development in A. hormuzensis took 156 days at room temperature. Four specific regions of scale formation were detected. The first scale development began 13 days post-hatching (dph) (total length [TL] = 8.5 mm) at the caudal peduncle region and is extended anteriorly 26 dph (TL = 13.6 mm) at the area below the dorsal fin. Scales began forming independently in the head region at 33 dph (TL = 21.7 mm), and in the abdominal region, began at 41 dph (TL = 25.8 mm). Additional points of scale origin were detected on the sides of the operculum or behind and below the eyes. Scale regeneration in the caudal peduncle started 6 days after removal (dar). In 16 dar, the microstructural features appeared and the growth circles, a wide and oblong focus (focus length = 0.6 ± 0.05 µm), and lepidonts were also formed. In 36 dar, the scale shape was gradually changed from circular to a polygon, and radii were distinguishable in the anterior field. The pattern of scale formation could be useful in enhancing the understanding of systematics and phylogeny, functional morphology, and habitat use. It could also be useful in helping to define the Larval/juvenile transition period.

Women's Experiences of and Perspectives on Transvaginal Mesh Surgery for Stress Urine Incontinency and Pelvic Organ Prolapse: A Qualitative Systematic Review.

BACKGROUND: Trans Vaginal Mesh (TVM) surgeries have been used to treat stress urine incontinency (SUI) and/or pelvic organ prolapse (POP). Systematic reviews of clinical studies of outcomes suggest that the procedures have benefited a majority of women, while noting that a small minority of women have experienced harms. To provide a more complete picture of outcomes, we conducted a systematic review of the qualitative literature to provide a comprehensive analysis of women's own accounts of their experience. METHOD: We conducted a systematic review and thematic synthesis of the evidence from the international qualitative literature on women's experiences of and perspectives on TVM surgery for SUI and/or POP between 1996 and 2020. We retrieved 6587 papers from PubMed, Cochrane, CINAHL, PsycINFO, Scopus, and Sociological Abstracts. After application of inclusion and exclusion criteria and full-text review of eligible articles, five articles were included in our systematic review. RESULTS: Findings from included articles were organised under three main themes: women's everyday lives were transformed by TVM surgery; women's expectations of and approach to their future lives; and women's critiques of TVM surgery. The transformation of women's everyday lives included a struggle to obtain recognition and support for their injuries before and after corrective surgery, ongoing limitations on their social, professional and personal lives, and compounding medical and psychological trauma as a result. Women's approaches to their future lives changed because of this transformation; we identified five main approaches, four were ways of accommodating change, a fifth involved being unable to accommodate life changes. Women's critiques included that TVM surgeries were overused, consent processes were poor, and surgeons' definitions of success were deficient. Women expressed concerns about the safety of TVM products and future risks of further complications and discussed multiple system failures in the health care they received. CONCLUSION: This review suggests that discounting women's experiences has caused compound trauma and skewed the clinical evidence base; while harms occurred in a minority of women, we suggest they should be recognised as an ethically significant potential outcome. Approaches to TVM injury should attend to historical epistemic injustice and recognise women's agency.

Concerns and potential improvements in end-of-life care from the perspectives of older patients and informal caregivers: a scoping review.

BACKGROUND: Overtreatment in advanced age i.e. aggressive interventions that do not improve survival and are potentially harmful, can impair quality of care near the end of life (EOL). As healthcare provider perspectives on care quality may differ from that of service users, the aim of this study was to explore the views of older patients near EOL or their caregivers about the quality of health care at the EOL based on their lived experience, and to identify healthcare service improvements. METHODS: Medline and backward citation searches were conducted for qualitative or quantitative studies reported on the views of patients and/or informal caregivers about EOL care quality. Thematic analysis was used to summarise qualitative data (primary analysis); narrative and tabulations were used to summarise quantitative data (secondary analysis). RESULTS: Thirty articles met the inclusion criteria. Five main qualitative themes regarding quality care emerged: (1) Effective communication between clinicians and patients/caregivers; (2) Healthcare that values patient preferences and shared decision making; (3) Models of care that support quality of life and death with dignity; (4) Healthcare services that meet patient expectations; and (5) Support for informal caregivers in dealing with EOL challenges. The quantitative articles supported various aspects of the thematic framework. CONCLUSION: The findings of this study show that many of the issues highlighted by patients or bereaved relatives have persisted over the past two decades. There is an urgent need for comprehensive evaluation of care across the healthcare system and targeted redesign of existing EOL care pathways to ensure that care aligns with what patients and informal caregivers consider high-quality patient-centred care at the EOL.

Scanning electron microscopy and morphological analysis reveal size-dependent changes in the scale surface ornamentation of tooth-carp Aphaniops hormuzensis (Teleostei; Aphaniidae).

Aphanius hormuzensis is an endemic tooth-carp found in the Hormuzgan drainage in S-Iran. This study aimed to investigate the size-dependent alternations of scale surface ornamentation in this species by conducting scanning electron microscopy and morphological analysis. A total of 50 wild fish individuals were captured from Shur River, and were classified into five size classes based on the standard length; SC-I (SL = 10-20 mm), SC-II (SL = 21-30 mm), SC-III (SL = 41-50 mm), SC-IV (SL = 51-60 mm), and SC-V (SL = 61-70 mm), and their scales were removed from below the dorsal fin (key scale) and caudal peduncle regions. The results revealed a clear trend of scale structural development in A. hormuzensis. The scale of small-sized (TL < 30 mm) and large-sized fishes (TL > 30 mm) differed, respectively, in the following characters; the overall shape (often circular vs. polygonal), relative focus size (large, FL/SL = 440-610 µm vs. intermediate and small, FL/SL = 100-330 µm), types of radii (only primary vs. three types), relative radii length (short, RL/SL = 100-180 µm vs. long, RL/SL = 320-450 µm), lepidont (absent or undeveloped vs. present and developed), and the relative lepidont length (short, LL/SL = 0.83-0.90 µm vs. intermediate and long, LL/SL = 1.2-2.2 µm). These character alternations could explain certain developmental stages in this species. The size-dependent changes in the surface micro-ornamentations as shown in this study suggest that these characters should be used cautiously for taxonomic studies of the aphaniid fishes.

Microanalysis of scale morphology in killifish, Aphaniops hormuzensis inhabiting ecologically diverse environments (Cyprinodontiformes; Aphaniidae).

Ecologically, Aphaniops hormuzensis populations occupying diverse environments in southern Iran and showed substantial morphological variation across its range. In this study, three different habitats were chosen and identified as group A (sulfur rich spring), group B (salty River), and group C (urban canal), and scale microstructures and scale shape was inspected among three groups. The SEM imaging indicated that lepidonts were more developed on the scale of larger (group C, SL > 30 mm) than younger fish (group A, SL < 30 mm). We tentatively concluded that lepidonts are formed during scale development so that in the earlier stages of fish development, scales probably do not have lepidont. Also, the size and shape of lepidonts vary between the populations, and their shape and orientation within a given species affected by the fish size rather than the local ecological conditions of habitats. The number of radii was relatively higher in group C (12.58 ± 0.66 in males and 13.00 ± 1.89 in females). Similar to what is mentioned before in the case of lepidont, the inter-population variation in the number of radii seems to be influenced by fish size. Group A (SL < 30 mm) had a relatively large focus diameter (0.14 ± 0.02 in males and 0.36 ± 0.44 in females). It is assumed that the focus size is large at the earlier stage of fish development, but later during the fish growth, and by increasing the scale size, the focus diameter is reduced. In conclusion and agreement with previous studies, scale surface morphology and microstructure could be employed to discriminate certain populations, while scale size and J-indices could not help in distinguishing the populations. It is also proposed that the characteristics of scale morphology in the population-level are influenced by the combination of genetic, and environmental factors, as well as fish development.

Adult neuronal regeneration in the telencephalon of the killifish Aphaniops hormuzensis.

The potential of central nervous system regeneration was evaluated for the first time in the injured brain of the old world killifish Aphaniops hormuzensis. The histomorphological organization in the regeneration procedure was evaluated using the hematoxylin and eosin (H&E) staining and the bromodeoxyuridine (BrdU) immunohistochemistry technique. The histological tissue sections were sampled daily for 10 days. Based on the H&E staining, a large gliosis reaction was detected along with vacuolization and telencephalon deformation on 1-day post-lesion (dpl). The vacuolated zone declined fast and the telencephalon hemisphere recovered on 3 dpl. The symptoms of injured telencephalon nervous tissue were resolved within 7 dpl in both genders. In the BrdU test of the control group, BrdU-labeled cells were observed in the ventricular zone (VZ), pallium (Pa), and lateral pallium (LPa). On 1 dpl, the BrdU+ cells accumulated in the VZ, Pa, and LPa (located near the injury area). From 3 dpl onwards, the BrdU+ cells were reduced in the telencephalic VZ, Pa, and LPa. Based on the BrdU+ results, the adult brain in A. hormuzensis possesses a remarkable capacity for neuronal regeneration. By taking into account the high neural regeneration potency of A. hormuzensis and its relatively short lifespan, it could be concluded that besides the currently known models, the members of aphaniid fishes could probably be valuable animals to study the regeneration phenomenon in the vertebrates.

Characterization of age-dependent variability in the flank scales of two scorpaeniformes fishes by applying light and scanning electron microscopy imaging.

The morphology of scales from four flank regions in two species of Scorpaeniforme fishes of the family Platycephalidae was studied by applying light and scanning electron microscopy, and the age-dependent variability of scale structures was discussed. The scales of four flank regions from three size classes in both species were ctenoid. The posterior margin of all the ctenoid scales was formed by two rows of cteni, while the three complete rows of cteni were not observed in the examined scales. The cteni of both rows were similar in morphology. Some scale characteristics showed alteration during the fish growth, including the shape of the anterior region of scale in Platycephalus indicus, the presence of lepidonts in Grammoplites suppositus, and the general shape of scale as well as the indices SCL.SCW and JSW.SL in both species. Also, the number of cteni in posterior margin of scales was increased during fish development, while their general morphology did not change significantly. The number of cteni in the scales of small and large fishes in G. suppositus was found to be obviously lower than P. indicus. By considering the function of lepidonts in improving the hydrodynamic efficiency of swimming, it can be assumed that G. suppositus is not probably very active in swimming as P. indicus. As a conclusion, modification in the ornamentations of the posterior region are subject to alteration during the growth of the fish. Besides its developmental changes, some scale characters in the adult forms have taxonomic significance, including the square-shaped scales in P. indicus vs. the oval-shaped scale in G. suppositus; a total of 26-31 radii in the anterior field in P. indicus vs. 11-12 radii in G. suppositus; the presence of many (54-58) cteni in the posterior part in P. indicus vs. a moderate (19-23) cteni in G. suppositus. These characters could be used as additional morphological data to be used for studying systematics and even phylogeny of the flathead fishes.

Apoptosis in Hydra: function of HyBcl-2 like 4 and proteins of the transmembrane BAX inhibitor motif (TMBIM) containing family.

Mechanisms of programmed cell death differ between animals, plants and fungi. In animals, apoptotic cell death depends on caspases and Bcl-2 family proteins. These protein families are only found in multicellular animals, including cnidarians, insects and mammals. In contrast, members of the TMBIM-family of transmembrane proteins are conserved across all eukaryotes. Sequence comparisons of cell death related proteins between phyla indicate strong conservation of the genes involved. However, often it is not known whether this is paralleled by conservation of function. Here we present the first study to support an anti-apoptotic function of Bcl-2 like proteins in the cnidarian Hydra within a physiological context. We used transgenic Hydra expressing GFP-tagged HyBcl-2-like 4 protein in epithelial cells. The protein was localised to mitochondria and able to protect Hydra epithelial cells from apoptosis induced by either the PI(3) kinase inhibitor wortmannin or by starvation. Moreover, we identified members of the TMBIM-family in Hydra including HyBax-Inhibitor-1, HyLifeguard-1a and -1b and HyLifeguard 4. Expressing these TMBIM-family members in Hydra and human HEK cells, we found HyBax-inhibitor-1 protein localised to ER-membranes and HyLifeguard-family members localised to the plasma membrane and Golgi-vesicles. Moreover, HyBax-inhibitor-1 protected human cells from camptothecin induced apoptosis. This work illustrates that the investigated Bcl-2- and TMBIM-family members represent evolutionarily conserved mitochondrial, ER, Golgi and plasma membrane proteins with anti-apoptotic functions. The participation of ER and Golgi proteins in the regulation of programmed cell death might be a very ancient feature.

Comparative Morphologic and Morphometric Study on the Developmental Aspects of In Vitro and In Vivo Reared Echinococcus granulosus Sensu Stricto Using Differential Interference Contrast (DIC)/Nomarski and Phase Contrast Microscopy.

BACKGROUND: Echinococcus granulosus is a zoonotic parasite with worldwide distribution. The present study focused on comparative morphologic and morphometric observations on the developmental aspects of whole body, more special the reproductive structures of in vitro reared adult worms (RAW) and in vivo reared adult worms in definitive host (AWIDH) using differential interference contrast (DIC)/Nomarski, phase contrast and routine optical microscopy. METHODS: A total number of 10 in vitro and 10 in vivo reared adult worms of E. granulosus sensu stricto, G1 strain were selected. The worms were processed by Formaldehyde-Alcohol-Azocarmine-Lactophenol (FAAL). The details of morphological factors and reproductive structures of each worm including 25 biometrical parameters were studied by routine optical, phase contrast and Nomarski microscopy. The details of the samples were photographed, measured and analyzed. The fine structures of the parasite including the details of cirrus sac and developmental stages in different strobila were more obvious observing by Nomarski microscopy. RESULTS: The morphometric characters in the RAW and AWIDH showed that length of immature proglottid, length of mature proglottid, length of suckers are larger in RAW than AWIDH worms with statistical difference. Characters in E. granulosus of RAW and AWIDH showed that total number of segments, number of mature segments and the total number of testes were greater in RAW than AWIDH worms; while only the number of mature segments was statistically different is two groups. CONCLUSION: Application of DIC/Nomarski and phase contrast microscopy together with morphometric criteria are useful means for comparing the developmental aspects of in vitro and in vivo reared adults of E. granulosus.

Histomicroscopy and normal anatomy of the adult killifish Aphanius hormuzensis (Teleostei; Aphaniidae) from the Persian Gulf coastal environment.

The histomicroscopy and normal anatomy of the major body organ systems were investigated in the adult killifish, Aphanius hormuzensis using histological examination, X-ray imaging, double staining, light microscopy and scanning electron microscopy (SEM). Based on the histomicroscopic observations, the kidney, liver and swim bladder in the studied species were comparable to other fish models. The anterior portion of the kidney is bulbous, while the posterior portion is narrow and elongated; the liver has a single lobe and the swim bladder is a single-chambered organ with no connection to the digestive tract (physoclistous). X-ray imaging and double staining examination showed 12 abdominal and 15 caudal vertebrae and a single hypural plate in the caudal skeleton. According to light microscopy, the scales were rounded to pentagonal in shape with three types of radii (primary, secondary and tertiary), and the urohyal bone was elongated. SEM microscopy showed a single row of tricuspid teeth on the upper and lower jaw, respectively, each tooth has two lateral cusps that are shorter than the middle one. The number of teeth was 17-18 in the upper jaw and 19-20 in the lower jaw. The saccular otoliths were rounded-trapezoid in shape with a moderately incised and V-shaped excisura. The members of killifishes are an important group for biologists because of their evolutionary properties, regeneration capacity and usefulness as biological control and also for the ecotoxicological assessment of environmental pollution. The outcomes of this study may provide a useful basis for future research on the genus Aphanius.