Factors affecting women's decision between uterine-preserving versus hysterectomy-based surgery for pelvic organ prolapse.

BACKGROUND: Given the prevalence of women seeking surgical treatment for pelvic organ prolapse (POP), there is a need to understand women's decision-making regarding uterine-preserving versus hysterectomy-based surgeries. Historically, hysterectomy-based surgeries have been the preferred treatment for pelvic organ prolapse; however, contemporary evidence supports uterine-preserving surgeries as equivalent. At present, the lack of information available to the general public and limited options presented at surgical consultation for pelvic organ prolapse may hinder women's autonomy as they navigate surgical treatment. OBJECTIVES: To examine the factors affecting women's decision-making processes regarding uterine-preserving or hysterectomy-based surgery for pelvic organ prolapse. DESIGN: This is a qualitative study. METHODS: We conducted semi-structured, qualitative interviews with women seeking surgery for pelvic organ prolapse to explore the factors affecting women's decision-making between hysterectomy-based and uterine-preserving surgeries. RESULTS: Women (n = 26) used clinical and personal factors to determine which surgery was best. Women noted that the lack of evidence (clinical and/or anecdotal) available to them hindered their decision-making, causing them to rely more on their own interpretations of the evidence, what they perceived to be "normal," and what their surgeon recommended. Even with standardized discussion regarding the existing clinical equipoise between surgeries at the clinical consultation, some women still had misperceptions that hysterectomy-based surgery would convey the lowest risk of prolapse recurrence and be best for severe prolapse. CONCLUSION: There is a need for more transparency in discussions about prolapse and the factors affecting women's decision-making for surgical repair of pelvic organ prolapse. Clinicians should be prepared to offer the option of hysterectomy-based or uterine-preserving surgeries and to clearly explain the clinical equipoise between these procedures.

Evaluating the impact of an emergency department protocol that guides management of methamphetamine-induced agitation and psychosis.

BACKGROUND: Methamphetamine is an addictive stimulant that may induce symptoms of agitation and psychosis. The estimated rate of methamphetamine use is 6.6 per 1000 people. Currently, no treatment guidelines exist to support the optimal management of patients presenting with methamphetamine-induced agitation. Emergency department (ED) providers may prescribe various benzodiazepines (BZDs) and antipsychotics (APs) as first-line agents to stabilize these agitated patients. This study aims to determine the effectiveness of a protocol to guide management of this condition. METHODS: This was a retrospective, pre- and poststudy conducted from July 2020 to March 2021 at a large academic medical center. A multidisciplinary protocol was designed to help manage methamphetamine-induced agitation in the ED. The primary outcome of the study was a reduction in the number of BZDs and APs used for the treatment of methamphetamine-induced agitation. This was measured by the incidence of overprescribing, defined as 3 or more APs or BZDs administered within 30 minutes. Secondary outcomes included the use of physical restraints, ED length of stay, and adverse events. RESULTS: We did not observe a significantly lower incidence of overprescribing, adverse events, or ED length of stay when comparing pre- and postprotocol groups. A subgroup analysis demonstrated that when protocol was followed, there was a statistically significant reduction in overprescribing (P = .001). DISCUSSION: We did not find any differences among our primary and secondary outcomes, which may be attributed to protocol nonadherence. Full compliance to the protocol may reduce the rate of overprescribing APs or BZDs in patients with methamphetamine-induced agitation.

A qualitative study of the impact of the COVID-19 pandemic on women seeking pelvic organ prolapse surgery in Alberta, Canada.

In addition to altering public infrastructure and social patterning, the COVID-19 pandemic has delayed many pelvic organ prolapse (POP) surgeries. POP-related stigma, symptomology and the experience of waiting for POP surgery can negatively impact women's quality of life and mental health. The experience of preoperative POP patients during the pandemic thus entails a new intersection of gendered, stigmatic and medical realities. Qualitative interviews were conducted with 26 preoperative POP patients as part of a larger qualitative study, 20 of whom spontaneously volunteered information about how the pandemic coloured their experience living with and awaiting surgery for POP. Interviews occurred between January and July 2021, which coincided with the second and third waves of the pandemic in Alberta, Canada, and before full immunisation was available for all Albertans. Pandemic-related interview excerpts were thematically analysed, and four main findings emerged. (1) Though surgical delay meant living with unpleasant symptoms for longer than anticipated, some sought this out in order to protect vulnerable loved ones from possible hospital-acquired infection, (2) shifting and unclear hospital policies and logistics resulted in intense preoperative stress, at times causing women to temporarily cease treatment, (3) decreased access to public restroom infrastructure caused women to reduce their outings and (4) the imperative to minimise social gatherings made it easier for women to engage in POP-related, shame-based self-isolation without the notice of friends and family. As they can influence postoperative outcomes and treatment adherence, trends observed should be of interest to clinicians and policymakers alike.

Health Disparities in Pharmacy Practice Within the Community: Let's Brainstorm for Solutions.

Health disparity is defined as a type of health difference that is closely linked with social, economic and/or environmental disadvantage. Over the past two decades, major efforts have been undertaken to mitigate health disparities and promote health equity in the United States. Within pharmacy practice, health disparities have also been identified to play a role in influencing pharmacists' practice across various clinical settings. However, well-characterized solutions to address such disparities, particularly within pharmacy practice, are lacking in the literature. Recognizing that a significant amount of work will be necessary to reduce or eliminate health disparities, the University of California, Irvine (UCI) School of Pharmacy and Pharmaceutical Sciences held a webinar in June 2021 to explore pertinent issues related to this topic. During the session, participants were given the opportunity to propose and discuss innovative solutions to overcome health disparities in pharmacy practice. The goal of this perspective article is to distill the essence of the presentations and discussions from this interactive session, and to synthesize ideas for practical solutions that can be translated to practice to address this public health problem.

"Broken"-How Identities as Women, Mothers and Partners Are Intertwined with the Experience of Living with and Seeking Treatment for Pelvic Organ Prolapse.

Pelvic Organ Prolapse (POP) occurs when one or more pelvic organs descend into or through the vaginal opening, significantly impacting physical and mental health. POP affects the female reproductive tract and, overwhelmingly, people who identify as women. However, little research has examined the impact of gendered expectations on women's treatment-seeking for POP and their decision-making around surgery for POP. To address this gap, we conducted semi-structured interviews with 26 women seeking surgery for POP in Alberta, Canada. Data were analyzed from a gender-based lens, using the Framework Method. Participants reported the need to balance their identities as women, partners, and mothers in their pursuit of treatment and faced many barriers to treatment related to their gendered responsibilities. Findings highlight the gendered experiences of prolapse in the context of healthcare needs and can inform policies and practices which promote more equitable access to prolapse treatment.

Transcranial magnetic stimulation-associated mania with psychosis: A case report.

Transcranial magnetic stimulation (TMS) is a noninvasive procedure used in the treatment of depression. We observed TMS-associated mania with psychotic symptoms in a 55-year-old male diagnosed with MDD and generalized anxiety disorder without history of psychosis or mania. Owing to poor pharmacotherapeutic response and worsening symptomatology, TMS was introduced while continuing phenelzine; this was initially successful in demonstrating positive effects on mood. However, the patient began to develop symptoms consistent with mania with psychosis and was hospitalized. Both TMS and phenelzine were discontinued, leading to significant improvement of the symptoms of mania and psychosis. Phenelzine was later reintroduced for maintenance treatment of depression and anxiety, with no recurrence of mania or psychosis. This case report implicates TMS as a possible cause of mania and psychosis symptoms.

Iatrogenic Delirium in Patients on Symptom-Triggered Alcohol Withdrawal Protocol: A Case Series.

In this report, we present a case series involving four patients placed on the Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar) protocol for alcohol or sedative-hypnotic withdrawal syndromes, who developed delirium on sustained or increasing symptom-triggered benzodiazepine dosages. In each of the four cases, delirium was not present on admission and resolved in the hospital itself with fixed benzodiazepine tapers. Cases were selected from an electronic medical record database of patients admitted to a United States-based university hospital and placed on CIWA-Ar between 2017 and 2018. This case series illustrates the major limitations of CIWA-Ar including its subjective nature, its susceptibility to inappropriate patient selection, and its requirement for providers to consider alternative etiologies to alcohol and benzodiazepine withdrawal syndromes. These cases demonstrate the necessity of considering other assessment and treatment options such as objective alcohol withdrawal scales, fixed benzodiazepine tapers, and even antiepileptics. An effective systems-based approach to overcoming these challenges may include setting time limits on CIWA-Ar orders within the electronic health record (EHR) system.

Iatrogenic delirium on symptom-triggered alcohol withdrawal protocol.

PURPOSE: The purpose of this paper is to illustrate delirium as a possible consequence of the application of symptom-triggered therapy for alcohol withdrawal and to explore alternative treatment modalities. In the management of alcohol withdrawal syndrome, symptom-triggered therapy directs nursing staff to regularly assess patients using standardized instruments, such as the Clinical Institute for Withdrawal Assessment of Alcohol, Revised (CIWA-Ar), and administer benzodiazepines at symptom severity thresholds. Symptom-triggered therapy has been shown to lower total benzodiazepine dosage and treatment duration relative to fixed dosage tapers (Daeppen et al., 2002). However, CIWA-Ar has important limitations. Because of its reliance on patient reporting, it is inappropriate for nonverbal patients, non-English speakers (in the absence of readily available translators) and patients in confusional states including delirium and psychosis. Importantly, it also relies on the appropriate selection of patients and considering alternate etiologies for signs and symptoms also associated with alcohol withdrawal. DESIGN/METHODOLOGY/APPROACH: The authors report a case of a 47-year-old male admitted for cardiac arrest because of benzodiazepine and alcohol overdose who developed worsening delirium on CIWA-Ar protocol. FINDINGS: While symptom-triggered therapy through instruments such as the CIWA-Ar protocol has shown to lower total benzodiazepine dosage and treatment duration in patients in alcohol withdrawal, over-reliance on such tools may also lead providers to overlook other causes of delirium. ORIGINALITY/VALUE: This case illustrates the necessity for providers to consider using other available assessment and treatment options including objective alcohol withdrawal scales, fixed benzodiazepine dosage tapers and even antiepileptic medications in select patients.

Clinical review of a long-acting, injectable formulation of risperidone.

BACKGROUND: A long-acting, injectable risperidone formulation is the first depot atypical antipsychotic drug to become available in the United States. OBJECTIVE: The intent of this article is to review the efficacy and safety data available for long-acting, injectable risperidone. METHODS: Information was identified via MEDLINE (years, 1990-May 2004) using the terms risperidone, long-acting injectable, depot, and delayed-action preparations. The manufacturer also provided information about risperidone in the form of abstracts and summaries of professional meetings. RESULTS: Several 12-week studies and one 12-month study suggest that long-acting risperidone is an effective and well-tolerated treatment option for the maintenance therapy of schizophrenia. Thus far, no unexpected adverse events have been reported with the long-acting formulation. Extrapyramidal symptoms with long-acting risperidone were uncommon, dose-related, and similar to those observed with oral risperidone in short-term trials. A small, dose related weight gain occurred with long acting risperidone, again similar to that seen with oral risperidone. Pain at the injection site was uncommon and decreased with continued administration. The long-acting, injectable formulation comes in an aqueous suspension of microspheres. There is no initial drug release after injection; the main release of risperidone begins at week 2 to 3 postinjection, increases during weeks 3 and 4, is maintained during weeks 4 through 6, and declines between weeks 6 and 7. With repeated injections every 2 weeks, steady-state levels are usually reached by weeks 6 to 8. For most patients, the initial dosage should be 25 mg every 2 weeks, and oral administration should continue for the first 3 weeks after initial injection. Doses can be increased every 8 weeks to a maximum of 50 mg every 2 weeks. CONCLUSION: Long-acting risperidone offers clinicians a combination of the benefits of a depot antipsychotic drug with the therapeutic advantages of an atypical antipsychotic drug.

Depression screening in a university campus pharmacy: a pilot project.

OBJECTIVE: To evaluate the usefulness of a depression screening tool in a university campus pharmacy. DESIGN: Uncontrolled study. SETTING: University campus pharmacy. PARTICIPANTS: 25 individuals were screened while waiting for a prescription to be dispensed or while browsing in the pharmacy. INTERVENTIONS: Completion of a depression screening tool and a follow-up participant satisfaction survey to rate the usefulness of the depression screening tool. MAIN OUTCOME MEASURES: Scores on the depression screening tool and descriptive analysis of participant satisfaction survey. RESULTS: One participant was rated as depressed and one participant as "borderline" depression on the screening tool. Overall, 64% (16/25) of participants rated the screening tool as very useful, 92% (23/25) felt very comfortable while completing the screening tool, 40% (10/25) were very likely to read the provided written information, and 60% (15/25) learned about depression or themselves by participating in the survey. CONCLUSION: Depression screening is feasible in a university campus pharmacy. Participants reported feeling comfortable discussing depression with a pharmacist in a university campus pharmacy. In addition, they considered the information provided by the pharmacist on depression to be useful.