Does Laparoscopic Hysterectomy Increase the Risk of Vaginal Cuff Dehiscence? An Analysis of Outcomes from Multiple Academic Centers and a Review of the Literature.

Vaginal cuff dehiscence represents a serious, but infrequent complication after hysterectomy, with a reported increased incidence following a laparoscopic approach. Various risk factors have been proposed including laparoscopically placed suture, surgical experience, use of electrosurgery, surgical indication, and obesity. Technical aspects of the procedure itself have also been questioned such as the variable use of monopolar electrosurgery during colpotomy and the suture type or number of layers chosen to reapproximate the vaginal cuff. Nothwithstanding the tendency for cuff dehiscence to occur following laparoscopic approach, there remains a paucity of high-quality data that supports or refutes this finding or clearly defines the mechanism(s) by which this event occurs allowing for the proposal of objective guidelines for reducing risk. Various techniques have been proposed to decrease the risk of vaginal cuff dehiscence during endoscopic hysterectomy, including use of monopolar current on cutting mode, achievement of cuff hemostasis with sutures rather than electrocoagulation, use of a two-layer cuff closure with polydioxanone suture, and use of bidirectional barbed suture for cuff closure. The authors experience at three university-based minimally invasive gynecologic surgery programs showed a low rate of vaginal cuff dehiscence in their own practices. Large randomized controlled trials are needed to truly determine whether there is a difference in vaginal cuff dehiscence between surgical modalities for hysterectomy as well as to determine the true risk factors.

From research to practice: lay adherence counsellors' fidelity to an evidence-based intervention for promoting adherence to antiretroviral treatment in the Western cape, South Africa.

In the Western Cape, lay counsellors are tasked with supporting antiretroviral (ARV) adherence in public healthcare clinics. Thirty-nine counsellors in 21 Cape Town clinics were trained in Options for Health (Options), an evidence-based intervention based on motivational interviewing (MI). We evaluated counsellors' ability to deliver Options for addressing poor adherence following 5 days training. Audio-recordings of counselling sessions collected following training were transcribed and translated into English. Thirty-five transcripts of sessions conducted by 35 counsellors were analysed for fidelity to the Options protocol, and using the Motivational Interviewing Treatment and Integrity (MITI) code. Counsellors struggled with some of the strategies associated with MI, such as assessing readiness-to-change and facilitating change talk. Overall, counsellors failed to achieve proficiency in the approach of MI according to the MITI. Counsellors were able to negotiate realistic plans for addressing patients' barriers to adherence. Further efforts aimed at strengthening the ARV adherence counselling programme are needed.