Effectiveness of Self-cut vs Mesh-Kit Titanium-Coated Polypropylene Mesh for Transvaginal Treatment of Severe Pelvic Organ Prolapse: A Multicenter Randomized Noninferiority Clinical Trial

IMPORTANCE

Transvaginal mesh (TVM) can increase the durability of vaginal surgical procedures for pelvic organ prolapse (POP) and may be indicated in certain situations despite concerns about mesh-related complications. In addition, the expense of commercial mesh kits has limited their use. The effectiveness, safety, and cost of a self-cut mesh procedure compared with a commercial mesh-kit procedure for the surgical treatment of women with POP is unclear.

OBJECTIVE

To assess the 1-year effectiveness and safety of self-cut titanium-coated polypropylene mesh compared with a precut commercial mesh kit for the transvaginal surgical treatment of women with severe symptomatic POP.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter randomized noninferiority clinical trial was conducted at 11 hospitals in 8 provinces of China. A total of 336 women with symptomatic stage 3 to 4 POP were enrolled between January 22, 2018, and November 11, 2019, with follow-up through December 11, 2020.

INTERVENTIONS

Participants were randomized to receive a TVM procedure using either self-cut mesh (self-cut mesh group) or a precut commercial mesh kit (mesh-kit group), both of which used the same titanium-coated polypropylene mesh.

MAIN OUTCOMES AND MEASURES

The primary outcome measure was composite surgical success at 1 year, which was defined as the absence of vaginal bulge symptoms, no additional retreatment for POP, and no vaginal prolapse at or beyond the hymen. Secondary outcomes included symptom-specific pelvic floor function and quality-of-life measures as well as perioperative complications, including mesh-related complications and hospitalization costs. Complications were categorized using the Clavien-Dindo system (with grade 1 indicating any deviation from the normal postoperative course but not requiring grade 2-4 interventions; grade 2, need for pharmacological treatment, blood transfusion, and/or total parenteral nutrition; grade 3, the need for surgical, endoscopic, and/or interventional radiological procedures; and grade 4, life threatening).

RESULTS

Among 336 female participants (mean [SD] age, 63.3 [5.9] years; all of Chinese ethnicity), 169 patients were randomized to the self-cut mesh group, and 167 were randomized to the mesh-kit group. Three patients were unavailable for follow-up after 1 year. In the intention-to-treat analysis, 162 women (95.9%) in the self-cut mesh group had outcomes that met the definition of surgical success; this result was noninferior to the surgical success rate observed in the mesh-kit group (146 women [87.4%]; risk difference, 8.5%; 95% CI, 2.2%-14.3%; P = .006). The frequency of Clavien-Dindo grade 1 to 3 perioperative complications was not significant between groups (12 of 166 women [7.2%] in the self-cut mesh group vs 20 of 161 women [12.4%] in the mesh-kit group; P = .14). Vaginal mesh exposure rates in women examined at 1 year were similar (4 women [2.4%] in the self-cut mesh group vs 8 women [4.8%] in the mesh-kit group; P = .23). Median (IQR) total hospitalization costs were $3663.00 ($3258.90-$4495.10) in the self-cut mesh group vs $6144.00 ($5434.90-$7160.20) in the mesh-kit group (P < .01), representing savings of $2481.00 (40.4%) with the use of self-cut mesh.

CONCLUSIONS AND RELEVANCE

In this clinical trial, the composite surgical success rate of a self-cut mesh procedure was noninferior to that of a commercial mesh-kit procedure using the same titanium-coated polypropylene mesh and reduced hospitalization expenses by 40.4%. These findings suggest that the use of self-cut mesh procedures may be advantageous for the surgical treatment of some women with severe POP, particularly those in countries with low and middle income.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03283124.

Optimal Follow-Up Duration for Assessment of Birth Defects After In Vitro Fertilization-Embryo Transfer: A Multicenter 5-Year Cohort Study in China

OBJECTIVE

To investigate the impact of a 5-year follow-up on the incidence of identified birth defects in children conceived using assisted reproductive technologies (ART).

METHODS

A 5-year cohort study was performed in three ART centers from January 2013 to October 2018. 1,543 women with 1,985 infants who delivered successfully or underwent termination of pregnancy due to malformations were recruited in this study. Follow-up was conducted by phone interview, 7 days, 1 year, 3 years, and 5 years after birth. Collected data included whether one or more birth defects were diagnosed, the category of birth defects, and when the malformation was diagnosed. Cumulative incidence of birth defects and the loss to follow-up rate of each follow-up was compared.

RESULTS

According to the diagnostic criterion of birth defects, 111 cases of one or more birth defects were recorded, with a total of 117 birth defects after the 5-year follow-up. 0.2% (4/1,985) of birth defects were diagnosed before delivery; 2.7% (54/1,985) at 7 days; 5.0% (100/1,985) after 1 year; 5.5% (109/1,985) after 3 years; and 5.6% (111/1,985) after 5 years. 3.4% (4/117) of defects were diagnosed prenatally, 45.3% (53/117) of defects diagnosed within the first 7 days after delivery, 40.2% (47/117) diagnosed during 7 days to 1 year, and 9.4% (11/117) of defects diagnosed in 1-3 years after birth. The remaining 1.7% (2/117) of defects were diagnosed between the ages of 3 and 5 years. Among the 1,543 patients, 99.9% patients (1,542/1,543) responded to the telephone interview at 7 days after delivery; the response rate was 89.0% (1,373/1,543) at 1 year, 81% (1,250/1,543) at 3 years, and 64.5% (995/1,543) after 5 years.

CONCLUSION

We suggest that in ART, 1-year follow-up should be the minimum requirement and 3-year follow up the optimal length of follow-up that balances resource requirements with ascertainment completeness.

A study of uterine inertia on the spontaneous of labor using uterine electromyography

OBJECTIVE

The purpose of this study is to analyze uterine electromyography burst patterns in patients with spontaneous labor and patients with uterine inertia.

MATERIALS AND METHODS

Uterine electromyography was recorded using 4 silver/silver chloride electrodes placed periumbilical. Thirty women in the spontaneous labor were enrolled. Uterine electromyography was also recorded from patients with uterine inertia before and after oxytocin treatment. EMG bursts were characterized by analysis of multiple variables including burst frequency, duration, root mean squared, amplitude, and total power.

RESULTS

There were significant reductions (P < .01) in all EMG burst characteristics. In addition, uterine electromyography parameters were all increased after oxytocin treatment and were comparable (P > .05) to patients in spontaneous labor.

CONCLUSIONS

Uterine electromyography can be used effectively to distinguish patients progressing with spontaneous labor from patients that develop uterine inertia. Uterine inertia is characterized by reduced EMG activity and failure of cervical dilation. Uterine electromyography is a quantitative, non-invasive assessment tool that contributes to the diagnosis, evaluation and management of patients with spontaneous labor and uterine inertia.

SARS-CoV-2 Is Not Detectable in the Vaginal Fluid of Women With Severe COVID-19 Infection

Background

Severe acute respiratory syndrome coronavirus 2(SARS-CoV-2) is mainly spread through respiratory droplets or direct contact. But the infection condition of genital system is still unknown. This study aimed to evaluate whether or not SARS-CoV-2 is found in the vaginal fluid of women with COVID-19 illness.

Methods

10 women with confirmed severe COVID-19 pneumonia admitted to in Tongji Zhongfa Hospital Intensive care union(ICU) ward from Feb 4, 2020 to Feb 24, 2020 were included. Clinical records, laboratory results, and computer tomography(CT)-scan examination were retrospectively reviewed. The evidence of genital infection potential was accessed by testing for the presence of SARS-CoV-2 in vaginal fluids obtained from vaginal swab samples. Reverse transcriptase polymerase chain reaction(RT-PCR) was used to confirm the SARS-CoV-2 infection in vaginal fluids.

Results

The clinical characteristics of these ten women were similar to those reported severe COVID-19 patients. All ten patients were tested for SARS-CoV-2 in vaginal fluid, and all samples tested negative for the virus.

Conclusion

Findings from this small group of cases suggest that no SARS-CoV-2 virus existing in the vaginal fluids of severe COVID-19 patients.

SARS-CoV-2 Is Not Detectable in the Vaginal Fluid of Women With Severe COVID-19 Infection

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is spread mainly through respiratory droplets or direct contact. However, the infection condition of the genital system is unknown. Our aim in this study was to determine if SARS-CoV-2 is present in the vaginal fluid of women with coronavirus disease 2019 (COVID-19).

METHODS

Ten women with confirmed severe COVID-19 pneumonia admitted to the Tongji Zhongfa Hospital intensive care unit from 4 February 2020 through 24 February 2020 were included. Clinical records, laboratory results, and computed tomography examinations were retrospectively reviewed. The potential for genital infection was accessed by testing for the presence of SARS-CoV-2 in vaginal fluids obtained from vaginal swab samples. Reverse transcriptase polymerase chain reaction was used to confirm the SARS-CoV-2 infection in vaginal fluids.

RESULTS

The clinical characteristics of the 10 women were similar to those reported in other severe COVID-19 patients. All 10 patients were tested for SARS-CoV-2 in vaginal fluid, and all samples tested negative for the virus.

CONCLUSIONS

Findings from this small group of cases suggest that SARS-CoV-2 virus does not exist in the vaginal fluids of severe COVID-19 patients.

Management of gynecology patients during the coronavirus disease 2019 pandemic: Chinese expert consensus

Since December 2019, the outbreak of novel coronavirus disease 2019 became a major epidemic threat in China and later spread worldwide. During the coronavirus disease 2019 outbreak in mainland China, the Chinese Obstetricians and Gynecologists Association distributed guidelines regarding the care of gynecologic patients. These guidelines were developed by the Department of Obstetrics and Gynecology at the Peking Union Medical College Hospital and represent an effort to integrate infection control strategy and promote professionalism in medical practice. The guidelines represent collaboration with experts from 31 provinces and autonomous regions of mainland China over 2 weeks’ time. With the implementation of these guidelines, no nosocomial infections of coronavirus disease 2019 have been identified at the Peking Union Medical College Hospital. We think these guidelines might be helpful to departments of obstetrics and gynecology internationally during these unprecedented times. In our guidelines, we describe basic infection precaution principles, an epidemiologic screening tool, prioritization of surgical procedures, and operating room requirements. Using these principles, we then review the management of gynecologic patients during the coronavirus disease 2019 epidemic in the outpatient and operative and nonoperative inpatient settings and in clinical trials.

1175 Sleep Disorders Screening in Primary Care: Prevalence of Diagnosis and Treatment in the EMR

Introduction

Undetected and untreated sleep disorders likely precipitate or exacerbate medical and/or psychiatric illnesses. Given this, primary care is an ideal point for managing sleep disorders, yet prior research shows that PCPs diagnose and/or treat sleep disorders at rates far below population prevalences. The purpose of this study was to determine the current rate of detection and treatment of sleep disorders within primary care settings.

Methods

EMR data from two health care systems was analyzed. The proportion of PCPs diagnosing and treating one or more sleep disorders was calculated (per year) for 5 years (2014-2018). Also calculated was the percent of PCP caseload diagnosed and/or treated for sleep disorders.

Results

The two systems comprised n=1021 PCPs. From 2014-2018, the proportion of PCPs diagnosing patients with sleep disorders fluctuated between 58-89%. The proportion treating sleep disorders fluctuated between 50-91%. Non-parametric one-sample run tests (SPSS) indicate these are random distributions (p&gt;0.05). PCPs’ use of medications to treat sleep disorders is trending downward over time within one system (per linear regression, p=0.03, R-squared=0.8). Other temporal trends were not evidenced. The average percentage of diagnosed and treated patients per PCP was around 2.5% of their caseloads. Between-system differences were observed.

Conclusion

There is a profound mismatch between percentage of PCPs identifying patients with sleep disorders (60-90%) and the percentage of patient caseload diagnosed and/or treated for sleep disorders (2.5%). This suggests that the majority of PCPs are willing to assess for sleep health but do so in only a small minority of patients. These data, along with our survey data (elsewhere in this volume) suggest that the intention-action gap could be closed if PCPs were appropriately resourced.

Support

There was no funding for this study.

1174 Assessing Sleep Disorders in Primary Care: A Provider Survey About the Importance of Sleep Health

Introduction

Conditions commonly managed by primary care providers (PCPs) such as depression, diabetes, and heart disease, commonly co-occur with sleep disorders. If PCPs could readily identify comorbid sleep disorders in this context, it may provide a pathway to more effective management of both types of disorders. Currently, it is unknown what might encourage or discourage PCPs from routinely screening their patients for sleep disorders.

Methods

PCPs from UPENN and GHS completed surveys regarding sleep health. The 30-item instrument comprised demographic, 14 VAS (0%-100%=strongly disagree-strongly agree), 4 open-ended, 3 yes/no, and 2 multiple-choice questions.

Results

Ninety-nine PCPs responded and were predominately female (61% F, 37%M, 2% other), Caucasian (81%), on-average 45yrs old (25-70) and in primary care for 16yrs (1-43). Fifty-six percent were MDs, 21%DOs, 17%PAs, and 6%NPs. PCPs rated sleep disorders as highly important for cardiopulmonary, mental, and general health (85, 84, & 83%), with no difference (per linear regression, p&gt;0.05) according to system or provider characteristics. PCPs reported high importance for knowing about and diagnosing sleep disorders (88% & 82%) within their practices. Lower comfort levels were reported for discussing (78%) sleep disorders, overseeing/following (62%), diagnosing (60%), or treating (48%) patients. Eighty percent of PCPs stated an efficient sleep disorders screener would be useful for their practice; this perception varied (per logistic regression) according to provider credentials (Wald=0.037) and Hispanic/Latino ethnicity (Wald=0.025). PCPs reported time constraints limit their responsiveness to sleep disorders

Conclusion

A large disparity exists between the importance PCPs place on sleep disorders and their low comfort levels with following, diagnosing, and treating sleep disorders. PCPs endorsed the need to have available an efficient sleep disorders screener to use in their practice.

Support

No funding was received for this study.

Self-cut titanium-coated polypropylene mesh versus pre-cut mesh-kit for transvaginal treatment of severe pelvic organ prolapse: study protocol for a multicenter non-inferiority trial

BACKGROUND

Pelvic organ prolapse (POP) is a common health problem and has significant negative effects on a woman's quality of life. The transvaginal mesh procedure is a durable reconstructive surgery, but the mesh kits are expensive for underdeveloped countries. Our previous case-series study showed that the use of self-cut mesh had a good success rate (91.8% at 1-year follow-up) and low complication rate. This trial is designed to compare a self-cut titanium-coated polypropylene mesh procedure with a mesh kit for the treatment of symptomatic stage III-IV anterior or apical prolapse in terms of efficacy, safety and cost-effectiveness.

METHODS

The trial is a randomized controlled multicenter non-inferiority trial. The primary outcome measure is the composite success rate at 1-year follow-up. The secondary outcomes are anatomic outcomes of each vaginal segment (anterior, posterior and apical) using the POP-Q score, subjective improvement of quality of life according to questionnaires, intraoperative parameters, complications and costs. Analysis will be performed according to the intention-to-treat principle. Based on a comparable success rate of 90% and 10% as the margin (β = 0.2 and one-sided α = 0.025), about 312 patients in total from 11 centers will be recruited including 10% dropout. The aims of the research are to demonstrate whether the self-cut mesh procedure is non-inferior to the mesh-kit procedure and to investigate the performance of titanium-coated mesh for vaginal prolapse repair.

DISCUSSION

This multicenter non-inferiority trial will evaluate whether the efficacy and safety of self-cut mesh is non-inferior to mesh kits in women with severe symptomatic stage III-IV anterior or apical prolapse. If we are able to show that the self-cut mesh procedure is non-inferior to the mesh-kit procedure in success rates, then the self-cut mesh procedure may be more cost-effective.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03283124. Registered on 17 January 2018.

Development of a core set of outcome measures for OAB treatment

INTRODUCTION AND HYPOTHESIS

Standardized measures enable the comparison of outcomes across providers and treatments giving valuable information for improving care quality and efficacy. The aim of this project was to define a minimum standard set of outcome measures and case-mix factors for evaluating the care of patients with overactive bladder (OAB).

METHODS

The International Consortium for Health Outcomes Measurement (ICHOM) convened an international working group (WG) of leading clinicians and patients to engage in a structured method for developing a core outcome set. Consensus was determined by a modified Delphi process, and discussions were supported by both literature review and patient input.

RESULTS

The standard set measures outcomes of care for adults seeking treatment for OAB, excluding residents of long-term care facilities. The WG focused on treatment outcomes identified as most important key outcome domains to patients: symptom burden and bother, physical functioning, emotional health, impact of symptoms and treatment on quality of life, and success of treatment. Demographic information and case-mix factors that may affect these outcomes were also included.

CONCLUSIONS

The standardized outcome set for evaluating clinical care is appropriate for use by all health providers caring for patients with OAB, regardless of specialty or geographic location, and provides key data for quality improvement activities and research.

Surgical Outcomes of a Combined Surgical Approach for Apical Prolapse Repair

Introduction We aimed to evaluate the safety, efficacy and surgical outcomes of combined laparoscopic/vaginal prolapse repair by two surgeons. Material and Methods A retrospective chart review of all patients (n = 135) who underwent apical prolapse repair from February 2009 to December 2012 performed in a collaborative manner by a Minimally Invasive Gynecologic Surgeon and a Urogynecologist. Demographic data (age, body mass index [BMI], race, gravidity, parity) and surgical information (estimated blood loss, operative time, intraoperative complications, readmission and reoperation rates, presence of postoperative infection) were collected. Results The majority of patients were postmenopausal (58.91%), multiparous (mean parity = 2.49) and overweight (mean BMI = 27.71). Nearly 20% had previous prolapse surgery. The most common surgical procedure was laparoscopic supracervical hysterectomy (LSH) with sacrocervicopexy (59.26%), and the most common vaginal repair was of the posterior compartment (78.68%). The median operative time was 149 minutes (82-302), and the estimated blood loss was 100 mL (10-530). Five intra-operative complications, five readmissions and four reoperations were noted. Performance of a concomitant hysterectomy did not affect surgical or anatomical outcomes. Conclusion Combination laparoscopic/vaginal prolapse repair by two separate surgeons seems to be an efficient option for operative management.

Endochondral fracture healing with external fixation in the Sost knockout mouse results in earlier fibrocartilage callus removal and increased bone volume fraction and strength

Sclerostin deficiency, via genetic knockout or anti-Sclerostin antibody treatment, has been shown to cause increased bone volume, density and strength of calluses following endochondral bone healing. However, there is limited data on the effect of Sclerostin deficiency on the formative early stage of fibrocartilage (non-bony tissue) formation and removal. In this study we extensively investigate the early fibrocartilage callus. Closed tibial fractures were performed on Sost(-/-) mice and age-matched wild type (C57Bl/6J) controls and assessed at multiple early time points (7, 10 and 14days), as well as at 28days post-fracture after bony union. External fixation was utilized, avoiding internal pinning and minimizing differences in stability stiffness, a variable that has confounded previous research in this area. Normal endochondral ossification progressed in wild type and Sost(-/-) mice with equivalent volumes of fibrocartilage formed at early day 7 and day 10 time points, and bony union in both genotypes by day 28. There were no significant differences in rate of bony union; however there were significant increases in fibrocartilage removal from the Sost(-/-) fracture calluses at day 14 suggesting earlier progression of endochondral healing. Earlier bone formation was seen in Sost(-/-) calluses over wild type with greater bone volume at day 10 (221%, p<0.01). The resultant Sost(-/-) united bony calluses at day 28 had increased bone volume fraction compared to wild type calluses (24%, p<0.05), and the strength of the fractured Sost(-/-) tibiae was greater than that that of wild type fractured tibiae. In summary, bony union was not altered by Sclerostin deficiency in externally-fixed closed tibial fractures, but fibrocartilage removal was enhanced and the resultant united bony calluses had increased bone fraction and increased strength.

Mechanical load increases in bone formation via a sclerostin-independent pathway

Sclerostin, encoded by the Sost gene, is an important negative regulator of bone formation that has been proposed to have a key role in regulating the response to mechanical loading. To investigate the effect of long-term Sclerostin deficiency on mechanotransduction in bone, we performed experiments on unloaded or loaded tibiae of 10 week old female Sost-/- and wild type mice. Unloading was induced via 0.5U botulinum toxin (BTX) injections into the right quadriceps and calf muscles, causing muscle paralysis and limb disuse. On a separate group of mice, increased loading was performed on the left tibiae through unilateral cyclic axial compression of equivalent strains (+1200 µe) at 1200 cycles/day, 5 days/week. Another cohort of mice receiving equivalent loads (-9.0 N) also were assessed. Contralateral tibiae served as normal load controls. Loaded/unloaded and normal load tibiae were assessed at day 14 for bone volume (BV) and formation changes. Loss of BV was seen in the unloaded tibiae of wild type mice, but BV was not different between normal load and unloaded Sost-/- tibiae. An increase in BV was seen in the loaded tibiae of wild type and Sost-/- mice over their normal load controls. The increased BV was associated with significantly increased mid-shaft periosteal mineralizing surface/bone surface (MS/BS), mineral apposition rate (MAR), and bone formation rate/bone surface (BFR/BS), and endosteal MAR and BFR/BS. Notably, loading induced a greater increase in periosteal MAR and BFR/BS in Sost-/- mice than in wild type controls. Thus, long-term Sclerostin deficiency inhibits the bone loss normally induced with decreased mechanical load, but it can augment the increase in bone formation with increased load.

Motives for eating tasty foods associated with binge-eating. Results from a student and a weight-loss seeking population

The aim of this study was to use the Palatable Eating Motives Scale (PEMS) to determine if and what motives for eating tasty foods (e.g., junk food, fast food, and desserts) are associated with binge-eating in two diverse populations. BMI and scores on the PEMS, Yale Food Addiction Scale (YFAS), and Binge-eating Scale (BES) were obtained from 247 undergraduates at the University of Alabama at Birmingham (UAB) and 249 weight-loss seeking patients at the UAB EatRight program. Regression analyses revealed that eating tasty foods to forget worries and problems and help alleviate negative feelings (i.e., the 4-item Coping motive) was associated with binge-eating independently of any variance in BES scores due to sex, age, ethnicity, BMI, other PEMS motives, and YFAS scores in both students (R² = .57) and patients (R² = .55). Coping also was associated with higher BMI in students (p < 0.01), and in patients despite their truncated BMI range (p < 0.05). Among students, the motives Conformity and Reward Enhancement were also independently associated with binge-eating. For this younger sample with a greater range of BES scores, eating for these motives, but not for Social ones, may indicate early maladaptive eating habits that could later develop into disorders characterized by binge-eating if predisposing factors are present. Thus, identifying one's tasty food motive or motives can potentially be used to thwart the development of BED and obesity, especially if the motive is Coping. Identifying one's PEMS motives should also help personalize conventional treatments for binge-eating and obesity toward improved outcomes.

Distal tibial fracture repair in a neurofibromatosis type 1-deficient mouse treated with recombinant bone morphogenetic protein and a bisphosphonate

Congenital pseudarthrosis of the tibia is an uncommon manifestation of neurofibromatosis type 1 (NF1), but one that remains difficult to treat due to anabolic deficiency and catabolic excess. Bone grafting and more recently recombinant human bone morphogenetic proteins (rhBMPs) have been identified as pro-anabolic stimuli with the potential to improve the outcome after surgery. As an additional pharmaceutical intervention, we describe the combined use of rhBMP-2 and the bisphosphonate zoledronic acid in a mouse model of NF1-deficient fracture repair. Fractures were generated in the distal tibiae of neurofibromatosis type 1-deficient (Nf1(+/-)) mice and control mice. Fractures were open and featured periosteal stripping. All mice received 10 μg rhBMP-2 delivered in a carboxymethylcellulose carrier around the fracture as an anabolic stimulus. Bisphosphonate-treated mice also received five doses of 0.02 mg/kg zoledronic acid given by intraperitoneal injection. When only rhBMP but no zoledronic acid was used to promote repair, 75% of fractures in Nf1(+/-) mice remained ununited at three weeks compared with 7% of controls (p < 0.001). Systemic post-operative administration of zoledronic acid halved the rate of ununited fractures to 37.5% (p < 0.07). These data support the concept that preventing bone loss in combination with anabolic stimulation may improve the outcome following surgical treatment for children with congenital pseudarthosis of the tibia and NF1.

Paper versus web-based administration of the Pelvic Floor Distress Inventory 20 and Pelvic Floor Impact Questionnaire 7

Web-based questionnaires are increasingly employed for clinical research. To investigate whether web-based and paper versions of the Pelvic Floor Distress Inventory 20 (PFDI-20) and Pelvic Floor Impact Questionnaire 7 (PFIQ-7) yield similar results, we compared results obtained with these two modes of administration. Women with pelvic floor disorders completed both versions of these questionnaires. Scores between modes of administration were compared using the paired t test and the intraclass correlation coefficient (ICC). Among the 52 participants, there were no significant differences in scores or scale scores between the web-based and paper questionnaires. The ICC was 0.91 for the PFDI-20 score and 0.81 for the PFIQ-7 score (p < 0.001 for each). The web-based format was preferred by 22 participants (53%), ten (24%) preferred the paper format, and nine (21%) had no preference. The acceptability and score equivalence recommend these web-based questionnaires as an alternative to paper questionnaires for clinical research.

Low adherence to guidelines for preventing TB among persons with newly diagnosed HIV infection, United States

SETTING

Persons infected with human immunodeficiency virus (HIV) are at risk for developing tuberculosis (TB) if latent TB infection remains untreated.

OBJECTIVE

To assess missed opportunities for preventing TB by selecting a population-based sample of 1093 persons diagnosed with HIV from June 1995 to June 1997 in Seattle, WA, New Orleans, LA, and Jersey City, NJ.

DESIGN

To determine the proportion of persons receiving a tuberculin skin test (TST) following HIV diagnosis, we conducted record reviews at providers and local TB control.

RESULTS

An estimated 53.7% (95% CI 49.9-57.4) had a TST following HIV diagnosis; 6.6% (95% CI 4.3-8.9%) of TST-tested patients were reactive. Median time between HIV diagnosis and TST was 1 month (mean 5.7 months, 95% CI 4.8-6.5). Factors associated with TST included additional risk factors for TB (OR 1.76, 95% CI 1.17-2.63), history of HIV-related preventive treatment (OR 5.84, 95% CI 3.74-8.75), higher number of clinic visits (OR 4.16, 95% CI 2.01-8.02), and attendance at facilities with a written policy to provide TST for all persons with HIV (OR 2.54, 95% CI 1.28-4.88).

CONCLUSION

About half of persons newly diagnosed with HIV infection had a TST following HIV diagnosis, with little variation by demographics, signaling a general need to improve interventions to prevent TB.

Perceptual correlates of neural representations evoked by odorant enantiomers

Spatial activation patterns within the olfactory bulb are believed to contribute to the neural representation of odorants. In this study, we attempted to predict the perceptions of odorants from their evoked patterns of neural activity in the olfactory bulb. We first describe the glomerular activation patterns evoked by pairs of odorant enantiomers based on the uptake of [(14)C]2-deoxyglucose in the olfactory bulb glomerular layer. Using a standardized data matrix enabling the systematic comparison of these spatial odorant representations, we hypothesized that the degree of similarity among these representations would predict their perceptual similarity. The two enantiomers of carvone evoked overlapping but significantly distinct regions of glomerular activity; however, the activity patterns evoked by the enantiomers of limonene and of terpinen-4-ol were not statistically different from one another. Commensurate with these data, rats spontaneously discriminated between the enantiomers of carvone, but not between the enantiomers of limonene or terpinen-4-ol, in an olfactory habituation task designed to probe differences in olfactory perception.

Survival patterns among HIV+ individuals based on health care utilization

The purpose of this study was to determine if HIV+ persons who first obtained health care in New Orleans through public hospital inpatient services had a higher risk of death or disease progression than patients who first entered care through public outpatient services. The sites included the largest HIV outpatient clinic in the Gulf South, two early intervention sites and a public hospital. A medical record review on patients who attended these sites from July 1995 through December 1999 and were enrolled in the Adult Spectrum of Disease (ASD) Study was conducted (n = 3402). The multivariate analysis examined the associations between inpatient services and the main effects. Kaplan-Meier analysis and Cox proportional hazards regression were performed. Risk of death or disease progression was analyzed for three different endpoints: time from study entry to death, time from HIV to AIDS, and time from AIDS to death. The multivariate analysis showed that patients first entering care through inpatient services were significantly more likely to be African American, have AIDS, and use drugs. The risk of death or disease progression was significantly higher for all three endpoints. Results from this study indicate that HIV+ individuals receiving initial care through public hospital inpatient services may require more effective early intervention.

The clinical profile of end-stage AIDS

The purpose of this study was to describe the clinical profile of end-stage AIDS in patients 12 months before death. A cross-sectional examination of HIV-infected patients who attended a public HIV outpatient clinic between 1990 and 1996 and who died was conducted. The prevalence and first-time acquisition of AIDS-defining conditions 12 months before death were evaluated. The AIDS-defining conditions with the highest percentages of first-time acquisition in the last 12 months of life were progressive multifocal leukoencephalopathy (100%), lymphoma (96%), dementia (78.6%), Mycobacterium avium complex (MAC) infection (74.0%), toxoplasmosis (72.6%), and cytomegalovirus (CMV) infection (69.6%). Of the concomitant conditions studied, those with the highest percentages of first-time acquisition in the last 12 months of life were CMV with MAC (99%) and CMV with wasting (88%). Patients who acquire these AIDS-defining conditions may be eligible to receive information about end-stage options, such as hospice care. However, administration of aggressive antiretroviral treatments, such as the protease inhibitors, may affect this profile in the future, as the majority of the patients in this study were receiving the standard antiretroviral treatments of the time, primarily zidovudine.

Characterization of tobacco plants expressing a bacterial salicylate hydroxylase gene

Transgenic tobacco plants that express the bacterial nahG gene encoding salicylate hydroxylase have been shown to accumulate very little salicylic acid and to be defective in their ability to induce systemic acquired resistance (SAR). In recent experiments using transgenic NahG tobacco and Arabidopsis plants, we have also demonstrated that salicylic acid plays a central role in both disease susceptibility and genetic resistance. In this paper, we further characterize tobacco plants that express the salicylate hydroxylase enzyme. We show that tobacco mosaic virus (TMV) inoculation of NahG tobacco leaves induces the accumulation of the nahG mRNA in the pathogen infected leaves, presumably due to enhanced stabilization of the bacterial mRNA. SAR-associated genes are expressed in the TMV-infected leaves, but this is localized to the area surrounding necrotic lesions. Localized acquired resistance (LAR) is not induced in the TMV-inoculated NahG plants suggesting that LAR, like SAR, is dependent on SA accumulation. When SA is applied to nahG-expressing leave's SAR gene expression does not result. We have confirmed earlier reports that the salicylate hydroxylase enzyme has a narrow substrate specificity and we find that catechol, the breakdown product of salicylic acid, neither induces acquired resistance nor prevents the SA-dependent induction of the SAR genes.

Evaluation of a program to remove barriers to public health care for women with HIV infection

To facilitate access to care for HIV-infected women, a maternal-child program was started at an HIV outpatient clinic in New Orleans. The program consisted of free child care and transportation, separate waiting and examination rooms, female care providers, merged visits for mother and child, and on-site colposcopy services. This study evaluates the efficacy of the program on improving attendance at the clinic by follow-up of 143 women and 557 men (serving as controls). Multivariate models were adjusted for history of intravenous drug abuse, race, age, CD4 cell count, staging of disease, and time in the clinic. Half of the clients achieved high attendance rates. Women were as likely as men to achieve high attendance rates before the interventions, but more likely to do so at both 6 months and 1 year postintervention (after adjustment for the other variables). These results suggest that responding to special gender-related needs can improve women's attendance for clinic visits.

Comparison of multiple drug therapy regimens for HIV-related disseminated Mycobacterium avium complex disease

In June 1993, the United States Public Health Service (USPHS) made recommendations for treatment of disseminated Mycobacterium avium complex (MAC) in patients infected with the human immunodeficiency syndrome (HIV). It was suggested that every treatment regimen include either azithromycin or clarithromycin plus one or more of the following drugs: ethambutol, clofazimine, rifabutin, rifampin, ciprofloxacin, or amikacin. This study compares the effect of multiple drug therapy regimens on the survival of patients of the HIV outpatient department of the Medical Center of New Orleans, Louisiana. A retrospective chart review of 122 confirmed cases of MAC was conducted. Three treatment groups were considered: no/monotreatment (n = 40), multitreatment without clarithromycin (n = 32), and multitreatment with clarithromycin (n = 50). Azithromycin, amikacin, and rifabutin were not used in this clinic during the study period. Both multitreatment without clarithromycin (p < 0.03) and multitreatment with clarithromycin (p < 0.005) were significantly protective for survival after adjusting for CD4 cell count at time of diagnosis, nonadherence to treatment, number of concomitant opportunistic infections at diagnosis, and weight loss > 10%. Neither of the groups that received multidrug therapy were significantly less likely to have MAC-related symptoms than the no/mono group at 3 and 6 months postdiagnosis. These findings support the USPHS recommendation for multiple drug treatment either with or without clarithromycin. Prospective controlled clinical trials will clarify the optimal regimen for disseminated MAC disease.

Compliance with public sector HIV medical care

Despite the availability of free or low-cost public sector human immunodeficiency virus (HIV) health-care services, important inequities in utilization exist. This study examined two measures of compliance with HIV medical care: attendance of scheduled outpatient visits and use of the emergency room. Clients of two public HIV outpatient clinics were followed from time of health-care initiation to either death or the end of the study. The association of race, sex, age, and injection drug use (IDU) with these measures were examined in multivariate logistic regression. Models were adjusted for disease staging at time of entry and for length of follow-up time in clinic. Of 1824 clients followed, 15% failed to attend scheduled visits and 18.1% had at least one emergency room visit. Clients who missed visits were more likely to be African American, to have a history of IDU, and to have a CD4 cell count < 500/mm3 or an acquired immunodeficiency syndrome (AIDS)-defining opportunistic infection at entry. They were also more likely to have > or = 12 months of follow-up time in the HIV clinic, but were less likely to have entered into health care from an early intervention clinic. Clients who had at least one emergency room visit were more likely to be African American, female, IDU, and under 22 years of age; these clients were also more likely to have entered with CD4 < 200/mm3 or with an opportunistic infection, and to have > or = 12 months of follow-up in the clinic.(ABSTRACT TRUNCATED AT 250 WORDS)

Salicylic Acid Is Not the Translocated Signal Responsible for Inducing Systemic Acquired Resistance but Is Required in Signal Transduction

Infection of plants by necrotizing pathogens can induce broad-spectrum resistance to subsequent pathogen infection. This systemic acquired resistance (SAR) is thought to be triggered by a vascular-mobile signal that moves throughout the plant from the infected leaves. A considerable amount of evidence suggests that salicylic acid (SA) is involved in the induction of SAR. Because SA is found in phloem exudate of infected cucumber and tobacco plants, it has been proposed as a candidate for the translocated signal. To determine if SA is the mobile signal, grafting experiments were performed using transgenic plants that express a bacterial SA-degrading enzyme. We show that transgenic tobacco root-stocks, although unable to accumulate SA, were fully capable of delivering a signal that renders nontransgenic scions resistant to further pathogen infection. This result indicated that the translocating, SAR-inducing signal is not SA. Reciprocal grafts demonstrated that the signal requires the presence of SA in tissues distant from the infection site to induce systemic resistance.

An audit of a radiographer based ultrasound service

A general ultrasound service has evolved over several years. Radiographers undertake the general ultrasound lists, and show the request card and the hard copy films to a radiologist prior to the patient leaving the department. Whilst it is generally accepted for radiographers to carry the burden of obstetric scanning, this is less so for general work. This audit is of a sample of 100 patients out of the general ultrasound lists. These patients underwent the standard service examination by a radiographer and subsequent report by the radiologist. They also had a separate examination and report by an independent radiologist. 42 patients were agreed to have normal findings. 75 diagnoses or observations were made in the remaining 58 patients. Discrepancies arose between the two limbs of the audit in 20 of the observations. Review of the hard copy films and repeat scanning of patients where necessary identified one relevant error by the auditing radiologist and three relevant errors by the standard service. Whilst errors are made both by radiologists and radiographers, it is concluded that the existing radiographer based ultrasound service provides a satisfactory level of accuracy.

Determining the prevalence of neurosyphilis in a cohort co-infected with HIV

A retrospective study of 767 HIV positive patients from a large urban public hospital, 238 of whom were co-infected with syphilis, was performed to determine the prevalence of neurosyphilis. A prevalence of 3% of neurosyphilis in the co-infected cohort was demonstrated. The 7 cases of neurosyphilis ascertained were of the early stage variety, with cranial nerve involvement the predominant focal deficit. Of the 5 cases presenting after initial diagnosis and treatment of syphilis, 4 were felt to be inadequately treated. An overall prevalence of 1% (7/767) was determined for the entire HIV(+) cohort. The majority of the cases of syphilis (90%) were characterized as latent syphilis. Based on these findings, the authors recommend routine CSF examination in all patients who are HIV positive and who present with latent syphilis. Treatment regimens should be maximized in an effort to reduce the prevalence of neurosyphilis in such a co-infected cohort.

A prospective study of human papillomavirus infection of the cervix

In a prospective study 42 women, diagnosed as having low grade cervical intraepithelial neoplasia (CIN), made a total of 281 clinic visits over a 45 month period. At each visit, they were subjected to cytological and colposcopical examination and samples were taken for human papillomavirus (HPV) DNA hybridization studies and for the detection of non-HPV infections. HPV types 16 and/or 18 were found in 25% of all the samples tested and these virus types were detected in five of six (83%) women whose lesions progressed compared to seven of 14 (50%) of those whose lesions regressed. The presence of HPV DNA was not a good prognostic indicator of progression since half of those whose disease regressed also harboured these viruses at some time. The recording of non-HPV infections almost 10 times more often in the women whose disease regressed than in those whose disease progressed could probably be accounted for by the former having a larger number of follow-up visits. Nevertheless, the significance of non-HPV infections also remains unclear.

Occupation and pancreatic cancer risk in Louisiana

To study the relation of occupational exposures and pancreatic cancer, we evaluated data from males (198 cases and 209 controls) participating in a hospital-based case-control study conducted in a high-risk area of Louisiana between 1979 and 1983. The questionnaire obtained information on lifetime occupational history, as well as dietary, smoking, and drinking habits and demographic characteristics. After adjustment for smoking and dietary patterns, white collar occupations showed consistent elevations in risk, whereas associations for other occupations were in general unremarkable. Although not significantly elevated, risks for truck drivers (OR = 1.7) and those with long-term employment in machine repair or as mechanics were suggestive (OR = 2.5). No association was found for jobs in oil refining or oil and gas extraction (ORs were 0.5 and 0.4, respectively), although risks were slightly elevated for long-term workers in the chemical processing industry (OR = 1.2). While these associations deserve further study, our findings are consistent with results of other studies which do not suggest that occupational exposures are important determinants of pancreatic cancer.

A cultural intervention model for developmentally disabled adults:

This paper describes Chavarim, a non-traditional community based program, founded in the Jewish cultural context. Chavarim is a socialization and life-skill development program for Jewish adults with developmental disabilities. The program incorporates occupational therapy precepts of independent living, community integration, cultural identification and development of life roles. Specific details of program development and implementation will be included. While this paper is concerned with service delivery in the area of developmental disabilities, recommendation for the applicability of the model for occupational therapy intervention with other cultural groups will be discussed. In this author's opinion, for a person with a disability to be adequately prepared to meet the challenges of full community integration, the meaning of culture in daily life must be understood and incorporated into life-skill training programs. This is an account of how one occupational therapist developed an innovative program to meet the challenge of the task.

An alternative to the diagnostic dilatation and curettage--endometrial cytology

Endometrial aspiration cytology has been shown by multicentre prospective studies to be an acceptable and valuable method of assessing the endometrium. A retrospective study was undertaken over three years' routine use of the Isaacs cell sampler. In 86% of the cases suitable endometrium was obtained, with experience of the technique being the important factor. When compared with histological findings, all 11 cases of malignancy were confirmed, including one ovarian adenocarcinoma. Of the cytological reports of endometrial hyperplasia, 78% were confirmed by the histological findings, with the remainder showing minor degrees of cystic hyperplasia or normal endometrium. In no case was a more abnormal lesion present on histological examination than had been suggested by cytological findings. The use of progestogens in reversing hyperplasia is seen to be effective, though the long term benefit remains uncertain. It is concluded that with an experienced cytologist, Isaacs endometrial aspiration should be used routinely for the primary investigation of dysfunctional uterine bleeding and postmenopausal bleeding.