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Information is carried between brain regions through neurotransmitter release from axonal presynaptic terminals. Understanding the functional roles of defined neuronal projection pathways requires temporally precise manipulation of their activity. However, existing inhibitory optogenetic tools have low efficacy and off-target effects when applied to presynaptic terminals, while chemogenetic tools are difficult to control in space and time. Here, we show that a targeting-enhanced mosquito homolog of the vertebrate encephalopsin (eOPN3) can effectively suppress synaptic transmission through the G i/o signaling pathway. Brief illumination of presynaptic terminals expressing eOPN3 triggers a lasting suppression of synaptic output that recovers spontaneously within minutes in vitro and in vivo. In freely moving mice, eOPN3-mediated suppression of dopaminergic nigrostriatal afferents induces a reversible ipsiversive rotational bias. We conclude that eOPN3 can be used to selectively suppress neurotransmitter release at presynaptic terminals with high spatiotemporal precision, opening new avenues for functional interrogation of long-range neuronal circuits in vivo., Competing Interests: Declaration of interests O.Y. and M.M. have disclosed these findings to Yeda, the Weizmann Institute Technology Transfer Arm, which is filing a patent application on these developments. The constructs and viral vectors remain freely available from the authors and through Addgene., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: This surgical simulation model for vaginal posterior repair is designed to enhance vaginal surgical training., Methods: A beef tongue simulation model was previously described and validated to practice the repair of obstetric laceration. The model was modified for surgical simulation of vaginal posterior repair. Chicken skin was used to simulate the anal canal. The model was secured in a PVC (polyvinyl chloride) pipe attached to a wooden base to simulate operating within the vaginal canal., Experience: Materials can be obtained from the local supermarket and hardware store. The total cost of the model is $35.47 for initial setup and $7.11 per use. Residents performing on the model felt it was realistic and useful for practicing the steps and skills for this procedure., Conclusion: The beef tongue simulation model of vaginal posterior repair is realistic, easy to construct, and affordable. It can be incorporated into a vaginal surgery curriculum to augment resident surgical education., Competing Interests: Financial Disclosure The authors did not report any potential conflicts of interest., (Copyright © 2021 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Significance: The prevalence of dry eye disease and low vision increases with age; they share risk factors and can be the result of underlying common causes. They are generally studied separately; however, combining these perspectives is relevant for research on assistive technology given that sustained focus affects the tear film because of decreased blinking rates., Purpose: The objective of this study was to elucidate to which extent dry eye disease risk factors, signs, and symptoms are assessed in low vision patients who receive an eye examination as part of their vision rehabilitation services., Methods: Using a retrospective chart review, dry eye disease risk factors, signs, or symptoms were extracted from 201 randomly selected files that contained an eye examination in the past 5 years from two vision rehabilitation centers., Results: Demographic variables of charts from the two sites did not differ (mean visual acuity, 0.85 logMAR [standard deviation, 0.53; range, 0 to 2.3]; mean age, 71.2 years [standard deviation, 19 years; range, 24 to 101 years]). Fifty charts (25%) mentioned at least one dry eye disease symptom. Sixty-one charts (30.3%) reported systemic medications that can exacerbate dry eye disease, whereas 99 (49.2%) contained at least one systemic disease thought to contribute to dry eye disease symptoms; 145 (72.1%) mentioned at least one type of ocular surgery. Artificial tears were documented in 74 charts (36.8%). Few specific dry eye tests were performed, with the exception of corneal integrity assessment reported in 18 charts (8.95%)., Conclusions: Low vision patients have multiple risk factors for dry eye disease; however, dry eye disease tests were not frequently performed in comprehensive low vision eye examinations in this sample. More efforts should be made to assess dry eye disease to enhance comfort and functional vision, especially with the increasing demands of digital devices as visual aids., Competing Interests: Conflict of Interest Disclosure: Both EB and WW are professors at the University of Montreal. Authors RA and GB-S were students (now graduated) at the time of the study. None of the authors have any direct conflict of interest with this article., (Copyright © 2021 American Academy of Optometry.)

Demodex is the most common parasite living on humans and yet little is understood about its pathogenicity with respect to the ocular surface. An increasing interest in Demodex over the past 20-years has increased our understanding of this mite and its pathogenetic role. This article begins with a review of the anatomy, life cycle, mode of transmission and advances in genetics that can distinguish between Demodex folliculorum and Demodex brevis, the only two Demodex species in humans. Additionally, a review of diagnostic procedures and existing and emerging ocular and systemic management options are presented. Despite the increasing interest in Demodex in the literature, there remains numerous obstacles for future studies, hence a section of this review is dedicated to the identification and proposal for future considerations. The lack of uniformity with respect to terminology, diagnostic technique and management approach for Demodex remain as obstacles for future study comparisons. This review summarised the current knowledge on Demodex and hopes to offer some recommendations for future directions in the study of Demodex in humans.

The population of Israel is ethnically diverse, and individuals from different ethnic groups share specific genetic variations. These variations, which have been passed on from common ancestors, are usually reported in public databases as rare variants. Here, we aimed to identify ethnicity-based benign copy number variants (CNVs) and generate the first Israeli CNV database. We applied a data-mining approach to the results of 10,193 chromosomal microarray tests, of which 2150 tests were from individuals of 13 common ethnic backgrounds (n ≥ 10). We found 165 CNV regions (> 50 kbp) that are unique to specific ethnic groups (uCNVRs). The frequency of more than 19% of these uCNVRs is between 1 and 20% of the common ethnic origin, while their frequency in the overall cohort is between 0.5 and 1.6%. Of these 165 uCNVRs, 98 are reported as variants of unknown significance or as not available in dbVar; we postulate that these uCNVRs should be annotated as either "likely benign" or "benign". The ethnic-specific CNVs extracted in this study will allow geneticists to distinguish between relevant pathogenic genomic aberrations and benign ethnicity-related variations, thus preventing variant misinterpretation that may lead to unnecessary pregnancy terminations.

Objective: To determine the relationship between age at first delivery and subsequent risk of pelvic organ prolapse., Study Design: We performed a retrospective cross-sectional study using the National Health and Nutrition Examination Survey data from 2005 to 2012. Our primary outcome was self-reported prolapse. Survival analyses and Cox proportional hazard models were used to estimate parous women's risks of reporting prolapse in terms of time since first delivery, adjusting for parity, body mass index, prior hysterectomy, ethnicity, and education. We performed subgroup analyses on women with at least 1 vaginal delivery and those with only cesarean deliveries., Results: The survey-weighted prevalence of prolapse was 2.82%. A total of 6203 women, 79% of all parous women surveyed, reported age at first delivery. Kaplan-Meier curves were different for women based on age at first delivery (P = 0.034). For each year increase in age at first delivery, there was a 6% increase in the rate of developing prolapse (adjusted hazard ratio, 1.06; 95% confidence interval, 1.01-1.11; P = 0.011). Compared with a woman who was 20 years at her first delivery, someone who was 30 years had 1.79 times the risk, while at 40 years the risk was 3.21 times. Among women with at least 1 vaginal delivery, the same relationship was found (adjusted hazard ratio, 1.06; 95% confidence interval, 1.01-1.12; P = 0.019). However, this was not significant for women with only cesarean deliveries (P = 0.367)., Conclusions: Older age at the time of first delivery was associated with a higher risk of subsequent prolapse. These results should be interpreted with caution given the limitations of cross-sectional survey data., Competing Interests: The authors report no conflict of interest., (Copyright © 2020 American Urogynecologic Society. All rights reserved.)

Objective: The aims of this study were to design and to validate a surgical simulation model for vaginal anterior colporrhaphy., Methods: Obstetrics and gynecology residents were divided into two groups: "novice" and "advanced." "Expert" group comprised female pelvic medicine and reconstructive surgery (FPMRS) fellows and faculty. All subjects were recorded performing anterior colporrhaphy using the simulation model. Deidentified, silent videos of recorded performances were evaluated by a blinded reviewer using the Objective Structured Assessment of Technical Skills (OSATS) and a procedure-specific assessment, based on the American Board of Obstetrics and Gynecology milestone evaluation. Analysis of variance was used for statistical comparisons., Results: Thirty-seven participants included 13 novices, 18 advanced residents, and six experts. The experts scored significantly higher than both resident groups in each of the domains of the OSATS and the procedure assessment. The mean OSATS score for experts was 32.30 (±6.06) (maximum, 35); novice, 17.15 (±5.84); and advanced, 21.11 (±5.61) (P = 0.001). The experts' scores for the procedure assessment (maximum, 25) was 23.00 (±3.95); novice, 10.62 (±4.70); and advanced, 14.33 (±4.73) (P < 0.001). The two trainee groups did not differ significantly in their overall performance. Most trainees (29 [94%]) evaluated the model as a useful tool in learning this procedure., Conclusions: This low-fidelity model can be constructed easily using common materials. The model cost is $43.92 with reusable components ($11 per use). Higher scores by experts versus trainees confirm construct validity of this model. It may serve as a valuable simulation tool allowing trainees to improve their surgical technique for anterior colporrhaphy., Competing Interests: The authors have declared they have no conflicts of interest., (Copyright © 2020 American Urogynecologic Society. All rights reserved.)

Objective: To describe bilateral mobilization of the superficial gluteal muscle (SGM) to treat ventral perineal hernias in dogs., Study Design: Cadaveric study and short case series., Sample Population: Male dog cadavers (n = 10) weighing between 5 and 42 kg and three dogs treated for ventral perineal hernia., Methods: Cadavers were positioned in right and left lateral recumbency to free the origin and insertion of the ipsilateral SGM except for muscle fibers originating on the first tail vertebra and sacrotuberous ligament. The dogs were placed in ventral recumbency to approach the perineum and rotate the muscle flaps. The insertions of the SGM were sutured together ventral to the anal sphincter muscle. The dorsal border of the overlapping tendons was sutured to the anal sphincter muscle, and the ventral border was sutured to the ischiourethralis muscle. The amount of overlap between bilateral flaps was measured. The SGM flaps were used to revise recurrent perineal hernias in three dogs., Results: Superficial gluteal muscle flaps were created without damage to the blood supply in all dogs. The overlap between the bilateral flaps ventral to the anal sphincter measured 0 to 2.4 cm. No recurrence was detected at follow-up (6-12 months) in the three dogs treated with these flaps., Conclusion: Superficial gluteal muscle flaps were mobilized without damage to the blood supply and crossed the midline ventral to the anal sphincter. Flaps were used successfully to repair ventral perineal hernias in three dogs., Clinical Significance: Bilateral SGM flaps can be considered to repair ventral perineal hernias., (© 2020 The American College of Veterinary Surgeons.)

Significance: Dry eye disease (DED) imposes a substantial burden on patients, which can lead to significant economic consequences for society. We provide insights into the DED patient population and DED diagnostic/management practices in Canada, which to date have been inadequately addressed in the literature., Purpose: The purpose of this study was to describe DED patient demographic/clinical characteristics alongside DED diagnosis/management in university-based optometry clinics in Canada., Methods: This was a retrospective chart review of nonconcurrent non-Sjögren patients with DED at two university-based optometry clinics in Montreal and Waterloo. Waterloo charts with a diagnosis of DED and all charts from the Montreal dry eye clinic were considered for inclusion., Results: Overall, 200 charts were reviewed. Most patients were female (Montreal, 76%; Waterloo, 72%), and the mean age was 57.2 ± 14.9 years at Montreal and 52.6 ± 20.1 years at Waterloo. Patients commonly reported multiple health conditions (e.g., allergies [Montreal, 44%; Waterloo, 36%]), and high use of systemic nonocular medications was observed (Montreal, 76%; Waterloo, 62%). Clinical signs and symptoms of DED were recorded more often in Montreal patients than in Waterloo patients (e.g., dryness symptoms, 100 vs. 72%; tear breakup time, 100 vs. 60%). Warm compresses (Montreal, 63%; Waterloo, 83%) and artificial tears (Montreal, 94%; Waterloo, 96%) were the most frequently recommended nonmedical treatment and ocular lubricant, respectively. Topical steroids were the most frequently prescribed medications (Montreal, 22%; Waterloo, 21%), with typically three to four different interventions recommended per patient at each clinic. No relationship was found between symptoms and clinical signs or recommended interventions., Conclusions: This retrospective chart review provided the demographics, clinical characteristics, diagnosis, and management options for DED patients in Canadian university-based optometry clinics. The more comprehensive assessments conducted at Montreal may be beneficial to better monitor the progression of DED and to determine treatment effects over time.

Background: Postoperative opioid prescription patterns play a key role in driving the opioid epidemic. A comprehensive system toward pain management in surgical patients is necessary to minimize overall opioid consumption., Objective: This study aimed to evaluate the efficacy of a pain management model in patients undergoing pelvic reconstructive surgery by measuring postdischarge narcotic use in morphine milligram equivalents., Study Design: This is a prospective clinical practice study that included women undergoing inpatient pelvic reconstructive surgery from December 2018 to June 2019 with overnight stay after surgery. As a routine protocol, all the patients followed an enhanced recovery after surgery protocol that included a preoperative multimodal pain regimen. Brief Pain Inventory surveys were collected preoperatively and on postoperative day 1. Brief pain inventory and activities assessment scale scores were collected at postoperative week 1 and postoperative weeks 4-6 after surgery. Patients were discharged with 15 tablets of an oral narcotic using an electronic prescription for controlled substances software platform, which is mandated in the state of Connecticut for all controlled substances, prescriptions, and refills. Patients were called at postoperative week 1 and postoperative weeks 4-6 to answer questions regarding their pain, the number of remaining narcotic tablets, and patient satisfaction regarding pain management. Patient electronic medical records and the Connecticut Prescription Monitoring and Reporting System were reviewed to determine whether patients received narcotic refills. Primary outcome was postdischarge narcotic use measured in morphine milligram equivalents. Secondary outcomes evaluated refill rate, brief pain inventory and activities assessment scale scores, and patient satisfaction with pain management. Descriptive statistics were described as mean and standard deviation and median and interquartile range. Bivariate comparisons used Spearman's rho (ρ) with α=0.05., Results: A total 113 patients were enrolled; the median (interquartile range) morphine milligram equivalent prescribed (including refills) was 112.5 (112.5-112.5). The median postdischarge narcotic use was 24.0 (0-82.5) morphine milligram equivalent, which is equivalent to fewer than 4 oxycodone (5 mg) tablets. About 75% of our participants required fewer than 11 oxycodone tablets. The median unused morphine milligram equivalent was 90.0 (45-112.5). 81.4% (92/113), and 83.2% (94/113) of patients at postoperative week 1 and postoperative weeks 4-6, respectively, reported being satisfied or extremely satisfied with their postdischarge pain control. About 88.5% (100/113) of patients felt that the number of opioids they were discharged with was sufficient for their pain needs at the postoperative 1 and postoperative weeks 4-6 time points. At postoperative weeks 4-6, 19.5% of patients said that they filled the narcotic prescription but did not use any of the pills. The overall refill rate was 10.6% (12/113). All patients who needed a refill described the refill process as easy. In-hospital narcotic use was not predictive of postdischarge narcotic use (ρ0.065, P=.495). Patients reported median brief pain inventory scores for "average pain" of 0 (no pain) at postoperative week 1 and postoperative weeks 4-6; however, the scores did not clinically correlate with postdischarge narcotic use. Activities assessment scale scores were not correlated with postdischarge narcotic use., Conclusion: Most patients after pelvic reconstructive surgery used fewer than 11 oxycodone (5 mg) tablets, averaging less than 4 tablets, with a third of patients not requiring any opioids. Pain and activities scores did not correlate with narcotic use. A minimal number of opioids can be prescribed because the secure electronic prescribing system allows for convenient electronic refill if required. Our practical and comprehensive pre- and postoperative protocol for pain management minimizes opioid consumption in addition to maximizing patient satisfaction., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: To evaluate facial Demodex densities in participants with varying severities of blepharitis secondary to Demodex folliculorum assessed by the highest number of cylindrical dandruff on one lid., Methods: This double masked cross-sectional study included 58 participants [19 control, 21 mild/moderate and 18 severe Demodex blepharitis] who underwent a standardized skin-surface biopsy and a lash epilation for each lid to obtain the forehead Demodex densities and the overall lash mite count, respectively. Also, facial photographs were taken to evaluate facial erythema and dermatological conditions. The Ocular Surface Disease Index [OSDI], non-invasive break-up time [NIBUT], tear meniscus height [TMH], bulbar conjunctival redness as well as additional questions on watery eyes, ocular itching and itching along the lids were assessed., Results: Both mild/moderate and severe Demodex blepharitis groups were over the cut-off value [≥ 5 mites/cm 2 ] that confirms a facial demodicosis (mild/moderate: 5 ± 1; severe: 6 ± 1) while the control group was below it (2 ± 1). Thereby, group comparisons showed that an increased severity of Demodex blepharitis was associated with higher forehead mite densities (p = 0.002) and increased lash mite count (p < 0.001). The degree of facial erythema was also positively correlated with forehead mite densities (rs = 0.31, p = 0.02). When compared to the controls, the mild/moderate group had more watery eyes (X 2  = 6.54, p = 0.02), a lower TMH (U = 100.5, p = 0.006) and the severe group had more itching along the lids (X 2 = 4.94, p = 0.04). The other ocular signs and symptoms [NIBUT, bulbar conjunctival redness, OSDI] were not affected by the severity of Demodex blepharitis (p > 0.05)., Conclusion: Palpebral and facial Demodex infestation can co-exist, as the presence of blepharitis secondary to Demodex is associated with increased facial mite densities., Competing Interests: Declaration of Competing Interest SA has received honorarium for conferences/consulting from Allergan and Shire. EB has received funding from Alcon, Allergan, Canadian Optometric Trust Fund, I-Med Pharma Inc, Shire and honorarium for conferences/consulting from Akorn, Alcon, Allergan, American Academy of Optometry, Canadian Association of Optometry, CooperVision, Labtician, Jobson Publishing, Novartis, Santen, Shire., (Copyright © 2019 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.)

Objective: To compare effects on activity between two catheter management systems after failed voiding trial after pelvic reconstructive surgery., Methods: Women with a failed postoperative voiding trial after reconstructive pelvic surgeries were randomized to plug-unplug or continuous drainage catheters. The primary outcome was a mean activity assessment scale score. Secondary outcomes included urinary tract infection (UTI), time to passing outpatient voiding trial, and patient satisfaction. Enrollees who passed the voiding trial were assigned to a "Reference" arm. Ninety participants (30 per arm) provided more than 80% power to detect an effect size of 0.33 in the primary outcome, using a two-sided alpha of 0.05., Results: Sixty-three patients were randomized (32 plug-unplug, 31 continuous drainage). The first 30 participants discharged without a catheter comprised the reference arm. There was no difference in postoperative activity assessment scale scores (total: plug-unplug 70.3, continuous drainage 67.7, reference arm 79.4; P=.090) between arms. Women in the continuous drainage arm noted more difficulty compared with the plug-unplug arm when managing the catheter "during the day" (P=.043) and "all the time" (P=.049) and felt the catheter impeded activities (P=.012) and wearing clothes (P=.005). The catheter arms had significantly higher rates of culture-positive UTI compared with the reference arm (58.7% vs 6.7%, P<.001). However, rate of UTI did not differ between catheter arms (plug-unplug, 68.8% vs continuous drainage, 48.4%, P=.625). The majority of patients passed their outpatient voiding trials at the initial postoperative visit (plug-unplug 71.9%, continuous drainage 58.1%, P=.250). There was no difference in patient satisfaction, with the majority reporting they were "very satisfied" (plug-unplug 78.1%, continuous drainage 80.0%, reference 66.7%, P=.202)., Conclusion: Postoperative activity does not differ in patients discharged with plug-unplug or continuous drainage catheters, but those with plug-unplug perceive easier management and ability to complete activities of daily living. The plug-unplug method is an acceptable alternative to traditional catheterization after pelvic reconstructive surgery., Clinical Trial Registration: ClinicalTrials.gov, NCT03071211.

Objective: The practice of obstetrics and gynecology poses specific ethical challenges for informed consent (IC). Data regarding resident confidence with the IC process are lacking. Our objective was to evaluate obstetrics and gynecology residents' education, experience, and confidence related to IC., Design: This was a cross-sectional survey of obstetrics and gynecology residents. Descriptive analyses were performed using mean and standard deviation or frequency expressed as a percentage. The results were analyzed for statistical significance using chi-square or Fisher's exact tests for categorical variables and Student t or Mann-Whitney U tests, as appropriate, for continuous variables; all results yielding p < 0.05 were deemed statistically significant., Setting: Electronic survey., Results: Two hundred eighty-one trainees completed the survey. The majority of participants were female (84.3%) and from an academic training program (65.1%). Two hundred seventy-seven trainees (98.6%) reported that they had obtained IC for operating room procedures; the majority had first done this in the first postgraduate year (PGY) (n = 258, 91.8%). Trainees most commonly obtain IC for resident and general gynecology attending cases. Most trainees primarily learn how to obtain IC via observation of their coresidents and attendings. Nearly 90% of trainees have obtained IC for a procedure for which they were unsure of all the risks. One hundred seventy-three trainees (61.6%) reported that they would like to have more training in IC. Increasing PGY was significantly associated with increasing confidence in obtaining IC for gynecologic, obstetric, and office procedures (all p < 0.01). There were no differences based on PGY in frequency of reviewing who will perform the surgical procedure (p = 0.75), how trainees will be involved in the procedure (p = 0.35), review of alternative treatments (p = 0.91), or in documentation of the IC process (p = 0.16)., Conclusions: Based on the findings of this survey study, education related to the IC process is warranted and curriculum development should be the focus of future study., (Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of the study was to evaluate the association of patient factors, amount of in-hospital postoperative narcotics, and pain scores on postdischarge narcotic use (PDNU)., Methods: This is a secondary analysis of a randomized controlled trial comparing a postoperative usual-care regimen with multimodal pain regimen after pelvic reconstructive surgery. This analysis evaluated patients in the multimodal arm. Postdischarge narcotic use (as mg oral morphine equivalents, MME, calculated from narcotic tablets remaining) was assessed postoperative days 7 to 10. Brief Pain Inventory (BPI) surveys were collected preoperatively and at postoperative day 1. Patient factors were evaluated using univariate and multivariate analysis. Correlations examined the relationships between PDNU and postoperative in-hospital narcotic use and BPI scores., Results: Sixty-eight patients randomized to the multimodal pain regimen arm had median (interquartile range) PDNU of 22.5 (0-159.4) MME. After excluding postdischarge narcotic nonusers (34.8%), the median PDNU was 127.5 (22.5-180.0) MME. The median PDNU was 172.5 (150.0-180.0) MME after abdominal reconstructive surgery (n = 7), 82.5 (28.1-180.0) MME after laparoscopic reconstructive surgery (n = 22), and 37.5 (13.1-181.2) MME after vaginal reconstructive surgery (n = 14). A linear correlation was noted between the amount of postoperative narcotics used in-hospital and the amount needed postdischarge after abdominal (r = 0.588, P = 0.057), laparoscopic (r = 0.439, P = 0.019), and vaginal (r = 0.455, P = 0.017) reconstructive surgeries. The BPI scores on postoperative day 1 for "average" pain (r = 0.388, P = 0.002) and "now" pain (r = 0.490, P < 0.001), and on postoperative week 1 for "average" pain (r = 0.383, P = 0.002) and "now" pain (r = 0.389, P = 0.002) correlated with PDNU., Conclusions: Amount of postoperative in-hospital use of narcotic medications and BPI scores can be valuable predictors of PDNU in patients undergoing pelvic reconstructive surgery.

Vision impairments are prevalent, but underdiagnosed in individuals with dementia living in long-term care (LTC). Effective screening tools could identify remediable vision problems. This scoping review was conducted to identify vision screening tests used with individuals with dementia and assesses their suitability for administration by nurses in LTC. A literature search using the Arksey and O'Malley (2005) method included research articles, conference proceedings, and dissertations. Data were included from participants over 65 years of age with a diagnosis of probable dementia. A panel of vision experts evaluated the suitability of the candidate vision tests. The search yielded 179 publications that met the inclusion criteria. Of 134 vision tests that were identified, 19 were deemed suitable for screening by nurses in LTC. Tests screened for acuity (12), visual field (1), anatomy (2), color vision (2), and general visual abilities (2). Tests were excluded because of complexity of interpretation (90), need for specialized training (83), use in research only (57), need for specialized equipment (54), not assessing visual function (44), long test duration (21), uncommonness (13), and needing an act reserved for specialists (7). Psychometric properties were not often reported for tests. Few of the tests identified had been validated for use with individuals with dementia. Based on our review, few tests were deemed suitable for use by nurses to assess this population in LTC. Identifying appropriate tools to screen vision in individuals with dementia is a necessary first step to interventions that could potentially improve functioning and quality of life.

The symptoms of constipation and obstructed defecation are common in women with pelvic floor disorders. Female pelvic medicine and reconstructive surgery specialists evaluate and treat women with these symptoms, with the initial consultation often occurring when a woman has the symptom or sign of posterior compartment pelvic organ prolapse (including rectocele or enterocele) or if a rectocele or enterocele is identified in pelvic imaging. This best-practice statement will review techniques used to evaluate constipation and obstructed defecation, with a special focus on the relationship between obstructed defecation, constipation, and pelvic organ prolapse.

Purpose: To quantify the discomfort over time of various eyelid cleansers against Demodex., Methods: This was a prospective, randomized, controlled, crossover, open-label study that enrolled 26 participants. The cleansers used in this study were Biotissue Cliradex (CD), OCuSOFT Lid Scrubs Plus (OP), OCuSOFT OUST Demodex Swabstix (ODS), TheraTears Theralid (TT), NovaBay Avenova (NA). Bausch+Lomb Sensitive Eyes Plus saline was used as a control. Participants were asked to close their eyes as the product was gently rubbed (10 cycles of gentle lateral motion) into the eyelashes. Participants verbally rated their discomfort (0 = no discomfort, 10 = maximum tolerable discomfort) every 15 sec for the first 5 min, and every 30 sec for 5 min after, for a total of 10 min. The order of products used was randomized, and washout period between cleansing was 48 hr., Results: Twenty-five participants completed the study (mean age=26±6). There was no significant difference in discomfort scores at pre-application. The discomfort levels of saline, OP, and NA over the 10-min period were not significantly different than their pre-application discomfort at all time points (all P≥0.99). The discomfort of CD was significantly higher than pre-application levels between t=15 sec and t=180 sec (all P≤0.01), with maximum median (interquartile range [IQR]) discomfort of 3.0 (5.0) occurring at t=45 sec. The discomfort of TT was significantly higher than pre-application levels between t=45 and t=90 (all P<0.02), with maximum median (IQR) discomfort of 1.0 (1.5) occurring at t=75 sec. The discomfort of ODS was significantly higher than pre-application levels starting from t=60 sec and onward, with maximum median (IQR) discomfort of 6.0 (5.0) occurring at t=300 sec., Conclusion: Of the cleansers used in this study, the ones that induced significant discomfort were CD, TT, and ODS. The results from this study may help clinicians educate patients about what to expect when approaching the topic of eyelid Demodex treatment.

The primary role of eyelashes is to protect and maintain the health of the lid margin. However, the mechanisms to fulfill this role are not fully understood. Unraveling these mechanisms will stand to greatly improve the efficiency of eye care professionals' interventions in anomalies of the eyelashes. The aim of this article is to provide a review on eyelashes including highlights and new avenues for research; the biology of both the lash and its follicle; the pathophysiology and management of lash anomalies by eye care professionals; and the effect of iatrogenic factors on lashes. Using the database of Ovid MEDLINE, we reviewed studies specifically directed on human/mammalian eyelashes and key articles on current trends in scalp hair methodologies that can be applicable to lash research. The eyelash morphology, pigmentation and growth rate have been documented using techniques ranging from lash imaging to follicle immunohistochemistry. Furthermore, studies have demonstrated that the lash follicle is sensitive to many factors of the external environment, a variety of systemic/topical medications and cosmetics. Recently, aerodynamic studies using a mammalian eye model confirmed that an optimal lash length was needed so that eyelashes serve a protective role in reducing the number of particles that can reach the eye. Despite recent advances in lash research, studies are still scarce, due to the limited availability of the human lid for sampling. This review brings awareness that further research is needed with respect to eyelashes and will hopefully reduce the gap with scalp hair research., (Copyright © 2018 Spanish General Council of Optometry. Published by Elsevier España, S.L.U. All rights reserved.)

Background: Refrigerated eye-drops have been advocated in cases of ocular allergies to provide a soothing effect upon instillation. This notion continues to be promoted by practitioners for artificial tears (AT) in the management of dry eye (DE) with little support in the literature. To further substantiate claims of a soothing effect of cold eye-drops, the aim of this study was to determine if refrigeration of an AT enhanced the subjective comfort upon instillation., Methods: Participants with mild to moderate DE participated in an open label contralateral study of two weeks duration. Each participant instilled Systane Ultra (Alcon Laboratories) in the morning (between 6.00-10.00 hours) and in the evening (between 18.00-22.00 hours). Participants were asked to report the subjective comfort immediately after both of these instillations, on a scale from 1 (poor) to 10 (excellent). This was done for ambient (aAT) and refrigerated (rAT) drops. An in vitro study evaluated if there were any changes in eye-drop pH and osmolarity with refrigeration., Results: Participants (n = 18, three male, 15 female, age 22-28 years, average 24.4 ± 1.6) reported mean comfort scores (± standard deviation) of 7.8 ± 0.9 and 7.6 ± 1.4, for the aAT and the rAT, respectively. Mean comfort scores (± standard deviation) for morning and evening, were 7.7 ± 1.2 and 7.8 ± 1.1, respectively. A non-parametric Friedman test of differences among repeated measures was conducted and rendered a chi-squared value of 3.74, which was not statistically significant (p = 0.29). The pH remained stable at 8.0 and the osmolality did not vary significantly with refrigeration., Conclusion: There is no advantage, with respect to patient perceived comfort, in refrigerating the Systane Ultra (Alcon Laboratories) AT for mild to moderate DE., (© 2018 Optometry Australia.)

Objective: The aim of this study was to evaluate practice preferences in catheter management after a failed inpatient voiding trial after pelvic reconstructive surgery., Methods: This is a cross-sectional study of postoperative catheter management after pelvic reconstructive surgery after failed voiding trial. Physicians practicing at ACGME-accredited residencies and fellowships in Obstetrics and Gynecology (Ob/Gyn), Urology, and Female Pelvic Medicine and Reconstructive Surgery (FPMRS) within the United States completed a Web-based questionnaire in March 2017. Respondents were asked about voiding trial protocols, definitions of abnormal postvoid residual (PVR), type of catheterization used after failed voiding trials, and antibiotic use. Primary outcome was type of catheterization after failure of an inpatient voiding trial. Data were analyzed using χ statistical tests., Results: One hundred five respondents had a mean age of 36.5 years (range, 36 years). A total of 45.9% of participants practiced in FPMRS, 36.5% in Ob/Gyn, and 17.6% in Urology. Catheters were discontinued most frequently by postoperative day 1 after all procedures. Distribution of catheterization by specialty differed. Clean-intermittent straight catheterization had the greatest prevalence in all specialties and was the highest, by percentage, in Urology (33% Ob/Gyn, 40.6% FPMRS, and 69% Urology); P = 0.026. Type of catheterization differed significantly between Ob/Gyn and FPMRS respondents (P = 0.045). A total of 77.7% measured PVR by ultrasound and 22.3% performed catheterization. This distribution was similar across the specialties (70% Ob/Gyn, 79% FPMRS, and 100% Urology; P = 0.092). Abnormal PVR was defined most frequently as 150 mL or greater (30.5%). A minority of respondents routinely administer antibiotics during catheterization (17.1%). Duration and time until repeat voiding trial varied from 1 day to 2 weeks., Conclusions: Practice variability in catheterization after pelvic reconstructive and incontinence surgery is high. Distribution of catheterization type by specialty varies significantly, with clean-intermittent straight catheterization most prevalent. Future studies are necessary to establish a consensus on optimal catheterization management technique for patients with acute postoperative voiding dysfunction.

Purpose: LATISSE is marketed for the treatment of hypotrichosis (loss of eyelashes), using a prostamide analogue and preserved with benzalkonium chloride, which is an effective preservative; however, it also causes irritation to the ocular surface. LATISSE is applied to the lid margin; however, with the blink, some solution may fall onto the ocular surface. The objective of this study was to assess the effects of LATISSE on the ocular surface over two months., Methods: Non-dry eye participants interested in eyelash lengthening were invited to a prospective uncontrolled, open-label clinical study using LATISSE for two months. Eyelash length, subjective symptoms, tear film stability, osmolarity, ocular redness and intraocular pressure were evaluated at baseline (T0) and at one (T1) and two months (T2)., Results: Twenty-eight women (ages 18 to 29) entered the study. Fifteen completed the study with five who discontinued due to burning upon instillation and eight were lost to follow-up. Average eyelash length increased at each time (p < 0.001). Dryness, burning and grittiness remained low (less than 25/100) throughout the trial with dryness showing a significant change between T0 and T1 (p = 0.04), but not between T1 and T2 (p > 0.05). No difference (p > 0.05) was noted for the non-invasive break-up time, photochromametry or tear osmolarity. Intraocular pressure showed a decrease with time but translated to only a one to two mmHg change, which was not clinically relevant., Conclusions: LATISSE increases eyelash length within a short time (less than two months). Patients seeking eyelash enhancement options should be educated as to the use, precautions and any secondary effects, including the potential for discomfort upon instillation., (© 2017 Optometry Australia.)

Purpose: The aim of this study was to evaluate the osmolality of commercially available ocular tear lubricants., Methods: Thirty-seven (n = 37) ocular lubricants, measured three times each, were evaluated for osmolality using a vapor pressure osmometer (Wescor VAPRO 5520). The osmometer was calibrated before each use, and the order of the lubricants was randomized. Ambient temperature and humidity were monitored for stability., Results: Of the 37 ocular lubricants tested, 35 (94.6%) had an osmolality of less than 295 mmol/kg, one (2.7%) had between 295 and 308 mmol/kg, and one (2.7%) had more than 308 mmol/kg. The ambient room temperature was stable and ranged from 21.9°C to 22.0°C, and the relative humidity ranged from 21.2% to 25.6% during experimentation. When ocular lubricants were grouped by ingredient (carboxymethylcellulose and hydroxylpropyl methylcellulose, hyaluronic acid, and hydroxypropyl guar), no significant difference in osmolality was noted between groups (Mann-Whitney U test, P > .05)., Conclusions: The majority of the ocular lubricants tested had low osmolalities, mimicking the osmolarity of newly formed tears (295 to 300 mOsm/L). Several factors need to be considered when choosing a tear lubricant, which have more complex formulations than ever. Knowledge of their osmolality may be an added parameter to consider when choosing therapeutic options for dry eye.

Objective: To evaluate the success rate and patient satisfaction ofperipheral tibial nerve stimulation (PTNS) therapy., Method: Retrospective cohort study assessing PTNS treatment success and patient satisfaction., Results: Data from 34 women were included. On average, patients were 70.2 (± 12) years of age, had a BMI of 29.9 (± 8.9) kg/M², and traveled 11.2 (± 12.3) miles to receive weekly PTNS treatments. Overall, 22 patients (64.7%) were satisfied, four (11.8%) unsatisfied, and eight (23.5%) undecided. Those who were satisfied completed an average of 10.9 treatments (± 2.4), those who were unsatisfied completed an average of 9.5 treatments (± 2.6), and those left undecided completed an average of 7.2 treatments (± 4.3). The fourth treatment visit was the most likely to predict whether a patient would be satisfied or unsatisfied by the 12th treatment., Conclusion: Overall the success of the PTNS therapy was 64.7%, consistent with previous studies. Most patients note improvement after the fourth treatment.

Objective: To evaluate the usefulness of phenazopyridine for confirmation of ureteral patency during intraoperative cystoscopy., Methods: We conducted a randomized controlled trial comparing use of phenazopyridine with no medications for evaluation of ureteral patency during intraoperative cystoscopy in women undergoing pelvic surgery. The primary study outcome was time to visualize ureteral urine efflux. To detect a 3-minute difference with α of 0.05 using a two-sided, two-sample t test and β 0.80 required 98 patients equally divided into two groups., Results: A total of 104 women were randomized from April to December 2015. Patients in the treatment group tended to be older (P=.02); otherwise, study groups were similar. Time to visualize ureteral urine efflux did not differ between study groups with a mean time of 2 minutes 40 seconds (±2 minutes 38 seconds) in the control group and 2 minutes 53 seconds (±4 minutes 35 seconds) in the treatment group (P=.77). Regarding the surgeon survey, surgeons felt less frustrated and impatient in visualization of ureteral urine efflux in the treatment group compared with the control group (mean response 1.5±0.8 in treatment compared with 2.0±1.0 in control, P=.007), and surgeons felt that the cystoscopy took too long more often in the control than in the treatment group (1.7±0.9 in treatment compared with 2.1±1.0 in control, P=.02). Trial of void result differed significantly between groups with fewer patients in the treatment group failing a void trial (P=.04). There were no adverse events related to phenazopyridine use., Conclusion: Preoperative phenazopyridine is a useful and cost-saving medication for use in planned cystoscopy for evaluation of ureteral patency., Clinical Trial Registration: ClinicalTrials.gov, https://clinicaltrials.gov/, NCT02424149.

Purpose: Meibomian gland dysfunction (MGD) is one of the most common causes of evaporative dry eye. Warm compresses (WC) are recommended as adjunct therapy to slowly transfer heat to the meibomian glands to melt or soften the stagnant meibum with targeted temperatures of 40-45°C. This clinical study evaluated the heat retention profiles of commercially available eyelid warming masks over a 12-min interval., Methods: Five eyelid-warming masks (MGDRx Eyebag(®), EyeDoctor(®), Bruder(®), Tranquileyes XR™, Thera°Pearl(®)) were heated following manufacturer's instructions and heat retention was assessed at 1-min intervals for 12min. A facecloth warmed with hot tap water was used as comparison., Results: Twelve (n=12) subjects participated in the study (10F:2M, ranging in age from 21 to 30 with an average of 23.2±3.8years). Each mask demonstrated a unique heat retention profile, reaching maximum temperature at different times and having a different final temperature at the end of the 12-min evaluation. After heating, all eyelid warming masks reached a temperature near 37°C within the first minute. The facecloth was significantly cooler than all other masks as of the 2-min mark (p<0.05)., Conclusions: Reusability, availability and heat retention profiles should be considered when selecting an eyelid warming masks for adjunct WC therapy in the management of MGD. All masks tested, with the exception of the facecloth, demonstrated stable heat retention throughout the 12min, bringing further awareness that patient education is required to discuss the shortcomings of the heat retention of the facecloth, if only heated once., (Copyright © 2016 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.)

Background: The number of robotically assisted hysterectomies is increasing, and therefore, the opportunities for trainees to become competent in performing traditional laparoscopic hysterectomy are decreasing. Simulation-based training is ideal for filling this gap in training., Objective: The objective of the study was to design a surgical model for training in laparoscopic vaginal cuff closure and to present evidence of its validity and reliability as an assessment and training tool., Study Design: Participants included gynecology staff and trainees at 2 tertiary care centers. Experienced surgeons were also recruited at the combined International Urogynecologic Association and American Urogynecologic Society scientific meeting. Participants included 19 experts and 21 trainees. All participants were recorded using the laparoscopic hysterectomy cuff closure simulation model. The model was constructed using the an advanced uterine manipulation system with a sacrocolopexy tip/vaginal stent, a vaginal cuff constructed from neoprene material and lined with a swimsuit material (nylon and spandex) secured to the vaginal stent with a plastic cable tie. The uterine manipulation system was attached to the fundamentals of laparoscopic surgery laparoscopic training box trainer using a metal bracket. Performance was evaluated using the Global Operative Assessment of Laparoscopic Skills scale. In addition, needle handling, knot tying, and incorporation of epithelial edge were also evaluated. The Student t test was used to compare the scores and the operating times between the groups. Intrarater reliability between the scores by the 2 masked experts was measured using the interclass correlation coefficient., Results: Total and annual experience with laparoscopic suturing and specifically vaginal cuff closure varied greatly among the participants. For the construct validity, the participants in the expert group received significantly higher scores in each of the domains of the Global Operative Assessment of Laparoscopic Skills Scale and for each of the 3 added items than did the trainees. The median total Global Operative Assessment of Laparoscopic Skills Scale score (maximum 20) for the experts was 18.8 (range, 11-20), whereas the median total Global Operative Assessment of Laparoscopic Skills Scale score for the trainees was 10 (range, 8-18) (P = .001). The overall score that included the 3 new domains (maximum 35) was 33 (range, 18-35) for the experts and 17.5 (range, 14-31.5) for trainees (P = .001). For the face validity testing, the majority of the study participants (32 [85%]) agreed or strongly agreed that the model is realistic and all participants agreed or strongly agreed that the model appears to be useful for improving technique required for this task. For the interrater reliability, the scores assigned by each observer had an interclass correlation coefficient of 0.8 (95% confidence interval, 0.7-0.93)., Conclusion: This model is easily constructed and has an acceptable cost. We have demonstrated evidence of construct validity. This is a valuable education tool that can serve to improve skills, which are essential to the gynecological surgeon but are often lacking in residency training because of national changes in practice patterns., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Extraosseous Ewing sarcoma (ES) tumors presenting in the genitourinary tract are highly uncommon. Few cases of primary vulvar and vaginal cases of ES have been published., Case: A 15-year-old adolescent presented with a bothersome 5-cm mass located on her left labium minorum. Following excision, a diagnosis of a primary ES was made. The patient was treated with multiagent chemotherapy and was doing well 20 months after treatment completion., Summary and Conclusion: Based on the few available case reports and our reported case, it appears that extraosseous ES arising in superficial sites such as the vulva have better prognosis and should be treated with complete excision and multiagent chemotherapy., (Copyright © 2015 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Objective: The primary objective was to evaluate the position and angle variation between 3 different midurethral slings (MUSs) using 3-dimensional ultrasound (US) technology. The secondary objective was to compare differences in findings on physical examination and symptoms of incontinence and sexual dysfunction between subjects., Methods: This was a cross-sectional study of 61 subjects who had undergone MUS placement without concomitant anterior or apical compartment prolapse surgery (21 retropubic [RP], 19 out-to-in transobturator [TOT], 21 in-to-out transobturator [TVT-O]). Subjects completed validated questionnaires (Sandvik Incontinence Severity Index, Urogenital Distress Inventory 6) and underwent a pelvic examination and standardized 2-dimensional and 3-dimensional ultrasonography evaluation., Results: On translabial US, the median RP sling angle was 108.2 degrees (72.6-135.9), significantly more acute than the angle of TOT and TVT-O slings (119.3 degrees [72.3-140.4, P = 0.02] and 118.5 degrees [99.0-154.7, P = 0.004]). There was no difference in the sling angles between the TOT and TVT-O slings (P = 0.86). No difference was noted in the position of the sling along the urethra (P = 0.82). The TOT sling was more often palpable (57.8%, P = 0.02) compared with the RP or TVT-O groups.Fifteen patients (4 RP, 5 TOT, 6 TVT-O) reported discomfort during intercourse that they attributed to the MUS. Three of 19 TOT subjects reported that their partner experienced pain with intercourse because of the sling. However, sexual function and urinary symptoms were not statistically different between the 3 groups., Conclusions: On 3-dimensional US, RP sling angle was found to be significantly more acute than the angles of the TOT and TVT-O slings, and there was no difference between the 2 transobturator slings. The TOT sling was more often palpable on examination, but this finding did not correlate with increased pain on palpation.

Supernumerary punctum is an under-reported congenital anomaly, in which there is more than one lacrimal punctum. Although usually asymptomatic, supernumerary puncta have been reported to cause dry eye or epiphora (excessive tearing) and should be included in their differential diagnosis. Tearing is often associated with dry eyes and can lead to discontinuation of contact lens wear. A comprehensive evaluation of the causes of tearing may uncover other contributory factors of epiphora. This case report highlights unilateral inferior double puncta in an otherwise asymptomatic patient. Due to increased evacuation of tears in the affected eye, manual occlusion of the puncta was advocated to allow topical medication to be more efficacious., (© 2014 The Authors. Clinical and Experimental Optometry © 2014 Optometrists Association Australia.)

Purpose: Meibomian gland dysfunction (MGD) appears to be the most common cause of evaporative dry eye, in which the meibum has an altered chemical structure that increases its melting point. Eyelid warming masks slowly transfer heat, preferably between 40 and 45°C to the inner meibomian glands, in an attempt to melt or soften the stagnant meibum. This ex vivo study evaluates the heat retention properties of commercially available masks over a 12-min interval., Methods: Five eyelid-warming masks (MGDRx EyeBag®, EyeDoctor®, Bruder®, Tranquileyes™, Thera°Pearl(®) were heated following manufacturer's instructions and heat retention was assessed at 1-min interval for 12 min on a non-conductive surface. A facecloth warmed with hot tap water was used as comparison., Results: All masks reached above 40°C within the first 2 min after heating and remained so for 5 min, with the exception of the facecloth, which lasted only 3 min and quickly degraded to 30°C within 10 min. The Bruder® and Tranquileyes™ reached >50°C, after heating and the Bruder® maintained >50°C for nearly 6 min. The MGDRx EyeBag®, and Thera°Pearl® had the most stable heat retention between 2 and 9 min, remaining between the targeted temperature., Conclusions: Heat retention profiles are different for commercially available eyelid warming masks. This ex vivo study highlights that despite the popularity of the time-honored facecloth, it is poor at retaining the desired heat over a 5-10 min interval. Clinical studies need to corroborate these results, remembering that ocular tissue parameters may be factors to consider., (Copyright © 2015 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.)

Objective: The objective of this study was to compare the backfill standard voiding trial (SVT) that relies on the assessment of voided volume to subjective patients' evaluation of their voiding based on the assessment of the force of stream (FOS) after an outpatient midurethral sling surgery., Study Design: This double-blinded randomized trial included patients undergoing an outpatient midurethral sling surgery without any other concomitant surgery. Participants were randomized to either the SVT group or to the FOS group. The primary outcome was the rate of catheterization any time up to 6 weeks after surgery. Both groups underwent the same backfill voiding trial protocol postoperatively. Measurements of the voided amount, postvoid residual, and the response to the FOS visual analog scale were collected. The criteria for passing the voiding trial in the SVT group was voiding at least two-thirds of the instilled amount; while the criteria for passing the trial in the FOS group was assessment of FOS at least 50% of the baseline, regardless of the voided volume. Participants were interviewed preoperatively and 2-4 days, 7-9 days, and 6 weeks postoperatively. All postoperative interviews included assessments of pain, tolerance of physical activity, urinary FOS, as well as satisfaction with the surgery. Validated questionnaires (Incontinence Severity Index and Urinary Distress Inventory, short form) before the surgery and 6 weeks after were used to evaluate urinary symptoms., Results: A total of 108 patients were enrolled and randomized, and 6-week follow-up data were available for 102 participants (FOS 50, SVT 52). The 2 groups were similar with respect to demographic characteristics and urinary symptoms. The incidence of catheterization was also similar between the groups (FOS 13 [26%], SVT 13 [25.5%]; P=.95). Amount voided had a moderate correlation with FOS assessment (Spearman rho 0.5; P<.001). There was no significant difference in mean catheter days, pain scores, Incontinence Severity Index, and Urinary Distress Inventory, short form scores between the 2 groups. Of the patients who were discharged home without a catheter in either group none required catheter reinsertion within 6 weeks after the surgery., Conclusion: Patient's subjective assessment of the urinary FOS correlated well with the measured voided amount and no difference in catheterization days was noted between the subjective and objective assessment of voiding. Thus subjective evaluation of the FOS is a reliable and safe method to use after outpatient midurethral surgery., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction: The Schirmer test (ST) evaluates the volume of tears in potential dry eye candidates via a strip placed in the lower tear lake. Previously reported inconsistencies in the results may be in part due to the lack of standardization as to the methodology, e.g. the eye position during the test. The purpose of this study was to evaluate the effect of eye position on the ST score., Methods: . A ST was performed in a randomized fashion with and without anesthesia in three open eye positions (primary, superior and inferior) at 20° from each other. Palpebral aperture, age and a dry eye questionnaire (OSDI) were evaluated for correlation with the ST., Results: In the 20 non-dry eye volunteers (n=20, ages 18-40, mean OSDI score 10.5), the ST results were, as expected, lower overall (p < .001) with anesthesia (11.33 ± 7.78 mm) than without (19.74 ± 2.83 mm). The inferior gaze position resulted in higher values (p < .03) than the other two positions, regardless of the use of anesthesia. No correlation was noted between the palpebral aperture, age, questionnaire and the ST., Conclusion: The ST seems to be influenced by the position of gaze. However, the mechanism for this, effect remains unclear. Further studies could focus on whether an inferior gaze of 20° compresses the tear film falsely, thereby elevating the tear volume. It is recommended that the clinician should adopt a standard eye position for the ST and that future reports provide specifics as to the methodology used., (Copyright © 2013 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.)

Study Objective: To develop a valid laparoscopic sacrocolpopexy simulation model for use as an assessment and learning tool for performing this procedure., Design: Simulation study (Canadian Task Force classification II-2)., Setting: Two tertiary academic centers., Intervention: A training model was developed to simulate performance of a laparoscopic sacrocolpopexy. Construct validity was measured by comparing observed masked performances on the model between experienced Female Pelvic Medicine and Reconstructive Surgeons (experts) and upper level trainees. All videotaped performances were scored by 2 surgeons who were masked to subject identity and using the valid and reliable Global Operative Assessment of Laparoscopic Skills scale., Measurements and Main Results: The expert group included Female Pelvic Medicine and Reconstructive Surgeons (n = 5) experienced in laparoscopic sacrocolpopexy, and the trainee group (n = 15) included fourth-year gynecology residents (n = 5) and fellows in Female Pelvic Medicine and Reconstructive Surgery and in Minimally Invasive Gynecologic Surgery (n = 10). The experts performed significantly better than the trainees in total score and in every domain of the Global Operative Assessment of Laparoscopic Skills scale (median [range] score: expert group, 33 [30.5-39] vs. trainee group, 20.5 [13.5-30.5]; p = .002). Previous surgical experience had a strong association with performance on the model (rho > 0.75). Most subjects "agreed" or "strongly agreed" that the model was authentic to the live procedure and a useful training tool. There was strong agreement between masked raters (interclass correlation coefficient 0.84)., Conclusion: This simulation model is valid and reliable for assessing performance of laparoscopic sacrocolpopexy and may be used for practicing key steps of the procedure., (Copyright © 2014 AAGL. Published by Elsevier Inc. All rights reserved.)

The 2 major functions of the lower urinary tract are the storage and emptying of urine. These processes are controlled by complex neurophysiologic mechanisms and are subject to injury and disease. When there is disruption of the neurologic control centers, dysfunction of the lower urinary tract may occur. This is sometimes referred to as the "neurogenic bladder." The manifestation of dysfunction depends on the level of injury and severity of disruption. Patients with lesions above the spinal cord often have detrusor overactivity with no disruption in detrusor-sphincter coordination. Patients with well-defined suprasacral spinal cord injuries usually present with intact reflex detrusor activity but have detrusor sphincter dyssynergia, whereas injuries to or below the sacral spinal cord usually lead to persistent detrusor areflexia. A complete gynecologic, urologic, and neurologic examination should be performed when evaluating patients with neurologic lower urinary tract dysfunction. In addition, urodynamic studies and neurophysiologic testing can be used in certain circumstances to help establish diagnosis or to achieve better understanding of a patient's vesicourethral functioning. In the management of neurogenic lower urinary tract dysfunction, the primary goal is improvement of a patient's quality of life. Second to this is the prevention of chronic damage to the bladder and kidneys, which can lead to worsening impairment and symptoms. Treatment is often multifactorial, including behavioral modifications, bladder training programs, and pharmacotherapy. Surgical procedures are often a last resort option for management. An understanding of the basic neurophysiologic mechanisms of the lower urinary tract can guide providers in their evaluation and treatment of patients who present with lower urinary tract disorders. As neurologic diseases progress, voiding function often changes or worsens, necessitating a good understanding of the underlying physiology in question.

Pyogenic spondylodiscitis includes a spectrum of spinal infections such as discitis, osteomyelitis, epidural abscess, meningitis, subdural empyema, and spinal cord abscess. This is a rare complication of sacral colpopexy, but can lead to devastating consequences for the patient. We present two cases of pyogenic spondylodiscitis following sacral colpopexy. In addition, we discuss 26 cases of pyogenic spondylodiscitis reported in the literature from 1957 to 2012. Techniques to decrease rates of infection include proper identification of the S1 vertebra, awareness of the suture placement depth at the level of the sacrum and at the vagina, and early treatment of post-operative urinary tract and vaginal infections. Awareness of symptoms, timely diagnosis and multidisciplinary approach to management is essential in preventing long-term complications.

Objective: To describe the direction and magnitude of the rotation of the radius relative to the ulna during extension of the carpus and to describe the effect of carpal extension on internal and external rotation of the radius relative to the ulna., Study Design: In vitro experiment., Animals: Cadaveric canine thoracic limbs (n = 11)., Methods: Eleven thoracic limbs were collected from 6 healthy mixed breed dogs of medium build. Each specimen was radiographed to ensure that the carpal and elbow joints were free of pathology. The elbow joint was disarticulated and the distal thoracic limb was prepared for biomechanical testing. Each specimen was stripped of soft tissue, leaving the soft tissues around the proximal aspect of the radius and ulna intact. The interosseous ligament, pronator teres muscle, and all the soft tissues distal to the distal metaphysis of the radius were also left intact. In the 1st part of the study, the rotation of the radius relative to the ulna was measured while extending the carpal joint using a system of weights and pulleys attached to the manus. In the 2nd part of the study, the internal and external rotation of the radius relative to the ulna was performed by applying an internal and external rotational load to the radius using a system of weights and pulleys attached to the radius. The internal and external rotation of the radius was measured with the carpus unloaded and with the carpus extended by applying a load of 5 kg to the manus., Results: Extension of the carpus resulted in internal rotation of the radius relative to the ulna. With the carpus extended under a maximum load of 2 kg, the mean (± SD) internal rotation of the radius was 4.3 ± 2.1° for all specimens. With the carpus unloaded, the mean internal and external rotation of the radius was 11.5 ± 2.9° and 22.5 ± 7.7° for all specimens, respectively. With the carpus loaded (extended under 5 kg load), the mean internal and external rotation of the radius was 3.3 ± 1.2° and 7.3 ± 2.0° for all specimens, respectively. The difference between internal and external rotation with the carpus loaded and unloaded was significant., Conclusion: Extending the carpus results in internal rotation, and proximal translation of the radius relative to the ulna. Loading the carpus in extension decreases the internal and external rotation of the radius relative to the ulna. A better understanding of the interaction between the carpus and the elbow may improve our understanding of the pathogenesis of elbow dysplasia., (© Copyright 2013 by The American College of Veterinary Surgeons.)

Objective: We sought to determine the frequency of laboratory studies after female pelvic reconstructive surgery and the rate of intervention based on the results of these laboratory values at a single institution., Study Design: We conducted a retrospective review of all patients undergoing female pelvic reconstructive surgery for pelvic organ prolapse by 5 fellowship-trained pelvic reconstructive surgeons at a single institution from Jan. 1, 2010, through Dec. 31, 2010. Exclusion criteria were outpatient procedures, isolated hysterectomy, and a combined surgery with another surgical team performing a separate procedure. Interventions based on the number of laboratory studies were classified as minor (electrolyte repletion, repeat laboratory tests, initiation of antibiotics) or major (transfusion, delayed discharge)., Results: A total of 356 patients were included in the final dataset and 100% of patients had routine postoperative laboratory studies. A total of 8771 laboratory values were obtained with a mean of 25 ± 18 laboratory values (0-133) per patient. One-third of postoperative patients (n = 120) underwent a total of 207 interventions based on abnormal laboratory results. The majority of interventions were minor (96%). Of the 120 patients who had a minor intervention, electrolyte repletion was the most common (78%), followed by repeat blood collection (40%) and initiation of antibiotics (4%). The major intervention rate was 4% (n = 8) and all underwent transfusion. Of the 8 transfused patients, 7 demonstrated clinical instability before transfusion and 1 was transfused based on laboratory values and a significant cardiac history., Conclusion: Routine postoperative laboratory studies are not necessary for all patients after female pelvic reconstructive surgery and more judicious use based on clinical findings may limit unnecessary minor interventions., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Objectives: This study aimed to develop and internally validate a nomogram that facilitates decision making between patient and physician by predicting a woman's individual probability of developing urinary (UI) or fecal incontinence (FI) after her first delivery., Methods: This study used Childbirth and Pelvic Symptoms Study data, which estimated the prevalence of postpartum UI and FI in primiparous women after vaginal or cesarean delivery. Two models were developed using antepartum variables, and 2 models were developed using antepartum plus labor and delivery variables. Urinary incontinence was defined by a response of leaking urine "sometimes" or "often" using the Medical, Epidemiological, and Social Aspects of Aging Questionnaire. Fecal incontinence was defined as any involuntary leakage of mucus, liquid, or solid stool using the Fecal Incontinence Severity Index. Logistic regression models allowing nonlinear effects were used and displayed as nomograms. Overall performance was assessed using the Brier score (zero equals perfect model) and concordance index (c-statistic)., Results: A total of 921 women enrolled in the Childbirth and Pelvic Symptoms Study, and 759 (82%) were interviewed by telephone 6 months postpartum. Two antepartum models were generated, which discriminated between women who will and will not develop UI (Brier score = 0.19, c-statistic = 0.69) and FI (Brier score = 0.10, c-statistic = 0.67) at 6 months and 2 models were generated (Brier score = 0.18, c-statistic= 0.68 and Brier score = 0.09, c-statistic = 0.68) for predicting UI and FI, respectively, for use after labor and delivery., Conclusions: These models yielded 4 nomograms that are accurate for generating individualized prognostic estimates of postpartum UI and FI and may facilitate decision making in the prevention of incontinence.

Purpose: Tear meniscus height (TMH) is an indirect measurement of tear film volume. This study investigated the temporal changes in the TMH during the blink interval in the morning (8-9 am) and at the end of the day (5-6 pm) in both soft contact lens (CL) and nonlens wearers (NLW)., Methods: Fifty participants (25 CL; 25 NLW) were evaluated for their subjective symptoms, TMH, noninvasive break up time, and bulbar hyperemia at the am and pm visits on the same day. The TMH was measured at set intervals between 2 and 15 sec during the blink interval, using an optical coherence tomographer., Results: The NLW group revealed no changes in a variety of symptoms during the day, whereas the CL group reported an increase in dryness (P=0.03) and grittiness (P=0.02) over the day. For both groups, the TMH and calculated tear meniscus volume revealed lower values immediately after the blink and increased progressively afterwards, mainly due to reflex tearing. The am tear meniscus volume values tended to be higher than the pm values for both groups, but this was not significant (NLW P=0.13; CL P=0.82). Noninvasive break up time deteriorated during the day for both groups but was only significant for the CL group (P=0.002), whereas bulbar hyperemia revealed no statistically significant change for either group., Conclusions: Reflex tearing may play a substantial role in the TMH differences observed over the blink interval. Standardization of the time when a TMH measurement is performed will be valuable in comparing tear film clinical studies.

Purpose: To date, few studies have correlated the overnight effects of the preocular tear film (POTF) with subjective symptoms. This study investigates the POTF volume and stability, bulbar hyperemia (BH), tear ferning (TF) and the participant's subjective symptoms, pre- and post-sleep., Methods: Thirty subjects were recruited, consisting of two evenly distributed groups who were symptomatic of dry eye (DE) and those that were asymptomatic dry eye, determined using the McMonnies questionnaire. Subjects were evaluated at 10 p.m. (baseline), on waking at 7 a.m., and then hourly until 10 a.m. At each visit, tear meniscus height (TMH), various subjective factors, BH and POTF stability by non-invasive break-up time (NIBUT) were assessed. Tear collection was performed at 10 p.m, 7 and 10 a.m. for TF analysis., Results: With the exception of burning, all other symptoms (comfort, dryness, clarity of vision, and grittiness) revealed an overnight change (p < 0.05) within each group, but not between the two groups (p > 0.05). Both the tear meniscus height and BH were elevated upon waking and differed significantly between test times for each group (p < 0.05), but not between groups (p > 0.05). NIBUT was lower for the DE group (p < 0.001). The non-dry eye (NDE) group did not significantly alter over time (p > 0.05), but the DE group did (p = 0.004), with a longer NIBUT in the morning. TF demonstrated a degraded pattern upon waking for both groups (p < 0.05). Most of the changes returned to baseline within an hour after waking., Conclusions: The properties of the POTF undergo a change during extended periods of eye closure and the human POTF is different upon waking to that present immediately before sleep. Most of the parameters determined rapidly revert to baseline levels once the POTF is allowed to refresh.

Corneal dystrophies are relatively rare bilateral anomalies. Meesman dystrophy is typically asymptomatic with little effect on visual performance. This case highlights the use of a high modulus silicone hydrogel (SiHy) lens in the management of an atypical presentation of Meesman's dystrophy with associated visual impairment due to epithelial defects. The selection of a SiHy material provided increased oxygenation to re-establish corneal integrity. However, selecting the appropriate modulus was an additional factor to consider in this case since it had a direct effect on the visual outcome. The higher modulus SiHy lenses provided a better visual success for this patient than one with a lower modulus. Modulus consideration may prove to be an additional factor in the lens choice of SiHy in the management of epithelial defects.

Purpose: Tear meniscus height (TMH) is an established parameter indicative of tear film volume and has recently been determined using an optical coherence tomographer (OCT). The purpose of this study was to evaluate the inter and intra observer variability in TMH assessment using OCT., Methods: Ten subjects (6 M, 4 F; aged 32.5 +/- 6.4 years) had 10 consecutive scans taken of their inferior central tear meniscus (5 scans originating at 90 degrees and 5 origination at 270 degrees) using the OCT2 (Humphrey-Zeiss). Images were analyzed by two observers using custom software on three separate occasions. Following a training session among observers, the images were reevaluated to assess differences in variability. Data were analyzed for differences within and across examiners, for the effect of examiner training and between scan directions., Results: The mean TMH and tear volume collapsed across subjects were between 0.24 and 0.25 mm and 25 to 27 nL/mm, respectively. No difference was noted within observers. An interobserver mean volume difference (p = 0.044) was present but was eliminated post training (p = 0.167). Variability was less with scans originating at 90 degrees., Conclusions: The values of the TMH and tear volume are similar to those reported in the literature. Due to the interobserver differences observed, a training session between examiners may prove to be valuable, especially in a large or multicenter study.

Anterior polar cataracts (APC) are a relatively rare but well-documented form of congenital cataract. Occasionally, these white disc-shaped opacities protrude towards the anterior chamber with an inverse cone-like morphology and are known as anterior pyramidal cataracts. These represent three to four per cent of all types of congenital cataracts. APCs portray a dominant mode of inheritance and generally do not progress over time. Due to their small size, APCs generally have little effect on vision and are simply monitored clinically. Photodocumentation of pyramidal cataracts has traditionally shown biomicroscopic views of the opacities. In addition to a review of APC, this report describes how a gonioscope offers a unique observational advantage in viewing an anterior pyramidal cataract.