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Pelvic reconstructive surgery is often associated with transient postoperative voiding dysfunction.This study aimed to compare postoperative active voiding trial (AVT) outcomes before and after implementation of an enhanced recovery program (ERP) for women undergoing pelvic reconstructive surgery. In addition, risk factors for postoperative urinary retention were identified.We retrospectively identified patients undergoing inpatient vaginal or robotic pelvic reconstructive surgery before and after implementation of an ERP at our institution. Demographics, operative and postoperative details, and AVT outcomes were collected. Primary outcome was AVT failure. Variables associated with increased risk of AVT failure were identified using multivariate analysis.Three hundred seventeen patients were included-75 pre-ERP and 242 ERP. There was no difference in AVT failures between pre-ERP and ERP groups (21.3% vs 21.9%, P = 0.92). The AVT failures were highest among those with abnormal preoperative postvoid residual volume (PVR ≥100 mL, 25.9% vs 12.2%, P = 0.01) and those who underwent an incontinence procedure (midurethral sling or Kelly plication, 30.4% vs 16.9%, P = 0.01). Compared with a reference procedure (total vaginal hysterectomy [TVH]), the following procedures were associated with statistically significant higher odds ratios (ORs) of AVT failure: TVH with incontinence procedure (OR, 15.0; confidence interval [CI], 4.58-48.9; P0.001), TVH with anterior repair (OR, 4.98; CI, 1.93-12.9; P = 0.001), and robotic sacrocolpopexy (OR, 3.6; CI, 1.18-11.2; P = 0.02).Postoperative AVT failure incidence did not differ pre- and post-ERP intervention. Abnormal preoperative PVR was associated with failed postoperative voiding trial. Concomitant incontinence procedures and/or anterior colporrhaphy were associated with increased incidence of voiding trial failure regardless of ERP cohort.

OBJECTIVES Enhanced recovery programs (ERPs) are evidence-based perioperative interventions designed to reduce narcotic use, decrease hospital length of stay, decrease medical costs, and improve patient satisfaction. Given the increase in outpatient procedures in female pelvic medicine and reconstructive surgery, we sought to compare patient outcomes before and after implementation of an ERP for women undergoing outpatient pelvic reconstructive surgery. METHODS This was a prospective nonrandomized cohort quality improvement practice initiative. The ERP intervention group included consecutive patients (n = 66) undergoing elective outpatient pelvic reconstructive surgery from March 2016 to October 2016. Historical controls were consecutive patients (n = 124) who had undergone outpatient pelvic reconstructive surgery in the same period a year before ERP implementation. Our primary outcome was opioid use and postoperative pain scores. Secondary outcomes included procedure time, use of intravenous fluids, time to discharge, and total hospital cost. RESULTS There was an observed reduction in opioid use between the ERP patients and historic controls as measured by intraoperative morphine milligram equivalents (MMEs) and total MMEs, with no difference in postoperative pain scores or postoperative MME. In addition, reduction in length of procedure (P = 0.03), intraoperative intravenous fluids (P < 0.0001), and total hospital cost (P ≤ 0.01) was noted between the ERP patients and historic controls. CONCLUSIONS Implementation of an outpatient ERP for female pelvic reconstructive surgery was associated with decreased intraoperative and total MMEs, decreased length of procedure, decreased administration of intravenous fluids, and decreased total hospital cost without changing postoperative pain scores.

The aim of this study was to identify which aspects/components of the enhanced recovery program (ERP) were associated with a positive patient surgical experience for patients undergoing urogynecologic surgery.A total of 198 patients who underwent pelvic reconstructive surgery requiring hospital admission were invited to complete questionnaires modeled after the validated Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey patient experience survey. Patients were asked about 3 phases of ERP interventions: (1) before surgery (patient education, carbohydrate loading), (2) during the hospital stay (pain control, nausea, early ambulation), and (3) after discharge (return of bladder and bowel function).One hundred patients completed the survey (51% response rate). Greater than 90% of patients rated their overall surgical experience favorably (≥8 on 1-10 scale) regardless of age (P = 0.98), race (P = 0.26), education level (P = 0.12), perception of overall health (P = 0.17), or number of prior surgical procedures (P = 0.86). Ninety-two percent of patients reported that preoperative teaching about surgery was "very helpful," and specifically 90% reported that the ERP educational handbook was useful. Patients who reported a poor perception of their overall mental health were more likely to rate their surgical experience less favorably (8 on 1-10 scale; P = 0.01), as were patients who left the hospital with a Foley catheter (P = 0.03).Greater than 90% of women surveyed who rated undergoing inpatient pelvic reconstructive surgery positively perceived their surgical experience within the ERP. The majority of patients who had a positive perception of the perioperative experience found the preoperative patient education useful.

The American Urogynecologic Society (AUGS) identified diversity, equity, and inclusion as the cornerstone of excellence in governance and operations. Although efforts to increase diversity of our membership have been ongoing for years, there had not previously been an adequate investment to ensure an inclusive climate that emphasizes equity across our volunteers and programs. In June 2020, the AUGS President, Dr Shawn Menefee, and Board of Directors called for a Presidential Task Force on Diversity, Equity, and Inclusion to study the current state of our society and make recommendations for future directions. The charge was intentionally broad. In review of the literature, there was little to inform the best means to proceed aside from administering climate surveys to gauge the current culture of inclusion and bias. The task force believed that the challenge was not only to describe the problem but also to articulate solutions. We ultimately moved to rewrite the Diversity and Inclusion and Code of Conduct Statements and develop an Action Plan that would accelerate the efforts of AUGS to foster inclusion and improve equity through the existing governance structure. In this document, we describe how the task force was organized and conducted the work to develop strategies that were aligned with the AUGS mission: "As the leader in female pelvic medicine and reconstructive surgery, AUGS drives excellence in care for women through education, research, advocacy, and interdisciplinary collaboration."

This review focuses on the diagnosis, evaluation, and treatment of urinary incontinence (UI). UI is a common diagnosis that is encountered among women in their lifetime. Stress, urge (overactive bladder), and overflow are the most commonly encountered types of incontinence, but anatomic and neurologic causes are important to rule out. There are many treatment options available for the management of UI, and most patients will benefit from conservative strategies including weight loss, timed voiding, fluid intake reduction, pelvic floor strengthening exercises, and medications. For those who do not achieve adequate improvement with conservative measures, surgical intervention can provide good symptom relief.

Perineal injury is the most common complication of vaginal delivery, and labor and delivery (LD) nurses are crucial in managing and educating women following perineal trauma.The aims of this study were to assess LD nurse experience, knowledge, and self-perception of preparedness in caring for women with obstetric anal sphincter injuries (OASIS) and to compare pre- and post-test scores using a computer-based learning module (CBL) for OASIS nurse education.All LD nurses were invited to complete a voluntary, self-assessment questionnaire inquiring about prior experience, training, and education and current clinical practice in caring for patients with OASIS. They were also asked to answer ten knowledge-based questions about OASIS. The primary outcome was change in pretest and posttest knowledge-based scores after completion of CBL.Forty-one LD nurses voluntarily responded to the self-assessment survey. Of respondents, 20% answered they were "very comfortable", 48% "comfortable", 23% "neutral," and 8% "uncomfortable" for caring for women with OASIS post-delivery. Fifty-three percent of reported having no formal education in nursing school about OASIS and 35% reported no formal training while at work. The average pretest knowledge test score was 66.3% and 93.5% (p 0.001) after completion of the CBL.Most LD nurses in this study reported having very limited formal nursing education in OASIS. Regardless of this lack of formal training, the majority of LD nurses in this sample described themselves as comfortable caring for patients with OASIS post-delivery. Completion of a CBL was associated with higher OASIS knowledge scores.

Enhanced recovery programs (ERPs) are evidence-based perioperative interventions designed to reduce narcotic use, decrease hospital length of stay, decrease medical costs, and improve patient satisfaction. Given the increase in outpatient procedures in female pelvic medicine and reconstructive surgery, we sought to compare patient outcomes before and after implementation of an ERP for women undergoing outpatient pelvic reconstructive surgery.This was a prospective nonrandomized cohort quality improvement practice initiative. The ERP intervention group included consecutive patients (n = 66) undergoing elective outpatient pelvic reconstructive surgery from March 2016 to October 2016. Historical controls were consecutive patients (n = 124) who had undergone outpatient pelvic reconstructive surgery in the same period a year before ERP implementation. Our primary outcome was opioid use and postoperative pain scores. Secondary outcomes included procedure time, use of intravenous fluids, time to discharge, and total hospital cost.There was an observed reduction in opioid use between the ERP patients and historic controls as measured by intraoperative morphine milligram equivalents (MMEs) and total MMEs, with no difference in postoperative pain scores or postoperative MME. In addition, reduction in length of procedure (P = 0.03), intraoperative intravenous fluids (P0.0001), and total hospital cost (P ≤ 0.01) was noted between the ERP patients and historic controls.Implementation of an outpatient ERP for female pelvic reconstructive surgery was associated with decreased intraoperative and total MMEs, decreased length of procedure, decreased administration of intravenous fluids, and decreased total hospital cost without changing postoperative pain scores.

Enhanced recovery protocols (ERPs) are evidenced-based interventions designed to standardize perioperative care and expedite recovery to baseline functional status after surgery. There remains a paucity of data addressing the effect of ERPs on pelvic reconstructive surgery patients. An ERP was implemented at our institution including: patient counseling, carbohydrate loading, avoidance of opioids, goal-directed fluid resuscitation, immediate postoperative feeding and early ambulation. Patients undergoing elective pelvic reconstructive surgery before and after implementation of the ERP were identified in this cohort study. One hundred eighteen patients underwent pelvic reconstructive surgery within the ERP compared with 76 historic controls. Reductions were seen in length of hospital stay (29.9 vs. 27.9 h, p = 0.04), total morphine equivalents (37.4 vs. 19.4 mg, p

Objective Patient surveys highlight a prevalence of moderate to severe pain in the postanesthesia care unit. Multimodal analgesia has been promoted to improve this with fewer opioid-induced adverse effects. The aim of this study was to evaluate the opioid sparing and analgesic effect of postoperative intravenous (IV) ketorolac after outpatient transvaginal surgery. Methods Forty patients were enrolled in this institutional review board-approved, randomized, double-blind, placebo-controlled study, to receive either 30 mg of IV ketorolac or IV saline placebo postoperatively. Pain was assessed by visual analog scale at timed intervals. Narcotic pain medication was provided upon request. Narcotic use was reassessed by telephone 5 to 7 days postoperatively. Categorical characteristics were compared by χ. Continuous variables were evaluated by Mann-Whitney U test. Results Twenty patients were randomized to each group. Groups were similar in age, health, and operative factors. There was no significant difference in mean pain scores at any interval. The ketorolac group had a total morphine equivalent consumption median of 7.5 mg versus 4.0 mg for placebo, which was not significant (P = 0.17). Total use of narcotic pills postoperatively was equivalent (median, 5). There was no difference in postoperative nausea. One Dindo grade II complication was reported in the ketorolac group of a postoperative pelvic hematoma requiring transfusion. Discussion Intravenous ketorolac administered after outpatient transvaginal surgery did not result in a reduction of pain scores or total morphine consumption. There was one Dindo grade II complication in the ketorolac group. Larger randomized control trials are needed to validate these findings.

Enhanced recovery programs (ERPs) are evidence-based protocols designed to improve functional rehabilitation after surgery. ERPs have gained widespread acceptance in many surgical disciplines, and their use leads to significant improvements in patient outcomes while reducing hospital length of stay (LOS). There remains a paucity of data on the use of ERPs in benign gynecologic surgery. The purpose of this review was to evaluate current literature on the use of ERP concepts in benign gynecologic surgery. A systematic search of PubMed, CINAHL, Web of Science, and the Cochrane databases was conducted, cross-referencing search terms related to gynecologic surgery and ERP concepts. The search was limited to publications available in English. Studies published prior to 2000, and those involving gynecologic oncology, nonadult patients, and outpatient surgery were excluded. Nine studies were included in the analysis. Due to heterogeneity of the included studies, no statistical pooling was possible and comparison between studies was limited to their respective themes. Primary study outcomes included LOS, postoperative nausea and vomiting (PONV), pain management, patient satisfaction, and hospital costs. Five studies investigated ERPs, two evaluated measures to improve PONV, and four focused on unique aspects of pain management. Across the studies, ERPs that focused on the patients’ basic symptoms and recovery were found to have equal, if not better, outcomes than standard practice. This integrative review supports the implementation of ERPs in benign gynecologic surgery. The results showed that the use of ERPs decreased LOS, improved pain scores, and reduced hospital costs, without increasing perioperative complications. We suggest additional randomized controlled trials of ERP concepts in benign gynecologic surgery to support their more widespread use and application.

To examine implementing an enhanced recovery after surgery (ERAS) protocol for women undergoing major gynecologic surgery at an academic institution and compare surgical outcomes before and after implementation.Two ERAS protocols were developed: a full pathway using regional anesthesia for open procedures and a light pathway without regional anesthesia for vaginal and minimally invasive procedures. Enhanced recovery after surgery pathways included extensive preoperative counseling, carbohydrate loading and oral fluids before surgery, multimodal analgesia with avoidance of intravenous opioids, intraoperative goal-directed fluid resuscitation, and immediate postoperative feeding and ambulation. A before-and-after study design was used to compare clinical outcomes, costs, and patient satisfaction. Complications and risk-adjusted length of stay were drawn from the American College of Surgeons' National Surgical Quality Improvement Program database.On the ERAS full protocol, 136 patients were compared with 211 historical controls and the median length of stay was reduced (2.0 compared with 3.0 days; P=.007) despite an increase in National Surgical Quality Improvement Program-predicted length of stay (2.5 compared with 2.0 days; P=.009). Reductions were seen in median intraoperative morphine equivalents (0.3 compared with 12.7 mg; P.001), intraoperative (285 compared with 1,250 mL; P.001) and total intravenous fluids (-917.5 compared with 1,410 mL; P.001), immediate postoperative pain scores (3.7 compared with 5.0; P.001), and total complications (21.3% compared with 40.2%; P=.004). On the ERAS light protocol, 249 patients were compared with 324 historical controls and demonstrated decreased intraoperative and postoperative morphine equivalents (0.0 compared with 13.0 mg; P.001 and 15.0 compared with 23.6 mg; P.001) and decreased intraoperative and overall net intravenous fluids (P.001). Patient satisfaction scores showed a marked and significant improvement on focus questions regarding pain control, nurses keeping patients informed, and staff teamwork; 30-day total hospital costs were significantly decreased in both ERAS groups.Implementation of ERAS protocols in gynecologic surgery was associated with a substantial decrease in intravenous fluids and morphine administration coupled with reduction in length of stay for open procedures combined with improved patient satisfaction and decreased hospital costs.

UNLABELLED Although complications of prosthesis products used for pelvic organ prolapse and stress urinary incontinence have been extensively characterized, little is known about their referral patterns and the time lapse from symptom onset to evaluation and treatment. The aim of our study was to retrospectively describe the patterns and timing of referral of prosthesis-related complications and initial prereferral treatments. METHODS We retrospectively identified patients referred to the University of Virginia from January 2002 to October 2012 with prosthesis complications related to previously placed devices for pelvic floor disorders. RESULTS We identified 55 prosthesis-related complications in 51 patients. The types of prostheses used included mesh or permanent suture for pelvic organ prolapse (vaginal prolapse, n = 24), tapes for stress urinary incontinence (midurethral, n = 21), and materials for abdominal sacrocolpopexies and vaginal vault suspensions (intraperitoneal, n = 10). Original surgeons, who most frequently were general obstetric/gynecology providers, were the referring physicians for only 3.6% of the time. Vaginal and midurethral prosthesis complications occurred most commonly in the early postoperative period, whereas intraperitoneal were more commonly delayed. Patients reported to have experienced adverse symptoms on average from several months up to years while receiving conservative therapies by secondary providers and/or surgical treatments with their original surgeon before referral to our institution. CONCLUSIONS Referral of prosthesis-related complications is often delayed, and most cases required evaluation by a secondary provider other than the original surgeon before a referral was initiated. Timing of symptom onset was dependent on the prosthesis type with up to 1 in 3 having a late presentation that may in part be delayed by prereferral treatments. Further education of original surgeons, primary care providers, and patients on the presentation, timing, and outcomes of potential prosthesis-related complications is needed to facilitate earlier management at tertiary care centers.

Study Objective To establish construct validity of the simulated vaginal hysterectomy trainer (SimVaHT). Design A cross-sectional validation study (Canadian Task Force classification II-2). Setting A single academic medical center in the United States. Subjects Fourteen residents in obstetrics and gynecology (4 postgraduate year [PGY] 1, 4 PGY-2, 3 PGY-3 and 3 PGY-4). PGY-1 and PGY-2 residents were grouped to form the “junior level” cohort, whereas PGY-3 and PGY-4 residents comprised the “senior level” cohort. Interventions Each participant underwent surgical skill simulation by performing a simulated vaginal hysterectomy on a practical, inexpensive vaginal hysterectomy trainer. Measurements and Main Results The primary outcome was resident surgical skill as assessed by the Objective Structured Assessment of Technical Skills Global Rating Scale (GRS). All obstetrics and gynecology residents were videotaped performing a simulated vaginal hysterectomy on the SimVaHT. The tapes were reviewed independently by 2 blinded urogynecology experts, each of whom provided a GRS score. The primary outcome was overall GRS scores. The secondary outcome was time to complete the exercise. GRS scores were compared between junior- and senior-level residents. Senior-level residents scored significantly higher on the GRS overall compared with junior-level residents (p = .008). Conclusion Construct validity was demonstrated for the SimVaHT. The SimVaHT is a practical and inexpensive tool that may improve resident vaginal surgical skills before their first case in the operating room.

Surgical treatment of pelvic organ prolapse (POP) and stress urinary incontinence (SUI) can include the use of synthetic materials. Placement of synthetic materials into the vaginal wall, through either the vagina or the abdomen, includes the risk of complications such as vaginal wall extrusion or pain. There is little data regarding outcomes following treatment of mesh complications. A retrospective chart review of patients who underwent excision of mesh placed for POP or SUI between 1 January 2001 and 31 October 2012 was performed at the University of Virginia. Chart abstraction queried patient demographics, clinical history, physical examination, pre- and post-excision symptoms, and operative findings. The International Continence Society (ICS) and International Urogynecological Association (IUGA) classification system was used to define the nature and location of mesh complications. A total of 57 patients (26 mid-urethral slings, 23 transvaginal prolapse, 9 intraperitoneal prolapse) with the diagnosis of mesh extrusion into the vaginal wall were analyzed. Twenty-five (average 2.8 cases/year) original mesh surgeries occurred between January 2001 and January 2010 and 41 (average 20.5 cases/year) occurred after January 2010. The most common presenting patient complaints were chronic pelvic pain (55.9 %), dyspareunia (54.4 %), and vaginal discharge (30.9 %). At a 6-week post-operative visit, 57.3 % of patient’s symptoms were completely resolved and 14.6 % were improved. Clinicians should be cognizant of the variable presentations of post-operative vaginal mesh complications. Mesh excision by experienced pelvic surgeons is an effective and safe treatment for these complications; however, a significant number of patients may have persistent symptoms following surgery.

We compared two hypotheses as to why obesity is associated with stress urinary incontinence (SUI): (1) obesity increases demand on the continence system (e.g. higher cough pressure) and (2) obesity compromises urethral function and urethrovaginal support. A secondary analysis was performed using data from a case–control study of SUI in women. Measurements of urethrovaginal support (POP-Q point Aa, urethral axis), urethral function (maximal urethral closure pressure, MUCP), and measures of continence system demand (intravesical pressures at rest and during maximal cough) were analyzed. Cases and controls were divided into three body mass index (BMI) groups: normal (18.5–24.9 kg/m2); overweight (25.0–29.9 kg/m2); and obese (≥30 kg/m2). Logistic regression models where created to investigate variables related to SUI for each BMI group. Structural equation modeling was used to test the direct and indirect relationships among BMI, SUI, maximal cough pressure, MUCP, and POP-Q point Aa. The study included 108 continent controls and 103 women with SUI. MUCP was the factor most strongly associated with SUI in all BMI groups. Maximal cough pressure was significantly associated with SUI in obese women (OR 3.191, 95% CI 1.326, 7.683; p

Six watersheds in New Hampshire were studied to determine the effects of road salt on stream water quality. Specific conductance in streams was monitored every 15 min for one year using dataloggers. Chloride concentrations were calculated from specific conductance using empirical relationships. Stream chloride concentrations were directly correlated with development in the watersheds and were inversely related to streamflow. Exceedances of the EPA water quality standard for chloride were detected in the four watersheds with the most development. The number of exceedances during a year was linearly related to the annual average concentration of chloride. Exceedances of the water quality standard were not predicted for streams with annual average concentrations less than 102 mg L(-1). Chloride was imported into three of the watersheds at rates ranging from 45 to 98 Mg Cl km(-2) yr(-1). Ninety-one percent of the chloride imported was road salt for deicing roadways and parking lots. A simple, mass balance equation was shown to predict annual average chloride concentrations from streamflow and chloride import rates to the watershed. This equation, combined with the apparent threshold for exceedances of the water quality standard, can be used for screening-level TMDLs for road salt in impaired watersheds.

Between 2000 and 2006, the New Hampshire Department of Environmental Services and the University of New Hampshire collected water quality samples at 25 to 40 stations per year in a 56.5-km(2) estuary as part of the Environmental Protection Agency's National Coastal Assessment program. Due to the high density of stations, probabilistic statistics for the estuary could be calculated with low uncertainty. The proportions of the estuary exceeding thresholds in each year were calculated for temperature, salinity, dissolved oxygen, chlorophyll a, nitrogen as nitrate and nitrite, nitrogen as ammonium, phosphorus as orthophosphate, total suspended solids, and fecal coliform bacteria. These values were tested for trends over time and correlations with climate variables. The same statistical tests were applied to monthly grab sample data from a representative station in the estuary. The outcomes of the statistical tests on the two datasets were compared to determine if they provided similar information to coastal managers. Trends and correlations were equally likely to be detected using the probability-based data and the fixed station data, but the results were different for the two datasets. The differences were likely due to the distributed nature of the probability-based sampling design, which places stations in all sections of the estuary. In addition, expressing the probabilistic datasets as estimated proportions reduced variability in volatile parameters, such as bacteria, relative to the grab sample dataset. It will be important to develop tools to rectify trends from probability-based surveys with fixed station monitoring to provide clear information to managers.

Impaired cognition has been correlated with adverse postoperative outcomes, such as an increased incidence of delirium, a longer length of hospital stay, and higher 6 month mortality. The incidence of cognitive impairment in the elderly is high. Per the Centers for Disease Control and Prevention, 1 in 8 adults aged 60 years and older deal with memory loss and confusion, and less than 20% inform their health care providers. Most studies in the elderly or cognitively impaired have been conducted at Veterans Administration hospitals, in which the majority of patients are male. As the female patient population ages, it is increasingly important to describe the prevalence of cognitive impairment in this specific population as well as identify and manage risk factors for cognitive decline in the ambulatory and perioperative setting.The objective of the study was to determine the prevalence of positive screening for cognitive impairment in a urogynecology ambulatory population and to establish the feasibility of using standardized, validated screening questionnaires in a tertiary care setting.After institutional review board approval, all English-speaking patients 65 years old or older presenting to our ambulatory urogynecology clinic were invited to participate. Cognitive impairment was assessed using both the validated Mini-Cog test and the Eight-Item Interview to Differentiate Aging and Dementia screen for mild dementia. A Mini-Cog score3 suggests cognitive impairment, whereas an Eight-Item Interview to Differentiate Aging and Dementia score of ≥2 discriminates dementia from normal cognition. Because of the association of depression and cognition in the elderly, the Geriatric Depression Scale (short form of 15 items) was administered, with a score5 suggesting depression. Demographic and medical history were abstracted from the medical record.A total of 371 subjects were asked to participate (39 were excluded and 37 declined); 295 subjects (79.5%) were included in the study. Mean subject age was 74.5 years, and 96.6% were white, with an average of 4.1 chronic medical comorbidities. Cognitive impairment was identified in all age groups per the Mini-Cog as follows: 65-74 years, 5.3%; 75-84 years, 13.7%; and 85 years and older, 30%. There was a significant difference in the positive screen for cognitive impairment between ages 65-74 vs75 (P ≤ .001). According to the Eight-Item Interview to Differentiate Aging and Dementia, all 3 age groups perceived themselves to have early cognitive changes: 65-74 years, 25.9%; 75-84 years, 31.9%; and 85 years and older, 40% (P = .231). The most commonly identified areas of impairment were having daily problems with thinking and memory (62%), problems with judgment (52%), and trouble learning new tools or gadgets (44%). There was no difference in the number of patients who screened positive for depression across age groups: 65-74 years, 5.9%; 75-84 years, 6.3%; and 85 years and older, 10% (P = .697).In our study population positive screening for cognitive impairment, as measured by validated questionnaires, was prevalent among women aged75 years. Screening for potential cognitive impairment in an ambulatory urogynecology population is feasible and useful in clinical practice. Our subjects were interested in cognitive screening because a third of them self-reported early cognitive changes. These tools are effective in screening for previously unrecognized impaired cognition, a definitive diagnosis, and hence treatment requires additional evaluation. Future studies could evaluate which screening tools for cognitive impairment would be most helpful in assessing patients prior to surgery in an effort to further decrease perioperative morbidity in elderly woman.

OBJECTIVE: To evaluate the effects of aging, independent of parity, on pelvic organ and urethral support, urethral function, and levator function in a sample of nulliparous women. METHODS: A cohort of 82 nulliparous women, aged 21–70 years, were recruited from the community through advertisements. Subjects underwent pelvic examination using pelvic organ prolapse quantification, urethral angles by cotton-tipped swab, and multichannel urodynamics and uroflow. Vaginal closure force was quantified using an instrumented vaginal speculum. Subjects were grouped into five age categories and analyses performed using t tests, Fisher exact tests, Kruskal-Wallace, and Pearson correlation coefficients. Multiple linear regression modeling was performed to adjust for factors that might confound the results of our primary outcomes. RESULTS: Increasing age was associated with decreasing maximal urethral closure pressure (r–0.758, P

Objective The purpose of this study was to determine the severity of anal incontinence and its impact on quality of life and sexual function in women after anal sphincteroplasty. Study design Eighty-six women who underwent anal sphincteroplasty during the years 1993 to 2004 were mailed validated survey instruments to evaluate continence status, health-related quality of life, and sexual functioning. Demographic and perioperative data were obtained from patient charts. Results At a mean follow-up time of 5.6 ± 3.0 years, 6 women (11%) were totally continent; 8 women (15%) were incontinent of flatus only, and 41 women (75%) were incontinent of liquid and/or solid stool. Sexual function scores were not correlated with continence scores; 24% vs 4% of subjects who had undergone an overlapping sphincteroplasty versus an end-to-end sphincteroplasty reported pain during intercourse ( P = .04). Conclusion Anal continence rates 5 years after anal sphincteroplasty are disappointing, adversely impact quality of life, yet do not appear to relate to sexual function.

Twenty-one sites known to be highly productive pine mushroom (Tricholoma magnivelare [Peck] Redhead) habitat were described in northwest British Columbia. Soils were well to very rapidly drained and generally coarse in texture, often with a high coarse fragment content and thin forest floor. Western hemlock (Tsuga heterophylla [Raf.] Sarg.) was consistently the dominant tree species, and lodgepole pine (Pinus contortavar. latifolia Engelm) was frequently, though not always, present in the tree layer. Plant communities typically featured sparse herb and shrub layers, and a high coverage of mosses. Using the British Columbia biogeoclimatic system of ecosystem classification, all sites in the interior cedar hemlock forests were classified as the (01) Hw-step moss site series, submesic phase, and in the coastal western hemlock forests, as the (03) HwPl-feathermoss site series. Four separate areas of interior cedar hemlock forests, encompassing approximately 60,000 ha were assessed using air photography for the described (01) Hw-step moss submesic habitat. The extent of the submesic habitat across study areas ranged from 4.3 to 21.5% of the hemlock forests. The relatively low areal extent of these valuable forests demonstrated the need to better protect and manage the pine mushroom resource.

Legumes were tested for their ability to increase soil N content and improve growth of lodgepole pine (Pinus contorta Dougl. ex Loud.) seedlings in west-central British Columbia. A trial with alsike clover at varying densities were tested at one site, while three legume species (alsike clover, birdsfoot trefoil, and white clover) were tested on a second site. After five years of legume cover, mineralizable N mass of the forest floor were 0.5 to 4.5 times those of controls. Total N of the forest floor more than doubled in the seeding density study compared with controls, but was insignificant in the multiple species study. Despite observed increases in soil nitrogen, lodgepole pine growth was not enhanced by the legume treatments. Factors such as N immobilization, root distribution, low S levels, and competition for B may have limited the response of lodgepole pine seedlings to additions of biologically fixed-N. Key words: nitrogen-fixation, legumes, lodgepole pine, soil nitrogen

Concentrations of Aroclor mixtures and specific polychlorinated biphenyl (PCB) congeners were measured in surface sediments and aquatic biota (striped bass fillet, mummichog, and blue crab muscle and hepatopancreas) collected from the lower Passaic River. Several of the 47 surface sediment samples contained Aroclor concentrations that exceeded a National Oceanic and Atmospheric Administration (NOAA) benchmark level for "total PCBs" (22.7 micrograms/kg). Each of the 18 PCB congeners analyzed in aquatic biota was detected in one or more tissue samples, and numerous congeners were detected in every sample (IUPAC numbers 77, 105, 114, 118, 123, 126, 156, 157, 167, and 189). PCB congener concentrations were similar to those that have been reported in fish from other waterways that contain elevated levels of PCBs. Congener 118 was present at the highest concentration in almost all samples, and constituted 14-60% of the total PCB mass (sum of all congener masses) measured in any given tissue sample. In spite of the prevalence of PCB congeners in biota tissues (up to 1314 micrograms/kg total PCBs), Aroclors were not detected in bass or crab samples at a limit of detection of 33-55 micrograms/kg. This anomaly may be due to selective degradation of certain PCB congeners that are used to analytically recognize and quantitate Aroclors. Using the measured sediment concentrations, a food web model accurately predicted blue crab muscle concentrations of individual PCB congeners (typically within a factor of two) and was also fairly accurate for mummichog (typically within an order of magnitude). Concentrations in striped bass fillet were underestimated by factors of approximately 20-140. Increased cancer risk estimates associated with fish and crab consumption were obtained using four different methods. Using Aroclor tissue concentrations (one-half the limit of detection) and an Aroclor slope factor, total risks were 2.6 x 10(-6); using the "total PCB" measurements and an Aroclor slope factor, total risks were 1.9 x 10(-5); the "PCB-TEQ" method yielded total risks of 6.5 x 10(-4); and USEPA's recent suggested approach for evaluating "dioxin-like" and non-"dioxin-like" effects resulted in a total risk of 6.6 x 10(-4). This wide range in risk estimates indicates that it is critical to the risk management decision-making process that data requirements and risk assessment objectives be carefully evaluated early in the investigation process.

We hypothesized that residents of Woburn, Massachusetts, had been exposed to as much as 70 microg/l of arsenic (As) and 240 microg/l of chromium (Cr) in drinking water from municipal supply wells G and H. To test this hypothesis, we measured the concentrations of As and Cr in 82 hair samples donated by 56 Woburn residents. Thirty-six samples were cut between 1964 and 1979, the period during which wells G and H were in operation. The remainder were cut either before 1964 (1938-1963; n = 26) or after 1979 (1982-1994; n = 20). Washed hair samples were analyzed by instrumental neutron activation. Exposure to the well water--measured as access--was estimated using well pumping records and a model of the Woburn water distribution system. Our results show that access to wells G and H water was not significantly correlated (95% confidence interval) with As and Cr concentrations measured in the hair of Woburn residents, but As concentrations have declined significantly over the last half century. Linear regression of As concentrations (micrograms per gram) upon year of hair cut and access to wells G and H water yielded a standard coefficient for year of -0. 0074 +/- 0.0017 (standard error; p = 2.5 -multiple- 10(-5)) and -0.12 +/- 0.10 (p = 0.22) for access. The r2 value for the model was 0.19. The geometric mean concentrations (geometric standard deviation) of As and Cr in the hair of residents who had access (i.e., relative access estimate >0) to wells G and H water (n = 27) were 0.14 (2.6) and 2.29 (1.8) microg/g, respectively; the geometric mean concentrations of As and Cr in all of the hair samples from residents who did not have access (1938-1994; n = 55) were 0.13 (3.0) and 2.19 (2.0) microg/g, respectively. Images Figure 1. Figure 2. Figure 3. Figure 4. A Figure 4. B

For a chemical that does not have a source inside a house, the ratio of its dust concentration indoors to its soil concentration outdoors is equal to the fraction of house dust that is composed of ...

The noncytopathic Australian bovine viral diarrhoea virus (BVDV) Trangie isolate was used to establish a one-step growth curve and to investigate previously uncharacterized aspects of pestivirus replication. The eclipse phase was found to be approximately 8 to 10 h and the first appearance of viral antigen assayed by immunofluorescence occurred around 6 h post-infection (p.i.). Both positive- and negative-sense virus RNAs were first detected at 4 h p.i. by Northern blot hybridization using strand-specific RNA probes generated by in vitro transcription from cDNA cloned from the NS3 region. The ratio of positive- to negative-sense virus RNA changed from 2:1 at 4 h p.i. to 10:1 at 12 h p.i. and thereafter. The kinetics of synthesis showed that the rate of synthesis of positive-strand viral RNA increased rapidly from 6 h p.i., whereas the rate of synthesis of the negative-strand remained constant. The copy number of genomic RNA determined by Northern blot hybridization analysis was estimated to be 1.5 x 10(4) copies per cell, 16 to 24 h p.i. Viral RNA species that were thought to represent replicative intermediate (RI) and replicative forms (RF) were detected after electrophoretic separation by urea-PAGE. Confirmation of the identity of the RI and RF was obtained using LiCl precipitation and RNase A digestion of [3H]uridine-labelled RNA. Pulse-chase labelling of BVDV-infected cells was consistent with synthesis of nascent BVDV RNA through an RI derived by strand displacement from an RF template and thus the synthesis of BVDV RNA is likely to be similar to the model proposed for flavivirus replication.

SUMMARY. The mechanism of hepatitis C virus (HCV) replication is unknown, although the classification of HCV in the Flaviviridae has led to the postulation that HCV may adopt a replication strategy similar to that of the flaviviruses. To determine if HCV double-stranded replicative forms, consistent with this strategy, were present in total liver RNA extracted from HCV-infected individuals, HCV-specific RNA was detected by reverse transcription followed by polymerase chain reaction (RT-PCR). Initially, a strand-specific RT-PCR resulting from chemical modification of the 3′ end of the RNA was established using in vitro transcribed HCV RNA. This procedure allowed the specific detection of positive and negative HCV RNA strands in HCV-infected liver tissue. The species of HCV RNA was then examined in RNA extracted from liver tissue from naturally infected individuals; total liver RNA was either: (i) fractionated with 2m LiCl (designed to precipitate single-stranded and partially double-stranded RNA); or (ii) digested with RNase A in high salt conditions (designed to digest single-stranded RNA only). Amplification of positive sense HCV RNA from the LiCl-insoluble fraction, but not from the LiCl-soluble fraction nor in the RNase A-digested sample, was consistent with the interpretation that single-strand, but not double-stranded HCV RNA, was contained in the liver samples. Thus, it is unclear if a double-stranded RNA species is formed during the HCV replication cycle.

The ecological effects of different treatments used to convert dense logdepole pine (Pinusconforta Dougl.) stands into young lodgepole pine plantations are being determined. The treatments used were bulldozing the trees and either broadcast burning the slash or bulldozing the slash into windrows, which were then burned. Burns were conducted under different fuel moisture conditions and state of fuel curing to achieve four classes of fire severity. Lodgepole pine seedling survival was affected by both site preparation and fire severity. Five years after outplanting, survival was significantly (p

The objective of the study was to examine the effect of center characteristics on educational experiences and female pelvic medicine knowledge changes in third-year students at 6 medical schools.: In this secondary analysis of data acquired during a prospective, multicenter study conducted from May 2008 through June 2009, preclerkship and postclerkship third-year medical students scored their knowledge of 12 female pelvic medicine topics and 4 office procedures (knowledge scores [KSs]). Postclerkship, students also reported the number and type of learning experiences they had encountered. Participating investigators provided data on length of clerkship, number of residents, number of fellowship-trained urogynecologists, presence of a fellowship program, clerkship grading system type, presence of a urogynecology clerkship rotation, and presence of a urogynecology lecture. Analyses used Wilcoxon tests/Spearman correlation, with an α = 0.05.: Paired preclerkship and postclerkship survey data were available for 323 students. Increased numbers of learning experiences were positively associated with number of clerkship weeks (rs = 0.22, P0.001), presence of a urogynecology rotation (P = 0.03), and urogynecology lecture (P0.001). Knowledge scores were positively associated with the number of fellowship-trained urogynecology faculty (rs = 0.17, P = 0.002) and grading system (letter gradespass/fail) (P0.001). Knowledge scores were negatively associated with increasing numbers of residents (rs = -0.29, P0.001) and presence of a urogynecology fellowship program (P0.001). The center characteristics of fellowship program and number of residents were highly correlated (rs = 0.74, P0.001); thus, multivariate modeling was not performed.: The presence of fellowship-trained faculty, urogynecology rotation, longer duration of clerkship, and urogynecology lecture were positively correlated with higher subjective KSs. The inverse association of KS with increased resident number and presence of fellowship was an unexpected finding.

OBJECTIVE : The objective of this study was to describe self-assessed student knowledge of female pelvic medicine (FPM) during the OBGYN clerkship. METHODS : Students at 6 sites scored their knowledge of 12 FPM topics and 4 procedures both before and after their clerkship. Analysis included Wilcoxon tests, Spearman correlation, and univariate and multivariate models. RESULTS : A total of 323 students completed paired surveys. Mean knowledge scores (KSs) across FPM topics (1.40 ± 0.12; 95% confidence interval) and procedures (0.77 ± 0.08) increased significantly, with larger increases for topics (P < 0.001). Topic and procedure KSs were correlated (rs = 0.32, P < 0.0001). Mean KSs were significantly related to number and number of types of learning experiences (r = 0.13 and 0.08, both P < 0.001). Learning through text and inpatient encounters had independent effects on KS change in multivariate analysis (P = 0.01 and 0.007). CONCLUSIONS : Students reported increased knowledge although less for procedures than for topics. Text and inpatient learning independently increased students' self-assessed change in knowledge.

Concentrations of chloride in excess of State of New Hampshire water-quality standards (230 mg/l) have been measured in watersheds adjacent to an interstate highway (I-93) in southern New Hampshire. A proposed widening plan for I-93 has raised concerns over further increases in chloride. As part of this effort, road-salt-contaminated groundwater discharge was mapped with terrain electrical conductivity (EC) electromagnetic (EM) methods in the fall of 2006 to identify potential sources of chloride during base-flow conditions to a small stream, Policy Brook. Three different EM meters were used to measure different depths below the streambed (ranging from 0 to 3 m). Results from the three meters showed similar patterns and identified several reaches where high EC groundwater may have been discharging. Based on the delineation of high (up to 350 mmhos/m) apparent terrain EC, seven-streambed piezometers were installed to sample shallow groundwater. Locations with high specific conductance in shallow groundwater (up to 2630 mmhos/m) generally matched locations with high streambed (shallow subsurface) terrain EC. A regression equation was used to convert the terrain EC of the streambed to an equivalent chloride concentration in shallow groundwater unique for this site. Utilizing the regression equation and estimates of one-dimensional Darcian flow through the streambed, a maximum potential groundwater chloride load was estimated at 188 Mg of chloride per year. Changes in chloride concentration in stream water during streamflow recessions showed a linear response that indicates the dominant process affecting chloride is advective flow of chloride-enriched groundwater discharge. Published in 2010 by John Wiley & Sons, Ltd.

An overdense lodgepole pine (Pinuscontorta Dougl. ex Loud.) stand was knocked down and the site was prepared by broadcast burn, windrow burn, or mechanical forest floor removal. Inoculated alsike clover (Trifoliumhybridum L.) was seeded at 0, 10, 20, and 30 kg/ha for the three different site preparation treatments to determine the effects of (i) site preparation on infection and effectiveness of the clover–Rhizobium symbiosis and clover percent cover and (ii) the clover–Rhizobium N2-fixing symbiosis on survival, early growth, and foliar nitrogen concentration of lodgepole pine seedlings. The N2-fixing symbiosis established well in all treatments. Clover percent cover increased with increasing rate of seeding, although by relatively few percent in the clover seeded plots. Broadcast burning, windrow burning, and mechanical forest floor removal did not affect the establishment of the N2-fixing symbiosis or clover percent cover. Lodgepole pine survival was not affected by the seeding treatments in any year, nor were height measurements during the first three growing seasons. Seedling height was slightly less in clover-seeded plots compared with controls in the fourth growing season. Lodgepole pine seedlings on clover-seeded plots had decreased diameter growth compared with controls during the first three growing seasons, but incremental diameter growth no longer showed this effect by the fourth growing season. Needle mass (g/100 needles) was less in clover-seeded plots at the end of the second growing season, but this effect was reversed by the fourth growing season, when both needle mass and foliar nitrogen concentration in lodgepole pine foliage were greater in clover-seeded plots.

The ecological effects of different treatments used to convert dense Pinuscontorta var. latifolia Engelm. stands into young P. contorta plantations are determined. The treatments used were felling the trees with a bulldozer and either broadcast burning the slash or bulldozing the slash into windrows, which were then burned. Burns were conducted under different fuel moisture conditions and state of fuel curing to achieve four classes of fire severity. The preburn surface fuel load was relatively high due largely to fallen dead woody materials (10−21 kg/m2). The biomass of the forest floor (5−10 kg/m2) was similar to that of the tree slash (5−13 kg/m2), while the understory vegetation was a minor component (0.3−0.5 kg/m2). The quantity of slash and understory vegetation consumed by burning increased with the preburn mass of the same components. Forest floor consumption depended primarily on the preburn forest floor mass for windrow burns and on forest floor moisture content as well as preburn forest floor mass for broadcast burns. Fire severity generally did not have a strong influence on biomass consumption, although it did significantly influence forest floor consumption. There was a general trend, however, of increasing biomass consumption in broadcast burns with increasing fire severity. Windrow burning consumed more biomass than did broadcast burning under similar weather and fuel moisture conditions. Windrow burning resulted in uniformly high biomass consumption that was relatively independent of fuel moisture over the wide range of fuel moistures studied.

Three different optical-fiber phase modulators utilizing the magnetostrictive properties of a metallic-glass alloy were constructed. By binding the optical fiber to the magnetostrictive metallic glass, the strain induced in the metallic glass that is due to the magnetic field is transferred to the optical fiber. Two ring and one flat linear modulator configurations were investigated. Each modulator's performance was evaluated by measuring the induced phase shift as a function of the excitation frequency of the magnetic field normalized by the fiber length. The highest sensitivity of 75 mrad/cm-Oe was attained for the linear modulator.

Twenty-five patients with soft tissue sarcomas were treated with Ir192 implants following wide local excision at our institution between 1982 and 1987. External beam radiotherapy was given in addition to the implant in a majority of patients. The median follow-up in these 25 patients is 36 months (12 to 75 months). Twenty patients have had no evidence of local recurrence following their primary treatment (FFR = 80%). A multivariate analysis using stepwise logistic regression was used to predict failure in 3 years or less. Potential predictors examined included age, sex, tumor location, primary versus recurrent disease, grade, histology, surgical margins, implant only versus implant plus external beam, and a ratio of the volume of tissue which received 65 Gy (TV65) to the tumor volume (TV), that is (TV65/TV). The single variable which was significantly associated with local failure by 3 years was a TV65/TV of less than one. Once this variable was entered into the analysis, no other factor proved statistically significant. Our data suggest that when attempting local control of soft tissue sarcomas with brachytherapy, the volume of tissue receiving 65 Gy (TV65) from both implant and external beam must exceed the volume of the excised lesion (TV). Since the volume of a tumor can be readily determined prior to surgical excision either by CT or MRI scanning, pre-planning of the implant volume could potentially reduce the rate of local failure.

We sought to determine the relationship of patient-centered goal achievement in pelvic floor disorder (PFD) treatment to PFD-specific quality-of-life (QOL), depression, health status, and patient satisfaction.Ninety women with PFD identified up to 5 goals for treatment and reported their level of goal attainment (-2 to +2) at 1.5, 3, 6, and 12 months; completed the Incontinence Impact Questionnaire, Urogenital Distress Inventory, Incontinence Quality-of-Life Scale, Patient Health Questionnaire, and Short Form-12 Health Survey; and indicated their satisfaction with treatment.Twelve-month mean goal attainment was moderately correlated with PFD-specific measures of QOL (r range, -0.40 to 0.55; P.05) but less strongly with depression and general health status (r range, -0.27 to 0.28). Twelve-month goal attainment differed significantly among those who were completely satisfied (1.6 +/- 0.5), very satisfied (1.2 +/- 0.6), satisfied (0.4-1.0), or not satisfied (-0.5 +/- 0.9; F = 24.2; P.01). Earlier follow-up results were similar.PFD treatment goal attainment is associated with improved condition-specific QOL and patient satisfaction.

Treatment strategies for stress incontinence are based on the concept that urethral mobility is the predominant causal factor with sphincter function a secondary contributor. To our knowledge the relative importance of these 2 factors has not been assessed in properly controlled studies.The Research on Stress Incontinence Etiology project is a case-control study that compared 103 women with stress incontinence and 108 asymptomatic controls in groups matched for age, race, parity and hysterectomy. Urethral closure pressure, urethral and pelvic organ support, levator ani muscle function and intravesical pressure were measured and analyzed using logistic regression and multivariable modeling.Mean +/- SD maximal urethral closure pressure was 42% lower in cases (40.8 +/- 17.1 vs 70.2 +/- 22.4 cm H(2)O, d = 1.47). Lesser effect sizes were seen for support parameters, including resting urethral axis and urethrovaginal support (d = 0.41 and 0.50, respectively). Other pelvic floor parameters, including genital hiatus size and urethral axis during muscle contraction (d = 0.60 and 0.58, respectively), differed but levator strength and levator defect status did not. Maximum cough pressure, which is an assessment of stress on the continence mechanism, was also different (d = 0.43). After adjusting for body mass index the maximal urethral closure pressure alone correctly classified 50% of cases. Adding the best predictors for urethrovaginal support and cough strength to the model added 11% of predictive ability.The finding that maximal urethral closure pressure and not urethral support is the factor most strongly associated with stress incontinence implies that improving urethral function may have therapeutic promise.

Pelvic floor disorders are known to increase with age. With the number of elderly women more than doubling in the coming decades, gynecologists will need to be skilled in the assessment and treatment of these conditions. Conservative forms of therapy such as pessaries can often be successfully employed. These devices are well suited for elderly patients as they are noninvasive with minimal risk, provide immediate relief of symptoms, and are cost-effective compared with surgery. Although there are some downsides in using pessaries in clinical practice, many of these pitfalls can be appropriately addressed with education and training of clinician and patients.

We examine racial differences in urinary incontinence prevalence, frequency, quantity, type, and risk factors in a population based sample of community dwelling black and white women.Women 35 to 64 years old were sampled from telephone records from 3 southeast Michigan counties. Women self-identifying as black or white race completed a telephone interview that assessed demographics, health history, lifestyle factors and urinary incontinence experience. Statistical analysis included descriptive statistics, factor analysis and multivariable logistic regression to determine adjusted odds of urinary incontinence. Estimates were weighted to reflect probability and nonresponse characteristics of the sample, and to increase generalizability of the findings.Interviews were completed by 1,922 black and 892 white women (response rate = 69%). The overall prevalence of urinary incontinence was 26.5%. By race, urinary incontinence prevalence was 14.6% for black women and 33.1% for white women (p0.001). Among incontinent women there was no difference by race in the frequency of urinary incontinence. However, black women reported more urine loss per episode (p0.05). A larger proportion of white women with incontinence (39.2%) reported symptoms of pure stress incontinence compared to black women (25.0%), whereas a larger proportion of black women (23.8%) reported symptoms of pure urge incontinence compared to white women (11.0%). Risk factors for urinary incontinence were generally similar for white and black women.In this population based study we observed racial differences in prevalence, quantity and type of urinary incontinence. Frequency of and risk factors for urinary incontinence were generally similar for white and black women.