Search

To compare mesh complications and failure rates after 1 year in laparoscopic minimally invasive sacrocolpopexy (MISC) with ultralightweight mesh attached vaginally during total vaginal hysterectomy (TVH), laparoscopically if posthysterectomy (PH), or laparoscopically during supracervical hysterectomy.Single-center retrospective cohort study.Tertiary referral center.Women with symptomatic pelvic organ prolapse who elected for MISC.Laparoscopic MISC with ultralightweight mesh attached vaginally during TVH, laparoscopically if PH, or laparoscopically during supracervical hysterectomy. Composite failure was defined as recurrent prolapse symptoms, prolapse past the hymen, or retreatment for prolapse.Between 2010 and 2017, 650 patients met the inclusion criteria with 278 PH, 82 supracervical hysterectomy, and 290 vaginal hysterectomy patients. Median follow-up was similar for all groups (382 days vs 379 vs 345; p = .31). The majority in all groups were white (66.6%), nonsmokers (74.8%), postmenopausal (82.5%), and did not use estrogen (70.3%). Mesh complications did not differ among groups (1.6% PH, 2.5% supracervical hysterectomy, 2.2% vaginal hysterectomy; p.99). There was no difference in anatomic failure (5% PH, 1.2% supracervical hysterectomy, 2.1% vaginal hysterectomy; p = .07), reoperation for prolapse (1.4% vs 1.2% vs 0.7%; p = .57), or composite failure (9.0% vs 3.7% vs 4.8%; p = .07).TVH with vaginal mesh attachment of ultralightweight mesh had similar adverse events, mesh exposure rates, and failure rates to those of laparoscopic PH sacrocolpopexy or supracervical hysterectomy with laparoscopic mesh attachment.

The prevalence of acute vulvovaginal involvement in toxic epidermal necrolysis can be as high as 70%; up to 28% of female patients will also develop chronic vulvovaginal sequelae. There is little consensus regarding prevention and treatment of the gynecologic sequelae of both Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN). We review acute and chronic sequelae, including erosions, scar formation, chronic skin changes, urethral complications, adenosis, malignant transformation, vulvodynia, and dyspareunia. We provide comprehensive recommendations for acute and long-term vulvovaginal care in adult and pediatric SJS/TEN patients. Treatment should include an ultrapotent topical steroid, followed by a nonirritating barrier cream applied to vulvar and perineal lesions. A steroid should be used intravaginally along with vaginal dilation in all adults (but should be avoided in prepubertal adolescents) with vaginal involvement. Menstrual suppression should be considered in all reproductive age patients until vulvovaginal lesions have healed. Last, referrals for pelvic floor physical therapy and to surgical subspecialties should be offered on a case-by-case basis. This guide summarizes the current available literature combined with expert opinion of both dermatologists and gynecologists who treat a high volume of SJS/TEN patients.

The objective was to determine the relationship between the preoperative D-point and apical outcomes at 24 months, using the Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) dataset. This was a secondary analysis of the OPTIMAL trial, a randomized multi-centered study comparing outcomes of sacrospinous ligament fixation and transvaginal uterosacral ligament suspension (USLS). The 2-year dataset utilized included women undergoing USLS with concomitant hysterectomy. The primary outcome was the relationship between preoperative D-point and apical outcomes at 24 months. Secondary objectives were to determine the relationship between preoperative D-point and anatomical, composite and subjective outcomes, and to determine a D-point cut-off that could be used to predict success in each of these categories. Of the 186 women in the USLS arm, 120 were available for analysis of anatomical failure at 24 months. A higher preoperative D-point correlated with improved apical outcome (C-point) at 24 months (r = 0.34; p value = 0.0002). Using ROC curves, a moderate association was found between the preoperative D-point and apical and anatomical success, (AUC 0.689 and 0.662). There was no relationship between preoperative D-point and composite or subjective success (AUC 0.577 and 0.458). Based on the ROC curves, a “cut-off” D-point value of −4.25 cm (sensitivity = 0.58, specificity = 0.67) was determined to be a predictor of postoperative anatomical success at 2 years. Preoperative D-point correlates with postoperative anatomical and apical support, but is less successful at predicting subjective outcomes. The strongest predictive D-point cut-off for anatomical and apical success at 24 months was −4.25 cm.

Community gardens have the potential to positively impact the quality of life for veterans in the process of reintegrating into the community. This Field Note will describe the implementation of a ...

The Veterans Health Administration Home Based Primary Care (VHA-HBPC) program serves Veterans with complex, chronic conditions. Emergency management is a concern for VHA-HBPC programs. Geographic information system (GIS) mapping has been implemented for local program operations in 30 locations. An evaluation assessed GIS mapping as a tool in emergency management, including frontline nurses' and nurse leaders' experiences. Nurses' roles included making and using maps for preparedness and response. Maps provided valuable information, including locations of vulnerable patients (eg, ventilator dependent), community emergency resources, and environmental threats (eg, hurricane). Nurses' willingness to embrace this new technology and skill set was notable.

Teens are vulnerable to food insecurity for both biological and social reasons. This study aimed to better understand the factors that underpin teen food insecurity and the coping strategies teens employ when faced with limited food access and hunger. A sociodemographic survey including the USDA's Self-Administered Food Security Survey Module for Children Ages 12 Years and Older, focus groups, and photovoice were used to collect data on the demographics, food insecurity prevalence, and experiences of food insecurity among thirty-eight teens from five different communities in Tampa Bay, Florida. Results showed that approximately 44 percent of teens were food insecure. Factors that associated with food insecurity included: (1) negative perceptions of food quality, food options, school administration, food waste, and food assistance utilization; (2) school and programming issues including the timing of meals, portion sizes, and regulations associated with food and access; (3) stigma and bullying; and (4) socioeconomics. Teens relied on their communities (e.g., friends, churches), illegal activities (e.g., stealing), cheap and unhealthy foods, jobs, or their teachers to cope with food insecurity. The findings highlight significant opportunities for food security interventions that target the unique nutritional needs and social experiences of adolescents. The study was funded by the county Juvenile Welfare Board.

Objective The aim of the study was to evaluate knowledge, attitudes, and practice patterns of physicians prescribing topical estrogen for women with urogenital atrophy and a history of breast cancer. Methods A cross-sectional survey of breast surgeons, urogynecologists, and gynecologists was distributed via their professional societies: the American Society of Breast Surgeons (ASBrS), the American Urogynecologic Society (AUGS), and the Society of Gynecologic Surgeons (SGS). Providers reported level of comfort prescribing vaginal estrogen for urogenital symptoms for women with different categories of breast cancer and current treatment: estrogen receptor (ER) negative, ER positive no longer on endocrine therapy, and ER positive currently on adjuvant endocrine therapy. General knowledge questions assessed agreement on a 5-point Likert scale to statements about vaginal estrogen safety and pharmacology. Results A total of 820 physicians completed the survey: 437 responses from the ASBrS (response rate, 26.7%), 196 from AUGS (15%), and 187 from SGS (44.5%). The majority of physicians (84%), regardless of specialty, felt comfortable prescribing vaginal estrogen to women with a history of ER-negative cancer: 65.7% felt comfortable prescribing for women with ER-positive breast cancer no longer on endocrine therapy; 51.3% for women on an aromatase inhibitor; and 31.4% for women on tamoxifen. Urogynecologists were significantly more comfortable than breast surgeons prescribing vaginal estrogen for the lowest risk patients, whereas breast surgeons had the highest level of comfort for women currently on endocrine therapy. Conclusions This study highlights heterogeneity in practice patterns both within and across specialties. The clinical variation seen in this study suggests providers may benefit from increased knowledge regarding vaginal estrogen.

BackgroundUrinary and fecal incontinence contribute to significant quality of life impairments for patients and caregivers. Preliminary research suggests that incontinence rates may be higher among Veterans. However, few studies have examined incontinence experiences among Veterans and their caregivers.ObjectivesWe aimed to demonstrate the feasibility of conducting a one-year, telephone survey with Veterans and their caregivers to help inform larger studies. By including both Veteran and caregiver perspectives, we explored how incontinence impacts Veterans’ self-management strategies, quality of life, and treatment experiences.DesignWe used a mixed methods design, employing quantitative (i.e., cross-sectional survey) and qualitative approaches (i.e., semi-structured interviews).ParticipantsOur sample included 64 Veterans with urinary incontinence, fecal incontinence, or mixed incontinence, and 36 caregivers. A subset of 18 Veterans and 8 caregivers completed semi-structured interviews.MethodsData were collected via telephone surveys over the course of 1-year from a small research team at the Veterans Health Administration (VHA). Participants completed measures about the Veteran’s incontinence severity, quality of life, and VHA treatment experiences. Interviews asked participants about their perceptions and satisfaction in receiving treatment for the Veterans’ incontinence. Qualitative themes were extracted using a Rapid Assessment Process model.ResultsVeterans’ self-reported physical quality of life correlated negatively and significantly with both urinary and fecal incontinence severity, as well as negatively and significantly with urinary continence bother (rs range: −.36 to −.47, ps < .01). Veterans’ mental quality of life correlated negatively and significantly with urinary incontinence bother (r = −.43, p < .001). About 67% Veterans experienced incontinence symptoms for 5-years or more, yet 44% waited at least 1-year to discuss incontinence with a VHA provider. Most Veterans (92%) reported speaking with a VHA provider about incontinence, while only 42% reported speaking with a non-VHA provider. Qualitative findings revealed that, upon speaking to a provider, Veterans felt comfortable but also desired more incontinence education from their providers, including obtaining more appropriate and tailored treatment options. While most Veterans followed their provider’s treatment recommendations, some felt unsatisfied with treatments that they perceived as embarrassing.ConclusionsRecruiting a substantial sample of Veterans with incontinence, and their caregivers, is feasible using our recruitment methods, which can inform larger studies. Our study revealed that incontinence symptoms interfere significantly with the quality of life of Veterans and their caregivers. Intervening at the healthcare level by educating providers and systematizing inquiry into incontinence for higher risk populations would be fruitful to explore.Contribution of the PaperWhat is already known about this topic?Urinary incontinence is more prevalent than fecal incontinence, and both are associated with significant impairments in physical, mental, and social functioning.Urinary and fecal incontinence become more prevalent with older age and additional chronic health conditions.There is a lack of incontinence diagnoses documented in Veteran’s medical records, even when incontinence is present. Few studies have reported on caregiver burden related to incontinence care.What this paper addsThis study is the first to report on the potential delay between Veteran’s experiencing symptoms of incontinence and informing their healthcare provider or caregiver about those symptoms (sometimes 5-years or more).Insights on Veteran and caregiver satisfaction with incontinence care can guide healthcare interventions to improve incontinence care.Both Veteran quality of life and caregiver burden correlated significantly and negatively with satisfaction with incontinence treatments tried and number of treatments tried. Only 21% of Veterans were satisfied with the treatment plan they were given, suggesting a potential knowledge gap or opportunity for improvement in healthcare provider approaches to incontinence management.

The objective was to determine the relationship between the preoperative D-point and apical outcomes at 24 months, using the Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) dataset.This was a secondary analysis of the OPTIMAL trial, a randomized multi-centered study comparing outcomes of sacrospinous ligament fixation and transvaginal uterosacral ligament suspension (USLS). The 2-year dataset utilized included women undergoing USLS with concomitant hysterectomy. The primary outcome was the relationship between preoperative D-point and apical outcomes at 24 months. Secondary objectives were to determine the relationship between preoperative D-point and anatomical, composite and subjective outcomes, and to determine a D-point cut-off that could be used to predict success in each of these categories.Of the 186 women in the USLS arm, 120 were available for analysis of anatomical failure at 24 months. A higher preoperative D-point correlated with improved apical outcome (C-point) at 24 months (r = 0.34; p value = 0.0002). Using ROC curves, a moderate association was found between the preoperative D-point and apical and anatomical success, (AUC 0.689 and 0.662). There was no relationship between preoperative D-point and composite or subjective success (AUC 0.577 and 0.458). Based on the ROC curves, a "cut-off" D-point value of -4.25 cm (sensitivity = 0.58, specificity = 0.67) was determined to be a predictor of postoperative anatomical success at 2 years.Preoperative D-point correlates with postoperative anatomical and apical support, but is less successful at predicting subjective outcomes. The strongest predictive D-point cut-off for anatomical and apical success at 24 months was -4.25 cm.

As part of a larger study to test the efficacy of the Concussion Coach cell phone application for patients with post-concussion symptoms, qualitative data were gathered to assess barriers and facilitators for app use and differences in use of the app among those who declined or improved in symptom severity, or were low-use users.Using a prospective descriptive study design, 35 semi-structured qualitative interviews were conducted between 2016-2018. Participants had a history of mild traumatic brain injury and were symptomatic. Interview data were analyzed using qualitative content analysis.Primary facilitators were the app's ease of use, privacy, availability/portability, and increased self-efficacy of the user. Primary barriers were a lack of sufficient app training, stigma, overly "basic" content, and symptom severity. While there were not prominent differences among user groups, users whose symptom severity improved described using more modules of the app than users who declined. Low-users attributed not using the app to content that was too basic or to their forgetting.Interview data suggest that Concussion Coach can benefit Veterans with post-concussive symptoms through increased agency, perceived benefits to emotional well-being, and the availability of non-stigmatized strategies for symptom management.

The Veterans Health Administration Home Based Primary Care (VHA-HBPC) program serves Veterans with complex, chronic conditions. Emergency management is a concern for VHA-HBPC programs. Geographic information system (GIS) mapping has been implemented for local program operations in 30 locations. An evaluation assessed GIS mapping as a tool in emergency management, including frontline nurses' and nurse leaders' experiences. Nurses' roles included making and using maps for preparedness and response. Maps provided valuable information, including locations of vulnerable patients (eg, ventilator dependent), community emergency resources, and environmental threats (eg, hurricane). Nurses' willingness to embrace this new technology and skill set was notable.

This article examines the relationship between food insecurity and health-care decision-making among mobile food pantry clients in Tampa Bay, Florida. Results show a high rate of food insecurity, high stress levels, and chronic health conditions among mobile pantry clients, many of whom are long-term users of food pantry services. The fruits and vegetables supplied by the pantry allow clients to manage chronic health conditions and mitigate some of the financial burden of health-care costs. Research was conducted in cooperation with the Anthropology Department at the University of South Florida, Feeding Tampa Bay, and WellCare .

Introduction Vaginal laxity (VL) is a sensation of vaginal looseness which may develop after pregnancy and vaginal delivery and may be affected by prior pelvic surgery, menopause and aging. Pelvic organ prolapse (POP) is a disorder in which pelvic organs descend from the normal position. VL has attracted recent attention due to the advent of energy-based treatments for this symptom. Aim To determine the correlation between VL symptoms and physical exam findings of POP, specifically the introital measurement of genital hiatus. Methods This was a multi-center cross-sectional study of sexually active women over 18 years of age with a parity of one or greater. Subjects completed the Vaginal Laxity Questionnaire (VLQ), the Pelvic Floor Distress Inventory-20, and the Female Sexual Function Index (FSFI), and were asked if a sexual partner had commented on laxity. Subjects underwent pelvic exam, including the pelvic organ prolapse quantification (POP-Q). Main Outcomes Measures Correlation between VL symptoms as measured by the VLQ and POP as measured by elements of the POP-Q. Results A total of 95 subjects with an average age was 54.3 ± 13.18 years were included. Sixty-three percent of patients were postmenopausal. The average VLQ score was 4.2 ± 1.35 and the average FSFI score was 23.42 out of 36. There was no significant correlation between VLQ score and POP or mid-vaginal caliber. Sensation of vaginal tightness was significantly associated with age (P=0.03) and menopausal status (P=0.04). Only 28% of partners commented on laxity and the majority commented on the vagina being tight (21%) rather than loose (7%). Conclusion VL was not correlated with physical exam findings quantifying POP or sexual function. This study emphasizes the need to develop a more standardized definition of VL and a better assessment tool for VL symptoms.

The Veteran's Health Administration (VHA) Home Based Primary Care (HBPC) program provides comprehensive in-home primary care services to elderly Veterans with complex chronic medical conditions. Nurses have prominent roles in HBPC including as program leaders, primary care providers and nurses who make home visits. Delivery of primary care services to patients in their homes can be challenging due to travel distances, difficult terrain, traffic, and adverse weather. Mapmaking with geographic information systems (GIS) can support optimization of resource utilization, travel efficiency, program capacity, and management during normal operations, and patient safety during disasters. This paper reports on the feasibility, acceptability and outcomes of an initiative to implement GIS mapmaking in VHA HBPC programs. A mixed method evaluation assessed extent of adoption and identified facilitators and barriers to uptake. Results indicate that GIS mapping in VHA HBPC is feasible and can increase effectiveness and efficiency of VHA HBPC nurses.