Patient-Centered Goals for Treatment of Pelvic Floor Disorders.

Purpose of review: To review the current literature on patient centered goals for the treatment of pelvic floor disorders (PFDs). Recent findings: Patients have a poor understanding of their PFDs, regardless if they had prior PFD treatments or received counseling, emphasizing the need for improved education from healthcare providers. Understanding the patient perspective provides insights into identifying patient goals, which facilitates communication and allows for tailored counseling, management of expectations, and assessment of treatment response. Functional outcomes are consistently important to patients, often listed as their main treatment goals. The achievement of these goals is fundamental to satisfaction. IMPACT and PROMIS are examples of PCO measures that can be utilized in both research and clinical settings. Finally, telemedicine has emerged as a viable alternative to clinic visits that offers improved access to care with no increase in adverse events or dissatisfaction, in order to aid in monitoring and meeting patient treatment goals. Summary: Patient involvement is fundamental to providing value-based care. Provider understanding of the patient perspective is necessary to guide counseling and treatment. Patient-centered goals offer a way to engage patients, facilitate communication, and improve patient satisfaction. Although there are multiple validated PCO tools, further development and research involving patient input is needed.

Does gabapentin impact response to anticholinergics for overactive bladder?

INTRODUCTION AND HYPOTHESIS: It is unknown whether gabapentin modulates the therapeutic effect of anticholinergics (AC) in patients with overactive bladder. We hypothesized that pre-existing gabapentin use would improve response rates in these patients. METHODS: Female patients treated with AC between 2010-2018 were identified. Data were collected on gabapentin use, indication, dose and duration of use as well as demographic and clinical characteristics. Patients were stratified by those that only took AC and those that took both AC and gabapentin ("combination therapy"). Response was determined through chart review. Descriptive statistics were expressed as medians and interquartile ranges (IQR). Pairwise analysis was performed using Wilcoxon rank-sum. Multivariable logistic regression was used to identify independent variables predicting response. A subgroup analysis was performed in patients with chronic pain disorders. RESULTS: Seven hundred fifty-six subjects met all criteria; 16.5% (n = 125) were on combination therapy. Those taking gabapentin were more likely to have chronic (49.6% vs. 22.5%, p < 0.001) or neuropathic pain (25.6% vs. 9.4%, p < 0.001) and to use narcotics (41.6% vs. 15.5%, p < 0.001). Patients taking combination therapy were not more likely to improve compared to patients taking AC alone (41.6% vs. 47.7%, p = 0.211), which persisted after adjusting for confounders (aOR = 1.02, 95% CI: 0.63-1.65). In the 182 patients with chronic pain, those receiving combination therapy were more likely to respond than those taking AC alone (35.2% vs. 21.9%, p = 0.0015), although this did not persist after adjusting for confounders (aOR = 1.15, 95% CI: 0.70-1.90). CONCLUSIONS: Pre-existing gabapentin use does not seem to influence response to AC in patients with overactive bladder.

Chronic Fentanyl Self-Administration Generates a Shift toward Negative Affect in Rats during Drug Use.

Drug addiction is thought to be driven by negative reinforcement, and it is thought that a shift from positive affect upon initial exposure to negative affect after chronic exposure to a drug is responsible for maintaining self-administration (SA) in addicted individuals. This can be modeled in rats by analyzing ultrasonic vocalizations (USVs), a type of intraspecies communication indicative of affective state based on the frequency of the emission: calls in the 22 kHz range indicate negative affect, whereas calls in the 50 kHz range indicate positive affect. We employed a voluntary chronic, long-access model of fentanyl SA to analyze affective changes in the response to chronic fentanyl exposure. Male Sprague-Dawley rats self-administered either fentanyl (N = 7) or saline (N = 6) for 30 consecutive days and USVs were recorded at four different time points: the day before the first SA session (PRE), the first day of SA (T01), the last day of SA (T30), and the first day of abstinence (ABS). At T01, the ratio of 50 to 22 kHz calls was similar between the fentanyl and saline groups, but at T30, the ratio differed between groups, with the fentanyl group showing significantly fewer 50 kHz calls and more 22 kHz calls relative to saline animals. These results indicate a shift toward a negative affect during drug use after chronic exposure to fentanyl and support negative reinforcement as a main driving factor of opioid addiction.

Evaluation of 30-day complication rates following vaginal anterior compartment repair with and without graft augmentation in a propensity score matched cohort.

OBJECTIVE: To determine if graft augmentation with anterior colporrhaphy (AC+G) is associated with higher complication rates compared to native tissue repair (AC). MATERIALS AND METHODS: Retrospective cohort study using data from the ACS-NSQIP database between 2010 and 2017. CPT codes were used to identify women undergoing AC+G and AC. Propensity scores for the likelihood of undergoing AC+G were calculated and were used to match to women undergoing native tissue repair at a ratio of 1:2. The primary outcome was the composite complication rate. Descriptive statistics are reported as means with standard deviations for parametric data and as medians and interquartile ranges for non-parametric data. Pairwise comparisons were performed using Fisher's exact test, Wilcoxon rank-sum and Student's t test as appropriate. Multivariable logistic regression was then used to adjust for confounders to identify statistically significant factors associated with the likelihood of experiencing a complication after prolapse repair. RESULTS: 582 women met inclusion criteria for AC+G and were matched with 1164 women undergoing AC. There were no differences in preoperative characteristics between groups. There was no difference in the composite complication rate, (10.8% vs. 8.5%, p = 0.13) between groups. Dependent functional status (aOR 4.31, 95% CI 1.96-13.58) was the strongest predictor of the likelihood of a complication: other significant predictors were operating time greater than 20 min (aOR 1.68, 95% CI 1.19-2.38) and ASA class greater than 2 (aOR 1.44, 95% CI 1.01-2.05). CONCLUSION: There is no increase in 30-day complication rates in women undergoing AC+G compared to a matched cohort of those undergoing AC alone.