SHAred DEcision making in Pelvic Organ Prolapse (SHADE-POP); Implementation is not as easy as it seems.

OBJECTIVE: Despite the positive effects of decision aids (DAs), implementation remains a significant challenge. The aim of the current study was to determine what barriers clinicians experience using a DA for pelvic organ prolapse (POP). METHODS: This study was conducted with a qualitative descriptive design including in-depth semi-structured interviews according to COREQ-criteria. Participants included clinicians and patients. Grounded theory analysis was used to describe the main themes. RESULTS: A total of 9 clinicians and 4 patients participated. Four major themes (1) opinions about shared decision making (SDM), (2) current practice, (3) experience with the DA, (4) suggestions for improvement and one minor theme (5) experience with the study, emerged. Clinicians were predominantly positive about the DA. CONCLUSION: Despite the positive attitudes of the clinicians in this study, the implementation of a DA is still challenging. The DA is forgotten regularly as improvement of logistics is needed, clinicians assume they already provide good care which might result in a reluctance to change and more engagement of physicians is needed. PRACTICE IMPLICATIONS: Regular contact with clinicians to remind, help and increase engagement and a decrease of the logistic burden is needed to ensure all patients can fully benefit of the DA.

Extracellular matrix plasticity and GABAergic inhibition of prefrontal cortex pyramidal cells facilitates relapse to heroin seeking.

Successful treatment of drug addiction is hampered by high relapse rates during periods of abstinence. Neuroadaptation in the medial prefrontal cortex (mPFC) is thought to have a crucial role in vulnerability to relapse to drug seeking, but the molecular and cellular mechanisms remain largely unknown. To identify protein changes that contribute to relapse susceptibility, we investigated synaptic membrane fractions from the mPFC of rats that underwent 21 days of forced abstinence following heroin self-administration. Quantitative proteomics revealed that long-term abstinence from heroin self-administration was associated with reduced levels of extracellular matrix (ECM) proteins. After extinction of heroin self-administration, downregulation of ECM proteins was also present in the mPFC, as well as nucleus accumbens (NAc), and these adaptations were partially restored following cue-induced reinstatement of heroin seeking. In the mPFC, these ECM proteins are condensed in the perineuronal nets that exclusively surround GABAergic interneurons, indicating that ECM adaptation might alter the activity of GABAergic interneurons. In support of this, we observed an increase in the inhibitory GABAergic synaptic inputs received by the mPFC pyramidal cells after the re-exposure to heroin-conditioned cues. Recovering levels of ECM constituents by metalloproteinase inhibitor treatment (FN-439; i.c.v.) prior to a reinstatement test attenuated subsequent heroin seeking, suggesting that the reduced synaptic ECM levels during heroin abstinence enhanced sensitivity to respond to heroin-conditioned cues. We provide evidence for a novel neuroadaptive mechanism, in which heroin self-administration-induced adaptation of the ECM increased relapse vulnerability, potentially by augmenting the responsivity of mPFC GABAergic interneurons to heroin-associated stimuli.

The incidence of parametrial tumor involvement in select patients with early cervix cancer is too low to justify parametrectomy.

OBJECTIVE: To determine the incidence of parametrial involvement in a select group of patients with early cervical cancer. METHODS: We retrospectively reviewed the records of patients with cervical cancer and a maximum tumor diameter of 2 cm, infiltration depth<10 mm and negative pelvic lymph nodes who underwent a radical hysterectomy in two university hospitals. In addition, the literature was reviewed. RESULTS: 103 patients were identified in our databases that met the abovementioned criteria. In two of these patients (1.94%), parametrial involvement was found. Both patients had LVSI. Literature review revealed 696 patients described in three studies that satisfied the selection criteria. Three (0.43%) of these patients had parametrial involvement. In patients with early stage cervical carcinoma, tumor size<2 cm, infiltration depth<10 mm, negative pelvic lymph nodes and absent LVSI the risk of parametrial involvement is 0.63%. CONCLUSION: Because of a very low risk on parametrial involvement, patients who fulfil strict selection criteria could be candidates for conization and pelvic lymphadenectomy instead of more extensive surgery. Morbidity and pregnancy complications may decrease while it is unlikely that survival will be compromised.

Systemic interleukin-10 concentrations do not alter between the first and second trimester in normal pregnancy.

BACKGROUND: Interleukin 10 (IL-10) is involved in normal fecundity and systemic IL-10 changes during gestation might reflect an immunologic shift at the maternal-fetal interface. METHODS: Serum IL-10 levels were measured in the first and second trimester of uncomplicated pregnancy in 32 women. The low interassay coefficient of variation of the low adjustor of the IL-10 assay (5.2%) enabled us to detect IL-10 concentrations between 0.50 pg/ml and 4.0 pg/ml. RESULTS: There was no statistically significant difference between serum IL-10 levels in the first trimester (median 1.10; range 0.53-4.60 pg/ml) and second trimester (median 1.05; range 0.64-3.30 pg/ml). CONCLUSION: IL-10 is not systemically activated to a detectable degree between the first and second trimester of normal pregnancy.

Biaxial total wrist arthroplasty in rheumatoid arthritis. Satisfactory functional results.

We reviewed 16 uncemented biaxial total wrist arthroplasties (TWA) in 14 patients with rheumatoid or juvenile arthritis. The mean follow-up was 25 months (range 5-60). According to the Hospital for Special Surgery scoring system (HSS), good-to-excellent results were accomplished in 69%, moderate in 19%, and poor in 12%. The mean pain score was 0.4 on a visual analog scale from 0-10 (0=no pain). The Wrightington activities of daily life assessment chart showed a 63% improvement, and we found a threefold increase in range of motion at follow-up. Four TWAs showed early dislocation, one of which was revised. Biaxial TWA yields good short-term results in rheumatoid patients, although instability is a frequent complication.

Solubilized benzodiazepine receptors for use in receptor assays.

In the development of non-radioactive receptor assays for benzodiazepines, employing fluorescent ligands, it was observed that the fluorescence measurements were hampered by the background fluorescence of the receptor preparation. This receptor preparation is a brain tissue homogenate in which the benzodiazepine receptors are membrane-bound. To minimize the influence of the receptor material on the fluorescence detection, the benzodiazepine receptors were solubilized with 0.5% sodium deoxycholate. The binding characteristics of the receptors were examined after solubilization and compared with membrane-bound receptors. The Kd and Bmax values for membrane-bound receptors were 1.20 nM and 1.01 pM mg-1 protein and for solubilized receptors they were 4.1 nM and 0.54 pM mg-1 protein respectively. Inhibition curves with the benzodiazepine antagonist flumazenil and the agonist lorazepam revealed that their affinities for the solubilized receptor as compared to the membrane-bound receptor were also reduced from 0.67 nM to 3.2 nM and from 1.49 nM to 8.4 nM respectively. The detection limits for the two benzodiazepines, however, were not affected by the solubilization. Furthermore, three different methods to separate the fraction of free labelled ligand and the fraction bound to the solubilized receptor were compared, namely polyethylene glycol precipitation/filtration, ion exchange filtration and charcoal adsorption. Polyethylene glycol precipitation/filtration gave the highest yield for the bound fraction and the best reproducibility.

A comparative evaluation of bedside capillary blood glucose monitoring devices designed for hospital use.

Capillary blood glucose monitoring devices (CBGMs) that incorporate "wipeless" technology recently have been designed and marketed for hospital use. Our objective was to evaluate three such devices for accuracy and precision, comparing them to a popular device that utilizes older technology and to a reference standard. Blood glucose level was simultaneously determined on the CBGMs and a reference standard. Results were analyzed for precision by performing repeated measurements of a single sample and for accuracy across the entire range of determinations. Clinically relevant subsets of the entire range also were determined and arbitrarily defined as low (< 60 mg/dL), normal (60 to 140 mg/dL), high (141 to 300 mg/dL), and very high (> 300 mg/dL). We found that accuracy and precision of these devices varied considerably. Lack of accuracy was particularly evident upon analysis of the clinically relevant subset ranges of blood glucose levels. Consequently, routine evaluation of CBGMs should include analysis of clinically relevant subset ranges of blood glucose levels. The marked differences in accuracy and precision between CBGMs that are currently.

Quality assurance of a diarrhoea control programme in northeastern Brazil.

In this study quality assurance methods were used in an evaluation of a programme for Control of Diarrhoeal Diseases (CDD) in northeastern Brazil. Seventy-eight randomly selected public primary care facilities in four states were assessed by trained surveyors. Problems observed in the facilities were lack of information on target population and coverage, lack of equipment to permit rehydration in the premises, and frequent unavailability of trained professionals. Health workers showed deficiencies in history taking, physical examination and knowledge on diarrhoea management. Many caretakers had difficulties in recalling information given to them in the health facilities. Eighty-four percent of the cases were treated with oral rehydration, but 90% were sent home immediately and not kept in the facilities to practice rehydration under guidance as recommended by the national CDD programme. An overuse of the medical treatment was observed. More than two-thirds of health professionals gave wrong indications for use of antibiotics. The study showed that oral rehydration therapy is well established in the government health services in the region but that the CDD programme needs to take early action to correct deficiencies in logistics, case management and health education.

PIP: The 9 states in the northeast of Brazil were divided into 4 groups based on population size and geographical distribution. In the capital cities of each state, 5-8 health units treating children with diarrhea were chosen at random. Overall, 78 health care units were studied. University-trained nurses evaluated each health care unit regarding diarrhea management and conducted interviews using questionnaires for the data collection. The survey team was split into groups of 4, each group covering 1 state. The field-work was carried out in May 1989 and took 4-6 weeks to complete. 88% of facilities surveyed were health centers, while the rest were outpatient departments in hospitals. In 40% of the facilities, the number of monthly consultations of children was known, while only 22% had information on the number of children attending for diarrhea each month. 62% of facilities had a special oral rehydration therapy (ORT) place for children. Utensils for administration of ORT were available in only half of the facilities. In 1/5 of the facilities the sugar-salt-solution packets were never or seldom available. In 32 of 65 facilities, the most recent shipment of ORS packets had arrived in the last month. 10 facilities had not received ORS for more than 6 months. In 67 facilities (86%) a physician, and in 9 a health auxiliary, was responsible for managing childhood diarrhea. 75 visits for childhood diarrhea were observed in 42 health facilities. 58 of the attendances (77%) were managed by doctors, 12 by health auxiliaries, and 5 by nurses. 90% of the patients were sent home, while the rest were treated. In 84% of cases oral rehydration therapy was prescribed, usually oral rehydration salts (ORS). Antimicrobial drugs were prescribed in 21% of the cases. Other drugs like metochlopramide, caolin-pectin, aspirin and vitamins were prescribed in 41% of the cases.

Electrohydraulic-clamshell heart with energy converter inside the compliance reservoir.

Two new ideas on the electrohydraulic actuation of blood pumps have been combined. The first idea was to put the energy converters that propel the hydraulic fluid inside the compliance reservoir instead of having them separate. Compactness of the device and better cooling of the energy converter by the surrounding fluid are two major advantages of this approach. Secondly, we put the pumping membrane inside a clamshell that fits over a soft ventricle (1). The ventricle can be implanted first, after which the shell is slid over it. These two ideas have resulted in devices described in this paper. Preliminary in vitro and in vivo data are presented.

Management of childhood diarrhoea at the household level: a population-based survey in north-east Brazil.

The management of childhood diarrhoea at the household level was studied in a population-based survey in four states in north-east Brazil. Of a representative sample of 6524 children under 5 years of age, 982 (15.1%) had diarrhoea on the day of the interview or had had diarrhoea at some time during the previous 15 days. A total of 66% of the children were not taken for treatment, while government health services were used by 14%, private doctors by 1%, and traditional healers (rezadeiras) by 24%. Oral rehydration therapy was given to 24.3% of the children as follows: solutions of oral rehydration salts (ORS) were received by 6.8%, salt-and-sugar solutions by 14.7%, and solutions of commercial ORS brands by 4.3%. Although 95% of the caretakers knew about rehydration solutions, only 18% prepared them correctly, the most common error being the use of insufficient water. Of the rehydration solutions used, 39% had a sodium concentration that was potentially dangerous (greater than 120 mmol/l), and 8% had a sodium concentration that was very low. Of those solutions prepared using ORS, 38% had too high a sodium concentration, while 14% of the salt-and-sugar solutions prepared using either the "scoop-and-pinch" approach or a plastic spoon were too concentrated. However, potentially the most dangerous were the salt-and-sugar solutions prepared using nonstandard recipes. More than half of these had an unacceptably high sodium concentration or osmolarity.