The impact of climate change on atopic dermatitis and mental health comorbidities: a review of the literature and examination of intersectionality.

Climate change, fueled by increasing concentrations of greenhouse gases, is associated with rising temperatures, extreme weather events, increased aeroallergen production, and air pollution. Our understanding that many inflammatory cutaneous diseases carry important mental health comorbidities is expanding. Simultaneously, the detrimental impacts of climate change on human health are now widely recognized as a global public health crisis. Importantly, these climate-associated phenomena exacerbate the environmental triggers of atopic dermatitis (AD) and are also associated with amplification of comorbid mental health conditions in AD including depression, anxiety, trauma-related disorders, and psychotic spectrum disorders. This review is the first to examine the nexus of climate change, atopic dermatitis, and mental health comorbidities and emphasizes the disproportionate impacts of climate change in vulnerable and marginalized populations.

C-L Case Conference: Applying Good Psychiatric Management for Borderline Personality Disorder in Hospitalized Patients With Co-occurring Substance Use Disorders.

We present a case illustrating common challenges in the hospital management and treatment of comorbid borderline personality disorder and substance use disorders. Experts in the field of personality disorders and substance use disorders discuss various topics and strategies for patient-centered management. Key learning points include evaluation and diagnosis of borderline personality disorder, good psychiatric management, withdrawal and pharmacologic management, harm reduction, team dynamics, and behavior planning all in the hospital setting. This paper provides actionable considerations with elements common to many clinical encounters that present challenges to the consultation-liaison psychiatrist in the general hospital setting.

The results of Oxford unicompartmental knee arthroplasty in the United States: a mean ten-year survival analysis.

AIMS: Approved by the Food and Drug Administration in 2004, the Phase III Oxford Medial Partial Knee is used to treat anteromedial osteoarthritis (AMOA) in patients with an intact anterior cruciate ligament. This unicompartmental knee arthroplasty (UKA) is relatively new in the United States, and therefore long-term American results are lacking. PATIENTS AND METHODS: This is a single surgeon, retrospective study based on prospectively collected data, analysing a consecutive series of primary UKAs using the Phase III mobile-bearing Oxford Knee and Phase III instrumentation. Between July 2004 and December 2006, the senior author (RHE) carried out a medial UKA in 173 patients (213 knees) for anteromedial osteoarthritis or avascular necrosis (AVN). A total of 95 patients were men and 78 were women. Their mean age at surgery was 67 years (38 to 89) and mean body mass index 29.87 kg/m2 (17 to 62). The mean follow-up was ten years (4 to 11). RESULTS: Survivorship of the Oxford UKA at ten years was 88%, using life table analysis. Implant survivorship at ten years was 95%. The most common cause for revision was the progression of osteoarthritis in the lateral compartment. The mean knee score element of the American Knee Society Score (AKSS) was 50 pre-operatively and increased to 93 post-operatively. The mean AKSS function score was 56 pre-operatively rising to 78 post-operatively CONCLUSION: This ten-year follow-up study of the Oxford UKA undertaken in the United States shows good survivorship and excellent function in a wide selection of patients with AMOA and AVN. Cite this article: Bone Joint J 2016;98-B(10 Suppl B):34-40.

Management of obstetric anal sphincter injuries (OASIS) in subsequent pregnancy.

Obstetric anal sphincter injuries (OASIS) are common and may greatly affect a patient's quality of life. There is very little information regarding optimum management in future pregnancies. Based upon anecdotal experience, this study describes the recommendations of a cohort of consultant obstetricians in the UK, in this clinical situation. There is limited adherence to the available national guidelines due to the absence of available equipment and expertise to perform endo-anal ultrasound and manometry. Elective episiotomy is still recommended by a small number of obstetricians but the majority of patients are routinely followed-up. Caesarean section is only advised for asymptomatic patients with a previous stage 4 tear, and for any symptomatic patient with a previous stage 3 or 4 tear, irrespective of subgrade. A request for elective caesarean section is likely to be granted, irrespective of OASIS grade. The use of postpartum endo-anal ultrasound would help identify those women in whom a further vaginal delivery is unlikely to exacerbate any symptoms of faecal incontinence.

The TRT Female Remeex System ® for recurrent female stress urinary incontinence: a 5-year follow-up study.

Conventional surgery for female stress incontinence is usually successful but recurrent cases are difficult to treat. This study of 20 such cases treated by the Remeex TRT system shows symptomatic benefit up to 5 years following insertion of the device. The benefit of this procedure is that the sling can be adjusted to the correct tension in the optimum leak position and circumstances, and anytime thereafter without the need to repeat the entire operation. As a result, the voiding dysfunction rate and need to intermittent self-catheterise is reduced, even with a low pressure urethra. The cost per procedure and complication rate is higher that standard TVT, and the device may occasionally need removal due to persistent seroma. However, the improved quality of life makes this operation an attractive option in recurrent cases of female stress incontinence.

Hysterectomy, endometrial ablation and Mirena® for heavy menstrual bleeding: a systematic review of clinical effectiveness and cost-effectiveness analysis.

OBJECTIVE: The aim of this project was to determine the clinical effectiveness and cost-effectiveness of hysterectomy, first- and second-generation endometrial ablation (EA), and Mirena® (Bayer Healthcare Pharmaceuticals, Pittsburgh, PA, USA) for the treatment of heavy menstrual bleeding. DESIGN: Individual patient data (IPD) meta-analysis of existing randomised controlled trials to determine the short- to medium-term effects of hysterectomy, EA and Mirena. A population-based retrospective cohort study based on record linkage to investigate the long-term effects of ablative techniques and hysterectomy in terms of failure rates and complications. Cost-effectiveness analysis of hysterectomy versus first- and second-generation ablative techniques and Mirena. SETTING: Data from women treated for heavy menstrual bleeding were obtained from national and international trials. Scottish national data were obtained from the Scottish Information Services Division. PARTICIPANTS: Women who were undergoing treatment for heavy menstrual bleeding were included. INTERVENTIONS: Hysterectomy, first- and second-generation EA, and Mirena. MAIN OUTCOME MEASURES: Satisfaction, recurrence of symptoms, further surgery and costs. RESULTS: Data from randomised trials indicated that at 12 months more women were dissatisfied with first-generation EA than hysterectomy [odds ratio (OR): 2.46, 95% confidence interval (CI) 1.54 to 3.93; p = 0.0002), but hospital stay [WMD (weighted mean difference) 3.0 days, 95% CI 2.9 to 3.1 days; p < 0.00001] and time to resumption of normal activities (WMD 5.2 days, 95% CI 4.7 to 5.7 days; p < 0.00001) were longer for hysterectomy. Unsatisfactory outcomes associated with first- and second-generation techniques were comparable [12.2% (123/1006) vs 10.6% (110/1034); OR 1.20, 95% CI 0.88 to 1.62; p = 0.2). Rates of dissatisfaction with Mirena and second-generation EA were similar [18.1% (17/94) vs 22.5% (23/102); OR 0.76, 95% CI 0.38 to 1.53; p = 0.4]. Indirect estimates suggested that hysterectomy was also preferable to second-generation EA (OR 2.32, 95% CI 1.27 to 4.24; p = 0.006) in terms of patient dissatisfaction. The evidence to suggest that hysterectomy is preferable to Mirena was weaker (OR 2.22, 95% CI 0.94 to 5.29; p = 0.07). In women treated by EA or hysterectomy and followed up for a median [interquartile range (IQR)] duration of 6.2 (2.7-10.8) and 11.6 (7.9-14.8) years, respectively, 962/11,299 (8.5%) women originally treated by EA underwent further gynaecological surgery. While the risk of adnexal surgery was similar in both groups [adjusted hazards ratio 0.80 (95% CI 0.56 to 1.15)], women who had undergone ablation were less likely to need pelvic floor repair [adjusted hazards ratio 0.62 (95% CI 0.50 to 0.77)] and tension-free vaginal tape surgery for stress urinary incontinence [adjusted hazards ratio 0.55 (95% CI 0.41 to 0.74)]. Abdominal hysterectomy led to a lower chance of pelvic floor repair surgery [hazards ratio 0.54 (95% CI 0.45 to 0.64)] than vaginal hysterectomy. The incidence of endometrial cancer following EA was 0.02%. Hysterectomy was the most cost-effective treatment. It dominated first-generation EA and, although more expensive, produced more quality-adjusted life-years (QALYs) than second-generation EA and Mirena. The incremental cost-effectiveness ratios for hysterectomy compared with Mirena and hysterectomy compared with second-generation ablation were £1440 per additional QALY and £970 per additional QALY, respectively. CONCLUSIONS: Despite longer hospital stay and time to resumption of normal activities, more women were satisfied after hysterectomy than after EA. The few data available suggest that Mirena is potentially cheaper and more effective than first-generation ablation techniques, with rates of satisfaction that are similar to second-generation techniques. Owing to a paucity of trials, there is limited evidence to suggest that hysterectomy is preferable to Mirena. The risk of pelvic floor surgery is higher in women treated by hysterectomy than by ablation. Although the most cost-effective strategy, hysterectomy may not be considered an initial option owing to its invasive nature and higher risk of complications. Future research should focus on evaluation of the clinical effectivesness and cost-effectiveness of the best second-generation EA technique under local anaesthetic versus Mirena and types of hysterectomy such as laparoscopic supracervical hysterectomy versus conventional hysterectomy and second-generation EA. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Hysterectomy, endometrial destruction, and levonorgestrel releasing intrauterine system (Mirena) for heavy menstrual bleeding: systematic review and meta-analysis of data from individual patients.

OBJECTIVE: To evaluate the relative effectiveness of hysterectomy, endometrial destruction (both "first generation" hysteroscopic and "second generation" non-hysteroscopic techniques), and the levonorgestrel releasing intrauterine system (Mirena) in the treatment of heavy menstrual bleeding. DESIGN: Meta-analysis of data from individual patients, with direct and indirect comparisons made on the primary outcome measure of patients' dissatisfaction. DATA SOURCES: Data were sought from the 30 randomised controlled trials identified after a comprehensive search of the Cochrane Library, Medline, Embase, and CINAHL databases, reference lists, and contact with experts. Raw data were available from 2814 women randomised into 17 trials (seven trials including 1359 women for first v second generation endometrial destruction; six trials including 1042 women for hysterectomy v first generation endometrial destruction; one trial including 236 women for hysterectomy v Mirena; three trials including 177 women for second generation endometrial destruction v Mirena). Eligibility criteria for selecting studies Randomised controlled trials comparing hysterectomy, first and second generation endometrial destruction, and Mirena for women with heavy menstrual bleeding unresponsive to other medical treatment. RESULTS: At around 12 months, more women were dissatisfied with outcome with first generation hysteroscopic techniques than with hysterectomy (13% v 5%; odds ratio 2.46, 95% confidence interval 1.54 to 3.9, P<0.001), but hospital stay (weighted mean difference 3.0 days, 2.9 to 3.1 days, P<0.001) and time to resumption of normal activities (5.2 days, 4.7 to 5.7 days, P<0.001) were longer for hysterectomy. Unsatisfactory outcomes were comparable with first and second generation techniques (odds ratio 1.2, 0.9 to 1.6, P=0.2), although second generation techniques were quicker (weighted mean difference 14.5 minutes, 13.7 to 15.3 minutes, P<0.001) and women recovered sooner (0.48 days, 0.20 to 0.75 days, P<0.001), with fewer procedural complications. Indirect comparison suggested more unsatisfactory outcomes with second generation techniques than with hysterectomy (11% v 5%; odds ratio 2.3, 1.3 to 4.2, P=0.006). Similar estimates were seen when Mirena was indirectly compared with hysterectomy (17% v 5%; odds ratio 2.2, 0.9 to 5.3, P=0.07), although this comparison lacked power because of the limited amount of data available for analysis. CONCLUSIONS: More women are dissatisfied after endometrial destruction than after hysterectomy. Dissatisfaction rates are low after all treatments, and hysterectomy is associated with increased length of stay in hospital and a longer recovery period. Definitive evidence on effectiveness of Mirena compared with more invasive procedures is lacking.

Prevalence of anorectal dysfunction in women attending health care services.

The aim of this study was to assess the prevalence of different bowel symptoms (constipation, faecal incontinence and faecal evacuation dysfunction) and associated urinary symptoms in women attending health care services. All women attending colposcopy clinics and general gynaecology clinics in a district general hospital in the southwest of England were invited to participate in the study. In addition, women attending the local family planning clinic were also recruited. Women attending these clinics routinely completed a history sheet and were asked to complete the Birmingham Bowel and Urinary Symptoms Questionnaire. Two hundred women participated in the study: 116 (64.4%) had at least one bowel symptom from the list in the questionnaire and 57 (31.6%) of women thought they had a bowel problem but only 26 (14.4%) consulted their family doctor regarding the problem while four (2.2%) were referred for specialist opinion. Six were unsure about their bowel symptoms. There were 46 (25.5%) of women who had constipation, 99 (55%) had faecal incontinence and 97 (53.8%) complained of faecal evacuation dysfunction. Only 48 (26.6%) of women were free of any bowel complaint. One patient with faecal incontinence discussed her problem with her midwife but no further action was taken as she was too embarrassed to discuss it with her doctor. Seventy-eight (43.3%) of patients had urinary symptoms. Fifty-five (30.5%) thought they had a urinary problem but only 29 (16.1%) consulted their doctor and 17 (9.4%) were referred for specialist opinion. Sixty-one (33.8%) of those who admitted to have urinary incontinence also had faecal incontinence. Forty-nine (27.2%) of the patients were free of all symptoms. The mode of delivery as well as previous surgery did not have any influence on urinary incontinence nor on anal incontinence. This study has demonstrated a high prevalence of bowel symptoms in women attending health care services.

A simple visual analogue scale to assess the quality of life in women with urinary incontinence.

AIM: The objective of this study is to determine whether a simple visual analogue scale; "incontinence bothersome scale (IBS)" can reliably assess the quality of life in women with urinary incontinence. DESIGN: A prospective cohort study in a UK district general hospital. METHODS: Two hundreds women with urinary incontinence participated in the study over 1-year period. They completed Kings health questionnaire version 7 (KHQ) and the incontinence bothersome scale (IBS). The results of the IBS were then compared to the total KHQ score and to each domain separately, using the Pearson correlation test. Women in the study were then classified into two main groups according to their urodynamics diagnosis (urodynamic stress incontinence group/detrusor overactivity group) and the total KHQ scores were compared with the IBS scores in each group. RESULTS: The IBS scores had poor correlation with the total KHQ scores (r=0.656) and the difference between both arms was not statistically significant (p=0.084). Further analysis of KHQ domains showed that except for the impact of incontinence domain (r=0.728) all other domains correlated poorly to the IBS. This poor correlation pertained in sub-analysis of women with DO and USI (r=0.65 and 0.48, respectively). CONCLUSION: This study has shown that a simple visual scale is not a reliable tool in assessing the QoL in women with urinary incontinence. A formal, validated and reliable QoL questionnaire is still the method of choice for QoL assessment, even if it takes longer to complete.

How are anterior repairs carried out in the UK?

The objective of this study was to evaluate how anterior repairs are carried out in the UK and how they differ from published recommended common practice. Postal questionnaires were sent within the first week of May 2005, to 300 consultant gynaecologists in the UK. The surveyed gynaecologists were randomly selected from the RCOG register of Fellows and Members. The questionnaire included questions regarding preoperative assessment, common operative techniques, postoperative management and follow-up. A total of 145 (48%) responses were returned; 110 (37%) consultant gynaecologists completed the survey and 35 (11%) incomplete questionnaires were returned by consultants who currently do not undertake pelvic reconstruction surgery. The results showed a wide variation in management approach and surgical techniques of anterior vaginal wall prolapse between gynaecologists. There appears to be no consensus as how an anterior repair is carried out in UK.

Bladder augmentation using Pelvicol implant for intractable overactive bladder syndrome.

The objective of the study was to evaluate the effectiveness of an implant of porcine dermis to augment the bladder in women with refractory overactive bladder syndrome (OAB). Twelve women underwent a Pelvicol bladder augmentation. A visual analogue score for severity of incontinence and a quality of life questionnaire was carried out pre-operatively and at 12 months post-operatively. Follow up cystoscopy was carried out in three women in addition. Three women were dry and cured; five women were significantly improved; two women were slightly improved and the procedure was unsuccessful in the remaining two women. There were no significant complications and voiding was spontaneous in every case. A bladder augmentation using porcine dermis may have a role in the surgical management of non-neuropathic women with OAB that has failed to respond to conservative therapy.

Serum calcium and magnesium levels in women with detrusor overactivity.

The aim of this study was to determine whether abnormal serum levels of magnesium and calcium occur in women with detrusor overactivity. These were compared with the serum level of magnesium and calcium ions in women with urodynamic stress incontinence as controls to see whether alteration of these levels offer a further therapeutic option. The study included 20 women with urodynamically proven detrusor overactivity compared with 20 women with urodynamic stress incontinence as controls. A blood test was taken to determine serum levels of total magnesium phosphate together with free and corrected calcium. In addition, the calcium and magnesium ratio (Ca:Mg) and calcium corrected and magnesium ratio (Ca Corr:Mg) were calculated. Both parametric and non-parametric tests were used to compare the two groups with respect to these variables. The mean, median and standard deviation of the two groups are very similar for each of the variables. There is no evidence to suggest that there is any difference between detrusor overactivity and urodynamic stress incontinence with respect to these variables. This study has shown that there is no abnormal correlation between serum calcium and magnesium ions in women with detrusor overactivity. There appears to be no therapeutic benefit in calcium and/or magnesium supplements for detrusor overactivity.

The accuracy of Bardscan: a new tool for the measurement of the bladder volume.

The Bardscan has been recently introduced into clinical practice with the potential advantage of providing real time ultrasound imaging and hence the ability for an accurate estimation of bladder volume, and concurrently the detection of any incidental bladder pathology. Independent clinical data regarding this machine is limited, and therefore this study was carried out to ascertain whether the Bardscan machine is accurate in the estimation of bladder volume for women in the urodynamic clinic and in the postoperative period. Fifty four women had a Bardscan estimation of their bladder volume which was compared with an immediately obtained catheter volume. The results show that the Bardscan volumes correlate closely with the bladder volumes detected on catheterization (r =0.982, p=0.16). This study has shown that the Bardscan is an accurate tool in the measurement of bladder volume in women with the advantages of being safe, non-invasive and well tolerated by patients. The aim of this study was to evaluate the accuracy of the Bardscan machine in the measurement of urinary bladder volume.

Comparison between porcine dermal implant (Permacol) and silicone injection (Macroplastique) for urodynamic stress incontinence.

The objective of this study was to compare the efficacy of porcine dermal implant injection (Permacol) and silicone injection (Macroplastique) in the treatment of female urodynamic stress incontinence (USI) in a prospective randomized trial. Fifty women with urodynamically proven stress incontinence were recruited and randomised to receive either Permacol or Macroplastique injection. Twenty-five patients were enrolled in each case. An International Continence Society (ICS) standard 1-h pad test was carried out prior to the injection and a subjective analysis of incontinence made using a Stamey scoring system. In addition, a Kings College Hospital Quality of Health Questionnaire (KCQ) was completed. The women were followed up at 6 weeks and 6 months and the same methods used to gauge the success or failure of the operation. Preoperatively there were no significant differences in pad losses, Stamey score or King's score between the two groups. The mean age of the women was 61 years (range 28-80 years). At 6 weeks there were significant reductions in the mean and median values in pad losses, Stamey score and King's score in both Permacol and Macroplastique patients but the effects were more pronounced in Permacol patients than Macroplastique patients. Of the Permacol patients, 64% were improved on quantified pad losses out of which 60% were dry whereas 54% of Macroplastique patients were improved on pad losses of which 41.6% were dry. Of the Permacol patients, 64% and 60% had reduction in Stamey and KCQ score, respectively, whereas Macroplastique patients had 46% reduction in one or more grades of Stamey scores and 42% reduction in KCQ scores. At 6 months the results in the Permacol patients appeared to be sustained but not for Macroplastique patients. This study has shown that Permacol injection when used as a urethral bulking agent appears to have a higher cure rate for urodynamic stress incontinence than Macroplastique and these results persist until the follow-up period of 6 months. The use of Permacol injection is an attractive alternative in the treatment of urodynamic stress incontinence.

Pelvicol pubovaginal sling versus tension-free vaginal tape for treatment of urodynamic stress incontinence: a prospective randomized three-year follow-up study.

OBJECTIVES: The aim of this study was to compare the long-term success rates, complication rates and patient satisfaction rates for Pelvicol pubovaginal sling (Bard) versus TVT (Gynecare) in surgical treatment of urodynamic stress incontinence (USI) in women. DESIGN: Prospective randomized cohort trial. SETTING: District General Hospital, South West of England. METHODS: One hundred and forty-two women with urodynamic stress incontinence were randomized to either surgical procedure (Pelvicol = 74, TVT = 68) with median follow-up of 36 month. A postal questionnaire was sent to all women and the response rate was excellent at approximately 90% in both groups. RESULTS: Cure of incontinence, as identified by a quality of life improvement >90%, and/or patient-determined continent status as dry, were comparable in both groups. When the cure rates were adjusted assuming the non-respondents as failures the figures were almost identical (p > 0.05). Preoperative continence pad usage was similar for both groups. Overall, a postoperative significant decrease in pad score was noted in both groups (p = 0.01) but there was no significant difference between the groups (p > 0.05). Statistical analysis failed to detect significant differences between both groups as regards complication rates such as frequency, nocturia, de-novo urgency or dyspareunia. CONCLUSION: Pelvicol sling is a safe procedure in the surgical management of USI with similar success rate and patient satisfaction rate to TVT up to three years of follow-up.

Longitudinal study of Pelvicol pubovaginal slings using magnetic resonance imaging.

The mechanism of urinary continence is complicated and is poorly understood. One current opinion is that there is an absence or weakness of the endopelvic fascial supports of the urethra. Pubovaginal slings are rapidly becoming the surgical procedure of choice in the management of urodynamic stress incontinence but their method of action is unclear. This study using magnetic resonance imaging shows how a pubovaginal sling can restore the normal anatomy and continence and adds to the global understanding of this condition.