Laparoscopic and robot-assisted suture versus mesh hysteropexy: a retrospective comparison.

INTRODUCTION AND HYPOTHESIS: Our study was aimed at comparing the outcomes of laparoscopic and robot-assisted laparoscopic suture-based hysteropexy (SutureH) versus sacral hysteropexy using mesh (MeshH) for bothersome uterine prolapse. Our hypothesis is that MeshH is more successful and provides better uterine support than SutureH. METHODS: A retrospective cohort study of 228 consecutive women who underwent re-suspension of the uterus using uterosacral ligaments (SutureH n=97) or a "U-shaped" mesh from the sacral promontory (MeshH, n=132). Surgery was performed by laparoscopy or robot-assisted laparoscopy. Subjects were assessed at baseline, 1 year, and beyond 1 year. The null hypothesis, that SutureH and MeshH have similar success, was based on a composite outcome ("composite success"), and that they provide the same level of uterine support, was based on POP-Q point C at 1 year. "Composite success" was defined as: POP-Q point C above the hymen; absence of a vaginal bulge; no repeat uterine prolapse surgery or pessary placement. Other outcomes included improvement in symptomology using Patient Global Impression of Improvement, POP-Q point C change and complications. RESULTS: Follow-up data were available for 191 out of 228 women. "Composite success" was not significantly different between MeshH and SutureH groups (81.7% vs 84.5%, p=0.616). MeshH provided better elevation of the uterus than SutureH (point C change: -7.38cm vs -6.99cm; p<0.001). Similar symptom improvement and low complications occurred in both groups. CONCLUSIONS: Laparoscopic and robot-assisted laparoscopic suture hysteropexy and mesh sacral hysteropexy provide women with minimally invasive, durable surgical options for uterine preservation. "Composite success" was similar in the two groups, but MeshH provided better uterine support than SutureH. However, SutureH gives women an effective mesh-free option.

Utility of TSH Receptor Antibodies in the Differential Diagnosis of Hyperthyroidism in Clinical Practice.

Graves' disease (GD) is the most common cause of hyperthyroidism in iodine-sufficient areas. It is important to distinguish GD from other causes of hyperthyroidism for optimal management. Thyroid stimulating hormone receptor antibody (TRAb) test is a commonly used test for this purpose. However, the sensitivity for this test in routine clinical practice may be affected by various factors leading to fallacies in diagnosis. Materials and Methods: A retrospective study was performed to assess the utility of an automated electrochemiluminescence TRAb immunoassay (Roche) in differentiating GD from non-Graves' disease (NGD) in routine clinical practice. Results: In 227 subjects, 146 had GD and 81 had NGD. Total T3, Total T4, Free T4, and TRAb were significantly higher in people with GD in comparison to NGD. The area under the receiver operating characteristics (ROC) curve for the assay was 0.96 (95% CI: 0.926 to 0.984, P < 0.0001). The optimal threshold for the test derived from the ROC was 3.37 IU/L, which is more than the cut-off of 1.75 IU/L suggested by the manufacturer. The sensitivity/specificity of TRAb in the diagnosis of GD at presentation was 98.4%/62.9% at 1.75 IU/L and 91.2%/90.12% at 3.37 IU/L, respectively. Conclusion: The TRAb test is a sensitive test to differentiate between subjects with GD and NGD presenting with hyperthyroidism. However, the cutoff (1.75 IU/L) as per the kit manufacturer may lead to a lower specificity for diagnosis. A modified cut-off of 3.37 IU/L should be considered for optimizing the diagnostic efficacy of the test.

Pessaries (mechanical devices) for managing pelvic organ prolapse in women.

BACKGROUND: Pelvic organ prolapse is a common problem in women. About 40% of women will experience prolapse in their lifetime, with the proportion expected to rise in line with an ageing population. Women experience a variety of troublesome symptoms as a consequence of prolapse, including a feeling of 'something coming down' into the vagina, pain, urinary symptoms, bowel symptoms and sexual difficulties. Treatment for prolapse includes surgery, pelvic floor muscle training (PFMT) and vaginal pessaries. Vaginal pessaries are passive mechanical devices designed to support the vagina and hold the prolapsed organs back in the anatomically correct position. The most commonly used pessaries are made from polyvinyl-chloride, polythene, silicone or latex. Pessaries are frequently used by clinicians with high numbers of clinicians offering a pessary as first-line treatment for prolapse.  This is an update of a Cochrane Review first published in 2003 and last published in 2013. OBJECTIVES: To assess the effects of pessaries (mechanical devices) for managing pelvic organ prolapse in women; and summarise the principal findings of relevant economic evaluations of this intervention. SEARCH METHODS: We searched the Cochrane Incontinence Specialised Register which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 28 January 2020). We searched the reference lists of relevant articles and contacted the authors of included studies. SELECTION CRITERIA: We included randomised and quasi-randomised controlled trials which included a pessary for pelvic organ prolapse in at least one arm of the study. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed abstracts, extracted data, assessed risk of bias and carried out GRADE assessments with arbitration from a third review author if necessary. MAIN RESULTS: We included four studies involving a total of 478 women with various stages of prolapse, all of which took place in high-income countries. In one trial, only six of the 113 recruited women consented to random assignment to an intervention and no data are available for those six women. We could not perform any meta-analysis because each of the trials addressed a different comparison. None of the trials reported data about perceived resolution of prolapse symptoms or about psychological outcome measures. All studies reported data about perceived improvement of prolapse symptoms. Generally, the trials were at high risk of performance bias, due to lack of blinding, and low risk of selection bias. We downgraded the certainty of evidence for imprecision resulting from the low numbers of women participating in the trials. Pessary versus no treatment: at 12 months' follow-up, we are uncertain about the effect of pessaries compared with no treatment on perceived improvement of prolapse symptoms (mean difference (MD) in questionnaire scores -0.03, 95% confidence interval (CI) -0.61 to 0.55; 27 women; 1 study; very low-certainty evidence), and cure or improvement of sexual problems (MD -0.29, 95% CI -1.67 to 1.09; 27 women; 1 study; very low-certainty evidence). In this comparison we did not find any evidence relating to prolapse-specific quality of life or to the number of women experiencing adverse events (abnormal vaginal bleeding or de novo voiding difficulty). Pessary versus pelvic floor muscle training (PFMT): at 12 months' follow-up, we are uncertain if there is a difference between pessaries and PFMT in terms of women's perceived improvement in prolapse symptoms (MD -9.60, 95% CI -22.53 to 3.33; 137 women; low-certainty evidence), prolapse-specific quality of life (MD -3.30, 95% CI -8.70 to 15.30; 1 study; 116 women; low-certainty evidence), or cure or improvement of sexual problems (MD -2.30, 95% -5.20 to 0.60; 1 study; 48 women; low-certainty evidence). Pessaries may result in a large increase in risk of adverse events compared with PFMT (RR 75.25, 95% CI 4.70 to 1205.45; 1 study; 97 women; low-certainty evidence). Adverse events included increased vaginal discharge, and/or increased urinary incontinence and/or erosion or irritation of the vaginal walls. Pessary plus PFMT versus PFMT alone: at 12 months' follow-up, pessary plus PFMT probably leads to more women perceiving improvement in their prolapse symptoms compared with PFMT alone (RR 2.15, 95% CI 1.58 to 2.94; 1 study; 260 women; moderate-certainty evidence). At 12 months' follow-up, pessary plus PFMT probably improves women's prolapse-specific quality of life compared with PFMT alone (median (interquartile range (IQR)) POPIQ score: pessary plus PFMT 0.3 (0 to 22.2); 132 women; PFMT only 8.9 (0 to 64.9); 128 women; P = 0.02; moderate-certainty evidence). Pessary plus PFMT may slightly increase the risk of abnormal vaginal bleeding compared with PFMT alone (RR 2.18, 95% CI 0.69 to 6.91; 1 study; 260 women; low-certainty evidence). The evidence is uncertain if pessary plus PFMT has any effect on the risk of de novo voiding difficulty compared with PFMT alone (RR 1.32, 95% CI 0.54 to 3.19; 1 study; 189 women; low-certainty evidence). AUTHORS' CONCLUSIONS: We are uncertain if pessaries improve pelvic organ prolapse symptoms for women compared with no treatment or PFMT but pessaries in addition to PFMT probably improve women's pelvic organ prolapse symptoms and prolapse-specific quality of life. However, there may be an increased risk of adverse events with pessaries compared to PFMT. Future trials should recruit adequate numbers of women and measure clinically important outcomes such as prolapse specific quality of life and resolution of prolapse symptoms.   The review found two relevant economic evaluations. Of these, one assessed the cost-effectiveness of pessary treatment, expectant management and surgical procedures, and the other compared pessary treatment to PFMT.

Topical or oral fluralaner efficacy against flea (Ctenocephalides felis) transmission of Dipylidium caninum infection to dogs.

BACKGROUND: Dipylidium caninum is a common tapeworm of dogs contracted from ingestion of fleas containing the infective cysticercoid stage. Fluralaner is a systemically distributed isoxazoline class insecticide that delivers highly effective activity against fleas and ticks for up to 12 weeks after a single oral or topical treatment. This study evaluated the impact of this flea insecticidal efficacy on the transmission of D. caninum to dogs. METHODS: Dogs were weighed and treated with a cestocide and then randomly assigned to 3 groups of 8. Fluralaner was administered topically (at the commercial dose) to one group and orally to another group while the third received topically administered sterile water. All dogs were subsequently infested with about 100 D. caninum infected Ctenocephalides felis at 7, 14, 21, 28, 35, 42, 49, 56, 63, 70, 77 and 83 days after treatment. Visual proglottid inspections and counts were conducted daily from 35 to 113 days post-treatment. Post-treatment D. caninum incidence was calculated for each group and compared between treated and untreated groups. RESULTS: All 8 dogs in the placebo-treated group became infected with D. caninum while no shed proglottids were observed at any point during the post-treatment period from any dog in either fluralaner treated group. CONCLUSIONS: The insecticidal efficacy of a single treatment of either orally or topically administered fluralaner prevented D. caninum transmission from infected fleas to susceptible dogs for up to 12 weeks following administration.

Sodium-glucose cotransporter 2 inhibitors with insulin in type 2 diabetes: Clinical perspectives.

The treatment of type 2 diabetes is a challenging problem. Most subjects with type 2 diabetes have progression of beta cell failure necessitating the addition of multiple antidiabetic agents and eventually use of insulin. Intensification of insulin leads to weight gain and increased risk of hypoglycemia. Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a class of antihyperglycemic agents which act by blocking the SGLT2 in the proximal tubule of the kidney. They have potential benefits in terms of weight loss and reduction of blood pressure in addition to improvements in glycemic control. Further, one of the SGLT2 inhibitors, empagliflozin has proven benefits in reducing adverse cardiovascular (CV) outcomes in a CV outcome trial. Adding SGLT2 inhibitors to insulin in subjects with type 2 diabetes produced favorable effects on glycemic control without the weight gain and hypoglycemic risks associated with insulin therapy. The general risks of increased genital mycotic infections, urinary tract infections, volume, and osmosis-related adverse effects in these subjects were similar to the pooled data of individual SGLT2 inhibitors. There are subsets of subjects with type 2 diabetes who may have insulin deficiency, beta cell autoimmunity, or is prone to diabetic ketoacidosis. In these subjects, SGLT2 inhibitors should be used with caution to prevent the rare risks of ketoacidosis.

Prolapse or incontinence: what affects sexual function the most?

INTRODUCTION AND HYPOTHESIS: Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) adversely affect sexual function in women. Comparative studies of the two subgroups are few and results are conflicting. The aim of this study was to compare the effect of POP and SUI on the sexual function of women undergoing surgery for these conditions. METHODS: The study population comprised women with POP or SUI in a tertiary referral hospital in the UK. Women who underwent SUI surgery had no symptoms of POP and had urodynamically proven stress incontinence. Patients with POP had ≥ stage 2 prolapse, without bothersome urinary symptoms. Pre-operative data on sexual function were collected and compared using an electronic pelvic floor assessment questionnaire (ePAQ). The incidence of sexual dysfunction and comparison of symptoms in both groups were calculated using the Mann-Whitney U test. RESULTS: Three hundred and forty-three women undergoing surgery for either SUI or POP were included. Patients were age-matched, with 184 undergoing SUI surgery (age range 33-77 years) and 159 POP surgery (age range 27-78 years; p = 0.869). The overall impact of POP and SUI was not significantly different in the two subgroups (p = 0.703). However, both patients (73 % vs 36 %; p = 0.00) and partners (50 % vs 24 %; p = 0.00) avoid intercourse significantly more frequently in cases with POP compared with SUI. This did not have a significant impact on quality of life. CONCLUSIONS: The impact of bothersome SUI or POP on sexual function was found to be similar, but patient and partner avoidance in women with POP was greater than those with SUI.

Multidisciplinary team meetings in urogynaecology.

INTRODUCTION AND HYPOTHESIS: The concept of multidisciplinary team (MDT) is well accepted in the current National Health Service (NHS) and is considered good practice for the management of chronic conditions. There has been a recent drive to have MDTs in managing women with incontinence and complex prolapse as a result of recommendations by National Institute for Health and Care Excellence (NICE) guidance, Medicines and Healthcare Products Regulatory Agency (MHRA) etc. Currently, there are no data on the outcome of case discussion at urogynaecology MDTs. The aim of this study was to review the clinical impact of discussion of a select group of cases at an urogynaecology MDT and review the clinical literature to justify the MDT approach. METHODS: MDT proformas of cases discussed from October 2012 to December 2013 were reviewed. Outcomes of the MDT were compared with recommendations at the initial consultation. This included change in management plan, type of surgery and surgeon as well as time delay due to MDT discussion. RESULTS: One hundred six proformas were available for analysis. Age range was 23-89 (58) years. Average time from clinic visit to MDT discussion was 8.32 + 5.9 days. The MDT recommended a change in management plan in 31 cases (29.3%), with 11 cases (10.4%) resulting in alternative surgery and 1 case (0.9%) with an alternative surgeon. In 18.5% of cases, MDT discussion formulated the initial management plan. CONCLUSIONS: Case discussions at our MDT provide an effective clinical forum to formulate management plans for complex cases. The decision-making process is made robust, without significant impact on waiting time. Investment in setting up MDTs has financial implications but provides patient benefit.

Meal related glucose monitoring is a method of diagnosing glucose intolerance in pregnancies with high probability of gestational diabetes but normal glucose tolerance by oral glucose tolerance test.

Gestational diabetes mellitus diagnosed by classical oral glucose tolerance test can result in fetal complications like macrosomia and polyhydramnios. Guidelines exist on management of patients diagnose by abnormal oral glucose tolerance test with diet modification followed by insulin. Even patients with abnormal oral glucose tolerance test maintaining apparently normal blood sugars with diet are advised insulin if there is accelerated fetal growth. But patients with normal oral glucose tolerance test can present with macrosomia and polyhydramnios. These patients are labelled as not having gestational diabetes mellitus and are followed up with repeat oral glucose tolerance test. We hypothesise that these patients may have an altered placental threshold to glucose or abnormal sensitivity of fetal tissues to glucose. Meal related glucose monitoring in these patients can identify minor abnormalities in glucose disturbance and should be treated to targets similar to physiological levels of glucose in non pregnant adults.

Pessaries (mechanical devices) for pelvic organ prolapse in women.

BACKGROUND: Pelvic organ prolapse is common, with some degree of prolapse seen in up to 50% of parous women in a clinic setting, although many are asymptomatic. The use of pessaries (a passive mechanical device designed to support the vagina) to treat prolapse is very common, and up to 77% of clinicians use pessaries for the first line management of prolapse. A number of symptoms may be associated with prolapse and treatments include surgery, pessaries and conservative therapies. A variety of pessaries are described which aim to alleviate the symptoms of prolapse and avert or delay the need for surgery. OBJECTIVES: To determine the effectiveness of pessaries (mechanical devices) for pelvic organ prolapse. SEARCH METHODS: We searched the Cochrane Incontinence Group Specialised Register of trials (searched 13 March 2012), which includes searches of CENTRAL, MEDLINE, PREMEDLINE and handsearching of conference proceedings, and handsearched the abstracts of two relevant conferences held in 2011. We also searched the reference lists of relevant articles. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials which included a pessary for pelvic organ prolapse in one arm of the study. DATA COLLECTION AND ANALYSIS: Abstracts were assessed independently by two authors with arbitration from a third if necessary. Data extraction was completed independently for included studies by two review authors. MAIN RESULTS: To date there is only one published randomised controlled trial assessing the use of pessaries in the treatment of pelvic organ prolapse. AUTHORS' CONCLUSIONS: The review authors identified one randomised controlled trial comparing ring and Gellhorn pessaries. The results of the trial showed that both pessaries were effective for the approximately 60% of women who completed the study with no significant differences identified between the two types of pessary. However, methodological flaws were noted in the trial, as elaborated under risk of bias assessment. There is no consensus on the use of different types of device, the indications nor the pattern of replacement and follow-up care. There is an urgent need for randomised studies to address the use of pessaries in comparison with no treatment, surgery and conservative measures.

Developments in undergraduate teaching of small-animal soft-tissue surgical skills at the University of Sydney.

This article discusses recent developments in soft-tissue surgery teaching at the University of Sydney, Faculty of Veterinary Science. An integrated teaching program was developed for Bachelor of Veterinary Science (BVSc) students with the aim of providing them with optimal learning opportunities to meet "Day One" small-animal soft-tissue surgical competencies. Didactic lectures and tutorials were introduced earlier into the curriculum to prepare students for live-animal surgery practical. In addition to existing clinics, additional spay/neuter clinics were established in collaboration with animal welfare organizations to increase student exposure to live-animal surgery. A silicon-based, life-like canine ovariohysterectomy model was developed with the assistance of a model-making and special effects company. The model features elastic ovarian pedicles and suspensory ligaments, which can be stretched and broken like those of an actual dog. To monitor the volume and type of student surgical experience, an E-portfolio resource was established. This resource allows for the tracking of numbers of live, student-performed desexing surgeries and incorporates competency-based assessments and reflective tasks to be completed by students. Student feedback on the integrated surgical soft-tissue teaching program was assessed. Respondents were assessed in the fourth year of the degree and will have further opportunities to develop Day One small-animal soft-tissue surgical competencies in the fifth year. Ninety-four percent of respondents agreed or strongly agreed that they were motivated to participate in all aspects of the program, while 78% agreed or strongly agreed that they received an adequate opportunity to develop their skills and confidence in ovariohysterectomy or castration procedures through the fourth-year curriculum.

Clinical performance indicators: intolerance for variety?

PURPOSE: The performance of NHS U.K. hospitals is under continuous scrutiny as they are constantly under pressure to perform well. A recent document published by an independent body has recommended a host of clinical indicators to assess non-financial performance of hospitals. This study aims to critically analyse the performance of a single U.K. hospital against several of these recommended indicators. DESIGN/METHODOLOGY/APPROACH: Data presented to the Hospital Trust Board for 12 months were used for this study. Previous years' data were used wherever available. FINDINGS: Based on data analysis, this hospital's performance is extremely difficult to calculate. The indicators use complex ratios and due to lack of standardisation, the hospital performance could be interpreted as better, worse or indifferent. RESEARCH LIMITATIONS/IMPLICATIONS: This study analyses most of the recommended indicators. Literature review did not reveal a similar analysis of another hospital against these indicators which precludes comparison. PRACTICAL IMPLICATIONS: This study highlights the difficulty in comparing the performance of hospitals due to the inherent lack of consistency. Therefore it is apparent that any reward-rebuke system linked to performance should interpret the data with caution. It is therefore suggested that easy to control single value activities and standardised routine activities could be used to measure hospital performance. Alternatively, the hospital could compare with its own statistics from previous years. ORIGINALITY/VALUE: Literature acknowledges the difficulties in measuring clinical performance. This paper elucidates these difficulties applied to the NHS and suggests alternatives.