Lessons learned from the experiences of patients with chronic pelvic pain syndrome (CPP syndrome) with a multidisciplinary consultation: a qualitative study.

INTRODUCTION: Chronic pelvic pain syndrome is a complex multifactorial condition with an increasing prevalence probably due to a rising awareness. Chronic pelvic pain syndrome is pain in the pelvic area and often accompanied with complaints in other organ systems of the lesser pelvis. Patients with chronic pelvic pain syndrome who present at our center are evaluated in a standardized care pathway with an integrated multidisciplinary consultation. The team works in a single center and consists of gynecologists, pain specialists, urologists, a pelvic floor physiotherapist and a psychologist. The aim of this interview study is to evaluate the value of the multidisciplinary consultation from the patient's perspectives. METHODS: In a qualitative study, we evaluated the experiences and perspectives of patients with chronic pelvic pain syndrome concerning the multidisciplinary consultation at the Radboud University Medical Center. Semistructured interviews were conducted with patients with chronic pelvic pain syndrome who attended a multidisciplinary consultation between 2019 and 2022. All interviews were transcribed verbatim, coded and analyzed via ATLAS.ti with the conventional content analysis. RESULTS: Data saturation was reached after seven interviews, followed by three confirmative interviews. In total, 10 patients (22-76 years) participated in the study. Three relevant themes were identified in the interviews: the deleterious effects of pain on overall health, the importance of the design of the multidisciplinary consultation, and the performance of healthcare professionals (knowledge, skills and interaction with patients and colleagues). Participants suggested that although the consultation did not improve their pain experience, there was value in having a comprehensive assessment of their disease. Patients preferred the consultation to occur at the beginning of the care. Additionally, they acknowledged the performance of healthcare providers and having their complaints recognized. However, some participants suggested the need for additional attention to mental health issues during the multidisciplinary consultation. DISCUSSION: Even though patients did not perceive the multidisciplinary consultation to improve their pain experience, they appreciated the sense of recognition by this team. CONCLUSION: A multidisciplinary consultation is of value from the patients' perspective. A suggestion for improvement emerged where the multidisciplinary consultation should occur at the beginning of the patient journey.

Coherent amplitude modulation of continuous-wave light in cesium vapor.

We report on observations of coherent, sustained oscillations in the absorption of continuous-wave light at 388 nm that excites the 6S1/2 → 8P3/2 transition in cesium (Cs) vapor. The oscillation frequency is close to the spacing of hyperfine levels of the 8P3/2 level that are excited simultaneously by the 388 nm field. We observe a threshold behavior of the oscillation amplitude with pump power and suggest that the effect is associated with infrared directional emission due to amplified spontaneous emission (ASE) from the 8P3/2 → 8S1/2 transition that is assisted by retro-reflections from cell windows. The effect may be used to probe a lasing process in an atomic vapor, by checking the temporal properties of the pump field transmitted through the vapor.

Patient Impression of Improvement 1 year After Sacrospinous Hysteropexy Versus Vaginal Hysterectomy in Women with Pelvic Organ Prolapse Stage 2 or Higher.

INTRODUCTION AND HYPOTHESIS: Patient-reported outcomes are relevant outcomes in studies on pelvic organ prolapse (POP) surgery, as anatomical recurrence alone does not have a significant correlation with perceived improvement. In the present study, the patient's impression of improvement after 1 year is studied after vaginal hysterectomy (VH) versus sacrospinous hysteropexy (SSH) in large cohorts from daily clinical practice. We hypothesize that there is no difference between the groups. METHODS: This is a secondary analysis on prospectively collected data in a multicenter cohort of patients who underwent VH or SSH for symptomatic POP. All patients had a POP-Q stage ≥ 2 in at least one compartment at baseline and were treated with VH or SSH between 2002 and 2019. The primary outcome was the patient-reported score on the patient global impression of improvement index (PGI-I) 1 year after surgery. The secondary outcome was a composite outcome of surgical success, defined as the absence of recurrent POP beyond the hymen with bothersome bulge symptoms and/or repeat surgery. RESULTS: A total of 378 women (196 VH and 182 SSH) were included. The median score on the PGI-I did not differ between VH and SSH. At 1 year post-operatively, 77 women after VH (73%) and 77 women after SSH (75%) considered their condition (very) much improved (p = 0.86). There was no difference in composite outcome of surgical success (126 out of 137 women [92%] after VH, 118 out of 125 women [94%] after SSH; p = 0.44). CONCLUSIONS: Our study shows that there was no difference in the type of surgery, VH or SSH, with regard to the patient's impression of improvement 1 year postoperatively in a large cohort from daily clinical practice.

Laparoscopic Davydov vs. laparoscopic Vecchietti neovaginoplasty in women with Mayer-Rokitansky-Küster-Hauser syndrome; a systematic review and meta-analysis.

OBJECTIVE: To summarize the available evidence on the laparoscopic Davydov and Vecchietti methods to create a neovagina and to compare these techniques with a focus on neovaginal length, sexual function, operative time, and complications. DESIGN: A systematic electronic search up to August 2022 using PubMed and Embase is performed. SETTING: Not applicable. PATIENTS: Women with Mayer-Rokistansky-Küster-Hauser syndrome. INTERVENTIONS: All published clinical studies concerning the laparoscopic Davydov and laparoscopic Vecchietti procedures as a surgical technique to create a neovagina in women with Mayer-Rokistansky-Küster-Hauser syndrome were obtained. The guidelines for the preferred reporting items for systematic reviews and meta-analysis were followed. The following data were extracted: operative time, hospital stay, major early complications (within 3 months postsurgery), dilation therapy, neovaginal length, vaginal discharge, vaginal stenosis, time to sexual activity, sexual satisfaction, penetrative sexual activity, dyspareunia, score on the Female Sexual Function Index (FSFI), and duration of follow-up. The Newcastle Ottawa Scale was used to assess the quality of articles. MAIN OUTCOME MEASURES: Neovaginal length, FSFI scores, operative time, and complications. RESULTS: A total of 1,163 articles were identified, of which 33 studies were included in this systematic review. Of these, 12 studies (380 patients) are related to the Davydov method, 19 studies (1,126 patients) to the Vecchietti method, and 2 articles concern both. There is clinical heterogeneity and variety in the quality of the studies. Eighteen studies were included in the meta-analyses. The mean neovaginal length 12 months after the Davydov method is 8.3 cm (95% confidence interval [CI] 8.1-8.6), vs. 8.7 cm (95% CI 7.2-10.3) after the Vecchietti method. The mean FSFI score after the Davydov method is 28.9 (95% CI 26.8-31.1), compared with 27.5 (95% CI 25.0-30.1) after the Vecchietti method. The operative time of the Davydov method is 126 minutes (95% CI 109-143), compared with 40 minutes (95% CI 35-45) of the Vecchietti method. CONCLUSIONS: The operations yield comparable neovaginal length, sexual function, and complication rates. The mean FSFI scores indicate no sexual dysfunction in either group. The operative time of the Davydov method is significantly longer. There is no superiority shown for one of the surgical techniques in functional terms.

Location and motion of vaginal pessaries in situ in women with successful and unsuccessful pessary treatment for pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: The objective was to compare the location and motion of pessaries between women with pelvic organ prolapse (POP) with a successful (fitting) and unsuccessful (non-fitting) pessary treatment on dynamic magnetic resonance imaging (dMRI). METHODS: A cross-sectional exploratory study of 15 women who underwent a mid-sagittal dMRI of the pelvic floor at rest, during contraction and during Valsalva with three different types of pessaries. The coordinates of the pessaries cross section, inferior pubic point (IPP) and sacrococcygeal junction (SCJ) were obtained and the location (position, orientation) and the motion (translation and rotation) were calculated. Differences between the groups and between the pessaries within the groups were compared. RESULTS: Nine women with a fitting pessary and 6 women with a non-fitting pessary were selected. In the non-fitting group, the pessaries were positioned more caudally and rotated more in clockwise direction and descended more, but not significantly, during Valsalva compared with the fitting group. The Falk pessary was positioned more anteriorly in the fitting group and more cranially in the non-fitting group compared with the ring and ring with support pessary. CONCLUSIONS: A non-fitting pessary was positioned more caudally at rest; on Valsalva, it rotated more clockwise and moved more caudally, suggesting that the dynamic characteristics of the pessary might play an important role in its effectiveness. Findings of this study serve as a basis for the development of new pessary designs.

Anatomy in the daily practice of the gynecologist, essential or just window dressing?

Traditionally, anatomy was one of the basic pillars of medical training. However, due to the expansion of medical science and medical knowledge in general, anatomy teaching has steadily declined and the way anatomy is taught has changed. These changes go hand in hand with growing literature about a perceived and proven lack of anatomical knowledge. While anatomy is important for all doctors, these developments seem to be more worrying for surgical residents. At the same time, little is known about how clinicians use anatomy in daily practice. The primary aim of this study was to increase understanding of the role of anatomy in the daily practice of gynecologists. An explorative qualitative study was performed to answer the question "What is the tangible utility of solid anatomical knowledge in the daily practice of the gynecologist"? Semi-structured interviews with gynecologists and obstetrics and gynecology (ObGyn) residents from Belgium and the Netherlands were held and the responses were analyzed using a phenomenographic inductive coding approach. Anatomical knowledge was important and used for technical skills and non-technical achievements in the daily practice of gynecologists, and three themes were distinguished. Specifically, anatomical knowledge was important and used (1) for daily activities, (2) for the feeling of self-efficacy, and (3) to gain a respected name as a doctor. These findings are discussed in light of (perceived) insufficient anatomical knowledge, and recommendations are made for the postgraduate education of ObGyn doctors.

Patient's preference for sacrospinous hysteropexy or modified Manchester operation: A discrete choice experiment.

OBJECTIVE: To investigate women's preference for modified Manchester (MM) or sacrospinous hysteropexy (SH) as surgery for uterine prolapse. DESIGN: Labelled discrete choice experiment (DCE). SETTING: Eight Dutch hospitals. POPULATION: Women with uterine prolapse, eligible for primary surgery and preference for uterus preservation. METHODS: DCEs are attribute-based surveys. The two treatment options were labelled as MM and SH. Attributes in this survey were treatment success ( levels SH: 84%, 89%, 94%; levels MM: 89%, 93%, 96%), dyspareunia (levels: 0%, 5%, 10%), cervical stenosis (levels: 1%, 6%, 11%) and severe buttock pain (levels: 0%, 1%). A different combination of attribute levels was used in each choice set. Women completed nine choice sets, making a choice based on attribute levels. Data were analysed in multinomial logit models. MAIN OUTCOME MEASURES: Women's preference for MM or SH. RESULTS: 137 DCEs were completed (1233 choice sets). SH was chosen in 49% of the choice sets, MM in 51%. Of all women, 39 (28%) always chose the same surgery. After exclusion of this group, 882 choice sets were analysed, in which women preferred MM, likely associated with a labelling effect, i.e. description of the procedure, rather than the tested attributes. In that group, MM was chosen in 53% of the choice sets and SH in 47%. When choosing MM, next to the label, dyspareunia was relevant for decision-making. For SH, all attributes were relevant for decision-making. CONCLUSIONS: The preference of women for MM or SH seems almost equally divided. The variety in preference supports the importance of individualised healthcare.

What do we need to know about anatomy in gynaecology? An international validation study.

OBJECTIVE: International validation of the Dutch Delphi study about which anatomical structures should be taught to ensure safe and competent practice among general gynaecologists. STUDY DESIGN: Validation study with gynaecologists and trainees in gynaecology from academic, non-academic teaching and non-academic, non-teaching hospitals worldwide. The relevance of 123 items included in the Dutch Delphi study was scored on a Likert scale between 1 (not relevant) and 5 (highly relevant). Consensus was defined when ≥70 % of the panellist scored the item as relevant or very relevant and the average rating was ≥4. RESULTS: A total of 192 gynaecologists and trainees from seven countries (Belgium, Germany, Norway, Oceania, Sweden, United Kingdom and United States) completed the questionnaire. Of the 123 structures, 72 (58.5%) were internationally relevant. When the 72 relevant structures from the international Delphi study were compared with the 86 relevant structures from the Dutch Delphi study, 70 (81.4%) structures matched. CONCLUSIONS: This study identified 70 anatomical structures that should be taught for safe and competent practice of general gynaecologists based on national and international validation. The results of our study identify the learning needs (i.e., the content) for an international anatomy curriculum. The development of the curriculum (i.e., the form) can be determined by each country and used to standardize and guide postgraduate training in gynaecology. This is an important step in the era of international teaching and training.

Ultrafast multi-cycle terahertz measurements of the electrical conductivity in strongly excited solids.

Key insights in materials at extreme temperatures and pressures can be gained by accurate measurements that determine the electrical conductivity. Free-electron laser pulses can ionize and excite matter out of equilibrium on femtosecond time scales, modifying the electronic and ionic structures and enhancing electronic scattering properties. The transient evolution of the conductivity manifests the energy coupling from high temperature electrons to low temperature ions. Here we combine accelerator-based, high-brightness multi-cycle terahertz radiation with a single-shot electro-optic sampling technique to probe the evolution of DC electrical conductivity using terahertz transmission measurements on sub-picosecond time scales with a multi-undulator free electron laser. Our results allow the direct determination of the electron-electron and electron-ion scattering frequencies that are the major contributors of the electrical resistivity.

Pain after midurethral sling; the underestimated role of mesh removal.

INTRODUCTION: The primary aim of this study was to evaluate the results of midurethral sling (MUS) removal in women who have pain as their single complication of MUS. MATERIAL AND METHODS: We performed a retrospective chart study supplemented with a cross sectional questionnaire. Women who underwent MUS removal for pain as the solitary reason for removal between 2004 and 2018 were included. Primary outcome was change in pain levels assessed by the visual analogue scale (VAS) pain score (range 0-10). Secondary outcome was the recurrence of stress urinary incontinence (SUI). RESULTS: Twenty-six of 31 patients returned the questionnaire. Median medical file follow-up was 12 months (range 2-66) and 25 months (range 5-104) regarding questionnaires. VAS pain score dropped from 7.8 (SD 1.9) at baseline to 4.5 (SD 3.2) at follow-up (p <.00). Seven (23%) patients were pain-free. Patients undergoing partial vaginal resection (n = 6) had a VAS pain score decrease of 4.7 (p = .02) versus 2.7 (p = .02) for complete vaginal removal (n = 14). Twenty-three (89%) patients experienced SUI at follow-up, whereof 10 (45%) reported (almost) no incidents of SUI. CONCLUSIONS: MUS removal is a viable and safe option with a significant drop in VAS pain score in patients with chronic pain after MUS placement. A post-operative increase of SUI and a possible renewed wish for SUI treatment have to be considered. This should not be a reason to refrain from information and/or referral for surgical removal.

Association between levator ani avulsion and urinary incontinence in women: A systematic review and meta-analysis.

BACKGROUND: Urinary incontinence is a bothersome symptom. Although the relationship between stress urinary incontinence (SUI) and vaginal delivery is established, the pathology underlying SUI after vaginal birth remains to be elucidated. OBJECTIVES: To determine whether levator ani muscle avulsion predisposes for SUI in women. SEARCH STRATEGY: Pubmed and Embase were searched for terms and their variations "levator ani muscle avulsion" and "urinary incontinence", from inception until 5 November 2019. SELECTION CRITERIA: Inclusion criterion: studies describing the relationship between urinary incontinence and levator ani muscle avulsion in women at least 1 year after delivery. Exclusion criterion: studies only analyzing the urethral sphincter or hiatus dimensions. DATA COLLECTION AND ANALYSIS: Odds ratios were used and if not available, were calculated as means of data synthesis, adjusted odds ratios if presented by the study, random-effects model to compute a pooled estimate. RESULTS: Seven studies were included, accounting for 2388 women. Comparing women with and without levator ani muscle avulsion, the overall odds ratio for SUI is 0.87 (95% confidence interval 0.56-1.34), and after adjustment for possible confounders was 0.72 (95% confidence interval 0.40-1.30). CONCLUSION: There is no relationship between levator ani muscle avulsion and SUI in women.

Does three-dimensional anatomy improve student understanding?

We aim to provide an overview of the various digital three-dimensional visualizations used for learning anatomy and to assess whether these improve medical students' understanding of anatomy compared to traditional learning methods. Furthermore, we evaluate the attitudes of the users of three-dimensional visualizations. We included articles that compared advanced newer three-dimensional anatomy visualization methods (i.e., virtual reality, augmented reality, and computer-based three-dimensional visualizations) to traditional methods that have been used for a long time (i.e., cadaver and textbooks) with regard to users' understanding of anatomy. Of the 1,148 articles identified, 21 articles reported data on the effectiveness of using three-dimensional visualization methods compared to two-dimensional methods. Twelve articles found that three-dimensional visualization is a significantly more effective learning method compared to traditional methods, whereas nine articles did not find that three-dimensional visualization was a significantly more effective method. In general, based on these articles, medical students prefer to use three-dimensional visualizations to learn anatomy. In most of the articles, using three-dimensional visualization was shown to be a more effective method to gain anatomical knowledge compared to traditional methods. Besides that, students are motivated and interested in using these new visualization methods for learning anatomical structures. Clin. Anat. 32:25-33, 2019. © 2019 Wiley Periodicals, Inc.

What do we need to know about anatomy in gynaecology: A Delphi consensus study.

OBJECTIVE: Determination of the anatomical structures that should be taught to ensure safe and competent practice among general gynaecologists. STUDY DESIGN: A two-round Delphi survey, face-to-face meeting in focus groups and an individual interview. Participants were medical doctors and trainees from gynaecology, surgery, urology and radiology from academic, non-academic teaching and non-academic, non-teaching hospitals in the Netherlands. Relevant structures were collected from gynaecology surgery atlas based on most common gynaecological surgeries and diseases. These structures were supplemented and critically viewed in focus groups followed by a Delphi survey. In the Delphi survey gynaecologist and trainee's gynaecology from all over the Netherlands scored the items on a Likert scale between 1 (not relevant) and 5 (highly relevant). Consensus was defined when ≥ 70 % of the panellist scored the item as relevant or very relevant and the average rating was ≥ 4. Main outcome was clinically relevant anatomical structures. RESULTS: Consensus on 86 clinically relevant anatomical structures divided by nine categories. CONCLUSIONS: This study identified a core list of anatomical structures that are relevant to the safe and competent practice of general gynaecologists and that can be used to guide gynaecology postgraduate education. This is the first step in a much wider and complex process of becoming a competent gynaecologist.

Betulinic acid inhibits high-fat diet-induced obesity and improves energy balance by activating AMPK.

BACKGROUND AND AIM: Metabolic syndromes are prevalent worldwide and result in various complications including obesity, cardiovascular disease and type II diabetes. Betulinic acid (BA) is a naturally occurring triterpenoid that has anti-inflammatory properties. We hypothesized that treatment with BA may result in decreased body weight gain, adiposity and hepatic steatosis in a diet-induced mouse model of obesity. METHODS AND RESULTS: Mice fed a high-fat diet and treated with BA showed less weight gain and tissue adiposity without any change in calorie intake. Gene expression profiling of mouse tissues and cell lines revealed that BA treatment increased expression of lipid oxidative genes and decreased that of lipogenesis-related genes. This modulation was mediated by increased AMP-activated protein kinase (AMPK) phosphorylation, which facilitates energy expenditure, lipid oxidation and thermogenic capacity and exerts protective effects against obesity and nonalcoholic fatty liver disease. Overall, BA markedly inhibited the development of obesity and nonalcoholic fatty liver disease in mice fed a high-fat diet, and AMPK activation in various tissues and enhanced thermogenesis are two possible mechanisms underlying the antiobesity and antisteatogenic effects of BA. CONCLUSIONS: The current findings suggest that treatment with BA is a potential dietary strategy for preventing obesity and nonalcoholic fatty liver disease.

Setup for meV-resolution inelastic X-ray scattering measurements and X-ray diffraction at the Matter in Extreme Conditions endstation at the Linac Coherent Light Source.

We describe a setup for performing inelastic X-ray scattering and X-ray diffraction measurements at the Matter in Extreme Conditions (MEC) endstation of the Linac Coherent Light Source. This technique is capable of performing high-, meV-resolution measurements of dynamic ion features in both crystalline and non-crystalline materials. A four-bounce silicon (533) monochromator was used in conjunction with three silicon (533) diced crystal analyzers to provide an energy resolution of ∼50 meV over a range of ∼500 meV in single shot measurements. In addition to the instrument resolution function, we demonstrate the measurement of longitudinal acoustic phonon modes in polycrystalline diamond. Furthermore, this setup may be combined with the high intensity laser drivers available at MEC to create warm dense matter and subsequently measure ion acoustic modes.

Heterogeneous to homogeneous melting transition visualized with ultrafast electron diffraction.

The ultrafast laser excitation of matters leads to nonequilibrium states with complex solid-liquid phase-transition dynamics. We used electron diffraction at mega-electron volt energies to visualize the ultrafast melting of gold on the atomic scale length. For energy densities approaching the irreversible melting regime, we first observed heterogeneous melting on time scales of 100 to 1000 picoseconds, transitioning to homogeneous melting that occurs catastrophically within 10 to 20 picoseconds at higher energy densities. We showed evidence for the heterogeneous coexistence of solid and liquid. We determined the ion and electron temperature evolution and found superheated conditions. Our results constrain the electron-ion coupling rate, determine the Debye temperature, and reveal the melting sensitivity to nucleation seeds.

Retention Improvement in Fluoride Application with Cold Atmospheric Plasma.

This study aimed to apply fluoride formulations to enamel with cold atmospheric plasma (CAP) and analyze the fluoride uptake, retention, and acid resistance quantitatively. Human enamel specimens were divided randomly into 2 groups: group APF1, 1.23% acidulated phosphate fluoride (APF) gel; group APF2, 1.23% APF gel with CAP. Fluoride and CAP were applied to the samples 4 times at 1-wk intervals. The specimens were also stored in artificial saliva for 4 wk to evaluate the retention of fluoride. The fluoride content on the fluoride-treated enamel was measured by an electron probe microanalyzer. To detect the resistance to demineralization, the calcium-to-phosphate ratio of the enamel samples was measured after the application of APF gel with or without CAP, followed by soaking in the demineralization solution. In groups APF1 and APF2, the amount of fluoride detected increased depending on the application frequency, and more fluoride was detected in group APF2 than in group APF1. In the experiment examining the maintenance effect, fluoride was not detected in group APF1, whereas fluoride was detected in group APF2 up to the fourth week. As for the resistance to demineralization, the calcium-to-phosphate ratio of the enamel treated with APF and CAP was higher than that treated with APF alone, and it increased with the frequency of treatment. This study suggests that the combination treatment of CAP and fluoride improves retention of fluoride on the enamel and resistance to demineralization when compared with treatment with fluoride alone.

Evaluation of treatment pattern and symptom control in patients with gastroesophageal reflux disease: multihospital questionnaire survey on the current situation in Korea.

Proton pump inhibitors (PPIs) are the most effective treatment for gastroesophageal reflux disease (GERD); however, a considerable number of patients fail to respond to PPI therapy and complain of nocturnal heartburn and sleep disturbance. The aims of this study are to evaluate the treatment pattern of GERD-related medications and their efficacy in relieving nocturnal heartburn. A total of 334 patients with GERD receiving PPI therapy within 6 months were enrolled in a multihospital questionnaire survey from January, 2014 to March, 2015. GERD symptoms and patients' satisfaction were assessed by patient questionnaires, and treatment patterns of GERD-related medications were assessed by investigators. Among the 334 patients, 95.8% used PPI once daily and 58.6% used a half-dose of PPI. The PPI treatment pattern was changed in 26.6% of all patients, of those, 54% of the patients doubled the PPI dose, and 29.2% of the patients switched to another PPI. Approximately 60.3% of all patients were prescribed more than three GERD-related medications. The overall satisfaction rate was 61.8%, and 32.2% of patients experienced nocturnal heartburn and sleep disturbance. In the extended-release PPI group, there were fewer nocturnal symptoms compared with the conventional PPI group (10% vs. 33.7%, respectively, P = 0.027). The use of more than three medications was inversely associated with patients' satisfaction (OR = 0.355, 95% CI; 0.197-0.642, P = 0.001). Most patients were prescribed adjunctive medications other than PPIs; however, patients' satisfaction was inversely associated with multiple drugs. Patients' satisfaction was superior in extended-release PPIs than conventional PPIs for the relief of nocturnal heartburn in Korean patients.