Investigating the relationships between motor skills, cognitive status, and area deprivation index in Arizona: a pilot study.

Introduction: Previous studies highlight the negative impact of adverse socioeconomic conditions throughout life on motor skills and cognitive health. Factors such as cognitive activity, physical activity, lifestyle, and socioeconomic position significantly affect general health status and brain health. This pilot study investigates the relationships among the Area Deprivation Index (ADI)-a measure of neighborhood-level socioeconomic deprivation, brain structure (cortical volume and thickness), and cognitive status in adults in Arizona. Identifying measures sensitive to ADI could elucidate mechanisms driving cognitive decline. Methods: The study included 22 adults(mean age = 56.2 ± 15.2) in Arizona, residing in the area for over 10 years(mean = 42.7 ± 15.8). We assessed specific cognitive domains using the NeuroTrax™ cognitive screening test, which evaluates memory, executive function, visual-spatial processing, attention, information processing speed, and motor function. We also measured cortical thickness and volume in 10 cortical regions using FreeSurfer 7.2. Linear regression tests were conducted to examine the relationships between ADI metrics, cognitive status, and brain health measures. Results: Results indicated a significant inverse relationship between ADI metrics and memory scores, explaining 25% of the variance. Both national and state ADI metrics negatively correlated with motor skills and global cognition (r's < -0.40, p's < 0.05). In contrast, ADI metrics generally positively correlated with motor-related volumetric and cortical thickness measures (r's > 0.40, p's < 0.05). Conclusion: The findings suggest that neighborhood-level social deprivation might influence memory and motor status, primarily through its impact on motor brain health.

Patterns in Physician Burnout in a Stable-Linked Cohort.

Importance: Physician burnout is widely reported to be an increasing problem in the US. Although prior analyses suggest physician burnout is rising nationally, these analyses have substantial limitations, including different physicians joining and leaving clinical practice. Objective: To examine the prevalence of burnout among physicians in a large multispecialty group over a 5-year period. Design, Setting, and Participants: This survey study was conducted in 2017, 2019, and 2021 and involved physician faculty members of the Massachusetts General Physicians Organization. Participants represented different clinical specialties and a full range of career stages. The online survey instrument had 4 domains: physician career and compensation satisfaction, physician well-being, administrative workload on physicians, and leadership and diversity. Exposure: Time. Main Outcomes and Measures: Physician burnout, which was assessed with the Maslach Burnout Inventory. A binary burnout measure was used, which defined burnout as a high score in 2 of the 3 burnout subscales: Exhaustion, Cynicism, and Reduced Personal Efficacy. Results: A total of 1373 physicians (72.9% of the original 2017 cohort) participated in all 3 surveys. The cohort included 690 (50.3%) male, 921 (67.1%) White, and 1189 (86.6%) non-Hispanic individuals. The response rates were 93.0% in 2017, 93.0% in 2019, and 92.0% in 2021. Concerning years of experience, the cohort was relatively well distributed, with the highest number and proportion of physicians (478 [34.8%]) reporting between 11 and 20 years of experience. Within this group, burnout declined from 44.4% (610 physicians) in 2017 to 41.9% (575) in 2019 (P = .18) before increasing to 50.4% (692) in 2021 (P < .001). Conclusions and Relevance: Findings of this survey study suggest that the physician burnout rate in the US is increasing. This pattern represents a potential threat to the ability of the US health care system to care for patients and needs urgent solutions.

Incidence of de novo stress urinary incontinence following minimally invasive sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: The objective was to investigate the incidence and risk factors of postoperative de novo stress urinary incontinence (SUI) in stress-continent women following minimally invasive sacrocolpopexy without an anti-incontinence procedure. METHODS: We completed a multicenter, retrospective cohort study of women undergoing laparoscopic sacrocolpopexy without concurrent anti-incontinence procedures from October 2006 through January 2021. RESULTS: Of the 169 women who underwent minimally invasive sacrocolpopexy, 17.1% (n=30) developed de novo SUI, and 7.1% eventually underwent a midurethral sling placement. On logistic regression, BMI, preoperative urinary urgency, and history of transvaginal mesh repair were found to be significantly associated with and predictive of de novo SUI. When the concordance index (C-index) was calculated with the model published by Jelovsek et al. for women who developed de novo SUI within 12 months of the prolapse surgery, the current de novo SUI calculator was able to discriminate de novo SUI outcome (C-index = 0.71). CONCLUSIONS: The incidence of de novo SUI after minimally invasive sacrocolpopexy without anti-incontinence procedure correlates directly with higher BMI, preoperative urinary urgency, and transvaginal mesh history for POP. Preoperative counseling for minimally invasive sacrocolpopexy should include discussing the risk of de novo SUI and preoperative factors that may increase this risk.

Asynchronous telehealth visits for the treatment of overactive bladder.

OBJECTIVE: Overactive bladder affects 17% of women, and adherence to treatment is notoriously low. The objective of this pilot study is to investigate the efficacy and feasibility of the use of asynchronous telehealth visits for the treatment of women with overactive bladder. METHODS: This is a pilot study of women who participated in the asynchronous telehealth program with a new diagnosis of overactive bladder presenting to the Massachusetts General Hospital from January of 2020 to March of 2021. Pre-post differences in Urogenital Distress Inventory score-6, and Incontinence Severity Index Scores were compared with paired t tests as coprimary endpoints. To assess potential mechanisms of association between asynchronous visits and patient-reported outcomes, total fluid intake, caffeinated beverage consumption, urinary frequency, episodes of urinary leakage were also compared as secondary endpoints. RESULTS: A total of 23 women participated, with 50 e-visits completed. The first asynchronous visit was completed after a median of 42days (IQR 36, 51.5) from the initial visit. There was a decrease in the Urogenital Distress Inventory-6 score between the first asynchronous visit and the last (29 points, IQR 16, 37 vs 12 points, IQR 12, 25), respectively (P = 0.014). Similar findings were seen with the Incontinence Severity Index questionnaire, from three (IQR 2, 4) to three (IQR 1, 3) after the asynchronous visit (P = 0.002). CONCLUSION: We demonstrate the feasibility of asynchronous visits for the treatment of overactive bladder. Although our results suggest efficacy, given the prepost change in overactive bladder-related questionnaire scores following asynchronous visits, the comparative effectiveness of asynchronous visits versus regular care needs to be confirmed in a randomized trial.

Video Summary:http://links.lww.com/MENO/A917 .

Synchronous Telemedicine Model in Urogynecology: Are Patients Willing to Continue Telemedicine in the Post-COVID-19 Pandemic Era?

IMPORTANCE: Following the recent expansion of telemedicine during the COVID-19 pandemic, this remote model of care in female pelvic medicine and reconstructive surgery will likely remain and continue to evolve. OBJECTIVE: This study was conducted to assess patients' perceptions of and willingness to participate in a synchronous telemedicine visit beyond the COVID-19 pandemic for women with pelvic floor disorders. STUDY DESIGN: We conducted a cross-sectional study of women who completed a synchronous telemedicine visit from March 16 through May 22, 2020, at a urogynecology practice in an academic medical center. An electronic survey was distributed to women after all telemedicine visits. Demographic data, visit type, and survey responses were analyzed. RESULTS: Two hundred two women received the survey, and 135 women completed it (response rate of 66.8%). The mean age of the respondents was 62.9 ± 16.4 years, and the 3 most common visit diagnoses were overactive bladder (43.7%), stress urinary incontinence (22.2%), and pelvic organ prolapse (21.4%). Most survey participants (88.9%) found that the quality of their telemedicine visits was better than expected, and 89.6% reported that they would like to continue telemedicine care. Our survey showed that 19.4% of women reported difficulty with technology. CONCLUSIONS: We found that most women presenting for synchronous telemedicine urogynecology care had a positive visit experience and would continue to use telemedicine for their care. Further developmental work needs to be done on improving the ease of technology as well as availability of telemedicine in the care of women affected by pelvic floor disorders.

Rectoceles: Is There a Correlation Between Presence of Vaginal Prolapse and Radiographic Findings in Symptomatic Women?

BACKGROUND: Constipation is highly prevalent. Women with constipation are evaluated for the presence of vaginal prolapse that may contribute to obstructed defecation syndrome. Defecography can identify anatomic causes of obstructed defecation syndrome (rectocele, intussusception, and enterocele). OBJECTIVE: This study aimed to assess the characteristics of women with obstructed defecation syndrome and radiographic rectoceles with and without posterior vaginal wall prolapse and to characterize the relationship between anatomical abnormalities and dysfunction. DESIGN: This is a retrospective case-control study of women with obstructed defecation syndrome who had radiographic rectoceles on defecography. SETTINGS: Women who presented to a Pelvic Floor Disorders Center were included. PATIENTS: Cases were defined as constipated women with radiographic rectoceles and at least stage II posterior vaginal wall prolapse on examination. Controls were patients with radiographic rectoceles but without posterior vaginal wall prolapse on examination. MAIN OUTCOME MEASURES: Patient characteristics, anorectal testing results, and validated questionnaires were compared between groups. RESULTS: A total of 106 women met inclusion criteria. Women with posterior vaginal wall prolapse (48 (45.3%)) had larger rectoceles on defecography than women without it on examination (3.4 cm vs 3.0 cm, p < 0.01). Women with posterior vaginal wall prolapse on examination were more likely to splint during defecation than women without vaginal wall prolapse (63.8% vs 27.3%, p < 0.01). All other defecatory symptoms, anorectal manometry parameters, and questionnaire responses were similar between groups. LIMITATIONS: This study was limited by its retrospective study design. Our data were taken from a single institution within a center specializing in the treatment of pelvic floor disorders, potentially limiting generalizability. CONCLUSIONS: Patients with constipation, radiographic rectoceles, and vaginal prolapse may differ from those without evidence of prolapse. Patients with vaginal prolapse were more likely to splint to aide evacuation and demonstrated larger rectoceles on defecography. Further studies are needed to determine whether constipation causes progression along this continuum or whether progression of prolapse is a cause of worsening defecatory dysfunction. See Video Abstract at http://links.lww.com/DCR/B626. RECTOCELES EXISTE UNA CORRELACIN ENTRE LA PRESENCIA DE PROLAPSO VAGINAL Y LOS HALLAZGOS RADIOLGICOS EN MUJERES SINTOMTICAS: ANTECEDENTES:El estreñimiento es una enfermedad muy prevalente. Las mujeres con estreñimiento se evalúan para detectar la presencia de prolapso vaginal que pueda contribuir al síndrome de defecación obstructiva. La defecografía puede identificar las causas anatómicas del síndrome de defecación obstructiva (rectocele, invaginación intestinal (intususcepción) y enterocele).OBJETIVO:Este estudio tiene como objetivo evaluar las características de las mujeres con síndrome de defecación obstructiva y la presencia de rectocele como hallazgo radiológico, con y sin prolapso de la pared vaginal posterior, y caracterizar la relación entre las anomalías anatómicas y la presencia de disfunción.DISEÑO:Este es un estudio retrospectivo de casos y controles, de mujeres con síndrome de defecación obstructiva, que tenían rectocele como hallazgo radiológico en una defecografía.MARCO:Mujeres que acudieron a un Centro de Trastornos del Piso Pélvico.PACIENTES:Los casos fueron definidos como mujeres con estreñimiento con hallazgos radiológicos de rectocele, con al menos un prolapso estadio II de la pared vaginal posterio, en el examen físico. Los controles fueron pacientes con solo rectocele por hallazgos radiológicos, sin prolapso de la pared vaginal posterior en el examen físico.PRINCIPALES MEDIDAS DE RESULTADO:Se compararon entre los grupos: las características de las pacientes, los resultados de las pruebas diagnósticas anorrectales y los cuestionarios validados.RESULTADOS:Un total de 106 mujeres cumplieron los criterios de inclusión. Las mujeres con prolapso de la pared vaginal posterior 48 (45,3%) tenían rectoceles de mayor tamaño en la defecografía en comparación con las mujeres sin rectocele en el examen físico (3,4 cm versus 3,0 cm, p <0,01). Las mujeres con prolapso de la pared vaginal posterior en el examen, tenían una mayor probabilidad de que les fuera necesario ejercer una maniobra de presión manual o digital del periné durante la defecación, comparado con las mujeres sin rectocele clínico (63,8% versus 27,3%, p <0,01). Todos los demás síntomas defecatorios, los parámetros de la manometría anorrectal, y las respuestas al cuestionario fueron similares entre los grupos.LIMITACIONES:Estudio retrospectivo. Los datos fueron obtenidos de la base de datos de un centro especializado en el tratamiento de los trastornos del piso pélvico lo que potencialmente limita generalizar.CONCLUSIONES:Las pacientes con estreñimiento, rectocele como hallazgo radiológico, y prolapso vaginal pueden ser diferentes de aquellas sin evidencia de prolapso. Las pacientes con prolapso vaginal, tenían una mayor probabilidad de que les fuera necesario ejercer maniobras manuales o digitales de presión a nivel del periné para ayudar a la evacuación, y tenían rectoceles de mayor tamaño en la defecografía. Se necesitan más estudios para determinar si el estreñimiento causa que el rectocele aumente progresivamente de tamaño, empeorando la disfunción defecatoria. Consulte Video Resumen en http://links.lww.com/DCR/B626.

Can sonographic fetal head circumference measurement help predict obstetric anal sphincter injury?

OBJECTIVE: To investigate whether sonographic fetal head circumference (sfHC) size assessed by ultrasound prenatally could help predict OASIS. METHODS: This study is a retrospective cohort study between 2005 and 2016. Antenatal sfHC assessment, maternal demographics, and labor and delivery data were abstracted and compared in women with and without OASIS. RESULTS: Of 2057 pregnant women that had sfHC assessment, 121 (5.8%) had OASIS. In the unadjusted analysis, sfHC above the 90th centile was associated with OASIS (odds ratio [OR] 1.12; 95% confidence interval [CI] 1.02-1.23; P = 0.015). When adjusted for gestational age at delivery, maternal age, race, prolonged second stage, body mass index, infant gender, and intrapartum oxytocin use, sfHC above the 90th centile remained significantly associated with OASIS (OR 1.13, 95% CI 1.00-1.27, P = 0.050). CONCLUSION: In our cohort, sfHC above the 90th centile was associated with a greater risk of OASIS. As OASIS significantly impacts both short-term and long-term health outcomes, such as perineal pain, dyspareunia, and urinary and fecal incontinence, sfHC could be an additional prenatal marker to help clinicians counsel pregnant women about the risk of OASIS.

Urinary symptoms in women with faecal incontinence.

AIM: Faecal incontinence (FI) is estimated to affect 8.9% of women in the United States, with a significant impact on quality of life. Our aim was to compare urinary symptoms in patients with and without FI with different degrees of severity. METHODS: This prospective cohort of women presented for care at a pelvic floor disorder centre between May 2007 and January 2019. We excluded women with a history of bowel resection, prior history of pelvic organ prolapse surgery or existing prolapse symptoms reported by the patient during intake. The primary outcome was the presence of urinary symptoms in women with and without FI by validated questionnaires. A logistic regression model for association of urinary symptoms with FI was performed, adjusting for age, smoking, diabetes, prior hysterectomy and irritable bowel syndrome. RESULTS: A total of 2932 met inclusion criteria, and of these 1404 (47.89%) reported FI. In the univariate analysis, patients with FI were more likely to have urgency urinary incontinence (P = 0.01) or mixed urinary incontinence (P < 0.001), report nocturnal enuresis (P < 0.001) or have leakage of urine during sex (P < 0.001). In an adjusted model, FI was associated with concurrent stress (adjusted OR 1.28, P = 0.034), urgency (adjusted OR 1.52, P < 0.001) and mixed incontinence (adjusted OR 1.94, P < 0.001). CONCLUSION: In women with pelvic floor disorders, the presence of FI is associated with a higher prevalence of urinary incontinence. Pelvic floor specialists should assess urinary incontinence symptoms along with the presence and severity of FI to provide comprehensive care and guide appropriate therapy.

Association Between Hemoglobin A1c and Midurethral Sling Complications in Diabetic Women: A Cohort Study.

OBJECTIVE: We aimed to evaluate the association between hemoglobin A1c (HbA1c) levels and midurethral sling (MUS) complications. METHODS: This was a multihospital, retrospective cohort study from 2010 to 2020. We included all women with diabetes mellitus who underwent a synthetic mesh MUS procedure and had a preoperative HbA1c within 3 months of surgery. The primary outcome was a composite of complications, including MUS mesh exposure, surgical site granulation tissue or infection, urinary tract infection, surgical site pain beyond 6 weeks postoperatively, and MUS failure. A sensitivity analysis analyzing MUS failure alone was performed. RESULTS: During the study period, 109 women met the inclusion criteria. Most were White (52.2%) and had a median body mass index of 31.2 kg/m2, and 84.9% were postmenopausal. Median HbA1c was 7.2% (interquartile range, 6.3%-7.7%). Urinary tract infection was the most common complication in 12 (11.0%) women. Mesh exposure was diagnosed in 7 (6.4%) women. Seventeen (15.6%) had MUS failure. On univariate regression analysis, a higher HbA1c was associated with increased odds of composite complications (odds ratio, 1.67; 95% confidence interval, 1.20-2.32; P = 0.002) and MUS failure (odds ratio, 1.81, 95% confidence interval, 1.26-2.60; P = 0.001). On multivariate analysis, higher HbA1c levels were associated with a composite of complications and failure (P < 0.05). Based on the receiver operating characteristic curve, HbA1c greater than 8% demonstrated a specificity of 85.7% and a sensitivity of 50% for MUS failure. CONCLUSIONS: In diabetic patients, a higher HbA1c was associated with a higher risk of MUS complications and failure. Obtaining an HbA1c within 3 months of surgery may help with risk stratification.

Updates in treating fecal incontinence in women.

PURPOSE OF REVIEW: Fecal incontinence is a chronic condition that can significantly affect a woman's quality of life. The pathogenesis of fecal incontinence is multifaceted and management ranges from supportive care, medical therapy to more invasive surgical procedures. This review will discuss the recent advancements in treating fecal incontinence. RECENT FINDINGS: The pelvic floor disorder consortium has created a consensus document with recommendations on pelvic floor symptom measurement tools, patient-reported instruments, and questionnaires that should be used when evaluating fecal incontinence. There is new robust data reinforcing the importance of conservative management prior to proceeding with more invasive treatment. Lastly, several novel therapies that were developed in the past decade now have longer term data on safety and efficacy. SUMMARY: Management of fecal incontinence is challenging, as no one therapy has been proven to be predominately effective. We should continue to first optimize patients with conservative therapy followed by induction of more advanced therapies. There needs to be continued efforts to develop and evaluate effective treatment guidelines and therapies for fecal incontinence.

Presacral Anatomy in Women With a Horseshoe Kidney.

OBJECTIVE: Horseshoe kidney (HSK) is the most common renal fusion defect that can alter vascular and upper urinary tract anatomy. Anatomic variations in the presacral space can make surgical dissection very challenging. The aim of this study was to characterize presacral anatomy in women with HSK. METHODS: Large academic centers' database was queried to identify imaging studies in adult women with HSK. Available multiplanar computed tomography and magnetic resonance imaging images were reviewed, and relevant vascular and upper urinary tract anatomy was measured and compared with published normal values. Study population was compared with the normal controls using Student t test, χ test, or Fisher exact test as appropriate. RESULTS: One hundred seventy-eight women were identified initially, and 20 confirmed to have HSK on imaging. The mean ± SD age was 54.5 ± 16.9 years, and body mass index was 27.3 ± 7.5 kg/m. Women with HSK had a narrower angle of aortic bifurcation (39.1 ± 18.7 degrees vs 55.6 ± 4.5 degrees, P = 0.014); the right ureter was closer to midline (22.9 ± 8.8 mm vs 32.3 ± 1.2 mm, P < 0.001) when compared with normal controls anatomy. In 40% of women with HSK, the bifurcation of the vena cava was below the level of L5 in contrast to the 8% in the normal population (P < 0.001). In 60% of women with HSK, the inferior pole of the kidney was at or below L5. CONCLUSIONS: Ureteral, renal, and vascular anatomic alterations in women with HSK may make presacral surgical anatomy challenging by obscuring the anterior longitudinal ligament anchoring point. Preoperative imaging is warranted to determine the feasibility of female pelvic reconstructive surgery in HSK patients.