Transvaginal mesh or grafts or native tissue repair for vaginal prolapse

BACKGROUND

Pelvic organ prolapse is the descent of one or more of the pelvic organs (uterus, vaginal apex, bladder, or bowel) into the vagina. In recent years, surgeons have increasingly used grafts in transvaginal repairs. Graft material can be synthetic or biological. The aim is to reduce prolapse recurrence and surpass the effectiveness of traditional native tissue repair (colporrhaphy) for vaginal prolapse. This is a review update; the previous version was published in 2016.

OBJECTIVES

To determine the safety and effectiveness of transvaginal mesh or biological grafts compared to native tissue repair or other grafts in the surgical treatment of vaginal prolapse.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and two clinical trials registers (March 2022).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing different types of vaginal repair (mesh, biological graft, or native tissue).

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed risk of bias, and extracted data. The primary outcomes were awareness of prolapse, repeat surgery, and recurrent prolapse on examination.

MAIN RESULTS

We included 51 RCTs (7846 women). The certainty of the evidence was largely moderate (ranging from very low to moderate). Transvaginal permanent mesh versus native tissue repair Awareness of prolapse at six months to seven years was less likely after mesh repair (risk ratio (RR) 0.83, 95% confidence interval (CI) 0.73 to 0.95; I2 = 34%; 17 studies, 2932 women; moderate-certainty evidence). This suggests that if 23% of women are aware of prolapse after native tissue repair, between 17% and 22% will be aware of prolapse after permanent mesh repair. Rates of repeat surgery for prolapse were lower in the mesh group (RR 0.71, 95% CI 0.53 to 0.95; I2 = 35%; 17 studies, 2485 women; moderate-certainty evidence). There was no evidence of a difference between the groups in rates of repeat surgery for incontinence (RR 1.03, 95% CI 0.67 to 1.59; I2 = 0%; 13 studies, 2206 women; moderate-certainty evidence). However, more women in the mesh group required repeat surgery for the combined outcome of prolapse, stress incontinence, or mesh exposure (RR 1.56, 95% CI 1.07 to 2.26; I2 = 54%; 27 studies, 3916 women; low-certainty evidence). This suggests that if 7.1% of women require repeat surgery after native tissue repair, between 7.6% and 16% will require repeat surgery after permanent mesh repair. The rate of mesh exposure was 11.8% and surgery for mesh exposure was 6.1% in women who had mesh repairs. Recurrent prolapse on examination was less likely after mesh repair (RR 0.42, 95% CI 0.32 to 0.55; I2 = 84%; 25 studies, 3680 women; very low-certainty evidence). Permanent transvaginal mesh was associated with higher rates of de novo stress incontinence (RR 1.50, 95% CI 1.19 to 1.88; I2 = 0%; 17 studies, 2001 women; moderate-certainty evidence) and bladder injury (RR 3.67, 95% CI 1.63 to 8.28; I2 = 0%; 14 studies, 1997 women; moderate-certainty evidence). There was no evidence of a difference between the groups in rates of de novo dyspareunia (RR 1.22, 95% CI 0.83 to 1.79; I2 = 27%; 16 studies, 1308 women; moderate-certainty evidence). There was no evidence of a difference in quality of life outcomes; however, there was substantial heterogeneity in the data. Transvaginal absorbable mesh versus native tissue repair There was no evidence of a difference between the two methods of repair at two years for the rate of awareness of prolapse (RR 1.05, 95% CI 0.77 to 1.44; 1 study, 54 women), rate of repeat surgery for prolapse (RR 0.47, 95% CI 0.09 to 2.40; 1 study, 66 women), or recurrent prolapse on examination (RR 0.53, 95% CI 0.10 to 2.70; 1 study, 66 women). The effect of either form of repair was uncertain for bladder-related outcomes, dyspareunia, and quality of life. Transvaginal biological graft versus native tissue repair There was no evidence of a difference between the groups at one to three years for the outcome awareness of prolapse (RR 1.06, 95% CI 0.73 to 1.56; I2 = 0%; 8 studies, 1374 women; moderate-certainty evidence), repeat surgery for prolapse (RR 1.15, 95% CI 0.75 to 1.77; I2 = 0%; 6 studies, 899 women; moderate-certainty evidence), and recurrent prolapse on examination (RR 0.96, 95% CI 0.71 to 1.29; I2 = 53%; 9 studies, 1278 women; low-certainty evidence). There was no evidence of a difference between the groups for dyspareunia or quality of life. Transvaginal permanent mesh versus any other permanent mesh or biological graft vaginal repair Sparse reporting of primary outcomes in both comparisons significantly limited any meaningful analysis.

AUTHORS' CONCLUSIONS

While transvaginal permanent mesh is associated with lower rates of awareness of prolapse, repeat surgery for prolapse, and prolapse on examination than native tissue repair, it is also associated with higher rates of total repeat surgery (for prolapse, stress urinary incontinence, or mesh exposure), bladder injury, and de novo stress urinary incontinence. While the direction of effects and effect sizes are relatively unchanged from the 2016 version of this review, the certainty and precision of the findings have all improved with a larger sample size. In addition, the clinical relevance of these data has improved, with 10 trials reporting 3- to 10-year outcomes. The risk-benefit profile means that transvaginal mesh has limited utility in primary surgery. Data on the management of recurrent prolapse are of limited quality. Given the risk-benefit profile, we recommend that any use of permanent transvaginal mesh should be conducted under the oversight of the local ethics committee in compliance with local regulatory recommendations. Data are not supportive of absorbable meshes or biological grafts for the management of transvaginal prolapse.

Surgery for women with apical vaginal prolapse

BACKGROUND

Apical vaginal prolapse is the descent of the uterus or vaginal vault (post-hysterectomy). Various surgical treatments are available, but there are no guidelines to recommend which is the best.

OBJECTIVES

To evaluate the safety and efficacy of any surgical intervention compared to another intervention for the management of apical vaginal prolapse.

SEARCH METHODS

We searched the Cochrane Incontinence Group's Specialised Register of controlled trials, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings and ClinicalTrials.gov (searched 14 March 2022).

SELECTION CRITERIA

We included randomised controlled trials (RCTs).

DATA COLLECTION AND ANALYSIS

We used Cochrane methods. Our primary outcomes were awareness of prolapse, repeat surgery and recurrent prolapse (any site).

MAIN RESULTS

We included 59 RCTs (6705 women) comparing surgical procedures for apical vaginal prolapse. Evidence certainty ranged from very low to moderate. Limitations included imprecision, poor methodology, and inconsistency. Vaginal procedures compared to sacral colpopexy for vault prolapse (seven RCTs, n=613; six months to f four-year review) Awareness of prolapse was more common after vaginal procedures (risk ratio (RR) 2.31, 95% confidence interval (CI) 1.27 to 4.21, 4 RCTs, n = 346, I2 = 0%, moderate-certainty evidence). If 8% of women are aware of prolapse after sacral colpopexy, 18% (10% to 32%) are likely to be aware after vaginal procedures. Surgery for recurrent prolapse was more common after vaginal procedures (RR 2.33, 95% CI 1.34 to 4.04; 6 RCTs, n = 497, I2 = 0%, moderate-certainty evidence). The confidence interval suggests that if 6% of women require repeat prolapse surgery after sacral colpopexy, 14% (8% to 25%) are likely to require it after vaginal procedures. Prolapse on examination is probably more common after vaginal procedures (RR 1.87, 95% CI 1.32 to 2.65; 5 RCTs, n = 422; I2 = 24%, moderate-certainty evidence). If 18% of women have recurrent prolapse after sacral colpopexy, between 23% and 47% are likely to do so after vaginal procedures. Other outcomes: Stress urinary incontinence (SUI) was more common after vaginal procedures (RR 1.86, 95% CI 1.17 to 2.94; 3 RCTs, n = 263; I2 = 0%, moderate-certainty evidence). The effect of vaginal procedures on dyspareunia was uncertain (RR 3.44, 95% CI 0.61 to 19.53; 3 RCTs, n = 106, I2 = 65%, low-certainty evidence). Vaginal hysterectomy compared to sacral hysteropexy/cervicopexy (six RCTS, 554 women, one to seven year review) Awareness of prolapse - There may be little or no difference between the groups for this outcome (RR 1.01 95% CI 0.10 to 9.98; 2 RCTs, n = 200, very low-certainty evidence). Surgery for recurrent prolapse - There may be little or no difference between the groups for this outcome (RR 0.85, 95% CI 0.47 to 1.54; 5 RCTs, n = 403; I2 = 9%, low-certainty evidence). Prolapse on examination- there was little or no difference between the groups for this outcome (RR 0.78, 95% CI 0.54 to 1.11; 2 RCTs n = 230; I2 = 9%, moderate-certainty evidence). Vaginal hysteropexy compared to sacral hysteropexy/cervicopexy (two RCTs, n = 388, 1-four-year review) Awareness of prolapse - No difference between the groups for this outcome (RR 0.55 95% CI 0.21 to 1.44; 1 RCT n = 257, low-certainty evidence). Surgery for recurrent prolapse - No difference between the groups for this outcome (RR 1.34, 95% CI 0.52 to 3.44; 2 RCTs, n = 345; I2 = 0%, moderate-certainty evidence). Prolapse on examination- There were little or no difference between the groups for this outcome (RR 0.99, 95% CI 0.83 to 1.19; 2 RCTs n =367; I2 =9%, moderate-certainty evidence). Vaginal hysterectomy compared to vaginal hysteropexy (four RCTs, n = 620, 6 months to five-year review) Awareness of prolapse - There may be little or no difference between the groups for this outcome (RR 1.0 95% CI 0.44 to 2.24; 2 RCTs, n = 365, I2 = 0% moderate-quality certainty evidence). Surgery for recurrent prolapse - There may be little or no difference between the groups for this outcome (RR 1.32, 95% CI 0.67 to 2.60; 3 RCTs, n = 443; I2 = 0%, moderate-certainty evidence). Prolapse on examination- There were little or no difference between the groups for this outcome (RR 1.44, 95% CI 0.79 to 2.61; 2 RCTs n =361; I2 =74%, low-certainty evidence). Other outcomes: Total vaginal length (TVL) was shorter after vaginal hysterectomy (mean difference (MD) 0.89cm 95% CI 0.49 to 1.28cm shorter; 3 RCTs, n=413, low-certainty evidence). There is probably little or no difference between the groups in terms of operating time, dyspareunia and stress urinary incontinence. Other analyses There were no differences identified for any of our primary review outcomes between different types of vaginal native tissue repair (4 RCTs), comparisons of graft materials for vaginal support (3 RCTs), pectopexy versus other apical suspensions (5 RCTs), continuous versus interrupted sutures at sacral colpopexy (2 RCTs), absorbable versus permanent sutures at apical suspensions (5 RCTs) or different routes of sacral colpopexy. Laparoscopic sacral colpopexy is associated with shorter admission time than open approach (3 RCTs) and quicker operating time than robotic approach (3 RCTs). Transvaginal mesh does not confer any advantage over native tissue repair, however is associated with a 17.5% rate of mesh exposure (7 RCTs).

AUTHORS' CONCLUSIONS

Sacral colpopexy is associated with lower risk of awareness of prolapse, recurrent prolapse on examination, repeat surgery for prolapse, and postoperative SUI than a variety of vaginal interventions. The limited evidence does not support the use of transvaginal mesh compared to native tissue repair for apical vaginal prolapse. There were no differences in primary outcomes for different routes of sacral colpopexy. However, the laparoscopic approach is associated with a shorter operating time than robotic approach, and shorter admission than open approach. There were no significant differences between vaginal hysteropexy and vaginal hysterectomy for uterine prolapse nor between vaginal hysteropexy and abdominal hysteropexy/cervicopexy. There were no differences detected between absorbable and non absorbable sutures however, the certainty of evidence for mesh exposure and dyspareunia was low.

Is levator ani avulsion a risk factor for prolapse recurrence? A systematic review and meta-analysis

Introduction and hypothesis

Levator ani muscle avulsion as a risk factor for prolapse recurrence is not well established. This systematic review was aimed at evaluating the correlation between levator ani avulsion and postoperative prolapse recurrence with meta-analysis, specifically, the risk of subjective or objective prolapse recurrence and reoperation.

Methods

The protocol was registered in the International Prospective Register of Systematic Reviews (registration number CRD42021256675). A systematic literature search was conducted using PubMed, EMBASE and Cochrane Database of Systematic Reviews to identify all peer-reviewed studies that described levator avulsion in women and investigated operative and postoperative outcomes. All peer-reviewed, English-language cohort studies in those with and without levator avulsion with a minimum of 3 months’ follow-up were included. Pooled unadjusted and adjusted odds ratios were calculated for subjective recurrence, objective recurrence and rates of re-operation. The Cochrane Collaboration Risk of Bias In Non-Randomized Studies (RoBINS) and The Grading of Recommendations Assessment, Development and Evaluation (GRADE) tools were used to assess the quality of the studies included.

Results

Twelve studies with a total of 2,637 subjects and a follow-up period 0.3–6.4 years were identified. There were insufficient data to report a pooled adjusted risk for subjective recurrence and reoperation. On low to moderate quality-adjusted data, the pooled odds of objective recurrence was not significantly associated with levator ani avulsion (aOR 1.68; 95% CI 0.78–3.66).

Conclusion

Levator ani avulsion has not been confirmed as a risk factor for objective prolapse recurrence. Further evidence is needed to investigate the correlation between levator ani avulsion and the risk of subjective recurrence and reoperation.

Supplementary information

The online version contains supplementary material available at 10.1007/s00192-022-05217-2

Older Adult Health and Remission of Risky Drinking and Alcohol Use Disorder: A Lifespan-Developmental Study

Older-adult drinking is a growing public-health concern. As part of a larger project investigating older adulthood by contrasting this with other adult developmental periods, this study used longitudinal U.S.-representative data to test bidirectional associations between drinking and health, emphasizing aging-related health concerns as potential mechanisms of remission from risky/problem drinking. In multiple-group cross-lag models, we found that effects of poor self-reported health on drinking reductions increased with age, reached significance around midlife, and were strongest in older adulthood. However, a caveat revealed by additional Markov transition models was that these effects did not extend to relatively severe older-adult drinkers (indexed by DSM-5 AUD). In some instances, poor health even predicted less older-adult AUD remission. Altogether, findings support the notion of aging-related health concerns as important mechanisms of older-adult drinking reduction; but highlight a need to understand barriers to these mechanisms among severe older-adult drinkers, in part toward guiding lifespan-developmentally-informed interventions.

Age Effect on the Bidirectional Relations Between Alcohol Consumption and Pain

Alcohol consumption reduces but pain rises over the life course. Thus, we hypothesized that developmental variability in the bidirectional association between alcohol consumption and pain would vary as a function of age. This hypothesis was tested across three age groups – younger (<29), middle (29-65), and older (>65) using NESARC wave 1 and 2 data (N=34,653). The effect of pain interference at baseline on alcohol consumption at follow-up was non-significant across the age groups, indicating that self-medication theory was unsupported. The effect of alcohol consumption at baseline on pain interference at follow-up was significant among the middle (Estimate -.007, p=.002) and older (Estimate -.019, p<.001) groups, but non-significant among the younger group. This latter effect differed significantly between the younger and older groups (p =.005) and the middle and older groups (p=.041). Results show that alcohol consumption reduces pain interference, especially later in life.

Systematic review and meta-analysis of tracheostomy outcomes in COVID-19 patients

A systematic review and meta-analysis of the entire COVID-19 Tracheostomy cohort was conducted to determine the cumulative incidence of complications, mortality, time to decannulation and ventilatory weaning. Outcomes of surgical versus percutaneous and outcomes relative to tracheostomy timing were also analysed. Studies reporting outcome data on patients with COVID-19 undergoing tracheostomy were identified and screened by 2 independent reviewers. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed. Outcome data were analysed using a random-effects model. From 1016 unique studies, 39 articles reporting outcomes for a total of 3929 patients were included for meta-analysis. Weighted mean follow-up time was 42.03±26 days post-tracheostomy. Meta-analysis showed that 61.2% of patients were weaned from mechanical ventilation [95%CI 52.6%-69.5%], 44.2% of patients were decannulated [95%CI 33.96%-54.67%], and cumulative mortality was found to be 19.23% [95%CI 15.2%-23.6%] across the entire tracheostomy cohort. The cumulative incidence of complications was 14.24% [95%CI 9.6%-19.6%], with bleeding accounting for 52% of all complications. No difference was found in incidence of mortality (RR1.96; p=0.34), decannulation (RR1.35, p=0.27), complications (RR0.75, p=0.09) and time to decannulation (SMD 0.46, p=0.68) between percutaneous and surgical tracheostomy. Moreover, no difference was found in mortality (RR1.57, p=0.43) between early and late tracheostomy, and timing of tracheostomy did not predict time to decannulation. Ten confirmed nosocomial staff infections were reported from 1398 tracheostomies. This study provides an overview of outcomes of tracheostomy in COVID-19 patients, and contributes to our understanding of tracheostomy decisions in this patient cohort.

Real-time screening tool for identifying post-traumatic stress disorder in facial trauma patients in a UK maxillofacial trauma clinic

Post-traumatic stress disorder (PTSD) is a distressing consequence of a traumatic event associated with an increased suicide risk and reduced quality of life. Surgeons often have low confidence in identifying psychological problems. The prevalence of PTSD following facial trauma ranges from 23% to 41%. This highlights the importance of identifying and managing at-risk patients to optimize both mental and physical recovery. IMPARTS (Integrating Mental and Physical healthcare: Research, Training and Services) provides electronic screening tools to guide the non-mental health clinician in the 'real-time' identification, documentation, and management of potential mental health problems. The bespoke IMPARTS facial trauma screening tool was piloted in a UK oral and maxillofacial surgery trauma clinic from July 2015 to November 2017. A total of 199 patients completed screening, with 48 (24%) screening positive for possible PTSD. Further analysis of these 48 patients revealed that four (8%) had PTSD symptoms alone; three (6%) also screened positive for depression, 17 (35%) for co-existing symptoms of anxiety, and 24 (50%) for PTSD, anxiety, and depression. IMPARTS was found to be a highly effective tool aiding the non-mental health clinician to screen for PTSD and initiate prompt management. The data captured informs planning of the psychological support service.

Challenges of tracheostomy in COVID-19 patients in a tertiary centre in inner city London

The rapid global spread of SARS-CoV-2, the causative agent of COVID-19, has dominated healthcare services, with exponential numbers requiring mechanical ventilation in the intensive care unit (ICU). Tracheostomy facilitates respiratory and sedative weaning but risks potential viral transmission. This study reviewed the tracheostomy provision, techniques, and outcomes for a single-centre prospective cohort during the resource-pressured COVID-19 period. Seventy-two of 176 patients underwent tracheostomy at a median 17 days: 44 surgical (open), 28 percutaneous. Their median age was 58 years, the male to female ratio was 2.4:1, 75.1% were of BAME backgrounds, 76% had a BMI≥25kg/m2, and 65% had ≥2 major co-morbidities. Seventy-nine percent of patients were weaned from sedation at a median 2 days, 61% were weaned from mechanical ventilation at a median 10 days, 39% were discharged from the ICU at a median 11.5 days, and 19.4% were discharged home at a median 24 days. All patients survived the procedure. The mortality rate was 9.7% at a median 12 days. No clinician reported COVID-19 symptoms within 14 days of the procedure. The role of tracheostomy in COVID-19 is currently unclear. Delivery of tracheostomy by maxillofacial surgeons relieved the workload pressure from ICU clinicians. The choice of technique was influenced by the patient and resource factors, resulting in a mixed cohort of open and percutaneous tracheostomy in COVID-19 patients. Preliminary data suggest that open tracheostomy is as favourable as percutaneous tracheostomy for COVID-19 patients, and is safe for clinicians.

Printed titanium implants in UK craniomaxillofacial surgery. Part I: access to digital planning and perceived scope for use in common procedures

This first part of a two-part study examines perceived applications for and barriers to using printed titanium in light of current caseloads, funding pathways, and use of digital planning. It aims to demonstrate the scope for printed titanium in modern practice and to guide industry about the needs of UK surgeons. A cross-sectional study over 14 weeks was performed electronically with support from the British Association of Oral and Maxillofacial Surgeons (BAOMS) and a national trainee-led recruitment team. Ethics approval was obtained at the lead centre. A total of 132 participants joined the study (70% consultants, 25% specialty registrars, and 5% other), approximating a 29% response rate from consultant/registrar BAOMS members throughout mainland UK. Eighty-eight per cent used CAD-CAM design, with highly variable funding/access, design/manufacturing workflows (in-house/outsourced). Eighty-eight per cent were involved with trauma, 61% with orthognathic, and 52% with oncology-reconstruction surgery. Favourite applications for printed titanium were orbital floor repair (89%) and free-flap jaw reconstruction (87%). Most participants also cited maxillary/zygomatic osteotomies and cranioplasty (range 61%-73%). Although a popular application (78%), the evidence base in temporomandibular joint surgery is limited. Those performing orthognathic surgery perceived more indications than those who did not (p=0.013). Key barriers included cost, turnaround time and logistics, and the need to be trained in traditional techniques. Printed titanium was useful for both common and niche procedures, but was specifically limited in emergency trauma. Most surgeons had experience in CAD-CAM surgery but technical understanding appeared unclear. Limiting factors included variable funding and production pathways, perceived costs, and logistics, but in-house design can minimise them. In part II, we quantify perceived benefits and limitations and whether surgeons' understanding and knowledge are sufficient to rationalise them.

Printed titanium implants in UK craniomaxillofacial surgery. Part II: perceived performance (outcomes, logistics, and costs)

This second part explores perceptions and understanding of clinical performance, turnaround, and costs for printed titanium implants or plates in common procedures, evaluating both 'in-house' and 'outsourced' CAD-CAM pathways. A cross-sectional study, supported by the British Association of Oral and Maxillofacial Surgeons (BAOMS) and a national trainee-led recruitment team, was conducted over 14 weeks. A total of 132 participants took part (demographic data is reported in Part I). For fibular-flap mandibular reconstruction, most participants (69% - 91%) perceived printed titanium as superior to intraoperatively or preoperatively hand-bent plates for surgical duration, accuracy, dental restorability, and aesthetics. There was less agreement about complications and plate-failure risks. Most perceived printed plates to be superior to traditional wafer-based maxillary osteotomy for surgical duration (61%) and maxillary positioning (60%). For orbital floor repair, most perceived improvements in surgical duration (83%, especially higher-volume operators p=0.009), precision (84%), and ease of placement (69%). Rarely (less than 5%) was any outcome rated inferior to traditional techniques for any procedure. Perceived turnaround times and costs were variable, but the greatest consensus was for two-segment fibular-flap reconstructions and orbital floor repair. Industry estimates were generally consistent between two company representatives, but manufacturing-only costs differed when using in-house (departmental) designers. Costs and turnaround times are questionable barriers since few understand 'real-world' figures. Designing in-house can dramatically alter costs. Improved accuracy and surgical duration are common themes but biomechanical benefits are less-well understood. This study paints a picture of the potentially routine applications and benefits of printed titanium, capacity for uptake, understanding amongst surgeons, and areas for improvement.

The influence of 2020 coronavirus lockdown on presentation of oral and maxillofacial trauma to a central London hospital

The novel coronavirus COVID-19 was first identified in China in December 2019. Its spread resulted in a pandemic, with the United Kingdom entering a period of national lockdown on 23 March 2020 to reduce disease burden on the National Health Service (NHS). King's College Hospital is a Major Trauma Centre serving an inner-city population of 700,000 with 120,000 patients attending the emergency department (ED) annually. We aimed to determine the effect of lockdown on OMFS trauma presentations and lessons learned from emergency service provision during a pandemic. All referrals to the oral and maxillofacial surgical (OMFS) team from ED during the first six weeks of the lockdown period - 23 March 2020 - 3 May 2020 - were compared with the same six-week period in 2019. A total of 111 referrals were made to OMFS during the first six weeks of the lockdown period in 2020 compared with 380 referrals in 2019. Of these, 50.5%, (n=192) were related to facial trauma in 2019 vs (63.1%, n=70) in 2020. Fewer patients were admitted under OMFS: 17.4% (n=35) in 2019 vs 2.9% (n=2) in 2020, and a greater number of patients were discharged from OMFS care directly from the ED: 63.2% (n=127) in 2019 vs 82.9% (n=58) in 2020. There was profound effect of the lockdown on referrals to OMFS from the ED, in number and type of diagnosis. This is potentially reflective of the increased availability of acute/emergency dental services in South-East London during the lockdown period. This gives us valuable insight for service planning in the event of further restrictions.

Family Strain Predicts Subsequent Depressive Symptoms in Middle-aged Adults: Hope Mediates and Self-compassion Moderates the Relation

Introduction

Interpersonal strain is linked with depressive symptoms in middle-aged adults. One possible mechanism accounting for this relation is a reduction in hope, defined as the belief in one's capacity both to reach and to generate a variety of ways to obtain goals. The strength of the strain-depressive symptoms relation is not uniform across individuals, however, pointing to the likelihood that individual differences in the ability to successfully navigate relationship strain play a role in mitigating its negative effects. One potential moderator of the strain - depressive symptoms relation is self-compassion, which encompasses the capacity to respond to one's own negative thoughts and experiences in a kind and nonjudgmental way. Although theory and empirical evidence suggest that self-compassion is protective against the impact of stress on mental health outcomes, little research has investigated how self-compassion operates in the context of relationship strain. In addition, few studies have examined psychological mechanisms by which self-compassion protects against mental health outcomes, depression in particular. Thus, this study examined 1) the extent to which hope mediates the relation between family strain and depressive symptoms, and 2) whether these indirect effects are conditional on self-compassion in a community sample of middle-aged adults.

Methods

Self-reported family strain, self-compassion, hope, and depressive symptoms were assessed in a community sample of 762 middle-aged adults aged 40-65. Follow-up measures of depressive symptoms were assessed approximately 20 months later.

Results

Results from structural equation models indicated that hope mediated the relation between family strain and depressive symptoms and the indirect effect was conditional on levels of self-compassion. For individuals high versus low in self-compassion, strain-related declines in hope predicted smaller increases in depressive symptoms.

Discussion

Taken together, the findings suggest that family strain may lead individuals to experience less hope and subsequent increases in depressive symptoms. However, a self-compassionate attitude may serve as a resilience resource, weakening the hope - depressive symptoms relation, a finding that holds promise for future research on the development and refinement of self-compassion interventions.

Real-time optical vascular imaging: a method to assess the microvascular circulation of myofascial free flaps used in the head and neck region

Microvascular free flaps are considered the gold standard in head and neck reconstructive surgery. Myofascial flaps, in particular, are useful in certain oral and maxillofacial reconstruction cases, where mucosal regeneration over the transplanted tissue is planned. Despite high success rates, 1-6% of free flaps fail. A plethora of methods are available to assess transplanted tissue viability after reconstruction, including clinical observational monitoring, surface Doppler, implantable Doppler probe, colour Doppler sonography, laser Doppler flowmeter, surface temperature and indocyanine green angiography. However, no method has demonstrated adequate reliability or has proven to be cost-effective. The authors tested a technique called real-time optical vascular imaging to evaluate the microvascular circulation of myofascial free flaps. This technique was develop at Guy's Hospital, London to observe the microvascular anatomy of the oral cavity in vivo, non-invasively and without the need for patient preparation, with the aim of detecting and monitoring oral diseases. This technology detects the red blood cells flowing inside the microvasculature at a depth of approximately 2mm, allowing the microvascular architecture and blood flow to be determined. This study showed that RTOVI may prove to be beneficial for the early detection of vascular compromise due to its immediacy and the feasibility of assessing multiple graft tissue regions.

Exposure to graphic warning labels on cigarette packages: Effects on implicit and explicit attitudes towards smoking among young adults

OBJECTIVE

To test the effect of exposure to the US Food and Drug Administration's proposed graphic images with text warning statements for cigarette packages on implicit and explicit attitudes towards smoking.

DESIGN AND METHODS

A two-session web-based study was conducted with 2192 young adults 18-25-years-old. During session one, demographics, smoking behaviour, and baseline implicit and explicit attitudes were assessed. Session two, completed on average 18 days later, contained random assignment to viewing one of three sets of cigarette packages, graphic images with text warnings, text warnings only, or current US Surgeon General's text warnings. Participants then completed post-exposure measures of implicit and explicit attitudes. ANCOVAs tested the effect of condition on the outcomes, controlling for baseline attitudes.

RESULTS

Smokers who viewed packages with graphic images plus text warnings demonstrated more negative implicit attitudes compared to smokers in the other conditions (p = .004). For the entire sample, explicit attitudes were more negative for those who viewed graphic images plus text warnings compared to those who viewed current US Surgeon General's text warnings (p = .014), but there was no difference compared to those who viewed text-only warnings.

CONCLUSION

Graphic health warnings on cigarette packages can influence young adult smokers' implicit attitudes towards smoking.

Differences in risk factors for incident and recurrent small-for-gestational-age birthweight: a hospital-based cohort study

OBJECTIVE

Examine whether small-for-gestational-age (SGA) risk factors differed by prior SGA birth.

DESIGN

Hospital-based cohort study.

SETTING

Utah, USA.

POPULATION

Electronic medical record data from 25,241 women who were nulliparous at study entry with ≥2 subsequent consecutive singleton deliveries (2002-2010).

METHODS

Estimated adjusted relative risks (RR) and 95% confidence intervals (95% CI) for the association between second pregnancy characteristics and SGA risk. Tested for risk factor differences between recurrence and incidence (Pdifference).

MAIN OUTCOME MEASURES

Second pregnancy incident (n = 1067) and recurrent SGA (n = 484) determined using a population-based reference.

RESULTS

SGA complicated 20.3 and 4.5% of deliveries to women with and without a prior SGA birth, respectively. Young maternal age (Pdifference = 0.01) and pregnancy hypertensive diseases (Pdifference = 0.03) were associated with incident but not recurrent SGA. Significant risk factors for incidence and recurrence were smoking (incident RR = 1.64 [95% CI 1.22-2.19]; recurrent RR = 1.59 [95% CI 1.17-2.17]), short stature (incident RR = 1.34 [95% CI 1.16-1.54]; recurrent RR = 1.54 [95% CI 1.31-1.82]), prepregnancy underweight (incident RR = 1.32 [95% CI 1.07-1.64]; recurrent RR = 1.30 [95% CI 1.03-1.64]), and inadequate weight gain (incident RR = 1.41 [95% CI 1.22-1.64]; recurrent RR = 1.33 [95% CI 1.10-1.60]). Race-ethnicity, marital or insurance status, alcohol, diabetes, asthma, thyroid disease, depression, or interpregnancy interval were not associated with incidence or recurrence.

CONCLUSION

There was considerable overlap in the risk factors for SGA recurrence and incidence. Recurrence and incidence risk factors included smoking, short stature, underweight, and inadequate weight gain. Maternal age and hypertensive diseases increased the risk for incidence only. Regardless of the SGA definition, some potentially modifiable risk factors for recurrence were identified.

Height and the risk of gestational diabetes: variations by race/ethnicity

AIMS

Gestational diabetes is a common pregnancy complication affecting races/ethnicities disproportionally. Adult height, an indicator of both genetic and early-life factors, is inconsistently associated with gestational diabetes risk. We examined the association and whether it varies by races in a nationally representative US cohort.

METHODS

Analyses were conducted among 135 861 pregnancies in the Consortium on Safe Labor, 5567 of which were diagnosed with gestational diabetes based on medical records review. Generalized estimating equations were used to estimate odds ratios (95% confidence intervals) of gestational diabetes, controlling for other risk factors including body weight. Additionally, a meta-analysis of 15 761 pregnancies with gestational diabetes and 205 828 without gestational diabetes was conducted to estimate the pooled mean difference in height between those with gestational diabetes and control subjects.

RESULTS

Height was inversely associated with gestational diabetes risk across races/ethnicities, with the strongest association among Asians (P for interaction < 0.01). Comparing extreme quartiles (> 168 vs. < 157 cm), adjusted odds ratios (95% confidence intervals) were 0.18 (0.09-0.36) for Asians/Pacific Islanders, 0.33 (0.29-0.38) for non-Hispanic white women, 0.39 (0.31-0.51) for Hispanics and 0.59 (0.47-0.75) for non-Hispanic black women. Meta-analysis found women with gestational diabetes to be significantly shorter than others.

CONCLUSIONS

Taller women are at lower risk of developing gestational diabetes, with the magnitude of association varying significantly across races/ethnicities.

Bone mineral density and blood metals in premenopausal women

Exposure to metals, specifically cadmium, lead, and mercury, is widespread and is associated with reduced bone mineral density (BMD) in older populations, but the associations among premenopausal women are unclear. Therefore, we evaluated the relationship between these metals in blood and BMD (whole body, total hip, lumbar spine, and non-dominant wrist) quantified by dual energy X-ray absorptiometry in 248 premenopausal women, aged 18-44. Participants were of normal body mass index (mean BMI 24.1), young (mean age 27.4), 60% were white, 20% non-Hispanic black, 15% Asian, and 6% other race group, and were from the Buffalo, New York region. The median (interquartile range) level of cadmium was 0.30 μg/l (0.19-0.43), of lead was 0.86 μg/dl (0.68-1.20), and of mercury was 1.10 μg/l (0.58-2.00). BMD was treated both as a continuous variable in linear regression and dichotomized at the 10th percentile for logistic regression analyses. Mercury was associated with reduced odds of decreased lumbar spine BMD (0.66, 95% confidence interval: 0.44, 0.99), but overall, metals at environmentally relevant levels of exposure were not associated with reduced BMD in this population of healthy, reproductive-aged women. Further research is needed to determine if the blood levels of cadmium, lead, and mercury in this population are sufficiently low that there is no substantive impact on bone, or if effects on bone can be expected only at older ages.

Ten year survival and outcomes in a prospective cohort of new onset Chinese Parkinson's disease patients

OBJECTIVE

The 10 year outcomes and impact of motor and non-motor features on survival of a cohort of new onset Chinese Parkinson's disease (PD) patients were prospectively studied.

METHOD

A cohort of new onset PD patients from 1995 to 2002 was recruited from a regional hospital based movement disorder clinic. Subjects were classified into postural instability gait disorder (PIGD), tremor predominant type or mixed subtypes at presentation. All were evaluated yearly for development of sensory complaints, first significant fall, hallucinations, dementia, postural hypotension, speech disturbances, dysphagia and postural instability persisted during 'on' medication state (PIPon). Mortality and predictors of death were determined.

RESULTS

171 new onset PD patients were recruited. After a mean follow-up of 11.3±2.6 years, 50 (29%) patients died. The standardised mortality ratio was 1.1 (CI 0.8 to 1.5, p=0.34). 83 (49%) developed dementia, 81 (47%) had psychosis and 103 (60%) had sensory complaints. Postural hypotension was found in 58 (34%) patients, 108 (63%) had PIPon, 101 (59%) had falls, 102 (60%) had dysphagia, 148 (87%) had freezing of gait and 117 (68%) had speech disturbances. 46 (27%) were institutionalised whereas 54 (32%) lived independently. Dementia (HR 5.0, 95% CI 2.1 to 13.0), PIPon (HR 2.8, 95% CI 1.2 to 6.8), older onset (HR 1.05, 1 year increase in age, 95% CI 1.0 to 1.1) and PIGD type (HR 2.1, 95% CI 1.2 to 3.7) were independent predictors of death.

CONCLUSIONS

10 years into PD, a significant proportion of patients developed dopa resistant motor and non-motor features. Older onset, PIGD type, PIPon and dementia had a negative impact on survival. Standardised mortality ratio was 1.1.

Influence of eicosapentaenoic acid supplementation on lean body mass in cancer cachexia

Cancer cachexia is characterised by a progressive loss of muscle, resulting in functional impairment and shorter survival. Eicosapentaenoic acid, an n-3 polyunsaturated fatty acid found in fish, has been studied for its role as an anti-cachexia therapy. Initial results of eicosapentaenoic supplementation in advanced cancer were promising with improvements in lean body mass (LBM), appetite and quality of life. However, subsequent larger phase III clinical trials reported minimal benefits of supplementation. Recently, several studies have used different study designs, which may provide insight on the effectiveness of eicosapentaenoic in cancer cachexia and also on potential sources of divergent results in previous trials. This review examines the potential benefit of eicosapentaenoic supplementation on LBM and discusses limitations with current studies to identify methods which may aid in progressing the research of future clinical trials.

The role of patient factors and implant position in squeaking of ceramic-on-ceramic total hip replacements

We investigated factors that were thought to be associated with an increased incidence of squeaking of ceramic-on-ceramic total hip replacements. Between June 1997 and December 2008 the three senior authors implanted 2406 primary total hip replacements with a ceramic-on-ceramic bearing surface. The mean follow-up was 10.6 years. The diagnosis was primary osteoarthritis in each case, and no patient had undergone previous surgery to the hip. We identified 74 squeaking hips (73 patients) giving an incidence of 3.1% at a mean follow-up of 9.5 years (4.1 to 13.3). Taller, heavier and younger patients were significantly more likely to have hips that squeaked. Squeaking hips had a significantly higher range of post-operative internal (p = 0.001) and external rotation (p = 0.003) compared with silent hips. Patients with squeaking hips had significantly higher activity levels (p = 0.009). A squeaking hip was not associated with a significant difference in patient satisfaction (p = 0.24) or Harris hip score (p = 0.34). Four implant position factors enabled good prediction of squeaking. These were high acetabular component inclination, high femoral offset, lateralisation of the hip centre and either high or low acetabular component anteversion. This is the largest study to date to examine patient factors and implant position factors that predispose to squeaking of a ceramic-on-ceramic hip. The results suggest that factors which increase the mechanical forces across the hip joint and factors which increase the risk of neck-to-rim impingement, and therefore edge-loading, are those that predispose to squeaking.

The effect of obesity on the mid-term survival and clinical outcome of cementless total hip replacement

The outcome of total hip replacement (THR) is potentially affected by the body mass index (BMI) of the patient. We studied the outcome of 2026 consecutive primary cementless THRs performed for osteoarthritis. The mean follow-up was 6.3 years (0 to 11.71) and no patient was lost to follow-up for survival analysis. The patients were divided into two groups according to their BMI as follows: non-obese (BMI < 30 kg/m(2)) and obese (BMI > or = 30 kg/m(2)). The obese patient undergoing surgery was found to be significantly younger (p < 0.001). The log-rank test for equality of survival showed no difference in the mid-term survival (p = 0.552) with an estimated survival at 11 years of 95.2% (95% CI 92.5 to 98.0) in the non-obese and 96.7% (95% CI 94.9 to 98.5) in the obese groups. The clinical and radiological outcome was determined in a case-matched study performed on 134 obese individuals closely matched with 134 non-obese controls. The non-obese group was found to have a significantly higher post-operative Harris hip score (p < 0.001) and an increased range of movement, but overall satisfaction with surgery was comparable with that of the obese patients. Radiological analysis of the acetabular and femoral components showed no significant differences with regard to radiolucent lines, osteolysis, ingrowth of the femoral component, the acetabular inclination angle or alignment of the femoral component. Our results suggest that the survival of cementless THR is not adversely affected by obesity. Obese patients can therefore be counselled that despite a lower clinical score, they should expect to be satisfied with the result of their THR with a mid-term survival rate equivalent to that of non-obese patients.

Family experience caring for terminally ill patients with cancer in Hong Kong

In this study, 24 family caregivers of terminally ill patients participated in in-depth interviews regarding their experiences of giving care. The data were analyzed using grounded theory qualitative method. Commitment emerged as the precondition of the caregiving process. The caregivers did not perceive the work of caring as a burden. Rather, they felt that despite any personal hardships, what they were doing was important to their loved ones and therefore meaningful to them as caregivers. The components of commitment can be described as relational commitment, the act of showing love, and determination. The process of caregiving includes four phases: 1) holding onto hope for a miracle, 2) taking care, 3) preparing for death, and 4) adjusting to another phase of life. A patient-caregiver relationship, Confucian concepts of yi (appropriateness or rightness), and filial duty are reflected in the process of caregiving. Consequences of the process include finding meaning in life and peace of heart and mind. The emotional aspect of the caregiving experience can be described as an intense emotional experience filled with feelings of hope and hopelessness, guilt, fear, and regret. As a result of the caregiving experience, most participants found they have had a change of worldviews and treasure their lives. Findings show a significant need for interventions at each phase of the caregiving process designed to provide effective and culturally sensitive support and affirmation to family members as they care for their loved ones with terminal illnesses.

Perception of empowerment by family caregivers of patients with a terminal illness in Hong Kong

The purpose of this study is to provide an in-depth description of the nurse-facilitated empowering experiences of family caregivers of terminally ill patients in Hong Kong. Data were collected through in-depth interviews with 24 family caregivers of patients with terminal cancer. Grounded theory strategies served as the basis for data collection and analysis. Data were analysed in terms of the strategies, consequences, and interactions involved in the empowering experience. Themes included establishing an engaged relationship; providing information, knowledge and skills; affirming self-worth; and giving reassurance that the patient is under good care. The consequences of empowerment included a trusting relationship, having confidence to carry out caregiving tasks, acceptance of patient's death, sustained self-worth and feeling peace at heart. The focus of empowering experiences was related to the quality of life of the dying patients. Family caregivers require information, education, encouragement and support, and nurses are in an ideal position to meet this need. Fundamental in the empowering process is the formation of a trusting relationship and as a result the caregivers feeling they are not being abandoned or left alone in the caring process. The results of this study can help nurse interact more effectively with family caregivers, giving them direction for effective nursing practice when caring for patients with a terminal illness.

A proteinase inhibitor II of Solanum americanum is expressed in phloem

Although proteinase inhibitor proteins are known to confer insect resistance in transgenic plants, their endogenous roles remain undefined. Here, we describe the expression of a proteinase inhibitor II (PIN2) protein from Solanum americanum in phloem of stems, roots and leaves suggesting a novel endogenous role for PIN2 in phloem. The phloem consists of parenchyma cells, sieve elements (SE), and companion cells (CC) which are in close association with SE. We isolated two cDNAs encoding PIN2, SaPIN2a and SaPIN2b, from a S. americanum cDNA library using a tomato PIN2 cDNA as hybridization probe. SaPIN2a shows 73.6% identity to SaPIN2b. Southern blot analysis confirmed that two genes occur in S. americanum. Northern blot analysis showed that both are wound-inducible and are expressed in flowers. Unlike SaPIN2b and other previously characterized plant PIN2 proteins, SaPlN2a is abundantly expressed in stems. In situ hybridization studies on stem sections showed that SaPIN2a mRNA is expressed in CC and some SE, likely the immature developing SE. of external and internal phloem. Western blot analysis using SaPIN2a-specific antibodies showed SaPIN2a accumulation in stems, leaf midribs and fruits. Immunohistochemical localization, using these antibodies, revealed SaPIN2a expression in external and internal phloem of stem. Immunoelectron microscopy of stem, root and leaf sections further localized SaPIN2a to the CC and predominantly to the SE, particularly the parietal cytoplasm adjacent to the cell wall, the lumen and the sieve-area pores. These results suggest that, other than a possible role in plant defense, SaPIN2a could be involved in regulating proteolysis in the SE.

Field measurements of electromagnetic interference in hearing aids

This investigation was a preliminary field study to determine the acoustic and perceptual characteristics of hearing aid distortion generated by digital wireless telephones, the usability of the telephones under field conditions, and the extent of bystander interference under field conditions. A two-channel analog-to-digital converter was used to monitor voltages generated by an acoustic (real-ear) and electromagnetic probe. Digital recordings of interference and speech plus interference were made on a laptop computer. Fifty-three hearing aid wearers listened to interference and speech plus interference through personal communication service 1900 and time division multiple access digital wireless telephones and rated them in terms of annoyance experienced and usability of the wireless telephone. Ratings of annoyance were also done for the bystander condition. Approximately 80 percent of the sample rated the telephones as unusable; on the other hand, 70 to 90 percent experienced no annoying interference from telephones being used by another person seated nearby (bystander condition).