The Design of a Prospective Trial to Evaluate the Role of Preoperative Frailty Assessment in Older Women Undergoing Surgery for the Treatment of Pelvic Organ Prolapse: The FASt Supplemental Trial

OBJECTIVE

We present the rationale for and the design of a prospective trial to evaluate the role of preoperative frailty and mobility assessments in older women undergoing surgery for the treatment of pelvic organ prolapse (POP) as a planned prospective supplemental trial to the ASPIRe (Apical Suspension Repair for Vault Prolapse In a Three-Arm Randomized Trial Design) trial. The Frailty ASPIRe Study (FASt) examines the impact of preoperative frailty and mobility on surgical outcomes in older women (≥65 years) participating in the ASPIRe trial. The primary objective of FASt is to determine the impact of preoperative age, multimorbidity, frailty, and decreased mobility on postoperative outcomes in older women (≥65 years old) undergoing surgery for POP.

METHODS

The selection of the preoperative assessments, primary outcome measures, and participant inclusion is described. Frailty and mobility measurements will be collected at the preoperative visit and include the 6 Robinson frailty measurements and the Timed Up and Go mobility test. The main outcome measure in the FASt supplemental study will be moderate to severe postoperative adverse events according to the Clavien-Dindo Severity Classification.

CONCLUSIONS

This trial will assess impact of preoperative age, multimorbidity, frailty, and decreased mobility on postoperative outcomes in older women (≥65 years old) undergoing surgical procedures for the correction of apical POP. Information from this trial may help both primary care providers and surgeons better advise/inform women on their individual risks of surgical complications and provide more comprehensive postoperative care to women at highest risk of complications.

Outcomes of native tissue transvaginal apical approaches in women with advanced pelvic organ prolapse and stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

Limited data exist comparing different surgical approaches in women with advanced vaginal prolapse. This study compared 2-year surgical outcomes of uterosacral ligament suspension (ULS) and sacrospinous ligament fixation (SSLF) in women with advanced prolapse (stage III-IV) and stress urinary incontinence.

METHODS

This was a secondary analysis of a multicenter 2 × 2 factorial randomized trial comparing (1) ULS versus SSLF and (2) behavioral therapy with pelvic floor muscle training versus usual care. Of 374 subjects, 117/188 (62.7%) in the ULS and 113/186 (60.7%) in the SSLF group had advanced prolapse. Two-year surgical success was defined by the absence of (1) apical descent > 1/3 into the vaginal canal, (2) anterior/posterior wall descent beyond the hymen, (3) bothersome bulge symptoms, and (4) retreatment for prolapse. Secondary outcomes included individual success outcome components, symptom severity measured by the Pelvic Organ Prolapse Distress Inventory, and adverse events. Outcomes were also compared in women with advanced prolapse versus stage II prolapse.

RESULTS

Success did not differ between groups (ULS: 58.2% [57/117] versus SSLF: 58.5% [55/113], aOR 1.0 [0.5-1.8]). No differences were detected in individual success components (p > 0.05 for all components). Prolapse symptom severity scores improved in both interventions with no intergroup differences (p = 0.82). Serious adverse events did not differ (ULS: 19.7% versus SSLF: 16.8%, aOR 1.2 [0.6-2.4]). Success was lower in women with advanced prolapse compared with stage II (58.3% versus 73.2%, aOR 0.5 [0.3-0.9]), with no retreatment in stage II.

CONCLUSIONS

Surgical success, symptom severity, and overall serious adverse events did not differ between ULS and SSLF in women with advanced prolapse. ClinicalTrials.gov Identifier: NCT01166373.

A deleterious gene-by-environment interaction imposed by calcium channel blockers in Marfan syndrome

Calcium channel blockers (CCBs) are prescribed to patients with Marfan syndrome for prophylaxis against aortic aneurysm progression, despite limited evidence for their efficacy and safety in the disorder. Unexpectedly, Marfan mice treated with CCBs show accelerated aneurysm expansion, rupture, and premature lethality. This effect is both extracellular signal-regulated kinase (ERK1/2) dependent and angiotensin-II type 1 receptor (AT1R) dependent. We have identified protein kinase C beta (PKCβ) as a critical mediator of this pathway and demonstrate that the PKCβ inhibitor enzastaurin, and the clinically available anti-hypertensive agent hydralazine, both normalize aortic growth in Marfan mice, in association with reduced PKCβ and ERK1/2 activation. Furthermore, patients with Marfan syndrome and other forms of inherited thoracic aortic aneurysm taking CCBs display increased risk of aortic dissection and need for aortic surgery, compared to patients on other antihypertensive agents.

DOI:http://dx.doi.org/10.7554/eLife.08648.001

Marfan syndrome is a disorder that affects the body's connective tissues, which maintain the structure of the body and support organs and other tissues. People with Marfan syndrome have connective tissues that can stretch more than those of other people, which put them at increased risk of a life-threatening tear in their aorta (the main artery in the body), muscle weakness and other problems.

A cell communication pathway called TGFβ signaling is involved in cell growth and many other important processes. TGFβ signaling is more active in patients with Marfan syndrome due to mutations in a gene called FBN1. Drugs that block TGFβ signaling—which are also used to treat high blood pressure—can reduce the symptoms of the disorder. Unfortunately, not all people with Marfan disease can tolerate these drugs and other medications called calcium channel blockers, which also lower blood pressure, are often used as an alternative. It is thought that calcium channel blockers help reduce stress on blood vessels, but there is little data to show whether these drugs are safe and helpful for patients with Marfan syndrome.

Now, Doyle, Doyle et al. studied the effect of two different calcium channel blockers on mice that have a mutation in Fbn1—the mouse equivalent of FBN1—that is similar to those found in humans with Marfan syndrome. The experiments show that the aortas of these mice grew more quickly and were more likely to tear when compared to mice that did not receive these drugs. Many of these aortic tears were fatal. The calcium channel blockers increased the activity of two signaling molecules that are regulated by TGFβ signaling. Treating the Marfan mice with other drugs that lower the activity of these signaling molecules protected the aorta, even if they were also treated with the calcium channel blockers.

Doyle, Doyle et al. examined a registry of human patients. This revealed preliminary evidence that aortic tears and aortic repair surgery were more common in patients with Marfan syndrome who had received calcium channel blockers than patients who had been treated with other drugs. Together, these findings suggest that it may be dangerous to treat patients with Marfan syndrome with calcium channel blockers. Additional work will be needed to confirm this risk, to find out if it extends to other similar conditions, and to explore the therapeutic potential of drugs that target the two enzymes.

DOI:http://dx.doi.org/10.7554/eLife.08648.002

Chronic back pain and associated work and non-work variables among farmworkers from Starr County, Texas

OBJECTIVES

This study estimated the prevalence of chronic back pain among migrant farmworker family members and identified associated work and non-work variables.

METHODS

Migrant farmworkers (n = 390 from 267 families) from Starr County, Texas were interviewed in their home once a year for 2 years. The original survey included items measuring demographics, smoking, sleep, farm work, and chronic back pain. For this cross-sectional analysis, multi-level logistic regression was used to identify associated work and other variables associated with chronic back pain while accounting for intraclass correlations due to repeated measures and multiple family members.

RESULTS

The prevalence of chronic back pain during the last migration season ranged from 9.5% among the youngest children to 33.3% among mothers. Variables significantly associated with chronic back pain were age (odds ratio [OR], 1.03, per year increase), depressive symptoms while migrating (OR, 8.72), fewer than 8 hours of sleep at home in Starr County (OR, 2.26), fairly bad/very bad quality of sleep while migrating (OR, 3.25), sorting crops at work (OR, 0.18), and working tree crops (OR, 11.72).

CONCLUSION

The role of work exposures, depressive symptoms, and sleep in chronic back pain among farmworkers warrants further examination. Refinements in outcome and exposure assessments are also needed given the lack of a standardized case definition and the variety of tasks and crops involved in farm work in the United States.

Pesticide safety training among farmworker adolescents from Starr County, Texas

This study of adolescent farmworkers describes employer compliance with pesticide safety training, a requirement of the EPA-mandated Worker Protection Standard (WPS), and identifies variables associated with having received training within the prior five years. Data are from "A Study of Work Injuries in Farmworker Children, " a three-year cohort study of high school students living along the Texas-Mexico border in Starr County. Data were collected using a web-based, self-administered, confidential survey. Of 324 students who participated in field work between January 1 and September 30, 2003, 68 (21.0%) reported ever receiving pesticide safety training. Overall, the 61 (18.8%) students who reported training within the prior five years also reported that their most recent instruction covered at least three key WPS areas (i.e., entry into a recently treated field, pesticide-related injuries/illnesses, and emergency care for pesticide exposure). Based on a multiple logistic regression, students who were male (OR = 1.97), worked only outside of Texas (OR = 2.73), worked only for commercial growers/owners (OR = 4.35), worked only for contractors (OR = 3.18), worked corn crops (OR = 2.93), and worked potato crops (OR = 3.11) were more likely to report receipt of training within the prior five years. Results suggest that increased enforcement may be needed, especially in Texas, and special educational efforts may be needed to reach female farmworker youth.

A Cohort Study of Injuries in Migrant Farm Worker Families in South Texas

PURPOSE

This cohort study estimated the frequency of and risk factors for work injuries among migrant farmworker families over a two-year period.

METHODS

The cohort consisted of 267 families. Bilingual interviewers asked mothers to respond for their family soliciting demographic, psychosocial, employment, and work-related injury information. Cox regression was used to examine risk factors for first injury events.

RESULTS

Of the 267 families, nearly 60% migrated and 96% of these completed the follow-up interviews. These families represented about 310 individuals each year who had participated in farmwork on average 6 days a week, 10 hours a day, for 2.7 months in the past year. Twenty-five work-related injuries were reported with an overall rate of 12.5/100 FTE (95% C.I., 8.6-19.0). Working for a contractor increased the hazard ratio, and use of car seat belts and working for more than one employer during the season decreased it.

CONCLUSIONS

If person-time at risk for injuries is taken into account the reported injuries are substantial. Because the injuries were quite diverse, specific interventions may have to focus on improved working conditions (physical and economic), ergonomic modifications, and enhanced enforcement of existing regulations.