Pelvic organ prolapse surgery with and without tension-free vaginal tape in women with occult or asymptomatic urodynamic stress incontinence: a randomised controlled trial.

INTRODUCTION: We set out to determine if insertion of a retropubic tension-free vaginal tape (TVT) sling at the time of pelvic organ prolapse surgery improves continence outcomes in women with pre-operative occult stress incontinence (OSI) or asymptomatic urodynamic stress incontinence (USI). METHODS: We conducted a randomised controlled study of prolapse surgery with or without a TVT midurethral sling. The pre- and post-operative assessment at 6 months included history, physical examination and urodynamic testing. Quality of life (QOL) and treatment success was assessed with the UDI-6 SF, IIQ-7 SF and a numerical success score. The primary outcome was symptomatic stress urinary incontinence (SUI) requiring continence surgery (TVT) at 6 months. Long-term follow-up continued to a minimum of 24 months. Secondary outcomes were quality of life parameters. RESULTS: Eighty women received prolapse surgery alone (n = 43) or prolapse surgery with concurrent TVT (n = 37). Six months following prolapse surgery 3 out of 43 (7 %) patients in the no TVT group requested sling surgery compared with 0 out of 37 (0 %) in the TVT group (ARR 7 % [95 %CI: 3 to 19 %], p = 0.11). After 24 months there was one further participant in the no TVT group who received a TVT for treatment of SUI compared with none in the TVT group (4 out of 43, 9.3 % versus 0 out of 37; ARR 9.3 % [95 %CI: -1 to 22 %], p = 0.06). Both groups showed improvement in QOL difference scores for within-group analysis, without difference between groups. CONCLUSION: These results support a policy that routine insertion of a sling in women with OSI at the time of prolapse repair is questionable and should be subject to shared decision-making between clinician and patient.

Trabecular Bone Score Helps Classifying Women At Riskof Fracture Prospectively In The Ofely Study

Objectives: Trabecular Bone Score (TBS, Med-Imaps, France) is an index of bone microarchitecture calculated from antero-posterior spine DXA scan and reported to be associated with fracture in prior case-control studies and in a large prospective study with the Prodigy DXA device. Our aim was to assess the ability of TBS to predict incident fracture and improve the classification of fracture prospectively in the OFELY study.Materials/Methods: TBS was assessed in 564 postmenopausal women (66±8 years old) from the OFELY cohort, who had a spine DXA scan (QDR 4500A, Hologic, USA) between year 2000 and 2001. During a mean follow up of 7.8±1.3 years, 94 women sustained a fragility fracture.Results: At the time of baseline DXA scan, women with incident fracture were significantly older (70±9 vs. 65± 8 years), had a lower spine BMD (T-score: −1.9±1.2 vs. −1.3±1.3, p<0.001) and spine TBS (−3.1%, p<0.001) than women without incident fracture. After adjustment for age, BMI and the presence of prevalent fracture, the magnitude of fracture prediction was similar for spine BMD (OR=1.42 [1.11;1.82] per SD decrease [95% CI]) and TBS (OR=1.34 [1.04;1.74]) but the combination of TBS and spine BMD did not improve fracture prediction. Spine BMD and TBS were both correlated with age (respectively r=−0.17 and −0.49, p<0.001) and correlated together with 39% of TBS explained by spine BMD (r=0.63, p<0.001). When using the WHO classification, 38% of the fractures occurred in osteoporotic (fracture rate=29%), 47% in osteopenic (fracture rate=16%) and 15% in women with T-score >−1 (fracture rate=9%). By classifying our population in tertiles of TBS, we found that 47% of the fractures occurred in the lowest tertile of TBS (fracture rate=23%) and 39% of the fracture that occurred in osteopenic women were in the lowest tertile of TBS.Conclusions: Spine BMD and TBS predicted fractures equally well. The addition of TBS to spine BMD added only limited information on fracture risk prediction in our cohort when considering the all range of BMD. Nevertheless combining the osteopenic T-score and the lowest TBS helped defining a subset of osteopenic women at higher risk of fracture.Disclosure of Interest: None declared.

Six years of denosumab treatment in postmenopausal women with osteoporosis: results from the first three years of the freedom extension

Background/Purpose: Denosumab (DMAb) is an approved therapy for the treatment of postmenopausal women with osteoporosis at increased risk for fracture. A favorable risk/benefit profile was demonstrated in the pivotal, 3-year FREEDOM trial (Cummings et al NEJM 2009). The open-label, active-treatment FREEDOM Extension study is investigating the efficacy and safety of DMAb for up to 10 years. The Extension trial enrolled women who had received DMAb or placebo in FREEDOM and provides an opportunity to evaluate the long-term efficacy and safety of continuous DMAb treatment (long-term group), and to replicate the DMAb findings observed in FREEDOM (cross-over group). Here, we report the results from the first 3 years of the Extension, representing up to 6 continuous years of DMAb exposure.Methods: During the Extension, each woman is scheduled to receive 60 mg DMAb every 6 months and supplemental calcium and vitamin D daily. For the analyses reported here, women from the FREEDOM DMAb group received 3 more years of DMAb for a total of 6 years of exposure (long-term group) and women from the FREEDOM placebo group received 3 years of DMAb exposure (cross-over group).Results: Of the 5928 women eligible for the Extension, 4550 (77%) enrolled (N_2343 long-term; N_2207 cross-over). In the long-term group, further significant mean increases in bone mineral density (BMD) occurred 4044 for cumulative 6-year gains of 15.2% at the lumbar spine and 7.5% at the total hip (Figure). During the first 3 years of DMAb treatment during the Extension, the cross-over group had significant mean gains in BMD at the lumbar spine (9.4%) and total hip (4.8%), similar to those observed in the long-term DMAb group during the first 3 years of FREEDOM (lumbar spine, 10.1%; total hip, 5.7%). Serum CTX was rapidly and similarly reduced after the 1st (cross-over) or 7th (long-term) DMAb dose with the characteristic attenuation observed at the end of the dosing period. In the cross-over group, yearly incidences of new vertebral and nonvertebral fractures were lower than in the FREEDOM placebo group. Fracture incidence remained low in the long-term group. Incidences of adverse events (AEs) and serious AEs did not increase over time with DMAb treatment. There were 2 subjects with AEs adjudicated to ONJ in the cross-over group and 2 in the long-term group. Both cases in the cross-over group healed completely and without further complications; 1 of these subjects continues to receive DMAb. Both women in the long-term group continue to be followed. No atypical femur fractures have been observed to date. Figure. Percent changes in bone mineral density during FREEDOM and the Extension Conclusion: DMAb treatment for 6 continuous years (long-term group) remained well tolerated, maintained reduced bone turnover, and continued to significantly increase BMD. Fracture incidence remained low. DMAb treatment for 3 years in the cross-over group reproduced the original observations in FREEDOM.

Active screening for pulmonary tuberculosis by chest x-ray among immigrants at the Swiss border

Summary : Aim: To assess the number of immigrants with pulmonary tuberculosis detected by chest x-ray screening at the Swiss border. Method: All adult immigrants entering Switzerland in 2004 were screened by chest x-ray (CXR). The number of radiological abnormalities suggestive of pulmonary tuberculosis, and the proportion requiring treatment for tuberculosis, were assessed retrospectively. The frequency of symptoms among immigrants with documented TB was compared with a sample of immigrants with a normal CXR. Results: Among 8995 immigrants, 8240 had a normal CXR, 630 had some abnormality not suggestive of active TB and 125 (1.4%) had a CXR suggestive of pulmonary TB. A final diagnosis of tuberculosis requiring treatment was made in SO (1 l with positive smear and culture, 16 with positive culture and 23 with negative culture), 57 had fibrotic lesions and 18 had another disease or a normal x-ray on control. The prevalence of symptoms did not differ between 27 immigrants with documented TB (smear+/culture+: 82%, smear-/ culture+: 75%), and 23 with smear-/culturetuberculosis (91%), but lower in 57 immigrants with fibrotic lesions (60%). Cough was more frequent among the 27 immigrants with documented TB (70%) than among 198 smokers without TB (37%) and among 229 non-smokers without TB (15%) Conclusions: Only 22% (27/125) of immigrants with CXR abnormalities suggestive of pulrnonary tuberculosis were documented by smear and/or culture and 40% (50/125) needed antituberculous treatment. 2/11 smear-positive immigrants would not have been detected by a questionnaire on symptoms. Rapport de synthèse : Le but de l'étude est d'évaluer le rendement du dépistage radiologique de la tuberculose pulmonaire chez les immigrés à l'entrée en Suisse. Méthode: parmi les immigrés adultes entrés en Suisse en 2004, qui ont tous passé un contrôle radiologique, le nombre de porteurs de clichés thoraciques suspects de tuberculose et la proportion de cas chez lesquels un traitement antituberculeux a été prescrit ont été évalués rétrospectivement. La fréquence des symptômes chez les immigrés atteints de tuberculose a été comparée à celle d'un groupe contrôle sans tuberculose. Résultats: parmi 8995 immigrés, 8240 avaient un cliché thoracique normal, 630 étaient porteurs d'une anomalie non suspecte de tuberculose active et 125 (1.4%) montraient des signes radiologiques suspects de tuberculose. Un diagnostic final de tuberculose nécessitant un traitement a été posé dans 50 cas (11 cas à frottis et culture positifs, 16 cas à culture positive, 23 cas à culture négative), 57 présentaient des lésions cicatricielles compatibles avec une ancienne tuberculose et 18 avaient une autre affection pulmonaire ou un cliché normal au contrôle. La prévalence des plaintes n'était pas différente entre les 27 immigrés porteurs d'une tuberculose documentée (frottis+ /culture+: 82%, frottis-/culture+ : 75%) et les 23 immigrés atteints d'une tuberculose non documentée (frottis-/culture-: 91%), mais elle était plus élevée que chez les 57 immigrés porteurs de lésions cicatricielles (59%). La toux était plus fréquente chez les 27 tuberculeux documentés (70%) que chez 198 fumeurs sans tuberculose (37%) et chez 229 non fumeurs sans tuberculose (15%). Conclusions: seuls 22% (27/125) des immigrés dont le cliché thoracique est suspect de tuberculose sont porteurs d'une tuberculose documentée par examen direct ou culture et 40% (50/125) nécessitent un traitement antituberculeux. Deux immigrants sur les 11 cas frottis positifs n'auraient pas été dépistés par un questionnaire.

Genital manifestations of schistosomiasis mansoni in women: important but neglected

Egg-induced lesions in the upper and the lower female reproductive tract are important complications of the infection with Schistosoma mansoni. The understanding of the pathophysiology and pathology of genital lesions is only rudimentary, simple and reliable diagnostic tools are not at hand, epidemiological data do not exist and how to treat best the women affected, is not known. In view of recent advances in the understanding of genital lesions induced by S. haematobium the existing literature is critically analysized and possible consequences of female genital schistosomiasis are outlined. We estimate that 6 to 27 % girls and women with intestinal schistosomiasis, at least temporarily, suffer from pathology induced by eggs sequestered somewhere in their genital organs. This is a mattern of concern and warrants more research into the epidemiology, pathology, diagnosis and therapy of this disease entity.

Population pharmacokinetics and clinical response for artemether-lumefantrine in pregnant and nonpregnant women with uncomplicated Plasmodium falciparum malaria in Tanzania.

Artemether-lumefantrine (AL) is the first-line treatment for uncomplicated malaria in the second and third trimesters of pregnancy. Its efficacy during pregnancy has recently been challenged due to altered pharmacokinetic (PK) properties in this vulnerable group. The aim of this study was to determine the PK profile of AL in pregnant and nonpregnant women and assess their therapeutic outcome. Thirty-three pregnant women and 22 nonpregnant women with malaria were treated with AL (80/480 mg) twice daily for 3 days. All patients provided five venous plasma samples for drug quantification at random times over 7 days. Inter- and intraindividual variability was assessed, and the effects of covariates were quantified using a nonlinear mixed-effects modeling approach (NONMEM). A one-compartment model with first-order absorption and elimination with linear metabolism from drug to metabolite fitted the data best for both arthemether (AM) and lumefantrine (LF) and their metabolites. Pregnancy status and diarrhea showed a significant influence on LF PK. The relative bioavailability of lumefantrine and its metabolism rate into desmethyl-lumefantrine were, respectively, 34% lower and 78% higher in pregnant women than in nonpregnant patients. The overall PCR-uncorrected treatment failure rates were 18% in pregnant women and 5% in nonpregnant women (odds ratio [OR] = 4.04; P value of 0.22). A high median day 7 lumefantrine concentration was significantly associated with adequate clinical and parasitological response (P = 0.03). The observed reduction in the relative bioavailability of lumefantrine in pregnant women may explain the higher treatment failure in this group, mostly due to lower posttreatment prophylaxis. Hence, a modified treatment regimen of malaria in pregnancy should be considered.

Violència de gènere i immigració: barreres idiomàtiques i paper de l’intèrpret

L’objectiu principal d’aquesta recerca és conèixer com funciona, dins de l’àmbit del procés penal (recursos socials públics, advocats, policia i jutjats), el servei d’interpretació en casos de dones que han patit violència de gènere i no parlen català ni castellà, si realment es garanteix la comunicació i si les dones que pateixen una barrera idiomàtica tenen accés als recursos en les mateixes condicions que les dones espanyoles

Women speaking across the Border: The impact of the Border and the conflict on women's health and roles

This research was commissioned by Derry Well Woman and carried out on its behalf by the Institute of Public Health in Ireland in association with the Institute for Conflict Research and Rethink.The research had two distinct aims:- to improve understanding of the impact of the border and of the conflict on both sidesof the border on women’s health- to improve understanding of women’s roles, particularly as they impact on mental health, in post conflict society.- The research was conducted with a view to its recommendations being used to inform the work of the Cross Border Women’  Health Network as well as other cross border health forums or organisations responsible for service planning and delivery.- The findings of this research are based on a series of 31 in-depth interviews and one focus group with women both north and south of the border and on one focus group and six interviews with women who were specifically consulted as service providers.

Major impact of body position on arterial stiffness indices derived from radial applanation tonometry in pregnant and nonpregnant women.

OBJECTIVE: To evaluate the impact of body position on the arterial stiffness indices provided by radial applanation tonometry in pregnant and nonpregnant women. METHODS: Twenty-four young women (18-30 years) in the third trimester of a normal pregnancy and 20 healthy nonpregnant women of the same age were enrolled. In each, applanation tonometry was carried out in the sitting and supine position. The following stiffness indices were analyzed: systolic augmentation index (sAix), sAix adjusted for heart rate (sAix@75) and diastolic augmentation index (dAix), all expressed in % of central aortic pulse pressure. RESULTS: The sAix was apparently not influenced by body position, but the transition from seated to supine was associated with a substantial decrease in heart rate. When correcting for this confounder by calculating the sAix@75, systolic augmentation was substantially lower when individuals were supine (mean ± SD: nonpregnant 3.0 ± 14.4%, pregnant 8.8 ± 9.7%) than when they were sitting (nonpregnant 5.7 ± 13.0%, pregnant 11.1 ± 83%, P = 0.005 supine vs. seated in both study groups, P > 0.2 for pregnant vs. nonpregnant). The influence of body position on the dAix went in the opposite direction (supine: nonpregnant 9.7 ± 6.6%, pregnant 4.4 ± 3.5%; seated: nonpregnant 7.7 ± 5.8%, pregnant 3.3 ± 2.4%, P < 0.00001 supine vs. seated in both study groups, P = 0.001 for pregnant vs. nonpregnant). CONCLUSION: Body position has a major impact on the pattern of central aortic pressure augmentation by reflected waves in healthy young women examined either during third trimester pregnancy or in the nonpregnant state.

Bone mineral density (BMD), micro-architecture estimation (TBS) and vertebral fracture assessment (VFA) extracted from a single DXA device in combination with clinical risk factors improve significantly the identification of women at high risk of fracture

Introduction: Osteoporosis (OP) is a systemic skeletal disease characterized by a low bone mineral density (BMD) and a micro-architectural (MA) deterioration. Clinical risk factors (CRF) are often used as a MA approximation. MA is yet evaluable in daily practice by the Trabecular Bone Score (TBS) measure. TBS is a novel grey-level texture measurement reflecting bone micro-architecture based on the use of experimental variograms of 2D projection images. TBS is very simple to obtain, by reanalyzing a lumbar DXA-scan. TBS has proven to have diagnosis and prognosis value, partially independent of CRF and BMD. The aim of the OsteoLaus cohort is to combine in daily practice the CRF and the information given by DXA (BMD, TBS and vertebral fracture assessment (VFA)) to better identify women at high fracture risk. Method: The OsteoLaus cohort (1400 women 50 to 80 years living in Lausanne, Switzerland) started in 2010. This study is derived from the cohort COLAUS who started in Lausanne in 2003. The main goals of COLAUS is to obtain information on the epidemiology and genetic determinants of cardiovascular risk in 6700 men and women. CRF for OP, bone ultrasound of the heel, lumbar spine and hip BMD, VFA by DXA and MA evaluation by TBS are recorded in OsteoLaus. Preliminary results are reported. Results: We included 631 women: mean age 67.4±6.7 y, BMI 26.1±4.6, mean lumbar spine BMD 0.943±0.168 (T-score -1.4 SD), TBS 1.271±0.103. As expected, correlation between BMD and site matched TBS is low (r2=0.16). Prevalence of VFx grade 2/3, major OP Fx and all OP Fx is 8.4%, 17.0% and 26.0% respectively. Age- and BMI-adjusted ORs (per SD decrease) are 1.8 (1.2- 2.5), 1.6 (1.2-2.1), 1.3 (1.1-1.6) for BMD for the different categories of fractures and 2.0 (1.4-3.0), 1.9 (1.4-2.5), 1.4 (1.1-1.7) for TBS respectively. Only 32 to 37% of women with OP Fx have a BMD < -2.5 SD or a TBS < 1.200. If we combine a BMD < -2.5 SD or a TBS < 1.200, 54 to 60% of women with an osteoporotic Fx are identified. Conclusion: As in the already published studies, these preliminary results confirm the partial independence between BMD and TBS. More importantly, a combination of TBS subsequent to BMD increases significantly the identification of women with prevalent OP Fx which would have been miss-classified by BMD alone. For the first time we are able to have complementary information about fracture (VFA), density (BMD), micro- and macro architecture (TBS & HAS) from a simple, low ionizing radiation and cheap device: DXA. Such complementary information is very useful for the patient in the daily practice and moreover will likely have an impact on cost effectiveness analysis.

Plasmodium/intestinal helminth co-infections among pregnant Nigerian women

Hospital based studies were conducted to investigate the occurrence of Plasmodium/intestinal helminth co-infections among pregnant Nigerian women, and their effects on birthweights, anaemia and spleen size. From 2,104 near-term pregnant women examined, 816 (38.8%) were found to be infected with malaria parasites. Among the 816 parasitaemic subjects, 394 (48.3%) were also infected with intestinal helminths, 102 (12.5%) having mixed helminth infections. The prevalence of the helminth species found in stool samples of parasitaemic subjects examined was, Ascaris lumbricoides (19.1%), hookworm (14.2%), Trichuris trichiura (7%) Schistosoma mansoni (3.4%), Enterobius vermicularis (2%), Hymenolepis sp. (1.6%) and Taenia sp. (1%). Mothers with Plasmodium infection but without intestinal helminth infection had neonates of higher mean birthweights than those presenting both Plasmodium and intestinal helminth infections and this effect was more pronounced in primigravids. The mean haemoglobin values of malarial mothers with intestinal helminth infections were lower than those with Plasmodium infection but without intestinal helminth infections but these were not statistically significant. Severe splenomegaly was predominant among parasitaemic gravidae who also harboured S. mansoni infection in two of the hospitals studied.