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Objective: This study was undertaken to evaluate continence rates 5 years after anterior colporrhaphy, anterior colporrhaphy with needle suspension of the bladder neck, and Burch colposuspension.Study Design: Among 544 women with stress incontinence who were operated on between 1989 and 1993, 327 women (60%) underwent clinical and urodynamic reevaluation 5 years after the operation. Choice of surgical procedure was made on the basis of clinical and urodynamic findings and of physician preference. Continence was defined as no loss of urine during cystometry or during coughing with the bladder filled to 300 mL.Results: The 327 patients underwent a total of 334 operations. The objective overall continence rates at 5 years were 61% (65/107) after anterior repair, 49% (59/121) after anterior repair with needle suspension, and 79% (84/106) after Burch colposuspension. Continence rates after anterior colporrhaphy were 82% (32/39) among patients with mild stress incontinence but 49% (33/68) among those with moderate or severe incontinence (P <.02). Continence rates among patients with moderate or severe incontinence were 49% (59/121) after anterior repair with needle suspension and 79% (84/106) after the Burch operation (P <.02).Conclusion: Anterior colporrhaphy can cure mild stress incontinence but is inadequate to correct severe incontinence. Additional needle suspension may be of benefit for patients with moderate to severe incontinence. Abdominal colposuspension is superior to the vaginal operations for long-term cure of stress incontinence. [ABSTRACT FROM AUTHOR]

Background: Dexmedetomidine is increasingly used for surgical patients requiring general anaesthesia. However, its effectiveness on patient-centred outcomes remains uncertain. Our main objective was to evaluate the patient-centred effectiveness of intraoperative dexmedetomidine for adult patients requiring surgery under general anaesthesia., Methods: We conducted a systematic search of MEDLINE, Embase, CENTRAL, Web of Science, and CINAHL from inception to October 2023. Randomised controlled trials (RCTs) comparing intraoperative use of dexmedetomidine with placebo, opioid, or usual care in adult patients requiring surgery under general anaesthesia were included. Study selection, data extraction, and risk of bias assessment were performed by two reviewers independently. We synthesised data using a random-effects Bayesian regression framework to derive effect estimates and the probability of a clinically important effect. For continuous outcomes, we pooled instruments with similar constructs using standardised mean differences (SMDs) and converted SMDs and credible intervals (CrIs) to their original scale when appropriate. We assessed the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Our primary outcome was quality of recovery after surgery. To guide interpretation on the original scale, the Quality of Recovery-15 (QoR-15) instrument was used (range 0-150 points, minimally important difference [MID] of 6 points)., Results: We identified 49,069 citations, from which 44 RCTs involving 5904 participants were eligible. Intraoperative dexmedetomidine administration was associated with improvement in postoperative QoR-15 (mean difference 9, 95% CrI 4-14, n=21 RCTs, moderate certainty of evidence). We found 99% probability of any benefit and 88% probability of achieving the MID. There was a reduction in chronic pain incidence (odds ratio [OR] 0.42, 95% CrI 0.19-0.79, n=7 RCTs, low certainty of evidence). There was also increased risk of clinically significant hypotension (OR 1.98, 95% CrI 0.84-3.92, posterior probability of harm 94%, n=8 RCTs) and clinically significant bradycardia (OR 1.74, 95% CrI 0.93-3.34, posterior probability of harm 95%, n=10 RCTs), with very low certainty of evidence for both. There was limited evidence to inform other secondary patient-centred outcomes., Conclusions: Compared with placebo or standard of care, intraoperative dexmedetomidine likely results in meaningful improvement in the quality of recovery and chronic pain after surgery. However, it might increase clinically important bradycardia and hypotension., Systematic Review Protocol: PROSPERO (CRD42023439896)., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Postoperative patient-centred outcome measures are essential to capture the patient's experience after surgery. Although a large number of pharmacologic opioid minimisation strategies (i.e. opioid alternatives) are used for patients undergoing surgery, it remains unclear which strategies are most promising in terms of patient-centred outcome improvements. This scoping review had two main objectives: (1) to map and describe evidence from clinical trials assessing the patient-centred effectiveness of pharmacologic intraoperative opioid minimisation strategies in adult surgical patients, and (2) to identify promising pharmacologic opioid minimisation strategies., Methods: We searched MEDLINE, Embase, CENTRAL, Web of Science, and CINAHL databases from inception to February 2023. We included trials investigating the use of opioid minimisation strategies in adult surgical patients and reporting at least one patient-centred outcome. Study screening and data extraction were conducted independently by at least two reviewers., Results: Of 24,842 citations screened for eligibility, 2803 trials assessed the effectiveness of intraoperative opioid minimisation strategies. Of these, 457 trials (67,060 participants) met eligibility criteria, reporting at least one patient-centred outcome. In the 107 trials that included a patient-centred primary outcome, patient wellbeing was the most frequently used domain (55 trials). Based on aggregate findings, dexmedetomidine, systemic lidocaine, and COX-2 inhibitors were promising strategies, while paracetamol, ketamine, and gabapentinoids were less promising. Almost half of the trials (253 trials) did not report a protocol or registration number., Conclusions: Researchers should prioritise and include patient-centred outcomes in the assessment of opioid minimisation strategy effectiveness. We identified three potentially promising pharmacologic intraoperative opioid minimisation strategies that should be further assessed through systematic reviews and multicentre trials. Findings from our scoping review may be influenced by selective outcome reporting bias., Study Registration: OSF - https://osf.io/7kea3., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction: Dexmedetomidine is a promising pharmaceutical strategy to minimise opioid use during surgery. Despite its growing use, it is uncertain whether dexmedetomidine can improve patient-centred outcomes such as quality of recovery and pain., Methods and Analysis: We will conduct a systematic review and meta-analysis following the recommendations of the Cochrane Handbook for Systematic Reviews . We will search MEDLINE, Embase, CENTRAL, Web of Science and CINAHL approximately in October 2023. We will include randomised controlled trials evaluating the impact of systemic intraoperative dexmedetomidine on patient-centred outcomes. Patient-centred outcome definition will be based on the consensus definition established by the Standardised Endpoints in Perioperative Medicine initiative (StEP-COMPAC). Our primary outcome will be the quality of recovery after surgery. Our secondary outcomes will be patient well-being, function, health-related quality of life, life impact, multidimensional assessment of postoperative acute pain, chronic pain, persistent postoperative opioid use, opioid-related adverse events, hospital length of stay and adverse events. Two reviewers will independently screen and identify trials and extract data. We will evaluate the risk of bias of trials using the Cochrane Risk of Bias Tool (RoB 2.0). We will synthesise data using a random effects Bayesian model framework, estimating the probability of achieving a benefit and its clinical significance. We will assess statistical heterogeneity with the tau-squared and explore sources of heterogeneity with meta-regression. We have involved patient partners, clinicians, methodologists, and key partner organisations in the development of this protocol, and we plan to continue this collaboration throughout all phases of this systematic review., Ethics and Dissemination: Our systematic review does not require research ethics approval. It will help inform current clinical practice guidelines and guide development of future randomised controlled trials. The results will be disseminated in open-access peer-reviewed journals, presented at conferences and shared among collaborators and networks., Prospero Registration Number: CRD42023439896., Competing Interests: Competing interests: IG has received consulting fees from GW Research, Eupraxia, Biogen and Novaremed., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: For close to a century opioid administration has been a standard of care to complement anaesthesia during surgery. Considering the worldwide opioid epidemic, this practice is now being challenged and there is a growing use of systemic pharmacological opioid minimising strategies. Our aim is to conduct a scoping review that will examine clinical trials that have evaluated the impact of intraoperative opioid minimisation strategies on patient-centred outcomes and identify promising strategies., Methods and Analysis: Our scoping review will follow the framework developed by Arksey and O'Malley. We will search MEDLINE, Embase, CENTRAL, Web of Science and CINAHL from their inception approximately in March 2023. We will include randomised controlled trials, assessing the impact of systemic intraoperative pharmacologic opioid minimisation strategies on patient-centred outcomes. We define an opioid minimisation strategy as any non-opioid drug with antinociceptive properties administered during the intraoperative period. Patient-centred outcomes will be defined and classified based on the consensus definitions established by the Standardised Endpoints in Perioperative Medicine initiative (StEP-COMPAC group) and informed by knowledge users and patient partners. We will use a coproduction approach involving interested parties. Our multidisciplinary team includes knowledge users, patient partners, methodologists and knowledge user organisations. Knowledge users will provide input on methods, outcomes, clinical significance of findings, implementation and feasibility. Patient partners will participate in assessing the relevance of our design, methods and outcomes and help to facilitate evidence translation. We will provide a thorough description of available clinical trials, compare their reported patient-centred outcome measures with established recommendations and identify promising strategies., Ethics and Dissemination: Ethics approval is not required for the review. Our scoping review will inform future research including clinical trials and systematic reviews through identification of important intraoperative interventions. Results will be disseminated through a peer-reviewed publication, presentation at conferences and through our network of knowledge user collaborators., Registration: Open Science Foundation (currently embargoed)., Competing Interests: Competing interests: IG has received consulting fees from GW Research, Eupraxia, Biogen and Novaremed., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background : Examination of readmission data is a standard method for evaluating health service outcomes. Limited work has evaluated the efficacy of mental health rehabilitation, despite the need for evidence-based approaches. Aims : To evaluate the impact of inpatient mental health rehabilitation using metrics of psychiatric readmissions routinely collected at occasions of service. Methods : Consumers ( n  = 252) of a nonacute inpatient mental health rehabilitation unit were case matched with normative clients from community mental health services. The impact of inpatient care was measured on: (1) the occurrence of a psychiatric readmission within 12 months of discharge; (2) the total number of psychiatric readmissions within 12 months of discharge; and (3) the number of days to a psychiatric readmission after discharge. Results : The proportion of consumers experiencing a readmission significantly decreased following inpatient care, comparable to the normative group. The number of readmissions also significantly decreased, approaching normative group levels, except in consumers with comorbid bipolar, substance use, or personality disorder. Time to a readmission significantly increased following inpatient care, approximating normative group values, and was related to the number of previous admissions. Conclusion : Routinely collected service data demonstrated nonacute inpatient mental health rehabilitation reduces re-hospitalization, which will have benefits for both consumers and health services.

Purpose : With appropriate mental health rehabilitation, schizophrenia is increasingly associated with reports of recovery and stability. However, there is little empirical evidence evaluating the efficacy of services delivering this care. This study evaluated the effectiveness of rehabilitation for improving psychosocial function in consumers with schizophrenia. Methods : An electronic database of standardized assessment instruments mandated and maintained by the health service was retrospectively reviewed to extract ratings of psychosocial function, daily living skills, and mood state from consecutive admissions to an inpatient rehabilitation service. Outcomes were compared at admission, discharge, and one-year follow-up to identify statistically significant change. Individual reliable and clinically significant change was also assessed by comparison with a normative group of clients functioning independently in the community. Results : From admission to discharge the rehabilitation group made statistically significant gains in psychosocial function and daily living skills. Improvements were reliable and clinically significant in one-quarter to one-third of individual consumers. Approximately half sustained their improvements at follow-up, although this represented only a small fraction of the overall cohort. Consumers not demonstrating gains exhibited psychometric floor effects at admission. Conclusions : Rehabilitation can produce statistically and clinically significant immediate improvement in psychosocial function for a sub-set of consumers with elevated scores at admission. The durability of any gains is less clear, and strategies promoting longer-term maintenance are encouraged. Furthermore, currently mandated outcome measures are confounded by issues of sensitivity and reporting compliance, and exploration of alternative instruments for assessing recovery is recommended.Implications for RehabilitationRoutinely collected standardized outcome measures can be used to investigate the effectiveness of mental health rehabilitationIn addition to statistical significance, the clinical significance of outcomes should be evaluated to identify change that is individually meaningfulCurrently mandated outcomes instruments do not adequately evaluate many individuals' recovery journeyMental health service evaluation and quality improvement processes would likely benefit from adoption of recovery-oriented measures.

The tension-free vaginal tape (TVT) operation and similar procedures are the newest development in the surgical treatment of female stress incontinence. In contrast to the Burch colposuspension and abdominovaginal sling procedures, the operation aims at supporting the midurethra and not the bladder neck. The only ongoing prospective randomized trial comparing TVT with the Burch colposuspension, conducted by the UK and Ireland TVT Trial Group, shows comparable 2-year results. The TVT operation is a technically simple procedure with a low rate intraoperative and postoperative complications. This and the good cure rates may make this procedure and similar methods the standard operation for the treatment of primary and recurrent stress incontinence.

In 1959 A.J. Pereyra published a simple transvaginal surgical method to elevate and fixate the bladder neck and proximal urethra with a specially designed needle in women with stress urinary incontinence. This method was repeatedly modified during the last 35 years. Mild to moderate stress incontinence with or without pelvic floor relaxation is regarded as an indication for needle bladder neck suspension. Contraindications include severe stress incontinence, low-pressure urethra, urge incontinence and recurrent stress incontinence. Postoperative continence rates range from 40% to 91% depending on inclusion criteria, preoperative diagnostics, criteria for success or failure, and duration of follow-up. There are no controlled clinical studies comparing different needle suspension techniques.

Vaginal surgery performed for pelvic floor relaxation, genuine stress incontinence or both can have intended and unintended effects on the lower urinary tract. Intended effects are restoration of anatomy and urinary continence; unintended effects include operative injury, recurrent prolapse, persistent or unmasked stress incontinence, and voiding difficulties. Objective long-term follow-up and new investigational techniques have led to a critical reexamination of standard and time-honoured vaginal operations, particularly anterior colporrhaphy. This review addresses the effects of different vaginal operations on the lower urinary tract and conduction studies of the perineal nerve.

Objective: To compare the separation in time of urethral and bladder pressure pulses and urodynamic parameters after successful and unsuccessful anterior colporrhaphy and needle suspension of the bladder neck in patients with stress urinary incontinence., Study Design: Retrospective evaluation of urethral pressure profiles at rest and under stress in 10 successfully and 10 unsuccessfully operated patients., Results: In the successfully treated group, the onset of the urethral pressure increase preceded that of the bladder pressure by an average of 300 ms. Pressure transmission ratios in the 3 proximal quartiles of the urethra were significantly improved after successful surgery. Women who remained incontinent showed neither an advanced onset of the urethral pressure pulse during stress nor improved pressure transmission ratios., Conclusion: Successful anterior repair and needle suspension of the bladder neck support the bladder neck and thus improve the pressure transmission to the urethra. Improved pressure transmission is associated with the finding that pressure increases in the urethra precede those in the bladder in continent women.

Objective: To evaluate results 5 years after anterior colporrhaphy with or without needle suspension of the bladder neck and after Burch colposuspension., Methods: 186/291 women (64%) operated on between 1989 and 1990 underwent clinical and urodynamic reevaluation., Results: Objective continence rates after anterior colporrhaphy were 80% (20/25), 46% (22/47) and 12.5% (1/8) in patients with first-, second- and third-degree stress incontinence according to Ingelman-Sundberg. Continence rates in patients with second- and third-degree stress incontinence were 59% (29/49) after additional needle suspension and 86% (50/58) after the Burch procedure., Conclusions: Anterior colporrhaphy can cure mild stress incontinence but is not indicated for severe incontinence. The Burch procedure provides the best continence rates in patients with severe stress incontinence.

This study aimed to investigate the influence of anterior repair on pudendal nerve terminal motor latency. Neurourodynamic investigation (urethral profilometry, measurement of pudendal nerve terminal motor latency according to the method of Snooks and Swash) was performed before and 8 weeks after anterior repair (n = 14) and before and after additional endoscopic bladder neck suspension (n = 23). Stress incontinence and pudendal neuropathy were found preoperatively in all patients. In 17/37 (48%) of patients who were incontinent postoperatively the pudendal nerve latency was significantly prolonged.

This study aimed to compare pelvic floor exercise only (group A) with pelvic floor exercise plus vaginal cones (group B) for the treatment of stress urinary incontinence. 46 premenopausal women were randomized into two groups. The subjective improvement or cure rates were 85.5% in group A and 84.5% in group B. Urethral pressure profiles showed a significant improvement in the transmission factor in the midurethra in each group and for the maximum urethral closure pressure in group A.