Algorithms for Managing Vulvovaginal Symptoms-a Practical Primer.

There is growing recognition of the degree to which symptoms negatively impact on children receiving cancer treatments. A recent study described that almost all inpatient pediatric oncology patients are experiencing at least one bothersome symptom and almost 60% are experiencing at least one severely bothersome symptom. Poor symptom control occurs because of challenges with communication of bothersome symptoms to clinicians, lack of clinical practice guidelines (CPGs) for most of these symptoms, and failure to administer preventative and therapeutic interventions known to be effective for symptom control. This article reviews approaches used to improve symptom control for children receiving cancer treatments. Areas addressed include systematic symptom screening and creation of CPGs for symptom management. Challenges with electronic health integration are also addressed. Several multi-symptom assessment scales have been developed but none have yet been used to directly influence patient management. The number of CPGs applicable to symptom control in pediatric oncology is increasing but remains small. Improving the creation of and adherence to CPGs for symptom management is an important priority. Finally, identifying ways that symptom management systems can be integrated into clinical work flows is essential; these will likely need to focus on electronic health records.

To assess the importance and usefulness of self-reported symptom data, especially the most bothersome symptom, in the evaluation of treatment for vulvovaginal atrophy. This was a double-blind, placebo-controlled multicenter study. Women rated symptoms associated with vaginal atrophy (vaginal dryness, vaginal/vulvar irritation/itching, vaginal/vulvar soreness, and dyspareunia) before and during treatment and selected one moderate to severe symptom as the most bothersome. Among 310 women (n = 156 placebo), vaginal dryness and dyspareunia were most commonly classified as moderate to severe and as most bothersome (44.4% and 30.2%, respectively). For both symptoms, the effect size favoring active treatment consistently increased as the cohort was more narrowly defined (all treated women, women who classified the symptom as moderate or severe, and those who classified the symptom as most bothersome). Compared with the standardized effect sizes for all women, those calculated from the most bothersome symptom were 49% and 62% greater for dyspareunia and dryness, respectively. : The most bothersome symptom approach represents a meaningful new standard for measurement of self-assessed vulvovaginal atrophy symptom change, but evaluation of change in individual symptoms remains an important, unbiased primary analysis of efficacy in vulvovaginal atrophy studies.

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Postmenopausal women commonly experience vulvovaginal, urinary, and sexual symptoms associated with genitourinary syndrome of menopause (GSM). To evaluate effectiveness and harms of vaginal estrogen, nonestrogen hormone therapies, and vaginal moisturizers for treatment of GSM symptoms. Medline, Embase, and CINAHL through 11 December 2023. Randomized controlled trials (RCTs) of at least 8 weeks' duration enrolling postmenopausal women with at least 1 GSM symptom and reporting effectiveness or harms of hormonal interventions or vaginal moisturizers. Risk of bias and data extraction were performed by one reviewer and verified by a second reviewer. Certainty of evidence (COE) was assessed by one reviewer and verified by consensus. From 11 993 citations, 46 RCTs evaluating vaginal estrogen (k = 22), nonestrogen hormones (k = 16), vaginal moisturizers (k = 4), or multiple interventions (k = 4) were identified. Variation in populations, interventions, comparators, and outcomes precluded meta-analysis. Compared with placebo or no treatment, vaginal estrogen may improve vulvovaginal dryness, dyspareunia, most bothersome symptom, and treatment satisfaction. Compared with placebo, vaginal dehydroepiandrosterone (DHEA) may improve dryness, dyspareunia, and distress, bother, or interference from genitourinary symptoms; oral ospemifene may improve dryness, dyspareunia, and treatment satisfaction; and vaginal moisturizers may improve dryness (all low COE). Vaginal testosterone, systemic DHEA, vaginal oxytocin, and oral raloxifene or bazedoxifene may provide no benefit (low COE) or had uncertain effects (very low COE). Although studies did not report frequent serious harms, reporting was limited by short-duration studies that were insufficiently powered to evaluate infrequent serious harms. Most studies were 12 weeks or less in duration and used heterogeneous GSM diagnostic criteria and outcome measures. Few studies enrolled women with a history of cancer. Vaginal estrogen, vaginal DHEA, oral ospemifene, and vaginal moisturizers may improve some GSM symptoms in the short term. Few long-term data exist on efficacy, comparative effectiveness, tolerability, and safety of GSM treatments. Agency for Healthcare Research and Quality and Patient-Centered Outcomes Research Institute. (PROSPERO: CRD42023400684).

Postpartum care: Clinical considerations for improving genital and sexual health

Data driven logistics-oriented value stream mapping 4.0: A guideline for practitioners

Convergent-Divergent Validity and Correlates of the Day-to-Day Impact of Vaginal Aging Domain Scales in the MsFLASH Vaginal Health Trial

Background: Patients with advanced chronic kidney disease (CKD) experience many bothersome symptoms, affecting their quality of life (QoL). The majority of these patients do not have the opportunity to receive a kidney transplant and need other treatments for these burdensome symptoms to improve their QoL and prognosis. With growing attention to the significance of symptom management in advanced CKD on haemodialysis (HD), the evidence regarding symptoms is increasing. Methods: In this review, we briefly summarise the current evidence of non-pharmacologic interventions to improve symptoms and QoL in patients with advanced CKD, on dialysis. Hence, we focused on symptoms that are commonly experienced by patients, such as pain, fatigue, sleep disturbances, itching, nausea and vomiting, cognitive impairment and anxiety and depression. Results: We noted that research on improving symptom management in CKD is still very limited. In addition to the lack of clinical practice guidelines to address those common symptoms, the evidence to how to incorporate effective symptom intervention approaches into clinical care is also rare. Conclusion: Although improving mortality remains an important area in the kidney community, there is an urgent need to focus on improving symptommanagement to improve QoL in advanced CKD on HD.

This expert consensus reviews current literature and provides clinical practice guidelines for the diagnosis and treatment of multiple ground glass nodule-like lung cancer. The main contents of this review include the following: ① follow-up strategies, ② differential diagnosis, ③ diagnosis and staging, ④ treatment methods, and ⑤ post-treatment follow-up.

This issue of the Southern African Journal of Critical Care, which coincides with the 2005 COPICON congress, carries review articles on ventilatory therapy of critically ill patients. Giles offers a comprehensive review and practical guidelines on the provision of non-invasive ventilatory support, while Hamel and Cheifetz focus on the non-conventional mode of high-frequency oscillation, providing in-depth background information on the development and physiology of this mode of therapy, and outlining practical clinical guidelines for its initiation.

Understanding the impact of testosterone on the vaginal microbiota of transgender men (TGM) and nonbinary people assigned female sex at birth over time is imperative as vaginal dysbiosis and incident bacterial vaginosis (iBV) may cause bothersome genital symptoms and increase human immunodeficiency virus/sexually transmitted infection (HIV/STI) acquisition risk. We investigated shifts in the composition of the vaginal microbiota over time in TGM initiating testosterone for gender-affirming hormone therapy, including development of vaginal dysbiosis and iBV. Participants ages ≥18 years, assigned female sex at birth and reporting TGM or nonbinary identity, interested in starting injectable testosterone, demonstrating optimal vaginal microbiota, with no current STI(s) were enrolled. Participants self-collected daily vaginal specimens for 7 days prior to testosterone initiation and 90 days thereafter for vaginal Gram staining and 16S rRNA gene sequencing. Episodes of vaginal dysbiosis and iBV were defined as Nugent scores ≥4 or ≥7, respectively, each for ≥2 consecutive days. Between February 2022 and November 2023, 9 participants enrolled, 89% (8/9) developed ≥1 episode(s) of vaginal dysbiosis after testosterone initiation, and 56% (5/9) developed iBV. Among those who developed iBV, most did so between days 20 and 40 after testosterone initiation. Community state type (CST) I was found most often in participants who did not develop iBV and CST IV-B most often in participants who developed iBV. Sexual activity and menses also appeared to influence the development of iBV. The majority of participants developed vaginal dysbiosis including iBV. Additional studies with larger sample sizes are needed to further elucidate how testosterone impacts the vaginal microbiota.

The aim of the presented publication is to discuss the changes in the practice of professional higher education which consist in strengthening and emphasis of an educational component in educational process. Methods. The methods involve the analysis of a condition of higher education and the provisions of the Federal Law on Education regulating its functioning in the Russian Federation; text-centered approach to education of the person of culture – the professional specialist, responsible for the activities. Results and scientific novelty. It states that some drawbacks of the existing present-day education organization are being constantly discussed by a pedagogical community of the Russian Federation: the absence of development stability; the absence of effective strategies and technologies of their implementation; the triumph of national nihilism confirmed by high schools and individual scientists participation in different foreign educational projects, usually having world notorious reputation; penetration of commercial principals in to an education system, the latter having been turned in to an education service, etc. As a result the personality quality itself has greatly deteriorated as well as Russia society intellect, on the whole, according to some law, psychological, philosophical and pedagogical analysis. The article stresses that the way out maybe found in restoring Russian national traditions and lost values and returning them to Russian education via adequate upbringing process. The authors describe their innovative model comprising three directions: 1) the integral three-factor spiritual, moral and intellectual upbringing of the students; 2) specially selected text content professional information using text-centered approach and 3) peculiar interaction of two education subjects: a student and a teacher. Their cooperation envisages the following stages: first, teacher’s strict guidance of a student; then – teacher’s soft support of a student; after this – teacher’s accompanying a student at a special request and, at last, – wise consulting a student if needed. In the long run, in the author’s opinion, this system should succeed in creating some special platform for student’s further self-upbringing and self-learning. The model described in the paper is considered on the example of the discipline «A foreign language in the professional sphere». The just described model was worked out for effective foreign language education process perceived as a part of professional high-school education. Due to this system, foreign language becomes a source of professionally demanded and personally valuable information. Practical significance. The model provided in the paper gives the chance to the student to be lifted to self-education level, to plan professional self-development and to build an individual trajectory of professional career.

Hypertension Treatment in Blacks: Discussion of the U.S. Clinical Practice Guidelines

BACKGROUNDPediatric survivors of hypothalamic/suprasellar tumors have significant morbidities that greatly impact their quality of life. Management of hypothalamic obesity has traditionally fallen between multiple subspecialties without a timely and comprehensive approach.METHODSA multidisciplinary group of key players from neuro-oncology, endocrinology, nutrition, neurosurgery, and bariatric surgery were identified. Through this collaboration, a clinical algorithm for early identification of and intervention for hypothalamic obesity was developed. The goal of the quality improvement process is to increase the number of encounters with a registered dietitian (RD) with earlier and more consistent referrals to a specialized, multidisciplinary weight management program [Lifestyle Medicine; (LM)] for counseling and pharmacologic interventions. Indications for referral to LM were BMI >95th percentile, crossing >2 BMI percentiles on growth curve and/or hyperphagia symptoms. A retrospective review of pediatric patients who have suprasellar/ hypothalamic tumors was also conducted. Data collected included demographics, tumor type, BMI, RD visit, and LM clinic referral/visit.RESULTSFifty patients were identified for analysis six months following clinical algorithm institution. Thirty-three (66%) patients had craniopharyngioma, 15 (30%) had low-grade gliomas, and two (4%) had germ cell tumors. Thirty-three (66%) patients were noted to be obese (defined as BMI >95th percentile) at review. The median BMI of the entire cohort was 93rd (range, 1st-137th) percentile. Thirty-four (68%) patients had been seen by an RD. Twenty-seven (82%) of the obese patients had been referred to LM.CONCLUSIONSThe development and implementation of the process for hypothalamic obesity prevention and intervention will be discussed.

Evaluating and treating patients with chronic nonmalignant pain, especially with opioid medications, often causes discomfort on the part of primary care physicians. A number of patient-, physician-, and system-related issues converge to make treating chronic pain a complex matter. Patient-related issues include an inability to define a clear anatomic cause for patients’ pain, comorbid psychiatric conditions, and past and current substance abuse. Physicians lack training on the appropriate evaluation and treatment of chronic nonmalignant pain, fear creating addicts, and often face intense pharmaceutical industry pressure to prescribe medications. A paucity of practical clinical practice guidelines, controversy over the effectiveness of opioids on chronic nonmalignant pain, and concern about potential legal and regulatory ramifications add to the complexity of caring for these patients. Possible multifaceted solutions exist to minimize provider discomfort and improve their ability to treat patients appropriately. Examples include comprehensive, practical multidimensional guidelines on the evaluation and treatment of chronic nonmalignant pain, Web-based teleconferenced consultations with subspecialists, reduced pharmaceutical pressure, enhanced continuing medical education and pregraduate training, multispecialty coordinated care of patients with adequate reimbursement for such care, and physician access to state-based systems to track opioid prescriptions.