The Effect of Hormonal Treatment on Ovarian Endometriomas: A Systematic Review and Meta-Analysis.

OBJECTIVE: To evaluate the effect of hormonal suppression of endometriosis on the size of endometriotic ovarian cysts. DATA SOURCES: The authors searched MEDLINE, PubMed, Cochrane Central Register of Controlled Trials, Embase, and ClinicalTrials.gov from January 2012 to December 2022. METHODS OF STUDY SELECTION: We included studies of premenopausal women undergoing hormonal treatment of endometriosis for ≥3 months. The authors excluded studies involving surgical intervention in the follow-up period and those using hormones to prevent endometrioma recurrence after endometriosis surgery. Risk of bias was assessed with the Newcastle-Ottawa Scale and Cochrane Risk of Bias Tool. The protocol was registered in PROSPERO (CRD42022385612). TABULATION, INTEGRATION, AND RESULTS: The primary outcome was the mean change in endometrioma volume, expressed as a percentage, from baseline to at least 6 months. Secondary outcomes were the change in volume at 3 months and analyses by class of hormonal therapy. The authors included 16 studies (15 cohort studies, 1 randomized controlled trial) of 888 patients treated with dienogest (7 studies), other progestins (4), combined hormonal contraceptives (2), and other suppressive therapy (3). Globally, the decrease in endometrioma volume became statistically significant at 6 months with a mean reduction of 55% (95% confidence interval, -40 to -71; 18 treatment groups; 730 patients; p <.001; I2 = 96%). The reduction was the greatest with dienogest and norethindrone acetate plus letrozole, followed by relugolix and leuprolide acetate. The volume reduction was not statistically significant with combined hormonal contraceptives or other progestins. There was high heterogeneity, and studies were at risk of selection bias. CONCLUSION: Hormonal suppression can substantially reduce endometrioma size, but there is uncertainty in the exact reduction patients may experience.

Evaluating the Quality of Endometriosis Operative Reports among High Volume Endometriosis Surgeons.

OBJECTIVE: To evaluate the quality of operative reports for endometriosis surgeries performed by fellowship-trained, high-volume endometriosis surgeons. METHODS: In this retrospective review, 5 consecutive deidentified surgical reports per surgeon were evaluated by two reviewers. Each dictation was assigned a quality score (between 0 and 28), based on the number of components from the American Association of Gynecologic Laparoscopists (AAGL) classification system that were documented. Primary outcome was the proportion of reports for which endometriosis AAGL 2021 stage could be assigned. Secondary outcomes included median dictation quality scores, proportion of dictations for fertility-preserving cases where Endometriosis Fertility Index (EFI) score could be assigned, individual quality score components, and quality score variation between surgeons, institutions, and reporting methods. RESULTS: 82 operative reports were reviewed from 16 surgeons across 7 sites in Ontario. AAGL stage could be assigned in 48/82 (59%) of cases, and EFI score could be assigned in 31/45 of fertility-preserving cases (69%). Median quality score was 57% (range 18%-86%). Only 13% of operative reports included comment on residual disease. Quality score consistency between reports was poor for a given surgeon (ICC = 0.22, 95% CI 0.03-0.49). Quality scores differed significantly between surgeons (chi-square = 30.6, df = 16, P = .015) and institutions (chi-square = 19.59, df = 7, P = .007). Operative report quality score did not differ based on completion by trainee or staff, template use, or whether the report was completed by telephone or typed. CONCLUSION: There is significant variability and inconsistency in endometriosis surgery documentation. There is a need to standardize surgical documentation for endometriosis surgeries, enhancing communication and ultimately patient care.

"I Had Bills to Pay": a Mixed-Methods Study on the Role of Income on Care Transitions in a Public-Payer Healthcare System.

BACKGROUND: Income disparities may affect patients' care transition home. Evidence among patients who have access to publicly funded healthcare coverage remains limited. OBJECTIVE: To evaluate the association between low income and post-discharge health outcomes and explore patient and caregiver perspectives on the role of income disparities. DESIGN: Mixed-methods secondary analysis conducted among participants in a double-blind randomized controlled trial. PARTICIPANTS: Participants from a multicenter study in Ontario, Canada, were classified as low income if annual self-reported salary was below $29,000 CAD, or between $30,000 and $50,000 CAD and supported ≥ 3 individuals. MAIN MEASURES: The associations between low income and the following self-reported outcomes were evaluated using multivariable logistic regression: patient experience, adherence to medications, diet, activity and follow-up, and the aggregate of emergency department (ED) visits, readmission, or death up to 3 months post-discharge. A deductive direct content analysis of patient and caregivers on the role of income-related disparities during care transitions was conducted. KEY RESULTS: Individuals had similar odds of reporting high patient experience and adherence to instructions regardless of reported income. Compared to higher income individuals, low-income individuals also had similar odds of ED visits, readmissions, and death within 3 months post-discharge. Low-income individuals were more likely than high-income individuals to report understanding their medications completely (OR 1.9, 95% CI: 1.0-3.4) in fully adjusted regression models. Two themes emerged from 25 interviews which (1) highlight constraints of publicly funded services and costs incurred to patients or their caregivers along with (2) the various ways patients adapt through caregiver support, private services, or prioritizing finances over health. CONCLUSIONS: There were few quantitative differences in patient experience, adherence, ED visits, readmissions, and death post-discharge between individuals reporting low versus higher income. Several hidden costs for transportation, medications, and home care were reported however and warrant further research.

Pain resolution and functional outcomes of total mesh excision: a case series.

INTRODUCTION AND HYPOTHESIS: The objective was to assess the impact of total excision of polypropylene midurethral slings (MUS) on patient pain levels and to report on functional outcomes including recurrent/de novo stress urinary incontinence (SUI), sexual function, and quality of life measures. METHODS: This is a retrospective analysis of patients who underwent total MUS excision from March 2017 to December 2019. The primary outcome was the impact on pain assessed by a Numeric Rating Scale (NRS). Questionnaires analyzed were: Pain Catastrophizing Scale, Pelvic Floor Distress Inventory Short Form-20, Female Sexual Function Index, and McGill Pain Index questionnaires. RESULTS: Thirty-two women underwent total mesh excision within the inclusion period; with follow-up data available for 31 out of 32; 14 (43.8%) had previously undergone one or more partial vaginal mesh excision procedures. Types of MUS removed were: 14 (43.8%) transobturator midurethral slings, 12 (37.5%) retropubic midurethral slings, 4 (12.5%) mini-slings, and 2 (6.3%) mesh slings placed by laparotomy. Pain was the main reason for referral in 31 patients (96.9%). Mean pain NRS reduced from 6.1 pre-operatively to 3.3 post-operatively, with paired comparison showing a significant difference (p<0.01). Qualitatively, complete symptoms resolution was observed in 10 out of 31 (32.3%), another 9 out of 31 (29.0%) patients experienced clinically significant improvement, 2 out of 31 (6.5%) did not experience improvement in pain, and 10 out of 31 (32.3%) reported new/worsening pain. Post-operative complications occurred in 9 (29.0%) patients; all were Clavien-Dindo grade II. Nineteen (61.3%) reported de novo/recurrent SUI post-operatively. CONCLUSION: Total MUS mesh excision yields high complication and SUI recurrence rates, counter-balanced by a 61.3% pain resolution/improvement rate. These data are pertinent for patient counseling.

Surgeon Gender and Performance Outcomes for Hysterectomies: Retrospective Cohort Study.

STUDY OBJECTIVE: To evaluate whether there are differences in several performance metrics between male and female surgeons for hysterectomies. DESIGN: Multicenter retrospective cohort study. We matched surgeries performed by female surgeons to those by male surgeons using a propensity score and compared outcomes by gender after adjusting for years in practice and fellowship training. SETTING: A total of 6 hospitals (3 academic, 3 community) in Ontario, Canada, between July 2016 and December 2019. PATIENTS: All consecutive patients. INTERVENTIONS: Hysterectomy. MEASUREMENTS AND MAIN RESULTS: Primary outcome was a composite of any complication or return to emergency room (ER) within 30 days. Secondary outcomes were grade II or greater complications, return to ER, and operative time. We included 2664 hysterectomies performed by 77 surgeons. After propensity matching, 963 surgeries performed by females were compared with 963 performed by males. There were no differences in the primary (relative risk [RR], 0.92; 95% confidence interval [CI], 0.71-1.20; p = .56) or secondary outcomes of grade II or greater complication (RR, 1.01; 95% CI, 0.71-1.45; p = .96) or return to ER (RR, 0.81; 95% CI, 0.55-1.20; p = .30). However, surgeries performed by males were 24.72 minutes shorter (95% CI, 18.09-31.34 minutes; p <.001). Entire cohort post hoc regression analysis confirmed these findings. E-value analysis indicated that it is unlikely for an unmeasured confounder to undo the observed difference. CONCLUSION: Although complication and readmission rates are similar, male surgeons may have a shorter operating time than female surgeons for hysterectomies, which may have implications for health systems and inequalities in surgeon renumeration.

The impact of semi-upright position on severity of sleep disordered breathing in patients with obstructive sleep apnea: a two-arm, prospective, randomized controlled trial.

BACKGROUND: The severity of sleep-disordered breathing is known to worsen postoperatively and is associated with increased cardio-pulmonary complications and increased resource implications. In the general population, the semi-upright position has been used in the management of OSA. We hypothesized that the use of a semi-upright position versus a non-elevated position will reduce postoperative worsening of OSA in patients undergoing non-cardiac surgeries. METHODS: This study was conducted as a prospective randomized controlled trial of perioperative patients, undergoing elective non-cardiac inpatient surgeries. Patients underwent a preoperative sleep study using a portable polysomnography device. Patients with OSA (apnea hypopnea index (AHI) > 5 events/hr), underwent a sleep study on postoperative night 2 (N2) after being randomized into an intervention group (Group I): semi-upright position (30 to 45 degrees incline), or a control group (Group C) (zero degrees from horizontal). The primary outcome was postoperative AHI on N2. The secondary outcomes were obstructive apnea index (OAI), central apnea index (CAI), hypopnea index (HI), obstructive apnea hypopnea index (OAHI) and oxygenation parameters. RESULTS: Thirty-five patients were included. Twenty-one patients were assigned to the Group 1 (females-14 (67%); mean age 65 ± 12) while there were fourteen patients in the Group C (females-5 (36%); mean age 63 ± 10). The semi-upright position resulted in a significant reduction in OAI in the intervention arm (Group C vs Group I postop AHI: 16.6 ± 19.0 vs 8.6 ± 11.2 events/hr; overall p = 0.01), but there were no significant differences in the overall AHI or other parameters between the two groups. Subgroup analysis of patients with "supine related OSA" revealed a decreasing trend in postoperative AHI with semi-upright position, but the sample size was too small to evaluate statistical significance. CONCLUSION: In patients with newly diagnosed OSA, the semi-upright position resulted in improvement in obstructive apneas, but not the overall AHI. TRIAL REGISTRATION: This trial was retrospectively registered in clinicaltrials.gov NCT02152202 on 02/06/2014.

Effectiveness of preoperative thoracic epidural testing strategies: a retrospective comparison of three commonly used testing methods.

PURPOSE: Thoracic epidural analgesia (TEA) is a well stablished technique for pain management in major thoracic and abdominal surgeries; however, it has considerable failure rates. Local anesthetic (LA) administration and subsequent assessment of sensory block through physical examination (e.g., decreased temperature perception determined via an LA temperature dissociation test [LATDT]) has been the historical standard for evaluation of thoracic epidural placement. Nevertheless, newer methods to objectively evaluate successful placement have recently been developed, e.g., the epidural electrical stimulation test (EEST) and epidural pressure waveform analysis (EWA). The purpose of this study was to evaluate the effectiveness of preoperative TEA catheter testing (LATDT, EEST, and EWA) on reducing TEA failure. METHODS: After obtaining an institutional research ethics board approval for a retrospective study, we conducted a single-institution retrospective review on all TEAs performed between January 2016 and December 2021. Patients were assigned to one of four groups based on the performed test method to verify the placement of the TEA catheter: no test, LATDT, EEST, and EWA. A TEA was deemed successful if it provided bilateral dermatomal sensory block to ice test in the postoperative period, and was used for patient analgesia for at least 24 hr. RESULTS: One thousand two hundred and forty-one patients submitted to preoperative TEA were included. Twenty-eight patients were excluded. Tested and untested epidurals had failure rates of 3.8% (95% confidence interval [CI], 1.8 to 6.2) and 11.5% (95% CI, 5.2 to 17.1), respectively (P < 0.001). CONCLUSION: Objective preoperative testing after placement of thoracic epidurals was associated with a reduction in failure rates.

RéSUMé: OBJECTIF: L'analgésie péridurale thoracique (APT) est une technique bien établie pour la prise en charge de la douleur dans les chirurgies thoraciques et abdominales majeures; cette modalité entraîne cependant des taux d'échec considérables. L'administration d'anesthésique local (AL) et l'évaluation subséquente du bloc sensitif par un examen physique (p. ex. diminution de la perception de la température déterminée par un test de dissociation de la température après l'AL [LATDT]) ont constitué la norme historique pour l'évaluation du positionnement de la péridurale thoracique. Néanmoins, de nouvelles méthodes permettant d'évaluer objectivement le positionnement réussi ont récemment été mises au point, par exemple le test de stimulation électrique péridurale (EEST) et l'analyse de la forme d'onde de pression péridurale (EWA). L'objectif de cette étude était d'évaluer l'efficacité des tests préopératoires de cathéters d'APT (LATDT, EEST et EWA) sur la réduction des échecs d'APT. MéTHODE: Après avoir obtenu l'approbation d'un comité d'éthique de la recherche de l'établissement pour une étude rétrospective, nous avons réalisé un examen rétrospectif monocentrique de toutes les APT réalisées entre janvier 2016 et décembre 2021. Les patient·es ont été assigné·es à l'un des quatre groupes en fonction de la méthode de test utilisée pour vérifier l'emplacement du cathéter d'APT, soit : aucun test, LATDT, EEST et EWA. Une APT a été jugée efficace si elle a fourni un bloc sensitif dermatomal bilatéral au test de glace en postopératoire et a été utilisée pour l'analgésie pendant au moins 24 heures. RéSULTATS: Mille deux cent quarante et un·e patient·es soumis·es à une APT préopératoire ont été inclus·es. Vingt-huit personnes ont été exclues. Les péridurales testées et non testées présentaient des taux d'échec de 3,8 % (intervalle de confiance [IC] à 95 %, 1,8 à 6,2) et de 11,5 % (IC 95 %, 5,2 à 17,1), respectivement (P < 0,001). CONCLUSION: Les tests préopératoires objectifs après la mise en place de péridurales thoraciques ont été associés à une réduction des taux d'échec.

Indications and Outcomes for Planned Cesarean Hysterectomy in Non-Placenta Accreta Spectrum Disorder Patients: A Systematic Review.

OBJECTIVE: Planned hysterectomy at the time of cesarean delivery may be reasonable in cases other than placenta accreta spectrum disorders. Our objective was to synthesize the published literature on the indications and outcomes for planned cesarean hysterectomy. DATA SOURCES: We performed a systematic review of published literature from the following databases from inception (1946) to June 2021: MEDLINE, PubMed, EMBASE, Cochrane CENTRAL, DARE, and clinicaltrials.gov. STUDY SELECTION: We included all study designs where subjects underwent planned cesarean delivery with simultaneous hysterectomy. Emergency procedures and those performed for placenta accreta spectrum disorders were excluded. DATA EXTRACTION AND SYNTHESIS: The primary outcome was surgical indication, though other surgical outcomes were evaluated when data permitted. Quantitative analysis was limited to studies published in 1990 or later. Risk of bias was assessed using an adaptation of the ROBINS-I tool. CONCLUSION: The most common indication for planned cesarean hysterectomy was malignancy, with cervical cancer being the most frequent. Other indications included permanent contraception, uterine fibroids, menstrual disorders, and chronic pelvic pain. Common complications included bleeding, infection, and ileus. The surgical skill for cesarean hysterectomy continues to be relevant in contemporary obstetrical practice for reproductive malignancy and several benign indications. Although the data indicate relatively safe outcomes, these studies show significant publication bias and, therefore, further systematic study of this procedure is justified. PROSPERO REGISTRATION NUMBER: CRD42021260545, registered June 16, 2021.

Development of Multivariable Prediction Models for the Identification of Patients Admitted to Hospital with an Exacerbation of COPD and the Prediction of Risk of Readmission: A Retrospective Cohort Study using Electronic Medical Record Data.

BACKGROUND: Approximately 20% of patients who are discharged from hospital for an acute exacerbation of COPD (AECOPD) are readmitted within 30 days. To reduce this, it is important both to identify all individuals admitted with AECOPD and to predict those who are at higher risk for readmission. OBJECTIVES: To develop two clinical prediction models using data available in electronic medical records: 1) identifying patients admitted with AECOPD and 2) predicting 30-day readmission in patients discharged after AECOPD. METHODS: Two datasets were created using all admissions to General Internal Medicine from 2012 to 2018 at two hospitals: one cohort to identify AECOPD and a second cohort to predict 30-day readmissions. We fit and internally validated models with four algorithms. RESULTS: Of the 64,609 admissions, 3,620 (5.6%) were diagnosed with an AECOPD. Of those discharged, 518 (15.4%) had a readmission to hospital within 30 days. For identification of patients with a diagnosis of an AECOPD, the top-performing models were LASSO and a four-variable regression model that consisted of specific medications ordered within the first 72 hours of admission. For 30-day readmission prediction, a two-variable regression model was the top performing model consisting of number of COPD admissions in the previous year and the number of non-COPD admissions in the previous year. CONCLUSION: We generated clinical prediction models to identify AECOPDs during hospitalization and to predict 30-day readmissions after an acute exacerbation from a dataset derived from available EMR data. Further work is needed to improve and externally validate these models.

Tacrolimus Impairs Kupffer Cell Capacity to Control Bacteremia: Why Transplant Recipients Are Susceptible to Infection.

BACKGROUND AND AIMS: Kupffer cells (KCs) are the resident intravascular phagocyte population of the liver and critical to the capture and killing of bacteria. Calcineurin/nuclear factor of activated T cells (NFAT) inhibitors (CNIs) such as tacrolimus are used to prevent rejection in solid organ transplant recipients. Although their effect on lymphocytes has been studied extensively, there are limited experimental data about if and how CNIs shape innate immunity, and whether this contributes to the higher rates of infection observed in patients taking CNIs. APPROACH AND RESULTS: Here, we investigated the impact of tacrolimus treatment on innate immunity and, more specifically, on the capability of Kupffer cells (KCs) to fight infections. Retrospective analysis of data of >2,700 liver transplant recipients showed that taking calcineurin inhibitors such as tacrolimus significantly increased the likelihood of Staphylococcus aureus infection. Using a mouse model of acute methicillin-resistant S. aureus (MRSA) bacteremia, most bacteria were sequestered in the liver and we found that bacteria were more likely to disseminate and kill the host in tacrolimus-treated mice. Using imaging, we unveiled the mechanism underlying this observation: the reduced capability of KCs to capture, phagocytose, and destroy bacteria in tacrolimus-treated animals. Furthermore, in a gene expression analysis of infected KCs, the triggering receptor expressed on myeloid cells 1 (TREM1) pathway was the one with the most significant down-regulation after tacrolimus treatment. TREM1 inhibition likewise inhibited KC bacteria capture. TREM1 levels on neutrophils as well as the overall neutrophil response after infection were unaffected by tacrolimus treatment. CONCLUSIONS: Our results indicate that tacrolimus treatment has a significant impact directly on KCs and on TREM1, thereby compromising their capacity to fend off infections.

Reducing Sedative-Hypnotics Among Hospitalized Patients: a Multi-centered Study.

BACKGROUND: Sedative-hypnotics are frequently prescribed for insomnia in hospital but are associated with preventable harms. OBJECTIVE, DESIGN, AND PARTICIPANTS: We aimed to examine whether a sedative-hypnotic reduction quality improvement bundle decreases the rate of sedative-hypnotic use among hospitalized patients, who were previously naïve to sedative-hypnotics. This interrupted time series study occurred between May 2016 and January 2019. Control data for 1 year prior to implementation and intervention data for at least 16 months were collected. The study occurred on 7 inpatient wards (general medicine, cardiology, nephrology, general surgery, and cardiovascular surgery wards) across 5 teaching hospitals in Toronto, Canada. INTERVENTION: Participating wards implemented a sedative-hypnotic reduction bundle (i.e., order set changes, audit-feedback, pharmacist-enabled medication reviews, sleep hygiene, daily sleep huddles, and staff/patient/family education) aimed to reduce in-hospital sedative-hypnotic initiation for insomnia in patients who were previously naïve to sedative-hypnotics. Each inpatient ward adapted the bundle prior to sustaining the intervention for a minimum of 16 months. MAIN MEASURES: The primary outcome measure was the proportion of sedative-hypnotic-naïve inpatients newly prescribed a sedative-hypnotic for sleep in hospital. Secondary measures include prescribing rates of other sedating medications, fall rates, length of stay, and mortality. KEY RESULTS: We included 8,970 patient discharges in the control period and 10,120 in the intervention period. Adjusted sedative-hypnotic prescriptions among naïve patients decreased from 15.48% (95% CI: 6.09-19.42) to 9.08% (p<0.001) (adjusted OR 0.814; 95% CI: 0.667-0.993, p=0.042). Unchanged secondary outcomes included mortality (adjusted OR 1.089; 95% CI: 0.786-1.508, p=0.608), falls (adjusted rate ratio 0.819; 95% CI: 0.625-1.073, p=0.148), or other sedating drug prescriptions (adjusted OR 1.046; 95% CI: 0.873-1.252, p=0.627). CONCLUSIONS: A sedative-hypnotic reduction quality improvement bundle implemented across 5 hospitals was associated with a sustained reduction in sedative-hypnotic prescriptions.

Individualized Assessment of Risk of Complications after Benign Hysterectomy.

STUDY OBJECTIVES: The primary objective of this study is to identify patient characteristics associated with postoperative complications or readmissions after hysterectomy for a benign indication. DESIGN: Retrospective cohort. SETTING: The Surgical Gynecologic Scorecard Database includes performance metrics and patient outcomes for hysterectomies across 7 sites in Ontario, Canada. PARTICIPANTS: Individuals who underwent hysterectomy for benign gynecologic indication and were recorded in the Surgical Gynecologic Scorecard Database between July 2016 and June 2019 were included in this study. MEASUREMENTS AND MAIN RESULTS: Two outcomes of interest were considered: (1) complications grade II or greater on the Clavien-Dindo classification scale and (2) emergency room visits or hospital readmissions within 6 weeks after operation. Logistic models were generated to determine the associations between outcome of interest and potential predictors using a mixed-step AIC selection algorithm. A total of 2792 patients underwent hysterectomy for a benign indication during the study period, with a mean age of 52.6 ± 11.7 years and mean body mass index of 29.0 ± 0.7 kg/m2. The most common indications for surgery were abnormal uterine bleeding (33.3%) and myomas (33.6%). Previous cesarean delivery (adjusted odds ratio [aOR], 1.22; 95% confidence interval [CI], 1.04-1.42), American Society of Anesthesiologists class ≥3 (aOR, 2.31; 95% CI, 1.42-3.99), preoperative anemia (aOR, 1.51; 95% CI, 1.12-2.02), and laparotomic approach (aOR, 1.73; 95% CI, 1.30-2.29) were associated with increased odds of complication. Perioperative complications (aOR, 2.95; 95% CI, 2.12-4.08), preoperative anemia (aOR, 1.43; 95% CI, 1.03-1.98), and vaginal (aOR, 1.94; 95% CI, 1.26-2.96) or laparotomic (aOR, 1.64; 95% CI, 1.10-2.43) approach were associated with increased odds of emergency room visit or readmission to hospital. CONCLUSION: This study identified several important risk factors for complications after hysterectomy. The utility of these data is important to help improve counseling for patients undergoing a hysterectomy and potentially optimize modifiable risk factors when identified preoperatively.

Evaluation of a quality improvement bundle aimed to reduce opioid prescriptions after Cesarean delivery: an interrupted time series study.

PURPOSE: To evaluate whether opioid prescriptions at discharge after Cesarean delivery decreased following implementation of a quality improvement bundle. METHODS: A quality improvement bundle was instituted at Mount Sinai Hospital in Toronto. Interventions included opioid prescribing instructions in resident orientation, nursing and patient education, and standard electronic prescriptions. We used an interrupted time series study design and included patients who had a Cesarean delivery six months pre intervention and six months post intervention. Primary outcome data (opioids prescribed at discharge in morphine milliequivalents [MME]), were aggregated (averaged) by calendar week and analyzed using interrupted time series. Secondary outcomes were assessed using bivariate methods and included opioid use for breakthrough pain in hospital, and amount of opioids prescribed by prescriber specialty and training level. RESULTS: We included 2,578 women in our analysis. Based on the segmented regression analysis, prescribed opioids decreased from 97.6 MME in 2018 to 35.8 MME in 2019 (difference in means, - 61.7; 95% confidence interval [CI], - 72.2 to - 51.3; P < 0.001), and this decrease was sustained over the study period. Post intervention, there were no visits to our postnatal assessment clinic for inadequate pain control. CONCLUSION: A quality improvement bundle was associated with a marked and sustained decrease in discharge prescriptions of opioids post Cesarean delivery at a large Canadian tertiary academic hospital.

RéSUMé: OBJECTIF: Déterminer si les ordonnances d'opioïdes au congé après un accouchement par césarienne avaient diminué à la suite de la mise en place d'un ensemble d'améliorations de la qualité. MéTHODE: Un ensemble d'améliorations de la qualité a été mis en place à l'Hôpital Mount Sinai de Toronto. Les interventions comprenaient des instructions de prescription d'opioïdes pendant l'orientation des résidents, la formation des soins infirmiers et des patients, ainsi que des ordonnances électroniques standard. Nous avons utilisé un plan d'étude de séries chronologiques interrompues et inclus des patientes ayant accouché par césarienne six mois avant et six mois après l'intervention. Les données sur le critère d'évaluation principal (soit les opioïdes prescrits au congé en équivalents de morphine en milligrammes [EMM]) ont été agrégées (moyennes) par semaine civile et analysées à l'aide de séries chronologiques interrompues. Les critères d'évaluation secondaires ont été estimés à l'aide de méthodes bivariées et comprenaient l'utilisation d'opioïdes pour les accès douloureux paroxystiques à l'hôpital, ainsi que la quantité d'opioïdes prescrits en fonction de la spécialité et du niveau de formation du prescripteur. RéSULTATS: Nous avons inclus 2578 femmes dans notre analyse. Selon l'analyse de régression segmentée, les opioïdes prescrits sont passés de 97,6 EMM en 2018 à 35,8 EMM en 2019 (différence de moyennes, − 61,7; intervalle de confiance [IC] à 95 %, − 72,2 à − 51,3; P < 0,001), et cette diminution s'est maintenue au cours de la période d'étude. Après l'intervention, il n'y a pas eu de visites à notre clinique d'évaluation postnatale pour remédier à un soulagement inadéquat de la douleur. CONCLUSION: Un ensemble d'améliorations de la qualité a été associé à une diminution marquée et soutenue des ordonnances d'opioïdes après les accouchements par césarienne dans un grand hôpital universitaire tertiaire canadien.

Surgeons disciplined by regulatory bodies in Canada between 2000 and 2017.

Identifying characteristics of disciplined surgeons is important for public safety. A database of all physicians disciplined by a Canadian provincial medical regulatory authority (College of Physicians and Surgeons) between 2000 and 2017 was constructed, and comparisons between surgeons and other physicians were undertaken. Of 1100 disciplined physicians, 174 (15.8 %) were surgeons. Obstetrics and gynecology was the specialty with the most disciplined surgeons (57 of 174 [32.8%]), followed by general surgery (48 of 174 [27.6%]). The overall disciplinary rate for surgeons was higher than for other physicians (12.59, 95 % confidence interval [CI] 10.69-14.83 v. 9.85, 95 % CI 8.88-10.94 cases per 10 000 physician-years, p = 0.013). Even after adjusting for surgeon age, sex, international medical graduation and years in practice, surgeons remained more likely than other physicians to be disciplined for standard of care issues (55.6%, 95% CI 46.6-64.2 v. 38.7%, 95% CI 32.6-45.2, p < 0.001).

Airway Oscillometry Detects Spirometric-Silent Episodes of Acute Cellular Rejection.

Rationale: Acute cellular rejection (ACR) is common during the initial 3 months after lung transplant. Patients are monitored with spirometry and routine surveillance transbronchial biopsies. However, many centers monitor patients with spirometry only because of the risks and insensitivity of transbronchial biopsy for detecting ACR. Airway oscillometry is a lung function test that detects peripheral airway inhomogeneity with greater sensitivity than spirometry. Little is known about the role of oscillometry in patient monitoring after a transplant.Objectives: To characterize oscillometry measurements in biopsy-proven clinically significant (grade ≥2 ACR) in the first 3 months after a transplant.Methods: We enrolled 156 of the 209 double lung transplant recipients between December 2017 and March 2019. Weekly outpatient oscillometry and spirometry and surveillance biopsies at Weeks 6 and 12 were conducted at our center.Measurements and Main Results: Of the 138 patients followed for 3 or more months, 15 patients had 16 episodes of grade 2 ACR (AR2) and 44 patients had 64 episodes of grade 0 ACR (AR0) rejection associated with stable and/or improving spirometry. In 15/16 episodes of AR2, spirometry was stable or improving in the weeks leading to transbronchial biopsy. However, oscillometry was markedly abnormal and significantly different from AR0 (P < 0.05), particularly in integrated area of reactance and the resistance between 5 and 19 Hz, the indices of peripheral airway obstruction. By 2 weeks after biopsy, after treatment for AR2, oscillometry in the AR2 group improved and was similar to the AR0 group.Conclusions: Oscillometry identified physiological changes associated with AR2 that were not discernible by spirometry and is useful for graft monitoring after a lung transplant.

Retrograde Bladder Filling after Laparoscopic Gynecologic Surgery: A Double-blind Randomized Controlled Trial.

STUDY OBJECTIVE: To evaluate whether retrofilling the bladder on completion of elective laparoscopic gynecologic surgery for benign indications has an effect on the timing of the first postoperative void and the timing of discharge from the hospital. DESIGN: Double-blind randomized controlled trial. SETTING: Single academic surgical day hospital. PATIENTS: Patients undergoing outpatient laparoscopic gynecologic surgery, excluding hysterectomy or pelvic reconstructive surgery. INTERVENTIONS: On completion of surgery, patients were randomized to either retrograde filling of the bladder with 200 mL of saline before catheter removal or standard care (immediate catheter removal). Patients and postanesthesia care unit nurses (outcome assessors) were both blinded. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the time to first void. The secondary outcomes were time to hospital discharge, postoperative urinary tract infection, and patient satisfaction. Over a 3-month period, 47 patients were approached on the day of surgery, 42 consented and were randomized (21 to intervention and 21 to control). There were no significant differences in baseline demographics between the groups. The median time to first void was significantly shorter for patients in the intervention arm than controls (104 ± 75 minutes vs 162 ± 76 minutes, p <.001). Patients who had retrofilled bladders were discharged faster from post-anesthesia care unit compared to controls (155.0 ± 74 minutes vs 227 ± 58 minutes, p = .001). There were no urinary tract infections in either group, and the proportion of satisfied or very satisfied patients was high (93.8% vs 88.2%, p = .512). CONCLUSION: Retrograde filling of the bladder after outpatient laparoscopic gynecologic surgery is a safe, effective method that significantly reduces the length of hospital stay.

Impact of Minimally Invasive Gynaecology Fellowship Training on Quality Performance Metrics for Hysterectomy.

OBJECTIVE: To evaluate differences in quality metrics between hysterectomies performed by fellowship-trained surgeons and those performed by generalists. METHODS: Retrospective review of 2845 consecutive hysterectomies by 75 surgeons (23 fellowship-trained, 52 generalists) at 7 hospitals in Ontario, Canada. The primary outcome was a composite of any complication or return to the emergency department (ED) within 30 days of hysterectomy. Secondary outcomes were 2 quality outcome measures (grade of complication and return to ED within 30 days) and 4 quality process measures (minimally invasive hysterectomy rate, rate of preoperative anemia, same-day discharge for laparoscopic hysterectomy [LH], and performing cystoscopy at LH). RESULTS: Fellowship-trained surgeons were more likely to perform concurrent resection of endometriosis, bilateral ureterolysis, lysis of adhesions, uterine/internal iliac artery ligation, and morcellation (all P < 0.001). Generalists performed more vaginal procedures, including vaginal repair, vault suspension, and insertion of mid-urethral sling (all P < 0.001). After controlling for patient and surgical factors, there was no difference in the primary outcome (adjusted odds ratio [aOR] 1.07; 95% CI 0.79-1.45, P = 0.667). Fellowship-trained surgeons were more likely to perform minimally invasive hysterectomy (aOR 2.38; 95% CI 1.15-4.93, P = 0.020), had higher rates of same-day discharge for LH (aOR 2.23; 95% CI 1.31-3.81, P = 0.003), and were more likely to perform cystoscopy (unadjusted OR 2.94; 95% CI 2.30-3.85, P < 0.001). There were no differences in the rates of preoperative anemia, surgical complications, and ED visits. CONCLUSION: Differences exist between fellowship-trained surgeons and generalists regarding case mix and process quality metrics. Postoperative complications and readmissions were comparable for both groups of surgeons.

Implementation, spread and impact of the Patient Oriented Discharge Summary (PODS) across Ontario hospitals: a mixed methods evaluation.

BACKGROUND: Traditional discharge processes lack a patient-centred focus. This project studied the implementation and effectiveness of an individualized discharge tool across Ontario hospitals. The Patient Oriented Discharge Summary (PODS) is an individualized discharge tool with guidelines that was co-designed with patients and families to enable a patient-centred process. METHODS: Twenty one acute-care and rehabilitation hospitals in Ontario, Canada engaged in a community of practice and worked over a period of 18 months to implement PODS. An effectiveness-implementation hybrid design using a triangulation approach was used with hospital-collected data, patient and provider surveys, and interviews of project teams. Key outcomes included: penetration and fidelity of the intervention, change in patient-centred processes, patient and provider satisfaction and experience, and healthcare utilization. Statistical methods included linear mixed effects models and generalized estimating equations. RESULTS: Of 65,221 discharges across hospitals, 41,884 patients (64%) received a PODS. There was variation in reach and implementation pattern between sites, though none of the between site covariates was significantly associated with implementation success. Both high participation in the community of practice and high fidelity were associated with higher penetration. PODS improved family involvement during discharge teaching (7% increase, p = 0.026), use of teach-back (11% increase, p < 0.001) and discussion of help needed (6% increase, p = 0.041). Although unscheduled healthcare utilization decreased with PODS implementation, it was not statistically significant. CONCLUSIONS: This project highlighted the system-wide adaptability and ease of implementing PODS across multiple patient groups and hospital settings. PODS demonstrated an improvement in patient-centred discharge processes linked to quality standards and health outcomes. A community of practice and high quality content may be needed for successful implementation.

Reducing Acute Hospitalization Length of Stay After Total Knee Arthroplasty: A Quality Improvement Study.

BACKGROUND: The introduction of bundled funding for total knee arthroplasty (TKA) has motivated hospitals to improve quality of care while minimizing costs. The aim of our quality improvement project is to reduce the acute hospitalization length of stay to less than 2 days and decrease the percentage of TKA patients discharged to inpatient rehabilitation using an enhanced recovery after surgery bundle. METHODS: This study used a before-and-after design. The pre-intervention period was January to December 2017 and the post-intervention period was January 2018 to August 2019. A root cause analysis was performed by a multidisciplinary team to identify barriers for rapid recovery and discharge. Four new interventions were chosen as part of an improvement bundle based on existing local practices, literature review, and feasibility analysis: (1) perioperative peripheral nerve block; (2) prophylactic antiemetic medication; (3) avoidance of routine preoperative urinary catheterization; and (4) preoperative patient education. RESULTS: The pre-intervention and post-intervention groups included 232 and 383 patients, respectively. Mean length of stay decreased from 2.82 to 2.13 days (P < .001). The need for inpatient rehabilitation decreased from 20.2% to 10.7% (P = .002). Mean 24-hour oral morphine consumption decreased from 60 to 38 mg (P < .001). The percentage of patients experiencing moderate-to-severe pain and postoperative nausea and vomiting within the first 24 hours decreased by 25% and 15%, respectively (P < .001). Thirty-day emergency department visits following discharge decreased from 12.9% to 7.3% (P = .030). CONCLUSION: Significant improvements in the recovery of patients after TKA were achieved by performing a root cause analysis and implementing a multidisciplinary, patient-centered enhanced recovery after surgery bundle. LEVEL OF EVIDENCE: Level III.

Dienogest and the Risk of Endometriosis Recurrence Following Surgery: A Systematic Review and Meta-analysis.

STUDY OBJECTIVE: To determine whether dienogest therapy after endometriosis surgery reduces the risk of endometriosis recurrence compared with expectant management. DATA SOURCES: Ovid MEDLINE, Ovid EMBASE, PubMed, Cochrane Central Register of Controlled Trials, Web of Science, LILACS, clinicaltrials.gov, and International Standard Randomized Controlled Trial Number Registry were searched from inception to March 2019 for observational and randomized controlled trials. METHODS OF STUDY SELECTION: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Medical Subject Heading terms and keywords such as "dienogest," "endometriosis," and "recurrence" were used to identify relevant studies. TABULATION, INTEGRATION, AND RESULTS: The search yielded 328 studies, 10 of which were eligible for inclusion, representing 1184 patients treated with dienogest and 846 expectantly managed controls. Among these studies, 9 looked exclusively at endometrioma recurrence, whereas 1 used reappearance of symptoms as evidence of disease recurrence. Data on both incidence of and time to recurrence of endometriosis were extracted. The incidence rate of endometriosis recurrence in patients treated with dienogest was 2 per 100 women over a mean follow-up of 29 months (95% confidence interval [CI], 1.43-3.11) versus 29 per 100 women managed expectantly over a mean follow-up of 36 months (95% CI, 25.66-31.74). The likelihood of recurrence was significantly reduced with postoperative dienogest (log odds -1.96, CI, -2.53 to -1.38, p <.001). CONCLUSION: Patients receiving dienogest after conservative surgery for endometriosis had significantly lower risk of postoperative disease recurrence than those who were expectantly managed.