Incidence of Intrauterine Adhesions After Hysteroscopic Myomectomy in Patients Seeking Fertility.

STUDY OBJECTIVE: To study the incidence of intrauterine adhesions (IUAs) after hysteroscopic myomectomy. Previous studies report a range of incidence for IUAs after hysteroscopic myomectomy. DESIGN: A retrospective review study. SETTING: An academic community hospital in the Boston metropolitan area. PATIENTS: Patients undergoing hysteroscopic myomectomy at our institution from January 2019 to February 2022. Patients were excluded if they did not have plans for future fertility or had a new diagnosis of cancer. INTERVENTIONS: All patients underwent hysteroscopic myomectomy using bipolar resectoscope without postoperative medical or barrier treatment. All procedures were performed by 1 of 4 fellowship-trained high-volume gynecologic surgeons with resident and fellow assistance. Incidence of postoperative IUAs was assessed and treated using second-look office hysteroscopy. MEASUREMENTS AND MAIN RESULTS: A total of 44 patients without preoperative IUAs underwent hysteroscopic myomectomy during our study period, and 4 patients (9.1%) developed new IUAs. Among 9 patients who were found to have preoperative IUAs and underwent concurrent hysteroscopic myomectomy and lysis of adhesions, we found a recurrence of IUAs in 5 patients (55.6%). We found the number, size, and deepest type of myoma removed were not correlated to an increased risk of new IUA formation. In addition, removing myomas on opposing walls during the same operation did not increase the incidence of new IUAs. CONCLUSION: Formation of IUAs after hysteroscopic myomectomy is a well-documented consequence. Our reported incidence of 9.1% of new IUAs that are not affected by the number, size, deepest type of myoma resected, and resection of myomas on opposing uterine walls contributes to the current literature. In addition, our finding of 55.6% of recurrent IUAs in patients undergoing both hysteroscopic myomectomy and lysis of adhesions highlights a high-risk population requiring additional study.

Use and Perceptions of Shared Decision-Making by General Surgery Faculty and Trainees.

INTRODUCTION: The purpose of this study was to assess the practice and perceptions of shared decision-making (SDM) by both faculty and residents at Boston Medical Center and explore barriers and facilitators to implementing SDM at our institution. METHODS: We created and distributed an online survey assessing provider demographic and training characteristics, experiences with the informed consent process, practices in SDM, and perceptions about SDM. We used descriptive statistics to summarize provider characteristics and survey responses and univariate analysis to determine associations between them. RESULTS: Fifteen surgeons and 19 surgical residents completed the survey (49% response rate). Most respondents were aware of and had a positive attitude toward SDM (91% and 76%, respectively); 35% reported having SDM training. Providers had varying levels of engagement with different SDM practices, and there were inconsistent associations between provider characteristics and the use of SDM. Often providers thought the patient's health literacy, foreign primary language, clinical condition, and socioeconomic factors were barriers to the SDM process. CONCLUSIONS: Although most general surgery faculty and residents at our institution had a positive view of SDM, they engaged in SDM behaviors inconsistently, with no clear association between clinician characteristics and specific behaviors. We identified several barriers to SDM consistent with those identified by providers in other specialties. This highlights the need for further research to study live general surgery provider-patient interactions, as well as structured SDM education to train general surgery providers to reliably engage their patients in effective SDM.

The Power of Community Voices for Enhancing Community Health Needs Assessments.

As required by the Affordable Care Act, Community Health Needs Assessments (CHNAs) are formalized processes nonprofit hospitals must perform at least every 3 years. CHNAs are designed to help hospitals better tailor health services to the needs of local residents. However, CHNAs most often use quantitative, population-level data, and rarely incorporate the actual voices of local community members. This is particularly a problem for meeting the needs of residents who are also racial or ethnic minorities. This article discusses one model for integrating residents' voices into the CHNA process. In this model, we videotaped interviews with community members and then coded and analyzed interview data to identify underlying themes. We created a short video aimed at starting conversations about community members' concerns. In addition to demonstrating how other nonprofit hospitals may use qualitative data in the CHNA process, this article illustrates how adding qualitative data may change how we think about health promotion. We find that community members requested that health care providers view culture as a health resource, foster community connections, and be present in the community.

Utilization of torso computed tomography for the evaluation of ground level falls: More imaging does not equal better care.

INTRODUCTION: Computed tomography (CT) of the chest (CTC), abdomen, and pelvis (CTAP) is common when assessing trauma patients in the emergency department. However, unnecessary imaging can expose patients to unneeded radiation and increase healthcare costs. Here, we characterize the use of torso CT imaging for the evaluation of ground level falls (GLF) at a single level 1 trauma center. PATIENTS AND METHODS: We conducted a retrospective review of all patients ≥18 years old presenting to a single level 1 trauma center with a GLF (1m or less) in 2015-2019. Data were obtained through chart review. Descriptive statistics were used to summarize patient characteristics. Multivariable logistic regression was used to assess factors leading to patients obtaining torso CT imaging. The utility of CT imaging in identifying injuries that changed management was also evaluated. RESULTS: Of the 1,195 patients captured during the study period, 492 patients had a positive torso physical exam (PE), and 703 had a negative torso PE. Of patients with a negative torso PE, 127 CTC and 142 CTAP were obtained, with only 5.5% CTC identifying traumatic injuries not previously diagnosed on chest radiograph (CXR), and only 0.7% CTAP identifying new injuries not identified on pelvic radiograph (PXR). Multivariable logistic regression demonstrated that only a positive PE was significantly associated with the identification of abnormal imaging findings on torso CT. A negative PE, CXR, and PXR have a negative predictive value of 98%. DISCUSSION: These data suggest that patients with a negative PE, even if intoxicated, intubated, or with a decreased GCS, are highly unlikely to have new, clinically relevant findings on torso CT imaging. CONCLUSION: Using PE, CXR, and PXR as a screening tool in patients sustaining GLF, which if negative close to obviates the need for torso CT, may reduce healthcare costs and radiation exposure without compromising patient care.

A Standardized Radiology Template Improves Incidental Adrenal Mass Follow-Up: A Prospective Effectiveness and Implementation Study.

PURPOSE: Incidental adrenal masses (IAMs) are common but rarely evaluated. To improve this, we developed a standardized radiology report recommendation template and investigated its implementation and effectiveness. METHODS: We prospectively studied implementation of a standardized IAM reporting template as part of an ongoing quality improvement initiative, which also included primary care provider (PCP) notifications and a straightforward clinical algorithm. Data were obtained via medical record review and a survey of radiologists. Outcomes included template adoption rates and acceptability (implementation measures), as well as the proportion of patients evaluated and time to follow-up (effectiveness outcomes). RESULTS: Of 4,995 imaging studies, 200 (4.0%) detected a new IAM. The standardized template was used in 54 reports (27.0%). All radiologists surveyed were aware of the template, and 91% affirmed that standardized recommendations are useful. Patients whose reports included the template were more likely to have PCP follow-up after IAM discovery compared with those with no template (53.7% versus 36.3%, P = .03). After adjusting for sex, current or prior malignancy, and provider ordering the initial imaging (PCP, other outpatient provider, or emergency department or inpatient provider), odds of PCP follow-up remained 2.0 times higher (95% confidence interval 1.02-3.9). Patients whose reports included the template had a shorter time to PCP follow-up (log-rank P = .018). PCPs ultimately placed orders for biochemical testing (35.2% versus 18.5%, P = .01), follow-up imaging (40.7% versus 23.3%, P = .02), and specialist referral (22.2% versus 4.8%, P < .01) for a higher proportion of patients who received the template compared with those who did not. CONCLUSIONS: Use of a standardized template to communicate IAM recommendations was associated with improved IAM evaluation. Our template demonstrated high acceptability, but additional strategies are necessary to optimize adoption.

Limited disease progression in endocrine surgery patients with treatment delays due to COVID-19.

BACKGROUND: The COVID-19 pandemic profoundly impacted the delivery of care and timing of elective surgical procedures. Most endocrine-related operations were considered elective and safe to postpone, providing a unique opportunity to assess clinical outcomes under protracted treatment plans. METHODS: American Association of Endocrine Surgeon members were surveyed for participation. A Research Electronic Data Capture survey was developed and distributed to 27 institutions to assess the impact of COVID-19-related delays. The information collected included patient demographics, primary diagnosis, resumption of care, and assessment of disease progression by the surgeon. RESULTS: Twelve out of 27 institutions completed the survey (44.4%). Of 850 patients, 74.8% (636) were female; median age was 56 (interquartile range, 44-66) years. Forty percent (34) of patients had not been seen since their original surgical appointment was delayed; 86.2% (733) of patients had a delay in care with women more likely to have a delay (87.6% vs 82.2% of men, χ2 = 3.84, P = .05). Median duration of delay was 70 (interquartile range, 42-118) days. Among patients with a delay in care, primary disease site included thyroid (54.2%), parathyroid (37.2%), adrenal (6.5%), and pancreatic/gastrointestinal neuroendocrine tumors (1.3%). In addition, 4.0% (26) of patients experienced disease progression and 4.1% (24) had a change from the initial operative plan. The duration of delay was not associated with disease progression (P = .96) or a change in operative plan (P = .66). CONCLUSION: Although some patients experienced disease progression during COVID-19 delays to endocrine disease-related care, most patients with follow-up did not. Our analysis indicated that temporary delay may be an acceptable course of action in extreme circumstances for most endocrine-related surgical disease.

Establishment of an Electrophysiological Platform for Modeling ALS with Regionally-Specific Human Pluripotent Stem Cell-Derived Astrocytes and Neurons.

Human pluripotent stem cell-derived astrocytes (hiPSC-A) and neurons (hiPSC-N) provide a powerful tool for modeling Amyotrophic Lateral Sclerosis (ALS) pathophysiology in vitro. Multi-electrode array (MEA) recordings are a means to record electrical field potentials from large populations of neurons and analyze network activity over time. It was previously demonstrated that the presence of hiPSC-A that are differentiated using techniques to promote a spinal cord astrocyte phenotype improved maturation and electrophysiological activity of regionally specific spinal cord hiPSC-motor neurons (MN) when compared to those cultured without hiPSC-A or in the presence of rodent astrocytes. Described here is a method to co-culture spinal cord hiPSC-A with hiPSC-MN and record electrophysiological activity using MEA recordings. While the differentiation protocols described here are particular to astrocytes and neurons that are regionally specific to the spinal cord, the co-culturing platform can be applied to astrocytes and neurons differentiated with techniques specific to other fates, including cortical hiPSC-A and hiPSC-N. These protocols aim to provide an electrophysiological assay to inform about glia-neuron interactions and provide a platform for testing drugs with therapeutic potential in ALS.

Implementation of a Frailty Assessment and Targeted Care Interventions and Its Association with Reduced Postoperative Complications in Elderly Surgical Patients.

BACKGROUND: Older patients with frailty syndrome have a greater risk of poor postoperative outcomes. In this study, we used a RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework to implement an assessment tool to identify frail patients and targeted interventions to improve their outcomes. STUDY DESIGN: We implemented a 5-question frailty assessment tool for patients 65 years and older admitted to the general and vascular surgery services from January 1, 2018 to December 31, 2019. Identified frail patients received evidence-based clinical orders and nursing care plan interventions tailored to optimize recovery. A RE-AIM framework was used to assess implementation effectiveness through provider and nurse surveys, floor audits, and chart review. RESULTS: Of 1,158 patients included in this study, 696 (60.1%) were assessed for frailty. Among these, 611 patients (87.8%) scored as frail or intermediately frail. After implementation, there were significant increases in the completion rates of frailty-specific care orders for frail patients, including delirium precautions (52.1% vs 30.7%; p < 0.001), aspiration precautions (50.0% vs 26.9%; p < 0.001), and avoidance of overnight vitals (32.5% vs 0%). Floor audits, however, showed high variability in completion of care plan components by nursing staff. Multivariate analysis showed significant decreases in 30-day complication rates (odds ratio 0.532; p < 0.001) after implementation. CONCLUSIONS: A frailty assessment was able to identify elderly patients for provision of targeted, evidence-based frailty care. Despite limited uptake of the assessment by providers and completion of care plan components by nursing staff, implementation of the assessment and care interventions was associated with substantial decreases in complications among elderly surgical patients.

Hyperendemic Chlamydia trachomatis sexually transmitted infections among females represent a high burden of asymptomatic disease and health disparity among Pacific Islanders in Fiji.

BACKGROUND: Chlamydia trachomatis is the most common bacterial sexually transmitted infection worldwide with some of the highest prevalence rates among Pacific Island Countries where syndromic management is practiced. However, little is known about the true prevalence and risk indicators for infection among neglected populations in these countries that suffer from health disparities. METHODOLOGY/PRINCIPAL FINDINGS: Consecutive sampling was used to enroll sexually active females, aged 18-40 years, attending 12 Fijian Ministry of Health and Medical Services Health Centers and outreach locations from February to December, 2018. A Behavioral Surveillance Survey was administered to assess risk indicators for infection. Signs and symptoms were recorded, and vaginal swabs were tested for C. trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, Candida and bacterial vaginosis. Bivariate and multivariate logistic regression analyses were performed using R-Studio. Of 577 participants, 103 (17.85%) were infected with C. trachomatis of whom 80% were asymptomatic and only 11 met criteria for syndromic management; 38.8% of infected women were 18-24 years old with a prevalence of 30.5%. 91.7% of participants intermittently or did not use condoms. C. trachomatis infection was associated with iTaukei ethnicity (OR 21.41 [95% CI: 6.38-133.53]); two lifetime partners (OR 2.12 [95% CI: 1.08-4.18]); and N. gonorrhoeae co-infection (OR 9.56 [95% CI: 3.67-28.15]) in multivariate analyses. CONCLUSIONS: A disproportionately high burden of C. trachomatis is present among young asymptomatic women in Fiji of iTaukei ethnicity despite the low number of lifetime partners. Syndromic management and lack of barrier contraceptives contribute to hyperendemic levels. Strategic STI education and screening of at-risk adolescents, young women, and their partner(s) with appropriate treatment are urgently needed to control the epidemic.