C-Clamp Technique: A Retrospective Review of a Novel Technique to Prevent Bladder Injury in Retropubic Midurethral Slings.

IMPORTANCE: Synthetic mesh midurethral slings have become the criterion-standard treatment for stress urinary incontinence with urethral hypermobility in women. Iatrogenic bladder injury is a known risk of the procedure. OBJECTIVE: Our objective was to show that a novel "C-clamp technique" can significantly reduce the risk of bladder and urethral injury at the time of bottom-up retropubic synthetic mesh midurethral sling placement. STUDY DESIGN: We conducted a retrospective review of the electronic medical records using Current Procedural Terminology coding of a single surgeon who performed synthetic mesh midurethral slings. Medical records were reviewed for demographic and clinical data for all bottom-up retropubic synthetic mesh midurethral slings placed using a novel C-clamp technique. All operative reports were reviewed for bladder and urethral injury at the time of implantation of the synthetic mesh midurethral sling using the C-clamp technique. RESULTS: Two hundred one consecutive bottom-up retropubic synthetic mesh midurethral slings were placed using the C-clamp technique from April 2012 through June 2022. The average age was 51 years (29-86 years); the average weight was 82 kg (46 -139 kg); and the average body mass index was 31 kg/m2 (15-57 kg/m2). No patients sustained a bladder or urethral injury at the time of implantation of a retropubic synthetic mesh midurethral sling using the C-clamp technique. CONCLUSION: The novel C-clamp technique shows promise in eliminating the risk of iatrogenic bladder and urethral injury at the time of implanting a bottom-up retropubic synthetic mesh midurethral sling.

Healthier together: a pilot study on the implementation of a novel family centered pediatric obesity prevention program.

CONTEXT: With pediatric obesity rates reaching epidemic scales across the United States, innovative research to identify key factors for successful implementation of obesity intervention programs is increasingly paramount. Project Healthy Attitudes Produces Positive Youth (HAPPY) is a family centered pediatric obesity prevention program targeting elementary age children and their families. OBJECTIVES: To determine whether Project HAPPY interventions emphasizing social networks were successful. METHODS: This was a small scale evaluation of the Project HAPPY pilot program, conducted after school at a public elementary campus in Solano County, California. From April 2018 to May 2018, first year medical students from Touro University California College of Osteopathic Medicine served as "family navigators," guiding participants through a 5 week curriculum of didactic lessons, cooking demonstrations, and physical exercises. Eligibility requirements for Project HAPPY included basic English proficiency, confirmed enrollment of at least one child at the elementary school, and willingness to attend all study sessions. The primary outcome evaluated was a shift in attitude toward individual health. Changes in body mass index (BMI) and health behaviors were assessed as secondary outcomes. Outcomes were assessed through surveys and measurements of BMI completed during Session 1, Session 10, and 4, 6, and 8 month follow up sessions. RESULTS: Initial study participants included seven families, consisting of elementary school students with their siblings and parents (n=27). Only four families (n=13) completed the entire 5 week intervention. Over the course of the study, survey results of participants' attitudes regarding health suggested a positive trend toward self efficacy, while BMI appeared stable or increased. Participants demonstrated retention of successful health behaviors up to 8 months after the end of the intervention through qualitative reports of being "more conscious of meals and what (they) are eating," "valu[ing their] nutrition on a daily basis," "play[ing] a lot outside and inside on the weekends," "carry[ing] a water bottle," and "cook(ing) a lot." A higher percentage of respondents in the final session compared selected the option "strongly agree" to each of the following statements: "I can be healthier if my family works together" (87.5% final session vs. 84.6% first session), "Drinking water makes me healthy" (87.5% final session vs. 84.6% first session), "Moving my body makes me healthy" (87.5% final session vs. 76.9% first session), "I reach my goals even when things get in my way" (62.5% final session vs. 46.2% first session), "Eating fruits and veggies make me healthy" (100% final session vs. 92.3% first session), "I can be healthy and enjoy my favorite foods" (87.5% final session vs. 66.7% first session), and "I can create a healthy balanced meal" (87.0% final session vs. 75.0% first session). Concrete data analysis was severely complicated by loss of study participants to follow up and incomplete data collection. CONCLUSIONS: Project HAPPY showed promising indications that should be further evaluated in studies of larger scale and longer duration.

A Delayed Diagnosis of Hemorrhagic Shock in a Patient with Alcoholic Cirrhosis and Ascites on Bedside Ultrasound.

Undifferentiated shock is a common and challenging problem in critical care. We present a case of hemorrhagic shock due to splenic and hepatic lacerations diagnosed by bedside paracentesis, initially misclassified as septic shock due to suspected spontaneous bacterial peritonitis (SBP). Case. A 47-year old man with a history of reported alcoholic cirrhosis and ongoing heavy alcohol use was brought to the emergency room after a syncopal event. He was found to be anemic (hemoglobin 9.9 g/dl) and hypotensive with a blood pressure of 64/34. Despite crystalloid infusion he remained hypotensive and required vasopressor support with norepinephrine. Bedside ultrasound revealed moderate ascites and as there was no evidence of active bleeding, his shock was attributed to sepsis due to SBP. A bedside paracentesis was performed which revealed gross blood. A repeat hemoglobin returned at 4.4 g/dl. Massive transfusion protocol was initiated and interventional radiology was emergently consulted due to concerns for intraabdominal hemorrhage; general surgery deemed the patient too unstable for surgical intervention. Angiogram revealed a splenic laceration and possible hepatic laceration, both embolized successfully. Internal medicine practitioners should keep the differential of hemorrhagic shock due to intraabdominal organ injury in mind for patients with undifferentiated shock.