Demographic Correlates of Endometriosis Diagnosis Among United States Women Aged 15-50.

OBJECTIVE: To compare demographic characteristics of women with and without a diagnosis of endometriosis. DESIGN: Data were collected from the National Survey of Family Growth-a publicly available survey designed and administered by the Centers for Disease Control, which uses a nationally-representative sample of the United States population. Univariate data were reported as survey-weighted percentages and means and were analyzed using chi-square, t tests, and logistic regression. Analyses accounted for complex survey design. SETTING: United States. PARTICIPANTS: Interviews were conducted with 6141 female respondents, aged 15 to 50, between 2017 and 2019. INTERVENTIONS: Data were collected through in-person interviews. RESULTS: Nationally, 5.7% reported a diagnosis of endometriosis (95% CI 4.6-6.9%). Those with endometriosis were older, with a mean age of 39 (95% CI 38.1-39.9), compared to 31.7 (95% CI 31.2-32.2) among those without (p <.0005). Endometriosis diagnosis was significantly associated with race. Compared to non-Hispanic White women, Hispanic women had an adjusted odds ratio (aOR) of 0.37 (95% CI 0.21-0.65) for diagnosis of endometriosis, and non-Hispanic Black women had an aOR of 0.54 (95% CI 0.35-0.84). We also observed a difference in diagnosis by health insurance: compared to those with private insurance or Medi-Gap coverage, those with Medicare or military insurance had an aOR for endometriosis diagnosis of 2.49 (95% CI 1.36-4.55). Finally, compared to those with less than a high school education, those who had completed high school or greater had an aOR for endometriosis diagnosis of 2.84 (95% CI 1.15-6.99). CONCLUSION: These disparities in endometriosis diagnosis suggest that intersecting barriers may preclude certain groups from accessing timely endometriosis diagnosis and management. Further studies are warranted to explore these hypothesis-generating data and to identify and address specific barriers to equitable endometriosis diagnosis and management.

Investigating racial/ethnic differences in procedure experience in obstetrics & gynecology trainees at a single academic institution: a retrospective cohort study.

BACKGROUND: Discrimination is common in medical education. Resident physicians of races and ethnicities underrepresented in medicine experience daily discrimination which has been proven to negatively impact training. There is limited data on the impact of resident race/ethnicity on OB/GYN surgical training. The objective of this study was to investigate the impact of race/ethnicity on procedural experience in OB/GYN training. METHODS: A retrospective analysis of graduated OB/GYN resident case logs from 2009 to 2019 was performed at a single urban academic institution. Self-reported race/ethnicity data was collected. Association between URM and non-URM were analyzed using t-tests. Trainees were categorized by self-reported race/ethnicity into underrepresented in medicine (URM) (Black, Hispanic, Native American) and non-URM (White, Asian). RESULTS: The cohort consisted of 84 residents: 19% URM (N = 16) and 79% non-URM (n = 66). Difference between URM and non-URM status and average case volume was analyzed using t-tests. There was no difference between non-URM and URM trainees and reported mean number of Total GYN (349 vs. 334, p = 0.31) and Total OB (624 vs. 597, P = 0.11) case logs. However, compared with non-URM, on average URM performed fewer Total procedures (1562 vs. 1469, P = 0.04). Analyzing individual procedures showed a difference in average number of abortions performed between URM and non-URM (76 vs. 53, P = 0.02). There were no other statistically significant differences between the two groups. CONCLUSIONS: This single institution study highlights potential differences in trainee experience by race/ethnicity. Larger national studies are warranted to further explore these differences to identify bias and discrimination, and to ensure equitable experience for all trainees.

Social media utilization, preferences, and patterns of behavior in patients with gynecologic pelvic pain.

BACKGROUND: Social media is increasingly becoming a health resource for people suffering from complex and debilitating health conditions. A comprehensive understanding of how and why social media and the Internet are used among patients with chronic gynecologic pain will allow for the intentional development and incorporation of web-based tools into patient care plans. OBJECTIVE: This study aimed to determine whether gynecologic patients with pain are more likely to use social media and the Internet to understand and manage their condition than those without pain. The survey was designed to explore how gynecologic patients with and without pain use and interact with social media and other web-based health resources and the clinical, personal, and demographic factors influencing these behaviors. STUDY DESIGN: Patients presenting with a new complaint to a gynecologist at 1 of 6 Fellowship in Minimally Invasive Gynecologic Surgery-affiliated hospital systems were screened, consented, and assigned to pain and no-pain groups. Participants were surveyed about social media and Internet use, symptoms, bother, physician selection, motivation, trust, and demographic information. Survey responses were compared using the Fisher exact tests, odds ratios, and risk ratios from standard tabular analysis, univariate or multivariate tests of means, and regression analyses, as appropriate. RESULTS: Of 517 participants included in the study, 475 (92%) completed the survey, 328 (69.1%) with pain and 147 (30.9%) without pain. Study participants in the pain group reported more than double the odds of using social media than those without pain (37.8% vs 19.7%; odds ratio, 2.47; 95% confidence interval, 1.54-3.96) and triple the odds of using the Internet (88.4% vs 69.4%; odds ratio, 3.37; 95% confidence, 2.04-5.56) to understand or manage their condition. Participants with pain were more likely than those without pain to engage in social media at a higher level (3.5 vs 1.7 on a scale of 0 to 10; P<.0001), be motivated by interpersonal elements of online engagement (Hotelling's T2=37.3; P<.0001), prefer an interactive component to their online health resource (35.6% vs 24.3%; risk ratio, 1.46; 95% confidence interval, 1.00-2.20; P=.0433), be influenced by others in their choice of a gynecologist (0.37 vs 0.32 on a scale of 0 to 1; P=.009), use social media as a coping tool (38.3% vs 17%; P=.0001), trust information found on social media (31.4% vs 16.7%; P=.0033), and trust other women with the same condition, informal health resources, and personal sources more and doctors and formal health resources less (P=.0083). Participants in both groups reported higher levels of social media engagement with higher levels of symptom bother (28% increase in engagement with every doubling of bother level (P<.0001). CONCLUSION: Patients with gynecologic pain were more likely than those without pain to use social media and the Internet to understand and manage their condition. Patients with pain engaged in and trusted social media at a higher level, with engagement rising directly with bother level.

Laparoscopic Repair of a Colo-Ovarian Fistula.

OBJECTIVE: To demonstrate a laparoscopic approach to managing a colo-ovarian fistula. DESIGN: Narrated video outlining surgical technique. SETTING: Colo-ovarian fistulas are a rare entity with a lack of systematized evidence to guide surgical treatment [1-3]. Available case reports describe open en-bloc resection of the colon and adnexal organs with colorectal anastomosis [3]. We present a case of a colo-ovarian fistula managed laparoscopically with discoid resection of the fistulous tract, a technique used for rectosigmoid endometriosis [4]. INTERVENTION: A 51-year-old G0 presented with fevers, leukocytosis, and computed tomography imaging showing a peripherally enhancing adnexal complex highly suspicious for tubo-ovarian abscess that was refractory to antibiotics and interventional-radiology guided drainage. The patient elected for definitive surgery with hysterectomy, bilateral salpingo-oophorectomy, and indicated procedures.

Impact of Simulation Exercises on Total Laparoscopic Hysterectomy Surgical Outcomes: A Systematic Review and Meta-Analysis.

BACKGROUND: As resources into gynecological surgical simulation training increase, research showing an association with improved clinical outcomes is needed. OBJECTIVE: To evaluate the association between surgical simulation training for total laparoscopic hysterectomy (TLH) and rates of intraoperative vascular/visceral injury (primary outcome) and operative time. SEARCH STRATEGY: We searched Medline OVID, Embase, Web of Science, Cochrane, and CINAHL databases from the inception of each database to April 5, 2022. Selection Critera: Randomized controlled trials (RCTs) or cohort studies of any size published in English prior to April 4, 2022. DATA COLLECTION AND ANALYSIS: The summary measures were reported as relative risks (RR) or as mean differences (MD) with 95% confidence intervals using the random effects model of DerSimonian and Laird. A Higgins I2 >0% was used to identify heterogeneity. We assessed risk of bias using the Cochrane Risk of Bias tool 2.0 (for RCTs) and the Newcastle Ottawa Scale (for cohort studies). MAIN RESULTS: The primary outcome of this systematic review and meta-analysis was to evaluate the impact of simulation training on the rates of vessel/visceral injury in patients undergoing TLH. Of 989 studies screened 3 (2 cohort studies, 1 randomized controlled trial) met the eligibility criteria for analysis. There was no difference in vessel/visceral injury (OR 1.73, 95% CI 0.53-5.69, p=0.36) and operative time (MD 13.28, 95% CI -6.26 to 32.82, p=0.18) when comparing before and after simulation training. CONCLUSION: There is limited evidence that simulation improves clinical outcomes for patients undergoing TLH.

Abdominal Wall Endometriosis.

Abdominal wall endometriosis (AWE) is a rare type of endometriosis defined as endometrial glands and stroma located within the abdominal wall. Patients with a history of prior abdominal surgery classically present with cyclic abdominal pain and a palpable mass. Definitive diagnosis is made by pathologic tissue examination, but preoperative imaging with ultrasonography or MRI helps narrow the differential and informs surgical management. Surgical management is traditionally via an open approach; however, laparoscopic removal of AWE is recommended for subfascial or rectus lesions. Following surgical excision, more than 90% of patients experience complete symptom relief.

Reliability and Discriminant Validity of a Checklist for Surgical Scrubbing, Gowning and Gloving.

Background: Surgical scrubbing, gowning, and gloving is challenging for medical trainees to learn in the operating room environment. Currently, there are few reliable or valid tools to evaluate a trainee's ability to scrub, gown and glove. The objective of this study is to test the reliability and validity of a checklist that evaluates the technique of surgical scrubbing, gowning and gloving (SGG). Methods: This Institutional Review Board-approved study recruited medical students, residents, and fellows from an academic, tertiary care institution. Trainees were stratified based upon prior surgical experience as novices, intermediates, or experts. Participants were instructed to scrub, gown and glove in a staged operating room while being video-recorded. Two blinded raters scored the videos according to the SGG checklist. Reliability was assessed using the intraclass correlation coefficient for total scores and Cohen's kappa for item completion. The internal consistency and discriminant validity of the SGG checklist were assessed using Cronbach alpha and the Wilcoxon rank sum test, respectively. Results: 56 participants were recruited (18 novices, 19 intermediates, 19 experts). The intraclass correlation coefficient demonstrated excellent inter-rater reliability for the overall checklist (0.990), and the Cohen's kappa ranged from 0.598 to 1.00. The checklist also had excellent internal consistency (Cronbach's alpha 0.950). A significant difference in scores was observed between all groups (p < 0.001). Conclusion: This checklist demonstrates a high inter-rater reliability, discriminant validity, and internal consistency. It has the potential to enhance medical education curricula.

Less is more: clinical impact of decreasing pneumoperitoneum pressures during robotic surgery.

The objective of this study was to investigate the effects of decreasing insufflation pressure during robotic gynecologic surgery. The primary outcomes were patient-reported postoperative pain scores and length of stay. Secondary outcomes include surgical time, blood loss, and intraoperative respiratory parameters. This is a retrospective cohort study of patients undergoing robotic surgery for benign gynecologic conditions by a single minimally invasive surgeon at an academic hospital between 2014 and 2017. Patients were categorized by the maximum insufflation pressure reached during the surgery as either 15, 12, 10, or 8 mmHg. Continuous variables were compared using analysis of variance and χ2 test was used for categorical variables. 598 patients were included in this study with no differences in age, BMI, race, prior abdominal surgeries, or specimen weight between the four cohorts. When comparing cohorts, each decrease in insufflation pressure correlated with a significant decrease in initial pain scores (5.9 vs 5.4 vs 4.4 vs. 3.8, p ≤ 0.001), and hospital length of stay (449 vs 467 vs 351 vs. 317 min, p ≤ 0.001). There were no differences in duration of surgery (p = 0.31) or blood loss (p = 0.09). Lower operating pressures were correlated with significantly lower peak inspiratory pressures (p < 0.001) and tidal volumes (p < 0.001). Surgery performed at lower-pressure pneumoperitoneum (≤ 10 mmHg) is associated with lower postoperative pain scores, shorter length of stay, and improved intraoperative respiratory parameters without increased duration of surgery or blood loss. Operating at lower insufflation pressures is a low-cost, reversible intervention that should be implemented during robotic surgery as it results in the improved pain scores and shorter hospital stays.

Two-Layer Compared With One-Layer Vaginal Cuff Closure at the Time of Total Laparoscopic Hysterectomy to Reduce Complications.

OBJECTIVE: To explore whether two-layer laparoscopic vaginal cuff closure at the time of laparoscopic hysterectomy is associated with a lower rate of postoperative complications compared with a standard one-layer cuff closure. METHODS: A retrospective cohort study of total laparoscopic hysterectomies performed by fellowship-trained minimally invasive gynecologic surgeons between 2011 and 2017 was performed. Surgeons sutured the vaginal cuff laparoscopically, either in a two- or one-layer closure. The primary outcome was a composite of total postoperative complications, including all medical and surgical complications within 30 days and vaginal cuff complications within 180 days. Factors known to influence laparoscopic vaginal cuff complications including age, postmenopausal status, body mass index, tobacco use, and immunosuppressant medications were examined and controlled for, while surgeon skill, colpotomy technique, and suture material remained standardized. We conducted statistical analyses including χ2, Fisher exact test, logistic regression, and post hoc power calculations. RESULTS: Of the 2,973 women who underwent total laparoscopic hysterectomies, 40.8% (n=1,213) of vaginal cuffs were closed with a two-layer closure and 59.2% (n=1,760) with a one-layer technique. Two-layer vaginal cuff closure was associated with decreased numbers of total postoperative complications (3.5% vs 5.7%; P<.01). The primary difference stemmed from lower vaginal cuff complications within 180 days (0.9% vs 2.6%; P<.01); no differences in 30-day medical and surgical postoperative complications were observed between the two groups (2.6% vs 3.1%; P=.77). No patients in the two-layer vaginal cuff closure cohort experienced a vaginal cuff dehiscence or mucosal separation compared with 1.0% in the one-layer group (P<.01). Compared with a one-layer closure, a two-layer closure was protective from postoperative complications (adjusted odds ratio 0.38, 95% CI 0.19-0.74). CONCLUSION: Although postoperative complications with laparoscopic hysterectomies are rare, two-layer laparoscopic vaginal cuff closure is associated with lower total postoperative complications compared with a one-layer closure. The difference was primary driven by cuff complications.

Postoperative Outcomes among Pediatric and Adolescent Patients Undergoing Minilaparotomy vs Laparoscopy in the Management of Adnexal Lesions.

STUDY OBJECTIVE: To compare institutional experience in postoperative recovery in children and adolescents who undergo laparoscopy vs minilaparotomy in the management of benign adnexal cystic lesions. DESIGN: Retrospective cohort study. SETTING: Tertiary care children's hospital. PARTICIPANTS: Patients ages 6-21 years who underwent surgical management for benign adnexal lesions. INTERVENTIONS AND MAIN OUTCOME MEASURES: Comparison of surgery times, size of lesions, pain scores, and patient length of stay after minilaparotomy vs laparoscopy. RESULTS: Forty-four patients were identified. Of those, 59% (n = 26) had a laparoscopic procedure and 41% (n = 18) underwent minilaparotomy. Patients who underwent minilaparotomy were more likely to have a larger adnexal mass than those in the laparoscopy group with a median size of 15.5 cm vs 6.0 cm, respectively (P < .001). Postoperative length of stay and recovery were comparable in both groups. CONCLUSION: Minilaparotomy offers a minimally invasive option for the management of benign adnexal lesions in the pediatric and adolescent age group with recovery comparable to that of laparoscopy. The minilaparotomy approach should be considered when laparoscopy is limited.

Validation of a rat behavioral avoidance model from a drug delivery perspective.

Conventional taste-masking strategies are used to overcome the bitter taste perception of pharmaceuticals by coating the drug particles and/or adding flavoring agents. However, for certain product categories such as rapid dissolve sublingual tablets, taste-masking is challenging. Programs exploring such formulation strategies in the LO-CS phase or post CS phase possess very little toxicological information available in order to conduct human taste panel studies. The potential of a bitter taste perception can present a significant business risk. The objective of the study was to validate a rat behavioral avoidance model that identifies bitter-tasting compounds. Most classic bitter substances elicit a response in the micromolar concentration range while most drugs elicit a response in the millimolar range, hence a validation exercise was conducted to examine if the existing biological model was sensitive enough to identify known bitter tasting drugs as such. Five compounds: ergotamine tartrate, fluoxetine, sucrose, sumatriptan and povidone were chosen to represent a spectrum of compounds. The bitter tasting compounds were identified as such in the model. Based on these results, the assay may serve as a useful surrogate test to identify compounds that may have bitter taste issues.