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OBJECTIVES: The objective of this study was to gather Ontario clinicians' and public members' views on the design of a pre-conception patient education program. METHODS: In this mixed-methods study, online surveys comprised of rank order, multiple choice, and short answer questions were completed by clinicians and public members. Semi-structured focus groups consisting of 2-6 participants each were then held via videoconference. Demographic variables and survey responses were analyzed quantitatively using descriptive and summary statistics. Descriptive thematic qualitative analysis using the constant comparative method of grounded theory was completed on each transcript to generate themes. RESULTS: A total of 168 public members and 43 clinicians in Ontario completed surveys, while 11 clinicians and 11 public members participated in the focus groups. A pre-conception program in Ontario was felt to be important. An individual appointment with a primary care provider was the favoured program format per survey responses, whereas a virtual format with an interactive component was preferred among focus group participants. Important topics to include were pre-conception health (infertility, genetic screening, folic acid), prenatal and postpartum counselling (diet, activity, substance use, prenatal care, postpartum course), and medical optimization in pregnancy (high-risk medical conditions, medications, mental health). Both groups emphasized the need to consider accommodations for marginalized populations and various cultures and languages. CONCLUSION: A standardized pre-conception patient education program is felt to be of high value by Ontario clinicians and public members. A pre-conception program may help improve obstetrical outcomes and decrease rates of major congenital anomalies in Ontario.
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Grupos Focales , Evaluación de Necesidades , Atención Preconceptiva , Humanos , Ontario , Femenino , Embarazo , Adulto , Encuestas y Cuestionarios , Educación del Paciente como Asunto/métodos , Masculino , Atención Prenatal , Persona de Mediana EdadRESUMEN
OBJECTIVES: Vulvovaginal diseases are common gynecologic complaints and patients often turn to social media (SM) for medical information. The objective of this study is to examine vulvovaginal content on SM and how it has changed over time. MATERIALS AND METHODS: Four SM platforms were searched (i.e., Facebook, Instagram, Twitter, and YouTube) at 2 time points from March 30 to May 7, 2021, and again from November 24 to December 10, 2022. Newer SM platforms became popular during this time interval and thus TikTok and Reddit were included in the search in 2022. This study focused on 2 common vulvovaginal conditions: lichen sclerosus and vulvodynia. The SM platforms were searched for content on these conditions and the type of content, language, and country of origin were assessed. RESULTS: A total of 1228 SM accounts, posts, and pages were assessed. Lichen sclerosus content on SM was mostly informational (32.6%), whereas vulvodynia content was mostly personal experience (30.5%). Patient support groups were significantly more popular in 2021 compared with 2022 and professional groups were more common in 2022 compared with 2021 ( p < .001). Overall, Facebook and Instagram consisted mostly of patient support groups, YouTube had both informational and professional videos, TikTok had mostly personal experiences and healthcare professional videos, and Reddit was mostly discussions about patient personal experiences. CONCLUSIONS: The current study highlights the content and quantifies user engagement of lichen sclerosus and vulvodynia on SM.
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Liquen Escleroso y Atrófico , Medios de Comunicación Sociales , Vulvodinia , Humanos , FemeninoRESUMEN
OBJECTIVES: The objective of this study is to investigate vulvovaginal disease (VVD) awareness in Italian obstetrics and gynecology (Ob/Gyn) residents. MATERIALS AND METHODS: A 25-question survey on VVD basic knowledge (17 questions) and willingness to improve it (8 questions) was distributed through Ob/Gyn resident online group chats, from different Italian Universities in January 2023. A total number of 250 residents were invited to participate; 124 responses were obtained (response rate: 50%). Data were collected and analyzed using descriptive statistics through REDCap. RESULTS: Overall, 87 of the 124 respondents (70%) fully completed the questionnaire and represented the study group. Residents were distributed among years of residency: 15% first year, 31% second year, 23% third year, 11% fourth year, and 20% fifth year. Most (60%) never attended a VVD clinic during residency, with an increasing percentage of attendance in later residency years (15% at first year vs 65% at fifth).Participants reported low knowledge of vulvar precancerous lesions and vulvoscopy but better knowledge of vaginitis, vulvar self-examination, and lichen sclerosus. Of the respondents, 50% were not satisfied with the education provided during residency, and more than 60% lacked confidence in managing VVD.All participants expressed a strong desire to improve their knowledge and skills, with 100% agreeing that every gynecologist should know the "basics" and 98% wanting to improve their knowledge through webinars (45%), lessons (34%), newsletters, and videos (19%). CONCLUSION: Our findings indicate a significant need to improve VVD knowledge among Italian Ob/Gyn residents. Further efforts are necessary to provide information about VVD and comprehensive training programs in Italian Universities.
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Ginecología , Internado y Residencia , Obstetricia , Enfermedades Vaginales , Femenino , Embarazo , Humanos , Ginecología/educación , Obstetricia/educación , Encuestas y Cuestionarios , ItaliaRESUMEN
OBJECTIVE: To determine patient knowledge and preferences about primary human papillomavirus (HPV) testing. DESIGN: Cross-sectional survey. SETTING: Two family practice clinics (urban and suburban) and the social media platforms of 2 hospitals in the greater Toronto area between January and February 2023. PARTICIPANTS: A total of 413 Ontario residents aged 25 to 69 years, with a cervix, who qualified for Papanicolaou (Pap) screening and could communicate in English. METHODS: Electronic survey containing questions about knowledge of, and preferences for, cervical cancer screening, including types of screening and screening intervals, and about education related to HPV and screening intervals. MAIN FINDINGS: Of 441 potential participants, 426 were eligible and consented to participate in the study; ultimately 413 provided completed or partially completed surveys (96.9% response rate). Of those who completed a recent Pap test, 57.8% (208 of 360) knew of HPV testing. Initially, 27.8% thought HPV testing was better than Pap testing for cervical cancer screening. After learning HPV tests exist and have self-sampling options, most participants preferred HPV testing (self-sampling 46.3%, provider sampling 34.1%). Annual cervical cancer screening was preferred by 50.1% of participants despite knowing that, for most people, Pap tests should be conducted every 3 years (74.8%). After learning about HPV testing, participants were more likely to prefer 5-year screening intervals (43.8%); however, those in the family practice group were still more likely to prefer 3-year intervals compared with those in the social media group (P<.01). CONCLUSION: Participants in this study identified a preference for HPV testing and self-sampling options. Concerns were raised about extended screening intervals and the safety of self-collected samples that need to be addressed in public health education initiatives during rollout of new screening programs.
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Detección Precoz del Cáncer , Conocimientos, Actitudes y Práctica en Salud , Prueba de Papanicolaou , Infecciones por Papillomavirus , Prioridad del Paciente , Neoplasias del Cuello Uterino , Humanos , Femenino , Ontario , Persona de Mediana Edad , Neoplasias del Cuello Uterino/diagnóstico , Neoplasias del Cuello Uterino/prevención & control , Adulto , Estudios Transversales , Detección Precoz del Cáncer/métodos , Detección Precoz del Cáncer/psicología , Infecciones por Papillomavirus/diagnóstico , Anciano , Encuestas y Cuestionarios , Frotis Vaginal/estadística & datos numéricos , Frotis Vaginal/psicología , Tamizaje Masivo/métodos , Papillomaviridae/aislamiento & purificación , Virus del Papiloma HumanoRESUMEN
BACKGROUND: Lichen sclerosus (LS) is a chronic inflammatory condition mainly affecting genital skin. It causes distressing symptoms that impact daily quality of life (QoL). It causes progressive anatomical changes and a potential risk of cancer. Published randomized controlled trials are of varying methodological quality and difficult to combine in meta-analyses. This is partly due to lack of agreed outcome measures to assess treatment response. Identification of core outcome sets (COSs), which standardize key outcomes to be measured in all future trials, is a solution to this problem. OBJECTIVES: To obtain international agreement on which outcome domains should be measured in interventional trials of genital LS. METHODS: Recommended best practice for COS domain development was followed: (i) identification of potential outcome domains: a long list was generated through an up-to-date LS literature search, including information collected during the LS priority-setting partnership; (ii) provisional agreement of outcome domains: a three-stage multi-stakeholder international electronic-Delphi (e-Delphi) consensus study; (iii) final agreement of outcome domains: online consensus meeting with international stakeholders including anonymized voting. RESULTS: In total, 123 participants (77 patients, 44 health professionals, 2 researchers) from 20 countries completed three rounds of the e-Delphi study. Eleven outcome domains were rated as 'critical' and were discussed at the online consensus meetings. The first set of consensus meetings involved 42 participants from 12 countries. Consensus was met for 'symptoms' (100% agreed) and 'QoL - LS-specific' (92% agreed). After the second set of meetings, involving 29 participants from 12 countries, 'clinical (visible) signs' also met consensus (97% agreed). CONCLUSIONS: The international community has agreed on three key outcome domains to measure in all future LS clinical trials. We recommend that trialists and systematic reviewers incorporate these domains into study protocols with immediate effect. CORALS will now work with stakeholders to select an outcome measurement instrument per prioritized core domain.
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Liquen Escleroso y Atrófico , Calidad de Vida , Humanos , Resultado del Tratamiento , Evaluación de Resultado en la Atención de Salud , Proyectos de Investigación , Técnica DelphiRESUMEN
OBJECTIVE: This study aimed to determine the quantity and quality of lower genital tract disease (LGTD) research by topic published across a variety of gynecology and dermatology journals. METHODS: Authors accessed all articles that were rejected (1,111, 59.5%) and accepted (755, 40.5%) by the Journal of Lower Genital Tract Disease ( JLGTD ) from 2008 to 2020. Studies were categorized by key topic: Cervix, Human Papillomavirus, Vulva, Vagina, Anal, and Other. Studies were further subcategorized based on methodology. These data were compared with all LGTD publications from 2018 to 2020 in 4 other widely recognized journals ( Obstetrics and Gynecology , The British Journal of Obstetrics and Gynaecology , JAMA Dermatology , and the British Journal of Dermatology ). RESULTS: Most JLGTD -accepted submissions were related to the cervix (298/755, 39.5%) and vulva (189/755, 25.0%). Rates of acceptance were similar across all key topic areas. Only 3.2% of publications in the other 4 journals (92/2,932) were related to LGTD topics. Across all 5 journals, vulva studies were most commonly case reports/case series (82/218, 37.6%), with a low prevalence of systematic reviews/meta-analyses (4/218 1.8%). In comparison, cervix studies had the highest number of systematic reviews/meta-analyses (14/317, 4.4%) and the lowest number of case reports (14/317, 4.4%). CONCLUSIONS: Vulvar research is of lower quality compared with cervix research published across 5 journals. Comparing accepted versus rejected articles in JLGTD , there is no publication bias against vulva topics noted; rather, the overall research quality in vulva is lower than that of cervical disease. This is a call to action for higher quality vulvar research.
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Ginecología , Obstetricia , Publicaciones Periódicas como Asunto , Femenino , Embarazo , Humanos , Revisiones Sistemáticas como Asunto , GenitalesRESUMEN
OBJECTIVE: Steroid phobia in people with dermatologic conditions is associated with noncompliance with topical corticosteroids (TCS). Although it has not been studied in those with vulvar lichen sclerosus (vLS), first-line therapy is lifelong maintenance TCS, and noncompliance is associated with impaired quality of life, progression of architecture changes, and vulvar skin cancer. The authors aimed to measure steroid phobia in patients with vLS and determine their most valued sources of information to direct future interventions to address this phenomenon. METHODS: The authors adapted a preexisting, validated scale for steroid phobia (TOPICOP), which is a 12-item questionnaire that produces a score of 0 = no phobia and 100 = maximum phobia. The anonymous survey was distributed across social media platforms with an in-person component at the authors' institution. Eligible participants included those with clinical or biopsy-proven LS. Participants were excluded if they did not consent or did not communicate in English. RESULTS: The authors obtained 865 online responses over a 1-week period. The in-person pilot obtained 31 responses, with a response rate of 79.5%. Mean global steroid phobia score was 43.02 (21.9)% and in-person responses were not significantly different (40.94 [16.03]%, p = .59). Approximately 40% endorsed waiting as long as they can before using TCS and stop as soon as possible. The most influential sources to improve patient comfort with TCS were physician and pharmacist reassurance over online resources. CONCLUSIONS: Steroid phobia is common in patients with vLS. Focused efforts to address steroid phobia among health care providers is the next best step toward improving patient comfort with TCS.
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Fármacos Dermatológicos , Liquen Escleroso Vulvar , Neoplasias de la Vulva , Femenino , Humanos , Liquen Escleroso Vulvar/complicaciones , Liquen Escleroso Vulvar/tratamiento farmacológico , Calidad de Vida , Glucocorticoides/uso terapéutico , Esteroides/uso terapéutico , Neoplasias de la Vulva/tratamiento farmacológicoRESUMEN
OBJECTIVE: The aim of the study is to identify whether vulvar self-examination learned from a web site could lead to a self-identification of vulvar lesions and the feasibility of virtual vulvar care with patient submitted photos. MATERIALS AND METHODS: The study used a prospective cohort design in a tertiary academic hospital over a 1-year period. Eligible participants who self-identified a vulvar lesion/skin changes were invited to send vulvar photos through a secure patient portal and schedule a phone consult to discuss diagnosis/management. Clinical data, photo interpretability, and patient satisfaction measures were collected. Self-referral patients versus vulva clinic waitlist patients were analyzed separately. RESULTS: Few people were interested in submitting vulvar photos online. Twenty-eight participants directly contacted the study, 8 consented, and 6 sent in vulvar photos. Forty four of 476 on the waitlist consented but only 24 of 44 sent in photos (5% of waitlist patients). The median time for a virtual assessment was 7 days for study participants while it was 18 months for the in-person usual care pathway. Most patient submitted photos were assessable. However, 60% participants needed help from another person to take the photos. More than 90% of patients required an in-person visit for their vulvar condition/concerns. While most patients were happy with the virtual process, 58% rated their satisfaction with the ease of taking photos of the genital region as "fair" or "poor." CONCLUSIONS: Virtual care with photos/phone calls might be feasible, although most patients are unlikely to participate. Because of patient discomfort, unease with taking photos, and patient privacy concerns, vulvar care should continue to be in-person for most new consults.
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Educación del Paciente como Asunto , Enfermedades de la Vulva , Femenino , Humanos , Proyectos Piloto , Estudios Prospectivos , VulvaRESUMEN
BACKGROUND: The provision of care to pregnant persons and neonates must continue through pandemics. To maintain quality of care, while minimizing physical contact during the Severe Acute Respiratory Syndrome-related Coronavirus-2 (SARS-CoV2) pandemic, hospitals and international organizations issued recommendations on maternity and neonatal care delivery and restructuring of clinical and academic services. Early in the pandemic, recommendations relied on expert opinion, and offered a one-size-fits-all set of guidelines. Our aim was to examine these recommendations and provide the rationale and context to guide clinicians, administrators, educators, and researchers, on how to adapt maternity and neonatal services during the pandemic, regardless of jurisdiction. METHOD: Our initial database search used Medical subject headings and free-text search terms related to coronavirus infections, pregnancy and neonatology, and summarized relevant recommendations from international society guidelines. Subsequent targeted searches to December 30, 2020, included relevant publications in general medical and obstetric journals, and updated society recommendations. RESULTS: We identified 846 titles and abstracts, of which 105 English-language publications fulfilled eligibility criteria and were included in our study. A multidisciplinary team representing clinicians from various disciplines, academics, administrators and training program directors critically appraised the literature to collate recommendations by multiple jurisdictions, including a quaternary care Canadian hospital, to provide context and rationale for viable options. INTERPRETATION: There are different schools of thought regarding effective practices in obstetric and neonatal services. Our critical review presents the rationale to effectively modify services, based on the phase of the pandemic, the prevalence of infection in the population, and resource availability.
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COVID-19/prevención & control , Control de Enfermedades Transmisibles/organización & administración , Atención a la Salud/organización & administración , Servicios de Salud Materno-Infantil/organización & administración , Atención Perinatal , Guías de Práctica Clínica como Asunto , Complicaciones Infecciosas del Embarazo/prevención & control , Centros Médicos Académicos , COVID-19/terapia , Canadá , Femenino , Humanos , Lactante , Recién Nacido , Pacientes Internos , Política Organizacional , Pacientes Ambulatorios , Embarazo , Complicaciones Infecciosas del Embarazo/terapia , SARS-CoV-2RESUMEN
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.
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Analgésicos Opioides , Mejoramiento de la Calidad , Analgésicos Opioides/uso terapéutico , Canadá , Prescripciones de Medicamentos , Femenino , Humanos , Análisis de Series de Tiempo Interrumpido , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/prevención & control , Pautas de la Práctica en Medicina , Embarazo , PrescripcionesRESUMEN
OBJECTIVE: The aim of the study was to evaluate the effectiveness of "The Vulva Diaries" podcast as a novel learning tool for vulvovaginal disease education. MATERIALS AND METHODS: Medical students and residents were invited to participate in the study using social media advertisements. Online pretests and posttests, one based on a podcast episode regarding genital herpes and the other on lichen sclerosus, were used to assess changes in knowledge level pre- and post-podcast listening in medical students and residents respectively. A second posttest was sent out 2 weeks after the first to assess knowledge retention. Results were analyzed using paired t tests comparing mean scores before and after podcast. RESULTS: In medical students, the average test score increased by 20% (n = 56, p < .001). Similarly, in residents the average test score increased by 23.1% (n = 22, p < .001). Medical students and residents rated their average preference for using podcasts as compared with other resources at 3.6 and 3.7/5, respectively. Furthermore, in both groups, there was no significant difference between average scores for posttest 1 versus posttest 2 written 2 weeks later suggested excellent knowledge retention. CONCLUSIONS: "The Vulva Diaries" podcast increases knowledge on vulvovaginal disease and is an effective learning tool for health care trainees in women's health. This study emphasizes the role of podcasts as a valuable educational resource within gynecology. The success of such initiatives will hopefully bolster the effort to correct the lack of provider knowledge in treating vulvovaginal diseases.
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Educación Médica , Ginecología , Internado y Residencia , Femenino , HumanosRESUMEN
OBJECTIVE: The aim of the study was to investigate the knowledge of vulvar anatomy and vulvar self-examination (VSE) in a sample of Italian women attending a gynecology clinic. METHODS: For this original research from May to July 2019, 512 women attending the Lower Genital Tract Clinic at the Department of Surgical Sciences of the University of Torino were invited to participate in a 29-question survey about vulvar anatomy, VSE, and sociodemographic details. Data were analyzed using descriptive statistics. RESULTS: Of 512 patients, 500 completed the questionnaire (98% response rate). The mean age of respondents was 41 years (range = 17-77 years). Education level was evenly distributed between elementary, high school, and university graduates. Only 15% of interviewed women were able correctly sketching vulvar anatomy. Seventy-six percent of the women had not heard about VSE, and 61% of the women approach their genitalia with feelings of shame and embarrassment. Only 23% of the women would seek medical advice after identification of possible abnormalities during VSE. A majority (69%) of the women would like to have more information about VSE and vulvar health through educational videos and social media. CONCLUSIONS: Education about VSE may lead to earlier diagnosis of vulvar cancers and other pathologies. Further efforts are needed to disperse information about normal external female genital anatomy and VSE to achieve self-confidence among women.
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Conocimientos, Actitudes y Práctica en Salud , Autoexamen/psicología , Vulva/anatomía & histología , Neoplasias de la Vulva/psicología , Adolescente , Adulto , Anciano , Femenino , Humanos , Italia , Persona de Mediana Edad , Autoexamen/métodos , Autoexamen/estadística & datos numéricos , Encuestas y Cuestionarios , Neoplasias de la Vulva/diagnóstico , Adulto JovenAsunto(s)
Carcinoma de Células Escamosas/patología , Papillomaviridae/aislamiento & purificación , Infecciones por Papillomavirus/complicaciones , Neoplasias de la Vulva/patología , Carcinoma de Células Escamosas/virología , Femenino , Humanos , Persona de Mediana Edad , Invasividad Neoplásica , Neoplasias de la Vulva/virologíaRESUMEN
BACKGROUND: Rh immunoglobulin (RhIg) is usually detectable a maximum of 12 to 14 weeks after administration. Positive antibodies beyond this time frame suggests alloimmunization. CASE: A woman had three pregnancies over a 6-month period, with two first-trimester losses. She received RhIg in the first pregnancy but not in the second. Two months after the second loss, in her third pregnancy, she received RhIg at week 6 due to first-trimester bleeding. She was subsequently anti-D antibody positive up to week 28 with antibodies too low to titre, leading to confusion about whether alloimmunization had occurred. CONCLUSION: Rh Ig administration led to positive anti-D antibodies lasting 22 weeks, suggesting keeping this differential diagnosis in mind when suspecting alloimmunization with positive antibodies at levels too low to titre.
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Isoinmunización Rh/diagnóstico , Sistema del Grupo Sanguíneo Rh-Hr , Globulina Inmune rho(D)/administración & dosificación , Femenino , Humanos , Embarazo , Resultado del EmbarazoRESUMEN
OBJECTIVE: To reduce opioids consumed after discharge from hospital after elective cesarean delivery by 50%. METHODS: This was a 2-week parallel group non-blinded randomized controlled trial at Mount Sinai Hospital. Eligible women undergoing elective cesarean delivery were assigned by random number generation to receive the hospital's standard post-cesarean opioid prescription of 20 1-mg hydromorphone tablets or a prescription for 10 1-mg hydromorphone tablets if opioids were required in hospital or no hydromorphone if no opioids were required in hospital. Patients completed a study questionnaire at 2 weeks postpartum detailing outcome measures. The primary outcome was the amount of opioid consumed after discharge. RESULTS: A total of 40 women were randomly assigned to a study group and 37 were included in the data analysis; 17 patients were in the control group and 20 in the experimental group. The median number of tablets consumed did not differ between groups (Pâ¯=â¯0.407). The median number of excess tablets prescribed was 20 (range 2-18) in the control group and 0 (range 0-10) in the experimental group (P < 0.001). CONCLUSIONS: The current standard discharge practice of giving 20 1-mg hydromorphone tablets to all patients post-discharge after cesarean delivery contributes to a substantial excess of opioids in the community. These opioids can be diverted for unintended or accidental usage, and exacerbate larger societal issues of opioid misuse and addiction. Decreasing the number of opioids prescribed with tailored discharge prescriptions based on in-hospital opioid use provides nearly all patients with adequate pain control.
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Analgésicos Opioides/administración & dosificación , Sobredosis de Droga/prevención & control , Hidromorfona/administración & dosificación , Dolor Postoperatorio/tratamiento farmacológico , Alta del Paciente , Pautas de la Práctica en Medicina/estadística & datos numéricos , Adulto , Cuidados Posteriores , Analgésicos Opioides/efectos adversos , Cesárea , Femenino , Humanos , Hidromorfona/efectos adversos , Dolor Postoperatorio/prevención & control , EmbarazoRESUMEN
OBJECTIVE: The aim of the study was to determine outcome measures that women with vulvar lichen sclerosus (LS) rate as important in assessing disease severity with the ultimate goal of including these items in a disease severity rating tool. METHODS: An online survey of women older than 18 years with a diagnosis of vulvar LS was performed. The survey was posted in Facebook LS support groups. Participants rated items on a scale from 1 to 5 (not important to include to essential to include) in a disease severity scale. Participants also rated how often they were affected by various symptoms on a scale from 1 to 5 (never to daily). Mean rating of importance and mean rating of frequency for each sign and symptom were calculated. T tests were used to compare patients with biopsy-proven disease with those with a clinical diagnosis of LS. RESULTS: Nine hundred fifty-eight participants completed the survey (86% completion rate). Patients felt that the most important items to assess disease severity were irritation (4.39), fusion of the labia (4.38), soreness (4.37), itch (4.34), change in vulvar skin (4.34), and decrease in quality of life (4.33). The most frequently experienced items by those with LS were irritation (3.92), changes in appearance of vulvar skin (3.92), and discomfort (3.89). There were no differences between patients with biopsy-proven LS versus those diagnosed on clinical examination. CONCLUSIONS: Future LS severity assessment tools will need to include a combination of patient-rated symptoms, clinical rated signs and anatomical changes, and quality of life measures.
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Índice de Severidad de la Enfermedad , Liquen Escleroso Vulvar/psicología , Adolescente , Adulto , Anciano , Femenino , Humanos , Persona de Mediana Edad , Encuestas y Cuestionarios , Vulva , Adulto JovenRESUMEN
OBJECTIVE: The aim of the study was to determine how experts treat vulvar high-grade squamous intraepithelial neoplasia (VHSIL) and differentiated vulvar intraepithelial neoplasia (dVIN). METHOD: A 26-question survey was designed through a literature review, reviewed by the Survey Committee of the International Society for the Study of Vulvovaginal Disease (ISSVD), and distributed to all ISSVD members via e-mail in January 2019. RESULTS: Overall, 90 of 441 physician members consented to participate and 78 of 90 were eligible to complete the survey. Most respondents were gynecologists (77%), followed by dermatologists (12%). Forty-five percent responded that their pathology was being reported using the 2015 ISSVD terminology of vulvar squamous intraepithelial lesions. The most common first-line treatments were as follows: unifocal VHSIL-excision (65%), multifocal VHSIL-imiquimod 5% (45%), VHSIL in a hair-bearing area-excision (69%), and clitoral disease-imiquimod 5% (47%). In the recurrent VHSIL, excision was favored (28%), followed by imiquimod 5% (26%) and laser (19%). Differentiated vulvar intraepithelial neoplasia was most often first treated with excision (82%), and more patients were referred to gynecologic oncology. Most patients were seen in follow-up at 3 months (range: 1 week-6 months). Sixty-seven respondents provided 26 different ways to follow treated patients, which were most commonly every 6 months for 2 years and then yearly (25%), followed by every 6 months indefinitely (18%). CONCLUSIONS: Treatment of VHSIL and dVIN varies among vulvar experts with excision being the most common treatment, except in multifocal VHSIL where imiquimod is commonly used. There is wide variation in how patients are followed after treatment.
Asunto(s)
Carcinoma in Situ/patología , Carcinoma de Células Escamosas/patología , Neoplasias de la Vulva/patología , Neoplasias de la Vulva/terapia , Femenino , Humanos , Guías de Práctica Clínica como Asunto , Sociedades Médicas , Encuestas y Cuestionarios , Vagina/patología , Vulva/patologíaRESUMEN
OBJECTIVE: The objective of this study was to test the severity rating of the signs and architectural changes for interrater reliability among world experts via analysis of lichen sclerosus (LS) photographs. METHODS: A recent Delphi consensus exercise established a list of symptoms, signs, and architectural changes, which experts feel are important to include in a severity scale. Photographs of vulvar LS were manually extracted from patient charts and 50 photographs with a range of severity of signs and architectural changes were chosen. Lichen sclerosus experts were invited to take part in the study and 3 dermatologists and 3 gynecologists were selected for their expertise and geographic variety. Raters assessed the photographs for multiple signs and architectural changes as well as an overall impression of disease severity on a 4-point Likert scale. Intraclass correlation coefficients were calculated. RESULTS: The intraclass correlation coefficients were very poor for individual signs and architectural changes as well as for overall disease severity when analyzed for all 6 raters as well as when analyzed with dermatologists' and gynecologists' responses grouped separately. There were no statistically significant correlations found. CONCLUSIONS: Global experts were unable to agree on any signs, architectural changes, or an overall global impression to assess vulvar LS disease severity based on analysis of vulvar photographs. Standardized descriptions regarding what constitutes mild, moderate, and severe signs and anatomical changes are required before further scale development can occur.
Asunto(s)
Ginecología/normas , Índice de Severidad de la Enfermedad , Liquen Escleroso Vulvar/diagnóstico , Adulto , Preescolar , Consenso , Femenino , Humanos , Persona de Mediana Edad , Dolor/etiología , Prurito/etiología , Sociedades Médicas , Liquen Escleroso Vulvar/terapiaRESUMEN
Genital ulcer disease can be caused by a wide variety of sources. Most commonly, genital ulcer disease is grouped into infectious and noninfectious causes. HSV, syphilis, lymphogranuloma venereum, and chancroid represent some common infectious ulcers. Noninfectious causes on the other hand can be inflammatory, noninflammatory, or malignant (eg, squamous cell carcinoma). Depending on the etiology, genital ulcers may present with unique features that can help clinicians identify the etiology and start treatment in a timely manner. The clinical presentation and management of infectious and noninfectious genital ulcers will be discussed in this review.