Possible sex and racial disparities in myasthenia gravis care.

INTRODUCTION/AIMS: Given the importance of early diagnosis and treatment of myasthenia gravis (MG), it is critical to understand disparities in MG care. We aimed to determine if there are any differences in testing, treatment, and/or access to neurologists for patients of varying sex and race/ethnicity with MG. METHODS: We used a nationally representative healthcare claims database of privately insured individuals (2001-2018) to identify incident cases of MG using a validated definition. Diagnostic testing, steroid-sparing agents, intravenous immunoglobulin (IVIG), plasma exchange (PLEX), and thymectomy were defined using drug names or CPT codes. Steroid use was defined using AHFS class codes. We also determined whether an individual had a visit to a neurologist and the time between primary care and neurologist visits. Logistic regression determined associations between sex and race/ethnicity and testing, treatments, and access to neurologists. RESULTS: Female patients were less likely to get a computed tomography (CT) chest (odds ratio (OR) 0.73, 95% confidence interval (CI): 0.64-0.83), receive steroids (OR: 0.85, 95% CI: 0.75-0.97), steroid-sparing agents (OR: 0.84, 95% CI: 0.72-0.97), and IVIG or PLEX (OR: 0.80, 95% CI: 0.67-0.95). Black patients were less likely to receive steroids (OR: 0.78, 95% CI: 0.63-0.96). No significant disparities were seen in access to neurologists. DISCUSSION: We found healthcare disparities in MG treatment with female and Black patients receiving less treatment than men and those of other races/ethnicities. Further research and detailed assessments accounting for individual patient factors are needed to confirm these apparent disparities.

Perceptions of reproductive risk among women with epilepsy of childbearing age.

BACKGROUND: Having children or planning to have children may raise many questions for women with epilepsy. Seizures and antiseizure medications (ASMs) impact contraception, fetal/early childhood development, and maternal health. Little is known regarding patients' perspectives about reproductive risk and how those perspectives influence reproductive decision-making. METHODS: As a quality improvement initiative, we distributed an electronic survey within our health system to women ages 21-45 with a primary diagnosis of epilepsy/seizures. We then performed an exploratory research study to investigate perceptions of risk of epilepsy and ASMs on reproductive health and decision making. Additionally, we looked at clinical characteristics as possible predictors of fear impacting reproductive decisions. RESULTS: There were 267 responses (32% responder rate); after exclusion criteria, 233 respondents were included in the study. There were mixed responses about how fear of ASM teratogenicity impacted decisions about having children (33% very much, 34% a little, 33% not at all). While 45% responded that fear of having a child with epilepsy/seizures did not at all affect decisions about having children, for 24% this very much affected their decision. In total 42% of respondents reported they had had children. When we evaluated the impact of certain clinical characteristics, we found ASM number and valproic acid use impacted reproductive decision making, while other expected characteristics (e.g., drug-refractoriness and convulsive seizures) did not. DISCUSSION: We found variation in perceptions of risk. Overall, our data support the very personalized nature of preferences and the need for individualized counseling when guiding patients in reproductive decision making.

Does preoperative resting genital hiatus size predict surgical outcomes?

AIM: To determine whether preoperative genital hiatus at rest is predictive of medium-term prolapse recurrence. METHODS: We conducted a retrospective study of women who underwent native tissue prolapse surgery from 2002 to 2017 with pelvic organ prolapse quantification data including resting genital hiatus at one of three time points: preoperatively, 6 weeks, and ≥1 year postoperatively. Demographics and clinical data were abstracted from the chart. Prolapse recurrence was defined by anatomic outcomes (Ba > 0, Bp > 0, and/or C ≥ -4) or retreatment. Descriptive statistics, bivariate analyses, and logistic regression analyses were performed. RESULTS: Of the 165 women included, 36 (21.8%) had prolapse recurrence at an average of 1.5 years after surgery. Preoperative resting genital hiatus did not differ between women with surgical success versus recurrence (3.5 cm [interquartile range, IQR 2.25, 4.0) vs 3.5 cm (IQR 3.0, 4.0), p = 0.71). Point Bp was greater in the recurrence group at every time point. Preoperative Bp (odds ratio [OR] 1.24, confidence interval [CI] [1.06-1.45], p = 0.01) and days from surgery (OR 1.001, CI [1.000-1.001], p < 0.01) were independently associated with recurrence. Preoperative genital hiatus at rest and strain were significantly larger among women who underwent a colpoperineorrhaphy (rest: 4.0 [3.0, 4.5] cm vs 3.5 [3.0, 4.0] cm, p < 0.01; strain: 6.0 [4.0, 6.5] cm vs 5.0 [4.0, 6.0] cm, p = 0.01). CONCLUSIONS: Preoperative genital hiatus at rest was not associated with prolapse recurrence when the majority of women underwent colpoperineorrhaphy. Preoperative Bp was more predictive of short-term prolapse recurrence. For every 1 cm increase in point Bp, there is a 24% increased odds of recurrence.

Indications for surgical intervention in a postpartum pelvic floor specialty clinic.

OBJECTIVE: To determine the prevalence and type of surgical procedures undergone by postpartum women seen in a specialty postpartum pelvic floor clinic over 11 years. METHODS: This study was a retrospective chart review of patients requiring surgical intervention within a 1-year period after their initial visit to the Michigan Healthy Healing After Delivery (MHHAD) clinic at the University of Michigan from July 2007 through January 2019. Chart review was performed to abstract demographics, obstetric data, indication for postpartum clinic visit, primary and secondary indications for surgery, and procedures performed. Descriptive analyses were used to describe the cohort. RESULTS: Of the 1138 new MHHAD patients seen during the study period, 9.1% (n = 103) underwent surgical management. Anal incontinence was the primary or secondary indication for surgery in 51.5% (n = 53) of women. The most common surgical interventions were anal sphincteroplasty (37.9%, n = 39), perineal laceration revision (33.0%, n = 34), and rectovaginal fistula repair/fistulotomy (19.4%, n = 20). Of the women who had a sphincteroplasty, 61.5% (24/39) had a prior fourth-degree perineal laceration. CONCLUSIONS: Anal sphincteroplasty was the most common surgical intervention undergone by women seen in a postpartum pelvic floor specialty clinic. Postpartum pelvic floor clinics, such as the Michigan Healthy Healing After Delivery Clinic, provide the expertise and specialized resources required to ensure the early diagnosis and treatment of pelvic floor conditions related to childbirth thus improving women's quality of life and preventing potential life-long sequelae.

Do women with prior obstetrical anal sphincter injury regret having a subsequent vaginal delivery?

BACKGROUND: Most women choose to have another vaginal delivery following one complicated by an obstetrical anal sphincter injury (OASIS). However, little is known about patient satisfaction or regret with this decision. Therefore, our objective was to assess decisional regret with subsequent route of delivery following one affected by an OASIS. METHODS: A survey study was conducted among women seen in a specialty postpartum perineal clinic at a tertiary teaching hospital following a vaginal delivery with an OASIS between March 2012 and December 2016 who also had a subsequent delivery during that time period. Women were mailed a 13-item questionnaire between June and October 2017 that addressed pelvic floor symptoms and regret with their decision regarding mode of subsequent delivery. Regret was assessed with a modified Decision Regret Scale. Bivariate analyses were used to compare women with no, mild, or moderate/severe regret. RESULTS: Among 115 eligible women, 50 completed the survey. The majority (82%, n = 41) had a subsequent vaginal delivery and 18% (n = 9) had a subsequent cesarean delivery. Over one-third (34.9%, n = 15) reported the counseling they received after the OASIS influenced their decision regarding route of subsequent delivery. Fifty-four percent (n = 27) had no regret regarding their decision about subsequent delivery route, while 18 (36%) had mild, and five (10%) had moderate/severe regret. Regret was associated with older age (none: 36.8 ± 3.6 vs mild: 37.3 ± 3.4 vs moderate/severe: 41.7 ± 3.8 years, p = .03) and prevalence of fecal incontinence after delivery with OASIS (none: 15% vs mild: 17% vs moderate/severe: 80%, p = .01). CONCLUSIONS: Most women with an OASIS and a subsequent pregnancy will choose a repeat vaginal delivery, and over half have no regret about this decision. Older age and fecal incontinence following the incident delivery with OASIS were associated with regret regarding subsequent delivery mode.