Postoperative Urinary Incontinence in Diabetic Patients Undergoing Pelvic Reconstructive Surgery.

IMPORTANCE: Diabetes is an independent risk factor for urinary incontinence, and its impact on rates of postoperative incontinence after pelvic reconstructive surgery remains unexplored. OBJECTIVE: The aim of the study was to compare the incidence of postoperative stress urinary incontinence (SUI), urgency urinary incontinence (UUI), and mixed urinary incontinence in patients with diabetes mellitus undergoing surgery for pelvic organ prolapse (POP) with or without SUI surgery. STUDY DESIGN: This is a secondary analysis of a multicenter retrospective cohort study involving 10 diverse medical centers that identified a cohort of women with diabetes who had prolapse and/or anti-incontinence surgery. We compared rates of postoperative urinary incontinence among patients who had surgery for prolapse and incontinence versus surgery for prolapse only. RESULTS: Three hundred five patients had surgery for prolapse and incontinence, 330 had surgery for prolapse only, and 189 had anti-incontinence surgery only. De novo UUI was higher among those who underwent surgery for POP and SUI compared with surgery for POP alone (26.4% vs 14.1%, P < 0.01). Rates of persistent SUI (21% vs 4.9%, P < 0.01) and mixed urinary incontinence (15.9% vs 2.7%, P < 0.01) were higher for those who underwent prolapse surgery alone versus prolapse and an incontinence procedure. No differences were seen in hemoglobin A1C levels between those who did and did not report postoperative UI. CONCLUSIONS: We found that postoperative de novo UUI rates were high among patients with diabetes after pelvic reconstructive surgery, with the incidence being significantly higher for those who had surgery for prolapse and incontinence compared with surgery for prolapse only.

Surgical Outcomes in Urogynecology-Assessment of Perioperative and Postoperative Complications Relative to Preoperative Hemoglobin A1c-A Fellows Pelvic Research Network Study.

OBJECTIVES: Poor control of diabetes mellitus is a known predictor of perioperative and postoperative complications. No literature to date has established a hemoglobin A1c (HbA1c) cutoff for risk stratification in the urogynecology population. We sought to identify an HbA1c threshold predictive of increased risk for perioperative and postoperative complications after pelvic reconstructive surgery. METHODS: This multicenter retrospective cohort study involving 10 geographically diverse U.S. female pelvic medicine and reconstructive surgery programs identified women with diabetes who underwent prolapse and/or stress urinary incontinence surgery from September 1, 2013, to August 31, 2018. We collected information on demographics, preoperative HbA1c levels, surgery type, complications, and outcomes. Sensitivity analyses identified thresholds of complications stratified by HbA1c. Multivariate logistic regression further evaluated the association between HbA1c and complications after adjustments. RESULTS: Eight hundred seven charts were identified. In this diabetic cohort, the rate of overall complications was 44.1%, and severe complications were 14.9%. Patients with an am HbA1c value of 8% or greater (reference HbA1c, <8%) had an increased rate of both severe (27.1% vs 12.8%, P < 0.001) and overall complications (57.6% vs 41.8%, P = 0.002) that persisted after multivariate logistic regression (odds ratio, 2.618; 95% confidence interval, 1.560-4.393 and odds ratio, 1.931; 95% confidence interval, 1.264-2.949, respectively). Mesh complications occurred in 4.6% of sacrocolpopexies and 1.7% of slings. The average HbA1c in those with mesh exposures was 7.5%. CONCLUSIONS: Preoperative HbA1c of 8% or higher was associated with a 2- to 3-fold increased risk of overall and severe complications in diabetic patients undergoing pelvic reconstructive surgery that persisted after adjustments.

Recurrent Urinary Tract Infection in Women: Primary Care Referral Patterns in a Tertiary Care Center.

OBJECTIVES: With more than 150 million urinary tract infections (UTIs) diagnosed globally per year, the impact on patient care is significant. We sought to examine appropriateness of management of recurrent UTI before referral to a female pelvic medicine and reconstructive surgery practice, as well as the characteristics of patients referred. METHODS: The medical records of 100 consecutive women with a diagnosis of "recurrent UTI" at a single institution between November 2010 and December 2015 were reviewed. The baseline clinical characteristics, laboratory testing, and treatments before and at referral to the female pelvic medicine and reconstructive surgery were examined by descriptive statistics. RESULTS: The evaluation and treatment patterns for recurrent UTI before specialist referral varied widely. Pelvic examination was performed in only 20.8% of patients before referral. Although most women had at least 1 culture performed (65.2%), treatments were variable. Only 42.7% of patients received recommended first-line antibiotic therapy. At symptom recurrence, only 47.2% of patients received a urine culture; most were empirically treated. Approximately 35.0% of patients received the same antibiotic upon their first recurrence. CONCLUSIONS: A large proportion of patients referred for recurrent UTI to a specialty practice had no prior culture, physical examination, or symptom-specific evaluation before referral. Despite existing guidelines, the evaluation, treatment, and referral patterns for recurrent UTI are highly varied and rarely conform to recommendations. Further studies are needed to confirm these trends and determine interventions to improve the efficacy and efficiency of primary care for women with recurrent UTI.

Family history and pelvic organ prolapse: a systematic review and meta-analysis.

INTRODUCTION AND HYPOTHESIS: Numerous analytic observational studies assess family history as a risk factor for POP and report a wide range of associations. This review aims to systematically evaluate the role of family history of POP in relation to POP risk and its recurrence. METHODS: A review was performed of the PubMed/MEDLINE database with search criteria specifying family history, risk factors, POP, and their synonyms as title/abstract keywords, as well as MESH terms, up to March 2020. We aggregated evidence across studies with fixed effects (FE) and random effects (RE) meta-analysis. RESULTS: Forty-three articles underwent full-text review. Eighteen independent studies evaluating the relationship between family history of POP and POP risk in 3639 POP cases and 10,912 controls were eligible for meta-analysis. Four studies evaluating family history and POP recurrence in 224 recurrent cases and 400 non-recurrent cases were eligible for inclusion into another meta-analyses. A positive family history of POP is on average associated with 2.3- to 2.7-fold increased risk for POP (RE OR = 2.64; 95% CI = 2.07, 3.35) as well as a 1.4-fold increased risk for POP recurrence (FE OR = 1.44; 95% CI = 1.00, 2.08). Meta-analysis estimates of POP risk varied by study design, definition of family history, and model adjustment status. We found evidence that publication bias and recall bias are a possibility. CONCLUSIONS: Family history of POP is a risk factor for both POP presence and recurrence. However, reported magnitudes may be overestimates due to confounding, recall bias, and publication bias.

Patient Discharge without an Order to Void in the Outpatient Gynecologic Surgery Setting.

STUDY OBJECTIVE: To evaluate if there is a difference in hospital readmission when patients are required to void versus not required to void before discharge after a same-day gynecologic procedure. DESIGN: A retrospective cohort study. SETTING: An urban tertiary care hospital. PATIENTS: A total of 4743 patients undergoing same-day gynecologic surgery. INTERVENTIONS: The readmission rates of patients discharged home without an order to void were compared with those with an order to void. Chart review was performed for readmission within 30 days and time to discharge from the postanesthesia recovery unit. MEASUREMENTS AND MAIN RESULTS: There was no statistically significant difference in the readmission rate between patients with or without an order to void before discharge (0.4% vs 0.9%, p = .08). Only 3 patients were readmitted for urinary retention, all with an order to void before discharge. Compared with gynecologic surgeons treating benign conditions, gynecologic oncologists were 23% more likely to place an order to void before discharge. Patients without an order to void spent approximately 59 minutes more in the postanesthesia care unit compared with those required to void (p <.01). CONCLUSION: Discharge without an order to void is a safe practice in patients undergoing same-day gynecologic procedures. The risk of postdischarge urinary retention is low, consistent with previously reported rates in the literature.

Opioid Prescriptions for Female Pelvic Reconstructive Surgery Patients Before and After Implementation of Tennessee State Legislation.

OBJECTIVES: Limited data exist regarding the impact of state legislation on opioid-prescribing patterns, particularly in states with the highest opioid-prescribing rates in the nation. Our primary objective was to examine the change in the amount of opioid morphine equivalents (OMEs) prescribed at discharge to patients undergoing female pelvic reconstructive surgery after the implementation of state legislation created in response to the opioid crisis. METHODS: At our institution, state legislation went into effect on July 1, 2018, implementing limitations on OMEs prescribed to patients. This retrospective cohort study examines all adult women undergoing female pelvic reconstructive surgery from January 1, 2018, to December 31, 2018. The study compares prescribing practices 6 months before and 6 months after the state law was enacted. RESULTS: In total, 346 patients met inclusion criteria. The 2 groups had similar demographics. Surgical procedures were well distributed, with 52% of cases occurring in the first 6 months of the calendar year. At the time of discharge, 324 (96.7%) patients received an opioid prescription, with an overall average of 197 OMEs. After the implementation of state legislation on July 1, 2018, the amount of OMEs prescribed at discharge significantly decreased, from a median of 210 mg (interquartile range, 150-225) to 150 mg (interquartile range 135-225; P = 0.02). CONCLUSIONS: State legislation was associated with a significant decrease in prescribed OMEs at the time of discharge in patients undergoing female pelvic reconstructive surgery. These results support ongoing legislative efforts to address the current opioid crisis.

Referral Patterns for the Evaluation of Asymptomatic Microscopic Hematuria in Women in a Single Health Care System: Room for Improvement.

OBJECTIVE: To identify patterns of care for women referred for asymptomatic microhematuria in a single, hospital-based health care system and estimate the cost of unindicated evaluation. METHODS: We conducted a retrospective study of 100 women with a diagnosis of asymptomatic microhematuria referred to a tertiary female pelvic medicine and reconstructive surgery practice. Our analysis focused on referral patterns by obstetrician-gynecologists and primary care physicians. Data analyzed included whether asymptomatic microhematuria was documented using urine microscopy (vs urine dipstick) and whether the urine microscopy correctly identified asymptomatic microhematuria with three red blood cells (RBCs). RESULTS: Forty-six patients were referred who met the American Urological Association's guidelines for asymptomatic microhematuria with a workup estimated at $8,298 per patient. Fifty-four were referred to a female pelvic medicine and reconstructive surgery specialist despite clearly not meeting the American Urological Association's definition of asymptomatic microhematuria. Of these, 33 patients were referred based on dipstick-positive results only, 11 were referred based on microscopic urinalysis demonstrating fewer than three RBCs per high-power field (HPF), and the remaining 10 patients were referred with urine microscopy demonstrating at least 3 RBC/HPF but in the setting of a clearly benign cause, such as infection or menstruation. The total estimated cost of the unnecessary asymptomatic microhematuria workup in patients who did not meet American Urological Association criteria for referral was $1,213 per patient. CONCLUSION: Fewer than half of the referrals for asymptomatic microhematuria were appropriate, leading to wasted and entirely preventable health care expenditures. This study highlights the need for education of health care providers making these referrals.

Quality of Life in Children with Asthma versus Healthy Children.

BACKGROUND: Asthma is the most prevalent chronic disease in the pediatric age group. The disease affects different aspects of the children's lives, such as physical, emotional, social and educational aspects. Thus, more focus has been on the quality of life in these patients rather than the duration of their illness in recent years. AIM: This study examined the different aspects of quality of life in asthmatic children for the first time in this geographic area. METHODS: The study was cross-sectional conducted in 2015-2016. The asthmatic group was 100 patients aged 8 to 12 admitted to the Asthma and Allergy Clinic of Ghaem Hospital (as) in Mashhad with the control group composed of 100 healthy children of the same age and gender. The standard questionnaire pedsQLTM was used for comparing the quality of life of children in the two groups. Statistical analysis was SPSS23 with P-value less than 0.05, which was statistically significant. RESULTS: In each group, 58 patients were boys, and 42 were girls. In a comparison of the quality of life of children, the asthma group with a mean total score of Peds QL 20.99 ± 12.54 compared to the healthy children with a mean total score of Peds QL of 8.8 ± 5.41 had a lower quality of life (P < 0.001). Moreover, regarding various aspects of quality of life asthma group had a lower quality of life in physical performance, emotional performance and performance in school (P < 0.001). Nonetheless, there was no significant difference between the two groups considering social function (P = 0.267). Examining the relationship between Peds QL score of patients with asthma with various variables was indicative of the fact that Peds QL scores were significantly correlated with the gender of the patients, showing better quality of life in the girls (P = 0.001). CONCLUSION: The results indicated that children with asthma have a significantly lower quality of life compared with healthy children of the same age. Also, in examining the different aspects of quality of life, these children had a lower quality of life in physical performance, emotional performance, and performance at school, and were at the level as that of healthy children only in social performance.

Hysterectomy for the Transgendered Male: Review of Perioperative Considerations and Surgical Techniques with Description of a Novel 2-Port Laparoscopic Approach.

Transgendered individuals can suffer a significant amount of psychological distress that can be alleviated through hormonal treatments and/or gender-affirming surgery. The World Professional Association for Transgender Health considers a hysterectomy and bilateral salpingo-oophorectomy medically necessary gender-affirming procedures for the interested transgendered male. Several surgical approaches have been described in the literature, most of which endorse a laparoscopic approach. This review summarizes the available literature on surgical techniques in addition to reporting our institutional outcomes using a novel 2-port laparoscopic approach. Additional preoperative and perioperative considerations are needed when caring for this patient population and are reviewed.

Globalization and economic growth: empirical evidence on the role of complementarities.

This study was carried out to investigate the effect of economic globalization on economic growth in OIC countries. Furthermore, the study examined the effect of complementary policies on the growth effect of globalization. It also investigated whether the growth effect of globalization depends on the income level of countries. Utilizing the generalized method of moments (GMM) estimator within the framework of a dynamic panel data approach, we provide evidence which suggests that economic globalization has statistically significant impact on economic growth in OIC countries. The results indicate that this positive effect is increased in the countries with better-educated workers and well-developed financial systems. Our finding shows that the effect of economic globalization also depends on the country's level of income. High and middle-income countries benefit from globalization whereas low-income countries do not gain from it. In fact, the countries should receive the appropriate income level to be benefited from globalization. Economic globalization not only directly promotes growth but also indirectly does so via complementary reforms.

Idiopathic granulomatous lobular mastitis - report of 43 cases from iran; introducing a preliminary clinical practice guideline.

BACKGROUND: We aimed to report a large series of idiopathic granulomatous lobular mastitis (IGLM) from Iran and sketch preliminary clinical practice guidelines (CPG) for approaching an inflammatory breast mass. PATIENTS AND METHODS: In a retrospective records review, 43 consecutive IGLM cases were studied. Data on baseline, clinical, imaging, and pathologic characteristics were collected. RESULTS: The mean age of the women was 33.5 years. All but 1 were married and had given birth. 16% had a cancer-like presentation. Inflammatory signs, architectural distortion, and a nodular pattern were the most common findings clinically, mammographically and ultrasonographically, respectively. 29.5% of the pathological reports indicated necrosis which was more common in younger subjects (p = 0.016); microabscesses were associated with a shorter lactation course (p = 0.006). Corticosteroids had been used as the initial treatment modality in 51%, immunosuppressive agents had not been administered, and a 16% relapse rate was recorded. We recognized the need for a multidisciplinary approach covering radiology, oncology, and surgery to best handle diagnostic and therapeutic issues and manage relevant infections as well as the major differential diagnosis, i.e. malignancy. CONCLUSION: We hypothesized that a shorter lactation period may cause more milk stasis and extravasation and be contributory to IGLM. CPGs are needed to incorporate the needed multidisciplinary approach and to standardize IGLM care. We present one such guideline.

Validity of the process of change for colorectal cancer screening among African Americans.

BACKGROUND: Process of change (POC) is a construct of the transtheoretical model that proposes to promote healthy behaviors. PURPOSE: African Americans participate in colorectal cancer (CRC) screening less often than whites, while disease onset is younger, and incidence and mortality from CRC are higher. METHODS: POC items for CRC screening were administered to 158 African Americans, the majority of whom were female (75.9%) and were not employed (85.4%). Confirmatory factor analysis was used to validate four factors reflecting the POC sub-domains. RESULTS: Support of the factor validity of the POC with internal consistency of standardized alpha for the four factors was found. A logistic regression showed predictive validity in predicting current screening stage for two of the four sub-domains. CONCLUSION: These data support the application of the POC to prediction of CRC screening intention among African Americans.

Remembering a critical triad in severe deceleration injuries to the chest: report of a traumatic aortic rupture case.

We aimed to present herein the case of a potentially preventable death involving traumatic aortic rupture and to develop a critical pathway for the management of isthmic aortic ruptures consistent with the available resources. A retrospective record review by a multidisciplinary panel of experts was done, and the probability of survival was estimated based on the Revised Trauma Score and Injury Severity Scale score. Literature review and expert consensus were used in a quality and safety analysis to develop a critical care pathway for future cases. A 32-year-old man, injured in a motorcycle accident, was referred to a trauma center in a state of shock. Thoracic aortic rupture was highly suspected. For educational purposes, the classic signs of a widened mediastinum, right tracheal deviation, and left-sided hemothorax (in a context of significant deceleration injury) are incorporated into an acute care triad for traumatic aortic rupture. In such cases, in the absence of poor access to aortography, we suggest (serial - if needed) contrast-enhanced chest computed tomography scanning for diagnosis confirmation and operative planning. Assumption of hemodynamic stability can be catastrophic, and transferring the patient to a second facility may endanger survival, when operative capacity exists at the initial trauma facility.