Comparison of the Outcomes of Enhanced Recovery After Surgery and Traditional Recovery Pathway in Robotic Hysterectomy for Benign Indications: A Randomized Controlled Trial.

STUDY OBJECTIVE: The present study aimed to evaluate the impact of the implementation of the enhanced recovery after surgery (ERAS) program in patients undergoing robotic hysterectomy for benign indications in comparison with conventional management. DESIGN: Randomized controlled trial. SETTING: North Indian tertiary care hospital. PARTICIPANTS: Patients aged 40 to 60 years willing to sign the informed written consent were included, whereas cases with contraindications for neuraxial anesthesia were excluded. A total of 130 subjects undergoing robotic hysterectomy were divided into ERAS (n = 65) and conventional (non-ERAS) (n = 65) groups. INTERVENTIONS: Components of the ERAS protocol included preoperative counseling, carbohydrate loading, early removal of catheter, and early ambulation. Both groups underwent optimization of medical conditions, standardized anesthesia, and venous thromboembolism prophylaxis. MEASUREMENTS AND MAIN RESULTS: Outcome measures included length of hospital stay (LOHS), time to tolerance of diet, postoperative complications, readmission rates, and quality of life assessed by WHO-QOL BREF. Baseline characteristics were comparable between groups. ERAS group showed significantly lower docking time (4.82 ± 0.73 vs 5.31 ± 0.92 minutes), faster tolerance of diet (0.14 ± 0.35 vs 1.14 ± 0.35 days), and earlier resumption of ambulation (0.42 ± 0.5 vs 1.26 ± 0.44 days). Time for "fit for discharge" (1.43 ± 0.61 vs 2.97 ± 1.1 days) and LOHS (2.85 ± 1.09 vs 3.78 ± 1.29 days) were significantly lower in the ERAS group. Postoperative complications and readmission rates were comparable. Quality-of-life scores favored the ERAS group at postoperative days 1 and 30. CONCLUSION: The combination of ERAS and robotic surgery improves patient outcomes, shortens hospital stays, and enhances postoperative recovery without increasing complications. This research serves as a pioneering effort in assessing the impact of ERAS on robotic hysterectomy for benign indications, providing valuable insights for future multicentric studies and supporting the integration of ERAS protocols to enhance patient outcomes and quality of life.

How to critically appraise a systematic review: an aide for the reader and reviewer.

The number of published systematic reviews has soared rapidly in recent years. Sadly, the quality of most systematic reviews in dermatology is substandard. With the continued increase in exposure to systematic reviews, and their potential to influence clinical practice, we sought to describe a sequence of useful tips for the busy clinician reader to determine study quality and clinical utility. Important factors to consider when assessing systematic reviews include: determining the motivation to performing the study, establishing if the study protocol was prepublished, assessing quality of reporting using the PRISMA checklist, assessing study quality using the AMSTAR 2 critical appraisal checklist, assessing for evidence of spin, and summarizing the main strengths and limitations of the study to determine if it could change clinical practice. Having a set of heuristics to consider when reading systematic reviews serves to save time, enabling assessment of quality in a structured way, and come to a prompt conclusion of the merits of a review article in order to inform the care of dermatology patients.

A Study of Clinical Profile and Fetomaternal Outcome of Obstetric Patients Admitted to Intensive Care Unit: A Prospective Hospital-based Study.

AIMS AND OBJECTIVES: To study clinical profile of obstetric patients admitted to intensive care unit (ICU) and to analyze the relation of demographic factors such as age, parity, literacy level, socioeconomic status, acute physiology and chronic health evaluation II (APACHE II) score, and level of delay with fetomaternal outcome. DESIGN: It is a prospective cross-sectional observational study. MATERIALS AND METHODS: After admission to ICU a detailed history, analysis of basic demographic variables along with level of delay was done. APACHE II score was calculated. These parameters were correlated with fetomaternal outcome. The Chi-squared test was used to compare categorical variables. The one-way analysis of variance was used to compare the continuous variables among the strata with Tukey's post hoc test. RESULTS: Incidence of obstetric ICU admission was 0.77%. Mean age was 26.03 years. Most common indication of ICU admission was obstetrical hemorrhage (37.1%) followed by hypertensive disorders of pregnancy (25.8%). Type I delay was the most common followed by type II delay. Mean APACHE II score was 14.77 ± 6.85. Observed mortality rate (30.6%) was found to be higher than predicted mortality rate (25%). APACHE II score was significantly high in the presence of level 1 (p = 0.003) and level 2 delays (p = 0.0001). Also, it was significantly increased with the duration of delays. CONCLUSION: Unbooked and referred cases had high incidence of ICU admission. The presence of delay was associated with poor outcome. HOW TO CITE THIS ARTICLE: Miglani U, Pathak AP, Laul P, Sarangi S, Gandhi S, Miglani S, et al. A Study of Clinical Profile and Fetomaternal Outcome of Obstetric Patients Admitted to Intensive Care Unit: A Prospective Hospital-based Study. Indian J Crit Care Med 2020;24(11):1071-1076.

Anxiety, Depression, and Quality of Life Among Infertile Women: A Case-Control Study.

Introduction Pregnancy holds significant cultural and social value for women. However, women facing challenges in conceiving often grapple with emotional distress, including depression and anxiety. The connection between psychological elements (stress, anxiety, and depression) and infertility is complex, influenced by multiple factors, and bidirectional. Infertile women are more likely to develop mental illnesses, marital dissatisfaction, and impaired quality of life compared to the individuals of the fertile group. Thus, the study aimed to assess levels of anxiety, depression, and quality of life among infertile women compared to fertile women. Methods This case-control study conducted at a tertiary care center recruited 100 nulliparous women between the age group of 20 and 38 years with primary or secondary infertility, while those with male factor infertility were excluded. The control group (N=100) comprised normal parous women who had at least one child. The primary objective of the study was to assess the impact of infertility on the mental health and quality of life of women seeking infertility treatment. Outcome measures included standardized tools such as the WHOQOL-BREF questionnaire to assess the quality of life across multiple domains (e.g., physical, psychological, social, and environmental) as well as the Depression Anxiety and Stress Scale (DASS-21) to measure levels of anxiety, depression, and stress. Cronbach's alpha was used to measure the tool's reliability. A P value of <0.05 was considered statistically significant. Results Baseline sociodemographic parameters were comparable between the two groups. The mean age of infertile women was 30.6±3.9 years compared to 31.5±3.2 years in fertile women (P=0.076). Using the WHOQOL-BREF scale, we found that the quality of life was better in the fertile group compared to the infertile group through all the physical, psychological, social, and environmental domains (P<0.001). The infertile group had a significantly higher number of women with anxiety, depression, and stress. The questionnaires showed high internal reliability. Conclusion Infertile women experienced a lower quality of life in various domains, higher levels of anxiety, and increased rates of depression compared to fertile counterparts. The study findings underscore the multidimensional impact of infertility, emphasizing the need for comprehensive healthcare approaches to address the psychosocial challenges faced by women undergoing infertility treatment.

Scrub typhus in pregnancy - A threat to maternal and fetal outcome.

Background and Objectives: Scrub typhus is an acute febrile illness transmitted by the bite of trombiculid mite in the larval stage. Scrub typhus is rare in pregnancy and there is paucity of data on the clinical outcome of scrub typhus during pregnancy. Material and Methods: We present five cases of scrub typhus complicating pregnancy who were admitted in the obstetric ward at AIIMS Rishikesh, India during the antenatal period for management. Results: The first patient presented at term pregnancy in semiconscious state while the rest were preterm between 31 and 34 weeks period of gestation. The age at presentation was 21-31 years. All five had febrile illness of >5 days' duration along with cough. Fever investigations like blood culture, peripheral smear for malarial parasite, dengue serology, widal test, and urine culture were negative. Serology for scrub typhus was positive in all. Once diagnosis was confirmed for scrub typhus, patients were given the drug of choice azithromycin 500 mg twice daily for five days. Scrub typhus complicating pregnancy led to maternal mortality in one patient. It resulted in one preterm delivery, one intrauterine fetal death, and rest three were delivered at term with good perinatal outcome. Conclusion: Scrub typhus is common in endemic areas like Uttarakhand, India. It has a poor fetal outcome. If diagnosed early and treatment started, maternal and fetal prognosis can be favorable. As large case series are unavailable in literature, it is difficult to predict the course of disease which at times may be fulminant.

May-Thurner Syndrome in a Case of Left Iliofemoral Vein Thrombosis With Contralateral Tubo-Ovarian Abscess in the Post-postpartum Period.

May-Thurner syndrome (MTS) is a rare, yet important, differential diagnosis in reproductive-age women with deep vein thrombosis (DVT). It is characterized by the compression of the left common iliac vein by the right common artery against the lumbar vertebra. The condition is complicated by recurrent DVT with pulmonary thromboembolism (PTE). Here is a case of multiparous women in early puerperium with right tubo-ovarian abscess and left lower limb DVT likely due to MTS. The diagnosis was further complicated by the presence of persistent thrombocytosis but a myeloproliferative neoplasm was ruled out by genetic mutation testing. She was given anticoagulants, and laparotomy was done for the excision of the tubo-ovarian mass in view of the persistent fever not responding to injectable antibiotics. PTE in the postoperative period was managed by anticoagulants followed by an inferior vena cava (IVC) filter for the risk of recurrent DVT and/or PTE in an MTS case.

Ureteric Leiomyosarcoma.

Ureteric leiomyosarcoma is a rare but aggressive tumor among other sarcomas. There is no established epidemiological data due to the scarcity of literature on this uncommon disorder. The present literature comprises about 20 case reports mostly of women above 40 years of age. The presenting complaint is mostly pain in the abdomen with only a few reporting urological symptoms like hematuria. Understandably, this tumor is diagnosed by histopathological examination with immunohistochemistry. We report one such case of a 32-year-old female who underwent an exploratory laparotomy with preoperative suspicion of adnexal neoplastic mass only to find normal ovaries and left ureteric tumor intraoperatively. She was managed with excision of the tumor with partial resection of the involved ureter and end-to-end anastomosis of the ureter followed by chemotherapy and radiation.

Longitudinal analysis of vertebral fracture and BMD in a Canadian cohort of adult cystic fibrosis patients.

BACKGROUND: Vertebral fractures in patients with cystic fibrosis (CF) may contribute to an accelerated decline in lung function and can be a contraindication to lung transplantation. In this study, we examined longitudinal change in bone mineral density (BMD) and the prevalence of vertebral fractures in adult CF patients, without lung-transplant, attending a Canadian specialty clinic. METHODS: Retrospective chart review of all patients attending an Adult Cystic Fibrosis Clinic at Hamilton Health Sciences in Hamilton, Canada. Forty-nine of 56 adults met inclusion criteria. Chest radiographs were graded by consensus approach using Genant's semi-quantitative method to identify and grade fractured vertebrae. Dual x-ray absorptiometry (DXA) scans were also reviewed. RESULTS: The mean age of the cohort was 25.2 years (SD 9.4), 43% were male. The mean body mass index (BMI) was 19.8 (2.8) for males and 21.7 (5.1) for females. At baseline, the rate of at least one vertebral fracture was 16.3%; rising to 21.3% (prevalent and incident) after a 3-year follow-up. The mean BMD T-or Z-scores at baseline were -0.80 (SD 1.1) at the lumbar spine, -0.57 (SD 0.97) at the proximal femur, and -0.71 (SD 1.1) at the whole body. Over approximately 4-years, the mean percent change in BMD was -1.93% at the proximal femur and -0.73% at the lumbar spine. CONCLUSION: Approximately one in five CF patients demonstrated at least one or more vertebral fractures. Moderate declines in BMD were observed. Given the high rate of vertebral fractures noted in this cohort of adult CF patients, and the negative impact they have on compromised lung functioning, regular screening for vertebral fractures should be considered on routine chest radiographs.

Patients' adherence to osteoporosis therapy: exploring the perceptions of postmenopausal women.

OBJECTIVE: To explore the experiences and perceptions of postmenopausal women regarding strategies to improve adherence to osteoporosis therapy. DESIGN: Qualitative, mixed phenomenologic study using focus groups. SETTING: Family physicians' and specialists' practices and community pharmacies in Hamilton, Ont. PARTICIPANTS: A total of 37 postmenopausal women currently taking at least 1 prescription or over-the-counter medication for osteoporosis. METHOD: Focus groups were conducted using a semistructured interview guide consisting of 10 open-ended questions about patients' perceptions of their osteoporosis medications, their reasons for adherence and non-adherence to therapy, and the effectiveness of strategies they had tried to improve adherence. At least 2 research team members analyzed the data to find primary themes. MAIN FINDINGS: Analysis of data from the 7 focus groups found 6 main factors that influenced adherence to medications: belief in the importance of taking medications for osteoporosis, medication-specific factors, beliefs regarding medications and health, relationships with health care providers, information exchange, and strategies to improve adherence. Strategies that facilitated adherence to medications included having a system for taking medications, using cues or reminders, being well informed about the reasons for taking medications, and having regular follow-up by health care providers for support and monitoring after having been prescribed medications. CONCLUSION: Results of this study provide a better understanding of how patients' perceptions and experiences affect their adherence to osteoporosis medications. Because each patient's reasons for non-adherence might be different, depending on individual beliefs or circumstances, strategies to improve adherence to medications should be individualized accordingly.

Determinants of health-related quality of life in women with vertebral fractures.

Health-related quality of life (HRQL) is an important consideration in the management of patients with vertebral fractures. The purpose of this study was to examine patient-related factors that contribute to HRQL after vertebral fractures, including co-morbidities, medications, fracture history, family disease history, demographics, exercise, education and living environment. A total of 1,129 post-menopausal women (mean age 67.2, SD 11.9 years) was studied from the Canadian Database of Osteoporosis and Osteopenia (CANDOO). HRQL was measured using the mini-osteoporosis quality of life questionnaire (mini-OQLQ). Separate multivariable linear regression analyses [parameter estimates and corresponding 95% confidence intervals (CI)] were performed for each of the five mini-OQLQ domains: symptoms, physical functioning, emotional functioning, activities of daily living and leisure domains. A strong positive association was found between HRQL and post-secondary education, a family history of osteoporosis, working and thiazide therapy. Exercise improved HRQL; however, several hours a week were required to be meaningful. Living in long-term care had the most marked negative effect on HRQL. Smoking, past surgery of the hip or spine, sedatives, anticonvulsants, atherosclerotic disease and hypertension were also associated with a substantially decreased HRQL across several domains. Calcium channel-blockers, chemotherapy, corticosteroids, diabetes, migraines, the number of non-vertebral fractures and falls had a negative impact on selected domains. We demonstrated that several modifiable factors influence HRQL in patients with vertebral fractures, and physicians should be aware of these and other markers of reduced HRQL to enhance patient care.

Morphologic diagnosis of thrombotic thrombocytopenic purpura.

The diagnosis of thrombotic thrombocytopenic purpura (TTP) rests on evidence of microangiopathic hemolytic anemia and thrombocytopenia in the absence of disseminated intravascular coagulation and other known causes of thrombotic microangiopathy. Highly specific diagnostic tools such as serum levels of ADAMTS13 are not routinely available for immediate clinical diagnosis. The presence of schistocytes on a blood smear is the morphologic hallmark of the disease, but no guidelines exist as to the number of schistocytes required to differentiate TTP from other thrombotic microangiopathies. We studied 6 patients with TTP and compared their schistocyte counts with those of 40 normal subjects, 28 patients with chronic renal disease, 5 with preeclampsia, and 5 with normal functioning mechanical heart valves. The mean schistocyte count for the TTP patients was 8.35% versus 0.05% for normal subjects, 0.2% for renal patients, 0.25% for preeclamptic patients, and 0.18% for patients with mechanical valves (P < 0.001). Schistocytes were found on 100% of blood films of TTP patients and ranged from 1.0% to 18.4% of red cells. Schistocytes are found on the smears of 58% of normal individuals and on 80-100% of the other patient groups studied, but always comprise less than 0.5% of the red cell population. An initial schistocyte count of greater than 1% strongly suggests a diagnosis of TTP in the absence of other known causes of thrombotic microangiopathy.