Oral versus intravenous iron for anemia in pregnancy: a cost-effectiveness analysis.

Our findings suggest that treating antepartum anemia with currently available iron therapies would result in significant cost-savings and reductions in adverse outcomes associated with anemia in this context. Ferric carboxymaltose likely confers the greatest overall benefit among competing options. This conclusion is robust to uncertainty, even when the cost these therapies is significantly higher than is demonstrated in the literature.

The correlation of non-invasive hemoglobin testing and lab hemoglobin in surgical patients: A systematic review and meta-analysis.

BACKGROUND: The decision regarding intraoperative transfusion has traditionally been based on hemodynamic instability and estimated blood loss. We performed a systematic review to determine the validity of the oximetry method compared to standard of care for hemoglobin measurement. METHODS: A systematic literature review was conducted, and several libraries were searched from inception to March 31,2023. The primary outcome was comparing the mean difference between laboratory-derived hemoglobin and non-invasive, point-of-care hemoglobin measurement. Subgroup analysis included comparing the mean difference in the pediatric population and among female patients. RESULTS: A total of 276 studies were identified, and 37 were included. We found that the pooled mean difference varied qualitatively between adult and pediatric population (p value for heterogeneity <0.001). In adult populations, lab hemoglobin measurements were on average slightly higher than non-invasive measurements (mean difference = 0.23; 95% CI -0.13, 0.59), though there was greater heterogeneity across studies (I2 = 97%, p value = <0.001). In the pediatric population, most studies showed lab hemoglobin to be slightly lower (mean difference = -0.42; 95% CI -0.87 to 0.03). CONCLUSIONS: In general, there was no clinically significant difference in mean hemoglobin among adult and pediatric populations. The percentage of female participants had no effect on the mean difference in hemoglobin.

Clinical predictors of mortality in patients with pseudomonas aeruginosa infection.

BACKGROUND: Infections caused by Pseudomonas aeruginosa are difficult to treat with a significant cost and burden. In Lebanon, P. aeruginosa is one of the most common organisms in ventilator-associated pneumonia (VAP). P. aeruginosa has developed widespread resistance to multiple antimicrobial agents such as fluoroquinolones and carbapenems. We aimed at identifying risk factors associated for P. aeruginosa infections as well as identifying independent risk factors for developing septic shock and in-hospital mortality. METHODS: We used a cross-sectional study design where we included patients with documented P. aeruginosa cultures who developed an infection after obtaining written consent. Two multivariable regression models were used to determine independent predictors of septic shock and mortality. RESULTS: During the observed period of 30 months 196 patients were recruited. The most common predisposing factor was antibiotic use for more than 48 hours within 30 days (55%). The prevalence of multi-drug resistant (MDR) P. aeruginosa was 10%. The strongest predictors of mortality were steroid use (aOR = 3.4), respiratory failure (aOR = 7.3), identified respiratory cultures (aOR = 6.0), malignancy (aOR = 9.8), septic shock (aOR = 18.6), and hemodialysis (aOR = 30.9). CONCLUSION: Understanding resistance patterns and risk factors associated with mortality is crucial to personalize treatment based on risk level and to decrease the emerging threat of antimicrobial resistance.

Human papillomavirus vaccination receipt and provider counseling rates among high-risk patients.

OBJECTIVE: We describe provider documented counseling patterns and perception regarding HPV vaccination among patients with a history of cervical dysplasia. METHODS: All patients ages 21-45 who underwent colposcopy at a single academic medical center from 2018 to 2020were sent a self-administered survey through the electronic medical record patient portal to assess their attitudes regarding human papillomavirus (HPV) vaccination. Demographic information, HPV vaccination history, and documented obstetrics and gynecology provider counseling at the time of colposcopy were examined. RESULTS: Of 1465patients, 434 (29.6 %) reported or had documented receipt of at least one dose of the human papillomavirus vaccine. The remainder reported they were not vaccinated or had no documentation of vaccination. Proportion of vaccinated patients was higher among White compared to Black and Asian patients (P = 0.02). On multivariate analysis, private insurance (aOR 2.2, 95 % CI 1.4-3.7) was associated with vaccinated status while Asian race (aOR 0.4, 95 % CI 0.2-0.7) and hypertension (aOR 0.2, 95 % CI 0.08-0.7) were less likely to be associated with vaccination status. Among patients with unvaccinated or unknown vaccination status, 112 (10.8 %) received documented counseling regardingcatch-up human papillomavirus vaccination at a gynecologic visit. Patients seen by a sub-specialist obstetrics and gynecologic provider were more likely to have documented provider counseling regarding vaccination compared to those seen by a generalist obstetric/gynecologist provider (26 % vs 9.8 %, p < 0.001). Patients cited lack of physician discussion (53.7 %) and the belief that they were too old to receive the HPV vaccine (48.8 %) as the main reasons for remaining unvaccinated. CONCLUSION: HPV vaccination and the rate of obstetric and gynecologic provider counseling regarding HPV vaccination among patients undergoing colposcopy remains low. When surveyed, many patients with a history of colposcopy cited provider recommendation as afactor in their decision to undergo adjuvant HPV vaccination, demonstrating the importance of provider counseling in thisgroup.

Diagnostic Utility of Endocervical Curettage During Colposcopy Among Patients of Varying Risk Factors.

OBJECTIVE: Endocervical curettage (ECC) during colposcopy is recommended in certain circumstances; however, diagnostic use remains unclear. We evaluate the utility of ECC among patients with non-fully visualized squamocolumnar junction (SCJ) and certain patient socioeconomic factors. METHODS: Retrospective chart analysis was completed for patients aged older than 21 years who underwent a colposcopy at 2 study sites between 2012 and 2021. Demographics and histopathologic results were analyzed. RESULTS: A total of 1,516 colposcopies were reviewed; 73.8% (n = 1,119) had an ECC with colposcopy. Of those, 92.1% (n = 1,031) had benign ECC whereas 13.9% (n = 156) had a positive ECC at time of colposcopy. Most patients with benign ECC had benign/low-grade squamous intraepithelial lesion pathology on colposcopy biopsy (82.3%; n = 914; p < .001), and most patients with high-grade squamous intraepithelial lesion (HSIL) on ECC had HSIL on colposcopy biopsy (63.4%; n = 52; p < .001) However, when looking at patients with high-grade pathology on colposcopy biopsy, it was seen that most had benign or low-grade squamous intraepithelial lesion on ECC (79.5%; n = 205; p < .001). Most patients with adequately visualized SCJ on colposcopy were noted to have HSIL on biopsy and negative ECC (73%; n = 81; p < .001). This result was similar in patients with non-fully visualized SCJ, although not statistically significant. When stratified by socioeconomic status, most patients with high-grade lesions had a benign ECC. CONCLUSIONS: Endocervical curettage has been described to increase the identification of high-grade lesions at time of colposcopy. This descriptive study shows that many high-grade lesions at time of excisional procedure had a benign ECC on colposcopy, with no demonstrated clear additional utility in high-risk groups.

Patterns of voiding following laparoscopic hysterectomy.

OBJECTIVE: Clarify the normal patterns of voiding after minimally invasive hysterectomy. We also aim to identify perioperative factors associated with delayed time to void immediately following hysterectomy. DESIGN: Retrospective cohort study SELECTION: Women undergoing laparoscopic hysterectomy between September 2012 to October 2018 at a single academic university hospital. RESULTS: 450 minimally invasive hysterectomies were included in the final analysis, 274 (60.9%) robotically-assisted, and 176 (39.1%) conventional laparoscopy. The overall median postoperative time-to-void following a retrograde bladder filling of 150 mL normal saline was 179 min. Based on the 50th percentile of the distribution of the time-to-void, two groups were created. Demographic characteristics between the groups were similar, except those who were above the 50th percentile were more likely to be older, have a reported history of previous myomectomy, and had a longer postoperative PACU stay compared to those below or equal to the 50th percentile. The mean time-to-void following conventional laparoscopic hysterectomy was less than that of robotic surgery (187.3 vs 200.5 min) however the difference was not statistically significant (p=.22). The use of hydromorphone intraoperatively and the combination of oxycodone-acetaminophen postoperatively were more likely to be associated with the group of patients above the 50th percentile but there was no significant difference in perioperative utilization of median morphine milliequivalents (MME) between the two groups. CONCLUSIONS: Following laparoscopic hysterectomy (either conventional or with robotic-assistance) with a retrograde bladder fill of 150 mL normal saline most patients will void within 4 h after surgery. This is consistent with historic data on normal voiding patterns facilitating safe same day discharge without prolonged time in the PACU.

Rates of anastomotic leak and fistula following surgical management of bowel endometriosis: a comparison of shaving, discoid excision, and segmental resection.

Endometriosis is a complex chronic inflammatory condition that can create a multitude of bothersome painful symptoms for women. Bowel endometriosis is often misdiagnosed or overlooked leading to years of suffering for many women. The surgical management of bowel endometriosis varies based on extent of disease as well as surgeon experience. Surgical treatment for bowel endometriosis is complex and a variety of intraoperative and postoperative complications must be considered. Two significant postoperative complications for bowel endometriosis include anastomotic leak and fistula formation. There is continued debate regarding the appropriate surgical treatment for bowel endometriosis. Aggressive surgery with segmental bowel resection is being utilized more cautiously, with an increase in less aggressive shaving or disc excision techniques. Historic beliefs regarding the limitations of shaving and disc excision are being challenged, and with a reduction in morbidity these less aggressive techniques are winning favor among gynecologic surgeons. Shaving, discoid excision, and segmental bowel resection are all feasible surgical management options for bowel endometriosis. Segmental resection is associated with the highest rates of both anastomotic leak and fistula formation, while shaving is associated with the lowest.

Safety and feasibility of the three-port robot-assisted hysterectomy across uterine weights.

One strategy thought to reduce direct costs associated with robotic surgery is minimizing the number of robotic arms used for a surgery. We aim to demonstrate the safety and feasibility of the three-port robot-assisted hysterectomy across uterine weights. Retrospective cohort study in a tertiary care university hospital of consecutive patients undergoing a three-port robot-assisted hysterectomy for benign indications. All surgeries were performed between 2012 and 2018 by fellowship-trained minimally invasive gynecologic surgeons. Data from 232 patients were collected. Eighty-eight (37.9%) patients had a uterine weight < 250 g, 63 (27.2%) had a uterine weight between 250 and 500 g, 51 (22.0%) had a uterine weight between 500 and 1000 g, and 30 (12.9%) had a uterine weight ≥ 1000 g. Multivariable regression analysis revealed no statistically significant differences between uterine weight groups and time spent in PACU, the total length of hospital stay, or direct cost. When setting the < 250 g as referent, patients with uterine weights between 500 and 1000 g, and more than 1000 g had an operative time that was on average 23.4% and 91.6% longer than patients with uterine weight < 250 g, respectively (p < 0.01). Patients with uterine weights between 500 and 1000 g and more than 1000 g had an EBL that was on average 35% and 156% higher than patients with uterine weight < 250 g, respectively (p < 0.01). Our data support the safety and feasibility of the three-port robot-assisted hysterectomy technique across uterine weights.

Cost variance across obesity class for women undergoing laparoscopic hysterectomy by high-volume gynecologic surgeons.

Health-care costs are affected by obesity with both the direct and indirect costs of health care increasing as body mass index (BMI) increases. However, one important aspect of obesity that lacks rigorous study is what impact BMI has on direct surgical cost. We performed a retrospective cohort study of women undergoing a laparoscopic hysterectomy at our single academic university center between January 2012 and December 2017. Women were excluded if their surgery was performed by anyone other than those surgeons with subspecialty training in minimally invasive gynecologic surgery (MIGS), if their hysterectomy was performed by a modality other than conventional laparoscopy or with robotic assistance, or if the indication for hysterectomy was related to any gynecologic malignancy. We identified 600 patients who underwent laparoscopic hysterectomy during the study period. Women who underwent robotic hysterectomy, compared to laparoscopic, had a shorter operative time, lower estimated blood loss, and shorter length of stay. Mean direct cost (± standard deviation) for the cohort was $6398.53 ± $2304.67, age was 44.5 ± 7.5 years, and BMI was 32.2 ± 7.6. Direct cost for all laparoscopic hysterectomies was evaluated across the five different BMI quintiles and no significant difference between groups was found. There was no significant difference in direct cost across procedures between obese and non-obese patients (p = 0.62) and this remained true when separated out by surgical modality. However, when evaluating morbidly obese patients, there appears to be a trend toward cost reduction with robotic hysterectomy compared to conventional laparoscopy. It does not appear that BMI has a statistically significant impact on direct cost between robotic-assisted and conventional laparoscopic hysterectomy. However, these findings may be due to surgical proficiency and warrant further investigation among surgeons with lesser volume.

B-cell acute lymphoblastic leukemia/lymphoma in relapse presenting as a cervical mass: A case report and review of literature.

The involvement of the cervix as a site of relapse for hematologic malignancies is rare. We herein present a case of relapsed B-cell Acute Lymphoblastic Leukemia/Lymphoma (ALL) mimicking advanced cervical cancer. The patient is a 61-year-old female with history B-cell ALL and had multiple relapses confined to the bone marrow and had received several different chemotherapy regimens. She presented with lower abdominal pain after the end of her last cycle for which an MRI abdomen and pelvis was done and it showed the presence of an asymmetrical cervical mass. Further imaging included a PET-CT showing the presence of hypermetabolic cervical mass with left pelvic and retroperitoneal lymph node involvement. She underwent a biopsy of 3 distinct lesions in the cervix and vagina and a diagnosis of relapsed B-cell ALL was confirmed in two out of the three specimens.