RNA Interference Effectors Selectively Silence the Pathogenic Variant GNAO1 c.607 G > A In Vitro.

RNA interference (RNAi)-based therapeutics hold the potential for dominant genetic disorders, enabling sequence-specific inhibition of pathogenic gene products. We aimed to direct RNAi for the selective suppression of the heterozygous GNAO1 c.607 G > A variant causing GNAO1 encephalopathy. By screening short interfering RNA (siRNA), we showed that GNAO1 c.607G>A is a druggable target for RNAi. The si1488 candidate achieved at least twofold allelic discrimination and downregulated mutant protein to 35%. We created vectorized RNAi by incorporating the si1488 sequence into the short hairpin RNA (shRNA) in the adeno-associated virus (AAV) vector. The shRNA stem and loop were modified to improve the transcription, processing, and guide strand selection. All tested shRNA constructs demonstrated selectivity toward mutant GNAO1, while tweaking hairpin structure only marginally affected the silencing efficiency. The selectivity of shRNA-mediated silencing was confirmed in the context of AAV vector transduction. To conclude, RNAi effectors ranging from siRNA to AAV-RNAi achieve suppression of the pathogenic GNAO1 c.607G>A and discriminate alleles by the single-nucleotide substitution. For gene therapy development, it is crucial to demonstrate the benefit of these RNAi effectors in patient-specific neurons and animal models of the GNAO1 encephalopathy.

General Versus Regional Anesthesia in Sacrospinous Ligament Fixation for Pelvic Organ Prolapse: Assessment of a National Database.

IMPORTANCE: Sacrospinous ligament fixation is a prolapse repair surgical procedure that can be performed under general or regional anesthesia. Little is known about the impact of anesthesia on postoperative outcomes. OBJECTIVES: The primary objective of this study was to compare 30-day complication rates for patients undergoing sacrospinous ligament fixation by anesthesia type. Secondary objectives were to assess factors associated with type of anesthesia selected. STUDY DESIGN: This was a retrospective cohort analysis of the American College of Surgeons National Surgical Quality Improvement Program for the years of 2015 to 2020. Cases were selected based on procedural codes for sacrospinous ligament fixation and diagnostic codes for prolapse. Complications, readmissions, and reoperations were compared between general versus regional anesthesia cohorts. RESULTS: A total of 2,984 cases were included with 2,742 (91.9%) performed under general and 242 (8.1%) performed under regional anesthesia. The regional anesthesia cohort was older (69.2 vs 65.4 years old; P < 0.001) with no differences in medical history variables. Fewer patients in the regional anesthesia cohort were Hispanic (0.4% in regional vs 10.8% in general cohorts, P < 0.001). More superficial surgical site infections (2.5% vs 0.8%, P = 0.026) and cardiac complications (0.8% vs 0.1%, P = 0.035) were noted in the regional anesthesia cohort. However, multivariable regression analysis showed that anesthesia type was not associated with increased rates of minor or major complications. CONCLUSIONS: Mode of anesthesia was not a significant predictor of minor or major complications. Racial and ethnic differences in mode of anesthesia warrant further investigation to reduce racial disparities.

Prevention of Postoperative Constipation in Urogynecology Patients: A Systematic Review.

IMPORTANCE: Constipation is common after pelvic surgery, and studies suggest that surgeons underestimate the negative impact of constipation on patients. Patients undergoing pelvic reconstructive surgery are a unique population requiring special consideration in the prevention and management of constipation. OBJECTIVE: This study aimed to systematically review the literature to identify evidence for prevention of postoperative constipation with medications or fiber in patients undergoing reconstructive pelvic surgery. STUDY DESIGN: A structured literature search was performed of five databases (MEDLINE, Embase, Scopus, Web of Science, the Cochrane Library) from inception to June 2022 for studies of postoperative laxative or fiber use in adult patients undergoing benign pelvic reconstructive surgery. Studies of preoperative bowel preparation and nonsurgical patients were excluded. Data on postoperative constipation were extracted for a qualitative analysis of the literature. Grading of Recommendations Assessment, Development, and Evaluation methodology was applied to assess the quality of evidence. RESULTS: We identified 86 references after deduplication. Only 4 studies with a total of 344 patients were eligible for inclusion in the review. The included studies were all randomized controlled trials assessing time to first bowel movement with the earliest published in 2010. Laxative use decreased constipation more than placebo. Multiple-agent laxative use appeared to decrease bothersome constipation more than single-agent docusate. Preoperative fiber did not decrease constipation. By Grading of Recommendations Assessment, Development, and Evaluation criteria, all four studies provide moderate-quality evidence. CONCLUSIONS: Few studies have investigated laxative regimens in patients after urogynecologic surgery. The available literature is moderate quality and suggests benefit of multiple-agent treatment over docusate only or no treatment.

Vacuum-assisted staged omphalocele reduction: A preliminary report.

Introduction: Omphalocele represents a rare congenital abdominal wall defect. In giant omphalocele, due to the viscero-abdominal disproportion, gradual reintegration of eviscerated organs is often associated with medical challenges. We report our preliminary experience combining staged gravitational reduction with vacuum (VAC) therapy as a novel approach for treatment of giant omphalocele. Patients and methods: Retrospective chart review of six patients (five females) born between September 2018 and May 2022 who underwent staged reduction of giant omphalocele in conjunction with VAC therapy was conducted. Treatment was performed at two German third-level Pediatric Surgery Departments. Biometric and periprocedural data were assessed. Main outcome measure was the feasibility of VAC therapy for giant omphalocele. Data are reported as median and interquartile range (Q1-Q3). Results: Gestational age was 37 (37-38) weeks, and birth weight was 2700 (2500-3000) g. VAC dressing was changed every 3 (3-4) days until abdominal fascia closure at the age of 9 (3-13) days. Time to first/full oral feeds was 3 (1-5)/20 (12-24) days with a hospital stay of 22 (17-30) days. Follow-up was 8 (5-22) months and complications were of minor extent (none: n = 2; Clavien-Dindo I: n = 3; Clavien-Dindo II: n = 1), comprising a delayed neo-umbilical cord rest separation (n = 2) and/or concomitant neo-umbilical site infection (n = 2) with no repeat surgery. Conclusion: In neonates with giant omphalocele, VAC constitutes a promising and technically feasible enhancement of the staged gravitational reduction method. This study shows evidence that VAC may accelerate restoration of the abdominal wall integrity in giant omphalocele, thus minimizing associated comorbidities inherent to a prolonged hospitalization.

Trends in Apical Suspension at the Time of Hysterectomy for Pelvic Organ Prolapse: Impact of American College of Obstetricians and Gynecologists Recommendations.

OBJECTIVE: The aim of the study was to compare national surgical practice patterns of performing apical suspension procedures (ASPs) at the time of hysterectomy for pelvic organ prolapse (POP) before and after the publication of the American College of Obstetricians and Gynecologists (ACOG) 2017 Practice Bulletin on POP. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried for hysterectomy cases performed for POP indications for the years 2015-2016 and 2018-2019. The primary outcome was the use of ASP at the time of hysterectomy for POP. Secondary outcomes included the use of anterior, posterior, and paravaginal prolapse repair procedures. Multivariable regression analysis was performed to identify factors associated with performing a hysterectomy without an ASP. RESULTS: A total of 11,336 cases were included, and apical prolapse was the primary POP diagnosis in 86.3% of these cases. There was no statistically significant change in the utilization of ASPs in 2018-2019 compared with 2015-2016 (51.4% vs 49.8%, P = 0.081). Urogynecologists were significantly more likely than general gynecologists to perform ASPs (65.6% vs 37.5%, P < 0.001), which was confirmed on multivariable logistic regression analysis (adjusted odds ratio, 3.257; P < 0.001). The use of concomitant anterior repairs (44.1% vs 39.5%, P < 0.001) and posterior repairs (47.5% vs 41.3%, P < 0.001) increased in the 2018-2019 cohort. CONCLUSIONS: There was no overall increase in the utilization of concomitant ASPs at the time of hysterectomy done for POP indications despite the 2017 American College of Obstetricians and Gynecologists practice bulletin. Urogynecologists were more likely to perform ASPs than general gynecologists.

Complications After Vesicovaginal Fistula Repair Based on Surgeon Specialty in the United States: Analysis of a National Database.

OBJECTIVES: This study aimed to compare the rates of major and minor complications for vesicovaginal fistula (VVF) repair based on surgeon specialty and to identify risk factors for adverse outcomes. METHODS: This was a retrospective cohort analysis of the American College of Surgeons National Surgical Quality Improvement Program between the years 2014 and 2019. Cases were identified using Current Procedural Terminology codes for VVF repair. Minor and major complication rates for VVF repair were compared between 2 cohorts defined by surgeon specialty: gynecology versus urology. Additional outcomes included readmissions and reoperations. Multivariable logistic regression analysis was performed to investigate risk factors for complications. RESULTS: A total of 319 VVF repairs were included in the analysis, of which 115 (36.1%) were performed by gynecologists and 204 (63.9%) by urologists. There were no significant differences in the demographic or medical characteristics between the gynecology and urology cohorts except for race. Gynecologists performed more concomitant hysterectomies (10.4% vs 1.0%, P < 0.001) and apical suspension procedures (6.1% vs 0%, P < 0.001). There were no differences in minor (7.8% vs 6.4%, P = 0.623) or major (2.6% vs 3.4%, P = 1.000) complications between the cohorts. The overall readmission rate was 4.7%, and the reoperation rate was 2.2% with no differences between specialties. On multivariable logistic regression analysis, body mass index and concurrent hysterectomy were risk factors for major or minor complications with no increased risk associated with surgeon specialty or route of surgery. CONCLUSIONS: Complication rates did not differ for VVF repairs performed by gynecologists compared with urologists. Readmission and reoperation rates were low for both groups.

Pediatric Urachal Anomalies: Monocentric Experience and Mini-Review of Literature.

BACKGROUND: Surgery is the current mainstay for the treatment of urachal anomalies (UA). Recent literature data support the theory of a spontaneous resolution within the first year of life. The aim of this study, comprising solely surgically treated children, was to identify age specific patterns regarding symptoms and outcomes that may support the non-surgical treatment of UA. METHODS: Retrospective review on the clinico-laboratory characteristics of 52 children aged < 17 years undergoing resection of symptomatic UA at our pediatric surgical unit during 2006-2017. Data was dichotomized into age > 1 (n = 17) versus < 1 year (n = 35), and complicated (pre-/post-surgical abscess formation or peritonitis, n = 10) versus non-complicated course (n = 42). RESULTS: Children aged < 1 year comprised majority (67%) of cohort and had lower complication rates (p = 0.062). Complicated course at surgery exclusively occurred in patients aged > 1 year (p = 0.003). Additionally, complicated group was older (p = 0.018), displayed leukocytosis (p < 0.001) and higher frequencies regarding presence of abdominal pain (p = 0.008) and abdominal mass (p = 0.034) on admission. Regression analysis identified present abdominal pain (OR (95% CI), 11.121 (1.152-107.337); p = 0.037) and leukocytosis (1.435 (1.070-1.925); p = 0.016) being associated with complicated course. CONCLUSIONS: This study provides evidence that symptomatic disease course follows an age-dependent complication pattern with lower complication rates at age < 1 year. Larger, studies have to clarify, if waiting for spontaneous urachal obliteration during the first year of life comprises a reasonable alternative to surgery.

Quality of life following maxillofacial trauma in the elderly: a multicenter, prospective study.

BACKGROUND/AIMS: When facial trauma involves elderly patients, the possible presence of frailty and comorbidities in victims of trauma may worsen the posttraumatic symptoms and decrease quality of life. The aim of this multicenter study was to assess the quality of life following surgical or non-operative management of maxillofacial trauma in elderly patients. MATERIALS AND METHODS: This cohort study was based on the administration of validated self-administered questionnaires to all the geriatric patients (70 years or more) with facial fractures from the involved maxillofacial surgical units across Europe, since 1st January 2019 to 31st June 2019. The following questionnaires were administered: SF36 questionnaire; the VFQ-25 questionnaire; the Oral Health Impact Profile - 14 (OHIP14). Outcome variables were VFQ-25 and OHIP-14 results. RESULTS: A total of 37 patients (14 male and 23 female patients) met the inclusion criteria and were included in the study. Elderly patients had an improvement in almost all the categories examined by the SF-36 questionnaire 6 months after trauma, with the only exception of a worsening as for role limitations due to physical health. An improvement was observed in almost all the categories at SF-36 test. A worsening of scores of OHIP-14 for all the considered dimensions in the whole study population was observed too. CONCLUSIONS: Elderly patients following facial trauma experience significant emotional, social, and functional disturbances. We observed that emotional problems, energy/fatigue, social functioning, and generally social limitations played a great role in the decrease of QoL in elderly patients following maxillofacial trauma.

Postoperative Opioid Utilization in Older Women Undergoing Pelvic Organ Prolapse Surgery.

OBJECTIVES: The objective of this study was to determine total postoperative opioid consumption by women 60 years and older during the first week after pelvic organ prolapse surgery. We secondarily aimed to describe opioid prescribing patterns in this cohort. METHODS: This is a secondary analysis of a prospective cohort study assessing changes in cognition in women 60 years and older undergoing prolapse surgery. Postoperative opioid use at home during the first week was collected through daily self-reported diary entries. Total postoperative opioid consumption was calculated by adding opioid administration in the postoperative anesthesia recovery unit, inpatient setting, and home opioid use (as documented in diary). Regression models were used to identify demographic and clinical factors associated with total postoperative opioid consumption in the top quartile of this cohort and home opioid use. RESULTS: Data from 80 women were analyzed. Mean ± SD age was 71.78 ± 6.14 years (range, 60-88 years). Fifty women (62.5%) underwent vaginal surgery, and 30 (7.5%) underwent laparoscopic/robotic surgery, with concomitant hysterectomy in 47 (58.8%). The median (interquartile range) total morphine milligram equivalents used during the first week after surgery was 30 (7.5-65.75). The median (interquartile range) total morphine milligram equivalents prescribed was 225 (150-225). CONCLUSIONS: Opioid consumption after prolapse surgery in older women is very modest and equates to a median (interquartile range) of 4 (1-9) oxycodone (5 mg) tablets. Opioid prescribing patterns should be adjusted accordingly.

Age and Perioperative Outcomes After Implementation of an Enhanced Recovery After Surgery Pathway in Women Undergoing Major Prolapse Repair Surgery.

OBJECTIVE: As perioperative care pathways are developed to improve recovery, there is a need to explore the impact of age. The aim of this study was to compare the impact of a urogynecology-specific enhanced recovery after surgery (ERAS) pathway on perioperative outcomes across 3 age categories: young, middle age, and elderly. METHODS: A retrospective cohort study was conducted assessing same-day discharge, opioid administration, pain scores, and complications differences across and within 3 age categories, young (<61 years), middle age (61-75 years), elderly (>75 years), before and after ERAS implementation. RESULTS: Among 98 (25.7%) young, 202 (52.9%) middle-aged, and 82 (21.5%) elderly women, distribution before and after ERAS implementation was similar. In each age category, we found a commensurate increase in same-day discharge and decrease in length of stay independent of age. Age was associated with a variable response to opioid administration after ERAS. In women who received opioids, we found there was a greater reduction in opioids in elderly. Young women received 22.5 mg more than middle-aged women, whereas elderly women received 24.3 mg less than middle-aged women (P < 0.0001, P < 0.0001) for a mean difference of 46.8 mg between the youngest and oldest group. We found no significant differences in postanesthesia care unit pain scores with ERAS implementation. Complications did not increase after ERAS implementation in any age group, although younger and elderly women were more likely to experience complications independent of ERAS. CONCLUSIONS: Elderly women had similar outcomes compared with their younger counterparts after implementation of an ERAS pathway. Further research is needed to assess whether our age-related observations are generalizable.

Involvement of palliative care in patients requesting medical assistance in dying.

OBJECTIVE: To determine the level of palliative care involvement before and after medical assistance in dying (MAID) requests, and to compare the differences between those who completed MAID and those who requested but did not complete MAID. DESIGN: Retrospective chart review. SETTING: The Ottawa Hospital (TOH) in Ontario. PARTICIPANTS: Ninety-seven patients who requested MAID at TOH between February 6, 2016, and June 30, 2017. MAIN OUTCOME MEASURES: Completion of MAID. RESULTS: Eighty-four patients were included in the study. Fifty patients (59.5%) completed MAID. The most common reasons for not completing MAID were death before completion of the required assessments (47.0%), ineligibility (26.5%), and loss of capacity (14.7%). The most common diagnoses were cancer (72.6%) and neurologic disease (11.9%). The most frequent reasons for requesting MAID were physical suffering (77.4%), loss of autonomy (36.9%), and poor quality of life (27.4%). Patients who completed MAID in this study were more likely to report physical suffering as the reason for their request than those who did not complete MAID (84.0% vs 67.6%; P = .08), yet only 23.8% of all patients requesting MAID had an Edmonton Symptom Assessment Scale completed. Before MAID request, 27.4% of patients had a community palliative care physician and 59.5% had palliative care involvement in any setting. The TOH palliative care team was involved in 46.4% of patients who requested MAID. CONCLUSION: There is still inadequate provision of palliative care for those requesting MAID. Guidelines, legislation, and guidance are needed to help physicians ensure patients are aware of and understand the benefits of palliative care in end-of-life decisions. However, the involvement of palliative care with patients who completed MAID was similar to those who did not complete MAID. Multicentre studies are needed to further explore the MAID process and clarify the role of palliative care in that process.

30-Day unanticipated healthcare encounters after prolapse surgery: impact of same day discharge.

BACKGROUND: Same-day discharge is becoming increasingly common in gynecologic surgery; however, data are limited for frequency, setting, and severity of unanticipated healthcare visits for women who are discharged on the day of surgery after major prolapse repair. OBJECTIVE: The purpose of this study was to evaluate whether discharge on the day of surgery is associated with increased 30-day unanticipated healthcare encounters after major pelvic organ prolapse surgery compared with discharge on or after postoperative day 1. STUDY DESIGN: This is a retrospective analysis of women who underwent pelvic organ prolapse surgery by 8 female pelvic medicine and reconstructive surgery surgeons from January 2016 to October 2017. Unanticipated healthcare encounter was a composite variable of any visit to the office, emergency department, or hospital readmission. Number of visits, visit diagnoses, and complication severity (Clavien-Dindo classification) were compared by day of discharge with the use of χ2 tests. Multivariable analyses were performed. RESULTS: Of 405 women, 258 (63.7%) were discharged on the day of surgery, and 147 (36.3%) were discharged on postoperative day 1 or later. Mean age was 66±11 years, body mass index was 27.9±4.8 kg/m2. Most had stage III prolapse (n=273; 67.4%). Procedures included laparoscopic or robotic sacrocolpopexy, (n=163; 40.2%), vaginal apical suspensions (n=115; 28.4%), obliterative (n=105; 25.9%), and concomitant hysterectomy (n=229; 56.5%). There was no increase in the number of women with at least 1 unanticipated healthcare encounter within 30 days of surgery, based on discharge on the day of surgery compared with postoperative day 1 (24.0% vs 26.5%; P=.572). The majority of visits occurred in the office (17.8% vs 19.0%; P=.760). There was no increase in 30-day readmissions (3.5% vs 4.8%; P=.527). The most common visit diagnosis was pain and accounted for 31.5% of all visits, followed by urologic and gastrointestinal symptoms. Diagnoses and complication severity did not vary by day of discharge, except that women who were discharged on the day of surgery were more likely to have a superficial wound separation (11.3% vs 0%; P=.011) and less likely to experience grade II complications (7.4% vs 15.6%, P=.009). Few women had >1 unscheduled visit, and rates were similar between the 2 groups (6.2% vs 6.8%; P=.810). On multivariable regression, younger women (adjusted odds ratio, 1.03; 95% confidence interval, 1.001-1.05), those with lower body mass index (adjusted odds ratio, 1.07; 95% confidence interval, 1.13-1.01), and higher initial postanesthesia recovery unit pain scores (adjusted odds ratio, 1.11; 95% confidence interval, 1.02-1.21) were more likely to have an unanticipated healthcare encounter. Pain complaints were evaluated most often in the office compared with the emergency department (41.1% vs 13.0%); medical complications such as cardiac (15.6% vs 0%) and respiratory (6.5% vs 0%) were more likely to be evaluated in the emergency department. Higher grade complications (II/III) were more likely to visit the emergence department (78.2% vs 27.1%; P<.0001). CONCLUSION: Same-day discharge after prolapse surgery did not result in an increase in 30-day unanticipated healthcare encounters.

The "European Mandibular Angle" research project: the analysis of complications after unilateral angle fractures.

OBJECTIVE: The aim of this study was to analyze the complications and outcomes of surgical treatment of angle fractures managed at departments of maxillofacial surgery in several European countries. STUDY DESIGN: Patients hospitalized with unilateral isolated angle fractures between 2013 and 2017 were included. The following data were recorded: gender and age of patients, fracture etiology, presence of the third molar, maxillomandibular fixation, osteosynthesis technique, and complications. RESULTS: In total, 489 patients were included in the study. The Champy technique was found to be the most frequently chosen osteosynthesis technique. Sixty complications were observed, at a rate of 12.3%. Complications were associated with the absence of third molars (P < .05). Instead, the Champy technique was associated with fewer complications (P < .05), in comparison with the other adopted techniques. CONCLUSIONS: The management of angle fractures still represents a challenging task with a significant complication rate. The Champy technique still seems to be a valid option for the treatment of such injuries.

The "European Mandibular Angle" Research Project: The Epidemiologic Results From a Multicenter European Collaboration.

PURPOSE: The aim of this study was to analyze the demographic variables and causes and characteristics of mandibular angle fractures managed at several European departments of maxillofacial surgery. MATERIALS AND METHODS: This study was based on a multicenter systematic database that allowed the recording of data from all patients with mandibular angle fractures between January 1, 2013, and December 31, 2017. The following data were recorded: gender, age, etiology, side of angle fracture, associated mandibular fractures, presence of third molar, intermaxillary fixation, and osteosynthesis. RESULTS: The study included 1,162 patients (1,045 male and 117 female patients). A significant association was found between the presence of a third molar and the diagnosis of an isolated angle fracture (P < .0000005). Furthermore, assaults were associated with the presence of voluptuary habits (P < .00005), a younger mean age (P < .00000005), male gender (P < .00000005), and left-sided angle fractures (P < .00000005). CONCLUSIONS: Assaults and falls actually represent the most frequent causes of angle fractures. The presence of a third molar may let the force completely disperse during the determination of the angle fracture, finding a point of weakness.

Implementation of a urogynecology-specific enhanced recovery after surgery (ERAS) pathway.

OBJECTIVE: Enhanced recovery after surgery protocols were developed for colorectal surgery to hasten postoperative recovery. Variations of the protocol are being adopted for gynecological procedures despite limited population and procedure-specific outcome data. Our objective was to evaluate whether implementation of an enhanced recovery after surgery pathway would facilitate reduced length of admission in a urogynecology population. MATERIALS AND METHODS: In this retrospective analysis of patients undergoing pelvic floor reconstructive surgery by 7 female pelvic medicine and reconstructive surgeons, we compared same-day discharge, length of admission and postoperative complications before and after implementation of an enhanced recovery after surgery pathway at a tertiary care hospital. Groups were compared using χ2 and Student t tests. Candidate variables that could have an impact on patient outcomes with P < .2 were included in multivariable logistic regression models. Satisfaction with surgical experience was assessed using a phone-administered questionnaire the day after discharge. RESULTS: Mean age and body mass index of 258 women (137 before enhanced recovery after surgery and 121 enhanced recovery after surgery) were 65.5 ± 11.3 years and 28.2 ± 5.0 kg/m2. The most common diagnosis was pelvic organ prolapse (n = 242, 93.8%) including stage III pelvic organ prolapse (n = 61, 65.1%). Apical suspension procedures included 58 transvaginal (25.1%), 112 laparoscopic/robotic (48.8%), and 61 obliterative (26.4%). Hysterectomy was performed in 57.4% of women. Demographic and surgical procedures were similar in both groups. Compared with before enhanced recovery after surgery, the enhanced recovery after surgery group had a higher proportion of same-day discharge (25.9% vs 91.7%, P < .001) and a 13.8 hour shorter duration of stay (25.9 ± 13.5 vs 12.1 ± 11.2 hours, P <.001). Operative and postsurgical recovery room times were similar (2.6 ± 0.8 vs 2.6 ± 0.9 hours, P =.955; 3.7 ± 2.1 vs 3.6 ± 2.2 hours, P = .879). Women in the enhanced recovery after surgery group were more likely to be discharged using a urethral catheter (57.9% enhanced recovery after surgery vs 25.4% before enhanced recovery after surgery, P = .005). There were no group differences in total 30 day postoperative complications overall and for the following categories: urinary tract infections, emergency room visits, unanticipated office visits, and return to the operating room. However, enhanced recovery after surgery patients had higher 30 day hospital readmission rates (n = 8, 6.7% vs n = 2, 1.5%, P = .048). Patients before enhanced recovery after surgery were readmitted for myocardial infarction and chest pain. Enhanced recovery after surgery patients were admitted for weakness, chest pain, hyponatremia, wound complications, nausea/ileus, and ureteral obstruction. Three enhanced recovery after surgery patients returned to the operating room for ureteral obstruction (n = 1), incisional hernia (n = 1), and vaginal cuff bleeding (n = 1). Enhanced recovery after surgery patients also had more postoperative nursing phone notes (2.6 ± 1.7 vs 2.1 ± 1.4, P = .030). On multivariable logistic regressions adjusting for age and operative time, same-day discharge was more likely in the enhanced recovery after surgery group (odds ratio, 32.73, 95% confidence interval [15.23-70.12]), while the odds of postoperative complications and emergency room visits were no different. After adjusting for age, operative time, and type of prolapse surgery, readmission was more likely in the enhanced recovery after surgery group (odds ratio, 32.5, 95% confidence interval [1.1-28.1]). In the enhanced recovery after surgery group, patient satisfaction (n = 77 of 121) was reported as very good or excellent by 86.7% for pain control, 89.6% for surgery preparedness, and 93.5% for overall surgical experience; 89.6% did not recall any postoperative nausea during recovery. CONCLUSION: Enhanced recovery after surgery implementation in a urogynecology population resulted in a greater proportion of same-day discharge and high patient satisfaction but with slightly increased hospital readmissions within 30 days.

Activity regulates functional connectivity from the vomeronasal organ to the accessory olfactory bulb.

The mammalian accessory olfactory system is specialized for the detection of chemicals that identify kin and conspecifics. Vomeronasal sensory neurons (VSNs) residing in the vomeronasal organ project axons to the accessory olfactory bulb (AOB), where they form synapses with principal neurons known as mitral cells. The organization of this projection is quite precise and is believed to be essential for appropriate function of this system. However, how this precise connectivity is established is unknown. We show here that in mice the vomeronasal duct is open at birth, allowing external chemical stimuli access to sensory neurons, and that these sensory neurons are capable of releasing neurotransmitter to downstream neurons as early as the first postnatal day (P). Using major histocompatibility complex class I peptides to activate a selective subset of VSNs during the first few postnatal days of development, we show that increased activity results in exuberant VSN axonal projections and a delay in axonal coalescence into well defined glomeruli in the AOB. Finally, we show that mitral cell dendritic refinement occurs just after the coalescence of presynaptic axons. Such a mechanism may allow the formation of precise connectivity with specific glomeruli that receive input from sensory neurons expressing the same receptor type.