"I'm Not Going Home With a Catheter": Patient-Perceived Outcomes Associated With Perioperative Intermittent Catheterization.

IMPORTANCE: Indwelling catheters are a known source of dissatisfaction for postoperative patients. There is a paucity of data describing patient-perceived outcomes associated with the alternative of intermittent self-catheterization (ISC). OBJECTIVES: The aim of this study was to describe patient satisfaction and outcomes associated with ISC after outpatient female pelvic reconstructive surgery. STUDY DESIGN: This was a secondary analysis of a prospective cohort study at an academic tertiary referral center from September 2018 to June 2021. Participants completed preoperative ISC instruction that included an instructional video, 1:1 demonstration with a health care provider, and provision of ISC supplies. Participants were instructed to perform ISC postoperatively until they had 2 consecutive outpatient PVRs less than one-half the voided volume. Participant satisfaction was assessed 2 weeks postprocedure, with adverse events evaluated at 6 weeks. RESULTS: One hundred sixty participants completed preoperative ISC instruction and were included in this analysis. Mean age was 52.1 (SD +/- 11.4) years, mean body mass index was 28.9 (SD +/- 5.8), and mean time from ISC instruction to surgery was 16.4 (SD +/- 15.7) days. Most participants reported no difficulty with ISC (124/160 [78%]) and had high levels of satisfaction (148/151 [98%]). Difficulty performing ISC was not associated with time since ISC instruction ( P = 0.32), difficulty noted at ISC instruction by the health care provider ( P = 0.24), or the duration of ISC instruction ( P = 0.16). On multiple logistic regression, age, body mass index, and prolapse beyond the hymen did not predict difficulty learning or performing ISC. At 6 weeks postprocedure, 22 of 155 participants (14%) endorsed symptoms of a urinary tract infection, and 15 of 160 (9%) had a culture-proven urinary tract infection. CONCLUSIONS: Women undergoing outpatient pelvic reconstructive surgery report ease and satisfaction with ISC.

Enhanced Recovery after Surgery for Cesarean Delivery Decreases Length of Hospital Stay and Opioid Consumption: A Quality Improvement Initiative.

OBJECTIVE: The aim of this study is to assess the effect of a resident-led enhanced recovery after surgery (ERAS) protocol for scheduled prelabor cesarean deliveries on hospital length of stay and postpartum opioid consumption. STUDY DESIGN: This retrospective cohort study included patients who underwent scheduled prelabor cesarean deliveries before and after implementation of an ERAS protocol at a single academic tertiary care institution. The primary outcome was length of stay following cesarean delivery. Secondary outcomes included protocol adherence, inpatient opioid consumption, and patient-centered outcomes. The protocol included multimodal analgesia and antiemetic medications, expedited urinary catheter removal, early discontinuation of maintenance intravenous fluids, and early ambulation. RESULTS: A total of 250 patients were included in the study: 122 in the pre-ERAS cohort and 128 in the post-ERAS cohort. There were no differences in baseline demographics, medical comorbidities, or cesarean delivery characteristics between the two groups. Following protocol implementation, hospital length of stay decreased by an average of 7.9 hours (pre-ERAS 82.1 vs. post-ERAS 74.2, p < 0.001). There was 89.8% adherence to the entire protocol as written. Opioid consumption decreased by an average of 36.5 mg of oxycodone per patient, with no significant differences in pain scores from postoperative day 1 to postoperative day 4 (all p > 0.05). CONCLUSION: A resident-driven quality improvement project was associated with decreased length of hospital stay, decreased opioid consumption, and unchanged visual analog pain scores at the time of hospital discharge. Implementation of this ERAS protocol is feasible and effective. KEY POINTS: · Enhanced recovery after surgery (ERAS) principles can be effectively applied to cesarean delivery with excellent protocol adherence.. · Patients who participated in the ERAS pathway had significant decreases in hospital length of stay and opioid pain medication consumption with unchanged visual analog pain scores postoperative days 1 through 4.. · Resident-driven quality improvement projects can make a substantial impact in patient care for both process measures (e.g., protocol adherence) and outcome measures (e.g., opioid use)..

Long-term Physical Activity Levels and Physical Functioning Outcomes After Midurethral Sling.

OBJECTIVES: The objective of this study was to describe changes in leisure physical activity (PA) levels and physical functioning (PF) in women 60 months or more after midurethral sling for stress urinary incontinence (SUI). METHODS: This is a long-term follow-up study of a previously published prospective study of women undergoing outpatient midurethral sling for SUI from 2009 to 2011. Women completed questionnaires for incontinence, PA, and PF at baseline, 6, 12, and 60 months or more postoperatively. Women were categorized as having sedentary, insufficient, or sufficient leisure PA levels by metabolic equivalents (MET min/week on the International Physical Activity Questionnaire). Physical functioning was measured from the National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System. Physical activity and PF levels were compared preoperatively and at 60 months or more. Statistical tests were applied as appropriate with a P < 0.05 considered significant. RESULTS: Of the 85 women enrolled in the primary study, contact was made with 49, and 35 completed surveys. The follow-up range was 5.8 to 8 years (median, 6.8). Baseline mean age was 49.8 (SD, 8) years. Urinary Impact Questionnaire scores were lower at 60 months or more postprocedure (33.33 vs 0, P < 0.001), with no differences at 6, 12, and 60 months or more. At baseline, 31.3% of patients had sedentary, 12.5% had moderate, and 56.3% had sufficient leisure PA levels. On long-term follow-up, this improved to 21.9% sedentary, 12.5% moderate, and 65.6% sufficient leisure PA levels. Physical functioning also improved (mean, 44.95 vs 53.18 points; P < 0.001). CONCLUSIONS: Midurethral sling procedures are associated with modest improvements in leisure PA levels and significant improvements in PF 60 months or more after surgery.

Provider miscategorization of frailty in an outpatient urogynecologic population.

INTRODUCTION AND HYPOTHESIS: Routine assessment of frailty preoperatively is recommended for older adults, because frailty is associated with adverse surgical outcomes. This study was aimed at describing the percentage of patients whose frailty status was correctly categorized by Female Pelvic Medicine and Reconstructive Surgery (FPRMS) providers and to determine patient predictors of accurate categorization. METHODS: Cross-sectional study was carried out of English speaking, new patients, >65 years old, presenting from March to June 2018. Providers categorized patients as frail, pre-frail, or not frail based on clinical impression. Frailty was defined using the Fried Frailty Assessment (FFA), a validated, objective measure including weight loss, exhaustion, physical activity, walk speed, and grip strength. Provider categorizations were compared with FFA results. Multiple logistic regression was used to estimate patient predictors of frailty categorization. Data from other fields that approximated a 45% proportion of miscategorization guided sample size estimates. RESULTS: Ten FPMRS providers participated, and 106 out of 110 patients (96%) had complete data. Primary diagnoses were pelvic organ prolapse (37%), incontinence (20%), and overactive bladder (17%). On FFA, 16 (15%) patients were frail, 50 (47%) were pre-frail, and 40 (38%) were not frail. The overall proportion of miscategorization was 58% (95% confidence interval 49-68%). Providers correctly categorized 50% of frail patients, 34% of pre-frail patients, and 48% of non-frail patients. Slow walk time was associated with provider categorization of frailty, regardless of frailty status (p = 0.01). CONCLUSIONS: Clinical impression may not adequately assess frailty. Miscategorization of frailty by FPMRS providers was higher than in other fields.

Health Care-Seeking Characteristics of Women With Pelvic Floor Disorders After Obstetric Anal Sphincter Injury.

OBJECTIVES: Obstetric anal sphincter injury (OASIS) is a potentially serious complication of vaginal delivery and can lead to both short-term and long-term sequelae. This study sought to identify health care seeking patterns of women who developed pelvic floor symptoms including pelvic pain after OASIS. It also identified demographic and clinical factors associated with seeking subspecialty care from a pelvic floor specialist and demographic and clinical factors associated with seeking care for pelvic pain after OASIS. METHODS: This study is a retrospective cohort study of 69 women who developed pelvic floor disorders after OASIS. RESULTS: For women diagnosed with a pelvic floor symptom, the mean time to follow-up was 2.4 years, the mean number of visits until diagnosis was 2.2 visits, and 2.9 visits were needed for treatment. The most common diagnoses were pelvic pain, lower urinary tract symptoms including incontinence, and defecatory dysfunction. Twenty-five percent of the cohort received treatment from a pelvic floor specialist. These women were more likely to be older and have urinary incontinence. Women with pain were more likely to be seen by a primary care provider and have longer time to diagnosis. CONCLUSIONS: The study showed that multiple visits were needed to both diagnose and treat pelvic floor disorders (PFD) after OASIS. Pelvic pain was the most common primary PFD after OASIS. There should be a high level of suspicion for pelvic floor disorders, especially pain disorders, in women who have sustained a third- or fourth-degree laceration.

Ruptured Thoracic and Abdominal Gastrointestinal Duplication Cysts Presenting With Failure to Thrive.

Gastrointestinal duplication cysts are rare congenital malformations, with esophageal and gastric duplication cysts being among the rarest. We report an 8-week-old female who presented to the emergency department with failure to thrive and was subsequently found to have multiple gastric and esophageal duplication cysts that had ruptured intrathoracically and intra-abdominally. We describe the diagnosis and management of this patient who underwent successful resection of 4 gastrointestinal duplication cysts. This report emphasizes the unexpected, and sometimes relatively benign, presentations of gastrointestinal duplication cysts. To our knowledge, this is the first reported occurrence of multiple duplication cysts that independently ruptured thoracically and abdominally.

Management of Low-Grade Cervical Müllerian Adenosarcoma in a 14-Year-Old Girl.

BACKGROUND: Müllerian adenosarcomas of the cervix are composed of benign epithelial and malignant stromal components. The purpose of this report is to describe the clinical and histologic difficulties in diagnosis and to propose fertility-preserving management of low-grade lesions. CASE: A 14-year-old girl presented with a friable lesion found to originate from the anterior cervical lip. Initially, clinical suspicion was for sarcoma botryoides, however, pathologic evaluation revealed a low-grade cervical Müllerian adenosarcoma. Cold knife conization was performed, and the mass was resected with clear margins. SUMMARY AND CONCLUSION: Müllerian adenosarcoma of the cervix is difficult to diagnose in adolescents because of features more commonly associated with alternative diagnoses. For patients with low-grade lesions desiring future fertility, local excision with close follow-up is reasonable.

Optimal surgical technique in spontaneous pneumothorax: a systematic review and meta-analysis.

BACKGROUND: Numerous thoracoscopic techniques have been used in the management of primary spontaneous pneumothorax (PSP), including wedge resection, pleurectomy, pleural abrasion, chemical pleurodesis, and staple line covering. The purpose of this systematic review was to compare outcomes for the most commonly reported techniques. MATERIALS AND METHODS: A systematic literature search looking at pneumothorax recurrence rate, length of stay, and chest tube duration after surgery was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the PubMed database. RESULTS: Fifty-one unique studies comprised of 6907 patients published between January 1988 and June 2015 were identified. Heterogeneity among effect sizes was significant for all outcomes. The lowest recurrence rates were observed in the wedge resection + chemical pleurodesis (1.7%; 95% confidence interval [CI], 1.0%-2.7%) and the wedge resection + pleural abrasion + chemical pleurodesis (2.8%; 95% CI, 1.7%-4.7%) groups. The shortest chest tube duration and length of stay were observed in the wedge resection + staple line covering ± other group (2.1 d; 95% CI, 1.4-2.9 and 3.3 d; 95% CI, 2.6-4.0, respectively). CONCLUSIONS: The variability in reported outcomes and the lack of published multicenter randomized controlled trials highlights a need for more robust investigations into the optimal surgical technique in the management of PSP. Based on the limited quality studies available, this systematic review favors wedge resection + chemical pleurodesis and wedge resection + pleural abrasion + chemical pleurodesis in terms of recurrence rate after surgery for PSP.

Paracrine Effects of Leydig Cell Nodular Hyperplasia, Two Case Reports: A Neglected Phenomenon.

Leydig cell nodular hyperplasia (LCNH) is a lesion that is less characterized than the familiar Leydig cell tumors. The paracrine effects of these lesions on adjacent gonadal stroma have not been widely documented. We present two cases of precocious puberty in pre-pubertal boys found to have a single LCNH with adjacent focal maturation of the seminiferous tubules. Blood tests showed elevated serum testosterone and dehydroepiandrosterone (DHEAS). Ultrasound revealed unilateral testicular enlargement with irregular echogenicity. Radical orchiectomy was performed. Histologically Leydig cell nodular proliferation without destruction of surrounding tubules was seen. Mature seminiferous tubules undergoing spermatogenesis were noted adjacent to the lesion, while away from the lesion seminiferous tubules were as expected in pre-pubescent boys. These cases emphasize the potential presence of both paracrine and endocrine effects in Leydig cell nodular hyperplasia. However, instances of the endocrine effects of hyperplastic Leydig cell lesions are more widely reported than the paracrine effects.

Student-Led Training Day Increases Student Confidence in Women's Primary Care Skills.

BACKGROUND AND OBJECTIVES: Medical students are often apprehensive in approaching basic women's health concepts, including wellness exams, reproductive health concerns, and patient counseling. This study evaluates a novel student-developed and student-run Women's Health Training Day (WHTD) as a means of cultivating medical student confidence in women's primary care early in medical training. METHODS: Sixty-six first-year medical students participated in WHTD, a voluntary 6-hour weekend day of interactive workshops. Students were divided into groups of six to eight students that rotated together through five workshops focused on the breast exam, pelvic exam, microscopy, family planning, and patient interviews. Before participating in WHTD, students completed surveys indicating their confidence in performing skills related to women's health on a 5-point Likert scale. Students completed an identical survey after participating in all of the WHTD workshops. Changes in pre- and post-training day confidence scores were assessed. RESULTS: Students reported increased confidence in all of the composite sessions that were assessed. The specific skillsets demonstrating the greatest increases in student confidence were speculum handling during pelvic examinations, detecting abnormal breast masses, and recognizing the clinical presentations of common sexually transmitted infections. All but one of the evaluated skills, using a microscope, demonstrated a significant increase in student confidence. CONCLUSIONS: These results indicate that the student-implemented and student-run Women's Health Training Day increases student confidence in women's primary care skills. Further studies are needed to determine whether this perceived increase in confidence is associated with increased objective knowledge pertaining to primary care and women's health.

Enhancing recovery in pediatric surgery: a review of the literature.

BACKGROUND: Enhanced recovery after surgery (ERAS), guidelines entail a strategy of perioperative management proven to hasten postoperative recovery and reduce complications in adult populations. Relatively few studies have investigated the applicability of this paradigm to pediatric populations. Our objective was to perform a systematic review of existing evidence regarding the use and efficacy of enhanced recovery protocols (ERPs) in the pediatric population. MATERIALS AND METHODS: Data were collected through a PubMed/MEDLINE literature search. Study eligibility criteria included a pediatric population and implementation of at least four components of published ERAS Society recommendations. RESULTS: One retrospective and four prospective cohort studies evaluating children undergoing gastrointestinal, urologic, and thoracic surgeries were identified. The overall quality of reporting was fair with few studies acknowledging limitations and bias and inconsistent outcome reporting. Studies included six or fewer interventions compared to 20 recommended interventions in most adult ERAS Society guidelines. None of the studies were well controlled. Nevertheless, these studies suggest that ERPs applied to the appropriate pediatric surgical populations may be associated with decreased length of stay, decreased narcotic use, and no detectable increase in complications. CONCLUSIONS: There is a paucity of high-quality literature evaluating implementation of ERPs in pediatric populations. The limited literature available indicates that ERPs would be safe and potentially effective. More studies are needed to assess the efficacy of ERPs in pediatric surgery.

Two Case Reports of Nodular Fasciitis: A Newly Recognized Placental Lesion.

We describe two occurrences of nontrophoblastic mesenchymal tumors of the placenta. The first placental tumor was found along the placental margin, and the second was identified close to the insertion of the fetal membranes along the placental disc. Microscopically both lesions demonstrated bland fibroblastic cells with intricate vasculature and inflammatory cells. Both lesions were negative for estrogen receptor (ER), progesterone receptor (PR), beta-HCG, PLAP, CD34, desmin, h-caldesmin, and smooth muscle actin by immunohistochemistry. Some cells were weakly positive for CD10, a nonspecific finding. The morphologic and immunohistochemical characteristics of these lesions were most consistent with nodular fasciitis, a tumor most commonly found in the soft tissues. FISH positive for USP6 gene rearrangement in our two patients confirmed the molecular similarity of these lesions to nodular fasciitis of soft tissue. Such lesions can be easily dismissed on gross placental examination as infarcts or thrombi, thus these rare entities are likely underreported.

Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia (ARVC/D): Review of 16 Pediatric Cases and a Proposal of Modified Pediatric Criteria.

Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is a heritable cardiomyopathy characterized by fibro-fatty replacement of right ventricular myocardium. Diagnostic criteria, established in 1994 and modified in 2010, are based on predominately adult manifestations of ARVC/D. The goal of this paper is to review a single-center experience with pediatric ARVC/D and propose modifications of current diagnostic criteria to appropriately include pediatric ARVC/D. We identified 16 pediatric cases of ARVC/D from our tertiary care center. Patient demographics, presentation, course, genetic testing, and family history were reviewed. Sixteen patients were diagnosed with ARVC/D through the modified diagnostic criteria, genetic testing, and pathology. Five patients had positive family histories. Five patients presented with cardiac arrest, and six were found to have ventricular tachycardia. Two patients presented with heart failure. Six autopsies, six explanted hearts, and three biopsies found massive fibro-fatty infiltration of the right ventricular wall. Six patients underwent heart transplantation, and two have received automatic implantable cardioverter defibrillator. Two patients had identifiable genetic mutations previously noted in the literature. One patient had a novel mutation of a known ARVC/D gene. Many pediatric patients do not meet the current ARVC/D diagnostic criteria, resulting in delays in diagnosis and treatment. The current criteria need further revision to encompass pediatric manifestations of ARVC/D. In our opinion, pathological and clinical findings alone are sufficient for accurate diagnosis of pediatric ARVC/D. Creating modified pediatric criteria would facilitate prompt diagnosis and management of ARVC/D and facilitate structured research with the goal of improving outcomes.

Obstetrician-gynecologists' opinions on elective bilateral oophorectomy at the time of hysterectomy in the United States: a nationwide survey.

OBJECTIVE: This study aims to assess obstetrician-gynecologists' opinions on elective bilateral oophorectomy (BO) at the time of hysterectomy in the United States and to describe factors that influence their views. METHODS: In April 2012, an anonymous survey was mailed twice to practicing obstetrician-gynecologists, randomly selected from a list produced by the American Medical Association, in an effort to assess their opinions regarding elective BO at the time of hysterectomy. The effects of gynecologists' various characteristics on their opinions were also evaluated. RESULTS: Of 1,002 mailed surveys, 443 (44%) were returned completed. Of the respondents, 59% were male and 79% were white. The largest age group was 51 to 55 years (20%), and the mean time since completion of residency was 23 years. In women with an average risk of ovarian cancer, the proportions of physicians who favored elective BO were as follows: women younger than 51 years, 32%; women aged 51 to 65 years, 62%; women older than 65 years, 6%. These recommendations were not influenced by the physicians' age, sex, training, or geographic region. If a hysterectomy candidate was younger than 51 years and had a personal history of breast or ovarian cancer and a family history of ovarian cancer, these proportions were increased to 77% and 64%, respectively. Other factors that influenced the respondents' recommendations were the women's personal history of cardiovascular disease (21%), osteoporosis (23%), and sexual dysfunction (23%). CONCLUSIONS: One third of obstetrician-gynecologists continue to recommend elective BO for hysterectomy candidates younger than 51 years. The majority recommend elective BO for women aged 51 to 65 years. Their demographic characteristics do not influence their opinions.