Projecting future prolapse outcomes with induction of labor at 39 weeks: a decision analysis.

INTRODUCTION AND HYPOTHESIS: In 2018, the ARRIVE trial (A Randomized Trial of Induction Versus Expectant Management) concluded that routine induction of labor (IOL) at 39 weeks gestation decreases cesarean delivery risk, with slightly lighter birthweight infants. We debated whether routine IOL would improve, worsen, or not change POP risk compared with expectant management (EM). METHODS: We constructed a decision analysis model with a lifetime horizon where nulliparous women reaching 39 weeks underwent IOL or EM. Subsequent vaginal versus cesarean delivery varied based on prior deliveries for up to four births. Subsequent delivery prior to 39 weeks and distribution of gestational age, birthweight, and delivery mode between 24 and 39 weeks was modeled from national data. We modeled increased POP risk with increasing vaginal parity, forceps delivery, and weight of largest infant delivered vaginally, accounting for differential infant weights in each strategy. RESULTS: IOL and EM have similar population-wide POP risk (15.9% and 15.7% respectively). Among women with only spontaneous vaginal deliveries that reached 39 weeks or beyond, the prevalence of POP was 20% after one delivery and 29% after four deliveries, with no difference between groups. The cesarean rate was lower with IOL (27.8% versus 29.8%). Sensitivity analysis revealed no meaningful thresholds among the variables, supporting model robustness. CONCLUSION: While routine induction of labor at 39 weeks results in a meaningfully higher vaginal delivery rate, there was no increase in POP, possibly due to the protective effect of lower birthweight.

Comparing Postoperative Pain With Laparoscopic Versus Robotic Sacrocolpopexy.

STUDY OBJECTIVE: To compare postoperative pain and pain-related outcomes after laparoscopic (LS-MISC) vs robotic minimally invasive sacrocolpopexy (R-MISC). DESIGN: A secondary analysis of an original placebo-controlled randomized controlled trial (RCT) examining preoperative intravenous (IV) acetaminophen on postoperative pain after MISC. SETTING: Planned secondary analysis of multicenter RCT. PATIENTS: Women undergoing MISC. INTERVENTIONS: Coprimary outcomes at 24 hours were total opioid use in morphine milligram equivalents (MMEs) and visual analog scale (VAS) pain scores comparing LS-MISC and R-MISC. The secondary outcome was pain scores using a pain diary through 7 days after the procedure. MEASUREMENTS AND MAIN RESULTS: The original study was a double-blind, multicenter, RCT comparing IV acetaminophen with placebo that took place between 2014 and 2017. Given that the original trial was unable to show an impact from the use of IV acetaminophen, our analysis focused on the impact of surgical modality. We included 90 subjects undergoing MISC: 65 LS-MISC and 25 R-MISC. Most were Caucasian (97.8%) and postmenopausal (88.9%) with mean age of 61.2 ± 7.2 years and body mass index of 27.6 ± 4.4 kg/m2. IV acetaminophen did not affect pain in the original study and was not different between LS-MISC and R-MISC. Concomitant hysterectomy was performed in 67% (LS-MISC) vs 60% (R-MISC, p = .49). LS-MISC underwent more perineorrhaphies (15.4% vs 0%, p = .04) and posterior repairs (18.5% vs 0%, p = .02). Operative time was longer with LS-MISC (208.5 ± 57.3 vs 143.6 ± 21.0 minutes, p <.01). Length of stay was longer with LS-MISC (0.9 ± 0.4 vs 0.7 ± 0.4 days, p = .02). Women undergoing LS-MISC consumed more opioid MMEs through 24 hours when including intraoperative opioids (48.5 ± 25.5 vs 35.1 ± 14.6 MME, p <.01). Using linear regression correcting for operative time and concomitant vaginal repairs, this difference disappeared. Likewise, when intraoperative opioids were excluded, there was no difference. There were no differences in 24-hour postoperative VAS scores, opioid use in the first week, or quality of life (Patient-Reported Outcomes Measurement Information System - Pain Interference Short Form, all p <.05). CONCLUSION: When comparing VAS pain scores, MME opioid usage, and quality of life between LS-MISC and R-MISC, either there was no difference or differences disappeared after adjusting for confounders. Overall, opioid use, pain scores, and opioid side effects were low.

Long-Term Costs of Minimally Invasive Sacral Colpopexy Compared to Native Tissue Vaginal Repair With Concomitant Hysterectomy.

STUDY OBJECTIVE: To determine the long-term costs of hysterectomy with minimally invasive sacrocolpopexy (MISCP) versus uterosacral ligament suspension (USLS) for primary uterovaginal prolapse repair. DESIGN: A hospital-based decision analysis model was built using TreeAge Pro (TreeAge Software Inc, Williamstown, MA). Those with prolapse were modeled to undergo either vaginal hysterectomy with USLS or minimally invasive total hysterectomy with sacrocolpopexy (MISCP). We modeled the chance of complications of the index procedure, prolapse recurrence with the option for surgical retreatment, complications of the salvage procedure, and possible second prolapse recurrence. The primary outcome was cost of the surgical strategy. The proportion of patients living with prolapse after treatment was the secondary outcome. SETTING: Tertiary center for urogynecology. PATIENTS: Female patients undergoing surgical repair by the same team for primary uterovaginal prolapse. INTERVENTIONS: Comparison analysis of estimated long-term costs was performed. MEASUREMENTS AND MAIN RESULTS: Our primary outcome showed that a strategy of undergoing MISCP as the primary index procedure cost $19 935 and that undergoing USLS as the primary index procedure cost $15 457, a difference of $4478. Furthermore, 21.1% of women in the USLS group will be living with recurrent prolapse compared to 6.2% of MISCP patients. Switching from USLS to MISCP to minimize recurrence risk would cost $30 054 per case of prolapse prevented. Additionally, a surgeon would have to perform 6.7 cases by MISCP instead of USLS in order to prevent 1 patient from having recurrent prolapse. CONCLUSION: The higher initial costs of MISCP compared to USLS persist in the long term after factoring in recurrence and complication rates, though more patients who undergo USLS live with prolapse recurrence.

Knowledge of the Human Papillomavirus Vaccine and Willingness to Accept Vaccination in the Postpartum Period.

OBJECTIVES: Human papillomavirus (HPV) vaccines prevent cervical cancer. The inpatient postpartum period presents a unique window for vaccination. Our study investigates HPV vaccine knowledge, barriers to vaccination, and willingness to get vaccinated during inpatient postpartum care. MATERIALS AND METHODS: We conducted a cross-sectional survey of 147 participants, age 18 to 26, who delivered at our institution between November 1, 2019, and April 30, 2020. Participants completed a questionnaire that included demographics, vaccine knowledge, hesitancies, and willingness to vaccinate. We used descriptive statistics and compared groups with chi-square or Wilcoxon rank sum for categorical variables and t-test for continuous variables. RESULTS: Of the 147 patients, 58 (39.46%) were fully vaccinated against HPV and 89 (60.54%) of participants were unvaccinated or partially vaccinated. There was a greater proportion of African American and Asian participants among unvaccinated women (28.1% vs 20.7% and 16.9% vs 1.7%, respectively). Most unvaccinated participants (52.9%) were willing to get vaccinated in the postpartum unit. Both vaccinated and unvaccinated groups were similarly aware that the HPV vaccine prevents cervical and oropharyngeal cancers and genital warts. The top barrier to future vaccination was forgetting to complete the vaccination series. CONCLUSIONS: Most women were not fully vaccinated but were willing to receive their first dose while in the postpartum unit. African American women were less likely to be vaccinated and expressed more unwillingness to accept vaccination. We identified barriers to HPV vaccination that can be tackled with the initiation of inpatient postpartum vaccination.

Characterization of the GU microbiome in women with self-perceived bladder health over the life course.

BACKGROUND: A variety of factors influence bladder health, including environmental factors, life experiences, biologic foundations, and coexistent medical conditions. A biologically diverse microbial community exists in the urine that is likely influenced by the microbial inhabitants of the vagina. The relationship between the genitourinary (GU) microbiome and self-perceived bladder health is unknown. OBJECTIVE: To longitudinally define the GU microbiome in women with self-percieved bladder health sampled across multiple time points over a year. STUDY DESIGN: Women with no reported lower urinary tract dysfunction or symptoms (LUTS) were recruited from six clinical sites and assessed every 6 weeks for 1 year. Voided urine and vaginal samples were longitudinally collected. Self-perceived bladder health was assessed with select items from the LURN comprehensive assessment of self-reported urinary symptoms (CASUS) tool. We defined four life phases as follows: young (18-34 years, nulliparous), midlife (35-45 years, menstruating), transitional (46-60 years, perimenopausal), mature (>60 years, not using vaginal and/or systemic hormone replacement therapy). DNA was extracted from samples, and the V4 region of the 16S rRNA gene was amplified with region-specific primers. The 16S rRNA sequencing on an Illumina NovaSeq. Microbial beta-diversity was calculated using DEICODE to identify microbial taxa that cluster in the samples. Longitudinal volatility analysis was performed using the gemelli plugin. Log-abundance ratios of microbial features were explored and visualized in Qurro. RESULTS: Fifty-four (N = 16 young, N = 16 midlife, N = 15 transitional, N = 7 mature) women were enrolled and provided baseline data. Most women in each life phase (93%-98%) continued to report self-perceived bladder health throughout the 1-year follow-up as assessed by CASUS items. Temporal-based microbial diversity of urinary and vaginal microbiome remained relatively stable over 1 year in all subjects. The GU microbiomes of mature women were distinct and microbially diverse from that of young, midlife, and transitional women, with genera of Gardnerella, Cupriavidus, and Dialister contributory to the microbial features of the mature microbiome. The mature GU microbiome was statistically different (p < 0.0001) from the midlife, transitional, and young microbiome for the log ratio of Gardnerella and Cupriavidus (in the numerator) and Lactobacillus (in the denominator) for voided samples and Gardnerella and Dialister (in the numerator) and Lactobacillus (in the denominator) for vaginal samples. Differences in the GU microbiome were also demonstrated via longitudinal beta-diversity between women developing urinary frequency as reported by CASUS responses or objectively on bladder diary compared to women without urinary frequency. CONCLUSION: In women with a self-perceived healthy bladder, the GU microbiome remained stable in all age groups over a 1 year period. Differences were seen with respect to life phase, where mature women were distinct from all other groups, and with respect to self-reported LUTS.

Financial analysis of minimally invasive sacrocolpopexy compared with native tissue vaginal repair with concomitant hysterectomy.

INTRODUCTION: Minimally invasive sacrocolpopexy (MISCP) is increasingly used for uterovaginal prolapse, but comparative cost data of MISCP versus native tissue vaginal repair (NTR) are lacking. The objective was to determine the cost difference, from a hospital perspective, between MISCP and NTR performed with hysterectomy for uterovaginal prolapse. METHODS: This was a retrospective cohort study at a tertiary care center of women who underwent NTR or MISCP with concomitant hysterectomy in 2021. Hospital charges, direct and indirect costs, and operating margin (revenue minus costs) were obtained from Strata Jazz and compared using SPSS. RESULTS: A total of 82 women were included, 33 MISCP (25 robotic, 8 laparoscopic) versus 49 NTR. Demographic and surgical data were similar, except that MISCP had younger age (50.5 vs 61.1 years, p<0.01). Same-day discharge and estimated blood loss were similar, but operative time was longer for MISCP (204 vs 161 min, p<0.01). MISCP total costs were higher (US$17,422 vs US$13,001, p<0.01). MISCP had higher direct costs (US$12,354 vs US$9,305, p<0.01) and indirect costs (US$5,068 vs US$3,696, p<0.01). Consumable supply costs were higher with MISCP (US$4,429 vs US$2,089, p<0.01), but the cost of operating room time and staff was similar (US$7,926 vs US$7,216, p=0.07). Controlling for same-day discharge, anti-incontinence procedures and smoking, total costs were higher for MISCP (adjusted beta = US$4,262, p<0.01). Mean charges (US$102,060 vs US$97,185, p=0.379), revenue (US$22,214 vs US$22,491, p=0.929), and operating margin (US$8,719 vs US$3,966, p=0.134) were not statistically different. CONCLUSION: Minimally invasive sacrocolpopexy had higher costs than NTR; however, charges, reimbursement, and operating margins were not statistically significantly different between the groups.

Surgical cost of robotic-assisted sacrocolpopexy: a comparison of two robotic platforms.

IMPORTANCE: Robotic assistance in pelvic organ prolapse surgery can improve surgeon ergonomics and instrument dexterity compared with traditional laparoscopy but at increased costs. OBJECTIVE: To compare total costs for robotic-assisted sacrocolpopexy (RSC) between two robotic platforms at an academic medical center. METHODS: Retrospective cohort of Senhance (Ascensus) RSC between 1/1/2019 and 6/30/21 who were matched 2:1 with DaVinci (Intuitive) RSC. Primary outcome was total costs to hospital system; secondarily we evaluated cost sub-categories. Purchase costs of the robotic systems were not included. T-test, chi-square, and Fisher's exact tests were used. A multivariable linear regression was performed to model total costs adjusting for potential confounders. RESULTS: The matched cohort included 75 subjects. The 25 Senhance and 50 DaVinci cases were similar overall, with mean age 60.5 ± 9.7, BMI 27.9 ± 4.7, and parity 2.5 ± 1.0. Majority were white (97.3%) and postmenopausal (86.5%) with predominantly stage III prolapse (64.9%). Senhance cases had longer OR times (Δ = 32.1 min, p = 0.01). There were no differences in concomitant procedures, intraoperative complications, or short-term postoperative complications between platforms (all p > 0.05). On univariable analysis, costs were similar (Senhance $5368.31 ± 1486.89, DaVinci $5741.76 ± 1197.20, p = 0.29). Cost subcategories (medications, supplies, etc.) were also similar (all p > 0.05). On multivariable linear regression, total cost was $908.33 lower for Senhance (p = 0.01) when adjusting for operative time, estimated blood loss, concomitant mid-urethral sling, and use of the GelPoint mini port system. CONCLUSIONS: Despite longer operating times, total cost of robotic-assisted sacrocolpopexy was significantly lower when using the Senhance compared to the DaVinci system.

Surgical correction of the genital hiatus at the time of sacrocolpopexy - a 7-year Markov analysis: a cost-effectiveness analysis.

INTRODUCTION AND HYPOTHESIS: To perform a cost-effectiveness analysis of concurrent posterior repair performed at the time of laparoscopic hysterectomy with sacrocolpopexy over a 7-year time period. We hypothesize it is not cost-effective to perform a posterior colporrhaphy. METHODS: We used TreeAge Pro® to construct a decision model with Markov modeling to compare sacrocolpopexy with and without concurrent posterior repair (SCP and SCP+PR) over a time horizon of 7 years. Outcomes included probability and costs associated with prolapse recurrence, prolapse retreatment, and complications including rectal injury, rectovaginal hematoma requiring reoperation, and postoperative dyspareunia. Cost-effectiveness was defined as an incremental cost-effectiveness ratio (ICER) calculated as ∆ costs /∆ effectiveness and the willingness to pay (WTP) was set at $100,000/QALY. RESULTS: Our model showed that SCP was the dominant strategy, with lower costs (-$ 2681.06) and higher effectiveness (+0.10) compared to SCP+PR over the 7-year period. In two-way sensitivity analyses, we varied the probability of prolapse recurrence after both strategies. Our conclusions would only change if the probability of recurrence after SCP was at least 29.7% higher than after SCP+PR. When varying the probabilities of dyspareunia for both strategies, SCP+PR only became the dominant strategy if the probability of dyspareunia for SCP+PR was lower than the rate of SCP alone. CONCLUSIONS: In this 7-year Markov cost-effectiveness analysis, SCP without concurrent PR was the dominant strategy. SCP+PR costs more with lower effectiveness than SCP alone, due to higher surgical cost of SCP+PR and higher probability of dyspareunia after SCP+PR.

Longitudinal urinary microbiome characteristics in women with urgency urinary incontinence undergoing sacral neuromodulation.

INTRODUCTION AND HYPOTHESIS: The objective was to evaluate the stability of the urinary microbiome communities in women undergoing sacral neuromodulation (SNM) for urgency urinary incontinence (UUI). We hypothesized that clinical response to SNM therapy would be associated with changes in the urinary microbiome. METHODS: Women completed the Overactive Bladder Questionnaire Short-Form, the International Consultation on Incontinence Questionnaire Short Form, and the Female Sexual Function Index at baseline and 3 months post-SNM implantation. Transurethral urinary specimens were obtained for microbiome analysis at baseline and 3 months postoperatively. The V4 region of the 16S rRNA gene (515F-806R) was amplified with region-specific primers, and Amplicon Sequence Variants (ASVs) were identified with a closed-reference approach of taxonomic classification. Alpha-diversity was calculated using the phylogenetic (i.e., Faith's phylogenetic diversity) and nonphylogenetic metrics (i.e., Shannon diversity, and Pielou's evenness) using the QIIME2 plugin. Longitudinal paired volatility analysis was performed using the DEICODE and Gemelli plugin to account for host specificity across both time and space. RESULTS: Nineteen women who underwent SNM and provided both baseline and 3-month urine samples were included in this analysis. Women reported improvement in objective (number of UUI episodes) and subjective (symptom severity and health-related quality of life) measures. Ninety percent of the bacteria were classified as Bacteroidetes, Firmicutes, Proteobacteria, and Actinobacteria. No significant differences were observed in each subject's beta-diversity at 3 months compared with their baseline microbiome. CONCLUSIONS: Our descriptive pilot study of a cohort of women who had achieved objective and subjective improvements in UUI following SNM therapy demonstrates that the urinary microbiome remains relatively stable, despite variability amongst the cohort.

Linking emergency care and police department data to strengthen timely information on violence-related paediatric injuries.

BACKGROUND: Combined ED and police department (PD) data have improved violence surveillance in the UK, enabling significantly improved prevention. We sought to determine if the addition of emergency medical service (EMS) data to ED data would contribute meaningful information on violence-related paediatric injuries beyond PD record data in a US city. METHODS: Cross-sectional data on self-reported violence-related injuries of youth treated in the ED between January 2015 and September 2016 were combined with incidents classified by EMS as intentional interpersonal violence and incidents in which the PD responded to a youth injury from a simple or aggravated assault, robbery or sexual offence. Nearest neighbour hierarchical spatial clustering detected areas in which 10 or more incidents occurred during this period (hotspots), with the radii of the area being 1000, 1500, 2000 and 3000 ft. Overlap of PD incidents within ED&EMS hotspots (and vice versa) was calculated and Spearman's r tested statistical associations between the data sets, or ED&EMS contribution to PD violence information. RESULTS: There were 935 unique ED&EMS records (ED=381; EMS=554). Of these, 877 (94%) were not in PD records. In large hotspots >2000 ft, ED&EMS records identified one additional incident for every three in the PD database. ED and EMS provided significant numbers of incidents not reported to PD. Significant correlations of ED&EMS incidents in PD hotspots imply that the ED&EMS incidents are as pervasive across the city as that reported by PD. In addition, ED and EMS provided unique violence information, as ED&EMS hotspots never included a majority (>50%) of PD records. Most (676/877; 77%) incidents unique to ED&EMS records were within 1000 ft of a school or park. CONCLUSIONS: Many violence locations in ED and EMS data were not present in PD records. A combined PD, ED and EMS database resulted in new knowledge of the geospatial distribution of violence-related paediatric injuries and can be used for data-informed and targeted prevention of violence in which children are injured-especially in and around schools and parks.

Using the Cardiff model to reduce late-night alcohol-related presentations in regional Australia.

INTRODUCTION: The Cardiff model is a data sharing approach that aims to reduce the volume of intoxicated patients in emergency departments (EDs). This approach has not been tested in a rural setting. OBJECTIVE: This study assessed whether this approach would reduce the number of alcohol-associated presentations during high-alcohol hours (HAH) in a regional ED. DESIGN: From July 2017, people over the age of 18 attending the ED were asked by the triage nurse (1) whether they had consumed alcohol in the past 12 h, (2) their typical alcohol consumption level, (3) the location where most alcohol was purchased and (4) the location of the last drink. From April 2018, quarterly letters were sent to the top five venues reported within the ED. Deidentified, aggregated data were shared with local police, licensing authorities and local government, identifying the top five venues reported in the ED and providing a summary of alcohol-related attendances to the ED. Interrupted time series analyses were used to estimate the influence of the intervention on monthly injury and alcohol-related ED presentations. FINDINGS: ITS models found that there was a significant gradual decrease in the monthly rate of injury attendances during HAH (Coefficient = -0.004, p = 0.044). No other significant results were found. DISCUSSION: Our study found that sharing last drinks data collected in the ED with a local violence prevention committee was associated with a small, but significant reduction in the rate of injury presentations compared with all ED presentations. CONCLUSION: This intervention continues to have promise for reducing alcohol-related harm.

Salpingo-oophorectomy or surveillance for ovarian endometrioma in asymptomatic premenopausal women: a cost-effectiveness analysis.

BACKGROUND: The lifetime risk of ovarian cancer is 1.9% among women with endometriosis compared with 1.3% among the general population. When an asymptomatic endometrioma is incidentally discovered on imaging, gynecologists must weigh the procedural complications and the potential for subsequent surgical menopause against future ovarian pathology or cancer. OBJECTIVE: We aimed to determine if performing unilateral salpingo-oophorectomy is a more cost-effective strategy for the prevention of death than surveillance for asymptomatic endometriomas. STUDY DESIGN: We created a cost-effectiveness model using TreeAge Pro (TreeAge Software Inc; Williamstown, MA) with a lifetime horizon. Our hypothetical cohort included premenopausal patients with 2 ovaries who did not desire fertility. Those diagnosed with asymptomatic endometrioma underwent either unilateral salpingo-oophorectomy or surveillance (ultrasound 6-12 weeks after diagnosis, then annually). Our primary effectiveness outcome was mortality, including death from ovarian cancer or surgery and all-cause mortality related to surgical menopause (± hormone replacement therapy) if the contralateral ovary is removed. We modeled the probabilities of surgical complications, occult malignancy, development of contralateral adnexal pathology, surgical menopause, use of hormone replacement therapy, and development of ovarian cancer. The costs included surgical procedures, complications, ultrasound surveillance, hormone therapy, and treatment of ovarian cancer, with information gathered from Medicare reimbursement data and published literature. Cost-effectiveness was determined using the incremental cost-effectiveness ratio of Δ costs / Δ deaths with a willingness-to-pay threshold of $11.6 million as the value of a statistical life. Multiple 1-way sensitivity analyses were performed to evaluate model robustness. RESULTS: Our model demonstrated that unilateral salpingo-oophorectomy is associated with improved outcomes compared with surveillance, with fewer deaths (0.28% vs 1.50%) and fewer cases of ovarian cancer (0.42% vs 2.96%). However, it costs more than sonographic surveillance at $6403.43 vs $5381.39 per case of incidental endometrioma. The incremental cost-effectiveness ratio showed that unilateral salpingo-oophorectomy costs $83,773.77 per death prevented and $40,237.80 per case of ovarian cancer prevented. As both values were well below the willingness-to-pay threshold, unilateral salpingo-oophorectomy is cost-effective and is the preferred strategy. If unilateral salpingo-oophorectomy were chosen over surveillance for premenopausal patients with incidental endometriomas, 1 diagnosis of ovarian cancer would be prevented in every 40 patients and 1 death averted in every 82 patients. We performed 1-way sensitivity analyses for all input variables and determined that there were no reasonable inputs that would alter our conclusions. CONCLUSION: Unilateral salpingo-oophorectomy is cost-effective and is the preferred strategy compared with surveillance for the management of incidental endometrioma in a premenopausal patient not desiring fertility. It incurs fewer deaths and fewer cases of ovarian cancer with costs below the national willingness-to-pay thresholds.

Assault-related injuries reported to police and treated by healthcare providers in the United States.

Research suggests that assault-related injuries known by the police significantly differ from those known by healthcare providers, but the magnitude and nature of these differences are poorly understood. To address this gap, our study examined the empirical differences between assault-related injuries reported to police and treated by healthcare providers. In June of 2021, we analyzed the National Crime Victimization Survey (1993-2019) to estimate the prevalence of police reporting and healthcare use among 5093 nonfatal victimizations that caused injury and were either reported to the police or treated by healthcare in the United States. Quasi-Poisson models identified the factors associated with whether people who sustained the injuries used healthcare (v. only reported to police) and reported to police (v. only used healthcare). Among victimizations that caused only minor injuries, 43% involved only a police report, 11% involved only healthcare, and 46% involved both services. Among victimizations that caused serious injuries, 14% involved only a police report, 13% involved only healthcare, and 73% involved both services. Whether people with violent injuries used healthcare (v. only reported to police) and reported to police (v. only used healthcare) was significantly associated with 13 different person- and incident-level factors. The number and nature of assault-related injuries reported to law enforcement significantly differ from those treated by healthcare providers. Therefore, public health efforts to link police and healthcare data are warranted and recommended.

Risk factors for the development of acute pyelonephritis in women with a positive urine culture.

INTRODUCTION: In treating lower urinary tract symptoms (LUTS), the risk of overtreatment with antibiotics must be reconciled with the risk of an untreated urinary tract infection (UTI) progressing to acute pyelonephritis (APN). Using Cerner HealthFacts, a longitudinal clinical informatics database, we aimed to determine risk factors associated with the development of APN from UTI in an effort to guide the initiation of empiric antibiotics. METHODS: We queried the Cerner HealthFacts database for women over age 18 with a positive urine culture. Any patient with an International Classification of Disease (ICD) code indicating chronic pyelonephritis was excluded. Development of APN within 30 days of the positive culture, specified by ICD coding, was our primary outcome. Patient and facility factors were assessed as potential risk factors for the development of APN using multivariable regression. RESULTS: Out of 58 344 women with a positive urine culture, 3.9% (2296) developed APN. Mean patient age was 54.4 ± 25.3 years. Overall, 12 variables were predictive for APN and 11 variables were protective against APN. Presence of obstructive and reflux uropathies (OR 4.58), presentation to an acute care facility (OR 3.19), urinary retention (OR 2.30), history of UTI (OR 2.19), and renal comorbidities (OR 2.07) conferred the highest odds of APN development. The most protective variable against APN development was cognitive impairment (OR 0.49). CONCLUSIONS: Identified risk factors associated with APN development may aid decisions regarding empiric antibiotic initiation for patients presenting with LUTS while awaiting urine culture results. The relationship between cognitive impairment and progression to APN deserves further study.

Sacrocolpopexy experience with a novel robotic surgical platform.

INTRODUCTION AND HYPOTHESIS: The objective was to describe early experience performing sacrocolpopexy using a novel robotic surgical platform. METHODS: This is a case series of all women who underwent robotic-assisted sacrocolpopexy using a new robotics platform (TransEnterix Senhance) between January 2019 and July 2021. All sacrocolpopexies were performed by a single Female Pelvic Medicine and Reconstructive surgeon at a large academic institution. Perioperative information including complications was abstracted from the medical record. Anatomical recurrence was defined as any anatomical point at or past the hymen (≥0). Data are descriptive, with Mann-Whitney U test used for comparison of operative time between the first and second half of the patients. RESULTS: A total of 25 sacrocolpopexies were performed using the new robotics platform. Mean age was 62.3 years (±9.2) and mean BMI was 26.5 (±3.8). Ten (40.0%) patients had a prior hysterectomy. Most (n = 21, 84.0%) had stage III or IV prolapse preoperatively. Mean operative time was 210.2 min (±48.6) and median estimated blood loss was 35 ml (IQR 25-50). Mean operative time decreased between the first and second half of the patients (231.7 min vs 190.3 min, p = 0.047). There were no major intraoperative complications. Median follow-up time was 16 weeks (IQR 4-34) and there were no subjective recurrences or retreatments during this period. Two patients (8.0%) had anatomical recurrence without subjective bother. There were two postoperative readmissions (8.0%) within 30 days for small bowel obstruction, one treated surgically and the other with nonsurgical management. CONCLUSIONS: Our case series demonstrates feasibility and successful early adoption of a new robotics platform for robotic sacrocolpopexy.

Alcohol affordability: implications for alcohol price policies. A cross-sectional analysis in middle and older adults from UK Biobank.

BACKGROUND: Increasing the price of alcohol reduces alcohol consumption and harm. The role of food complementarity, transaction costs and inflation on alcohol demand are determined and discussed in relation to alcohol price policies. METHODS: UK Biobank (N = 502,628) was linked by region to retail price quotes for the years 2007 to 2010. The log residual food and alcohol prices, and alcohol availability were regressed onto log daily alcohol consumption. Model standard errors were adjusted for clustering by region. RESULTS: Associations with alcohol consumption were found for alcohol price (ß = -0.56, 95% CI, -0.92 to -0.20) and availability (ß = 0.06, 95% CI, 0.04 to 0.07). Introducing, food price reduced the alcohol price consumption association (ß = -0.26, 95% CI, -0.50 to -0.03). Alcohol (B = 0.001, 95% CI, 0.0004 to 0.001) and food (B = 0.001, 95% CI, 0.0005 to 0.0006) price increased with time and were associated (ρ = 0.57, P < 0.001). CONCLUSION: Alcohol and food are complements, and the price elasticity of alcohol reduces when the effect of food price is accounted for. Transaction costs did not affect the alcohol price consumption relationship. Fixed alcohol price policies are susceptible to inflation.

Clinical and genomic assessment of PD-L1 SP142 expression in triple-negative breast cancer.

PURPOSE: The SP142 PD-L1 assay is a companion diagnostic for atezolizumab in metastatic triple-negative breast cancer (TNBC). We strove to understand the biological, genomic, and clinical characteristics associated with SP142 PD-L1 positivity in TNBC patients. METHODS: Using 149 TNBC formalin-fixed paraffin-embedded tumor samples, tissue microarray (TMA) and gene expression microarrays were performed in parallel. The VENTANA SP142 assay was used to identify PD-L1 expression from TMA slides. We next generated a gene signature reflective of SP142 status and evaluated signature distribution according to TNBCtype and PAM50 subtypes. A SP142 gene expression signature was identified and was biologically and clinically evaluated on the TNBCs of TCGA, other cohorts, and on other malignancies treated with immune checkpoint inhibitors (ICI). RESULTS: Using SP142, 28.9% of samples were PD-L1 protein positive. The SP142 PD-L1-positive TNBC had higher CD8+ T cell percentage, stromal tumor-infiltrating lymphocyte levels, and higher rate of the immunomodulatory TNBCtype compared to PD-L1-negative samples. The recurrence-free survival was prolonged in PD-L1-positive TNBC. The SP142-guided gene expression signature consisted of 94 immune-related genes. The SP142 signature was associated with a higher pathologic complete response rate and better survival in multiple TNBC cohorts. In the TNBC of TCGA, this signature was correlated with lymphocyte-infiltrating signature scores, but not with tumor mutational burden or total neoantigen count. In other malignancies treated with ICIs, the SP142 genomic signature was associated with improved response and survival. CONCLUSIONS: We provide multi-faceted evidence that SP142 PDL1-positive TNBC have immuno-genomic features characterized as highly lymphocyte-infiltrated and a relatively favorable survival.

Disparity in Medicare payments by gender and training track in female pelvic medicine and reconstructive surgery.

BACKGROUND: Gender disparities in medicine have been demonstrated in the past, including differences in the attainment of roles in administration and in physician income. OBJECTIVE: Our objective was to determine the differences in Medicare payments based on the provider gender and training track among female pelvic medicine and reconstructive surgeons. STUDY DESIGN: Medicare payments from the Provider Utilization Aggregate Files were used to determine the payments made by Medicare to urogynecologists. This database was merged with the National Provider Identifier registry with information on subspecialty training, years since graduation, and the geographic pricing cost index used for Medicare payment adjustments. Physicians with <90% female patients and those who graduated medical school <7 years ago in obstetrics and gynecology or <8 years ago in urology were excluded. The effects of gender, specialty of training, number of services provided, years of practice, and geographic pricing cost index on physician reimbursement were evaluated using linear mixed modeling. RESULTS: A total of 578 surgeons with female pelvic medicine and reconstructive surgery subspecialty training met the inclusion criteria. Of those, 517 (89%) were trained as gynecologists, whereas 61 (11%) were trained as urologists. Furthermore, 265 (51%) of the gynecology-trained surgeons and 39 (80%) of the urology-trained surgeons were women. Among the urology-trained surgeons, the median female surgeon was paid $85,962 and their male counterparts were paid $121,531 (41% payment difference). In addition, urology-trained female pelvic medicine and reconstructive surgery surgeons performed a median of 1135 services and their male counterparts performed a median of 1793 services (57% volume difference). Similarly, among gynecology-trained surgeons, the median female payment was $59,277 with 880 services performed, whereas male gynecology-trained surgeons received a median of $66,880 with 791 services performed, representing a difference of 12% in payments and 11% in services. With linear mixed modeling, male physicians were paid more than female physicians while controlling for specialty training, number of services performed, years of practice, and geographic pricing cost index (P<.001). CONCLUSION: Although Medicare payments are based on an equation, differences in reimbursement by physician gender exist in female pelvic medicine and reconstructive surgery with female surgeons receiving lower payments from Medicare. The differences in reimbursement could not be solely explained by differences in patient volume, area of practice, or years of experience alone, suggesting that, similar to other fields in medicine, female surgeons in female pelvic medicine and reconstructive surgery are not paid as much as their male counterparts.

Assessing pelvic organ prolapse recurrence after minimally invasive sacrocolpopexy: does mesh weight matter?

INTRODUCTION AND HYPOTHESIS: There has been a trend toward the use of ultra-lightweight mesh types for minimally invasive sacrocolpopexy. We hypothesized that ultra-lightweight mesh would have a greater proportion of composite anatomical pelvic organ prolapse recurrence than lightweight mesh. METHODS: Retrospective cohort study of minimally invasive sacrocolpopexies at two academic institutions from 2009 to 2016. Our primary outcome was composite anatomical prolapse recurrence, defined as prolapse beyond the hymen or retreatment with pessary or surgery, compared between ultra-lightweight (≤21 g/m2 [range 19-21]) and lightweight (>21 g/m2 [range 35-50]) mesh types. We assessed time to prolapse recurrence using Kaplan-Meier and Cox regression. RESULTS: The cohort consisted of 1,272 laparoscopic (n = 530, 41.7%) and robotic-assisted sacrocolpopexies (n = 742, 58.4%). Lightweight mesh was used in 745 procedures (58.6%) and ultra-lightweight mesh in 527 (41.4%). The lightweight mesh had longer median follow-up than the ultra-lightweight group (344 [IQR 50-670] vs 143 days [IQR 44-379], p < 0.01). There was no difference in composite anatomical prolapse recurrence between lightweight and ultra-lightweight mesh (54 [7.2%] vs 35 [6.6%], p = 0.68). Ultra-lightweight mesh demonstrated a shorter time to prolapse recurrence (p < 0.01), which remained significant on multivariate Cox regression (HR 2.38 [95% CI 1.47-3.87]). The lightweight mesh had significantly more mesh complications (43 [5.8%] vs 7 [1.3%], p < 0.01). CONCLUSIONS: Ultra-lightweight mesh for minimally invasive sacrocolpopexy was not associated with a higher proportion of composite anatomical prolapse recurrence; however, it was associated with a shorter time to recurrence. Longer follow-up is needed to assess the clinical importance of this finding, particularly given the trade-off of more complications with lightweight mesh.