Analysis of changes in sexual function in women undergoing pelvic organ prolapse repair with abdominal or vaginal approaches.

INTRODUCTION AND HYPOTHESIS: To examine changes in sexual function after abdominal and transvaginal pelvic organ prolapse repair. METHODS: Women enrolled in our prospective, longitudinal prolapse database with abdominal sacrocolpopexy (ASC) or transvaginal (TVR) pelvic organ prolapse (POP) repair with or without mesh, between 19 December 2008 through 4 June 2014. The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) and the Pelvic Floor Distress Inventory (PFDI -20) were mailed preoperatively, and at 6 and 12 months postoperatively. Patients completed Global Response Assessments to rate their overall satisfaction. RESULTS: Two hundred and four of the 300 women met the inclusion criteria: 74 out of 204 (36 %) had ASC and 130 out of 204 (64 %) had TVR. Seventy-two out of seventy-four ASCs were performed robotically and 2 were open. Baseline demographics were similar except that the ASC patients were significantly younger (60 vs 63, P = 0.019) and had a higher rate of apical repair (77 % vs 55 %). Thirty-six out of seventy-four ASC (48.7 %) and 63 out of 128 TVR patients (49.2 %) were sexually active at baseline (P = 0.94). Sixteen out of thirty-eight ASC (42.1 %) and 18 out 63 TVR patients (28.6 %; P = 0.16) reported dyspareunia at baseline. Seventy-two out of seventy-four ASC (97 %) and 86 out of 130 TVR patients (66 %) had mesh-augmented repairs. There was no difference in sexual activity or dyspareunia between the groups at the 6- or 12-month follow-up. PISQ and PFDI scores improved significantly in both the ASC and TVR groups over time compared with the baseline (p < 0.0001). Most women in the ASC (77.5 %) and TVR (64.8 %) groups were satisfied with the results of prolapse surgery at 12 months. CONCLUSIONS: Sexual function and pelvic floor symptoms improved in a similar manner in patients after abdominal and transvaginal POP surgery.

Short-term outcomes of balloon angioplasty versus stent placement for patients undergoing primary percutaneous coronary intervention: Implications for patients requiring early coronary artery bypass surgery.

BACKGROUND: In patients with acute ST-elevation myocardial infarction (STEMI) needing early coronary artery bypass graft (CABG) surgery, it is unknown whether primary percutaneous balloon angioplasty (PTCA)-without stent implantation-allows safe transition to subsequent CABG. METHODS: We examined acute STEMI patients enrolled in the Stent-PAMI and CADILLAC trials to study the differences in the early clinical events between those treated with primary PTCA (n = 1494) or primary stenting (n = 1488). RESULTS: Baseline clinical and pre- and post-procedural angiographic features including post-intervention TIMI 3 flow rates were similar in the 2 groups with the exception of higher median infarct-artery residual stenosis in the PTCA group (26% [IQR 19%-34%] vs. 18% [IQR 11-25%], P < .001]. Provisional stenting was required in 16% of patients in PTCA group, while stents could not be implanted in 2% of the stent group. Sixty-percent of PTCA patients had stent-like balloon result. The rate of 30-day ischemia-driven target vessel revascularization was higher in the PTCA group (4.3% vs. 2.0%, P < .001 [4.6% vs 2.3%, P < .001 among patients with multivessel disease and 3.4% vs. 2.0%, P = .044 in patients with stent-like balloon results]) while 30-day major adverse cardiac events (6.2% vs 4.9%), death (1.8% versus 2.8%), and reinfarction (0.9% vs. 0.7%) were similar in the 2 groups. CONCLUSIONS: Compared with primary stenting, primary PTCA of infarct artery in STEMI patients was associated with significant increase in ischemia-driven target vessel revascularization (ITVR) rate, yet with no increased risk of major adverse cardiac events, reinfarction or death. Thus, provided close surveillance is maintained and prompt treatment initiated for early ischemic events, PTCA (particularly in those with stent-like balloon result) may be a reasonable and safe option in STEMI patients needing early CABG.

Variation in hospital length of stay in patients with acute myocardial infarction undergoing primary angioplasty and the need to change the diagnostic-related group system.

Our findings show significant variation in length of hospital stay among patients with acute myocardial infarction treated with primary percutaneous coronary intervention; length of stay can be predicted from baseline clinical and angiographic characteristics. Our investigation suggests the need for a multi-tier diagnostic-related group system for patients with acute myocardial infarction treated with percutaneous coronary intervention.

Effect of cardiorespiratory fitness on short-term morbidity and mortality after coronary artery bypass grafting.

Although preoperative risk assessment for coronary artery bypass grafting (CABG) has been evaluated with multiple predictive models, none have incorporated a low level of cardiorespiratory fitness, which represents one of the strongest predictors of all-cause and cardiovascular mortality in subjects with and without heart disease. The aim of the present study was to evaluate preoperative cardiorespiratory fitness, expressed as METs (1 MET = 3.5 ml O2/kg/min), and short-term morbidity and mortality after CABG. The Society of Thoracic Surgeons database was queried for patients who underwent CABG from January 2002 to December 2010 at Beaumont Health Systems. Electronic medical records were reviewed for peak or symptom-limited exercise testing <90 days before CABG. Peak METs were estimated from the achieved treadmill speed, grade, and duration or the cycle ergometer workload, corrected for body weight. Patients who met eligibility criteria (n = 596) were categorized into 2 groups: those with reduced aerobic capacity (<5 METs [n = 78]) and those achieving ≥5 METs (n = 518). Fisher's exact tests were used to compare preoperative aerobic capacity and short-term postoperative morbidity and mortality between the 2 groups. After adjusting for potential confounding variables, an inverse relation was found between cardiorespiratory fitness and complications after CABG. Specifically, low preoperative cardiorespiratory fitness (<5 METs) was associated with higher operative and 30-day mortality after CABG (p <0.05). In conclusion, these data suggest that preoperative cardiorespiratory fitness provides an independent and additive marker for mortality after CABG.

Does proximal location of culprit lesion confer worse prognosis in patients undergoing primary percutaneous coronary intervention for ST elevation myocardial infarction?

ST segment elevation myocardial infarction (STEMI) from proximally located culprit lesion is associated with greater myocardium at jeopardy. In STEMI patients treated with thrombolytics, proximal culprit lesions are known to have worse prognosis. This relation has not been studied in patients undergoing primary percutaneous coronary intervention (PCI). In 3,535 STEMI patients with native coronary artery occlusion pooled from the primary angioplasty in myocardial infarction database, we compared in-hospital and 1-year outcomes between those with proximal (n = 1,606) versus non-proximal (n = 1,929) culprit lesions. Patients with proximal culprits were more likely to die and suffer major adverse cardiovascular events (MACE) during the index hospital stay (3.8% vs 2.2%, P = 0.006; 8.2% vs 5.8%, P = 0.0066, respectively) as well as during 1-year follow-up (6.9% vs 4.5%, P = 0.0013; 22% vs 17%, P = 0.003, respectively) compared to those with non-proximal culprits. After adjustment for baseline differences, proximal culprit was independently predictive of in-hospital death (adjusted odds ratio% 1.58, 95% confidence intervals, CI 1.05-2.40) and MACE (OR 1.41, CI 1.06-1.86), but not 1-year death or MACE. In addition, proximal culprit was independently associated with higher incidence of ventricular arrhythmias and sustained hypotension during the index hospitalization. The univariate impact of proximal culprit lesion on in-hospital death and MACE was comparable to other adverse angiographic characteristics, such as multivessel disease and poor initial thrombolysis in myocardial infarction flow, and greater than that of anterior wall STEMI. In conclusion, proximal location of the culprit lesion is a strong independent predictor of worse in-hospital outcomes in patients with STEMI undergoing primary PCI.