Trends, Outcomes, and Economic Implications of Peritoneal Dialysis-Associated Peritonitis Hospitalizations: A National Cohort Study.

INTRODUCTION: Peritoneal dialysis-associated peritonitis (PDAP) is a serious complication of peritoneal dialysis, associated with significant morbidity, modality transition, and mortality. Here, we provide an update on the national burden of this significant complication, highlighting trends in demographics, treatment practices, and in-hospital outcomes of PDAP from 2016 to 2020. METHODS: Utilizing a national all-payer dataset of hospitalizations in the USA, we conducted a retrospective cohort study of adult hospitalizations with a primary diagnosis of PDAP from 2016 to 2020. We analyzed demographic, clinical, and hospital-level data, focusing on in-hospital mortality, PD catheter removal, length of stay, and healthcare expenses. Multivariable logistic regression adjusted for demographic and clinical covariates was employed to identify risk factors associated with adverse outcomes. RESULTS: There was a stable burden of annual PDAP admissions from 2016 to 2020. Healthcare expenditures associated with PDAP were high, totaling over USD 75,000 per admission. Additionally, our data suggest geographic inconsistencies in treatment patterns, with treatment at western and teaching hospitals associated with increased rates of catheter removal relative to northeastern and non-teaching centers and a mean cost of nearly USD 55,000 more in Western states compared to Midwest states. 23.2% of episodes resulted in the removal of the PD catheter. Risk factors associated with adverse outcomes included older age, higher Charlson comorbidity index scores, peripheral vascular disease, and the need for vasopressors. CONCLUSION: PDAP is a major cause of mortality among PD patients, and there is a vital need for future studies to examine the impact of hospital location and teaching status on PDAP outcomes, which can inform treatment practices and resource allocation.

Financial toxicity in BRCA1 and BRCA2 carriers.

OBJECTIVE: Financial toxicity (FT), the cumulative financial burden experienced due to medical care, is a well-established adverse effect of healthcare. Patients with BRCA mutations have significantly increased cancer risks compared to non-affected individuals, requiring more frequent screenings and, at times, prophylactic surgery, increasing their risk for FT. Our primary aim in this study was to describe rates of FT among BRCA carriers. METHODS: We performed a novel, cross-sectional study of FT in BRCA1/2 carriers. Participants were recruited via phone and/or email to complete consents and surveys on REDCap. The FACIT-COST tool, a validated tool for measuring FT, was used to assess FT; scores were divided into tertiles, with high FT defined as COST score < 24. RESULTS: 265 BRCA positive female participants met enrollment criteria; 76 (28.7%) consented to participate and completed the survey. Participants were primarily non-Hispanic White (97.4%), privately insured (82.9%), and employed full time (67.1%). A significant proportion (22.7%) of participants reported delaying or avoiding care secondary to finances. No statistically significant association was seen between financial toxicity groups and analyzed demographics. Participants with high FT were more likely to engage in all surveyed cost-saving measures, with 41.7% of participants reporting delays/avoidance of care due to cost (p = 0.02). CONCLUSIONS: This study of FT in BRCA carriers shows that financial toxicity exists as an issue in this high-risk patient population. This work serves as the first description of FT in BRCA mutation carriers and highlights the importance of incorporating routine counseling on cost when discussing recommendations for screening and clinical care with this patient population.

A randomized trial comparing the 52-mg levonorgestrel system with combination oral contraceptives for treatment of heavy menstrual bleeding.

BACKGROUND: The levonorgestrel intrauterine system and combined oral contraceptives are the 2 most commonly used nonsurgical treatments for heavy menstrual bleeding in the United States. However, there are limited data on their relative effectiveness and on their impact on bleeding-specific quality of life. OBJECTIVE: This study aimed to compare the effectiveness of the 52-mg levonorgestrel intrauterine system with that of combined oral contraceptives for improving quality of life among individuals who self-report heavy menstrual bleeding. We hypothesized that the levonorgestrel intrauterine system would be more effective than combined oral contraceptives at 6 and 12 months after treatment. STUDY DESIGN: We conducted a pragmatic randomized trial of individuals who self-reported heavy menstrual bleeding. Individuals were eligible if they did not have contraindications to either the levonorgestrel intrauterine system or combined oral contraceptives and were determined to have a nonstructural cause of heavy menstrual bleeding. Eligible and consenting participants were randomly assigned in a 1:1 ratio to receive a 52-mg levonorgestrel intrauterine system or a monophasic 30- or 35-µg ethinyl estradiol-containing combined oral contraceptive. The main outcome was mean change in bleeding-related quality of life, measured by the 20-question Menstrual Bleeding Questionnaire (score range, 0-75) at 6 and 12 months. Differences in group means and confidence intervals for the Menstrual Bleeding Questionnaire score were computed by multivariable linear mixed-effects regression; 24 participants per group were needed to detect a 10-point difference in change in mean Menstrual Bleeding Questionnaire score between individuals treated with the levonorgestrel intrauterine system and those treated with combined oral contraceptives at each follow-up time point. RESULTS: A total of 62 individuals were randomly assigned to treatment (n=29 allocated to levonorgestrel intrauterine system and n=33 allocated to combined oral contraceptives) and included in the intention-to-treat analyses; 19 of 29 received the levonorgestrel intrauterine system and 31 of 33 received combined oral contraceptives. Eleven percent identified as Black or African American and 44% identified as Hispanic or Latina. Participant characteristics were similar among study groups. Bleeding-related quality of life increased in both study arms, as reflected by a significant decrease in Menstrual Bleeding Questionnaire scores beginning at 6-week follow-up. In the main intention-to-treat analyses (n=62), there were no differences in mean change in Menstrual Bleeding Questionnaire scores at 6 months (difference=-2.5; 95% confidence interval, -10.0 to +5.0) or 12 months (difference=-1.1; 95% confidence interval, -8.7 to +6.5). Findings were similar in the subsets of participants with any follow-up visits (n=52) and who completed all follow-up visits (n=42). In the per-protocol analyses (n=47), a significantly greater decrease in Menstrual Bleeding Questionnaire score was observed in the levonorgestrel intrauterine system arm at 6 months after treatment (difference=-7.0; 95% confidence interval, -13.8 to -0.2) but not at 12 months (difference=-4.8; 95% confidence interval, -11.8 to 2.3) compared with the combined oral contraceptive arm. CONCLUSION: No differences in change of bleeding-related quality of life were observed between the levonorgestrel intrauterine system and combined oral contraceptives at 6 or 12 months. Patients should be counseled that the levonorgestrel intrauterine system and combined oral contraceptives are both effective options for improving bleeding-related quality of life.

Sexual health and function among patients receiving systemic therapy for primary gynecologic cancers.

OBJECTIVE: Sexual dysfunction has been reported after gynecologic cancer treatment but few studies have examined sexual function during treatment. Our objectives were to describe sexual function among women receiving systemic therapy for gynecologic cancers and to compare sexual function between women receiving upfront treatment versus treatment for cancer recurrence. METHODS: We conducted a prospective study of women 18yo and older receiving systemic therapy for gynecologic cancer in the upfront or recurrent setting. Patients receiving radiation were excluded. Participants completed a survey with questions from the Patient Reported Outcome Measurement Information System (PROMIS) SexFS and Female Sexual Function Index (FSFI). Clinical information was collected from chart review. Statistical analysis included t-test, Wilcoxon rank sum test, and Fisher's exact test. RESULTS: Of 145 patients approached, 100 (69%) enrolled and 97 (67%) completed the survey. Median age was 65yo. Most patients had ovarian cancer (58%), then endometrial cancer (34%) and cervical cancer (8%). Fifty-two (54%) were receiving recurrent treatment and 45 (46%) upfront treatment. Thirty-eight (76%) in the recurrent group and 34 (75%) in the upfront group hadn't been sexually active in the last month (p = 1.0); however, 61 (67%) participants reported a desire for future sexual activity. Of the 31 patients who completed all FSFI questions, the median FSFI score was 24.0 and 21 (68%) had sexual dysfunction. Vaginal dryness was more common among patients receiving recurrent treatment (p = 0.09) while a "health condition" was a more common reason for sexual inactivity in the upfront setting (p = 0.07). CONCLUSION: Many patients receiving systemic therapy for gynecologic cancers are willing to discuss sexual function. Most patients reported sexual dysfunction and weren't currently sexually active. Understanding patients' sexual function concerns will allow providers to intervene.

Oral phenazopyridine vs intravesical lidocaine for bladder onabotulinumtoxinA analgesia: a randomized controlled trial.

BACKGROUND: The efficacy of intradetrusor onabotulinumtoxinA injections for the management of idiopathic overactive bladder has been well-established. The injections are typically performed in the office setting using local analgesia, most commonly a 20 to 30-minute intravesical instillation of lidocaine. There are limited data evaluating alternative bladder analgesics. OBJECTIVE: To compare pain scores with preprocedure oral phenazopyridine vs intravesical lidocaine in women undergoing intradetrusor onabotulinumtoxinA injections for idiopathic overactive bladder. STUDY DESIGN: Nonpregnant adult females with idiopathic overactive bladder, scheduled for office injection of 100 units of intradetrusor onabotulinumtoxinA were randomized to either 200 mg of oral phenazopyridine taken 1 to 2 hours preprocedure or a 20-minute preprocedure intravesical instillation of 50 mL of 2% lidocaine. We excluded participants with neurogenic bladders, and those who had received intradetrusor onabotulinumtoxinA injections in the previous 12 months. The primary outcome was pain measured by a 100-mm visual analog scale. Demographic characteristics and overall satisfaction with the procedure were also recorded. Providers answered questions about cystoscopic visualization, ease of procedure, and perception of participant comfort. Prespecified noninferiority margin was set to equal the anticipated minimum clinically important difference of 14 mm. A planned sample of 100 participants, 50 in each treatment arm, provided 80% power to detect noninferiority at a significance level of.05. We performed a modified intention-to-treat analysis and compared variables with the t test or the Fisher exact test. RESULTS: A total of 111 participants were enrolled, and complete data were obtained for 100 participants; 47 participants were randomized to phenazopyridine and 53 to lidocaine. Baseline characteristics did not differ between groups. There were 19.6% and 20.8% of participants in the phenazopyridine and lidocaine groups, respectively, who previously underwent intradetrusor onabotulinumtoxinA injections. The mean postprocedure pain was 2.7 mm lower in the phenazopyridine group than in the lidocaine group (95% confidence interval, -11.3 to 10.7), demonstrating noninferiority. More than 90% of participants in both groups stated that the pain was tolerable. Slightly more participants reported being "very satisfied" in the lidocaine group, although this was not statistically significant (50.0% vs 40.4%; P=.34). Providers reported clear visualization in 89.4% of participants in the phenazopyridine group and in 100% of participants in the lidocaine group (P=.02). Provider perception of participant comfort and overall ease of procedure were not different between groups. Length of time in the exam room was significantly shorter in the phenazopyridine than in the lidocaine group (44.4 vs 57.5 minutes; P=.0003). CONCLUSION: In women receiving intradetrusor onabotulinumtoxinA injections for idiopathic overactive bladder, oral phenazopyridine was noninferior to intravesical lidocaine for procedural pain control. Phenazopyridine is well-tolerated by participants, allows for the procedure to be performed with similar ease, and is associated with shorter appointment times.

Family planning in carriers of BRCA1 and BRCA2 pathogenic variants.

BRCA1 and BRCA2 pathogenic variant carriers have a high lifetime risk of developing breast and ovarian malignancies. Given the risks and significant ramifications of undergoing risk-reducing surgeries, many pathogenic variant carriers unaffected by cancer (previvors) struggle with family planning and reproductive decision making. The objective of this study was to determine the attitudes and practices of BRCA1 and BRCA2 pathogenic variant carriers with respect to family planning decision making. A cross-sectional survey was conducted of BRCA1 and BRCA2 previvors at four Northeastern medical centers. The survey was administered electronically via email using REDCap. The survey included demographic information as well as questions about genetic testing, prophylactic surgeries, family planning, and partnering. Data were analyzed with Fisher's exact tests and t tests. The survey was completed by 139 of 422 BRCA1 and BRCA2 pathogenic variant carriers (response rate 33%). Thirteen were excluded from analysis due to self-reported cancer history. Of the remaining 126, 21 (16.7%) were male and 105 (83.3%) were female. Female participants <35 years old at the time of genetic testing were significantly more likely than those 35 or greater to report feeling urgency to have a family after finding out about their BRCA1 and BRCA2 pathogenic variant (p < 0.0001). Younger women also reported their genetic status had a stronger impact on their romantic relationships (p = 0.029). Men were significantly more likely to report that they felt no urgency to have a family compared to women (p < 0.0001). Our study reflects the complex decision making for previvors and the intricacies of family planning in this population. Providers can use this knowledge as a guide to counsel patients about reproductive options.

Variability in gynecologic case volume of obstetrician-gynecologist residents graduating from 2009 to 2017.

BACKGROUND: Residency training in obstetrics-gynecology has changed significantly over time, with residents expected to master an increasing number of surgical procedures. Residency operative case logs are tracked by the Accreditation Council for Graduate Medical Education, which sets case minimums for all procedures. In 2018, the Accreditation Council for Graduate Medical Education created a combined minimally invasive hysterectomy category and now requires graduating residents to complete a minimum of 70 minimally invasive hysterectomies. OBJECTIVES: The objectiges of the study were to evaluate the range of operative gynecological experience across graduating obstetrician-gynecologist residents in the United States and to estimate the number of residents able to meet new Accreditation Council for Graduate Medical Education minimum hysterectomy cases. STUDY DESIGN: Accreditation Council for Graduate Medical Education surgical case logs of graduating obstetrician-gynecologist residents from 2009 to 2017 were analyzed for case volume trends. RESULTS: The average total number of gynecological cases per resident decreased from 438.2 to 431.5 (P < .0001). Minimally invasive hysterectomy averages increased from 43.6 to 69.3 (P < .0001), a trend driven principally by an increase in total laparoscopic hysterectomies. Mean case log decreases were noted in invasive cancer (70.7 to 54.3), incontinence and pelvic floor (85.6 to 56.7), and total abdominal hysterectomies (74.4 to 42.9); (P < .0001 for all). Mean increases were seen in total laparoscopic (118.8 to 146.3) and operative hysteroscopy (68.6 to 77.1) cases (P < .0001 for all). The ratio of the 90th percentile to the 10th percentile of resident case logs showed substantial variation in surgical volume for all procedures, although this ratio decreased over time. Graduates who logged 70 minimally invasive hysterectomy cases were estimated to fall at the 51st percentile in 2017; this was down from the 91st percentile in 2009. CONCLUSION: Nationwide, graduates of obstetrician-gynecologist residency experience significant variability in their surgical training. Based on our extrapolation of Accreditation Council for Graduate Medical Education data, approximately half of residency graduates fell below the 70 case minimally invasive hysterectomy minimum in 2017. Meeting the new Accreditation Council for Graduate Medical Education hysterectomy minimums may be challenging for a significant proportion of residency programs. Understanding the scope and variability of gynecology training is needed to continue to improve and address gaps in resident education.

Identifying cardiovascular severe maternal morbidity in epidemiologic studies.

BACKGROUND: Cardiovascular severe maternal morbidity (CSMM) is rising and has become the leading cause of maternal mortality. Research using administrative data sets may allow for better understanding of this critical group of diseases. OBJECTIVE: To validate a composite variable of CSMM for use in epidemiologic studies. METHODS: We analysed delivery hospitalisations at an obstetric teaching hospital from 2007 to 2017. We utilised a subset of indicators developed by the Centers for Disease Control and Prevention based on ICD codes to form the composite variable for CSMM. Two expert clinicians manually reviewed all qualifying events using a standardised tool to determine whether these represented true CSMM events. Additionally, we estimated the number of CSMM cases among delivery hospitalisations without qualifying ICD codes by manually reviewing all hospitalisations with severe preeclampsia, a population at high risk of CSMM, and a random sample of 1000 hospitalisations without severe preeclampsia. We estimated validity of the composite variable. RESULTS: Among 91 355 admissions for delivery, we captured 113 potential CSMM cases using qualifying ICD codes. Of these, 65 (57.5%) were true CSMM cases. Indicators for acute myocardial infarction, cardiac arrest, and cardioversion had the highest true-positive rates (100% for all). We found an additional 70 CSMM cases in the 2102 admissions with severe preeclampsia and a single CSMM case in the random sample. Assuming a rate of 1 CSMM case per 1000 deliveries in the remaining cohort, the composite variable had a positive predictive value of 57.5% (95% CI 47,9, 66.8), a negative predictive value of 99.8% (95% CI 99.8, 99.9), a sensitivity of 29.0% (95% CI 23.2, 35.4), and a specificity of 100% (95% CI 99.9, 100.0). CONCLUSION: A novel composite variable for CSMM had reasonable PPV but limited sensitivity. This composite variable may enable epidemiologic studies geared towards reducing maternal morbidity and mortality.

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.

Perioperative peer support and surgical preparedness in women undergoing reconstructive pelvic surgery.

INTRODUCTION AND HYPOTHESIS: The benefits of peer support for pelvic floor disorders are unclear. We hypothesize that perioperative peer support might be associated with greater preoperative preparedness compared with usual care in women undergoing pelvic reconstruction. METHODS: A multicenter prospective cohort study of women undergoing pelvic reconstruction compared peer support (group or one-to-one) with usual care. The primary outcome was preparedness, measured by a Preoperative Preparedness Questionnaire at baseline and before surgery. Assuming 48% preparedness in usual care preoperatively, 44 women per group (Group, One-to-One, or Usual care) would detect a 30% difference in preparedness (alpha = 0.05, 80% power). Chi-squared or Fisher's exact test compared categorical variables, t test and analysis of variance compared continuous variables, independent sample tests compared changes in mean or composite scores, and multiple logistic regression estimated the effect. RESULTS: One hundred and sixty-eight patients were included (113 with peer support, 55 undergoing usual care). A greater proportion of women in peer support had college or higher education versus usual care (78 vs 58%, P = 0.02). After the intervention, the proportion of women feeling prepared was not different between groups (66 vs 63%, P = 0.9). However, a greater proportion in peer support reported improved preparedness from baseline compared with usual care (71 vs 44%, P = 0.001). Peer support was associated with improved preparedness on multiple regression adjusting for age, study site, education, and surgery type (OR 4.14, 95% CI 1.69, 10.14). CONCLUSION: Peer support was associated with improved preoperative preparedness compared with usual care, but did not result in a greater proportion of women feeling prepared before surgery.

A randomized controlled trial of a computer-based brief intervention for victimized perinatal women seeking mental health treatment.

Intimate partner victimization (IPV) during the perinatal period is associated with adverse outcomes for the woman, her developing fetus, and any children in her care. Maternal mental health concerns, including depression and anxiety, are prevalent during the perinatal period particularly among women experiencing IPV. Screening and interventions for IPV targeting women seeking mental health treatment are lacking. In the current study, we examine the feasibility, acceptability, and the preliminary efficacy of a brief, motivational computer-based intervention, SURE (Strength for U in Relationship Empowerment), for perinatal women with IPV seeking mental health treatment. The study design was a two-group, randomized controlled trial with 53 currently pregnant or within 6-months postpartum women seeking mental health treatment at a large urban hospital-based behavioral health clinic for perinatal women. Findings support the acceptability and feasibility of the SURE across a number of domains including content, delivery, and retention. All participants (100%) found the information and resources in SURE to be helpful. Our preliminary results found the degree of IPV decreased significantly from baseline to the 4-month follow-up for the SURE condition (paired t-test, p < 0.001), while the control group was essentially unchanged. Moreover, there was a significant reduction in emotional abuse for SURE participants (p = 0.023) relative to participants in the control condition. There were also reductions in physical abuse although non-significant (p = 0.060). Future work will test SURE in a larger, more diverse sample. ClinicalTrials.gov Identifier: NCT02370394.

Nonurgent and urgent emergency department use during pregnancy: an observational study.

BACKGROUND: Emergency department use is common among pregnant women. Nonurgent emergency department use may represent care that would be better provided by an established obstetric provider in an ambulatory setting. OBJECTIVE: The objective of the study was to identify sociodemographic factors associated with nonurgent emergency department use in pregnancy. STUDY DESIGN: This is a cross-sectional study of women recruited during their postpartum hospitalization. Data regarding prenatal care and emergency department visits were collected from medical records; participants completed a survey with questions regarding demographics and emergency department use. Urgency of an emergency department visit was prespecified based on a priori criteria abstracted from medical record review. Women with any nonurgent emergency department use were compared with women without nonurgent emergency department use. Logistic regression was performed to identify factors associated with nonurgent emergency department use. RESULTS: Two hundred thirty-three women participated in this study; 197 (84%) received care in the emergency department during pregnancy. Eighty-three women (35.6%) had at least 1 visit to the emergency department that was nonurgent. In a regression analysis, the increased odds of nonurgent emergency department use was associated with a preferred language other than English (odds ratio, 2.02; 95% confidence interval,1.01-4.05) and lack of private insurance (odds ratio, 5.55; 95% confidence interval, 2.54-12.12). The 2 most common reasons for presentation to the emergency department were concern that there was an emergency (45%) or being referred by a health care provider (36%). CONCLUSION: Women frequently use the emergency department during pregnancy, including visits for nonurgent indications. Identifying risk factors for nonurgent emergency department use in pregnancy is important for identifying women likely to use the emergency department, including for nonurgent visits, and the development of strategies to decrease nonurgent emergency department utilization in pregnancy.

Obesity risk awareness in women with endometrial cancer.

PURPOSE: To assess whether women with endometrial cancer could accurately classify their weight and identify the association between obesity and risk of endometrial, breast, and colon cancers. METHODS: This was an IRB-approved (Project No. 14-0075), survey-based cross-sectional study of women ages 18-80 years with a diagnosis of endometrial cancer. Patients were at least 6 months from hysterectomy and 3 months from chemotherapy or radiation. Statistical analysis was completed using Fisher's exact test, T test, ANOVA, Wilcoxon rank-sum test, or Kruskal-Wallis test. P values were two-tailed with P < 0.05 considered statistically significant. RESULTS: 140 women met inclusion criteria, and 133 questionnaires (95.0%) were completed. Mean age was 63.2 years (range 35-80), and mean BMI was 33.4 kg/m2 (range 17.6-72.2). Patients were primarily Caucasian (88.7%) and reported education beyond high school (67.8%). Among women with BMI 30.0-34.99 kg/m2, 12.9% perceived themselves as obese, compared to 32.0% of women with BMI 35.0-39.99 kg/m2, and 72.7% of women with BMI >40.0 kg/m2. Ability to correctly classify weight correlated significantly with education level (P = 0.02). Less than half of women identified obesity as a risk factor for breast (49.6%), colon (48.1%), and endometrial cancer (44.4%). 77% of all patients had discussed weight with their primary care doctor, and 38% had discussed weight with their oncologist (P < 0.001). CONCLUSIONS: The majority of obese women with endometrial cancer surveyed were unable to accurately classify their weight. Given the inconsistency between patient weight and perception of cancer risk, this represents an opportunity for gynecologic oncologists to educate their patients about weight control.

Understanding Women's Sexual Behaviors That May Put Them at Risk for Human Papillomavirus-Related Neoplasias: What Should We Ask?

OBJECTIVES: Human papillomavirus is a multifocal infection that can involve the cervix, vagina, vulva, anus, and oropharynx. Our study aimed to determine whether standard sexual history questions regarding anal intercourse identify women participating in anal-related sexual practices. MATERIALS AND METHODS: A cross-sectional survey was conducted at the dysplasia clinic of a large academic medical center. Women presenting with human papillomavirus-related cervical, vulvar, or vaginal abnormalities were eligible. Participants completed a self-administered sexual history questionnaire that included standard sexual history questions and more detailed questions about sexual practices. Additional demographic information was obtained from chart review. RESULTS: A total of 149 eligible women were approached, 125 (84%) consented and enrolled (ages = 21-65 years). Forty-seven (44%) reported participating in some type of anal-related sexual practice: anal fingering, oral-anal penetration, or anal intercourse. Of those participating in anal-related practices, 5 (11%) reported only anal fingering or oral-anal penetration. Thus, adding the new anal questions detected an additional 5% of women with high-risk anal behaviors that may have been missed by the standard question (p = .06). Seventy-nine women (63%) reported receiving oral penetration of the vagina, and 102 (82%) reported receiving vaginal fingering. Fifty-nine women (47%) used sex toys: 58 (98%) used sex toys vaginally, with 5 (8.5%) using them also anally. CONCLUSIONS: Women are willing to report their participation in a range of sexual practices. Of those who participated in anal practices, 11% did not have anal intercourse. Adding additional sexual health questions to clinical intake forms may enable clinicians to better counsel their patients on risky sexual behaviors.

Item bank development, calibration and validation for patient-reported outcomes in female urinary incontinence.

PURPOSE: Current patient-reported outcomes for female urinary incontinence (UI) are limited by their inability to be tailored. Our objective is to describe the development and field testing of seven item banks designed to measure domains identified as important UI in females (UIf). We also describe the calibration and validation properties of the UIf-item banks, which allow for more efficient computerized adaptive testing (CAT) in the future. METHODS: The UIf-measures included 168 items covering seven domains: Stress UI (SUI), overactive bladder (OAB), urinary frequency, physical, social and emotional health impact and adaptation. Items underwent rigorous qualitative development and psychometric testing across two sites. Items were calibrated using item response theory and evaluated for internal consistency, construct validity and responsiveness. RESULTS: A total of 750 women (249 SUI, 249 OAB and 252 mixed UI) participated. Mean age was 55 ± 14 years, and 23 % were Hispanic and 80 % white. In addition to face and content validity, the measures demonstrated good internal consistency (coefficient alpha 0.92-0.98) and unidimensionality. There was evidence for construct validity with moderate-to-strong correlations with the UDI (r's ≥ 0.6) and IIQ (r's = ≥0.6) scales. The measures were responsive to change for SUI treatment (paired t test p < .001, ES range 1.3-2.9; SRM range 1.3-2.5) and OAB treatment (paired t test p < .05 for all domains except social health impact and adaptation, ES range 0.3-1.5, SRM range 0.4-1.0). The measures were responsive based on concurrent changes with the UDI and IIQ (p < 0.05). CAT versions were developed and pilot-tested. CONCLUSIONS: The UIf-item banks demonstrate good psychometric characteristics and are a sufficiently valid set of customizable tools for measuring UI symptoms and life impact.

The accuracy of surgeons' provided estimates for the duration of hysterectomies: a pilot study.

STUDY OBJECTIVE: To determine the accuracy of gynecologic surgeons' estimate of operative times for hysterectomies and to compare these with the existing computer-generated estimate at our institution. DESIGN: Pilot prospective cohort study (Canadian Task Force classification II-2). SETTING: Academic tertiary women's hospital in the Northeast United States. PARTICIPANTS: Thirty gynecologic surgeons including 23 general gynecologists, 4 gynecologic oncologists, and 3 urogynecologists. INTERVENTION: Via a 6-question survey, surgeons were asked to predict the operative time for a hysterectomy they were about to perform. The surgeons' predictions were then compared with the time predicted by the scheduling system at our institution and with the actual operative time, to determine accuracy and differences between actual and predicted times. Patient and surgery data were collected to perform a secondary analysis to determine factors that may have significantly affected the prediction. MEASUREMENTS AND MAIN RESULTS: Of 75 hysterectomies analyzed, 36 were performed abdominally, 18 vaginally, and 21 laparoscopically. Accuracy was established if the actual procedure time was within the 15-minute increment predicted by either the surgeons or the scheduling system. The surgeons accurately predicted the duration of 20 hysterectomies (26.7%), whereas the accuracy of the scheduling system was only 9.3%. The scheduling system accuracy was significantly less precise than the surgeons, primarily due to overestimation (p = .01); operative time was overestimated on average 34 minutes. The scheduling system overestimated the time required to a greater extent than the surgeons for nearly all data examined, including patient body mass index, surgical approach, indication for surgery, surgeon experience, uterine size, and previous abdominal surgery. CONCLUSION: Although surgeons' accuracy in predicting operative time was poor, it was significantly better than that of the computerized scheduling system, which was more likely to overestimate operative time.

Concomitant apical prolapse repair and incontinence procedures: trends from 2001-2009 in the United States.

OBJECTIVE: Recent evidence supports improved outcomes in women who undergo an incontinence procedure at the time of apical prolapse repair compared with apical repair alone. Our primary objective was to describe national trends in concomitant apical repair and incontinence procedures that were performed in the United States from 2001-2009. A secondary objective was to describe complications and length of stay. STUDY DESIGN: We used the Nationwide Inpatient Sample to collect data on hospital discharges for women who had inpatient apical prolapse surgery from 2001-2009. We included women whose records included the International Classification of Disease-9 Clinical Modification procedure codes for apical procedures with and without incontinence procedures. We examined annual trends in the proportion of concomitant procedures using chi-square testing and multiple logistic regression. RESULTS: Of all apical procedures, the percentage of concomitant incontinence procedures performed increased from 37.9% in 2001 to 47% in 2009 (P = .0002 for trend). In-hospital complications (hemorrhage, bowel obstruction, and/or abscess) were less common with concomitant procedures (6.8% vs 11.7%; P = .02). All geographic regions had increasing trends of concomitant incontinence procedures with no difference among regions (P = .7 for interaction). Both community and academic institutions had increasing trends of concomitant procedures over the study period, with no difference among the types of institutions. Age was not associated with increasing trends in concomitant procedures. CONCLUSION: The proportion of concomitant apical and incontinence procedures increased in the United States from 2001-2009. Length of stay was slightly longer for the concomitant group, but complications were not increased.

Preoperative uterine bleeding pattern and risk of endometrial ablation failure.

OBJECTIVE: The objectives of the study were to compare among women who had an endometrial ablation the risks of treatment failure and subsequent gynecological procedures between women with regular and irregular heavy uterine bleeding and to determine other characteristics associated with the risk of treatment failure. STUDY DESIGN: This study was a retrospective cohort of 968 women who underwent endometrial ablation between January 2007 and July 2009. Preoperative bleeding pattern was categorized as regular or irregular. Treatment failure was defined as reablation or hysterectomy. Subsequent gynecological procedures included endometrial biopsy, dilation and curettage, hysteroscopy, reablation, or hysterectomy. We calculated the odds of treatment failure and gynecological procedures using multiple logistic regression. RESULTS: Bleeding pattern prior to ablation was heavy and regular in 30% (n = 293), heavy and irregular in 36% (n = 352), and unspecified in 30% (n = 286). We found no differences in treatment failure (13% vs 12%, P = .9) or subsequent procedures (16% vs 18%, P = .7) between women with regular and irregular bleeding. Compared with the women with regular bleeding, the women with irregular bleeding were not at increased odds of treatment failure or subsequent procedures (odds ratio [OR], 1.07; 95% confidence interval [CI], 0.65-1.74 and OR, 1.17; 95% CI, 0.76-1.80, respectively). Factors associated with an increased odds of treatment failure and subsequent procedures included tubal ligation (OR, 1.94; 95% CI, 1.30-2.91 and OR, 1.71; 95% CI, 1.20-2.43, respectively); dysmenorrhea (OR, 2.42; 95% CI, 1.44-4.06 and OR, 1.93; 95% CI, 1.20-3.13, respectively); and obesity (OR, 1.82; 95% CI, 1.21-2.73 and OR, 1.75; 95% CI, 1.22-2.50, respectively). CONCLUSION: Preoperative bleeding pattern did not appear to affect failure rates or the need for gynecological procedures after endometrial ablation. Other risk factors for ablation failure identified included preoperative dysmenorrhea, prior tubal ligation, and obesity.