Does a Preoperative Bowel Regimen Change Time to Bowel Movement? A Randomized Clinical Trial.

IMPORTANCE: This study is important because it aimed to assess an intervention to decrease patient discomfort after a robotic sacral colpopexy. OBJECTIVE: Our primary outcome was to determine whether preoperative use of polyethylene glycol decreases time to first bowel movement postoperatively. Secondary outcomes include degree of pain with first bowel movement and stool consistency. STUDY DESIGN: This was a randomized controlled trial. The experimental group was assigned polyethylene glycol daily for 7 days before surgery and the control group was not. All patients received polyethylene glycol postoperatively. RESULTS: There was no statistically significant reduction in the time to first postoperative bowel movement when preoperative polyethylene glycol was used (mean [SD] in days for the control and experimental groups of 2.32 [0.99] and 1.96 [1.00], P = 0.21). There was a statistically significant reduction in pain levels with the first postoperative bowel movement in the experimental group (median [IQR] of 4 [2-5] vs 1 [0-2], P = 0.0007). Postoperative day 1 pain levels were also significantly lower in the experimental group (median [IQR] of 4 [3-6] vs 2 [0-4], P = 0.0484). In addition, patients had decreased average postoperative pain levels over 7 days with an estimated difference in the median pain levels of 1.88 units (95% confidence interval, 0.64-3.12; P = 0.0038). CONCLUSIONS: Preoperative administration of polyethylene glycol did not decrease time to first postoperative bowel movement. Patients in the experimental group exhibited less pain with their first postoperative bowel movement and had improved pain levels on postoperative day 1.

Impulsivity dimensions and their associations with disinhibited and actual eating behaviour.

BACKGROUND: Previous research has suggested that there is an association between impulsivity, assessed via self-report measures and behaviourally, and disinhibited eating patterns, but it remains unclear which specific dimension of impulsivity is the most salient in this relationship. Furthermore, it remains uncertain whether any such associations would extend to actual eating behaviours and food consumption. AIMS: The present study aimed to examine whether impulsivity, assessed both behaviourally and via self-report, is associated with self-reported disinhibited and actual eating behaviour in a controlled eating task. METHOD: 70 women from a community sample (aged 21-35) completed the Disinhibition subscale of the Three Factor Eating Questionnaire (TFEQ), the Barratt Impulsiveness Scale (BIS-11), the Matching Familiar Figures Task (MFFT-20), and a behavioural food consumption task. RESULTS: Bivariate correlational analyses revealed significant associations between self-report measure of impulsivity, the scores on the MFFT-20 (assessing reflection impulsivity), and self-report measure of disinhibited eating. All these measures were associated with overall food consumption in a taste task, with reflection impulsivity, that is poor ability to reflect on information before making a decision, having the strongest association with the amount of food consumed. Self-reported impulsivity was most strongly associated with disinhibited eating. Partial correlations controlling for BMI and age did not diminish any significant correlations within these relationships. CONCLUSIONS: Significant associations between both trait and behavioural (reflection) impulsivity, and self-reported disinhibited eating and actual eating behaviour were demonstrated. The implications of these findings on uncontrolled eating patterns in real life are discussed.

Dynamic, High-Fidelity, 3-Dimensional Pelvic Model Improves Education on Pelvic Organ Prolapse and the Pelvic Organ Prolapse Quantification System and Interest in Urogynecology.

IMPORTANCE: Pelvic organ prolapse (POP) affects millions of women globally. Still, medical students and obstetrics and gynecology residents gain minimal exposure to POP during training. OBJECTIVES: Our goal was to increase exposure to POP by creating a high-fidelity, dynamic, 3-dimensional pelvic model of prolapse and using it to teach through didactic learning sessions. STUDY DESIGN: This was a prospective cohort study from November 2021 to July 2022. Presession and postsession surveys were administered to assess for change in POP knowledge both subjectively and objectively. Statistical analysis was performed using the Wilcoxon signed-rank test with a P value of 0.05 denoting significance. RESULTS: Thirty-three learners participated in the study, including 18 residents and 15 medical students. Most participants had interacted with urogynecologists and had seen at least 1 patient with POP. Fewer participants had received prior education on POP and the Pelvic Organ Prolapse Quantification (POP-Q) examination, witnessed or performed a POP-Q examination, or participated in POP surgical procedures. After learning with the model, comfort with identifying POP doubled (P < 0.001), the ability to understand the POP-Q examination quadrupled (P < 0.001), the ability to perform a POP-Q examination tripled (P < 0.001), and the ability to teach a POP-Q examination doubled (P < 0.001). The median score on a multiple-choice knowledge assessment increased by 40% (P < 0.001). Learners felt that the pelvic model was an effective teaching tool that increased interest in the field of urogynecology. CONCLUSIONS: Using a high-fidelity, dynamic model in didactic sessions enhances education about POP and the POP-Q system and should be used to improve learner exposure and experience.

A robotic approach to management of failed sacrocolpopexy and sacrocolpopexy complications: a case series.

INTRODUCTION AND HYPOTHESIS: Approximately 5% of patients pursue reoperation after sacrocolpopexy (SCP). Reasons for re-operation include recurrence of prolapse, mesh erosion, bowel and bladder dysfunction, and pain. We aim to describe patient presentation, intraoperative findings, and subsequent robotic approach to management of SCP failures and complications. METHODS: This is a case series of patients who underwent abdominal re-exploration after SCP over 7 years at a single institution. Demographic data, previous prolapse surgery, presenting complaint, prolapse stage, operative notes, and outcomes were reviewed. Nineteen patients were identified by CPT codes; ten met inclusion criteria. RESULTS: Seven of the ten patients presented with vaginal bulge, urinary frequency and urgency; four also had stress urinary incontinence. Two patients presented with vaginal bleeding and another with vaginal pain. Operative findings on reoperation for patients who had vaginal bulge included detachment from the vagina or cervix (n = 4, 57%) and the anterior longitudinal ligament (n = 3, 43%). Of these, two had their SCP mesh reattached, and five had SCP mesh removal and replacement. The patients with vaginal bleeding and pain underwent mesh excisions. All ten patients had uncomplicated postoperative courses with resolution of symptoms in most cases. CONCLUSIONS: Prolapse recurrence and complications after SCP have a significant impact on patient quality of life. Recurrent prolapse after SCP theoretically occurs because of mesh detachment from the cervix/vagina, the anterior longitudinal ligament, or disruption/stretching of the mesh. Our case series demonstrates that abdominal re-exploration is feasible and valuable in these rare cases.

Gunshot Fractures of the Forearm: A Multicenter Evaluation.

OBJECTIVES: To evaluate a large series of open fractures of the forearm after gunshot wounds (GSWs) to determine complication rates and factors that may lead to infection, nonunion, or compartment syndrome. DESIGN: Multicenter retrospective review. SETTING: Nine Level 1 Trauma Centers. PATIENTS/PARTICIPANTS: One hundred sixty-eight patients had 198 radius and ulna fractures due to firearm injuries. All patients were adults, had a fracture due to a firearm injury, and at least 1-year clinical follow-up or follow-up until union. The average follow-up was 831 days. INTERVENTION: Most patients (91%) received antibiotics. Formal irrigation and debridement in the operating room was performed in 75% of cases along with either internal fixation (75%), external fixation (6%), or I&D without fixation (19%). MAIN OUTCOME MEASURES: Complications including neurovascular injuries, compartment syndrome, infection, and nonunion. RESULTS: Twenty-one percent of patients had arterial injuries, and 40% had nerve injuries. Nine patients (5%) developed compartment syndrome. Seventeen patients (10%) developed infections, all in comminuted or segmental fractures. Antibiotics were not associated with a decreased risk of infection. Infections in the ulna were more common in fractures with retained bullet fragments and bone loss. Twenty patients (12%) developed a nonunion. Nonunions were associated with high velocity firearms and bone defect size. CONCLUSIONS: Open fractures of the forearm from GSWs are serious injuries that carry high rates of nonunion and infection. Fractures with significant bone defects are at an increased risk of nonunion and should be treated with stable fixation and proper soft-tissue handling. Ulna fractures are at a particularly high risk for deep infection and septic nonunion and should be treated aggressively. Forearm fractures from GSWs should be followed until union to identify long-term complications. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Combined Orthopaedic and Vascular Injuries With Ischemia: A Multicenter Analysis.

OBJECTIVES: To review a large, multicenter experience to identify the current salvage and amputation rates of these combined injuries and, where possible, the variables that predict amputation. DESIGN: Retrospective. SETTING: Nine trauma centers. PATIENTS: This study involved 199 patients presenting to 9 trauma centers with orthopaedic and vascular injuries resulting in ischemic limbs for whom the orthopaedic service was involved with the decision for salvage versus amputation. RESULTS: We reviewed 199 patients, 17-85 years of age. One hundred seventy-two of the injuries were open. Thirty-eight patients (19%) were treated with amputation upon admission as they were deemed to be unsalvageable. Of the remaining 161 patients who had attempted salvage, 36 (30%) required late amputation. Closed injuries were successfully salvaged in 25 of 27 cases (93%). The highest rate of amputation was in tibia fractures with a combined amputation rate of 62%. In those attempted to be salvaged, 21 of 48 (44%) required amputation. The ischemia time for successful salvage was significantly less, P = 0.03. One hundred twenty-four patients had their definitive vascular repair before the bony reconstruction. There were 15 vascular complications, of which 13 (86%) had the definitive vascular repair performed before the definitive osseous repair, although this was not statistically significant. CONCLUSIONS: In this series of combined orthopaedic and vascular injuries, we found a high rate of acute and late amputations. It is possible that other protocols, such as shunting and stabilizing the osseous injury, before vascular repair may benefit limb salvage, although this needs more study. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Henry Versus Thompson Approach for Fixation of Proximal Third Radial Shaft Fractures: A Multicenter Study.

OBJECTIVE: To compare the volar Henry and dorsal Thompson approaches with respect to outcomes and complications for proximal third radial shaft fractures. DESIGN: Multicenter retrospective cohort study. PATIENTS/PARTICIPANTS: Patients with proximal third radial shaft fractures ± associated ulna fractures (OTA/AO 2R1 ± 2U1) treated operatively at 11 trauma centers were included. INTERVENTION: Patient demographics and injury, fracture, and surgical data were recorded. Final range of motion and complications of infection, neurologic injury, compartment syndrome, and malunion/nonunion were compared for volar versus dorsal approaches. MAIN OUTCOME: The main outcome was difference in complications between patients treated with volar versus dorsal approach. RESULTS: At an average follow-up of 292 days, 202 patients (range, 18-84 years) with proximal third radial shaft fractures were followed through union or nonunion. One hundred fifty-five patients were fixed via volar and 47 via dorsal approach. Patients treated via dorsal approach had fractures that were on average 16 mm more proximal than those approached volarly, which did not translate to more screw fixation proximal to the fracture. Complications occurred in 11% of volar and 21% of dorsal approaches with no statistical difference. CONCLUSIONS: There was no statistical difference in complication rates between volar and dorsal approaches. Specifically, fixation to the level of the tuberosity is safely accomplished via the volar approach. This series demonstrates the safety of the volar Henry approach for proximal third radial shaft fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Does surgical treatment of atypical endometrial hyperplasia require referral to a gynecologic oncologist?

Patients with atypical endometrial hyperplasia in the United States are commonly referred to a gynecologic oncologist, given a moderate risk of concurrent carcinoma. However, selective referral of patients to nononcologic gynecologic surgeons for surgical treatment of atypical endometrial hyperplasia may offer increased access to care without compromising clinical outcomes. Nononcologic surgeons who consider providing surgical treatment for atypical endometrial hyperplasia must be able to offer minimally invasive surgery when appropriate and have sufficient surgical volume to deliver optimal clinical outcomes. Patients considering referral to a nononcologic surgeon must be thoroughly counseled regarding the risk of occult malignancy, the possibility of a second surgery for lymph node evaluation and/or oophorectomy, and the risk of morbidity that may accompany a second surgery. Available data suggest that approximately 2-6% of patients will have postoperative risk factors meriting consideration of a second surgery. Patients who are high-risk surgical candidates or who may desire nonsurgical or fertility-sparing treatment should universally be referred for consultation with a gynecologic oncologist.

Interventions for Frequently Hospitalized Patients and Their Effect on Outcomes: A Systematic Review.

BACKGROUND: A small subset of patients account for a substantial proportion of hospital readmissions. Programs to reduce utilization among this subset of frequently hospitalized patients have the potential to improve health and reduce unnecessary spending. PURPOSE: To conduct a systematic review of interventions targeting frequently hospitalized patients. DATA SOURCES: PubMed MEDLINE; Embase (embase.com); and Cochrane Central Register of Controlled Trials, January 1, 1980 to January 1, 2018. STUDY SELECTION: Four physicians screened 4762 titles and abstracts for inclusion. Authors reviewed 116 full-text studies and included 9 meeting criteria. DATA EXTRACTION: Study characteristics, outcomes, and details regarding interventions were extracted. Risk of bias was assessed by the Downs and Black Scale. DATA SYNTHESIS: Out of the nine included studies, three were randomized controlled trials, three were controlled retrospective cohort studies, and three were uncontrolled pre-post studies. Inclusion criteria, interventions used, and outcomes assessed varied across studies. While all nine studies demonstrated reduced utilization, studies with lower risk of bias generally found similar reductions in utilization between intervention and control groups. Interventions commonly consisted of interdisciplinary teams interacting with patients across health care settings. CONCLUSIONS: Interventions targeting high need, high-cost patients are heterogeneous, with many studies observing a regression to the mean. More rigorous studies, using multifaceted interventions which can adapt to patients' unique needs should be conducted to assess the effect on outcomes relevant to both providers and patients.

Isokinetic Strength Testing Following Intramedullary Nailing of Tibial Shaft Fractures Predicts Time to Recovery and Return of Muscle Strength in the Injured Extremity: A Prospective Case Series.

BACKGROUND: The speed and degree of functional recovery over time after surgery for tibial shaft fracture has been previously described using subjective methods. QUESTIONS/PURPOSE: This study aimed to quantitatively measure recovery of isokinetic strength in the injured leg after surgical repair of isolated closed tibial shaft fracture. METHODS: In this prospective case series, patients were recruited after intramedullary nailing for isolated closed tibial shaft fracture at an academic medical center from January 2012 to December 2015. Recovery of isokinetic strength was quantified using an isokinetic dynamometer. Eight measures of isokinetic strength at 3, 6, and 12 months' follow-up were used to compare strength in the injured leg to the healthy leg. RESULTS: In 36 patients recruited, there was a significant difference in strength between the healthy and injured legs at 3 months for seven of the eight metrics used, at 6 months for five of the eight metrics, and at 12 months for none of the eight metrics. Observing recovery of strength longitudinally, we saw significant improvement between 3 and 6 months for four of eight metrics and overall between 3 and 12 months for five of the eight metrics. All four metrics that showed a significant improvement between 3 and 6 months involved plantar flexion. No metrics showed significant improvement between 6 and 12 months. CONCLUSIONS: Patients exhibited equal strength between their healthy and injured legs at 12 months after surgery. Improvement in strength occurred to a greater extent between 3 and 6 months after surgery than between 6 and 12 months. Plantar flexion appeared to improve more rapidly than dorsal extension.