The Feasibility and Safety of vNOTES Hysterectomy and Uterosacral Ligament Suspension: A Case Series.

The transvaginal natural orifice transluminal endoscopic surgery (vNOTES) is a recently introduced surgical approach that is even less invasive than conventional laparoscopy or robotic surgery. We conducted this study to report our experience in vNOTES hysterectomy and uterosacral ligament suspension and determine the feasibility and safety of this approach. Surgeries on 23 women were performed by a single surgeon in 1 tertiary medical center. Patient demographics, perioperative data, and follow-up details of 23 women were collected prospectively. Average age was 56.7 ± 8.9 years. Median parity was 3. Nine patients were smokers, and 4 patients had diabetes. Median stage of prolapse was 3. One patient had extensive adhesions, and after vNOTES hysterectomy was completed, decision was made to perform uterosacral suspension by conventional vaginal access. Another patient had intraoperative identification by cystoscopy of unilateral kinking of the ureter that was resolved after the most distal uterosacral stitch was released. Mean uterine weight was 271.9 ± 131.9 g. Average estimated blood loss was 85.22 ± 55.6 mL. Median length of stay in the hospital was 1 day. Only 1 patient had intermittent voiding postoperatively and required an indwelling catheter for 3 days. Hysterectomy and uterosacral ligament suspension when performed via vNOTES is a safe and feasible procedure. Large prospective trials are on the way to continue shedding light on this new surgical modality.

The efficacy of force of stream assessment for post-operative catheter management: a retrospective cohort study.

INTRODUCTION AND HYPOTHESIS: Postoperative urinary retention is common after urogynecologic procedures. Our objective is to determine the efficacy of force of stream (FOS) assessment without a visual analog scale for postoperative catheter management. METHODS: We conducted a retrospective cohort study of 110 women undergoing an inpatient gynecologic procedure. They were asked to subjectively assess FOS after surgery without a visual analog scale. If it was 50% or better than the usual preoperative void, they were discharged home without a catheter. If < 50%, the catheter was replaced and the patients were sent home and asked to follow up in 3 to 5 days for another void trial. RESULTS: Average age was 56.9 ± 10.2 years; 63.6% underwent surgery for pelvic organ prolapse, 23.6% underwent sling for urinary incontinence, and 12.7% underwent a combination of both. Force of stream was > 50% in 93.6% of the patients; 6.4% had force of stream < 50% and hence were discharged home with a Foley catheter. Only two patients (1.8%) were discharged without a Foley catheter and returned to the emergency department for signs of urinary retention. Sensitivity, specificity, positive and negative predictive values were 77.8%, 100%, 100% and 98.1%, respectively. CONCLUSION: The subjective assessment of flow of stream is a reliable and safe method to assess postoperative voiding. Given it is less invasive than backfilling the bladder and easier than using a bladder scan, it should be the primary method to assess postoperative voiding.

An Overlooked Disease: Minimal Autonomous Cortisol Secretion (MACS). A Narrative Review.

BACKGROUND: A far more common disease than Cushing's syndrome is subclinical hypercortisolism or mild autonomous cortisol secretion (MACS), with an overall prevalence of 0.2-2%. OBJECTIVE: This review aims to shed light on the prevalence, screening and diagnostic criteria, comorbidities, and management of Mild Autonomous Cortisol Secretion (MACS). METHODS: Studies eligible targeted MACS regarding prevalence, screening, comorbidities, management, and clinical outcome. This is a mini-review. IRB approval was not needed. RESULTS: The 1 mg Dexamethasone suppression test (DST) remains the first screening test. MACS is associated with adverse cardiometabolic and renal outcomes, osteoporosis and osteopenia, immunodeficiency, depression, coagulopathy, and sarcopenia. Surgery is the gold standard treatment. Medical therapy is recommended when surgery is contraindicated or not feasible. Clinically silent hypercortisolism is a frequent entity that necessitates early detection and treatment. The production of cortisol should be looked at as a spectrum where subtle, undetectable levels can still be produced. They know its association with adverse health outcomes. CONCLUSION: MACS is no longer considered an asymptomatic disorder; repeated hormonal and functional tests are crucial to prevent multiorgan damage.

Primary Hyperparathyroidism in Older Adults: A Narrative Review of the Most Recent Literature on Epidemiology, Diagnosis and Management.

BACKGROUND: Primary hyperparathyroidism (PHPT) is a common endocrine disorder among older adults. The aim of this review is to shed light on PHPT, particularly in this age group, in terms of prevalence, clinical manifestations, medical and surgical management, and post-operative complications. METHODS: Eligible studies were those considering PHPT exclusively in the older population (main databases: PubMed, Medline, Google Scholar and the University Online database). Articles published in the last 10 years (2013-2023) were considered. Eligibility criteria followed the SPIDER (sample, phenomenon of interest, design, evaluation, research type) tool. The methodological quality of the studies was assessed using the Joanna Briggs Institute critical appraisal tool. A total of 29 studies (mainly observational) matched the inclusion criteria. RESULTS: The prevalence of PHPT is approximately 1 per 100 in the elderly, and it is more common in females. The clinical presentation varies by age and can include osteoporosis, fractures, and neuropsychiatric symptoms. Conservative management can be an option whenever surgery is not indicated or feasible. However, parathyroidectomy (PTX) remains a safe and effective modality in aging populations with improvement to symptoms, bone mineral density, fracture risk, frailty, quality of life, and metabolic derangements. Complication rates are similar in elderly people compared to younger ones, except for mildly longer length of hospital stay and reoperation for those with higher frailty. CONCLUSION: PHPT is a common yet overlooked and underdiagnosed condition among the older population. The safety and efficacy of PTX in the older population on different levels is now well demonstrated in the literature.

A review of monkeypox infection during pregnancy.

The present study aimed to review monkeypox infection during pregnancy: its epidemiology and etiology, transmission, clinical manifestations and complications, diagnosis, management, antenatal testing and delivery, prevention, awareness, and recommendations. Monkeypox can spread via vertical transmission. The usual clinical symptoms include fever, rash (vesicles, crust), new genital lesions, or sore throat. It is only recommended to use cidofovir in pregnant patients when they are severely infected with monkeypox. All woman who are at high risk of exposure for monkeypox need to be vaccinated with the smallpox vaccine regardless of their pregnancy status. Monitoring includes regular non-stress test monitoring in addition to ultrasound performed at various stages of pregnancy. High index of suspicion, informed physicians, reporting of cases, and support of research are all needed for the management of monkeypox infection during pregnancy.

Effect of COVID-19 vaccinations on menstrual cycle and postmenopausal bleeding among health care workers: A cross-sectional study.

OBJECTIVE: To determine the effect of coronavirus disease 2019 (COVID-19) vaccination and its association with sociodemographic factors on the menstrual cycle in premenopausal women and on postmenopausal bleeding. METHODS: This is a retrospective cross-sectional study conducted between September 22, 2022, and November 30, 2022, via a questionnaire distributed to 359 health care workers (HCWs) at Lebanese American University Medical Center-Rizk Hospital and St John's Hospital. Inclusion criteria included female Lebanese HCWs who were vaccinated and aged 18 to 65 years. RESULTS: Change in cycle length was significantly associated with age (P = 0.025 after the first dose and P = 0.017 after the second dose), level of education (P = 0.013 after the first dose and P = 0.012 after the second dose), and fibroids (P = 0.006 after the second dose and P = 0.003 after the third dose). The change in cycle flow was significantly associated with age (P = 0.028), fibroids (P = 0.002 after the second dose and P = 0.002 after the third dose), bleeding disorders (P = 0.000), and chronic medications (P = 0.007). The change in symptoms was associated with polycystic ovary syndrome (P = 0.021), chronic medications (P = 0.019 after the second dose and P = 0.045 after the third dose), and fibroids (P = 0.000). CONCLUSION: COVID-19 vaccination can influence the menstrual cycle. Age, body mass index, level of education, underlying comorbidities, and use of chronic medications are significantly associated with changes in menstrual length, flow, and symptoms following vaccination.

A systematic review on the efficacy of vitamin B supplementation on diabetic peripheral neuropathy.

CONTEXT: Diabetic peripheral neuropathy (DPN) is a common complication. OBJECTIVE: To re-evaluate the role of vitamin B supplementation on reducing the signs and symptoms of DPN. DATA SOURCES: Electronic databases such as PubMed, Cochrane Library, and Medline. DATA EXTRACTION: An Excel spreadsheet was used to report the extracted relevant data. DATA ANALYSIS: Fourteen randomized controlled trials were selected, comprising a pooled sample of 997 study subjects. The pooled odds ratio values were 3.1 (95%CI, 1.197-8.089) and 3.04 (95%CI, 1.556-5.937) for pain and dysesthesia outcomes, respectively. For the amplitude change in electromyography of the sensory sural nerve, the weighted difference from 2 studies was 0.37 (95%CI, 0.034-0.709) in favor of intervention. Peak latency changes were in favor of the intervention group. Two studies yielded a weighted difference of 0.571 (95%CI, 0.310-0.831) for the velocity outcome in favor of intervention. Unlike the fibular nerve, the electromyographic motor outcomes of the tibial nerve were in favor of vitamin B supplementation. CONCLUSION: Vitamin B supplementation could improve many symptoms and signs of DPN.

Complete androgen insensitivity syndrome in a 13-year-old Lebanese child, reared as female, with bilateral inguinal hernia: a case report.

BACKGROUND: Androgen insensitivity syndrome is a rare X-linked disorder of sex development, caused by mutations in the androgen receptor. In this case, a 13-year-old child, reared as female, presenting for primary amenorrhea, was diagnosed with complete androgen insensitivity syndrome. CASE PRESENTATION: A 13-year-old Caucasian child, reared as female, presents with primary amenorrhea. Physical examination revealed female appearance and a short vagina with blind-ended pouch. Laboratory examination showed high levels of testosterone and anti-Müllerian hormone; uterus and ovaries were absent. Karyotype confirmed a 46,XY pattern. Deoxyribonucleic acid analysis of the androgen receptor gene revealed a homozygous mutation p.R856C in exon 7. Gender was assigned as female, and she was started on hormonal therapy and underwent gonadectomy. CONCLUSION: Androgen insensitivity syndrome comprises a large spectrum of presentations. High index of suspicion is needed. Investigation of girls with bilateral inguinal hernia is critical.

DIABETIC KETOACIDOSIS ASSOCIATED WITH ALPELISIB TREATMENT OF METASTATIC BREAST CANCER.

OBJECTIVE: Alpelisib-induced diabetic ketoacidosis (DKA) is a rare, but life-threatening, adverse event. There have been only 2 reported cases in the literature. We describe such a case, with emphasis on the importance of screening and achieving adequate glycemic control prior to and after initiation of therapy. METHODS: A 49-year-old woman, known to have advanced breast cancer, presented with a 3-day history of nausea, vomiting, and diffuse abdominal pain. She had started alpelisib at 300 mg/day 2 months prior to presentation, after failing other options. She was diagnosed with DKA using her clinical and laboratory features, leading to treatment with hydration and intravenous insulin therapy. RESULTS: Laboratory data showed high anion gap metabolic acidosis, hyperglycemia, and ketonemia with negative GAD-65 antibodies, leading to the diagnosis of alpelisib-associated DKA. Alpelisib was held, and she was treated with intravenous insulin and hydration. When DKA and hyperglycemia resolved, alpelisib was resumed at a lower dose (200 mg/day) and her blood glucose was managed using a regimen combining insulin and metformin. CONCLUSION: Phosphatidylinositol-3 kinase signaling is important for the metabolic actions of insulin, and alpelisib has been associated with severe hyperglycemia. Metformin is the first-line treatment, however when DKA is the presenting syndrome, insulin needs to be considered. Blood glucose and hemoglobin A1c should be checked prior to treatment initiation and monitored closely after drug initiation. DKA, albeit rare, must be considered in an acutely ill, alpelisib-treated patients presenting with metabolic acidosis, and if drug discontinuation is not an option, insulin treatment may be required to control glycemia.