Vasopressin Injection Purse-String Ectopic Resection technique for laparoscopic management of cornual ectopic pregnancy.

Although cornual pregnancy is a rare form of ectopic pregnancy, the associated mortality rate is considerably higher than that of ectopic pregnancy overall. Historically, cornual ectopic pregnancy has been treated via laparotomy. With advancements in technology, equipment, and technique, laparoscopy offers a safer approach for the management of cornual pregnancy. However, laparoscopy of this nature requires excellent technique. The Vasopressin Injection Purse-String Ectopic Resection technique serves as an effective strategy for the laparoscopic management of cornual ectopic pregnancy. First, dilute vasopressin is administered into the myometrium surrounding the pregnancy. Next, a purse-string stitch is placed in the myometrium circumferential to the pregnancy. Finally, the pregnancy is excised by cornual wedge resection, and the defect is repaired using the attached remaining suture from the purse-string stitch. The Figure shows the graphical depiction of the Vasopressin Injection Purse-String Ectopic Resection technique, and the Video shows a laparoscopic recording of the Vasopressin Injection Purse-String Ectopic Resection technique. Between 2012 and 2022, 17 patients underwent a laparoscopic cornual ectopic pregnancy resection at a high-volume academic hospital and its affiliated community hospital. This case series revealed a mean operative time of 107 minutes, with a mean estimated blood loss of 41 mL for nonruptured ectopic pregnancies and 412 mL for ruptured ectopic pregnancies. No case was converted to laparotomy. Our findings suggest that the integration of the vasopressin administration and the pursue-string stitch placement minimizes blood loss and mitigates the risk of conversion to laparotomy for both nonruptured and ruptured cornual ectopic pregnancies.

Understanding barriers to treatment among individuals not engaged in treatment who misuse opioids: A structural equation modeling approach.

Background: Many individuals misusing opioids do not enter into treatment. The question of who enters into treatment for their opioid abuse and under what circumstances is complex and shaped by multiple factors. The objective of the current study is to explore the risk factors for wide-ranging and numerous barriers to treatment among social media users. Method: Opioid-related forums within a popular social media platform were used to recruit non-treatment engaged individuals (≥15 years) who had misused opioids in the past month (n = 144; 66% male; median age 28). Four treatment barrier factors were identified utilizing principle component analysis: (1) stigma, (2) awareness, (3) attitudinal, and (4) denial. A structural equation model (SEM) was then created to explore the risk factors for different types of barriers to OUD treatment. Results: The most common barriers among participants not engaged in treatment for their opioid misuse were the belief that one should be able to help themselves with their condition (66%), treatment was too expensive (63%), and worries about being labeled or judged (57%). Additionally, SEM results demonstrate stigma barriers, awareness, and attitudinal barriers were associated with mental health comorbidities, opioid abuse and dependence severity, and treatment history. Denial barriers, however, were only associated with treatment history, and structural/financial barriers were only associated with opioid abuse and dependence severity. Conclusions: Our research findings are relevant for underscoring the wide-ranging and numerous barriers to treatment faced by individuals misusing opioids that are especially concentrated among those who also struggle with comorbid mental illness.

Assessing Physician Adherence to Guidelines for Cervical Cancer Screening and Management of Abnormal Screening Results.

OBJECTIVE: The aim of the study was to survey obstetrician-gynecologists' cervical cancer screening practices and management of cervical abnormalities to ascertain adherence to guidelines. METHODS: From January to July 2019, obstetrician-gynecologists at 5 St. Louis area hospitals were surveyed online about cervical cancer screening and management practices through 13 clinical vignettes. Survey scores and the American Society of Colposcopy and Cervical Pathology (ASCCP) app use were compared using Mann-Whitney tests. RESULTS: When screening 30- to 65-year-old participants, 114 (98%) of the 116 total participants used co-testing, but only 71 (61%) screened at 5-year intervals. None used primary human papillomavirus (HPV) testing. For 21- to 29-year-old participants, 17 (15%) screened with annual cytology, whereas 14 (12%) used annual or every 3-year co-testing. Forty eight (41%) screened younger than 21 years, regardless of risk factors or only if immunocompromised. Eleven (9%) continued screening after total hysterectomy for benign indications. Only 2 (2%) responded to all clinical vignettes in adherence to guidelines. More than 30% of participants would pursue unnecessary HPV testing and/or loop electrosurgical excision procedure for persistent low-grade cytology. Fifty eight (48%) incorrectly reported hysterectomy as management for adenocarcinoma in situ on biopsy. Participants would undertreat young women with high-grade abnormalities including high-grade squamous intraepithelial lesion/cervical intraepithelial neoplasia 3 (48, 41%) and high-grade squamous intraepithelial lesion/cervical intraepithelial neoplasia 1 (65, 56%). Forty one (35%) reported exiting women from screening prematurely. The median score for participants using the ASCCP app was significantly greater than those who did not (79% vs 71%, p = .002). CONCLUSIONS: Midwestern obstetrician-gynecologists' adherence to the guidelines for cervical cancer screening and management of abnormal results is suboptimal. Although co-testing for women aged 30-65 years has been broadly adopted, primary HPV testing has not. Physicians overscreen, overtreat low-grade lesions, and undertreat high-grade lesions in young women.

Investigating racial differences in risk factors for primary cesarean delivery.

OBJECTIVE: The objective of the study was to investigate differences in sociodemographic, medical, and obstetric risk factors for primary cesarean delivery between black and white women. STUDY DESIGN: We conducted a retrospective cohort study among 25,251 black and white women delivering a live, singleton infant with vertex presentation at a large, regional hospital between 2004 and 2010. Demographic and clinical data were derived from electronic hospital records. Differences in risk factors for primary cesarean delivery were analyzed using a modified Poisson regression approach stratified by race and parity. RESULTS: Black and white women had a primary cesarean delivery rate of 24.7% and 22.2%, respectively (P < .001). Black women had an increased risk of cesarean delivery after adjusting for sociodemographic and clinical risk factors (adjusted relative risk [RR], 1.23; 95% confidence interval [CI], 1.17-1.29). Among nulliparas, labor induction had a greater effect on cesarean delivery for black women (adjusted RR, 1.32; 95% CI, 1.20-1.44) than for white women (adjusted RR, 1.13; 95% CI, 1.07-1.20). Among multiparas, labor induction reduced the risk of cesarean delivery for white women (adjusted RR, 0.63; 95% CI, 0.55-0.72), whereas no association was observed for black women (adjusted RR, 1.08; 95% CI, 0.92-1.28). Advanced maternal age was a stronger risk factor for black women (adjusted RR, 1.72; 95% CI, 1.43-2.08) than for white women (adjusted RR, 1.30; 95% CI, 1.11-1.52) among multiparas only. Among nulliparas, delivery at 37-38 weeks' gestation reduced the risk of cesarean delivery for black women (adjusted RR, 0.82; 95% CI, 0.73-0.92), whereas no association was observed for white women (adjusted RR, 0.96; 95% CI, 0.90-1.04). CONCLUSION: Labor induction, among nulliparous women, and advanced maternal age, among multiparous women, are stronger risk factors for primary cesarean delivery for black women than for white women.

Posttraumatic carotid cavernous fistula that presented as seizure and focal neurological deficits with symptom resolution after therapeutic coil embolization.

BACKGROUND: A posttraumatic carotid cavernous fistula can remain unrecognized and ultimately present with symptoms characteristic for a middle cerebral artery stroke. Progressive neurologic deterioration can occur until the condition is diagnosed and treated. If unrecognized and untreated, permanent damage may result. CASE REPORT: A 46-year-old white man with the history of a motor vehicle crash 6 months prior presented with complaints of acute onset of expressive aphasia and seizure-like activity for 3 days. On presentation, the patient was noted to have moderate proptosis and chemosis of the left eye. Magnetic resonance imaging of the brain showed an arteriovenous fistula arising from the anterolateral precavernous left internal carotid artery. This was directly communicating with the adjacent cortical veins along the medial aspect of the left temporal lobe, resulting in venous congestion in the left frontal opercular region, the left insula, and subinsular tracks. The patient underwent an intracranial coil embolization of a left carotid cavernous fistula. No complications were encountered, and the patient had near-complete resolution of neurologic deficits and left eye proptosis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although posttraumatic carotid cavernous fistula is a rare condition, it is important to be aware of this entity because immediate diagnosis and treatment may improve outcome.

Parental consent: A potential barrier for underage teens' participation in an mHealth mental health intervention.

PURPOSE: We sought to examine whether underage adolescents displaying symptoms for a mental illness (i.e., an eating disorder) would be willing to obtain parental consent to participate in a study to test the efficacy of an evidence-based mobile mental health intervention targeting teens with eating disorders. METHODS: The participants (n = 366) were 15 to 17 year-old English-speakers who post or follow social media accounts on Instagram that emphasize being thin as important or attractive. The participants were administered a survey through Qualtrics to assess eating disorder pathology, interest in trying an evidence-based mobile mental-health intervention, and comfort level with obtaining parental consent to partake in a research study about such an intervention. RESULTS: About 85% of participants met clinical or subclinical criteria for an eating disorder; however, only 12% had received a treatment within the past six months. While 83% of participants were interested in trying a mobile health interventions app, only 35% indicated willingness to obtain parental consent to participate in a research study. The primary reasons presented for unwillingness to obtain consent included importance of retaining privacy and feeling that parents lack awareness or understanding about mental health issues. CONCLUSIONS: While barriers exist to obtaining treatment for eating disorders, a mobile intervention app may close some of these gaps. Many underage participants indicated interest in obtaining such treatment, yet only a third were willing to obtain parental consent. Future studies should investigate how to reduce these barriers to obtaining parental consent to facilitate teen access to research and mobile mental health treatment.