Predictive factors of return to work after hysterectomy: a retrospective study.

PURPOSE: Although hysterectomy is one of the most frequently performed gynaecological surgeries, there is a dearth of evidence on perioperative care. The aim of the current study was to identify sociodemographic, surgical-related and work-related predictors of recovery following different approaches of hysterectomy. METHODS: Eligible patients for this retrospective cohort study were women who underwent vaginal, abdominal or laparoscopic hysterectomy for both benign and malignant gynaecological disease in 2014 in Máxima Medical Centre in the Netherlands. The main outcome measure was full return to work (RTW). Data were collected using a patient survey. Potential prognostic factors for time to RTW were examined in univariate Cox regression analyses. The strongest prognostic factors were combined in a multivariable model. RESULTS: In total 83 women were included. Median time to full return to work was 8 weeks (interquartile range [IQR] 6-12). The multivariable analysis showed that higher age (hazard ratio [HR] 1.053, 95% confidence interval [CI] 1.012-1.095) and same day removal of indwelling catheter (HR 0.122, 95% CI 0.028-0.539) were predictors of shorter duration until full RTW after hysterectomy. CONCLUSIONS: This study provided insight in the predictors of recovery after hysterectomy. By identifying patient specific factors, pre-operative counselling can be individualized, changes can be made in perioperative care and effective interventions can be designed to target those factors.

Using patient data to optimize an expert-based guideline on convalescence recommendations after gynecological surgery: a prospective cohort study.

BACKGROUND: Convalescence advice is often based on tradition and anecdote from health care providers, rather than being based on experiences from patients themselves. The aim of this study was to analyse recovery in terms of resumption of various daily activities including work, following different laparoscopic and abdominal surgery in order to optimize an expert-based guideline on convalescence recommendations. METHODS: This is a prospective cohort study conducted in nine general and one university hospital in the Netherlands. Women aged 18-65 years and scheduled for a hysterectomy (laparoscopic, vaginal, abdominal) and/or laparoscopic adnexal surgery (n = 304) were eligible to participate. Preoperatively, participants were provided with tailored expert-based convalescence recommendations on the graded resumption of several daily activities including sitting, standing, walking, climbing stairs, bending, lifting, driving, cycling, household chores, sport activities and return to work (RTW). Postoperatively, time until the resumption of these activities was tracked. Convalescence recommendations were considered correct when at least 25% and less than 50% of the women were able to resume an activity before or at the recommended recovery time. RESULTS: There was a wide variation in the duration until the resumption of daily activities within and between groups of patients undergoing different types of surgery. Recovery times lengthened with increasing levels of physical burden as well as with increasing levels of invasiveness of the surgery. For the majority of activities actual recovery times exceeded the recovery time recommended by the expert panel. CONCLUSIONS: This study provided insight in the resumption of daily activities after gynecological surgery and the adequacy of an expert-based convalescence guideline in clinical practice. Patient data was used to optimize the convalescence recommendations. TRIAL REGISTRATION: Dutch trial registry, NTR2087 (August 2009) and NTR2933 (June 2011).

Using e-health in perioperative care: a survey study investigating shortcomings in current perioperative care and possible future solutions.

BACKGROUND: An e-health care program has previously shown to have a positive effect on return to work, quality of life and pain in patients who underwent gynaecological surgery. Plausibly, providing the care program to a population undergoing other types of surgery will be beneficial as well. The objectives of this study are to evaluate patients' opinions, needs and preferences regarding the information and guidance supplied to patients during the perioperative period, to investigate whether e-health may be of assistance and to explore if gender specific needs exist. METHODS: A questionnaire was sent to all patients between 18 and 75 years (n = 362), who underwent various forms of abdominal surgery between August 2013 to September 2014 in a university hospital in the Netherlands. The questionnaire contained questions about the current situation in perioperative care and questions about patients' preferences in an e-health care program. Gender differences were evaluated. RESULTS: Two hundred seven participants (57.2%) completed the survey. The majority of the participants were relatively satisfied with the perioperative care they received (68.6%). Most reported shortcomings in perioperative care concerning the supply of information regarding the resumption of activities and guidance during the recovery course. An e-health care program was expected to be of added value in perioperative care by 78% of the participants; a website was reported as most useful. In particular practical functions on a website focusing on the preparation to surgery and monitoring after surgery were appraised to be highly valuable. Overall, women had slightly more needs for extra information and support during the perioperative course than men. CONCLUSIONS: In abdominal surgery, there is a need for an e-health care program, which should focus mainly on the supply of information about the resumption of activities as well as guidance in the postoperative course.

A modified Delphi method toward multidisciplinary consensus on functional convalescence recommendations after abdominal surgery.

BACKGROUND: Evidence-based information on the resumption of daily activities following uncomplicated abdominal surgery is scarce and not yet standardized in medical guidelines. As a consequence, convalescence recommendations are generally not provided after surgery, leading to patients' insecurity, needlessly delayed recovery and prolonged sick leave. The aim of this study was to generate consensus-based multidisciplinary convalescence recommendations, including advice on return to work, applicable for both patients and physicians. METHOD: Using a modified Delphi method among a multidisciplinary panel of 13 experts consisting of surgeons, occupational physicians and general practitioners, detailed recommendations were developed for graded resumption of 34 activities after uncomplicated laparoscopic cholecystectomy, laparoscopic and open appendectomy, laparoscopic and open colectomy and laparoscopic and open inguinal hernia repair. A sample of occupational physicians, general practitioners and surgeons assessed the recommendations on feasibility in daily practice. The response of this group of care providers was discussed with the experts in the final Delphi questionnaire round. RESULTS: Out of initially 56 activities, the expert panel selected 34 relevant activities for which convalescence recommendations were developed. After four Delphi rounds, consensus was reached for all of the 34 activities for all the surgical procedures. A sample of occupational physicians, general practitioners and surgeons regarded the recommendations as feasible in daily practice. CONCLUSION: Multidisciplinary convalescence recommendations regarding uncomplicated laparoscopic cholecystectomy, appendectomy (laparoscopic, open), colectomy (laparoscopic, open) and inguinal hernia repair (laparoscopic, open) were developed by a modified Delphi procedure. Further research is required to evaluate whether these recommendations are realistic and effective in daily practice.

Magnetic resonance-guided focused ultrasound of uterine leiomyomas: review of a 12-month outcome of 130 clinical patients.

PURPOSE: To assess 12-month outcomes and safety of clinical magnetic resonance (MR)-guided focused ultrasound (US) treatments of uterine leiomyomas. MATERIALS AND METHODS: Between March 2005 and December 2009, 150 women with symptomatic uterine leiomyomas were clinically treated with MR-guided focused US at a single institution; 130 patients completed treatment and agreed to have their data used for research purposes. Patients were followed through retrospective review of medical records and phone interviews conducted at 3-, 6-, and 12-month intervals after treatment to assess additional procedures and symptom relief. Outcome measures and treatment complications were analyzed for possible correlations with the appearance of the tumors on T2-weighted imaging. RESULTS: The cumulative incidence of additional tumor-related treatments 12 months after MR-guided focused US was 7.4% by the Kaplan-Meier method. At 3-, 6-, and 12-month follow-up, 86% (90 of 105), 93% (92 of 99), and 88% (78 of 89) of patients reported relief of symptoms, respectively. No statistically significant correlation between tumor appearance on T2-weighted imaging and 12-month outcome was found. Treatment-related complications were observed in 17 patients (13.1%): 16 patients had minor complications and one had a major complication (deep vein thrombosis). All complications were resolved within the 12-month follow-up period. CONCLUSIONS: MR-guided focused US is a noninvasive treatment option that can be used to effectively and safely treat uterine leiomyomas and delivers significant and lasting symptom relief for at least 12 months. The incidence of additional treatment during this time period is comparable with those in previous reports of uterine artery embolization.

Development of a Personalized m/eHealth Algorithm for the Resumption of Activities of Daily Life Including Work and Sport after Total and Unicompartmental Knee Arthroplasty: A Multidisciplinary Delphi Study.

Evidence for recommendations concerning the resumption of activities of daily life, including work and sport, after knee arthroplasty is lacking. Therefore, recommendations vary considerably between hospitals and healthcare professionals. We aimed to obtain multidisciplinary consensus for such recommendations. Using a Delphi procedure, we strived to reach consensus among a multidisciplinary expert panel of six orthopaedic surgeons, three physical therapists, five occupational physicians and one physician assistant on recommendations regarding the resumption of 27 activities of daily life. The Delphi procedure involved three online questionnaire rounds and one face-to-face consensus meeting. In each of these four rounds, experts independently decided at what time daily life activities could feasibly and safely be resumed after knee arthroplasty. We distinguished patients with a fast, average and slow recovery. After four Delphi rounds, the expert panel reached consensus for all 27 activities. For example, experts agreed that total knee arthroplasty patients with a fast recovery could resume cycling six weeks after the surgery, while those with an average and slow recovery could resume this activity after nine and twelve weeks, respectively. The consensus recommendations will subsequently be integrated into an algorithm of a personalized m/eHealth portal to enhance recovery among knee arthroplasty patients.

Cost-effectiveness of an internet-based perioperative care programme to enhance postoperative recovery in gynaecological patients: economic evaluation alongside a stepped-wedge cluster-randomised trial.

OBJECTIVES: To evaluate the cost-effectiveness and cost-utility of an internet-based perioperative care programme compared with usual care for gynaecological patients. DESIGN: Economic evaluation from a societal perspective alongside a stepped-wedge cluster-randomised controlled trial with 12 months of follow-up. SETTING: Secondary care, nine hospitals in the Netherlands, 2011-2014. PARTICIPANTS: 433 employed women aged 18-65 years scheduled for a hysterectomy and/or laparoscopic adnexal surgery. INTERVENTION: The intervention comprised an internet-based care programme aimed at improving convalescence and preventing delayed return to work (RTW) following gynaecological surgery and was sequentially rolled out. Depending on the implementation phase of their hospital, patients were allocated to usual care (n=206) or to the intervention (n=227). MAIN OUTCOME MEASURES: The primary outcome was duration until full sustainable RTW. Secondary outcomes were quality-adjusted life years (QALYs), health-related quality of life and recovery. RESULTS: At 12 months, there were no statistically significant differences in total societal costs (€-647; 95% CI €-2116 to €753) and duration until RTW (-4.1; 95% CI -10.8 to 2.6) between groups. The incremental cost-effectiveness ratio (ICER) for RTW was 56; each day earlier RTW in the intervention group was associated with cost savings of €56 compared with usual care. The probability of the intervention being cost-effective was 0.79 at a willingness-to-pay (WTP) of €0 per day earlier RTW, which increased to 0.97 at a WTP of €76 per day earlier RTW. The difference in QALYs gained over 12 months between the groups was clinically irrelevant resulting in a low probability of cost-effectiveness for QALYs. CONCLUSIONS: Considering that on average the costs of a day of sickness absence are €230, the care programme is considered cost-effective in comparison with usual care for duration until sustainable RTW after gynaecological surgery for benign disease. Future research should indicate whether widespread implementation of this care programme has the potential to reduce societal costs associated with gynaecological surgery. TRIAL REGISTRATION NUMBER: NTR2933; Results.

Effectiveness of an internet-based perioperative care programme to enhance postoperative recovery in gynaecological patients: cluster controlled trial with randomised stepped-wedge implementation.

OBJECTIVE: To evaluate the implementation and effectiveness of an internet-based perioperative care programme for patients following gynaecological surgery for benign disease. DESIGN: Stepped-wedge cluster randomised controlled trial. SETTING: Secondary care, nine hospitals in the Netherlands, 2011-2014. PARTICIPANTS: 433 employed women aged 18-65 years scheduled for hysterectomy and/or laparoscopic adnexal surgery. INTERVENTIONS: An internet-based care programme was sequentially rolled out using a multifaceted implementation strategy. Depending on the implementation phase of their hospital, patients were allocated to usual care (n=206) or the care programme (n=227). The care programme included an e-health intervention equipping patients with tailored personalised convalescence advice. MAIN OUTCOME MEASURES: The primary outcome was duration until full sustainable return to work (RTW). The degree of implementation of the care programme was evaluated at the level of the patient, healthcare provider and organisation by indicators measuring internet-based actions by patients and providers. RESULTS: Median time until RTW was 49 days (IQR 27-76) in the intervention group and 62 days (42-85) in the control group. A piecewise Cox model was fitted to take into account non-proportionality of hazards. In the first 85 days after surgery, patients receiving the intervention returned to work faster than patients in the control group (HR 2.66, 95% CI 1.88 to 3.77), but this effect was reversed in the small group of patients that did not reach RTW within this period (0.28, 0.17 to 0.46). Indicators showed that the implementation of the care programme was most successful at the level of the patient (82.8%) and professional (81.7%). CONCLUSIONS: Implementation of an internet-based care programme has a large potential to lead to accelerated recovery and improved RTW rates following different types of gynaecological surgeries. TRIAL REGISTRATION NUMBER: NTR2933; Results.

Sperm morphology: classification drift over time and clinical implications.

OBJECTIVE: To assess sperm morphology with Tygerberg (strict) and World Health Organization (WHO) 3rd criteria for intrauterine inseminations (IUI) between two eras to determine if there was a difference in pregnancy rates. DESIGN: Retrospective study. SETTING: Academic institution. PATIENT(S): 127 couples with 290 IUI treatments during 1996-97 (era 1) and 133 couples with 317 IUI treatments during 2005-06 (era 2). INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Pregnancy rates per cycle and couple. RESULT(S): Average sperm morphology was higher in era 1 than era 2 for both WHO 3rd (37 ± 13% vs. 23 ± 10%) and strict criteria (8.0 ± 5.0% vs. 4.0 ± 3.0%). Pregnancy rates per cycle were 5.9% versus 19.8% in era 1 and 16.7% versus 19.3% in era 2 for couples with WHO 3rd morphology <30% or ≥30%, respectively. Pregnancy rates per cycle were 2.7% versus 15.0% in era 1 and 13.3% versus 14.7% in era 2 for couples with strict morphology ≤4% or >4%, respectively. CONCLUSION(S): There was a strong relationship between morphology and IUI outcome in era 1 that was not present in era 2. These results suggest that classification drift increased the percentage of men diagnosed with teratozoospermia and resulted in a loss of predictive value.

Magnetic resonance-guided focused ultrasound surgery for leiomyoma-associated infertility.

OBJECTIVE: To describe magnetic resonance-guided focused ultrasound surgery (FUS) as a treatment for a case of leiomyoma-associated infertility. DESIGN: Case report from a randomized clinical trial. SETTING: Academic medical center. PATIENT(S): A 37-year-old woman with known leiomyomas and a history of 18 months of home-inseminations from a known donor. INTERVENTION(S): Magnetic resonance-guided FUS treatment of uterine fibroids, where the dominant fibroid distorted the uterine cavity. MAIN OUTCOME MEASURE(S): Pregnancy. RESULT(S): A viable intrauterine pregnancy, with a full-term vaginal delivery, was conceived after a single clomiphene citrate and intrauterine insemination cycle. CONCLUSION(S): The role of FUS for enhancement of fertility in women with nonhysteroscopically resectable uterine fibroids distorting the uterine cavity should be investigated further.

Comparing focused ultrasound and uterine artery embolization for uterine fibroids-rationale and design of the Fibroid Interventions: reducing symptoms today and tomorrow (FIRSTT) trial.

OBJECTIVE: To present the rationale, design, and methodology of the Fibroid Interventions: Reducing Symptoms Today and Tomorrow (FIRSTT) study. DESIGN: Randomized clinical trial. SETTING: Two academic medical centers. PATIENT(S): Premenopausal women with symptomatic uterine fibroids. INTERVENTION(S): Participants are randomized to two U.S. Food and Drug Administration-approved minimally invasive treatments for uterine leiomyomas: uterine artery embolization and magnetic resonance-guided focused ultrasound. MAIN OUTCOME MEASURE(S): The primary endpoint is defined as the need for an additional intervention for fibroid symptoms following treatment. Secondary outcomes consist of group differences in symptom alleviation, recovery trajectory, health-related quality of life, impairment of ovarian reserve, treatment complications, and the economic impact of these issues. RESULT(S): The trial is currently in the phase of active recruitment. CONCLUSION(S): This randomized clinical trial will provide important evidence-based information for patients and health care providers regarding optimal minimally invasive treatment approach for women with symptomatic uterine leiomyomas. CLINICAL TRIAL REGISTRATION: NCT00995878.