Postoperative Opioid Filling Patterns in Women Undergoing Midurethral Sling Placement.

OBJECTIVE: To evaluate postoperative opioid filling patterns for patients undergoing isolated midurethral sling placement. METHODS: Patients undergoing midurethral sling placement from 2005 to 2016 were identified in the Truven Health MarketScan database. We determined whether sling placement was an isolated procedure or performed in conjunction with other benign gynecologic procedures. All outpatient prescription drug claims for opioids were extracted from 28 days before surgery to 28 days after surgery. We identified the number of prescriptions filled and calculated morphine milligram equivalents (MMEs) in the allotted perioperative windows. The proportion of patients with opioid prescription claims and cumulative MMEs were compared for multiple versus isolated procedures using χ2 and Wilcoxon tests, respectively. RESULTS: The cohort included 153,631 patients, with 79,069 (51.5%) having an isolated procedure and 74,562 (48.5%) having multiple benign procedures. Seventy-two percent of the patients undergoing isolated midurethral sling placement received at least 1 opioid prescription in the study period compared with 79% of those undergoing combined procedures (P < 0.001). The median cumulative MMEs for isolated midurethral sling and midurethral sling + multiple procedures were 150 and 225 MMEs, respectively (P < 0.001). Across the years under study, the proportion of patients filling opioid prescription claims increased, but the median cumulative MME was unchanged. CONCLUSIONS: Patients undergoing isolated midurethral sling placement filled a median of 150 cumulative MMEs, and the proportion of patients filling perioperative opioid prescriptions increased over the study period.

Factors associated with the successful completion of randomized controlled trials in gynecological oncology.

PURPOSE: The aim of our review was to ascertain factors associated with the successful completion of a randomized controlled trial in gynecological oncology. MATERIALS AND METHODS: This retrospective cohort study utilized data collected from the National Institutes of Health's US National Library of Medicine database on ClinicalTrials.gov. Data was collected over a five year period (2009-2013). Utilizing the search terms under the National Institutes of Health recommended "Studies by Topics" gynecological oncology studies were identified. Randomized controlled trials were selected for based on intervention and randomization criteria. Elements were then compared with statistical analysis performed using SASS. RESULTS: As of September 1st 2018, 149 of the 318 identified randomized controlled trials were successfully completed over a median length of 44 months (IQR 30.0-55.0). Completed randomized controlled trials were more likely to be performed at single centers (p < 0.005). Interventional, drug and device trials were not significantly more likely to be completed. There was no difference in funding sources for completed or not completed randomized controlled trials. CONCLUSIONS: Prospective randomized trials are essential for establishing the standard of care in clinical medicine. They are, however, time and resource intensive. Herein we have attempted to identify factors associated with successful and timely completion of gynecologic oncology randomized controlled trials including site of origin, number of participating sites, funding source, intervention type, enrollment size, and study length; however, none of these factors were observed to have an association with increased rates of trial publication.

Pathway to the Papanicolaou smear: The development of cervical cytology in twentieth-century America and implications in the present day.

George Papanicolaou, a Greek immigrant and cytopathologist, was responsible for what is now colloquially known as the "Pap smear"-undoubtedly one of the greatest advances in medicine and public health of the last century. However, his landmark research on the development of cervical cytology for the detection of precancerous lesions of the cervix ("New Cancer Diagnosis," 1928) made a rather inauspicious debut in an unlikely venue: John Harvey Kellogg's Third Race Betterment Conference-a meeting devoted to the furtherance of the concept and implementation of eugenics. Herein, we discuss the stark juxtaposition of Papanicolaou's landmark discovery amid the pseudoscience of the third Race Betterment Conference. We discuss the latency of Papnicolaou's discovery-its potential implications unrealized-until co-publication with Herbert Traut, which catapulted Papanicolaou's research to the scientific foreground. This gave rise to public health initiatives aimed at establishing the Pap smear as a screening tool. We further delineate the progress made in recent decades with the identification of HPV as the etiological agent for cervical cancer, and the subsequent development of the HPV vaccine, and discuss ongoing research in the present day. In this way, we hope to provide a background and historical context for the development of the Pap smear.

Intimate partner violence discussions in the healthcare setting: A cross-sectional study.

In 2013, the United States Preventive Services Task Force recommended routine intimate partner violence (IPV) screening for reproductive-age women. Given the increased attention paid to IPV on a national scale, and broader recognition of its social and physical implications, we sought to characterize the discussions resulting from routine IPV screening-specifically regarding provider response and patient perceptions. In a cross-sectional analysis, we implemented a survey to examine outcomes of IPV screening, including use of guideline-concordant discussion topics and interventions, as well as patient perception of the encounters. Women aged 18-65 with lifetime history of IPV and a past-year healthcare appointment were recruited from clinics and women's shelters in Pennsylvania. Data collection took place from May 2014-January 2015. Of 253 women, 39% were screened for IPV at a healthcare visit in the year prior to survey administration. Of women who were screened, guideline-concordant discussion topics were employed in 70% of encounters and guideline-concordant interventions were offered in 72% of encounters. 58% of women reported being "extremely" or "very satisfied," and 53% reported being "extremely" or "very comfortable" with IPV-related discussions. The low rate of screening in this population reiterates the importance of focusing efforts on educating providers on the importance of screening, promoting the availability of community resources, and developing systems-based practices that foster IPV screening, discussion, and referral following disclosure.

Tumor lysis syndrome in a patient with ovarian yolk sac tumor.

•Tumor lysis syndrome is an oncologic emergency with profound metabolic derangements.•Germ cell tumors with large disease burden increase the risk for tumor lysis syndrome.•Herein we present a case of tumor lysis syndrome prior to initiation of cytotoxic chemotherapy for ovarian yolk sac tumor.

The cost of seeking an edge: Recurrent renal infarction in setting of recreational use of anabolic steroids.

INTRODUCTION: Anabolic-androgenic steroid (AAS) use and testosterone therapy have been well established risk factors for the creation of a pro-thrombotic state, and to precipitate formation of thromboemboli in individuals already predisposed to thrombosis. CASE REPORT: Here, we present the case of an amateur bodybuilder, with a negative thrombophilia workup, who experienced primary renal infarction while using the AAS trenbolone acetate and testosterone, as well as a subsequent renal infarction while anticoagulated with apixaban. DISCUSSION: The development of subsequent infarctions in an anticoagulated patient with discontinued recreational steroid use poses a unique situation and challenges the current understanding of a thrombophilic state associated with steroids. The lifetime prevalence of anabolic steroid use is estimated to be 1% in the male population in the United States which is significant. CONCLUSION: Further understanding and recommendations of appropriate anticoagulant should be further elucidated to appropriately medically manage patients from this confounding social and medical history.

The Wertheim hysterectomy: Development, modifications, and impact in the present day.

Ernst Wertheim was a pioneer in the history of the surgical treatment of cervical cancer. His English-language manuscript "The extended abdominal operation for carcinoma uteri (based on 500 operative cases)," which was published in 1912, detailed his standardization of the radical hysterectomy and formed the basis of the current treatment for early stage cervical cancer. We contextualize the Wertheim hysterectomy, emphasizing medical advances that allowed for its development and subsequent modification. We then discuss modifications to the originally proposed procedure, including a maximally extended parametrical resection pioneered by Takayama, and the addition of the Taussig en bloc lymph node dissection by Meigs, both of which afforded an improved mortality profile due to decreased disease recurrence. Finally, we discuss progress that has been made in the present day, such as the development of nerve-sparing and fertility-sparing surgeries, as well as the introduction of the robotic platform. In this way, we hope to provide a historical background for the Wertheim hysterectomy-a cornerstone of gynecologic oncology.

Intimate partner violence screening and counseling in the health care setting: Perception of provider-based discussions as a strategic response to IPV.

Intimate partner violence (IPV) affects women worldwide, and is addressable in the health care setting not only via screening, but also through provider-based counseling and referral to legal or social services, as appropriate. We conducted a study in Pennsylvania (USA) examining factors associated with receipt of IPV screening and women's perceptions of counseling discussions as a strategic response. We found that women with past-year IPV were more likely to receive screening (aOR: 2.0, 95%CI: 1.2,3.5) and to consider counseling discussions to be a strategic response to IPV exposure (aOR: 2.7, 95%CI: 1.008,7.2) than women with a more distant history of IPV. Scholars and clinicians may learn that, especially for women with a recent history of IPV, screening may provide a conduit to meaningful counseling discussions and referrals that women view as a helpful strategy in responding to IPV.

Fine Mapping of 6q23.1 Identifies TULP4 as Contributing to Clefts.

Objective : The aim of this work was to fine-map the region 6q23.1, which obtained suggestive linkage signal (logarithm of the odds [LOD] score = 2.22 under a recessive model) to cleft lip with or without cleft palate (CL±P) in our previous genome-wide linkage scan to identify possible genetic variants that may contribute to CL±P. Design : We used densely spaced markers spanning the entire 6q23.1 region to test for association with CL±P in a family cohort sample. Setting : Clinical information and DNA samples were obtained from families in the Philippines at their homes or primary health care clinics. Participants : The study sample consisted of 477 subjects (224 females and 253 males), segregating isolated CL±P, from 72 living in the same area in the Philippines. Main Outcome Measure : Overtransmission of alleles to persons born with CL±P. Results : We found statistical evidence of association between a marker of TULP4 (rs651333) with CL±P (P = .00007). Conclusions : Our results further support the linkage results for the chromosome 6q region and reveal a novel candidate gene for CL±P.