Association between perimenopausal age and greater posttraumatic stress disorder and depression symptoms in trauma-exposed women.

OBJECTIVE: This study aimed to determine the relationship between stages of the menopause transition (premenopausal, perimenopausal, and postmenopausal) on symptoms of posttraumatic stress disorder (PTSD) and depression in trauma-exposed women. METHODS: A cross-sectional study conducted between 2005 and 2017 recruited and enrolled an urban community sample (n = 6,093) from nonpsychiatric medical clinic waiting rooms of Grady Memorial Hospital, a public safety net hospital in Atlanta, Georgia. Participants were female, 18 to 65 years old, and predominantly Black/African American. RESULTS: Of the 6,093 participants, 93.8% were Black/African American, 2.5% were White, and 3.8% were of all other races (Hispanic/Latino, Asian, multiracial). Participants younger than 40 years were categorized as premenopausal (n = 3,166), between 40 and 55 years of age were categorized as perimenopausal (n = 2,127), and older than 55 years were categorized as postmenopausal (n = 790). Menopause status was associated with total PTSD symptom severity ( F2,5416 = 9.61, P < 0.001), symptom severity within all three PTSD symptom clusters (avoidance/numbing symptoms: F2,5416 = 7.10, P < 0.001; intrusive symptoms: F2,5416 = 7.04, P < 0.001; hyperarousal symptoms: F2,5409 = 8.31, P < 0.001), and depression symptom severity ( F2,5148 = 11.4, P < 0.001). Compared with both premenopausal and postmenopausal women, perimenopausal women reported significantly worse total PTSD symptoms, symptoms in the hyperarousal cluster, and depressive symptoms. CONCLUSIONS: The current cross-sectional data show that symptoms of PTSD and depression in women are associated with reproductive age, such that perimenopausal women show higher symptom severity than premenopausal and postmenopausal women. Future longitudinal studies can reveal how changes in hormones over the course of the menopause transition impact the symptoms, neurobiology, and psychophysiology of PTSD.

Implementation of a Postpartum Hemorrhage Safety Bundle at an Urban Safety-Net Hospital.

Background Postpartum hemorrhage (PPH) is a leading cause of preventable maternal morbidity and mortality. Standardized response to obstetric hemorrhage is associated with significant improvement in maternal outcomes, yet implementation can be challenging. Objective The primary objective is to describe the methodology for program implementation of the Alliance for Innovation on Maternal Health Safety Bundle on PPH at an urban safety-net hospital. Methods Over an 18-month period, interventions geared toward (1) risk assessment and stratification, (2) hemorrhage identification and management, (3) team communication and simulation, and (4) debriefs and case review were implemented. Hemorrhage risk assessment stratification rates were tracked overtime as an early measure of bundle compliance. Results Hemorrhage risk assessment stratification rates improved to >90% during bundle implementation. Conclusion Keys to implementation included multidisciplinary stakeholder commitment, stepwise and iterative approach, and parallel systems for monitoring and evaluation Implementation of a PPH safety bundle is feasible in a resource-constrained setting.

Factors that Lengthen Patient Hospitalizations Following Laparoscopic Hysterectomy.

OBJECTIVE: To establish descriptive observations associated with prolonged hospitalization after laparoscopic hysterectomy prior to the implementation of a department-wide Enhanced Recovery After Surgery protocol. METHODS: A retrospective cohort study at three academic affiliated hospitals in the southeastern United States was conducted evaluating length of hospitalization by patient, surgical, and physician factors for 384 patients who underwent total laparoscopic hysterectomy, laparoscopic assisted vaginal hysterectomy, and robotic assisted total laparoscopic hysterectomy for benign conditions by general and subspecialized gynecologists from 2010 to 2015. RESULTS: Among 384 patients, 19.5% experienced prolonged hospitalization, defined as greater than one day. After adjusting for covariates, robotic assisted total laparoscopic hysterectomy (aOR 3.13), dietary restrictions on postoperative day 1 (aOR 4.42), postoperative nausea or vomiting (aOR 2.01), and postoperative complications (aOR 3.58) were associated with prolonged hospitalization. CONCLUSION: Data from this study were collected prior to implementation of department-wide enhanced recovery after surgery protocols and highlights areas for improvement. Implementation of specific aspects of these protocols, including aggressive prevention of postoperative nausea and vomiting and early feeding, are easily made changes which may help to effectively decrease length of stay after laparoscopic hysterectomy. Patient and provider education on enhanced recovery protocols is also key to reducing length of stay.

Essentials in Minimally Invasive Gynecology Manual Skills Construct Validation Trial.

OBJECTIVE: To establish validity evidence for the Essentials in Minimally Invasive Gynecology laparoscopic and hysteroscopic simulation systems. METHODS: A prospective cohort study was IRB approved and conducted at 15 sites in the United States and Canada. The four participant cohorts based on training status were: 1) novice (postgraduate year [PGY]-1) residents, 2) mid-level (PGY-3) residents, 3) proficient (American Board of Obstetrics and Gynecology [ABOG]-certified specialists without subspecialty training); and 4) expert (ABOG-certified obstetrician-gynecologists who had completed a 2-year fellowship in minimally invasive gynecologic surgery). Qualified participants were oriented to both systems, followed by testing with five laparoscopic exercises (L-1, sleeve-peg transfer; L-2, pattern cut; L-3, extracorporeal tie; L-4, intracorporeal tie; L-5, running suture) and two hysteroscopic exercises (H-1, targeting; H-2, polyp removal). Measured outcomes included accuracy and exercise times, including incompletion rates. RESULTS: Of 227 participants, 77 were novice, 70 were mid-level, 33 were proficient, and 47 were experts. Exercise times, in seconds (±SD), for novice compared with mid-level participants for the seven exercises were as follows, and all were significant (P<.05): L-1, 256 (±59) vs 187 (±45); L-2, 274 (±38) vs 232 (±55); L-3, 344 (±101) vs 284 (±107); L-4, 481 (±126) vs 376 (±141); L-5, 494 (±106) vs 420 (±100); H-1, 176 (±56) vs 141 (±48); and H-2, 200 (±96) vs 150 (±37). Incompletion rates were highest in the novice cohort and lowest in the expert group. Exercise errors were significantly less and accuracy was greater in the expert group compared with all other groups. CONCLUSION: Validity evidence was established for the Essentials in Minimally Invasive Gynecology laparoscopic and hysteroscopic simulation systems by distinguishing PGY-1 from PGY-3 trainees and proficient from expert gynecologic surgeons.

Trans-stomal single-port laparoscopic Hartmann's reversal is an efficacious and efficient procedure: a case-controlled study.

BACKGROUND: Hartman's reversal remains challenging and is associated with a widely variable success rate. In a previous study, we reported that laparoscopy may lower the mortality and morbidity rates of the procedure. The aim of the current study was to assess the operative results of single-port laparoscopic Hartmann's reversal (SP-HR) as compared to the more standard, multi-port laparoscopic variant (MP-HR). METHODS: We performed a retrospective, non-randomized, case-controlled study of 44 consecutive patients who had SP-HR (Group A) compared to 44 patients who had MP-HR (Group B). The study was conducted in a high-volume colorectal unit in a 1200-bed university affiliated hospital, The Poissy-Saint Germain Medical Complex, France. RESULTS: Preoperative patients' characteristics (sex, body mass index, American Society of Anesthesiologists status, prior surgery, comorbidities, colonic disease) were comparable in both groups. The conversion rate was 13.6% and 4.5% in Group A and in Group B, respectively (p = 0.084) and consisted of placement of any additional ports. Conversion to open surgery did not occur in any patient in either group (p = 1). Mean operative time was shorter in Group A than in in Group B, (105 vs. 155 min; p = 0.0133). The mortality rate was 2.2% in Group A and 0% in Group B (p = 0.3145). The overall morbidity rate was 11.4% in Group A and 18.2% in Group B (p = 0.5344). The median length of hospital stay was significantly shorter in Group than in Group B (4.8 vs. 6.8 days; p = 0.0102). CONCLUSIONS: The SP-HR technique was found to be safe and efficient. It compares favorably with MP-HR. Moreover, indirect cost savings could be induced by the reduction in the length of hospital stay.

Surgical treatment of gastric outlet obstruction from a large trichobezoar: A case report.

INTRODUCTION: Bezoars are concretions of foreign indigestible material accumulating in the gastrointestinal tract leading to intraluminal mass formation that impairs the gastrointestinal motility and can lead to gastric obstruction of the small or the large bowel. There are different types of bezoars, named according to the material they are made of. These include phytobezoar, lactobezoar, pharmacobezoar, trichobezoar, and polybezoar. Trichobezoars (hair ball) are usually located in the stomach but may extend through the pylorus into the duodenum and small bowel (Rapunzel syndrome). CASE PRESENTATION: Herein, we report a case of a young adult female known to have a long-standing trichophagia who presented with gastric outlet obstruction due to a large trichobezoar. Endoscopy revealed a large and hard gastric trichobezoar not amenable to endoscopic retrieval leading to surgical extraction as a last resort. DISCUSSION: They are almost always associated with trichotillomania and trichophagia or other psychiatric disorders. Trichobezoar can be treated either surgically by laparotomy/laparoscopy or by endoscopic intervention. CONCLUSION: Treatment should be coupled to psychiatric evaluation and therapy to prevent recurrence.

Interactive Pelvic Anatomy Model: A Tool for Teaching Basic Pelvic Anatomy.

BACKGROUND: A knowledge deficit of pelvic anatomy has been noted in obstetrics and gynecology residents. In this article, we introduce an innovative anatomic model that uses readily accessible and reusable materials to simulate and teach anatomic relationships in the female pelvis. INSTRUMENT: Our anatomic model is a reusable and cost-effective modification of an existing pelvic model. We used felt fabric pieces with hook-and-loop fasteners to simulate the pelvic floor, perineum, and surrounding musculature as they attach to corresponding sites on a standard bony pelvis. Our design incorporates the relationship of the ureter and major blood vessels in the pelvis by using yarn and ribbon. By allowing the student to build the anatomy of the pelvis piece by piece, the model provides the student a hands-on illustration of anatomic relationships in three dimensions. EXPERIENCE: At our institution, both learners and faculty have positively evaluated our model. We have used it to teach residents and fourth-year medical students surgically relevant anatomy. It is currently being evaluated as an addition to standard anatomy lectures in medical student clerkships. CONCLUSION: Our model introduces an innovative design that uses inexpensive and reusable materials. Residents, faculty, and student learners at our institution have positively received the model.

Transanal NOTES total mesorectal excision (TME) in patients with rectal cancer: Is anatomy better preserved?

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopy are spreading worldwide. Total mesorectal excision (TME), the standard treatment for patients with distal rectal tumors, is usually performed in an "up-to-down" approach, either laparoscopically (LAPTME) or as an open procedure. We have already reported a NOTES-inspired, transanal, "down-to-up" variant of TME (NOTESTME). The main aim of this study was to assess the quality of the resected specimen in patients who had undergone either NOTESTME or LAPTME. METHODS: All patients with distal rectal neoplasia presenting between January 2011 and December 2014 were considered for the study. Additional inclusion criteria comprised American Society of Anesthesiologists score ≤ III and the absence of previous open surgery. Assignment to either group was sequential and based on the rank of inclusion in the study. The primary endpoint was the macroscopic quality of the specimen. Secondary endpoints included nerve visualization, tumor perforation, operating time, status of margins, and number of retrieved nodes. RESULTS: Eighteen patients (6 men, 12 women) were in the NOTESTME group and 15 (7 men, 8 women) in the LAPTME group, respectively. The TME specimen was considered complete or mainly regular in 16 patients who had undergone NOTESTME (88.9 %) and in 11 patients who had undergone LAPTME (73.3 %), (p > 0.05). During the procedure, we visually identified the neurovascular bundles of Walsh in 14 patients in the NOTESTME group (77.8 %) and in only 5 patients in the LAPTME group (33.3 %), (p < 0.05). Mean operative time was 245 min (range 155-440 min) in the NOTESTME group and 275 min (range 180-400 min) in the LAPTME group (p > 0.05). A median of 11 nodes per specimen (range 8-22 nodes) was retrieved in the NOTESTME group and 12 nodes (range 6-41 nodes) in the LAPTME group, respectively (p > 0.05). Distal and radial margins were comparable in both groups. CONCLUSIONS: Compared to the LAPTME, the NOTESTME seems to be associated with a more frequent intraoperative identification of the sacral nerves. However, the difference in overall quality of the retrieved specimen, although favoring NOTESTME, did not reach statistical significance in this small series.

NOTES total mesorectal excision (TME) for patients with rectal neoplasia: a preliminary experience.

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopy are emerging, minimally invasive techniques. Total mesorectal excision (TME), the gold standard treatment for patients with resectable distal rectal tumors, is usually performed in an "up-to-down" approach, either laparoscopically or via open techniques. A transanal, "down-to-up" TME has already been reported. Our NOTES variant of TME (NOTESTME) is based on a transperineal approach without any form of abdominal assistance. The aim was to reduce further the invasiveness of the procedure while optimizing the anatomical definition of the distal mesorectum. This approach may lead to reduced postoperative pain, decreased hernia formation and improved cosmesis when compared to standard laparoscopy. METHODS: NOTESTME was attempted in 16 patients with distal rectal neoplasia (i.e., distal edge of the tumor lower than the pouch of Douglas, between 0 and 12 cm from the dentate line). Additional inclusion criteria consisted of an ASA status ≤III and the absence of previous abdominal surgery. RESULTS: NOTESTME was completed in all patients. Additional abdominal, single-incision laparoscopic assistance was required in 6 (38 %) patients. Mean operative time was 265 min (range 155-440 min). The morbidity rate was 18.8 % (two small bowel obstructions and one pelvic abscess), requiring re-operation in each case. No leaks occurred, and the mortality rate at 30 and 90 days was 0 %. Resection margins were negative in all patients. A median of 17 nodes (range 12-81) was retrieved per specimen. Mean length of hospital stay was 10 days (range 4-29 days). Patients were followed for an average of 7 months (range 3-23 months). CONCLUSION: NOTESTME was feasible and safe in this series of patients with mid- or low rectal tumors. The short-term mortality and morbidity rates are acceptable, with no apparent compromise in the oncological quality of the resection. Larger, randomized controlled trials with long-term follow-up are warranted.

Internal hernia as a complication of congenital falciform ligament window.

Commonly, small bowel obstruction (SBO) is caused by either postoperative adhesions or external hernias. Internal hernias are rare, accounting for less than 2% of all cases of intestinal obstruction. An internal hernia through the falciform ligament is extremely uncommon and is usually secondary to a congenital or iatrogenic defect caused by trocars insertion. In this article, we report a case of SBO in a virgin abdomen that appeared to be caused by a congenital defect in the falciform ligament. A search of the literature was done identifying all reported cases of internal hernias caused by falciform ligament defect in order to guide diagnosis and management as well as avoidance of hernias caused by iatrogenic defects.

Acute limb ischaemia due to embolisation of biological glue 45 days after surgery.

INTRODUCTION: Since their introduction, biological glues have been more often used in cardiac and vascular surgery in order to control bleeding and reinforce surgical anastomotic sites. REPORT: We report a case of a 54-year-old woman diagnosed with acute limb ischaemia due to embolisation of biological glue, 45 days after her surgery for ascending aortic dissection. Her ischaemia was successfully relieved by an urgent thrombectomy. DISCUSSION: Complications due to the use of biological glues remain rare but are very serious. Preventive measures and intra-operative precautions must be considered in order to avoid most of these complications.

Retrieval of port-A catheter fragment from the main and right pulmonary arteries 3 years after dislodgment.

Vascular access (VA) is one of the serious problems that chemotherapy recipient cancer patients face. Fractures of catheter and cardiac migration rarely occur; the catheter fragments migrate distally along the blood stream finally lodging anywhere in the vena cava, right atrium, right ventricle, or the main pulmonary artery or one of its branches. Percutaneous retrieval method is always suggested first.

Fluorescence detection of cervical intraepithelial neoplasia for photodynamic therapy with the topical agents 5-aminolevulinic acid and benzoporphyrin-derivative monoacid ring.

OBJECTIVE: The aim of this study was to determine whether 2 photosensitizers, benzoporphyrin-derivative monoacid ring and 5-aminolevulinic acid, are selectively absorbed by dysplastic cervical cells after topical administration. STUDY DESIGN: This phase I clinical trial involved 18 women with biopsy-proven cervical intraepithelial neoplasia at the Beckman Laser Institute, Irvine, Calif. Colposcopically directed cervical biopsy specimens obtained after 1.5, 3, or 6 hours of exposure to a randomly assigned photosensitizer were evaluated for selective drug absorption with hematoxylin and eosin staining and fluorescence microscopy. RESULTS: After exposure to 5-aminolevulinic acid, cervical tissue showed maximal fluorescence in dysplastic cells relative to normal cells, with negligible stromal fluorescence. According to our detection methods benzoporphyrin-derivative monoacid ring demonstrated nonselective, diffusion-driven uptake, with fluorescence appearing in the superficial cells, followed by nonselective drug absorption in the remaining cells and stroma of the epithelium. CONCLUSION: Our data demonstrated selective absorption of 5-aminolevulinic acid by dysplastic cervical cells. This agent therefore represents a promising photosensitizing prodrug for the treatment of cervical intraepithelial neoplasia with photodynamic therapy.