Hysterectomy and Oophorectomy for Transgender Patients: Preoperative and Intraoperative Considerations.

OBJECTIVE: To review the preoperative and intraoperative considerations for gynecologic surgeons when performing hysterectomy with or without oophorectomy for transgender patients. DESIGN: Stepwise demonstration of techniques with narrated video footage. SETTING: Approximately 0.3% of hysterectomies performed annually in the United States are for transgender men. While some transgender men choose hysterectomy for the same indications as cisgender women, the most prevalent diagnosis for the performed surgeries is gender dysphoria [1]. Hysterectomy with or without oophorectomy can be offered to patients who meet the World Professional Association for Transgender Health criteria [2]. INTERVENTIONS: Important perioperative counseling points for transgender patients include establishing the terminology for the relevant anatomy as well as the patient's name and pronouns; if applicable, discussing options for fertility preservation if the patient desires biological children [3,4] and discussing the use of hormone therapy post oophorectomy to reduce the loss of bone density [5,6]; and reviewing intraoperative and postoperative expectations. When performing an oophorectomy on a transgender patient for gender affirmation, it is especially important to minimize the risk of ovarian remnant syndrome and the need for additional surgery, as, for example, caused by persistent menstruation. A 2-layer vaginal cuff closure should be considered to reduce the risk of vaginal cuff complications and is preferable for patients whose pelvic organs cause gender dysphoria [7,8]. CONCLUSION: Special considerations outlined in this video and the World Professional Association for Transgender Health guidelines should be reviewed by gynecologic surgeons to minimize the transgender patient's experiences of gender dysphoria before, during, and after surgery.

Risk Factors Associated with the Development of Hospital-Acquired Infections in Hospitalized Patients with Severe COVID-19.

Recognition of risk factors for hospital-acquired infections (HAI) in patients with COVID-19 is warranted. We aimed to describe factors associated with the development of HAI in patients with severe COVID-19. We conducted a retrospective cohort study including all adult patients admitted with severe COVID-19 between March 2020 and November 2020. The primary outcome was HAI development. Bivariate and multiple logistic regression models were constructed. Among 1540 patients, HAI occurred in 221 (14%). A total of 299 episodes of HAI were registered. The most common HAI were hospital-acquired/ventilation-associated pneumonia (173 episodes) and primary bloodstream infection (66 episodes). Death occurred in 387 (35%) patients and was more frequent in patients with HAI (38% vs. 23%, p < 0.01). Early mechanical ventilation (aOR 18.78, 95% CI 12.56-28.07), chronic kidney disease (aOR 3.41, 95% CI 1.4-8.27), use of corticosteroids (aOR 2.95, 95% CI 1.92-4.53) and tocilizumab (aOR 2.68, 95% CI 1.38-5.22), age ≥ 60 years (aOR 1.91, 95% CI 1.27-2.88), male sex (aOR 1.52, 95% CI 1.03-2.24), and obesity (aOR 1.49, 95% CI 1.03-2.15) were associated with HAI. In patients with severe COVID-19, mechanical ventilation within the first 24 h upon admission, chronic kidney disease, use of corticosteroids, use of tocilizumab, age ≥ 60 years, male sex, and obesity were associated with a higher risk of HAI.

Don't forget to look up: operating in the upper abdomen.

Given the marked improvement in laparoscopic technology, gynecologic surgeons feel comfortable operating in the pelvis for a variety of gynecologic pathologies. When pathology is found outside of the pelvis, however, gynecologic surgeons find operating in the upper abdomen challenging. Operating in the upper abdomen is difficult because of the loss of ergonomics and the impression of operating backward. It is prudent for gynecologic surgeons to master operating in the upper abdomen given the variety of pathologies a gynecologist can encounter outside of the pelvis, both benign, such as endometriosis and adhesions, and malignant, like staging procedures, omentectomy, and debulking. We aimed to describe our operating room modifications that help to simulate operating in the upper abdomen as if one was operating in the pelvic cavity. Strategies to improve efficiency and ergonomics when operating in the upper abdomen include operating room setup, switching monitors to the patient's shoulders bilaterally, changing surgeon location to the right side of the patient, port hopping, and 30-degree camera selection. We have also created an instructional video with the tools to improve surgeon confidence and ergonomics when operating in the upper abdomen.

Large-scale screening for severe acute respiratory coronavirus virus 2 (SARS-CoV-2) among healthcare workers: Prevalence and risk factors for asymptomatic and pauci-symptomatic carriers, with emphasis on the use of personal protective equipment (PPE).

Healthcare workers (HCWs) not fulfilling the coronavirus disease 2019 (COVID-19) case definition underwent severe acute respiratory coronavirus virus 2 (SARS-CoV-2) screening. Risk of exposure, adherence to personal protective equipment (PPE), and symptoms were assessed. In total, 2,000 HCWs were screened: 5.5% were positive for SARS-CoV-2 by polymerase chain reaction (PCR). There were no differences in PPE use between SARS-CoV-2-positive and -negative HCWs (adherence, >90%). Nursing and kitchen staff were independently associated with positive SARS-CoV-2 results.

Descriptive study of the complete blood count in newborn infants with Down syndrome.

The usefulness of the complete blood count (CBC) during the first week of life in infants with Down syndrome (DS) has been recognized; however, studies are limited and have evaluated only some of the parameters of the CBC. Here, we report a prospective study of 135 infants with cytogenetically confirmed DS and a reference group of 226 infants without birth defects all born during the period 2009-2015 at the Dr. Juan I. Menchaca Civil Hospital of Guadalajara (Guadalajara, Mexico). The goal was to evaluate hematological findings in the CBC during the first 7 days of life, interpreted according to gestational and postnatal age. Data were analyzed using multivariate logistic regression analysis expressed as adjusted odds ratio (aORs) with 95% confidence intervals (95% CIs). Infants with DS had a significantly higher risk for polycythemia (aOR = 12.4, 95% CI: 4.6-33.3), macrocytosis (aOR = 15.9, 95% CI: 1.8-143.4), high values of mean corpuscular hemoglobin (aOR = 36.4, 95% CI: 4.5-294.9), anisocytosis (red blood cells of unequal size) (aOR = 3.9, 95% CI: 2.1-7.6), thrombocytopenia (aOR = 32.4, 95% CI: 15.2-68.9), white blood cell (WBC) count ≥30 × 103 /µl (aOR = 19.4, 95% CI: 4.1-91.5), lymphocytosis (aOR = 73.3, 95% CI: 9.5-565.4), and basophilia (aOR = 16.8, 95% CI: 1.9-151.5). Overall, 74% of infants with DS in our study had polycythemia, thrombocytopenia, WBC count >30 × 103 /µl, or lymphocytosis (aOR = 35.6, 95% CI: 18.8-79.2). Compared with those in other studies, our infants with DS had distinctive hematological findings including a lower frequency of thrombocytopenia, infrequent neutrophilia, and frequent lymphocytosis and neutropenia. This suggests ethnic, socioeconomic, or nutritional differences. © 2017 Wiley Periodicals, Inc.

Advances in oncologic head and neck reconstruction: systematic review and future considerations of virtual surgical planning and computer aided design/computer aided modeling.

BACKGROUND: Mastery of craniomaxillofacial reconstruction has been traditionally considered to be learning curve dependent, often with inconsistent results during the skill acquisition phase. Until recently, the overall success in bony oncologic reconstruction of the craniomaxillofacial skeleton has relied mainly on the use of 2D imaging modalities, as well as surgical trial-and-error. Virtual surgical planning (VSP) and computer aided design (CAD)/computer aided modeling (CAM) are gaining traction in oncologic applications and offers opportunity for increased accuracy, improved efficiency, and enhanced outcomes. Its role in oncologic head and neck reconstruction has not been formally evaluated. METHODS: A systematic review of the current literature was conducted by three independent reviewers. Three separate search schemes were utilized to identify cases incorporating VSP-CAD/CAM technology in head and neck reconstruction for an oncologic indication. Inclusion and exclusion criteria were applied; articles that met criteria were evaluated for cohort demographics, osteocutaneous flap type and usage, oncologic indication, recipient bone reconstructed, flap survival, follow up, VSP technology usage, specific reported benefits of the technology, and qualitative and quantitative outcome assessments. RESULTS: The systematic literature review yielded 87 articles; of these, 33 met inclusion criteria describing a total of 220 cases of oncologic head and neck reconstruction incorporating virtual planning technology. Numerous qualitative benefits of VSP were reported including increased accuracy of the reconstruction (93%), decreased intraoperative time (80%), and ease of use (24%) among others. However, quantitative results using survey data or preoperative/postoperative CT scan comparisons were given for only 33% (3%, 30% respectively) of cases. CONCLUSION: VSP represents an evolving technology that ushers oncological craniomaxillofacial reconstruction into a modern era that holds potential to advance the field with increased reconstructive accuracy, expedition of the surgical phase, and improved outcomes. While qualitative improvements from the technology are delineated, specific quantifiable benefits and cost-benefit analysis are limited and need to be further investigated.