Obesity and Reconstructive Pelvic Surgery: An ACS NSQIP Study.

IMPORTANCE: Obesity is steadily increasing in the United States and is a risk factor for many medical and surgical complications. Literature is limited regarding obesity as an independent risk factor for perioperative complications after reconstructive pelvic surgery (RPS). OBJECTIVE: This study aimed to analyze the association of obesity on 30-day perioperative complications after RPS. STUDY DESIGN: This was a database study comparing perioperative complications after RPS of obese versus nonobese patients using the American College of Surgeons National Surgical Quality Improvement Program. Patients who underwent surgery for uterovaginal or vaginal vault prolapse were selected, and perioperative outcomes were compared between obese and nonobese patients. Obesity was defined as a body mass index ≥30 (calculated as weight in kilograms divided by height in meters squared). RESULTS: A total of 13,302 patients met the inclusion criteria and were included in this study; 4,815 patients were obese, whereas 8,487 were nonobese. The overall rate of any 30-day postoperative complication was 6.8%, and the rate of complications did not differ between groups. Superficial and organ space surgical site infections were significantly higher in the obese cohort, whereas nonobese patients were more likely to receive a blood transfusion. A multivariable logistic regression model was performed with variables that were statistically significant on bivariate analysis and deemed clinically significant. Variables included obesity, age, American Society of Anesthesiologists class, current smoker, diabetes, hypertension, operative time, colpopexy, and obliterative procedure. After controlling for potential confounding factors, obesity was not associated with any 30-day postoperative complications after pelvic organ prolapse surgery. CONCLUSION: Obesity was not associated with 30-day postoperative complications after RPS after controlling for possible confounding variables.

Secondary and tertiary transfer of latent fingermarks using a sticky note - A feasibility study.

Latent fingermarks are enhanced in order to be visible and available for comparison to determine source. Once a fingermark has been identified to a source, the activity that led to it being left on a particular surface may need to be determined. It has been previously shown that under certain conditions fingermarks initially deposited onto a surface (the primary transfer) can be transferred on to another substrate through direct contact - secondary transfer. This study investigates the possibility of secondary and subsequent tertiary transfer using sticky notes. To explore secondary transfer, fingermarks were deposited directly onto two different brands of sticky notes, spanning the adhesive and non-adhesive areas, and then placed in direct contact with paper for up to 72 h under a 5 kg weight. For some donors, there was transfer of fingermarks from the sticky note to the paper, with better results for the adhesive areas. The quality of the transferred fingermarks was dependent on initial fingermark quality and the transferred fingermark was a mirror image of the original. The type of paper used as the secondary substrate was also shown to have an effect. Given the adhesive nature of sticky notes tertiary transfer was also investigated and the potential to lift fingermarks from a glass slide and transfer them onto paper or a second glass slide. In the case of transfer to paper, there were only tertiary transferred fingermarks considered to be of useful quality (score 3 or 4) in 6% of samples and a further 33% of samples were detected but provided evidence of contact only (score 1 or 2) (n = 120). For transfer to glass, tertiary transferred samples were of poorer quality with no useful fingermarks and only 3% of samples scoring 1 or 2 (n = 120). The latter was in part due to the deposition of sticky note adhesive traces obscuring the fingermarks. In the case of tertiary transfer, fingermarks on the final tertiary surface were in the correct orientation. This work demonstrates that whilst tertiary transfer of fingermarks is possible under the laboratory conditions used, the likelihood of the effective transfer of a useful and potentially identifiable fingermark is in reality low.

Optimal overall treatment time for adjuvant therapy for women with completely resected, node-positive vulvar cancer.

INTRODUCTION: The optimal overall treatment time (OTT) from radical surgery to the end of adjuvant radiation therapy for some squamous cell carcinomas has been found to impact treatment outcomes. This study aims to identify the impact of OTT on overall survival (OS) for women with completely resected, node-positive squamous cell carcinomas of the vulva. MATERIALS AND METHODS: The National Cancer Data Base was queried for women with surgically resected, node-positive vulvar squamous cell carcinomas between 2004 and 2016 who were treated with adjuvant radiation therapy. Kaplan-Meier analysis with log-rank test and Cox proportional hazards tests were utilized for OS calculations. RESULTS: A total of 1500 women met inclusion criteria. The median OTT was 104 days. Shorter OTT was associated with age, facility volume, private insurance, and duration of post-operative hospitalization. Median OS with OTT ≤ 104 days was 56.1 months vs 45.4 months if ≥105 days (p = 0.015). On multivariable Cox analysis, OTT was independently associated with an increased risk of death of 0.4% per additional day (95%CI 1.001-1.007, p = 0.003), as were age at diagnosis (HR 1.031 [95%CI 1.024-1.037], p < 0.001), number of nodes positive (HR 1.031 [95%CI 1.024-1.037], p = 0.006), the use of concurrent chemotherapy (HR 0.815 [95%CI 0.693-0.960], p = 0.014) and increasing pT/pN stage. After propensity adjustment for factors predicting a shorter OTT, OTT continued to be associated with an increased risk of death per additional day (HR 1.004 [95%CI 1.001-1.007], p = 0.007). CONCLUSION: Overall treatment time is an independent risk factor for death in women being treated with adjuvant radiation therapy following complete resection of node-positive squamous cell carcinoma of the vulva.

The Role of Socioeconomic Status in Individuals that Leave Against Medical Advice.

INTRODUCTION: Individuals leaving against medical advice (AMA) are at risk for adverse health outcomes including a 40 percent increased mortality rate a year after self-discharge. Additionally, leaving AMA may dramatically increase medical costs due to failure to complete treatment resulting in higher risk of readmission with additional co-morbidities. METHODS: Retrospective study of inpatients utilizing the Healthcare Cost and Utilization Project (HCUP) 2012 National Inpatient Sample (NIS) database. Primary outcome of interest was discharge type (AMA versus non-AMA) examined against primary payer type, patient and hospital characteristics. Analysis performed on the weighted discharges using Proc Surverylogistic. Statistical significance set at p less than 0.05. All analysis was performed in SAS version 9.4 (SAS Institute). RESULTS: After adjustment for possible cofounders and socioeconomic factors, there were increased odds of leaving against medical advice in those that lacked insurance (ORadj = 4.16, p less than 0.001) or had Medicare (ORadj = 2.10, p less than 0.001) or Medicaid (ORadj = 2.94, p less than 0.001). Compared to individuals in the lower income brackets, groups with higher incomes had a 20-30 percent decrease in leaving AMA. However, in comparison to white individuals, black (ORadj = 1.023, p = 0.2688) and Native Americans (ORadj = 0.994, p=0.9322) were not at an increased risk of leaving AMA. Hispanic (ORadj = 0.665, p less than 0.001) and the Asian/Pacific Islander (ORadj = 0.56, p less than 0.001) groups had decreased odds of leaving AMA. CONCLUSION: Groups at risk for leaving AMA were individuals lacking insurance, having public insurance, and those within the 0-25th percentile in income. Although ethnicity does play a factor in leaving against medical advice, our data indicates that the gap is not as extreme as previously stated. Additional work needs to be done to help health care providers set targeted preventative measures to address those at increased risk for leaving AMA in order to provide a higher standard of care for the patient.

Aneurysm of the Splenomesenteric Portal Venous Confluence: A Case Report.

A 62-year-old Caucasian woman was found to have an aneurysm of the splenomesenteric portal venous confluence via computed tomography (CT) scan after presenting with left upper abdominal tenderness. Venous aneurysms typically occur in the popliteal, jugular, and saphenous veins, but visceral venous aneurysms are rare. These aneurysms most commonly arise from the main portal vein and the confluence of the splenic and superior mesenteric veins. There have been fewer than 50 reported cases of portal venous aneurysm. Evaluation involves imaging modalities such as ultrasound, CT, magnetic resonance imaging (MRI), and angiography. There is currently no clear guideline for management, but options include observation, resection, thrombectomy, or portal venous decompression.

The Collaborative Laborist and Midwifery Model: An Accepted and Sustainable Model.

In 2010, the OB/GYN physicians at this mid-sized midwestern medical center implemented a laborist model on the obstetrics ward. A laborist is a dedicated obstetrician within the obstetric ward who oversees the management of labor and performs deliveries as both the primary physician and also when consulted by other providers, including community obstetricians, family physicians and nurse midwives. In 2014, a collaborative obstetric model was implemented with the addition of an in-house certified nurse midwife (CNM) to assist the laborist in obstetric care. This retrospective study analyzes the impact of these care models on clinical outcomes, including rates of induction of labor, total (primary and repeat) cesarean sections, and vaginal births after cesarean section. The three time periods (i.e., pre-laborist, laborist, laborist plus CNM) periods are compared. Induction rates decreased from 48.6 percent to 46.5 percent to 28.8 percent during the three time periods. Primary cesarean section rates decreased from 15.9 percent to 14.6 percent to 13.6 percent. Total cesarean section rates slightly decreased but this was not statistically significant, going from 28.9 percent to 28.4 percent, to 27.7 percent. Vaginal births after cesarean section increased from 9.2 percent to 12.9 percent to 15 percent. Staff satisfaction was also measured utilizing anonymous surveys during the first two time periods. There was improvement in seven of the eight questions from the pre-laborist to the laborist model. In conclusion, a collaborative care model on the obstetric floor at this Institution has had a positive impact on patient care outcomes and staff satisfaction.