Validation of the Canadian Institute for Health Information Diagnostic Codes for Benign Gynaecologic Surgery.

We investigated the validity of the 10th Revision Canadian modification of International Statistical Classification of Disease and Related Health Problems (ICD-10-CA) diagnostic codes for surgery for benign gynaecologic conditions in the Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD), the main source of routinely collected data in Canada. Reabstracted data from patient charts was compared to ICD-10-CA codes and measures of validity were calculated with 95% confidence intervals. A total of 1068 procedures were identified. More objective, structural diagnoses (fibroids, prolapse) had higher sensitivity and near-perfect Kappa coefficients, while more subjective, symptomatic diagnoses (abnormal uterine bleeding, pelvic pain) had lower sensitivity and moderate-substantial Kappa coefficients. Specificity, positive predictive values, and negative predictive values were generally high for all diagnoses. These findings support the use of CIHI-DAD data for gynaecologic research.

Does adding hydroxychloroquine to empiric treatment improve the live birth rate in refractory obstetrical antiphospholipid syndrome? A systematic review.

PROBLEM: The current standard prevention of obstetric complications in patients with antiphospholipid antibody syndrome (APS) is the use of combination low-dose aspirin and low molecular weight heparin. However, 20-30% of women still experience refractory obstetrical APS. Hydroxychloroquine (HCQ) is an immunomodulatory agent that has been shown in laboratory studies to decrease thrombosis risk, support placentation, and minimize the destructive effects of antiphospholipid antibodies. The objective of this study was to evaluate the risk of pregnancy loss upon treatment with HCQ among women with refractory obstetrical APS. METHOD OF STUDY: A systematic review was conducted according to PRISMA guidelines. Studies that evaluated the use of HCQ during pregnancy in women with primary APS were included. The primary outcomes of interest were live birth and pregnancy losses after treatment with HCQ. RESULTS: Twelve studies met inclusion criteria. Three retrospective cohort studies demonstrated improved live birth rate, and four studies demonstrated a reduction in pregnancy loss rate. Two case reports also demonstrated a benefit in the use of HCQ compared to previous obstetrical outcomes. CONCLUSIONS: Our findings suggest a significant benefit of HCQ in addition to aspirin and heparin for patients with APS to mitigate the risk of antiphospholipid antibody mediated obstetrical complications. Randomized controlled trials with standardized patient selection criteria need to be conducted to corroborate these findings.

Uterine Septum and Other Müllerian Anomalies in a Recurrent Pregnancy Loss Population: Impact on Reproductive Outcomes.

STUDY OBJECTIVE: To study the impact of Müllerian anomalies on reproductive outcomes in a recurrent pregnancy loss (RPL) population and to evaluate the effect of surgical correction of uterine septum on the odds of achieving live birth in RPL patients with a septate uterus. DESIGN: A retrospective cohort study. SETTING: A specialized RPL clinic at a tertiary center. PATIENTS: RPL patients with ≥ 2 pregnancy losses before 20 weeks' gestation who attended a specialized RPL clinic. INTERVENTION: We aimed to assess the association between a possible risk factor (Müllerian anomalies) and reproductive outcomes and that between having surgery for septate uterus and achieving a live birth. MEASUREMENTS AND MAIN RESULTS: The primary outcome is live birth rate in RPL patients with Müllerian anomalies compared with those without; secondary outcome measures include rates of full-term live birth, preterm live birth, first and second trimester pregnancy loss, and stillbirth. After adjusting for patient age at the initial RPL visit, the number of pregnancy losses, and the presence of any other abnormal RPL investigation, the odds of achieving live birth were on average 49.4% lower for patients with a septate uterus than those without Müllerian anomalies (odds ratio, 0.51; 95% confidence interval, 0.30-0.86) in the studied cohort (n = 377). A subanalysis of 72 patients with septate uterus demonstrated a higher likelihood of live birth in those who underwent septum resection (46/72; 63.9%) than those who elected to go for expectant management (26/72; 36.1%), yet this study was underpowered to establish a significant difference (52.2% vs 34.6%; p = .22). CONCLUSION: In RPL patients, having a septate uterus significantly decreased the chances of achieving live birth. Patients with septate uterus who received hysteroscopic septum division had a higher tendency to achieve more live births than those who elected expectant management. However, our study was underpowered to detect a statistically significant difference.

Evaluation of Early Frozen Blastocyst Transfer in A True Natural Cycle Protocol in Comparison to A Hormone Replacement Protocol: A Single-Center Cohort Study.

OBJECTIVE: Timing of frozen embryo transfer (FET) within a purported window of implantation is of increasing interest, and there is a paucity of evidence surrounding the transfer of frozen embryos early within these frozen embryo transfer protocols. This study aimed to evaluate whether live birth rates were equivalent after FET of blastocysts 4 days after luteinizing hormone (LH) surge in a true natural cycle protocol, compared to a hormone replacement (HR) protocol. MATERIALS AND METHODS: Single-centre, retrospective cohort study involving patients undergoing autologous frozen blastocyst transfer from January 1st, 2013, to December 31st, 2016. Cycles were grouped according to their protocol: true natural cycle (hormonal detection of LH surge with FET scheduled four days later) versus HR cycle (luteal phase gonadotropin-releasing hormone agonist suppression, oral or vaginal estradiol and intramuscular progesterone starting five days before FET). A total of 850 cycles were included, 501 true natural cycles and 349 HR cycles. The primary outcome was the live birth rate, secondary outcomes included clinical pregnancy rate and miscarriage. Logbinomial regression models were performed adjusting for a priori selected variables. RESULTS: Adjusted resulted in live birth rates of 38.7 and 40.4%, [adjusted risk ratio (aRR): 0.96, 95% confidence interval (CI): 0.76-1.22, P=0.729] in the natural cycle and HR groups, respectively. The secondary outcome analyses did not demonstrate any statistically significant difference in the rate of positive human chorionic gonadotropin (hCG), clinical intrauterine pregnancy rate, or miscarriage rate. CONCLUSION: The timing of the FET four days after LH surge in a true natural cycle protocol results in equivalent live birth rates compared to a HR protocol. Results of this study suggest that the window of implantation within the natural cycle may be less finite than currently believed and further prospective studies evaluating the timing of frozen embryo transfer are warranted.

Spin in Randomized Controlled Trials in Obstetrics and Gynecology: A Systematic Review.

Objectives: The objective of this study was to evaluate the extent, type, and severity of spin in randomized controlled trials (RCTs) in obstetrics and gynecology. Data Sources: The top five highest impact journals in obstetrics and gynecology were systematically searched for RCTs with non-significant primary outcomes published between January 1, 2019, and December 31, 2020. Methods: Study selection and data extraction assessment were conducted independently and in duplicate. The extent, type, and severity of spin was identified and reported with previously established methodology, and risk of bias was assessed with the Cochrane Risk-of-Bias 2 Tool independently and in duplicate. Fisher's exact tests were used to evaluate the association between study characteristics, risk of bias, and spin. Results: We identified 1475 publications, of which 59 met our inclusion criteria. Articles evaluated interventions in obstetrics (n = 37, 63%) and gynecology (n = 22, 37%). Spin was not detected in 28 (47%) of the articles: Three (5%) had one, 10 (17%) had two, and 18 (31%) had greater than two occurrences of spin. Compared with articles where no spin was detected, spin was associated with the Cochrane Risk-of-Bias domain pertaining to missing data (p < 0.05). No association was observed with the journal, funding source, number of authors, types of interventions, and whether the study involved gynecology or obstetrics. Conclusions: Spin was detected in nearly half of 1:1 parallel two-arm RCTs in obstetrics and gynecology, highlighting the need for caution in the interpretation of RCT findings, particularly when the primary outcome is nonsignificant.

Online Patient Information for Hysterectomies: A Systematic Environmental Scan of Quality and Readability.

OBJECTIVE: Hysterectomy is a common gynaecological procedure, and therefore online information is highly valuable to patients. Our objective was to evaluate the quality, readability, and comprehensiveness of online patient information on hysterectomy. METHODS: The first 25 patient-directed websites on hysterectomy, identified using 5 online search engines (Google, Yahoo, AOL, Bing, Ask.com) as well as clinical professional societies, were assessed using validated tools for quality (DISCERN, JAMA benchmark), readability (Flesch-Kincaid Grade Level [FKGL], Gunning Fog, Simple Measure of Gobbledygook [SMOG], Flesch Reading Ease Score [FRES]), and completeness of information. RESULTS: We identified 50 websites for inclusion. Overall, websites were of good quality (median DISCERN score 53/80 [interquartile range {IQR} 47-61]; median JAMA score 3/4 [IQR 1-4]). Most websites described surgical risks (39, 78%), benefits (45, 90%), and types of hysterectomy (48, 96%). Content readability corresponded to grade 11 using FKGL (median 11.1 [IQR 10.2-13.0]) and SMOG (median 10.9 [IQR 10.2-12.4]), or 15 years education using Gunning Fog (median 14.7 [IQR 13.8-16.4]). Websites were assessed as difficult to read using FRES (median 45.6/100 [IQR 37.9-50.9]). No differences were observed in readability scores when we compared websites from clinical professional societies, government, health care, or academic organizations with other websites (P > 0.05). CONCLUSION: Online patient information on hysterectomy is of good quality and comprehensive. However, the content is above the American Medical Association's recommended grade 6 reading level. Website authors should consider readability to make their content more accessible to patients.

Reduced live birth rates after embryo transfer in patients with prior cesarean delivery: A retrospective cohort study.

OBJECTIVE: To evaluate whether live birth rates following first embryo transfer (ET) among patients after cesarean delivery are lower compared to patients with only prior vaginal delivery. STUDY DESIGN: Retrospective cohort study including patients with prior delivery who underwent first subsequent embryo transfer (fresh or frozen) between January 2013 and September 2019. The primary outcome was live birth rate among patients with at least one prior cesarean delivery compared to vaginal delivery only. Secondary outcomes included positive serum hCG, clinical intrauterine pregnancy and miscarriage rates. We performed a subgroup analysis with the cesarean delivery group based on labour status at the time of delivery. We fit a multivariable log-binomial regression model. RESULTS: Total of 962 patients met inclusion criteria: 351 in the cesarean delivery group and 611 in the vaginal delivery group. Live birth rate was significantly lower in the cesarean delivery group compared to vaginal delivery group at 30.0% vs 36.9% [aRR 0.81, 95% CI 0.67-0.98]. We also found lower positive hCG [aRR 0.82, 95% CI 0.72-0.94] and clinical pregnancy [aRR 0.85, 95% CI 0.73-0.99]. There was no significant difference in miscarriage rate. A subgroup analysis within the cesarean delivery group in active labour demonstrated significantly lower live birth rates compared to the vaginal delivery group [aRR 0.67, 95% CI 0.49-0.92]. CONCLUSIONS: Live birth rates following first ET were significantly lower after cesarean delivery compared to vaginal delivery. These findings may be largely attributable to a subgroup of patients with prior cesarean delivery in active labour who may be at particular risk of reduced live birth rates after ET.

A Validation of Hysterectomy Procedural Codes in the Canadian Institute for Health Information Discharge Abstract Database.

OBJECTIVE: The Canadian Institute of Health Information (CIHI) Discharge Abstract Database (DAD) is the main source of routinely collected data for gynaecologic surgery in Canada and is increasingly used for research. These data are prone to error as they were originally collected for administrative purposes, and they therefore should be validated for clinical research. The objective of this study was to validate hysterectomy codes from the DAD at a single institution. METHODS: This was a retrospective observational study using an existing hospital database. We obtained a consecutive sample of all gynaecologic procedures performed at The Ottawa Hospital from April 2016 to March 2017 using the DAD. Patient data, including diagnosis, procedure type, concomitant procedure, and surgical approach, were reabstracted from records. These data were compared with the DAD Canadian Classification of Health Interventions (CCI) codes using sensitivity, specificity, positive predictive value (PPV), and κ coefficient with associated 95% confidence intervals (CIs). RESULTS: Of 1068 gynaecologic procedures, 639 hysterectomies were performed: 39.2% vaginally, 35.4% laparoscopically, and 25.4% abdominally. Median patient age was 46 years (IQR 41-54 y). The κ, sensitivity, specificity, and PPV for all hysterectomies were 0.92 (95% CI 0.90-0.95), 95.1% (95% CI 93.2-96.7), 97.9% (95% CI 96.6-99.3), and 98.5% (95% CI 97.6-99.5), respectively. The κ coefficients for vaginal, laparoscopic, and abdominal hysterectomy were 0.91 (95% CI 0.88-0.94), 0.92 (95% CI 0.89-0.95), and 0.92 (95% CI 0.89-0.95), respectively. Agreement for sub-total hysterectomy and bilateral salpingectomy with oophorectomy was excellent, with κ exceeding 0.80. The level of agreement for salpingectomy alone was poor, though specificity and PPV were high. CONCLUSIONS: Our study suggests that hysterectomy-associated CCI codes in CIHI's DAD have a high level of validity for clinical research purposes.

Predictors of adherence to positive airway pressure therapy in children: a systematic review and meta-analysis.

BACKGROUND: While positive airway pressure (PAP) is effective for treating sleep-disordered breathing (SDB) in children, adherence is poor. Studies evaluating predictors of PAP adherence have inconsistent findings, and no rigorous reviews have been conducted. This systematic review aims to summarize the literature on predictors of PAP therapy adherence in children. METHODS: Studies evaluating baseline predictors of PAP therapy adherence in children (≤20 years) with SDB were included. We searched MEDLINE, Embase, CENTRAL, CINAHL, Clinicaltrials.gov, and the last four years of conference abstracts. Results were described narratively, with random-effects meta-analyses performed where feasible. Risk of bias and confidence in the evidence were assessed. RESULTS: We identified 50 factors evaluated across 28 studies (21 full text articles, seven abstracts). The highest rates of PAP therapy adherence were most consistently found with female sex, younger age, Caucasian race, higher maternal education, greater baseline apnea-hypopnea index (AHI), and presence of developmental delay. Pooled estimates included odds ratios of 1.48 (95%CI: 0.75-2.93) favoring female sex, 1.26 (95%CI: 0.68-2.36) favoring Caucasian race, and a mean difference in AHI of 4.32 (95%CI: -0.61-9.26) events/hour between adherent and non-adherent groups. There was low quality evidence to suggest that psychosocial factors like health cognitions and family environment may predict adherence. CONCLUSION: In this novel systematic review, we identified several factors associated with increased odds of PAP therapy adherence in children. These findings may help guide clinicians to identify and support children less likely to adhere to PAP therapy and should be considered when developing interventions to improve adherence.

Risk of Lower Birth Weight and Shorter Gestation in Oocyte Donation Pregnancies Compared With Other Assisted Reproductive Technology Methods: Systematic Review.

OBJECTIVE: Oocyte donation (OD) is associated with an increased risk of pregnancy-induced hypertension, but the evidence of an association between OD and infant outcomes, including birth weight and gestational age, is conflicting. This study sought to determine the associations between oocyte donation and birth weight or gestational age compared with other forms of autologous oocyte assisted reproductive technology (ART). METHODS: Medline, Embase, and the CENTRAL Trials Registry of the Cochrane Collaboration were searched using a comprehensive search strategy. Studies of women over 24 weeks gestation compared infant outcomes among OD pregnancies versus other ART. Study quality was assessed, and a meta-analysis of mean birth weight and gestational age was conducted using a random effects model. RESULTS: Nineteen studies were included. Four studies showed a significant association between OD and lower birth weights, and five studies found significant differences in gestational age between OD and autologous oocyte ART. The pooled difference in birth weight means between OD and autologous ART was -42 (-88, 4) . The pooled difference in gestational age was -0.4 weeks (-0.8, 0.0 weeks). CONCLUSION: A high degree of interstudy heterogeneity exists, and the association between OD and infant outcomes remains unclear.

Transversus Abdominis Plane Block for Post Hysterectomy Pain: A Systematic Review and Meta-Analysis.

The objective of this study was to address the efficacy of transversus abdominis plane (TAP) blocks in pain management among women who undergo elective hysterectomy for benign pathology in both open and minimally invasive surgeries. We performed a systematic review by searching for bibliographic citations from Medline, Embase, and Cochrane Library. MeSH headings for TAP blocks and hysterectomy were combined and restricted to the English language. We included randomized controlled trials comparing TAP blocks with placebo or no block in patients who underwent elective hysterectomy. Pain was measured using a visual analog scale (VAS) on a scale of 0 to 100. We calculated pooled mean differences in VAS and total morphine consumption at 2 and 24 hours by performing a random effects meta-analysis. Fourteen studies met the inclusion criteria, comprising 855 participants. At 2 hours mean VAS scores for patients who underwent TAP blocks were significantly lower after both total abdominal hysterectomy (TAH) (mean difference, -14.97; 95% confidence interval [CI], -20.35 to -9.59) and total laparoscopic hysterectomy (TLH; mean difference, -18.16; 95% CI, -34.78 to -1.53) compared with placebo or no block. Pain scores at 24 hours for patients who underwent TAP blocks were significantly lower after both TAH (-10.09; 95% CI, -17.35 to -2.83) and TLH (-9.12; 95% CI, -18.12 to -.13) compared with placebo or no block. Mean difference in morphine consumption was -9.53 mg (95% CI, -15.43 to -3.63) for TAH and -3.15 mg (95% CI, -8.41 to 2.12) for TLH. In conclusion, TAP blocks provide significant postoperative early and delayed pain control compared with placebo or no block among women who undergo hysterectomy. There was reduced morphine consumption among patients who underwent TAH but not TLH. (Registration: International Prospective Register of Systematic Reviews ID: CRD42016036791.).

Is Immigrant Status Associated With Cervical Cancer Screening Among Women in Canada? Results From a Cross-Sectional Study.

OBJECTIVE: Cervical cancer accounts for the highest mortality rate from cancer in women worldwide. Despite widespread availability of cervical cancer screening programs in Canada, immigrant women are largely underscreened. The most recently published Canadian-wide study evaluated screening uptake from 2001 to 2002. The objectives included identifying the prevalence of underscreened women in Canada, determining the risk of underscreening for cervical cancer among immigrant women, and providing an update on Canadian screening practices. METHODS: This study included women aged 20 to 69 who completed the Canadian Community Health Survey 2012. The prevalence of underscreening among Canadian-born and immigrant women was estimated. A log-binomial model was fit to estimate the relative risk (RR) of underscreening for immigrant women while controlling for age, income level, visible minority status, smoking status, and access to a regular physician. A secondary analysis compared immigrants residing in Canada for greater or less than 10 years to Canadian-born women. RESULTS: Of the 17 854 women eligible for this study, 18.6% of Canadian-born women and 28.9% of immigrant women were underscreened (P < 0.05). Immigrant women were at significantly higher risk of being underscreened compared with Canadian-born women (RR 1.32; 95% CI 1.20-1.45). The relative risk did not change when stratifying by length of time since immigration (RRrecent immigrant 1.32; 95% CI 1.16-1.50; and RRlong-term immigrant 1.32; 95% CI 1.19-1.47). CONCLUSION: Immigrant status continues to be associated with a significantly higher risk of underscreening, irrespective of time in Canada. Social and educational programs targeted towards immigrants are needed to mitigate the disparity in cervical cancer screening.

Intraoperative assessment of technical skills on live patients using economy of hand motion: establishing learning curves of surgical competence.

BACKGROUND: On surgical simulators, measures of economy of hand motion have been shown to be reliable, valid, and objective measures of technical competence. Our goal was to validate hand-motion analysis (HMA) as an objective measure of surgical skill on real patients. METHODS: HMA (hand movement frequency, hand travel distance) was evaluated serially on 2 standardized, live patient surgeries (vasectomy, vasectomy reversal) for both a novice and experienced surgeon. HMA parameters were correlated with blinded, case-matched assessments of technical skill using previously validated global rating scales and surgical checklist scores applied to unedited surgical videos. Serial hand-motion data from the novice and experienced surgeon were plotted to establish competency-based learning curves over time. RESULTS: Intraoperative HMA correlated significantly with case-matched global rating and checklist scores. Meaningful improvements in the number of hand movements and hand travel distance were shown over time for the novice surgeon, but remained stable for the experienced surgeon. CONCLUSIONS: Intraoperative assessment of economy of hand motion represents a feasible, objective, and valid measure of technical skill and can be used to establish competency-based surgical learning curves.

Correlation of degree of penile curvature between patient estimates and objective measures among men with Peyronie's disease.

INTRODUCTION: : Among men with Peyronie's disease (PD), the degree of penile curvature has significant implications on psychological well-being, sexual function, treatment planning, and posttherapy evaluations. AIM: The primary objective of the current study was to correlate patients' estimates of penile angulation with objective measures. MAIN OUTCOME MEASURES: (i) Proportion of patients over- or underestimating their actual degree of curvature; and (ii) degree differences between patient estimates and objective measures of penile curvature. Methods. At baseline, patients with established PD were asked to provide a "best estimate" of their degree of penile curvature. Objective measures of penile angulation were then performed using standardized photographs and protractor-based measurement of penile curvature during full erection. Correlations were performed between patient estimates of penile curvature and objective measures of penile angulation. RESULTS: Eighty-one men with established PD and a mean age of 52 years (range: 20-72 years) were prospectively evaluated. Mean duration of disease was 33 months (range: 6-276 months), and mean plaque size was 1.4 cm +/- 0.1 standardized error (SE). The proportion of patients with dorsal, lateral, and ventral curvatures was 39%, 57%, and 4%, respectively. Patient estimates of baseline penile curvature (mean 51 degrees +/- 3.1 SE) differed significantly from objective measurements (mean 40 degrees +/- 2.4, P = 0.001). A significantly higher proportion of patients overestimate their actual degree of penile curvature (54% overestimate, 26% underestimate, and 20% are accurate within 5 degrees, P = 0.002). Compared with objective measures, patients' estimates of degree of penile curvature differed by an average of 20 degrees +/- 2.2 SE. CONCLUSIONS: Patients with PD tend to overestimate their degree of penile curvature. Objective measurement of penile angulation is necessary to accurately counsel patients regarding disease severity, recommend appropriate treatment strategies, and objectively evaluate outcomes following therapy.