Correlation of surgical case volume and fellowship training with performance on simulated procedural tasks.

BACKGROUND: High-volume and fellowship-trained surgeons have superior outcomes. However, in gynecology, a large proportion of cases are performed by low-volume surgeons. Simulation has been shown to be useful in assessing surgical skill and may be a useful tool in hospital credentialing and maintenance of privileges. OBJECTIVE: To determine the correlation between a surgical case volume and fellowship training with performance on simulated procedural tasks. STUDY DESIGN: A total of 108 obstetricians and gynecologists with laparoscopic privileges at 2 academic institutions completed a pre-test survey and performed 3 tasks on the LapSim laparoscopic virtual reality simulator. The pre-test survey inquired about the monthly laparoscopic case volume and prior training. Simulations included a basic skills task (peg transfer) followed by a procedural task (salpingectomy) of 2 difficulty levels (low and moderate). Spearman correlation and Wilcoxon tests were used to determine correlations between the survey responses and performance metrics. RESULTS: Participants included 67 generalists (62%) and 41 fellowship-trained specialists (38%). There was an observed weak correlation among surgical volume (more than 6 cases per month), time to completion, and the amount of blood loss when performing the low-difficulty level salpingectomy (r=-0.32, P=.0007 and r=-0.29, P=.002, respectively). The economy of movement (instrument path length) was correlated to high surgical volume (r=-0.35, P=.0002). Compared with generalists, surgeons with fellowship training performed tasks faster (410.8 seconds [interquartile range, 309.7-595.2]) vs 530.2 seconds (interquartile range, 406.2-605.0; P=.0009), more efficiently at 6.1 m (interquartile range, 4.8-7.3) vs 8.1 m (interquartile range, 5.8-10.7; P=.0003), and with less blood loss at 21.7 mL (interquartile range, 11.8-37.7) vs 42.9 mL (interquartile range, 18.1-70.6; P=.002). Regarding the case volume and fellowship background, there was no difference in ovarian diathermy damage. In addition, there was no difference among most performance parameters for the peg transfer task and the moderate-difficulty salpingectomy procedure. CONCLUSION: Surgical experience obtained through higher case volume and fellowship training correlate with higher performance scores during simulated procedural tasks. In a previous study, we found a similar correlation with simulated basic skills tasks. The current study is a continuation of an ongoing quality initiative to establish a summative assessment of laparoscopic surgical skills using virtual reality simulator for the maintenance of credentials among obstetrical and gynecologic surgeons. Future studies will compare the performance metrics from laparoscopic procedures performed on virtual reality simulator with the performance in the operating room and clinical outcomes.

Quality metrics in minimally invasive gynecologic surgery.

PURPOSE OF REVIEW: Quality improvement and patient safety are relevant to the advancement of clinical care, particularly in the field of minimally invasive gynecologic surgery (MIGS). Although safety and feasibility of MIGS have been established, identification of quality metrics in this field is also necessary. RECENT FINDINGS: Surgical quality improvement has focused on national overarching measures to reduce mortality, surgical site infections (SSIs), and complications. Quality improvement in minimally invasive surgery has additionally led to advancements in postoperative patient recovery and long-term outcomes. Process measures in minimally invasive surgery include use of bundles and enhanced recovery after surgery (ERAS) programs. However, procedure-specific quality metrics for MIGS outcomes are poorly defined at this time. SUMMARY: Quality metrics in minimally invasive gynecology are well defined for structural measures and select process measures. Creation of relevant benchmarks for outcome measures in minimally invasive gynecologic surgery are needed.

Community-Institutional Partnerships to Strengthen Maternal Health Care: Case Study of the First Obstetrics and Gynecology Specialty Training Program in Liberia.

Despite major setbacks to its health infrastructure and health workforce capacity, Liberia began its first post-graduate training program for physicians in 2013. Specialty training in Internal Medicine, Pediatrics, General Surgery and Obstetrics and Gynecology were the four inaugural Residency programs that recruited graduates from the country's only medical school, A.M. Dogliotti College of Medicine. The Obstetrics and Gynecology residency program was designed to combat the rising maternal mortality and strengthen health systems to improve maternal care. The program adapted in the face of challenges posed by limited financial support, lack of specialist-faculty and general physician shortages and the Ebola virus outbreak. The manuscript discusses the challenges and successes of the program and demonstrates how the shortage of teaching faculty was addressed by developing a collaboration between local government and educational communities, a United States (US) academic institution and volunteers from the Global Health Service Partnership.

The midlife transition and the risk of cardiovascular disease and cancer Part I: magnitude and mechanisms.

Heart disease and cancer are the leading causes of death in the United States. In women, the clinical appearance of both entities-coronary heart disease and cancer (breast, endometrium, and ovary)-escalate during the decades of the midlife transition encompassing the menopause. In addition to the impact of aging, during the interval between the age of 40 and 65 years, the pathophysiologic components of metabolic syndrome also emerge and accelerate. These include visceral adiposity (measured as waist circumference), hypertension, diabetes, and dyslipidemia. Osteoporosis, osteoarthritis, sarcopenia, depression, and even cognitive decline and dementia appear, and most, if not all, are considered functionally related. Two clinical reports confirm the interaction linking the emergence of disease: endometrial cancer and metabolic syndrome. One describes the discovery of unsuspected endometrial cancer in a large series of elective hysterectomies performed in aged and metabolically susceptible populations. The other is from the Women's Health Initiative Observational Study, which found a positive interaction between endometrial cancer and metabolic syndrome regardless of the presence or absence of visceral adiposity. Both provide additional statistical support for the long-suspected causal interaction among the parallel but variable occurrence of these common entities-visceral obesity, heart disease, diabetes, cancer, and the prevalence of metabolic syndrome. Therefore, 2 critical clinical questions require analysis and answers: 1: Why do chronic diseases of adulthood-metabolic, cardiovascular, endocrine-and, in women, cancers of the breast and endometrium (tissues and tumors replete with estrogen receptors) emerge and their incidence trajectories accelerate during the postmenopausal period when little or no endogenous estradiol is available, and yet the therapeutic application of estrogen stimulates their appearance? 2: To what extent should identification of these etiologic driving forces require modification of the gynecologist's responsibilities in the care of our patients in the postreproductive decades of the female life cycle? Part l of this 2-part set of "expert reviews" defines the dimensions, gravity, and interactive synergy of each clinical challenge gynecologists face while caring for their midlife (primarily postmenopausal) patients. It describes the clinically identifiable, potentially treatable, pathogenic mechanisms driving these threats to quality of life and longevity. Part 2 (accepted, American Journal of Obstetrics & Gynecology) identifies 7 objectives of successful clinical care, offers "triage" prioritization targets, and provides feasible opportunities for insertion of primary preventive care initiatives. To implement these goals, a reprogrammed, repurposed office visit is described.

The midlife transition and the risk of cardiovascular disease and cancer Part II: strategies to maximize quality of life and limit dysfunction and disease.

Chronic dysfunction, disabilities, and complex diseases such as cardiovascular disease, diabetes mellitus type 2, osteoporosis and certain cancers, among other burdens, emerge and accelerate in midlife women. Previously in part l, we described the clinical and laboratory research findings that more readily explain and clarify the underlying pathogenetic mechanisms driving these clinical burdens, including new findings on how in particular visceral obesity and the emergence and acceleration of various components of metabolic syndrome-glucotoxicity and lipotoxicity-and a chronic systemic inflammatory state abetted by the loss of ovarian production of estradiol and the inevitable inroads of aging generate this spectrum of clinical problems. These research insights translate into opportunities for effective care strategies leading to prevention, amelioration, possible correction, and enhanced quality of life. To achieve these goals, updated detailed diagnostic, management, and therapeutic guidelines implemented by a reprogrammed and repurposed "menopause" office visit are described. A triage mechanism-when to refer to other specialists for further care-is emphasized. The previously polarized views of menopausal hormone therapy have narrowed significantly, leading to the construction of a more confident, unified, and wider clinical application. Accordingly, a menopausal hormone therapy program providing maximum benefit and minimum risk, accompanied by an algorithm for enhanced shared decision making, is included.

Characteristics and Outcomes of 241 Births to Women With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection at Five New York City Medical Centers.

OBJECTIVE: To describe the characteristics and birth outcomes of women with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection as community spread in New York City was detected in March 2020. METHODS: We performed a prospective cohort study of pregnant women with laboratory-confirmed SARS-CoV-2 infection who gave birth from March 13 to April 12, 2020, identified at five New York City medical centers. Demographic and clinical data from delivery hospitalization records were collected, and follow-up was completed on April 20, 2020. RESULTS: Among this cohort (241 women), using evolving criteria for testing, 61.4% of women were asymptomatic for coronavirus disease 2019 (COVID-19) at the time of admission. Throughout the delivery hospitalization, 26.5% of women met World Health Organization criteria for mild COVID-19, 26.1% for severe, and 5% for critical. Cesarean birth was the mode of delivery for 52.4% of women with severe and 91.7% with critical COVID-19. The singleton preterm birth rate was 14.6%. Admission to the intensive care unit was reported for 17 women (7.1%), and nine (3.7%) were intubated during their delivery hospitalization. There were no maternal deaths. Body mass index (BMI) 30 or higher was associated with COVID-19 severity (P=.001). Nearly all newborns tested negative for SARS-CoV-2 infection immediately after birth (97.5%). CONCLUSION: During the first month of the SARS-CoV-2 outbreak in New York City and with evolving testing criteria, most women with laboratory-confirmed infection admitted for delivery did not have symptoms of COVID-19. Almost one third of women who were asymptomatic on admission became symptomatic during their delivery hospitalization. Obesity was associated with COVID-19 severity. Disease severity was associated with higher rates of cesarean and preterm birth.

Testing of Patients and Support Persons for Coronavirus Disease 2019 (COVID-19) Infection Before Scheduled Deliveries.

OBJECTIVE: To evaluate the rate of coronavirus disease 2019 (COVID-19) infection with the use of universal testing in our obstetric population presenting for scheduled deliveries, as well as the concordance or discordance rate among their support persons during the initial 2-week period of testing. Additionally, we assessed the utility of a screening tool in predicting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing results in our cohort. METHODS: This was an observational study in which all women who were scheduled for a planned delivery within the Mount Sinai Health system from April 4 to April 15, 2020, were contacted and provided with an appointment for themselves as well as their support persons to undergo COVID-19 testing 1 day before their scheduled delivery. Both the patients and the support persons were administered a standardized screen specific for COVID-19 infection by telephone interview. Those support persons who screened positive were not permitted to attend the birth. All patients and screen-negative support persons underwent SARS-CoV-2 testing. RESULTS: During the study period, 155 patients and 146 support persons underwent SARS-CoV-2 testing. The prevalence of asymptomatic COVID-19 infection was 15.5% (CI 9.8-21.2%) and 9.6% (CI 4.8-14.4%) among patients and support persons, respectively. The rate of discordance among tested pairs was 7.5%. Among patients with COVID-19 infection, 58% of their support persons also had infection; in patients without infection, fewer than 3.0% of their support persons had infection. CONCLUSION: We found that more than 15% of asymptomatic maternity patients tested positive for SARS-CoV-2 infection despite having screened negative with the use of a telephone screening tool. Additionally, 58% of their asymptomatic, screen-negative support persons also tested positive for SARS-CoV-2 infection. Alternatively, testing of the support persons of women who had tested negative for COVID-19 infection had a low yield for positive results. This has important implications for obstetric and newborn care practices as well as for health care professionals.

Race and Ethnicity, Medical Insurance, and Within-Hospital Severe Maternal Morbidity Disparities.

OBJECTIVE: To examine within-hospital racial and ethnic disparities in severe maternal morbidity rates and determine whether they are associated with differences in types of medical insurance. METHODS: We conducted a population-based, cross-sectional study using linked 2010-2014 New York City discharge and birth certificate data sets (N=591,455 deliveries) to examine within-hospital black-white, Latina-white, and Medicaid-commercially insured differences in severe maternal morbidity. We used logistic regression to produce risk-adjusted rates of severe maternal morbidity for patients with commercial and Medicaid insurance and for black, Latina, and white patients within each hospital. We compared these within-hospital adjusted rates using paired t-tests and conditional logit models. RESULTS: Severe maternal morbidity was higher among black and Latina women than white women (4.2% and 2.9% vs 1.5%, respectively, P<.001) and among women insured by Medicaid than those commercially insured (2.8% vs 2.0%, P<.001). Women insured by Medicaid compared with those with commercial insurance had similar risk for severe maternal morbidity within the same hospital (P=.54). In contrast, black women compared with white women had significantly higher risk for severe maternal morbidity within the same hospital (P<.001), as did Latina women (P<.001). Conditional logit analyses confirmed these findings, with black and Latina women compared with white women having higher risk for severe maternal morbidity (adjusted odds ratio [aOR] 1.52; 95% CI 1.46-1.62 and aOR 1.44; 95% CI 1.36-1.53, respectively) and women insured by Medicaid compared with those commercially insured having similar risk. CONCLUSION: Within hospitals in New York City, black and Latina women are at higher risk of severe maternal morbidity than white women; this is not associated with differences in types of insurance.

The Association between Solo versus Group Obstetrical Practice Model and Delivery Outcomes.

OBJECTIVE: To determine if women under the care of obstetricians in solo practice have different delivery outcomes from women in a group practice. STUDY DESIGN: This is a retrospective cohort of live, term, singleton, vertex (LTSV) deliveries at one hospital from 2011 to 2015. We compared outcomes between women whose obstetrician was in solo practice with women in a group practice model. RESULTS: There were 18,214 LTSV deliveries by private obstetricians. Solo obstetricians were more likely to deliver at night (41.0 vs. 37.5%, p = 0.002) and less likely to induce labor (22.6 vs. 30.6%, p < 0.001). Solo obstetricians had a significantly higher rate of cesarean delivery (35.7 vs. 27.2%, adjusted odds ratio, aOR: 1.53, 95% confidence interval, CI [1.32, 1.78]), but also had a significantly lower rate of shoulder dystocia (0.4 vs. 1.4, aOR: 0.42, 95% CI [0.19, 0.89]), third or fourth degree lacerations (1.6 vs. 2.4%, aOR: 0.56, 95% CI [0.35, 0.914]), and neonatal intensive care unit admission rates (3.2 vs. 6.2%, aOR: 0.57, 95% CI [0.42, 0.77]). CONCLUSION: In a large, tertiary care hospital, solo obstetricians have similar neonatal outcomes as group obstetricians. Their higher cesarean delivery rate is balanced by fewer shoulder dystocias and third/fourth degree lacerations, indicating a more conservative approach to labor management. Patient outcomes should not be a reason to discourage a solo practice model.

Detection of endometrial precancer by a targeted gynecologic cancer liquid biopsy.

Endometrial cancer is the most common gynecologic malignancy in industrialized countries, and both its incidence and its associated mortality are increasing. The "liquid biopsy" is becoming an important transformative precision oncology tool, but barriers intrinsic to blood sampling have limited its use in early cancer detection. We hypothesized that using a more targeted sample for analysis-namely, a uterine lavage-should provide a more sensitive and specific diagnostic test for endometrial cancer. Using a custom 12-gene endometrial cancer panel, molecular analysis of uterine lavage fluid from an asymptomatic 67-yr-old female without histopathologic evidence of premalignant lesions or cancer in her uterine tissue revealed two oncogenic PTEN mutations. Ten months later, the patient returned with postmenopausal bleeding and a single microscopic focus of endometrial cancer. DNA isolated and sequenced from laser-capture microdissected tumor tissue revealed the same two PTEN mutations. These mutations were unlikely to occur by chance alone (P < 3 × 10-7). This illustrative case provides the first demonstration that future, tumor-specific mutations can be identified in an asymptomatic individual without clinical or pathologic evidence of cancer by using already established sequencing technologies but targeted sampling methods. This finding provides the basis for new opportunities in early cancer screening, detection, and prevention.

Provider preferences for postoperative analgesia in obese and non-obese patients undergoing ambulatory surgery.

BACKGROUND: Few guidelines exist on safe prescription of postoperative analgesia to obese patients undergoing ambulatory surgery. This study examines the preferences of providers in the standard treatment of postoperative pain in the ambulatory setting. METHODS: Providers from five academic medical centers within a single US city were surveyed from May-September 2015. They were asked to provide their preferred postoperative analgesic routine based upon the predicted severity of pain for obese and non-obese patients. McNemar's tests for paired observations were performed to compare prescribing preferences for obese vs. non-obese patients. Fisher's exact tests were performed to compare preferences based on experience: > 15 years vs. ≤15 years in practice, and attending vs. resident physicians. RESULTS: A total of 452 providers responded out of a possible 695. For mild pain, 119 (26.4%) respondents prefer an opioid for obese patients vs. 140 (31.1%) for non-obese (p = 0.002); for moderate pain, 329 (72.7%) for obese patients vs. 348 (77.0%) for non-obese (p = 0.011); for severe pain, 398 (88.1%) for obese patients vs. 423 (93.6%) for non-obese (p < 0.001). Less experienced physicians are more likely to prefer an opioid for obese patients with moderate pain: 70 (62.0%) attending physicians with > 15 years in practice vs. 86 (74.5%) with ≤15 years (p = 0.047), and 177 (68.0%) attending physicians vs. 129 (83.0%) residents (p = 0.002). CONCLUSIONS: While there is a trend to prescribe less opioid analgesics to obese patients undergoing ambulatory surgery, these medications may still be over-prescribed. Less experienced physicians reported prescribing opioids to obese patients more frequently than more experienced physicians.

A perioperative care map improves outcomes in patients with morbid obesity undergoing major surgery.

BACKGROUND: The surgical management of patients with morbid obesity (body mass index ≥ 40) is notable for a relatively high risk of complications. To address this problem, a perioperative care map was developed using precautions and best practices commonly employed in bariatric surgery. It requires additional medical assessments, sleep apnea surveillance, more stringent guidelines for anesthetic management, and readily available bariatric operating room equipment, among other items. This care map was implemented in 2013 at 4 major urban teaching hospitals for use in patients undergoing all types of nonambulatory surgery with a body mass index greater than 40 kg/m2. The impact on patient outcomes was evaluated. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was used to compare 30-day outcomes of morbidly obese patients before the year 2013 and after the years 2015 care-map implementation. In addition, trends in 30-day outcomes for morbidly obese patients were compared with those for non-obese patients. RESULTS: Morbidly obese patients, between 2013 and 2015, saw an adjusted decrease in the rate of unplanned return to the operating room (OR = 0.49; P = .039), unplanned readmission (OR = 0.57; P = .006), total duration of stay (-0.87 days; P = .009), and postoperative duration of stay (-0.69 days; P = .007). Of these, total duration of stay (-0.86 days; P = .015), and postoperative duration of stay (-0.69 days; P = .012) improved significantly more for morbidly obese patients than for nonmorbidly obese patients. CONCLUSION: Outcomes in morbidly obese patients improved from 2013 to 2015. Implementation of a perioperative care map may have contributed to these improvements. The care map should be further investigated and considered for more widespread use.

Predictors of laparoscopic simulation performance among practicing obstetrician gynecologists.

BACKGROUND: While simulation training has been established as an effective method for improving laparoscopic surgical performance in surgical residents, few studies have focused on its use for attending surgeons, particularly in obstetrics and gynecology. Surgical simulation may have a role in improving and maintaining proficiency in the operating room for practicing obstetrician gynecologists. OBJECTIVE: We sought to determine if parameters of performance for validated laparoscopic virtual simulation tasks correlate with surgical volume and characteristics of practicing obstetricians and gynecologists. STUDY DESIGN: All gynecologists with laparoscopic privileges (n = 347) from 5 academic medical centers in New York City were required to complete a laparoscopic surgery simulation assessment. The physicians took a presimulation survey gathering physician self-reported characteristics and then performed 3 basic skills tasks (enforced peg transfer, lifting/grasping, and cutting) on the LapSim virtual reality laparoscopic simulator (Surgical Science Ltd, Gothenburg, Sweden). The association between simulation outcome scores (time, efficiency, and errors) and self-rated clinical skills measures (self-rated laparoscopic skill score or surgical volume category) were examined with regression models. RESULTS: The average number of laparoscopic procedures per month was a significant predictor of total time on all 3 tasks (P = .001 for peg transfer; P = .041 for lifting and grasping; P < .001 for cutting). Average monthly laparoscopic surgical volume was a significant predictor of 2 efficiency scores in peg transfer, and all 4 efficiency scores in cutting (P = .001 to P = .015). Surgical volume was a significant predictor of errors in lifting/grasping and cutting (P < .001 for both). Self-rated laparoscopic skill level was a significant predictor of total time in all 3 tasks (P < .0001 for peg transfer; P = .009 for lifting and grasping; P < .001 for cutting) and a significant predictor of nearly all efficiency scores and errors scores in all 3 tasks. CONCLUSION: In addition to total time, there was at least 1 other objective performance measure that significantly correlated with surgical volume for each of the 3 tasks. Higher-volume physicians and those with fellowship training were more confident in their laparoscopic skills. By determining simulation performance as it correlates to active physician practice, further studies may help assess skill and individualize training to maintain skill levels as case volumes fluctuate.

Association Between Senior Obstetrician Supervision of Resident Deliveries and Mode of Delivery.

OBJECTIVE: In December 2012, the Mount Sinai Hospital implemented a program to have senior obstetricians (more than 20 years of experience) supervise residents on labor and delivery during the daytime. The objective of this study was to estimate the association of resident supervision by senior obstetricians with mode of delivery. METHODS: This was a retrospective cohort study of all resident deliveries at Mount Sinai from July 2011 to June 2015. We included all patients with live, term, singleton, vertex fetuses. We compared delivery outcomes between patients delivered before December 2012 and patients delivered December 2012 and later using logistic regression analysis to control for age, body mass index, parity, induction, and prior cesarean delivery. During the study period there were no other specific departmental initiatives to increase forceps deliveries aside from having six obstetricians with significant experience in operative deliveries supervise and teach residents on labor and delivery. RESULTS: There were 5,201 live, term, singleton, vertex deliveries under the care of residents, 1,919 (36.9%) before December 2012 and 3,282 (63.1%) December 2012 or later. The rate of forceps deliveries significantly increased from 0.6% to 2.6% (adjusted odds ratio [OR] 8.44, 95% confidence interval [CI] 3.1-23.1), and the rate of cesarean deliveries significantly decreased from 27.3% to 24.5% (adjusted OR 0.68, 95% CI 0.55-0.83). There were no statistically significant differences in the rates of third- or fourth-degree lacerations or 5-minute Apgar scores less than 7. Among nulliparous women, the forceps rate increased from 1.0% to 3.4% (adjusted OR 4.87, 95% CI 1.74-13.63) and the cesarean delivery rate decreased from 25.6% to 22.7% (adjusted OR 0.69, 95% CI 0.53-0.89). The increase in forceps deliveries and the decrease in cesarean deliveries were seen only in daytime hours (7 AM to 7 PM), that is, the shift that was covered by senior obstetricians. CONCLUSION: Having senior obstetricians supervise resident deliveries is significantly associated with an increased rate of forceps deliveries and a decreased rate of cesarean deliveries.

Team Training in the Perioperative Arena: A Methodology for Implementation and Auditing Behavior.

Preventable medical errors in the operating room are most often caused by ineffective communication and suboptimal team dynamics. TeamSTEPPS is a government-funded, evidence-based program that provides tools and education to improve teamwork in medicine. The study hospital implemented TeamSTEPPS in the operating room and merged the program with a surgical safety checklist. Audits were performed to collect both quantitative and qualitative information on time out (brief) and debrief conversations, using a standardized audit tool. A total of 1610 audits over 6 months were performed by live auditors. Performance was sustained at desired levels or improved for all qualitative metrics using χ2 and linear regression analyses. Additionally, the absolute number of wrong site/side/person surgery and unintentionally retained foreign body counts decreased after TeamSTEPPS implementation.

A pilot study of cardiac electrophysiology catheters to map and pace bladder electrical activity.

AIMS: This is a pilot study to evaluate the feasibility of using diagnostic cardiac electrophysiology catheters for recording intrinsic urinary bladder electrical activity and for electrical pacing capture of bladder tissue. METHODS: During cystoscopy, a curved quadripolar catheter was introduced and contact was made with the right and left halves of the dome and trigone in adult female patients undergoing cystoscopy. Electrical activity was recorded, using a commercially available cardiac electrophysiologic recording system, before and during pacing at 0.5-3.0 Hz. RESULTS: Apparent spontaneous electrical depolarizations were detected in both the trigone and the dome. The amplitude of these depolarizations was in the microVolt range. During pacing, local electrical capture was noted in the trigone, but not in the dome. CONCLUSIONS: Spontaneous low-amplitude electrical activity was detected in the bladder through the use of commercially available cardiac electrophysiology equipment. While these low-level signals could represent noise, the voltage, and morphology resemble detrusor muscle action potentials previously seen in animal studies. Pacing induced local electrical capture in the trigone but not the dome.

Perioperative care map improves compliance with best practices for the morbidly obese.

BACKGROUND: Morbid obesity can complicate perioperative management. Best practice guidelines have been published but are typically followed only in bariatric patients. Little is known regarding physician awareness of and compliance with these clinical recommendations for nonbariatric operations. Our study evaluated if an educational intervention could improve physician recognition of and compliance with established best practices for all morbidly obese operatively treated patients. METHODS: A care map outlining best practices for morbidly obese patients was distributed to all surgeons and anesthesiologists at 4 teaching hospitals in 2013. Pre- and postintervention surveys were sent to participants in 2012 and in 2015 to evaluate changes in clinical practice. A chart audit performed postintervention determined physician compliance with distributed guidelines. RESULTS: In the study, 567 physicians completed the survey in 2012 and 375 physicians completed the survey in 2015. Postintervention, statistically significant improvements were seen in the percentage of surgeons and anesthesiologists combined who reported changing their management of morbidly obese, operatively treated patients to comply with best practices preoperatively (89% vs 59%), intraoperatively (71% vs 54%), postoperatively (80% vs 57%), and overall (88% vs 72%). Results were similar when surgeons and anesthesiologists were analyzed separately. A chart audit of 170 cases from the 4 hospitals found that 167 (98%) cases were compliant with best practices. CONCLUSION: After care map distribution, the percentage of physicians who reported changing their management to match best practices significantly improved. These findings highlight the beneficial impact this educational intervention can have on physician behavior. Continued investigation is needed to evaluate the influence of this intervention on clinical outcomes.

Obesity May Be Protective against Severe Perineal Lacerations.

Objective. To determine if there is an association between BMI and 3rd- or 4th-degree perineal lacerations in normal spontaneous and operative vaginal deliveries. Study Design. We performed a retrospective case control study using a large obstetric quality improvement database over a six-year period. Cases were identified as singleton gestations with third- and fourth-degree lacerations. Controls were obtained randomly from the database of patients without third- or fourth-degree lacerations in a 1 : 1 ratio. Univariate and multivariate logistic regression analyses were performed. Results. Of 32,607 deliveries, 22,011 (67.5%) charts with BMI documented were identified. Third- or fourth-degree lacerations occurred in 2.74% (n = 605) of patients. 37% (n = 223) were identified in operative vaginal deliveries. In the univariate analysis, obesity, older maternal age, non-Asian race, and birth weight <4000 g were all protective against 3rd- and 4th-degree lacerations. After controlling for age, race, mode of vaginal delivery, and birth weight, obesity remained significant. Conclusion. Being obese may protect against third- and fourth-degree lacerations independent of parity, race, birth weight, and mode of delivery.

Improved obstetric safety through programmatic collaboration.

Healthcare safety and quality are critically important issues in obstetrics, and society, healthcare providers, patients and insurers share a common goal of working toward safer practice, and are continuously seeking strategies to facilitate improvements. To this end, 4 New York City voluntary hospitals with large maternity services initiated a unique collaborative quality improvement program. It was facilitated by their common risk management advisors, FOJP Service Corporation, and their professional liability insurer, Hospitals Insurance Company. Under the guidance of 4 obstetrics and gynecology departmental chairmen, consensus best practices for obstetrics were developed which included: implementation of evidence based protocols with audit and feedback; standardized educational interventions; mandatory electronic fetal monitoring training; and enhanced in-house physician coverage. Each institution developed unique safety related expertise (development of electronic documentation, team training, and simulation education), and experiences were shared across the collaborative. The collaborative group developed robust systems for audit of outcomes and documentation quality, as well as enforcement mechanisms. Ongoing feedback to providers served as a key component of the intervention. The liability carrier provided financial support for these patient safety innovations. As a result of the interventions, the overall AOI for our institutions decreased 42% from baseline (January-June 2008) to the most recently reviewed time period (July-December 2011) (10.7% vs 6.2%, p < 0.001). The Weighted Adverse Outcome Score (WAOS) also decreased during the same time period (3.9 vs 2.3, p = 0.001.) Given the improved outcomes noted, our unique program and the process by which it was developed are described in the hopes that others will recognize collaborative partnering with or without insurers as an opportunity to improve obstetric patient safety.

Long-term quality of life and pelvic floor dysfunction after bariatric surgery.

OBJECTIVE: To evaluate effects of bariatric surgery on pelvic floor mediated quality of life in morbidly obese women. STUDY DESIGN: Prospective cohort study of 44 women undergoing bariatric surgery. RESULTS: Thirty-six women gave data at baseline and at mean follow-up of 3.15 years following bariatric surgery. Although urinary impact questionnaire scores improved (-34.92, P = .0020), colorectal-anal impact questionnaire and pelvic organ prolapse impact questionnaire scores did not improve despite significant weight loss. Baseline female sexual function index scores were low (17.70 ± 8.38) and did not improve with weight loss (16.91 ± 9.75, P = .5832). Pelvic organ prolapse/urinary incontinence sexual questionnaire scores did improve (35.78 ± 6.06 preoperatively vs 38.22 ± 6.03 postoperatively, P = .0193). CONCLUSION: Bariatric surgery is associated with significant improvement in the impact of urinary incontinence on quality of life. Sexual function was poor, and improved only on the pelvic organ prolapse/urinary incontinence sexual questionnaire that evaluated urinary incontinence.