Understanding the Pursuit of Third-Line Therapies for Overactive Bladder: A Mixed Methods Study.

IMPORTANCE: Overactive bladder (OAB) affects millions of women in the United States, with negative effects in multiple domains that have an impact on quality of life. Third-line therapies for OAB are as effective or superior to lifestyle/behavior modification and medical management, yet few women access these treatments and often spend more than 36 months to reach these treatments after starting medication. Factors associated with time to reach third-line therapy are not well studied, and little is known about how patients progress through care pathways for OAB. OBJECTIVES: The aim of the study was to determine factors associated with the time spent between second- and third-line therapy for OAB at an academic urogynecology and reconstructive pelvic surgery practice. We sought to identify demographic, treatment, clinical factors, and themes in barriers to receiving treatment for OAB. STUDY DESIGN: This was a mixed methods study consisting of a retrospective cohort study followed by qualitative key informant interviews. RESULTS: Eighty-five total participants were included in the analysis, and 42 (49.5%) spent more than 36 months between initiation of medical management and initial third-line therapy for OAB. No significant (P > 0.05) demographic, clinical, or treatment differences were found between groups. Facilitators and obstacles to receiving third-line therapy were identified among key informants, and a treatment decision framework was developed. CONCLUSIONS: Women often spend more than 36 months to pursue third-line therapy for OAB. Existing objective variables are poor predictors of pursuit of third-line treatment, and leveraging known facilitators and obstacles can be used to develop improved care pathways for OAB.

Osteocutaneous radial forearm free flap in nonmandible head and neck reconstruction.

BACKGROUND: The osteocutaneous radial forearm free flap (RFFF) is a versatile flap primarily used to reconstruct composite defects involving the mandible. The purpose of this study was to describe our experience with this flap for nonmandible reconstruction. METHODS: All patients undergoing nonmandible osseous reconstruction with free-tissue transfer were reviewed. Patients with osteocutaneous RFFF reconstructions were evaluated. The retrospective review of all osteocutaneous RFFFs was performed from 1998 to 2014. RESULTS: One hundred forty-two nonmandible osseous reconstructions were performed. Twenty-five patients underwent nonmandible osteocutaneous RFFF reconstruction. Eleven patients failed previous nonmicrovascular reconstruction. Reconstruction was for defects of the: palatomaxillary complex (n = 15), orbitomaxillary complex (n = 4), nasomaxillary complex (n = 4), larynx (n = 1), and clavicle (n = 1). There were no flap compromises. Postoperative complications included: 2 partial intraoral dehiscences; 1 recipient-site infection; and 1 seroma. Eight reconstructions required secondary procedures to improve functional and/or cosmetic outcomes. CONCLUSION: The osteocutaneous RFFF is a robust flap that can be used to reconstruct composite defects involving bone and soft-tissue beyond the mandible.

Secondary free-flap reconstruction following ablation for acute invasive fungal sinusitis.

OBJECTIVE: Acute invasive fungal sinusitis (AIFS) is a frequently fatal infection for which extensive and debilitating surgical debridement is a mainstay of therapy. Resulting defects are often composite in nature, mandating free tissue-transfer reconstruction. Outcomes data for free flap reconstruction are limited. The purpose of this study was to examine surgical outcomes and survival in patients undergoing free flap transfer following invasive fungal sinusitis. STUDY DESIGN: Retrospective case series. METHODS: Between 1995 and 2015, patients undergoing operative debridement for AIFS were identified. Surgical records were used to identify survivors of acute infection who subsequently underwent free flap reconstructive surgery. Patient demographics, cause of immune compromise, defect description, flap type, perioperative complications, indications for revision surgery, functional outcomes, and long-term survival were reviewed. RESULTS: Forty-four patients were treated for AIFS, of those, 30 (68%) survived acute infection. Ten patients underwent maxillectomy, six with orbital exenteration, and were designated candidates for reconstruction. Eight patients underwent reconstruction. Median time from debridement to reconstruction was 67.5 days. Flap types included latissimus dorsi, scapula, anterolateral thigh, rectus, radial forearm, and fibula. Median follow-up was 7.7 months. No perioperative complications were encountered, and all subjects remained disease-free, able to speak and eat normally without prosthetic supplementation. Seven patients (87%) are currently alive. CONCLUSION: Reconstruction of defects left by invasive fungal sinusitis using free-tissue transfer resulted in successful flap survival, with no disease recurrence for all defects and flap types reviewed. Survivors of AIFS are able to tolerate midface reconstruction, with favorable functional outcomes and survival rates. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:815-819, 2017.

The role of postoperative hematoma on free flap compromise.

OBJECTIVES/HYPOTHESIS: Hematomas may develop in the postoperative setting after free tissue transfer. When hematomas occur, they can exert pressure on surrounding tissues. Their effect on the vascular pedicle of a free flap is unknown. We describe our incidence of hematoma in free flaps and outcomes when the flap is compromised. STUDY DESIGN: Retrospective chart review of 1,883 free flaps performed between July 1998 and June 2014 at a tertiary referral center. METHODS: Patients with free flap compromise due to hematoma were identified. Etiology, demographic data, and outcomes were evaluated. RESULTS: Eighty-eight (4.7%) patients developed hematomas. Twenty (22.7%) of those had flap compromise. Twelve compromises (60%) showed evidence of pedicle thrombosis. The salvage rate was 75% versus 54% in 79 flaps with compromise from other causes (P = .12). Mean time to detection of the hematoma was 35.3 hours in salvaged flaps compared to 91.6 hours in unsalvageable flaps (P = .057). Time to operating room (OR) from detection was 2.8 hours in salvageable flaps compared to 12.4 hours in nonsalvageable flaps (P = .053). The salvage rate for flaps that returned to the OR in <5 hours was 93.3% compared to 20% (P = .0049) for those that did not. Vascular thrombosis reduced salvage rate to 58.3% from 100% (P = .002) when there was no thrombosis. CONCLUSIONS: In our series hematomas developed rarely. When they did, 23% went on to develop flap compromise. Prompt recognition and re-exploration allowed for a high salvage rate. Vessel thrombosis predicted inability to salvage the flap. LEVEL OF EVIDENCE: 4

Comportamiento de la TSH y la T4 en una cohorte de pacientes con arritmia cardiaca tratados con amiodarona u otros antiarrítmicos / Behavior of TSH and T4 in a cohort of patients with cardiac arrhythmia treated with amiodarone or other antiarrhythmics

La amiodarona es uno de los antiarrítmicos de uso más extendido, pero de la misma forma es un medicamento con efectos adversos bien conocidos y a múltiples niveles; uno de los más importantes es el que se describe para el tejido tiroideo. Cerca de 80 porciento de los pacientes que la toman de forma indefinida, presentarán algún efecto adverso; sin embargo, menos de 15 porciento la suspenderán. En la glándula tiroides, los mecanismos de lesión se relacionan, por su semejanza estructural, con la levotiroxina, la liberación de altas concentraciones de yodo y la inducción de reactividad inmune, entre otras. No obstante, la mayoría de los pacientes permanece eutiroideos.Este estudio describe la variación de la función tiroidea a corto plazo, en 77 pacientes que recibieron diferentes tipos de antiarrítmicos, que no tenían factores de riesgo asociados a disfunción tiroidea, y que se reclutaron en el servicio de hospitalización. Se tomaron muestras de TSH al inicio y al cabo de tres meses de seguimiento. Se observaron niveles de TSH normales en 26 porciento (43 pacientes) y tendencia a valores más altos en el control al tercer mes en el grupo medicado con amiodarona. De manera adicional, se describió una proporción mayor de trastornos de la función de la glándula tiroides en la población masculina.