Patient experience with enhanced recovery and early discharge after minimally invasive sacrocolpopexy: a qualitative study.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to describe patient experiences with an enhanced recovery protocol (ERP) after minimally invasive sacrocolpopexy (SCP). METHODS: We conducted 14 semi-structured telephone interviews with women who had undergone SCP and were discharged the day of the surgery (POD#0, n = 7) or spent 1 night at the hospital (POD#1, n = 7). Interviews occurred between 2 and 6 weeks after surgery. We explored the following topics: patient preparedness, preoperative education, physical recovery, emotional recovery, and overall perception of the ERP. Interviewing continued until thematic saturation was achieved. All interviews were recorded, transcribed, and analyzed to identify relevant themes. RESULTS: Both POD#0 and POD#1 discharge patients reported largely positive experiences regarding their preparation for surgery, at-home recovery, and access to follow-up care. Yet for some patients, the accelerated pace of the ERP felt rushed and was perceived as an absence of care rather than as an advance in treatment. Patients that elected to stay the night lived farther from ready access to care, had less robust systems of postoperative support, and worried more about the management of their pre-existing conditions. CONCLUSIONS: Our research found that despite having consistently positive impressions of the ERP, patients shared common anxieties surrounding their surgeries including worries about access to care and the prospect of going home with a urinary catheter. Furthermore, we found that the therapeutic value of protocol recommendations such as early discharge must be made explicit to patients and often individualized to avoid being interpreted as sub-standard care.

Rhabdomyolysis-Associated Acute Kidney Injury With Normal Creatine Phosphokinase.

Rhabdomyolysis is a syndrome characterized by the breakdown of skeletal muscle and leakage of intracellular myocyte contents, such as creatine phosphokinase (CPK) and myoglobin, into the interstitial space and plasma resulting in acute kidney injury (AKI). Elevated CPK of at least 5 times the upper limit of normal is an important diagnostic marker of Rhabdomyolysis. We present a case of rhabdomyolysis with severe AKI with a normal CPK at presentation. A 32-year-old man presented with acute respiratory failure and AKI after an overdose of recreational drugs. Urinalysis at presentation showed trace amounts of blood, identified as rare red blood cells under microscopy. CPK was 156 U/L at presentation. Workup for glomerulonephritis and vasculitis was negative. He was initiated on renal replacement therapy, and a kidney biopsy showed severe acute tubular injury with positive myoglobin casts. Supportive management and renal replacement therapy was provided, and renal function spontaneously improved after a few weeks. This is an uncommon clinical presentation of severe rhabdomyolysis complicated by AKI. This suggests that CPK alone may not be a sensitive marker for rhabdomyolysis-induced AKI in some cases.

Voxel based versus region of interest analysis in diffusion tensor imaging of neurodevelopment.

There are two main methods of quantitative analysis in diffusion tensor imaging (DTI) studies: manual region of interest (ROI) and automated voxel based. The purpose of this study is to compare the results of each of these methods applied to the same data set. Linear correlative analysis was performed for mean diffusivity (Trace/3 ADC) and for fractional anisotropy (FA) versus age within 8-12 years (N = 32) and within 21-27 years (N = 28), as well as a group comparison. SPM analysis identified more structures changing with age, partly due to the limited regions measured with ROI analysis. In general, ROI and voxel-based analysis methods produced comparable results for widespread reductions of Trace/3 ADC and increases of FA with age, particularly for group comparison. The discrepancies (i.e., missed regions) were likely related to problems of spatial normalization for SPM analysis, and masking localized changes by averaging all the voxels within a region of interest for ROI analysis. These two analysis methods for DTI offer complementary results, but neither one yields the complete story of neurodevelopment.

Diffusion tensor imaging of neurodevelopment in children and young adults.

Diffusion tensor magnetic resonance imaging (DTI) was used to study regional changes in the brain's development from childhood (8-12 years, mean 11.1 +/- 1.3, N = 32) to young adulthood (21-27 years, mean 24.4 +/- 1.8, N = 28). Mean diffusivity (Trace/3 apparent diffusion coefficient, ADC) and fractional anisotropy (FA) were measured in 30 regions of interest (ROIs) in 13 distinct brain structures. Correlational analysis was performed to detect changes within 8-12 years and within 21-27 years, and group analysis to compare childhood diffusion properties with young adult values. Increases of fractional anisotropy were seen in the genu of the corpus callosum, splenium of the corpus callosum, corona radiata, putamen, and head of the caudate nucleus within 8-12 years, and also between childhood and young adulthood. Reductions in Trace/3 ADC were observed in 9 of 13 structures within 8-12 years and into young adulthood as well. DTI demonstrates more widespread changes in the brain's microstructure with maturation than previous reports using conventional T1-weighted MRI scans. These findings suggest a continuation of the brain's microstructural development through adolescence.

Imaging brain connectivity in children with diverse reading ability.

Reading is a complex cognitive skill that requires the coordination of multiple brain regions. Although functional neuroimaging studies highlight the cortical brain regions associated with a specific cognitive task like reading, they do not directly address the underlying neural connections necessary for efficient performance of this task. Adults with reading disability have demonstrated lower regional white matter connectivity, but it is not known whether this relationship between neuronal wiring and reading performance also holds in younger readers. Using diffusion tensor magnetic resonance imaging (DTI) that highlights the structural integrity of the brain wiring, we show that regional brain connectivity in the left temporo-parietal white matter correlates with a wide range of reading ability in children as young as 8-12 years old. Diffusion tensor tractography suggests that the posterior limb of the internal capsule is consistent with the location of the largest cluster of correlation between reading ability (Word Identification subtest) and fractional anisotropy. The maturation of the white matter may play a key role in the development of cognitive processes such as reading.