Evaluating the Quality of Endometriosis Operative Reports among High Volume Endometriosis Surgeons.

OBJECTIVE: To evaluate the quality of operative reports for endometriosis surgeries performed by fellowship-trained, high-volume endometriosis surgeons. METHODS: In this retrospective review, 5 consecutive deidentified surgical reports per surgeon were evaluated by two reviewers. Each dictation was assigned a quality score (between 0 and 28), based on the number of components from the American Association of Gynecologic Laparoscopists (AAGL) classification system that were documented. Primary outcome was the proportion of reports for which endometriosis AAGL 2021 stage could be assigned. Secondary outcomes included median dictation quality scores, proportion of dictations for fertility-preserving cases where Endometriosis Fertility Index (EFI) score could be assigned, individual quality score components, and quality score variation between surgeons, institutions, and reporting methods. RESULTS: 82 operative reports were reviewed from 16 surgeons across 7 sites in Ontario. AAGL stage could be assigned in 48/82 (59%) of cases, and EFI score could be assigned in 31/45 of fertility-preserving cases (69%). Median quality score was 57% (range 18%-86%). Only 13% of operative reports included comment on residual disease. Quality score consistency between reports was poor for a given surgeon (ICC = 0.22, 95% CI 0.03-0.49). Quality scores differed significantly between surgeons (chi-square = 30.6, df = 16, P = .015) and institutions (chi-square = 19.59, df = 7, P = .007). Operative report quality score did not differ based on completion by trainee or staff, template use, or whether the report was completed by telephone or typed. CONCLUSION: There is significant variability and inconsistency in endometriosis surgery documentation. There is a need to standardize surgical documentation for endometriosis surgeries, enhancing communication and ultimately patient care.

Assessing the impact of obesity on surgical quality outcomes among patients undergoing hysterectomy for benign, non-urgent indications.

OBJECTIVE: To evaluate the impact of body mass index (BMI) on surgical quality metrics for patients undergoing benign, non-urgent hysterectomy. STUDY DESIGN: A multicentre, retrospective review at 7 hospitals in Ontario, Canada (4 academic, 3 community) was conducted. Patients undergoing hysterectomy from July 2016 to June 2019 were included. Hysterectomies for premalignant, malignant and emergency indications were excluded. The primary outcome was a composite of any complication or readmission. Secondary outcomes were grade 2 or greater complication, postoperative emergency department (ED) visit, hospital readmission, operative time (ORT) and estimated blood loss (EBL). Patient characteristics (age, ASA class, preoperative diagnoses, preoperative anemia, prior surgeries), surgical factors (endometriosis, adhesions, hysterectomy route, uterine weight, concomitant procedures, ORT, EBL) and surgeon characteristics (volume, fellowship/generalist training, academic/community hospital) were recorded along with complications, hospital readmissions and ED visits. Outcomes were evaluated using logistic regression and log-regression linear analysis grouping patients by BMI category (normal, overweight, obesity class 1, 2, and 3) and by hysterectomy route (abdominal, laparoscopic, and vaginal). RESULTS: 2528 hysterectomies were performed by 67 surgeons. 828 (33%) patients had a normal BMI, 889 (35%) were overweight. 500 (20%) patients had a BMI corresponding to obesity class 1, 205 (8%) class 2 and 106 (4%) class 3. Obese patients had higher ASA class (p <.001) and more prior surgeries (p <.001) compared to patients with normal BMI. Those with class 2 and 3 obesity were younger (p <.001), had greater uterine weight (p <.001) and more intra-operative adhesions (p <.001). After controlling for covariates, there were no differences in the odds of the primary or secondary outcomes, with the exception of patients with class 2 obesity who underwent vaginal hysterectomy. They had 9.1% (11 min) significantly longer ORT (0.091, 95% CI 0.002-0.18, p <.05) and patients with an overweight BMI who underwent vaginal hysterectomy had 28 ml significantly less EBL (-0.154, 95% CI -0.26 to -0.05, p <.01) compared to patients with normal BMI. CONCLUSION: BMI was not independently associated with surgical quality outcomes in patients undergoing hysterectomy for benign, non-urgent indications. Abdominal, laparoscopic, and vaginal hysterectomy can be performed safely in overweight and obese patients.

Pharmacological treatment of hypertension and hyperlipidemia in Izhevsk, Russia.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death in Russia. Hypertension and hyperlipidemia are important risk factors for CVD that are modifiable by pharmacological treatment and life-style changes. We aimed to characterize the extent of the problem in a typical Russian city by examining the prevalence, treatment and control rates of hypertension and hyperlipidemia and investigating whether the specific pharmacological regimes used were comparable with guidelines from a country with much lower CVD rates. METHODS: The Izhevsk Family Study II included a cross-sectional survey of a population sample of 1068 men, aged 25-60 years conducted in Izhevsk, Russia (2008-2009). Blood pressure and total cholesterol were measured and self-reported medication use was recorded by a clinician. We compared drug treatments with the Russian and Canadian treatment guidelines for hypertension and hyperlipidemia. RESULTS: The prevalence of hypertension was 61 % (age-standardised prevalence 51 %), with 66 % of those with hypertension aware of their diagnosis and 50 % of those aware taking treatment. 17 % of those taking treatment achieved blood pressure control. The majority (59 %) of those taking treatment were not doing so regularly. Prevalence of hyperlipidemia was 45 % (age-standardised prevalence 40 %), however less than 2 % of those with hyperlipidemia were taking any treatment. Types of lipid-lowering and anti-hypertensive medications prescribed were broadly in line with Russian and Canadian guidelines. CONCLUSION: The prevalence of hypertension and hyperlipidemia is high in Izhevsk while the proportion of those treated and attaining treatment targets is very low. Prescribed medications were concurrent with those in Canada, but adherence is a major issue.

Wilms tumor suppressor, WT1, suppresses epigenetic silencing of the ß-catenin gene.

The mammalian kidney is derived from progenitor cells in intermediate mesoderm. During embryogenesis, progenitor cells expressing the Wilms tumor suppressor gene, WT1, are induced to differentiate in response to WNT signals from the ureteric bud. In hereditary Wilms tumors, clonal loss of WT1 precludes the ß-catenin pathway response and leads to precancerous nephrogenic rests. We hypothesized that WT1 normally primes progenitor cells for differentiation by suppressing the enhancer of zeste2 gene (EZH2), involved in epigenetic silencing of differentiation genes. In human amniotic fluid-derived mesenchymal stem cells, we show that exogenous WT1B represses EZH2 transcription. This leads to a dramatic decrease in the repressive lysine 27 trimethylation mark on histone H3 that silences ß-catenin gene expression. As a result, amniotic fluid mesenchymal stem cells acquire responsiveness to WNT9b and increase expression of genes that mark the onset of nephron differentiation. Our observations suggest that biallelic loss of WT1 sustains the inhibitory histone methylation state that characterizes Wilms tumors.