Fertility and Pregnancy Outcomes After Robotic-assisted Laparoscopic Myomectomy in a Canadian Cohort.

STUDY OBJECTIVE: Myomectomy is the gold standard treatment for patients with symptomatic fibroids who desire fertility preservation. Given the relatively recent application of robotic surgery in the field of gynecology, there is only a small amount of data describing fertility outcomes after robotic-assisted laparoscopic myomectomy (RALM). The objective of this study was to determine the pregnancy rate in patients trying to conceive after RALM. DESIGN: A single-center, retrospective case series. SETTING: Department of Obstetrics and Gynecology, St. Michael's Hospital, Toronto, Ontario, Canada. PATIENTS: All patients who underwent RALM between October 2008 and September 2015 and who consented to a telephone interview were included. INTERVENTION: None. The primary outcome was pregnancy rate after RALM. Secondary outcomes included whether patients underwent fertility treatment, rate of live births after RALM, rate of spontaneous abortion mode of delivery in pregnancies following RALM, obstetric complications, and symptoms experienced postoperatively. MEASUREMENTS AND MAIN RESULTS: A total of 123 patients underwent RALM between 2008 and 2015. Of them, 101 consented to be interviewed. Average age ± standard deviation was 34.4 ± 4.4 years. Average myoma size was 8.9 ± 2.2 cm. Of all myomas, 64 (63.4%) were intramural, 35 (34.7%) were subserosal, and 2 (2%) were submucosal according to preoperative imaging. The pregnancy rate after RALM was 42/60 (70.0%). Three additional patients became pregnant who were not trying to conceive. Of the 45 patients who became pregnant, 38 (84.4%) successfully delivered or were pregnant at the time of data collection. CONCLUSION: The pregnancy rate after RALM was 70.0%, which is similar to that reported in previous studies. Future research should aim to conduct larger, prospective studies investigating fertility outcomes after RALM and should aim to identify variables that predict pregnancy.

Diagnostic Performance of a Sonographic Volume and Solid Vascular Tissue Score (VSVTS) for Preoperative Risk Assessment of Pediatric and Adolescent Adnexal Masses.

STUDY OBJECTIVE: To evaluate the diagnostic performance of a Volume and Solid Vascular Tissue Score (VSVTS) for preoperative risk assessment of pediatric and adolescent adnexal masses. DESIGN: A retrospective cohort study comprised of all female individuals who presented with an adnexal mass that was managed surgically between April 2011 and March 2016. SETTING: The Hospital for Sick Children (Toronto, Ontario, Canada). PARTICIPANTS: Female individuals 1-18 years of age who presented to a large tertiary pediatric hospital with an adnexal mass that was managed surgically. MAIN OUTCOME MEASURES: Main outcome measures included diagnostic performance of the VSVTS for malignancy via sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), negative likelihood ratio (LR-), and receiver operating characteristic area-under-the-curve (AUC) analysis. RESULTS: A total of 179 masses in 169 subjects were included. The malignancy rate was 10.6%. The AUC for the VSTVS was 0.919. A VSTVS cut-off value of 4 achieved a sensitivity of 79% (95% CI 0.54-0.93), specificity of 88% (95% CI 0.82-0.93), PPV of 0.44 (95% CI 0.33-0.56), NPV of 0.97 (95% CI 0.94-0.99), LR+ of 6.77 (95% CI 4.18-10.97), and LR- of 0.24 (95% CI 0.10-0.57). CONCLUSIONS: A sonographic scoring system based on the volume and presence of solid vascular tissue improves PPV for preoperative risk stratification of adnexal masses in the pediatric and adolescent population compared to existing ultrasound-only approaches. Further prospective research is needed to determine how best to incorporate components of such scoring systems into clinical management algorithms.

Computerised clinical decision support systems and absolute improvements in care: meta-analysis of controlled clinical trials.

OBJECTIVE: To report the improvements achieved with clinical decision support systems and examine the heterogeneity from pooling effects across diverse clinical settings and intervention targets. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Medline up to August 2019. ELIGIBILITY CRITERIA FOR SELECTING STUDIES AND METHODS: Randomised or quasi-randomised controlled trials reporting absolute improvements in the percentage of patients receiving care recommended by clinical decision support systems. Multilevel meta-analysis accounted for within study clustering. Meta-regression was used to assess the degree to which the features of clinical decision support systems and study characteristics reduced heterogeneity in effect sizes. Where reported, clinical endpoints were also captured. RESULTS: In 108 studies (94 randomised, 14 quasi-randomised), reporting 122 trials that provided analysable data from 1 203 053 patients and 10 790 providers, clinical decision support systems increased the proportion of patients receiving desired care by 5.8% (95% confidence interval 4.0% to 7.6%). This pooled effect exhibited substantial heterogeneity (I2=76%), with the top quartile of reported improvements ranging from 10% to 62%. In 30 trials reporting clinical endpoints, clinical decision support systems increased the proportion of patients achieving guideline based targets (eg, blood pressure or lipid control) by a median of 0.3% (interquartile range -0.7% to 1.9%). Two study characteristics (low baseline adherence and paediatric settings) were associated with significantly larger effects. Inclusion of these covariates in the multivariable meta-regression, however, did not reduce heterogeneity. CONCLUSIONS: Most interventions with clinical decision support systems appear to achieve small to moderate improvements in targeted processes of care, a finding confirmed by the small changes in clinical endpoints found in studies that reported them. A minority of studies achieved substantial increases in the delivery of recommended care, but predictors of these more meaningful improvements remain undefined.

The Prevalence of Children and Adolescents at Risk for Avoidant Restrictive Food Intake Disorder in a Pediatric and Adolescent Gynecology Clinic.

STUDY OBJECTIVE: The purpose of this study was to determine the prevalence of child and adolescent females at risk for Avoidant Restrictive Food Intake Disorder (ARFID) in a tertiary care pediatric and adolescent gynecology (PAG) clinic. DESIGN: Cross-sectional study design. SETTING: Tertiary care PAG clinic at the Hospital for Sick Children in Toronto, Ontario, Canada. PARTICIPANTS: Females between 8 and 18 years of age presenting to the tertiary care PAG clinic. INTERVENTION: Between October 2017 and April 2019, eligible patients completed a 3-part, self-administered questionnaire that included demographic and anthropometric information, reason(s) for referral, medical history, menstrual history and function, and the Eating Disorders in Youth-Questionnaire (EDY-Q). MAIN OUTCOME MEASURES: The main outcome measure was the prevalence of child and adolescent females who were identified to be at risk for ARFID in a tertiary care PAG clinic. RESULTS: Seven (3.7%) of 190 patients were identified to be at risk for ARFID based on the EDY-Q. All patients at risk for ARFID had a significantly lower body mass index (17.4 ± 1.6 vs 24.4 ± 6.7, P < .001) than patients not at risk for ARFID. CONCLUSIONS: This study demonstrated that 3.7% of patients seeking treatment in a tertiary care PAG clinic were identified to be at risk for ARFID. Clinicians in tertiary care PAG clinics can play a pivotal role in the identification and referral of children and adolescents at risk for ARFID. Referral to the patients' primary care physician or to an eating disorder program is important so as not to delay the diagnosis and treatment.

Association Between Web-Based Physician Ratings and Physician Disciplinary Convictions: Retrospective Observational Study.

BACKGROUND: Physician rating websites are commonly used by the public, yet the relationship between web-based physician ratings and health care quality is not well understood. OBJECTIVE: The objective of our study was to use physician disciplinary convictions as an extreme marker for poor physician quality and to investigate whether disciplined physicians have lower ratings than nondisciplined matched controls. METHODS: This was a retrospective national observational study of all disciplined physicians in Canada (751 physicians, 2000 to 2013). We searched ratings (2005-2015) from the country's leading online physician rating website for this group, and for 751 matched controls according to gender, specialty, practice years, and location. We compared overall ratings (out of a score of 5) as well as mean ratings by the type of misconduct. We also compared ratings for each type of misconduct and punishment. RESULTS: There were 62.7% (471/751) of convicted and disciplined physicians (cases) with web-based ratings and 64.6% (485/751) of nondisciplined physicians (controls) with ratings. Of 312 matched case-control pairs, disciplined physicians were rated lower than controls overall (3.62 vs 4.00; P<.001). Disciplined physicians had lower ratings for all types of misconduct and punishment-except for physicians disciplined for sexual offenses (n=90 pairs; 3.83 vs 3.86; P=.81). Sexual misconduct was the only category in which mean ratings for physicians were higher than those for other disciplined physicians (3.63 vs 3.35; P=.003). CONCLUSIONS: Physicians convicted for disciplinary misconduct generally had lower web-based ratings. Physicians convicted of sexual misconduct did not have lower ratings and were rated higher than other disciplined physicians. These findings may have future implications for the identification of physicians providing poor-quality care.

Preoperative Risk Stratification of Adnexal Masses in the Pediatric and Adolescent Population: Evaluating the Decision Tree System.

STUDY OBJECTIVE: To evaluate the diagnostic performance of the Decision Tree System (DTS) rules 2 and 3 for surgically managed adnexal masses in the North American population and to compare it with the risk stratification criteria used at The Hospital for Sick Children (≥8 cm and complex/solid). DESIGN: A retrospective cohort study of patients who presented with adnexal masses and were surgically treated between April 2011 and March 2016. SETTING: The Hospital for Sick Children (Toronto, Ontario, Canada). PARTICIPANTS: Patients 1-18 years of age with adnexal masses who underwent surgical treatment. INTERVENTIONS AND MAIN OUTCOME MEASURES: Main outcome measures included diagnostic performance (preoperative sensitivity, specificity, positive predictive value [PPV], and negative predictive value [NPV] for malignancy) of the DTS rules 2 and 3 and ≥8 cm and complex/solid criteria. RESULTS: The malignancy rate was 10.4%. The DTS rules 2 and 3 had a sensitivity of 84% (95% confidence interval [CI], 79-90), specificity of 77% (95% CI, 71-83), PPV of 30% (95% CI, 17-42), and NPV of 98% (95% CI, 94-100). The 8 cm or larger and complex/solid criteria had a sensitivity of 89% (95% CI, 85-94), specificity of 71% (95% CI, 64-77), PPV of 27% (95% CI, 16-38), and NPV of 98% (95% CI, 96-100). CONCLUSION: Our study showed that DTS rules 2 and 3 had similar diagnostic performance as the 8 cm or larger and complex/solid criteria in the same population, with a very high NPV and a low PPV. Future prospective investigations should be conducted to further assess how DTS components can be incorporated into future algorithms for the management of adnexal masses in the pediatric population.

The Characteristics of Physicians Who are Re-Disciplined by Medical Boards: A Retrospective Cohort Study.

BACKGROUND: Physician misconduct adversely affects patient safety and is therefore of societal importance. Little work has specifically examined re-disciplined physicians. A study was conducted to compare the characteristics of re-disciplined to first-time disciplined physicians. METHODS: A retrospective review of Canadian physicians disciplined by medical boards between 2000 and 2015 was conducted. Physicians were divided into those disciplined once and those disciplined more than once. Differences in demographics, transgressions, and penalties were evaluated. RESULTS: There were 938 disciplinary events for 810 disciplined physicians with 1 in 8 (n = 101, 12.5%) being re-disciplined. Re-disciplined physicians had up to six disciplinary events in the study period and 4 (4.0%) had events in more than one jurisdiction. Among those re-disciplined, 94 (93.1%) were male, 34 (33.7%) were international medical graduates, and 88 (87.1%) practiced family medicine (n = 59, 58.4%), psychiatry (n = 11, 10.9%), surgery (n = 9, 8.9%), or obstetrics/gynecology (n = 9, 8.9%). The proportion of obstetrician/gynecologists was higher among re-disciplined physicians (8.9% vs. 4.2%, p = 0.048). Re-disciplined physicians had more mental illness (1.7% vs. 0.1%, p = 0.01), unlicensed activity (19.2% vs. 7.2%, p <0.01), and less sexual misconduct (20.1% vs. 27.9%, p = 0.02). License suspension occurred more frequently among those re-disciplined (56.8% vs. 48.0%, p = 0.02) as did license restriction (38.4% vs. 26.7%, p <0.01). License revocation was not different between cohorts (10.9% vs. 13.5%, p = 0.36). CONCLUSION: Re-discipline is not uncommon and underscores the need for better identification of at-risk individuals and optimization of remediation and penalties. The distribution of transgression argues for a national disciplinary database that could improve communication between jurisdictional medical boards.

The representation of vulnerable populations in quality improvement studies.

PURPOSE: A mapping review to quantify representation of vulnerable populations, who suffer from disparity and often inequitable healthcare, in quality improvement (QI) research. DATA SOURCES: Studies published in 2004-2014 inclusive from Medline, Embase and Cochrane databases for English language research with the terms 'quality improvement' or 'quality control' or 'QI' and 'plan-do-study-act' or 'PDSA' in the years 2004-2014 inclusively. STUDY SELECTION: Published clinical research that was a QI-themed, as identified by its declared search terms, MESH terms, abstract or title. DATA EXTRACTION: Three reviewers identified the eligible studies independently. Excluded were publications that were not trials, evaluations or analyses. RESULTS OF DATA SYNTHESIS: Of 2039 results, 1660 were eligible for inclusion. There were 586 (33.5%) publications that targeted a specific vulnerable population: children (184, 10.54%), mental health patients (125, 7.16%), the elderly (100, 5.73%), women (57, 3.27%), the poor (30, 1.72%), rural residents (29, 1.66%), visible minorities (27, 1.55%), the terminally ill (17, 0.97%), adolescents (16, 0.92%) and prisoners (1 study). Seventy-four articles targeted two or more vulnerable populations, and 11 targeted three population categories. On average, there were 158 QI research studies published per year, increasing from 69 in 2004 to 396 in 2014 (R2 = 0.7, P < 0.001). The relative representation of vulnerable populations had a mean of 33.58% and was stable over the time period (standard deviation (SD) = 5.9%, R2 = 0.001). Seven countries contributed to over 85% of the publications targeting vulnerable populations, with the USA contributing 62% of the studies. CONCLUSIONS: Over 11 years, there has been a marked increase in QI publications. Roughly one-third of all published QI research is on vulnerable populations, a stable proportion over time. Nevertheless, some vulnerable populations are under-represented. Increased education, resources and attention are encouraged to improve the health of vulnerable populations through focused QI initiatives.

Bariatric Surgery in Adolescents: Is Routine Nutrient Supplementation Sufficient to Avoid Anemia Following Bariatric Surgery?

BACKGROUND: Anemia following bariatric surgery is a known complication. To prevent nutrient deficiencies, adolescents require multivitamin/mineral supplementation following bariatric surgery. The purpose of this study was to investigate if routine multivitamin/mineral supplementation is sufficient to prevent anemia in adolescents undergoing bariatric surgery, particularly sleeve gastrectomy (SG), a procedure that may induce nutrient malabsorption. METHODS: We conducted a retrospective review of pediatric patients who underwent SG (34 patients) and laparoscopic adjustable gastric banding (LAGB) (141 patients) (January 2006 through December 2013). We examined anemia marker levels (iron, ferritin, folate, B12, hemoglobin, and hematocrit) at first visit and 3, 6, and 12 months postsurgery by repeated-measures analysis adjusting for weight loss. RESULTS: Following SG, folate levels decreased 3 and 6 months postsurgery but returned to baseline levels at 12 months. Furthermore, the SG group demonstrated lower folate levels compared with LAGB at 3 and 6 months. B12 levels decreased 6 months post-SG but returned to baseline at 12 months. Following LAGB, B12 levels decreased 12 months postsurgery compared with baseline. Ferritin levels decreased 3 months post-LAGB but returned to baseline levels at 6 months. There were no changes within groups or differences between groups in iron, hemoglobin, or hematocrit. CONCLUSIONS: While anemia did not occur in any patients while on recommended routine supplementation, folate levels were significantly reduced following SG and were lower in SG compared with LAGB patients. Additional folate supplementation seemed to improve folate levels, which highlights the importance of ongoing surveillance by primary care providers and the need for additional folate supplementation following SG.

The Characteristics of International Medical Graduates Who Have Been Disciplined by Professional Regulatory Colleges in Canada: A Retrospective Cohort Study.

PURPOSE: This study evaluated the proportion and characteristics of international medical graduates (IMGs) who have been disciplined by professional regulatory colleges in Canada in comparison with disciplined North American medical graduates (NAMGs). METHOD: The authors compiled a database of the nature of professional misconduct and penalties incurred by disciplined physicians from January 2000 to May 2015 using public records. They compared discipline data for IMGs versus those for NAMGs, and calculated risk ratios (RRs) and 95% confidence intervals (CIs) for select outcomes. RESULTS: There were 794 physicians disciplined; 922 disciplinary cases during the 15-year study period. IMGs composed an average of 23.4% (standard deviation = 1.1%) of the total physician population and represented one-third of disciplined physicians and discipline cases. The overall disciplinary rate for all Canadian physicians was 8.52 cases per 10,000 physician years (95% CI [7.77, 9.31]). This rate per group was higher for IMGs than for NAMGs (12.91 [95% CI (11.50, 14.43)] vs. 8.16 [95% CI (7.53, 8.82)] cases per 10,000 physician years, P < .01, and RR 1.58 (95% CI [1.38, 1.82]). IMGs were disciplined at significantly higher rates than NAMGs if they were trained in South Africa (RR 1.73 [95% CI (1.14, 2.51), P < .01), Egypt (RR 3.59 [95% CI (2.18, 5.52)], P < .01), or India (RR 1.66 [95% CI (1.01, 2.55)], P = .03). CONCLUSIONS: IMGs are disciplined at a higher rate than NAMGs. Future initiatives should be focused to delineate the exact cause of this observation.

Fetiform Teratoma in the Ovary of a 7-Year-Old Girl: A Case Report.

BACKGROUND: Fetiform teratoma, a highly differentiated mature cystic teratoma resembling a fetus, is rare and typically found in the ovaries of women of reproductive age. In this report we describe, to our knowledge, the youngest case of ovarian fetiform teratoma. CASE: A 7-year-old girl presented with acute abdominal pain. Radiological examinations revealed a 5.2-cm ovarian complex cystic mass with fetal-like components in favor of fetus in fetu and teratoma. After surgical removal, the mass resembled a fetus consisting of a head, two eye slits, two small upper limb projections, and hair. Pathology indicated mature cystic teratoma supporting the diagnosis of fetiform teratoma. SUMMARY AND CONCLUSION: Although not commonly found in children, fetiform teratoma must be considered in the diagnosis of a child who presents with an adnexal mass resembling a fetus.

A Cross-Sectional Survey of Population-Wide Wait Times for Patients Seeking Medical vs. Cosmetic Dermatologic Care.

BACKGROUND: Though previous work has examined some aspects of the dermatology workforce shortage and access to dermatologic care, little research has addressed the effect of rising interest in cosmetic procedures on access to medical dermatologic care. Our objective was to determine the wait times for Urgent and Non-Urgent medical dermatologic care and Cosmetic dermatology services at a population level and to examine whether wait times for medical care are affected by offering cosmetic services. METHODS: A population-wide survey of dermatology practices using simulated calls asking for the earliest appointment for a Non-Urgent, Urgent and Cosmetic service. RESULTS: Response rates were greater than 89% for all types of care. Wait times across all types of care were significantly different from each other (all P < 0.05). Cosmetic care was associated with the shortest wait times (3.0 weeks; Interquartile Range (IQR) = 0.4-3.4), followed by Urgent care (9.0 weeks; IQR = 2.1-12.9), then Non-Urgent Care (12.7 weeks; IQR = 4.4-16.4). Wait times for practices offering only Urgent care were not different from practices offering both Urgent and Cosmetic care (10.3 vs. 7.0 weeks). INTERPRETATION: Longer wait times and greater variation for Urgent and Non-Urgent dermatologic care and shorter wait times and less variation for Cosmetic care. Wait times were significantly longer in regions with lower dermatologist density. Provision of Cosmetic services did not increase wait times for Urgent care. These findings suggest an overall dermatology workforce shortage and a need for a more streamlined referral system for dermatologic care.

Characteristics of Internal Medicine Physicians Disciplined by Professional Colleges in Canada.

Physician misconduct is of serious concern to patient safety and quality of care. Currently, there are limited data on disciplinary proceedings involving internal medicine (IM) physicians.The aim of this study was to investigate the number and nature of disciplinary cases among IM physicians compared with those of other disciplined physicians.Our retrospective study reviewed information from all provincial Colleges of Physicians and Surgeons (CPS) and compiled a database of all disciplined physicians from 2000 to 2013 in Canada. Disciplinary rate differences (RDs) were calculated for IM physicians and compared with other physicians.From 2000 to 2013, overall disciplinary rates were low (9.6 cases per 10,000 physician years). There were 899 disciplinary cases, 49 of which involved 45 different IM physicians. IM physicians comprised 10.8% of all disciplined physicians and were disciplined at a lower rate than non-IM physicians, incurring 5.18 fewer cases per 10,000 physician years than other physicians (95% confidence interval [CI] 3.62-6.73; P < 0.001). They were significantly less likely to be disciplined for: unprofessional conduct (RD 1.16; CI 0.45-1.87; P = 0.001); unlicensed activity (RD 0.78; CI 0.37-1.19; P < 0.001); standard of care issues (RD 1.37; CI 0.49-2.26; P = 0.002); sexual misconduct (RD 1.65; CI 0.90-2.40; P < 0.001); miscellaneous (RD 0.80; CI 0.11-1.50; P = 0.020); mental illness (RD 0.06; CI 0.01-0.12; P = 0.025); inappropriate prescribing (RD 0.74; CI 0.15-1.33; P = 0.010); and criminal conviction (RD 0.33; CI 0.00-0.65; P = 0.048). No significant differences were found with respect to unclear violations, fraudulent behavior/prevarication, or offenses involving drugs/alcohol (all RDs less than 0.32). IM physicians were also less likely to incur the following penalties: voluntary license surrender (RD 0.53; CI 0.37-0.69; P < 0.001); suspension (RD 2.39; CI 1.26-3.51; P < 0.001); retraining/assessment (RD 1.58; CI 0.77-2.39; P < 0.001); restriction (RD 1.60; CI 0.74-2.46; P < 0.001); other (RD 0.52; CI 0.07-0.97; P = 0.030); formal reprimand (RD 2.78; CI 1.77-3.79; P < 0.001); or fine (RD 3.28; CI 1.89-4.67; P < 0.001). No significant differences were found with respect to revocation or mandated counseling/rehabilitation (all RDs less than 0.46).Generally, disciplinary rates among physicians were low. Compared with other physicians, IM physicians have significantly lower disciplinary rates overall and are less likely to incur the majority of disciplinary offenses and penalties.