Hypertrophic cervical elongation: clinical and histological correlations.

INTRODUCTION AND HYPOTHESIS: The objective of this study is to define the diagnosis of hypertrophic cervical elongation clinically and to perform histochemical and histological evaluations of patients with and without hypertrophic cervical elongation. METHODS: This prospective study was conducted at Louisiana State University between December 2005 and May 2008. Fourteen women with cervical elongation and 28 women without prolapse were studied. RESULTS: The amounts of elastin, collagen, and smooth muscle did not differ between study and control groups. Estrogen and progesterone receptor content in cervical elongation were elevated compared to the cervix of women without prolapse. Hypertrophic cervical elongation was defined as the difference between point C and point D of the Pelvic Organ Prolapse Quantification system greater than 8 cm. CONCLUSIONS: Estrogen and progesterone receptor levels are greater in women with hypertrophic cervical elongation compared with a normal cervix.

Complications of transvaginal monofilament polypropylene mesh in pelvic organ prolapse repair.

INTRODUCTION AND HYPOTHESIS: This study aimed to document intraoperative and postoperative complications associated with the use of transvaginal polypropylene mesh in the repair of pelvic organ prolapse (POP). METHODS: This is a retrospective review of 127 cases of transvaginal repair of POP using synthetic mesh. RESULTS: Mean postoperative value (+/-SD) for pelvic organ prolapse quantification (POPQ) measurements Aa, Ap, and C were: -2.4 +/- 1.1 (cm), -2.4 +/- 0.9 (cm), and -7.7 +/- 1.2 (cm), respectively. The difference between preoperative and postoperative values of these points was significant (p < 0.0001). Mesh erosion rate was 13/127 (10.2%) with significant correlation between mesh erosion and concurrent vaginal hysterectomy (p = 0.008). Combined anterior and posterior vaginal mesh surgery increased the risk of intraoperative bleeding and blood transfusion (p < 0.05). CONCLUSIONS: Concurrent vaginal hysterectomy is associated with increased risk of vaginal mesh erosion. Combined anterior and posterior vaginal mesh repair is an increased risk factor for intraoperative bleeding and blood transfusion.

Urinary tract injury during hysterectomy based on universal cystoscopy.

OBJECTIVE: To estimate the incidence and location of injury to the urinary tract during hysterectomy for benign gynecologic disease. METHODS: This was a prospective clinical study in an academic environment performed at three sites. Diagnostic cystourethroscopy was performed on all patients after hysterectomy for benign disease. RESULTS: Eight hundred thirty-nine patients were enrolled. The incidence of urinary tract injury associated with hysterectomy for benign disease was 4.3% (39 of 839 cases). The rate of bladder injury was 2.9% (24 of 839 cases), and rate of ureteral injury was 1.8% (15 of 839 cases). There were three cases of simultaneous bladder and ureteral injuries, resulting in a cumulative injury rate of 4.3%. The injury detection rate using intraoperative diagnostic cystoscopy was 97.4% (817 of 839 cases). The most common site of injury to the ureter was at the junction of the ureter and the uterine artery in 80% (12 of 15 cases) of ureteral injuries. Transection and kinking injuries were the most frequent type of injury. There were 21 cases of subnormal dye efflux from the ureteral orifices, with no subsequent injury detected on further evaluation. CONCLUSION: Ureteral injury occurred most commonly at the level of the uterine artery, and transection and kinking injuries were most frequent. Diminished dye efflux from ureteral orifices was not associated with injury. LEVEL OF EVIDENCE: III.

Surviving disaster: assessment of obstetrics and gynecology training at Louisiana State University-New Orleans before and after Hurricane Katrina.

BACKGROUND: After Hurricane Katrina, the 2 primary teaching sites for Louisiana State University Health Sciences Center in New Orleans were destroyed. In this study, we examine the measures the Louisiana State University Department of Obstetrics and Gynecology took to provide uninterrupted education for Obstetrics and Gynecology residents and the outcome of those measures. METHODS: Information was gathered from the program director's office and the Accreditation Council for Graduate Medical Education website. Resident turnover during the disaster and where residents trained before and after Katrina were tabulated. Council on Resident Education in Obstetrics and Gynecology scores, obstetric statistics, and American Board of Obstetrics and Gynecology pass rates before and after Katrina were analyzed for significant differences from year to year. RESULTS: After Katrina, all residents were shifted to other teaching sites in the state, and the program gained 2 additional private teaching sites. The department lost 10 residents in the year following Katrina and replaced them with 5 new residents for the next academic year. There was no significant difference in Council on Resident Education in Obstetrics and Gynecology scores for individual residents from 2004 to 2006, and the median score for the program has not changed significantly for the past 4 years. The only number that has changed is the number of cesarean sections performed by second-year residents, which decreased significantly from 2005-2006 to 2006-2007 but has stabilized over the last year. The classes of 2004-2006 had 100% pass rates on the written American Board of Obstetrics and Gynecology examination, with 1 failure in 2007. CONCLUSIONS: The Obstetrics and Gynecology program at Louisiana State University Health Sciences Center provided uninterrupted training for residents through cooperation with other Louisiana State University facilities and private institutions in the state. We saw a small decrease in the number of cesarean sections performed by our second-year residents 1 year after Katrina; however, the rest of the resident experience has remained stable.

Computer use in an urban university hospital: technology ahead of literacy.

The linkage of patient safety and care quality to the implementation of computerized information systems assumes that clinical staff are skilled with computers. Nurses and nursing support staff increasingly require computers to carry out their work. Minimum computer competencies for nurses have been identified. The determination of whether the current nursing workforce has acquired these competencies remains uncertain. We administered a self-assessment survey to nurses and nursing support staff to determine proficiency with computer skills they might perform at work. Respondents reported inadequacies in basic and work-related computer skills. More than 28% scored themselves as having fair or poor proficiency on all skills, and more than 50% as fair or poor on five of 11 skills. Respondents over age 50 and those graduating before 1984 tended to score proficiency lower. Our study suggests that many nurses and nursing support staff may not have the minimum computer competencies to effectively and efficiently perform their work.

The effects of standing, lifting and noise exposure on preterm birth, growth restriction, and perinatal death in healthy low-risk working military women.

OBJECTIVE: The effects of standing, lifting and noise in low-risk, healthy pregnant women are uncertain. In the past, the heterogeneity of the populations studied, the limitations of the designs of the retrospective and case control studies, and a failure of some of the larger investigations to evaluate all the potential confounding variables has hampered many studies. The purpose of this investigation was to evaluate, throughout pregnancy, the effects of standing, repetitive lifting, and noise in the workplace compared with no standing, lifting or noise exposure, on maternal and perinatal outcomes in a large prospective study of a low-risk healthy population of working women cared for by a single group of health providers. METHODS: This prospective observational study used an extensive questionnaire to collect antepartum, intrapartum, and postpartum information. Information was collected on the initial visit, each subsequent visit, and immediately after delivery. The participating women were divided into groups based on the amount of time spent standing, the amount and extent of repetitive lifting, and noise exposure in the workplace. RESULTS: Eight hundred and fourteen low-risk active duty women participated in this investigation over a 4-year period. Multivariate analysis with non-exposure compared with exposure reinforced the effect of standing on preterm labor (OR 1.80, 95% CI 1.05, 3.16) and preterm birth (OR 1.69, 95% CI 1.03, 2.80) and showed a trend toward an effect of noise exposure on preterm labor (OR 1.76, 95% CI 0.78, 3.39) after controlling for other exposures. CONCLUSIONS: This investigation suggests an association of occupational standing with preterm labor and preterm birth.

Symptomatic cecal perforation by an intrauterine device with appendectomy removal.

BACKGROUND: The intrauterine device is the most used contraceptive in the world, but it is not without risk of perforation of intra-abdominal organs. We report a perforation of the cecum and removal via appendectomy. CASE: A 23-year-old woman developed chronic abdominal pain after insertion of an intrauterine device 8 weeks postpartum. At laparoscopy, the device was found in the cecum and removed via appendectomy. CONCLUSION: Perforation is more common in the immediate postpartum state. An alternate method of removal via appendectomy proved useful.

The incidence of urinary tract injury during hysterectomy: a prospective analysis based on universal cystoscopy.

OBJECTIVE: To evaluate the incidence of urinary tract injury due to hysterectomy for benign disease. STUDY DESIGN: Patients were enrolled prospectively from 3 sites. All patients undergoing abdominal, vaginal, or laparoscopic hysterectomy for benign disease underwent diagnostic cystourethroscopy. RESULTS: Four hundred seventy-one patients participated. Ninety-six percent (24/25) of urinary tract injuries were detected intraoperatively. There were 8 cases of ureteral injury (1.7%) and 17 cases of bladder injury (3.6%). Ureteral injury was associated with concurrent prolapse surgery (7.3% vs 1.2%; P = .025). Bladder injury was associated with concurrent anti-incontinence procedures (12.5% vs 3.1%; P = .049). Abdominal hysterectomy was associated with a higher incidence of ureteral injury (2.2% vs 1.2%) but this was not significant. Only 12.5% of ureteral injuries and 35.3% of bladder injuries were detected before cystoscopy. CONCLUSION: The incidence of urinary tract injury during hysterectomy is 4.8%. Surgery for prolapse or incontinence increases the risk. Routine use of cystoscopy during hysterectomy should be considered.

A prescription for the rogue doctor: part I--begin with diagnosis.

Among the most serious problems a doctor can have may be those which are the result of a defect of character or a flaw in ethics. Under these circumstances, unacceptable behavior patterns may arise. Examples of unacceptable patterns of behavior include dishonesty, intentionally harming a patient, sexual harassment, and substance abuse. For years, doctors who have these patterns have been handled with kid gloves by those who educate, train, and supervise professionals in the healthcare industry. Counseling, coaching, training, supervising, transfers to less critical disciplines, disciplinary warnings, and offering opportunities to resign have been the typical protocols. Traditionally, outright firing of residents and doctors has been relatively taboo and too radical for the medical profession. Why has this been the case? Reasons may include unwillingness to get involved or to deal with the stress of disciplining a colleague, an unwillingness which often is grounded in fears of retaliation. In a litigious society, fears of slander lawsuits, for example, may be all-too-real. However, the implied paternalism and the practice of protecting doctors' careers by preserving their professional status as practicing doctors have become increasingly problematic. Aside from the fact that it is unethical, allowing problem doctors to continue to practice medicine may have an adverse impact on the well-being of patients and therefore may represent an enormous legal liability for organizations that employ them. In this first of a two-part series, problems that now exist and implementation of a performance management system as a starting point for removing rogues from the system are discussed. A subsequent paper will detail how such a system operates.

A prescription for the rogue doctor: part II ready, aim, fire.

As discussed in Part I of this series, rogue doctors have serious sociopathic behavioral deficiencies which may be the result of a defect of character or a flaw in ethics. Under these circumstances, unacceptable behavior patterns will arise. For years, counseling, coaching, training, supervising, transfers to less critical disciplines, disciplinary warnings, and offering opportunities to resign have been the typical approaches in dealing with rogues; the outright firing of residents and doctors has been relatively taboo. However, preserving a rogue's professional status as a practicing doctor has become increasingly problematic. In Part II of this two-part series, implementation of a performance management system to remove rogues from the system is discussed. This paper will detail exactly how such a system can work.

Morbidity and mortality rates of elective gynecologic surgery in the elderly woman.

OBJECTIVE: The purpose of this study was to report perioperative morbidity and mortality rates in elderly women who undergo gynecologic surgery. STUDY DESIGN: The charts of 54 consecutive women ages 70 to 85 years who underwent major gynecologic surgery between June 1998 and November 2002 were reviewed retrospectively. RESULTS: The mean age was 76.7 years. Fifty procedures (92.6%) were performed for pelvic organ prolapse and/or urinary incontinence. Forty-nine of the procedures were performed vaginally, and 27 of the procedures (50%) were performed with the use of general anesthesia. Postoperative cardiac complications occurred in five patients (10%), including three myocardial infarctions, two of which were fatal. Other complications included benign cardiac arrhythmias in two patients, slow return of gastrointestinal function in five patients (9.3%), and transient mental status changes in four patients (7.4%). The mean length of stay was 4 days. CONCLUSION: Postoperative complications occurred infrequently among elderly women who underwent gynecologic surgery. Although age alone is not a contraindication to elective surgery, there may be increased risks for geriatric women.

Necrotizing fasciitis in gynecologic and obstetric patients: a surgical emergency.

OBJECTIVE: We reviewed the cases of 23 patients who were admitted to the hospital with a primary diagnosis of histopathologically confirmed necrotizing fasciitis in the lower abdomen or pelvis. Rapid demise of a healthy postpartum women piqued our interest in trying to identify the early signs and symptoms that may lead to earlier diagnosis and treatment of this often fatal disease. STUDY DESIGN: A retrospective analysis of charts of all patients who were admitted to the gynecology and obstetrics services of our hospital systems with a diagnosis of necrotizing fasciitis for the past 14 years was performed. Age, comorbid factors, precipitating events, weight, symptoms and signs, microbiologic factors, radiographs, surgical therapy, and morbidity were correlated. RESULTS: Definitive operation was accomplished within 48 hours of the diagnosis of necrotizing fasciitis in all but 3 patients. Of the 17 patients who were not puerperal, 88% of the women were obese; 65% of the women were hypertensive, and 47% of the women were diabetic. Of the total 23 patients, 70% of the women complained of severe pain, and 35% of the women had radiographic diagnostics for necrotizing fasciitis ("gas"). Four patients had diverting colostomies, and 39% of the patients had flaps or synthetic grafts. Three patients died (mortality rate, 13%). One patient who was puerperal died of a severe rapid septicemia; the 2 late deaths were the result of systemic candidiasis. CONCLUSION: Necrotizing fasciitis is a rapidly progressive, often lethal, infectious disease process that requires early aggressive debridement. Any patient with inordinate pain and unilateral edema in the pelvis, especially in the puerperium, should be suspected of having this disease. Radiographic studies are often diagnostic of this condition. The triad of pelvic pain, edema, and any sign of septicemia carries an extremely grave prognosis and mandates immediate surgical intervention.

Methods in vascular infusion biotechnology in research with rodents.

Infusion of experimental compounds into the vascular system of rodents and the need to collect blood and other biological fluids from small animals comprise an area of emerging importance to biomedical research and drug discovery and development. The advances in the development of transgenic rodents coupled with technical progress in the manufacture and commercial availability of various catheters, swivels, tethers, infusion pumps, and sample collection systems that are described have enabled biomedical scientists to miniaturize vascular infusion and sample collection systems previously used in animal species larger than the rat or mouse. Use of these advanced, miniature vascular infusion systems in rodents is possible only when careful planning of experimental design, expert surgical technique, adequate postoperative care, and fundamental animal welfare considerations are meticulously taken into consideration. Use of these vascular infusion systems in rodents promotes animal welfare and scientific progress through the reduction and refinement of animal models.

Recognition of occult bladder injury during the tension-free vaginal tape procedure.

OBJECTIVE: To identify signs and the etiology of occult bladder injury during the tension-free vaginal tape sling procedure. METHOD: The charts of 140 women who underwent a tension-free vaginal tape procedure were reviewed, and complications were tabulated and analyzed. The tension-free vaginal tape procedure was performed in six fresh-frozen pelves to demonstrate the mechanism of the occult bladder injury. RESULTS: Occult bladder injury was suspected when cystoscopy instillation fluid flowed from the plastic sheath that covers the prolene tape after the extraction of the tension-free vaginal tape trocar. Three of six cases of intraoperative bladder injury had occult bladder injury identified on repeat cystoscopic inspection. The bladder injury caused by the rough edge at the point of attachment of the tension-free vaginal tape to the trocar was reproducible in three of 12 tension-free vaginal tape applications in fresh-frozen pelves. Traction on the tension-free vaginal tape reapproximates the injured bladder edges and potentially promotes spontaneous healing. CONCLUSION: Bladder injuries may go unrecognized during a tension-free vaginal tape procedure. Continuous seepage of water through the prolene plastic sleeve is suggestive of occult bladder injury and requires repeat cystoscopy to identify the potential site of injury.

Chronic pelvic pain.

Preview What do complaints of sleeplessness, depression, childhood sexual abuse, and dysfunctional family and marital relationships have to do with chronic pelvic pain? Maybe a lot, according to the authors' findings in studies of patients at a clinic for chronic pain. The authors describe diagnostic clues to watch for during history taking, an approach to differential diagnosis (including use of the "torso score"), and therapeutic options.