Hysterectomy for benign conditions: Complications relative to surgical approach and other variables that lead to post-operative readmission within 90 days of surgery.

OBJECTIVE: To examine variables associated with hysterectomy-related complications, relative to surgical approach and other variables, that lead to readmission within 90 days of surgery. METHODS: We conducted an observational cohort study for which data were extracted from electronic health records. Data were extracted of all patients (n = 3106) who underwent hysterectomies at 10 Kaiser Permanente Southern California medical centers between June 2010 and September 2011. Patients who were pregnant or had a cancer diagnosis were excluded from the study. To identify univariate associations between examined variables and procedure type, chi-square tests for categorical variables and t-tests or analysis of variance for continuous variables were used. Generalized estimating equations methods were used to test associations between independent variables and primary outcomes of interest. Statistical significance was determined using a p-value <.05. RESULTS: Of 3106 patients, 109 experienced 168 post-operative complications. The most common post-operative complications were related to pelvic abscesses, bowel obstruction, or severe ileus, and the vaginal cuff. Pelvic abscesses were most frequent among total laparoscopic hysterectomy and total abdominal hysterectomy cases (p = .002), and vaginal cuff complications were most frequent among total laparoscopic hysterectomy cases (p = .015). Patients who underwent total vaginal hysterectomy (odds ratio = 2.13, confidence interval = 1.15-3.92), laparoscopic supracervical hysterectomy (odds ratio = 3.11, confidence interval = 1.13-8.57), and total laparoscopic hysterectomy (odds ratio = 5.60, confidence interval = 2.90-10.79) experienced increased occurrence of post-operative complications resulting in readmission. Other variables associated with an increased risk for readmission included high estimated blood loss (201-300 mL and 301+ mL, relative to 0-50 mL; odds ratio = 2.28, confidence interval = 1.24-4.18 and odds ratio = 2.63, confidence interval = 1.67-4.14) and long length of stay of 3 days or more (relative to 0 days; odds ratio = 2.93, confidence interval = 1.28-6.69). Pelvic specimen weight in the 151-300 g and 501+ g ranges appeared protective (odds ratio = 0.40, confidence interval = 0.25-0.64 and odds ratio = 0.54, confidence interval = 0.33-0.90). In a sub-analysis of 1294 patients, 74 hospital operative complications directly related to hysterectomy were identified among 59 patients. The most common hospital operative complications were excessive bleeding associated with surgery or injury to nearby structures. Among the sub-sample of 1294 patients, those with hospital operative complications were more likely to experience post-operative complications that lead to readmission (odds ratio = 3.82, confidence interval = 1.55-9.43, p = .004). CONCLUSION: The observed increased risk of complications among patients of Black race, who underwent laparoscopic supracervical hysterectomy or total laparoscopic hysterectomy, who experienced more than 300 mL surgical blood loss, who suffered hospital operative complications, and those whose hospitalization was 3 days or greater, offers an opportunity for higher scrutiny and preventive measures during usual hysterectomy care to prevent later readmission.

Progestin-based contraceptive on the same day as medical abortion.

OBJECTIVE: To determine the success rate of medical abortion when a progestin-based contraceptive-either an etonogestrel implant or depot medroxyprogesterone acetate (DMPA) injection-is given on the same day as mifepristone for medical abortion. METHODS: In a retrospective chart review, data were assessed for women aged 15-49years who underwent medical abortion (≤63days of pregnancy) at two hospitals in KwaZulu Natal, South Africa, between August 2013 and July 2014. The women were given oral mifepristone (200mg) and buccal misoprostol (800µg), and received an etonogestrel implant or DMPA injection on the same day as mifepristone. The primary outcome was the success rate of medical abortion. Comparative data were obtained through a PubMed search. RESULTS: A total of 89 women were included. Complete termination was achieved in 87 (98%, 95% confidence interval 95%-100%) women. This success rate is similar to that reported in a previous systematic review of the rate of medical abortion success without progestin contraceptive administration (94.8%). CONCLUSIONS: Administration of a progestin-based contraceptive such as an etonogestrel implant or DMPA injection on the same day as mifepristone for medical abortion did not alter the success rates.

Reproductive coercion: uncloaking an imbalance of social power.

Reproductive coercion involves behavior that interferes with contraceptive and pregnancy choices of women and occasionally men. This includes birth control sabotage (intentional destruction of a woman's chosen method of contraception), pregnancy pressure (behaviors to coerce pregnancy against one's wishes), and pregnancy coercion (threats to direct the outcome of a pregnancy). All are associated with serious reproductive consequences including unintended pregnancy, abortion, sexually transmitted infections, poor pregnancy outcomes, and psychological trauma. This article presents an overview of the recent literature surrounding reproductive coercion and how it relates to the reproductive health outcomes of women, adolescents, and the lesbian, gay, bisexual, and transgender community. Men's experience with reproductive coercion will also be discussed. Clinical implications and evidence-based strategies for assessment and intervention will be identified.

Phase 2a study assessing colonization efficiency, safety, and acceptability of Lactobacillus crispatus CTV-05 in women with bacterial vaginosis.

BACKGROUND: Bacterial vaginosis (BV) is a common vaginal infection caused by a lack of endogenous lactobacilli and overgrowth of pathogens that frequently recurs following antibiotic treatment. METHODS: A phase 2a study assessed colonization efficiency, safety, tolerability, and acceptability of Lactobacillus crispatus CTV-05 (LACTIN-V) administered by a vaginal applicator. Twenty-four women with BV were randomized in a 3:1 ratio of active product to placebo. Participants used LACTIN-V at 2 × 10 colony-forming units (cfu)/dose or placebo for 5 initial consecutive days, followed by a weekly application over 2 weeks. They returned for follow-up on Days 10 and 28. RESULTS: Sixty-one percent of the 18 women randomized to the LACTIN-V group were colonized with L. crispatus CTV-05 at Day 10 or Day 28. Among LACTIN-V users with complete adherence to the study regimen, 78% were colonized at Day 10 or Day 28. Of the 120 adverse events (AEs) that occurred, 108 (90%) and 12 (10%) were of mild and moderate severity, respectively. AEs were evenly distributed between the LACTIN-V and placebo group. Of the total AEs, 93 (78%) were genitourinary in origin. The most common genitourinary AEs included vaginal discharge (46%), abdominal pain (46%), dysuria (21%), pollakiuria (21%), vaginal odor (21%), and genital pruritus (17%). No grade 3 or 4 AEs or serious AEs occurred and no deep epithelial disruption was seen during colposcopic evaluation. The product was well tolerated and accepted. CONCLUSIONS: LACTIN-V colonized well, and was safe and acceptable in women treated for BV.

Phase 1 dose-ranging safety trial of Lactobacillus crispatus CTV-05 for the prevention of bacterial vaginosis.

BACKGROUND: Bacterial vaginosis is a very common vaginal infection. The lack of endogenous lactobacilli and overgrowth of pathogens facilitate numerous gynecological complications. METHODS: A phase I dose-ranging safety trial tested the safety, tolerability, and acceptability of Lactobacillus crispatus CTV-05 (LACTIN-V) administered by vaginal applicator. Twelve healthy volunteers were enrolled in 3 blocks of 4 (5 x 10, 1 x 10, and 2 x 10 cfu/dose). Each block was randomized in a 3:1 ratio of active product to placebo. Participants used study product for 5 consecutive days, returned for follow-up on days 7 and 14, and had phone interviews on days 2 and 35. RESULTS: All 12 participants took 5 doses and completed study follow-up.Overall, 45 adverse events (AEs) occurred, of which 31 (69%) were genitourinary (GU) AEs. GU AEs appeared evenly distributed between the 3 treatment blocks and between LACTIN-V and placebo arms. The most common GU AEs were vaginal discharge in 5 subjects (42%), abdominal pain in 4 subjects (33%), metrorrhagia in 4 subjects (33%), vulvovaginitis in 4 subjects (33%), vaginal candidiasis in 3 subjects (25%), and vaginal odor in 3 subjects (25%). Forty-one (91%) AEs were mild (grade 1) in severity. All 4 moderate AEs (grade 2) were unrelated to product use. No grade 3 or 4 AEs or serious adverse events (SAE) occurred. Laboratory parameters and colposcopy findings were within normal limits or clinically insignificant. The product was well-tolerated and accepted. CONCLUSION: All 3 dose levels of LACTIN-V appeared to be safe and acceptable in healthy volunteers.

Long-term outcomes in patients with treated childhood hydrocephalus.

OBJECT: The goal in this study was to determine the long-term effects of childhood hydrocephalus. METHODS: A patient-reported survey completed by 1953 participants was used to collect data in a subgroup of 1459 individuals who had been treated for hydrocephalus in childhood. Data on shunt complications, including total shunt revisions and infections, were examined in those whose hydrocephalus had been diagnosed at least 10 years earlier (718 patients). Social and functional outcomes were examined in patients who were 20 years of age or older at the time of survey completion (403 individuals). Specific questions addressed the presence of depression, the patient's marital status, independent living arrangements, and the educational level attained. Shunt complications were common; 54% of patients had four or more shunt revisions, and 9% had three or more shunt infections. Depression requiring treatment occurred in 45% of participants. Other measures of social functioning all reflected a major impact of childhood hydrocephalus. In general, a worse outcome was found in patients whose hydrocephalus was diagnosed before 18 months of age. CONCLUSIONS: The lifelong morbidity associated with shunt placement to treat childhood hydrocephalus is substantial, and it includes shunt-related complications and comorbidities that adversely affect social functioning.

Sorting of vesicular monoamine transporter 2 to the regulated secretory pathway confers the somatodendritic exocytosis of monoamines.

The release of monoamine neurotransmitters from cell bodies and dendrites has an important role in behavior, but the mechanism (vesicular or non vesicular) has remained unclear. Because the location of vesicular monoamine transporter 2 (VMAT2) defines the secretory vesicles capable of monoamine release, we have studied its trafficking to assess the potential for monoamine release by exocytosis. In neuroendocrine PC12 cells, VMAT2 localizes exclusively to large dense-core vesicles (LDCVs), and we now show that cytoplasmic signals target VMAT2 directly to LDCVs within the biosynthetic pathway. In neurons, VMAT2 localizes to a population of vesicles that we now find undergo regulated exocytosis in dendrites. Although hippocampal neurons do not express typical LDCV proteins, transfected chromogranins A, B, and brain-derived neurotrophic factor (BDNF) colocalize with VMAT2. VMAT2 thus defines a population of secretory vesicles that mediate the activity-dependent somatodendritic release of multiple retrograde signals involved in synaptic function, growth, and plasticity.