Counseling, contraception, and conception rates in patients undergoing bariatric surgery: A retrospective review.

OBJECTIVES: To determine conception rates, contraceptive use patterns, and frequency of counseling regarding pregnancy recommendations in patients undergoing bariatric surgery. STUDY DESIGN: Using a database of bariatric surgery patients at our institution, we identified female patients aged 18 to 45 who underwent surgery from 2013 to 2018. Patient charts were reviewed for demographic information, documentation of counseling regarding pregnancy recommendations, conception during the postoperative period, and pre and postoperative contraception use. We examined rates of contraception use and used standard statistical tests to compare conception rates between groups. RESULTS: Of the 460 patients that met inclusion criteria and did not have a history of permanent contraception, 54% (95% CI 49-58) had documented postoperative contraception use, most commonly the levonorgestrel-releasing intrauterine device followed by combination oral contraceptive pills. In the 18 months following bariatric surgery, 6% of patients (95% CI 4-8) had a documented pregnancy. Over 50% (95% CI 35-71) of pregnancies occurred in patients without documented postoperative contraception. CONCLUSIONS: For bariatric surgery patients at risk of pregnancy, postoperative contraception use patterns and conception rates are not consistent with the recommendation to refrain from pregnancy for 18 months. IMPLICATIONS: Individualized contraceptive counseling that includes a discussion of fertility and weight loss goals, planned bariatric procedure type, and patient preference should be implemented as part of standard preoperative care for patients at risk of pregnancy undergoing bariatric surgery.

A Patient-Centered Approach to Refractory Overactive Bladder and Barriers to Third-Line Therapy.

OBJECTIVE: To explore the decision-making process in women who do not pursue treatment with onabotulinumtoxinA, sacral neuromodulation, or percutaneous nerve stimulation in patients with overactive bladder (OAB). METHODS: This was a qualitative research study. Participants were females aged 18-80 years with a diagnosis of OAB and were evaluated by a urologic or urogynecologic physician between January 2017 and March 2018. Patients who were counseled for third-line therapy, refractory to two or more medications, or lost to follow-up after initiating a second medication were considered study candidates. Data were gathered using a semi-structured phone interview. Interview topics included medical knowledge and beliefs, quality of life, and treatment experience. The interviews were transcribed and coded thematically using grounded theory. RESULTS: Of a total of 381 women, 56 women qualified for our study. The average interview length was 30 minutes, and theoretical saturation occurred at 30 interviews. General themes included treatment delay, education, treatment attitudes, and office factors. The most common modifiable barrier to third-line therapy was insufficient in-office education. Participants expressed a poor understanding of the etiology, natural history, and treatment options for OAB. Participants were heavily influenced by outside factors including the opinions of friends and the media. Negative experiences with less-advanced options and treatment fatigue negatively affected participants' perceptions of third-line therapies. Office factors such as wait times and male physicians also negatively affected participants' ability to discuss their bladder symptoms. CONCLUSION: In conclusion, office education is tremendously important to patients' understanding of OAB, expectations of therapy, and treatment compliance. Education about third-line therapy counseling should be incorporated into the initial office visit. This may mitigate expectations, improve patient compliance, and promote graduation to advanced therapy in women who later go on to develop refractory symptoms.

Observed racial disparity in the negative predictive value of multi-parametric MRI for the diagnosis for prostate cancer.

OBJECTIVE: To evaluate the trend that despite recent advances in the screening, diagnosis, and management of prostate cancer (PCa), African-Americans (AAs) continue to have poorer outcomes compared to their Caucasian (CAU) counterparts. The reason for this may be rooted in biological differences in the cancer between the two groups; however, there may be some inherent disparities within the efficacy of the screening modalities. In this study, we aim to evaluate the negative predictive value (NPV) of multi-parametric MRI (mpMRI) between AA compared to CAUs. METHODS: All mpMRI between January 2014 and June 2017 were evaluated. The MRIs were read by dedicated genitourinary radiologists. Subsequently, the readings were correlated to final pathology after the patients underwent radical prostatectomy. The NPV and negative likelihood ratios (-LR) of mpMRI were evaluated in AAs versus CAUs based on four cutoffs (≥ Grade I, ≥ Grade II, ≥ Grade III and ≥ Grade IV). RESULTS: The mpMRI was almost equally as effective between AAs and CAUs in excluding Grade III (NPV = 89 and 94, respectively), and Grade IV or above (NPV = 96 and 98, respectively) PCa; however, the NPV of mpMRI was significantly lower for Grade I (NPV = 32 and 52, respectively) and Grade II (NPV = 50 and 79, respectively) PCa. CONCLUSION: Despite advances in the screening for PCa, there are disparities noted in the efficacy of screening tools between AAs and CAUs. For this reason, patients should be risk stratified and their screening results should be evaluated with consideration given to their baseline risk.

Increased Metabotropic Glutamate Receptor 5 Signaling Underlies Obsessive-Compulsive Disorder-like Behavioral and Striatal Circuit Abnormalities in Mice.

BACKGROUND: Development of treatments for obsessive-compulsive disorder (OCD) is hampered by a lack of mechanistic understanding about this prevalent neuropsychiatric condition. Although circuit changes such as elevated frontostriatal activity are linked to OCD, the underlying molecular signaling that drives OCD-related behaviors remains largely unknown. Here, we examine the significance of type 5 metabotropic glutamate receptors (mGluR5s) for behavioral and circuit abnormalities relevant to OCD. METHODS: Sapap3 knockout (KO) mice treated acutely with an mGluR5 antagonist were evaluated for OCD-relevant phenotypes of self-grooming, anxiety-like behaviors, and increased striatal activity. The role of mGluR5 in the striatal circuit abnormalities of Sapap3 KO mice was further explored using two-photon calcium imaging to monitor striatal output from the direct and indirect pathways. A contribution of constitutive signaling to increased striatal mGluR5 activity in Sapap3 KO mice was investigated using pharmacologic and biochemical approaches. Finally, sufficiency of mGluR5 to drive OCD-like behavior in wild-type mice was tested by potentiating mGluR5 with a positive allosteric modulator. RESULTS: Excessive mGluR5 signaling underlies OCD-like behaviors and striatal circuit abnormalities in Sapap3 KO mice. Accordingly, enhancing mGluR5 activity acutely recapitulates these behavioral phenotypes in wild-type mice. In Sapap3 KO mice, elevated mGluR5 signaling is associated with constitutively active receptors and increased and imbalanced striatal output that is acutely corrected by antagonizing striatal mGluR5. CONCLUSIONS: These findings demonstrate a causal role for increased mGluR5 signaling in driving striatal output abnormalities and behaviors with relevance to OCD and show the tractability of acute mGluR5 inhibition to remedy circuit and behavioral abnormalities.