Repeat anatomic surveys performed for an initial incomplete study: the sonographer and physician factors.

BACKGROUND: Repeat obstetrical anatomic surveys are often performed because of incomplete initial studies despite conflicting evidence on their utility. OBJECTIVE: To determine the frequency and yield of repeat obstetrical anatomic surveys performed because of incomplete initial studies and to determine patient and provider factors associated with the recommendation for a second study. STUDY DESIGN: A 10-year retrospective cohort study of women having an initial anatomic survey at 18 weeks to 21 weeks and 6/7 days of gestation at a single nonreferral county hospital. We identified the number of patients needed to scan to detect an anatomic abnormality for the overall cohort and for women having a repeat study. Select patient, sonographer, and reading physician factors were compared between the repeat-ultrasound and no-repeat-ultrasound groups by the 2-sample t test, chi-squared analysis, or analysis of variance, as appropriate. Multivariate logistic regression was used to assess the significance of multiple factors contributing to the recommendation for repeat ultrasounds. RESULTS: A total of 18,911 women had an initial anatomic survey between 18 weeks and 21 weeks and 6/7 days of gestation, and 2310 (12.2%) had a repeat ultrasound because of an incomplete initial study. For the overall cohort, there were 642 structural anomalies detected, with the number of patients needed to scan being 29. Among the 2310 repeat ultrasounds, only 7 structural anomalies were detected, whereas the number of patients needed to scan was 330, representing only 1.1% of all prenatally-identified anomalies. The frequency of recommended repeat ultrasounds varied by performing sonographer (4.5%-45.8%) and reading physician (7.1%-21.6%), both with P<.001 by 1-way analysis of variance. Clinical factors significantly impacting the odds of repeat ultrasounds included body mass index, gestational age, and previous cesarean delivery, but were less impactful than the sonographer and physician. CONCLUSION: The primary determinants of the perceived need for a repeat ultrasound are the sonographer and physician reader, with clinical factors having less but still significant importance. Repeat anatomic surveys account for a significant fraction of our total anatomic surveys and are of limited diagnostic utility. Recommendation of repeat anatomic surveys should be considered within the context of these findings.

The evolution of incontinence into resolved, refractory and de novo urgency urinary incontinence following sling placement at time of prolapse repair in a large urodynamic cohort.

PURPOSE: To improve counseling in women at risk of refractory and/or de novo urgency urinary incontinence (UUI) following sling placement at time of prolapse repair, we created an outcome model to characterize changes in storage dysfunction. MATERIALS AND METHODS: We identified 139 women who underwent urodynamics followed by sling or no sling placement at the time of prolapse repair over a 6-year period. Our primary outcome was the presence of UUI following sling placement. Data were analyzed in SAS using chi-square, Fisher's exact, Student's t-test, and Kaplan-Meier methods. RESULTS: At baseline, the sling group had significantly higher subjective (62/81 [76.5%] vs. 18/58 [31.0%]; p<0.001), objective (62/81 [76.5%] vs. 6/58 [10.3%]; p<0.001), and occult (41/81 [50.6%] vs. 6/58 [10.3%]; p<0.001) stress urinary incontinence (SUI); and rates of subjective and objective UUI were similar to the no sling group prior to surgery. After surgery (mean follow-up 859 days) there was no difference with or without sling, in the rate of SUI (subjective, objective) and further SUI treatments (bulking agent, repeat sling). Higher rates of de novo (13/81 [16.0%] vs. 6/58 [10.3%]; p=0.454) and refractory (31/81 [38.3%] vs. 14/58 [24.1%]; p=0.048) UUI were noted in the sling group following surgery. On Kaplan-Meier analysis, a greater proportion of women in the no sling group did not report UUI at longest follow-up (hazard ratio 0.63; 95% confidence interval 0.37-1.06; p=0.081). CONCLUSIONS: Women should be counseled on the risk of de novo and refractory UUI following sling placement at time of prolapse repair.

The effects of sildenafil on ciliary beat frequency in patients with pulmonary non-tuberculous mycobacteria disease: phase I/II trial.

RATIONALE: Pulmonary non-tuberculous mycobacterial (PNTM) disease has increased over the past several decades, especially in older women. Abnormal mucociliary clearance and abnormal nasal nitric oxide (nNO) have been associated with PNTM disease in other patient cohorts. Mucociliary clearance can be affected by NO-cyclic guanosine monophosphate signalling and, therefore, modulation of the pathway may be possible with phosphodiesterase inhibitors such as sildenafil as a novel therapeutic approach. OBJECTIVE: To define ex vivo characteristics of PNTM disease affected by sildenafil. METHODS: Subjects with PNTM infections were recruited into an open-label dose-escalation trial of sildenafil. Laboratory measurements and mucociliary measurements-ciliary beat frequency, nNO and 24-hour sputum production-were collected throughout the study period. Patients received sildenafil daily during the study period, with escalation from 20 to 40 mg three times per day. MEASUREMENTS AND MAIN RESULTS: Increased ciliary beat frequency occurred after a single dose of 40 mg sildenafil and after extended dosing of 40 mg sildenafil. The increase ciliary beat frequency was not seen with 20 mg sildenafil dosing. There were no changes in sputum production, nNO production, Quality of Life-Bronchiectasis-NTM module (QOL-B-NTM) questionnaire or the St George's Respiratory Questionnaire during the study period. CONCLUSION: Sildenafil, 40 mg, increased ciliary beat frequency acutely as well as with extended administration.

Urodynamic factors associated with the large capacity bladder and incomplete emptying after prolapse repair (2009-2015).

AIMS: To identify the clinical and urodynamic factors associated with the large capacity bladder and incomplete bladder emptying after prolapse repair. METHODS: We identified 592 women who underwent anterior and/or apical prolapse repair at our institution from 2009 to 2015. Women were stratified by urodynamic capacity. The primary outcome was incomplete emptying at the longest follow-up (postvoid residual [PVR] > 200 mL). Data were analyzed in the Statistical Analysis System software. RESULTS: Two hundred and sixty-six women (mean age, 61 years) had preoperative urodynamic tracings available for review. After surgery, there were 519 PVRs in 239 women recorded at up to 2949 days (mean, 396) and nine time points (median, 2; IQR, 1-3). The receiver operator curve for predicted probability of longest follow-up PVR greater than 200 mL (area under curve = 0.67) identified the 600 mL cutpoint which defined large capacity bladder. Large capacity bladders (capacity, >600 mL [n=79] vs ≤600 mL, [n=160]) had a mean: detrusor pressure at maximum flow (21 vs 22 cm H2 O; P = 0.717), maximum flow rate (19 vs 17 mL/s; P = 0.148), significantly elevated PVR (202 vs 73 mL; P < 0.001), and significantly lower voiding efficiency (VE) (74 vs 82%, P < 0.05). Following prolapse repair, elevated PVR was associated with large capacity (PVR 101 vs 49 mL, P < 0.05). Large bladders had a two- to three-fold risk of longest follow-up PVR greater than 200 mL (14.3%-20.3% [capacity, >600 mL] vs 4.1%-7.0% [capacity, ≤600 mL]). VE was similar after surgery regardless of the capacity (87% vs 88%, P = 0.772). CONCLUSIONS: The decision to pursue prolapse repair should be individualized and take into account, the bladder capacity and goals for PVR improvement after surgery.

Are fibroid and bony pelvis characteristics associated with urinary and pelvic symptom severity?

BACKGROUND: Urinary and pelvic floor symptoms often are attributed to size and location of uterine fibroid tumors. However, direct supporting evidence that links increased size to worsening symptoms is scant and limited to ultrasound evaluation of fibroid tumors. Because management of fibroid tumors is targeted towards symptomatic relief, the identification of fibroid and pelvic characteristics that are associated with worse symptoms is vital to the optimization of therapies and prevention needless interventions. OBJECTIVE: We examined the correlation between urinary, pelvic floor and fibroid symptoms, and fibroid size and location using precise uterine fibroid and bony pelvis characteristics that were obtained from magnetic resonance imaging. STUDY DESIGN: A retrospective review (2013-2017) of a multidisciplinary fibroid clinic identified 338 women who had been examined via pelvic magnetic resonance imaging, Pelvic Floor Distress Inventory questionnaire (score 0-300), and a Uterine Fibroid Symptoms questionnaire (score 1-100). Multiple linear regression analysis was used to assess the influence of clinical factors and magnetic resonance imaging findings on scaled Pelvic Floor Distress Inventory and Uterine Fibroid Symptoms scores. Data were analyzed with statistical software. RESULTS: Our cohort of 338 women had a median Pelvic Floor Distress Inventory of 72.7 (interquartile range, 41-112.3). Increased Pelvic Floor Distress Inventory score was associated with clinical factors of higher body mass index (P<.001), noncommercial insurance (P<.001), increased parity (P=.001), and a history of incontinence surgery (P=.003). Uterine volume, dominant fibroid volume, dimension and location, and fibroid tumor location relative to the bony pelvis structure did not reach significance when compared with pelvic floor symptom severity. The mean Uterine Fibroid Symptoms score was 52.0 (standard deviation, 23.5). An increased Uterine Fibroid Symptoms score was associated with dominant submucosal fibroid tumors (P=.011), body mass index (P<.0016), and a clinical history of anemia (P<.001) or any hormonal treatment for fibroid tumors (P=.009). CONCLUSION: Contrary to common belief, in this cohort of women who sought fibroid care, size and position of fibroid tumors or uterus were not associated with pelvic floor symptom severity. Whereas, bleeding symptom severity was associated with dominant submucosal fibroid tumor and previous hormonal treatment. Careful attention to clinical factors such as body mass index and medical history is recommended when pelvic floor symptoms are evaluated in women with uterine fibroid tumors.

Evaluation of the routine use of pelvic MRI in women presenting with symptomatic uterine fibroids: When is pelvic MRI useful?

BACKGROUND: Pelvic ultrasound (US) diagnosis of uterine fibroids may overlook coexisting gynecological conditions that contribute to women's symptoms. PURPOSE: To determine the added value of pelvic MRI for women diagnosed with symptomatic fibroids by US, and to identify clinical factors associated with additional MRI findings. STUDY TYPE: Retrospective observational study. POPULATION: In all, 367 consecutive women with fibroids diagnosed by US and referred to our multidisciplinary fibroid center between 2013-2017. FIELD STRENGTH/SEQUENCE: All patients had both pelvic US and MRI prior to their consultations. MRIs were performed at 1.5 T or 3 T and included multiplanar T2 -weighted sequences, and precontrast and postcontrast T1 -weighted imaging. ASSESSMENT: Demographics, symptoms, uterine fibroid symptom severity scores, and health-related quality of life scores, as well as imaging findings were evaluated. STATISTICAL TESTS: Patients were separated into two subgroups according to whether MRI provided additional findings to the initial US. Univariate and multivariate regression analyses were performed. RESULTS: Pelvic MRI provided additional information in 162 patients (44%; 95% confidence interval [CI] 39-49%). The most common significant findings were adenomyosis (22%), endometriosis (17%), and partially endocavitary fibroids (15%). Women with pelvic pain, health-related quality of life scores less than 30 out of 100, or multiple fibroids visualized on US had greater odds of additional MRI findings (odds ratio [OR] 1.68, 2.26, 1.63; P = 0.02, 0.004, 0.03, respectively), while nulliparous women had reduced odds (OR 0.55, P = 0.01). Patients with additional MRI findings were treated less often with uterine fibroid embolization (14% vs. 36%, P < 0.001) or MR-guided focused US (1% vs. 5%, P = 0.04), and more often with medical management (17% vs. 8%, P = 0.01). DATA CONCLUSION: Pelvic MRI revealed additional findings in more than 40% of women presenting with symptoms initially ascribed to fibroids by US. Further evaluation using MRI is particularly useful for parous women with pelvic pain, poor quality of life scores, and/or multiple fibroids. LEVEL OF EVIDENCE: 4 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2019.

Thirty-day unplanned postoperative inpatient and emergency department visits following thoracotomy.

BACKGROUND: Unplanned visits to the emergency department (ED) and inpatient setting are expensive and associated with poor outcomes in thoracic surgery. We assessed 30-d postoperative ED visits and inpatient readmissions following thoracotomy, a high morbidity procedure. MATERIALS AND METHODS: We retrospectively analyzed inpatient and ED administrative data from California, Florida, and New York, 2010-2011. "Return to care" was defined as readmission to inpatient facility or ED within 30 d of discharge. Factors associated with return to care were analyzed via multivariable logistic regressions with a fixed effect for hospital variability. RESULTS: Of 30,154 thoracotomies, 6.3% were admitted to the ED and 10.2% to the inpatient setting within 30 d of discharge. Increased risk of inpatient readmission was associated with Medicare (odds ratio [OR] 1.30; P < 0.001) and Medicaid (OR 1.31; P < 0.0001) insurance status compared to private insurance and black race (OR 1.18; P = 0.02) compared to white race. Lung cancer diagnosis (OR 0.83; P < 0.001) and higher median income (OR 0.89; P = 0.04) were associated with decreased risk of inpatient readmission. Postoperative ED visits were associated with Medicare (OR 1.24; P < 0.001) and Medicaid insurance status (OR 1.59; P < 0.001) compared to private insurance and Hispanic race (OR 1.19; P = 0.04) compared to white race. CONCLUSIONS: Following thoracotomy, postoperative ED visits and inpatient readmissions are common. Patients with public insurance were at high risk for readmission, while patients with underlying lung cancer diagnosis had a lower readmission risk. Emphasizing postoperative management in at-risk populations could improve health outcomes and reduce unplanned returns to care.

Emergency Department Visits Following Elective Total Hip and Knee Replacement Surgery: Identifying Gaps in Continuity of Care.

BACKGROUND: Major joint replacement surgical procedures are common, elective procedures with a care episode that includes both inpatient readmissions and postoperative emergency department (ED) visits. Inpatient readmissions are well studied; however, to our knowledge, little is known about ED visits following these procedures. We sought to characterize 30-day ED visits following a major joint replacement surgical procedure. METHODS: We used administrative records from California, Florida, and New York, from 2010 through 2012, to identify adults undergoing total knee and hip arthroplasty. Factors associated with increased risk of an ED visit were estimated using hierarchical regression models controlling for patient variables with a fixed hospital effect. The main outcome was an ED visit within 30 days of discharge. RESULTS: Among the 152,783 patients who underwent major joint replacement, 5,229 (3.42%) returned to the inpatient setting and 8,883 (5.81%) presented to the ED for care within 30 days. Among ED visits, 17.94% had a primary diagnosis of pain and 25.75% had both a primary and/or a secondary diagnosis of pain. Patients presenting to the ED for subsequent care had more comorbidities and were more frequently non-white with public insurance relative to those not returning to the ED (p < 0.001). There was a significantly increased risk (p < 0.05) of isolated ED visits with regard to type of insurance when patients with Medicaid (odds ratio [OR], 2.28 [95% confidence interval (CI), 2.04 to 2.55]) and those with Medicare (OR, 1.38 [95% CI, 1.29 to 1.47]) were compared with patients with private insurance and with regard to race when black patients (OR, 1.38 [95% CI, 1.25 to 1.53]) and Hispanic patients (OR, 1.12 [95% CI, 1.03 to 1.22]) were compared with white patients. These increases in risk were stronger for isolated ED visits for patients with a pain diagnosis. CONCLUSIONS: ED visits following an elective major joint replacement surgical procedure were numerous and most commonly for pain-related diagnoses. Medicaid patients had almost double the risk of an ED or pain-related ED visit following a surgical procedure. The future of U.S. health-care insurance coverage expansions are uncertain; however, there are ongoing attempts to improve quality across the continuum of care. It is therefore essential to ensure that all patients, particularly vulnerable populations, receive appropriate postoperative care, including pain management. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Practice transition in graduate medical education.

BACKGROUND: Debt repayment, professional negotiation and practice management skills are vital to a successful medical practice, yet are undervalued and seldom taught in graduate medical education. Medical residents need additional training to confidently transition to independent practice, requiring the development of novel curricula. Medical residents need additional training to confidently transition to independent practice METHODS: We developed a trial practice management curriculum to educate senior residents and fellows through voluntary workshops. Topics discussed in the workshops included debt repayment, billing compliance, medical malpractice, contract negotiations, and lifestyle and financial management. Resident self-confidence was assessed, and feedback was obtained through voluntary survey responses before and after attendance at a workshop, scored using a Likert scale. RESULTS: Twenty-five residents from 20 specialties attended a 1-day session incorporating all lectures; 53 residents from 17 specialties attended a re-designed quarterly session with one or two topics per session. Survey evaluations completed before and after the workshop demonstrated an improvement in residents' self-assessment of confidence in contract negotiations (p < 0.001) and their first year in practice (p < 0.001): after the curriculum, 94 per cent (n = 42) of respondents felt confident participating in contract negotiations, and 93 per cent (n = 38) of respondents felt confident about their first year in practice. One hundred per cent of respondents agreed that the presentation objectives were relevant to their needs as residents. DISCUSSION: Participant responses indicated a need for structured education in practice management for senior trainees. Senior residents and fellows will benefit most from curricula, but have high familial and professional demands on their schedules.

Analyzing treatment aggressiveness and identifying high-risk patients in diabetic foot ulcer return to care.

Rates of diabetes and its associated comorbidities have been increasing in the United States, with diabetic foot ulcer treatment representing a large cost to the patient and healthcare system. These ulcers often result in multiple hospital admissions. This study examined readmissions following inpatient care for a diabetic foot ulcer and identified modifiable factors associated with all-cause 30-day readmissions to the inpatient or emergency department (ED) setting. We hypothesized that patients undergoing aggressive treatment would have lower 30-day readmission rates. We identified patient discharge records containing International Classification of Disease ninth revision codes for both diabetes mellitus and distal foot ulcer in the State Inpatient and Emergency Department databases from the Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project in Florida and New York, 2011-2012. All-cause 30-day return to care visits (ED or inpatient) were analyzed. Patient demographics and treatment characteristics were evaluated using univariate and multivariable regression models. The cohort included 25,911 discharges, having a mean age of 63 and an average of 3.8 comorbidities. The overall rate of return to care was 30%, and 21% of subjects underwent a toe or midfoot amputation during their index stay. The most common diagnosis codes upon readmission were diabetes mellitus (19%) and infection (13%). Patients with a toe or midfoot amputation procedure were less likely to be readmitted within 30 days (odds ratio: 0.78; 95% confidence interval: 0.73, 0.84). Presence of comorbidities, black and Hispanic ethnicities, and Medicare and Medicaid payer status were also associated with higher odds of readmission following initial hospitalization (p < 0.05). The study suggests that there are many factors that affect readmission rates for diabetic foot ulcer patients. Understanding patients at high-risk for readmission can improve counseling and treatment strategies for this fragile patient population.

The challenge of antibiotic-resistant Staphylococcus: lessons from hospital nurseries in the mid-20th century.

In the late 1940s, epidemics of antibiotic-resistant strains of Staphylococcus aureus began to plague postpartum nurseries in hospitals across the United States. Exacerbated by overcrowding and nursing shortages, resistant S. aureus outbreaks posed a novel challenge to physicians and nurses heavily reliant on antibiotics as both prophylaxis and treatment. This paper explores the investigation of the reservoir, mode of transmission, and virulence of S. aureus during major hospital outbreaks and the subsequent implementation of novel infection control measures from the late 1940s through the early 1960s. The exploration of these measures reveals a shift in infection control policy as hospitals, faced with the failure of antibiotics to slow S. aureus outbreaks, implemented laboratory culture routines, modified nursery structure and layout, and altered nursing staff procedures to counter various forms of S. aureus transmission. Showcasing the need for widespread epidemiologic surveillance, ultimately manifesting itself in specialized "hospital epidemiology" training promoted in the 1970s, the challenges faced by hospital nurses in the 1950s prove highly relevant to the continued struggle with methicillin-resistant Staphylococcus aureus (MRSA) and other resistant nosocomial infections.

Effect of fiber diameter and alignment of electrospun polyurethane meshes on mesenchymal progenitor cells.

Effective strategies to guide cell alignment and the deposition of an oriented extracellular matrix are critical for the development of anisotropic engineered tissues suitable for the repair of ligament defects. Electrospinning is a promising means to create meshes that can align adherent cells, but the effect of fiber mesh architecture on differentiation has not been examined closely. Therefore, the goal of this study was to determine the effect of fiber diameter and the degree of fiber alignment on mesenchymal progenitor cell morphology, proliferation, and ligament gene expression. Specifically, a poly(ester urethane)urea elastomer was electrospun onto rigid supports under conditions designed to independently vary the mean fiber diameter (from 0.28 to 2.3 microm) and the degree of fiber alignment. Bone marrow stromal cells--seeded onto supported meshes--adhered to and proliferated on all surfaces. Cells assumed a more spindle-shaped morphology with increasing fiber diameter and degree of fiber alignment, and oriented parallel to fibers on aligned meshes. Expression of the ligament markers collagen 1alpha1, decorin, and tenomodulin appeared to be sensitive to fiber diameter and greatest on the smallest fibers. Concurrently, expression of the transcription factor scleraxis appeared to decrease with increasing fiber alignment. These results suggest that the formation of a ligament-like tissue on electrospun scaffolds is enhanced when the scaffolds consist of aligned submicron fibers.