Evolving Referral Patterns and Management Following Implementation of a Multidisciplinary Fibroid Center: A Retrospective Cohort Study.

Background/Objectives: Our objective was to evaluate changes in the management of symptomatic fibroids after establishing a multidisciplinary fibroid center with minimally invasive gynecologic surgery (MIGS) and interventional radiology (IR). Methods: A retrospective cohort study was conducted at the fibroid center created in September 2020. Patients were offered same-day consults with both MIGS and IR providers. Data were collected for patients with initial consultations from January to June 2019 (pre-fibroid center) and from January to June 2021 (post-fibroid center). Results: Among 615 patients meeting inclusion criteria, 273 had consultations pre-center and 342 post-center. More patients seen post-center had previously attempted medical management (30.1% vs. 20.2%), with a significant proportion having no prior medical or surgical treatment (53.2% vs. 61.5%). Post-center, there were more MIGS consultations (65.5% vs. 53.1%) and a decrease in general gynecology (GYN) consultations (19.0% vs. 25.6%). More patients sought additional opinions post-center (83.6% vs. 67.0%), particularly with MIGS (58.8% vs. 37.0%). General GYNs referred to MIGS (79.3% vs. 73.1%) and IR specialists (16.0% vs. 13.0%) more often in 2021. In 2021, use of MRI increased (66.5% vs. 52.4%), and more patients underwent uterine artery embolization (UAE) within 1 year of consultation compared to the pre-center period (13.8% vs. 6.9%). Conclusions: Patients with symptomatic fibroids often seek the expertise of specialists to explore treatment options. A multidisciplinary fibroid center that integrates efforts of MIGS and IR enables thorough counseling and a rise in the utilization of minimally invasive procedures, including UAE.

Patient Experiences With a Multidisciplinary Fibroid Program.

STUDY OBJECTIVE: Although medical, interventional, and surgical treatment options for fibroids have expanded over the last decade, many patients are not thoroughly counseled about all available therapies. Patients desire a more comprehensive approach with shared decision-making tailored to their health goals. The aim of this study is to assess patient knowledge regarding treatment options before and after consultation with a multidisciplinary fibroid center. DESIGN: Prospective survey study. SETTING: Academic medical center in New York, NY. PATIENTS AND PARTICIPANTS: Patients who presented for initial consultation with a multidisciplinary fibroid program from July 2021 through January 2022. INTERVENTIONS: Patients were offered same-day office consultation with a minimally invasive gynecologic surgeon (MIGS) followed by a telemedicine visit with an interventional radiologist (IR) within 3 weeks of the appointment request. Collaborative discussions were held between providers regarding patient care. Patients were asked to complete the survey following both appointments. Data was collected regarding demographics, prior evaluation of fibroids, knowledge about treatment options, and overall experience. RESULTS: A total of 102 patients completed the survey (response rate 77%). A majority (55.9%) had known about their fibroids for at least 2 years. Most patients sought out the fibroid program for a 2nd (28.4%), 3rd (22.5%) or 4th (7.8%) opinion. Notably, 35.3% of patients who had previously been seen by an obstetrician-gynecologist (OB/GYN) were not offered any treatment. Of those who had been offered treatment, 24.5% were counseled on medical management with oral contraceptives, 28.4% on surgical options, and 5.9% on uterine artery embolization. Nearly all patients (86.3%) endorsed that they would not have sought 2 separate consultations had it not been for the program. Patients were overall well-informed after their experience, with 95.1% reporting they were more knowledgeable about their options and none reporting the 2 separate consults created more confusion for them. CONCLUSION: Many patients with symptomatic fibroids seeking secondary opinions have not been adequately counseled on fibroid management options. A collaborative approach to fibroid management better educates patients, provides an opportunity to be thoroughly counseled by the specialists performing either surgical or interventional procedures, and increases patient knowledge about fibroid treatment options.

Suicidal ideation and attempt among young people living in gosiwons in South Korea.

INTRODUCTION: Young people living in gosiwons could be at high risk for suicide owing to inadequate living conditions and the social stigma towards them. However, this topic has not received adequate academic attention. Gosiwon is a type of small residence consisting of several tiny rooms densely packed together and usually does not meet minimum housing standards. However, gosiwons are favored by low-income groups, especially young people, because they are cheaper than other residences. This study aimed to examine the factors that increase the risk of suicidal ideation and attempt among young people living in gosiwons. METHODS: A sample of 300 young people aged 19-34 years living in gosiwons for over 6 months was analyzed. A set of multinomial logistic regression was conducted to examine the factors that differentiate the suicidal ideation and attempt group from the no-suicidal risk group. RESULTS: Approximately 30% of the study participants experienced suicidal ideation or attempted suicide. Among several risk factors, social exclusion and depressive symptoms distinguished the group with suicidal ideation from the no-risk group. Depressive symptoms were the only factor that differentiated the group with suicide attempts history from the no-risk group. CONCLUSION: The results emphasize the need to focus on social exclusion and depressive symptoms among young people living in poor housing conditions. Interventions to address social exclusion and depressive symptoms may help prevent suicide risk among young people exposed to housing exclusion.

Examining Reduced Opioid Prescriptions after Gynecologic Laparoscopy: A Randomized Controlled Trial.

STUDY OBJECTIVE: To examine whether prescribing 5 tablets, as opposed to 10 tablets, of 5-mg oxycodone adequately treats pain after gynecologic laparoscopy. DESIGN: Single-blinded randomized trial. SETTING: Academically affiliated ambulatory surgery center. PATIENTS: One hundred twenty women scheduled to undergo minor gynecologic laparoscopy. INTERVENTIONS: Patients scheduled for ambulatory gynecologic laparoscopy were allocated to the standard tablet or low-tablet number prescription groups (10 tablets or 5 tablets of 5-mg oxycodone). The patients also received prescriptions for acetaminophen and ibuprofen. MEASUREMENTS AND MAIN RESULTS: Telephone surveys were conducted on postoperative days 1 and 7 to assess medication use and pain. The primary outcome was the number of oxycodone tablets used by days 1 and 7. Prespecified secondary outcomes included unscheduled patient contacts and pain scores. With N = 50 in each group and assuming standardized effect sizes, the study was powered to detect a 0.6 difference or greater when comparing the primary outcome between the groups. Forty-five and 47 patients in the 5-tablet and 10-tablet groups, respectively, completed the day-7 survey. The median number of oxycodone tablets taken by day 7 was 2.0 (interquartile range 0.0, 4.0) in the 5-tablet group and 2.5 (interquartile range 0.0, 5.0) in the 10-tablet group (p = .36). Most of the patients in both groups reported taking 3 oxycodone tablets or fewer by day 7. There were no significant differences in unscheduled patient contacts, need for additional prescriptions, or pain scores. There were significantly fewer unused tablets in the 5-tablet group by day 7. CONCLUSION: Prescribing 5 tablets of 5-mg oxycodone, acetaminophen, and ibuprofen is likely sufficient for most patients after minor laparoscopic surgery.

Transversus Abdominis Plane Block for Laparoscopic Hysterectomy Pain: A Meta-Analysis.

OBJECTIVE: Review the analgesic effect of the transversus abdominis plane (TAP) block and its impact on postoperative pain scores and opioid usage for patients undergoing laparoscopic and robotic hysterectomies. METHODS: Systematic review with meta-analysis of randomized controlled trials that compared the effect of TAP block to either placebo or no block on narcotic use (in morphine equivalent units [MEq]) and pain (per visual analog scale) within 24] h after a laparoscopic or robotic hysterectomy for benign or malignant indications. Searches were conducted in PubMed and Embase through May 31, 2019. RESULTS: Nine randomized controlled trials met eligibility criteria; 7 evaluated laparoscopic hysterectomy and 2 robotic hysterectomy. A total of 688 subjects were included (559 laparoscopic hysterectomy, 129 robotic hysterectomy). Opioid consumption was similar in the first 24] h postoperative with or without TAP block (-0.8 MEq; 95% CI, -2.9, 1.3; 8 TAP arms; N] = 395). Pain scores (visual analog scale) were also similar with or without TAP block (-0.01 U; 95% CI, -0.34, 0.32; 10 TAP arms; N] = 636). Neither meta-analysis showed statistical heterogeneity across studies. CONCLUSIONS: The evidence does not support a benefit of TAP block to reduce pain or opioid use for patients receiving laparoscopic or robotic hysterectomies.

Updates in uterine artery embolization for leiomyomas.

PURPOSE OF REVIEW: Uterine leiomyomas are a common condition estimated to affect 70-80% of reproductive-aged women. An evolving body of evidence continues to guide our understanding of various surgical and interventional treatment options, such as uterine artery embolization (UAE). This article provides an updated review of novel findings regarding UAE. RECENT FINDINGS: Despite an abundance of observational studies and several small randomized controlled trials, large scale long-term comparative efficacy studies are lacking. Although short-term outcomes continue to be favorable, recent trials show reoperation rate of up to 35% in 10 years and may raise some concerns regarding ovarian reserve, fertility and pregnancy outcomes. SUMMARY: UAE remains a safe and effective alternative to surgery in the management of leiomyomas. A deeper investigation into understanding this treatment's optimal use in various patient populations is needed.

MicroRNA-9 suppresses cell migration and invasion through downregulation of TM4SF1 in colorectal cancer.

Transmembrane-4-L6 family 1 (TM4SF1) is upregulated in colorectal carcinoma (CRC). However, the mechanism leading to inhibition of the TM4SF1 is not known. In the present study, we investigated the regulation of TM4SF1 and function of microRNAs (miRNAs) in CRC invasion and metastasis. We analyzed 60 colon cancers and paired normal specimens for TM4SF1 and miRNA-9 (miR-9) expression using quantitative real-time PCR. A bioinformatics analysis identified a putative miR-9 binding site within the 3'-UTR of TM4SF1. We also found that TM4SF1 was upregulated in CRC tissues and CRC cell lines. The expression of TM4SF1 was positively correlated with clinical advanced stage and lymph node metastasis. Moreover, a luciferase assay revealed that miR-9 directly targeted 3'-UTR-TM4SF1. Overexpression of miR-9 inhibited expression of TM4SF1 mRNA and protein, wound healing, transwell migration and invasion of SW480 cells, whereas, overexpression of anti-miR-9 and siRNA-TM4SF1 inversely regulated the TM4SF1 mRNA and protein level in HCT116 cells. Furthermore, miR-9 suppressed not only TM4SF1 expression but also MMP-2, MMP-9 and VEGF expression. In clinical specimens, miR-9 was generally down-regulated in CRC and inversely correlated with TM4SF1 expression. These results suggest that miR-9 functions as a tumor-suppressor in CRC, and that its suppressive effects mediate invasion and metastasis by inhibition of TM4SF1 expression. Our results also indicate that miR-9 might be a novel target for the treatment of CRC invasion and metastasis.

Abdominal wall nerve injury during laparoscopic gynecologic surgery: incidence, risk factors, and treatment outcomes.

STUDY OBJECTIVE: To determine the incidence and clinical significance of iliohypogastric-ilioinguinal neuropathy from lower abdominal lateral port placement and fascial closure during laparoscopic gynecologic surgery. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: University-based referral center specializing in minimally invasive gynecologic surgery and chronic abdominopelvic pain. PATIENTS: Women who underwent a laparoscopic procedure because of benign gynecologic indications during a 3-year study period from 2008 to 2011. A total of 317 women met study criteria. INTERVENTIONS: Operative laparoscopy using a lateral port in the lower abdomen. Closure of port-site fascial defects was achieved using either a Carter-Thomason or EndoClose suture device. MEASUREMENTS AND MAIN RESULTS: Nerve injury was identified by symptoms, and was confirmed with a nerve block after a positive test for allodynia in the distribution of the iliohypogastric-ilioinguinal nerve. Of 173 cases that did not involve fascial closure of a port-site defect, none were associated with nerve injury. Of 144 cases that involved fascial closure, 7 (4.9%) included nerve injury that resulted in pain requiring treatment (p = .004). In 1 patient, symptoms improved with medical management alone. Six patients required surgical management, and 5 of them had resolution of pain after removal of the fascial suture. There was no statistically significant difference in the incidence of nerve injury between the Carter-Thomason and EndoClose groups (4.7% vs 5.4%; p = .87). CONCLUSIONS: There is an estimated 5% risk of clinically significant postoperative neuropathic pain due to injury of the iliohypogastric-ilioinguinal nerve with fascial closure of laparoscopic incisions in the lower abdomen. Pain seems to be due to suture entrapment of sensory fibers because it is usually resolved by removal of the suture. Prompt recognition and treatment may prevent subsequent development of chronic abdominopelvic pain.

Management of chronic pelvic pain.

Chronic pelvic pain is a complex condition that requires evaluation of the reproductive, gastrointestinal, urologic, musculoskeletal, psychological, and neurological systems. Usually, diagnosis and management entail identifying a network of disorders rather than a single cause of pain with a definitive cure. Only disorders that we commonly encounter in our practice will be discussed in this review.

Vaginal extraction of large uteri with the Alexis retractor.

Removal of large uteri via minimally invasive methods propose a number of challenges that can be diminished by technique, instrumentation, and skill of the surgeon. We propose that the Alexis Wound Retraction System, initially designed for circumferential and atraumatic retraction during abdominal surgery, is a viable alternative to standard retraction techniques when large uteri are removed vaginally.

Obesity and immune cell counts in women.

Obesity is common in women and is associated with a number of adverse health outcomes including cardiovascular disease, infectious diseases, and cancer. We explore the relationship between obesity and immune cell counts in women in a longitudinal study of 322 women from 1999 through 2003 enrolled as HIV-negative comparators in the Women's Interagency HIV Study. Body mass index (BMI, kg/m(2)) was categorized as normal weight (BMI 18.5-24.9), overweight (BMI 25-29.9), obese (BMI 30-34.9), and morbidly obese (BMI >/=35). CD4 and CD8 counts and percents and total lymphocyte and white blood cell (WBC) counts were measured annually using standardized techniques. A mixed model repeated measures analysis was performed using an autoregressive correlation matrix. At the index visit, 61% of women were African American; mean age was 35 years, and median BMI was 29 kg/m(2). Immunologic parameters were in the reference range (median CD4 count, 995 cells/mm(3); CD8 count, 488 cells/mm(3); total lymphocyte count, 206 cells/mm(3); median WBC, 6 x 10(3) cells/mm(3)). In multivariate analyses, being overweight, obese, or morbidly obese were independently associated with higher CD4, total lymphocyte, and WBC counts than being normal weight; morbid obesity was associated with a higher CD8 count. The strongest associations between body weight and immune cell counts were demonstrated in the morbidly obese. Increasing body weight is associated with higher CD4, CD8, total lymphocyte, and WBC counts in women. Investigation into the impact of obesity on immune function and long-term adverse outcomes is needed.