Association between pathological positivity rate of endometriosis, demographics, and concomitant gynecological conditions.

Background: To date, there remains a paucity of present-day literature on the topic of demographics and the biopsy-proven pathological positivity rate of endometriosis. Objective: The goal of this study was to explore the association between patients' demographics and other concomitant gynecological conditions or procedures and the pathological positivity rate of excision of endometriosis. Design: Retrospective cohort study. Methods: All women >18 years old who underwent laparoscopic surgery for endometriosis at a tertiary care hospital from October 2011 to October 2020. Women were classified into two groups: (1) Study group: women with >80% pathological positivity rate of endometriosis and (2) Control group: women with <80% pathological positivity rate. Results: A total of 401 women were included in the analysis. No difference was noted in the 80% pathological positivity rate based on body mass index [BMI; 68.7% in normal BMI versus 80% in underweight, versus 74.5% in overweight, and 74.1% in obese patients (p = 0.72)]. The percentage of patients reaching 80% pathological positivity of endometriosis was lower in women who had undergone previous laparoscopy for endometriosis compared to surgery naïve women (66.5% versus 76.5%, p = 0.03). In addition, a higher percentage of women who underwent concomitant hysterectomy (83.5% versus 68.8% for non-hysterectomy, p = 0.005) or bilateral oophorectomy (92.7% versus 70.0% for non-oophorectomy, p = 0.002) reached 80% pathological positivity. Women with an associated diagnosis of fibroids (79.7% versus 70.5%) or adenomyosis (76.4% versus 71.7%) were more likely to reach 80% pathological positivity compared to women without any other coexisting pathology; however, the observed differences were not statistically significant. After applying a log-binomial regression model, compared to White non-Hispanics, Hispanic patients were 30% less likely to reach 80% positivity (RR: 0.70, 95% CI: 0.49-1.02), although not statistically significant. Conclusion: No significant racial difference was found when comparing the rates of 80% pathological positivity of suspected endometriosis lesions among groups. Endometriosis pathological positivity rate was unaffected by patients' BMI and the presence of concomitant pathologies. In addition, prior laparoscopic surgery for endometriosis might cause tissue changes that result in a decrease in the observed pathological positivity rate of endometriosis lesions during subsequent surgeries.

Feasibility and safety of planned early discharge following laparotomy in gynecologic oncology with enhanced recovery protocol including opioid-sparing anesthesia.

Objective: This study aims to evaluate the feasibility and safety of planned postoperative day 1 discharge (PPOD1) among patients who undergo laparotomy (XL) in the department of gynecology oncology utilizing a modified enhanced recovery after surgery (ERAS) protocol including opioid-sparing anesthesia (OSA) and defined discharge criteria. Methods: Patients undergoing XL and minimally invasive surgery (MIS) were enrolled in this prospective, observational cohort study after the departmental implementation of a modified ERAS protocol. The primary outcome was quality of life (QoL) using SF36, PROMIS GI, and ICIQ-FLUTS at baseline and 2- and 6-week postoperative visits. Statistical significance was assessed using the two-tailed Student's t-test and non-parametric Mann-Whitney two-sample test. Results: Of the 141 subjects, no significant demographic differences were observed between the XL group and the MIS group. The majority of subjects, 84.7% (61), in the XL group had gynecologic malignancy [vs. MIS group; 21 (29.2%), p < 0.001]. All patients tolerated OSA. The XL group required higher intraoperative opioids [7.1 ± 9.2 morphine milligram equivalents (MME) vs. 3.9 ± 6.9 MME, p = 0.02] and longer surgical time (114.2 ± 41 min vs. 96.8 ± 32.1 min, p = 0.006). No significant difference was noted in the opioid requirements at the immediate postoperative phase and the rest of the postoperative day (POD) 0 or POD 1. In the XL group, 69 patients (73.6%) were successfully discharged home on POD1. There was no increase in the PROMIS score at 2 and 6 weeks compared to the preoperative phase. The readmission rates within 30 days after surgery (XL 4.2% vs. MIS 1.4%, p = 0.62), rates of surgical site infection (XL 0% vs. MIS 2.8%, p = 0.24), and mean number of post-discharge phone calls (0 vs. 0, p = 0.41) were comparable between the two groups. Although QoL scores were significantly lower than baseline in four of the nine QoL domains at 2 weeks post-laparotomy, all except physical health recovered by the 6-week time point. Conclusions: PPOD1 is a safe and feasible strategy for XL performed in the gynecologic oncology department. PPOD1 did not increase opioid requirements, readmission rates compared to MIS, and patient-reported constipation and nausea/vomiting compared to the preoperative phase.

Inpatient Hospitalization Costs Associated with Birth Defects Among Persons Aged <65 Years - United States, 2019.

Changing treatments and medical costs necessitate updates to hospitalization cost estimates for birth defects. The 2019 National Inpatient Sample was used to estimate the service delivery costs of hospitalizations among patients aged <65 years for whom one or more birth defects were documented as discharge diagnoses. In 2019, the estimated cost of these birth defect-associated hospitalizations in the United States was $22.2 billion. Birth defect-associated hospitalizations bore disproportionately high costs, constituting 4.1% of all hospitalizations among persons aged <65 years and 7.7% of related inpatient medical costs. Updating estimates of hospitalization costs provides information about health care resource use associated with birth defects and the financial impact of birth defects across the life span and illustrates the need to determine the continued health care needs of persons born with birth defects to ensure optimal health for all.

Evaluation of Administrative Data for Identifying Maternal Opioid Use at Delivery in Florida.

OBJECTIVES: Studies have shown significant increases in the prevalence of maternal opioid use. Most prevalence estimates are based on unverified ICD-10-CM diagnoses. This study determined the accuracy of ICD-10-CM opioid-related diagnosis codes documented during delivery and examined potential associations between maternal/hospital characteristics and diagnosis with an opioid-related code. METHODS: To identify people with prenatal opioid use, we identified a sample of infants born during 2017-2018 in Florida with a NAS related diagnosis code (P96.1) and confirmatory NAS characteristics (N = 460). Delivery records were scanned for opioid-related diagnoses and prenatal opioid use was confirmed through record review. The accuracy of each opioid-related code was measured using positive predictive value (PPV) and sensitivity. Modified Poisson regression was used to calculate adjusted relative risks (aRR) and 95% confidence intervals (CI). RESULTS: We found the PPV was nearly 100% for all ICD-10-CM opioid-related codes (98.5-100%) and the sensitivity was 65.9%. Non-Hispanic Black mothers were 1.8 times more likely than non-Hispanic white mothers to have a missed opioid-related diagnosis at delivery (aRR:1.80, CI 1.14-2.84). Mothers who delivered at a teaching status hospital were less likely to have a missed opioid-related diagnosis (p < 0.05). CONCLUSIONS FOR PRACTICE: We observed high accuracy of maternal opioid-related diagnosis codes at delivery. However, our findings suggest that over 30% of mothers with opioid use may not be diagnosed with an opioid-related code at delivery, although their infant had a confirmed NAS diagnosis. This study provides information on the utility and accuracy of ICD-10-CM opioid-related codes at delivery among mothers of infants with NAS.

From 2010 to 2017, maternal opioid-related diagnoses at delivery increased by 100% in the US. Most prevalence estimates are based on unverified ICD-10-CM diagnosis codes. Evaluations of maternal opioid-related diagnoses at delivery are extremely limited but essential for utilizing prevalence estimates generated from administrative data.

Effect of Using Silver Nylon Dressings on Postoperative Pain after Cesarean Delivery.

OBJECTIVE: Silver dressings have been associated with a decrease in postoperative pain in selected populations, but it is unknown if the benefit can be observed after cesarean deliveries. We sought to evaluate the impact of silver nylon dressings in reducing postoperative pain after cesarean delivery. STUDY DESIGN: A secondary analysis of data from a blinded randomized clinical trial of women undergoing cesarean delivery scheduled and unscheduled at a single site was conducted. Women were recruited for participation from a single site and randomized to a silver nylon dressing or an identical-appearing gauze wound dressing. Wounds were evaluated in the outpatient clinic at 1 and 6 weeks after delivery and patient responded to the modified patient scar assessment scale. The primary outcome of this analysis was inpatient opioid and nonopioid analgesic dispensed. The secondary outcome was patient-reported pain at the 1- and 6-week postpartum visits. Data were analyzed using chi-square test, Student's t-test, Fisher's exact test, Wilcoxon-Mann-Whitney's test, and logistic regression where appropriate. A p-value of < 0.05 was considered significant. RESULTS: Among the 649 participants, women allocated to the silver nylon dressing group, when compared with the gauze group, were similar in the amount of dispensed opioid and nonopioid analgesic medications (morphine equivalent milligrams of opioids dispensed [82.5 vs. 90 mg, p = 0.74], intravenous nonsteroidal anti-inflammatory drugs (NSAIDs) [120 vs. 120 mg, p = 0.55], and oral NSAIDs [4,800 vs. 5,600 mg in the gauze group, p = 0.65]). After adjusting for confounding variables, postoperative wound infection (adjusted odds ratio [aOR]: 11.70; 95% confidence interval [CI]: 4.51-30.31) at 1-week postoperative and again at 6-week postoperative (aOR: 5.59; 95% CI: 1.03-30.31) but not gauze dressing was associated with patient-reported postoperative pain. CONCLUSION: Among women undergoing cesarean delivery, silver nylon dressing was not associated with a reduction in postoperative pain. KEY POINTS: · Silver dressings showed no decrease in pain medications.. · Wound infection is associated with pain postoperatively.. · Silver dressings did not reduce postoperative pain..

Postprocedural Pain Associated With 5 Versus 20 Intradetrusor Injections of onabotulinumtoxinA for Treatment of Overactive Bladder: A Multicenter Randomized Clinical Trial.

IMPORTANCE: Intradetrusor injection of onabotulinumtoxinA is performed via varying injection paradigms but no studies have studied the various effects of these paradigms on patient experience with the procedure. OBJECTIVES: This randomized clinical trial aims to compare pain and procedure time between patients receiving a 100-unit dose of onabotulinumtoxinA in 5 injections compared to 20 injections for the treatment of idiopathic overactive bladder or urgency urinary incontinence. STUDY DESIGN: Patients presenting with refractory overactive bladder or urgency urinary incontinence at 2 clinical sites were identified and randomized to undergo onabotulinumtoxinA treatment with 5 injections versus 20 injections. Patients rated their pain level on a 10-point visual analog scale at procedure completion. The procedure duration was recorded with a stopwatch. Patients were followed up 6 weeks postprocedure, at which time they completed a Global Response Assessment to determine subjective efficacy of treatment. Participants were additionally monitored for incidence of adverse events in the follow-up period. RESULTS: The average pain score was not statistically significant between groups (2; interquartile range, 1-4 for the 5 injection group vs 3; interquartile range, 2-4 for the 20 injection group; P = 0.27). Patients who received 5 injections experienced significantly shorter mean procedure time as compared with patients who received 20 injections (76 seconds vs 176 seconds; P < 0.001). There were no differences in subjective efficacy or adverse events between groups. CONCLUSIONS: Perceived pain, efficacy, and postprocedure complications did not significantly differ between patients receiving 5 injections and 20 injections, but procedure time was significantly shorter.

A Retrospective Cohort Study to Identify the Risk Factors for Urinary Tract Infection After Office Procedures.

OBJECTIVE: The objective of this study is to identify the incidence of and risk factors for urinary tract infection (UTI) after office cystoscopy and urodynamic studies (UDS) in a female population. METHODS: This was a retrospective cohort study investigating incidence of and risk factors for UTI after office testing. Inclusion criteria included women presenting for either cystoscopy or UDS from September 2019 to February 2020. Modified Poisson regression with robust error variance was used to identify risk factors for UTI after cystoscopy and UDS in a female population. RESULTS: A total of 274 patients met inclusion criteria. One hundred eighty-five patients underwent office cystoscopy. Nine (4.8%) had a postcystoscopy UTI. Significant risk factors for postcystoscopy UTI included recurrent UTI (relative risk, 7.51; 95% confidence interval, 1.66-34.05) and a history of interstitial cystitis (relative risk, 4.56; 95% confidence interval, 1.52-13.73). Of those with recurrent UTI, 13.7% had a postcystoscopy UTI. Among patients with interstitial cystitis, 25% had a postcystoscopy UTI. One hundred ninety-two patients underwent UDS. Ten (5.2%) developed a post-UDS UTI. No risk factors were identified. CONCLUSIONS: Patients with recurrent UTI were 7.51 times more likely to develop a UTI after cystoscopy, whereas those with interstitial cystitis were 4.56 times more likely to develop a UTI after cystoscopy. The incidence of UTI after UDS was low overall. Understanding who is at higher risk of postprocedural UTIs may help identify subpopulations that may benefit from prophylactic strategies.

Proportion of critical congenital heart defects attributable to unhealthy prepregnancy body mass index among women with live births in Florida, 2005-2016.

BACKGROUND: Associations between maternal prepregnancy body mass index (BMI) and congenital heart defects have been reported, however, the proportion of critical congenital heart defects (CCHDs) attributable to unhealthy prepregnancy BMI has not been determined. Our objective was to investigate the association between maternal prepregnancy BMI and CCHDs. METHODS: The Florida Birth Defects Registry was used to identify infants with CCHDs born between 2005-2016. Birth certificate data were used to define the source population and identify perinatal and socio-demographic characteristics. BMI values were categorized as underweight (<18.5), normal weight (18.5-24.9), overweight (25.0-29.9), obese I (30.0-34.9), obese II (35.0-39.9), and obese III (≥40.0). Multi-predictor logistic regression models were used to estimate adjusted odds ratios (aORs) and 99% confidence intervals representing the association between maternal prepregnancy BMI and CCHDs. Adjusted population attributable fractions (PAFs) for the aORs were calculated. RESULTS: We observed a significantly increased risk of "any CCHD" in infants born to women at any level of obesity. Among the 12 CCHDs examined, 5 showed a significantly increased risk among mothers in the two highest obesity levels (II & III). Approximately 8% of all CCHDs may be attributed to suboptimal maternal prepregnancy BMI, with the highest total individual CCHD PAFs for pulmonary valve atresia (21.7%) and total anomalous pulmonary venous return (12.8%). CONCLUSIONS: Women with suboptimal prepregnancy BMI are at increased odds of having a child born with a CCHD. We found evidence of a direct dose-response relationship between prepregnancy BMI and odds for CCHD; with variation by CCHD subtype.

Adnexal surgery at the time of hysterectomy in women 65 years and older undergoing hysterectomy for prolapse: do practice trends differ by route of surgery?

INTRODUCTION AND HYPOTHESIS: The objective was to determine whether the rate of adnexal surgery varies by route of hysterectomy in women over the age of 65 undergoing hysterectomy for prolapse. We hypothesized that women undergoing vaginal hysterectomy would be less likely to undergo bilateral salpingo-oophorectomy (BSO) at the time of their hysterectomy for prolapse. METHODS: This was a cross-sectional analysis using the National Inpatient Sample (NIS) database. Our primary outcome was concomitant adnexal surgery performed at the time of hysterectomy, classified into five groups: BSO, unilateral salpingo-oophorectomy (USO), bilateral salpingectomy (BS), other adnexal surgery, and no adnexal surgery. The study sample included women aged 65 years and older who underwent hysterectomy between 1 January 2009 and 31 December 2014 and with a diagnosis of genital prolapse. RESULTS: Of the 91,292 patients over the age of 65 who underwent a hysterectomy for prolapse, the majority of hysterectomies were vaginal (69%), followed by abdominal (13%), laparoscopic (11%), and robotic (7%). The number of women having a hysterectomy and undergoing a BSO was much lower for vaginal than for other hysterectomy types; 20.3% of women undergoing vaginal hysterectomies had a BSO, compared with 79.2% in abdominal, 81.8% in laparoscopic, and 73.8% in robotic-assisted procedures. Women who received vaginal hysterectomies were five times as likely (RR: 5.02, 95% CI: 4.70-5.35) to have no concomitant adnexal procedure compared with other routes of hysterectomy. CONCLUSIONS: Women over the age of 65 undergoing hysterectomy for prolapse are significantly less likely to have adnexal surgery if undergoing hysterectomy via vaginal route compared with the other routes.

Vaginal Estrogen as First-Line Therapy for Recurrent Urinary Tract Infections in Postmenopausal Women and Risk Factors for Needing Additional Therapy.

OBJECTIVES: This retrospective cohort study aims to determine the proportion of postmenopausal women with recurrent urinary tract infections (rUTIs) who improve with vaginal estrogen cream alone and to identify risk factors for those who go on to require additional therapies. METHODS: Postmenopausal women presenting with rUTIs seen at a single institution over a 29-month period were identified. Patients who had not undergone previous treatment and were started on vaginal estrogen cream alone as first-line therapy were included in the study. Descriptive statistics were used to compare demographic and clinical characteristics between therapy groups. Log-binomial regression was used to explore the association between treatment failure (ie, the need for additional therapy for rUTIs) and patient sociodemographic and clinical characteristics. RESULTS: During the study period, 167 patients with rUTIs met inclusion criteria. Of these, 67.7% noted improvement or resolution in their symptoms with vaginal estrogen cream alone. Women with a concomitant diagnosis of urinary incontinence, as defined as subjective report of bothersome stress or urgency urinary incontinence, were 2.3 times more likely to need additional therapy compared with women not reporting urinary incontinence (relative risk, 2.28; 95% confidence interval, 1.06-4.90). CONCLUSIONS: Sixty-eight percent of postmenopausal women with rUTIs treated with vaginal estrogen alone did not go on to receive additional therapy. A risk factor for needing additional therapy in our study population is the presence of urinary incontinence.

Risk factors for early and late failures following repair of urogenital fistulas.

INTRODUCTION AND HYPOTHESIS: In Sub-Saharan Africa, obstetric fistulas are a health crisis of extensive proportions. Although risk factors for failure are described, little data exist regarding differences in risk factors for early and late recurrences. METHODS: A retrospective cohort study was conducted to evaluate risk factors for fistula recurrence. Inclusion criteria included women who underwent repair of urogenital fistula at a Fistula Hospital in Uganda between 2013 and 2019. Our primary objective was to determine the incidence of both early and late failures and to identify and compare risk factors for each. Logistic regression was used to calculate crude odds ratios (ORs) and 95% confidence intervals (CIs) representing the association between each risk factor for early and late failures. Covariates significantly associated with early or late failure in univariate analyses were included in multivariate logistic regression models. RESULTS: A total of 541 patients were included. The incidence of early failure was 10.9%. Risk factors for early failure included stillbirth (aOR = 3.71, 95% CI: 1.38-9.96), fistula larger than 3 cm, (aOR = 3.12 95% CI: 1.40-6.93), presence of foot drop (aOR = 4.74, 95% CI:1.88-11.97), and perioperative blood transfusion (aOR = 3.10, 95% CI: 1.11-8.66). Risk factors for late failures included stillbirth (aOR = 4.63, 95% CI:1.04-20.51), and previous fistula repairs (aOR = 3.13, 95% CI:1.30-7.56). CONCLUSION: Both early and late failures can occur and risk factors for each may be different. Identifying patients at risk for late failures is important for improved counseling and highlights the importance of developing risk-reducing strategies to improve patient outcomes after discharge.

Diagnosis Codes and Case Definitions for Neonatal Abstinence Syndrome.

BACKGROUND AND OBJECTIVES: The increase in neonatal abstinence syndrome (NAS) has underscored the need for NAS surveillance programs, but many rely on passive surveillance using unverified diagnosis codes. Few studies have evaluated the validity of these codes, and no study has assessed the recently proposed Council of State and Territorial Epidemiologists (CSTE) case definition. The Florida Birth Defects Registry investigated the accuracy of International Classification of Diseases, 10th Revision, Clinical Modification codes related to NAS (P96.1 and P04.49) and assessed the sensitivity of the CSTE case definition. METHODS: We identified a sample of infants born during 2016 coded with P96.1 and/or P04.49. Record review was completed for 128 cases coded with P96.1, 68 with P04.49, and 7 with both codes. Lacking consensus regarding a gold standard definition of NAS, we used clinical data to classify each case using the Florida and CSTE definitions. The code-specific accuracy was measured by using the positive predictive value (PPV). The clinical characteristics indicative of NAS were compared for case classification based on both definitions. RESULTS: By using the Florida definition, the overall PPV was 68% but varied by code: 95.3% for P96.1 and 13.2% for P04.49. The overall (47.8%) and code-specific PPVs were lower by using the CSTE definition. Comparison of clinical characteristics demonstrated that 60.7% of cases classified as no NAS by using the CSTE definition had robust clinical signs of NAS. In our sample, the CSTE case definition underestimated NAS prevalence. CONCLUSIONS: Only the P96.1 International Classification of Diseases, 10th Revision, Clinical Modification code displayed high accuracy. Discordance in NAS case definitions and surveillance methodologies may result in erroneous comparisons and conclusions that negatively impact NAS-related surveillance and research.

An Evaluation of Florida's Zika Response Using the WHO Health Systems Framework: Can We Apply These Lessons to COVID-19?

OBJECTIVES: From 2016 to 2018 Florida documented 1471 cases of Zika virus, 299 of which were pregnant women (Florida Department of Health, https://www.floridahealth.gov/diseases-and-conditions/mosquito-bornediseases/surveillance.html , 2019a). Florida's response required unprecedented rapid and continuous cross-sector communication, adaptation, and coordination. Zika tested public health systems in new ways, particularly for maternal child health populations. The systems are now being challenged again, as the Coronavirus COVID-19 pandemic spreads throughout Florida. This qualitative journey mapping evaluation of Florida's response focused on care for pregnant women and families with infants exposed to Zika virus. METHODS: Fifteen focus groups and interviews were conducted with 33 public health and healthcare workers who managed outbreak response, case investigations, and patient care in south Florida. Data were thematically analyzed, and the results were framed by the World Health Organization's (WHO) Healthcare Systems Framework of six building blocks: health service delivery, health workforce, health information systems, access to essential medicines, financing, and leadership and governance (World Health Organization, https://www.who.int/healthsystems/strategy/everybodys_business.pdf , 2007, https://www.who.int/healthinfo/systems/monitoring/en/ , 2010). RESULTS: Results highlighted coordination of resources, essential services and treatment, data collection, communication among public health and healthcare systems, and dissemination of information. Community education, testing accuracy and turnaround time, financing, and continuity of health services were areas of need, and there was room for improvement in all indicator areas. CONCLUSIONS: The WHO Framework encapsulated important infrastructure and process factors relevant to the Florida Zika response as well as future epidemics. In this context, similarities, differences, and implications for the Coronavirus COVID-19 pandemic response are discussed.

Perspectives on challenges and opportunities for birth defects surveillance programs during and after the COVID-19 era.

In recent months, various public health measures have been implemented throughout the world in response to the coronavirus disease 2019 (COVID-19) pandemic. This outbreak, and the subsequent containment policies, may have a range of potential short- and long-term impacts on the monitoring and surveillance of other conditions, such as birth defects. In this commentary, we provide a perspective on these potential impacts on birth defects surveillance and analysis. We discuss possible effects on clinical birth defect diagnoses, routine birth defects surveillance system activities, and epidemiologic considerations, as well as opportunities for mitigating the impact of COVID-19. Like many other sectors of public health and medicine, birth defects surveillance programs may be faced with organizational and methodological obstacles in the wake of a changing landscape. A better understanding of these potential challenges faced by birth defects surveillance programs could facilitate better planning and collaboration across programs to overcome barriers to core activities and to prepare for novel opportunities for research and prevention.

Family-Centered Management of Birth Defects Diagnosis and Referral in Hospital Settings in Florida.

OBJECTIVE: Families' experiences of children diagnosed with birth defects vary greatly in navigating care systems and there is no comprehensive national protocol or standards for support and referral processes at birth. This study builds on the results of previous literature examining these variations in access to care. A survey was conducted among providers from across Florida to determine current practices and recommendations for providing information, medical/community referrals, discharge planning, and family-centered care in hospital settings. METHODS: Fifty-four hospital health care providers across Florida completed an online survey for 11 congenital conditions through closed and open-ended responses. Survey questions were based on a literature review that focused on identifying and understanding the current practices related to providing information, support and referrals to families of infants born with birth defects. Analyses included descriptive statistics, and content analysis of the open-ended responses. RESULTS: Survey respondents identified key personnel, practices, and challenges related to family-centered care in birth hospitals. While information and referral are often provided to the family by the physician or nurse, other health care providers and community agencies also play an important role. Processes for information and referral vary by birth defect; however common structures that support Family-centered management include written materials for family information and support, participatory discharge planning, interdisciplinary communication and coordination, and provider training/awareness. CONCLUSION: Through additional resources, staffing, increased communication, education, and coordination between health care providers, families and hospitals improvements can be made in the management of birth defect diagnosis and referrals. Best practices must be agreed upon, operationalized, disseminated, and evaluated so that parents consistently receive sensitive, individualized, timely information and referrals relative to their child's condition.

Association between Preoperative Adenomyosis Detection Rate during Pelvic Ultrasonography and the Specialty of the Reading Physician.

STUDY OBJECTIVE: To compare the detection rate of adenomyosis when ultrasound is performed by a radiologist compared with a gynecologic expert sonologist. DESIGN: A retrospective, single-center study. SETTING: A university teaching hospital. PATIENTS: All women above 18 years of age with a positive histopathology diagnosis of adenomyosis obtained in a hysterectomy specimen from October 1, 2011, to October 1, 2017, were screened for inclusion. Cases without a preoperative pelvic ultrasound report, those with coexisting premalignant/malignant conditions, and patients presenting to the clinic with symptoms other than abnormal uterine bleeding, dysmenorrhea, or abdominal pain were excluded. A total of 412 cases were included in the final analysis. MEASUREMENTS AND MAIN RESULTS: The preoperative ultrasound was performed by a radiologist in 241 patients (59%) and by an expert gynecologic sonologist in 171 patients (42%). Patients' age, body mass index, race, ethnicity, parity, and history of prior cesarean section were comparable between the 2 groups. The adenomyosis detection rate was significantly higher in the expert gynecologic sonologist group compared with radiologists (95 [56%] vs 29 [12%], p <.01). After controlling for patients' race, body mass index, prior cesarean sections, and presence of myomas using multivariable logistic regression, gynecologic expert sonologists were 7.8 times more likely to detect adenomyosis than radiologists (odds ratio = 7.84; 95% confidence interval, 4.58-13.44). Regardless of medical specialty, the presence of myomas significantly decreased the detection of adenomyosis compared with the absence of myomas (odds ratio = 0.23; 95% confidence interval, 0.13-0.39). CONCLUSION: The detection rate of adenomyosis was significantly higher when ultrasound was performed by expert gynecologic sonologists compared with radiologists. The presence of myomas significantly decreased detection rates regardless of specialty. Ultrasound evaluation for detecting adenomyosis should be preferentially performed by gynecologic expert sonologists.

The impact of the ICD-9-CM to ICD-10-CM transition on the prevalence of birth defects among infant hospitalizations in the United States.

BACKGROUND: Many public health surveillance programs utilize hospital discharge data in their estimation of disease prevalence. These databases commonly use the International Classification of Diseases (ICD) coding scheme, which transitioned from the ICD-9 clinical modification (ICD-9-CM) to ICD-10-CM on October 1, 2015. This study examined this transition's impact on the prevalence of major birth defects among infant hospitalizations. METHODS: Using data from the Agency for Health Care Research and Quality-sponsored National Inpatient Sample, hospitalizations during the first year of life with a discharge date between January 1, 2012 and December 31, 2016 were used to estimate the monthly national hospital prevalence of 46 birth defects for the ICD-9-CM and ICD-10-CM timeframes separately. Survey-weighted Poisson regression was used to estimate 95% confidence intervals for each hospital prevalence. Interrupted time series framework and corresponding segmented regression was used to estimate the immediate change in monthly hospital prevalence following the ICD-9-CM to ICD-10-CM transition. RESULTS: Between 2012 and 2016, over 21 million inpatient hospitalizations occurred during the first year of life. Among the 46 defects studied, statistically significant decreases in the immediate hospital prevalence of five defects and significant increases in the immediate hospital prevalence of eight defects were observed after the ICD-10-CM transition. CONCLUSIONS: Changes in prevalence were expected based on changes to ICD-10-CM. Observed changes for some conditions may result from variation in monthly hospital prevalence or initial unfamiliarity of coders with ICD-10-CM. These findings may help birth defects surveillance programs evaluate and interpret changes in their data related to the ICD-10-CM transition.

Exploring classification of birth defects severity in national hospital discharge databases compared to an active surveillance program.

OBJECTIVE: To explore the extent to which the severity of birth defects could be differentiated using severity of illness (SOI) and risk of mortality (ROM) measures available in national discharge databases. METHODS: Data from the 2012-14 National Inpatient Sample (NIS) was used to identify hospitalizations with one or more major birth defects reported annually to the National Birth Defects Prevention Network using the International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) diagnosis codes. Each hospitalization also contained a 4-level SOI and 4-level ROM classification measure. For each birth defect and for each individual birth defect-related ICD-9-CM code, we calculated mean and median SOI and ROM, the proportion of hospitalizations in each level of SOI and ROM, the inpatient mortality rate, and level of agreement between various existing or derived severity proxies in the NIS and the Texas Birth Defects Registry (TBDR). RESULTS: Mean SOI ranged from 1.5 (cleft lip alone) to 3.7 (single ventricle), and mean ROM ranged from 1.1 (cleft lip alone) to 3.9 (anencephaly). As a group, critical congenital heart defects had the highest average number of co-occurring defects, mean SOI, and ROM, whereas orofacial and genitourinary defects had the lowest SOI and ROM. We found strong levels of agreement between TBDR severity classifications and NIS severity classifications defined using Level 3 or 4 SOI or ROM Level 3 or 4. CONCLUSIONS: This preliminary investigation demonstrated how severity indices of birth defects could be differentiated and compared to a severity algorithm of an existing surveillance program.

Furosemide Use and Time to Confirmation of Ureteral Patency During Intraoperative Cystoscopy: A Randomized Controlled Trial.

OBJECTIVE: To investigate the effect of intravenous administration of furosemide on the time to confirmation for ureteral patency during intraoperative cystoscopy. METHODS: In a double-blind randomized controlled trial, intravenous administration of furosemide 10 mg was compared with placebo (normal saline) to investigate the effect of furosemide on the time to confirmation for ureteral patency during intraoperative cystoscopy. The primary outcome was time to confirmation of ureteral patency. Secondary outcomes included adverse reaction to study medication and delayed diagnosis of ureteric injury. A sample size of 72 per group (N=144) was powered to detect a 3-minute difference in time to confirmation of ureteral patency between groups. RESULTS: From May 2017 to March 2018, 215 patients were eligible for inclusion and 150 were randomized, with 145 available for final evaluation. The two groups were similar in regard to baseline characteristics. The administration of intravenous furosemide 10 mg in a routine cystoscopy resulted in a shorter time to confirmation compared with the administration of the placebo (86.5 seconds, interquartile range 55.0-137.0 vs 165.0 seconds, interquartile range 77.0-280.0; P<.05). Furthermore, at any given time period, patients receiving intravenous administration of furosemide 10 mg were 2.3 times more likely to have ureteral patency confirmed compared with patients receiving normal saline (95% CI 1.59-3.23). There were no adverse events related to administration of intravenous furosemide and no delayed diagnoses of ureteric injury. CONCLUSION: Compared with placebo, intravenous administration of 10 mg furosemide at time of intraoperative cystoscopy resulted in a statistically significantly shorter time to confirmation of ureteral patency, though the clinical significance of this finding is small. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02960412.

Delivery-associated sepsis: trends in prevalence and mortality.

BACKGROUND: Sepsis is a leading cause of pregnancy-related mortality. Previous studies have reported an increased prevalence of sepsis during pregnancy. Despite national campaigns to increase sepsis awareness, there is a lack of pregnancy-specific guidelines. OBJECTIVE: We aimed to provide updated national estimates of the prevalence and trends of sepsis, sepsis-related in-hospital mortality, and factors associated with in-hospital mortality among women with sepsis at delivery. STUDY DESIGN: We conducted a serial, cross-sectional analysis using data from the 2002-2015 National Inpatient Sample, the largest publicly available all-payer inpatient database in the United States. We used International Classification of Diseases, ninth edition, Clinical Modification diagnosis and procedure codes to identify the study sample of delivery-associated hospitalizations and to capture diagnoses of sepsis (defined as infection with associated end-organ dysfunction). The primary outcome was in-hospital mortality. Obstetric comorbidities and pregnancy-related outcomes were also analyzed. Logistic regression was used to explore factors associated with sepsis during pregnancy and, among those with sepsis, to identify predictors of in-hospital mortality. Joinpoint regression was used to estimate the temporal trends in both sepsis and in-hospital mortality. RESULTS: Of the more than 55 million delivery-associated hospitalizations, 13,129 women met criteria for sepsis, corresponding to a rate of 2.4 per 10,000 deliveries. This rate increased from 1.2 to 3.7 per 10,000 over the study period, representing an annual increase of 6.6% (95% confidence interval, 4.2-9.1). The highest crude rates of sepsis (per 10,000) were among deliveries paid for by Medicare (14.8), deliveries to women aged 40 years or older (8.0), and deliveries to non-Hispanic black women (4.6). Compared with women without sepsis, women with sepsis had a greater than 10-fold increased prevalence of most selected obstetric comorbidities. One in 11 women with sepsis died prior to discharge, compared with 1 death in every 15,411 deliveries without sepsis. The sepsis-related mortality rate decreased 21.8% each year from 2010 through 2015. Maternal age greater than 40 years and nonprivate insurance demonstrated the highest odds of sepsis-related in-hospital mortality. CONCLUSION: While rates of delivery-associated sepsis have increased, case fatality has decreased.