Duration of Induction of Labor for Second-Trimester Medication Abortion and Adverse Outcomes.

OBJECTIVE: To evaluate the relationship between duration of labor during second-trimester medication abortion and adverse outcomes. METHODS: We conducted a retrospective cohort study including all individuals with a singleton gestation undergoing second-trimester medication abortion without evidence of advanced cervical dilation, rupture of membranes, or preterm labor at four centers. The primary exposure was duration of labor (ie, hours spent from receiving misoprostol to fetal expulsion). The primary outcome was composite morbidity, defined as uterine rupture, need for blood transfusion, clinical chorioamnionitis, intensive care unit admission, or need for readmission. We performed bivariate and multivariate negative binomial analyses. A post hoc subgroup analysis was performed to assess for the risk of the primary outcome by gestational age. We performed tests of homogeneity based on history of uterine scarring and parity. RESULTS: Six hundred eighty-one individuals were included. The median duration of labor was 11 hours (interquartile range 8-17 hours). One hundred thirty-one (19.2%) experienced the primary outcome. When duration of labor was evaluated continuously, a longer duration of labor was associated with an increased frequency of morbidity (adjusted ß=0.68, 95% CI, 0.32-1.04). When duration of labor was evaluated categorically, those experiencing the highest quartile of duration (ie, 17 hours or more) had a statistically higher risk for experiencing morbidity compared with individuals in all other quartiles (adjusted relative risk 1.99, 95% CI, 1.34-2.96). When we focused on components of the composite outcome, clinical chorioamnionitis was significantly different between those experiencing a longer duration and those experiencing a shorter duration of labor (26.2% vs 10.6%, P<.001). On subgroup analysis, gestational age was not associated with the risk of composite morbidity. Tests of homogeneity demonstrated no significant difference in the risk for morbidity among individuals with a history of uterine scarring or based on parity. CONCLUSION: Duration of labor was independently associated with risks for adverse maternal outcomes during second-trimester medication abortion, specifically clinical chorioamnionitis.

Sexual Health for Transgender and Gender Diverse Individuals: Routine Examination, Sexually-Transmitted Infection Screening, and Prevention.

Gynecologists play a critical role in the office evaluation of transgender and gender diverse individuals. This includes the provision of essential healthcare services including the treatment and prevention of human immunodeficiency virus and sexually-transmitted infections and screening for human papillomavirus infection-related diseases and cancers. Caring for patients who identify as transgender or gender diverse (TGD) and who have undergone gender-affirming surgical treatments is challenging due in part to clinical gaps in knowledge resulting from insufficient training and educational resources. A patient-centered approach to the care of TGD individuals requires knowledge of the general principles of affirming, holistic care with attention to the risk factors, and anatomic considerations unique to this population. This review aims to provide basic knowledge needed for the successful gynecologic evaluation of a gender diverse patient.

Anticipatory Counseling About Miscarriage Management in Catholic Hospitals: A Qualitative Exploration of Women's Preferences.

CONTEXT: Catholic hospitals represent a large and growing segment of U.S. health care. Because these facilities follow doctrines that restrict reproductive health services, including miscarriage management options when a fetal heartbeat is present, it is critical to understand whether and how women would want to learn about miscarriage treatment restrictions from providers. METHODS: From May 2018 to January 2019, semistructured interviews were conducted with 31 women aged 21-44 who had had exposure to religious-based health care; all were drawn from a nationally representative survey sample. Participants responded to a hypothetical scenario regarding the anticipatory disclosure of miscarriage management policy during routine prenatal care. Responses were inductively coded and thematically analyzed using modified grounded theory to understand women's attitudes and considerations related to receiving anticipatory miscarriage management information. RESULTS: Respondents supported the routine disclosure of miscarriage management policies during prenatal care. Some expressed concern that this might increase patient anxiety during pregnancy, but most felt that the information would serve to prepare and empower patients, and likened the topic to other anticipatory health information provided during prenatal care. Identified themes related to how providers can disclose this information (including the need for a precautionary framing to reduce patient stress), sharing the rationale for institutional policy, and the importance of provider neutrality to ensure patient autonomy. CONCLUSIONS: To respect patient autonomy, health care providers working in Catholic hospitals should routinely discuss institutional miscarriage management policies with patients, and anticipatory counseling should give patients the balanced information they need to decide where to go for care should pregnancy complications arise.

Restrictions on Reproductive Care at Catholic Hospitals: A Qualitative Study of Patient Experiences and Perspectives.

BACKGROUND: Previous studies have shown that many women who would seek care at Catholic hospitals are unaware of the hospital's religious affiliation. Furthermore, women often do not realize that these institutions operate according to religious beliefs that restrict access to certain reproductive services. Our study aimed to gain patient perspectives on experiences seeking reproductive care at religiously affiliated institutions. METHODS: We conducted a qualitative study using in-depth interviews with 33 women who reported experiences seeking reproductive services at Catholic hospitals. Interview questions focused on women's experiences with religious restrictions, their attitudes towards religious healthcare, and whether and how they think women should be informed of these restrictions. Interviews were thematically analyzed using Dedoose software, applying both a priori concepts such as patient autonomy, informed decision making, and transparency, as well as new concepts that emerged from the data or denoted unanticipated distinctions within codes. RESULTS: In this paper, we present three findings. First, women value both patient autonomy and hospital religious freedom. Struggling to reconcile these, many blamed themselves for not anticipating religious restrictions. Second, barriers to information prevent women from researching restrictions ahead of time. Third, women would like more information about these restrictions from both doctors and hospitals. CONCLUSION: Public policy that regulates hospitals should require transparency from hospitals and physicians about religious restrictions on care. Informing the public about religious policies and how they affect reproductive care will allow patients to better anticipate differences and make informed decisions about where to seek care.

Do women know whether their hospital is Catholic? Results from a national survey.

OBJECTIVES: Catholic healthcare limits access to common reproductive care. We assessed what percentage of US women seeking care at Catholic hospitals are aware of their hospital's religious affiliation and identified variables associated with correct identification. STUDY DESIGN: We conducted a national survey of women ages 18-45 (response rate 50%). The survey asked participants what hospital they would go to for reproductive care and what the religious affiliation of that hospital was. We verified responses as correct or incorrect against a known Catholic hospital list. We used bivariate analysis and logistic regressions to evaluate factors associated with correct identification. RESULTS: Sixteen percent of women reported a Catholic hospital as their primary hospital for reproductive care. Among women whose primary hospital was Catholic, 63% [95% confidence interval (CI): 54.5-70.7] correctly identified this, compared to 93% who correctly identified their hospital as non-Catholic (95% CI 91.4 - 95.0). Two thirds of respondents who misidentified their Catholic hospital's affiliation reported that their hospital was secular (66%), and 48% of those women felt sure or very sure of their incorrect response. Factors associated with correctly identifying Catholic hospitals included hospital with a religious-sounding name [adjusted odds ratio (aOR)=2.80; 95% CI: 1.07-7.34], respondent older age (aOR=3.77; 95% CI: 1.35-10.56), metropolitan residence (aOR=3.35; 95% CI: 1.01-11.10) and income over $100,000 (aOR 4.95; 95% CI 1.35 - 18.17). CONCLUSION: Over one third of US women who named a Catholic hospital as their primary hospital for reproductive care are unaware it is Catholic. Women are more likely to correctly identify a hospital as Catholic when that hospital has a religious sounding name. IMPLICATIONS: Patients need accurate information in order to make decisions about where to seek reproductive healthcare. Our results suggest that women are often unaware of their hospital's religious affiliation. Efforts are needed to increase hospital transparency and patient awareness of the implications that arise when healthcare is restricted by religion.

Incidence and Characterization of Hypoesthesia in the Distribution of the Infrapatellar Branch of the Saphenous Nerve after Anterior Cruciate Ligament Reconstruction: A Prospective Study of Patient-Reported Numbness.

The purpose of this study was to determine the incidence of patient-reported numbness following anterior cruciate ligament reconstruction (ACLR), if postoperative numbness dissipates with time, and how the graft type affects numbness severity. A total of 218 patients undergoing ACLR were prospectively enrolled. At 6 weeks, 6 months, and 1 year postoperatively, patients completed a questionnaire assessing numbness severity and location. Each time, patients rated their sensory deficit from 0 to 10 (0 = no deficit; 10 = complete lack of sensation) and indicated the location of their sensory deficit by marking a picture of a knee divided into nine rectangular segments. A mixed effect linear regression model was used to identify predictors for the patient-reported numbness severity. Overall, 69.8% (150/218) of patients reported numbness at 6 weeks, 50.0% (97/194) at 6 months, and 42.2% (78/185) at 1 year. Allograft patients reported a mean numbness severity of 2.9 ± 0.3 (mean ± standard error), 1.7 ± 0.2, and 1.4 ± 0.3 at 6 weeks, 6 months, and 1 year, respectively. The 6-week, 6-month, and 1-year averages were 4.7 ± 0.4, 2.7 ± 0.4, and 1.7 ± 0.4 for bone-patellar tendon-bone (BTB) autograft patients and 4.3 ± 0.4, 2.9 ± 0.4, and 2.5 ± 0.4 for hamstring autograft patients. The model indicated that the use of hamstring autografts increased patient-reported numbness by an average of 1.4 ± 0.5 across all time points, and the use of a BTB autograft increased patient-reported numbness by 1.2 ± 0.4 across all time points. Time from surgery decreased the severity of patient-reported numbness for all graft types (-1.3 ± 0.2 at 6 months and -1.7 ± 0.2 at 1 year). Hypoesthesia in the distribution of the infrapatellar branch of the saphenous nerve is common after ACLR but is likely to dissipate with time. Patients undergoing ACLR with allograft may be less likely to develop sensory deficits, and these deficits may be less severe.

Anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft versus allograft in skeletally mature patients aged 25 years or younger.

PURPOSE: The purpose of this study is to evaluate the clinical outcomes and revision rates of skeletally mature patients aged 25 years or younger who have undergone either BPTB autograft or deep-frozen, non-irradiated BPTB allograft ACL reconstruction by a single surgeon. METHODS: Two hundred and twenty-four patients aged 25 or younger at the time of surgery were identified as having a transtibial ACL reconstruction with either a BPTB autograft or deep-frozen, non-irradiated BPTB allograft by one senior surgeon (101 autografts vs. 123 allografts) over the study time period. Primary outcome measure included the need for ACL revision. One hundred and nineteen patients with at least 2-year clinical follow-up agreed to participate in secondary outcome measurement arm of the study and were administered the Lysholm Knee Scoring Scale and IKDC Subjective Knee Evaluation Form. RESULTS: The median Lysholm scores were 95 (40-100) and 95 (68-100) and the median IKDC scores were 95.4 (54.0-100) and 95.4 (72.4-100) in the allograft and autograft groups, respectively. The differences in the Lysholm scores and the IKDC scores were not statistically significant (P = n.s.). There were 13 patients requiring ACL revision, 12 allograft versus one autograft (P = 0.005). CONCLUSION: Although there is no significant difference in patient-rated outcome between ACL reconstructions using BPTB autografts versus BPTB allografts, a significantly higher rate of ACL revision was found in allograft patients. The results of our study support a growing body of literature that BPTB autograft reconstruction leads to lower retear rates in younger individuals, an important factor in the graft selection process for these patients. LEVEL OF EVIDENCE: III.

Functional outcomes after bilateral arthroscopic rotator cuff repair.

BACKGROUND: Arthroscopic repair of rotator cuff tears is a common procedure performed by orthopedic surgeons. There is a well-known incidence of up to 35% of bilateral rotator cuff tear disease in patients who have a known unilateral tear. The majority of the literature focuses on outcomes after unilateral surgery. The purpose of this study was to determine if there are clinical differences in shoulders of patients who underwent staged bilateral rotator cuff repairs during their lifetime. METHODS: A retrospective review of all patients who underwent staged bilateral arthroscopic rotator cuff surgery at our institution was performed. All patients had at least 2 years of follow-up. Clinical outcome scores including the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation, and Rowe measures were obtained. A subset of patients returned for clinical and ultrasound evaluation performed by an independent fellowship-trained musculoskeletal radiologist. RESULTS: Overall, 110 shoulders in 55 patients, representing 68% of all eligible patients, participated. No clinical or statistical difference was found in any outcome measure. ASES scores averaged 86.5 (36.7-100) in the dominant shoulder compared with 89.6 (23.3-100) in the nondominant shoulder (P = .42). Ultrasound was available on 34 shoulders and showed complete healing rate of 88%. The shoulders with retearing of the rotator cuff (12%) demonstrated clinically relevant lower ASES scores (72.5) compared with shoulders with confirmed healed repairs (86.2; P = .2). DISCUSSION: Patients who undergo staged bilateral rotator cuff repair can expect to have similarly good clinical outcomes regardless of hand dominance or chronologic incidence with excellent healing rates in both shoulders.

Results of ACL reconstruction with tibial Retroscrew fixation: Comparison of clinical outcomes and tibial tunnel widening.

UNLABELLED: ACL reconstruction with the RetroScrew™ shows superior clinical outcomes compared to historical Achilles allograft studies with antegrade screws. Addition of antegrade screw augmentation to retrograde fixation causes an increase in tibial tunnel widening. INTRODUCTION: In traditional antegrade screw fixation of Anterior cruciate ligament (ACL) soft tissue allografts, the screw is secured in the opposite direction of graft tension, potentially altering the appropriate tension on the graft. The RetroScrew (Arthrex) is a bioabsorbable screw placed in a retrograde fashion, potentially improving the tension of the graft by placing the screw in a proximal-to-distal direction. In addition, the RetroScrew theoretically decreases tibial tunnel widening by closing the aperture of the tibial tunnel, which prevents ingress of synovial fluid. Early tunnel expansion has been implicated due to excessive transverse and longitudinal graft motion. The clinical effects of tunnel expansion have yet to be fully understood. The purpose of this study is to assess the clinical results and tunnel width after ACL soft tissue fixation in the tibia with the RetroScrew. METHODS: Fifty-nine patients who underwent ACL reconstruction performed by two surgeons using the RetroScrew device returned for postoperative evaluation at an average of 25 months following surgery with a minimum follow-up of 12 months. Clinical evaluation, SF-36, IKDC and KT-1000 scores were recorded, and knee radiographs were used to measure tibial tunnel widening. Thirty-five patients had backup antegrade screw fixation in conjunction with the RetroScrew, and 24 patients had RetroScrew fixation alone. The results were compared to two previously reported studies on ACL reconstruction with Achilles tendon allograft that used antegrade screws. RESULTS: The average IKDC score was 87 (range: 44-100), with mean KT-1000 side-to-side difference of 1.2 mm (range: 0-5 mm). Tibial tunnel widening was 4.93 mm (SD 3.32) on AP radiographs and 4.40 mm (SD 2.72) on lateral radiographs greater than the native tunnel drilling. Patients with additional backup fixation had significantly more tunnel widening than patients without backup fixation (P < 0.05). There was one failure based on KT-1000 measurements. When compared to previous studies using ACL allografts, RetroScrew patients had statistically superior Lachman exams, KT-1000 side-to-side differences and decreased tibial tunnel widening (P < 0.05) when antegrade fixation was excluded. CONCLUSION: Patients who underwent Achilles allograft ACL reconstruction with the RetroScrew had improved clinical results compared to historical controls using antegrade fixation. Tibial tunnel widening was increased when using additional antegrade screw fixation, suggesting that the amount of bioabsorbable material within the tibial tunnel was related to the degree of tunnel widening.