Pudendal Neuromodulation is Feasible and Effective After Pudendal Nerve Entrapment Surgery.

BACKGROUND: Patients with intractable pain in the pudendal nerve distribution may benefit from pudendal neuromodulation; however, some may have previously undergone pudendal nerve entrapment surgery (PNES), potentially altering nerve anatomy and function. AIM: We examined pudendal neuromodulation outcomes in patients with prior PNES. METHODS: Patients with a history of PNES and quadripolar, tined pudendal lead placement for urogenital pain were reviewed. Symptoms and outcomes were collected from existing medical records. OUTCOMES: Patients with pudendal neuromodulation and prior PNES were compared to patients with no prior PNES who had pudendal lead placement. RESULTS: Fifteen patients with a history of 1, 2, or 3 prior PNES (n = 13, 1, and 1, respectively) were evaluated. Most (10; 67%) were female, with bilateral pain (9; 60%), and symptoms of 5-26 years. After trialing the lead, bladder symptoms and pain were improved in 8 of 12 and 9 of 14 patients, respectively, and 80% of patients (12/15) underwent permanent generator implantation. When prior PNES patients were compared to those with no prior PNES (n = 43), gender (67% vs 77% female; P = .50) and age (median 63 vs 58 years; P = .80), were similar; however, BMI differed (mean 24 vs 29; P = .008) and a lower proportion (12/15; 80% vs 42/43; 98%; P = .049) had generator implantation. Importantly, median lead implant time (48 vs 50 minutes; P = .65) did not differ between the 2 groups. CLINICAL IMPLICATIONS: Pudendal neuromodulation has the potential to provide pain relief for a very difficult-to-treat population; furthermore, it does not appear that prior PNES surgery made lead placement significantly more challenging. STRENGTHS & LIMITATIONS: Study strengths include being a tertiary referral center for urogenital pain and having a single surgeon perform all procedures in a regimented way. Limitations include the retrospective study design, small sample size and various approaches to PN CONCLUSION: Chronic pudendal neuromodulation can be a viable option even after prior PNES. Kristen M. Meier, Patrick M. Vecellio, Kim A. Killinger, Judith A. Boura, Kenneth M. Peters. Pudendal Neuromodulation is Feasible and Effective After Pudendal Nerve Entrapment Surgery. J Sex Med 2022;19:995-1001.

Does seasonal variation in orthopaedic trauma volume correlate with adverse hospital events and burnout?

INTRODUCTION: Assessing workload and mitigating burnout risk should be a constant goal within training programs. By using work relative value unit (wRVU) data in a non-elective orthopaedic trauma practice, we investigated seasonal variation in workload on an orthopaedic trauma service at a level I trauma centre. We also investigated whether there was a correlation in seasonal preventable adverse patient safety events (PSEs) and resident Epworth Sleepiness Scale (ESS) scores. MATERIALS AND METHODS: Data on wRVUs were collected over an 8-year period for a single orthopaedic trauma surgeon with a non-elective practice. Monthly wRVU totals were tabulated over this 8-year period and compared with total hospital orthopaedic surgical trauma volume. The total number of wRVUs and surgical cases analysed were 80,955 and 9,928 respectively. A total of 1,560 PSEs and four years of resident ESS scores were analysed. Data on seasonal variations was evaluated for significance utilizing the Kruskal-Wallis test. WRVUs were then compared to total case volume, PSEs, and resident ESS scores using Spearman's correlation coefficients. RESULTS: We found that wRVUs significantly differed by month (P-value < 0.001) and season (P-value < 0.001) with the highest volume occurring in the summer months. Seasonal variation in wRVUs demonstrated a positive linear correlation with total surgical volume (P-value <0.001) and resident reported ESS scores (P-value = 0.001). PSEs were highest in the summer (P = 0.026), but were not correlated with our findings of seasonal variations in orthopaedic volume (P-value = 0.741). CONCLUSION: WRVUs of our single surgeon's orthopaedic trauma practice had a seasonal variation with significantly higher volume during the summer. These findings were representative of seasonal variations in total hospital orthopaedic trauma volume and also demonstrated correlation with objective resident sleepiness scores. PSEs were more frequent in the summer but not correlated with seasonal variation in volume. Burnout poses a risk to patient safety and has been shown to be correlated with increased work volume. These topics are important and applicable to various specialties involved in the care of patients with orthopaedic trauma injuries.

Comparison of Three Groups of Patients Having Low Dose Rate Prostate Brachytherapy: Prostate-Specific Antigen Failure and Overall Survival.

Purpose To examine dosimetric and clinical outcomes for Cs-131 radioactive seed implant compared to Pd-103 and I-125.  Background/Significance Cs-131 is a novel isotope with relatively short half-life (9.7 days) that may have clinical advantages in seed implant treatments of prostate cancers. There may be a shorter duration of symptoms and increased PSA control rates. Methods We performed a retrospective study in which clinical and dosimetric outcomes were compared for 186 prostate implants performed over a ten-year time period at three different Ascension hospitals. Isotopes that were used included Cs-131 (n=66; half-life 9.7 days), I-125 (n=60; half-life 60 days), and Pd-103 (n=60; half-life 17 days) Results The implants used standard radiation dosages. These were 145 Gy for I-125 alone or 109 Gy when combined with external beam radiation. In the case of Cs-131 used alone, the dose was 115 Gy or 85 Gy when combined with an external beam. For Pd-103, 125 Gy was used for monotherapy and 90 Gy when combined with an external beam. The Cs-131 dosimetry was found to be similar to I-125 and Pd-103 on a quantitative basis. However, there was better homogeneity, and the delivered activity per seed and the number of seeds employed were greater compared to other isotopes. We compared the corrected total source strengths (i.e. normalized to sample mean values) and were able to demonstrate similar distributions for the three isotopes. Dosimetric analysis also suggested there was superior homogeneity with Cs-131. The median PSA value at 60 months was 0.11 ng/ml. There were only a few PSA failures in the three groups of cases, nonetheless, the Cs-131 had the fewest.  Conclusions One attractive option for men with early-stage prostate cancer is interstitial brachytherapy. The use of the shorter-acting Cs-131 isotope may be expected to have dose-related side effects that resolve more rapidly. This series suggests a trend for improved PSA control outcomes for Cs-131 patients compared with I-125 and Pd-103.

The Use of Bedside Ultrasound for Gallstone Disease Care within a Community-based Emergency Department: A Confirmation Bias.

INTRODUCTION: Traditional evaluation for suspicion of gallstone or gallbladder-related disease includes evaluation with a formal technician-performed ultrasound. However, the use of point-of-care bedside ultrasounds (Bedside US) has been shown to be a viable alternative for the diagnosis of gallstones and gallbladder-related diseases. Purpose Statement: The purpose of this study was to evaluate the impact of Bedside US use in gallbladder evaluation on key patient care outcomes within our community-based emergency department setting. METHODS: This retrospective study compared the use of no ultrasound (No US), a formal technician performed ultrasound (Tech US) and Bedside US for gallstone and gallbladder related diseases within a community hospital emergency department between January 1, 2015 and January 1, 2018. Initial vitals, lab work, patient socio-demographics, medical history, emergency department length of stay in hours and disposition were reviewed. RESULTS: Of a total N = 449 patients included, patients who received a Bedside US had the fewest computerized tomography scans (No US 62% vs. Tech US 29% vs. Bedside US 16%; p < 0.0001), the shortest median emergency department length of stay (No US 4.5 days vs. Tech US 5.0 days vs. Bedside US 3.0 days; p < 0.0001), and were more likely to be discharged home (No US 41% vs. Tech US 55% vs. Bedside US 81%; p = 0.0006) compared to those that received no ultrasound or a formal ultrasound. Patients who received a Bedside US also had the statistically significant highest incidence of prior cholelithiasis (No US 29.4% vs Tech US 14.3% vs. Bedside US 31.3%; p = 0.001) and lowest total median bilirubin levels (No US 0.5 vs. Tech US 0.5 vs. Bedside US 0.3; p = 0.016) when compared to the other two groups. CONCLUSIONS: Although there was a confirmation bias, these study results indicate that point-of-care bedside ultrasound could be a viable alternative for gallstones and gallbladder-related diseases with benefits of use in a community hospital setting.

Invasive versus echocardiographic gradients in degenerated surgical aortic valve prostheses: A multicenter study.

Objectives: To compare echocardiographic and invasive mean gradients obtained concomitantly in degenerated bioprosthetic surgical aortic valves (SAVRs). Methods: In a multicenter study, we compared concomitant echocardiographic and invasive mean gradients of SAVR, obtained before valve-in-valve transcatheter aortic valve replacement in all patients, patients with primary stenosis (AS), primary aortic regurgitation (AR), and mixed aortic valve disease (MAVD), and in small versus large valves (≤ or >23 mm). Dimensionless index (DI) was calculated in all groups. Results: In total, 74 patients were included and data presented as median (interquartile range). Echocardiography-catheterization mean gradient discordance was observed in all patients (invasive = 22 mm Hg [11-34] vs echocardiographic = 32 mm Hg [21-42], P = .013), small valves (invasive = 15 mm Hg [8-34] vs echocardiographic = 28 mm Hg [21-41], P = .013), and large valves (invasive = 20 mm Hg [8.5-27.13] vs echocardiographic = 32 mm Hg [25.5 - 41.5], P < .0001), with a bias of 8 ± 15 mm Hg and wide limits of agreement (-22 to 39 mm Hg) on Bland-Altman plots, indicating these modalities may not be interchangeable. Discordance occurred in AR (invasive = 3 mm Hg [1-6] vs echocardiographic = 12 mm Hg [7-22], P = .017) and in MAVD (invasive = 19 mm Hg [12-29] vs echocardiographic = 31 mm Hg [23-39], P < .0001) but not in AS (invasive = 35 mm Hg [24-45] vs echocardiographic = 41 mm Hg [30-50], P = .45). A lower DI (0.21 [0.14-0.25]) occurred in AS compared with MAVD (0.31 [0.19-0.39]) and AR (0.55 [0.51-0.69]), P < .0001. Conclusions: Discordance between echocardiography and invasive mean gradients exists in degenerated SAVR, regardless of valve size, but depends on mechanism of failure and DI helps stratify these patients. With a discrepancy between echocardiographic mean gradients AND the patient's symptoms OR the valve leaflet structure and/or mobility on imaging, especially before redo-SAVR or valve-in-valve transcatheter aortic valve replacement, invasive gradients may adjudicate the true valvular hemodynamics.

Factors Associated with Delayed Paracentesis in Patients with Spontaneous Bacterial Peritonitis.

BACKGROUND AND AIM: In patients with spontaneous bacterial peritonitis (SBP), studies show that delayed paracentesis (DP) is associated with worse outcomes and mortality. We aimed to assess the rate of DP in the community setting and associated factors with early versus delayed paracentesis. METHODS: Patients hospitalized with SBP were retrospectively studied between 12/2013 and 12/2018. DP was defined as paracentesis performed > 12 h from initial encounter. Data collected included: patient factors (i.e., age, race, symptoms, history of SBP, MELD) and physician factors (i.e., admission service, shift times, providers ordering and performing paracentesis). Logistic regression analysis was performed to assess for factors associated with DP. RESULTS: DP occurred 82% of the time (n = 97). The most significant factors in predicting timing of paracentesis were ordering physician [emergency department (ED) physician was associated with early paracentesis (57% vs 8%, p < 0.001) and specialty of physician performing paracentesis (interventional radiology was associated with DP (88% vs 48%, p < 0.001)]. Younger patients were more likely to receive early paracentesis. In regression analysis, the factor most associated with early paracentesis was when the order was made by the ED provider (OR 0.07, 95% CI 0.02-0.22). No differences were observed in patients with prior history of SBP, abdominal pain, encephalopathy, or creatinine level. CONCLUSIONS: Studies have suggested that DP is associated with increased mortality in patients with SBP. Despite this, DP is common in the community setting and is influenced by ordering physician and specialty of physician performing paracentesis. Future efforts should assess interventions to improve this important quality indicator.

Symptom and Quality of Life Improvements After Pelvic Floor Physical Therapy in a Clinical Population of Women With Pelvic Pain and Other Symptoms.

OBJECTIVES: This study aimed to evaluate changes in validated symptom scores at intake and discharge in women undergoing pelvic floor physical therapy (PFPT) for pain and other pelvic floor symptoms. METHODS: Consecutive women starting PFPT during 1 year were reviewed. History, demographics, and Pelvic Floor Distress Inventory Questionnaire - Short Form 20 (PFDI) total and domain scores (Pelvic Organ Prolapse Distress Inventory-6, Urogenital Distress Inventory-6, Colorectal-Anal Distress Inventory-8), Pelvic Floor Impact Questionnaire (PFIQ-7), and pain levels on a numeric rating scale (NRS) were collected at intake and discharge. Data were analyzed with descriptive statistics and sign tests. RESULTS: Of 474 women, mean age was 50.3 ± 16.7 years (range, 18-87 years) and the most common indication for PFPT was pelvic pain (208/474; 43.9%). In women with complete data, pretreatment to posttreatment median scores improved on the PFDI (77.3 vs 41.8; P < 0.0001), Urogenital Distress Inventory (37.5 vs 16.0; P < 0.0001), and PFIQ (58.0 vs 19.0; P < 0.0001), and the minimal clinically important difference was met for the PFDI, PFIQ, and Colorectal-Anal Distress Inventory. Women with primarily pelvic pain (n = 208) achieved significant improvements in PFDI, PFIQ, and NRS scores (P < 0.0001 for all) as well as the minimal clinically important difference for these measures. Pain patients with a history of pelvic surgery (n = 50) also had significant improvements in PFIQ and NRS but not PFDI scores. CONCLUSIONS: Most women referred to PFPT demonstrated symptom improvements as measured by validated instruments.

Readmission Risk Factors and Heart Failure With Preserved Ejection Fraction.

CONTEXT: Cases of heart failure with preserved ejection fraction (HFpEF) exacerbations continue to affect patients' quality of life and cause significant financial burden on our healthcare system. OBJECTIVE: To identify risk factors for readmission in patients discharged with a diagnosis of HFpEF. METHODS: Electronic health records of patients over 18 years of age with a primary diagnosis of HFpEF treated between August 1, 2017 and March 1, 2018 in a community hospital were retrospectively reviewed. The study population included patients with HFpEF greater than 40% who were screened but did not qualify for the ongoing CONNECT- HF trial being conducted by Duke Clinical Research. To be included, subjects had to fall into 1 of 2 classifications (NYHA Class II-IV or ACC/AHA Stage B-D) and have a life expectancy greater than 6 months. Patients were excluded if they had terminal illness other than HF, a prior heart transplant or were on a transplant list, a current or planned placement of a left ventricular assist device, chronic kidney disease requiring hemodialysis, inability to use mobile applications, or inability to participate in longitudinal follow up. Readmission rate was analyzed at 30 and 90 days along with patients' demographics and associated comorbidities, including peripheral vascular disease, anemia, pulmonary hypertension, arrythmia, and valvular heart disease. Patients were risk stratified using the LACE index readmission score and the Charlson comorbidity index. RESULTS: Of the 492 cases of HFpEF identified during the 7-month study period, 212 patients were included. The majority of patients were women (126; 59.4%), had a median body mass index above 30 kg/m2 (123; 58%), and had pulmonary hypertension (94; 44.3%), anemia (146; 68.8%), and arrhythmia (101, 47.6%). Forty-five (21.2%) patients were readmitted for HFpEF within 90 days of initial discharge; 32 of those (71.1%) were readmitted within 30 days of initial discharge. Patients with higher LACE and Charlson comorbidity index scores were more likely to be readmitted within 90 days. Peripheral vascular disease (P=.002), tricuspid regurgitation (P=.001), pulmonary hypertension (P=.049), and anemia (P=.029) were risk factors associated with readmissions. Use of ACEi/ARBs (P=.017) was associated with fewer readmissions. CONCLUSION: Anemia, peripheral vascular disease, pulmonary hypertension, and valvular heart disease are not only postulated mechanisms of HFpEF, but also important risk factors for readmission. These study findings affirm the need for continued research of the pathophysiology and associated comorbidities of the HFpEF population to improve quality of life and lower healthcare costs.

Management of Prostate Cancer During COVID-19 Pandemic: Perspective From Urologists and Radiation Oncologists in COVID Dense Metro Detroit.

Objective To survey Urologists and Radiation Oncologists in Metropolitan Detroit regarding practice patterns in managing non-metastatic prostate cancer during the pandemic.  Methods An online survey was created to capture the perspective of the impact the COVID-19 restrictions have on the management of prostate cancer by Urologists and Radiation Oncologists in the Detroit Metropolitan area.  Results While most physicians felt that their facilities had adequate quantities of personal protective equipment (PPE), one in four offices reported that they did not have sufficient access to PPE. Urologists surveyed indicated that most of the low risk prostate cancer surgeries were cancelled and 56.2% had half or more of intermediate and high risk disease prostatectomies cancelled as well. Treatment options were then shifted towards either temporary surveillance or hormone therapy. Radiation Oncologists indicated that prostate cancer patients ready to start treatment were mostly delayed with temporary surveillance or hormone therapy depending on risk category (60% indicated they delayed low risk and favorable intermediate risk cases, 56% unfavorable intermediate risk cases, and 44% high risk cases). More than 80% of patients already undergoing treatment continued radiation.  Conclusion In the setting of this pandemic, the management of prostate cancer has shifted to a much more conservative approach. While the response to the crisis has not been uniform, the majority of the practitioners followed newly established guidelines. The long-term outcomes of delays and deviations from standard treatment approaches will remain to be seen.

Resuscitation Resident Impact in the Treatment of Sepsis.

Background The resuscitation of septic patients is a fundamental skill of emergency medicine (EM) training. We developed a required rotation designed to augment resident training in resuscitating critically ill patients in the emergency department (ED). The purpose of this study was to evaluate the successful completion of sepsis core measures alongside clinical outcomes between patients with a resuscitation resident (RR) involved in care versus patients without. Methods This retrospective study was conducted at a single site tertiary care Level 1 trauma center with an ED census of 130,000 visits annually. Data were collected from January 1, 2015, to December 31, 2016, using the electronic medical record (EMR) via an Epic query (Epic Systems Corp., Verona, WI). Patients admitted with severe sepsis or septic shock (Surviving Sepsis Campaign guidelines) were included and separated into two groups, one with RR involvement and one without. Emergency department length of stay, time to initial lactic acid draw, lactic acid value, time to bolus fluid initiation, time to antibiotic initiation, need for medical intensive care unit (ICU) admission, and 30-day mortality were compared between the two groups. Chi-square tests and Fisher's exact tests were used to analyze the categorical variables. Two-sided t-tests and Wilcoxon rank-sum tests were used to examine continuous variables. Results Out of 4,746 patients admitted, 101 patients had an RR participate in their care. The median time to initial lactic acid draw was shorter (0.53 vs 1.05 hours; p < 0. 0001) and the lactic acid level was higher (2.5 vs 1.8 mmol/L; p < 0. 0001) with the presence of an RR. Resuscitation resident was correlated with a decrease in time to antibiotics and appropriate 30 cc/kg bolus, however, these were not statistically significant (p = 0.10 and p = 0.09 respectively). Resuscitation resident involvement was also associated with more medical ICU (45.5% vs 18.8%; p<0.0001) admissions and a higher 30-day mortality (14.9% vs 29.7%; p < 0. 0001). All other variables were not statistically significant. Conclusion Resuscitation residents demonstrate a statistically significant impact on lactic acid-related bundle compliance and help facilitate the care of higher acuity severe sepsis and septic shock patients.

Investigating the Reliability of Fluorodeoxyglucose 18 Positive Emission Tomography-Computed Tomography Detection of Regional Lymph Node Metastasis in Head and Neck Malignancy.

PURPOSE: This study investigated whether fluorodeoxyglucose 18 positive emission tomography (PET)-computed tomography (CT) may be relied on to direct surgical management of the neck in patients with head and neck cancer by assessing the accuracy with which it is able to detect the presence and location of regional lymph node metastasis compared with histologic examination. PATIENTS AND METHODS: This retrospective study reviewed consecutive cases of head and neck cancer in which patients received a PET-CT scan within 3 weeks of undergoing a neck dissection performed by the Ascension Macomb-Oakland oral and maxillofacial surgery residency program from July 2013 through July 2018. Neck dissection specimens were orientated by the surgeon according to neck level and submitted for histopathologic examination. These histopathologic results served as the standard reference with which preoperative PET-CT results were compared. RESULTS: A total of 156 cases were reviewed in this study, 84 of which were included for data analysis. PET-CT exhibited an overall sensitivity of 68.9% and specificity of 61.5% in detecting regional lymph node metastasis (positive predictive value, 67.4%; negative predictive value, 63.2%). PET-CT showed a sensitivity of 71.4% and specificity of 75.0% for 34 cases involving pT1 lesions (positive predictive value, 66.7%; negative predictive value, 79.0%). Of 25 true-positive PET-CT scans correctly correlating with pN+ neck specimens, 16 (64%) were inaccurate in identifying the proper levels of metastatic disease identified by histopathologic assessment. These scans flagged 44 neck levels positive for disease, 18 (41%) of which were histologically proven false positive. Of the 48 neck levels in these cases confirmed positive for metastasis by histopathologic assessment, 22 (46%) failed detection by what would otherwise be considered true-positive PET-CT scans. CONCLUSIONS: The results of this study suggest that PET-CT is unable to adequately detect the overall presence or precise location of metastatic disease in the neck and so cannot be relied on to direct surgical management of the neck in patients with head and neck cancer.

Incidence of Heterotopic Ossification in Direct Anterior Approach to Total Hip Arthroplasty with use of Aspirin as Thromboembolic Prophylaxis.

CONTEXT: Heterotopic ossification (H.O.) is a common occurrence after total hip arthroplasty (THA) with significant potential clinical ramifications. Controversy still exists regarding the exact etiology of the disorder, including possible risk factors. Surgical technique, surgical approach, postoperative medication protocols and even thromboembolic prophylaxis have been implicated in the formation of H.O. Our study looked at one institution with a single surgeon performing direct anterior THA (DAA THA) in patients who received aspirin (ASA) as monotherapy for thromboembolic prophylaxis. METHODS: Patients at a single institution who underwent DAA THA between 2015 and 2019 were identified by CPT code. 45 patients ultimately met inclusion criteria. Postoperative radiographs were analyzed retrospectively for H.O. according to the Brooker classification. Several patient characteristics and comorbidities were statistically analyzed using Chi-square tests, Fisher Exact tests, Wilcox rank sum tests, and Pearson correlation. RESULTS: 12 patients (26.7%) were found to have heterotopic ossification (67% Class 1, 8% Class 2, 25% Class 3, and 0% Class 4); with a median follow up of 35 weeks (range: 12-96). 25% of these patients received ASA 325mg BID while 75% received ASA 81 BID. No statistical differences in development of H.O. were detected among age, gender, BMI, sex, race, diabetes, or NSAID use in the post-operative interval. There were significantly more smokers in the H.O. group (50% vs. 9%, p<0.006). CONCLUSIONS: Our analysis aimed to quantify the incidence of H.O. with consistency in surgical approach and post-operative protocol. There have been few studies on this topic, and we believe it is very relevant with the increasing use of aspirin in the post-operative protocol for thromboembolic prophylaxis. Our retrospective analysis identified H.O. at rates similar to previous studies in DAA.

Transvaginal Trigger Point Injections Improve Pain Scores in Women with Pelvic Floor Hypertonicity and Pelvic Pain Conditions.

OBJECTIVES: Chronic pelvic pain in women often requires multimodal treatment regimens. We describe our method of transvaginal trigger point injections (TPIs) and report outcomes using change in pain scores. METHODS: This was a retrospective review of women treated with in-office pelvic floor muscle injections from January 2012 to August 2015. Lidocaine 1% and 2%, bupivacaine 0.5%, or ropivacaine 0.5% with or without the addition of triamcinolone 40 mg was used for the injections. Pain was reported on a 0- to 10-point numerical rating scale before and after injection. Differences in pretreatment and posttreatment pain scores were analyzed after the first injection and after subsequent injections. Repeated-measures analysis was used to determine if any variable affected treatment response. RESULTS: One hundred one women with a mean age of 44 years had a total of 257 separate visits for pelvic floor muscle injections. Triamcinolone was used at 90.2% (230/255) of the TPI visits. After the initial TPI visit, there was significant decrease in total levator numerical rating scale score (maximum score, 20; mean, -6.21 ± 4.7; P < 0.0001), and 77% (70/91) of patients had improved. These significant improvements were noted at all visits 1 through 4 and whether bilateral or unilateral injections were done. Only the total amount of local anesthestic used had a significant effect on the change in total levator pain scores (P = 0.002). Minor adverse effects including leg numbness, dizziness, nausea, bleeding, and headache occurred at 10% of visits. CONCLUSIONS: Pelvic floor muscle injections decrease pain levels in women with pelvic floor dysfunction.

Pelvic Floor Distress Inventory Scores Improve After Prolapse Surgery Regardless of Surgical Approach but Not After Observation Alone.

OBJECTIVE: To evaluate the effect of different surgical procedures on Pelvic Floor Distress Inventory (PFDI) scores in women with pelvic organ prolapse. MATERIALS AND METHODS: Women with prolapse were enrolled from 2008 to 2014. Baseline data and outcomes at 1 year were collected including subscales of the PFDI. Patients who had surgery (SGY) within the first year were compared to those who did not (N-SGY). Subanalyses of SGY included vaginal vs abdominal, with or without concurrent hysterectomy (HYST, N-HYST), placement of mesh (MESH, N-MESH), and concurrent posterior repair/perineorrhaphy (POST, N-POST). RESULTS: A total of 233/239 patients underwent surgery in the first year. For SGY vs N-SGY, SGY had significant improvements in PFDI and all subscale scores at 1 year while N-SGY did not. When comparing vaginal to abdominal approach, MESH to N-MESH and HYST to N-HYST, there were no differences between any scores at baseline or 1 year between the groups. However, all within group symptom scores improved from baseline to 1 year (P <.0001 for all). In comparing POST to N-POST, there were no differences between groups at 1 year in PFDI and Urogenital Distress Inventory and Pelvic Organ Prolapse Distress Inventory subscale scores. Colorectal-Anal Distress Inventory scores were significantly higher at baseline for POST (P <.0001) but not at 1 year (P = 0.37). All within group scores statistically significant improved at 1 year. CONCLUSION: Women who underwent surgical repair for prolapse had significantly improved overall PFDI and subscale scores regardless of surgical approach and concurrent procedures.

Effect of Group-Administered Behavioral Treatment on Urinary Incontinence in Older Women: A Randomized Clinical Trial.

Importance: Urinary incontinence (UI) guidelines recommend behavioral interventions as first-line treatment using individualized approaches. A one-time, group-administered behavioral treatment (GBT) could enhance access to behavioral treatment. Objective: To compare the effectiveness, cost, and cost-effectiveness of GBT with no treatment for UI in older women. Design, Setting, and Participants: Multisite randomized clinical trial (the Group Learning Achieves Decreased Incidents of Lower Urinary Symptoms [GLADIOLUS] study), conducted from July 7, 2014, to December 31, 2016. The setting was outpatient practices at 3 academic medical centers. Community-dwelling women 55 years or older with UI were recruited by mail and screened for eligibility, including a score of 3 or higher on the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), symptoms of at least 3 months' duration, and absence of medical conditions or treatments that could affect continence status. Of 2171 mail respondents, 1125 were invited for clinical screening; 463 were eligible and randomized; 398 completed the 12-month study. Interventions: The GBT group received a one-time 2-hour bladder health class, supported by written materials and an audio CD. Main Outcomes and Measures: Outcomes were measured at in-person visits (at 3 and 12 months) and by mail or telephone (at 6 and 9 months). The primary outcome was the change in the ICIQ-SF score. Secondary outcome measures assessed UI severity, quality of life, perceptions of improvement, pelvic floor muscle strength, and costs. Evaluators were masked to group assignment. Results: Participants (232 in the GBT group and 231 in the control group) were aged 55 to 91 years (mean [SD] age, 64 [7] years), and 46.2% (214 of 463) were African American. In intent-to-treat analyses, the ICIQ-SF scores for GBT were consistently lower than control across all time points but did not achieve the projected 3-point difference. At 3 months, the difference in differences was 0.96 points (95% CI, -1.51 to -0.41 points), which was statistically significant but clinically modest. The mean (SE) treatment effects at 6, 9, and 12 months were 1.36 (0.32), 2.13 (0.33), and 1.77 (0.31), respectively. Significant group differences were found at all time points in favor of GBT on all secondary outcomes except pelvic floor muscle strength. The incremental cost to achieve a treatment success was $723 at 3 months; GBT dominated at 12 months. Conclusions and Relevance: The GLADIOLUS study shows that a novel one-time GBT program is modestly effective and cost-effective for reducing UI frequency, severity, and bother and improving quality of life. Group-administered behavioral treatment is a promising first-line approach to enhancing access to noninvasive behavioral treatment for older women with UI. Trial Registration: ClinicalTrials.gov identifier: NCT02001714.

Exploring Racial Differences Surrounding Prostate Cancer Screening: Beliefs and Attitudes in Community Dwelling Men Attending an Urban Men's Health Event.

The purpose of the study was to explore attitudes/beliefs in men attending an urban health fair to explore barriers to prostate cancer (PCa) screening. Five hundred and forty-four men attending the PCa booth at the fair in 2014 or 2015 completed questionnaires about PCa. Data were examined using Pearson's χ2, Fisher's Exact, and Wilcoxon rank tests after grouping men by African American (AA) and non-African American ethnicity. Three hundred and twenty-six (60%) men were AA and two hundred and eighteen (40%) were non-AA (89% white). Median age (54 vs. 56 years) and prior PCa screening were similar between AA and non-AA; income ( p = .044) and education ( p = .0002) differed. AA men were less likely to have researched prostate-specific antigen (PSA) on the internet ( p = .003), but more used TV ( p = .003) and media ( p = .0014) as information sources. Family members had a stronger influence over screening decisions for AA men ( p = .005). After reading PSA information, AA men were more likely to still be confused ( p = .008). A higher proportion of AA men were less worried about dying from PCa ( p = .0006), but would want treatment immediately instead of watchful waiting ( p < .0001). Interestingly, a higher proportion of AA men indicated that they would prefer not to know if they had PCa ( p = .001). Ultimately, more AA men had a PSA done (98.4% vs. 95.1%; p = .031). When considering screening eligible men, a higher proportion of AA men had an abnormal PSA (13.1% vs. 5.3%; p = .037). AA men's beliefs surrounding PCa differ from non-AA men, and should be considered when developing culturally appropriate education, screening, and treatment strategies for this group.

An assessment of repeat computed tomography utilization in the emergency department in the setting of blunt trauma.

PURPOSE: Computed tomography (CT) is a standard imaging modality utilized during the evaluation of trauma patients in the emergency department (ED). However, while it is common to utilize intravenous (IV) contrast as an adjunct, the use of multiple CT scans and how it impacts patient flow can lead to changes in patient management. Our objectives are to assess length of stay (LOS) and rates of acute kidney injury (AKI), when two CT scans of the abdomen/pelvis are performed compared to one CT scan. METHODS: Data of trauma hospital encounters were retrospectively collected during a 5-year period at a large, level 1 trauma center. Encounters were categorized into patients who received one or two CT scans of the abdomen/pelvis, as well as if they had received IV contrast or not. CT scan reads were extracted from chart records, and groups were compared. RESULTS: Of 5787 patient encounters, 5335 (93.4%) received IV contrast and 75 (1.3%) received two CT scans. Lower rates of AKI were associated with IV contrast (2.5 vs 12.5%). Receiving two CT scans was associated with increased rates of AKI (20.0 vs 3.0%; p < 0.0001), ICU admissions (88.0 vs 25.1%; p < 0.0001), and hospital LOS (21.9 vs 1.4 days; p < 0.0001). Of the repeat CT scans, 59.4% demonstrated no significant difference and did not require blood products or the operating room. CONCLUSION: Two CT scans performed during blunt trauma encounters demonstrated mixed benefit and were associated with an increased hospital LOS. Additionally, IV contrast was associated with lower rates of AKI.

Does sex matter? A matched pairs analysis of neuromodulation outcomes in women and men.

AIMS: To evaluate whether baseline symptoms and outcomes are influenced by gender in a matched cohort undergoing neuromodulation. METHODS: Patients in our prospective neuromodulation database that had a tined lead placed were reviewed. Those that had implantable pulse generator (IPG) placed were matched on age and urologic diagnosis. History, voiding diaries, satisfaction, Interstitial Cystitis Symptom/Problem Index (ICSIPI), and overactive bladder symptom severity (OABq ss)/health-related quality of life (HRQOL) preimplant and over 3 years were evaluated using descriptive statistics, repeated measures, and matched pair GEE or mixed analyses. RESULTS: Of 590 patients in the database, more women than men received an IPG (450/488; 92.2 vs. 84/102; 82.4%; p = 0.0011). Eighty matched pairs (n = 160; 81% ≥ 50 years old; 56.25% had urgency/frequency with urge incontinence-UI) were identified and evaluated. On voiding diaries, volume/void was greater in women only at baseline (p = 0.040); both groups improved over time (p < 0.0001). Urinary frequency improved in both women and men (p = 0.0010; p = 0.0025). Over 3 years, UI episodes/day improved only in men (p = 0.017) and UI severity improved only in women (p < 0.0001). ICSIPI, OABq ss, and HRQOL scores improved similarly in both groups (p < 0.0001 for all measures in both groups), and although more women were satisfied at 3 months (p = 0.027), groups did not differ at other time points. CONCLUSIONS: More women undergo neuromodulation and have initial success and subsequent IPG implantation. UI episodes improved only in men, and UI severity improved only in women. Both women and men experienced similar levels of symptom improvement on other measures.

Additional treatments, satisfaction, symptoms and quality of life in women 1 year after vaginal and abdominal pelvic organ prolapse repair.

OBJECTIVES: To evaluate additional treatments, symptoms, satisfaction and quality of life 1 year after vaginal and abdominal pelvic organ prolapse (POP) repair. METHODS: Adult women enrolled in a prospective POP database were reviewed. Baseline and outcomes data 1 year after surgery were collected including the Pelvic Floor Distress Inventory (PFDI) and mailed surveys. Data were analyzed with descriptive statistics, Fisher's exact tests and t tests. RESULTS: Of 222 women, 147 (66%) had vaginal and 75 (34%) had abdominal repair. Vaginal group patients were older (64.1 vs. 59.7 years; p = 0.003), but other demographic characteristics did not differ. Vaginal group patients had lower baseline anterior and apical prolapse grades (anterior 2.7 vs. 3.1, p = 0.003; apical 2.1 vs. 3.1, p < 0.001). Baseline PFDI scores were similar. Scores improved significantly for both groups after 1 year, but 1-year PFDI scores were significantly higher in the vaginal group (45.6 vs. 32.6, p = 0.032). Scores were not different when adjusted for age and prolapse grade (p = 0.24). At 1 year, most patients in the vaginal and abdominal groups reported moderately/markedly improved overall symptoms (72/108 vs. 50/60, p = 0.030) and quality of life (89/101 vs. 54/59, p = 0.601). Most were satisfied with surgery (68/101 vs. 48/59, p = 0.067). Retreatment rates (pelvic floor physical therapy, medications, coping strategies, surgical procedures) were similar (34/109 vs. 15/62, p = 0.381). Vaginal mesh use did not affect additional treatments, patient satisfaction or symptoms. CONCLUSIONS: Although symptoms improve and most women are satisfied with surgery, about one in four women have additional therapy in the first year after POP repair.

Exercise Training in "At-Risk" Black and White Women: A Comparative Cohort Analyses.

PURPOSE: Few data on the effect of exercise interventions in black women at risk for cardiovascular disease are available. METHODS: Women ≥18 yr of age without known cardiovascular disease with ≥1 coronary risk factor were enrolled in a community-based exercise program ≥3 d·wk for ≥30 min per session for 6 months. Exercise training intensity ~50% to 80% of functional capacity, using heart rate (HR) and/or rating of perceived exertion (RPE) as the primary intensity modulators. Preconditioning versus postconditioning quality of life assessments (depression and level of daytime sleepiness), dietary fat intake, Duke Activity Status Index score, changes in cardiovascular efficiency (systolic/diastolic blood pressure (SBP/DBP), HR, RPE during a standardized submaximal workload), and anthropometric measures, including body weight, body mass index, and waist circumference, were evaluated. RESULTS: Of 556 volunteers, 143 were excluded, leaving 413 women (222 white, 191 black; mean ± SD age, 61 ± 9 yr) who met compliance criteria. Both groups demonstrated significant (P < 0.05) postconditioning decreases in body mass index, waist circumference, resting SBP/DBP, and total and LDL cholesterol, and reductions in HR, SBP/DBP, and RPE at a fixed submaximal workload, and in fat screener, depression, and sleep scores. Duke Activity Status Index scores increased significantly (P < 0.0001) for both groups, signifying increases in self-reported functional capacity. Although 87 women (21%) experienced a musculoskeletal injury/discomfort during the program, there were no exercise-related cardiovascular events. CONCLUSIONS: A progressive moderate-to-vigorous exercise intervention without preliminary exercise testing elicited comparable improvements in coronary risk factors, anthropometric and quality of life measures, and cardiovascular efficiency in "at-risk" black and white women. These adaptations were achieved at exercise levels below those recommended in contemporary physical activity guidelines.