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Meyer SR, Carver A, Joo H, Venkatesh KK, Jelovsek JE, Klumpner TT, Singh K. External Validation of Postpartum Hemorrhage Prediction Models Using Electronic Health Record Data. Am J Perinatol 2024; 41:598-605. [PMID: 35045573 DOI: 10.1055/a-1745-1348] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE A recent study leveraging machine learning methods found that postpartum hemorrhage (PPH) can be predicted accurately at the time of labor admission in the U.S. Consortium for Safe Labor (CSL) dataset, with a C-statistic as high as 0.93. These CSL models were developed in older data (2002-2008) and used an estimated blood loss (EBL) of ≥1,000 mL to define PPH. We sought to externally validate these models using a more recent cohort of births where blood loss was measured using quantitative blood loss (QBL) methods. STUDY DESIGN Using data from 5,261 deliveries between February 1, 2019 and May 11, 2020 at a single tertiary hospital, we mapped our electronic health record (EHR) data to the 55 predictors described in previously published CSL models. PPH was defined as QBL ≥1,000 mL within 24 hours after delivery. Model discrimination and calibration of the four CSL models were measured using our cohort. In a secondary analysis, we fit new models in our study cohort using the same predictors and algorithms as the original CSL models. RESULTS The original study cohort had a substantially lower rate of PPH, 4.8% (7,279/228,438) versus 25% (1,321/5,261), possibly due to differences in measurement. The CSL models had lower discrimination in our study cohort, with a C-statistic as high as 0.57 (logistic regression). Models refit in our study cohort achieved better discrimination, with a C-statistic as high as 0.64 (random forest). Calibration improved in the refit models as compared with the original models. CONCLUSION The CSL models' accuracy was lower in a contemporary EHR where PPH is assessed using QBL. As institutions continue to adopt QBL methods, further data are needed to understand the differences between EBL and QBL to enable accurate prediction of PPH. KEY POINTS · Machine learning methods may help predict PPH.. · EBL models do not generalize when QBL is used.. · Blood loss estimation alters model accuracy..
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Affiliation(s)
- Sean R Meyer
- Michigan Institute for Data Science, University of Michigan, Ann Arbor, Michigan
| | - Alissa Carver
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Hyeon Joo
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Kartik K Venkatesh
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
| | - J Eric Jelovsek
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - Thomas T Klumpner
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Karandeep Singh
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, Michigan
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2
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Hendrickson WK, Zhang C, Jelovsek JE, Nygaard IE, Presson AP. Reply by Authors. J Urol 2024; 211:142-143. [PMID: 38063172 DOI: 10.1097/ju.0000000000003746.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/29/2023] [Indexed: 12/18/2023]
Affiliation(s)
- Whitney K Hendrickson
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Chong Zhang
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - J Eric Jelovsek
- Division of Urogynecology, Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - Ingrid E Nygaard
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Angela P Presson
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
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3
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Venkatesh KK, Jelovsek JE, Hoffman M, Beckham AJ, Bitar G, Friedman AM, Boggess KA, Stamilio DM. Postpartum readmission for hypertension and pre-eclampsia: development and validation of a predictive model. BJOG 2023; 130:1531-1540. [PMID: 37317035 PMCID: PMC10592357 DOI: 10.1111/1471-0528.17572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/25/2023] [Accepted: 05/31/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To develop a model for predicting postpartum readmission for hypertension and pre-eclampsia at delivery discharge and assess external validation or model transportability across clinical sites. DESIGN Prediction model using data available in the electronic health record from two clinical sites. SETTING Two tertiary care health systems from the Southern (2014-2015) and Northeastern USA (2017-2019). POPULATION A total of 28 201 postpartum individuals: 10 100 in the South and 18 101 in the Northeast. METHODS An internal-external cross validation (IECV) approach was used to assess external validation or model transportability across the two sites. In IECV, data from each health system were first used to develop and internally validate a prediction model; each model was then externally validated using the other health system. Models were fit using penalised logistic regression, and accuracy was estimated using discrimination (concordance index), calibration curves and decision curves. Internal validation was performed using bootstrapping with bias-corrected performance measures. Decision curve analysis was used to display potential cut points where the model provided net benefit for clinical decision-making. MAIN OUTCOME MEASURES The outcome was postpartum readmission for either hypertension or pre-eclampsia <6 weeks after delivery. RESULTS The postpartum readmission rate for hypertension and pre-eclampsia overall was 0.9% (0.3% and 1.2% by site, respectively). The final model included six variables: age, parity, maximum postpartum diastolic blood pressure, birthweight, pre-eclampsia before discharge and delivery mode (and interaction between pre-eclampsia × delivery mode). Discrimination was adequate at both health systems on internal validation (c-statistic South: 0.88; 95% confidence interval [CI] 0.87-0.89; Northeast: 0.74; 95% CI 0.74-0.74). In IECV, discrimination was inconsistent across sites, with improved discrimination for the Northeastern model on the Southern cohort (c-statistic 0.61 and 0.86, respectively), but calibration was not adequate. Next, model updating was performed using the combined dataset to develop a new model. This final model had adequate discrimination (c-statistic: 0.80, 95% CI 0.80-0.80), moderate calibration (intercept -0.153, slope 0.960, Emax 0.042) and provided superior net benefit at clinical decision-making thresholds between 1% and 7% for interventions preventing readmission. An online calculator is provided here. CONCLUSIONS Postpartum readmission for hypertension and pre-eclampsia may be accurately predicted but further model validation is needed. Model updating using data from multiple sites will be needed before use across clinical settings.
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Affiliation(s)
- Kartik K Venkatesh
- Department of Obstetrics and Gynecology, The Ohio State University (Columbus, OH)
| | - J Eric Jelovsek
- Department of Obstetrics and Gynecology, Duke University (Durham, NC)
| | - Matthew Hoffman
- Department of Obstetrics and Gynecology, Christiana Care (Newark, Delaware)
| | - A Jenna Beckham
- Department of Obstetrics and Gynecology, WakeMed Health and Hospitals (Raleigh, NC)
| | - Ghamar Bitar
- Department of Obstetrics and Gynecology, Christiana Care (Newark, Delaware)
| | - Alexander M Friedman
- Department of Obstetrics and Gynecology, Columbia University (New York City, NY)
| | - Kim A Boggess
- Department of Obstetrics and Gynecology, University of North Carolina (Chapel Hill, NC)
| | - David M Stamilio
- Department of Obstetrics and Gynecology, Wake Forest University (Winston-Salem, NC)
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Borello-France D, Newman DK, Markland AD, Propst K, Jelovsek JE, Cichowski S, Gantz MG, Balgobin S, Jakus-Waldman S, Korbly N, Mazloomdoost D, Burgio KL. Adherence to Perioperative Behavioral Therapy With Pelvic Floor Muscle Training in Women Receiving Vaginal Reconstructive Surgery for Pelvic Organ Prolapse. Phys Ther 2023; 103:pzad059. [PMID: 37318279 PMCID: PMC10476875 DOI: 10.1093/ptj/pzad059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 02/05/2023] [Accepted: 06/13/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE The objective of this study was to describe adherence to behavioral and pelvic floor muscle training in women undergoing vaginal reconstructive surgery for organ prolapse and to examine whether adherence was associated with 24-month outcomes. METHODS Participants were women ≥18 years of age, with vaginal bulge and stress urinary incontinence symptoms, planning to undergo vaginal reconstructive surgery for stages 2 to 4 vaginal or uterine prolapse. They were randomized to either sacrospinous ligament fixation or uterosacral ligament suspension and to perioperative behavioral and pelvic floor muscle training or usual care. Measurements included anatomic failure, pelvic floor muscle strength, participant-reported symptoms, and perceived improvement. Analyses compared women with lower versus higher adherence. RESULTS Forty-eight percent of women performed pelvic floor muscle exercises (PFMEs) daily at the 4- to 6-week visit. Only 33% performed the prescribed number of muscle contractions. At 8 weeks, 37% performed PFMEs daily, and 28% performed the prescribed number of contractions. No significant relationships were found between adherence and 24-month outcomes. CONCLUSION Adherence to a behavioral intervention was low following vaginal reconstructive surgery for pelvic organ prolapse. The degree of adherence to perioperative training did not appear to influence 24-month outcomes in women undergoing vaginal prolapse surgery. IMPACT This study contributes to the understanding of participant adherence to PFMEs and the impact that participant adherence has on outcomes at 2, 4 to 6, 8, and 12 weeks and 24 months postoperatively. It is important to educate women to follow up with their therapist or physician to report new or unresolved pelvic symptoms.
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Affiliation(s)
- Diane Borello-France
- Department of OB/GYN, Magee-Womens Hospital, Department of Physical Therapy, Duquesne University, Pittsburgh, Pennsylvania, USA
| | - Diane K Newman
- Division of Urology, Penn Center for Continence and Pelvic Health, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alayne D Markland
- Department of Medicine, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center at the Birmingham VA Health Care System, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Katie Propst
- Department of Obstetrics & Gynecology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - J Eric Jelovsek
- Department of Obstetrics & Gynecology, Duke University, Durham, North Carolina, USA
| | - Sara Cichowski
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, Oregon, USA
| | - Marie G Gantz
- Department of Biostatistics and Epidemiology, RTI International, Triangle Park, North Carolina, USA
| | - Sunil Balgobin
- Department of Obstetrics & Gynecology, University of Texas Southwestern, Dallas, Texas, USA
| | - Sharon Jakus-Waldman
- Department of Obstetrics, Gynecology and Urogynecology, Kaiser Permanente, Downey, California, USA
| | - Nicole Korbly
- Department of Obstetrics & Gynecology, Brown University, Providence, Rhode Island, USA
| | - Donna Mazloomdoost
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | - Kathryn L Burgio
- Department of Medicine, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center at the Birmingham VA Health Care System, University of Alabama at Birmingham, Birmingham, Alabama, USA
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5
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Peddireddi A, Roby LC, Lynch CD, Wu J, Adesomo A, DeMari J, Pawlik TM, Grobman WA, Costantine MM, Jelovsek JE, Venkatesh KK. Predictive performance of the American College of Surgeons risk calculator for postoperative complications in nonobstetrical individuals undergoing nonobstetric surgery. Am J Obstet Gynecol MFM 2023; 5:101083. [PMID: 37433346 DOI: 10.1016/j.ajogmf.2023.101083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/29/2023] [Accepted: 07/05/2023] [Indexed: 07/13/2023]
Affiliation(s)
| | - Lauren C Roby
- Department of Obstetrics and Gynecology, Christiana Care Health Services, Newark, DE
| | - Courtney D Lynch
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, College of Medicine, The Ohio State University, Columbus, OH
| | - Jiqiang Wu
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, College of Medicine, The Ohio State University, Columbus, OH
| | - Ade Adesomo
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, School of Medicine, The University of Utah, Salt Lake City, UT
| | - Joseph DeMari
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, School of Medicine, Wake Forest University, Winston-Salem, NC
| | - Timothy M Pawlik
- Department of Surgery, College of Medicine, The Ohio State University, Columbus, OH
| | - William A Grobman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, College of Medicine, The Ohio State University, Columbus, OH
| | - Maged M Costantine
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, College of Medicine, The Ohio State University, Columbus, OH
| | - J Eric Jelovsek
- Department of Obstetrics and Gynecology, School of Medicine, Duke University, Durham, NC
| | - Kartik K Venkatesh
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, College of Medicine, The Ohio State University, 395 W. 12 Ave., Floor 5, Columbus, OH 43210.
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6
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Gill BC, Thomas S, Barden L, Jelovsek JE, Meyer I, Chermansky C, Komesu YM, Menefee S, Myers D, Smith A, Mazloomdoost D, Amundsen CL. Intraoperative Predictors of Sacral Neuromodulation Implantation and Treatment Response: Results From the ROSETTA Trial. J Urol 2023; 210:331-340. [PMID: 37126070 PMCID: PMC10523414 DOI: 10.1097/ju.0000000000003498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 04/14/2023] [Indexed: 05/02/2023]
Abstract
PURPOSE We determined the utility of intraoperative data in predicting sacral neuromodulation outcomes in urgency urinary incontinence. MATERIALS AND METHODS Intraoperative details of sacral neuromodulation stage 1 were recorded during the prospective, randomized, multicenter ROSETTA trial, including responsive electrodes, amplitudes, and response strengths (motor and sensory Likert scales). Stage 2 implant was performed for stage 1 success on 3-day diary with 24-month follow-up. An intraoperative amplitude response score for each electrode was calculated ranging from 0 (no response) to 99.5 (maximum response, 0.5 V). Predictors for stage 1 success and improvement at 24 months were identified by stepwise logistic regression confirmed with least absolute shrinkage and selection operator and stepwise linear regression. RESULTS Intraoperative data from 161 women showed 139 (86%) had stage 1 success, which was not associated with number of electrodes generating an intraoperative motor and/or sensory response, average amplitude at responsive electrodes, or minimum amplitude-producing responses. However, relative to other electrodes, a best amplitude response score for bellows at electrode 3 was associated with stage 1 failure, a lower reduction in daily urgency urinary incontinence episodes during stage 1, and most strongly predicted stage 1 outcome in logistic modeling. At 24 months, those who had electrode 3 intraoperative sensory response had lower mean reduction in daily urgency urinary incontinence episodes than those who had no response. CONCLUSIONS Specific parameters routinely assessed intraoperatively during stage 1 sacral neuromodulation for urgency urinary incontinence show limited utility in predicting both acute and long-term outcomes. However, lead position as it relates to the trajectory of the sacral nerve root appears to be important.
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Affiliation(s)
| | - Sonia Thomas
- RTI International, Research Triangle Park, North Carolina
| | - Lindsey Barden
- RTI International, Research Triangle Park, North Carolina
| | | | - Isuzu Meyer
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - Shawn Menefee
- University of California San Diego, San Diego, California
| | | | - Ariana Smith
- University of Pennsylvania, Philadelphia, Pennsylvania
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
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Gill BC, Thomas S, Barden L, Jelovsek JE, Meyer I, Chermansky C, Komesu YM, Menefee S, Myers D, Smith A, Mazloomdoost D, Amundsen CL. Reply by Authors. J Urol 2023:101097JU000000000000349802. [PMID: 37211805 DOI: 10.1097/ju.0000000000003498.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Affiliation(s)
| | - Sonia Thomas
- RTI International, Research Triangle Park, North Carolina
| | - Lindsey Barden
- RTI International, Research Triangle Park, North Carolina
| | | | - Isuzu Meyer
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - Shawn Menefee
- University of California San Diego, San Diego, California
| | | | - Ariana Smith
- University of Pennsylvania, Philadelphia, Pennsylvania
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
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8
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Bretschneider CE, Liu Q, Smith AR, Kirkali Z, Amundsen CL, Lai HH, Geynisman-Tan J, Kirby A, Cameron AP, Helmuth ME, Griffith JW, Jelovsek JE. Treatment patterns in women with urinary urgency and/or urgency urinary incontinence in the symptoms of Lower Urinary Tract Dysfunction Research Network Observational Cohort Study. Neurourol Urodyn 2023; 42:194-204. [PMID: 36579974 PMCID: PMC9811511 DOI: 10.1002/nau.25067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 09/19/2022] [Accepted: 10/06/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Limited epidemiological data exist describing how patients engage with various treatments for overactive bladder (OAB). To improve care for patients with OAB, it is essential to gain a better understanding of how patients interface with OAB treatments longitudinally, that is, how often patients change treatments and the pattern of this treatment change in terms of escalation and de-escalation. OBJECTIVES To describe treatment patterns for women with bothersome urinary urgency (UU) and/or urgency urinary incontinence (UUI) presenting to specialty care over 1 year. STUDY DESIGN The Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN) study enrolled adult women with bothersome UU and/or UUI seeking care for lower urinary tract symptoms (LUTS) between January 2015 and September 2016. An ordinal logistic regression model was fitted to describe the probabilities of escalating or de-escalating level of treatment during 1-year follow-up. RESULTS Among 349 women, 281 reported UUI and 68 reported UU at baseline. At the end of 1 year of treatment by a urologist or urogynecologist, the highest level of treatment received by participants was 5% expectant management, 36% behavioral treatments (BT), 26% physical therapy (PT), 26% OAB medications, 1% percutaneous tibial nerve stimulation, 3% intradetrusor onabotulinum toxin A injection, and 3% sacral neuromodulation. Participants using BT or PT at baseline were more likely to be de-escalated to no treatment than participants on OAB medications at baseline, who tended to stay on medications. Predictors of the highest level of treatment included starting level of treatment, hypertension, UUI severity, stress urinary incontinence, and anticholinergic burden score. CONCLUSIONS Treatment patterns for UU and UUI are diverse. Even for patients with significant bother from OAB presenting to specialty clinics, further treatment often only involves conservative or medical therapies. This study highlights the need for improved treatment algorithms to escalate patients with persistent symptoms, or to adjust care in those who have been unsuccessfully treated.
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Affiliation(s)
| | - Q. Liu
- Arbor Research Collaborative for Health, Ann Arbor, MI USA
| | | | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD USA
| | | | - H. Henry Lai
- Division of Urologic Surgery, Departments of Surgery and Anesthesiology, Washington University School of Medicine, St Louis, MO, USA
| | | | - Anna Kirby
- University of Washington Medical Center, Seattle, WA, USA
| | | | | | - James W. Griffith
- Northwestern University – The Feinberg School of Medicine, Chicago, IL, USA
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9
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Kowalski JT, Wiseman JB, Smith AR, Helmuth ME, Cameron A, DeLancey JOL, Hendrickson WK, Jelovsek JE, Kirby A, Kreder K, Lai HH, Mueller M, Siddiqui N, Bradley CS. Natural history of lower urinary tract symptoms in treatment-seeking women with pelvic organ prolapse; the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN). Am J Obstet Gynecol 2022; 227:875.e1-875.e12. [PMID: 35934118 PMCID: PMC9729365 DOI: 10.1016/j.ajog.2022.07.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/07/2022] [Accepted: 07/19/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND The association of pelvic organ prolapse with overactive bladder and other lower urinary tract symptoms, and the natural history of those symptoms are not well characterized. Previous cross-sectional studies demonstrated conflicting relationships between prolapse and lower urinary tract symptoms. OBJECTIVE This study primarily aimed to determine the baseline association between lower urinary tract symptoms and prolapse and to assess longitudinal differences in symptoms over 12 months in women with and without prolapse. Secondary aims were to explore associations between lower urinary tract symptoms and prolapse treatment. We hypothesized that: (1) prolapse is associated with the presence of lower urinary tract symptoms, (2) lower urinary tract symptoms are stable over time in patients with and without prolapse, and (3) prolapse treatment is associated with lower urinary tract symptom improvement. STUDY DESIGN Women enrolled in the Symptoms of Lower Urinary Tract Dysfunction Research Network Observational Cohort Study with adequate 12-month follow-up data were included. Prolapse and lower urinary tract symptom treatment during follow-up was guided by standard of care. Outcome measures included the Lower Urinary Tract Symptoms Tool total severity score (in addition to overactive bladder, obstructive, and stress urinary incontinence subscales) and Urogenital Distress Inventory-6 Short Form. Prolapse (yes or no) was defined primarily when Pelvic Organ Prolapse Quantification System points Ba, C or Bp were >0 (beyond the hymen). Mixed-effects models with random effects for patient slopes and intercepts were fitted for each lower urinary tract symptom outcome and prolapse predictor, adjusted for other covariates. The study had >90% power to detect differences as small as 0.4 standard deviation for less prevalent group comparisons (eg, prolapse vs not). RESULTS A total of 371 women were analyzed, including 313 (84%) with no prolapse and 58 (16%) with prolapse. Women with prolapse were older (64.6±8.8 vs 55.3±14.1 years; P<.001) and more likely to have prolapse surgery (28% vs 1%; P<.001) and pessary treatment (26% vs 4%; P<.001) during the study. Average baseline Lower Urinary Tract Symptoms Tool total severity scores were lower (fewer symptoms) for participants with prolapse compared with those without (38.9±14.0 vs 43.2±14.0; P=.036), but there were no differences in average scores between prolapse groups for other scales. For all urinary outcomes, average scores were significantly lower (improved) at 3 and 12 months compared with baseline (all P<.05). In mixed-effects models, there were no statistically significant interactions between pelvic organ prolapse measurement and visit and time-dependent prolapse treatment groups (P>.05 for all regression interaction coefficients). The Lower Urinary Tract Symptoms Tool obstructive severity score had a statistically significant positive association with Pelvic Organ Prolapse Quantification System Ba, Bp, and point of maximum vaginal descent. The Lower Urinary Tract Symptoms Tool total severity scale had a statistically significant negative association with Pelvic Organ Prolapse Quantification System Ba and point of maximum vaginal descent. No other associations between prolapse and lower urinary tract symptoms were significant (P>.05 for all regression coefficients). Symptom differences between prolapse groups were small: all regression coefficients (interpretable as additive percentage change in each score) were between -5 and 5 (standard deviation of outcomes ranged from 14.0-32.4). CONCLUSION Among treatment-seeking women with urinary symptoms, obstructive symptoms were positively associated with prolapse, and overall lower urinary tract symptom severity was negatively associated with prolapse. Lower Urinary Tract Symptoms Tool scores improved over 12 months regardless of prolapse status, including in those with treated prolapse, untreated prolapse, and without prolapse.
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Affiliation(s)
- Joseph T Kowalski
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, IA.
| | | | | | | | | | | | - Whitney K Hendrickson
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT
| | | | - Anna Kirby
- University of Washington Medical Center, Seattle, WA
| | - Karl Kreder
- Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - H Henry Lai
- Division of Urologic Surgery, Departments of Surgery and Anesthesiology, Washington University School of Medicine, St. Louis, MO
| | - Margaret Mueller
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Catherine S Bradley
- Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, IA, and the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN) Observational Cohort Study Group
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10
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Bedoya AD, Economou-Zavlanos NJ, Goldstein BA, Young A, Jelovsek JE, O'Brien C, Parrish AB, Elengold S, Lytle K, Balu S, Huang E, Poon EG, Pencina MJ. A framework for the oversight and local deployment of safe and high-quality prediction models. J Am Med Inform Assoc 2022; 29:1631-1636. [PMID: 35641123 DOI: 10.1093/jamia/ocac078] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 04/08/2022] [Accepted: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
Artificial intelligence/machine learning models are being rapidly developed and used in clinical practice. However, many models are deployed without a clear understanding of clinical or operational impact and frequently lack monitoring plans that can detect potential safety signals. There is a lack of consensus in establishing governance to deploy, pilot, and monitor algorithms within operational healthcare delivery workflows. Here, we describe a governance framework that combines current regulatory best practices and lifecycle management of predictive models being used for clinical care. Since January 2021, we have successfully added models to our governance portfolio and are currently managing 52 models.
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Affiliation(s)
- Armando D Bedoya
- Department of Medicine, Duke University, Durham, North Carolina, USA.,Duke University Health System, Durham, North Carolina, USA
| | | | - Benjamin A Goldstein
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Allison Young
- Duke University School of Medicine, Durham, North Carolina, USA
| | - J Eric Jelovsek
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina, USA
| | - Cara O'Brien
- Department of Medicine, Duke University, Durham, North Carolina, USA.,Duke University Health System, Durham, North Carolina, USA
| | | | - Scott Elengold
- Office of Counsel, Duke University, Durham, North Carolina, USA
| | - Kay Lytle
- Duke University Health System, Durham, North Carolina, USA
| | - Suresh Balu
- Duke Institute for Health Innovation, Durham, North Carolina, USA
| | - Erich Huang
- Department of Medicine, Duke University, Durham, North Carolina, USA.,Duke University Health System, Durham, North Carolina, USA
| | - Eric G Poon
- Department of Medicine, Duke University, Durham, North Carolina, USA.,Duke University Health System, Durham, North Carolina, USA.,Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Michael J Pencina
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA.,Duke AI Health, Duke University School of Medicine, Durham, North Carolina, USA
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11
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Green CA, Adams JC, Goodnight WH, Odibo AO, Bromley B, Jelovsek JE, Stamilio DM, Venkatesh KK. Frequency and prediction of persistent urinary tract dilation in third trimester and postnatal urinary tract dilation in infants following diagnosis in second trimester. Ultrasound Obstet Gynecol 2022; 59:522-531. [PMID: 34369632 DOI: 10.1002/uog.23758] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/28/2021] [Accepted: 08/02/2021] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To determine the frequency, associated characteristics and prognostic value of the current risk stratification system for prenatal urinary tract dilation (UTD) for predicting persistent UTD in the third trimester and subsequent postnatal UTD in the infant, following diagnosis in the second trimester. METHODS This was a single-institution retrospective cohort study of singleton pregnancies diagnosed with unilateral or bilateral UTD in the second trimester (before 28 weeks' gestation) with follow-up in the third trimester (at or after 28 weeks) between January 2017 and May 2019. In all cases, the prenatal diagnosis and stratification to low-risk (Grade A1) or increased-risk (Grade A2-3) UTD was made using the 2014 UTD consensus classification system. The primary outcomes included persistent prenatal UTD in the third trimester and postnatal UTD up to 6 months of age. We performed multivariable analysis to assess whether patient and second- and third-trimester sonographic characteristics (such as UTD laterality, other renal abnormality (calyceal dilation, abnormal parenchymal appearance, abnormal ureter or bladder) and anteroposterior renal pelvic diameter (AP-RPD)) were associated with the study outcomes. We assessed the predictive value of the current risk stratification system (Grade A1 vs Grade A2-3) in the second and third trimesters for persistent prenatal UTD and postnatal UTD using the area under the receiver-operating-characteristics curve (AUC). RESULTS Of 26 620 second-trimester ultrasound assessments in the study period, 347 patients were diagnosed with UTD in the second trimester and had third-trimester follow-up, of whom 150/347 (43% (95% CI, 38-49%)) had persistent UTD in the third trimester. Among the 282/347 (81%) patients with postnatal follow-up available, the frequency of postnatal UTD was 49/282 (17% (95% CI, 13-22%)), and among the subset with persistent UTD in the third trimester, the frequency of postnatal UTD was 46/102 (45% (95% CI, 35-55%)). The most frequent postnatal diagnosis was transient UTD (76%), followed by duplicated collecting system (10%). Of infants originally diagnosed with UTD in the second trimester, 2% (7/347) required surgery; stated differently, of the 49 infants with postnatal UTD, 14% (7/49) required surgery. At second-trimester diagnosis, sonographic predictors of both persistent prenatal UTD and postnatal UTD included the presence of other renal abnormality and UTD Grade A2-3. At third-trimester follow-up, predictors of postnatal UTD were larger mean AP-RPD and UTD Grade A2-3, while all cases had other renal abnormality. Second-trimester diagnosis of UTD Grade A2-3 had satisfactory discrimination for predicting persistent prenatal UTD (AUC, 0.64 (95% CI, 0.58-0.70)) and postnatal UTD (AUC, 0.72 (95% CI, 0.63-0.81)), as did third-trimester UTD Grade A2-3 for predicting postnatal UTD (AUC, 0.66 (95% CI, 0.56-0.76)). CONCLUSIONS The majority of cases of prenatal UTD did not result in postnatal UTD, and of those that did, very few required surgery. Follow-up third-trimester assessment after a second-trimester diagnosis of UTD is warranted. The current risk stratification system by UTD grade, based on the 2014 UTD consensus classification, can be used to predict postnatal UTD with fair accuracy. Further research is needed to determine whether the predictive performance of this system can be improved by incorporating additional risk factors. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- C A Green
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, USA
| | - J C Adams
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, USA
| | - W H Goodnight
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, USA
| | - A O Odibo
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of South Florida, Tampa, FL, USA
| | - B Bromley
- Department of Obstetrics and Gynecology and Reproductive Biology, Massachusetts General Hospital and Diagnostic Ultrasound Associates, Boston, MA, USA
| | - J E Jelovsek
- Department of Obstetrics and Gynecology, Duke University, Durham, NC, USA
| | - D M Stamilio
- Department of Obstetrics and Gynecology, Duke University, Durham, NC, USA
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Wake Forest University, Winston-Salem, NC, USA
| | - K K Venkatesh
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH, USA
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12
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Jelovsek JE, Gantz MG, Lukacz ES, Zyczynski HM, Sridhar A, Kery C, Chew R, Harvie HS, Dunivan G, Schaffer J, Sung V, Varner RE, Mazloomdoost D, Barber MD. Subgroups of failure after surgery for pelvic organ prolapse and associations with quality of life outcomes: a longitudinal cluster analysis. Am J Obstet Gynecol 2021; 225:504.e1-504.e22. [PMID: 34157280 PMCID: PMC8578254 DOI: 10.1016/j.ajog.2021.06.068] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 06/14/2021] [Accepted: 06/15/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Treatment outcomes after pelvic organ prolapse surgery are often presented as dichotomous "success or failure" based on anatomic and symptom criteria. However, clinical experience suggests that some women with outcome "failures" are asymptomatic and perceive their surgery to be successful and that other women have anatomic resolution but continue to report symptoms. Characterizing failure types could be a useful step to clarify definitions of success, understand mechanisms of failure, and identify individuals who may benefit from specific therapies. OBJECTIVE This study aimed to identify clusters of women with similar failure patterns over time and assess associations among clusters and the Pelvic Organ Prolapse Distress Inventory, Short-Form Six-Dimension health index, Patient Global Impression of Improvement, patient satisfaction item questionnaire, and quality-adjusted life-year. STUDY DESIGN Outcomes were evaluated for up to 5 years in a cohort of participants (N=709) with stage ≥2 pelvic organ prolapse who underwent surgical pelvic organ prolapse repair and had sufficient follow-up in 1 of 4 multicenter surgical trials conducted by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Pelvic Floor Disorders Network. Surgical success was defined as a composite measure requiring anatomic success (Pelvic Organ Prolapse Quantification system points Ba, Bp, and C of ≤0), subjective success (absence of bothersome vaginal bulge symptoms), and absence of retreatment for pelvic organ prolapse. Participants who experienced surgical failure and attended ≥4 visits from baseline to 60 months after surgery were longitudinally clustered, accounting for similar trajectories in Ba, Bp, and C and degree of vaginal bulge bother; moreover, missing data were imputed. Participants with surgical success were grouped into a separate cluster. RESULTS Surgical failure was reported in 276 of 709 women (39%) included in the analysis. Failures clustered into the following 4 mutually exclusive subgroups: (1) asymptomatic intermittent anterior wall failures, (2) symptomatic intermittent anterior wall failures, (3) asymptomatic intermittent anterior and posterior wall failures, and (4) symptomatic all-compartment failures. Each cluster had different bulge symptoms, anatomy, and retreatment associations with quality of life outcomes. Asymptomatic intermittent anterior wall failures (n=150) were similar to surgical successes with Ba values that averaged around -1 cm but fluctuated between anatomic success (Ba≤0) and failure (Ba>0) over time. Symptomatic intermittent anterior wall failures (n=82) were anatomically similar to asymptomatic intermittent anterior failures, but women in this cluster persistently reported bothersome bulge symptoms and the lowest quality of life, Short-Form Six-Dimension health index scores, and perceived success. Women with asymptomatic intermittent anterior and posterior wall failures (n=28) had the most severe preoperative pelvic organ prolapse but the lowest symptomatic failure rate and retreatment rate. Participants with symptomatic all-compartment failures (n=16) had symptomatic and anatomic failure early after surgery and the highest retreatment of any cluster. CONCLUSION In particular, the following 4 clusters of pelvic organ prolapse surgical failure were identified in participants up to 5 years after pelvic organ prolapse surgery: asymptomatic intermittent anterior wall failures, symptomatic intermittent anterior wall failures, asymptomatic intermittent anterior and posterior wall failures, and symptomatic all-compartment failures. These groups provide granularity about the nature of surgical failures after pelvic organ prolapse surgery. Future work is planned for predicting these distinct outcomes using patient characteristics that can be used for counseling women individually.
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Affiliation(s)
- J Eric Jelovsek
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC.
| | - Marie G Gantz
- Biostatistics and Epidemiology Division, Research Triangle Institute International, Research Triangle Park, NC
| | - Emily S Lukacz
- Department of Obstetrics and Gynecology, University of California San Diego, San Diego, CA
| | - Halina M Zyczynski
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh, PA
| | - Amaanti Sridhar
- Biostatistics and Epidemiology Division, Research Triangle Institute International, Research Triangle Park, NC
| | - Caroline Kery
- Division for Statistical and Data Sciences, Research Triangle Institute International, Research Triangle Park, NC
| | - Rob Chew
- Division for Statistical and Data Sciences, Research Triangle Institute International, Research Triangle Park, NC
| | - Heidi S Harvie
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA
| | - Gena Dunivan
- Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque, NM
| | - Joseph Schaffer
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Vivian Sung
- Department of Obstetrics and Gynecology, Women & Infants Hospital of Rhode Island, the Warren Alpert Medical School, Brown University, Providence, RI
| | - R Ed Varner
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, MD
| | - Matthew D Barber
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, MD
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13
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Hendrickson WK, Amundsen CL, Rahn DD, Meyer I, Bradley MS, Smith AL, Myers DL, Jelovsek JE, Lukacz ES. Comparison of 100 U With 200 U of Intradetrusor OnabotulinumToxinA for Nonneurogenic Urgency Incontinence. Female Pelvic Med Reconstr Surg 2021; 27:140-146. [PMID: 33620895 PMCID: PMC8117667 DOI: 10.1097/spv.0000000000001020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The objective of this study was to compare efficacy and adverse events between 100 U and 200 U of onabotulinumtoxinA for 6 months in women with nonneurogenic urgency incontinence. METHODS This is a secondary analysis of 2 multicenter randomized controlled trials assessing efficacy of onabotulinumtoxinA in women with nonneurogenic urgency incontinence; one compared 100 U to anticholinergics and the other 200 U to sacral neuromodulation. Of 307 women who received onabotulinumtoxinA injections, 118 received 100 U, and 189 received 200 U. The primary outcome was mean adjusted change in daily urgency incontinence episodes from baseline over 6 months, measured on monthly bladder diaries. Secondary outcomes included perceived improvement, quality of life, and adverse events. The primary outcome was assessed via a multivariate linear mixed model. RESULTS Women receiving 200 U had a lower mean reduction in urgency incontinence episodes by 6 months compared with 100 U (-3.65 vs -4.28 episodes per day; mean difference, 0.63 episodes per day [95% confidence interval (CI), 0.05-1.20]). Women receiving 200 U had lower perceptions of improvement (adjusted odds ratio, 0.32 [95% CI, 0.14-0.75]) and smaller improvement in severity score (adjusted mean difference, 12.0 [95% CI, 5.63-18.37]). Upon subanalysis of only women who were treated with prior anticholinergic medications, these differences between onabotulinumtoxinA doses were no longer statistically significant. There was no statistically significant difference in adverse events in women receiving 200 U (catheterization, 32% vs 23%; adjusted odds ratio, 1.4 [95% CI, 0.8-2.4]; urinary tract infection, 37% vs 27%; adjusted odds ratio, 1.5 [95% CI, 0.9-2.6]). CONCLUSIONS A higher dose of onabotulinumtoxinA may not directly result in improved outcomes, but rather baseline disease severity may be a more important prediction of outcomes.
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Affiliation(s)
- Whitney K Hendrickson
- From the Division of Urogynecology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Cindy L Amundsen
- From the Division of Urogynecology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - David D Rahn
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, UT Southwestern Medical Center, Dallas, TX
| | - Isuzu Meyer
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Megan S Bradley
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics, Gynecology and Reproductive Services, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Ariana L Smith
- Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Deborah L Myers
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, Brown University, Providence, RI
| | - J Eric Jelovsek
- From the Division of Urogynecology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Emily S Lukacz
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics, Gynecology and Reproductive Sciences, UC San Diego, San Diego, CA
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14
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Geynisman-Tan J, Helmuth M, Smith AR, Lai HH, Amundsen CL, Bradley CS, Mueller MG, Lewicky-Gaupp C, Harte SE, Jelovsek JE. Prevalence of childhood trauma and its association with lower urinary tract symptoms in women and men in the LURN study. Neurourol Urodyn 2021; 40:632-641. [PMID: 33508156 DOI: 10.1002/nau.24613] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 12/07/2020] [Accepted: 12/24/2020] [Indexed: 11/12/2022]
Abstract
AIMS To describe the association between childhood traumas (death of a family member, severe illness, sexual trauma, parental separation) reported by women and men and lower urinary tract symptoms (LUTS). METHODS In this secondary analysis of the Lower Urinary Tract Research Network Observational Cohort Study, participants completed the LUTS tool, childhood trauma events scale (CTES), PROMIS depression and anxiety and perceived stress scale. LUTS tool responses were combined to quantify urinary urgency, frequency, incontinence, and overall LUTS severity. Multivariable linear regression tested associations between trauma and LUTS; mental health scores were tested for potential mediation. RESULTS In this cohort (n = 1011; 520 women, 491 men), more women reported experiencing at least one trauma (75% vs. 64%, p < .001), greater than three traumas (26% vs. 15%, p < .001), and childhood sexual trauma (23% vs. 7%, p < .001), and reported higher impact from traumatic events compared with men (median [interquartile rnage] CTES score = 10 [5-15] vs. 6 [4-12], p < .001). The number of childhood traumatic events was not associated with severity of overall LUTS (p = .79), urinary frequency (p = .75), urgency (p = .61), or incontinence (p = .21). Childhood sexual trauma was significantly associated with higher incontinence severity (adjusted mean difference 4.5 points, 95% confidence interval= 1.11-7.88, p = .009). Mental health was a mediator between trauma and LUTS among those with at least one childhood trauma. CONCLUSION Although total childhood trauma is not associated with LUTS, childhood sexual trauma is associated with urinary incontinence severity. For patients with childhood trauma, half of the effect of CTE Impact score on overall LUTS severity is mediated through the association between trauma and the patient's mental health.
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Affiliation(s)
- Julia Geynisman-Tan
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois, USA
| | - Margaret Helmuth
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Abigail R Smith
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - H Henry Lai
- Departments of Surgery (Urology) and Anesthesiology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Cindy L Amundsen
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina, USA
| | - Catherine S Bradley
- Department of Obstetrics and Gynecology, University of Iowa, Iowa City, Iowa, USA
| | - Margaret G Mueller
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois, USA
| | | | - Steven E Harte
- Departments of Anesthesiology and Internal Medicine-Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | - J Eric Jelovsek
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina, USA
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15
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Stamilio DM, Beckham AJ, Boggess KA, Jelovsek JE, Venkatesh KK. Risk factors for postpartum readmission for preeclampsia or hypertension before delivery discharge among low-risk women: a case-control study. Am J Obstet Gynecol MFM 2021; 3:100317. [PMID: 33493701 DOI: 10.1016/j.ajogmf.2021.100317] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 12/31/2020] [Accepted: 01/19/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Postpartum hypertension or preeclampsia is one of the most frequent reasons for readmission after delivery discharge, and risk factors for readmission remain poorly characterized. OBJECTIVE This study aimed to determine risk factors of postpartum readmission for hypertension or preeclampsia among low-risk women before delivery discharge. STUDY DESIGN We conducted a nested case-control study from 2012 to 2015 at a tertiary care medical center. Cases were identified using diagnostic codes for postpartum transient hypertension, mild preeclampsia, severe preeclampsia, eclampsia, superimposed preeclampsia, and unspecified hypertension and readmission within 6 weeks of delivery. Controls not readmitted for hypertension or preeclampsia were time matched within 4 weeks of the delivery date to each case. We fit multivariable logistic regression models to identify independent risk factors for postpartum readmission for hypertension or preeclampsia and then calculated a receiver operating characteristic curve of the final model to assess model discrimination. RESULTS Within the source cohort resulting in 58 cases and 232 matched controls, the rate of postpartum readmission for preeclampsia or hypertension was 0.4% (n=58 of 14,503). The median time to readmission was 6 days (range, 2-15 days), and 40% of cases had an outpatient postpartum visit before readmission. In multivariable analysis, non-Hispanic black race (adjusted odds ratio, 2.14; 95% confidence interval, 0.99-4.59), gestational hypertension (adjusted odds ratio, 2.70; 95% confidence interval, 1.12-6.54), preeclampsia during delivery admission (adjusted odds ratio, 3.12; 95% confidence interval, 1.29-7.50), and maximum postpartum systolic blood pressure during delivery admission (adjusted odds ratio, 1.05; 95% confidence interval, 1.03-1.08) were risk factors for readmission. This model had a good discriminative ability to predict women who would require readmission for preeclampsia or hypertension (area under the curve, 0.83; 95% confidence interval, 0.74-0.89). Using these 4 factors to illustrate this model, the predicted risk of readmission ranged from <1% in the lowest risk scenario (eg, postpartum systolic blood pressure of 120 mm Hg + no hypertensive disorders of pregnancy + white race) to 26% in the highest risk scenario (eg, postpartum systolic blood pressure of 160 mm Hg + preeclampsia + black race). CONCLUSION Risk factors of postpartum readmission for hypertension or preeclampsia can be identified at the time of delivery discharge among low-risk women, regardless of an antenatal hypertensive disorder. A next step could be using these risk factors to develop a predictive model to guide postpartum care.
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Affiliation(s)
- David M Stamilio
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Wake Forest University, Winston-Salem, NC (Dr Stamilio)
| | - A Jenna Beckham
- Department of Obstetrics and Gynecology, WakeMed Raleigh Campus, Raleigh, NC (Dr Beckham)
| | - Kim A Boggess
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC (Dr Boggess)
| | - J Eric Jelovsek
- Department of Obstetrics and Gynecology, Duke University, Durham, NC (Dr Jelovsek)
| | - Kartik K Venkatesh
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH (Dr Venkatesh).
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16
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Andy UU, Jelovsek JE, Carper B, Meyer I, Dyer KY, Rogers RG, Mazloomdoost D, Korbly NB, Sassani JC, Gantz MG. Impact of treatment for fecal incontinence on constipation symptoms. Am J Obstet Gynecol 2020; 222:590.e1-590.e8. [PMID: 31765640 DOI: 10.1016/j.ajog.2019.11.1256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 10/17/2019] [Accepted: 11/17/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Defecatory symptoms, such as a sense of incomplete emptying and straining with bowel movements, are paradoxically present in women with fecal incontinence. Treatments for fecal incontinence, such as loperamide and biofeedback, can worsen or improve defecatory symptoms, respectively. The primary aim of this study was to compare changes in constipation symptoms in women undergoing treatment for fecal incontinence with education only, loperamide, anal muscle exercises with biofeedback or both loperamide and biofeedback. Our secondary aim was to compare changes in constipation symptoms among responders and nonresponders to fecal incontinence treatment. STUDY DESIGN This was a planned secondary analysis of a randomized controlled trial comparing 2 first-line therapies for fecal incontinence in a 2 × 2 factorial design. Women with at least monthly fecal incontinence and normal stool consistency were randomized to 4 groups: (1) oral placebo plus education only, (2) oral loperamide plus education only, (3) placebo plus anorectal manometry-assisted biofeedback, and (4) loperamide plus biofeedback. Defecatory symptoms were measured using the Patient Assessment of Constipation Symptoms questionnaire at baseline, 12 weeks, and 24 weeks. The Patient Assessment of Constipation Symptoms consists of 12 items that contribute to a global score and 3 subscales: stool characteristics/symptoms (hardness of stool, size of stool, straining, inability to pass stool), rectal symptoms (burning, pain, bleeding, incomplete bowel movement), and abdominal symptoms (discomfort, pain, bloating, cramps). Scores for each subscale as well as the global score range from 0 (no symptoms) to 4 (maximum score), with negative change scores representing improvement in defecatory symptoms. Responders to fecal incontinence treatment were defined as women with a minimally important clinical improvement of ≥5 points on the St Mark's (Vaizey) scale between baseline and 24 weeks. Intent-to-treat analysis was performed using a longitudinal mixed model, controlling for baseline scores, to estimate changes in Patient Assessment of Constipation Symptoms scores from baseline through 24 weeks. RESULTS At 24 weeks, there were small changes in Patient Assessment of Constipation Symptoms global scores in all 4 groups: oral placebo plus education (-0.3; 95% confidence interval, -0.5 to -0.1), loperamide plus education (-0.1, 95% confidence interval, -0.3 to0.0), oral placebo plus biofeedback (-0.3, 95% confidence interval, -0.4 to -0.2), and loperamide plus biofeedback (-0.3, 95% confidence interval, -0.4 to -0.2). No differences were observed in change in Patient Assessment of Constipation Symptoms scores between women randomized to placebo plus education and those randomized to loperamide plus education (P = .17) or placebo plus biofeedback (P = .82). Change in Patient Assessment of Constipation Symptoms scores in women randomized to combination loperamide plus biofeedback therapy was not different from that of women randomized to treatment with loperamide or biofeedback alone. Responders had greater improvement in Patient Assessment of Constipation Symptoms scores than nonresponders (-0.4; 95% confidence interval, -0.5 to -0.3 vs -0.2; 95% confidence interval, -0.3 to -0.0, P < .01, mean difference, 0.2, 95% confidence interval, 0.1-0.4). CONCLUSION Change in constipation symptoms following treatment of fecal incontinence in women are small and are not significantly different between groups. Loperamide treatment for fecal incontinence does not worsen constipation symptoms among women with normal consistency stool. Women with clinically significant improvement in fecal incontinence symptoms report greater improvement in constipation symptoms.
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Affiliation(s)
- Uduak U Andy
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA.
| | - J Eric Jelovsek
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | | | - Isuzu Meyer
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Keisha Y Dyer
- Department of Obstetrics and Gynecology, Kaiser Permanente, San Diego, CA
| | - Rebecca G Rogers
- Department of Women's Health, Dell Medical School, University of Texas at Austin. Austin, TX; University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - Nicole B Korbly
- Department of Obstetrics and Gynecology, Alpert Medical School of Brown University, Providence, RI
| | - Jessica C Sassani
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh Medical Center, Pittsburgh, PA
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17
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Schimmoeller T, Neumann EE, Owings TM, Nagle TF, Colbrunn RW, Landis B, Jelovsek JE, Hing T, Ku JP, Erdemir A. Reference data on in vitro anatomy and indentation response of tissue layers of musculoskeletal extremities. Sci Data 2020; 7:20. [PMID: 31941894 PMCID: PMC6962198 DOI: 10.1038/s41597-020-0358-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 12/20/2019] [Indexed: 12/05/2022] Open
Abstract
The skin, fat, and muscle of the musculoskeletal system provide essential support and protection to the human body. The interaction between individual layers and their composite structure dictate the body's response during mechanical loading of extremity surfaces. Quantifying such interactions may improve surgical outcomes by enhancing surgical simulations with lifelike tissue characteristics. Recently, a comprehensive tissue thickness and anthropometric database of in vivo extremities was acquired using a load sensing instrumented ultrasound to enhance the fidelity of advancing surgical simulations. However detailed anatomy of tissue layers of musculoskeletal extremities was not captured. This study aims to supplement that database with an enhanced dataset of in vitro specimens that includes ultrasound imaging supported by motion tracking of the ultrasound probe and two additional full field imaging modalities (magnetic resonance and computed tomography). The additional imaging datasets can be used in conjunction with the ultrasound/force data for more comprehensive modeling of soft tissue mechanics. Researchers can also use the image modalities in isolation if anatomy of legs and arms is needed.
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Affiliation(s)
- Tyler Schimmoeller
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio, USA
- Computational Biomodeling (CoBi) Core, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Erica E Neumann
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio, USA
- Computational Biomodeling (CoBi) Core, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tammy M Owings
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tara F Nagle
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio, USA
- BioRobotics and Mechanical Testing Core, Medical Device Solutions, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Robb W Colbrunn
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio, USA
- BioRobotics and Mechanical Testing Core, Medical Device Solutions, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Benjamin Landis
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio, USA
- Computational Biomodeling (CoBi) Core, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - J Eric Jelovsek
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Tod Hing
- Department of Bioengineering, Stanford University, Stanford, California, USA
| | - Joy P Ku
- Department of Bioengineering, Stanford University, Stanford, California, USA
| | - Ahmet Erdemir
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio, USA.
- Computational Biomodeling (CoBi) Core, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA.
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Jelovsek JE. Biofeedback or loperamide for faecal incontinence in women – Author's reply. Lancet Gastroenterol Hepatol 2019; 4:904-905. [DOI: 10.1016/s2468-1253(19)30334-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 08/30/2019] [Indexed: 10/25/2022]
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Amundsen CL, Helmuth ME, Smith AR, DeLancey JOL, Bradley CS, Flynn KE, Kenton KS, Henry Lai H, Cella D, Griffith JW, Andreev VP, Eric Jelovsek J, Liu AB, Kirkali Z, Yang CC. Longitudinal changes in symptom-based female and male LUTS clusters. Neurourol Urodyn 2019; 39:393-402. [PMID: 31765491 DOI: 10.1002/nau.24219] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 10/31/2019] [Indexed: 11/09/2022]
Abstract
AIMS Lower urinary tract symptoms (LUTS) are diverse in type and variable in severity. We examined symptom change within the Symptoms of the Lower Urinary Tract Dysfunction Research Network (LURN) Observational Cohort study identified clusters over time and tested associations with treatments received. METHODS Patient-reported LUTS and treatment data were collected at multiple time points between baseline and 12 months from the LURN Observational Cohort study. LUTS severity scores were calculated to summarize changes in symptom reporting over time in previously identified LURN clusters. Repeated measures linear regression models tested adjusted associations between cluster membership and severity scores. RESULTS Four-hundred seventeen men and 396 women were classified into improved, unchanged, and worsened symptoms between baseline and 12 months (men: 44.1%, 40.5%, and 15.3%; women: 55.8%, 33.1%, 11.1%, respectively). Improvement in LUTS severity scores varied by cluster (estimated adjusted mean change from baseline range: -.04 change in standard deviations of severity scores (ΔSD) to -.67 ΔSD). Prostate surgery was associated with improved severity scores (-.63 ΔSD) in men, while stress incontinence surgery was associated with improved severity scores (-.88 ΔSD) in women. CONCLUSION Symptom improvement varied by cluster indicating response to therapy differs amongst subtypes of patients with LUTS. The differential improvement of patients in clusters suggests mechanistic differences between clusters and may aid in selecting more targeted treatments in the future.
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Affiliation(s)
- Cindy L Amundsen
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | | | - Abigail R Smith
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | | | | | | | - Kimberly S Kenton
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - H Henry Lai
- Washington University School of Medicine, St. Louis, Missouri
| | - David Cella
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - James W Griffith
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - J Eric Jelovsek
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Alice B Liu
- University of Washington, Seattle, Washington
| | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
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Jelovsek JE, Markland AD, Whitehead WE, Barber MD, Newman DK, Rogers RG, Dyer K, Visco AG, Sutkin G, Zyczynski HM, Carper B, Meikle SF, Sung VW, Gantz MG. Controlling faecal incontinence in women by performing anal exercises with biofeedback or loperamide: a randomised clinical trial. Lancet Gastroenterol Hepatol 2019; 4:698-710. [PMID: 31320277 PMCID: PMC6708078 DOI: 10.1016/s2468-1253(19)30193-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 05/08/2019] [Accepted: 05/09/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Well designed, large comparative effectiveness trials assessing the efficacy of primary interventions for faecal incontinence are few in number. The objectives of this study were to compare different combinations of anorectal manometry-assisted biofeedback, loperamide, education, and oral placebo. METHODS In this randomised factorial trial, participants were recruited from eight clinical sites in the USA. Women with at least one episode of faecal incontinence per month in the past 3 months were randomly assigned 0·5:1:1:1 to one of four groups: oral placebo plus education only, placebo plus anorectal manometry-assisted biofeedback, loperamide plus education only, and loperamide plus anorectal manometry-assisted biofeedback. Participants received 2 mg per day of loperamide or oral placebo with the option of dose escalation or reduction. Women assigned to biofeedback received six visits, including strength and sensory biofeedback training. All participants received a standardised faecal incontinence patient education pamphlet and were followed for 24 weeks after starting treatment. The primary endpoint was change in St Mark's (Vaizey) faecal incontinence severity score between baseline and 24 weeks, analysed by intention-to-treat using general linear mixed modelling. Investigators, interviewers, and outcome evaluators were masked to biofeedback assignment. Participants and all study staff other than the research pharmacist were masked to medication assignment. Randomisation took place within the electronic data capture system, was stratified by site using randomly permuted blocks (block size 7), and the sizes of the blocks and the allocation sequence were known only to the data coordinating centre. This trial is registered with ClinicalTrials.gov, number NCT02008565. FINDINGS Between April 1, 2014, and Sept 30, 2015, 377 women were enrolled, of whom 300 were randomly assigned to placebo plus education (n=42), placebo plus biofeedback (n=84), loperamide plus education (n=88), and the combined intervention of loperamide plus biofeedback (n=86). At 24 weeks, there were no differences between loperamide versus placebo (model estimated score change -1·5 points, 95% CI -3·4 to 0·4, p=0·12), biofeedback versus education (-0·7 points, -2·6 to 1·2, p=0·47), and loperamide and biofeedback versus placebo and biofeedback (-1·9 points, -4·1 to 0·3, p=0·092) or versus loperamide plus education (-1·1 points, -3·4 to 1·1, p=0·33). Constipation was the most common grade 3 or higher adverse event and was reported by two (2%) of 86 participants in the loperamide and biofeedback group and two (2%) of 88 in the loperamide plus education group. The percentage of participants with any serious adverse events did not differ between the treatment groups. Only one serious adverse event was considered related to treatment (small bowel obstruction in the placebo and biofeedback group). INTERPRETATION In women with normal stool consistency and faecal incontinence bothersome enough to seek treatment, we were unable to find evidence against the null hypotheses that loperamide is equivalent to placebo, that anal exercises with biofeedback is equivalent to an educational pamphlet, and that loperamide and biofeedback are equivalent to oral placebo and biofeedback or loperamide plus an educational pamphlet. Because these are common first-line treatments for faecal incontinence, clinicians could consider combining loperamide, anal manometry-assisted biofeedback, and a standard educational pamphlet, but this is likely to result in only negligible improvement over individual therapies and patients should be counselled regarding possible constipation. FUNDING Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institutes of Health Office of Research on Women's Health.
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Affiliation(s)
- J Eric Jelovsek
- Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA.
| | - Alayne D Markland
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Birmingham, AL, USA
| | - William E Whitehead
- Department of Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Matthew D Barber
- Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - Diane K Newman
- Division of Urology, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Rebecca G Rogers
- Departments of Obstetrics and Gynecology and Surgery, University of New Mexico Health Sciences Center, Albuquerque, NM, USA; Department of Women's Health, Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Keisha Dyer
- Department of Obstetrics and Gynecology, Kaiser Permanente, San Diego, CA, USA
| | - Anthony G Visco
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - Gary Sutkin
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Magee-Womens Research Institute, Pittsburgh, PA, USA; Department of Obstetrics and Gynecology, University of Missouri, Kansas City, MO, USA
| | - Halina M Zyczynski
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Magee-Womens Research Institute, Pittsburgh, PA, USA
| | | | | | - Vivian W Sung
- Department of Obstetrics and Gynecology, Alpert Medical School of Brown University, Providence, RI, USA
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Brubaker L, Jelovsek JE, Lukacz ES, Balgobin S, Ballard A, Weidner AC, Gantz MG, Whitworth R, Mazloomdoost D. Recruitment and retention: A randomized controlled trial of video-enhanced versus standard consent processes within the E-OPTIMAL study. Clin Trials 2019; 16:481-489. [PMID: 31347384 DOI: 10.1177/1740774519865541] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND/AIMS In this study, we compared two research consent techniques: a standardized video plus usual consent and usual consent alone. METHODS Individuals who completed 24-month outcomes (completers) in the Operations and Pelvic Muscle Training in the Management of Apical Support Loss study were invited to participate in an extended, longitudinal follow-up study (extended Operations and Pelvic Muscle Training in the Management of Apical Support Loss). Potential participants who were (1) able to provide consent and (2) not in long-term care facilities were randomized 1:1 to a standardized video detailing the importance of long-term follow-up studies of pelvic floor disorders followed by the usual institutional consent process versus the usual consent process alone. Randomization, stratified by site, used randomly permuted blocks. The primary outcome was the proportion of participants who enrolled in the extended study and completed data collection events 5 years after surgery. Secondary outcomes included the proportion enrolled in the extended study, completion of follow-up at each study year, completion of data collection points, completion of in-person visits, and completion of quality of life calls. Motivation and barriers to enrollment (study-level and personal-level) and satisfaction with the study consent process were measured by questionnaire prior to recruitment into extended Operations and Pelvic Muscle Training in the Management of Apical Support Loss. Groups were compared using an intention-to-treat principle, using unadjusted Student's t-test (continuous) and chi-square or Fisher's exact (categorical) test. A sample size of 340 (170/group) was estimated to detect a 15% difference in enrollment and study completion between groups with p < 0.05. RESULTS Of the 327 Operations and Pelvic Muscle Training in the Management of Apical Support Loss completers, 305 were randomized to the consent process study (153 video vs 152 no video). Groups were similar in demographics, surgical treatment, and outcomes. The overall rate of extended study enrollment was high, without significant differences between groups (video 92.8% vs no video 94.1%, p = 0.65). There were no significant differences in the primary outcome (video 79.1% vs no video 75.7%, p = 0.47) or in any secondary outcomes. Being "very satisfied" overall with study information (97.7% vs 88.5%, p = 0.01); "strong agreement" for feeling informed about the study (81.3% vs 70.8%, p = 0.06), understanding the study purpose (83.6% vs 71.0%, p = 0.02), nature and extent (82.8% vs 70.2%, p = 0.02), and potential societal benefits (82.8% vs 67.9%, p = 0.01); and research coordinator/study nurse relationship being "very important" (72.7% vs 63.4%, p = 0.03) were better in the video compared to the no video consent group. CONCLUSION The extended study had high enrollment; most participants completed most study tasks during the 3-year observational extension, regardless of the use of video to augment research consent. The video was associated with a higher proportion of participants reporting improved study understanding and relationship with study personnel.
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Affiliation(s)
- Linda Brubaker
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Diego, San Diego, CA, USA
| | - J Eric Jelovsek
- Department of Obstetrics and Gynecology, Duke University, Durham, NC, USA
| | - Emily S Lukacz
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Diego, San Diego, CA, USA
| | - Sunil Balgobin
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Alicia Ballard
- Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Alison C Weidner
- Department of Obstetrics and Gynecology, Duke University, Durham, NC, USA
| | | | | | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
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Cella D, Smith AR, Griffith JW, Flynn KE, Bradley CS, Gillespie BW, Kirkali Z, Talaty P, Jelovsek JE, Helfand BT, Weinfurt KP. A new outcome measure for LUTS: Symptoms of Lower Urinary Tract Dysfunction Research Network Symptom Index-29 (LURN SI-29) questionnaire. Neurourol Urodyn 2019; 38:1751-1759. [PMID: 31225927 DOI: 10.1002/nau.24067] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 04/25/2019] [Accepted: 05/21/2019] [Indexed: 11/09/2022]
Abstract
AIMS To develop a representative, self-report assessment of lower urinary tract symptoms (LUTS) for men and women, the symptoms of Lower Urinary Tract Dysfunction Research Network Symptom Index-29 (LURN SI-29). METHODS Women and men seeking treatment for LUTS at one of six academic medical centers in the US were assessed at baseline, 3-month and 12-month intervals. Twelve-month data on 78 LURN SI-29 items were analyzed among 353 women and 420 men using exploratory factor analysis (EFA), with factor structure confirmed using confirmatory factor analysis (CFA). Internal consistency, reliability, and validity of the five developed scales were evaluated by assessing correlations with the American Urological Association Symptom Index (AUA-SI), the genitourinary pain index (GUPI), and the Pelvic Floor Distress Inventory-20 (PFDI-20), and by examining expected sex differences in scores. RESULTS EFA results (n = 150 women; 150 men) produced an interpretable eight-factor solution, with three of the factors comprised of dichotomous items addressing LUTS-associated sensations. The remaining five factors, confirmed with CFA in an independent sample of 473 participants, produced five scales: incontinence, urgency, voiding difficulty, bladder pain, and nocturia. Subscales and total LURN SI-29 scores were correlated as expected with AUA-SI, GUPI, and PFDI-20. LURN SI-29 scores also performed as expected in differentiating men from women based upon clinically expected differences, with men reporting more voiding difficulties and nocturia, and women reporting more urgency and incontinence. CONCLUSIONS The LURN SI-29 questionnaire has the potential to improve research and clinical outcome measurement for both men and women with LUTS.
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Affiliation(s)
- David Cella
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Abigail R Smith
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - James W Griffith
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | - Catherine S Bradley
- Department of Obstetrics and Gynecology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Brenda W Gillespie
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | - Pooja Talaty
- NorthShore University Health System, Glenview, Illinois
| | - J Eric Jelovsek
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
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Schimmoeller T, Colbrunn R, Nagle T, Lobosky M, Neumann EE, Owings TM, Landis B, Jelovsek JE, Erdemir A. Instrumentation of off-the-shelf ultrasound system for measurement of probe forces during freehand imaging. J Biomech 2019; 83:117-124. [PMID: 30514629 DOI: 10.1016/j.jbiomech.2018.11.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 11/19/2018] [Accepted: 11/21/2018] [Indexed: 11/18/2022]
Abstract
Ultrasound is a popular and affordable imaging modality, but the nature of freehand ultrasound operation leads to unknown applied loads at non-quantifiable angles. The purpose of this paper was to demonstrate an instrumentation strategy for an ultrasound system to measure probe forces and orientation during freehand imaging to characterize the interaction between the probe and soft-tissue as well as enhance repeatability. The instrumentation included a 6-axis load cell, an inertial measurement unit, and an optional sensor for camera-based motion capture. A known method for compensation of the ultrasound probe weight was implemented, and a novel method for temporal synchronization was developed. While load and optical sensing was previously achieved, this paper presents a strategy for potential instrumentation on a variety of ultrasound machines. A key feature was the temporal synchronization, utilizing the electrocardiogram (EKG) feature built-in to the ultrasound. The system was used to perform anatomical imaging of tissue layers of musculoskeletal extremities and imaging during indentation on an in vivo subject and an in vitro specimen. The outcomes of the instrumentation strategy were demonstrated during minimal force and indentation imaging. In short, the system presented robust instrumentation of an existing ultrasound system to fully characterize the probe force, orientation, and optionally its movement during imaging while efficiently synchronizing all data. Researchers may use the instrumentation strategy on any EKG capable ultrasound systems if mechanical characterization of soft tissue or minimization of forces and deformations of tissue during anatomical imaging are desired.
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Affiliation(s)
- Tyler Schimmoeller
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA; Computational Biomodeling (CoBi) Core, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Robb Colbrunn
- BioRobotics and Mechanical Testing Core, Medical Device Solutions, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tara Nagle
- BioRobotics and Mechanical Testing Core, Medical Device Solutions, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mark Lobosky
- Engineering Design Core, Medical Device Solutions, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Erica E Neumann
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA; Computational Biomodeling (CoBi) Core, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tammy M Owings
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Benjamin Landis
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA; Computational Biomodeling (CoBi) Core, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - J Eric Jelovsek
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC, USA
| | - Ahmet Erdemir
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA; Computational Biomodeling (CoBi) Core, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA.
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Bretschneider CE, Frazzini Padilla P, Das D, Jelovsek JE, Unger CA. The impact of surgeon volume on perioperative adverse events in women undergoing minimally invasive hysterectomy for the large uterus. Am J Obstet Gynecol 2018; 219:490.e1-490.e8. [PMID: 30222939 DOI: 10.1016/j.ajog.2018.09.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 08/27/2018] [Accepted: 09/06/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND There are currently sparse data on the relationship between surgeon- and patient-related factors and perioperative morbidity in the setting of elective hysterectomy for the larger uterus. OBJECTIVE We sought to evaluate the impact of surgeon case volume on perioperative adverse events in women undergoing minimally invasive hysterectomy for uteri >250 g. STUDY DESIGN This is a retrospective cohort study of all women who underwent total vaginal, total laparoscopic, laparoscopic-assisted vaginal, or robotic-assisted total laparoscopic hysterectomy from January 2014 through July 2016. Hysterectomy was performed for: fibroids, pelvic pain, abnormal uterine bleeding, or prolapse. Patients were identified by Current Procedural Terminology codes and the systemwide electronic medical record was queried for demographic and perioperative data. Perioperative adverse events were defined a priori and classified using the Clavien-Dindo scale. Surgeon case volume was defined as the mean number of minimally invasive hysterectomy cases performed per month by each surgeon during the study period. RESULTS In all, 763 patients met inclusion criteria: 416 (54.5%) total laparoscopic hysterectomy, 196 (25.7%) robotic-assisted total laparoscopic hysterectomy, 90 (11.8%) total vaginal hysterectomy, and 61 (8%) laparoscopic-assisted vaginal hysterectomy. Mean (±SD) age was 47.3 ± 6.1 years, and body mass index was 31.1 ± 7.4 kg/m2. In all, 66 surgeons performed minimally invasive hysterectomy for uteri >250 g during the study period, and the median rate of minimally invasive hysterectomy cases for large uteri per month was 3.4 (0.4-3.7) cases/month. The median (IQR) uterine weight was 409 (308-606.5) g. The rate of postoperative adverse events Dindo grade >2 was 17.8% (95% confidence interval, 15.2-20.7). The overall rate of intraoperative adverse events was 4.2% (95% confidence interval, 2.9-5.9). The rate of conversion to laparotomy was 5.5% (95% confidence interval, 4.0-7.4). There was no significant difference in adverse event rates between the routes of minimally invasive hysterectomy cases (25.6% vs 17.5% vs 18.0% vs 14.8% for total laparoscopic hysterectomy, robotic-assisted laparoscopic hysterectomy, total vaginal hysterectomy, and laparoscopic-assisted vaginal hysterectomy, respectively, P = .2). In a logistic regression model controlling for age, body mass index, uterine weight, operating time, and history of laparotomy, higher monthly minimally invasive hysterectomy volume was significantly associated with the likelihood that a patient would experience a postoperative adverse event (adjusted odds ratio, 1.1 for each additional minimally invasive hysterectomy case for large uteri per month; 95% confidence interval, 1.0-1.3). When controlling for the same variables, a higher incidence of intraoperative complications was significantly associated with monthly minimally invasive hysterectomy case volume (adjusted odds ratio, 1.5 for each additional minimally invasive hysterectomy case for large uteri per month; 95% confidence interval, 1.20-2.08). Increasing age was associated with a lower incidence of complications (adjusted odds ratio, 0.9 for each additional year; 95% confidence interval, 0.8-0.9). Higher monthly minimally invasive hysterectomy volume was associated with a lower rate of conversion from a minimally invasive approach to laparotomy (adjusted odds ratio, 0.4 for each additional minimally invasive hysterectomy case for large uteri per month; 95% confidence interval, 0.2-0.5). CONCLUSION The overall rate of serious adverse events associated with minimally invasive hysterectomy for uteri >250 g was low. Higher monthly minimally invasive hysterectomy case volume was associated with a higher rate of intraoperative and postoperative adverse events but was associated with a lower rate of conversion to laparotomy.
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Affiliation(s)
- C Emi Bretschneider
- Center for Urogynecology and Pelvic Reconstructive Surgery, Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, OH.
| | | | - Deepanjana Das
- Center for Urogynecology and Pelvic Reconstructive Surgery, Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - J Eric Jelovsek
- Department of Obstetrics and Gynecology, Duke University, Durham, NC
| | - Cecile A Unger
- Center for Urogynecology and Pelvic Reconstructive Surgery, Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, OH
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Rogers RG, Nolen TL, Weidner AC, Richter HE, Jelovsek JE, Shepherd JP, Harvie HS, Brubaker L, Menefee SA, Myers D, Hsu Y, Schaffer JI, Wallace D, Meikle SF. Open sacrocolpopexy and vaginal apical repair: retrospective comparison of success and serious complications. Int Urogynecol J 2018; 29:1101-1110. [PMID: 29802413 PMCID: PMC6046257 DOI: 10.1007/s00192-018-3666-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 04/25/2018] [Indexed: 10/16/2022]
Abstract
INTRODUCTION AND HYPOTHESIS We compared treatment success and adverse events between women undergoing open abdominal sacrocolpopexy (ASC) vs vaginal repair (VAR) using data from women enrolled in one of three multicenter trials. We hypothesized that ASC would result in better outcomes than VAR. METHODS Participants underwent apical repair of stage 2-4 prolapse. Vaginal repair included uterosacral, sacrospinous, and iliococcygeal suspensions; sacrocolpopexies were via laparotomy. Success was defined as no bothersome bulge symptoms, no prolapse beyond the hymen, and no retreatment up to 24 months. Adverse events were collected at multiple time points. Outcomes were analyzed using longitudinal mixed-effects models to obtain valid outcome estimates at specific visit times, accounting for data missing at random. Comparisons were controlled for center, age, body mass index (BMI), initial Pelvic Organ Prolapse Quantification (POP-Q) stage, baseline scores, prior prolapse repair, and concurrent repairs. RESULTS Of women who met inclusion criteria (1022 of 1159 eligibile), 701 underwent vaginal repair. The ASC group (n = 321) was older, more likely white, had prior prolapse repairs, and stage 4 prolapse (all p < 0.05). While POP-Q measurements and symptoms improved in both groups, treatment success was higher in the ASC group [odds ratio (OR) 6.00, 95% confidence interval (CI) 3.45-10.44). The groups did not differ significantly in most questionnaire responses at 12 months and overall improvement in bowel and bladder function. By 24 months, fewer patients had undergone retreatment (2% ASC vs 5% VAR); serious adverse events did not differ significantly through 6 weeks (13% vs 5%, OR 2.0, 95% CI 0.9-4.7), and 12 months (26% vs 13%, OR 1.6, 95% CI 0.9-2.9), respectively. CONCLUSIONS Open sacrocolpopexy resulted in more successful prolapse treatment at 2 years.
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Affiliation(s)
- Rebecca G Rogers
- Department of Women's Health, Dell Medical School, University of Texas, 1301 W 38th Street, Suite 705, Austin, TX, 78756, USA.
- Department of Obstetrics and Gynecology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA.
| | | | - Alison C Weidner
- Department of Obstetrics and Gynecology, Duke University, Durham, NC, USA
| | - Holly E Richter
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - J Eric Jelovsek
- Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jonathan P Shepherd
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Heidi S Harvie
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA
| | - Linda Brubaker
- Department of Obstetrics and Gynecology, Stritch School of Medicine, Maywood, IL, USA
| | - Shawn A Menefee
- Department of Obstetrics and Gynecology, Kaiser Permanente, San Diego, CA, USA
| | - Deborah Myers
- Department of Obstetrics and Gynecology, Brown University, Providence, RI, USA
| | - Yvonne Hsu
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
| | - Joseph I Schaffer
- Department of Obstetrics and Gynecology, University of Texas, Southwestern, Dallas, TX, USA
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Wohlrab K, Jelovsek JE, Myers D. Incorporating simulation into gynecologic surgical training. Am J Obstet Gynecol 2017; 217:522-526. [PMID: 28511894 DOI: 10.1016/j.ajog.2017.05.017] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 03/22/2017] [Accepted: 05/07/2017] [Indexed: 01/22/2023]
Abstract
Today's educational environment has made it more difficult to rely on the Halstedian model of "see one, do one, teach one" in gynecologic surgical training. There is decreased surgical volume, but an increased number of surgical modalities. Fortunately, surgical simulation has evolved to fill the educational void. Whether it is through skill generalization or skill transfer, surgical simulation has shifted learning from the operating room back to the classroom. This article explores the principles of surgical education and ways to introduce simulation as an adjunct to residency training. We review high- and low-fidelity surgical simulators, discuss the progression of surgical skills, and provide options for skills competency assessment. Time and money are major hurdles when designing a simulation curriculum, but low-fidelity models, intradepartmental cost sharing, and utilizing local experts for simulation proctoring can aid in developing a simulation program.
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Affiliation(s)
- Kyle Wohlrab
- Warren Alpert Medical School of Brown University, Division of Female Pelvic Medicine and Reconstructive Surgery, Women & Infants Hospital, Providence, RI.
| | - J Eric Jelovsek
- Obstetrics, Gynecology, and Women's Health Institute and Simulation and Advanced Skills Center, Cleveland Clinic, Cleveland, OH
| | - Deborah Myers
- Warren Alpert Medical School of Brown University, Division of Female Pelvic Medicine and Reconstructive Surgery, Women & Infants Hospital, Providence, RI
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Moulton LJ, Eric Jelovsek J, Lachiewicz M, Chagin K, Goje O. A model to predict risk of postpartum infection after Caesarean delivery. J Matern Fetal Neonatal Med 2017. [PMID: 28629241 DOI: 10.1080/14767058.2017.1344632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE The purpose of this study is to build and validate a statistical model to predict infection after caesarean delivery (CD). METHODS Patient and surgical variables within 30 d of CD were collected on 2419 women. Postpartum infection included surgical site infection, urinary tract infection, endomyometritis and pneumonia. The data were split into model development and internal validation (1 January-31 August; N = 1641) and temporal validation subsets (1 September-31 December; N = 778). Logistic regression models were fit to the data with concordance index and calibration curves used to assess accuracy. Internal validation was performed with bootstrapping correcting for bias. RESULTS Postoperative infection occurred in 8% (95% CI 7.3-9.9), with 5% meeting CDC criteria for surgical site infections (SSI) (95% CI 4.1-5.8). Eight variables were predictive for infection: increasing BMI, higher number of prior Caesarean deliveries, emergent Caesarean delivery, Caesarean for failure to progress, skin closure using stainless steel staples, chorioamnionitis, maternal asthma and lower gestational age. The model discriminated between women with and without infection on internal validation (concordance index = 0.71 95% CI 0.67-0.76) and temporal validation (concordance index = 0.70, 95% CI 0.62, 0.78). CONCLUSIONS Our model accurately predicts risk of infection after CD. Identification of patients at risk for postoperative infection allows for individualized patient care and counseling.
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Affiliation(s)
- Laura J Moulton
- a Obstetrics, Gynecology and Women's Health Institute , Cleveland Clinic , Desk A81 , Cleveland , OH , USA
| | - J Eric Jelovsek
- a Obstetrics, Gynecology and Women's Health Institute , Cleveland Clinic , Desk A81 , Cleveland , OH , USA
| | - Mark Lachiewicz
- b Department of Gynecology and Obstetrics , Emory University , Atlanta , GA , USA
| | - Kevin Chagin
- c Department of Quantitative Health Sciences , Cleveland Clinic , Cleveland , OH , USA
| | - Oluwatosin Goje
- a Obstetrics, Gynecology and Women's Health Institute , Cleveland Clinic , Desk A81 , Cleveland , OH , USA
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Richter HE, Amundsen CL, Erickson SW, Jelovsek JE, Komesu Y, Chermansky C, Harvie HS, Albo M, Myers D, Gregory WT, Wallace D. Characteristics Associated with Treatment Response and Satisfaction in Women Undergoing OnabotulinumtoxinA and Sacral Neuromodulation for Refractory Urgency Urinary Incontinence. J Urol 2017; 198:890-896. [PMID: 28501541 DOI: 10.1016/j.juro.2017.04.103] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE We sought to identify clinical and demographic characteristics associated with treatment response and satisfaction in women undergoing onabotulinumtoxinA and sacral neuromodulation therapies. MATERIALS AND METHODS We analyzed data from the ROSETTA (Refractory Overactive Bladder: Sacral NEuromodulation versus BoTulinum Toxin Assessment) trial. Baseline participant characteristics and clinical variables were associated with 2 definitions of treatment response, including 1) a reduction in mean daily urgency incontinence episodes during 6 months and 2) a 50% or greater decrease in urgency incontinence episodes across 6 months. The OAB-S (Overactive Bladder-Satisfaction) questionnaire was used to assess satisfaction. RESULTS A greater reduction in mean daily urgency incontinence episodes was associated with higher HUI-3 (Health Utility Index-3) scores in the onabotulinumtoxinA group and higher baseline incontinence episodes (each p <0.001) in the 2 groups. Increased age was associated with a lesser decrease in incontinence episodes in the 2 groups (p <0.001). Increasing body mass index (adjusted OR 0.82/5 points, 95% CI 0.70-0.96) was associated with reduced achievement of a 50% or greater decrease in incontinence episodes after each treatment. Greater age (adjusted OR 0.44/10 years, 95% CI 0.30-0.65) and a higher functional comorbidity index (adjusted OR 0.84/1 point, 95% CI 0.71-0.99) were associated with reduced achievement of a 50% or greater decrease in urgency incontinence episodes in the onabotulinumtoxinA group only (p <0.001 and 0.041, respectively). In the onabotulinumtoxinA group increased satisfaction was noted with higher HUI-3 score (p = 0.002) but there was less satisfaction with higher age (p = 0.001). CONCLUSIONS Older women with multiple comorbidities, and decreased functional and health related quality of life had decreased treatment response and satisfaction with onabotulinumtoxinA compared to sacral neuromodulation for refractory urgency incontinence.
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Affiliation(s)
| | | | - S W Erickson
- RTI International, Research Triangle Park, North Carolina
| | | | - Y Komesu
- University of New Mexico, Albuquerque, New Mexico
| | - C Chermansky
- Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh
| | - H S Harvie
- University of Pennsylvania, Philadelphia, Pennsylvania
| | - M Albo
- University of California-San Diego, San Diego, California
| | - D Myers
- Brown University, Providence, Rhode Island
| | - W T Gregory
- Oregon Health and Science University, Portland, Oregon
| | - D Wallace
- RTI International, Research Triangle Park, North Carolina
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Siff LN, Jelovsek JE, Barber MD. The effect of major depression on quality of life after surgery for stress urinary incontinence: a secondary analysis of the Trial of Midurethral Slings. Am J Obstet Gynecol 2016; 215:455.e1-9. [PMID: 27133008 DOI: 10.1016/j.ajog.2016.04.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 04/16/2016] [Accepted: 04/20/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Depression has been associated with symptom amplification, functional impairment, and lower incontinence-specific quality of life in women with urinary incontinence. Although depression has been shown to impact both subjective and objective outcomes after many different surgeries, there are limited data on the effects of major depression on postoperative outcomes after antiincontinence surgery. OBJECTIVE The purpose of this study was to determine whether major depression affects urinary incontinence severity and quality of life after midurethral sling surgery. STUDY DESIGN This was a secondary analysis of the Trial of Midurethral Slings. Participants were assigned randomly either to a retropubic or transobturator sling for stress urinary incontinence. Each was classified as having major depression or not by the validated depression screening Patient Health Questionnaire-9. Pre- and postoperative urinary incontinence severity (which was assessed by the International Consultation on Incontinence Questionnaire), urinary incontinence-specific quality of life (which was assessed by the Incontinence Impact Questionnaire and the Urinary Distress Inventory), and sexual function (which was assessed by the Prolapse/Urinary Incontinence Sexual Questionnaire) was compared between groups at baseline and at 12 months. RESULTS Five hundred twenty-six patients were included: 79 patients (15%) had major depression before surgery; 447 patients (85%) did not. Baseline incontinence severity was higher in women with major depression than in those without (International Consultation on Incontinence Questionnaire, 14.7 ± 4.1 vs 12.9 ± 4.0; P < .001). Similarly, baseline quality of life and sexual function were worse in depressed women than in nondepressed women (Incontinence Impact Questionnaire, 235.6 ± 95.8 vs 134.8 ± 89.8; P < .001; Urinary Distress Inventory, 162.7 ± 46 vs 128.6 ± 41.3; P < .001; and Prolapse/Urinary Incontinence Sexual Questionnaire-12, 27.2 ± 7.3 vs 33.9 ± 6.4; P < .001). After adjustment for differences between groups, baseline major depression did not negatively affect 12-month incontinence severity or quality of life. However, at 12 months after surgery, despite significant improvement in sexual function scores in depressed women, the 12-month scores were still significantly worse in the major depression group (Prolapse/Urinary Incontinence Sexual Questionnaire-12, 34.1 ± 7.1 vs 37.7 ± 6.1; P < .001); multivariable analysis showed independent association of baseline major depression with 12-month sexual function. At 12 months, 83% of those women (66/79) with baseline major depression were no longer depressed. CONCLUSION Women with major depression who are planning surgery for stress urinary incontinence have worse quality of life than nondepressed women. However, women with major depression improve significantly more than those without major depression such that, at 12 months postoperatively, incontinence severity and quality of life are not different between groups. Sexual function is worse before and after the operation for depressed women.
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Affiliation(s)
- Lauren N Siff
- Center for Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic, Cleveland, OH.
| | - J Eric Jelovsek
- Center for Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - Matthew D Barber
- Center for Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic, Cleveland, OH
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Eric Jelovsek J, Markland AD, Whitehead WE, Barber MD, Newman DK, Rogers RG, Dyer K, Visco A, Sung VW, Sutkin G, Meikle SF, Gantz MG. Controlling anal incontinence in women by performing anal exercises with biofeedback or loperamide (CAPABLe) trial: Design and methods. Contemp Clin Trials 2015; 44:164-174. [PMID: 26291917 PMCID: PMC4757512 DOI: 10.1016/j.cct.2015.08.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 08/10/2015] [Accepted: 08/12/2015] [Indexed: 12/14/2022]
Abstract
The goals of this trial are to determine the efficacy and safety of two treatments for women experiencing fecal incontinence. First, we aim to compare the use of loperamide to placebo and second, to compare the use of anal sphincter exercises with biofeedback to usual care. The primary outcome is the change from baseline in the St. Mark's (Vaizey) Score 24weeks after treatment initiation. As a Pelvic Floor Disorders Network (PFDN) trial, subjects are enrolling from eight PFDN clinical centers across the United States. A centralized data coordinating center supervises data collection and analysis. These two first-line treatments for fecal incontinence are being investigated simultaneously using a two-by-two randomized factorial design: a medication intervention (loperamide versus placebo) and a pelvic floor strength and sensory training intervention (anal sphincter exercises with manometry-assisted biofeedback versus usual care using an educational pamphlet). Interventionists providing the anal sphincter exercise training with biofeedback have received standardized training and assessment. Symptom severity, diary, standardized anorectal manometry and health-related quality of life outcomes are assessed using validated instruments administered by researchers masked to randomized interventions. Cost effectiveness analyses will be performed using prospectively collected data on care costs and resource utilization. This article describes the rationale and design of this randomized trial, focusing on specific research concepts of interest to researchers in the field of female pelvic floor disorders and all other providers who care for patients with fecal incontinence.
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Affiliation(s)
- J Eric Jelovsek
- Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic, Cleveland, OH, United States.
| | - Alayne D Markland
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - William E Whitehead
- Department of Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Matthew D Barber
- Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Diane K Newman
- Division of Urology, Department of Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Rebecca G Rogers
- Departments of Obstetrics and Gynecology and Surgery, University of New Mexico Health Sciences Center, Albuquerque, NM, United States
| | - Keisha Dyer
- Department of Obstetrics and Gynecology Kaiser Permanente, San Diego, CA, United States
| | - Anthony Visco
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, United States
| | - Vivian W Sung
- Department of Obstetrics and Gynecology, Alpert Medical School of Brown University, Providence, RI, United States
| | - Gary Sutkin
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Susan F Meikle
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
| | - Marie G Gantz
- RTI International, Research Triangle Park, NC, United States
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Kow N, Walters MD, Karram MM, Sarsotti CJ, Jelovsek JE. Assessing intraoperative judgment using script concordance testing through the gynecology continuum of practice. Med Teach 2014; 36:724-729. [PMID: 24819908 DOI: 10.3109/0142159x.2014.910297] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To measure surgical judgment across the Obstetrics and Gynecology (OBGYN) continuum of practice and identify factors that correlate with improved surgical judgment. METHODS A 45-item written examination was developed using script concordance theory, which compares an examinee's responses to a series of "ill-defined" surgical scenarios to a reference panel of experts. The examination was administered to OBGYN residents, Female Pelvic Medicine and Reconstructive Surgery (FPMRS) fellows, practicing OBGYN physicians and FPMRS experts. Surgical judgment was evaluated by comparing scores against the experts. Factors related to surgical experience were measured for association with scores. RESULTS In total, 147 participants including 11 residents, 37 fellows, 88 practicing physicians and 11 experts completed the 45-item examination. Mean scores for practicing physicians (65.2 ± 7.4) were similar to residents (67.2 ± 7.1), and worse than fellows (72.6 ± 4.2, p < 0.001) and experts (80 ± 5, p < 0.001). Positive correlations between scores and surgical experience included: annual number of vaginal hysterectomies (r = 0.32, p = <0.001), robotic hysterectomies (r = 0.17, p = 0.048), stress incontinence (r = 0.29, p < 0.001) and prolapse procedures (r = 0.37, p < 0.001). Inverse correlation was seen between test scores and years in practice. (r = -0.19, p = 0.02). CONCLUSION Intraoperative judgment in practicing OBGYN physicians appears similar to resident physicians. Practicing physicians who perform FPMRS procedures perform poorly on this examination of surgical judgment; lower performance correlates with less surgical experience and the greater amount of time in practice.
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Jelovsek JE, Kow N, Diwadkar GB. Tools for the direct observation and assessment of psychomotor skills in medical trainees: a systematic review. Med Educ 2013; 47:650-673. [PMID: 23746155 DOI: 10.1111/medu.12220] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Revised: 10/02/2012] [Accepted: 02/18/2013] [Indexed: 06/02/2023]
Abstract
CONTEXT The Accreditation Council for Graduate Medical Education (ACGME) Milestone Project mandates programmes to assess the attainment of training outcomes, including the psychomotor (surgical or procedural) skills of medical trainees. The objectives of this study were to determine which tools exist to directly assess psychomotor skills in medical trainees on live patients and to identify the data indicating their psychometric and edumetric properties. METHODS An electronic search was conducted for papers published from January 1948 to May 2011 using the PubMed, Education Resource Information Center (ERIC), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Web of Science electronic databases and the review of references in article bibliographies. A study was included if it described a tool or instrument designed for the direct observation of psychomotor skills in patient care settings by supervisors. Studies were excluded if they referred to tools that assessed only clinical or non-technical skills, involved non-medical health professionals, or assessed skills performed on a simulator. Overall, 4114 citations were screened, 168 (4.1%) articles were reviewed for eligibility and 51 (1.2%) manuscripts were identified as meeting the study inclusion criteria. Three authors abstracted and reviewed studies using a standardised form for the presence of key psychometric and edumetric elements as per ACGME and American Psychological Association (APA) recommendations, and also assigned an overall grade based on the ACGME Committee on Educational Outcome Assessment grading system. RESULTS A total of 30 tools were identified. Construct validity based on associations between scores and training level was identified in 24 tools, internal consistency in 14, test-retest reliability in five and inter-rater reliability in 20. The modification of attitudes, knowledge or skills was reported using five tools. The seven-item Global Rating Scale and the Procedure-Based Assessment received an overall Class 1 ACGME grade and are recommended based on Level A ACGME evidence. CONCLUSIONS Numerous tools are available for the assessment of psychomotor skills in medical trainees, but evidence supporting their psychometric and edumetric properties is limited.
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Affiliation(s)
- J Eric Jelovsek
- Obstetrics, Gynaecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH 44195, USA.
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Muffly TM, Barber MD, Karafa MT, Kattan MW, Shniter A, Jelovsek JE. Nomogram to predict successful placement in surgical subspecialty fellowships using applicant characteristics. J Surg Educ 2012; 69:364-370. [PMID: 22483140 DOI: 10.1016/j.jsurg.2011.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2011] [Revised: 11/04/2011] [Accepted: 11/22/2011] [Indexed: 05/31/2023]
Abstract
PURPOSE The purpose of the study was to develop a model that predicts an individual applicant's probability of successful placement into a surgical subspecialty fellowship program. METHODS Candidates who applied to surgical fellowships during a 3-year period were identified in a set of databases that included the electronic application materials. RESULTS Of the 1281 applicants who were available for analysis, 951 applicants (74%) successfully placed into a colon and rectal surgery, thoracic surgery, vascular surgery, or pediatric surgery fellowship. The optimal final prediction model, which was based on a logistic regression, included 14 variables. This model, with a c statistic of 0.74, allowed for the determination of a useful estimate of the probability of placement for an individual candidate. CONCLUSIONS Of the factors that are available at the time of fellowship application, 14 were used to predict accurately the proportion of applicants who will successfully gain a fellowship position.
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Affiliation(s)
- Tyler M Muffly
- Center for Urogynecology and Pelvic Reconstructive Surgery, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA.
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Abstract
PURPOSE We determined the genetic contribution of and associated factors for bladder pain syndrome using an identical twin model. MATERIALS AND METHODS Multiple questionnaires were administered to adult identical twin sister pairs. The O'Leary-Sant Interstitial Cystitis Symptom and Problem Index was administered to identify individuals at risk for bladder pain syndrome. Potential associated factors were modeled against the bladder pain syndrome score with the twin pair as a random effect of the factor on the bladder pain syndrome score. Variables that showed a significant relationship with the bladder pain syndrome score were entered into a multivariable model. RESULTS In this study 246 identical twin sister pairs (total 492) participated with a mean age (± SD) of 40.3 ± 17 years. Of these women 45 (9%) were identified as having a moderate or high risk of bladder pain syndrome (index score greater than 13). There were 5 twin sets (2%) in which both twins met the criteria. Correlation of bladder pain syndrome scores within twin pairs was estimated at 0.35, suggesting a genetic contribution to bladder pain syndrome. Multivariable analysis revealed that increasing age (estimate 0.46 [95% CI 0.2, 0.7]), irritable bowel syndrome (1.8 [0.6, 3.7]), physical abuse (2.5 [0.5, 4.1]), frequent headaches (1.6 [0.6, 2.8]), multiple drug allergies (1.5 [0.5, 2.7]) and number of self-reported urinary tract infections in the last year (8.2 [4.7, 10.9]) were significantly associated with bladder pain syndrome. CONCLUSIONS Bladder pain syndrome scores within twin pairs were moderately correlated, implying some genetic component. Increasing age, irritable bowel syndrome, frequent headaches, drug allergies, self-reported urinary tract infections and physical abuse were factors associated with higher bladder pain syndrome scores.
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Affiliation(s)
- E Tunitsky
- Center for Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio 44195 , USA.
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Jeppson PC, Paraiso MFR, Jelovsek JE, Barber MD. Accuracy of the digital anal examination in women with fecal incontinence. Int Urogynecol J 2011; 23:765-8. [PMID: 22057427 DOI: 10.1007/s00192-011-1590-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2011] [Accepted: 10/17/2011] [Indexed: 02/07/2023]
Abstract
INTRODUCTION AND HYPOTHESIS This study aims to determine the accuracy of digital rectal examination (DRE) to detect anal sphincter defects when compared to endoanal ultrasound (US) in women with fecal incontinence (FI). METHODS Seventy-four patients identified by retrospective chart review who presented with complaints of bothersome FI who underwent endoanal US are the subjects of this analysis. Sensitivity, specificity, and positive and negative likelihood ratios were calculated for the ability of the DRE to detect anal sphincter defects. RESULTS Anal sphincter defect was suspected on DRE in 75%. At endoanal US, external sphincter defects were noted in all three segments in 41% (complete defect) while partial defects were noted in 30%. DRE demonstrated a sensitivity of 82%, specificity of 32%, +likelihood ratio 1.2 (95% confidence interval (CI), 0.95-1.16) and -likelihood ratio of 0.6 (95% CI, 0.2-1.24) for detecting a complete EAS defect on endoanal US. CONCLUSION DRE has poor specificity for detecting anal sphincter defects seen on endoanal US.
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Affiliation(s)
- Peter C Jeppson
- Obstetrics, Gynecology, & Women's Health Institute, Cleveland Clinic, Cleveland, OH 44195, USA.
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Reddy J, Barber MD, Walters MD, Paraiso MFR, Jelovsek JE. Lower abdominal and pelvic pain with advanced pelvic organ prolapse: a case-control study. Am J Obstet Gynecol 2011; 204:537.e1-5. [PMID: 21345412 DOI: 10.1016/j.ajog.2011.01.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Revised: 12/16/2010] [Accepted: 01/13/2011] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The objective of the study was to compare the relative frequencies of pain in women with and without pelvic organ prolapse (POP). STUDY DESIGN This was an ancillary analysis of a case-control study investigating functional bowel disorders in women with and without POP. Cases were defined as subjects with stage 3 or 4 POP and controls were subjects with normal pelvic support. RESULTS Women with POP were more likely to experience lower abdominal or pelvic pain that was significantly bothersome and interfered with daily activities (odds ratio [OR], 9.7; 95% confidence interval [CI], 4.7-20.4). After controlling for confounders, women with prolapse were more likely to report pressure in the lower abdomen (OR, 2.3; 95% CI, 1.6-3.2), heaviness in the pelvic region (OR, 3.3; 95% CI, 2.3-4.3), and pain in the lower abdomen (OR, 2.6; 95% CI, 1.8-4.1). CONCLUSION Women with prolapse are more likely to report pain, pressure, or heaviness in the lower abdomen or pelvis compared with women with normal support.
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Affiliation(s)
- Jhansi Reddy
- Center for Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology, Women's Health Institute, Cleveland Clinic, OH, USA
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Diwadkar GB, Jelovsek JE. Measuring surgical trainee perceptions to assess the operating room educational environment. J Surg Educ 2010; 67:210-216. [PMID: 20816355 DOI: 10.1016/j.jsurg.2010.04.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2009] [Revised: 02/15/2010] [Accepted: 04/13/2010] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To determine measurable differences in the perception of learning between junior and senior residents in the operating rooms of an obstetrics and gynecology (OBGYN) residency program. DESIGN, SETTING, AND PARTICIPANTS Using a cross-sectional design, the Operating Room Educational Environment Measure (OREEM), a 40-item educational environment inventory, was administered to 28 OBGYN residents from 1 training program, who train at 3 hospital sites. The OREEM measures a trainee's perceptions of the teaching surgeon, learning opportunities, operating room atmosphere, and workload. The primary outcome was total OREEM scores and secondary outcomes were OREEM subscale scores, global impression of education, and internal consistency and validity of the OREEM scale. Group sample sizes of 10 and 10 achieved 80% power to detect a 10% difference between group mean OREEM scores +/- 10% with a significance level of 0.05. RESULTS Twenty-four residents including 11 junior (postgraduate years 1 and 2) and 13 senior (postgraduate years 3 and 4) residents were included in the analysis. Total OREEM scores, learning opportunities, and workload/support subscale scores were significantly lower for junior residents compared with senior residents across all sites. Perceptions of learning at a multispecialty tertiary referral hospital were lower than the community and regional hospitals. This was secondary to complexity of cases, subspecialty fellows, and decreased opportunities to first-assist in the operating room. The OREEM demonstrated acceptable reliability and construct validity. CONCLUSIONS There are measurable differences in perception of the operating room educational environment between junior and senior OBGYN residents using the reliable and valid Operating Room Educational Environment Measure.
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Affiliation(s)
- Gouri B Diwadkar
- Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA.
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Abstract
BACKGROUND Vaginal mesh kits are being used to surgically treat apical vaginal prolapse; however, their safety and efficacy are currently unknown. OBJECTIVES To summarise success and complication rates for commonly used vaginal mesh kits in the treatment of apical prolapse. SEARCH STRATEGY MEDLINE and other scientific databases were queried for primary research addressing the use of vaginal mesh kits for apical prolapse published between 1950 and 2007, including abstracts presented in major scientific meetings. SELECTION CRITERIA Studies describing the use of mesh to support either the anterior or posterior compartment alone, for incontinence or fistula repair or not addressing the vaginal apex were excluded. DATA COLLECTION AND ANALYSIS Identified studies were grouped by the mesh kit and complications categorised using the Dindo classification system. Weighted averages and confidence intervals were calculated on objective success, follow-up length and complications. MAIN RESULTS Thirty studies totalling 2653 women met inclusion criteria. Objective success rates (95% CI) were Apogee (American Medical Systems Inc., Minnetonka, MN, USA) 95% (95-96), Prolift (Ethicon Women's Health and Urology, Somerville, NJ, USA) 87% (86-87) and posterior intravaginal slingplasty 88% (87-89). Reoperations not requiring anaesthesia (Dindo IIIa) occurred in 0.4-2.3% and requiring anaesthesia (Dindo IIIb) in 1.5-6.0%, with a follow up between 26 and 78 weeks. Mesh erosion was the most commonly reported complication occurring in 4.6-10.7%. AUTHOR'S CONCLUSIONS Overall objective success using transvaginal mesh kits in restoring apical vaginal prolapse is high. However, an increasing number of women require surgical intervention for mesh-related complications based on limited data quality and short follow up. Further research addressing functional outcomes and the impact of these procedures on women's symptoms and quality of life is mandatory.
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Affiliation(s)
- B Feiner
- Division of Urogynaecology and Reconstructive Pelvic Surgery, Royal Women's, Mater and Wesley Hospitals, Brisbane, Queensland, Australia.
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Ridgeway B, Walters MD, Paraiso MFR, Barber MD, McAchran SE, Goldman HB, Jelovsek JE. Early experience with mesh excision for adverse outcomes after transvaginal mesh placement using prolapse kits. Am J Obstet Gynecol 2008; 199:703.e1-7. [PMID: 18845292 DOI: 10.1016/j.ajog.2008.07.055] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2008] [Revised: 05/13/2008] [Accepted: 07/21/2008] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the complications, treatments, and outcomes in patients choosing to undergo removal of mesh previously placed with a mesh procedural kit. STUDY DESIGN This was a retrospective review of all patients who underwent surgical removal of transvaginal mesh for mesh-related complications during a 3-year period at Cleveland Clinic. At last follow-up, patients reported degree of pain, level of improvement, sexual activity, and continued symptoms. RESULTS Nineteen patients underwent removal of mesh during the study period. Indications for removal included chronic pain (6/19), dyspareunia (6/19), recurrent pelvic organ prolapse (8/19), mesh erosion (12/19), and vesicovaginal fistula (3/19), with most patients (16/19) citing more than 1 reason. There were few complications related to the mesh removal. Most patients reported significant relief of symptoms. CONCLUSION Mesh removal can be technically difficult but appears to be safe with few complications and high relief of symptoms, although some symptoms can persist.
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Affiliation(s)
- Beri Ridgeway
- Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
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Park AJ, Bohrer JC, Bradley LD, Diwadkar GB, Moon E, Newman JS, Jelovsek JE. Incidence and risk factors for surgical intervention after uterine artery embolization. Am J Obstet Gynecol 2008; 199:671.e1-6. [PMID: 18986639 DOI: 10.1016/j.ajog.2008.07.060] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2008] [Revised: 05/28/2008] [Accepted: 07/28/2008] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the incidence and risk factors for surgical intervention after uterine artery embolization for symptomatic uterine fibroids. STUDY DESIGN Electronic medical records of all patients who underwent uterine artery embolization for symptomatic uterine leiomyomata were reviewed. Logistic regression was used to identify independent risk factors for any surgical intervention and for hysterectomy alone after uterine artery embolization. RESULTS Uterine artery embolization was performed in 454 patients during the study period, with a median follow-up time (range) of 14 (0-128) months. Overall, 99 patients (22%) underwent any surgical intervention after uterine artery embolization in the operating room. Risk factors for any surgical intervention included younger age (P < .003), bleeding as an indication for uterine artery embolization (P < .01), presence of significant collateral ovarian vessel contribution to the uterus (P < .01), or use of 355-500 mum particles (P < .008). CONCLUSION Patients undergoing uterine artery embolization have a 22% risk for requiring additional surgical intervention, but overall uterine artery embolization is an effective minimally invasive option.
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Affiliation(s)
- Amy J Park
- Department of Gynecology and Obstetrics, Cleveland Clinic, Cleveland, OH, USA
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Jelovsek JE, Walters MD, Barber MD. Psychosocial impact of chronic vulvovagina conditions. J Reprod Med 2008; 53:75-82. [PMID: 18357797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To describe the degree of psychosocial impairment resulting from chronic vulvovaginal disorders (VVDs). STUDY DESIGN Seventy-five consecutive women suffering from a chronic VVD were recruited and classified using current International Society for the Study of Vulvovaginal Disease (ISSVD) classification criteria. They completed a 69-item, self-administered, comprehensive questionnaire to assess the impact of chronic VVD on psychosocial functioning and quality of life. Summary scores were calculated for 5 domains including pain, body image, relationships, emotion, quality of life and sexual function. RESULTS After adjusting for age and duration of vulvovaginal symptoms, women with vulvodynia were more likely than women with other chronic VVDs to score significantly worse on relationship (p < 0.001), emotion (p < 0.03) and physical activity (p = 0.001) areas. The majority of subjects suffered from a worsening impact of sexual function, and no differences were detected between the groups. The overall intensity of vulvar or vaginal pain correlated weakly with the degree of psychosocial impairment in the domains of relationships, emotion and physical quality of life. CONCLUSION Differences in quality of life exist between women with vulvodynia and those with other chronic VVDs. The presence, not the intensity, of vulvovaginal pain correlates with degree of psychosocial impairment.
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Affiliation(s)
- J Eric Jelovsek
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Gynecology and Obstetrics, Cleveland Clinic, 9500 Euclid Avenue/ A81, Cleveland, OH 44195, USA.
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Jelovsek JE, Barber MD, Karram MM, Walters MD, Paraiso MFR. Randomised trial of laparoscopic Burch colposuspension versus tension-free vaginal tape: long-term follow up. BJOG 2007; 115:219-25; discussion 225. [DOI: 10.1111/j.1471-0528.2007.01592.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Colombo JR, Haber GP, Jelovsek JE, Nguyen M, Fergany A, Desai MM, Kaouk JH, Gill IS. Complications of laparoscopic surgery for urological cancer: a single institution analysis. J Urol 2007; 178:786-91. [PMID: 17631354 DOI: 10.1016/j.juro.2007.05.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2007] [Indexed: 01/09/2023]
Abstract
PURPOSE We determined the incidence of and risk factors for perioperative complications associated with laparoscopic oncological surgery for urological malignancy. MATERIALS AND METHODS All records of patients undergoing laparoscopic surgery for urological malignancy at a tertiary care institution from April 1997 through January 2006 were reviewed. Relevant demographic and perioperative data during and within 6 weeks of surgery were evaluated retrospectively. Various factors were analyzed to estimate risk of a perioperative complication such as the Charlson Comorbidity Index, American Society of Anesthesiologists score, European Scoring System for laparoscopic urological operations and surgeon experience. Logistic regression was used to identify independent risk factors for perioperative complications. RESULTS A total of 1,867 laparoscopic oncological surgeries were performed, including radical or partial nephrectomy, nephroureterectomy, radical prostatectomy and radical cystectomy. Perioperative complications occurred in 12.4% of patients, including 3.5% intraoperatively and 8.9% postoperatively. Intraoperative (2.3%) and postoperative hemorrhage (2.7%) accounted for 40% of all perioperative complications. All cause perioperative mortality occurred in 8 patients (0.4%). On multivariate analysis radical cystectomy (adjusted OR 4.9, p <0.001), partial nephrectomy (adjusted OR 2.4, p <0.001), length of surgery greater than 4 hours (adjusted OR 2.5, p <0.001) and preoperative serum creatinine greater than 1.5 mg/dl (adjusted OR 2.1, p = 0.04) were independent risk factors for perioperative complications. Comparing the periods of 1997 to 2000 vs 2001 to 2005, despite a significant increase in technical complexity of procedures (European Scoring System 9.8 vs 60.6, p <0.001), the incidence of complications tended to decrease (17.3% vs 12.5%, p = 0.3). CONCLUSIONS In appropriately selected patients laparoscopic urological oncological surgery is safe. These data on perioperative complications could possibly serve as a reference benchmark for practicing urologists.
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Affiliation(s)
- Jose R Colombo
- Section of Laparoscopic and Robotic Surgery, Glickman Urological Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
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Collins SA, Jelovsek JE, Chen CCG, Gustilo-Ashby AM, Barber MD. De novo rectal prolapse after obliterative and reconstructive vaginal surgery for urogenital prolapse. Am J Obstet Gynecol 2007; 197:84.e1-3. [PMID: 17618769 DOI: 10.1016/j.ajog.2007.02.050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2006] [Revised: 01/06/2007] [Accepted: 02/27/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The purpose of this study was to compare the incidence of de novo rectal prolapse after obliterative vaginal surgery with the incidence that was seen after reconstructive vaginal surgery for urogenital prolapse. STUDY DESIGN A chart review was performed on subjects who underwent vaginal surgery for urogenital prolapse from Jan. 1, 2001, through Dec. 31, 2004, at the Cleveland Clinic. Diagnosis of postoperative rectal prolapse was identified with ICD-9 code 569.1. RESULTS Nine hundred sixteen women underwent vaginal surgery for urogenital prolapse. Ninety-two percent of the women (n = 840) underwent reconstructive surgery, and 8% of the women (n = 76) underwent obliterative surgery. The incidence of postoperative full-thickness rectal prolapse in women who were > or = 65 years old who underwent obliterative surgery was 3 of 74 (4.1%; 95% CI, 1.4-11), with an estimated odds ratio of 22 (95% CI, 2.3-196; P < .002) compared with women who were > or = 65 years old who underwent reconstructive surgery. CONCLUSION Obliterative surgery is associated with a substantially greater risk of de novo rectal prolapse than reconstructive vaginal surgery for urogenital prolapse.
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Affiliation(s)
- Sarah A Collins
- Section of Urogynecology and Reconstructive Pelvic Surgery, Division of Surgery, Department of Gynecology and Obstetrics, Cleveland Clinic Foundation, Cleveland, OH, USA
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Abstract
Pelvic organ prolapse is downward descent of female pelvic organs, including the bladder, uterus or post-hysterectomy vaginal cuff, and the small or large bowel, resulting in protrusion of the vagina, uterus, or both. Prolapse development is multifactorial, with vaginal child birth, advancing age, and increasing body-mass index as the most consistent risk factors. Vaginal delivery, hysterectomy, chronic straining, normal ageing, and abnormalities of connective tissue or connective-tissue repair predispose some women to disruption, stretching, or dysfunction of the levator ani complex, connective-tissue attachments of the vagina, or both, resulting in prolapse. Patients generally present with several complaints, including bladder, bowel, and pelvic symptoms; however, with the exception of vaginal bulging, none is specific to prolapse. Women with symptoms suggestive of prolapse should undergo a pelvic examination and medical history check. Radiographic assessment is usually unnecessary. Many women with pelvic organ prolapse are asymptomatic and do not need treatment. When prolapse is symptomatic, options include observation, pessary use, and surgery. Surgical strategies for prolapse can be categorised broadly by reconstructive and obliterative techniques. Reconstructive procedures can be done by either an abdominal or vaginal approach. Although no effective prevention strategy for prolapse has been identified, considerations include weight loss, reduction of heavy lifting, treatment of constipation, modification or reduction of obstetric risk factors, and pelvic-floor physical therapy.
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Affiliation(s)
- J Eric Jelovsek
- Department of Obstetrics and Gynecology A81, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Abstract
OBJECTIVE To determine accuracy of the 7-8-9 Rule in a cohort of neonates. STUDY DESIGN This study was cross-sectional in design. Seventy-five consecutive neonates who required oral intubation from June 2004 to November 2004 for cardiopulmonary failure, respiratory distress, or surfactant administration were the subjects of this study. The initial endotracheal tube (ETT) depth of insertion was determined using either an estimated birth weight or actual weight in the 7-8-9 Rule calculation followed by auscultation and subsequent adjustment if necessary. Midtracheal position was identified as the point halfway between the inferior clavicle and carina on a chest radiograph. The initial depth was compared to the midtracheal depth to determine clinical accuracy of the 7-8-9 Rule. The depth predicted by the 7-8-9 Rule was also calculated using only actual weights. This predicted depth was compared to the midtracheal depth to determine true accuracy of the 7-8-9 Rule. Accuracy was determined using mean paired differences with 95% confidence intervals (CI) between initial or predicted depth and ideal, midtracheal ETT depth. Linear regression was used to adjust for confounding variables. RESULTS Mean (range) gestational age was 32 weeks (23 to 44 weeks) and weight was 2001 g (490 to 4400 g). Eighteen (24%) infants weighed 1000 g or less, 20 (27%) weighed between 1001 and 2000 g, 21 (28%) weighed between 2001 and 3000 g, 15 (20%) weighed between 3001 and 4000 g, and one (1%) weighed more than 4000 g. Thirteen of the 18 extremely low birth weight infants weighed <750 g. The initial depth of insertion was 0.004 cm above midtracheal position (95% CI -0.13 to 0.14, P = 0.96). After controlling for head position, the initial depth did not significantly differ from the midtracheal position among weight groups. Predicted depth using the 7-8-9 Rule placed the ETT 0.12 cm above midtracheal position (95% CI -0.30 to 0.06, P = 0.20). However, after controlling for head position, the 7-8-9 Rule positioned the ETT significantly below midtracheal position in infants weighing <750 g (mean 0.62 cm; 95% CI 0.30 to 0.93, P=0.002). CONCLUSIONS The 7-8-9 Rule appears to be an accurate clinical method for endotracheal tube placement in neonates weighing more than 750 g. When the 7-8-9 Rule is applied to infants weighing <750 g, caution is warranted. The current rule may lead to an overestimated depth of insertion and potentially result in clinically significant consequences.
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Affiliation(s)
- J Peterson
- Division of Neonatology, Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, OH, USA. petersj2@.ccf.org
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Gustilo-Ashby AM, Jelovsek JE, Barber MD, Yoo EH, Paraiso MFR, Walters MD. The incidence of ureteral obstruction and the value of intraoperative cystoscopy during vaginal surgery for pelvic organ prolapse. Am J Obstet Gynecol 2006; 194:1478-85. [PMID: 16647931 DOI: 10.1016/j.ajog.2006.01.064] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2005] [Revised: 11/19/2005] [Accepted: 01/13/2006] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objective of the study was to determine the incidence of ureteral obstruction during vaginal surgery for pelvic organ prolapse and the accuracy and efficacy of intraoperative cystoscopy. STUDY DESIGN The study was a retrospective review of 700 consecutive patients who underwent vaginal surgery for anterior and/or apical pelvic organ prolapse with universal intraoperative cystoscopy. RESULTS Thirty-seven patients (5.3%) had no spillage of dye from 1 or both ureters intraoperatively. The false-positive and negative cystoscopy rates were 0.4% and 0.3%, respectively. Thus, the true incidence of intraoperative ureteral obstruction was 5.1%. Intraoperative cystoscopy was accurate in 99.3% of cases, with a sensitivity and specificity of 94.4% and 99.5%, respectively. Suture removal relieved ureteral obstruction in 88% of cases. Six subjects (0.9%) had true ureteral injuries. CONCLUSION Vaginal surgery for anterior and/or apical pelvic organ prolapse is associated with an intraoperative ureteral obstruction rate of 5.1%. Intraoperative cystoscopy accurately detects ureteral obstruction and allows for relief of obstruction in the majority of cases.
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Affiliation(s)
- A Marcus Gustilo-Ashby
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, The Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
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Jelovsek JE, Barber MD. Women seeking treatment for advanced pelvic organ prolapse have decreased body image and quality of life. Am J Obstet Gynecol 2006; 194:1455-61. [PMID: 16647928 DOI: 10.1016/j.ajog.2006.01.060] [Citation(s) in RCA: 291] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2005] [Revised: 10/14/2005] [Accepted: 01/13/2006] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Women who seek treatment for pelvic organ prolapse strive for an improvement in quality of life. Body image has been shown to be an important component of differences in quality of life. To date, there are no data on body image in patients with advanced pelvic organ prolapse. Our objective was to compare body image and quality of life in women with advanced pelvic organ prolapse with normal controls. STUDY DESIGN We used a case-control study design. Cases were defined as subjects who presented to a tertiary urogynecology clinic with advanced pelvic organ prolapse (stage 3 or 4). Controls were defined as subjects who presented to a tertiary care gynecology or women's health clinic for an annual visit with normal pelvic floor support (stage 0 or 1) and without urinary incontinence. All patients completed a valid and reliable body image scale and a generalized (Short Form Health Survey) and condition-specific (Pelvic Floor Distress Inventory-20) quality-of-life scale. Linear and logistic regression analyses were performed to adjust for possible confounding variables. RESULTS Forty-seven case and 51 control subjects were enrolled. After controlling for age, race, parity, previous hysterectomy, and medical comorbidities, subjects with advanced pelvic organ prolapse were more likely to feel self-conscious (adjusted odds ratio 4.7; 95% confidence interval 1.4 to 18, P = .02), less likely to feel physically attractive (adjusted odds ratio 11; 95% confidence interval 2.9 to 51, P < .001), less likely to feel feminine (adjusted odds ratio 4.0; 95% confidence interval 1.2 to 15, P = .03), and less likely to feel sexually attractive (adjusted odds ratio 4.6; 95% confidence interval 1.4 to 17, P = .02) than normal controls. The groups were similar in their feeling of dissatisfaction with appearance when dressed, difficulty looking at themselves naked, avoiding people because of appearance, and overall dissatisfaction with their body. Subjects with advanced pelvic organ prolapse suffered significantly lower quality of life on the physical scale of the SF-12 (mean 42; 95% confidence interval 39 to 45 versus mean 50; 95% confidence interval 47 to 53, P < .009). However, no differences between groups were noted on the mental scale of the SF-12 (mean 51; 95% confidence interval 50 to 54 versus mean 50; 95% confidence interval 47 to 52, P = .56). Additionally, subjects with advanced pelvic organ prolapse scored significantly worse on the prolapse, urinary, and colorectal scales and overall summary score of Pelvic Floor Distress Inventory-20 than normal controls (mean summary score 104; 95% confidence interval 90 to 118 versus mean 29; 95% confidence interval 16 to 43, P < .0001), indicating a decrease in condition-specific quality of life. Worsening body image correlated with lower quality of life on both the physical and mental scales of the SF-12 as well as the prolapse, urinary, and colorectal scales and overall summary score of Pelvic Floor Distress Inventory-20 in subjects with advanced pelvic organ prolapse. CONCLUSION Women seeking treatment for advanced pelvic organ prolapse have decreased body image and overall quality of life. Body image may be a key determinant for quality of life in patients with advanced prolapse and may be an important outcome measure for treatment evaluation in clinical trials.
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Affiliation(s)
- J Eric Jelovsek
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Gynecology and Obstetrics, The Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
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