Novel Catheter Multiscope: A Feasibility Study

Open Challenges: Continuous monitoring of fundamental cardiovascular hemodynamic parameters is essential to accomplish critical care diagnostics. Today's standard of care measures these critical parameters using multiple monitoring technologies. These state-of-the-art technologies require expensive instrumentation and complex infrastructure. Therefore, it is challenging to use current technologies to accomplish monitoring in a low resource setting.

OBJECTIVE

In order to address the challenges caused by having to use multiple monitoring systems, a point of care monitoring device was developed in this work to provide multiple critical parameters by uniquely measuring the hemodynamic process.

METHODS

To demonstrate the usability of this novel catheter multiscope, a feasibility study was performed using an animal model. The developed measurement system first acquires the dynamics of blood flow through a minimally invasive catheter. Then, a signal processing framework was developed to characterize the blood flow dynamics and to obtain critical parameters such as heart rate, respiratory rate, and blood pressure. The framework used to extract the physiological data corresponding to the acoustic field of the blood flow consisted of a noise cancellation method and wavelet-based source separation.

RESULTS

The preliminary results of the acoustic pressure field of the blood flow revealed the presence of acoustic heart and respiratory pulses. A unique framework was also developed to extract continuous blood pressure from the acoustic pressure field of the blood flow. Finally, the computed heart and respiratory rates, systolic and diastolic pressures were benchmarked with actual values measured using conventional devices to validate the hypothesis.

CONCLUSION

The results confirm that catheter multiscope can provide multiple critical parameters with clinical reliability.

SIGNIFICANCE

A novel critical care monitoring system has been developed to accurately measure heart rate, respiratory rate, systolic and diastolic pressures from the blood flow dynamics.

Estimation of External Contamination and Exposure Rates Due to Fission Product Release

In the event of a radiological incident, the release of fission products into the surrounding environment and the ensuing external contamination present a challenge for triage assessment by emergency response personnel. Reference exposure rate and skin dose rate calibration data for emergency response personnel are currently lacking for cases where receptors are externally contaminated with fission products. Simulations were conducted to compute reference exposure rate coefficients and skin dose rate coefficients from photon-emitting fission products of radiological concern. To accomplish this task, simplified mathematical skin phantoms were created using surface area and height specifications from International Commission on Radiological Protection Publication 89. Simulations were conducted using Monte Carlo radiation transport code using newborn, 1-y-old, 5-y-old, 10-y-old, 15-y-old, and adult phantoms for 22 photon-emitting radionuclides. Exposure rate coefficient data were employed in a case study simulating the radionuclide inventory for a 17 × 17 Westinghouse pressurized water reactor, following three burn-up cycles at 14,600 MWd per metric ton of uranium. The decay times following the final cycle represent the relative activity fractions over a period of 0.5-30 d. The resulting data can be used as calibration standards for triage efforts in emergency response protocols.

Fracture prevention: a population-based intervention delivered in primary care

BACKGROUND

Osteoporosis is common, increasing as the population ages and has significant consequences including fracture. Effective treatments are available.

AIM

To support proactive fracture risk assessment (FRAX) and optimizing treatment for high-risk patients in primary care.

DESIGN

Clinical cohort.

SETTING

November 2017 to November 2018, support was provided to 71 practices comprising 69 of 90 practices within two National Health Service Clinical Commissioning Groups areas. Total population 579 508 (207 263 aged over 50 years).

PARTICIPANTS

FRAX (National Institute for Care and Clinical Excellence, NICE CG146) in (i) males aged 75 years and over, (ii) females aged 65 years and over, (iii) females aged under 65 years and males aged under 75 years with risk factors and (iv) under 50 years with major risk factors.

RESULTS

A total of 158 946 met NICE CG146, 11 961 were coded with an osteoporosis diagnosis (7.5%), of those, 42% were prescribed treatment with a bone sparing agent (BSA). In total, 6942 were assessed to initiate BSA. Thirty percent of untreated osteoporosis diagnosis patients had never been prescribed BSA. Even when prescribed, 1700 people (35%) were for less than minimum recommended duration. Of the total 9784 patients within the FRAX recommended to treat threshold, 3197 (33%) were currently treated with BSA and 3684 (37%) had no history of ever receiving BSA. From untreated patients, expected incidence of 875 fractures over a 3-year period (approximately £3.4 million). Treatment would prevent 274 fractures (cost reduction: £1 274 045, with prescribing costs: saving £805 145 after 3 years of treatment).

CONCLUSION

Underdiagnosis and suboptimal treatment of osteoporosis was identified. Results suggest that implementing NICE guidance and optimizing treatment options in practice is possible and could prevent significant fractures.

Sheep tick Ixodes ricinus management on Welsh hill farms of designated conservation importance: implications for nationally declining birds

Impacts of sheep ticks Ixodes ricinus on livestock, gamebirds and wildlife are of concern across Europe. The present study describes livestock and tick management by 36 farmers from three upland sites of conservation importance in North Wales, where farmers consider that ticks have increased during the last 25 years. Sheep, average densities of 2.0 animals per ha were treated with pour-on acaricides in spring, again in July, and also when removed from the moor in autumn. Given acaricide efficacy rates, sheep were susceptible to tick bites for half the period on the moor. Sheep from 17 farms were examined for ticks. Infestations were similar between farms and in relation to the acaricide used, averaging 9.3 ticks per sheep, although they were lower where the interval between successive acaricide treatments was shorter. Repeated sampling of sheep and red grouse chicks showed no annual difference in tick burdens on grouse chicks, which averaged 6.2 ticks per chick, although there were three-fold fewer ticks on sheep in 2018 than in previous years. Tick bite rates on sheep and grouse were higher than elsewhere in the U.K. Most farmers interviewed would aim to improve their tick management using longer-lasting acaricides and treating sheep more frequently, although they would need advice and financial help, which is currently unavailable via Government funded agri-environment schemes.

The Association Between Hospital Surgical Volume and the Uptake of Minimally Invasive Surgical Approach and Outpatient Setting for Hysterectomy

BACKGROUND

There are large variations in the use of minimally invasive surgery (MIS), and outpatient hysterectomy (OP) among Medicare patients according to hospital surgical volume and geographical distribution.

OBJECTIVE

To explore the changing trend in OP and MIS hysterectomy in the United States.

STUDY DESIGN

We used all Medicare fee-for-service claims data for 2012 and 2014 to determine the incidence of OP and MIS hysterectomy according to hospital surgical volume and geographical distribution. MIS included both laparoscopy and robotic surgery. OP procedures included only same-day discharge hysterectomies.

RESULTS

A total of 55,562 and 53,054 hysterectomies were performed in the years 2012 and 2014, respectively. OP rate in 2014 in high-volume centers (16,828 [47.1%]) exceeded low-volume centers (136 [16%]) by 31.1% (p<0.001). Time trends between 2014 and 2012 show that a rise in OP rate was 17.7% and 7% for high- and low-volume hospitals (p<0.001), respectively. High-volume hospitals showed an increase of 3.1% (p=0.003) in MIS hysterectomy rate in 2014 (69%) as compared to 2012 (65.9%). There was no change in MIS rate among low-volume hospitals.

CONCLUSION

In the Medicare population, the rate of OP and MIS hysterectomy for high-volume centers is significantly different form low-volume centers. Over the years, outpatient hysterectomy is being practiced widely but an increase in MIS rate is limited to high-volume centers.

Quality of Life among Mastectomy Patients Using External Breast Prostheses

Background

Most women who undergo mastectomy for breast cancer use external breast prostheses. Yet, little is known about patterns of use, satisfaction levels, and quality of life associated with their use as compared to other options.

Patients and Methods

We report longitudinal, self-report questionnaire data regarding prosthetic use from 592 Italian mastectomy patients. Women who report satisfaction with their prostheses are compared on medical, demographic, and quality of life variables to a matched sample of women who report dissatisfaction. We also compare matched samples of women who do not use prostheses and women who had reconstruction to prosthetic users.

Results

Most women used and were satisfied with their prostheses. However, there was a small group of women who were dissatisfied. These women reported greater disruption to their sense of feminility and worse quality of life in some areas. We found few differences between prosthetic users and women who used either of the other two options available following mastectomy - taking no action to restore the appearance of the amputated breast or having reconstructive surgery.

Conclusions

No one technique for restoring the appearance of the mastectomized breast is necessary to optimize quality of life for all women. Physicians should describe the options to women, along with the average satisfaction rates for women choosing those options, and help women to make the best personal decisions.

Automated contour tracking and trajectory classification of pelvic organs on dynamic MRI

A method is presented to automatically track and segment pelvic organs on dynamic magnetic resonance imaging (MRI) followed by multiple-object trajectory classification to improve understanding of pelvic organ prolapse (POP). POP is a major health problem in women where pelvic floor organs fall from their normal position and bulge into the vagina. Dynamic MRI is presently used to analyze the organs' movements, providing complementary support for clinical examination. However, there is currently no automated or quantitative approach to measure the movement of the pelvic organs and their correlation with the severity of prolapse. In the proposed method, organs are first tracked and segmented using particle filters and [Formula: see text]-means clustering with prior information. Then, the trajectories of the pelvic organs are modeled using a coupled switched hidden Markov model to classify the severity of POP. Results demonstrate that the presented method can automatically track and segment pelvic organs with a Dice similarity index above 78% and Hausdorff distance of [Formula: see text] for 94 tested cases while demonstrating correlation between organ movement and POP. This work aims to enable automatic tracking and analysis of multiple deformable structures from images to improve understanding of medical disorders.

A Simplified Novel Approach for Total Laparoendoscopic Single-Site (LESS) Hysterectomy

Total laparoendoscopic single-site (LESS) hysterectomy is a technically challenging minimally-invasive gynecologic procedure. Multiple technological innovations assist surgeons to overcome the challenges that are usually encountered during this advanced approach. Simplifying the steps of this advanced surgery is an invaluable addition in overcoming associated challenges with this procedure. We present our novel technique for a total laparoscopic hysterectomy that will optimize a single-site approach (LESS) for surgeons.

A novel acoustic catheter stethoscope based acquisition and signal processing framework to extract multiple bio signals

In this study, a novel acoustic stethoscope based on an intravenous catheter was introduced to measure vascular pressures from a Yorkshire pig. Our hypothesis is that by means of this single device (measurement system) and by applying signal analysis and processing framework, multiple vital bio signals can be extracted. In contrast, current conventional state-of-the-art technologies use multiple devices to provide the same information. The framework used to extract these bio signals consisted of a noise cancellation technique and wavelet based source separation. The preliminary results obtained from the acquired pressure data revealed the presence of acoustic heart and respiratory pulses. Finally, the computed heart and respiratory rates were benchmarked with actual values measured using conventional devices to validate our hypothesis.

Evaluation of patient preparedness for surgery: a randomized controlled trial

BACKGROUND

Patient preparedness for pelvic reconstructive surgery has important implications for patient satisfaction and the perception of improvement after surgery. The ideal method in which to optimally prepare patients for surgery has not been determined.

OBJECTIVE

The objective of the study was to evaluate the impact of a preoperative patient education video on patient preparedness prior to sacrocolpopexy as measured by a preoperative preparedness questionnaire.

STUDY DESIGN

We performed a single-blind, randomized, stratified clinical trial at a single academic center evaluating the use of a preoperative patient education video as an adjunct to preoperative counseling on patient preparedness. Eligible patients presenting for their preoperative appointment prior to undergoing pelvic reconstructive surgery were randomized to watch a preoperative video vs usual care. Preoperative questionnaires assessing patient preparedness, understanding, perception of time, and actual time spent with a health care team were administered at the end of this visit. The primary outcome was patient preparedness for pelvic reconstructive surgery as measured by a preoperative preparedness questionnaire. Secondary outcomes included actual time spent during the physician-patient encounter, perception of time spent with the health care team, and identification of patient factors associated with patient preparedness.

RESULTS

Of the total 100 recruited patients, 52 were randomized to the video group and 48 to the usual-care group. The use of the video did not increase overall patient preparedness (71.1% with video vs 68.8% usual care, P = .79) prior to surgery. The use of the video did not decrease the amount of time spent during the physician-patient encounter (16.9 ± 5.6 min vs 17.1 ± 5.4 min, P = .87). There was a significant association between patient preparedness and perception that the health care team spent sufficient time with the patient (89.5% vs 10.5%; P < .001), but no association was observed between preparedness and actual time spent (17.4 ± 5.4 min vs16.5 ± 5.5 min, P = .47). Those with a history of a previous surgery (82.1% vs 33.3%, P = .002) and those with more significant apical prolapse (0.6 ± 4.6 vs -1.6 ± 3.9, P = .05) were more likely to report feeling prepared for surgery.

CONCLUSION

The majority of patients undergoing pelvic surgery at our institution felt prepared prior to undergoing surgery. The use of preoperative education video did not increase overall patient preparedness for surgery. Greater preparedness was associated with patient perception of how much time the health care team spent with the patient but not actual time spent.

Demonstration of a box-stitch technique for laparoscopic uterosacral ligament suspension

AIM

We demonstrate a novel box stitch technique of laparoscopic post-hysterectomy uterosacral ligament suspension for apical prolapse in restorative pelvic reconstructive surgery.

MATERIAL AND METHODS

We present a case of a 58yo female with symptomatic stage III pelvic organ prolapse with a history of a total abdominal hysterectomy 30 years prior. She strongly desired the usage of no synthetic or biologic mesh for her restorative surgical repair. This video provides a step-by-step guide on how to perform a laparoscopic box stitch as a technique for uterosacral ligament suspension as an apical native tissue option for patients with the need for post hysterectomy apical prolapse.

CONCLUSION

This video demonstrates a novel box-stitch technique of laparoscopic post-hysterectomy uterosacral ligament suspension as a native tissue option for minimally invasive reconstructive surgery. The procedure is a reasonable option to address apical prolapse in patients who do not desire or who are unable to have synthetic or biologic mesh placed for restorative reconstructive prolapse surgery.

Automatic vertebra segmentation on dynamic magnetic resonance imaging

The automatic extraction of the vertebra's shape from dynamic magnetic resonance imaging (MRI) could improve understanding of clinical conditions and their diagnosis. It is hypothesized that the shape of the sacral curve is related to the development of some gynecological conditions such as pelvic organ prolapse (POP). POP is a critical health condition for women and consists of pelvic organs dropping from their normal position. Dynamic MRI is used for assessing POP and to complement clinical examination. Studies have shown some evidence on the association between the shape of the sacral curve and the development of POP. However, the sacral curve is currently extracted manually limiting studies to small datasets and inconclusive evidence. A method composed of an adaptive shortest path algorithm that enhances edge detection and linking, and an improved curve fitting procedure is proposed to automate the identification and segmentation of the sacral curve on MRI. The proposed method uses predetermined pixels surrounding the sacral curve that are found through edge detection to decrease computation time compared to other model-based segmentation algorithms. Moreover, the proposed method is fully automatic and does not require user input or training. Experimental results show that the proposed method can accurately identify sacral curves for nearly 91% of dynamic MRI cases tested in this study. The proposed model is robust and can be used to effectively identify bone structures on MRI.

Implementation of the Needs Assessment Tool for patients with interstitial lung disease (NAT:ILD): facilitators and barriers

A Needs Assessment Tool (NAT) was developed previously to help clinicians identify the supportive/palliative needs of people with interstitial lung disease (ILD) (NAT:ILD). This letter presents barriers and facilitators to clinical implementation. Data from (1) a focus group of respiratory clinicians and (2) an expert consensus group (respiratory and palliative clinicians, academics, patients, carers) were analysed using Framework Analysis. Barriers related to resources and service reconfiguration, and facilitators to clinical need, structure, objectiveness, flexibility and benefits of an ‘aide-memoire’. Identified training needs included communication skills and local service knowledge. The NAT:ILD was seen as useful, necessary and practical in everyday practice.

CrossFitter’s knee: patellofemoral chondral injury following high-intensity functional training

We present a case series of patients with patellofemoral joint (PFJ) chondral injuries presenting as anterior knee pain secondary to participation in high-intensity functional training programmes. We aim to highlight PFJ chondral injuries as a potential complication of military servicemen engaging in high-intensity functional training programmes. This may allow medical staff to identify the injuries early, and highlight this possible injury mechanism to Physical Training staff to help educate participants and mitigate the risk of injury.

Trends of Bilateral Salpingectomy During Vaginal Hysterectomy With and Without Laparoscopic Assistance Performed for Benign Indications in the United States

STUDY OBJECTIVE

To estimate the recent temporal trends of concurrent bilateral salpingectomy (BS) during vaginal hysterectomy (total vaginal hysterectomy [TVH] and laparoscopic-assisted vaginal hysterectomy [LAVH]) in the United States.

DESIGN

A cross-sectional analysis was conducted using data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample, including all female patients 18 years and older whose inpatient discharge record indicated a TVH or LAVH performed for benign indications between January 1, 1998, and December 31, 2011. Joinpoint regression was used to identify statistically significant changes in overall and subgroup temporal trends of TVH and LAVH as well as concomitant BS during the 14-year study period (Canadian Task Force Classification II).

SETTING

Not applicable.

PATIENTS

All patients who underwent TVH and LAVH from 1998 to 2011 registered in the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database.

INTERVENTIONS

Not applicable.

MEASUREMENTS AND MAIN RESULTS

Regarding TVH, between 1998 and 2001, there was a steep negative trend with an annual percentage change of -5.2 (95% confidence interval [CI], -8.8 to -2.2). From 2001 to 2011, the negative trend was still observed but with a more gradual 2% annual decrease (95% CI, -2.4 to -1.3). Conversely, the rate of LAVH increased at a rate of 4.4% each year (95% CI, 3.7-5.0). From 1998 to 2004, the national rate of BS during TVH increased sharply with an annual increase of 42.8% (95% CI, 22.7-66.3). Beginning in 2004, the BS rate during TVH decreased and remained stable. During LAVH, the rate of concomitant BS increased an estimated 15% each year during the entire study period (95% CI, 11.9-17.8).

CONCLUSION

The proportion of annual LAVH with concomitant BS procedures performed across the nation is on the rise while TVH is declining with a stable rate of concomitant BS.

Automated tracking, segmentation and trajectory classification of pelvic organs on dynamic MRI

Pelvic organ prolapse is a major health problem in women where pelvic floor organs (bladder, uterus, small bowel, and rectum) fall from their normal position and bulge into the vagina. Dynamic Magnetic Resonance Imaging (DMRI) is presently used to analyze the organs' movements from rest to maximum strain providing complementary support for diagnosis. However, there is currently no automated or quantitative approach to measure the movement of the pelvic organs and their correlation with the severity of prolapse. In this paper, a two-stage method is presented to automatically track and segment pelvic organs on DMRI followed by a multiple-object trajectory classification method to improve the diagnosis of pelvic organ prolapse. Organs are first tracked using particle filters and K-means clustering with prior information. Then, they are segmented using the convex hull of the cluster of particles. Finally, the trajectories of the pelvic organs are modeled using a new Coupled Switched Hidden Markov Model (CSHMM) to classify the severity of pelvic organ prolapse. The tracking and segmentation results are validated using Dice Similarity Index (DSI) whereas the classification results are compared with two manual clinical measurements. Results demonstrate that the presented method is able to automatically track and segment pelvic organs with a DSI above 82% for 26 out of 46 cases and DSI above 75% for all 46 tested cases. The accuracy of the trajectory classification model is also better than current manual measurements.

Leucocyte depleting filters and cardiothoracic surgery

Leucocyte filtration technology is now beginning to be used in cardiothoracic surgery. The leucocyte depletion of banked homologous blood has been shown to reduce its immunosuppressive effects, along with a range of other benefits. Use of such a blood product appears to be an attractive option during cardiopulmonary bypass (CPB) as this procedure is recognized as causing immune disturbance and long-term immunosuppression.

White-cell removal filters also appear to have a novel application in the reduction of neutrophil-mediated damage associated with CPB procedures. A strong database from animal work has been recently supplemented by human data that shows clinical benefits from autologous white-cell removal by filtration.

Estimated levator ani subtended volume: a novel assay for predicting surgical failure after uterosacral ligament suspension

BACKGROUND

Levator ani muscle complex plays an important role in pelvic support and defects or laxity in this muscle complex contributes to pelvic organ prolapse and recurrence after surgical repair.

OBJECTIVE

The purpose of this study was to determine whether estimated levator ani subtended volume can predict surgical outcomes for laparoscopic bilateral uterosacral ligament suspension.

STUDY DESIGN

A retrospective cohort study was performed in patients who underwent laparoscopic uterosacral ligament suspension from 2010-2012. Only patients with a preoperative pelvic magnetic resonance image were included. Surgical failure was defined as a composite score that included the presence of anatomic bulge beyond the hymen with sensation of vaginal bulge or repeat treatment for prolapse via pessary or surgery by 1-year follow-up evaluation. Standard protocol pelvic magnetic resonance imaging measurements pubococcygeal line, H-line, and M-line were collected along with the calculation of the width of the levator ani hiatus. Estimated levator ani subtended volume was calculated for each subject. An optimal cutoff point was calculated and compared against categoric values of surgical success/failure. A Fisher exact test, an area under receiver operating characteristics curve, and logistic regression analysis were performed. A probability value of <.05 was considered statistically significant.

RESULTS

Ninety-three women underwent laparoscopic bilateral uterosacral ligament suspension during study period. Of these, 66 women had a standardized preoperative pelvic magnetic resonance image per institutional protocol. Thirteen patients (19.6%) met the criteria for surgical failure by 1 year. An optimal cutoff point of 38.5 was calculated by Liu's method for optimization. Among the patients with defined surgical failures, 84.6% (11/13) had an estimated levator ani subtended volume above cutoff point of 38.5. Among the patients with defined surgical success, 39.6% (21/53) had an estimated levator ani subtended volume above the cutoff point (84.6% vs 39.6%; P = .0048) with a significant odds ratio of 8.38 (95% confidence interval, 1.69-41.68; P = .009). An area under receiver operating characteristics curve of 0.725 (95% confidence interval, 0.603-0.847), sensitivity of 84.6% (95% confidence interval, 54.6%-98.1%), and specificity of 60.4% (95% confidence interval, 46%-73.5%) at 38.5 were predictors of surgical success/failure by 1 year. Logistic regression analysis demonstrated no significant confounders among age, body mass index, stage, or parity.

CONCLUSIONS

Estimated levator ani subtended volume may predict surgical failure for laparoscopic bilateral uterosacral ligament suspension. Patients with a calculated estimated levator ani subtended volume above 38.5 on a preoperative pelvic magnetic resonance imaging were associated with an increased risk for surgical failure by 1 year, regardless of age, body mass index, stage, or parity. Future investigation that will include repeatability, reliability analysis, and a prospective study is warranted.

Barbed Sutures in Minimally Invasive Gynecologic Surgery

The introduction of knotless barbed suture into the surgical market has decreased the challenges of laparoscopic suturing. Since its introduction, barbed suture has gained popularity in the field of minimally invasive gynecologic surgery and is now commonly used to close the vaginal cuff in total laparoscopic hysterectomy, to re-approximate the myometrium after laparoscopic myomectomy, and to shorten the procedure time during a laparoscopic sacrocolpopexy. Barbed sutures facilitate rapid and consistent wound closure, allowing for equal distribution of tissue tension across the suture line, and thereby providing a more secure wound closure. The most commonly encountered complication after the use of barbed sutures is postoperative bowel obstruction. Proposed methods to decrease the likelihood of this complication include ensuring that the ends of the barbed suture are either buried, over-sewn, or cut flush with the tissue.

Does Laparoscopic Hysterectomy Increase the Risk of Vaginal Cuff Dehiscence? An Analysis of Outcomes from Multiple Academic Centers and a Review of the Literature

Vaginal cuff dehiscence represents a serious, but infrequent complication after hysterectomy, with a reported increased incidence following a laparoscopic approach. Various risk factors have been proposed including laparoscopically placed suture, surgical experience, use of electrosurgery, surgical indication, and obesity. Technical aspects of the procedure itself have also been questioned such as the variable use of monopolar electrosurgery during colpotomy and the suture type or number of layers chosen to reapproximate the vaginal cuff. Nothwithstanding the tendency for cuff dehiscence to occur following laparoscopic approach, there remains a paucity of high-quality data that supports or refutes this finding or clearly defines the mechanism(s) by which this event occurs allowing for the proposal of objective guidelines for reducing risk. Various techniques have been proposed to decrease the risk of vaginal cuff dehiscence during endoscopic hysterectomy, including use of monopolar current on cutting mode, achievement of cuff hemostasis with sutures rather than electrocoagulation, use of a two-layer cuff closure with polydioxanone suture, and use of bidirectional barbed suture for cuff closure. The authors experience at three university-based minimally invasive gynecologic surgery programs showed a low rate of vaginal cuff dehiscence in their own practices. Large randomized controlled trials are needed to truly determine whether there is a difference in vaginal cuff dehiscence between surgical modalities for hysterectomy as well as to determine the true risk factors.

National trends of adnexal surgeries at the time of hysterectomy for benign indication, United States, 1998-2011

OBJECTIVE

We sought to investigate the most recent national trends of bilateral salpingectomy (BS) and bilateral salpingo-oophorectomy (BSO) at the time of hysterectomy performed for benign indications.

STUDY DESIGN

We conducted a national cross-sectional analysis of all inpatient discharges for women aged ≥18 years who underwent a hysterectomy for benign indications from 1998 through 2011 using the largest publicly available all-payer inpatient database in the United States. We scanned International Classification of Diseases, Ninth Revision codes for an indication of specific bilateral adnexal surgeries, including BSO and BS. Joinpoint regression was used to characterize and estimate 14-year national trends in performing BSO and BS at the time of hysterectomy for benign indications, overall and in population subgroups.

RESULTS

During the study period, there were approximately 428,523 inpatient hysterectomy procedures performed annually for benign indications. Of these, >53% had no adnexal surgery performed during the same hospitalization, whereas 43.7% and 1.3% of those discharges had BSO and BS procedures, respectively. The rate of BSO was directly correlated with increasing age for patients <65 years. Conversely, we observed an inverse relationship between BS and patient age, with the BS rate among women aged <25 years twice that of women aged ≥45 years. From 1998 through 2001, there was a 2.2% increase in the rate of BSO per year (95% confidence interval, 0.4-4.0); however, this was followed by a consistent 3.6% (95% confidence interval, -4.0 to -3.3) annual decline in the BSO rate, from 49.7% in 2001 to 33.4% in 2011. National rates of BS among women undergoing hysterectomy for benign indications increased significantly throughout the study period, with an estimated 8% annual increase from 1998 through 2008, followed by a sharp 24% increase annually during the last 4 years of the study period. The BS rate nearly quadrupled in 14 years.

CONCLUSION

The type of adnexal surgery performed concomitantly with hysterectomy for benign indications has undergone a significant shift since 2001. Significantly more BS and less BSO procedures are being performed among gynecologic surgeons in the United States.

MRI-based segmentation of pubic bone for evaluation of pelvic organ prolapse

Pelvic organ prolapse (POP) is a major women's health problem. Its diagnosis through magnetic resonance imaging (MRI) has become popular due to current inaccuracies of clinical examination. The diagnosis of POP on MRI consists of identifying reference points on pelvic bone structures for measurement and evaluation. However, it is currently performed manually, making it a time-consuming and subjective procedure. We present a new segmentation approach for automating pelvic bone point identification on MRI. It consists of a multistage mechanism based on texture-based block classification, leak detection, and prior shape information. Texture-based block classification and clustering analysis using K-means algorithm are integrated to generate the initial bone segmentation and to identify leak areas. Prior shape information is incorporated to obtain the final bone segmentation. Then, the reference points are identified using morphological skeleton operation. Results demonstrate that the proposed method achieves higher bone segmentation accuracy compared to other segmentation methods. The proposed method can also automatically identify reference points faster and with more consistency compared with the manually identified point process by experts. This research aims to enable faster and consistent pelvic measurements on MRI to facilitate and improve the diagnosis of female POP.

Automated Localization of Multiple Pelvic Bone Structures on MRI

In this paper, we present a fully automated localization method for multiple pelvic bone structures on magnetic resonance images (MRI). Pelvic bone structures are at present identified manually on MRI to locate reference points for measurement and evaluation of pelvic organ prolapse (POP). Given that this is a time-consuming and subjective procedure, there is a need to localize pelvic bone structures automatically. However, bone structures are not easily differentiable from soft tissue on MRI as their pixel intensities tend to be very similar. In this paper, we present a model that combines support vector machines and nonlinear regression capturing global and local information to automatically identify the bounding boxes of bone structures on MRI. The model identifies the location of the pelvic bone structures by establishing the association between their relative locations and using local information such as texture features. Results show that the proposed method is able to locate the bone structures of interest accurately (dice similarity index >0.75) in 87-91% of the images. This research aims to enable accurate, consistent, and fully automated localization of bone structures on MRI to facilitate and improve the diagnosis of health conditions such as female POP.