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OBJECTIVE To examine the prevalent understanding of and management approaches to chronic endometritis among obstetricians/gynecologists. METHODS In a cross-sectional observational study, 262 members of national and international professional obstetrician/gynecologist societies were surveyed via anonymous electronic survey that investigated knowledge of the pathophysiology, diagnostic criteria, clinical implications, and treatment strategies for chronic endometritis. Statistical analyses of results were performed using Fisher's exact tests, chi square tests and odds ratios with 95% confidence intervals. A two-sided P

Although visual estimate of urine output via urimeter bag is common, data on accuracy are limited.This study aimed to assess the accuracy of a visual estimate of urine output in standard urimeter bags by health care workers.This is a prospective observational study. Perioperative health care workers were asked to visually estimate fluid volumes in 5 standard urimeter bags. Actual volumes were 50, 150, 350, 500, and 750 mL. Visual estimates were recorded. The primary outcome was accuracy, defined as estimated visual volume within 20% of actual volume. Secondary outcomes included effect of health care provider type, specialty, experience, sex, and age on accuracy.A total of 159 responses were analyzed. There were 55 (35.3%) registered nurses, 19 (12.2%) certified registered nurse anesthetists, 18 (11.5%) advanced practice providers not identified as a certified registered nurse anesthetist, and 64 (41%) physicians. Mean estimated volumes (in milliliters) ± standard deviation and accuracy for the bags were as follows: (a) actual volume of 50 mL and estimated volume of 66 ± 29 mL (45% accuracy), (b) actual volume of 150 mL and estimated volume of 149 ± 43 mL (46% accuracy), (c) actual volume of 350 mL and estimated volume of 356 ± 74 mL (76% accuracy), (d) actual volume of 500 mL and estimated volume of 452 ± 77 mL (85% accuracy), and (e) actual volume of 750 mL and estimated volume of 675 ± 108 mL (85% accuracy). There was reasonable accuracy for individual volume estimates, but accuracy across all 5 urimeter bags was low: 22 of 159 (13.8%). There were no significant differences in accuracy based on health care provider type, specialty, experience, sex, or age.Consistent accuracy of visual assessment of calibrated urimeter bag volumes was low and not influenced by health care provider characteristics.

Background: Vaginal cuff dehiscence with abdominal content evisceration is typically a surgical emergency. Case: A 45-year-old woman with a history of vaginal hysterectomy, anterior/posterior repai...

Posterior compartment surgery is considered a risk factor for postoperative urinary retention because of the impact of postoperative pain on the pelvic floor; however, few studies have examined the association between posterior compartment reconstructive surgery and urinary retention.The aim of the study was to compare rates of urinary retention in patients undergoing vaginal reconstructive surgery, without hysterectomy, in the posterior compartment only versus any apical and/or anterior compartment (with or without posterior compartment).In this retrospective cohort study, we evaluated patients who underwent surgery, without hysterectomy, in the posterior compartment only versus any apical and/or anterior compartment (with or without posterior compartment) from January 2015 to November 2020. Our primary outcome was rate of postoperative urinary retention, defined as a failed voiding trial before discharge. Secondary outcome was days of catheterization. Multivariable logistic regression was performed to assess variables associated with a failed voiding trial.Of 362 patients, 141 (39.0%) underwent surgery in the posterior compartment only and 221 (61.0%) underwent vaginal apical and/or anterior compartment surgical procedures. Rate of retention was significantly lower in the posterior compartment only group (9.9% vs 41.6%, P0.001). The median numbers of days of catheterization were significantly fewer in the posterior compartment only group (0 [0,0] vs 0 [0,3], P0.001). In multivariable logistic regression, posterior compartment only surgery was associated with passing the voiding trial (odds ratio, 6.0; 95% confidence interval, 2.97-12.03).Rates of postoperative urinary retention after surgery in the posterior compartment are low, and these patients may not require formal voiding trials after surgery.

Background Addison's disease is an uncommon condition encountered during pregnancy; however, pregnant patients with Addison's disease are at higher risk for multiple pregnancy related complications. Treatment during pregnancy involves steroid replacement therapy. Case report A 34-year-old previously healthy G2P1001 presented with lethargy, skin hyperpigmentation, polyuria, and salt craving. Laboratory evaluation showed hyperkalemia, hyponatremia, elevated ACTH, and low cortisol. The patient terminated the pregnancy due to her symptoms. She was then placed on a regimen of hydrocortisone and fludrocortisone, leading to symptom resolution. On second presentation as a G5P1031, her Addison's disease was managed with hydrocortisone and fludrocortisone. When Addison's symptoms recurred, ACTH levels were checked to determine if her current medications could be optimized. She ultimately delivered a healthy male infant vaginally. For her third presentation as a G6P2032, her pregnancy was managed in a similar manner to the previous pregnancy. Conclusion There is currently minimal cohesive literature on the management of Addison's disease during pregnancy. Patients can be managed successfully by monitoring for recurrence of Addison's symptoms and adjusting medication dosing as needed.

There are limited data comparing patient and operative characteristics for vaginal repair of vesicovaginal fistula (VVF) by surgeon specialty. Our objective was to compare national practice patterns by surgeon specialty for vaginal repair of VVF.Using the American College of Surgeons National Surgical Quality Improvement Program database, we conducted a retrospective cohort analysis of women who underwent vaginal repair of VVF from 2010 to 2019. Demographic and perioperative characteristics were compared by surgeon specialty.A total of 252 women were analyzed. Urologists performed 57% of cases (n=144), gynecologists performed 38% (n=96), and general surgeons performed 5% (n=12). There were differences among surgeon specialties in patient characteristics including age (p=0.002), creatinine (p=0.002), hypertension (p=0.02), morbidity probability (p0.001), hospital stay (p0.001), inpatient status (p=0.03). Urologists were more likely than gynecologists to use grafts/flaps (p=0.002). There were trending differences among surgeon specialties in patient race (p=0.07) and ethnicity (p=0.06). Urologists and gynecologists were more likely to operate on younger, healthier patients with differences in racial populations. When directly comparing urologists with gynecologists, there were differences in race (p=0.05) and a trending difference in ethnicity (p=0.06), General surgeons were more likely to operate on older white women with worse health status, more concomitant procedures, and longer hospital stay.Urologists, gynecologists, and general surgeons perform vaginal repair of VVF. Among these specialties, there were differences in patient and perioperative characteristics. This information may help referring providers and patients to understand which types of surgical providers most commonly manage VVF.

While acute endometritis is a reasonably well-defined entity of ascending infection and attendant active inflammation, chronic endometritis is less well defined. As part of a broad effort to define and refine the diagnostic criteria and management of the disease, we conducted a survey of pathologists to understand the variability in diagnostic criteria and implications of the diagnosis of nonspecific, nonobstetric chronic endometritis. Members of national and international professional pathology societies were surveyed utilizing anonymous electronic surveys designed to examine diagnostic criteria, etiological understanding and treatment implications of a pathologic diagnosis of nonspecific, nonobstetric chronic endometritis. There was substantial variability among pathologists in the diagnostic criteria used for making a diagnosis of nonspecific, nonobstetric chronic endometritis, with 28.5% of pathologists using the presence of a single plasma cell for making the diagnosis. There was additional variability in the use of special stains, reporting in the presence of coexisting lesions and the hormonal stage of the endometrium. There were no differences between generalists and specialists in the diagnostic criteria used, except the significantly greater likelihood of specialists making the diagnosis in gestational endometrium. The substantial variability in diagnostic criteria for nonspecific, nonobstetric chronic endometritis among pathologists, including among gynecologic pathologists, has the potential to confound the management of patients. Standardization of diagnostic criteria for chronic endometritis is essential to understand the implications of the diagnosis.

Study Objective To assess whether a robotic simulation curriculum for novice surgeons can improve performance of a suturing task in a live porcine model. Design Randomized controlled trial (Canadian Task Force classification I). Setting Academic medical center. Patients Thirty-five medical students without robotic surgical experience. Interventions Participants were enrolled in an online session of training modules followed by an in-person orientation. Baseline performance testing on the Mimic Technologies da Vinci Surgical Simulator (dVSS) was also performed. Participants were then randomly assigned to the completion of 4 dVSS training tasks (camera clutching 1, suture sponge 1 and 2, and tubes) versus no further training. The intervention group performed each dVSS task until proficiency or up to 10 times. A final suturing task was performed on a live porcine model, which was video recorded and blindly assessed by experienced surgeons. The primary outcomes were Global Evaluative Assessment of Robotic Skills (GEARS) scores and task time. The study had 90% power to detect a mean difference of 3 points on the GEARS scale, assuming a standard deviation (SD) of 2.65, and 80% power to detect a mean difference of 3 minutes, assuming an SD of 3 minutes. Measurements and Main Results There were no differences in demographics and baseline skills between the 2 groups. No significant differences in task time in minutes or GEARS scores were seen for the final suturing task between the intervention and control groups, respectively (9.2 [2.65] vs 9.9 [2.07] minutes, p = .406; and 15.37 [2.51] vs 15.25 [3.38], p = .603). The 95% confidence interval for the difference in mean task times was –2.36 to .96 minutes and for mean GEARS scores −1.91 to 2.15 points. Conclusions Live suturing task performance was not improved with a proficiency-based virtual reality simulation suturing curriculum compared with standard orientation to the da Vinci robotic console in a group of novice surgeons.

Objective To determine the frequency of maternity health employee experiences with maternal and perinatal/neonatal adverse outcomes and gain a deeper understanding of how these experiences impact the providers. Design Single-institution observational study from 2016. Setting The George Washington University Hospital. Population Labor and delivery, postpartum, and neonatal intensive care staff. Methods An anonymous survey was distributed to maternity staff inquiring about feelings surrounding maternal and perinatal/neonatal adverse outcomes. Predictors included demographics and job-related variables. Associations were examined using univariable and multivariable analyses. Main Outcome Measures Outcomes included depression, post-traumatic stress disorder symptoms, and work-related problems following the event. Results A total of 105 employees of approximately 230 eligible employees answered the survey, including obstetrics and gynecology and anesthesia physicians (residents and attendings), midwives, nurses, nurse practitioners, and medical technicians with a response rate of 46%. Being a physician was protective against symptoms of depression and post-traumatic stress disorder symptoms. Resident physicians had higher levels of anxiety/depression compared to attendings. Statistically significant variables predictive of negative repercussions included non-physician status (p=.045), substance use (p=.0036), considering a career change (p

To determine the association of operative time (ORT) with perioperative morbidity and whether there is an ORT at which minimally invasive myomectomy becomes inferior to laparotomy.Retrospective cohort study.Not applicable.Myomectomy cases identified by CPT code from 2005 to 2016.Cases were stratified and analyzed by surgical approach and 90-minute intervals.Thirty-day postoperative morbidity.A total of 11,709 myomectomies were identified; 4,673 (39.9%) were minimally invasive, 6,997 (59.8%) were abdominal, and 39 (0.3%) were conversions. The incidence of complications significantly increased with ORT. After adjusting for confounders, mean ORT in minutes (95% confidence interval) was 113 (111-115) for abdominal, 156 (153-159) for minimally invasive, and 172 (148-200) for conversions. Despite shorter ORT, morbidity was greater in abdominal cases (16% vs. 5.7%), with the highest rates in converted cases (20.5%). The minimally invasive approach in general had lower odds of complications (odds ratio, 0.23; 95% confidence interval, 0.19-0.26). However, when minimally invasive surgery ORT reached ≥ 270 minutes, the odds of a composite complication variable increased compared with abdominal cases90 minutes (odds ratio, 2.30; 95% confidence interval, 1.69-3.13). Of minimally invasive cases, 88% were completed in270 minutes.ORT was predictive of complications for both minimally invasive and abdominal myomectomies. Despite longer ORTs, minimally invasive procedures generally had superior 30-day outcomes up to 270 minutes. Careful patient counseling and preparation to increase surgical efficiency should be prioritized for either approach.

While laparoscopic hysterectomy has benefits compared to abdominal hysterectomy, the operative times are longer. Longer operative times have been associated with negative outcomes. This study’s purpose was to elucidate if there is an operative time at which 30-day outcomes for laparoscopic hysterectomy become inferior to a more expeditiously completed abdominal hysterectomy. This was a retrospective cohort study (Canadian Task Force classification II-2) using the American College of Surgeons National Surgical Quality Improvement Program database to identify women undergoing hysterectomy for benign indications from 2010 to 2016 by current procedural terminology code. Hysterectomy cases were stratified by approach and 60-min intervals. 30-day post-operative outcomes were analyzed by operative time and approach. 109,821 hysterectomies were included in our analysis, of which 66,560 (61%) were laparoscopic, and 43,261 (39%) were abdominal. In a multivariable logistic regression analysis comparing outcomes by surgical approach and operative time, there was no time combination in which patients who had a abdominal hysterectomy had significantly lower odds of the composite complications variable. This was true even in laparoscopic hysterectomies greater than 240 min compared to abdominal hysterectomies completed between 20 and 60 min. When compared to laparoscopic hysterectomies greater than 240 min, abdominal hysterectomies between 20 and 60 min had lower odds of sepsis and abdominal hysterectomies less than 180 min had lower odds of urinary tract infection. Given that benefits persist even in prolonged cases, a laparoscopic approach should be offered to most patients undergoing benign hysterectomy. Surgical efficiency should be prioritized for any surgical approach.

To foster medical students to become physicians who will be lifelong independent learners and critical thinkers with healthy skepticism and provide high-quality patient care guided by the best evidence, teaching of evidence-based medicine (EBM) has become an important component of medical education. Currently, the teaching and learning of biochemistry in medical schools incorporates its medical relevance and applications. However, to our knowledge there have been no reports on integrating EBM with teaching and learning medical biochemistry. Here, we present a case study to illustrate the significance of this approach. This case study was based on a biochemistry/nutrition question in a popular board review book about whether a homeless alcoholic man is at risk of developing a deficiency of vitamin E. The possible answers and explanation provided in the book raised a question about the correct answer, which provided us with an opportunity to adapt the philosophy and certain basic EBM principles to find evidence for the clinical applicability of a commonly taught biochemistry topic. The outcome of this case study not only taught us how to conduct an EBM exercise to answer a specific patient question, but also provided us with an opportunity for in-depth teaching and learning of the medical relevance of a specific biochemistry topic based on the best clinical evidence obtained from a systematic research of medical literature.

There is a very high prevalence of vitamin D deficiency, which is defined by a serum level of 25-hydroxyvitamin D [25(OH)D] of lower than 20 ng/mL, in all populations of the world. Unfortunately, the prevalence of vitamin D deficiency in patients with intestinal malabsorption syndromes, including cystic fibrosis (CF), celiac disease (CD), short bowel syndrome and inflammatory bowel disease (IBD), is higher than that in the general population, indicating the presence of disease-specific causative factors. In this review, we aimed to present clinical findings to highlight the roles of insufficient exposure to sunlight and inflammation in the development of vitamin D deficiency in patients with intestinal malabsorption syndromes. Furthermore, we aimed to present experimental evidence that supported a role of vitamin D deficiency in the pathogenesis of IBD. Finally, we reviewed clinical intervention strategies aiming to normalize vitamin D status in and even to improve the conditions of patients and to discuss certain issues that needed to be addressed in future research.

We present a case of lipoatrophy treated successfully with intralesional normal saline injections. Localized lipodystrophy, or lipoatrophy, presents as focal loss of subcutaneous fat with variable overlying skin changes and depth depending on the cause. Lipoatrophy could result from both oral and local intralesional corticosteroid use, with the buttocks and proximal extremities being the most commonly affected sites with oral use.1 Minimal literature exists about corticosteroid-induced lipoatrophy. Localized reactions to injected corticosteroids are thought to occur in less than 0.5% of cases, which primarily include hemorrhage, atrophy, secondary infection, changes in pigment, hypersensitivity reactions, and panniculitis.2 The observed lipoatrophy typically begins 2 to 3 months after injection and can resolve spontaneously.3 Here we report a case of acquired localized lipodystrophy, which results mostly in cosmetic concerns but has limited treatment options to offer patients.4 We describe the technique for intralesional saline injections to assist clinicians in use of this treatment. Success of this technique has been previously described, and our case report confirms this previous report3 but uses different time intervals between injections.

Clinical findings have shown that approximately 40% of patients with pancreatitis, acute or chronic, have severe vitamin D deficiency; this can reach up to 60% of patients with chronic pancreatitis. These findings raise an important question: Is vitamin D deficiency a cause or a result of pancreatitis? The answer(s) to this question is clinically important given that high oral doses of vitamin D supplementation are widely prescribed for individuals with vitamin D deficiency. Considering that there is active conversion of 25(OH)D3 to 1,25(OH)2D3 by activated macrophages in tissues undergoing inflammation, that elevation of the blood levels of 1,25(OH)2D3 levels can cause hypercalcemia, that hypercalcemia can precipitate pancreatitis, that excessive use of vitamin D supplementation can cause acute pancreatitis and that sarcoidosis causes elevated blood levels of 1,25(OH)2D3, hypercalcemia and acute pancreatitis, it is reasonable to consider both 25(OH)D3 and 1,25(OH)2D3 as negative acute-phase reactants, specifically in the context of the pathogenesis of pancreatitis. Thus, down-regulation of blood levels of 25(OH)D3 and 1,25(OH)2D3 in patients with pancreatitis appears to be a protective mechanism to prevent the development hypercalcemia, which would exacerbate the pancreatitis. Therefore, it is reasonable to consider that vitamin D replacement treatment may produce more harm than benefit for patients with pancreatitis.

To foster medical students to become physicians who will be lifelong independent learners and critical thinkers with healthy skepticism and provide high-quality patient care guided by the best evidence, teaching of evidence-based medicine (EBM) has become an important component of medical education. Currently, the teaching and learning of biochemistry in medical schools incorporates its medical relevance and applications. However, to our knowledge there have been no reports on integrating EBM with teaching and learning medical biochemistry. Here, we present a case study to illustrate the significance of this approach. This case study was based on a biochemistry/nutrition question in a popular board review book about whether a homeless alcoholic man is at risk of developing a deficiency of vitamin E. The possible answers and explanation provided in the book raised a question about the correct answer, which provided us with an opportunity to adapt the philosophy and certain basic EBM principles to find evidence for the clinical applicability of a commonly taught biochemistry topic. The outcome of this case study not only taught us how to conduct an EBM exercise to answer a specific patient question, but also provided us with an opportunity for in-depth teaching and learning of the medical relevance of a specific biochemistry topic based on the best clinical evidence obtained from a systematic research of medical literature.

There is a very high prevalence of vitamin D deficiency, which is defined by a serum level of 25-hydroxyvitamin D [25(OH)D] of lower than 20 ng/mL, in all populations of the world. Unfortunately, the prevalence of vitamin D deficiency in patients with intestinal malabsorption syndromes, including cystic fibrosis (CF), celiac disease (CD), short bowel syndrome and inflammatory bowel disease (IBD), is higher than that in the general population, indicating the presence of disease-specific causative factors. In this review, we aimed to present clinical findings to highlight the roles of insufficient exposure to sunlight and inflammation in the development of vitamin D deficiency in patients with intestinal malabsorption syndromes. Furthermore, we aimed to present experimental evidence that supported a role of vitamin D deficiency in the pathogenesis of IBD. Finally, we reviewed clinical intervention strategies aiming to normalize vitamin D status in and even to improve the conditions of patients and to discuss certain issues that needed to be addressed in future research.