bluuebunny/crossref_metadata_2025 huggingface dataset:
Defining Failed Induction of Labor
Authors: Grobman W.A. , Bailit J. , Lai Y. , Reddy U.M. , Wapner R.J. , Varner M.W. , Thorp J.M. , Leveno K.J. , Caritis S.N. , Prasad M. , Tita A.T.N. , Saade G. , Sorokin Y. , Rouse D.J. , Blackwell S.C. , Tolosa J.E. ,   for the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network
Published: November 2018

(Am J Obstet Gynecol. 2018;218:122.e1–122.e8)

Labor is induced in approximately a quarter of pregnant women. When a laboring patient spends an extended period of time in the latent phase, clinicians must decide whether it would be beneficial to continue labor. There is no consensus on the criteria for labeling labor as “failed,” which is important in decreasing unnecessary cesarean deliveries. This study aimed to analyze the maternal and neonatal outcomes associated with the length of the latent phase of labor in a large population of nulliparous women.
Maternal Body Mass Index as a Predictor for Delivery Method
Authors: Pettersen-Dahl A. , Murzakanova G. , Sandvik L. , Laine K.
Published: November 2018

(Acta Obstet Gynecol Scand. 2018;97:212–218)

The risk of complications during pregnancy and delivery—such as gestational diabetes, preeclampsia, need for labor induction or cesarean delivery, macrosomia, shoulder dystocia, and admission to the neonatal intensive care unit—increases with maternal obesity [body mass index (BMI) ≥30]. The objective of this retrospective register study was to assess the association between maternal prepregnancy BMI and the risk for operative delivery.
Maternal Prepregnancy Obesity and the Risk of Shoulder Dystocia: A Meta-Analysis
Authors: Zhang C. , Wu Y. , Li S. , Zhang D.
Published: November 2018

(BJOG. 2018;125:407–413)

Shoulder dystocia has been reported to affect between 0.1% and 2.4% of pregnancies, and is associated with maternal and fetal complications. While obesity is associated with many adverse pregnancy outcomes, including preeclampsia, postpartum hemorrhage, and cesarean delivery, previous studies examining a link between prepregnancy obesity and shoulder dystocia have yielded conflicting results. This meta-analysis aimed to assess the risk of shoulder dystocia in obese parturients using combined results from all available observational studies.
Vaginal Progesterone for Preventing Preterm Birth and Adverse Perinatal Outcomes in Singleton Gestations With a Short Cervix: A Meta-Analysis of Patient Data
Authors: Romero R. , Conde-Agudelo A. , Da Fonseca E. , O’Brien J.M. , Cetingoz E. , Creasy G.W. , Hassan S.S. , Nicolaides K.H.
Published: November 2018

(Am J Obstet Gynecol. 2018;218(2):161–180)

Approximately 15 million babies worldwide are born preterm every year. A short cervical length has high predictive accuracy for spontaneous preterm birth before 34 weeks’ gestation, and a lower predictive accuracy for spontaneous preterm birth before 37 weeks. A 2012 study found vaginal progesterone was associated with a reduction in risk of preterm birth between <28 weeks gestation and <35 weeks gestation, as well as a reduction in adverse neonatal outcomes, in pregnant women with a short cervix (≤25 mm). In 2016 a randomized controlled trial (RCT) published conflicting results and showed vaginal progesterone did not reduce the risk of preterm birth or perinatal morbidity. This systematic review and meta-analysis aimed to determine whether vaginal progesterone reduced the incidence of preterm birth in women with a singleton gestation and short cervix.
I. ALTERNATIVE METHODS OF ANALGESIA Preoperative Cesarean Delivery Intravenous Acetaminophen Treatment for Postoperative Pain Control: A Randomized Double-blinded Placebo Control Trial
Authors: Towers C.V. , Shelton S. , van Nes J. , Gregory E. , Liske E. , Smalley A. , Mobley E. , Faircloth B. , Fortner K.B.
Published: November 2018

(Am J Obstet Gynecol. 2018;218:353.e1–353.e4)

Most patients first encounter opioid medications after surgery or during an acute pain episode. The ongoing opioid use disorder epidemic in the United States has prompted research to minimize opioid treatment in the postsurgical setting. Nonobstetrical studies have reported improved pain scores and decreased opioid use after surgery with the preoperative administration of intravenous (IV) acetaminophen. The primary outcome in the current study was to examine if maternal opioid use was significantly less in the postoperative period when preoperative IV acetaminophen was given. Secondary outcomes included hospital length of stay, pain scores, and cord blood acetaminophen levels.
II. REGIONAL ANALGESIA Dose-Response Curves for Intrathecal Bupivacaine, Levobupivacaine and Ropivacaine Given for Labor Analgesia in Nulliparous Women
Authors: Ngan Kee W.D. , Ng F.F. , Khaw K.S. , Tang S.P.Y. , Koo A.G.P.
Published: November 2018

(Reg Anesth Pain Med. 2017;42(6):788–792)

As part of the combined spinal-epidural (CSE) technique, bupivacaine, levobupivacaine and ropivacaine are often administered intrathecally to establish labor analgesia with a rapid onset of action. Data on the dose-response relationships of bupivacaine, levobupivacaine and ropivacaine for this purpose are limited. This double-blind, random allocation, graded dose-response study aimed to describe dose-response curves for the intrathecal use of these drugs.
Pharmacokinetics of Levobupivacaine With Epinephrine in Transversus Abdominis Plane Block for Postoperative Analgesia After Caesarean Section
Authors: Lacassie H.J. , Rolle A. , Cortínez L.I. , Solari S. , Corvetto M.A. , Altermatt F.R.
Published: November 2018

(Br J Anaesth. 2018;121:469–475)

Transversus abdominis plane (TAP) block is a technique that provides postcesarean section analgesia and serves as a reasonable alternative for patients who are unable to receive neuraxial morphine. However, it often requires large volumes of local anesthetic, such as levobupivacaine, which has raised concerns about local anesthetic toxicity. Currently, there is a scarcity of information on levobupivacaine pharmacokinetics (PK) after TAP block in pregnant patients. The authors of the present study thus generated a PK model derived with data from pregnant patients after cesarean section and in healthy volunteers and compared levobupivacaine with epinephrine disposition after TAP block in both populations.
Tobacco use results in inferior outcomes after anatomic total shoulder arthroplasty
Authors: Walters Jordan D. , George L. Watson , Wan Jim Y. , Brolin Tyler J. , Azar Frederick M. , Throckmorton Thomas W.
Published: November 2018

Background:

This study examined the effect of tobacco use on outcomes of primary anatomic total shoulder arthroplasty (TSA).

Methods:

A retrospective search identified 59 nonsmokers, 29 former smokers, and 14 current smokers with primary anatomic TSA and at least 2 yr of follow-up. At mean follow-up of 3 yr, patients were assessed with a visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES), and Single Assessment Numeric Evaluation (SANE) scores and range-of-motion testing.

Results:

Smokers were significantly younger than nonsmokers or former smokers; there were no other statistically significant differences. VAS scores were significantly higher in current smokers and ASES scores were significantly lower. Complication rates were 36% in current smokers, 15% in nonsmokers, and 7% in former smokers (P = 0.05).

Conclusions:

Current smokers had significantly worse pain and functional scores and more complications. Former smokers had results similar to nonsmokers, suggesting improved outcomes are possible in patients who quit smoking preoperatively.
Operative Reduction for Developmental Dysplasia of the Hip: Epidemiology Over 16 Years
Authors: Nelson Susan E. , DeFrancesco Christopher J. , Sankar Wudbhav N.
Published: November 2018

Background:

The burden of surgical treatment for infantile developmental dysplasia of the hip (DDH) is unknown. We aimed to investigate the epidemiology of operative DDH reductions in the United States and identify potential at-risk populations.

Methods:

The Healthcare Utilization Project Kids’ Inpatient Database (1997 to 2012) were analyzed. International Classification of Diseases (ICD-9) codes identified inpatient hospitalizations for DDH reductions excluding neuromuscular cases. Hospital variables and patient demographics were captured. Weighted population-level counts were calculated to allow for national estimates.

Results:

An estimated 5525 (95% confidence interval, 4907.8-6142.2) operative reductions were performed. In total, 73.3% were open with a mean age at the reduction of 2.3 years (95% confidence interval, 2.1-2.5). In total, 70.0% were female and 42.3% were white. Regional distribution varied: 36.4% of reductions occurred in the West, 22.8% in the South, 21.9% in the Midwest, and 18.9% in the Northeast. Operative reductions decreased over time; open reductions decreased by 5.6% and closed by 53.4%. Mean age at treatment increased from 1.6 to 3.7 years (P<0.001). On multivariate analysis, age (P<0.001) and geographic location (P<0.05) were associated with open reduction. Patients in the West had increased odds of being Hispanic or Asian/Pacific Islander [odds ratio (OR), 4.9, P<0.001 and OR, 2.8; P=0.008]. In the South and Midwest, the highest income quartile was protective (OR, 0.4; P=0.001 and OR, 0.5; P=0.018).

Conclusions:

The frequency of closed reductions decreased more over time compared with open reductions. However, the mean age of children undergoing reductions increased suggesting a possible delay in diagnosis. The data suggests that there is room for improvement in screening. Targeted research in identified populations may reduce the burden of surgical disease in infantile DDH.

Level of Evidence:

Level III.
The Spatial Order of Physeal Maturation in the Normal Human Knee Using Magnetic Resonance Imaging
Authors: Margalit Adam , Cottrill Ethan , Nhan Derek , Yu Lingjia , Tang Xin , Fritz Jan , Lee R. Jay
Published: November 2018

Background:

The spatial order of physeal maturation around the distal tibia has been shown to place adolescent patients at risk for certain transitional injuries, such as Tillaux or triplane fractures. Less is known about physeal maturation around the knee. The purpose of this study was to establish the spatial order of physeal maturation in the normal human knee using magnetic resonance imaging (MRI).

Methods:

We retrospectively collected all knee MRI scans from patients presenting to our institution from January 2004 to January 2014. Patients who were suspected on the basis of clinical or radiographic findings of having abnormal knee physeal development or injury were excluded. We then applied a previously described MRI staging system of knee physeal maturation to the MRI scans of the remaining patients at 8 defined knee locations. Associations between the stage of maturation and mean chronological age were then evaluated across the 8 knee locations. Interrater and intrarater reliabilities were assessed.

Results:

A total of 165 knee MRI scans (from 98 boys, 67 girls) met the inclusion criteria. Significant differences were found between each stage of physeal maturation and the mean chronological ages at all 8 knee locations for both boys and girls (each, P<0.001). Interestingly, within each stage of physeal maturation, no significant difference was found in the mean chronological ages at any of the 8 knee locations, suggesting that physeal development occurs uniformly in the normal human knee for both boys and girls. Interrater and intrarater reliability were nearly perfect at all locations.

Conclusions:

The spatial order of physeal maturation in the normal human knee was uniform across 8 knee locations for both boys and girls. This uniformity may help to explain why transitional injuries do not follow a recognizable pattern in the knee. Furthermore, the uniformity aids with surgical decision making, because minimal growth modulation or disturbance is likely when early physeal closure is present in a portion of the physis.

Level of Evidence:

Level III.
High Correlation Between Achieved and Expected Distraction Using Magnetically Controlled Growth Rods (MCGR) With Rib to Pelvis Fixation in Pediatric Spine Deformity
Authors: Lorenz Heiko M. , Braunschweig Lena , Badwan Batoul , Groenefeld Katharina , Hecker Marina M. , Tsaknakis Konstantinos , Grote Jasmin , Hell Anna K.
Published: November 2018

Purpose:

Magnetically controlled implant systems have been established to treat severe progressive spinal deformity in children. The purpose of this study was to evaluate (1) the ratio between achieved and expected distraction length, (2) the complication rate and its risk factors as well as (3) the correlation of the distraction length and the length of the spine.

Methods:

A total of 40 patients with an average follow-up of 34 (14 to 57) months were prospectively included in the study. Children underwent lengthening procedures every three months. The ratio between the distraction lengths was determined by comparing the measured distraction length of the rod on radiographs with the distraction length displayed on the external remote controller for the magnetically controlled growing rod (MCGR). Age, weight, height, and complications were repeatedly recorded.

Results:

The analysis of 746 procedures showed the actual distraction to be 94.4% of the expected one. No difference between implants on the concave and convex spinal side was observed. The overall complication rate was 4.6% mainly because of failure of the implant or lack of implant extension, which was directly related to an increased BMI. There was also a strong correlation between achieved implant distraction length and gain in spinal length.

Conclusions:

Our study demonstrates a high ratio (0.94) between achieved and expected distraction length of magnetically controlled spinal rods. The complication rate was low (4.6%) and correlated to a high BMI. The correlation between the achieved implant distraction length and spinal length indicates the efficiency of the MCGR therapy.

Level of Evidence:

Therapeutic Level IV.
A Classification System for Spinal Cord Compression and its Association With Neurological Deficit in Spinal Epidural Abscess
Authors: Shah Akash A. , Yang Huiliang , Harris Mitchel B. , Schwab Joseph H.
Published: November 2018

Study Design:

This was a retrospective case-control study.

Objective:

We aim to describe a novel 5-point grading system to determine the degree and severity of spinal cord compression secondary to a spinal epidural abscess (SEA). Secondarily, we aim to correlate the degree of compression with clinical presentation and outcomes.

Summary of Background Data:

Mechanical compression plays an important role in the pathophysiology of neurological dysfunction in SEA. Unfortunately, no standardized classification system for describing the degree of spinal cord compression exists. The lack of a validated grading system makes it challenging to study and consistently report the relationship between cord compression and clinical presentation/outcomes in SEA.

Materials and Methods:

Patients 18 years and older admitted to our hospital system with a diagnosis of SEA located above the conus medullaris between 1993 and 2016 were included. Using pretreatment axial magnetic resonance images, we developed a 5-point classification scale to determine the degree of spinal cord compression. After assigning a compression grade to each abscess, we investigated the relationship between the degree of compression and presenting neurological symptoms. Furthermore, we assessed the association between compression grade and clinical outcomes.

Results:

Three hundred thirty-nine patients were included in the study. Patients with high-grade cord compression (grades 4 and 5) were significantly more likely to present with pretreatment motor deficit, sensory changes, and bowel/bladder incontinence. With respect to clinical outcomes, increasing degree of compression was not associated with failure of nonoperative management, residual motor deficit, or 90-day mortality.

Conclusions:

We report a novel grading system for spinal cord compression in SEA with 5 progressively increasing grades of compression. High-grade abscesses with cord compression were significantly associated with neurological deficit at presentation but not with poor outcomes. We hope that this classification system will allow for greater consistency in reporting the association between cord compression and neurological deficit in SEA.
Natural killer cell-based immunotherapy: a new fighter against melanoma?
Authors: Urbonas Vincas , Smailyte Giedre , Urbonaite Greta V. , Dulskas Audrius , Burokiene Neringa , Kasiulevicius Vytautas
Published: November 2018

Changes in the expression of proteins on cancer cell surface are a typical outcome of malignant transformation. Natural killers (NKs) utilize a set of activating and inhibitory receptors that enable them to recognize altered protein expression and then destroy ‘stressed’ cells such as cancer or virus-infected cells. Major histocompatibility complex class I polypeptide-related sequence A and B (MICA and MICB, respectively) are expressed by various human tumors and can be recognized by activating NK cell receptor NKG2D. However, cancer frequently escapes recognition by NK cells by proteolytic shedding of MICA and MICB proteins. A study carried out by Ferrari de Andrade and colleagues showed that monoclonal antibody targeting the site of proteolytic shedding of MICA and MICB reduced the progression of melanoma in immunocompromised and immune competent mice models by activation of NKG2D. This approach prevented the reduction of essential immunostimulatory ligands (MICA/MICB) and restored NK cell-driven anticancer immunity.
Accelerated Hypofractionated Radiation Therapy for Elderly Frail Bladder Cancer Patients Unfit for Surgery or Chemotherapy
Authors: Hammer Liat , Laufer Menahem , Dotan Zohar , Leibowitz-Amit Raya , Berger Raanan , Felder Shira , Weiss Ilana , Lawrence Yaacov Richard , Symon Zvi
Published: November 2018

Purpose/Objectives:

The main purpose of this study was to report treatment outcomes of definitive image-guided accelerated hypofractionated radiation therapy for elderly patients with muscle-invasive bladder cancer unsuitable for surgery or trimodality therapy.

Materials and Methods:

Patients with confirmed muscle-invasive or high-risk T1 transitional cell carcinoma of the bladder, stage T1-T4aN0M0, who underwent transurethral resection of bladder tumor were irradiated with 45 Gy in 15 fractions. Comorbidity was assessed by Charlson Comorbidity Index. Cystoscopy, cytology, and computerised tomography imaging were used to evaluate treatment outcomes.

Results:

Seventeen patients with a median age of 87 (range, 81 to 95) years and age-adjusted Charlson Comorbidity Index ≥3 were included. Transurethral resection of bladder tumor was incomplete in 65%. Radiation technique evolved from 3-dimensional conformal radiotherapy (3D CRT, 47%) to volumetric modulated arc therapy (VMAT, 53%). Ninety-four percent completed radiotherapy, with a median time of 20 days. The median follow-up was 65.3 months. Complete local response at 3-month cystoscopy was 69%. Six patients developed a local recurrence (35%), and 2 patients developed distant metastases (11.7%). Overall survival at 1 year was 47% and 23% at 2 years. Cancer-specific survival at 1 and 2 years were 85% and 63%, respectively. Acute grade 3 gastrointestinal or genitourinary toxicities were 6% and 24%, respectively. No grade 4 toxicity was documented. Diarrhea of any grade occurred in 35% of patients treated with 3D CRT, but in none of the patients treated with VMAT (P=0.002).

Conclusions:

Accelerated hypofractionated radiotherapy alone provides good local control in elderly patients unfit for chemoradiotherapy. Contemporary radiation techniques such as VMAT were associated with reduced bowel toxicity compared with 3D CRT.
A Qualitative Comparison of Caregiver and Youth with Autism Perceptions of Sexuality and Relationship Experiences
Authors: Teti Michelle , Cheak-Zamora Nancy , Bauerband L. A. , Maurer-Batjer Anna
Published: November 2018

Objectives:

Caregivers play a critical role in educating their youth with autism about sex and relationships; yet, we know little about caregivers' ability to deliver this support, youth's perspectives, or the congruence of youth and caregiver experiences. To help fill this gap, we explored and compared the perspectives of caregivers and their youth with autism spectrum disorder about and interactions regarding sex and relationships.

Methods:

We conducted qualitative one-on-one interviews with youth (n = 27) and focus groups with their caregivers (n = 29). A semi-structured guide elicited information from both the groups about the youth's physical, emotional, and social transition to adulthood. Thematic analysis, including coding and analytical memos, identified key themes within and across youth and caregiver discussions about sex and relationships.

Results:

Thematic analysis of interviews revealed overarching themes about companionship, interest and experience, and access to sexual information across both the groups. Themes included different nuances among caregivers and youth, however. Caregivers expressed more future-oriented concerns than youth and overestimated their knowledge of their youth's interest and experience with sex and comfort confiding in caregivers. Youth described relationships and information sources of which their caregivers were unaware.

Conclusion:

Interventions for both caregivers and youth can support healthy and safe intimate relationships among youth with autism spectrum disorder. By comparing youth and caregiver dialogues, this study adds to what we know, and it can be used to develop a blueprint for improving communication patterns that not only include but also extend well beyond sexual health.
Accuracy of Anal Cytology for Diagnostic of Precursor Lesions of Anal Cancer: Systematic Review and Meta-analysis
Authors: Gonçalves João Carlos N. , Macedo Ana C. L. , Madeira Kristian , Bavaresco Daniela Vicente , Dondossola Eduardo Ronconi , Grande Antônio José , da Rosa Maria Inês
Published: November 2018

BACKGROUND:

Anal canal carcinoma is relevant because it commonly occurs in high-risk groups, and its incidence has been increasing.

OBJECTIVE:

This study evaluated the accuracy of anal cytology in the screening of precursor lesions of anal cancer, compared with histopathologic examination as the reference, in all subjects and in men who have sex with men, HIV-infected men and women, and men who have sex with men and HIV-infected subgroups.

DATA SOURCES:

The data included studies identified in the MEDLINE, Latin American and Caribbean Health Sciences, Cochrane Library, and Embase electronic databases, as well as in the grey literature. The search terms included anal cancer, anal dysplasia, anal intraepithelial neoplasia, screening, and anal cytology.

STUDY SELECTION:

After excluding studies with no histopathological data and those with duplicate and missing data, 34 primary studies were included.

INTERVENTION:

Cytology of anal smears was studied.

MAIN OUTCOME MEASURES:

Sensitivity, specificity, diagnostic OR, and area under the curve were measured.

RESULTS:

A total of 5093 patients were included. The pooled sensitivity of anal cytology was 85.0% (95% CI, 82.0%–87.0%) and pooled specificity was 43.2% (95% CI, 41.4%–45.1%) for the detection of anal intraepithelial neoplasia grade 2 or worse versus anal intraepithelial neoplasia grade 1 and normal when measuring all subjects. The accuracy of anal cytology was higher in the men who have sex with men and HIV-infected and men who have sex with men only subgroups.

LIMITATIONS:

This study was limited by its specificity.

CONCLUSIONS:

The study results support the hypothesis that cytology is a good test for the screening of anal cancer.
Conditional Probability of Survival After Neoadjuvant Chemoradiation and Proctectomy for Rectal Cancer: What Matters and When
Authors: Karagkounis Georgios , Liska David , Kalady Matthew F.
Published: November 2018

BACKGROUND:

Disease-free survival estimated from the time of surgery does not account for the changing likelihood of survival based on time already accrued. Conditional disease-free survival is defined as the probability of remaining disease free after reaching a specific time point without recurrence.

OBJECTIVE:

The purpose of this study was to evaluate conditional disease-free survival for patients with rectal cancer who were treated by proctectomy after neoadjuvant chemoradiation.

DESIGN:

Demographics, tumor characteristics, and tumor regression scores were assessed. Three-year conditional disease-free survival was estimated at x year after surgery based on the formula cDFS3 = DFS(x+3)/DFS(x), where DFS is disease-free survival and cDFS is conditional disease-free survival. Analyses were performed using Cox proportional hazards models.

SETTING:

The study was conducted at a single tertiary referral center.

PATIENTS:

A total of 545 patients with rectal cancer who were treated by neoadjuvant chemoradiation and curative intent surgery between 1992 and 2012 were included.

MAIN OUTCOME MEASURES:

Disease-free survival and conditional disease-free survival were measured.

RESULTS:

The median patient age was 57.5 years, and 28.4% were women. Median follow-up was 5.9 years. Disease-free survival at 1, 3, and 5 years was 89%, 71%, and 63%. The probability of remaining disease free for an additional 3 years for patients disease free at 1, 3, and 5 years was 75%, 83%, and 82%. Tumor regression, pathologic stage, margin status, differentiation, and procedure (low anterior versus abdominoperineal resection) were associated with disease-free survival on multivariable analysis (p < 0.05), but their relevance varied over time. R1 resection and differentiation were initially significant but not at 5 years. In contrast, tumor regression after neoadjuvant chemoradiation had a long-lasting impact on survival (at 5 y, conditional disease-free survival for an additional 3 y: 91%, 85%, 76%, and 71% for regression scores 0, 1, 2, and 3; p = 0.002).

LIMITATIONS:

This was a retrospective study over 20 years, with evolution in adjuvant therapies during this time.

CONCLUSIONS:

Conditional disease-free survival estimates improved over time, confirming that most patients will see a recurrence within the first few years. The impact of specific prognostic factors evolves variably over time. This information is useful to patients and providers and can help guide counseling and surveillance. See Video Abstract at http://links.lww.com/DCR/A771.
A Quality-of-Life Comparison of Two Fecal Incontinence Phenotypes: Isolated Fecal Incontinence Versus Concurrent Fecal Incontinence With Constipation
Authors: Cauley Christy E. , Savitt Lieba R. , Weinstein Milena , Wakamatsu May M. , Kunitake Hiroko , Ricciardi Rocco , Staller Kyle , Bordeianou Liliana
Published: November 2018

BACKGROUND:

Many patients with fecal incontinence report coexisting constipation. This subset of patients has not been well characterized or understood.

OBJECTIVE:

The purpose of this study was to report the frequency of fecal incontinence with concurrent constipation and to compare quality-of-life outcomes of patients with fecal incontinence with and without constipation.

DESIGN:

This was a prospective cohort study. Survey data, including Fecal Incontinence Severity Index, Constipation Severity Instrument, Fecal Incontinence Quality of Life survey (categorized as lifestyle, coping, depression, and embarrassment), Pelvic Organ Prolapse Inventory and Urinary Distress Inventory surveys, and anorectal physiology testing were obtained.

SETTINGS:

The study was conducted as a single-institution study from January 2007 to January 2017.

PATIENTS:

Study patients had fecal incontinence presented to a tertiary pelvic floor center.

MAIN OUTCOME MEASURES:

Quality-of-life survey findings were measured.

RESULTS:

A total of 946 patients with fecal incontinence were identified, and 656 (69.3%) had coexisting constipation. Patients with fecal incontinence with constipation were less likely to report a history of pregnancy (89.2% vs 91.4%; p = 0.001) or complicated delivery, such as requiring instrumentation (9.1% vs 18.1%; p = 0.005), when compared with patients with isolated fecal incontinence. Patients with fecal incontinence with constipation had higher rates of coexisting pelvic organ prolapse (Pelvic Organ Prolapse Inventory: 18.4 vs 8.2; p < 0.01), higher rates of urinary incontinence (Urinary Distress Inventory: 30.2 vs 23.4; p = 0.01), and higher pressure findings on manometry; intussusception on defecography was common. Patients with fecal incontinence with concurrent constipation had less severe incontinence scores at presentation (21.0 vs 23.8; p < 0.001) and yet lower overall health satisfaction (28.9% vs 42.5%; p < 0.001). Quality-of-life scores declined as constipation severity increased for lifestyle, coping, depression, and embarrassment.

LIMITATIONS:

This was a single-institution study, and surgeon preference could bias population and anorectal physiology testing.

CONCLUSIONS:

Patients with fecal incontinence with concurrent constipation represent a different disease phenotype and have different clinical and anorectal physiology test findings and worse overall quality of life. Treatment of these patients requires careful consideration of prolapse pathology with coordinated treatment of coexisting disorders. See Video Abstract at http://links.lww.com/DCR/A783.
The Contributions of Internal Intussusception, Irritable Bowel Syndrome, and Pelvic Floor Dyssynergia to Obstructed Defecation Syndrome
Authors: Cavallaro Paul M. , Staller Kyle , Savitt Lieba R. , Milch Holly , Kennedy Kevin , Weinstein Milena M. , Ricciardi Rocco , Bordeianou Liliana G.
Published: November 2018

BACKGROUND:

Recently, there has been a trend toward surgical management of internal intussusception despite an unclear correlation with constipation symptoms.

OBJECTIVE:

This study characterizes constipation in patients with obstructed defecation syndrome and identifies whether internal intussusception or other diagnoses such as irritable bowel syndrome may be contributing to symptoms.

DESIGN:

Patients evaluated for obstructed defecation at a pelvic floor disorder center were studied from a prospectively maintained database. With the use of defecography, patients were classified by Oxford Rectal Prolapse Grade. Coexisting disorders such as enterocele, rectocele, and dyssynergia were also identified. The presence of irritable bowel syndrome was defined using Rome IV criteria, and constipation severity was quantified with the Varma constipation severity instrument.

SETTINGS:

This study was conducted at a tertiary care university medical center (Massachusetts General Hospital).

PATIENTS:

The study included 317 consecutive patients with defecography imaging and a completed constipation severity instrument survey from May 2007 to July 2016.

MAIN OUTCOME MEASURES:

The primary outcome measures were the Varma Constipation Severity Instrument overall score and obstructed defecation subscale score.

RESULTS:

Of 317 patients evaluated, 95 (30.0%) had no internal intussusception, 126 (39.7%) had intra-rectal intussusception, and 96 (30.3%) had intra-anal intussusception. There was no association between rising grade of internal intussusception and either overall constipation score or obstructed defecation subscale score. Irritable bowel syndrome was associated with an increase in overall constipation score and obstructed defecation subscale score (40.5 ± 13.6 vs 36.0 ± 15.1,p= 0.007, and 22.3 ± 5.8 vs 20.0 ± 6.6,p< 0.001). Multivariate regression found irritable bowel syndrome and dyssynergia to be associated with a significant increase in obstructed defecation subscale scores.

LIMITATIONS:

The study was limited because it was an observational study from a single center.

CONCLUSIONS:

Patients referred for surgical management of obstructive defecation syndrome should be screened and treated for irritable bowel syndrome and dyssynergia before considering surgical intervention. SeeVideo Abstractat http://links.lww.com/DCR/A782.
Short- and Long-term Outcomes of Minimally Invasive Versus Open Multivisceral Resection for Locally Advanced Colorectal Cancer
Authors: Nishikawa Takeshi , Nozawa Hiroaki , Kawai Kazushige , Sasaki Kazuhito , Otani Kensuke , Tanaka Toshiaki , Hata Keisuke , Watanabe Toshiaki
Published: November 2018

BACKGROUND:

Colorectal cancer invading the adjacent organs/structures is detected in 5% to 20% of all surgical interventions performed for the management of colorectal cancer.

OBJECTIVE:

Our purpose is to verify the safety and feasibility of laparoscopic surgery for the treatment of locally advanced colorectal cancer invading the adjacent organs.

DESIGN:

This is a retrospective study.

SETTINGS:

The study was conducted at a single institution in Japan.

PATIENTS:

We compared the morbidity, appropriate oncological resection, and disease-free survival of laparoscopic and open multivisceral resection in patients with colorectal carcinoma in the period between 2007 and 2015.

MAIN OUTCOME MEASURES:

The primary outcome measures were curative resection rate, morbidity rate, and recurrence of laparoscopic and open multivisceral resection in patients with colorectal cancer.

RESULTS:

Thirty-one patients received laparoscopic surgery, and 50 received open surgery. The amount of blood loss was smaller in the laparoscopic group than in the open group (60 vs 595 mL, p < 0.01). Curative surgery was performed in 46 patients of the open group (92.0%) and in 30 patients of the laparoscopic group (96.8%). Days until oral intake (5 vs 7 days, p < 0.01) and postoperative hospital stay (14 vs 19 days, p < 0.01) were shorter in the laparoscopic group. Overall morbidity was not different between the groups (22.5% vs 40.0%). Three-year disease-free survival rates were 62.7% in the open group and 56.7% in the laparoscopic group (p = 0.5776).

LIMITATION:

This study was a retrospective small study conducted at a single institute.

CONCLUSION:

Laparoscopic multivisceral resection may be a safe, less invasive alternative to open surgery, with less blood loss and shorter hospital stay, and was not inferior to open surgery based on long-term oncological end points. See Video Abstract at http://links.lww.com/DCR/A785.
Topical Oxymetazoline for Fecal Incontinence in Patients with Spinal Cord Injury: A Double-Blind Randomized Controlled Crossover Study
Authors: Barak Nir , Gecse Krisztina B. , Takács István
Published: November 2018

BACKGROUND:

Topical α-agonists contract the internal anal sphincter muscle; therefore, they may serve as treatment for fecal incontinence.

OBJECTIVES:

The aim of this study was to investigate the effect of the α-agonist oxymetazoline 1.0% on fecal incontinence in patients with spinal cord injury.

DESIGN:

This was a double-blind, crossover study. Before randomization, all patients underwent a 1-day, open-label anal manometry and pharmacokinetic study.

SETTINGS:

The study was conducted at the Department of Internal Medicine, Semmelweis University, Hungary.

PATIENTS:

Nineteen patients were enrolled into a randomized double-blind, placebo-controlled clinical trial with 2 arms: placebo for 4 weeks followed by oxymetazoline for 4 weeks, or vice versa, with an interval 2-week washout period, in a crossover trial design. Treatment order was randomly assigned, and fecal incontinence was captured with daily diaries.

MAIN OUTCOME MEASURES:

The primary outcome measured was the number of fecal incontinence episodes in the 8 and 12 hours after drug administration.

RESULTS:

Resting anal pressure increased in response to oxymetzoline (25.2%). The change in the mean fecal incontinence episodes per month (12 hours post drug application) favored oxymetazoline over placebo: 26.3 (SD ±28.4) versus 36 (SD ±39.8) (p = 0.021). When only nongas episodes were included, the mean number of episodes decreased from 10.1 (+4.3) to 6.3 (±2.1) fecal incontinence episodes per month (p = 0.022). No difference was observed in adverse events between treatment and placebo periods. All pharmacokinetic samples were below the detection limit.

LIMITATIONS:

The study was limited by the small number of participants.

CONCLUSIONS:

In this study, oxymetazoline gel presented a clear clinical beneficial effect accompanied by a favorable safety and tolerability profile. Results of the pharmacokinetic analysis indicate that the clinical benefit was mainly due to a local effect of oxymetazoline. Future studies are planned to investigate higher doses of oxymetazoline for this indication. See Video Abstract at http://links.lww.com/DCR/A797.
Female Representation and Implicit Gender Bias at the 2017 American Society of Colon and Rectal Surgeons’ Annual Scientific and Tripartite Meeting
Authors: Davids Jennifer S. , Lyu Heather G. , Hoang Chau M. , Daniel Vijaya T. , Scully Rebecca E. , Xu Ting Y. , Phatak Uma R. , Damle Aneel , Melnitchouk Nelya
Published: November 2018

BACKGROUND:

Women surgeons are underrepresented in academic surgery and may be subject to implicit gender bias. In colorectal surgery, women comprise 42% of new graduates, but only 19% of Diplomates in the United States.

OBJECTIVE:

We evaluated the representation of women at the 2017 American Society of Colon and Rectal Surgeons Scientific and Tripartite Meeting and assessed for implicit gender bias.

DESIGN:

This was a prospective observational study.

SETTING:

The study occurred at the 2017 Tripartite Meeting.

MAIN OUTCOME MEASURES:

The primary outcome measured was the percentage of women in the formal program relative to conference attendees and forms of address.

METHODS:

Female program representation was quantified by role (moderator or speaker), session type, and topic. Introductions of speakers by moderators were classified as formal (using a professional title) or informal (using name only), and further stratified by gender.

RESULTS:

Overall, 31% of meeting attendees who are ASCRS members were women, with higher percentages of women as Candidates (44%) and Members (35%) compared with Fellows (24%). Women comprised 28% of moderators (n = 26) and 28% of speakers (n = 80). The highest percentage of women moderators and speakers was in education (48%) and the lowest was in techniques and technology (17%). In the 41 of 47 sessions evaluated, female moderators were more likely than male moderators to use formal introductions (68.7% vs 54.0%, p = 0.02). There was no difference when female moderators formally introduced female versus male speakers (73.9% vs 66.7%, p = 0.52); however, male moderators were significantly less likely to formally introduce a female versus male speaker (36.4% vs 59.2%, p = 0.003).

LIMITATIONS:

Yearly program gender composition may fluctuate. Low numbers in certain areas limit interpretability. Other factors potentially influenced speaker introductions.

CONCLUSIONS:

Overall, program representation of women was similar to meeting demographics, although with low numbers in some topics. An imbalance in the formality of speaker introductions between genders was observed. Awareness of implicit gender bias may improve gender equity and inclusiveness in our specialty. See Video Abstract at http://links.lww.com/DCR/A802.
Outcomes for Ulcerative Colitis With Delayed Emergency Colectomy Are Worse When Controlling for Preoperative Risk Factors
Authors: Leeds Ira L. , Sundel Margaret H. , Gabre-Kidan Alodia , Safar Bashar , Truta Brindusa , Efron Jonathan E. , Fang Sandy H.
Published: November 2018

BACKGROUND:

Increasing evidence supports immediate colectomy in acute fulminant ulcerative colitis in comparison with ongoing medical management. Prior studies have been limited to inpatient-only administrative data sets or single-institution experiences.

OBJECTIVE:

The purpose of this study was to compare outcomes of early versus delayed emergency colectomy in patients admitted with ulcerative colitis flares while controlling for known preoperative risks and acuity.

DESIGN:

This is a cohort study of patients undergoing emergent total abdominal colectomies for ulcerative colitis compared by the timing of surgery.

SETTING:

Adult patients undergoing an emergent total abdominal colectomy for ulcerative colitis, 2005 to 2015, were identified in the American College of Surgeons National Surgical Quality Improvement Program database.

PATIENTS:

Patients undergoing total abdominal colectomy with an operative indication of ulcerative colitis admitted on a nonelective basis were selected.

MAIN OUTCOME MEASURE:

The primary outcomes measured were 30-day National Surgical Quality Improvement Program-reported mortality and postoperative complications, and early operation within 2 days of admission.

RESULTS:

We identified 573 total abdominal colectomies after propensity score matching. Median time to surgery was 1 hospital day in the early group versus 6 hospital days in the delayed group (p < 0.001). Early operation was associated with a lower mortality rate (4.9% versus 20.3% in matched groups, p < 0.001) and lower complication rate (64.5% versus 72.0%, p = 0.052). Multivariable logistic regression with propensity weighting of mortality on preoperative risk factors demonstrated that early surgery is associated with an 82% decrease in the odds of death compared with delayed surgery (p < 0.001). Regression of morbidity on preoperative risk factors demonstrated that early surgery is associated with a 35% decrease in the odds of a complication with delayed surgery (p = 0.034).

LIMITATIONS:

Quality improvement data were used for clinical research questions.

CONCLUSIONS:

Patients undergoing immediate surgical intervention for acute ulcerative colitis have decreased postoperative complications and mortality rates. Rapid and early transitioning from medical to surgical management may benefit those expected to require surgery on the same admission. See Video Abstract at http://links.lww.com/DCR/A800.
Update in the use and evaluation of poly (ADP-ribose) polymerase inhibitors in epithelial ovarian cancer: current and pending clinical research
Authors: Washington Christina , Gunderson Camille C. , Moore Kathleen N.
Published: November 2018

Purpose of review

This review will provide an update of recently presented clinical data as well as discuss ongoing trials focused on the incorporation of poly (ADP-ribose) polymerase inhibitors (PARPi) into the treatment paradigm for ovarian cancer.

Recent findings

As of this publication, PARPi have indications in many parts of the globe as maintenance therapy following response to platinum-based chemotherapy in the setting of platinum-sensitive recurrence. In addition, in the United States, two PARPi have indications as monotherapy treatment for recurrent ovarian cancer in patients with a BRCA mutation and at least two prior lines of therapy. Exciting data was published in October 2018, demonstrating an unprecedented benefit to utilization of olaparib following response to front-line platinum-based chemotherapy among patients with a BRCA mutation and this data is expected to expand the indication for olaparib globally.

Ongoing studies will seek to expand the benefit of PARPi beyond the BRCA population in front-line therapy as well as to overcome inherent and acquired resistance to PARPi with studies of novel combinations with antiangiogenesis agents, immune-oncology agents and chemotherapy. These efforts may identify more settings and populations in which PARPi provide clinical benefit.
The “Butterfly” Wrap: A Simplified Technique for Consistent Prosthesis Coverage in Prepectoral Breast Reconstruction
Authors: Hill Elspeth J.R. , Buck Donald W.
Published: November 2018

Background:

Here, we describe our simple, systematic, reproducible, and effective method for prosthesis coverage in prepectoral breast reconstruction.

Methods:

Our Butterfly Wrap is a simple technique, which provides prosthesis coverage with a single sheet of acellular dermal matrix (ADM) in a reproducible and elegant manner. The wrap design creates an anatomic tear-shaped pocket to guide expansion and encourage lower pole fullness, without ADM folding or bunching for optimal incorporation and minimal overlap. Further, it minimizes waste, allowing for smaller sheets of ADM to be used per breast, and can easily be performed in minimal time on the back table while the mastectomies are being performed, as a means of minimizing cost.

Results:

Our technique can be applied to effectively cover all shapes and sizes of expanders and implants, both teardrop and round. As a result, the surgeon need only focus on the critical nuances of prosthesis-based prepectoral breast reconstruction, without the anxiety of how to wrap the prosthesis and what size of ADM to use.

Conclusions:

The Butterfly Wrap is a simple, systematic, reproducible, and effective method for prosthesis coverage in prepectoral reconstruction.
Objective and Patient-reported Assessments of Skin Grafts and Keystone Flaps—A Pilot Retrospective Cohort Study
Authors: Dobbs Thomas D. , Jovic Thomas H. , Jessop Zita M. , Kyle Amanda , Hutchings Hayley A. , Whitaker Iain S.
Published: November 2018

Background:

The keystone perforator island flap provides a versatile form of reconstruction. Perceived benefits include better donor-recipient color match, less contour defect, and fewer complications. To date, there has been no high-quality evidence comparing keystone flaps to split-thickness skin grafts (SSG) from both a qualitative and quantitative point of view.

Methods:

The Objective and Patient Reported Assessments of Skin grafts versus Keystone flap cohort study compares keystone flaps with SSGs for the reconstruction of skin cancer defects. Patient-reported outcome measures were collected using the EuroQol 5 dimension scale and Patient and Observer Scar Assessment Scale (POSAS) questionnaires. Objective assessments of skin quality were assessed with the Courage and Khazaka system. Cost analysis was also performed.

Results:

Thirty-eight patients were studied: 20 keystone flaps and 18 SSGs. The keystone group had higher EuroQol 5 dimension scale scores (keystone median = 1.0; SSG median = 0.832; P = 0.641) indicating better general quality of life and lower POSAS scores indicating better disease/condition specific quality of life (keystone mean = 27.7; SSG mean = 35.7; P = 0.323). Observer POSAS scores were significantly lower in the keystone group compared with the SSG group (keystone mean = 10.889; SSG mean = 17.313; P < 0.001). Preservation of sensation was significantly better in keystone flaps (P = 0.006). There was an average £158/$207 (15%) saving when performing a keystone flap.

Conclusion:

This pilot study demonstrates a number of possible benefits of keystone flaps over SSGs. The results demonstrate the need for further research comparing these reconstructive options. We propose a prospective, controlled study using the methods developed in this pilot study.