IMPORTANCE:The Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) Trial compared sacrospinous ligament fixation (SSLF) and uterosacral ligament suspension (ULS) surgical outcomes. Increasing body mass index (BMI) is associated with an increased risk of pelvic organ prolapse, and the prevalence of obesity is increasing worldwide. OBJECTIVE:The purpose of this study was to better understand the effect of obesity on the results of native tissue vaginal apical suspension procedures. STUDY DESIGN:This was a secondary analysis of the OPTIMAL Trial data set. Subgroup analysis was performed to compare surgical failure rates between SSLF and ULS across BMI subgroups after 2 years. RESULTS:There were 75, 120, 63, and 39 patients in the normal, overweight, class 1 obesity, and class 2 obesity or greater BMI subgroups, respectively. There were no statistically significant differences in surgical failure rates between SSLF and ULS within BMI subgroups; however, failure rates increased in the ULS group between the nonobese and obese groups (normal, 35.9% SSLF vs 30.6% ULS [ P = 0.81]; overweight, 38.6% vs 30.2% [ P = 0.44]; class 1 obesity, 38.7% vs 40.6% [ P = 0.92]; class 2 obesity or greater, 21.1% vs 45% [ P = 0.21]). CONCLUSIONS:The risk of surgical failure between SSLF and ULS was not significant across BMI subgroups. Additional investigation is required to further elucidate whether SSLF or ULS is a more reliable option for obese patients.

OBJECTIVE:The lack of objective prognostication tools for severe traumatic brain injury (TBI) causes variability in the application of withdrawal of life-saving treatment (WLST). We aimed to determine whether WLST in persons with severe TBI is associated with known indicators of poor prognosis. METHODS:This retrospective descriptive study focused on adult (18-64 years) and geriatric (≥65 years) patients with severe TBI who were admitted between August 1, 2018 and July 31, 2021 at a Level I trauma center and subsequently underwent WLST. The data collected from the Trauma Registry and electronic health records included information regarding demographic characteristics, injury severity, clinical variables, and length of hospital stay and were used to examine the indicators of poor prognosis and WLST. RESULTS:Among the 164 participants with TBI who met the inclusion criteria, 61.0% were geriatric, and 122 (74.4%) patients had 0 or only 1 of the poor prognostic indicators prior to WLST. The non-geriatric group had more indicators of poor prognosis than the geriatric group. Participants with fewer indicators of poor prognosis had a longer length-of-stay. CONCLUSION:In severe TBI cases, standardized prognostication tools can help guide informed WLST decisions, particularly in geriatric patients, improving care consistency.

OBJECTIVE:This study compared the effectiveness of traditional lectures and microvideos in teaching baclofen pump programming and refilling to physicians who have completed less than 10 refills for the previous 2 yrs. DESIGN:A mixed-method approach was used with 60 participating physicians specializing in physical medicine and rehabilitation or pain management. Preintervention and postintervention assessments were conducted using a rubric, and the participants' perceptions and preferences were gathered through focus group sessions. RESULTS:Two thirds of the participants specialized in physical medicine and rehabilitation. No significant differences in the preintervention, postintervention, or knowledge retention scores were found between the traditional lecture and microvideo groups. Both methods demonstrated comparable effectiveness in improving the baclofen pump refilling and programming skills. Qualitatively, participants perceived both approaches as equally helpful, but those in the microvideo group raised concerns because of instructors' unavailability and online platform navigation. Nevertheless, they preferred the convenience, accessibility, and time efficiency of the microvideos. CONCLUSIONS:The study concluded that microvideos are an effective alternative to traditional lectures for acquiring knowledge on baclofen pump programming and refilling. Further research should consider learners' characteristics and investigate the benefits of blended learning in medical education.

Background: The American Association of Hip and Knee Surgeons tasked a 2013 workgroup to provide obesity-related recommendations in total joint arthroplasty. Morbidly obese patients (body mass index (BMI) >= 40) seeking hip arthroplasty were determined to be at increased perioperative risk, and surgeons were recommended to encourage these patients to reduce their BMI <40 presurgery. We report the effect of instituting a 2014 BMI <40 threshold on our primary total hip arthroplasties (THAs). Methods: We queried our institutional database to select all primary THAs from January 2010 to May 2020. There were 1,383 THAs that were pre-2014 and 3,273 THAs that were post-2014. The 90-day emergency department (ED) visits, readmissions, and returns to operating room (OR) were identified. Patients were propensity score weight-matched according to comorbidities, age, initial surgical consultation (consult) BMI, and sex. We conducted 3 comparisons: A) pre-2014 patients who had a consult and surgical BMI >= 40 against post-2014 patients who had a consult BMI >= 40 and surgical BMI <40; B) pre-2014 patients against post-2014 patients who had a consult and surgical BMI <40; and C) post-2014 patients who had a consult BMI >= 40 and surgical BMI <40 against post-2014 patients who had a consult BMI >= 40 and surgical BMI >= 40. Results: Post-2014 patients who had a consult BMI >= 40 and surgical BMI <40 had less ED visits (7.6 versus 14.1%, P =.0007), but similar readmissions (11.9 versus 6.3%, P =.22) and returns to OR (5.4 versus 1.6%, P =.09) compared to pre-2014 patients who had a consult BMI and surgical BMI >= 40. Post-2014 BMI <40 had less readmissions (5.9 versus 9.3%, P <.0001), and similar all-cause returns to OR and ED visits than patients pre-2014. Post-2014 patientswho had a consult and surgical BMI >= 40 had lower readmissions (12.5 versus 12.8%, P =.05), and similar ED visits and returns to OR than consult BMI >= 40 and surgical BMI <40. Conclusion: Patient optimization prior to total joint arthroplasty is critical. However, the BMI optimization that mitigates risk in primary total knee arthroplasty may not apply to primary THA. We observed a paradoxical increased readmission rate for patients who reduced their BMI before THA. Level of Evidence: III. (c) 2023 Elsevier Inc. All rights reserved.

Background: In 2013, the American Association of Hip and Knee Surgeons tasked a workgroup to provide obesity-related recommendations in total joint arthroplasty and determined that patients who had body mass index (BMI) >= 40 seeking hip/knee arthroplasty were at increased perioperative risk and recommended preoperative weight reduction. Few studies have shown the actual results of instituting this; therefore, we reported the effect of instituting a BMI < 40 threshold in 2014 on our elective, primary total knee arthroplasties (TKAs). Methods: We queried an institutional database to select all TKAs conducted from January 2010 to May 2020. There were 2,514 TKA pre-2014 and 5,545 TKA post-2014 that were identified. The 90-day emergency department (ED) visits, readmissions, and returns-to-operating room (OR) outcomes were identified. Patients were propensity score weight-matched as per comorbidities, age, initial surgical consultation (consult) BMI, and sex. We conducted 3 outcome comparisons: (1) pre-2014 patients who had a consult and surgical BMI >= 40 against post-2014 patients who had a consult BMI >= 40 and surgical BMI < 40; (2) pre-2014 patients against post-2014 patients who had a consult and surgical BMI < 40; (3) post-2014 patients who had a consult BMI >= 40 and surgical BMI < 40 against post-2014 patients who had a consult BMI >= 40 and surgical BMI >= 40. Results: Pre-2014 patients who had a consult and surgical BMI >= 40 had more ED visits (12.5% versus 6%, P = .002) but similar readmissions and returns-to-OR than post-2014 patients who had a consult BMI >= 40 and surgical BMI < 40. Pre-2014 patients who had a consult and surgical BMI < 40 had more readmissions (8.8% versus 6%, P < .0001) but similar ED visits and returns-to-OR when compared to their post-2014 counterparts. Post-2014 patients who had a consult BMI >= 40 and surgical BMI < 40 had fewer ED visits (5.8% versus 10.6%) but similar readmissions and returns-to-OR than patients who had a consult BMI >= 40 and surgical BMI >= 40. Discussion: Patient optimization prior to total joint arthroplasty is essential. Enacting BMI reduction pathways prior to total knee arthroplasty seems to afford morbidly obese patients major risk mitigation. We must continue to ethically balance the pathology, expected improvement after surgery, and the overall risks of complications for each patient. (c) 2023 Elsevier Inc. All rights reserved.

Objectives. To determine if radial artery (RA) access compared with femoral artery (FA) access for percutaneous coronary intervention (PCI) is associated with a lower incidence of acute kidney injury (AKI). Background. AKI results in substantial morbidity and cost following PCI. Prior studies comparing the occurrence of AKI associated with radial artery (RA) versus femoral artery (FA) access have mixed results. Methods. Using a large state-wide database, 14,077 patients (8,539 with RA and 5,538 patents with FA access) were retrospectively compared to assess the occurrence of AKI following PCI. To reduce selection bias and balance clinical data across the two groups, a novel machine learning method called a Generalized Boosted Model was conducted on the arterial access site generating a weighted propensity score for each variable. A logistic regression analysis was then performed on the occurrence of AKI following PCI using the weighted propensity scores from the Generalized Boosted Model. Results. As shown in other studies, multiple variables were associated with an increase in AKI after PCI. Only RA access (OR 0.82; 95% CI 0.74–0.91) and male gender (OR 0.80; 95% CI 0.72–0.89) were associated with a lower occurrence of AKI. Based on the calculated Mehran scores, patients were stratified into groups with an increasing risk of AKI. RA access was consistently found to have a lower risk of AKI compared with FA access across these groups of increasing risk. Conclusions. Compared with FA access, RA access is associated with an 18% lower rate of AKI following PCI. This effect was observed among different levels of risk for developing AKI. Although developed from a retrospective analysis, this study supports the use of RA access when technically possible in a diverse group of patients.

To describe the incidence of abnormal gynecologic examination findings in asymptomatic compared with symptomatic patients during preventive visits, we conducted a retrospective study of 1,121 visits for patients between the ages of 21 and 35 years from January 2017 to March 2017. Only 1.2% (95% CI, 0.5%,1.9%) of asymptomatic patients had abnormal findings on pelvic examination, compared with 32.4% (95% CI, 27.0%, 37.8%) of those with symptoms ( P ≤.001). In symptomatic patients, the most common symptoms were vaginal discharge (25.1%), pelvic pain (16.4%), and vaginal bleeding (15.7%). In asymptomatic patients, the most common findings were bacterial vaginosis and Candida infection. Asymptomatic patients presenting for a routine preventive visit have low rates of abnormalities detected on examination, and routine pelvic examinations should be re-considered.

Objective: Determine the impact AA have on IPM and PDM TBI patients Background: Antithrombotic agents (AA) protect against thrombotic events with high risk of bleeding. It is unclear whether risks associated with TBI should impact decisions to start AA in the elderly, a group with the highest incidence of head injury. We hypothesize AA increase inpatient mortality (IPM) and 1y post-discharge mortality (PDM) rates in elderly TBI patients. Design/Methods: Elderly (age >65) and adult (age 18–64) TBI patients were identified in a level I Trauma registry 2008–2017. Patients were sorted by AA exposure (+AA and −AA). The Trauma registry was merged with the National Death Index. Mortality was evaluated by chi-square, Fisher's exact, and Wilcoxon rank-sum tests. Logistic regression determined the effect of AA on IPM and PDM. Results: Of 1,265 patients, 625 were using antithrombotic agents at the time of injury (+AA) and 640 were not (−AA). There were 537 adults and 687 elderly patients. AA was associated with older age, presence of a comorbidity (p-value ≤0.0001), and higher Glascow Coma Score on arrival (+AA Median=15 and -AA Median=14, p-value ≤0.0001). There was no difference in AIS head (+AA=4, −AA=4 p-value 0.12), or IPM (+AA=14.9%, −AA=16.4% p-value <0.4551). The +AA had higher PDM (+AA=36.0%, −AA=24.7%, p-value ≤ 0.0001) and was older at death (+AA Median=84 and −AA Median=64, p-value ≤0.0001). To control for age, the data were grouped into adult and elderly populations. Logistic regression showed AA had no impact on elderly IPM (AUC=0.8890), PDM (Odds Ratio=0.970, p-value <0.8937, AUC=0.7230), or adult IPM (AUC=0.9405). AA-adults had decreased PDM (OR= 0.155, p-value=0.0008, AUC=0.7716). Conclusions: Antithrombotic therapy is a confounder for age and co-morbidities, and not associated with IPM or PDM. These data should be considered when discussing risks and benefits of AA in the elderly. Functional outcomes may be more pertinent and require future study. Disclosure: Miss DeStefano has nothing to disclose. Mr. Vedula has nothing to disclose. Dr. Stodghill has nothing to disclose. Dr. Gillen has nothing to disclose. Dr. Nussbaum has nothing to disclose. Dr. Bower has nothing to disclose. Tonja Locklear has nothing to disclose. Dr. Collier has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for Law Firm.

Background: Patient return-to-driving following minor hand surgery is unknown. Through daily text message surveys, we sought to determine return-to-driving after minor hand surgery and the factors that influence return-to-driving. Methods: One hundred five subjects undergoing minor hand surgery received daily text messaging surveys postoperatively to assess: (1) if they drove the day before and if so; (2) whether they wore a cast, sling, or splint. Additional patient-, procedure-, and driving-related data were collected. Results: More than half of subjects, 54 out of 105, returned to driving by the end of postoperative day #1. While patient-related factors had no effect on return-to-driving, significant differences were seen in anesthesia type, procedure laterality, driving assistance, and distance. Return-to-driving was significantly later for subjects who had general anesthetic compared to wide awake local anesthetic with no tourniquet (4 ± 4 days vs 1 ± 3 days, P = 0.020), as well as for bilateral procedures versus unilateral procedures (5 ± 5 days vs 1 ± 3 days, P = 0.046). Lack of another driver and driving on highways led to earlier return-to-driving ( P = 0.040 and, P = 0.005, respectively). Conclusions: Most patients rapidly return to driving after minor hand surgery. Use of general anesthetic and bilateral procedures may delay return-to-driving. Confidential real-time text-based surveys can provide valuable information on postoperative return-to-driving and other patient behaviors.

Aim: The purpose of the study was to understand the impact of a pain management consult for acute pancreatitis patients on their inpatient length of stay, morphine milligram equivalences (MMEs) and pancreatitis severity. Materials & methods: Adult patient data were extracted from the electronic health records from 1 October 2016 to 31 December 2018. Results & conclusion: Of 277 patients with a single acute pancreatitis hospitalization, 23 had a pain consultation (treatment group), whereas 254 did not (control group). There were statistically significant differences in median length of stay, median MME total and median MME per day between the treatment and control groups with comparable severity and pain scores (6.8 vs 3.1 days, 196.5 vs 33.8 MMEs, 30.9 vs 12.1 MMEs, respectively, p < 0.0001). This study emphasizes the complexity of pain management and the importance of further research in the field.

OBJECTIVES To describe clinicopathologic characteristics and survival outcomes of endometrial adenocarcinomas stratified by mismatch repair (MMR) status. METHODS Single-institution, retrospective study of all women with endometrioid adenocarcinomas treated from January 2012 through December 2017. Patients were categorized into one of three groups based on MMR testing: intact MMR expression (MMR+), probable MMR mutation (MMR-), or MLH1 hypermethylation (hMLH1+). Demographics, pathologic characteristics, recurrence rates, and survival differences were analyzed. RESULTS In total, 316 women were included in the analysis: 235 (74.4%) patients in the MMR+ group, 10 (3.1%) in the MMR- group, and 71 (22.5%) in the hMLH1+ group. Patients with hMLH1+ were significantly older, exhibited higher-grade histology and presence of lymphovascular space invasion, and were more likely to have received adjuvant treatment. The early stage hMLH1+ patients were more likely to recur (15.3% hMLH1+ vs 2.3% MMR+ vs 12.5% MMR-, P < .001). Hypermethylation remained a significant predictor of recurrence in multivariable analysis (odds ratio, 5.09; 95% confidence interval [CI], 1.54-16.86; P = .008). Recurrence-free survival was significantly reduced in early stage hMLH1+ (hazard ratio, 7.40; 95% CI, 2.80-21.62; P < .001). CONCLUSIONS Women with hMLH1+ endometrial cancer have worse prognostic features and recur more frequently, even in patients traditionally considered low risk for recurrence.

Moral distress occurs when moral integrity is compromised and can affect any healthcare professional. This study examined the impact of Schwartz Center Rounds (SCRs) on moral distress using a longitudinal, quasi-experimental design to examine SCR attendees from 2015 to 2019. Data were collected via a 2-part survey composed of demographics and Moral Distress Thermometer (MDT) readings before rounds and immediately after rounds. Most participants experienced either no change in moral distress (50.6%) or a decrease in moral distress (33.7%) after attending one of the SCRs. Participants who worked with adult populations had higher moral distress after participation for most topics. An increase in moral distress was associated with a longer time in the current position. Fifty percent of the physicians had a decrease in their moral distress immediately after the rounds. Schwartz Center Rounds is a promising approach to foster high-functioning teams while promoting wellness and mitigating moral distress among employees.

Objectives: Identify 5-year mortality rates in trauma patients greater than 18 years old who undergo tracheostomy and/or gastrostomy tube placement. Design: Retrospective convenience sample with two cohorts. Setting: Academic level 1 trauma center. Patients: Hospitalized patients admitted to the trauma service from July 2008 to December 2012 who underwent tracheostomy and/or gastrostomy tube placement. Interventions: Patients were placed into two cohorts: adult 18–64 and geriatric greater than or equal to 65; mortality data were obtained from the National Death Index. Measurements and Main Results: The primary outcome was 5-year mortality of both cohorts as well as those admitted who did not receive tracheostomy or gastrostomy. Univariate analysis was performed using Fisher exact and Wilcoxon signed-rank tests. Kaplan-Meier curves were plotted to examine mortality up to 5 years after discharge. Conclusions: Five-year postdischarge mortality is significantly higher in geriatric patients undergoing tracheostomy and/or gastrostomy after traumatic injury. Fifty percent die within the first 28 weeks following discharge and 93% die within 2 years.

Trauma recidivists are a high-risk patient population. The effects of recidivism on Geriatric trauma mortality have not been investigated. Our hypothesis is that trauma recidivism is associated with high postdischarge mortality after the initial index admission in both the geriatric and adult trauma populations. The trauma registry of our Level I trauma center was queried for patients evaluated between 2008 and 2012. Patients were stratified adult (18–64) and geriatric (≥65) groups and matched with mortality data from the National Death Index. Unique patients were identified and recidivists flagged. Statistical analysis was performed based on characteristics from the index admission using nonparametric tests, and Kaplan–Meier curves were plotted to examine postdischarge mortality after index admission for recidivists. A total of 8716 records met inclusion criteria; 800 recidivist records were identified representing 369 unique patients. Recidivists presented between 2 and 7 times. Recidivists were more likely to be male, required ICU admission and mechanical ventilation, had a longer median length of stay, were less likely to discharge home, and had a higher postdischarge mortality. Stratifying into adult and geriatric groups demonstrated significant differences in injury severity, injury patterns, length of stay, race, gender, mechanism, and postdischarge mortality. Recidivists demonstrated a higher postdischarge mortality in both groups with the geriatric group approaching 46 per cent. Trauma recidivists represent an at-risk group with significantly higher postdischarge mortality. Group characteristics differ significantly between the adult and geriatric recidivist populations. Further research is needed to identify modifiable risk factors in these populations to minimize risks of morbidity and mortality.

Background: Intentional self-inflicted injuries present unique challenges in treatment and prevention. We hypothesized intentional self-inflicted injuries would have higher in-hospital and postdischarge mortality than nonintentional self-inflicted injuries trauma. Methods: Adult patients evaluated 2008 to 2012 were identified in our trauma registry and matched with mortality data from the National Death Index. Intentional self-inflicted injuries were identified using E-Codes. Readmissions were identified and analyzed. Intentional self-inflicted injuries patients who died inhospital were compared with those surviving to discharge. Univariate analysis was performed using nonparametric tests. Kaplan-Meier curves were plotted to compare mortality <= 5 years postdischarge between intentional self-inflicted injuries and non-intentional self-inflicted injuries patients. Results: In the study, 8,716 patient records were evaluated with 245 (2.8%) classified as intentional self-inflicted injuries. Eighteen (7.8%) patients with intentional self-inflicted injuries had multiple admissions, compared with 352 (4.4%) patients with nonintentional self-inflicted injuries with readmissions (P = .0210). In-hospital mortality was higher for intentional self-inflicted injuries compared with patients with non-intentional self-inflicted injuries (18.7% vs 4.9%, P < .0001). Survival analysis demonstrated that patients with intentional self-inflicted injuries had significantly lower postdischarge mortality at multiple time points. Conclusion: Patients with intentional self-inflicted injuries trauma have high in-hospital mortality, but low postdischarge mortality. We attribute this to high lethality mechanisms but appropriate psychiatric treatment and rehabilitation. However, the high intentional self-inflicted injuries readmission rate indicates further study of intentional self-inflicted injuries follow-up is warranted. Better prevention strategies are needed to identify and intervene in patients at-risk for intentional self-inflicted injuries. (C) 2019 Elsevier Inc. All rights reserved.

Geriatric trauma patients with low-level falls often have multiple comorbidities and limited physiologic reserve. Our aim was to investigate postdischarge mortality in this population. We hypothesized that five-year mortality would be higher relative to other blunt mechanisms. The registry of our Level 1 trauma center was queried for patients evaluated between July 2008 and December 2012. Adult patients identified were matched with mortality data from 2008 to 2013 from the National Death Index. Low-level falls were identified by E Codes; other types of blunt trauma were based on registry classification. Patients with multiple admissions were excluded. Univariate analysis was performed using Fisher's exact and Wilcoxon tests. Kaplan-Meier curves were plotted to compare postdischarge mortality. Seven thousand nine hundred sixteen patients were evaluated, 35.1 per cent were females. Patients aged less than 65 years and penetrating trauma were excluded, yielding 1997 patients-63.7 per cent with low-level falls versus 36.3 per cent with other blunt traumas. Geriatric patients sustaining low-level falls were older, more likely female, had a higher inpatient mortality, and were less likely to return home at discharge. Injury severity score, hospital length of stay, and intensive care unit length of stay were similar. Survival analysis demonstrated increased postdischarge mortality in the low-level fall group with 25 per cent mortality at 120 days. Geriatric patients with other blunt trauma had a significantly lower postdischarge mortality. Geriatric patients injured in low-level falls have a higher inhospital mortality, are more likely to be functionally dependent on discharge, and have a high postdischarge mortality. Opportunities likely exist for injury prevention, consideration of palliative care, and postdischarge rehabilitation.