Recent Publications by CFE Educators

Importance

Multiple states have laws requiring abortion facilities to meet ambulatory surgery center (ASC) standards. There is limited evidence regarding abortion-related morbidities and adverse events following abortions performed at ASCs vs office-based settings.

Objective

To compare abortion-related morbidities and adverse events at ASCs vs office-based settings.

Design, Setting, and Participants

Retrospective cohort study of women with US private health insurance who underwent induced abortions in an ASC or office-based setting (January 1, 2011-December 31, 2014). Outcomes were abstracted from a large national private insurance claims database during the 6 weeks following the abortion (date of final follow-up, February 11, 2015).

Exposures

Facility type for abortion (ASCs vs office-based settings, including facilities such as abortion clinics, nonspecialized clinics, and physician offices).

Main Outcomes and Measures

The primary outcome was any abortion-related morbidity or adverse event (such as retained products of conception, abortion-related infection, hemorrhage, and uterine perforation) within 6 weeks after an abortion. Two secondary outcomes, both subsets of the primary outcome, were major abortion-related morbidities and adverse events (such as hemorrhages treated with a transfusion, missed ectopic pregnancies treated with surgery, and abortion-related infections that resulted in an overnight hospital admission) and abortion-related infections.

Results

Among 49 287 women (mean age, 28 years [SD, 7.3]) who had 50 311 induced abortions, (23 891 [47%] first-trimester aspiration, 13 480 [27%] first-trimester medication, and 12 940 [26%] second trimester or later), 5660 abortions (11%) were performed in ASCs and 44 651 (89%) in office-based settings. Overall, 3.33% had an abortion-related morbidity or adverse event; 0.32% had a major abortion-related morbidity or adverse event; and 0.74% had an abortion-related infection. In adjusted analyses, there was no statistically significant difference between ASCs vs office-based settings, respectively, in the rates of abortion-related morbidities or adverse events (3.25% vs 3.33%, difference, -0.08%; [corrected] 95% CI, -0.58% to 0.43%; adjusted OR, 0.97; 95% CI, 0.81-1.17), major morbidities or adverse events (0.26% vs 0.33%; difference, -0.06%; 95% CI, -0.18% to 0.06%; adjusted OR, 0.78; 95% CI, 0.45-1.37), or infections (0.58% vs 0.77%; difference, -0.16%; 95% CI, -0.35% to 0.03%; adjusted OR, 0.75; 95% CI, 0.52-1.09).

Conclusions and Relevance

Among women with private health insurance who had an induced abortion, performance of the abortion in an ambulatory surgical center compared with an office-based setting was not associated with a significant difference in abortion-related morbidities and adverse events. These findings, in addition to individual patient and individual facility factors, may inform decisions about the type of facility in which induced abortions are performed.

BACKGROUND

Postoperative pancreatic fistula (POPF) remains the most common complication after distal pancreatectomy. The International Study Group on Pancreatic Surgery definition of POPF is used worldwide. Recently, an update of the definition was published. The aim of this study was to determine the clinical impact of the update.

METHODS

An international retrospective validation study, including patients who underwent DP (2005 -2016) in 5 centers was performed. Distribution of complications amongst POPF grades were compared for the old and updated definition.

RESULTS

In total, 1089 patients were included. The incidence of POPF decreased with the updated definition from 47% to 24% (P 0.01), largely because a downgrade of grade A and grade B into biochemical leak. Comparable morbidity was seen in the old and updated 'no POPF group' (Clavien -Dindo 3 5% vs. 6% P = 0.320 and hospital stay (7 vs. 7 days P = 0.301). The change in definition of POPF grade B resulted in more Clavien -Dindo 3 (38% vs. 51%) P 0.01) and longer hospital stay (9 [9 -13] vs. 9 days [7 -15] P 0.01) in the updated `grade B group'.

CONCLUSION

Applying the updated POPF definition showed improved discrimination between grades and should therefore be used to report POPF after DP.

OBJECTIVE

The decision to undergo a surgical or medical method of second-trimester termination for pregnancy complications should be preference-sensitive. Decision satisfaction has not been described in this population; understanding how women describe decision satisfaction in this setting could inform decision support efforts.

METHODS

We conducted qualitative interviews with women one to three weeks after termination who chose either a surgical or medical termination for fetal anomalies, pregnancy complications or fetal demise. We analyzed transcripts using modified grounded theory in an iterative manner with a generative thematic approach.

RESULTS

We interviewed 36 women (24 surgical and 12 medical). Subjects connected decision satisfaction with counseling experiences and their personal values, including (1) importance of adequate information, (2) autonomous decision making, and (3) choosing the method that facilitates coping.

CONCLUSION

Offering women a choice between surgical and medical termination procedures in the setting of pregnancy complications is integral to decision satisfaction. Women in our study reported wanting this decision to be driven by their personal values.

PRACTICE IMPLICATIONS

Women should be able to choose between surgical and medical termination based on preference and not availability of services. Decision support from women's health providers should be based on values clarification and providing accurate information.

BACKGROUND

Genital numbness and erectile dysfunction in cyclists may result from repeated perineal impacts on the bicycle saddle (micro-trauma) that occur during routine cycling.

AIM

To evaluate the relationship between oscillation forces and perineal pressures among cyclists in a simulated laboratory setting.

METHODS

Participants were fit to a study bicycle to ensure all cyclists had the same torso angle (60 ± 1 degree) and maximum knee angle (150 ± 1 degree). A lever system was used to generate oscillation events of 3 progressively increasing magnitudes. Perineal pressure was continuously measured using a pressure sensor on the bicycle saddle. This process was carried out in each of the following conditions: (1) stationary (not pedaling) with the standard seatpost, (2) pedaling with standard seatpost, (3) stationary with seatpost shock absorber, and (4) pedaling with seatpost shock absorber.

OUTCOMES

We compared perineal pressure changes during oscillation events in the stationary and pedaling states, with and without the seatpost shock absorber.

RESULTS

A total of 39 individuals were recruited (29 men and 10 women). As the amount of oscillation increased from an average of 0.7g (acceleration due to Earth's gravity) to 1.3g, the perineal pressure increased from 10.3% over baseline to 19.4% over baseline. There was a strong linear relationship between the amount of oscillation and increase in pressure (r = 0.8, P .001). A seatpost shock absorber decreased the impact of oscillation by 53% in the stationary condition. Men and women absorbed the majority of shock in areas corresponding to pelvic bony landmarks.

CONCLUSION

This study represents one of the first characterizations of cycling-associated perineal micro-trauma in a laboratory setting. We found a strong linear relationship between oscillation magnitude and perineal pressure during cycling, which was mitigated by a seatpost shock absorber. The use of shock absorption in bicycle design may reduce perineal micro-trauma and potentially improve cycling-associated perineal numbness and erectile dysfunction. Sanford T, Gadzinski AJ, Gaither T, et al. Effect of Oscillation on Perineal Pressure in Cyclists: Implications for Micro-Trauma. Sex Med 2018;6:239-247.

BACKGROUND

Synoptic operative reports (SOR) are more accurate than dictated operative reports (DOR) in a few single institution experiences. We sought to examine the completeness of SOR for laparoscopic cholecystectomy (LC) and pancreaticoduodenectomy (PD) in a multi institutional pilot study.

METHODS

Six institutions participated in SOR submission via a web-based survey. One institution collected DOR and case matched historical dictated operative reports (HOR) for subset analysis. A checklist evaluated completeness of all reports. A post-survey assessed participant opinions.

RESULTS

40 PD SORs were 98.5% complete and 35 LC SORs were 99.7% complete. Single institution subset analysis respective percent complete were: 11 PD SORs 99%, DORs 70% and HORs 74% and 14 LC SORs 99.7%, DORs 76%, and HORs 75%. Post-survey results yielded 10 PD and 24 LC responses. An overwhelming majority agreed that SOR were easy to use and would prefer to use SOR compared to DOR.

CONCLUSION

SOR are more complete than both study associated DOR and HOR. The majority of surgeons indicated their preference for SOR and their willingness to use them.

BACKGROUND & AIMS

Adenoma detection rate (ADR) and serrated polyp detection rate (SDR) vary significantly among colonoscopists. Colonoscopy inspection quality (CIQ) is the quality with which a colonoscopist inspects for polyps and may explain some of this variation. We aimed to determine the relationship between CIQ and historical ADRs and SDRs in a cohort of colonoscopists and assess whether there is variation in CIQ components (fold examination, cleaning, and luminal distension) among colonoscopists with similar ADRs and SDRs.

METHODS

We conducted a prospective observational study to assess CIQ among 17 high-volume colonoscopists at an academic medical center. Over 6 weeks, we video-recorded >28 colonoscopies per colonoscopist and randomly selected 7 colonoscopies per colonoscopist for evaluation. Six raters graded CIQ using an established scale, with a maximum whole colon score of 75.

RESULTS

We evaluated 119 colonoscopies. The median whole-colon CIQ score was 50.1/75. Whole-colon CIQ score (r=0.71; P.01) and component scores (fold examination r=0.74; cleaning r=0.67; distension r=0.77; all P.01) correlated with ADR. Proximal colon CIQ score (r=0.67; P.01) and component scores (fold examination r=0.71; cleaning r=0.62; distension r=0.65; all P.05) correlated with SDR. CIQ component scores differed significantly between colonoscopists with similar ADRs and SDRs for most of the CIQ skills.

CONCLUSION

In a prospective observational study, we found CIQ and CIQ components to correlate with ADR and SDR. Colonoscopists with similar ADRs and SDRs differ in their performance of the 3 CIQ components-specific, actionable feedback might improve colonoscopy technique.