Publications by authors named "Avisek Datta"

16 Publications

  • Page 1 of 1

Culture That Facilitates Change: A Mixed Methods Study of Hospitals Engaged in Reducing Cesarean Deliveries.

Ann Fam Med 2021 May-Jun;19(3):249-257

Stanford University, California Maternal Quality Care Collaborative, Stanford, California.

Purpose: Large-scale efforts to reduce cesarean deliveries have shown varied levels of impact; yet understanding factors that contribute to hospitals' success are lacking. We aimed to characterize unit culture differences at hospitals that successfully reduced their cesarean rates compared with those that did not.

Methods: A mixed methods study of California hospitals participating in a statewide initiative to reduce cesarean delivery. Participants included nurses, obstetricians, family physicians, midwives, and anesthesiologists practicing at participating hospitals. Hospitals' net change in nulliparous, term, singleton, and vertex cesarean delivery rates classified them as successful if they achieved either a minimum 5 percentage point reduction or rate of fewer than 24%. The Labor Culture Survey was used to quantify differences in unit culture. Key informant interviews were used to explore quantitative findings and characterize additional cultural barriers and facilitators.

Results: Out of 55 hospitals, 37 (n = 840 clinicians) meeting inclusion criteria participated in the Labor Culture Survey. Physicians' individual attitudes differed by hospital success on 5 scales: best practices ( = .003), fear ( = .001), cesarean safety ( = .014), physician oversight ( <.001), and microculture ( = .044) scales. Patient ability to make informed decisions showed poor agreement across all hospitals, but was higher at successful hospitals (38% vs 29%, = .01). Important qualitative themes included: ease of access to shared resources on best practices, fear of bad outcomes, personal resistance to change, collaborative practice and effective communication, leadership engagement, and cultural flexibility.

Conclusions: Successful hospitals' culture and context was measurably different from nonresponders. Leveraging these contextual factors may facilitate success.
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July 2020

Reinventing the Medical Assistant Staffing Model at No Cost in a Large Medical Group.

Ann Fam Med 2020 03;18(2):180

Department of Family Medicine, NorthShore University Health-System, Lincolnwood, Illinois.

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March 2020

One Key Question® and the Desire to Avoid Pregnancy Scale: A comparison of two approaches to asking about pregnancy preferences.

Contraception 2020 04 11;101(4):231-236. Epub 2020 Jan 11.

Advancing New Standards in Reproductive Health (ANSIRH), Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, 1330 Broadway #1100, Oakland, CA 94612, USA.

Objective: To facilitate assessment of patients' pregnancy preferences, we compared responses to One Key Question® with the validated Desire to Avoid Pregnancy (DAP) scale and assessed their relationships to patient-reported reproductive health behaviors.

Methods: In this after-visit survey in primary care and obstetrics-gynecology practices, women ages 18-49 (n = 177) answered "Would you like to become pregnant in the next year?" and the 14-item DAP scale. We performed one-way ANOVA to compare DAP scores (0-4 scale, 4 = highest preference to avoid pregnancy) across One Key Question® responses ("Yes," "Unsure," "Ok either way," "No but sometime in the future," "No never"). We used logistic regression to test association of One Key Question® and DAP with contraceptive and folic acid use.

Results: Most patients did not want to become pregnant in the next year, based on One Key Question® (7% "Yes," 4% "Unsure," 11% "Ok either way," 53% "In the future," 25% "Never"). The mean DAP score overall was 2.52 (SD = 1.03, Range: 0-4, Cronbach's α = 0.96). Scores differed by One Key Question® response ("Yes" mean DAP = 0.84, "Unsure" 1.64, "Ok" 1.42, "In the future" 2.94, "Never" 2.78, p < 0.001) yet varied markedly within each One Key Question® response group. Contraceptive use was lower among those who answered "Yes" (46%; OR = 0.14, 95% CI 0.04-0.48) vs. "No, future" (86%). Similarly, odds of contraceptive use increased with DAP score (OR = 1.69, 9% CI 1.18-2.42; predicted 51% for DAP = 0, 90% for DAP = 4).

Conclusion: One Key Question® responses correlate with DAP scores, and contraceptive use correlates with not desiring pregnancy by both approaches.

Implications Statement: One Key Question® and the Desire to Avoid Pregnancy scale can both identify women wishing to avoid pregnancy to help clinicians address patients' contraceptive needs. Given the range of preferences associated with One Key Question® responses, clinicians who use it should proceed with further discussion to fully understand patients' feelings.
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April 2020

A Multifaceted Surgical Site Infection Prevention Bundle for Cesarean Delivery.

Am J Perinatol 2021 06 30;38(7):690-697. Epub 2019 Dec 30.

Department of Obstetrics and Gynecology, NorthShore University Health System, Evanston, Illinois.

Objective: Surgical site infections (SSI, including wound infections, endometritis, pelvic abscess, and sepsis) may complicate cesarean section (C/S). We report outcomes before and after the introduction of an SSI prevention bundle that did not include antibiotics beyond routine prophylaxis (cefazolin, or gentamicin/clindamycin for penicillin-allergic patients).

Study Design: The prevention bundle was introduced following an increase in C/S-associated SSI, which itself was associated with an institutional switch in preoperative scrub from povidone-iodine to chlorhexidine gluconate (CHG)/isopropanol. Components of the bundle included: (1) full-body preoperative wash with 4% CHG cloths; (2) retraining on surgeon hand scrub; (3) retraining for surgical prep; and (4) patient education regarding wound care. Patients delivered by C/S at ≥24 weeks of gestation were segregated into four epochs over 7 years: (1) baseline (18 months when povidone-iodine was used); (2) CHG scrub (18 months after skin prep was switched to CHG); (3) bundle implementation (24 months); and (4) maintenance (24 months following implementation).

Results: A total of 3,637 patients were included ( = 667, 796, 1098, and 1076, respectively, in epochs 1-4). A rise in SSI occurred with the institutional switch from povidone-iodine to CHG (i.e., from baseline to the CHG scrub epoch, 8.4-13.3%,  < 0.01). Following the intervention (maintenance epoch), this rate decreased to below baseline values (to 4.5%,  < 0.01), attributable to a decline in wound infection (rates in the above three epochs 6.9, 12.9, and 3.5%, respectively,  < 0.01), with no change in endometritis. In multivariable analysis, only epoch and body mass index (BMI) were independently associated with SSI. The improvement associated with the prevention bundle held for stratified analysis of specific risk factors such as chorioamnionitis, prior C/S, obesity, labor induction, and diabetes.

Conclusion: Implementation of a prevention bundle was associated with a reduction in post-C/S SSI. This improvement was achieved without the use of antibiotics beyond standard preoperative dosing.
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June 2021

Clinical profile of comorbid dysmenorrhea and bladder sensitivity: a cross-sectional analysis.

Am J Obstet Gynecol 2020 06 20;222(6):594.e1-594.e11. Epub 2019 Dec 20.

Department of Obstetrics and Gynecology, Northshore University HealthSystem, Evanston, IL; Pritzker School of Medicine, University of Chicago, Chicago, IL.

Background: Antecedents of chronic pelvic pain are not well characterized, but pelvic organ visceral sensitivity is a hallmark of these disorders. Recent studies have identified that some dysmenorrhea sufferers are much more likely to exhibit comorbid bladder hypersensitivity. Presumably, these otherwise healthy women may be at higher risk of developing full-blown chronic bladder pain later in life. To encourage early identification of patients harboring potential future risk of chronic pain, we describe the clinical profile of women matching this putative pain-risk phenotype.

Objective(s): The objectives of the study were to characterize demographic, menstrual, pelvic examination, and psychosocial profiles of young women with comorbid dysmenorrhea and bladder hypersensitivity, defined using a standardized experimental visceral provocation test, contrasted with healthy controls, pure dysmenorrhea sufferers, and women with existing bladder pain syndrome.

Study Design: This prospective cohort study acquired data on participants with moderate to severe dysmenorrhea (n = 212), healthy controls (n = 44), and bladder pain syndrome (n = 27). A subgroup of dysmenorrhea patients was found on screening with noninvasive oral water challenge to report significantly higher bladder pain during experimentally monitored spontaneous bladder filling (>15 out of 100 on visual analogue scale, based on prior validation studies) and separately defined as a group with dysmenorrhea plus bladder pain. Medical/menstrual history and pain history were evaluated with questionnaires. Psychosocial profile and impact were measured with validated self-reported health status Patient Reported Outcomes Measurement Information System short forms and a Brief Symptom Inventory for somatic sensitivity. Pelvic anatomy and sensory sensitivity were examined via a standardized physical examination and a tampon provocation test.

Results: In our largely young, single, nulliparous cohort (24 ± 1 years old), approximately a quarter (46 out of 212) of dysmenorrhea sufferers tested positive for the dysmenorrhea plus bladder pain phenotype. Dysmenorrhea-only sufferers were more likely to be African American (24%) than healthy controls (5%, post hoc χ, P = .007). Pelvic examination findings did not differ in the nonchronic pain groups, except for tampon test sensitivity, which was worse in dysmenorrhea plus bladder pain and dysmenorrhea sufferers vs healthy controls (2.6 ± 0.3 and 1.7 ± 0.2 vs 0.7 ± 0.2, P < .05). Consistent with heightened pelvic sensitivity, participants with dysmenorrhea plus bladder pain also had more nonmenstrual pain, dysuria, dyschezia, and dyspareunia (P's < .05). Participants with dysmenorrhea plus bladder pain had Patient Reported Outcomes Measurement Information System Global Physical T-scores of 47.7 ± 0.9, lower than in women with dysmenorrhea only (52.3 ± 0.5), and healthy controls 56.1 ± 0.7 (P < .001). Similarly, they had lower Patient Reported Outcomes Measurement Information System Global Mental T-score than healthy controls (47.8 ± 1.1 vs 52.8 ± 1.2, P = .017). Similar specific impairments were observed on Patient Reported Outcomes Measurement Information System scales for anxiety, depression, and sleep in participants with dysmenorrhea plus bladder pain vs healthy controls.

Conclusion: Women with dysmenorrhea who are unaware they also have bladder sensitivity exhibit broad somatic sensitivity and elevated psychological distress, suggesting combined preclinical visceral sensitivity may be a precursor to chronic pelvic pain. Defining such precursor states is essential to conceptualize and test preventative interventions for chronic pelvic pain emergence. Dysmenorrhea plus bladder pain is also associated with higher self-reported pelvic pain unrelated to menses, suggesting central nervous system changes are present in this potential precursor state.
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June 2020

Antenatal Periviability Counseling and Decision Making: A Retrospective Examination by the Investigating Neonatal Decisions for Extremely Early Deliveries Study Group.

Am J Perinatol 2020 01 22;37(2):184-195. Epub 2019 Aug 22.

Department of Pediatrics, Division of Neonatology, Medical College of Wisconsin, Milwaukee, Wisconsin.

Objective: To describe periviability counseling practices and decision making.

Study Design: This is a retrospective review of mothers and newborns delivering between 22 and 24 completed weeks from 2011 to 2015 at six U.S. centers. Maternal and fetal/neonatal clinical and maternal sociodemographic data from medical records and geocoded sociodemographic information were collected. Separate analyses examined characteristics surrounding receiving neonatology consultation; planning neonatal resuscitation; and centers' planned resuscitation rates.

Results: Neonatology consultations were documented for 40, 63, and 72% of 498 mothers delivering at 22, 23, and 24 weeks, respectively. Consult versus no-consult mothers had longer median admission-to-delivery intervals (58.7 vs. 8.7 h,  < 0.001). Consultations were seen more frequently when parental decision making was evident. In total, 76% of mothers had neonatal resuscitation planned. Resuscitation versus no-resuscitation newborns had higher mean gestational ages (24.0 vs. 22.9 weeks,  < 0.001) and birthweights (618 vs. 469 g,  < 0.001). Planned resuscitation rates differed at higher (HR) versus lower (LR) rate centers at 22 (43 vs. 7%,  < 0.001) and 23 (85 vs. 58%,  < 0.001) weeks. HR versus LR centers' populations had more socioeconomic hardship markers but fewer social work consultations (odds ratio: 0.31; confidence interval: 0.15-0.59,  < 0.001).

Conclusion: Areas requiring improvement included delivery/content of neonatology consultations, social work support, consideration of centers' patient populations, and opportunities for shared decisions.
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January 2020

Clinical outcomes in ovarian cancer patients receiving three versus more cycles of chemotherapy after neoadjuvant treatment and interval cytoreductive surgery.

Int J Gynecol Cancer 2019 09 27;29(7):1156-1163. Epub 2019 Jul 27.

Division of Gynecologic Oncology, NorthShore University HealthSystem, Evanston, Illinois, USA.

Objectives: To compare clinical outcomes for stage IIIC and IV ovarian cancer patients receiving neoadjuvant chemotherapy and interval cytoreductive surgery followed by up to three versus more cycles of post-operative chemotherapy.

Methods: We conducted a multi-institution retrospective cohort study of patients treated from January 2005 to February 2016 with neoadjuvant platinum-based therapy followed by interval surgery and post-operative chemotherapy. The following were exclusion criteria: more than four cycles of neoadjuvant chemotherapy, bevacizumab with neoadjuvant chemotherapy, non-platinum therapy, prior chemotherapy, and elevated CA125 values after three post-operative chemotherapy cycles. Progression-free and overall survival and toxicity profiles were compared between groups receiving up to three cycles versus more that three cycles post-operatively.

Results: A total of 100 patients met inclusion criteria: 41 received up to three cycles and 59 received more than three cycles. The groups were similar in terms of age, body mass index, performance status, tumor histology, optimal cytoreduction rates, and median number of neoadjuvant chemotherapy cycles. Median progression-free survival was 14 vs 16.6 months in those receiving up to three cycles versus more than three cycles, respectively (HR 0.99, 95% CI 0.58 to 1.68, p=0.97). Similarly, median overall survival was not different at 47.1 vs 69.4 months, respectively (HR 1.96, 95% CI 0.87 to 4.42, p0.10). There were no differences in grade 2 or higher chemotherapy-related toxicities.

Conclusions: Extending post-operative chemotherapy beyond three cycles in patients receiving neoadjuvant chemotherapy and interval cytoreductive surgery with normalization of CA125 levels was not associated with improved survival or greater toxicity. Future study in a larger cohort is warranted to define optimal length of cytotoxic treatment.
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September 2019

Development and validation of an asthma exacerbation prediction model using electronic health record (EHR) data.

J Asthma 2020 12 8;57(12):1339-1346. Epub 2019 Aug 8.

Department of Family Medicine, Case Western Reserve University/University Hospitals, Cleveland, OH, USA.

Asthma exacerbations are associated with significant morbidity, mortality, and cost. Accurately identifying asthma patients at risk for exacerbation is essential. We sought to develop a risk prediction tool based on routinely collected data from electronic health records (EHRs). From a repository of EHRs data, we extracted structured data for gender, race, ethnicity, smoking status, use of asthma medications, environmental allergy testing BMI status, and Asthma Control Test scores (ACT). A subgroup of this population of patients with asthma that had available prescription fill data was identified, which formed the primary population for analysis. Asthma exacerbation was defined as asthma-related hospitalization, urgent/emergent visit or oral steroid use over a 12-month period. Univariable and multivariable statistical analysis was completed to identify factors associated with exacerbation. We developed and tested a risk prediction model based on the multivariable analysis. We identified 37,675 patients with asthma. Of those, 1,787 patients with asthma and fill data were identified, and 979 (54.8%) of them experienced an exacerbation. In the multivariable analysis, smoking (OR = 1.69, CI: 1.08-2.64), allergy testing (OR = 2.40, CI: 1.54-3.73), obesity (OR = 1.66, CI: 1.29-2.12), and ACT score reflecting uncontrolled asthma (OR = 1.66, CI: 1.10-2.29) were associated with increased risk of exacerbation. The area-under-the-curve (AUC) of our model in a combined derivation and validation cohort was 0.67. Despite use of rigorous methodology, we were unable to produce a predictive model with an acceptable degree of accuracy and AUC to be clinically useful.
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December 2020

Cesarean overuse and the culture of care.

Health Serv Res 2019 04 20;54(2):417-424. Epub 2019 Feb 20.

Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California.

Objective: To assess hospital unit culture and clinician attitudes associated with varying rates of primary cesarean delivery.

Data Sources/study Setting: Intrapartum nurses, midwives, and physicians recruited from 79 hospitals in California participating in efforts to reduce cesarean overuse.

Study Design: Labor unit culture and clinician attitudes measured using a survey were linked to the California Maternal Data Center for birth outcomes and hospital covariates.

Methods: Association with primary cesarean delivery rates was assessed using multivariate Poisson regression adjusted for hospital covariates.

Principal Findings: 1718 respondents from 70 hospitals responded to the Labor Culture Survey. The "Unit Microculture" subscale was strongly associated with primary cesarean rate; the higher a unit scored on 8-items describing a culture supportive of vaginal birth (eg, nurses are encouraged to spend time in rooms with patients, and doulas are welcomed), the cesarean rate decreased by 41 percent (95% CI = -47 to -35 percent, P < 0.001). Discordant attitudes between nurses and physicians were associated with increased cesarean rates.

Conclusions: Hospital unit culture, clinician attitudes, and consistency between professions are strongly associated with primary cesarean rates. Improvement efforts to reduce cesarean overuse must address culture of care as a key part of the change process.
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April 2019

Persistent autonomic dysfunction and bladder sensitivity in primary dysmenorrhea.

Sci Rep 2019 02 18;9(1):2194. Epub 2019 Feb 18.

Department of Obstetrics and Gynecology, NorthShore University HealthSystem, Evanston IL, 60201, USA.

Menstrual pain, also known as dysmenorrhea, is a leading risk factor for bladder pain syndrome (BPS). A better understanding of the mechanisms that predispose dysmenorrheic women to BPS is needed to develop prophylactic strategies. Abnormal autonomic regulation, a key factor implicated in BPS and chronic pain, has not been adequately characterized in women with dysmenorrhea. Thus, we examined heart rate variability (HRV) in healthy (n = 34), dysmenorrheic (n = 103), and BPS participants (n = 23) in their luteal phase across a bladder-filling task. Both dysmenorrheic and BPS participants reported increased bladder pain sensitivity when compared to controls (p's < 0.001). Similarly, dysmenorrheic and BPS participants had increased heart rate (p's < 0.01), increased diastolic blood pressure (p's < 0.01), and reduced HRV (p's < 0.05) when compared to controls. Dysmenorrheic participants also exhibited little change in heart rate between maximum bladder capacity and after micturition when compared to controls (p = 0.013). Our findings demonstrate menstrual pain's association with abnormal autonomic activity and bladder sensitivity, even two weeks after menses. Our findings of autonomic dysfunction in both early episodic and chronic visceral pain states points to an urgent need to elucidate the development of such imbalance, perhaps beginning in adolescence.
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February 2019

The Current State of Research Capacity in US Family Medicine Departments.

Fam Med 2019 02;51(2):112-119

NorthShore University HealthSystem, Department of Family Medicine, Evanston, IL.

Background And Objectives: Capacity for conducting family medicine research has grown significantly since the specialty was founded. Many calls to increase this capacity have been published, but there has been no consistent, systematic, and longitudinal assessment. This survey was designed to gather baseline data with an easily replicable set of measures associated with research productivity that can guide and monitor the impact of efforts to build research capacity in US departments of family medicine (DFMs).

Methods: We surveyed family medicine department chairs regarding departmental research capacity using well-established empirical measures of capacity (trained research faculty, infrastructure, research leadership, and funding) and a self-assessment. We used bivariate analyses to assess correlation between the empirical measures and the self-assessed stage of research capacity.

Results: Self-assessed capacity was significantly associated with every empirical measure. High-capacity departments have more research-trained faculty, more faculty effort, utilize more research "laboratories," have more faculty serving on federal peer-review panels, more faculty as principal investigators, devote more internal funding to research, and garner larger amounts of funding from more external funding sources than moderate or minimal-capacity departments.

Conclusions: US DFMs have made great strides over the past half century in building research capacity. However, much more capacity in family medicine and primary care research is needed to produce new knowledge necessary to improve the health and health care of the nation. Periodic measurement using the simple, replicable, and valid minimum measures of this study provides an opportunity to establish longitudinal tracking of change in research capacity in US DFMs.
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February 2019

Measuring labor and delivery unit culture and clinicians' attitudes toward birth: Revision and validation of the Labor Culture Survey.

Birth 2019 06 8;46(2):300-310. Epub 2018 Nov 8.

Department of Obstetrics and Gynecology, California Maternal Quality Care Collaborative, Stanford University School of Medicine, Stanford, California.

Background: Cesarean delivery rates in the United States vary widely between hospitals, which cannot be fully explained by hospital or patient factors. Cultural factors are hypothesized to play a role in cesarean overuse, yet tools to measure labor culture are lacking. The aim of this study was to revise and validate a survey tool to measure hospital culture specific to cesarean overuse.

Methods: A panel of clinicians and researchers compiled an item bank from validated surveys, added newly created items, and performed four rounds of iterative revision and consolidation. Obstetricians, family physicians, midwives, anesthesiologists, and labor nurses were recruited from 79 hospitals in California. Exploratory factor analysis was used to reduce the number of survey items and identify latent constructs to form the basis of subscales. Confirmatory factor analysis examined reliability in 31 additional hospitals. Poisson regression assessed associations between hospitals' mean score on each individual item and cesarean rates.

Results: A total of 1718 individuals from 70 hospitals were included in the exploratory factor analysis. The final Labor Culture Survey (LCS) consisted of 29 items and six subscales: "Best Practices to Reduce Cesarean Overuse," "Fear of Vaginal Birth," "Unit Microculture," "Physician Oversight," "Maternal Agency," and "Cesarean Safety."

Conclusions: The revised LCS is a valid and reliable tool to measure constructs shown to be associated with cesarean rates. These findings support prior research that has shown that hospital culture is measurable, and that clinician attitudes are predictive of clinician behaviors. Unique to our survey is the construct of labor and delivery unit microculture.
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June 2019

Identification of experimental bladder sensitivity among dysmenorrhea sufferers.

Am J Obstet Gynecol 2018 07 25;219(1):84.e1-84.e8. Epub 2018 Apr 25.

Department of Obstetrics/Gynecology, NorthShore University HealthSystem, Evanston, IL; Pritzker School of Medicine, University of Chicago, Chicago, IL. Electronic address:

Background: Dysmenorrhea is a common risk factor for chronic pain conditions including bladder pain syndrome. Few studies have formally evaluated asymptomatic bladder pain sensitivity in dysmenorrhea, and whether this largely reflects excess pelvic symptom reporting due to comorbid psychological dysfunction.

Objective: We sought to determine whether bladder hypersensitivity is more common among women reporting moderate or greater dysmenorrhea, without chronic pain elsewhere, after accounting for anxiety and depression. Demonstrating this would suggest that dysmenorrhea might be an early clue for visceral or widespread pain hypersensitivity and improve understanding of potential precursors to bladder pain syndrome.

Study Design: We compared cohorts of regularly menstruating women, without symptoms of chronic pain elsewhere, reporting (1) moderate-to-severe dysmenorrhea (n = 98) and (2) low levels or no menstrual pain (n = 35). Participants underwent rapid bladder filling following a standard water ingestion protocol, serially rating bladder pain and relative urgency during subsequent distension. Potential differences in bladder volumes were controlled for by sonographic measurement at standard cystometric thresholds. Bladder sensitivity was also measured with complementary measures at other times separately including a simplified rapid filling test, palpation of the bladder wall, and through ambulatory self-report. Anxiety and depression were evaluated with the National Institutes of Health Patient-Reported Outcomes Measurement Information System measures.

Results: Women with moderate-to-severe dysmenorrhea reported more urinary symptoms than controls and had a lower maximum capacity (498 ± 18 mL vs 619 ± 34 mL, P < .001) and more evoked bladder filling pain (0-100 visual analog scale: 25 ± 3 vs 12 ± 3, P < .001). The dysmenorrhea-bladder capacity relationship remained significant irrespective of menstrual pain severity, anxiety, depression, or bladder pain (R = 0.13, P = .006). Severity of menstrual pain predicted evoked bladder pain (R = 0.10, P = .008) independent of anxiety (P = .21) and depression (P = .21). Women with moderate-to-severe dysmenorrhea exhibiting provoked bladder pain (24/98, 24%) also reported higher pain during the screening rapid bladder test (P < .001), in response to transvaginal bladder palpation (P < .015), and on prospective daily diaries (P < .001) than women with dysmenorrhea without provoked bladder pain.

Conclusion: Women experiencing moderate-to-severe dysmenorrhea also harbor a higher pain response to naturally evoked bladder distension. Noninvasive bladder provocation needs to be tested further longitudinally in those with dysmenorrhea to characterize the course of visceral sensitivity and determine if it may help predict individuals at risk for developing subsequent pain in the bladder or elsewhere.
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July 2018

Pubovesical sling for residual incontinence after successful vesicovaginal fistula closure: a new approach to an old procedure.

Int Urogynecol J 2018 Oct 21;29(10):1551-1556. Epub 2018 Feb 21.

Bingham University Teaching Hospital, Jos, Nigeria.

Introduction And Hypothesis: For decades, the pubovesical (PV) sling has been in the armamentarium of the fistula surgeon for treating persistent urinary incontinence after successful fistula closure. We report our early experience with slings, and then also introduce a new "tight" PV sling technique for management of post-fistula urethral leak. Our hypothesis is that performance of tight slings might result in improved continence for women with persistent urinary incontinence after obstetric fistula closure.

Methods: Data from 120 patients in whom some type of sling procedure had been performed between 1996 and 2012 were extracted and labeled as "early slings." Beginning in October 2014, more complete data were recorded and a more uniform approach was undertaken in 40 patients. Data were extracted from their charts and recorded as "tight slings." This information was analyzed using Chi-squared analysis.

Results: Tight slings were more successful in patients who had less severe fibrosis and who had a shorter time since initial injury. Thirty percent of women who underwent tight slings had improved continence at follow-up.

Conclusion: Persistent urinary incontinence despite successful surgical closure of obstetrical fistula remains a difficult problem. Tight slings may be warranted in an attempt to avoid urinary diversion.
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October 2018

The Shifting Paradigm for Breast Cancer Surgery in Patients Undergoing Neoadjuvant Chemotherapy.

Ann Surg Oncol 2018 Jan 10;25(1):164-172. Epub 2017 Nov 10.

Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA.

Introduction: Surgical therapy for newly diagnosed breast cancer has changed over the past decade, but these trends have not been well documented in patients undergoing neoadjuvant therapy (NAC).

Methods: In a retrospective cohort study of the National Cancer Database (NCDB), we selected 285,514 women with clinical stage I-III breast cancer who underwent NAC or adjuvant therapy (AC) from 2006 to 2014. Breast-conserving surgery (BCS), unilateral mastectomy (UM), and bilateral mastectomy (BM) rates were compared between patients undergoing NAC and AC.

Results: Of 285,514 women, 68,850 (24.1%) underwent NAC. Of NAC patients, 18,158 (26.4%) underwent BM and 27,349 (39.7%) BCS compared with 31,886 (14.7%) and 120,626 (55.7%) AC patients, respectively. From 2006 to 2014, BM increased from 16.1 to 28.8% (p < 0.001) for NAC and from 7.4 to 17.5% (p < 0.001) for AC. After adjusting for patient, tumor, and facility factors, NAC patients were 1.50 times [odds ratio (OR) 1.50, confidence interval (CI) 1.42-1.51] more likely to undergo BM then AC patients. The difference in BM rates between patients receiving NAC versus AC varied significantly by cT classification. This difference was the greatest among cT1 tumors between NAC and AC (31.7 vs. 13.0%, p < 0.001), followed by cT2 tumors (24.1 vs. 16.6%, p < 0.001) and cT3 tumors (24.3 vs. 22.3%).

Conclusions And Relevance: More NAC patients are undergoing BM while fewer are undergoing BCS compared with patients undergoing AC. This trend is particularly striking for those patients with smaller tumors who would otherwise be candidates for BCS.
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January 2018