Publications by authors named "Christopher C DeStephano"

29 Publications

  • Page 1 of 1

Can loratadine help in treating granulocyte-colony stimulating factor-induced bone pain?

JAAPA 2021 Jul;34(7):29-31

Shilpa N. Gajarawala practices in the Department of Medical and Surgical Gynecology at Mayo Clinic Florida, is an assistant professor in obstetrics and gynecology in the Mayo Clinic College of Medicine, and is an adjunct faculty member for the DMSc program at Rocky Mountain University of Health Science in Provo, Utah. Jessica N. Pelkowski is an NP in the Department of Orthopedic Surgery at Mayo Clinic Florida, and an assistant professor of orthopedic surgery and instructor of nursing in the Mayo Clinic College of Medicine. Christopher C. DeStephano practices in the Department of Medical and Surgical Gynecology at Mayo Clinic Florida and is an assistant professor of obstetrics and gynecology in the Mayo Clinic College of Medicine. The authors have disclosed no potential conflicts of interest, financial or otherwise.

Abstract: Febrile neutropenia is an oncologic emergency with serious consequences. Granulocyte colony stimulating factors (G-CSFs), used to stimulate neutrophil production to prevent febrile neutropenia, can cause bone pain in more than 25% of patients. Severe bone pain may not respond to acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, or dose reduction of the G-CSF agent. A study found that patients taking loratadine had fewer treatment-associated adverse reactions and discontinuations than those on naproxen. Although more research is needed, loratadine's tolerability, ease of administration, and potential benefit mean that it should be considered for management of pegfilgrastim-associated bone pain. This article describes a patient whose G-CSF-induced bone pain was completely alleviated by loratadine.
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http://dx.doi.org/10.1097/01.JAA.0000753896.78290.12DOI Listing
July 2021

Decisions and Consequences: Validation of High-Stakes Simulation-Based Assessments in Gynecologic Surgery.

J Minim Invasive Gynecol 2021 Jul 23;28(7):1285-1290. Epub 2021 May 23.

Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland (Dr. Chen).

Study Objective: Simulation-based assessment is poised for application in educational promotion and credentialing in gynecologic surgery. With high-stakes assessment, validation necessitates evidence, not just about the trustworthiness of decisions but of beneficial consequences to education and healthcare as well. In this paper, we unpack the modern conceptualization of validity as it pertains to surgical simulation and high-stakes competency assessment.

Design: N/A SETTING: N/A PATIENTS: N/A INTERVENTIONS: N/A MEASUREMENTS AND MAIN RESULTS: N/A CONCLUSION: Validity in high-stakes simulation-based assessment necessitates evidence, not just about the trustworthiness of score-based decisions but of beneficial consequences to education and healthcare as well.
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http://dx.doi.org/10.1016/j.jmig.2021.05.013DOI Listing
July 2021

Correcting the Fundamentals of Laparoscopic Surgery "Illusion of Validity" in Laparoscopic Vaginal Cuff Suturing.

J Minim Invasive Gynecol 2021 May 16. Epub 2021 May 16.

Department of Medical and Surgical Gynecology (Drs. Leon, Dinh, and DeStephano).

Study Objective: The "illusion of validity" is a cognitive bias in which the ability to interpret and predict surgical performance accurately is overestimated. To address this bias, we assessed participants comparing fundamentals of laparoscopic surgery (FLS) and non-FLS tasks with cadaveric vaginal cuff suturing to determine the most representative simulation task for laparoscopic vaginal cuff suturing.

Design: Validity (Messick framework) study comparing FLS and non-FLS tasks with cadaveric vaginal cuff suturing.

Setting: Simulation center cadaver laboratory.

Participants: Obstetrics and gynecology residents (n = 21), minimally invasive gynecologic surgery fellows (n = 3), gynecologic surgical subspecialists (n = 4), general obstetrician/gynecologists (n = 10).

Interventions: Tasks included a simulated vaginal cuff (ipsilateral port placement), needle passage through a metal eyelet loop (contralateral and ipsilateral), and intracorporeal knot tying (contralateral and ipsilateral). Simulation task times were compared with the placement of the first cadaveric vaginal cuff suture time, as well as the in-person and blinded Global Operative Assessment of Laparoscopic Skills (GOALS) score ("relations to other variables" validity evidence). Statistical analyses included Spearman's test of correlation (continuous and ordinal variables) or Wilcoxon rank sum test (categoric variables).

Measurements And Main Results: There was a stronger association with cadaver cuff suturing time for simulated vaginal cuff suturing time (r = 0.73, p <.001) compared with FLS intracorporeal contralateral suturing time (r = 0.54, p <.001). Additional measures associated with cadaveric performance included subspecialty training (median: 82 vs 185 seconds, p = .002), number of total laparoscopic hysterectomies (r = -0.53, p <.001), number of laparoscopic cuff closures (r = -0.61, p <.001), number of simulated laparoscopic suturing experiences (r = -0.51, p <.001), and eyelet contralateral time (r = 0.52, p <.001). Strong agreement between the in-person and blinded GOALS (intraclass correlation coefficient = 0.80) supports response process evidence. Correlations of cadaver cuff time with in-person (Spearman's r = -0.84, p <.001) and blinded GOALS (r = -0.76, p <.001) supports relations to other variables evidence CONCLUSION: The weaker correlation between FLS suturing and cadaver cuff suturing compared with a simulated vaginal cuff model may lead to an "illusion of validity" for assessment in gynecology. Since gynecology specific validity evidence has not been well established for FLS, we recommend prioritizing the use of a simulated vaginal cuff suturing assessment in addition to FLS.
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http://dx.doi.org/10.1016/j.jmig.2021.05.002DOI Listing
May 2021

Disparities and interventions in the timeliness of endometrial cancer diagnosis and treatment in the United States: a scoping review protocol.

Syst Rev 2021 04 13;10(1):107. Epub 2021 Apr 13.

Department of Obstetrics and Gynecology, Mayo Clinic, Jacksonville, FL, USA.

Background: Disparities in the stage at diagnosis of endometrial cancer (EC) account for a significant proportion of the disparities in morbidity and mortality experienced by vulnerable groups in the USA. Evidence suggests that disparities in timeliness of care and treatment play a significant role in stage at diagnosis. Despite an increase in literature on EC disparities, the issue remains largely unchanged. The objectives of this review will be to synthesize the evidence to identify important remaining research questions and inform future interventions to reduce the disparity in stage at diagnosis of EC in the USA.

Methods: This scoping review protocol will use the five-step framework developed by Arksey and O'Malley. A literature search will be conducted from January 2000 onwards in PubMed, EMBASE, Scopus, and Cochrane CENTRAL databases. Studies on delays in care of EC will be included if they were published in English and reported findings for the US population. Two reviewers will independently screen all citations, full-text articles, and abstract data. The study methodological quality and bias will be appraised using appropriate tools. A narrative summary of findings will be conducted. Data analysis will involve quantitative (e.g., frequencies) and qualitative (e.g., content and thematic analysis) methods. The literature search, data extraction, and evidence synthesis will be informed by the Pathway to Treatment Model, which divides time to cancer care initiation into appraisal, help-seeking, diagnostic, and pre-treatment intervals. Results will be reported in accordance with the PRISMA statement.

Discussion: EC disparities research is currently benefitting form a growing expectation that studies have a real impact on disparities. Patient, healthcare, and disease factors impact the amount of time patients spend in different intervals of the Pathway to Treatment Model, so research and interventions aimed at reducing disparities in EC survival should be designed with cognizance to how these factors impact their target population. Reviews on disparities in stage at diagnosis of EC exist but do not provide a comprehensive picture of the pathway to treatment. This review will seek to provide an expanded bedrock of evidence for future studies to build on as they aim to more actively reduce EC disparities.

Trial Registration: Open Science Framework ( osf.io/v2zxy ).
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http://dx.doi.org/10.1186/s13643-021-01649-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8042979PMC
April 2021

Choosing and Using Patient-Reported Outcome Measures in Clinical Practice.

Arch Phys Med Rehabil 2021 Mar 10. Epub 2021 Mar 10.

Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.

The increasing use of patient-reported outcome (PRO) measures is forcing clinicians and health care systems to decide which to select and how to incorporate them into their records and clinical workflows. This overview addresses 3 topics related to these concerns. First, a literature review summarizes key psychometric and practical factors (such as reliability, responsiveness, computer adaptive testing, and interpretability) in choosing PROs for clinical practice. Second, 3 clinical decision support issues are highlighted: gathering PROs, electronic health record effect on providers, and incorporating PROs into clinical decision support design and implementation. Lastly, the salience of crosscutting domains as well as 9 key pragmatic decisions are reviewed. Crosscutting domains are those that are relevant across most medical and mental health conditions, such as the SPADE symptom pentad (sleep problems, pain, anxiety, depression, low energy/fatigue) and physical functioning. The 9 pragmatic decisions include (1) generic vs disease-specific scales; (2) single- vs multidomain scales; (3) universal scales vs user-choice selection; (4) number of domains to measure; (5) prioritization of domains when multiple domains are assessed; (6) action thresholds; (7) clinical purpose (screening vs monitoring); as well as the (8) frequency and (9) logistical aspects of PRO administration.
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http://dx.doi.org/10.1016/j.apmr.2020.12.033DOI Listing
March 2021

Use of Cannabis for Self-Management of Chronic Pelvic Pain.

J Womens Health (Larchmt) 2020 Nov 16. Epub 2020 Nov 16.

Department of Gynecologic Surgery, Mayo Clinic, Jacksonville, Florida, USA.

Chronic pelvic pain (CPP) affects up to 15% of women in the United States. The endocannabinoid system is a potential pharmacological target for pelvic pain as cannabinoid receptors are highly expressed in the uterus and other nonreproductive tissues. We hypothesize that cannabis use is common for self-management of CPP, and our primary objective was to determine the prevalence of cannabis use in this population. A cross-sectional survey of women with pelvic and perineal pain, dyspareunia, or endometriosis was performed between March and August 2019. Subjects were recruited in an outpatient gynecology office. An anonymous, confidential, electronic survey was performed using a tablet. Statistical analysis was performed using JMP (SAS, Cary, NC). A total of 240 patients were approached, with 113 responses (47.1% response rate). There were 26 patients who used cannabis (23%). The majority used at least once per week ( = 18, 72%). Most users ( = 24, 96%) reported improvement in symptoms, including pain, cramping, muscle spasms, anxiety, depression, sleep disturbances, libido, and irritability. Over one-third (35%) stated that cannabis use decreased the number of phone calls or messages sent to their provider, and 39% reported decreased number of clinical visits. Side effects, including dry mouth, sleepiness, and feeling "high," were reported by 84% ( = 21). Almost one-quarter of patients with CPP report regular use of cannabis as an adjunct to their prescribed therapy. Although side effects are common, most users report improvement in symptoms. Our study highlights the potential of cannabis as a therapeutic option for patients with CPP.
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http://dx.doi.org/10.1089/jwh.2020.8737DOI Listing
November 2020

Establishing Validity for a Vaginal Hysterectomy Simulation Model for Surgical Skills Assessment.

Obstet Gynecol 2020 11;136(5):942-949

Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland; the Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland; the Department of Gynecology, Mayo Clinic, Jacksonville, Florida; the Department of Obstetrics and Gynecology, University of California Riverside, Riverside, California; the Department of Obstetrics and Gynecology, Oklahoma University College of Medicine, Oklahoma City, Oklahoma; Augmented Reality Systems Inc., Windham, New Hampshire; and the Department of Obstetrics and Gynecology, Wake Forest School of Medicine, Winston-Salem, North Carolina. At the time of study, all participating institutions were members of the American College of Obstetricians and Gynecologists Simulations Working Group.

Objective: To use the Messick validity framework for a simulation-based assessment of vaginal hysterectomy skills.

Methods: Video recordings of physicians at different levels of training and experience performing vaginal hysterectomy on a high-fidelity vaginal surgery model were objectively assessed using a modified 10-item Vaginal Surgical Skills Index, a one-item global scale of overall performance, and a pass-fail criterion. Participants included obstetrics and gynecology trainees and faculty from five institutions. Video recordings were independently assessed by expert surgeons blinded to the identities of the study participants.

Results: Fifty surgeons (11 faculty, 39 trainees) were assessed. Experience level correlated strongly with both the modified Vaginal Surgical Skills Index and global scale score, with more experienced participants receiving higher scores (Pearson r=0.81, P<.001; Pearson r=0.74, P<.001). Likewise, surgical experience was also moderately correlated with the modified Vaginal Surgical Skills Index and global scale score (Pearson r=0.55, P<.001; Pearson r=0.58, P<.001). The internal consistency of the modified Vaginal Surgical Skills Index was excellent (Cronbach's alpha=0.97). Interrater reliability of the modified Vaginal Surgical Skills Index and global scale score, as measured by the intraclass correlation coefficient, was moderate to good (0.49-0.95; 0.50-0.87). Using the receiver operating characteristic curve and the pass-fail criterion, a modified Vaginal Surgical Skills Index cutoff score of 27 was found to most accurately (area under the curve 0.951, 95% CI 0.917-0.983) differentiate competent from noncompetent surgeons.

Conclusion: We demonstrated validity evidence for using a high-fidelity vaginal surgery model with the modified Vaginal Surgical Skills Index or global scale score to assess vaginal hysterectomy skills.
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http://dx.doi.org/10.1097/AOG.0000000000004085DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7575024PMC
November 2020

Association of uterine dimensions and route of contained morcellation following laparoscopic hysterectomy.

Minerva Ginecol 2020 Oct 17;72(5):316-324. Epub 2020 Jul 17.

Department of Gynecologic Surgery, Mayo Clinic Florida, Jacksonville, FL, USA.

Background: The aim of this study was to determine if uterine dimensions on preoperative imaging are associated with route of contained morcellation during laparoscopic hysterectomy.

Methods: This is a prospective cohort study of patients undergoing laparoscopic hysterectomy and requiring morcellation for specimen extraction from March 2017 through August 2019. A contained extraction system was inserted and manual morcellation was performed vaginally, abdominally, or via a combination of both methods in cases of failed vaginal extraction.

Results: A total of 47 patients were treated. Median age was 47 (range 38-70). Morcellation was performed vaginally for 29 patients (61.7%), abdominally for 13 patients (27.7%), and via combined approach for 5 patients (10.6%). The combined group had the highest frequency of patients who were black (vaginal: 24%, abdominal: 31%, combined: 100%; P=0.005), the longest median total operating time (vaginal: 167 minutes, abdominal: 183 minutes, combined: 268 minutes; P=0.006) and the longest median time of uterine morcellation (vaginal: 14 minutes, abdominal: 37 minutes, combined: 85 minutes; P<0.001). There was strong evidence of a positive correlation with time of uterine morcellation for both largest uterine diameter (Spearman's r: 0.62, P<0.001) and uterine volume (Spearman's r: 0.70, P<0.001). These associations remained consistent after multivariable linear regression models that were adjusted for route of morcellation, hysterectomy type, and BMI (both P<0.001).

Conclusions: Larger uterine dimensions are associated with increased total operating and morcellation times. Uterine size and volume on preoperative imaging were not associated with route of morcellation, but there was a trend towards failed vaginal extraction when uterine dimensions exceeded 16 centimeters.
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http://dx.doi.org/10.23736/S0026-4784.20.04602-XDOI Listing
October 2020

Essentials in Minimally Invasive Gynecology Manual Skills Construct Validation Trial.

Obstet Gynecol 2020 07;136(1):83-96

Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, and Kaiser Permanente, Los Angeles Medical Center, Los Angeles, California; Columbia University, New York, New York; Albert Einstein College of Medicine, Bronx, New York; MedStar Washington Hospital Center/MedStar Georgetown, Washington, DC; Emory University, Atlanta, Georgia; Johns Hopkins School of Medicine, Baltimore, Maryland; Vanderbilt University Medical Center, Nashville, Tennessee; Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; University of Wisconsin, Madison, Wisconsin; University of Washington and VA Puget Sound Health Care System, Seattle, Washington; Northwestern University, Chicago Illinois; University of Arizona College of Medicine, Phoenix, Arizona; Cedars-Sinai Hospital, Los Angeles, California; University of Toronto, Toronto, Ontario, Canada; Mayo Clinic, Jacksonville Florida; and Certification Management Services, Heber City, Utah.

Objective: To establish validity evidence for the Essentials in Minimally Invasive Gynecology laparoscopic and hysteroscopic simulation systems.

Methods: A prospective cohort study was IRB approved and conducted at 15 sites in the United States and Canada. The four participant cohorts based on training status were: 1) novice (postgraduate year [PGY]-1) residents, 2) mid-level (PGY-3) residents, 3) proficient (American Board of Obstetrics and Gynecology [ABOG]-certified specialists without subspecialty training); and 4) expert (ABOG-certified obstetrician-gynecologists who had completed a 2-year fellowship in minimally invasive gynecologic surgery). Qualified participants were oriented to both systems, followed by testing with five laparoscopic exercises (L-1, sleeve-peg transfer; L-2, pattern cut; L-3, extracorporeal tie; L-4, intracorporeal tie; L-5, running suture) and two hysteroscopic exercises (H-1, targeting; H-2, polyp removal). Measured outcomes included accuracy and exercise times, including incompletion rates.

Results: Of 227 participants, 77 were novice, 70 were mid-level, 33 were proficient, and 47 were experts. Exercise times, in seconds (±SD), for novice compared with mid-level participants for the seven exercises were as follows, and all were significant (P<.05): L-1, 256 (±59) vs 187 (±45); L-2, 274 (±38) vs 232 (±55); L-3, 344 (±101) vs 284 (±107); L-4, 481 (±126) vs 376 (±141); L-5, 494 (±106) vs 420 (±100); H-1, 176 (±56) vs 141 (±48); and H-2, 200 (±96) vs 150 (±37). Incompletion rates were highest in the novice cohort and lowest in the expert group. Exercise errors were significantly less and accuracy was greater in the expert group compared with all other groups.

Conclusion: Validity evidence was established for the Essentials in Minimally Invasive Gynecology laparoscopic and hysteroscopic simulation systems by distinguishing PGY-1 from PGY-3 trainees and proficient from expert gynecologic surgeons.
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http://dx.doi.org/10.1097/AOG.0000000000003936DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7316146PMC
July 2020

Diagnostic office hysteroscopy with the Storz TrophyScope® versus Cooper surgical Endosee®.

Minerva Ginecol 2020 Oct 13;72(5):310-315. Epub 2020 May 13.

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Background: Office hysteroscopy (OH) is becoming increasingly popular. Our objective was to determine the use patterns, reported pain scores, and success rates of OH with the 2.9 mm Storz TrophyScope® and handheld portable Cooper surgical Endosee® device in a clinic without previous office hysteroscopy experience.

Methods: A prospective cohort study of a hysteroscopy quality improvement database was conducted in a tertiary care center gynecology clinic. Patients undergoing OH with either the Storz TrophyScope® or Cooper Surgical Endosee® device were included.

Results: Of the 171 office hysteroscopies, 77 utilized the TrophyScope®, with 8 (10%) being inadequate, while 94 utilized Endosee®, with 13 (14%) being inadequate (P=0.50). Of the 13 inadequate Endosee® hysteroscopies, 4 (31%) were due to visualization, 4 (31%) to patient intolerance, 3 (23%) to cervical stenosis, and 2 (15%) to a combination of these factors. Of the 8 inadequate TrophyScope® hysteroscopies, 7 (87%) were due to patient intolerance and 1 (13%) to cervical stenosis. Of the 150 adequate office procedures performed, 52 cases underwent subsequent procedures in the operating room (OR). Of these, 26 (84%) of 31 Endosee® cases and 18 (86%) of 21 TrophyScope® cases were in agreement with OR procedure findings. A subgroup analysis comparing mean pain levels did not significantly differ between the two hysteroscopes.

Conclusions: There was no difference in accuracy with OR pathologic diagnoses, adequacy of procedure, and reported pain scores when comparing the TrophyScope® and Endosee® in this prospective cohort. Larger studies are needed to confirm the sensitivity, and specificity for these newer, disposable office hysteroscopic devices.
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http://dx.doi.org/10.23736/S0026-4784.20.04568-2DOI Listing
October 2020

Factors Associated with Burnout and Frustration among Minimally Invasive Gynecologic Surgery Fellows.

J Minim Invasive Gynecol 2021 01 28;28(1):75-81. Epub 2020 Mar 28.

Department of Gynecologic Surgery (Drs. Jijon, Carrubba, Destephano, and Dinh), Mayo Clinic Florida, Jacksonville, Florida.

Study Objective: Determine the prevalence of burnout and frustration among participants currently completing a fellowship in minimally invasive gynecologic surgery (FMIGS).

Design: Cross-sectional survey.

Setting: An anonymous survey was distributed to fellows in November 2018.

Participants: Current FMIGS fellows.

Interventions: Not applicable.

Measurements And Main Results: A total of 57 of 83 (67.7%) FMIGS participants in American Association of Gynecologic Laparoscopists-accredited programs completed a survey regarding fellowship characteristics and experiences. Overall, 40 participants (70.2%) indicated that they were satisfied with their fellowship program experience. There were 33 participants (57.9%) who reported burnout, and 38 participants (66.7%) had experienced anxiety, depression, or extreme fatigue during the last month. Of those who reported burnout, 26 (76.5%) reported that they did not receive support from their fellowship program. Participants who experienced burnout were more likely to be in their second year (p = .003), spent less time per week doing scholarly activities (p = .048), and were less satisfied with their fellowship experience (p <.001). Participants who experienced anxiety, depression, or extreme fatigue had more cofellows in their program (p = .031), worked on average more hours per week (p = .020), and were more often required to practice obstetrics in their fellowship (p = .022).

Conclusion: Burnout symptoms are common among physicians across multiple specialties. Our findings suggest that this issue is prevalent among FMIGS participants. In addition, there is a lack of access to emotional and psychologic support programs for fellows experiencing burnout. We hope that this study will prompt attention to this important topic by both individual programs and American Association of Gynecologic Laparoscopists as a society to increase awareness and access to resources and promote wellness for fellows.
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http://dx.doi.org/10.1016/j.jmig.2020.03.004DOI Listing
January 2021

Intercepting Endometrial Cancer: Opportunities to Expand Access Using New Technology.

Cancer Prev Res (Phila) 2020 07 11;13(7):563-568. Epub 2020 Feb 11.

Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida.

Although endometrial cancer is often diagnosed at an early curable stage, the incidence and mortality from endometrial cancer is rising and minority women are particularly at risk. We hypothesize that delays in clinical presentation contribute to racial disparities in endometrial cancer mortality and treatment-related morbidity. Improved methods for endometrial cancer risk assessment and distinguishing abnormal uterine bleeding and postmenopausal bleeding from physiologic variation are needed. Accordingly, we propose a multipronged strategy that combines innovative patient education with novel early detection strategies to reduce health impacts of endometrial cancer and its precursors, especially among Black women. Futuristic approaches using gamification, smartphone apps, artificial intelligence, and health promotion outside of the physical clinic hold promise in preventing endometrial cancer and reducing morbidity and mortality related to the disease, but they also raise a number of questions that will need to be addressed by future research.
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http://dx.doi.org/10.1158/1940-6207.CAPR-19-0556DOI Listing
July 2020

ACOG Simulation Working Group: A Needs Assessment of Simulation Training in OB/GYN Residencies and Recommendations for Future Research.

J Surg Educ 2020 May - Jun;77(3):661-670. Epub 2019 Dec 16.

Division of Gynecologic Specialty Surgery, Department of Obstetrics and Gynecology, New York Presbyterian Hospital, Columbia University Medical Center, New York, New York.

Objective: To evaluate current availability and needs of simulation training among obstetrics/gynecology (OB/GYN) residency programs.

Design: Cross-sectional survey.

Setting: Accreditation Council for Graduate Medical Education accredited OB/GYN residency programs in the United States.

Participants: Residency program directors, gynecology simulation faculty, obstetrics simulation faculty, and fourth-year residents.

Results: Of 673 invited participants, 251 (37.3%) completed the survey. Among the survey responses, OB procedures were more broadly represented compared to the GYN procedures for simulation teaching: 8 (50%) of 16 OB procedures versus 4 (18.2%) of 22 GYN procedures had simulation teaching. Among the simulated procedures, a majority of residents and faculty reported that simulation teaching was available for operative vaginal delivery, postpartum hemorrhage, shoulder dystocia, perineal laceration repair, conventional laparoscopic procedures, and robotic surgery. There were significant differences between residents and faculty perceptions regarding the availability and needs of simulated procedures with a minority of residents having knowledge of Council on Resident Education in Obstetrics and Gynecology (47.2%) and American College of Obstetrics and Gynecology (27.8%) simulation tools compared to the majority of faculty (84.7% and 72.1%, respectively). More than 80% of trainees and faculty reported they felt the average graduating resident could perform vaginal, laparoscopic, and abdominal hysterectomies independently.

Conclusions: Simulation is now widely available for both gynecologic and obstetric procedures, but there remains tremendous heterogeneity between programs and the perceptions of residents, program directors, and faculty. The variations in simulation training and readiness for performing different procedures following residency support the need for objective, validated assessments of actual performance to better guide resident learning and faculty teaching efforts.
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http://dx.doi.org/10.1016/j.jsurg.2019.12.002DOI Listing
June 2021

Variability between individual surgeons in route of hysterectomy for patients with endometrial cancer in Florida.

Surg Oncol 2019 Dec 12;31:55-60. Epub 2019 Sep 12.

Mayo Clinic Department of Surgical Gynecology, Jacksonville, FL, USA.

Objectives: Minimally invasive surgery (MIS) was designated as a quality measure for endometrial cancer in 2014. However, national database analyses demonstrate that laparotomy is still performed for this indication. This study aims to assess the route of hysterectomy performed by gynecologic surgeons who manage endometrial cancer in the state of Florida.

Materials And Methods: All patients in Florida who were diagnosed with endometrial cancer (both ICD-9 Code 182.0 and ICD-10 Code C54.10), and who received a related surgical procedure from 2014 to 2016 were included. Eligible patients were identified using the Florida Inpatient Discharge Dataset, the Florida Ambulatory and Emergency Discharge Dataset, the Hospital Compare dataset, and the Healthcare Cost Report Information System. The primary surgeon was identified using their national provider identifier (NPI) number. Each surgeon's overall operative volume, MIS volume, and percentage of MIS procedures were collected.

Results: Hysterectomy for endometrial cancer was performed in 6086 patients; 4959 (81.5%) underwent MIS and 1127 (18.5%) had an abdominal approach. Hysterectomy for endometrial cancer was performed by 368 providers in Florida (range of 2-244 surgeries). The percentage of MIS to total hysterectomies for providers who performed 1-10 cases was 72.1%; 11-25 cases was 40.9%; 26-100 cases was 80.1%; and more than 100 cases was 86.1%. Variation in operative route exists amongst low- and high-volume providers.

Conclusions: Statewide databases can be used to identify surgical trends for policy purposes. These findings support the referral of patients with endometrial cancer to surgeons with high MIS volumes.
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http://dx.doi.org/10.1016/j.suronc.2019.09.004DOI Listing
December 2019

Surgical Care for Women with Endometrial Cancer in Florida.

J Gynecol Surg 2019 Jun 29;35(3):163-171. Epub 2019 May 29.

Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL.

The goal of this research was to analyze if disparities in route of hysterectomy for endometrial cancer exist in Florida. In this retrospective cohort study, Florida inpatient and ambulatory surgery databases (2014-2016) were examined to find cases of patients with endometrial cancer who underwent hysterectomy in the state. Logistic regression models were used to compare patient- and hospital-level factors associated with having minimally invasive surgery (MIS) versus open surgery, and complications in patients having open hysterectomy versus MIS. Overall, 6513 patients met the inclusion criteria. MIS was performed in 81.4% of cases. The odds of using a minimally invasive approach to hysterectomy (vaginal, robotic, or laparoscopic) were significantly lower for black women (odds ratio [OR]: 0.41; 95% confidence interval [CI]: 0.34-0.50) as well as for other non-white patients (OR: 0.64; 95% CI: 0.49-0.84). Patients with Medicaid (OR: 0.42; 95% CI: 0.30-0.59) or Medicare managed care (OR: 0.73; 95% CI: 0.59-0.91), or who received care at a teaching hospital (OR: 0.82; 95% CI: 0.68-0.98) or government hospital (OR: 0.50; 95% CI: 0.38-0.65) were also less likely to receive MIS. Patients receiving care at a high-volume (OR: 1.69; 95% CI: 1.30-2.20) or medium-volume (OR: 3.11; 95% CI: 2.37-4.08) hospital, or patients who were located in the Central (OR: 1.71; 95% CI: 1.17-2.48) or Peninsula (OR: 1.73; 95% CI: 1.17-2.56) regions, compared to the Florida Panhandle, had greater odds of receiving MIS. Although Florida has a high adoption of MIS for treating endometrial cancer, disparities persist. Efforts of state-level entities should focus on improving access to minimally invasive hysterectomy for racial minorities with endometrial cancer.
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http://dx.doi.org/10.1089/gyn.2018.0086DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6610027PMC
June 2019

Discharge Readiness after Robotic and Laparoscopic Hysterectomy.

J Minim Invasive Gynecol 2019 Jul - Aug;26(5):910-918. Epub 2018 Sep 18.

Department of Surgical Gynecology (Drs. DeStephano, Gajarawala, Espinal, and Robertson).

Study Objective: To evaluate which factors may be predictive of patient readiness of discharge after robotic and laparoscopic hysterectomy.

Design: A prospective cohort study (Canadian Task Force classification II-2).

Setting: A single tertiary care center in the United States.

Patients: All 230 patients undergoing robotic and laparoscopic hysterectomy between November 2015 and April 2017.

Interventions: The primary outcome measure was whether or not the patient felt ready for discharge when she was sent home, and this was assessed using a survey 4 to 6 weeks after surgery. Secondary outcomes included the number of postoperative phone calls, 30-day readmission, and also whether the patient felt knowledgeable about postoperative symptoms and restrictions (both assessed via a 4- to 6-week survey). Associations of baseline, operative, and postoperative characteristics with outcomes were evaluated using regression models appropriate for the nature of the given outcome measure.

Measurements And Main Results: Of the 230 patients, 207 (90%) reported they felt ready for discharge on the postoperative survey. The majority of patients strongly agreed that they felt knowledgeable about what symptoms to expect postoperatively (60%) and about postoperative restrictions (71%). The median number of postoperative phone calls was 1 (range, 0-11), with 104 patients (45%) having more than 1 postoperative call. The only factor that was significantly associated with a lack of readiness for discharge was a longer total operating room time (p = .011). Factors associated with more postoperative phone calls were a urogynecologic indication (p = .005), a cancer indication (p = .024), a longer total operative room time (p = .014), a postoperative complication (p <.001), and not seeing a patient education video (p = .018). Knowledge of postoperative restrictions was significantly worse for older patients (p = .004) and varied significantly according to surgeon (p = .038). No significant predictors of knowledge of postoperative symptoms were identified.

Conclusions: Discharge readiness and knowledge of postoperative restrictions and symptoms were high in patients who underwent laparoscopic and robotic hysterectomies. The risk factors for outcomes that were identified highlight groups of patients who can be targeted for preemptive interventions both preoperatively and postoperatively.
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http://dx.doi.org/10.1016/j.jmig.2018.09.766DOI Listing
December 2019

The uterus as venous overflow reservoir: one result of chronic iliac vein occlusion.

Am J Obstet Gynecol 2018 10 16;219(4):412-413. Epub 2018 Apr 16.

Department of Medical and Surgical Gynecology, Mayo Clinic, Jacksonville, FL. Electronic address:

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http://dx.doi.org/10.1016/j.ajog.2018.04.016DOI Listing
October 2018

Use of the Limbs and Things Hysterectomy Model to Describe the Process for Establishing Validity.

J Minim Invasive Gynecol 2018 Sep - Oct;25(6):1051-1059. Epub 2018 Feb 9.

Department of Surgical Gynecology, Mayo Clinic, Jacksonville, Florida.

Study Objective: To demonstrate the process for establishing or refuting validity for the Limbs and Things hysterectomy model.

Design: Prospective study using Kane's framework for establishing validity (Canadian Task Force classification: II-2).

Setting: Total laparoscopic hysterectomy (TLH) assessments completed in the operating room (OR) and simulation at 3 academic medical centers.

Participants: Obstetrics and gynecology residents (n = 26 postgraduate years 3-4), a gynecologic oncology fellow (postgraduate year 5), and a gynecology oncology attending.

Interventions: Participants were rated with the myTIPreport feedback application by nonblinded faculty in the OR after TLH. In-person, simulation-based assessments were provided by 2 faculty members blinded to experience level using myTIPreport and Global Operative Assessment of Laparoscopic Skills (GOALS). Videos of simulated TLHs were rated by 2 minimally invasive gynecology fellows.

Measurements And Main Results: OR scores for TLH steps were significantly higher than simulation assessments (p < .001) with "competent" marked more frequently in the OR. Number of robotic + conventional TLHs performed as primary surgeon was not significantly correlated with OR myTIPreport rating (Spearman r = .30, p = .14) but was significantly correlated with myTIPreport and GOALS in-person simulation ratings (Spearman r = .39-.58, p = .001-.04). Agreement between in-person simulation rater 1 and 2 myTIPreport assessments was 71.4% (weighted κ, .68; 95% confidence interval, .45-.90), and intraclass correlation for the GOALS overall assessment was .71 (95% confidence interval, .46-.85), indicating substantial agreement. Blinded video reviews showed similar agreement (73.1%) between raters but less correlation with experience (Spearman r = .32-.42, p = .11-.03) than in-person reviews. Using area under the receiver operating characteristic curve, mean score for the individual components of GOALS that best differentiated myTIPreport noncompetent and competent levels of performance was 4.3. Feedback acceptability and model realism were rated highly.

Conclusion: The scoring and generalization validity inferences for Limbs and Things and myTIPreport are supported when global assessments of performance are evaluated but not for individual components of the assessment instruments.
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http://dx.doi.org/10.1016/j.jmig.2018.02.003DOI Listing
July 2019

Robotic Placement of the FENIX Continence Restoration System in a Patient with Previous Radiation to the Pelvis: A Case Report.

J Minim Invasive Gynecol 2018 Mar - Apr;25(3):528-532. Epub 2017 Jul 17.

Department of Medical and Surgical Gynecology, Mayo Clinic, Jacksonville, Florida.

Fecal incontinence (FI) is a disabling problem affecting women. Conservative treatment includes dietary modification, antimotility agents, and pelvic floor physical therapy. If conservative medical management is unsuccessful, surgical intervention may be required. Surgical options include rectal sphincteroplasty, bulking agent injection, radiofrequency anal sphincter remodeling, and sacral nerve stimulation therapy. Recently, a new therapy for FI, the FENIX Continence Restoration System (Torax Medical, Inc., Shoreview, MN), has become available. The FENIX device is placed through a perineal incision; however, pelvic radiation and previous anal carcinoma are both contraindications. We report the case of a 62-year-old woman with FI after anal carcinoma. Treatment included surgery, chemotherapy, and pelvic radiation. Initially, she was treated with conservative therapy and sacral nerve stimulation, which were only partially effective. A physical examination showed perineal skin changes consistent with previous radiation, which increased the patient's risk of infection and a nonhealing wound. Therefore, a robotic approach was used to place the FENIX device and improve the patient's quality of life. Our case sets a precedent for expanding the treatment options of FI in patients with previous pelvic radiation and using a robotic approach for the placement of the FENIX device.
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http://dx.doi.org/10.1016/j.jmig.2017.07.006DOI Listing
May 2019

The Fenix System for Fecal Incontinence: An Overview and Surgical Demonstration.

J Minim Invasive Gynecol 2017 Nov - Dec;24(7):1078. Epub 2017 May 3.

Department of Medical and Surgical Gynecology, Mayo Clinic, Jacksonville, Florida.

Study Objective: This video shows a new technique for the surgical management of fecal incontinence using the Fenix Continence Restoration System (TORAX Medical Inc, Shoreview, MN) in 2 patients.

Design: A step-by-step explanation of the video using videos and pictures (educational video) for surgeons (Canadian Task Force classification III).

Setting: The use of the Fenix System received United States Food and Drug Administration approval under a humanitarian device exemption and can be used with institutional review board approval in patients who have failed previous medical and surgical management of fecal incontinence. The device is a small, flexible band of interlinked titanium, magnetic beads on a titanium string that is placed using a perineal approach around the anal canal. Increased intra-abdominal pressure opens the beads to allow for the passage of stool.

Interventions: Placement of the device was performed in 2 patients. Case 1 is a 63-year-old woman with a long-standing history of fecal incontinence who failed sphincteroplasty, sacral neuromodulation, and an artificial sphincter cuff and pump. Case 2 is a 60-year-old woman with a long-standing history of fecal incontinence secondary to radiation therapy for rectal cancer who failed physical therapy and sacral neuromodulation.

Conclusion: Both Fenix Continence Restoration Systems were placed successfully. Long-term postoperative effectiveness is currently being evaluated.
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http://dx.doi.org/10.1016/j.jmig.2017.04.012DOI Listing
April 2018

Nonoperative management of an anastomotic leak following rectosigmoid resection and anastomosis for Stage IV endometriosis.

J Surg Case Rep 2016 May 3;2016(5). Epub 2016 May 3.

Mayo Clinic, Jacksonville, FL, USA.

Anastomotic leakage is a dreaded complication of gastrointestinal surgery. The complication is difficult to manage and is associated with prolonged hospitalizations and increased morbidity and mortality. We present the nonsurgical management and the use of a fibrin sealant for an anastomotic leak that followed rectosigmoid resection and anastomosis for Stage IV endometriosis. This approach requires a clinically stable patient who is willing to follow-up over a prolonged period of time until the leak is completely sealed. Tissue sealants can be considered when an air leak or fistulous tract persists despite drainage and antibiotics.
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http://dx.doi.org/10.1093/jscr/rjw066DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4855210PMC
May 2016

Iatrogenic Uterine Diverticulum in Pregnancy After Robotic-assisted Myomectomy.

J Minim Invasive Gynecol 2015 Jul-Aug;22(5):902-5. Epub 2015 Mar 28.

Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Uterine diverticula are rare outpouchings of the uterus associated with abnormal uterine bleeding, pelvic pain, dysmenorrhea, and adverse obstetric events. At the time of cesarean delivery at 36 5/7 weeks' gestation during the patient's first pregnancy and 36 6/7 weeks during the second pregnancy, a fundal iatrogenic uterine diverticulum at the site of a prior robotic-assisted myomectomy was noted. The outpouching communicated with the endometrial cavity and was extremely attenuated, palpably 2 to 3 mm thick. Further research is needed to determine the incidence of iatrogenic uterine diverticulum after robotic myomectomy and whether these malformations increase the risk of adverse obstetric outcomes.
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http://dx.doi.org/10.1016/j.jmig.2015.03.016DOI Listing
December 2015

A randomized controlled trial of birth simulation for medical students.

Am J Obstet Gynecol 2015 Jul 12;213(1):91.e1-91.e7. Epub 2015 Mar 12.

Department of Gynecology and Obstetrics, The Johns Hopkins University School of Medicine, Baltimore, MD.

Objective: The objective of the study was to evaluate the effectiveness of a high-fidelity birth simulator (Noelle; Gaumard Scientific, Coral Gables, FL) compared with a lower-cost, low-tech, birth simulator (MamaNatalie; Laerdal Medical, Stavanger, Norway) in teaching medical students how to perform a spontaneous vaginal delivery (SVD).

Study Design: Prior to the obstetrics-gynecology clerkship, students were randomly assigned to 2 groups. The MamaNatalie group (MG) completed 45 minutes of SVD simulation using an obstetrical abdominal-pelvic model worn by an obstetrics-gynecology faculty member. The Noelle group (NG) completed 45 minutes of SVD simulation using a high-fidelity, computer-controlled mannequin facilitated by an obstetrics-gynecology faculty member. The primary outcome was student performance during his or her first SVD as rated by supervising preceptors. Surveys were also completed by students on confidence in performing steps of a SVD (secondary outcome).

Results: One hundred ten medical students (95% of those eligible) participated in this research study. The final postclerkship survey was completed by 93 students (85% follow-up rate). There were no significant differences in performance of SVD steps between MG and NG students as rated by preceptors. The SVD step with the least involvement by students was controlling the head (20.5% in MG, 23.3% in NG performed step with hands-off supervision). Delivery of the placenta was the SVD step with the most involvement (65.9% in MG, 52.3% in NG performed step with hands-off supervision). Baseline presimulation confidence levels were similar between MG and NG. On the immediate postsimulation survey of confidence, MG students were significantly more confident in their ability to deliver the abdomen and legs and perform fundal massage with hands-off supervision (P < .05) than NG students. Following the clerkship, MG students were significantly more confident in their ability to control the head and deliver the abdomen and legs (P < .05) than NG students.

Conclusion: MamaNatalie is as effective as Noelle in training medical students how to perform a SVD and may be a useful, lower-cost alternative in teaching labor and delivery skills to novice learners. Because birth simulation interventions involve both a simulation model and facilitator, research is required to further determine the effect of human interaction on learning outcomes.
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http://dx.doi.org/10.1016/j.ajog.2015.03.024DOI Listing
July 2015

Shrinking lung syndrome in pregnancy complicated by antiphospholipid antibody syndrome.

Obstet Gynecol 2011 Feb;117(2 Pt 2):506-508

From the Division of Maternal Fetal Medicine and the Mayo Medical School, Mayo Clinic College of Medicine, Rochester, Minnesota.

Background: Shrinking lung syndrome is characterized by pulmonary compromise secondary to unilateral or bilateral paralysis of the diaphragm.

Case: Shrinking lung syndrome was diagnosed in a patient with antiphospholipid syndrome after a cesarean delivery at 28 4/7 weeks of gestation. Signs and symptoms included unexplained right-side chest pain, dyspnea, tachypnea, and absent breath sounds at the right base of the lungs. After initiation of corticosteroids, her symptoms resolved.

Conclusion: Although seen in association with systemic lupus erythematosus, shrinking lung syndrome has not been described with antiphospholipid syndrome or during pregnancy. Diagnosis and awareness are important because treatment with moderate- to high-dose corticosteroids appears to improve the clinical outcome.
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http://dx.doi.org/10.1097/AOG.0b013e318206c254DOI Listing
February 2011

Sonographic diagnosis of conjoined diamniotic monochorionic twins.

Am J Obstet Gynecol 2010 Dec;203(6):e4-6

Mayo Medical School, Mayo Clinic, Rochester, MN, USA.

According to traditional theories for the pathogenesis of conjoined twins, diamniotic placentation should not occur. We present an unusual case with diamniotic/monochorionic conjoined twins and discuss possible etiologic hypotheses. The diagnosis of this improbable case was made in the first trimester using ultrasound, which assisted in making an early decision regarding further management.
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http://dx.doi.org/10.1016/j.ajog.2010.09.007DOI Listing
December 2010

Don't patients have two knees?

Anesthesiology 2010 Jul;113(1):256-7; author reply 257-8

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http://dx.doi.org/10.1097/ALN.0b013e3181e19d4eDOI Listing
July 2010

Somali prenatal education video use in a United States obstetric clinic: a formative evaluation of acceptability.

Patient Educ Couns 2010 Oct 13;81(1):137-41. Epub 2010 Jan 13.

Mayo Medical School, Mayo Clinic, Rochester, MN, USA.

Objective: Because of low health literacy and low priority in seeking prenatal information, health education videos were explored for acceptability by Somali refugee women in a clinical setting.

Methods: Focus groups led to the development of six targeted Somali prenatal education videos. Topics include: preparation for pregnancy, nutrition and exercise, pregnancy myths/facts, the father's role, episiotomies, and caesarean sections. Somali participants were recruited to view programs, and completed an 8-item survey prior to regularly scheduled prenatal appointments. Following the clinical visit, providers completed a 4-item survey indicating the video's helpfulness in facilitating client-provider communication.

Results: All study participants "strongly recommended" and rated the videos as "appropriate for Somali clients", 57% indicated the information was "just the right amount," and 60% found the videos "extremely helpful." The primary language spoken at home was Somali (72.7%) and 54.5% indicated Somali as the preferred language to receive health information. Providers indicated 24% of appointments were "more interactive" with 72% finding videos "somewhat" or "extremely helpful."

Conclusion: Preliminary results from this pilot study suggest that a video format for prenatal education is acceptable to Somali clients with most clients preferring video health education materials presented in the Somali language.

Practice Implications: Culturally tailored health education video series for Somali women appear well for use in a clinic setting to facilitate client-provider communication.
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http://dx.doi.org/10.1016/j.pec.2009.12.003DOI Listing
October 2010

Anesthesia for combined cardiac surgery and liver transplant.

J Cardiothorac Vasc Anesth 2010 Apr 29;24(2):285-92. Epub 2009 Dec 29.

Mayo Medical School, College of Medicine, Mayo Clinic, Jacksonville, FL 32224, USA.

Objective: To describe aspects of anesthesia for combined cardiac surgery and orthotopic liver transplant (OLT).

Design: Retrospective case series.

Setting: Hospital with cardiac surgery and liver transplant programs.

Participants: Nine patients between September 1998 and July 2006.

Intervention: Combined cardiac surgery and OLT.

Measurement And Main Results: Demographic and outcome data were recorded for each patient. Multiple intraoperative parameters were collected at baseline, after induction of anesthesia, after cardiac surgery, and after OLT. Five patients underwent combined OLT and coronary artery bypass graft (CABG) surgery. Four patients underwent combined OLT and aortic valve replacement (AVR) to relieve aortic stenosis. One of these 4 patients also had a saphenous vein graft to the left anterior descending artery. The CABG/OLT patients had hypertension, diabetes, or both, and multiple coronary arteries were affected although ejection fraction was preserved. The 1 death in this group was unrelated to a coronary event. The AVR/OLT patients had aortic stenosis that met American Heart Association guidelines for AVR. One death, within 24 hours of surgery, was associated with severe pulmonary artery hypertension. The median transfusion volumes were 12 units of packed red blood cells, 22 units of fresh frozen plasma, and 30 units of platelets. Three of the 9 patients required renal replacement therapy postoperatively. The median duration of intubation was 2 days, and length of stay in the intensive care unit was 5.5 days.

Conclusion: Combined cardiac and OLT surgery is complex and serious morbidity occurs, but successful outcomes are attainable.
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http://dx.doi.org/10.1053/j.jvca.2009.10.014DOI Listing
April 2010

Transesophageal echocardiographic detection of papillary fibroelastoma in the pulmonary artery.

Anesth Analg 2006 Sep;103(3):576-7

Department of Anesthesiology, Mayo Clinic, Jacksonville, Florida 32224, USA.

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http://dx.doi.org/10.1213/01.ane.0000230606.27440.2fDOI Listing
September 2006
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