Schroeder, Darrell

Purpose To assess if the choice of acetaminophen formulation (intravenous vs oral) when administered preoperatively for ambulatory cystoscopy procedures is associated with differences in anesthetic outcomes. Methods Medical records of adult patients undergoing ambulatory cystoscopy procedures at an outpatient procedural center from July 1, 2014, through November 30, 2017, were abstracted. The association between anesthetic outcomes (severe pain, rescue opioids, postoperative nausea, and vomiting) and acetaminophen formulation was assessed. Propensity-adjusted analyses were performed using inverse probability of treatment weighting to account for potential confounders. Results During the study time frame, there were 611 intravenous and 2955 oral acetaminophen administrations for cystoscopy procedures. Postoperative bladder spasms were a major contributor to severe pain and complicated 1036 cases, with similar rates between intravenous (N = 183, 29.9%) and oral (N = 853, 28.9%) formulations, P = .625. After adjusting for bladder spasms, intravenous acetaminophen was associated with longer anesthesia recovery (estimate 5.2 [95% CI 0.5-9.9] minutes, P = .030), use of rescue opioids (odds ratio 1.33 [1.07-1.66], P = .012), and postoperative nausea and vomiting (1.40 [1.02-1.93], P = .037), but not severe pain (1.07 [0.81-1.40], P = .640). Conclusion Preoperative intravenous acetaminophen compared to oral acetaminophen for ambulatory cystoscopy procedures was not associated with better anesthetic outcomes. Bladder spasms were a major contributor to postoperative pain.

Abstract Objective: Weight gain and vasomotor symptoms (VMS) are common complaints in midlife women going through the menopause transition. A selective serotonin 2C (5-HT2C) receptor agonist, lorcaserin, which was previously approved by the Food and Drug Administration for weight loss, has unreported observational evidence suggesting improvement in VMS with its use. The goal of this pilot study was to evaluate the efficacy of lorcaserin for weight loss and management of VMS in overweight midlife women. Methods: This was a 24-week open label pilot study of 20 overweight midlife women, aged 45-60 years, who were experiencing severe VMS. Participants received lorcaserin at the standard dose of 10 mg twice daily for 12 weeks, followed by 12 weeks of observation off the drug. The primary outcomes were changes in weight and subjectively reported VMS. Results: At the end of 12 weeks, mean change in weight was −2.4 kg (90% CI, −3.2 to −1.7, P < 0.001). However, the participants returned to the baseline weight at 24 weeks. Participants also reported significant subjective improvement in VMS, with a mean ± SD change in self-reported hot flash frequency from baseline to week 12 of −5.4 ± 3.9 (decrease of 1.4 standard deviations). There was a rapid increase in the frequency of VMS within 2 weeks of discontinuation of lorcaserin with a tendency to approach the baseline frequency of VMS. Conclusions: In addition to its weight loss-inducing effect, 5-HT2C receptor modulation may have an additional beneficial effect on VMS in midlife women. A treatment option that targets both weight and VMS in midlife women is attractive. Video Summary: http://links.lww.com/MENO/A622.

Abstract Background Sexual dysfunction is often complex and biopsychosocial. Traditional sexual health care management involves individual providers not in a multi-disciplinary setting. A multi-disciplinary team may consist of a medical provider, pelvic floor physical therapist, and sex therapist. Aim The aim was to explore the patient perceptions of benefit from management of their sexual dysfunction by a biopsychosocial multi-disciplinary team. Methods A survey was e-mailed to women patients seen by multi-disciplinary teams at 2 different settings: San Diego Sexual Medicine or Mayo Clinic Women's Health Clinic during a 27-month period. Data are reported using summary statistics for age and count for remaining survey responses. Cochran-Armitage tests for trend were used to compare pre- and post-comfort levels. Outcomes Main outcome measures included perceived benefit of being managed in a team-based model of care, level of benefit and satisfaction from each provider, and difference from pre-conceived level of comfort to actual comfort after each provider visit. Results 89 of 270 e-mailed surveys were analyzed. Patient populations (mean age 47.6, range 23–77 years) were similar between sites. Overall, 82% of respondents reported moderate/great benefit from the team-based model; 72.1% reported management by all 3 providers valuable/extremely valuable; and 84.3% were somewhat/very satisfied with the model. Women endorsed specific ways in which they benefitted from the team-based model including: improved sexual function (58.1%), feeling validated (72.1%) and listened to (62.8%), that they better understood their health concerns (65.1%), that their partner better understood their health concerns (46.5%), and feeling normal (46.5%). There were no significant differences between the 2 clinics in terms of patient-perceived benefit, value, or satisfaction. Conclusions The team-based model of care for management of sexual dysfunction in women including a medical provider, physical therapist, and sex therapist is associated with patient-perceived benefit, satisfaction, and value.

ObjectiveTo evaluate circulating cytokine profiles in patients with antineutrophil cytoplasmic antibody–associated vasculitis (AAV), classified by antineutrophil cytoplasmic antibody (ANCA) specificity (proteinase 3 ANCA [PR3‐ANCA] versus myeloperoxidase ANCA [MPO‐ANCA]) or by clinical diagnosis (granulomatosis with polyangiitis [GPA] versus microscopic polyangiitis [MPA]).MethodsA panel of 29 cytokines was tested in 186 patients with active AAV at inclusion into the Rituximab in AAV trial. Cytokine concentrations were compared between groups within each classification system. Multivariable analyses adjusted for age, sex, and renal insufficiency were performed, with each biomarker as a dependent variable and ANCA specificity and clinical diagnosis as explanatory variables of interest.ResultsLevels of 9 circulating cytokines (interleukin‐6 [IL‐6], granulocyte–macrophage colony‐stimulating factor [GM‐CSF], IL‐15, IL‐18, CXCL8/IL‐8, CCL‐17/thymus and activation–regulated chemokine [TARC], IL‐18 binding protein [IL‐18 BP], soluble IL‐2 receptor α [sIL‐2Rα], and nerve growth factor β [NGFβ]) were significantly higher in PR3‐AAV than MPO‐AAV, 4 cytokines (sIL6R, soluble tumor necrosis factor receptor type II [sTNFRII], neutrophil gelatinase–associated lipocalin [NGAL], and soluble intercellular adhesion molecule 1 [sICAM‐1]) were higher in MPO‐AAV than in PR3‐AAV, 6 cytokines (IL‐6, GM‐CSF, IL‐15, IL‐18, sIL‐2Rα, and NGFβ) were higher in GPA than in MPA, and 3 cytokines (osteopontin, sTNFRII, and NGAL) were higher in MPA than in GPA (all P < 0.05). For nearly all cytokines, the difference between PR3‐AAV and MPO‐AAV was larger than that between GPA and MPA. The multivariate analysis showed that 8 cytokines (IL‐15, IL‐8, IL‐18 BP, NGF‐β, sICAM‐1, TARC, osteopontin, and kidney injury molecule 1 (P < 0.05) distinguished patients with AAV better (lower P values and larger effect sizes) when grouped by ANCA specificity than by clinical diagnosis.ConclusionDistinct cytokine profiles were identified for PR3‐AAV versus MPO‐AAV and for GPA versus MPA. Differences in these circulating immune mediators are more strongly associated with ANCA specificity than with clinical diagnosis, suggesting that heterogeneity in the AAV subtypes extends beyond clinical phenotypes.

Incidental imaging findings require an assessment of risk and clinical relevance, as well as consideration of further evaluation. Incidental findings are common on imaging obtained in the hospital, with pulmonary nodules being among the most frequent findings that may require additional evaluation. We conducted a retrospective study to determine the factors associated with documentation of incidental findings in the hospital discharge summary, using pulmonary nodules reported on abdominal computed tomography (CT) as an example of incidental findings with well‐defined follow‐up guidelines. Between January 1, 2012 and December 31, 2014, 7173 patients underwent in‐patient abdominal CT without concurrent chest CT; of these patients, 62.2% were ≥60 years old, 50.6% were men, and 45.5% were current or former smokers. Incidental pulmonary nodules were reported in 402 patients (5.6%; 95% confidence interval [CI], 5.1%‐6.2%). Based on nodule size, reported size stability, and patients' smoking status, 208 patients (2.9%; 95% CI, 2.5%‐3.3%) required follow‐up surveillance, per the 2005 Fleischner Society guidelines. Of these 208 patients, 48 (23%) received discharge summaries that included documentation of the incidental findings, with 34 summaries including a recommendation for nodule follow‐up and 19 summaries including a time frame for repeat CT. Three factors were positively associated with the inclusion of the pulmonary nodule in the discharge summary: mention of the pulmonary nodule in the summary headings of the radiology report (P ≤ 0.001), radiologist recommendations for further surveillance (P ≤ 0.001), and medical discharging service (P = 0.016). These findings highlight the need for a multidisciplinary systems‐based approach to incidental pulmonary nodule documentation and surveillance.

BACKGROUND: Increasing numbers of robotic hysterectomies (RH) are being performed. To provide ventilation (with pneumoperitoneum and steep Trendelenburg position) for these procedures, utilization of lung protective strategies with limiting airway pressures and tidal volumes is difficult. Little is known about the effects of intraoperative mechanical ventilation and high peak airway pressures on perioperative complications. We performed a retrospective review to determine whether patients undergoing RH had increased pulmonary complications compared to total abdominal hysterectomy (TAH). METHODS: We performed a single center retrospective review comparing the intraoperative, anesthetic, and immediate and 30-day postoperative course of patients undergoing RH to TAH, including intraoperative ventilatory parameters and respiratory complications. Patients undergoing TAH (201) from 2004 to 2006 were compared to RH (251) from 2009 to 2012. It was our hypothesis that patients undergoing RH would have increased incidence of postoperative pulmonary complications. A secondary hypothesis was that morbid obesity predicts pulmonary complications in patients undergoing RH. Complications were compared between groups using Fisher’s exact test. To account for potential confounders, the primary analysis was performed for a subgroup of patients matched on the propensity for RH. RESULTS: A total of 351 RH and 201 TAH procedures are included. Higher inspiratory pressures were required in ventilation of the RH group (median [25th, 75th] 31 [26, 36] cm H 2 O) than the TAH group (23 [19, 27] cm H 2 O) ( P < .001) at 30 minutes after incision. Peak inspiratory pressures at 30 minutes after incision for RH increased according to increasing body mass index group ( P < .001). There were 163 RH and 163 TAH procedures included in the propensity matched analysis. From this analysis, there were no significant differences in cardiopulmonary complications between RH and TAH (0.6% vs 1.2%; odds ratio = 2.0, 95% confidence interval = 0.2–2.4; P = 1.00). Surgical site infection was significantly lower in the RH compared to TAH group (0.6% vs 8.6%; P < .001). Hospital length of stay was longer for those who underwent TAH versus RH (median [25th, 75th] 2 [2, 3] vs 1 [0, 2] days; P < .001). CONCLUSIONS: There was no significant difference in perioperative complications in obese and morbidly obese women compared to nonobese undergoing RH. Patients undergoing RH had shorter hospital stays, fewer infectious complications, and no increase in overall complications compared to TAH. Higher ventilatory airway pressures (RH versus TAH and obese versus nonobese) did not result in an increase in cardiopulmonary or overall complications. We believe that peritoneal insufflation attenuates the effect of high airway pressures by raising intrapleural pressure and reducing the gradient across terminal bronchioles and alveoli. Thus, we propose that lung protective strategies for patients undergoing RH account for the markedly elevated intraperitoneal and intrapleural pressures, whereas transpulmonary airway pressures remain static. This reduced transpulmonary gradient attenuates the strain on lung tissue that would otherwise be imposed by ventilation at high pressures.