Alexander Knee

Antral follicle count in clinical practice: analyzing clinical relevance

OBJECTIVEnTo determine the clinical relevance of obtaining antral follicle counts (AFC) before ovarian stimulation in an IVF program.nnnDESIGNnRetrospective cohort study.nnnSETTINGnAn IVF program in a large academic teaching hospital.nnnPATIENT(S)nA total of 1,049 stimulated IVF cycles in 734 subjects between September 2003 and December 2007 selected from our programs database.nnnINTERVENTION(S)nBasal antral follicles (AFCs) (3 mm-10 mm) were counted via ultrasound scan on cycle day 3 in luteal leuprolide acetate stimulations, or after at least 2 weeks of oral contraceptives in microdose leuprolide acetate stimulations. Patients were grouped according to basal AFC, and outcome parameters compared for AFC groups within each stimulation protocol.nnnMAIN OUTCOME MEASURE(S)nOocytes retrieved, ovarian response, implantation rate, cancellations, pregnancy, pregnancy loss, and live births per cycle start.nnnRESULT(S)nAntral follicle count grouping is predictive of threefold change in ovarian response to gonadotropins and oocytes retrieved. Low AFC did predict a higher cancellation rate. Antral follicle count did not predict implantation rate, pregnancy rate, or live birth rate per cycle start.nnnCONCLUSION(S)nAntral follicle count may be helpful in determining stimulation protocol, as it is the most reliable determinant of oocytes retrieved per starting FSH dose. Antral follicle count predicts ovarian response, not embryo quality or pregnancy.

Validity of Using ICD-9-CM Codes to Identify Selected Categories of Obstetric Complications, Procedures and Co-morbidities

BACKGROUNDnThe ability to measure and track changes in risk-adjusted obstetric complication rates using administrative data underpins efforts to improve obstetric quality of care, but the validity of this approach has not been adequately evaluated. We sought to assess the validity of using composites of ICD-9-CM codes to identify selected categories obstetric complications and risk factors associated with complications.nnnMETHODSnPatients with ICD-9-CM codes for obstetric trauma/laceration, infection, haemorrhage, episiotomy or obesity discharged between January 2009 and March 2010 were identified in the study hospitals administrative data. One hundred medical records with ICD-9-CM codes of interest were randomly selected for review from each of the five categories. An additional 60 medical records without the ICD-9-CM codes of interest served as controls for each category. Sensitivity and specificity for the selected categories was estimated using inverse proportional weighting to adjust for sampling based on presence of one of the ICD-9-CM codes of interest.nnnRESULTSnWeighted sensitivities ranged from 0.15 [95% CI 0.11, 0.20] for obesity to 1.00 for overall infection while specificities ranged from 0.994 [95% CI 0.987, 0.998] for obesity to 0.999 [95% CI 0.996, 1.000] for episiotomy. Obese patients were not reliably identified and it was not possible ascertain whether some diagnoses were present on admission.nnnCONCLUSIONSnFor selected categories of obstetric complication diagnoses, use of composite sets of ICD-9-CM codes may be a valid method to identify patients within these complication categories.

Does surgical volume influence short-term outcomes of laparoscopic hysterectomy

OBJECTIVEnTo evaluate whether surgical volume has an impact on short-term outcomes of laparoscopic hysterectomy.nnnSTUDY DESIGNnThis is a retrospective analysis of 1016 laparoscopic hysterectomies.nnnRESULTSnThe surgeons were divided into 2 groups based on a cutoff of 30 cases. Patient characteristics, the rates of laparotomy (4.5% vs 6.7%), and serious complications (3.6% vs 5.5%) were similar between 9 high and the remaining 39 low volume gynecologists, respectively (P < .05). Mean operating time was longer in the low volume group. Compared with their first 29 hysterectomies, the high volume surgeons decreased their operating time significantly in their subsequent cases. The high volume surgeons improved their conversion rate (9.2% vs 2.4%; P < .0001) over time but not their serious complications.nnnCONCLUSIONnIn laparoscopic hysterectomy, increasing the surgical volume can reduce the operating time and the risk for conversion to laparotomy but not the rate of serious complications.

A comparison of short-term outcomes between laparoscopic supracervical and total hysterectomy

OBJECTIVEnThe purpose of this study was to compare perioperative outcome measures of laparoscopic supracervical (LSH) and total hysterectomies (TLH).nnnSTUDY DESIGNnThis is a retrospective analysis of 1016 LSHs and TLHs at a tertiary medical center between November 1999 and August 2008 in a multivariate logistic regression model.nnnRESULTSnOverall, the groups were similar. Most of the perioperative outcome measures did not differ statistically between the groups. However, the risk of serious complications was higher for TLH (5.8% vs 2.5%; odds ratio [OR], 2.72; 95% confidence interval [CI], 1.35-5.49). Specifically, urinary tract injury occurred more frequently in TLH (2.2% vs 0.5%; OR, 4.75; 95% CI, 1.21-18.56). Conversion to laparotomy was significantly more common in TLH (5.8% vs 4.1%; OR, 2.25; 95% CI, 1.20-4.22).nnnCONCLUSIONnIn this largest comparison, short-term morbidity of TLH and LSH is overall similar. TLH presents a clinically small, but statistically significant, increased risk of urinary tract injury and conversion to laparotomy.

Lidocaine jelly and plain aqueous gel for urethral straight catheterization and the Q-tip test: A randomized controlled trial

OBJECTIVE: To compare the pain perception between lidocaine and plain aqueous gel during assessment of postvoid residual volume and the Q-tip test. METHODS: Patients were randomly assigned to either to 2% lidocaine hydrochloride jelly or plain aqueous gel. The allocated gel was first used to lubricate a catheter that was inserted into the bladder to measure the postvoid residual volume. After removal of the catheter, a cotton swab, coated with the same allocated gel, was advanced to the urethrovesical junction until resistance was felt. The angle of the swab with the horizontal plane was measured at rest and with Valsalva maneuver. Relevant baseline characteristics and the Wong-Baker FACES pain scores (where 0 is for no pain and 5 for worst pain) were compared. RESULTS: After randomization, lidocaine and the plain aqueous gel arms consisted of 69 and 68 women, respectively. Baseline characteristics of the groups were similar. Significantly fewer women in the lidocaine group (62.3%) reported any pain than those allocated to plain aqueous gel (80.9%) (odds ratio 0.39, 95% confidence interval 0.18–0.85). The median pain score was significantly lower in the lidocaine group (1, range 0–5) compared with 2 (range 0–4), P<.001). CONCLUSION: When compared with plain aqueous gel, 2% lidocaine jelly significantly reduces pain perception during evaluation of postvoid residual volume and the Q-tip test. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00883103. LEVEL OF EVIDENCE: I

Utility of Fetal Echocardiography After Normal Cardiac Imaging Findings on Detailed Fetal Anatomic Ultrasonography

Objective. The purpose of this study was to assess the utility of fetal echocardiography (FE) after normal fetal cardiac imaging findings during detailed fetal anatomic ultrasonography (FAU). Methods. We conducted a retrospective cohort review of obstetric ultrasonographic studies from November 2001 through July 2005. We identified women with a singleton gestation with increased risk for congenital heart disease who received FAU performed by a maternal‐fetal medicine specialist at 16 to 20 weeks gestation with subsequent FE. These records were compared with newborn outcomes. Results. Of 789 pregnancies that had FAU and FE, 481 had satisfactory cardiac imaging. Of those, only 1 fetus had abnormal FE findings. After delivery, 4 of the 480 neonates with normal FAU and FE findings had a diagnosis of a heart defect. Conclusions. Fetal echocardiography does not substantially increase the detection rate of major cardiac anomalies after normal findings on detailed FAU performed by a maternal‐fetal medicine specialist.

Effect of Transient and Sustained Acute Kidney Injury on Readmissions in Acute Decompensated Heart Failure

Although acute kidney injury (AKI) is common in heart failure, yet the impact of the onset, timing, and duration of AKI on short-term outcomes is not well studied. AKI was defined as an increase in serum creatinine SCr of ≥0.3xa0mg/dl or 1.5 times relative to the admission and further categorized as transient AKI (T-AKI: SCr returning to within 10% of baseline); sustained AKI (S-AKI: those with at least 72xa0hours of hospital stay and did not meet T-AKI); and unknown duration AKI (U-AKI: those with less than 72xa0hours stay and did not meet T-AKI). Reference category was no AKI (stable or <0.3xa0mg/dl change in SCr). The main outcome was 30-day all-cause hospital readmission. Unadjusted and adjusted association between AKI category of interest and main outcome was represented as percent and relative risks with 95% CIs. Statistical significance was set at an alpha of 0.05. From the Cerner Health Facts sample, 14,017 of 22,059 available subjects met the eligibility criteria. Approximately, 19.2% of our sample met the primary outcome. Compared with no AKI (readmission rate of 17.7%; 95% CI 16.4% to 18.9%), the adjusted rate of readmission was highest in patients with S-AKI (22.8%, 95% CI 20.8% to 24.8%; p <0.001), followed by 20.2% (95% CI 17.5% to 22.8%; pxa0= 0.05) in T-AKI patients. Compared with no AKI, the adjusted relative risk of 30-day readmission was 1.29 (95% CI 1.17 to 1.42), 1.14 (95% CI 1.00 to 1.31), and 1.12 (95% CI, 1.01 to 1.26) in S-AKI, T-AKI, and U-AKI, respectively. In conclusion, both sustained AKI and patients with transient elevation still remain at a higher risk of readmission within 30 days. Future studies should focus on examining process-of-care after discharge in patients with different patterns of AKI.

Promoting high value inpatient care via a coaching model of structured, interdisciplinary team rounds.

The professional development of early career hospital physicians may be improved by embedding an experienced physician in a coaching role during structured, interdisciplinary team rounds. This article gives a descriptive report of such a model and discusses how it may promote delivery of high-value care to adult inpatients.

Women's perceptions about female reproductive system: a survey from an academic obstetrics and gynecology practice.

ObjectiveTo assess women’s knowledge about female reproductive system and the demographic factors that may influence their perceptions.Study designIn this cross-sectional study, all qualifying adult women at our academic practice were asked to complete a self-administered anonymous questionnaire about the effects of female reproductive system between June and August 2009. We assessed the accuracy of their knowledge and analyzed the effect of demographic factors.ResultsThe majority of the 500 participants were in 18- to 59-year age range (93xa0%), Caucasian (81xa0%), married (56xa0%), college graduates (74xa0%) and had private insurance (82xa0%). Mean correct score was 63xa0±xa020xa0%. In univariate analysis, those respondents who were older, Caucasian, and had private insurance scored significantly higher (pxa0<xa00.05) When all the variables were entered in a fractional logit model, only age, race and reason for the visit remained as independent predictors for a better overall score in this survey. Twenty-nine percent of the participants thought hysterectomy included removal of ovaries and tubes. About a quarter of the respondents thought menstrual function would continue after hysterectomy. The question for whether removal of the uterus resulted in climacteric changes was correctly answered only by 34xa0%. While 59xa0% of women did not agree that removing the entire uterus eliminated the cervical cancer risk, 66xa0% concluded that they would continue to need Pap smears after total hysterectomy.ConclusionWomen’s knowledge about female reproductive system is limited, especially for those who are younger and from a minority.

Physician communication coaching effects on patient experience

Background Excellent communication is a necessary component of high-quality health care. We aimed to determine whether a training module could improve patients’ perceptions of physician communication behaviors, as measured by change over time in domains of patient experience scores related to physician communication. Study design We designed a comprehensive physician-training module focused on improving specific “etiquette-based” physician communication skills through standardized simulations and physician coaching with structured feedback. We employed a quasi-experimental pre-post design, with an intervention group consisting of internal medicine hospitalists and residents and a control group consisting of surgeons. The outcome was percent “always” scores for questions related to patients’ perceptions of physician communication using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey and a Non-HCAHPS Physician-Specific Patient Experience Survey (NHPPES) administered to patients cared for by hospitalists. Results A total of 128 physicians participated in the simulation. Responses from 5020 patients were analyzed using HCAHPS survey data and 1990 patients using NHPPES survey data. The intercept shift, or the degree of change from pre-intervention percent “always” responses, for the HCAHPS questions of doctors “treating patients with courtesy” “explaining things in a way patients could understand,” and “overall teamwork” showed no significant differences between surgical control and hospitalist intervention patients. Adjusted NHPPES percent excellent survey results increased significantly post-intervention for the questions of specified individual doctors “keeping patient informed” (adjusted intercept shift 9.9% P = 0.019), “overall teamwork” (adjusted intercept shift 11%, P = 0.037), and “using words the patient could understand” (adjusted intercept shift 14.8%, p = 0.001). Conclusion A simulation based physician communication coaching method focused on specific “etiquette-based” communication behaviors through a deliberate practice framework was not associated with significantly improved HCAHPS physician communication patient experience scores. Further research could reveal ways that this model affects patients’ perceptions of physician communication relating to specific physicians or behaviors.