Michael Brodman

Influence of human immunodeficiency virus infection on pelvic inflammatory disease.

Objective To examine the influence of human immunodeficiency virus (HIV) infection on clinical and microbiologic characteristics of pelvic inflammatory disease (PID). Methods Forty-four HIV-infected women and 163 HIV noninfected women diagnosed with PID by standard case definition were evaluated by using clinical severity scores, transabdominal sonograms, and endometrial biopsies. After testing for bacterial infections, patients were prescribed antibiotics as recommended by the Centers for Disease Control and Prevention (CDC). Results Symptoms of PID and analgesic use before enrollment did not differ by HIV serostatus. More HIV-infected women had received antibiotics before enrollment (40.9% versus 27.2%, P = .08), a factor associated with milder signs regardless of serostatus. More HIV-infected women had sonographically diagnosed adnexal masses at enrollment (45.8% versus 27.1%, P = .08), a difference that yielded higher median severity scores (17.5 of 42 points versus 15 of 42 points, P = .07). However, those differences were not significant at the P < .05 level. Mycoplasma (50% versus 22%, P < .05) and streptococcus species (34% versus 17%, P < .05) were isolated more commonly from biopsies of HIV-infected women. Within 30 days after enrollment, HIV-infected women generally responded as well to therapy as HIV-noninfected women did, regardless of initial CD4 T-lymphocyte percentage. Conclusion Among women with acute PID, HIV infection was associated with more sonographically diagnosed adnexal masses. Clinical response to CDC-recommended antibiotics did not differ appreciably by serostatus. Mycoplasmas and streptococci were isolated more commonly from HIV-infected women, but those organisms also might be associated with PID in immunocompetent women.

Staging of cervical carcinoma: accuracy of magnetic resonance imaging and computed tomography.

A prospective study was undertaken to assess the ability of magnetic resonance imaging (MRI) to stage cervical carcinoma. Compared to computed tomography (CT), MRI showed a high degree of accuracy in correctly demonstrating involvement of the vagina, parametria and sidewalls, bladder, and lymph nodes but tended to overestimate disease in all of the categories studied. Large-scale studies comparing the two modalities are necessary because the most accurate staging of cervical carcinoma is crucial for selecting the best treatment protocols.

A comparative study of computerized tomography, magnetic resonance imaging, and clinical staging for the detection of early cervix cancer

Sixteen patients with cervical cancer underwent radical surgery following standard clinical staging, MRI, and CT. The sensitivity of the CT scan was 14%, the specificity 100%. MRI had a sensitivity of 28% and a specificity of 64%. The clinical stage was correct in 10 of 16 patients (62%). CT and MRI are not individually or collectively better than clinical staging in predicting extent of disease, and currently should not be included in the FIGO staging for cervix cancer.

Professionalism: A Necessary Ingredient in a Culture of Safety

BACKGROUND A safety culture requires the highest levels of professionalism. A Code of Professionalism was created in an obstetrics service line as a mechanism to address unprofessional behavior. In this initiative, a multidisciplinary Code of Professionalism was established, with the support of leadership and the employee and nursing unions, to help create a safety culture. METHODS In 2005 the Code of Professionalism was introduced to physicians, nurses, and support staff. The U.S. Agency for Healthcare Research and Quality (AHRQ) Patient Safety Culture Survey was used, along with a portion of the Institute for Safe Medication Practices (ISMP) Survey on Workplace Intimidation to measure changes in the safety culture. Data were collected in 2005, 2008, and 2011. RESULTS One hundred thirty-four reports were made to the committee on professionalism between February 2005 and December 2010. Some 96 (72%) of the reports were submitted by nurses, with physicians accounting for 13%. Seventy-five of the reports (56%) were about unprofessional behavior by physicians and 46 (34%) were about unprofessional nursing behavior. On the AHRQ Patient Safety Culture Survey, statistically significant improvement was shown in the Teamwork Within Units dimension, from 2005 to 2008; the Management Support dimension, from 2005 to 2008; the Organizational Learning dimension, from 2005 to 2008 and also from 2008 to 2011; and the Frequency of Events Reported dimension, from 2008 to 2011. DISCUSSION Implementing a multidisciplinary Code of Professionalism can improve the safety culture in a hospital. When leadership sets clear standards and holds physicians and staff to the same standard, improvements in an organizations safety culture can serve as the foundation for the delivery of safer care.

Laparoscopic pomeroy tubal ligation in a residency training program

STUDY OBJECTIVE To evaluate the efficacy of the laparoscopic Pomeroy method of tubal ligation as a teaching tool during the initial acquisition of advanced laparoscopic skills by 14 residents in a 28-person, 4-year program. DESIGN A prospective, nonrandomized study. SETTING A metropolitan teaching hospital. PATIENTS Fifty-seven women who desired permanent sterilization, and 56 controls who underwent laparoscopic sterilization by standard coagulation. One refused entry and had standard sterilization by bipolar coagulation. In two women, both with several previous laparotomies, visualization of the pelvic organs was incomplete and the procedure was abandoned at the discretion of the surgeon. One had a minilaparotomy Pomeroy tubal ligation and the other was sterilized by standard two-puncture laparoscopic coagulation. One patient was excluded due to an incomplete data profile. INTERVENTIONS Laparoscopic sterilizations using the Pomeroy technique and standard coagulation were performed by gynecology residents with an attending physician present. First-year residents performed 36 (68%) of the 53 procedures. MEASUREMENTS AND MAIN RESULTS Operative times to teach this technique to house officers rotating on the gynecologic service were recorded by postgraduate year and stratified by the number of cases performed by each operator. The average operative times for residents in postgraduate years 1 through 4 were 18.6, 15.4, 21.7, and 14.8 minutes, respectively. These diminished with experience. A statistically longer time of 7.1 minutes was required to teach residents the Pomeroy technique compared with standard bipolar coagulation (p<0.0003). CONCLUSION Laparoscopic Pomeroy tubal ligation as a method to begin educating residents in advanced operative video-laparoscopy appears to have great potential.

Differences in perioperative outcomes after laparoscopic management of benign and malignant adnexal masses

Objective To compare the feasibility and safety of the laparoscopic management of adnexal masses appearing preoperatively benign with those suspicious for malignancy. Methods Retrospective study of 694 women that underwent laparoscopic management of an adnexal mass. Results Laparoscopic management of an adnexal mass was completed in 678 patients. Six hundred and thirty five patients had benign pathology (91.5%) and 53 (7.6%) had primary ovarian cancers. Sixteen patients (2.3%) were converted to laparotomy; there were 13 intraoperative (1.9%) and 16 postoperative complications (2.3%). Patients divided in 2 groups: benign and borderline/malignant tumors. Patients in the benign group had a higher incidence of ovarian cyst rupture (26% vs. 8.7%, p<0.05). Patients in the borderline/malignant group had a statistically significant higher conversion rate to laparotomy (0.9% vs. 16.9%, p<0.001), postoperative complications (1.9% vs. 12.2%, p<0.05), blood loss, operative time, and duration of hospital stay. The incidence of intraoperative complications was similar between the 2 groups. Conclusion Laparoscopic management of masses that are suspicious for malignancy or borderline pathology is associated with an increased risk in specific intra-operative and post-operative morbidities in comparison to benign masses. Surgeons should tailor the operative risks with their patients according to the preoperative likelihood of the mass being carcinoma or borderline malignancy.

Effect of hormone replacement and selective estrogen receptor modulators (SERMs) on the biomechanics and biochemistry of pelvic support ligaments in the cynomolgus monkey (Macaca fascicularis)

OBJECTIVE To evaluate the effect of selective estrogen receptor modulators and ethinyl estradiol on the biomechanical and biochemical properties of the uterosacral and round ligaments in the monkey model of menopause. STUDY DESIGN A randomized, double-blind, placebo-controlled study on 11 female macaque monkeys. Ovariectomized monkeys received 12 weeks of placebo, raloxifene, tamoxifen, or ethinyl estradiol. Biomechanical step-strain testing and real-time polymerase chain reaction was performed on the uterosacral and round ligaments. RESULTS Tamoxifen and raloxifene uterosacrals expressed differing collagen I/III receptor density ratios, but both selective estrogen receptor modulators showed decreased tensile stiffness compared to ethinyl estradiol and controls. CONCLUSION These findings support a possible effect of selective estrogen receptor modulators on biomechanical and biochemical properties of uterosacrals. This may play a role in pelvic organ prolapse.

Association Between Senior Obstetrician Supervision of Resident Deliveries and Mode of Delivery

OBJECTIVE In December 2012, the Mount Sinai Hospital implemented a program to have senior obstetricians (more than 20 years of experience) supervise residents on labor and delivery during the daytime. The objective of this study was to estimate the association of resident supervision by senior obstetricians with mode of delivery. METHODS This was a retrospective cohort study of all resident deliveries at Mount Sinai from July 2011 to June 2015. We included all patients with live, term, singleton, vertex fetuses. We compared delivery outcomes between patients delivered before December 2012 and patients delivered December 2012 and later using logistic regression analysis to control for age, body mass index, parity, induction, and prior cesarean delivery. During the study period there were no other specific departmental initiatives to increase forceps deliveries aside from having six obstetricians with significant experience in operative deliveries supervise and teach residents on labor and delivery. RESULTS There were 5,201 live, term, singleton, vertex deliveries under the care of residents, 1,919 (36.9%) before December 2012 and 3,282 (63.1%) December 2012 or later. The rate of forceps deliveries significantly increased from 0.6% to 2.6% (adjusted odds ratio [OR] 8.44, 95% confidence interval [CI] 3.1-23.1), and the rate of cesarean deliveries significantly decreased from 27.3% to 24.5% (adjusted OR 0.68, 95% CI 0.55-0.83). There were no statistically significant differences in the rates of third- or fourth-degree lacerations or 5-minute Apgar scores less than 7. Among nulliparous women, the forceps rate increased from 1.0% to 3.4% (adjusted OR 4.87, 95% CI 1.74-13.63) and the cesarean delivery rate decreased from 25.6% to 22.7% (adjusted OR 0.69, 95% CI 0.53-0.89). The increase in forceps deliveries and the decrease in cesarean deliveries were seen only in daytime hours (7 AM to 7 PM), that is, the shift that was covered by senior obstetricians. CONCLUSION Having senior obstetricians supervise resident deliveries is significantly associated with an increased rate of forceps deliveries and a decreased rate of cesarean deliveries.

Perioperative care map improves compliance with best practices for the morbidly obese

BACKGROUND Morbid obesity can complicate perioperative management. Best practice guidelines have been published but are typically followed only in bariatric patients. Little is known regarding physician awareness of and compliance with these clinical recommendations for nonbariatric operations. Our study evaluated if an educational intervention could improve physician recognition of and compliance with established best practices for all morbidly obese operatively treated patients. METHODS A care map outlining best practices for morbidly obese patients was distributed to all surgeons and anesthesiologists at 4 teaching hospitals in 2013. Pre- and postintervention surveys were sent to participants in 2012 and in 2015 to evaluate changes in clinical practice. A chart audit performed postintervention determined physician compliance with distributed guidelines. RESULTS In the study, 567 physicians completed the survey in 2012 and 375 physicians completed the survey in 2015. Postintervention, statistically significant improvements were seen in the percentage of surgeons and anesthesiologists combined who reported changing their management of morbidly obese, operatively treated patients to comply with best practices preoperatively (89% vs 59%), intraoperatively (71% vs 54%), postoperatively (80% vs 57%), and overall (88% vs 72%). Results were similar when surgeons and anesthesiologists were analyzed separately. A chart audit of 170 cases from the 4 hospitals found that 167 (98%) cases were compliant with best practices. CONCLUSION After care map distribution, the percentage of physicians who reported changing their management to match best practices significantly improved. These findings highlight the beneficial impact this educational intervention can have on physician behavior. Continued investigation is needed to evaluate the influence of this intervention on clinical outcomes.

Obesity May Be Protective against Severe Perineal Lacerations.

Objective. To determine if there is an association between BMI and 3rd- or 4th-degree perineal lacerations in normal spontaneous and operative vaginal deliveries. Study Design. We performed a retrospective case control study using a large obstetric quality improvement database over a six-year period. Cases were identified as singleton gestations with third- and fourth-degree lacerations. Controls were obtained randomly from the database of patients without third- or fourth-degree lacerations in a 1 : 1 ratio. Univariate and multivariate logistic regression analyses were performed. Results. Of 32,607 deliveries, 22,011 (67.5%) charts with BMI documented were identified. Third- or fourth-degree lacerations occurred in 2.74% (n = 605) of patients. 37% (n = 223) were identified in operative vaginal deliveries. In the univariate analysis, obesity, older maternal age, non-Asian race, and birth weight <4000 g were all protective against 3rd- and 4th-degree lacerations. After controlling for age, race, mode of vaginal delivery, and birth weight, obesity remained significant. Conclusion. Being obese may protect against third- and fourth-degree lacerations independent of parity, race, birth weight, and mode of delivery.