Catalogue Search | MBRL
Are you sure you want to remove the book from the shelf?
{{itemTitle}}
1,070
result(s) for
"Morgan, Daniel M."
Sort by:
Now you see me 2 : the closer you look, the less you'll see
The Four Horsemen are on a new mission to steal a chip that can decrypt any electronic device in the world.
DVD
Decreasing Utilization of Vaginal Hysterectomy in the United States: An Analysis by Candidacy for Vaginal Approach
Introduction and Hypothesis
The objective was to assess trends in hysterectomy routes by patients who are likely and unlikely candidates for a vaginal approach.
Methods
We performed a retrospective cohort study of patients who underwent vaginal, abdominal, or laparoscopic/robotics-assisted laparoscopic hysterectomy between 2017 and 2020 using the National Surgical Quality Improvement Program database. Patients undergoing hysterectomy for a primary diagnosis of benign uterine pathology, dysplasia, abnormal uterine bleeding, or pelvic floor disorders were eligible for inclusion. Patients who were parous, had no history of pelvic or abdominal surgery, and had a uterine weight ≤ 280 g on pathology were considered likely candidates for vaginal hysterectomy based on an algorithm developed to guide the surgical approach. Average annual changes in the proportion of likely vaginal hysterectomy candidates and route of hysterectomy were assessed using logistic regression.
Results
Of the 77,829 patients meeting the inclusion criteria, 13,738 (17.6%) were likely vaginal hysterectomy candidates. Among likely vaginal hysterectomy candidates, the rate of vaginal hysterectomy was 34.5%, whereas among unlikely vaginal hysterectomy candidates, it was 14.1%. The overall vaginal hysterectomy rate decreased −1.2%/year (
p
< 0.01). This decreasing trend was nearly twice as rapid among likely vaginal hysterectomy candidates (−1.9%/year,
p
< .01) compared with unlikely vaginal hysterectomy candidates (−1.1%/year,
P
< 0.01); the difference in trends was statistically significant (
p
< 0.01).
Conclusions
The rate of vaginal hysterectomy performed for eligible indications decreased between 2017 and 2020 in a national surgical registry. This negative trend was more pronounced among patients who were likely candidates for vaginal hysterectomy based on favorable parity, surgical history, and uterine weight.
Journal Article
Obesity and stress urinary incontinence in women: compromised continence mechanism or excess bladder pressure during cough?
Introduction and hypothesis
We compared two hypotheses as to why obesity is associated with stress urinary incontinence (SUI): (1) obesity increases demand on the continence system (e.g. higher cough pressure) and (2) obesity compromises urethral function and urethrovaginal support.
Methods
A secondary analysis was performed using data from a case–control study of SUI in women. Measurements of urethrovaginal support (POP-Q point Aa, urethral axis), urethral function (maximal urethral closure pressure, MUCP), and measures of continence system demand (intravesical pressures at rest and during maximal cough) were analyzed. Cases and controls were divided into three body mass index (BMI) groups: normal (18.5–24.9 kg/m
2
); overweight (25.0–29.9 kg/m
2
); and obese (≥30 kg/m
2
). Logistic regression models where created to investigate variables related to SUI for each BMI group. Structural equation modeling was used to test the direct and indirect relationships among BMI, SUI, maximal cough pressure, MUCP, and POP-Q point Aa.
Results
The study included 108 continent controls and 103 women with SUI. MUCP was the factor most strongly associated with SUI in all BMI groups. Maximal cough pressure was significantly associated with SUI in obese women (OR 3.191, 95% CI 1.326, 7.683;
p
< 0.01), but not in normal weight or overweight women. Path model analysis showed a significant relationship between BMI and SUI through maximal cough pressure (indirect effect,
p
= 0.038), but not through MUCP (indirect effect,
p
= 0.243) or POP-Q point Aa (indirect effect,
p
= 0.410).
Conclusions
Our results support the first hypothesis that obesity is associated with SUI because of increased intravesical pressure, which therefore increases demand on the continence mechanism.
Journal Article
Hospital contribution to variation in rates of vaginal birth after cesarean
ObjectiveTo determine the influence of delivery hospital on the rate of vaginal birth after cesarean (VBAC).Study designThis retrospective cohort study used claims data from Blue Cross and Blue Shield of Michigan. Women with a prior cesarean and a singleton livebirth between 2012 and 2016 were included. We calculated the hospital-specific risk-standardized VBAC rates and median odds ratio as a measure of variation.ResultHospital-level adjusted rates varied nearly tenfold (3.7%–35.5%). Compared to the lowest volume hospitals (1st quartile), the likelihood of VBAC increased for those in the 2nd (adjusted OR 2.75 [95% CI 1.23–6.17]), 3rd (adjusted OR 3.73 [95% CI 1.59–8.75]), and 4th quartiles (adjusted OR 2.9 [95% CI 1.11–7.72]). The median OR suggested significant variation by hospital after adjustment.ConclusionThe delivery hospital itself explains a large amount of the variation in rates of VBAC after adjustment for patient and hospital characteristics.
Journal Article
Levator ani defect scores and pelvic organ prolapse: is there a threshold effect?
Introduction and hypothesis
The goal of this study was to use a well-described system of quantifying levator ani defect (LAD) severity using magnetic resonance imaging (MRI) to examine the relationship between defect severity and the presence or absence of prolapse.
Methods
This is a secondary analysis of two case–control studies comparing 284 cases (with prolapse) to 219 controls (normal support) defined by using Pelvic Organ Prolapse Quantification (POP-Q) exams. LAD were assessed on MRI, with scores from 0 (no defects) to 6 (complete, bilateral defects). The number of cases and controls at each score were compared. Logistic regression and receiver operating characteristic (ROC) analyses were used to quantify relationships between LAD and prolapse.
Results
The proportion of cases exceeds the overall prolapse rate in this study at LAD scores ≥3, with higher rates of prolapse at higher LAD scores (
p
< 0.0000001). Prolapse risk stratifies into low risk at LAD scores 0–2, moderate at 3–5, and high at 6. ROC analysis for classification of prolapse based on LAD scores has an area under the curve of 69.9 % (
p
< 0.001), suggesting LAD alone can discriminate between normal support and prolapse for nearly 70 % of patients. Logistic regression identified higher parity and higher LAD scores as independent predictors of prolapse.
Conclusions
There are three clusters of prolapse risk: low (0–2), moderate (3–5), and high (6). Although LAD have a dose-response-like effect for prolapse, other factors are clearly involved.
Journal Article
Documenting pessary offer prior to hysterectomy for management of pelvic organ prolapse
ObjectivesTo (1) determine the proportion of hysterectomy cases with documentation of pessary counseling prior to prolapse surgery and (2) identify variables associated with women offered a pessary.Study designThe Michigan Surgical Quality Collaborative (MSQC) is a hysterectomy improvement initiative. Hysterectomies from 2013 to 2015 in which prolapse was the principal diagnosis were included. “Pessary offer” was defined as documentation showing the patient declined, could not tolerate, or failed a pessary trial. Bivariate analyses were used to compare demographics, medical history, surgical route, concomitant procedures (colpopexy or colporrhaphy), and intra- and postoperative complications between women with and without pessary offer. Hierarchical logistic regression was used to determine factors independently associated with pessary offer. Risk-adjusted pessary offer rates by hospital were calculated.ResultsThe adjusted rate of pessary offer was 25.2%, ranging from 3 to 76% per hospital. Bivariate comparisons showed differences between women with and without pessary offer in age, tobacco use, prior pelvic surgery, insurance status, surgical approach, secondary indication for surgery, concomitant prolapse procedure, teaching hospital status and hospital bed size. In logistic regression, odds of pessary offer increased with age > 55 years (OR 1.45, 95% CI 1.12–1.88, p = 0.006), Medicare insurance (OR 1.65, 95% CI 1.30–2.10, p < 0.0001), and a concomitant procedure (OR 1.5, 95% CI 1.16–1.93, p = 0.002). Postoperative urinary tract infections were more common in patients offered a pessary (6.4% vs. 2.5%, p < 0.0001), but other complications were similar.ConclusionsOverall, only one-quarter of hysterectomies for prolapse in MSQC hospitals had documentation of pessary counseling—suggesting an opportunity to improve documentation, counseling regarding pessary use, or both.
Journal Article
The long and short of it: anterior vaginal wall length before and after anterior repair
Introduction and hypothesis
Anterior vaginal wall length (AVL) is on average 6.1 ± 1.3 cm in women with normal support and lengthened in women with cystocele. We hypothesize that AVL is reduced after anterior repair and that women with larger cystoceles will have greater reduction in AVL.
Methods
Demographic, clinical, and surgical data were collected for women undergoing hysterectomy and anterior repair in whom intraoperative vaginal wall measurements had been made between November 2009 and April 2014. In the operating room, AVL was defined preoperatively as the distance from the hymenal ring to the anterior cervicovaginal junction at the hysterectomy incision site, and postoperatively, from the hymenal ring to the same location on the anterior cuff. During the anterior repair the fibromuscular tissues were plicated using an interrupted technique.
Results
Measurements were available for 40 women. Average age was 61.7 ± 10 years, median parity was 2.5 and median preoperative Pelvic Organ Prolapse Quantification System (POP-Q) point Ba was 3 cm distal to the hymen. On average, AVL was reduced after surgery by 2.5 cm. Mean postoperative AVL was similar to mean AVL in women with normal pelvic support (6.4 ± 0.8 cm vs 6.1 ± 1.3 cm,
p
= 0.15). Longer preoperative AVLs had greater AVL change (
R
2
= 0.78,
p
= <0.0001).
Conclusions
In women undergoing anterior repair, mean AVL was reduced by 28 % and returned to the normal range after surgery. These data highlight a rarely discussed effect of anterior repair, which is restoration of normal anterior vaginal wall length.
Journal Article
Ligament shortening compared to vaginal colpopexy at the time of hysterectomy for pelvic organ prolapse
Introduction and Hypothesis
The performance of a colpopexy at the time of hysterectomy for pelvic organ prolapse is a potential indicator of surgical quality. However, vaginal colpopexy has not been directly compared with the classic technique of ligament shortening and reattachment. We sought to test the null hypothesis that there is no difference in prolapse recurrence between the techniques.
Methods
We performed a retrospective chart review of 330 vaginal hysterectomies performed for prolapse, comparing symptomatic and/or anatomic recurrence rates between patients having a vaginal colpopexy (uterosacral ligament suspension or sacrospinous ligament suspension) and those having ligament shortening and reattachment. Clinically relevant variables significantly associated with recurrence in a univariate analysis were used to create a multivariable logistic regression model to predict recurrence.
Results
With a mean follow-up of 20 months, there was no significant difference between symptomatic and/or anatomic recurrence rates: 19.4 % of patients (41 of 211) having colpopexy vs. 11.8 % of patients (14 of 119) having ligament shortening (
p
= 0.07). Baseline prolapse stage was higher in patients having colpopexy (median 3, IQR 2 – 5) than in those having ligament shortening (median 2, IQR 1 – 3;
p
≤ 0.0001). In the multivariable logistic regression analysis, the procedure performed was not associated with recurrence (OR 1.57, 95 % CI 0.79 – 3.12). A baseline prolapse of 4 cm or greater was associated with recurrence (OR 2.63, 95 % CI 1.32 – 5.22), as was the time since hysterectomy (OR 1.02 per month, 95 % CI 1.01 – 1.04).
Conclusions
When compared with vaginal colpopexy, selective use of the ligament shortening technique at the time of vaginal hysterectomy was associated with similar rates of prolapse recurrence. Preoperative prolapse size was the factor most strongly associated with recurrence.
Journal Article
Levator ani defect status and lower urinary tract symptoms in women with pelvic organ prolapse
Introduction and hypothesis
Among women with pelvic organ prolapse, compare rates of lower urinary tract symptoms by levator ani defect (LAD) status.
Methods
Urinary incontinence and obstructive voiding are analyzed among 151 women with prolapse whose LAD status was determined with magnetic resonance imaging.
Results
Women with major LAD are less likely to experience stress incontinence when “coughing, laughing, or sneezing” (odds ratio (OR) 0.27) and when “twisting, reaching, lifting, or bending over” (OR 0.26) than women with normal muscles. They are less likely to have obstructive symptoms characterized by assuming an “unusual toileting position” or “changing positions…to start or complete urination” (OR 0.27). Women with minor LAD are more likely to experience stress incontinence with exercise (OR 3.1) and urge incontinence (OR 4.0) than those with normal muscles.
Conclusions
Lower urinary tract symptoms are less common among women with prolapse and major levator ani defects and more common among those with minor defects.
Journal Article
Interrater reliability of assessing levator ani muscle defects with magnetic resonance images
The objective of this study is to determine interrater reliability of assessing pubovisceral levator ani muscle defects with magnetic resonance images. Normal pubovisceral muscle was assigned a grade of 0; PVM defects were graded as mild = 1 (less than half missing), moderate = 2 (more than half missing), and severe = 3 (total or near total loss). Among six pairs of examiners, percent agreement and weighted kappa coefficients were calculated to determine agreement between pairs of examiners and among all examiners (i.e., “overall”). For unilateral scoring, exact agreement was found in 83.7%, and differences of one, two, and three grades were found in 14.7, 1.5, and 0.1%, respectively. For bilateral scoring, exact agreement and differences of one, two and three grades were found in 75.4, 15.9, 6.9, and 1.6%, respectively. Thus, exact agreement or a one-point difference was reached in 91.3% of cases. When defect status was categorized as none/normal, minor, and major, the overall weighted kappa coefficient was 0.86 (95% CI 0.83, 0.89). There was variation among examiner pairs with unilateral (p = 0.002) and bilateral (p = 0.02) scoring, but not when defect status was categorized as none/normal, minor, and major (p = 0.59). There was agreement to within one point in 91% of cases when six examiner pairs scored levator ani defects on a seven-point scale. Examiner pairs discriminated injury similarly when defect status was categorized as normal/none, minor, or major.
Journal Article