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ABSTRACT: Frequently, a fixed pelvis is encountered that is caused by a benign disease, either severe endometriosis or severe adhesions
with or without fibroid uterus. We present two cases of nulligravida and multiparous women who had absolute frozen pelvises
with no motion whatsoever of their pelvic structures on bimanual examination. Conventionally, these patients would have been
approached by open hysterectomy only. We do not consider a frozen pelvis from what appears to be a benign case a contraindication
to the laparoscopic approach.
KeywordsFixed pelvis–Impacted uterus–Retroverted uterus–Obliterated cul-de-sac–Adhesions–Endometriosis–Laparoscopic hysterectomy
Gynecological Surgery 04/2012; 8(2):157-159.
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ABSTRACT: In this paper, we present our experience with cystoscopy and hydrodistension for the diagnosis of interstitial cystitis (IC)
and association with endometriosis/adenomyosis. This is a retrospective study of 116 patients who have undergone cystoscopy
and hydrodistension because of suspicion of interstitial cystitis as shown by elevated Pain Urgency and Frequency questionnaire
(PUF) scores and, in some patients, positive potassium sensitivity test (PST) or anesthetic bladder challenge (ABC) tests
as well. Cystoscopic findings were grouped into “no IC,” “atypical IC,” and “typical IC” groups. Chi-square analysis was used
for comparing percentages. PUF questionnaire showed high sensitivity (98%) with ≥5 score but low specificity (0%). The best
specificity was found with PST (30%). Among IC patients, 60 (60%) had adenomyosis or endometriosis with an increasing endometriosis/adenomyosis
rate from “no IC” to “typical IC” groups (37.5% to 67.74%, P < 0.05). PST is the most specific of the screening tests for IC, and cystoscopy with hydrodistension is the only test that
allows direct visualization and grading of bladder abnormalities as “typical”, “atypical”, and “no IC”. The presence of endometriosis
has a stronger association with typical IC findings on cystoscopy including glomerulations, ulcers, and reduced bladder capacity.
KeywordsInterstitial cystitis-Endometriosis-Adenomyosis-PUF-PST-ABC
Gynecological Surgery 04/2012; 7(4):353-357.
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ABSTRACT: Hospital patient databases are typically used by administrative staff to estimate loss-profit ratios and to help with the allocation of hospital resources. These databases can also be very useful in following rehospitalization. This paper studies the recurrence of spine surgery patients in our hospital population based on administrative data analysis.
Hospital data on 4,958 spine surgery patients operated between 2002 and 2009 were retrospectively reviewed. After sorting the cohort per ascending discharge date, the patient official name, consisting of first, middle and last names, was used as the variable determining duplicate cases in the SPSS statistical program, designating the first case in each group as primary. Yearly recurrence rate and change in procedure distribution were studied. In addition, hospital charges and length of stay were compared using the Wilcoxon-Mann-Whitney test.
Of 4,958 spine surgery patients 364 (7.3%) were categorized as duplicate cases by SPSS. The number of primary cases from which duplicate cases emerged was 327 meaning that some patients had more than two spine surgeries.Among primary patients (N=327) the percentage of excision of intervertebral disk procedures was 33.3% and decreased to 15.1% in recurrent admissions of the same patients (N=364). This decrease was compensated by an increase in lumbar fusion procedures. On the other hand, the rate of cervical fusion remained the same.The difference in hospital charges between primary and duplicate patients was $2,234 for diskectomy, $6,319 for anterior cervical fusion, $8,942 for lumbar fusion--lateral technique, and $12,525 for lumbar fusion--posterior technique. Recurrent patients also stayed longer in hospital, up to 0.9 day in lumbar fusion - posterior technique patients.
Spine surgery is associated with an increasing possibility of additional spine surgery with rising invasiveness and cost.
German medical science : GMS e-journal 01/2012; 10:Doc03.
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ABSTRACT: BACKGROUND AND INTRODUCTION: Triple H therapy is conventionally used to treat vasospasm following sub-arachnoid hemorrhage (SAH) but can sometimes have side effects. In order to investigate pulmonary complications in SAH patients and relationship with age we conducted the following study.
The charts of 121 sub-arachnoid hemorrhage patients who underwent clipping or coiling of an aneurysm were retrospectively reviewed. The diagnosis of vasospasm was documented based on Doppler and angiographic findings. All patients with vasospasm received the standard Triple H therapy (hematocrit 33-38%, central venous pressure 10-12 mmHg, systolic blood pressure 160-200 mmHg). We studied intravenous intake, artificial ventilation, hypoxemia/pulmonary edema, postoperative fever, pneumonia and death rates as outcome variables.
Sixty five patients developed vasospasm (15 mild, 23 moderate, 27 severe). These were significantly younger than non-vasospasm patients (51 years vs. 61 years, p=0.004). The average daily intravenous input was 1,730 cc in novasospasm patients, 2,123 cc in the mild vasospasm group, 2,399 cc in the moderate vasospasm group, and 3,040 cc in the severe vasospasm group. Younger patients with moderate to severe vasospasm received more fluids than older patients. Ten patients (8.3%) developed hypoxemia or pulmonary edema. No patient developed hypoxemia/pulmonary edema in the mild vasospasm group and the rates did not show a trend and were not statistically different (7.1%, 0.0%, 13.0%, 11.1%, p>0.05) between vasospasm and non-vasospasm groups. Likewise, postoperative fever and pneumonia rates were not different between the vasospasm and non-vasospasm groups. Using the mean age as a threshold, pulmonary-related complications including death rates tended to be higher in the older group. The rates of postoperative ventilation (30.8% vs. 57.1%, P<0.01) and hypoxemia/pulmonary edema (3.1% vs. 14.3%, P<0.05) rates were statistically higher in the older group. Patients who developed hypoxemia/pulmonary edema in the vasospasm group tended to be younger than those who developed hypoxemia/pulmonary edema in the non-vasospasm group.
Younger patients are at a higher risk of developing vasospasm than older patients possibly referable to vessel elasticity and reactive sensitivity factors. Likewise, patients who developed hypoxemia/pulmonary edema in the vasospasm group were younger than in the non-vasospasm group possibly secondary to fluid overload from triple H therapy.
Journal of vascular and interventional neurology 07/2011; 4(2):29-33.
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ABSTRACT: The social disruption experienced by people with neuropsychiatric disorders may be pervasive and manifest in divorce. It has been estimated that 90% of marriages involving a partner with bipolar disorder culminate in divorce. To verify this information we studied the results of the 2004 National Nursing Home Survey. We found that the percentage of divorced residents was 7%. However, “lonesome” status (widowed, divorced, separated, never married, and single) was prevailing in 79% of residents. The rates of divorce were highest among bipolar, paranoid, and schizophrenic residents (18%, 12%, and 12%, respectively). Lonesome status was also highest among bipolar, paranoid, and schizophrenic residents (85%, 84%, and 83%, respectively). Never married status was highest among those with schizophrenia, obsessive-compulsive residents, and bipolar patients (12%, 12%, and 11%, respectively). We conclude that shizophrenic and bipolar patients are very likely to never get married or to end up divorced.
Journal of Divorce & Remarriage 05/2011; 52(4):220-224.
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ABSTRACT: Interstitial cystitis (IC) is a common cause of pelvic pain in the general female population and is thought to be understated in young female patients.
A 12-year-old girl with IC and endometriosis.
A single case report.
It is important to screen for IC in young patients with endometriosis and vice versa.
Archives of Gynecology 03/2011; 283 Suppl 1:115-7. · 0.91 Impact Factor
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ABSTRACT: Conization of the uterine cervix is a common gynecological procedure that sometimes causes cervical stenosis which creates difficulties for future gynecological procedures.
We present a very unusual case where strenuous effort was needed to obtain safe access to the endocervical canal and endometrial cavity.
A single case report.
In patients with stenotic invisible cervical os and no palpable cervix, it may be necessary to examine the patient under general anesthesia because surgical intervention may be necessary to access the cervical canal.
Archives of Gynecology 01/2011; 283 Suppl 1:121-2. · 0.91 Impact Factor
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ABSTRACT: Background: Chronic back pain is a known risk factor for unemployment, disability, and depression. This paper discusses the interaction of unemployment, depression, and history of prior spine surgery.Methods: We retrospectively reviewed the charts of 629 patients who underwent spine surgery and who were between the ages of 25 and 65 years. We collected data on their employment status, history of depression, and history of prior spine surgery (yes or no). Three types of spine surgery were included in the study: lumbar microdiscectomy, anterior cervical decompression and fusion, and lumbar decompression and fusion.Results: Approximately 29% (183) of the patients were unemployed and 32% (200) had a history of depression. Unemployment was more common among depressed patients (44% vs 27%; p < 0.001), and depression was more common among unemployed patients (41% vs 24%; p < 0.001). A history of prior spine surgery was most prevalent in unemployed female patients with a history of depression.Conclusion: Unemployment and depression were strongly associated with a history of prior spine surgery in the female cohort of our study population.
The Permanente journal 01/2011; 15(1):19-22.
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ABSTRACT: Comorbidities in patients undergoing spine surgery may reasonably be factors that increase health care costs. To verify this hypothesis, the authors conducted the following study.
Major comorbidities and age-adjusted Charlson Comorbidity Index scores were retrospectively analyzed for 816 patients who underwent spine surgery at the authors' institutions between 2005 and 2008, and treatment costs (hospital charges) were assessed with the help of statistical software. The sample was collected by a nonmedical staff (hired at the beginning of 2006). Patients underwent one of the three most common types of spine surgery: lumbar microdiscectomy (20.5%), anterior cervical decompression and fusion (ACDF; 60.3%), or lumbar decompression and fusion (LDF; 19.2%). Patients were nearly equally divided by sex (53% were female and 47% male), and 78% were Caucasian versus 21% who were African American; the rest were of mixed or unidentified race. The average age was 54 years, with an SD of ± 14 years.
There were significant differences in the prevalence of major comorbidities between male and female and between severely obese and nonseverely obese patients. The impact of comorbidities on the cost of spine surgery was more prominent in older patients, and an additive effect from some comorbidities was recorded in various types of spine surgery. For instance, in the ACDF group, female patients with both severe obesity and diabetes mellitus (DM) had significantly higher hospital charges than those with only one or neither of these conditions ($34,943 for both severe obesity and DM vs $25,633 for severe obesity only; $25,826 for DM only; and $25,153 for those with neither condition [p < 0.05]). In the LDF group, female patients with both DM and a history of depression had significantly higher hospital charges than those with only one or neither of these conditions ($65,782 for both DM and depression vs $53,504 for DM only; $55,990 for depression only; and $52,249 for those with neither condition [p < 0.05]). A significant difference was also found in hospital cost ($16,472 [p < 0.01]; 32% increase over baseline) in the LDF group between patients with the lowest and highest scores on the Charlson Index.
Comorbidities additively increase hospital costs for patients who undergo spine surgery, and should be considered in payment arrangements.
Journal of neurosurgery. Spine 01/2011; 14(3):318-21. · 1.61 Impact Factor
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ABSTRACT: To study the interaction of obesity and age in patients with multiple spine surgeries.
Data on the body mass index (BMI) of 956 patients were collected and classified into four groups: non-obese (BMI <30 kg/m(2)), obese-class I (BMI ≥30 kg/m(2)), obese-class II (BMI ≥35 kg/m(2)) and obese-class III (BMI ≥40 kg/m(2)). Patients' age was categorized into the following age groups: ≤40, 41-65 and ≥66. T-test and Chi-square test were applied using SPSS v16.
In lumbar patients aged ≥66 years with previous spine surgery, the average number of previous spine surgeries significantly increased with increasing obesity from 1.4 in nonobese patients to 1.7, 2.5 and 3.5 in obese class I, II and III patients. In lumbar decompression and fusion patients aged ≥66 years with previous spine surgery, the average number of previous spine surgeries significantly increased with increasing obesity from 1.7 in nonobese patients to 1.6, 2.0 and 3.5 in obese class I, II and III patients. A similar trend was noted in lumbar microdiskectomy patients aged ≥66 years but it was statistically nonsignificant due probably to small numbers.
Obesity is associated with an increased number of previous spine surgeries in patients over 65 years of age undergoing lumbar surgery.
German medical science : GMS e-journal 01/2011; 9:Doc05.
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ABSTRACT: Degenerative spine disorders are steadily increasing parallel to the aging of the population with considerable impact on cost and productivity. In this paper we study the prevalence and risk factors for multiple spine surgery and its impact on cost.
Data on 1,153 spine surgery inpatients operated between October 2005 and September 2008 (index spine surgery) in regard to the number of previous spine surgeries and location of surgeries (cervical or lumbar) were retrospectively collected. Additionally, prospective follow-up over a period of 2-5 years was conducted.
Retrospectively, 365 (31.7%) patients were recurrent spine surgery patients while 788 (68.3%) were de novo spine surgery patients.Nearly half of those with previous spine surgery (51.5%) were on different regions of the spine. There were no significant differences in length of stay or hospital charges except in lumbar decompression and fusion (LDF) patients with multiple interventions on the same region of the spine. Significant differences (P<.05) in length of stay (5.4 days vs. 7.4 days) and hospital charges ($55,477 vs. $74,878) between LDF patients with one previous spine versus those with ≥3 previous spine surgeries on the same region were noted.Prospectively, the overall reoperation rate was 10.4%. The risk of additional spine surgery increased from 8.0% in patients with one previous spine surgery (index surgery) to 25.6% in patients with ≥4 previous spine surgeries on different regions of the spine (including index surgery).After excluding patients with previous spine surgeries on different regions of the spine, 17.2% of reoperated patients had additional spine surgery on a different spine region. The percentage of additional spine surgery on a distant spine region increased from 14.0% in patients with one spine surgery to 33.0% in patients with two spine surgeries on the same region. However, in patients with three or more spine surgeries on the same spine region there were no interventions on a distant spine region during the follow-up period.
De novo spine surgery is associated with an increased incidence of additional spine surgery at the same or distant spine regions. Large prospective studies with extended follow-up periods and multifaceted cost-outcome analysis are needed to refine the appropriateness of spine surgery.
German medical science : GMS e-journal 01/2011; 9:Doc10.
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ABSTRACT: Postoperative fever is a common sequel of spine surgery. In the presence of rigid nationally mandated clinical guidelines, fever management may consume more health care resources than is reasonably appropriate.
To study the relationship between postoperative fever, infection rate, and hospital charges in a cohort of spine surgery patients.
We retrospectively reviewed 578 spine surgery patients (lumbar microdiskectomy [LMD], anterior cervical decompression and fusion [ACDF], and lumbar decompression and fusion [LDF]). Differences in length of stay and hospital charges as well as risk factors and correlation with infection and readmission rates were studied.
Postoperative fever occurred in 41.7% of all spine surgery patients and more often in LDF patients (77.2%). Type of surgery was the most important variable affecting the prevalence of postoperative fever. Significant differences in length of stay were elicited between patients with and without postoperative fever in the ACDF and LMD groups and in hospital cost in the LMD group. The average length of stay was 2.41 vs 4.47 (P < .01) in the LMD group, 1.67 vs 2.80 (P < .05) in the ACDF group, and 5.03 vs 5.65 (P > .05) in the LDF group. The average hospital charges were $16 261 vs $22 166 (P < .01) in the LMD group, $26 021 vs $29 125 (P > .05) in the ACDF group, and $53 627 vs $53 210 (P > .05) in the LDF group. Obesity, female sex, and ≥102°F postoperative temperature were the most significant predictors of infection. Delayed discharge referable to postoperative fever did not seem to influence the infection readmission rate.
Postoperative fever in spine surgery patients is associated with a delay in patient discharge and increases in hospital charges. Postoperative fever discharge guidelines should be regularly and publicly subjected to appropriate cost-benefit analysis.
Neurosurgery 01/2011; 68(4):945-9; discussion 949. · 2.79 Impact Factor
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ABSTRACT: In this paper, we report the case of a left round liga-ment fibroid in a 24 year-old, gravida 0, female that was successfully managed laparoscopically. Operative findings also included severe adnexal adhesions bila-terally, severe adhesions of the liver to the anterior abdominal wall (Fitz-Hugh-Curtis syndrome), pig-mented areas on the left tube, uterus and posterior broad ligament (that proved to be endometriosis), and low capacity bladder (450 cc at 70 cm water pre-ssure) with florid glomerulations and Hunner's ulcers consistent with typical interstitial cystitis. Beside the feasibility of laparoscopic management of intra-liga-mentous tumors this case highlights the common mul-tifactorial nature of chronic pelvic pain and the fre-quent association of endometriosis and interstitial cystitis.
Open Journal of Obstetrics and Gynecology. 01/2011; 1:136-138.
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ABSTRACT: Outpatient spine surgery is becoming popular because of its substantial economic advantages. We retrospectively studied 97 spine surgery outpatients and 578 inpatients who had proceeded through a common process of surgical venue selection. No differences (p > 0.05) were found in gender, race, obesity rate (46.9% versus [vs.] 42.9%), hypertension (9.7% vs. 8.8%), chronic obstructive pulmonary disease (11.8% vs. 13.5%), and history of stroke (1.9% vs. 2.5%). However, age was statistically different between inpatients (55 years) and outpatients (49 years) (p < 0.001). The prevalence of diabetes mellitus (19% vs. 10%), congestive heart disease (19.7% vs. 1.3%), coronary artery procedures (15.9% vs. 3.8%), and use of antidepressants (25.4% vs. 11.6%) was higher in the inpatient group (p < 0.05). There were more comorbidities in the inpatient cohort of each spine surgery type except for chronic obstructive pulmonary disease (COPD) and history of stroke in the outpatient cervical surgery group (p < 0.05). Among outpatients, only one patient (∼ 1%) had postoperative infection while among the inpatients, 16 patients had postoperative infections (2.8%) (p > 0.05). All seven patients readmitted due to infection were obese (body mass index ≥ 30). Obese patients in the inpatient cohort had higher chronic disease rates. Comorbidities are the main determinants of inpatient/outpatient selection. Postoperative infection was not a significant complication for appropriately selected patients for outpatient spine surgery. Despite increased hospital care and observation in the inpatient group, infection rates were not statistically different. Obesity seems to be a predictor of readmission with infection.
Journal of Clinical Neuroscience 12/2010; 17(12):1497-8. · 1.25 Impact Factor
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Archives of Gynecology 11/2010; · 0.91 Impact Factor
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ABSTRACT: To present the experience of a single provider with total laparoscopic hysterectomy (TLH) for benign gynecological pathology in order to promote awareness of the feasibility and merits of this minimally-invasive procedure.
An intention-to-treat prospective study was conducted in a suburban gynecological practice in Central Georgia, USA. The study data were collected over a 7-year period.
From March 2003 to December 2009, 623 total laparoscopic hysterectomies including 379 pure laparoscopic hysterectomies (without additional procedures) were performed and 12 patients were referred to a gyn-oncologist. The majority of our patients (93.6%) had a uterine weight of less than 500 g. The median operative time was 60 minutes for pure total laparoscopic hysterectomies. There were 14 intraoperative organ injuries of which 13 were repaired intraoperatively and no returns to the operation room within the first 24 hours. The average hospital charges for TLH were US $13,468 with an average length of stay of 1 day. The average charges for total abdominal hysterectomy were US $12514 with an average length of stay of 2.3 days.
An advanced laparoscopist can replace the majority of inpatient total abdominal hysterectomies performed for benign indications with outpatient total laparoscopic hysterectomy.
International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics 10/2010; 111(1):57-61. · 1.41 Impact Factor
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ABSTRACT: Chronic obstructive pulmonary disease (COPD) and obesity may be more common among spine surgery patients than in the general population and may affect hospital cost.
We retrospectively studied the prevalence of COPD and obesity among 605 randomly selected spine surgery inpatients operated between 2005 and 2008, including lumbar microdiskectomy, anterior cervical decompression and fusion and lumbar decompression and fusion patients. The length of hospital stay and hospital charges for patients with and without COPD and obesity (body mass index [BMI]≥30 kg/m(2)) were compared.
Among 605 spine surgery patients, 9.6% had a history of COPD. There were no statistical difference in the prevalence of COPD between the three spine surgery groups. Obesity was common, with 47.4% of the patients having a BMI≥30 kg/m(2). There were no significant differences in obesity rates or BMI values between the three types of spine surgery patients. Obesity rates between patients with and without COPD were 62.1% vs. 45.9%, and were statistically different (P<0.05). Similarly, significant difference (P<0.01) in BMI values between COPD and non-COPD groups, 32.66±7.19 vs. 29.57±6.048 (mean ± std. deviation), was noted. There was significant difference (P<0.01) in cost between nonobese female patients without COPD and those with obesity and COPD in the anterior cervical decompression and fusion (ACDF) group. No association with increased hospital length of stay or cost was found in the other two types of spine surgery or in male ACDF patients.
COPD and obesity seem to additively increase the length of hospital stay and hospital charges in ACDF female patients, an important finding that requires further investigation.
Indian Journal of Orthopaedics 10/2010; 44(4):424-7. · 0.50 Impact Factor
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ABSTRACT: Previous research has suggested that increases in length of stay and hospital cost in patients undergoing spine surgery can be due to comorbidities, especially diabetes mellitus. To study how endocrine comorbidities impact spine surgery cost, we conducted the further analysis.
We reviewed the charts of 787 patients operated between 2005 and 2008 and their treatment cost. Patients underwent one of three of the most common types of spine surgery: lumbar microdiskectomy (N = 237), anterior cervical decompression and fusion (N = 339), and lumbar decompression and fusion (N = 211). Patients were 14 to 92 years of age (mean 54.5 years), nearly equally divided by gender and mostly white. Demographics, body mass index, and comorbidities were studied versus length of stay and hospital charges. Data were analyzed using the Mann-Whitney and Pearson χ(2) tests with the help of the SPSS v16 software.
Among the 653 patients who had their glycosylated hemoglobin (HbA1c) level measured, 32.5% had an HbA1c level ≥6.1% and 4.3% had high HbA1c level and hypothyroidism. These two comorbidities increased with age. Cost analysis showed that in the lumbar decompression and fusion group, length of stay and hospital cost significantly increased with these comorbidities. Without HbA1c elevation or hypothyroidism, the average length of stay for lumbar decompression and fusion patients was 5 days. This increased to 6 days with hypothyroidism. With both comorbidities the average length of stay increased to 8 days (P < .01). Regarding hospital cost, without these comorbidities the average was approximately $52,449. With elevated HbA1c the cost increased to $56,176 and with hypothyroidism to $63,278 (P < .01 and P < .05, respectively). When both comorbidities were present the average hospital cost was $71,352. It was also noted that 89.7% of the patients with hypothyroidism were women. Cost and length of stay increased with age in the female lumbar decompression and fusion group. In addition, there was a surge in length of stay and cost in the ≥70-year-old female group with hypothyroidism undergoing anterior cervical decompression and fusion.
HbA1c elevation and hypothyroidism have an additive effect on hospital cost in lumbar decompression and fusion female patients. The finding of a surge in hospital cost parameters in elderly female hypothyroid patients undergoing surgery on their cervical spine needs more investigation.
World Neurosurgery 05/2010; 73(5):578-81. · 0.68 Impact Factor
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Southern medical journal 04/2010; 103(5):489-90. · 0.92 Impact Factor
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ABSTRACT: Laparoscopic skills are indispensable to the practice of present-day gynecologists. Hence, we investigated the share of minimal invasive surgery in the training of obstetricians and gynecologists.
Information on resident experience from 197 obstetrics and gynecology (OBGYN) residency programs was obtained from the Association of Professors of Gynecology and Obstetrics.
Over a period of 4 years, an OBGYN resident performs--as surgeon or assistant--on average 190 abdominal procedures including 111 abdominal hysterectomies as well as 53 vaginal hysterectomies and 95 operative laparoscopic procedures with or without hysterectomy. The average laparoscopy-tolaparotomy quotient (LPQ) is 0.54, and the average vaginal-to-abdominal hysterectomy quotient (VAQ) is 0.50.
More attention to minimal invasive surgery is needed in OBGYN residency programs.
Archives of Gynecology 04/2010; 283(5):1027-31. · 0.91 Impact Factor
