Medical School-affiliated Hospital Research Articles

Adult endocrinologists' perspectives on transitioning adolescent patients with congenital adrenal hyperplasia.

The study aimed to evaluate adult endocrinologists' perspectives on caring for patients with congenital adrenal hyperplasia (CAH) and views on their transition from pediatric to adult care. An online survey was conducted among adult clinical endocrinologists at Harvard Medical School-affiliated hospitals from March to October 2022. Most participants (25/34, 73.5 %) treat patients with CAH and expressed moderate to high confidence (23/32, 71.9 %) in their care. Those that did not treat or accept referrals cited insufficient expertise, knowledge, and resources as reasons. Only half of respondents correctly answered at least 50 % ofstandard of care questions. The main transition of care barrieridentified was the absence of standardized policies (12/34, 35.3 %). Participants, though involved in care of patients with CAH, had varied responses to standard of care questions and transition of care barriers, emphasizing the need for standardized transition protocols and additional training to ensure up-to-date clinical knowledge.

Consent Policies for Pelvic Exams Under Anesthesia Performed by Medical Students: A National Assessment.

Background: Medical students report low confidence in their ability to perform pelvic exams. Pelvic exams under anesthesia (EUA) are one way for students to practice the exam, but this needs to be balanced with patients' bodily autonomy through explicit disclosure and consent. This study seeks to characterize U.S. medical schools' policies regarding the consent process for students to perform pelvic EUA. Materials and Methods: Obstetrics and gynecology clerkship directors were anonymously surveyed about their medical school affiliated hospitals' (MSAH) consent policies for pelvic EUA in general and explicitly for medical students. Chi-square and Fisher's exact test were used to test for differences between categorical variables and thematic analysis was used to review qualitative responses. Results: A total of 87 clerkship directors completed the survey (44.4% response rate). Most MSAH explicitly consent patients for pelvic EUA (80.2%), and specifically for performance by medical students (79.1%). Sixty-nine respondents (79.3%) stated that performing pelvic EUA is important for medical student education. Five themes were identified from review of qualitative responses, including consent policy details, the importance of pelvic EUA, other opportunities for pelvic exam teaching, barriers to standardization, and outside guidance. Conclusions: The pelvic EUA is a necessary part of both surgical care and medical education but patient dignity must be protected too. Most MSAH have consent policies for students to perform pelvic EUA. Still, these policies need to be further strengthened and standardized across institutions to protect patients' rights while continuing to teach students the pelvic exam.

MP75-07 ACCESS TO UROLOGIC CANCER CARE FOR MEDICAID-INSURED PATIENTS

You have accessJournal of UrologyCME1 Apr 2023MP75-07 ACCESS TO UROLOGIC CANCER CARE FOR MEDICAID-INSURED PATIENTS Folawiyo Laditi, James Nie, Walter Hsiang, Waez Umar, Afash Haleem, Victoria Marks, Mathew Buck, and Michael Leapman Folawiyo LaditiFolawiyo Laditi More articles by this author , James NieJames Nie More articles by this author , Walter HsiangWalter Hsiang More articles by this author , Waez UmarWaez Umar More articles by this author , Afash HaleemAfash Haleem More articles by this author , Victoria MarksVictoria Marks More articles by this author , Mathew BuckMathew Buck More articles by this author , and Michael LeapmanMichael Leapman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003349.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: While the Affordable Care Act has led to increased insurance rates amongst patients seeking urologic oncology care, most estimates on the improvement in oncologic outcomes have been conducted through hospital-based registries. These registries may not account for biases and variations in Medicaid acceptance amongst facilities. Empirical, patient-based estimates are needed to better understand barriers in access for Medicaid-practices for urologic malignancies. METHODS: Using a secret shopper approach, we contacted a representative sample of 389 Commission-on-Cancer accredited hospitals across the United States. Trained volunteers posed as a family member seeking urologic cancer care for their father with a simulated newly diagnosed renal mass. Facility-level characteristics were accessed from several publicly available databases. The primary outcome was to estimate Medicaid acceptance for urologic cancer care nationally. The secondary outcomes were to determine facility characteristics linked that increased or decreased the likelihood of Medicaid acceptance. RESULTS: 14.4% of Commission-on-Cancer urologic facilities did not accept new Medicaid patients. Importantly, acceptance was positively linked with state Medicaid expansion status (90.1% for expansion states vs non-expansion states 22.6% p<0.001), and higher state Medicaid-to-Medicare Fee indices (average of 0.700 for accepting facilities vs 0.649 for non-accepting facilities). Major teaching hospitals (93.8%) were more likely to accept Medicaid than non-major teaching hospitals (83.4%, p=0.018). Medical school affiliated hospitals were also more likely to accept Medicaid (89.2% acceptance for medical school affiliated hospitals vs 79.7% for non-medical school affiliated facilities, p=0.01). All other queried facility-level characteristics did not reach statistical significance. CONCLUSIONS: Using a secret shopper approach, we estimated Medicaid acceptance for urologic cancer care in a nationally representative sample of accredited cancer facilities from the patient perspective. We show that factors such as state Medicaid expansion status, Medicaid reimbursement, and teaching status were strongly associated with Medicaid Acceptance. Source of Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1081 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Folawiyo Laditi More articles by this author James Nie More articles by this author Walter Hsiang More articles by this author Waez Umar More articles by this author Afash Haleem More articles by this author Victoria Marks More articles by this author Mathew Buck More articles by this author Michael Leapman More articles by this author Expand All Advertisement PDF downloadLoading ...

A Gap in Mission: The Disparate Missions of Medical Schools and Teaching Hospitals

Objective The social contract mandates that in return for the government-funded labor of residents and fellows, the medical profession trains, to the best of its ability, the physicians of our future. This contract obligates graduate medical education (GME) to utilize all available information to create an optimal learning environment for its trainees. Business research has determined that a clearly defined mission statement is associated with improved employee engagement, retention, and wellness. Given that GME trainees are situated at the intersection of at least two institutions, each with its own separate mission, trainees could potentially be hindered by incongruent missions in the learning environment. The literature on mission statements has analyzed medical schools and hospitals separately; however, investigations comparing the statements of these affiliated institutions have not been conducted. Therefore, we plan to compare the content and assess the consistency of mission statements from affiliated medical schools and hospitals to determine if incongruencies exist. Methods In 2023, the mission statements from the Association of American Medical Colleges (AAMC) medical schools and affiliated teaching hospitals (n = 163) were aggregated from their public websites. The content of each mission statement was thematically analyzed to assess variation. Results According to content analysis of the mission statements from 163 AAMC medical school members and affiliated teaching hospitals, less than half of their top priorities are shared by their affiliated hospitals (45%). Additionally, themes of diversity, religion, and global care were found to be contrasting priorities between affiliated institutions. Conclusion Given the precedence within the business and the observed discrepancies in mission, further research is needed to determine whether collaborating medical schools and hospitals could provide a more favorable graduate training environment by uniting their priorities and identifying shared goals.

Hand-foot-mouth disease and use of steroids, intravenous immunoglobulin, and traditional Chinese herbs in a tertiary hospital in Shantou, China

BackgroundIn contrast to the guidelines of World Health Organization (WHO) and United States-Centers for Disease Control and prevention (US-CDC), the Chinese national guidelines recommend the use of steroids, intravenous immunoglobulin (IVIG), or traditional Chinese herbs (TCHs) in hand-foot-mouth disease (HFMD) management. Their use and therapeutic efficacies are, however, unclear. We aimed to describe their use in and the clinical outcomes of hospitalized HFMD cases.MethodsA retrospective review of hospital medical records for HFMD cases during 2008–2016 was conducted in a medical school-affiliated tertiary hospital in Shantou, Guangdong, China.ResultsHospitalized children with the discharge diagnosis of HFMD (n = 3778), comprising mild (58.4%), severe (41.5%), and very severe (0.1%) cases, were enrolled in the study. Steroids, IVIG, and antiviral TCH Lan-Qin were respectively prescribed in 60.5, 37.1, and 71.0% of cases. Most cases (99.8%) recovered and six died. Recovery rate was lower with the use of IVIG and higher with Lan-Qin (alone or in combination with steroid) in the mild cases (Ps < 0.05). Longer hospital stay was observed with steroid/IVIG with or without Lan-Qin in the severe cases (Ps < 0.05).ConclusionsThis nine-year retrospective review shows 1) an increase in the incidence of HFMD as well as the use of steroids, IVIG, and TCH over time, 2) no significant advantage of using steroids and IVIG, either alone or in combination, in the management of mild HFMD cases, and 3) a higher recovery rate in mild HFMD cases with the use of antiviral TCH (Lan-Qin). Our findings need verification in a larger prospect study with cases from hospitals in other regions of China. Lan-Qin efficacy should be evaluated in randomized trials. Meanwhile, caution should be exercised in the extensive use of steroids and IVIG in HFMD management.

Assessment of orientation practices for ethics consultation at Harvard Medical School-affiliated hospitals

BackgroundFew studies have been conducted to assess the quality of orientation practices for ethics advisory committees that conduct ethics consultation. This survey study focused on several Harvard teaching hospitals, exploring...

Radiologic Knowledge and Ordering Habits of Clinical Residents: ACR Appropriateness Criteria Awareness and Perceptions

anefforttoinformorderingphysicians on various imaging studies and their indications according to the ACR Appropriateness Criteria, we developed a short presentation that highlights some of the most commonly used studies. We also used a questionnairetodetermine the importance of imaging studies in these residents’ practice of medicine, their levels of comfort with ordering these studies, their perceptions of the amount of education they receive in radiology during their training, and their perceived need for more education to help them adequately select radiologic studies for their patients. WHAT WAS DONE A radiology resident at a large, urban, medical school-affiliated hospital devised a 45-min educational session preceded and followed by a short questionnaire (see Additional Resources) to assess participants’ knowledge of imaging tests and their indications to test the effectiveness of the intervention. The course was presented to 83 residents in the departments of internal medicine, family medicine, psychiatry, and emergency medicine. Figure 1 shows residents’ postgraduate years. The pretest consisted of three sections. The first part addressed the participants’ awareness of the ACR Appropriateness Criteria and their usefulness in clinical practice. The second part of the pretest assessed clinicians’ knowledge of basic radiology, including correct indications and contraindications of select imaging studies and contrast agent selection. The final portion of the pretest addressed participants’ opinions about the importance of radiology in their clinical practice, their comfort levels when ordering imaging studies, their perceptions of the amount of education they receive during their training, and their thoughts on integrating more radiology education. The posttest was administered afterthesessionandaskedparticipantsif they were now more likely to consult

Risk Adjustment for Determining Surgical Site Infection in Colon Surgery: Are All Models Created Equal?

Colon surgical site infections (SSIs) are being utilized increasingly as a quality measure for hospital reimbursement and public reporting. The Centers for Medicare and Medicaid Services (CMS) now require reporting of colon SSI, which is entered through the U.S. Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN). However, the CMS's model for determining expected SSIs uses different risk adjustment variables than does NHSN. We hypothesize that CMS's colon SSI model will predict lower expected infection rates than will NHSN. Colon SSI data were reported prospectively to NHSN from 2012-2014 for the six Fairview Hospitals (1,789 colon procedures). We compared expected quarterly SSIs and standardized infection ratios (SIRs) generated by CMS's risk-adjustment model (age and American Society of Anesthesiologist [ASA] classification) vs. NHSN's (age, ASA classification, procedure duration, endoscope [including laparoscope] use, medical school affiliation, hospital bed number, and incision class). The patients with more complex colon SSIs were more likely to be male (60% vs. 44%; p = 0.011), to have contaminated/dirty incisions (21% vs. 10%; p = 0.005), and to have longer operations (235 min vs. 156 min; p < 0.001) and were more likely to be at a medical school-affiliated hospital (53% vs. 40%; p = 0.032). For Fairview Hospitals combined, CMS calculated a lower number of expected quarterly SSIs than did the NHSN (4.58 vs. 5.09 SSIs/quarter; p = 0.002). This difference persisted in a university hospital (727 procedures; 2.08 vs. 2.33; p = 0.002) and a smaller, community-based hospital (565 procedures; 1.31 vs. 1.42; p = 0.002). There were two quarters in which CMS identified Fairview's SIR as an outlier for complex colon SSIs (p = 0.05 and 0.04), whereas NHSN did not (p = 0.06 and 0.06). The CMS's current risk-adjustment model using age and ASA classification predicts lower rates of expected colon SSIs than does NHSN. This may lead to financial penalties because of the use of limited risk factors. Further efforts at elucidating appropriate risk adjustment measures without unnecessarily burdening hospitals with expensive data collection are necessary.

Creating a Fellowship Curriculum in Patient Safety and Quality.

The authors sought to create a curriculum suitable for a newly created clinical fellowship curriculum across Harvard Medical School-affiliated teaching hospitals as part of a newly created 2-year quality and safety fellowship program described in the companion article "Design and Implementation of the Harvard Fellowship in Patient Safety and Quality." The aim of the curriculum development process was to define, coordinate, design, and implement a set of essential skills for future physician-scholars of any specialty to lead operational quality and patient safety efforts. The process of curriculum development and the ultimate content are described in this article.

Quality of Breast Cancer Care in the U.S.: A National Analysis of Medicare Beneficiaries, 2003-2007

Quality of Breast Cancer Care in the U.S.: A National Analysis of Medicare Beneficiaries, 2003-2007

Differential receipt of sentinel lymph node biopsy within practice-based research networks.

Practice-based research networks (PBRNs) are promising for accelerating not only research, but also dissemination of research-based evidence into broader community practice. Sentinel lymph node biopsy (SLNB) is an innovation in breast cancer care associated with equivalent survival and lower morbidity, as compared with standard axillary lymph node dissection. We examined the diffusion of SLNB into practice and whether affiliation with the Community Clinical Oncology Program (CCOP), a cancer-focused PBRN, was associated with more rapid uptake of SLNB. Surveillance Epidemiology and End Results-Medicare data were used to study women diagnosed with stage I or II breast cancer in the years 2000-2005 and undergoing breast-conserving surgery with axillary staging (n=6226). The primary outcome was undergoing SLNB. CCOP affiliation of the surgical physician was ascertained from NCI records. Multivariable generalized linear modeling with generalized estimating equations was used to measure association between CCOP exposure and undergoing SLNB, controlling for potential confounders. Women treated by a CCOP physician had significantly higher odds of receiving SLNB compared with women treated by a non-CCOP physician (OR 2.68; 95% CI, 1.35-5.34). The magnitude of this association was larger than that observed among patients treated by physicians operating in medical school-affiliated hospitals (OR 1.76; 95% CI, 1.30-2.39). Women treated by CCOP-affiliated physicians were more likely to undergo SLNB irrespective of the hospital's medical school affiliation, suggesting that the CCOP PBRN may play a role in the rapid adoption of research-based innovation in community practice.

공간분석기법을 이용한 경쟁병원이 병원내원 환자 수에 미치는 영향 분석

Abstract This study purposed to evaluate the influences of rival hospita ls on the number of patients who visited the a study territory hospital. Spatial analysis technique was used to measure the impact of rival hospitals in study region. Selected hospitals were all medical school affiliated hospitals which were located in Daejeon metropolitan city and Chungchungnamdo. Patient data was collected from the claims dat a of the study hospital, and the number of inpatient and outpatients who visited the study hospital between January and June in 2008 were calculated on the smallest admin-istrative district, Eup, Myeon, and Dong, in study region. To c ontrol the differences of regional characteristics among Eup, Myeon, Dong, socio-economic variables (total population, n umber of people aged over 65, number of basic live-lihood security recipients, distance from the study hospital to the centroid point of each Eup, Myeon, Dong, number of business, and number of employees) were included in analysis model. These variables were collected from the annual year book of city as well as county located in study region. Cluster analysis classified the study region into three groups by using the difference of between th actual number of inpatient/outpatient and the predicted number of inpatient/o utpatient in Eup, Myeon, and Dong. Most areas around the rivalry hospitals were categorized into same group. Multipl e regression analysis indicated that areas around rivalry hospitals had statistically significantly negative relationship with the number of inpatients and outpatients who visited the study hospital. As the buffer size was increased from 5Km t o 10Km, the standardized regression coefficients were decreased. These study results confirmed that rivalry hospitals in region had negative impacts on the performance of hospitals. It suggests that hospitals will require not only to select their location to minimize the effects of rivalry hospitals, but also to establish their strategy to cope with the rivalry’s threats in their region.

The curative effect of 61 patients with procedure for prolapse and hemorrhoids

Objective To evaluate the curative effect of procedure for prolapse and hemorrhoids.Methods To retrospectively anabpe the clinical data of 61 patients with procedure for prolapse and hemorrhoids of Inner Mongolia medical school affiliated hospitals form 2002 to 2009.Results The average time of operation was 20～30 minutes.After operation,2 cases appeared urine retention,2 cases appeared bleeding and 1 case appeared prolapse lightly.The average time of being hospitalized was 5 days.The curative effect of allpatients was well after 1～6 years follow-up.Conclusion It was a safe and effective method to use procedure for prolapse and hemorrhoids,but the longterm curative effect of it still need further observation. Key words: Hemorrhoids; Procedure for prolapse and hemorrhoids

Sustainability and performance of the National Cancer Institute's Community Clinical Oncology Program

Introduction The National Cancer Institute's (NCI) Community Clinical Oncology Program (CCOP) contributes one third of NCI treatment trial enrollment (“accrual”) and most cancer prevention and control (CP/C) trial enrollment. Prior research indicated that the local clinical environment influenced CCOP accrual performance during the 1990s. As the NCI seeks to improve the operations of the clinical trials system following critical reports by the Institute of Medicine and the NCI Operational Efficiency Working Group, the current relevance of the local environmental context on accrual performance is unknown. Materials and methods This longitudinal quasi-experimental study used panel data on 45 CCOPs nationally for years 2000–2007. Multivariable models examine organizational, research network, and environmental factors associated with accrual to treatment trials, CP/C trials, and trials overall. Results For total trial accrual and treatment trial accrual, the number of active CCOP physicians and the number of trials were associated with CCOP performance. Factors differ for CP/C trials. CCOPs in areas with fewer medical school-affiliated hospitals had greater treatment trial accrual. Conclusions Findings suggest a shift in the relevance of the clinical environment since the 1990s, as well as changes in CCOP structure associated with accrual performance. Rather than a limited number of physicians being responsible for the preponderance of trial accrual, there is a trend toward accrual among a larger number of physicians each accruing relatively fewer patients to trial. Understanding this dynamic in the context of CCOP efficiency may inform and strengthen CCOP organization and physician practice.

Isolation of mitotically-active germ cells from adult human ovaries: in-vitro propagation and generation of immature oocytes

To determine if adult human ovaries contain germline or oogonial stem cells (OSCs). Experimental study in a medical school-affiliated hospital using an IRB-approved protocol. Ovarian cortex was obtained from 6 patients (28.5 ± 4.0y) undergoing sex reassignment surgery, and processed using an adapted protocol validated for purification of mouse OSCs, based on immunological detection of cell-surface expression of VASA (Nat Cell Biol 2009 11:631). VASA-positive cells were collected by FACS for in-vitro culture, and gene expression analysis using RT-PCR and immunocytochemistry. VASA-positive cells 5-8 μm in diameter were isolated from ovaries of all 6 patients (1.7% ± 0.6% yield per sample). Freshly-isolated cells express primitive germline markers (Stella/DPPA3, Blimp1/PRDM1, Tert, c-Kit/CD117). Using mouse OSC propagation conditions, human cells were established successfully in culture, forming defined VASA-positive germ cell colonies. Cells positive for VASA and bromodeoxyuridine incorporation indicate that human VASA-positive cells actively proliferate in vitro. Gene expression analysis confirmed maintenance of early germline markers in cultured human cells. In culture, cells initiated spontaneous generation of large (35-50 μm) round cells resembling immature oocytes that expressed markers (c-KIT, VASA, LHX8) expressed in human immature oocytes in vivo. A rare population of mitotically-active VASA-positive cells with a gene expression profile, growth characteristics and in-vitro oogenic potential entirely consistent with mouse OSCs can be reliably isolated from ovaries of healthy young women and propagated in vitro. Taken with studies of OSCs in mice (Nature 2004 428:145; Nat Cell Biol 2009 11:631; Differentiation 2010 79:159), we feel it is reasonable to conclude that these cells represent adult human OSCs. The isolation of human OSCs sets the foundation for potential management of the ovarian reserve and fertility through regenerative medicine.

Study of coping style and the economic burden of disease in the patients of cerebral ischemic stroke

Objective To explore coping style and the economic burden of disease in the patients of cerebral ischemic stroke and to find new psychological nursing measures. Methods Questionnaire and homemade scale was used, 233 cases with cerebral ischemic stroke in Xuzhou Medical School Affiliated Hospital neurology department were collected and were divided into four groups( social insurance group, own expense group, residence health insurance group, and new cooperative medical service insurance group). Data were classified and analyzed by SPSS 16.0 software. Results Face factors, avoid factors, yield factors and total score in the coping style were significantly different in the four groups ( F = 32. 11,9. 23,22. 12,5. 82 ; P 0. 05 ). Conclusions Social insurance system as a society' s important support affects coping style in the patients of cerebral ischemic stroke. Key words: Cerebral ischemic stroke; Coping style; Financial burden of disease

Clifton Joseph Latiolais (1926–1995): Enthusiasm for excellence

Past residents and colleagues gathered for a memorial service during the 1995 annual meeting of the American Society of Hospital (now Health-System) Pharmacists (ASHP) to honor past president Clifton Joseph Latiolais. A consistent theme ran through the memorials: innovator, leader, visionary, teacher, and preceptor. Especially noted was his philosophy of enthusiasm for excellence, of doing the very best at all times, not just sometimes. A student of Don Francke, Latiolais was clearly his own man with a vision of what pharmacy was about, not just hospital pharmacy but all pharmacy. He engaged a generation of residents and students to develop their own talents to the fullest so that the profession would meet its full potential.1 A 1979 survey of pharmacy directors of medical school–affiliated hospitals identified Clifton Latiolais as “the pharmacist most responsible for their success.”2

One-Year Outcome of Concurrent Anterior and Posterior Transvaginal Mesh Surgery for Treatment of Advanced Urogenital Prolapse: Case Series

Study Objective To estimate the safety and efficacy of performing concurrent anterior and posterior transvaginal mesh surgery using a commercially available kit (Gynecare PROLIFT Pelvic Floor Repair System; Ethicon, Inc., Somerville, NJ) for treatment of advanced urogenital prolapse (stage III or higher, Pelvic Organ Prolapse Quantification [POP-Q] system staging). Design Case control series study (Canadian Task Force classification II-2). Setting Medical school–affiliated hospital. Patients Forty-three patients with severe prolapse, POP-Q stage III (n = 23) or IV (n = 20), underwent surgery and were followed up for more than 1 year. In patients with any prolapse greater than stage I, surgery were considered to have functional failure. The Surgical Satisfaction Questionnaire was used for subjective evaluation at 1 year postoperatively. Interventions Extensive pelvic reconstructive procedures were primarily performed using a combination of the PROLIFT anterior and posterior pelvic systems (i.e., similar to sparing the intermediate section of the PROLIFT total pelvic system). The concurrent pelvic surgery included sequential vaginal total hysterectomy, perineorrhaphy, and suburethra sling, if indicated. Additional subjective and objective evaluations included POP-Q staging, urodynamic assessment, and preoperative and 12-month postoperative questionnaires. Measurements and Main Results Objective and subjective data were available for 42 patients. The subjective cure rate and objective success rate for prolapse at 12-month follow-up was 95.2% and 97.6%, respectively. Mean follow-up was 15.7 months, operation time was 79.2 minutes, operative blood loss was 109.1 mL, and postoperative hospital stay was 4.1 days. Intraoperative and postoperative complications were minor. All patients voided spontaneously before discharge. One mesh extrusion, no wound defective healing, and no rejection were observed. Two patients developed asymptomatic recurrent rectocele (stage II, POP-Q staging) that required no surgical intervention. Urodynamic parameters related to voiding dysfunction improved after surgery. Significant improvements were found using the Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Conclusion Using concurrent anterior and posterior transvaginal mesh for pelvic reconstructive surgery is a safe and an effective method for treating advanced pelvic prolapse. Mesh-related complications are likely minimal, and mesh protrusion at the apex is likely to not occur. Further studies with longer follow-up are required to evaluate long-term effectiveness.

Combined Pelvic Reconstructive Surgery and Transobturator Tape (Monarc) in Women with Advanced Prolapse and Urodynamic Stress Incontinence: A Case Control Series

Study Objective The aim was to evaluate the safety and efficacy of transobturator tape (TOT) using Monarc with extensive vaginal reconstructive surgery in patients with urodynamic stress incontinence (USI) and advanced genital prolapse (stage ≥ III pelvic organ prolapse quantification system staging). Design Case control study. Canadian Task Force classification II-2. Setting Medical school-affiliated hospital. Patients A total of 57 women were surgically treated (28 stage III and 29 stage IV prolapse). Urodynamic stress incontinence was defined as demonstrable involuntary urine leakage with negative pressure transmission observed at stress urethral pressure profile. Severe USI was defined as leak on 1-hour pad test of more than 10 g. Interventions The indicated extensive pelvic reconstructive procedures including anterior colporrhaphies, posterior colporrhaphies, vaginal total hysterectomies, sacrospinous ligament fixations, and LeFort procedures were completed before the TOT procedure. The TOT procedure using Monarc device was performed through a separate small vaginal incision sparing vaginal reconstructive procedures. Measurements and Main Results The mean follow-up period was 18.2 months. Objective data were available for 51 patients. In all, 44 (86.3%) were completely dry at 1 year postoperatively. Among the 7 failures, 5 had severe preoperative USI. No major surgical complications, including bladder injury, occurred. The mean blood loss was 154 mL; the mean operating time for complete procedure and TOT alone was 86 minutes and 18 minutes, respectively; and the mean postoperative hospital stay was 4.1 days. Six (10.5%) patients maintained intermittent catheterization for more than 72 hours. All were classified as having severe bladder outlet obstruction preoperatively. Two patients developed recurrent prolapse onto stage II (pelvic organ prolapse quantification system staging). Urodynamic parameters related to voiding dysfunction showed an improvement after the surgery. De nova detrusor instability was observed in 2 patients. Conclusion Using separate incisions and sequencing the TOT as the last procedure, the combination surgery is safe and effective for USI and advanced pelvic prolapse. The bladder outlet obstructions caused by severe prolapse and preoperative severity of urinary incontinence seem to be a risk factor for prolonged postoperative catheterization and failure of antiincontinent procedure, respectively. Additional information on treatment of recurrent prolapse required a longer period of follow-up.

Variability in Access to Hospital Palliative Care in the United States

Hospital palliative care programs provide high-quality, comprehensive care for seriously ill patients and their families. To examine geographic variation in patient and medical trainee access to hospital palliative care and to examine predictors of these programs. Primary and secondary analyses of national survey and census data. Hospital data including hospital palliative care programs were obtained from the American Hospital Association (AHA) Annual Survey Databasetrade mark for fiscal year 2006 supplemented by mailed surveys. Medical school-affiliated hospitals were obtained from the American Association of Medical Colleges, Web-site review, and telephone survey. Health care utilization data were obtained from the Dartmouth Atlas of Health Care 2008. Multivariate logistic regression was used to identify characteristics significantly associated with the presence of hospital palliative care. A total of 52.8% of hospitals with 50 or more total facility beds reported hospital palliative care with considerable variation by state; 40.9% (144/352) of public hospitals, 20.3% (84/413) of for-profit hospitals, and 28.8% (160/554) of Medicare sole community providers reported hospital palliative care. A total of 84.5% of medical schools were associated with at least one hospital palliative care program. Factors significantly associated (p < 0.05) with hospital palliative care included geographic location, owning a hospice program, having an American College of Surgery approved cancer program, percent of persons in the county with a university education, and medical school affiliation. For-profit and public hospitals were significantly less likely to have hospital palliative care when compared with nonprofit institutions. States with higher hospital palliative care penetration rates were observed to have fewer Medicare hospital deaths, fewer intensive care unit/cardiac care unit (ICU/CCU) days and admissions during the last 6 months of life, fewer ICU/CCU admission during terminal hospitalizations, and lower overall Medicare spending/enrollee. This study represents the most recent estimate to date of the prevalence of hospital palliative care in the United States. There is wide geographic variation in access to palliative care services although factors predicting hospital palliative care have not changed since 2005. Overall, medical students have high rates of access to hospital palliative care although complete penetration into academic settings has not occurred. The association between hospital palliative care penetration and lower Medicare costs is intriguing and deserving of further study.