Laceration Repair Research Articles

Structured Workshop for Repair of High-Grade Perineal Lacerations Among Obstetrics and Gynecology Residents, The Need for Repetition and Retraining.

The objective of this study was to evaluate the effectiveness of structured workshops in improving the knowledge and skills of obstetrics and gynecology residents for repairing high-grade perineal lacerations. This quasi-experimental multicenter study evaluated the baseline knowledge of obstetrics and gynecology residents using an online patient-management problem (PMP) tool. After the initial evaluation, a workshop was conducted using sponge models to teach the practical technique for repairing high-grade perineal lacerations, including external and internal anal sphincter repair. The residents' knowledge was reassessed by PMP exams at 3 and 6months after the workshop, and the scores were compared to the baseline statistics. Eighty residents participated in the study, including 26, 22, and 32 at the first, second, and third-year levels of residency, respectively. The total PMP scores significantly improved after three months of the workshop, with an increasing total score from 15.5 (baseline) to 31.3 (p = 0.027) (range of total score from - 63 to + 52). The senior residents performed better before and after three months of the intervention. However, in the six-month follow-up, the total PMP score of all residents decreased to 12.3 with no significant difference with pre-education scores at all levels. Similar significant results were also reported for each PMP question at all levels of residency. The study found that obstetrics and gynecology residents had substandard knowledge in repairing perineal lacerations. Although the training workshop significantly increased residents' knowledge, its effectiveness diminished over time, indicating a need for continuous or periodic training. The online version contains supplementary material available at 10.1007/s13224-023-01792-6.

Monocanalicular versus bicanalicular annular intubation for treatment of lacrimal canalicular laceration

Purpose The aim of this study was to compare the safety and efficacy of monocanalicular and bicanalicular annular intubation for treatment of lacrimal canalicular laceration. Patients and methods This is a retrospective review of the medical records of 52 patients for whom primary repair of lacrimal canalicular laceration was done. The patients were allocated into two groups. Group I included 26 patients who underwent primary repair with monocanalicular intubation while group II included 26 patients who underwent primary repair with bicanalicular annular intubation. Three months after removal of the stent, negative fluorescein dye disappearance test and patency of the canaliculus on lacrimal irrigation were defined as anatomical success, while functional success was defined as absence of epiphora. Complications like stent prolapse, granuloma formation, and medial canthal deformity were recorded. Results Complete anatomical success was achieved in 18 (69.2%) patients in group I and in 21 (80.8%) patients in group II, with no statistically significant difference (P=0.594). Complete functional success was achieved in 20 (76.9%) patients in group I and in 22 (84.6%) patients in group II, with no statistically significant difference (P=0.683). In addition, there was no statistically significant difference between the two groups regarding the postoperative complications including punctum granuloma, punctum slitting, and medial canthal region deformities (P>0.05). Conclusion Both monocanalicular intubation and bicanalicular annular intubation were safe and effective for treatment of lacrimal canalicular laceration with no statistically significant difference regarding the anatomical and functional outcomes as well as postoperative complications.

Muscle Belly Repair: Biomechanical Assessment of the Anchor Suture and the Modified Kessler Techniques.

Background: Treatment of muscle belly lacerations remains a problem for surgeons. Inadequate repair of lacerations can cause functional disability. To date, there is no consensus on the method of repair for these injuries. We have previously described a technique of repairing mid-substance muscle belly lacerations. The aim of this study was to determine the ultimate strength of an intact muscle belly and to compare the anchor suture (AS) technique with the modified Kessler (MK) technique. Methods: Fifteen fresh frozen hind-legs from adolescent pigs were divided into three groups and used for the testing. Each group consisted of five specimens. Group one was the intact control group, group two was repaired with the MK technique and group three was repaired with the AS technique. Following repair, the muscles were secured in a custom-made fixation apparatus and underwent linear tensioning at a rate of 25 mm/min, generating a load-displacement curve for each specimen. The data regarding ultimate strength, modes of failure and number of intact suture/anchor constructs (for groups 2 and 3) was calculated. Results: The ultimate strength of the intact muscle group of was found to be 608.1 ± 107.9 N. This was significantly (p < 0.05) higher than the pull-out strength of the MK and AS groups. The pull-out strength of the AS group was 143.1 ± 36.7 N, nearly twice that of the MK group 69.8 ± 16.4 N (p = 0.11). Suture pull-out was the most common mode of failure. Conclusions: The AS technique was found to have both higher strain and nearly twice the ultimate pull-out strength compared to the MK repair group. We suggest the AS technique as a viable technique for mid-substance muscle belly repairs.

The Efficacy and Cost-Effectiveness of a Simulation-Based Primary Care Procedural Skills Training Program for Advanced Practice Providers.

The purpose of this program evaluation was to investigate the efficacy of simulation-based primary care procedural skills training to increase participant confidence, knowledge, and skill in performing the procedures included in the training and to evaluate the cost-effectiveness of the training. A retrospective, within-subjects analysis of the change in perceived confidence, skill, and knowledge in procedure performance after the simulation-based primary care procedural skills training program measured by pretraining and post-training Likert scale surveys and change in clinical procedure performance frequency for abscess incision and drainage and laceration repair up to 6 months before and 6 months after the training in the outpatient setting was performed. Participants self-reported higher median confidence, perceived skill, and perceived knowledge of all procedures included in the training course, with statistically significant increases for all procedures. A mean increase in laceration repairs in the clinical setting of 10% after training was found. Higher median performance of abscess incision and drainage after training (median = 20.00%, n = 25) compared with before training (median = 0.00%, n = 25) and a mean increase in performance of abscess incision and drainage in the clinical setting of 6% after training was found, but increases were not statistically significant. Participation in a 2-day simulation-based primary care procedural skills training program was an effective method to increase confidence, perceived skill, and knowledge of outpatient procedures among practicing providers. Further evaluation to establish return on investment is needed, because statistically significant increases in clinical procedure performance were unable to be demonstrated.

The Impact of Parental Presence on Invasive Procedures in the Pediatric Emergency Department: A Prospective Study.

Parental presence during invasive pediatric procedures is controversial, and its benefits are under-researched. The objective of this study was to assess the effects of parental presence during invasive procedures on the parents themselves and the physician performing the procedure. This prospective study was conducted at a single tertiary center in Jerusalem, Israel. During 10 shifts, all physicians and the families of patients who underwent invasive procedures in the pediatric emergency department (PED) were asked to fill in questionnaires related to their experiences. A total of 98 parental questionnaires and 101 physician questionnaires were collected. The most commonly performed procedures were laceration repair (65%) and abscess drainage (18%). Sedation was required in 75% of cases. In total, 73% of the cited family members were present during these procedures. The main reason for refusing to allow family members access was the physicians' concern that the procedure would be hard for parents to watch. However, in more than 85% of cases, the physicians felt that the presence of a family member contributed to the success of the procedure, augmented the child's sense of safety and lessened the family members' feelings of anxiety. All parents who opted to be present during the procedure felt very satisfied, compared to 67% of parents who were not present (p < 0.0001). When asked if, in retrospect, they would have made the same decision, 100% of the parents who were present during the procedure indicated that they would have made the same decision, compared to only 68% of the parents who were not present (p < 0.001). Overall, these findings highlight the positive effects of parental presence during invasive procedures performed in the PED, even when procedures were performed under sedation. Encouraging parental attendance during invasive procedures may, thus, enhance family-centered practices in the PED.

Prognostic factors for visual outcome after surgical repair of limbal corneal laceration at a tertiary eye care center in South India.

To determine the factors affecting the visual outcome after surgical repair of limbal corneal lacerations at a tertiary eye care center in South India. A retrospective analysis of patients diagnosed with limbal tears between 2011 and 2021 was conducted. Demographic information such as age, gender, cause of injury, and size of the laceration was recorded. Comprehensive ocular examination was performed, including gentle B scan evaluation whenever not contraindicated for detailed posterior segment evaluation. Only those cases with a minimum follow-up of one year were included. Postoperative best-corrected visual acuity, intraocular pressure (IOP), cornea clarity, and integrity of the wound at last follow-up were noted. Out of the 20 patients, 15 (75%) were males and 5 (25%) were females. The mean age was 42.6 ± 22.4 years. All 20 patients had a penetrating injury, with four (20%) injured by a stick, two (10%) by an iron rod, three (15%) due to road traffic accident (RTA), three (15%) by glass, and eight (40%) with other nonspecific objects [two (10%) with needle, two (10%) with elastic rope, two (10%) with bangle, and two (10%) with metal]. The average time between the injury and the surgery was 48 hours (2 days). Four (20%) patients underwent a second surgery within a week of repair. After limbal tear repair, at final follow-up at 3 years, 7 (35%) had VA worse than 20/800, 3 (15%) had VA between 20/100 and 20/800, and 10 (50%) achieved VA better than 20/80. Preoperative visual acuity (VA), mode of injury, and size of wound affect the final visual outcome after surgical repair of limbal corneal laceration. Preoperative VA and mode of injury were statistically significant even in the multivariate analysis.

Application of Field Sterility to Safely Reduce Cost and Waste in Cleft Surgery.

Healthcare spending in the United States remains a major concern, requiring reforms to control spending and curtail costs. Medical supply is one of the largest expenses for hospitals and strategies should be utilized to reduce nonbeneficial service delivery, which increases cost without concomitant increase in value. Introduction of field sterility is one of the potential strategies that has been applied in several surgical disciplines to improve cost-efficiency by reducing overuse of resources and decreasing enormous medical waste. Of course, this must be applied without a diminution in safety. The PubMed, Medline, and Cochrane databases from 1980 to 2022 were used to review literature. Key words included "cleft surgery and field sterility," "sterile gloves and oral surgery," "oral surgery and field sterility," "sterile techniques and cleft palate surgery," "sterile versus nonsterile gloves," "sterile and non-sterile gloves and minor surgery," "skin laceration repair and sterile techniques," "sterile gloves and wound suture," "surgical site infection and field sterility," "operating room versus clinical setting," "operating rooms economics and hand surgery," and "main operating room versus ambulatory." The literature search yielded 827 articles. Following evaluation of titles, abstracts, and manuscript contents, 23 articles were ultimately included, of which 10 discussed field sterility and cost-efficiency for cutaneous procedures, 9 hand surgery, and 4 oral surgery. There was no study evaluating field sterility application in cleft surgery. In the reviewed studies, no statistical significance was observed in surgical site infection (SSI) with substantial cost savings and medical waste reduction when hand procedures were performed in ambulatory settings with field sterility compared to the main operating room (OR). Furthermore, no difference was observed for SSI in wound closure, excision of skin lesions, or Mohs micrographic surgery when nonsterile gloves were used. The incidence of infection following most cleft-related procedures remains low. As such, the application of field sterility may be ideal for this setting. The cost and waste associated with standard operating protocols are not warranted for many cleft procedures.

Comparative sensitivity and accuracy of 24vs.18 MHz ultrasound probes for the diagnosis of flexor tendon repair integrity.

To determine whether a 24 MHz transducer significantly improves sensitivity, specificity and accuracy in evaluating flexor tendon repair integrity compared with an 18 MHz transducer. One hundred and twelve cadaveric digits were randomised to an intact repair or simulated 'failed' repair, and to a two- or eight-strand repair of a flexor digitorum profundus laceration. A blinded sonologist evaluated specimens in static mode using 18 and 24 MHz transducers. Gaps were remeasured after scanning, and final gap width recorded. McNemar's exact test calculated differences between sensitivity, specificity and accuracy, and chi-squared test to compare sensitivity, specificity and accuracy between number of strands (2 vs. 8) and repair gap (≥4 mm). The 24 MHz transducer had higher sensitivity (81 vs. 59%), lower specificity (67 vs. 70%) and higher overall accuracy (74 vs. 64%), than the 18 MHz transducer. The difference for sensitivity was significant (P = 0.011), but not differences for specificity and overall accuracy (P > 0.05). Pearson's correlation (r = 0.61) demonstrated a moderate-to-strong positive correlation between measured and true gap sizes. Increased number of suture strands (2 vs. 8) did not impair sensitivity, specificity nor accuracy. Ultrasound may tend to overestimate gap width, and a slight risk that some intact repairs, or those with small, clinically insignificant gaps may undergo surgical exploration that may not be indicated. A 24 MHz transducer is a more sensitive and accurate transducer for assessing flexor tendon repair integrity and measuring small gaps.

Association of the Range of Outpatient Services Provided by Primary Care Physicians with Subsequent Health Care Costs and Utilization.

Broader primary care practice range of services (ROS), defined as the diversity of professional services delivered, is associated with lower utilization. ROS provided by individual primary care physicians (PCPs) varies considerably with unclear implications for patients. Create a PCP-ROS measure covering six categories of outpatient services, including expanded codes for mental health counseling services and point of care ultrasound (POCUS) technology in physician offices. Determine whether PCP-ROS is associated with total Medicare expenditures, inpatient admissions, acute hospital utilization (AHU), and emergency department (ED) visits. Examine physician and practice characteristics associated with PCP-ROS. Retrospective cohort study. 4,569,711 Medicare fee-for-service beneficiaries and 27,008 PCPs observed during the evaluation of the Comprehensive Primary Care Plus (CPC +) initiative. PCP-ROS, hospitalizations, AHU (includes observation stays as well as inpatient admissions), ED visits, and total Medicare expenditures. Physicians varied substantially in the range of services provided. Broader PCP-ROS was significantly, independently associated with 1 - 3% lower Medicare expenditures (p ≤ 0.01), inpatient admissions (p ≤ 0.027), AHU (p ≤ 0.025), and ED visit rates (p ≤ 0.000). PCP-ROS score was associated with improved patient outcomes, independent of physician provision of procedures (such as laceration repair or skin excisions). Physicians in practice sites affiliated with a hospital or health system had narrower PCP-ROS than independent physicians by 0.3 to 0.4 (p < 0.001). Internal medicine specialty was associated with narrower PCP-ROS than family medicine by 0.3 (p < 0.001). Patients cared for by primary care physicians who provide a broader range of services subsequently experience lower acute care utilization and expenditures than do those cared for by physicians with narrower ROS. Practice leaders and professional associations should consider how best to ensure that primary care physicians efficiently and effectively provide the office-based professional services most needed by their patients.

Camel-Related Facial Injuries: A Seven-Year Retrospective Study.

Facial injuries caused by camels can be associated with adverse long-term effects on patients' quality of life. We aimed to investigate camel-related facial injuries in Al-Ain City, UAE, focusing on their incidence, types, mechanisms, anatomical distribution, and outcomes, to enhance preventive measures. We retrospectively collected data from all patients who were admitted to our hospital with camel-related facial injuries from January 2014 through January 2021. Thirty-six patients were included; all were males, with a mean (range) age of 31 (14-66) years, 29 (80.5%) were camel caregivers. The most common mechanisms of injury were falling while riding a camel and camel kicks. The head was the most commonly injured region in 52.7%. Twenty-three (63.8%) patients had facial bone fractures. The middle third of the face accounted for 71.4% of the bony fractures. The most performed surgical procedures in our patients were soft tissue laceration repair and open reduction with internal fixation of fractures (ORIF). Camel-related facial injuries affect young adult male camel caregivers working on camel farms. Orbital and maxillary bone fractures are the most predominant fractures requiring operative management. Legislation for compulsory helmet usage may reduce the incidence of these injuries and their serious consequences.

Bedside Ultrasonographic Assessment of the Optic Nerve Sheath Diameter to Assess Intracranial Pressure in Patients Given Ketamine in Emergency Department

Background: There is an ongoing debate if ketamine exerts any effect on intracranial pressure (ICP). ICP can be evaluated noninvasively by means of optic nerve sheath diameter (ONSD) measurement. In the present study, we aimed to determine if ketamine has any perceivable effect on ICP using ONSD.&#x0D; Material and Methods: In this single-center observational study, we prospectively enrolled patients who were admitted to the ED and received intravenous ketamine for induction, analgesia, procedural sedation for any procedure (ie, fracture reduction, laceration repair, pacemaker implantation). ONSD was used to rate ICP changes noninvasively both before and after ketamine application.&#x0D; Results: There were a total of 75 patients with a mean age of 59.8 ± 20.5 years. The majority of patients were applied Procedural Sedation (53.3%). In patients who were administered ketamine for induction, the median ONSD before and after ketamine were 5.10 (IQR: 1) mm and 5.00 (IQR: 1.30) mm, respectively. There occurred no significant diameter change (p=0.832). In patients who were administered ketamine for analgesia, the median ONSD 3.70 (IQR: 0.40) mm and 3.65 (IQR: 0.23) mm prior to and after the procedure, respectively. There occurred no significant diameter change (p=0.549). In patients who were administered ketamine for procedural sedation, the median ONSD before and after the procedure were 4.05 (IQR:0.67) mm and 3.97 (IQR: 0.69) mm, respectively. This time, however, ONSD was significantly reduced after ketamine administration (p=0.001).&#x0D; Conclusions: In this patient population, ketamine did not cause any incremental effect on ONSD, a surrogate marker of ICP.

Modified technique for corneal laceration repair using amniotic membrane

Background Water-tight closure of lacerated corneal wounds may require a lot of sutures and result in significant corneal scarring and irregular astigmatism. Aim The aim of this study was to describe the technique of amniotic membrane (AM) onlay strip for corneal lacerations repair and to evaluate its outcome. Patients and methods This is a retrospective case series that included eight eyes with traumatic corneal lacerations. A strip of AM was applied to the corneal surface to cover the wound which was then sutured with 10/0 Nylon sutures involving the membrane. The sutures were well-spaced, and the suturing was avoided in the visual axis. Average keratometric (K) reading, keratometric astigmatism (KA), manifest refractive astigmatism (RA) in diopters (D), and spectacle or soft contact lens best corrected visual acuity (BCVA) were assessed 2 months after suture removal. Results Transient postoperative hypotony was encountered in five cases (62.5%). The average K was 44.61±2.81 D, KA 2.20±0.71 D, and RA 1.78±0.73 D (range=1–3 D). The postoperative LogMAR BCVA was 0.39±0.18 (range=0.22–0.70). Conclusions The application of AM inlay strip during repair of corneal lacerations was associated with good visual outcome possibly due to the reduction of wound and suture related corneal astigmatism.

Remote Synchronous Laceration Repair Instruction With Summary Feedback.

Social distancing and quarantine requirements imposed during the COVID-19 pandemic necessitated remote training in many learning situations that formerly focused on traditional in-person training. In this context, we developed an adaptive approach to teaching laceration repair remotely while allowing for synchronous instruction and feedback. In April 2020, 35 family medicine residents from 4 programs in the Midwest United States participated in a real-time, remotely-delivered, 2-hour virtual procedure workshop of instruction in suture techniques for laceration repair. Paired-sample t tests compared scores of learner self-confidence obtained during pre- and posttests. We interpreted short-answer responses with a mixed-methods analysis. Residents submitted photos and videos of suture techniques and received formative feedback based on a predefined rubric. All residents completed the pre- and posttests. The posttest scores for self-confidence across the participants showed significant improvement for all suture techniques. Of the 67 short-answer responses, 38 responses (56.7%) were positive; 9 (13.4%) negative; 8 (11.9%) neutral; and 12 (17.9%) a combination of positive and negative. The workshop was rated by 34 residents (97.1%) as either "about the same as prior training experiences," "better than prior training experiences," or "much better than prior training experiences." Learners reported that a remotely-delivered, real-time, synchronous suture technique workshop was a valuable experience. Further research is needed to establish the efficacy of this platform to promote procedural competence.

Utility of VATS in Thoracic Trauma: When? Why? and How?

Background: Thoracoscopy/VATS is an under utilized modality in thoracic trauma. In this article we aim to review the utility of thoracoscopy in chest trauma patients. We have also illustrated a case from our hospital, to demonstrate the effective use of VATS in trauma. Main Body: Indications for VATS in trauma can be divided into emergency, early and late, based on the timing of the intervention. In emergency situations, if the patient is hemodynamically stable, VATS can be used to control bleeding from the chest wall and intercostal vessels, it can also be useful for evacuation of clots, removal of foreign bodies, diagnosing diaphragmatic injuries and to visualize other internal organs of the thoracic cavity. In a delayed setting it can be used for evaluation and control of persistent pneumothorax, repair of lung lacerations and diaphragmatic injuries and also for fixing rib fractures. Uniportal VATS is a new technology that is coming up quickly, but is yet to be proven superior to traditional 3 port VATS in chest trauma. Conclusion: VATS is an important tool in the armamentarium of surgeons involved in dealing with chest trauma. However, it is not a substitute for emergency thoracotomy, but can only be a supplement to it.

Incidence and management of dural tears in full-endoscopic unilateral laminotomies for bilateral lumbar decompression.

To report incidence of dural lacerations in lumbar endoscopic unilateral laminotomy for bilateral decompression (LE-ULBD) and to describe patient outcomes following a novel full-endoscopic bimanual durotomy repair. Retrospective review of prospectively collected database including 5.5years of single surgeon experience with LE-ULBD. Patients with no durotomy were compared with patients who experienced intraoperative durotomy, including demographics, ASA score, prior surgery, number of levels treated, procedure time, hospital length of stay (LOS), visual analogue scale, perioperative complications, revision surgeries, use of analgesics, and Oswestry Disability Index (ODI). In total, 13/174 patients (7.5%) undergoing LE-ULBD experienced intraoperative durotomy. No significant differences in demographic, clinical or operative variables were identified between the 2 groups. Sustaining a durotomy increased LOS (p = 0.0019); no differences in perioperative complications or rate of revision surgery were identified. There was no difference in minimally clinically important difference for ODI between groups (65.6% for no durotomy versus 55.6% for durotomy, p = 0.54). In this cohort, sustaining a durotomy increased LOS but, with accompanying intraoperative repair, did not significantly affect rate of complications, revision surgery or functional outcomes. Our method of bimanual endoscopic dural repair provides an effective approach for repair of dural lacerations in interlaminar ULBD cases.

A 31-Year-Old Woman With Postpartum Abdominal Pain and Fever

(N Engl J Med. 2022;387:2367–2375) This case presented 15 days after the patient’s vaginal delivery of a healthy baby, when she was admitted to the hospital with abdominal pain and fever. Sixteen days prior, spontaneous labor had been augmented by artificial membrane rupture (showing clear, odorless fluid) and oxytocin infusion. An elevated white-cell count was noted (13,800/mL, 4500 to 11,000/mL reference range) and intravenous penicillin was administered. Hemoglobin was noted to be 14.0 g/dL (12.0 to 16.0 g/dL reference range). Delivery occurred 6 hours later, followed immediately by uterine atony hemorrhage with 500 mL of blood loss. Hemostasis was achieved by bimanual massage of the uterus, and administration of oxytocin and methylergonovine. A routine repair of a perineal laceration was also performed. The patient discharged from the hospital on postpartum day 1.

Inhaled nitrous oxide for painful procedures in children and youth: a systematic review and meta-analysis.

The objective of this study was to synthesize indication-based evidence for N2O for distress and pain in children. We included trials of N2O in participants 0-21years, reporting distress or pain for emergency department procedures. The primary outcome was procedural distress. Where meta-analysis was not possible, we used Tricco et al.'s classification of "neutral" (p ≥ 0.05), "favorable," or "unfavorable" (p < 0.05, supporting N2O or comparator, respectively). We used the Cochrane Collaboration's Risk of Bias tool and the Grading of Recommendations Assessment, Development, and Evaluation system to evaluate risk of bias and quality of evidence, respectively. We included 30 trials. For pain using the Visual Analog Scale (0-100mm) during IV insertion, 70% N2O (delta:-16.5; 95%CI:-28.6 to -4.4; p = 0.008; three trials; I2 = 0%) and 50% N2O plus eutectic mixture of local anesthetics (EMLA) (delta:-1.2; 95%CI:-2.1 to -0.3; p = 0.007; two trials; I2 = 43%) were superior to EMLA. 50% N2O was not superior to EMLA (delta:-0.4; 95%CI:-1.2 to 0.3; p = 0.26; two trials; I2 = 15%). For distress and pain during laceration repair, N2O was "favorable" versus each of SC lidocaine, oxygen, and oral midazolam but "neutral" versus IV ketamine (five trials). For distress and pain during fracture reduction (three trials), N2O was "neutral" versus each of IM meperidine plus promethazine, regional anesthesia, and IV ketamine plus midazolam. For distress and pain during lumbar puncture (one trial), N2O was "favorable" versus oxygen. For distress and pain during urethral catheterization (one trial), N2O was "neutral" versus oral midazolam. For pain during intramuscular injection (one trial), N2O plus EMLA was "favorable" versus N2O and EMLA alone. Common adverse effects of N2O included nausea (4.4%), agitation (3.7%), and vomiting (3.6%) AEs were less frequent with N2O alone (278/1147 (24.2%)) versus N2O plus midazolam (48/52 (92.3%)) and N2O plus fentanyl (123/201 (61.2%)). There is sufficient evidence to recommend N2O plus topical anesthetic for IV insertion and laceration repair. Adverse effects are greater when combined with other sedating agents.

Development of a Departmental Resident Educational Program to Increase Knowledge and Confidence Related to Obstetric Anal Sphincter Injuries [ID: 1375536

INTRODUCTION: Obstetric anal sphincter injuries (OASIS) have been reported in up to 35% of vaginal deliveries; thus, understanding these injuries is a critical part of obstetrics and gynecology training. Formal educational programs with incorporated simulation training can have an advantageous effect, particularly when provided as part of residency education. This project seeks to evaluate the positive effect of departmental resident education related to OASIS, on confidence and knowledge of obstetrics and gynecology residents at Wake Forest University. METHODS: A structured OASIS curriculum was developed by the urogynecology program, including 2 hours of didactic lecture followed by stepwise simulation with swine models to demonstrate and practice anatomic repair techniques. Participants completed pre- and post-class surveys including skill confidence assessments via Likert scale (range 1–10), and standardized knowledge assessments adapted from ACOG Obstetric Laceration Repair Module, along with educational experience reports. These items were scored and analyzed. RESULTS: In August 2022, 16 residents (4 per residency year) participated. Prior to education, mean confidence level with techniques was 4.2 among all areas (range 1.6–7.4), with mean knowledge assessment score 64% (range 33–100%). Post-education, confidence improved across several domains including effectively applying perineal support (7.3–7.9), identifying lacerations and performing rectal examinations (6.1–8.0), and OASIS repair (1.9–5.4) (P&lt;.05). Knowledge assessment scores remained similar, at 70% (P&gt;.05). In qualitative analysis, all individuals reported beneficial aspects of the program. CONCLUSION: Introduction of an OASIS curriculum including repair simulation utilizing an animal model, increased resident skill confidence. Future research will investigate longitudinal data to improve outcomes.

Endometrioid adenocarcinoma arising in adenomyosis in a patient with pelvic organ prolapse—case report

BackgroundAdenomyosis is a frequent finding in endometrial carcinoma patients. Endometrioid adenocarcinoma is the most common type of endometrial carcinoma; however, endometrioid adenocarcinoma arising from adenomyosis is extremely rare.Case presentationIn this case report, we describe a 69-year-old woman who required surgical treatment for pelvic organ prolapse (POP). The patient had been postmenopausal for 20 years and had no abnormal bleeding after menopause. The patient underwent transvaginal hysterectomy, repair of anterior and posterior vaginal walls, ischium fascial fixation and repair of an old perineal laceration. Histological examination of surgical specimens revealed endometrioid adenocarcinoma of the uterus. Bilateral adnexectomy, pelvic lymphadenectomy and para-aortic lymphadenectomy were then performed. The postoperative histopathological diagnosis was stage IB endometrial cancer (endometrioid carcinoma G2).ConclusionsIn summary, endometrioid adenocarcinoma arising from adenomyosis (EC-AIA) is a rare entity and the early diagnosis is difficult. Adequate preoperative assessment and enhanced inquiry of occult clinical symptoms of postmenopausal women before hysterectomy may contribute to the diagnosis of EC-AIA preoperatively.

Racial disparities in care escalation for postpartum hemorrhage requiring transfusion

Postpartum hemorrhage is a leading cause of maternal morbidity and mortality in the United States and disproportionately affects pregnant persons of color. This study aimed to identify the demographic and obstetrical characteristics of those who received different levels of antihemorrhagic intervention in the setting of severe postpartum hemorrhage requiring blood transfusion. This was a retrospective cohort study of patients with documented postpartum hemorrhage (estimated blood loss of ≥1000 mL) and blood product transfusion. Moreover, 3 levels of antihemorrhagic intervention were defined as follows: level 1, administration of uterotonics only; level 2, performance of a procedure (ie, B-Lynch suture, O'Leary stitch, Bakri balloon, dilation and curettage, laceration repair, or embolization); and level 3, hysterectomy. Maternal demographics, obstetrical characteristics, and comorbidities were extracted from electronic health records. Ordinal logistic regression was used to estimate the odds of higher intervention levels adjusting for maternal demographic and obstetrical characteristics. Of note, 365 patients were included in this study, with a racial or ethnic composition of 30% White, 42% Black, 18% Hispanic, and 10% other. Moreover, 233 patients (64%) received level 1 intervention, 98 patients (27%) received level 2 intervention, and 34 patients (9%) received level 3 intervention. Patients receiving higher levels of intervention were more likely to have greater estimated blood loss (P<.001), have more transfusions (P<.001), and be of advanced maternal age (P=.004). Black and Hispanic patients were less likely to have received higher levels of intervention than White patients (P=.034). After adjusting for estimated blood loss, advanced maternal age, placenta accreta spectrum, and fibroids, Black patients remained significantly less likely to receive higher levels of intervention (adjusted odds ratio, 0.55; 95% confidence interval, 0.30-0.98). This difference persisted at an estimated blood loss of ≥3000 mL, with Black and Hispanic patients being significantly less likely to receive higher levels of intervention than White patients (odds ratio, 0.31 [95% confidence interval, 0.10-0.92] and 0.10 [95% confidence interval, 0.01-0.53], respectively). Among patients experiencing postpartum hemorrhage and receiving transfusion, Black patients are less likely to receive higher levels of antihemorrhagic intervention. This disparity is concerning in this high-risk population and requires further attention and investigation.