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Wieslander CK, Grimes CL, Balk EM, Hobson DTG, Ringel NE, Sanses TVD, Singh R, Richardson ML, Lipetskaia L, Gupta A, White AB, Orejuela F, Meriwether K, Antosh DD. Health Care Disparities in Patients Undergoing Hysterectomy for Benign Indications: A Systematic Review. Obstet Gynecol 2023; 142:1044-1054. [PMID: 37826848 DOI: 10.1097/aog.0000000000005389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/30/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVE To explore how markers of health care disparity are associated with access to care and outcomes among patients seeking and undergoing hysterectomy for benign indications. DATA SOURCES PubMed, EMBASE, and ClinicalTrials.gov were searched through January 23, 2022. METHODS OF STUDY SELECTION The population of interest included patients in the United States who sought or underwent hysterectomy by any approach for benign indications. Health care disparity markers included race, ethnicity, geographic location, insurance status, and others. Outcomes included access to surgery, patient level outcomes, and surgical outcomes. Eligible studies reported multivariable regression analyses that described the independent association between at least one health care disparity risk marker and an outcome. We evaluated direction and strengths of association within studies and consistency across studies. TABULATION, INTEGRATION, AND RESULTS Of 6,499 abstracts screened, 39 studies with a total of 46 multivariable analyses were included. Having a Black racial identity was consistently associated with decreased access to minimally invasive, laparoscopic, robotic, and vaginal hysterectomy. Being of Hispanic ethnicity and having Asian or Pacific Islander racial identities were associated with decreased access to laparoscopic and vaginal hysterectomy. Black patients were the only racial or ethnic group with an increased association with hysterectomy complications. Medicare insurance was associated with decreased access to laparoscopic hysterectomy, and both Medicaid and Medicare insurance were associated with increased likelihood of hysterectomy complications. Living in the South or Midwest or having less than a college degree education was associated with likelihood of prior hysterectomy. CONCLUSION Studies suggest that various health care disparity markers are associated with poorer access to less invasive hysterectomy procedures and with poorer outcomes for patients who are undergoing hysterectomy for benign indications. Further research is needed to understand and identify the causes of these disparities, and immediate changes to our health care system are needed to improve access and opportunities for patients facing health care disparities. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42021234511.
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Affiliation(s)
- Cecilia K Wieslander
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, California; the Division of Urogynecology & Reconstructive Pelvic Surgery, Departments of Obstetrics and Gynecology and Urology, New York Medical College, Valhalla, New York; the Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island; the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, Wayne State University School of Medicine, Detroit, Michigan; the Division of Urogynecology & Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, Yale School of Medicine, New Haven, Connecticut; the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, Howard University College of Medicine, Washington, DC; the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, University of Florida Health, Jacksonville, Florida; Occom Health, Newton, Massachusetts; the Division of Urogynecology & Reconstructive Pelvic Surgery, Cooper Health University, Cooper Medical School at Rowan University, Camden, New Jersey; the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, University of Louisville Health, Louisville, Kentucky; the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, University of Texas at Austin Dell Medical School, Austin, and the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, Baylor College of Medicine, the Division of Urogynecology, Department of Obstetrics & Gynecology, Houston Methodist Hospital, Houston, Texas; and the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, University of New Mexico, Albuquerque, New Mexico
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Gupta A, Balk EM, Lenger SM, Yang LC, Misal M, Balgobin S, Chang OH, Sharma V, Stuparich M, Behbehani S, Nihira M, Alas A, Jampa A, Sheyn D, Meriwether K, Antosh DD. Changes in Pelvic Floor Symptoms After Procedural Interventions for Uterine Leiomyomas: A Systematic Review. Obstet Gynecol 2023; 142:319-329. [PMID: 37411023 DOI: 10.1097/aog.0000000000005260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/11/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE To conduct a systematic review to evaluate the effect of procedural interventions for leiomyomas on pelvic floor symptoms. DATA SOURCES PubMed, EMBASE, and ClinicalTrials.gov were searched from inception to January 12, 2023, searching for leiomyoma procedures and pelvic floor disorders and symptoms, restricted to primary study designs in humans. METHODS OF STUDY SELECTION Double independent screening for studies of any study design in all languages that reported pelvic floor symptoms before and after surgical (hysterectomy, myomectomy, radiofrequency volumetric thermal ablation) or radiologic (uterine artery embolization, magnetic resonance-guided focused ultrasonography, high-intensity focused ultrasonography) procedures for management of uterine leiomyomas. Data were extracted, with risk-of-bias assessment and review by a second researcher. Random effects model meta-analyses were conducted, as feasible. TABULATION, INTEGRATION, AND RESULTS Six randomized controlled trials, one nonrandomized comparative study, and 25 single-group studies met criteria. The overall quality of the studies was moderate. Only six studies, reporting various outcomes, directly compared two procedures for leiomyomas. Across studies, leiomyoma procedures were associated with decreased symptom distress per the UDI-6 (Urinary Distress Inventory, Short Form) (summary mean change -18.7, 95% CI -25.9 to -11.5; six studies) and improved quality of life per the IIQ-7 (Incontinence Impact Questionnaire, Short Form) (summary mean change -10.7, 95% CI -15.8 to -5.6; six studies). There was a wide range of resolution of urinary symptoms after procedural interventions (7.6-100%), and this varied over time. Urinary symptoms improved in 19.0-87.5% of patients, and the definitions for improvement varied between studies. Bowel symptoms were inconsistently reported in the literature. CONCLUSION Urinary symptoms improved after procedural interventions for uterine leiomyomas, although there is high heterogeneity among studies and few data on long-term outcomes or comparing different procedures. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42021272678.
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Affiliation(s)
- Ankita Gupta
- Division of Female Pelvic Medicine & Reconstructive Surgery, University of Louisville Health, and the Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics, Gynecology, & Women's Health, University of Louisville School of Medicine, Louisville, Kentucky; the Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island; the Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Northwestern Medicine, Chicago, Illinois; the Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, and the Division of Female Pelvic Medicine and Reconstructive Surgery, Urology Institute, University Hospitals, Cleveland, Ohio; the Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, the Department of OBGYN, Division of Urogynecology, UT Health Science Center at San Antonio, San Antonio, and the Division of Urogynecology, Department of Obstetrics and Gynecology, Houston Methodist Hospital, Houston, Texas; the Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington; the Department of Obstetrics and Gynecology, Jacobi Medical Center, and the Albert Einstein College of Medicine, Bronx, New York; the Department of Obstetrics and Gynecology, University of California, Riverside School of Medicine, Riverside, and KPC Healthcare, Hemet, California; the Jawaharlal Nehur Medical College, Belgaum, India; and the Division of Urogynecology, Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque, New Mexico
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McDermott CD, Tunitsky-Bitton E, Dueñas-Garcia OF, Willis-Gray MG, Cadish LA, Edenfield A, Wang R, Meriwether K, Mueller ER. Postoperative Urinary Retention. Urogynecology (Phila) 2023; 29:381-396. [PMID: 37695249 DOI: 10.1097/spv.0000000000001344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
ABSTRACT This clinical consensus statement on the management of postoperative (<6 weeks) urinary retention (POUR) reflects statements drafted by content experts from the American Urogynecologic Society's POUR writing group. The writing group used a modified Delphi process to evaluate statements developed from a structured literature search and assessed for consensus. After the definition of POUR was established, a total of 37 statements were assessed in the following 6 categories: (1) incidence of POUR, (2) medications, (3) patient factors, (4) surgical factors, (5) urodynamic testing, and (6) voiding trials. Of the 37 original statements, 34 reached consensus and 3 were omitted.
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Affiliation(s)
| | - Elena Tunitsky-Bitton
- Hartford Hospital, Hartford, CT; University of Connecticut School of Medicine, Farmington, CT
| | | | | | | | | | - Rui Wang
- Penn Medicine Princeton Health, Princeton, NJ
| | | | - Elizabeth R Mueller
- Loyola University Chicago Stritch School of Medicine, Loyola University Medical Center, Maywood, IL
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Rockefeller NF, Petersen TR, Komesu YM, Meriwether K, Dunivan G, Ninivaggio C, Jeppson PC. Chlorhexidine gluconate vs povidone-iodine vaginal antisepsis for urogynecologic surgery: a randomized controlled noninferiority trial. Am J Obstet Gynecol 2021; 227:66.e1-66.e9. [PMID: 34973179 DOI: 10.1016/j.ajog.2021.12.260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/29/2021] [Accepted: 12/24/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Although povidone-iodine (iodine) is the only Food and Drug Administration-approved vaginal antiseptic solution, there is a lack of comparative data evaluating alternatives. Chlorhexidine gluconate is readily accessible, recommended by multiple societies as an alternative for patients with iodine allergy, and preliminary data indicate that it may provide superior antisepsis. OBJECTIVE This study aimed to compare the effectiveness of chlorhexidine and iodine as presurgical vaginal antiseptic solutions in preventing the most common surgery-associated infection after gynecologic surgery, urinary tract infections. STUDY DESIGN We conducted a randomized controlled noninferiority trial among women undergoing urogynecologic surgery. The primary outcome measure was symptomatic urinary tract infection within 2 weeks after surgery. The secondary outcomes included culture-proven urinary tract infection at 2 and 6 weeks after surgery, symptomatic urinary tract infections at 6 weeks after surgery, any surgical site infection at 2 weeks after surgery, and patient-reported vaginal irritation after surgery. We required 58 participants per arm to demonstrate noninferiority of chlorhexidine vs iodine (margin of relative risk of <1.5 for the upper limit of 95% confidence interval) between groups for the primary outcome. RESULTS A total of 119 participants (61 in the chlorhexidine group and 58 in the iodine group) completed the primary outcome and were included in the analyses. There was no difference in the groups' demographic characteristics, medical history, operations performed, or perioperative factors. Chlorhexidine was not inferior to iodine concerning the primary outcome, symptomatic urinary tract infection at 2 weeks after surgery (10% vs 17%; relative risk, 0.6; 95% confidence interval [-∞, 1.3]). Furthermore, chlorhexidine was not inferior to iodine for the secondary urinary tract infection outcomes (culture-proven urinary tract infection at 2 and 6 weeks after surgery and symptomatic urinary tract infection at 6 weeks after surgery). Groups were similar in terms of surgical site infection (overall 3/119 [2.5%]) and presence of any vaginal irritation (4/54 [7.4%], for both groups). CONCLUSION Chlorhexidine was not inferior to iodine for vaginal antisepsis before urogynecologic surgery concerning urinary tract infection. Given the similar postoperative urinary tract infection rates demonstrated in this study and the lack of difference in vaginal irritation, chlorhexidine seemed to be a safe and reasonable option for vaginal antisepsis before surgical procedures. Additional studies are needed to further examine surgical site infection.
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Affiliation(s)
- Nicholas F Rockefeller
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of New Mexico Health Science Center, Albuquerque, NM.
| | - Timothy R Petersen
- Department of Anesthesia and Critical Care Medicine, University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque, NM
| | - Yuko M Komesu
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of New Mexico Health Science Center, Albuquerque, NM
| | - Kate Meriwether
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of New Mexico Health Science Center, Albuquerque, NM
| | - Gena Dunivan
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of New Mexico Health Science Center, Albuquerque, NM
| | - Cara Ninivaggio
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of New Mexico Health Science Center, Albuquerque, NM
| | - Peter C Jeppson
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of New Mexico Health Science Center, Albuquerque, NM
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Polland A, Hamner J, Arunachalam D, Dwarica D, Gupta A, Pennycuff J, Tran A, Tefera E, Meriwether K, Gutman R. 128 STOMP: Sexual function Trial of Overactive bladder: Medication versus PTNS. J Sex Med 2021. [DOI: 10.1016/j.jsxm.2021.01.147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Gupta A, Meriwether K, Tuller M, Sekula M, Gaskins J, Stewart JR, Hobson D, Cardenas-Trowers O, Francis S. Candy Cane Compared With Boot Stirrups in Vaginal Surgery: A Randomized Controlled Trial. Obstet Gynecol 2020; 136:333-341. [PMID: 32649498 DOI: 10.1097/aog.0000000000003954] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate differences in physical function at 6 weeks after vaginal surgery among women positioned in candy cane and boot stirrups. METHODS We conducted a single-masked, randomized controlled trial of women undergoing vaginal surgery with either candy cane or boot stirrup use. The primary outcome was a change in the PROMIS (Patient-Reported Outcomes Measurement Information System) physical function short form-20a from baseline to 6 weeks after surgery. To achieve 80% power to detect a moderate Cohen effect (d=0.5), we required 64 participants in each group. RESULTS From March 2018 to October 2019, 141 women were randomized, and 138 women (72 in the candy cane group and 66 in the boot stirrup group) were included in the final analysis. There were no baseline differences in participant characteristics including age, body mass index, comorbidities, or preoperative history of joint replacements. There were no between-group differences in surgery type, duration of surgery, estimated blood loss, or adverse events at 6 weeks postoperation. Participants in the candy cane group demonstrated worse physical function at 6 weeks compares with the improvement seen in those in the boot stirrup group; this was significantly different between groups (-1.9±7.9 candy cane vs 1.9±7.0 boot, P<.01). CONCLUSION Women undergoing vaginal surgery positioned in boot stirrups have significantly better physical function at 6 weeks after surgery when compared with women positioned in candy cane stirrups. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT03446950.
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Affiliation(s)
- Ankita Gupta
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, and the Department of Obstetrics & Gynecology, University of Louisville School of Medicine, and the Department of Bioinformatics & Biostatistics, School of Public Health and Information Sciences, University of Louisville, Louisville, Kentucky; the Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics & Gynecology, University of New Mexico, Albuquerque, New Mexico; and the Department of Obstetrics & Gynecology, Wayne State University School of Medicine, Detroit, Michigan
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Gupta A, Meriwether K, Petruska S, Fazenbaker-Crowell S, McKenzie C, Goble A, Stewart JR. Viewer interaction with YouTube videos about hysterectomy recovery. Wiki J Med 2020. [DOI: 10.15347/wjm/2020.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
OBJECTIVES The United States has seen an increasing number of child-bearing women in medical training. We aimed to compare the prevalence of exclusive breastfeeding across varied specialties, whose trainees may face different obstacles to breastfeeding. MATERIALS AND METHODS An online survey querying the duration and barriers to breastfeeding was sent to Accreditation Council for Graduate Medical Education (ACGME) and American Osteopathic Association (AOA) programs. Female residents with at least one living child born during residency were eligible. We compared the prevalence of exclusive breastfeeding for 6 months between Obstetrics and Gynecology (OBGYN), nonsurgical, and non-OBGYN surgical specialties. A multiple regression model correcting for ethnicity, years lived in the United States, medical degree, year of residency at childbearing, geographical location, and clinical hours was performed. RESULTS There were 708 completed surveys, including 561 nonsurgical, 73 OBGYN, and 74 non-OBGYN surgical residents. More OBGYN residents reported exclusive breastfeeding at 6 months (43/73, 59%) than nonsurgical (217/561, 39%) and non-OBGYN surgical residents (30/74, 41%) (p < 0.01). After adjusting for confounders, OBGYN trainees were twice as likely to breastfeed (adjusted odds ratio [AOR] = 2.18, 95% confidence interval [CI] 1.28-3.72) with no difference between non-OBGYN surgical and nonsurgical residents (AOR = 1.24, 95% CI 0.70-2.19). Less OBGYN residents reported the lack of breastfeeding facilities at work (2.7% versus 17.6%, p < 0.01) and inadequate leave (4.1% versus 17.6%, p = 0.01) than non-OBGYN surgical residents. CONCLUSIONS In this national survey of trainees in accredited programs, OBGYN residents were twice as likely to breastfeed and fewer OBGYN residents cited barriers to breastfeeding compared to other residents.
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Affiliation(s)
- Ankita Gupta
- 1 Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, University of Louisville School of Medicine, Louisville, Kentucky.,2 Department of Obstetrics and Gynecology, Crozer Chester Medical Center, One Medical Center Boulevard, Upland, Pennsylvania
| | - Kate Meriwether
- 1 Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, University of Louisville School of Medicine, Louisville, Kentucky
| | - Guy Hewlett
- 2 Department of Obstetrics and Gynecology, Crozer Chester Medical Center, One Medical Center Boulevard, Upland, Pennsylvania.,3 Department of Obstetrics and Gynecology, Cooper University Hospital, Camden, New Jersey
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Olivera CK, Meriwether K, El-Nashar S, Grimes CL, Chen CCG, Orejuela F, Antosh D, Gleason J, Kim-Fine S, Wheeler T, McFadden B, Balk EM, Murphy M. Nonantimuscarinic treatment for overactive bladder: a systematic review. Am J Obstet Gynecol 2016; 215:34-57. [PMID: 26851599 DOI: 10.1016/j.ajog.2016.01.156] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 01/04/2016] [Accepted: 01/13/2016] [Indexed: 10/22/2022]
Abstract
The purpose of the study was to determine the efficacy and safety of nonantimuscarinic treatments for overactive bladder. Medline, Cochrane, and other databases (inception to April 2, 2014) were used. We included any study design in which there were 2 arms and an n > 100, if at least 1 of the arms was a nonantimuscarinic therapy or any comparative trial, regardless of number, if at least 2 arms were nonantimuscarinic therapies for overactive bladder. Eleven reviewers double-screened citations and extracted eligible studies for study: population, intervention, outcome, effects on outcome categories, and quality. The body of evidence for categories of interventions were summarized and assessed for strength. Ninety-nine comparative studies met inclusion criteria. Interventions effective to improve subjective overactive bladder symptoms include exercise with heat and steam generating sheets (1 study), diaphragmatic (1 study), deep abdominal (1 study), and pelvic floor muscle training exercises (2 studies). Pelvic floor exercises are more effective in subjective and objective outcomes with biofeedback or verbal feedback. Weight loss with diet and exercise, caffeine reduction, 25-50% reduction in fluid intake, and pelvic floor muscle exercises with verbal instruction and or biofeedback were all efficacious. Botulinum toxin A improves urge incontinence episodes, urgency, frequency, quality of life, nocturia, and urodynamic testing parameters. Acupuncture improves quality of life and urodynamic testing parameters. Extracorporeal magnetic stimulation improves urodynamic parameters. Mirabegron improves daily incontinence episodes, nocturia, number of daily voids, and urine volume per void, whereas solabegron improves daily incontinence episodes. Short-term posterior tibial nerve stimulation is more efficacious than pelvic floor muscle training exercises and behavioral therapy for improving: urgency, urinary incontinence episodes, daily voids, volume per void, and overall quality of life. Sacral neuromodulation is more efficacious than antimuscarinic treatment for subjective improvement of overactive bladder and quality of life. Transvaginal electrical stimulation demonstrates subjective improvement in overactive bladder symptoms and urodynamic parameters. Multiple therapies, including physical therapy, behavioral therapy, botulinum toxin A, acupuncture, magnetic stimulation, mirabegron, posterior tibial nerve stimulation, sacral neuromodulation, and transvaginal electrical stimulation, are efficacious in the treatment of overactive bladder.
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Welch JD, Meriwether K, Trautman R. Stigmata: part I. Shame, guilt, and anger. Plast Reconstr Surg 1999; 104:65-71. [PMID: 10597675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
The aesthetic surgeon may occasionally be consulted by a patient who wishes to discuss what can be done for the scars of self-inflicted wounds on the forearms. These scars are popularly referred to as "hesitation marks" or "suicide gestures." Unlike patients suffering from factitial ulcers or Münchhausen syndrome, these patients will admit to the physician that the scars are the result of self-inflicted wounds. These scars often consist of multiple, parallel, white lines extending up and down the forearms (usually volar surface), with more on the nondominant side. Although the pattern of these scars is apparently what drives these patients to the aesthetic surgeon for relief (because even lay people identify these scars as self-inflicted suicide marks), the authors propose a new and deeper motivation for surgery. Recent experiences with three of these patients resulted in an epiphany that prompted this report. Once the symbolic meaning of these scars was broached, a torrent of thoughts and theories followed. This article will recount these three cases and present a central thesis for this type of self-inflicted injury. A proposal for the proper surgical treatment of this condition will be offered. Uniquely, two of the patients will relate their own stories and propose guidelines and warnings for the aesthetic surgeon.
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Affiliation(s)
- J D Welch
- Department of Plastic Surgery, University of Washington, USA.
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