Riverside Regional Medical Center

INTRODUCTION: Stress urinary incontinence (SUI) and pelvic organ prolapse (POP) are common pelvic floor disorders that significantly affect quality of life in reproductive-age d and post-menopausal women. Shared risk factors include age, parity, obesity, connective tissue dysfunctions, chronic straining, and a history of pelvic surgery. As obesity rates continue to rise, disproportionately among women, recurrence of SUI and POP is a growing concern. Midurethral sling (MUS) is one of the most effective treatments for SUI, while surgical options for POP include sacrospinous ligament suspension, uterosacral suspension, sacrocolpopexy, vaginal hysterectomy, and related reconstructive procedures. Outcomes in severely obese women remain poorly defined. While some studies report higher rates of MUS failure or POP recurrence with BMI ≥40, others show no difference. No study has specifically evaluated BMI ≥45 as a threshold. This study examines the association between obesity and surgical outcomes after MUS and POP repair, focusing on reoperation, recurrence, and need for additional treatment in women with BMI ≥45. OBJECTIVE: To evaluate the association between obesity and surgical outcomes after MUS and procedures for pelvic organ prolapse, with a focus on reoperation, recurrence, and the need for additional treatment in women with BMI ≥45. METHODS: We conducted a retrospective cohort study using the TriNetX U.S. Collaborative Network, a database of de-identified electronic health records from 68 healthcare organizations. Patients with POP who underwent related surgical procedures, including MUS, were included. A BMI cutoff of ≥45 kg/m2 was applied. Propensity score matching (1:1) was used to balance age, comorbidities, and prior pelvic surgeries. Outcomes assessed over 10 years included prolapse recurrence, reoperation, repeat sling, additional treatments (e.g., bladder Botox, bulking agent injection, high-intensity focused ultrasound), and pessary use. RESULTS: Among women undergoing MUS, BMI ≥45 was not associated with differences in pessary use, procedure reversal, repeat sling, or overall failure, excluding sling. However, women with BMI ≥45 had higher rates of additional treatment (4.2% vs 2.2%, p=0.006). For POP repair, BMI ≥45 likewise did not affect pessary use, procedure reversal, repeat sling, or overall failure excluding sling, but was associated with an increased risk of additional treatment (2.8% vs 1.4%, p=0.016). No other statistically significant differences were identified between groups. CONCLUSIONS: In this large, multicenter cohort, morbid obesity (BMI ≥45) was not associated with an increased risk of structural failure after MUS or POP repair. However, women with BMI ≥45 were more likely to require additional treatment interventions, suggesting that while surgical durability is preserved, obesity may contribute to persistent or recurrent lower urinary tract symptoms. These findings underscore the importance of preoperative counseling, close postoperative follow-up, and individualized management for women with severe obesity undergoing pelvic floor reconstructive surgery.Table 1Table 2

Available reports of surgeon efficiency when transitioning from laparoscopic to robotic-assisted (RA) inguinal hernia repair (IHR) are retrospective or describe single-center experience. The purpose of this study is to provide a prospective, multi-surgeon, multi-center assessment of surgeon efficiency when transitioning from Lap-IHR to RA-IHR. General surgeons with Lap-IHR experience (≥300 Lap-IHRs prior to the study) but with no robotic experience (no RA cases one year prior to the study) consented to participate in this prospective, observational pilot study of their surgical efficiency as they adopted RA-IHR. Efficiency was measured through procedure durations, including skin-to-skin time and time to establish critical view of the myopectineal orifice (MPO). Rates of conversions, and adverse events (AEs) through 30 days post RA-IHR procedure were also reported. Outcomes with 95% confidence intervals (95% CI) describe surgeons' collective and individual unilateral and bilateral early, middle, and late-phase cases, with each surgeon contributing 25 consecutive cases at each phase. Four surgeons consented to enroll in the study and provided 75 consecutive, prospective RA-IHR cases. Collectively, the surgeons reached relative skin-to-skin time efficiencies for their unilateral repairs in the mid-phase of their prospective cases. For RA-IHR bilateral procedures, skin-to-skin time efficiency was reached in the late-phase cases. Surgeons' skin-to-skin efficiency times varied relative to their retrospective Lap-IHRs. Possible confounders included practice patterns, referrals, proctoring periods, and-for one surgeon-Covid interruptions. One conversion from RA-IHR to open resulted from severe adhesions present after prior prostatectomy. AEs varied broadly from surgeon to surgeon. The four surgeons improved their skin-to-skin efficiencies.

Scholarly activities are essential for enhancing the pharmacy profession, as well as for personal career development. New practitioner pharmacists in academic or community medical center settings may hesitate to incorporate research into their practice if they feel that they do not have the appropriate resources and guidance. While residency provides structured support for research endeavors, new pharmacists may still find research activities daunting to initiate on their own. Many factors should be considered, including strategies for incorporating research into current roles, collaboration efforts, professional opportunities, and timeline considerations, to help pharmacists effectively implement research early in their careers. This article provides new practitioners with a roadmap to navigate challenges and achieve success when integrating scholarly activities into their practice.

Ultrasound-guided erector spinae plane block (ESPB) has emerged as a valuable technique in pain management. Though frequently used in chronic and postoperative pain, it remains underutilized in the emergency department (ED) setting. In particular, this block has become attractive because it is rapid, safe, and efficacious for a variety of different pain syndromes that are commonly encountered in the emergency department setting. Of particular importance is that this block results in pure sensory blockade, allowing patient movement after the procedure has been performed. This case series explores the efficacy of the ESPB in various clinical scenarios, including refractory cervical radiculopathy, rib fractures, obstructive nephrolithiasis, and sciatica. Each of these patients presented with symptoms of refractory aggressive pain management strategies, including non-steroidal anti-inflammatory drugs (NSAIDS), acetaminophen, narcotics, muscle relaxers, and ketamine. After undergoing ESPB, the patients were able to be successfully discharged without return visits to the emergency department for the return of their pain. This case series aims to show the utility of this procedure for refractory painful conditions and also reviews other indications where the block may be used. While previous reports have shown the utility of this block at individual levels, we present the flexibility of this block being used at multiple levels of the spine.

Background:We published proof-of-principle study results demonstrating the potential utility of computer vision (Deep Neural Network/DNN) methods applied to trichrome-stained skin biopsy sections from patients with systemic sclerosis (SSc) as a novel quantitative skin outcome. Briefly, an DNN algorithm (AlexNet) was applied to each of one hundred randomly selected image patches (0.16mm2) to generate 4,096 quantitative image features (QIFs)/ image patch (409,600 QIFs/ section). A linear regression model comprised of QIFs (predictor variables) was generated that predicted the modified Rodnan Skin Score (mRSS) termed ‘DNN Fibrosis Score’. Others published 16 SSc-associated histological variables (Figure 1a) (Van Praet 2011).Objectives:The present study compared real world ‘DNN Fibrosis Score’ changes with histopathologic and modified Rodnan Skin Score (mRSS) changes for clinical trial participants.Methods:Ten adults with early (≤ 6 y) diffuse cutaneous SSc (15 ≤ mRSS ≤ 35) in a belumosudil (ROCK2 inhibitor, 200 mg PO BID) open-label trial had mRSS and 4mm, dorsal arm skin biopsies performed at weeks (W) 0, 24, and 52. Biopsies were stained with CD34, CD3, CD8, alpha smooth muscle actin (ASMA), H&E, and trichrome. Two blinded dermatopathologists assessed biopsies for 16 histopathological parameters. CD3+, CD8+ cells were counted, and ordinal scales were used to score CD34, ASMA, and relative SSc severity on H&E and trichrome-stained slides (Figure 1a). As above, AlexNet was applied to image patches to generate QIFs, and a linear regression model to predict mRSS was generated (‘DNN Fibrosis Score’). ‘DNN Fibrosis Scores’ were compared to mRSS (ρcorrelation). Histopathologic parameters were compared to mRSS or DNN Fibrosis Scores using logistic regression models where odds ratios and p-values were used to show the relationship between DNN Fibrosis Scores or mRSS changes and histological parameter changes (Figure 1d). A p≤0.05 was considered significant.Results:Ten participants were enrolled, and the median (interquartile range/IQR) mRSS change between 0 - 52W was -2.5 (-11 to 7.5) (Figure 1b). Due to fixation issues, only five patients had paired biopsies available (Figure 2). The median/IQR DNN Fibrosis Score change (W0 - last follow-up) was -6 (-10.5 to 6.5) (Figure 1b). Of the histopathological scores, subcutaneous (SC) fat loss (p-value = 0.012), eccrine entrapment (p-value = 0.008), % CD8+ among CD3+ cells (p-value = 0.006) changed most during treatment. The correlation between mRSS and DNN Fibrosis Score for the five paired biopsies was 0.18, p-value =0.674 (weaker correlation at higher mRSS] (Figure 1c). Per 1-unit mRSS change, the histopathological parameter odds ratio (OR); p-values were: telangiectasia =2.01; 0.001, perivascular CD3+ =1.03; 0.015, and % of CD8+ among CD3+ =1.08; 0.031 (Figure 1d). Likewise, per 1-unit DNN Fibrosis Score change, OR; p-values for histopathological parameters were: hyalinized collagen =1.1; 0.00033, SC fat loss =1.47; 0.00033, thickened vascular intimal wall =1.21; 0.005, and eccrine entrapment =1.14; 0.046 (Figure 1d).Conclusion:In this novel analysis to explore the potential utility of artificial intelligence applied to stained skin biopsies from patients with SSc as a quantity, the DNN Fibrosis Score mirrored changes in the mRSS and was sensitive to histopathologic changes. Belumosudil treatment was associated with non-clinically important mRSS improvement that mirrored decreases in telangiectasia, perivascular CD3+, and % CD8+ among CD3+ cells. The weak correlation between mRSS and DNN-Fibrosis Score contrasted with our previous findings that we attribute to batch effects from staining protocols between our published and our current analysis which may be overcome with analyses of larger cohorts.Figure 1.Histopathology assessment and Belumosudil open-label trial results. a. Ordinal scales for histopathology. b. Subject’s mRSS W0 to last follow-up. c. Scatter plot of DNN Fibrosis Score and mRSS. d. Logistic regression comparing DNN Fibrosis Score to histologic parameters.Figure 2.Stained skin biopsy slide images with corresponding mRSS. Stained sections from participants with the largest mRSS changes (40x).REFERENCES: NIL. Acknowledgements:Kadmon CorporationDisclosure of Interests:Baran Gunes: None declared, Lucy Duran Camacho: None declared, Shawn Cowper: None declared, Gauri Panse: None declared, Nicolas Page: None declared, Elizabeth Bundschuh: None declared, Alyssa Williams: None declared, Mary Carns: None declared, Kathleen Aren: None declared, Niki Pradhan: None declared, Elana Bernstein Boehringer Ingelheim, Boehringer Ingelheim, Pfizer, Sarah Fantus: None declared, Elizabeth Volkmann Boehringer Ingelheim, Boehringer Ingelheim, GSK, CSL Behring, Boehringer Ingelheim, Kadmon, Horizon, Prometheus, Heather Bukiri: None declared, Chase Correia: None declared, Francis Wilson AstraZeneca, Amgen, and Vifor Pharma., Seamus Mawe: None declared, J. Matthew Mahoney: None declared, Rui Wang Sanofi, Monqiue Hinchcliff Kadmon Corporation and Boehringer Ingelheim.

A 68-year-old Hispanic man was referred to our center for cutaneous vasculitis of the lower extremities, diagnosed via skin biopsy. He had a 10-year history of erythematous plaques complicated by persistent, non-healing ulcers previously treated with prednisone and hydroxychloroquine. Laboratory testing was significant for positive U1-ribonucleoprotein antibody, antinuclear antibody human epithelial-2, and an elevated erythrocyte sedimentation rate. A repeat skin biopsy revealed nonspecific ulcerations. The patient was diagnosed with a mixed connective tissue disease with features of scleroderma. Mycophenolate was initiated, and prednisone was tapered. After two years of relapsing ulcerations on his lower extremities, a third skin punch biopsy showed dermal granulomas with numerous acid-fast organisms, and a polymerase chain reaction identifiedMycobacterium lepromatosis, indicating polar lepromatous leprosy with an erythema nodosum leprosum reaction. After three months of minocycline and rifampin therapy, his lower extremity ulcerations and erythema resolved. Our case highlights the variable and elusive nature of this disease, which can mimic many systemic rheumatologic conditions.