Something has Fallen: Pelvic Organ Prolapse or Vaginal Cuff Dehiscence and Evisceration? A Case Report.

SOMETHING HAS FALLEN: PELVIC ORGAN PROLAPSE OR VAGINAL CUFF DEHISCENCE AND EVISCERATION? A CASE REPORT.Learning Objectives: 1) Recognize late presenting complications of hysterectomy. 2) Include vaginal cuff dehiscence with evisceration (VCDE) in the differential diagnosis of women suspected of having acute pelvic organ prolapse (POP).3) Appreciate the relative rarity of VCDE in younger women.Case Summary: A 36 year old G0P0 female presented to the ED with a chief complaint of sudden onset excruciating epigastric pain, followed by diarrhea and visible vaginal bulge. Pertinent past medical and surgical history includes breast cancer diagnosed 15 months prior, status post bilateral mastectomy, radiation, chemotherapy, and robotic-assisted prophylactic hysterectomy and BSO 6 months prior. Relevant social history includes tobacco use and first postoperative coitus 2 days prior. CT abdomen/pelvis findings included microscopic pneumoperitoneum, pelvic organ prolapse, prolapse of bowel loops into the vaginal vault, and localized small bowel obstruction. In the ED she was diagnosed with POP, which was reduced, leading to a reduction in her pain. Subsequent examination revealed an abdomen tender to palpation. Speculum exam displayed no pelvic organ prolapse. Bowel was visible at the vaginal cuff with clear yellow fluid pooling in the vaginal vault. Vesicovaginal fistula was ruled out and VCDE was suspected. During exploratory laparoscopy, a 4 cm vaginal cuff defect was found and transvaginal cuff closure was performed. Post-operative course was uncomplicated, and the patient was discharged on POD #2

Baseline Results:The Association between Cardiovascular Risk and Preclinical Alzheimer's Disease Pathology (ASCEND) Study

BACKGROUND: The rate of AD for African Americans (AAs) is 64% higher than for non-Hispanic White Americans (Whites). It is hypothesized that poor peripheral vascular function, in combination with genetics, stress, and inflammation may directly contribute to the accumulation of AD pathologic biomarkers. These risk factors may disproportionately affect AAs. OBJECTIVE: Our objective was to determine if in a healthy middle-aged cohort at risk for AD (1) AD biomarkers in CSF differ by race, (2) peripheral vascular dysfunction and cognition are related to a higher burden of CSF AD biomarkers, and (3) these relationships differ by race. METHODS: We enrolled 82 cognitively normal, middle-aged (45 and older) adults including AAs and Whites at high risk for AD due to parental history. Study procedures included lumbar puncture, vascular ultrasound, and cognitive testing. RESULTS: While participants were in overall good health, AAs exhibited poorer indices of preclinical vascular health, including higher central SBP, central MAP, and EndoPAT AI, a marker of arterial stiffness. AAs also had significantly less cerebrospinal fluid tau burden than Whites. After polynomial regression analysis, adjusted for age, gender, education, and ApoE4 status, race significantly modified the relationship between total tau, phospho-tau, and Trails B, a marker of executive function. Small differences in tau correlated with poorer cognition in AAs. CONCLUSION: In a healthy middle-aged cohort at risk for AD, AAs had worse peripheral vascular health and worse cognition than Whites. Despite lower tau burden overall, race modified the relationship between tau and cognition, such that small differences in tau between AAs was related to worse cognition when compared to Whites

Postpartum Urinary Retention: An Expert Review

Postpartum urinary retention is a relatively common condition that can have a significant impact on women in the immediate days following childbirth. If left untreated, postpartum urinary retention can lead to repetitive overdistention injury that may damage the detrusor muscle and the parasympathetic nerve fibers within the bladder wall. In rare circumstances, postpartum urinary retention may even lead to bladder rupture, which is a potentially life-threatening yet entirely preventable complication. Early diagnosis and timely intervention are necessary to decrease long-term consequences. There are three types of postpartum urinary retention: overt, covert, and persistent. Overt retention is associated with an inability to void, while covert is associated with incomplete bladder emptying. Persistent urinary retention continues beyond the third postpartum day and can persist for several weeks in rare cases. Recognition of risk factors and prompt diagnosis is important for proper management and prevention of negative sequelae. However, lack of knowledge from providers and patients alike creates barriers to accessing and receiving evidence-based care and may further delay diagnosis for patients, especially those who experience covert postpartum urinary retention. Nationally accepted definitions and management algorithms for postpartum urinary retention are lacking, and development of such guidelines is essential for both patient care and research design. We propose intrapartum recommendations and a standardized postpartum bladder management protocol that will improve patient outcomes and contribute to the growing body of evidence-based practice in this field