Giant cystic degeneration of a uterine leiomyoma in a patient with autosomal dominant polycystic kidney disease

Objective: To report the management of a large uterine leiomyoma with diffuse cystic degeneration in a patient with autosomal dominant polycystic kidney disease (ADPKD). Design: Case Report. Setting: Cleveland Clinic Florida, Department of Gynecology, Section of Minimally Invasive Gynecologic surgery, Weston Florida. Patient(s): A 52-year old woman with ADPKD with a large abdominal mass, abnormal uterine bleeding and symptomatic anemia. Imaging revealed a giant intramural cystic lesion of the uterus compressing the inferior vena cava. Intervention(s): Uterine artery embolization and blood transfusion followed by a computed tomography guided cyst aspiration were performed on admission to alleviate anemia and abdominal pain and distension. Total laparoscopic hysterectomy with bilateral salpingectomy was performed in an outpatient setting. Main Outcome Measure(s): Management of large cystic degeneration of leiomyoma. Results: Normal recovery from definitive surgery. Surgical pathology confirmed a benign, cystically dilated leiomyoma. Conclusion: This case demonstrates the management of giant intramural cyst lesion of the uterus using a minimally invasive surgical approach, as opposed to emergency surgery via laparotomy. Capsule: Large uterine leiomyoma with diffuse cystic degeneration in a patient with autosomal dominant polycystic kidney disease, in which step-wise treatments allows successful minimally invasive hysterectomy

It's how you say it: Systematic A/B testing of digital messaging cut hospital no-show rates.

Failure to attend hospital appointments has a detrimental impact on care quality. Documented efforts to address this challenge have only modestly decreased no-show rates. Behavioral economics theory has suggested that more effective messages may lead to increased responsiveness. In complex, real-world settings, it has proven difficult to predict the optimal message composition. In this study, we aimed to systematically compare the effects of several pre-appointment message formats on no-show rates. We randomly assigned members from Clalit Health Services (CHS), the largest payer-provider healthcare organization in Israel, who had scheduled outpatient clinic appointments in 14 CHS hospitals, to one of nine groups. Each individual received a pre-appointment SMS text reminder five days before the appointment, which differed by group. No-show and advanced cancellation rates were compared between the eight alternative messages, with the previously used generic message serving as the control. There were 161,587 CHS members who received pre-appointment reminder messages who were included in this study. Five message frames significantly differed from the control group. Members who received a reminder designed to evoke emotional guilt had a no-show rates of 14.2%, compared with 21.1% in the control group (odds ratio [OR]: 0.69, 95% confidence interval [CI]: 0.67, 0.76), and an advanced cancellation rate of 26.3% compared with 17.2% in the control group (OR: 1.2, 95% CI: 1.19, 1.21). Four additional reminder formats demonstrated significantly improved impact on no-show rates, compared to the control, though not as effective as the best performing message format. Carefully selecting the narrative of pre-appointment SMS reminders can lead to a marked decrease in no-show rates. The process of a/b testing, selecting, and adopting optimal messages is a practical example of implementing the learning healthcare system paradigm, which could prevent up to one-third of the 352,000 annually unattended appointments in Israel

Mortality After Complex Displaced Proximal Humerus Fractures in Elderly Patients: Conservative Versus Operative Treatment With Reverse Total Shoulder Arthroplasty

Introduction: Proximal humerus fractures (PHFs) are a common fragility fracture and have been shown to increase mortality in elderly patients. In the last decade, reverse total shoulder arthroplasty (RTSA) was introduced as a reliable operative treatment option for this indication. In other fragility fractures, most notably hip fractures, urgent surgical treatment can reduce mortality. The purpose of this study is to evaluate whether treatment with RTSA can reduce 1-year mortality in elderly patients with complex displaced PHFs. Materials and Methods: A retrospective study was performed to compare 1-year mortality between 2 groups of elderly patients (>75 years old) who presented to a level 1 trauma center emergency department with complex displaced PHFs. The conservative treatment group (n = 83; mean age, 83.7 years) presented from 2008 to 2010 when RTSA was not yet available, and treatment was nonoperative. The surgical treatment group (n = 62; mean age, 82.2 years) presented from 2012 to 2015 and underwent RTSA. Results: One-year mortality was 8.1% (male 7.1%; female 8.3%) in the surgical treatment group and 10.8% (male 18.8%; female 9.0%) in the conservative treatment group. The reduction in mortality in the surgical treatment group was not significant (entire cohort P = .56; males P = .35; females P = .59). Discussion: Recent studies failed to show better functional results after surgical treatment with RTSA when compared to conservative treatment. This study suggests that a benefit of surgical treatment with RTSA that was not examined until now might exist—a reduction in the increased mortality risk associated with PHFs. Conclusions: There was no significant difference in 1-year mortality between the groups, although there was a trend showing lower mortality with RTSA, mostly in men. Further studies with larger populations and longer follow-up times are needed to determine whether this trend is of clinical significance