Article

Work-related musculoskeletal disorders (WMSDs) are “musculoskeletal disorders (injuries or disorders of the muscles, nerves, tendons, joints, cartilage, and spinal discs) in which the work environment and performance of work contribute significantly to the condition; and/or the condition is made worse or persists longer due to work conditions.”¹ The health care industry has one of the highest rates of WMSDs, even when compared with traditional labor-intensive occupations, such as coal mining. In 2017, the health care industry reported more than a half million incidents of work-related injury and illness.^2,3 In particular, surgeons are at increased risk for WMSDs, since they repetitively perform the classic tenets of poor ergonomics, including operating in static, extreme, and awkward positions and for prolonged periods of time.³

Gynecologic surgeons face unique ergonomic challenges. Operating in the pelvis requires an oblique approach that adds complexity and inhibits appropriate ergonomic positioning.⁴ All modalities of surgery incur their own challenges and risks to the surgeon, including minimally invasive gynecologic surgery (MIGS), which has become the standard of care for most conditions. Although MIGS has several benefits for the patient, a survey of gynecologic oncologists found that 88% of respondents reported discomfort related to MIGS.⁵ Several factors contribute to the development of WMSDs in surgery, including lack of ergonomic awareness, suboptimal ergonomic education and training,^5,6 and ergonomically poor operating room (OR) equipment and instrument design.⁷ Furthermore, surgical culture does not generally prioritize ergonomics in the OR or requests for ergonomic accommodations.^7,8

Within 5 years, a physician workforce shortage is projected for the United States.⁹ WMSDs contribute to workforce issues as they are associated with decreased productivity; time off needed for pain and treatment, including short-term disability; and possibly early retirement (as those who are older and have more work experience may be more likely to seek medical attention).¹⁰ In a 2013 study of vaginal surgeons, 14% missed work; 21% modified their work hours, work type, or amount of surgery; and 29% modified their surgical technique because of injury.¹⁰ Work-related pain also can negatively affect mental health, sleep, relationships, and quality of life.⁶

Recently, awareness has increased regarding WMSDs and their consequences, which has led to significant strides in the study of ergonomics among surgeons, a growing body of research on the topic, and guidance for optimizing ergonomics in the OR.

Risk factors for ergonomic strain

Several factors contribute to ergonomic strain and, subsequently, the development of WMSDs. Recognizing these factors can direct strategies for injury prevention.

Patient factors

The prevalence of obesity in the United States increased from 30.5% in 1999–2000 to 41.9% between 2017 and 2020.¹¹ As the average patient’s body mass index (BMI) has increased, there is concern for a parallel increase in the ergonomic strain on laparoscopic surgeons.

A study of simulated laparoscopic tasks at varying model BMI levels demonstrated increased surgeon postural stress and workload at higher model BMIs (50 kg/m²) when compared with lower model BMIs (20 and 30 kg/m²).¹¹ This result was supported in another study, which demonstrated both increased muscle activity and increased time needed to complete a surgical task with laparoscopic surgery; interestingly, when the same study measured these parameters for robotic surgery, this association was not seen.¹² This suggests that a robotic rather than a laparoscopic approach may avoid some of the ergonomic strain associated with increased patient BMI.

Continue to: Surgeon factors...

Surgeon factors

Various surgeon characteristics have been shown to influence ergonomics in the OR. Surgeons with smaller hand sizes, for example, reported greater physical discomfort and demonstrated greater ergonomic workload when operating laparoscopically.^13-15 In particular, those with a glove size of 6.5 or smaller have more difficulty using laparoscopic instruments, and those with a glove size smaller than 7 demonstrate a larger decline in grip strength when using laparoscopic instruments repeatedly.^14,16

Surgeon height also can affect the amount of time spent in high-risk, nonergonomic positions. In a study that evaluated video recordings of surgeon posture during gynecologic laparoscopy, shorter surgeons were noted to use greater degrees of neck rotation to look at the monitor.¹⁷ Furthermore, surgeons with shorter arm lengths experienced more “extreme positions” of the nondominant shoulder and elbow.¹⁷ This trend also was seen in open and robotic surgery, where surgeons with a height of 66 cm or less reported increased pain scores after operating.¹⁸

Surgical instruments and OR setup

Surgical instrument characteristics can contribute to ergonomic strain, especially when the instruments have been designed with a one-size-fits-all mentality.^8,19 In an examination of the anthropometric measurements of surgeon hand sizes and their correlation with difficulty when using a “standard” laparoscopic instrument, surgeons with smaller finger and hand spans had trouble using these instruments.¹⁹ Another study compared surgeon grip strength and ergonomic workloads after using 3 laparoscopic advanced bipolar instruments.¹⁶ Gender and hand size aside, the authors found that use of several of the laparoscopic devices led to greater decline in grip strength.¹⁶

The setup of the OR also can have a profound effect on the surgeon’s ergonomics. Monitor placement, for example, is crucial to ergonomic success. One study found that positioning the monitor directly in front of the surgeon at eye level was associated with the lowest neck muscle activity during a simulated task.²⁰

Route of surgery

Each surgical approach has intrinsic ergonomic risks. With laparoscopy, surgeons often remain in straight head and back positions without much trunk motion, especially when compared with open surgery.²¹ In one study, laparoscopic surgeons spent more than 60% of a case in a static position and more than 80% of a case in a high-risk, “demanding” neck position.²²

Robotic surgery, in contrast to laparoscopy, often has been cited as being more “ergonomic.” While robotic surgery has less of an effect on the neck, shoulders, arms, and legs than laparoscopy²³ and often is associated with less physical discomfort than either open or laparoscopic surgery,^23,24 robotic surgery still maintains its own innate ergonomic risks. Of robotic surgeons surveyed, 56.1% reported neck stiffness, finger fatigue, and eye symptoms in one study.²⁵ In another survey study, more robotic surgeons (72%) reported physical symptoms than laparoscopic (57%) and open (49%) surgeons.²⁶Vaginal surgery also puts surgeons at ergonomic risk. A majority of surgeons (87.2%) who completed more than 50% of their cases vaginally reported a history of WMSDs.¹⁰ Vaginal surgery places surgeons in awkward positions of the neck, shoulder, and trunk frequently and for longer durations.²⁷

Continue to: Strategies for preventing WMSDs...

Strategies for preventing WMSDs

As factors that contribute to the development of WMSDs are identified, preventive strategies can be targeted to these individual factors. Research has focused on appropriate setup of the OR, surgeon posture, intraoperative microbreaks, and stretching both in and outside of the OR.

1. OR setup and positioning of the surgeon by MIGS route

The route of MIGS affects OR setup and surgeon posture. Ergonomic recommendations for laparoscopy, robotic surgery, and vaginal surgery are all unique to the risks posed by each particular approach.

Laparoscopic surgery. Laparoscopic monitors should face the surgeon directly, with the screen just below eye level to maintain the surgeon’s neck in a neutral position.²⁸ The table height should be set for the tallest surgeon, and shorter surgeons should stand on steps as needed.²⁸ The table height also should allow for the surgeon’s hands to be at elbow height, with the elbows bent at 90 degrees with the wrists straight.²⁹ Foot pedals should be placed at the surgeons’ foot level and should be reached easily.²⁸ Additionally, the patient’s arms should be tucked at their sides to allow surgeons a larger operative space.²⁹ When using laparoscopic instruments, locking and ratcheting features should be used whenever possible to reduce prolonged grip or squeeze forces.²⁸ The laparoscopic camera should be held in the palm with the wrist in a neutral position.²⁹

Robotic surgery. Positioning and setup of the robotic console is a main focus of ergonomic recommendations. The surgeon’s chair should be brought as close to the console as possible, and the knees positioned in a 90-degree angle.³⁰ The foot pedals should be brought toward the surgeon to maintain this angle of the knees.³⁰ The console should be rotated toward the surgeon and then the height adjusted so that the surgeon can look through the eyepiece while sitting upright and can maintain the neck in a neutral position.^28,30 The surgeon’s forehead should rest comfortably on the headrest.²⁹ The forearms should rest on the armrest while the arms are maintained in a neutral position and the shoulders remain relaxed while the surgeon holds the robotic controls.³⁰ It is important to utilize the armrest often to relieve stress on the arm while operating.²⁸ Frequent use of the clutch function can keep the robotic controls in the center of the workspace.²⁸

Vaginal surgery. Both seated and standing positions are associated with high-risk positioning of the trunk and bilateral shoulders, respectively, in vaginal surgery.³¹ However, surgeons who stand while operating vaginally reported more discomfort in the bilateral wrists, thighs, and lower legs than those who operated while seated.³¹ This suggests a potential ergonomic advantage to the seated position for vaginal surgery. Chair height should be adjusted so the surgeon can look straight ahead with the neck in a neutral position.³² Surgeons should consider using a headlamp, as this may prevent repetitive awkward movements to adjust overhead lights.³² For standing surgery, the table height should be adjusted for the tallest surgeon, and shorter surgeons or assistants should use steps as needed.³

Surgical assistants should switch sides during the course of the case to avoid excessive unilateral upper-extremity strain.³² The addition of a table-mounted vaginal retractor system may be useful in relieving physical strain for surgical assistants, but data currently are lacking to demonstrate this ergonomic benefit.³³ Further studies are needed, especially since many surgeons take on the role of surgical assist in the teaching environment and subsequently report more WMSDs than their colleagues who do not work in teaching environments.^10,34

2. Pain relief from individual ergonomic positioning devices

Apart from adjusting how the OR equipment is arranged or how the surgeons adjust their positioning, several devices that assist with surgeon positioning—including gel mats or insoles, exoskeletons, and “augmented reality” glasses—are being studied.

The use of gel mats or insoles in the OR has mixed evidence in the literature.^35-37

Exoskeletons, external devices that support a surgeon’s posture and positioning, have been studied thus far in simulated nonsterile surgical environments. Preliminarily, it appears that use of an exoskeleton can decrease muscle activity and time spent in static positions, with a reported decrease in post-task user discomfort.^38,39 More data are needed to determine if exoskeletons can be used in the sterile setting and for longer durations as may occur in actual OR cases.

Augmented reality glasses project the laparoscopic monitor image to the glasses, which frees the surgeon to place the “monitor” in a more neutral, ergonomic position. In one study, use of augmented reality glasses was associated with decreased muscle activity and a reduction in Rapid Entire Body Assessment (REBA) scores when compared with use of the conventional laparoscopic monitor.⁴⁰More data are needed on these emerging technologies to determine whether adverse effects occur with prolonged use.

Continue to: 3. Implementing intraoperative microbreaks and stretching...

 

 

3. Implementing intraoperative microbreaks and stretching

The American College of Surgeons (ACS) recommends that surgeons avoid prolonged static postures during procedures.²⁸ One strategy for preventing sustained positioning is to incorporate breaks with associated stretching routinely during surgery.²⁸

Microbreaks. In a landmark study by Park and colleagues in 2017, 120-second long targeted stretching microbreaks (TSMBs) were completed every 20 to 40 minutes during a surgery, and results demonstrated improved postoperative surgeon pain scores without an associated increase in the length of the case.⁴¹ These surgeons reported improved pain in the neck, bilateral shoulders, bilateral hands, and lower back. Eighty-eight percent of surgeons reported either improvement or “no change” in their mental focus, and 100% reported improvement or “no change” in their physical performance after TSMBs were implemented.⁴² Of surveyed surgeons, 87% wanted TSMBs incorporated routinely.^41,42

Stretches. Multiple resources, such as the ACS and the Mayo Clinic, for intraoperative stretches are available. The ACS recommends performing neck and shoulder stretches during intraoperative microbreaks, including a range-of-movement neck exercise, deep cervical flexor training, and standing scapular retraction.²⁸ The ACS also demonstrates lumbrical stretches for the fingers and passive wrist extension exercises to be used intraoperatively (or between cases) (FIGURE 1).²⁸ The Mayo Clinic Hallbeck Human Factors Engineering Laboratories has a publicly available “OR Stretch Instructional Video” in which the surgeon is guided through several different short stretches, including shoulder shrugging and side bends, that can be used during surgery.⁴³

Both the ACS and the Mayo Clinic provide examples of pertinent stretch exercises for use when not in the sterile environment, between cases or after cases are complete. The ACS recommends several neck and shoulder stretches for the trapezius, levator scapulae, and pectoralis and recommends the use of a foam roller to improve thoracic mobility (FIGURE 2).²⁸ As above, the Mayo Clinic Hallbeck Human Factors Engineering Laboratories has a publicly available “OR-Stretch Between Surgery Stretches Video” in which the surgeon is guided through several short stretches that are done in a seated position, including stretches for the hamstring, lower back, and arms (FIGURE 3).⁴³

Many of the above-mentioned stretches were designed for use in the context of open, laparoscopic, or robotic surgery. For the vaginal surgeon, the intraoperative ergonomic stressors differ from those of other routes of surgery, and thus stretches tailored to the positioning during vaginal surgery are necessary. In a video recently published by the Society of Gynecologic Surgeons, several stretches are reviewed that target high-risk positions often held by the surgeon or assistant when operating vaginally.⁴⁴ These stretches include cervical retraction, thoracic extension, external arm rotation, cervical side bending, and lumbar extension (FIGURE 4).⁴⁴ The recommendation is to complete these exercises 2 times per day, with 8 to 10 repetitions per set.⁴⁴

Prioritizing ergonomic awareness and training

As caregivers, it is not uncommon for us to prioritize the needs of others before those of ourselves. However, WMSDs are prevalent, and their downstream effects may cause catastrophic professional and personal losses. Cumulatively, the global impact of WMSDs is a significant issue for the health care workforce and its longevity.

To prevent WMSDs, it is imperative that surgeons are aware of the factors that contribute to injury development and the appropriate, accessible modifications for these factors. While each surgical modality confers its own ergonomic challenges, these risks can be mitigated through increased awareness of OR setup, surgeon positioning, and incorporation of microbreaks and stretching exercises during and after surgical procedures.

Formal training in surgical ergonomics is lacking across specialties, including gynecology.⁴⁵ Multiple educational interventions have been proposed and studied to help fill this training gap.^30,46-49When used, these interventions have been associated with increased knowledge of surgical ergonomic principles or reduction in surgeon pain scores, including trainees.⁵⁰ As we become more cognizant of WMSDs, standardized resident curricula should be developed in an effort to reduce the prevalence of these potentially career-ending injuries.

In addition to education, cultivating a culture in which ergonomics is prioritized is essential. Although most surgeons report work-related pain, very few report their injuries to occupational health. For example, while 29% of gynecologic oncologists reported seeking treatment for a WMSD, only 1% had reported their injury to their employer.⁵ In a study of ACS members, only 19% of injuries were reported, 30% of surgeons stated that they did not know how to report an injury, and 21% felt that the resources for surgeons during and after an injury were inadequate.⁶

As we prioritize the health and safety of our patients, we also need to promote ergonomic awareness in the OR, respect the need for accommodations, encourage injury reporting, support surgeons who need to take time away for medical treatment, and partner with industry to develop new instruments and technology with effective ergonomic features. ●

Work-related musculoskeletal disorders (WMSDs) are “musculoskeletal disorders (injuries or disorders of the muscles, nerves, tendons, joints, cartilage, and spinal discs) in which the work environment and performance of work contribute significantly to the condition; and/or the condition is made worse or persists longer due to work conditions.”¹ The health care industry has one of the highest rates of WMSDs, even when compared with traditional labor-intensive occupations, such as coal mining. In 2017, the health care industry reported more than a half million incidents of work-related injury and illness.^2,3 In particular, surgeons are at increased risk for WMSDs, since they repetitively perform the classic tenets of poor ergonomics, including operating in static, extreme, and awkward positions and for prolonged periods of time.³

Gynecologic surgeons face unique ergonomic challenges. Operating in the pelvis requires an oblique approach that adds complexity and inhibits appropriate ergonomic positioning.⁴ All modalities of surgery incur their own challenges and risks to the surgeon, including minimally invasive gynecologic surgery (MIGS), which has become the standard of care for most conditions. Although MIGS has several benefits for the patient, a survey of gynecologic oncologists found that 88% of respondents reported discomfort related to MIGS.⁵ Several factors contribute to the development of WMSDs in surgery, including lack of ergonomic awareness, suboptimal ergonomic education and training,^5,6 and ergonomically poor operating room (OR) equipment and instrument design.⁷ Furthermore, surgical culture does not generally prioritize ergonomics in the OR or requests for ergonomic accommodations.^7,8

Within 5 years, a physician workforce shortage is projected for the United States.⁹ WMSDs contribute to workforce issues as they are associated with decreased productivity; time off needed for pain and treatment, including short-term disability; and possibly early retirement (as those who are older and have more work experience may be more likely to seek medical attention).¹⁰ In a 2013 study of vaginal surgeons, 14% missed work; 21% modified their work hours, work type, or amount of surgery; and 29% modified their surgical technique because of injury.¹⁰ Work-related pain also can negatively affect mental health, sleep, relationships, and quality of life.⁶

Recently, awareness has increased regarding WMSDs and their consequences, which has led to significant strides in the study of ergonomics among surgeons, a growing body of research on the topic, and guidance for optimizing ergonomics in the OR.

Risk factors for ergonomic strain

Several factors contribute to ergonomic strain and, subsequently, the development of WMSDs. Recognizing these factors can direct strategies for injury prevention.

Patient factors

The prevalence of obesity in the United States increased from 30.5% in 1999–2000 to 41.9% between 2017 and 2020.¹¹ As the average patient’s body mass index (BMI) has increased, there is concern for a parallel increase in the ergonomic strain on laparoscopic surgeons.

A study of simulated laparoscopic tasks at varying model BMI levels demonstrated increased surgeon postural stress and workload at higher model BMIs (50 kg/m²) when compared with lower model BMIs (20 and 30 kg/m²).¹¹ This result was supported in another study, which demonstrated both increased muscle activity and increased time needed to complete a surgical task with laparoscopic surgery; interestingly, when the same study measured these parameters for robotic surgery, this association was not seen.¹² This suggests that a robotic rather than a laparoscopic approach may avoid some of the ergonomic strain associated with increased patient BMI.

Continue to: Surgeon factors...

Surgeon factors

Various surgeon characteristics have been shown to influence ergonomics in the OR. Surgeons with smaller hand sizes, for example, reported greater physical discomfort and demonstrated greater ergonomic workload when operating laparoscopically.^13-15 In particular, those with a glove size of 6.5 or smaller have more difficulty using laparoscopic instruments, and those with a glove size smaller than 7 demonstrate a larger decline in grip strength when using laparoscopic instruments repeatedly.^14,16

Surgeon height also can affect the amount of time spent in high-risk, nonergonomic positions. In a study that evaluated video recordings of surgeon posture during gynecologic laparoscopy, shorter surgeons were noted to use greater degrees of neck rotation to look at the monitor.¹⁷ Furthermore, surgeons with shorter arm lengths experienced more “extreme positions” of the nondominant shoulder and elbow.¹⁷ This trend also was seen in open and robotic surgery, where surgeons with a height of 66 cm or less reported increased pain scores after operating.¹⁸

Surgical instruments and OR setup

Surgical instrument characteristics can contribute to ergonomic strain, especially when the instruments have been designed with a one-size-fits-all mentality.^8,19 In an examination of the anthropometric measurements of surgeon hand sizes and their correlation with difficulty when using a “standard” laparoscopic instrument, surgeons with smaller finger and hand spans had trouble using these instruments.¹⁹ Another study compared surgeon grip strength and ergonomic workloads after using 3 laparoscopic advanced bipolar instruments.¹⁶ Gender and hand size aside, the authors found that use of several of the laparoscopic devices led to greater decline in grip strength.¹⁶

The setup of the OR also can have a profound effect on the surgeon’s ergonomics. Monitor placement, for example, is crucial to ergonomic success. One study found that positioning the monitor directly in front of the surgeon at eye level was associated with the lowest neck muscle activity during a simulated task.²⁰

Route of surgery

Each surgical approach has intrinsic ergonomic risks. With laparoscopy, surgeons often remain in straight head and back positions without much trunk motion, especially when compared with open surgery.²¹ In one study, laparoscopic surgeons spent more than 60% of a case in a static position and more than 80% of a case in a high-risk, “demanding” neck position.²²

Robotic surgery, in contrast to laparoscopy, often has been cited as being more “ergonomic.” While robotic surgery has less of an effect on the neck, shoulders, arms, and legs than laparoscopy²³ and often is associated with less physical discomfort than either open or laparoscopic surgery,^23,24 robotic surgery still maintains its own innate ergonomic risks. Of robotic surgeons surveyed, 56.1% reported neck stiffness, finger fatigue, and eye symptoms in one study.²⁵ In another survey study, more robotic surgeons (72%) reported physical symptoms than laparoscopic (57%) and open (49%) surgeons.²⁶Vaginal surgery also puts surgeons at ergonomic risk. A majority of surgeons (87.2%) who completed more than 50% of their cases vaginally reported a history of WMSDs.¹⁰ Vaginal surgery places surgeons in awkward positions of the neck, shoulder, and trunk frequently and for longer durations.²⁷

Continue to: Strategies for preventing WMSDs...

Strategies for preventing WMSDs

As factors that contribute to the development of WMSDs are identified, preventive strategies can be targeted to these individual factors. Research has focused on appropriate setup of the OR, surgeon posture, intraoperative microbreaks, and stretching both in and outside of the OR.

1. OR setup and positioning of the surgeon by MIGS route

The route of MIGS affects OR setup and surgeon posture. Ergonomic recommendations for laparoscopy, robotic surgery, and vaginal surgery are all unique to the risks posed by each particular approach.

Laparoscopic surgery. Laparoscopic monitors should face the surgeon directly, with the screen just below eye level to maintain the surgeon’s neck in a neutral position.²⁸ The table height should be set for the tallest surgeon, and shorter surgeons should stand on steps as needed.²⁸ The table height also should allow for the surgeon’s hands to be at elbow height, with the elbows bent at 90 degrees with the wrists straight.²⁹ Foot pedals should be placed at the surgeons’ foot level and should be reached easily.²⁸ Additionally, the patient’s arms should be tucked at their sides to allow surgeons a larger operative space.²⁹ When using laparoscopic instruments, locking and ratcheting features should be used whenever possible to reduce prolonged grip or squeeze forces.²⁸ The laparoscopic camera should be held in the palm with the wrist in a neutral position.²⁹

Robotic surgery. Positioning and setup of the robotic console is a main focus of ergonomic recommendations. The surgeon’s chair should be brought as close to the console as possible, and the knees positioned in a 90-degree angle.³⁰ The foot pedals should be brought toward the surgeon to maintain this angle of the knees.³⁰ The console should be rotated toward the surgeon and then the height adjusted so that the surgeon can look through the eyepiece while sitting upright and can maintain the neck in a neutral position.^28,30 The surgeon’s forehead should rest comfortably on the headrest.²⁹ The forearms should rest on the armrest while the arms are maintained in a neutral position and the shoulders remain relaxed while the surgeon holds the robotic controls.³⁰ It is important to utilize the armrest often to relieve stress on the arm while operating.²⁸ Frequent use of the clutch function can keep the robotic controls in the center of the workspace.²⁸

Vaginal surgery. Both seated and standing positions are associated with high-risk positioning of the trunk and bilateral shoulders, respectively, in vaginal surgery.³¹ However, surgeons who stand while operating vaginally reported more discomfort in the bilateral wrists, thighs, and lower legs than those who operated while seated.³¹ This suggests a potential ergonomic advantage to the seated position for vaginal surgery. Chair height should be adjusted so the surgeon can look straight ahead with the neck in a neutral position.³² Surgeons should consider using a headlamp, as this may prevent repetitive awkward movements to adjust overhead lights.³² For standing surgery, the table height should be adjusted for the tallest surgeon, and shorter surgeons or assistants should use steps as needed.³

Surgical assistants should switch sides during the course of the case to avoid excessive unilateral upper-extremity strain.³² The addition of a table-mounted vaginal retractor system may be useful in relieving physical strain for surgical assistants, but data currently are lacking to demonstrate this ergonomic benefit.³³ Further studies are needed, especially since many surgeons take on the role of surgical assist in the teaching environment and subsequently report more WMSDs than their colleagues who do not work in teaching environments.^10,34

2. Pain relief from individual ergonomic positioning devices

Apart from adjusting how the OR equipment is arranged or how the surgeons adjust their positioning, several devices that assist with surgeon positioning—including gel mats or insoles, exoskeletons, and “augmented reality” glasses—are being studied.

The use of gel mats or insoles in the OR has mixed evidence in the literature.^35-37

Exoskeletons, external devices that support a surgeon’s posture and positioning, have been studied thus far in simulated nonsterile surgical environments. Preliminarily, it appears that use of an exoskeleton can decrease muscle activity and time spent in static positions, with a reported decrease in post-task user discomfort.^38,39 More data are needed to determine if exoskeletons can be used in the sterile setting and for longer durations as may occur in actual OR cases.

Augmented reality glasses project the laparoscopic monitor image to the glasses, which frees the surgeon to place the “monitor” in a more neutral, ergonomic position. In one study, use of augmented reality glasses was associated with decreased muscle activity and a reduction in Rapid Entire Body Assessment (REBA) scores when compared with use of the conventional laparoscopic monitor.⁴⁰More data are needed on these emerging technologies to determine whether adverse effects occur with prolonged use.

Continue to: 3. Implementing intraoperative microbreaks and stretching...

 

 

3. Implementing intraoperative microbreaks and stretching

The American College of Surgeons (ACS) recommends that surgeons avoid prolonged static postures during procedures.²⁸ One strategy for preventing sustained positioning is to incorporate breaks with associated stretching routinely during surgery.²⁸

Microbreaks. In a landmark study by Park and colleagues in 2017, 120-second long targeted stretching microbreaks (TSMBs) were completed every 20 to 40 minutes during a surgery, and results demonstrated improved postoperative surgeon pain scores without an associated increase in the length of the case.⁴¹ These surgeons reported improved pain in the neck, bilateral shoulders, bilateral hands, and lower back. Eighty-eight percent of surgeons reported either improvement or “no change” in their mental focus, and 100% reported improvement or “no change” in their physical performance after TSMBs were implemented.⁴² Of surveyed surgeons, 87% wanted TSMBs incorporated routinely.^41,42

Stretches. Multiple resources, such as the ACS and the Mayo Clinic, for intraoperative stretches are available. The ACS recommends performing neck and shoulder stretches during intraoperative microbreaks, including a range-of-movement neck exercise, deep cervical flexor training, and standing scapular retraction.²⁸ The ACS also demonstrates lumbrical stretches for the fingers and passive wrist extension exercises to be used intraoperatively (or between cases) (FIGURE 1).²⁸ The Mayo Clinic Hallbeck Human Factors Engineering Laboratories has a publicly available “OR Stretch Instructional Video” in which the surgeon is guided through several different short stretches, including shoulder shrugging and side bends, that can be used during surgery.⁴³

Both the ACS and the Mayo Clinic provide examples of pertinent stretch exercises for use when not in the sterile environment, between cases or after cases are complete. The ACS recommends several neck and shoulder stretches for the trapezius, levator scapulae, and pectoralis and recommends the use of a foam roller to improve thoracic mobility (FIGURE 2).²⁸ As above, the Mayo Clinic Hallbeck Human Factors Engineering Laboratories has a publicly available “OR-Stretch Between Surgery Stretches Video” in which the surgeon is guided through several short stretches that are done in a seated position, including stretches for the hamstring, lower back, and arms (FIGURE 3).⁴³

Many of the above-mentioned stretches were designed for use in the context of open, laparoscopic, or robotic surgery. For the vaginal surgeon, the intraoperative ergonomic stressors differ from those of other routes of surgery, and thus stretches tailored to the positioning during vaginal surgery are necessary. In a video recently published by the Society of Gynecologic Surgeons, several stretches are reviewed that target high-risk positions often held by the surgeon or assistant when operating vaginally.⁴⁴ These stretches include cervical retraction, thoracic extension, external arm rotation, cervical side bending, and lumbar extension (FIGURE 4).⁴⁴ The recommendation is to complete these exercises 2 times per day, with 8 to 10 repetitions per set.⁴⁴

Prioritizing ergonomic awareness and training

As caregivers, it is not uncommon for us to prioritize the needs of others before those of ourselves. However, WMSDs are prevalent, and their downstream effects may cause catastrophic professional and personal losses. Cumulatively, the global impact of WMSDs is a significant issue for the health care workforce and its longevity.

To prevent WMSDs, it is imperative that surgeons are aware of the factors that contribute to injury development and the appropriate, accessible modifications for these factors. While each surgical modality confers its own ergonomic challenges, these risks can be mitigated through increased awareness of OR setup, surgeon positioning, and incorporation of microbreaks and stretching exercises during and after surgical procedures.

Formal training in surgical ergonomics is lacking across specialties, including gynecology.⁴⁵ Multiple educational interventions have been proposed and studied to help fill this training gap.^30,46-49When used, these interventions have been associated with increased knowledge of surgical ergonomic principles or reduction in surgeon pain scores, including trainees.⁵⁰ As we become more cognizant of WMSDs, standardized resident curricula should be developed in an effort to reduce the prevalence of these potentially career-ending injuries.

In addition to education, cultivating a culture in which ergonomics is prioritized is essential. Although most surgeons report work-related pain, very few report their injuries to occupational health. For example, while 29% of gynecologic oncologists reported seeking treatment for a WMSD, only 1% had reported their injury to their employer.⁵ In a study of ACS members, only 19% of injuries were reported, 30% of surgeons stated that they did not know how to report an injury, and 21% felt that the resources for surgeons during and after an injury were inadequate.⁶

As we prioritize the health and safety of our patients, we also need to promote ergonomic awareness in the OR, respect the need for accommodations, encourage injury reporting, support surgeons who need to take time away for medical treatment, and partner with industry to develop new instruments and technology with effective ergonomic features. ●

Work-related musculoskeletal disorders (WMSDs) are “musculoskeletal disorders (injuries or disorders of the muscles, nerves, tendons, joints, cartilage, and spinal discs) in which the work environment and performance of work contribute significantly to the condition; and/or the condition is made worse or persists longer due to work conditions.”¹ The health care industry has one of the highest rates of WMSDs, even when compared with traditional labor-intensive occupations, such as coal mining. In 2017, the health care industry reported more than a half million incidents of work-related injury and illness.^2,3 In particular, surgeons are at increased risk for WMSDs, since they repetitively perform the classic tenets of poor ergonomics, including operating in static, extreme, and awkward positions and for prolonged periods of time.³

Gynecologic surgeons face unique ergonomic challenges. Operating in the pelvis requires an oblique approach that adds complexity and inhibits appropriate ergonomic positioning.⁴ All modalities of surgery incur their own challenges and risks to the surgeon, including minimally invasive gynecologic surgery (MIGS), which has become the standard of care for most conditions. Although MIGS has several benefits for the patient, a survey of gynecologic oncologists found that 88% of respondents reported discomfort related to MIGS.⁵ Several factors contribute to the development of WMSDs in surgery, including lack of ergonomic awareness, suboptimal ergonomic education and training,^5,6 and ergonomically poor operating room (OR) equipment and instrument design.⁷ Furthermore, surgical culture does not generally prioritize ergonomics in the OR or requests for ergonomic accommodations.^7,8

Within 5 years, a physician workforce shortage is projected for the United States.⁹ WMSDs contribute to workforce issues as they are associated with decreased productivity; time off needed for pain and treatment, including short-term disability; and possibly early retirement (as those who are older and have more work experience may be more likely to seek medical attention).¹⁰ In a 2013 study of vaginal surgeons, 14% missed work; 21% modified their work hours, work type, or amount of surgery; and 29% modified their surgical technique because of injury.¹⁰ Work-related pain also can negatively affect mental health, sleep, relationships, and quality of life.⁶

Recently, awareness has increased regarding WMSDs and their consequences, which has led to significant strides in the study of ergonomics among surgeons, a growing body of research on the topic, and guidance for optimizing ergonomics in the OR.

Risk factors for ergonomic strain

Several factors contribute to ergonomic strain and, subsequently, the development of WMSDs. Recognizing these factors can direct strategies for injury prevention.

Patient factors

The prevalence of obesity in the United States increased from 30.5% in 1999–2000 to 41.9% between 2017 and 2020.¹¹ As the average patient’s body mass index (BMI) has increased, there is concern for a parallel increase in the ergonomic strain on laparoscopic surgeons.

A study of simulated laparoscopic tasks at varying model BMI levels demonstrated increased surgeon postural stress and workload at higher model BMIs (50 kg/m²) when compared with lower model BMIs (20 and 30 kg/m²).¹¹ This result was supported in another study, which demonstrated both increased muscle activity and increased time needed to complete a surgical task with laparoscopic surgery; interestingly, when the same study measured these parameters for robotic surgery, this association was not seen.¹² This suggests that a robotic rather than a laparoscopic approach may avoid some of the ergonomic strain associated with increased patient BMI.

Continue to: Surgeon factors...

Surgeon factors

Various surgeon characteristics have been shown to influence ergonomics in the OR. Surgeons with smaller hand sizes, for example, reported greater physical discomfort and demonstrated greater ergonomic workload when operating laparoscopically.^13-15 In particular, those with a glove size of 6.5 or smaller have more difficulty using laparoscopic instruments, and those with a glove size smaller than 7 demonstrate a larger decline in grip strength when using laparoscopic instruments repeatedly.^14,16

Surgeon height also can affect the amount of time spent in high-risk, nonergonomic positions. In a study that evaluated video recordings of surgeon posture during gynecologic laparoscopy, shorter surgeons were noted to use greater degrees of neck rotation to look at the monitor.¹⁷ Furthermore, surgeons with shorter arm lengths experienced more “extreme positions” of the nondominant shoulder and elbow.¹⁷ This trend also was seen in open and robotic surgery, where surgeons with a height of 66 cm or less reported increased pain scores after operating.¹⁸

Surgical instruments and OR setup

Surgical instrument characteristics can contribute to ergonomic strain, especially when the instruments have been designed with a one-size-fits-all mentality.^8,19 In an examination of the anthropometric measurements of surgeon hand sizes and their correlation with difficulty when using a “standard” laparoscopic instrument, surgeons with smaller finger and hand spans had trouble using these instruments.¹⁹ Another study compared surgeon grip strength and ergonomic workloads after using 3 laparoscopic advanced bipolar instruments.¹⁶ Gender and hand size aside, the authors found that use of several of the laparoscopic devices led to greater decline in grip strength.¹⁶

The setup of the OR also can have a profound effect on the surgeon’s ergonomics. Monitor placement, for example, is crucial to ergonomic success. One study found that positioning the monitor directly in front of the surgeon at eye level was associated with the lowest neck muscle activity during a simulated task.²⁰

Route of surgery

Each surgical approach has intrinsic ergonomic risks. With laparoscopy, surgeons often remain in straight head and back positions without much trunk motion, especially when compared with open surgery.²¹ In one study, laparoscopic surgeons spent more than 60% of a case in a static position and more than 80% of a case in a high-risk, “demanding” neck position.²²

Robotic surgery, in contrast to laparoscopy, often has been cited as being more “ergonomic.” While robotic surgery has less of an effect on the neck, shoulders, arms, and legs than laparoscopy²³ and often is associated with less physical discomfort than either open or laparoscopic surgery,^23,24 robotic surgery still maintains its own innate ergonomic risks. Of robotic surgeons surveyed, 56.1% reported neck stiffness, finger fatigue, and eye symptoms in one study.²⁵ In another survey study, more robotic surgeons (72%) reported physical symptoms than laparoscopic (57%) and open (49%) surgeons.²⁶Vaginal surgery also puts surgeons at ergonomic risk. A majority of surgeons (87.2%) who completed more than 50% of their cases vaginally reported a history of WMSDs.¹⁰ Vaginal surgery places surgeons in awkward positions of the neck, shoulder, and trunk frequently and for longer durations.²⁷

Continue to: Strategies for preventing WMSDs...

Strategies for preventing WMSDs

As factors that contribute to the development of WMSDs are identified, preventive strategies can be targeted to these individual factors. Research has focused on appropriate setup of the OR, surgeon posture, intraoperative microbreaks, and stretching both in and outside of the OR.

1. OR setup and positioning of the surgeon by MIGS route

The route of MIGS affects OR setup and surgeon posture. Ergonomic recommendations for laparoscopy, robotic surgery, and vaginal surgery are all unique to the risks posed by each particular approach.

Laparoscopic surgery. Laparoscopic monitors should face the surgeon directly, with the screen just below eye level to maintain the surgeon’s neck in a neutral position.²⁸ The table height should be set for the tallest surgeon, and shorter surgeons should stand on steps as needed.²⁸ The table height also should allow for the surgeon’s hands to be at elbow height, with the elbows bent at 90 degrees with the wrists straight.²⁹ Foot pedals should be placed at the surgeons’ foot level and should be reached easily.²⁸ Additionally, the patient’s arms should be tucked at their sides to allow surgeons a larger operative space.²⁹ When using laparoscopic instruments, locking and ratcheting features should be used whenever possible to reduce prolonged grip or squeeze forces.²⁸ The laparoscopic camera should be held in the palm with the wrist in a neutral position.²⁹

Robotic surgery. Positioning and setup of the robotic console is a main focus of ergonomic recommendations. The surgeon’s chair should be brought as close to the console as possible, and the knees positioned in a 90-degree angle.³⁰ The foot pedals should be brought toward the surgeon to maintain this angle of the knees.³⁰ The console should be rotated toward the surgeon and then the height adjusted so that the surgeon can look through the eyepiece while sitting upright and can maintain the neck in a neutral position.^28,30 The surgeon’s forehead should rest comfortably on the headrest.²⁹ The forearms should rest on the armrest while the arms are maintained in a neutral position and the shoulders remain relaxed while the surgeon holds the robotic controls.³⁰ It is important to utilize the armrest often to relieve stress on the arm while operating.²⁸ Frequent use of the clutch function can keep the robotic controls in the center of the workspace.²⁸

Vaginal surgery. Both seated and standing positions are associated with high-risk positioning of the trunk and bilateral shoulders, respectively, in vaginal surgery.³¹ However, surgeons who stand while operating vaginally reported more discomfort in the bilateral wrists, thighs, and lower legs than those who operated while seated.³¹ This suggests a potential ergonomic advantage to the seated position for vaginal surgery. Chair height should be adjusted so the surgeon can look straight ahead with the neck in a neutral position.³² Surgeons should consider using a headlamp, as this may prevent repetitive awkward movements to adjust overhead lights.³² For standing surgery, the table height should be adjusted for the tallest surgeon, and shorter surgeons or assistants should use steps as needed.³

Surgical assistants should switch sides during the course of the case to avoid excessive unilateral upper-extremity strain.³² The addition of a table-mounted vaginal retractor system may be useful in relieving physical strain for surgical assistants, but data currently are lacking to demonstrate this ergonomic benefit.³³ Further studies are needed, especially since many surgeons take on the role of surgical assist in the teaching environment and subsequently report more WMSDs than their colleagues who do not work in teaching environments.^10,34

2. Pain relief from individual ergonomic positioning devices

Apart from adjusting how the OR equipment is arranged or how the surgeons adjust their positioning, several devices that assist with surgeon positioning—including gel mats or insoles, exoskeletons, and “augmented reality” glasses—are being studied.

The use of gel mats or insoles in the OR has mixed evidence in the literature.^35-37

Exoskeletons, external devices that support a surgeon’s posture and positioning, have been studied thus far in simulated nonsterile surgical environments. Preliminarily, it appears that use of an exoskeleton can decrease muscle activity and time spent in static positions, with a reported decrease in post-task user discomfort.^38,39 More data are needed to determine if exoskeletons can be used in the sterile setting and for longer durations as may occur in actual OR cases.

Augmented reality glasses project the laparoscopic monitor image to the glasses, which frees the surgeon to place the “monitor” in a more neutral, ergonomic position. In one study, use of augmented reality glasses was associated with decreased muscle activity and a reduction in Rapid Entire Body Assessment (REBA) scores when compared with use of the conventional laparoscopic monitor.⁴⁰More data are needed on these emerging technologies to determine whether adverse effects occur with prolonged use.

Continue to: 3. Implementing intraoperative microbreaks and stretching...

 

 

3. Implementing intraoperative microbreaks and stretching

The American College of Surgeons (ACS) recommends that surgeons avoid prolonged static postures during procedures.²⁸ One strategy for preventing sustained positioning is to incorporate breaks with associated stretching routinely during surgery.²⁸

Microbreaks. In a landmark study by Park and colleagues in 2017, 120-second long targeted stretching microbreaks (TSMBs) were completed every 20 to 40 minutes during a surgery, and results demonstrated improved postoperative surgeon pain scores without an associated increase in the length of the case.⁴¹ These surgeons reported improved pain in the neck, bilateral shoulders, bilateral hands, and lower back. Eighty-eight percent of surgeons reported either improvement or “no change” in their mental focus, and 100% reported improvement or “no change” in their physical performance after TSMBs were implemented.⁴² Of surveyed surgeons, 87% wanted TSMBs incorporated routinely.^41,42

Stretches. Multiple resources, such as the ACS and the Mayo Clinic, for intraoperative stretches are available. The ACS recommends performing neck and shoulder stretches during intraoperative microbreaks, including a range-of-movement neck exercise, deep cervical flexor training, and standing scapular retraction.²⁸ The ACS also demonstrates lumbrical stretches for the fingers and passive wrist extension exercises to be used intraoperatively (or between cases) (FIGURE 1).²⁸ The Mayo Clinic Hallbeck Human Factors Engineering Laboratories has a publicly available “OR Stretch Instructional Video” in which the surgeon is guided through several different short stretches, including shoulder shrugging and side bends, that can be used during surgery.⁴³

Both the ACS and the Mayo Clinic provide examples of pertinent stretch exercises for use when not in the sterile environment, between cases or after cases are complete. The ACS recommends several neck and shoulder stretches for the trapezius, levator scapulae, and pectoralis and recommends the use of a foam roller to improve thoracic mobility (FIGURE 2).²⁸ As above, the Mayo Clinic Hallbeck Human Factors Engineering Laboratories has a publicly available “OR-Stretch Between Surgery Stretches Video” in which the surgeon is guided through several short stretches that are done in a seated position, including stretches for the hamstring, lower back, and arms (FIGURE 3).⁴³

Many of the above-mentioned stretches were designed for use in the context of open, laparoscopic, or robotic surgery. For the vaginal surgeon, the intraoperative ergonomic stressors differ from those of other routes of surgery, and thus stretches tailored to the positioning during vaginal surgery are necessary. In a video recently published by the Society of Gynecologic Surgeons, several stretches are reviewed that target high-risk positions often held by the surgeon or assistant when operating vaginally.⁴⁴ These stretches include cervical retraction, thoracic extension, external arm rotation, cervical side bending, and lumbar extension (FIGURE 4).⁴⁴ The recommendation is to complete these exercises 2 times per day, with 8 to 10 repetitions per set.⁴⁴

Prioritizing ergonomic awareness and training

As caregivers, it is not uncommon for us to prioritize the needs of others before those of ourselves. However, WMSDs are prevalent, and their downstream effects may cause catastrophic professional and personal losses. Cumulatively, the global impact of WMSDs is a significant issue for the health care workforce and its longevity.

To prevent WMSDs, it is imperative that surgeons are aware of the factors that contribute to injury development and the appropriate, accessible modifications for these factors. While each surgical modality confers its own ergonomic challenges, these risks can be mitigated through increased awareness of OR setup, surgeon positioning, and incorporation of microbreaks and stretching exercises during and after surgical procedures.

Formal training in surgical ergonomics is lacking across specialties, including gynecology.⁴⁵ Multiple educational interventions have been proposed and studied to help fill this training gap.^30,46-49When used, these interventions have been associated with increased knowledge of surgical ergonomic principles or reduction in surgeon pain scores, including trainees.⁵⁰ As we become more cognizant of WMSDs, standardized resident curricula should be developed in an effort to reduce the prevalence of these potentially career-ending injuries.

In addition to education, cultivating a culture in which ergonomics is prioritized is essential. Although most surgeons report work-related pain, very few report their injuries to occupational health. For example, while 29% of gynecologic oncologists reported seeking treatment for a WMSD, only 1% had reported their injury to their employer.⁵ In a study of ACS members, only 19% of injuries were reported, 30% of surgeons stated that they did not know how to report an injury, and 21% felt that the resources for surgeons during and after an injury were inadequate.⁶

As we prioritize the health and safety of our patients, we also need to promote ergonomic awareness in the OR, respect the need for accommodations, encourage injury reporting, support surgeons who need to take time away for medical treatment, and partner with industry to develop new instruments and technology with effective ergonomic features. ●

The theme of the 49th Annual Scientific Meeting of the Society of Gynecologic Surgeons was Impact Factor—an allusion to scientific journal impact factor, as well as how we as gynecologic surgeons have a societal impact through our innovation, education, equity, and enterprise-level efforts. This theme and the diverse roster of speakers and presentations on contemporary and controversial issues impacting today’s gynecologic surgeons clearly resonated, breaking the prior registration record with more than 200 additional attendees than the previous year.

As always, the preconference postgraduate courses delivered relevant content that spanned the educational and surgical spectrum, including: “Innovations in training gynecologic surgeons”; “Urologic surgery for the gynecologic surgeon”; the social media workshop “Gynfluencing: Using social media to find your digital voice”; and “The sim factor: Making an impact in surgical education.” This also marked the first year of offering a specific SGS Fellows/Young Attendings’ course. The featured speaker of the SGS Equity Council was Patty Brisben, philanthropist, CEO, and founder of Pure Romance.

Dr. Beri Ridgeway, Cleveland Clinic Chief of Staff, delivered the Mark D. Walters Lecture, “Surgeon in the C-suite,” on leading approximately 5,000 physicians and the importance of surgeons and specifically ObGyns having a seat at the table. The TeLinde lecturer, Dr. Pam Moalli, Professor and Division Director for Urogynecology at the University of Pittsburgh Magee Womens Hospital, spoke on “Biomaterials for gynecologic surgeons: Toward bioinspired biomimetic devices.” The panel on the “Ergonomics of gynecologic surgery” was moderated by Dr. Amanda Fader and Dr. Kim Kho, who shared their experiences with work-related musculoskeletal injury, and featured esteemed panelists Dr. Noor Abu-Alnadi from UNC, Dr. Sue Hallbeck from Mayo Clinic, and Dr. Ladin Yurteri-Kaplan from Columbia University.

The conference also featured a new format of Ted Med Talks:

• Dr. Jason Wright, Editor-in-Chief, Obstetrics & Gynecology, and Division Director of Gynecologic Oncology at Columbia University, who spoke on “Surgical volume and outcomes for gynecologic surgery: Is more always better?”
• Dr. Kelly Wright, Division Director, Minimally Invasive Gynecologic Surgery, Cedars Sinai, on “Climate change starts at 7:15”
• Dr. Ebony Carter, Associate Editor, Equity, Obstetrics & Gynecology, and Division Director, Maternal Fetal Medicine, Washington University, on “Centering equity in reproductive health research.”

In this special section, several of these talks are presented. Additionally, Dr. Laura Homewood and her coauthors will discuss gender and racial biases in a large multi-institutional sample of more than 15,000 Press Ganey patient satisfaction surveys.

Dr. Cheryl Iglesia, SGS former president, and I hope that you will consider attending #SGS2024 in Orlando, Florida, led by Dr. Suzie As-Sanie, program chair, and Dr. Rosanne Kho, current SGS president, which promises to be another exciting meeting. ●

The theme of the 49th Annual Scientific Meeting of the Society of Gynecologic Surgeons was Impact Factor—an allusion to scientific journal impact factor, as well as how we as gynecologic surgeons have a societal impact through our innovation, education, equity, and enterprise-level efforts. This theme and the diverse roster of speakers and presentations on contemporary and controversial issues impacting today’s gynecologic surgeons clearly resonated, breaking the prior registration record with more than 200 additional attendees than the previous year.

As always, the preconference postgraduate courses delivered relevant content that spanned the educational and surgical spectrum, including: “Innovations in training gynecologic surgeons”; “Urologic surgery for the gynecologic surgeon”; the social media workshop “Gynfluencing: Using social media to find your digital voice”; and “The sim factor: Making an impact in surgical education.” This also marked the first year of offering a specific SGS Fellows/Young Attendings’ course. The featured speaker of the SGS Equity Council was Patty Brisben, philanthropist, CEO, and founder of Pure Romance.

Dr. Beri Ridgeway, Cleveland Clinic Chief of Staff, delivered the Mark D. Walters Lecture, “Surgeon in the C-suite,” on leading approximately 5,000 physicians and the importance of surgeons and specifically ObGyns having a seat at the table. The TeLinde lecturer, Dr. Pam Moalli, Professor and Division Director for Urogynecology at the University of Pittsburgh Magee Womens Hospital, spoke on “Biomaterials for gynecologic surgeons: Toward bioinspired biomimetic devices.” The panel on the “Ergonomics of gynecologic surgery” was moderated by Dr. Amanda Fader and Dr. Kim Kho, who shared their experiences with work-related musculoskeletal injury, and featured esteemed panelists Dr. Noor Abu-Alnadi from UNC, Dr. Sue Hallbeck from Mayo Clinic, and Dr. Ladin Yurteri-Kaplan from Columbia University.

The conference also featured a new format of Ted Med Talks:

• Dr. Jason Wright, Editor-in-Chief, Obstetrics & Gynecology, and Division Director of Gynecologic Oncology at Columbia University, who spoke on “Surgical volume and outcomes for gynecologic surgery: Is more always better?”
• Dr. Kelly Wright, Division Director, Minimally Invasive Gynecologic Surgery, Cedars Sinai, on “Climate change starts at 7:15”
• Dr. Ebony Carter, Associate Editor, Equity, Obstetrics & Gynecology, and Division Director, Maternal Fetal Medicine, Washington University, on “Centering equity in reproductive health research.”

In this special section, several of these talks are presented. Additionally, Dr. Laura Homewood and her coauthors will discuss gender and racial biases in a large multi-institutional sample of more than 15,000 Press Ganey patient satisfaction surveys.

Dr. Cheryl Iglesia, SGS former president, and I hope that you will consider attending #SGS2024 in Orlando, Florida, led by Dr. Suzie As-Sanie, program chair, and Dr. Rosanne Kho, current SGS president, which promises to be another exciting meeting. ●

The theme of the 49th Annual Scientific Meeting of the Society of Gynecologic Surgeons was Impact Factor—an allusion to scientific journal impact factor, as well as how we as gynecologic surgeons have a societal impact through our innovation, education, equity, and enterprise-level efforts. This theme and the diverse roster of speakers and presentations on contemporary and controversial issues impacting today’s gynecologic surgeons clearly resonated, breaking the prior registration record with more than 200 additional attendees than the previous year.

As always, the preconference postgraduate courses delivered relevant content that spanned the educational and surgical spectrum, including: “Innovations in training gynecologic surgeons”; “Urologic surgery for the gynecologic surgeon”; the social media workshop “Gynfluencing: Using social media to find your digital voice”; and “The sim factor: Making an impact in surgical education.” This also marked the first year of offering a specific SGS Fellows/Young Attendings’ course. The featured speaker of the SGS Equity Council was Patty Brisben, philanthropist, CEO, and founder of Pure Romance.

Dr. Beri Ridgeway, Cleveland Clinic Chief of Staff, delivered the Mark D. Walters Lecture, “Surgeon in the C-suite,” on leading approximately 5,000 physicians and the importance of surgeons and specifically ObGyns having a seat at the table. The TeLinde lecturer, Dr. Pam Moalli, Professor and Division Director for Urogynecology at the University of Pittsburgh Magee Womens Hospital, spoke on “Biomaterials for gynecologic surgeons: Toward bioinspired biomimetic devices.” The panel on the “Ergonomics of gynecologic surgery” was moderated by Dr. Amanda Fader and Dr. Kim Kho, who shared their experiences with work-related musculoskeletal injury, and featured esteemed panelists Dr. Noor Abu-Alnadi from UNC, Dr. Sue Hallbeck from Mayo Clinic, and Dr. Ladin Yurteri-Kaplan from Columbia University.

The conference also featured a new format of Ted Med Talks:

• Dr. Jason Wright, Editor-in-Chief, Obstetrics & Gynecology, and Division Director of Gynecologic Oncology at Columbia University, who spoke on “Surgical volume and outcomes for gynecologic surgery: Is more always better?”
• Dr. Kelly Wright, Division Director, Minimally Invasive Gynecologic Surgery, Cedars Sinai, on “Climate change starts at 7:15”
• Dr. Ebony Carter, Associate Editor, Equity, Obstetrics & Gynecology, and Division Director, Maternal Fetal Medicine, Washington University, on “Centering equity in reproductive health research.”

In this special section, several of these talks are presented. Additionally, Dr. Laura Homewood and her coauthors will discuss gender and racial biases in a large multi-institutional sample of more than 15,000 Press Ganey patient satisfaction surveys.

Dr. Cheryl Iglesia, SGS former president, and I hope that you will consider attending #SGS2024 in Orlando, Florida, led by Dr. Suzie As-Sanie, program chair, and Dr. Rosanne Kho, current SGS president, which promises to be another exciting meeting. ●

Key clinical point: Galcanezumab was safe and effective in a patient population severely impaired by chronic migraine (CM) and medication overuse headache (MOH).

Major finding: Galcanezumab led to a significant reduction in migraine days per month, painkillers per month, number of days on medication, numeric rating scale scores, 6-item Headache Impact Test scores, and Migraine Disability Assessment questionnaire scores (all P < .001), with improvements being the greatest during the first 3 months of treatment. Adverse events were mostly mild, with only one case of treatment discontinuation because of severe low back pain.

Study details: The data come from a single-center, prospective study including 78 patients with CM and MOH who received galcanezumab.

Disclosures: This study did not report the funding source. S Guerzoni and C Baraldi declared receiving honoraria from various sources. L Pani declared serving as the Chief Scientific Officer of EDRA-LSWR Publishing Company and Inpeco SA Total Lab Automation Company and had ties to other sources. Other authors declared no conflicts of interest.

Source: Guerzoni S et al. Galcanezumab for the treatment of chronic migraine and medication overuse headache: Real-world clinical evidence in a severely impaired patient population. Brain Behav. 2023;13:e2799 (May 19). doi: 10.1002/brb3.2799

Key clinical point: Galcanezumab was safe and effective in a patient population severely impaired by chronic migraine (CM) and medication overuse headache (MOH).

Major finding: Galcanezumab led to a significant reduction in migraine days per month, painkillers per month, number of days on medication, numeric rating scale scores, 6-item Headache Impact Test scores, and Migraine Disability Assessment questionnaire scores (all P < .001), with improvements being the greatest during the first 3 months of treatment. Adverse events were mostly mild, with only one case of treatment discontinuation because of severe low back pain.

Study details: The data come from a single-center, prospective study including 78 patients with CM and MOH who received galcanezumab.

Disclosures: This study did not report the funding source. S Guerzoni and C Baraldi declared receiving honoraria from various sources. L Pani declared serving as the Chief Scientific Officer of EDRA-LSWR Publishing Company and Inpeco SA Total Lab Automation Company and had ties to other sources. Other authors declared no conflicts of interest.

Source: Guerzoni S et al. Galcanezumab for the treatment of chronic migraine and medication overuse headache: Real-world clinical evidence in a severely impaired patient population. Brain Behav. 2023;13:e2799 (May 19). doi: 10.1002/brb3.2799

Key clinical point: Galcanezumab was safe and effective in a patient population severely impaired by chronic migraine (CM) and medication overuse headache (MOH).

Major finding: Galcanezumab led to a significant reduction in migraine days per month, painkillers per month, number of days on medication, numeric rating scale scores, 6-item Headache Impact Test scores, and Migraine Disability Assessment questionnaire scores (all P < .001), with improvements being the greatest during the first 3 months of treatment. Adverse events were mostly mild, with only one case of treatment discontinuation because of severe low back pain.

Study details: The data come from a single-center, prospective study including 78 patients with CM and MOH who received galcanezumab.

Disclosures: This study did not report the funding source. S Guerzoni and C Baraldi declared receiving honoraria from various sources. L Pani declared serving as the Chief Scientific Officer of EDRA-LSWR Publishing Company and Inpeco SA Total Lab Automation Company and had ties to other sources. Other authors declared no conflicts of interest.

Source: Guerzoni S et al. Galcanezumab for the treatment of chronic migraine and medication overuse headache: Real-world clinical evidence in a severely impaired patient population. Brain Behav. 2023;13:e2799 (May 19). doi: 10.1002/brb3.2799

Key clinical point: Ketogenic diet (KD) significantly improved sleep complaints in patients with migraine, irrespective of migraine improvements and anthropometric modifications.

Major finding: Migraine intensity, headache frequency, and the severity of headache-related disability improved significantly after 3 months of KD therapy (all P < .001) along with a significant decrease in the rate of insomnia (before vs after treatment: 60% vs 40%; P < .001) and number of patients experiencing poor sleep (reduced to half at follow-up; P < .001). The modifications in sleep features showed no correlation with migraine improvements and anthropometric changes.

Study details: This study included 70 patients with migraine who received KD as a preventive therapy for migraine.

Disclosures: This study did not receive any funding. The authors declared no conflicts of interest.

Source: Merlino G et al. Sleep of migraine patients is ameliorated by ketogenic diet, independently of pain control. Sleep Med. 2023;107:196-201 (May 9). doi: 10.1016/j.sleep.2023.05.006

Key clinical point: Ketogenic diet (KD) significantly improved sleep complaints in patients with migraine, irrespective of migraine improvements and anthropometric modifications.

Major finding: Migraine intensity, headache frequency, and the severity of headache-related disability improved significantly after 3 months of KD therapy (all P < .001) along with a significant decrease in the rate of insomnia (before vs after treatment: 60% vs 40%; P < .001) and number of patients experiencing poor sleep (reduced to half at follow-up; P < .001). The modifications in sleep features showed no correlation with migraine improvements and anthropometric changes.

Study details: This study included 70 patients with migraine who received KD as a preventive therapy for migraine.

Disclosures: This study did not receive any funding. The authors declared no conflicts of interest.

Source: Merlino G et al. Sleep of migraine patients is ameliorated by ketogenic diet, independently of pain control. Sleep Med. 2023;107:196-201 (May 9). doi: 10.1016/j.sleep.2023.05.006

Key clinical point: Ketogenic diet (KD) significantly improved sleep complaints in patients with migraine, irrespective of migraine improvements and anthropometric modifications.

Major finding: Migraine intensity, headache frequency, and the severity of headache-related disability improved significantly after 3 months of KD therapy (all P < .001) along with a significant decrease in the rate of insomnia (before vs after treatment: 60% vs 40%; P < .001) and number of patients experiencing poor sleep (reduced to half at follow-up; P < .001). The modifications in sleep features showed no correlation with migraine improvements and anthropometric changes.

Study details: This study included 70 patients with migraine who received KD as a preventive therapy for migraine.

Disclosures: This study did not receive any funding. The authors declared no conflicts of interest.

Source: Merlino G et al. Sleep of migraine patients is ameliorated by ketogenic diet, independently of pain control. Sleep Med. 2023;107:196-201 (May 9). doi: 10.1016/j.sleep.2023.05.006

Key clinical point: The risk of developing Alzheimer’s disease (AD) dementia is significantly higher in individuals with vs without migraine, with younger age, obesity, and chronic migraine being significant risk factors for AD dementia among individuals with migraine.

Major finding: A prior history of migraine is a significant risk factor for AD dementia (hazard ratio [HR] 1.32; 95% CI 1.30-1.35). The risk was prominently higher among individuals with vs without migraine who were younger (HR 1.58; 95% CI 1.52-1.64) and had obesity (HR 1.39; 95% CI 1.35-1.43) and among those with chronic vs episodic migraine (CM HR 1.48, 95% CI 1.44-1.52; vs EM HR 1.26, 95% CI 1.27-1.29).

Study details: This retrospective, nationwide cohort study included individuals without (n = 5,863,348) and with (n = 212,836) migraine.

Disclosures: This study was supported by grants from the National Research Foundation funded by the Ministry of Education, the Technology Development Program funded by the Ministry of SMEs and Startups (Korea), and others. The authors declared no conflicts of interest.

Source: Kim J et al. Association between migraine and Alzheimer’s disease: A nationwide cohort study. Front Aging Neurosci. 2023;15:1196185 (May 25). doi: 10.3389/fnagi.2023.1196185

Key clinical point: The risk of developing Alzheimer’s disease (AD) dementia is significantly higher in individuals with vs without migraine, with younger age, obesity, and chronic migraine being significant risk factors for AD dementia among individuals with migraine.

Major finding: A prior history of migraine is a significant risk factor for AD dementia (hazard ratio [HR] 1.32; 95% CI 1.30-1.35). The risk was prominently higher among individuals with vs without migraine who were younger (HR 1.58; 95% CI 1.52-1.64) and had obesity (HR 1.39; 95% CI 1.35-1.43) and among those with chronic vs episodic migraine (CM HR 1.48, 95% CI 1.44-1.52; vs EM HR 1.26, 95% CI 1.27-1.29).

Study details: This retrospective, nationwide cohort study included individuals without (n = 5,863,348) and with (n = 212,836) migraine.

Disclosures: This study was supported by grants from the National Research Foundation funded by the Ministry of Education, the Technology Development Program funded by the Ministry of SMEs and Startups (Korea), and others. The authors declared no conflicts of interest.

Source: Kim J et al. Association between migraine and Alzheimer’s disease: A nationwide cohort study. Front Aging Neurosci. 2023;15:1196185 (May 25). doi: 10.3389/fnagi.2023.1196185

Key clinical point: The risk of developing Alzheimer’s disease (AD) dementia is significantly higher in individuals with vs without migraine, with younger age, obesity, and chronic migraine being significant risk factors for AD dementia among individuals with migraine.

Major finding: A prior history of migraine is a significant risk factor for AD dementia (hazard ratio [HR] 1.32; 95% CI 1.30-1.35). The risk was prominently higher among individuals with vs without migraine who were younger (HR 1.58; 95% CI 1.52-1.64) and had obesity (HR 1.39; 95% CI 1.35-1.43) and among those with chronic vs episodic migraine (CM HR 1.48, 95% CI 1.44-1.52; vs EM HR 1.26, 95% CI 1.27-1.29).

Study details: This retrospective, nationwide cohort study included individuals without (n = 5,863,348) and with (n = 212,836) migraine.

Disclosures: This study was supported by grants from the National Research Foundation funded by the Ministry of Education, the Technology Development Program funded by the Ministry of SMEs and Startups (Korea), and others. The authors declared no conflicts of interest.

Source: Kim J et al. Association between migraine and Alzheimer’s disease: A nationwide cohort study. Front Aging Neurosci. 2023;15:1196185 (May 25). doi: 10.3389/fnagi.2023.1196185

Key clinical point: Use of opioids is still prevalent among patients with migraine, thus indicating non-adherence to evidence-based international guidelines; moreover, the opioid use is more frequent and prolonged among patients with chronic migraine (CM) than among those with episodic migraine (EM).

Major finding: Overall, 13.4% of patients reported ever using an opioid for headache, with 46.3% using opioids occasionally, whereas 27.0% and 11.3% reported using them for >1 month and >1 year, respectively. Additionally, 2.4% of participants used opioids without a prescription. Patients with CM vs EM reported more frequent (21.6% vs 11.7%; P < .001) and prolonged (>1 month: 33.6% vs 24.4%; P < .003; >1 year: 17.7% vs 8.7%; P < .001) opioid use.

Study details: Findings are from a cross-sectional questionnaire-based study including 3712 patients with migraine (CM n = 629; EM n = 3,083).

Disclosures: This study did not receive any funding. GM Terwindt declared receiving consultancy support and independent support from various sources. No other conflicts of interest were declared.

Source: van Welie RF, van Welie FC, et al. Characterizing opioid use in a Dutch cohort with migraine. Cephalalgia. 2023;43(5) (May 11). doi: 10.1177/03331024231174160

Key clinical point: Use of opioids is still prevalent among patients with migraine, thus indicating non-adherence to evidence-based international guidelines; moreover, the opioid use is more frequent and prolonged among patients with chronic migraine (CM) than among those with episodic migraine (EM).

Major finding: Overall, 13.4% of patients reported ever using an opioid for headache, with 46.3% using opioids occasionally, whereas 27.0% and 11.3% reported using them for >1 month and >1 year, respectively. Additionally, 2.4% of participants used opioids without a prescription. Patients with CM vs EM reported more frequent (21.6% vs 11.7%; P < .001) and prolonged (>1 month: 33.6% vs 24.4%; P < .003; >1 year: 17.7% vs 8.7%; P < .001) opioid use.

Study details: Findings are from a cross-sectional questionnaire-based study including 3712 patients with migraine (CM n = 629; EM n = 3,083).

Disclosures: This study did not receive any funding. GM Terwindt declared receiving consultancy support and independent support from various sources. No other conflicts of interest were declared.

Source: van Welie RF, van Welie FC, et al. Characterizing opioid use in a Dutch cohort with migraine. Cephalalgia. 2023;43(5) (May 11). doi: 10.1177/03331024231174160

Key clinical point: Use of opioids is still prevalent among patients with migraine, thus indicating non-adherence to evidence-based international guidelines; moreover, the opioid use is more frequent and prolonged among patients with chronic migraine (CM) than among those with episodic migraine (EM).

Major finding: Overall, 13.4% of patients reported ever using an opioid for headache, with 46.3% using opioids occasionally, whereas 27.0% and 11.3% reported using them for >1 month and >1 year, respectively. Additionally, 2.4% of participants used opioids without a prescription. Patients with CM vs EM reported more frequent (21.6% vs 11.7%; P < .001) and prolonged (>1 month: 33.6% vs 24.4%; P < .003; >1 year: 17.7% vs 8.7%; P < .001) opioid use.

Study details: Findings are from a cross-sectional questionnaire-based study including 3712 patients with migraine (CM n = 629; EM n = 3,083).

Disclosures: This study did not receive any funding. GM Terwindt declared receiving consultancy support and independent support from various sources. No other conflicts of interest were declared.

Source: van Welie RF, van Welie FC, et al. Characterizing opioid use in a Dutch cohort with migraine. Cephalalgia. 2023;43(5) (May 11). doi: 10.1177/03331024231174160

Key clinical point: Switching to fremanezumab may provide clinical benefits in patients with difficult-to-treat episodic or chronic migraine who have not responded to prior monoclonal antibody (mAb) therapy targeting the calcitonin gene-related peptide (anti-CGRP) pathway.

Major finding: Overall, 42.8% of patients achieved a 50% reduction in the monthly migraine days (MMD) after switching to fremanezumab. The MMD decreased from 13.6 to 7.2 (P < .0001), Migraine Disability Assessment scores were reduced from 73.3 to 50.3 (P = .0014), and acute migraine medication use decreased from 9.7 to 4.9 days/month (P < .0001) after 3 months of fremanezumab therapy.

Study details: This subgroup analysis of the real-world, non-interventional Finesse study included 153 patients with episodic or chronic migraine who switched to fremanezumab from other anti-CGRP mAb treatments.

Disclosures: This study was funded by TEVA GmbH. Two authors declared being employees of TEVA GmbH. Several authors, including the lead author, declared serving as consultants or on advisory or speaker boards or receiving research grants from various sources, including TEVA GmbH.

Source: Straube A et al. Real-world effectiveness of fremanezumab in patients with migraine switching from another mAb targeting the CGRP pathway: A subgroup analysis of the Finesse Study. J Headache Pain. 2023;24:59 (May 23). doi: 10.1186/s10194-023-01593-2

Key clinical point: Switching to fremanezumab may provide clinical benefits in patients with difficult-to-treat episodic or chronic migraine who have not responded to prior monoclonal antibody (mAb) therapy targeting the calcitonin gene-related peptide (anti-CGRP) pathway.

Major finding: Overall, 42.8% of patients achieved a 50% reduction in the monthly migraine days (MMD) after switching to fremanezumab. The MMD decreased from 13.6 to 7.2 (P < .0001), Migraine Disability Assessment scores were reduced from 73.3 to 50.3 (P = .0014), and acute migraine medication use decreased from 9.7 to 4.9 days/month (P < .0001) after 3 months of fremanezumab therapy.

Study details: This subgroup analysis of the real-world, non-interventional Finesse study included 153 patients with episodic or chronic migraine who switched to fremanezumab from other anti-CGRP mAb treatments.

Disclosures: This study was funded by TEVA GmbH. Two authors declared being employees of TEVA GmbH. Several authors, including the lead author, declared serving as consultants or on advisory or speaker boards or receiving research grants from various sources, including TEVA GmbH.

Source: Straube A et al. Real-world effectiveness of fremanezumab in patients with migraine switching from another mAb targeting the CGRP pathway: A subgroup analysis of the Finesse Study. J Headache Pain. 2023;24:59 (May 23). doi: 10.1186/s10194-023-01593-2

Key clinical point: Switching to fremanezumab may provide clinical benefits in patients with difficult-to-treat episodic or chronic migraine who have not responded to prior monoclonal antibody (mAb) therapy targeting the calcitonin gene-related peptide (anti-CGRP) pathway.

Major finding: Overall, 42.8% of patients achieved a 50% reduction in the monthly migraine days (MMD) after switching to fremanezumab. The MMD decreased from 13.6 to 7.2 (P < .0001), Migraine Disability Assessment scores were reduced from 73.3 to 50.3 (P = .0014), and acute migraine medication use decreased from 9.7 to 4.9 days/month (P < .0001) after 3 months of fremanezumab therapy.

Study details: This subgroup analysis of the real-world, non-interventional Finesse study included 153 patients with episodic or chronic migraine who switched to fremanezumab from other anti-CGRP mAb treatments.

Disclosures: This study was funded by TEVA GmbH. Two authors declared being employees of TEVA GmbH. Several authors, including the lead author, declared serving as consultants or on advisory or speaker boards or receiving research grants from various sources, including TEVA GmbH.

Source: Straube A et al. Real-world effectiveness of fremanezumab in patients with migraine switching from another mAb targeting the CGRP pathway: A subgroup analysis of the Finesse Study. J Headache Pain. 2023;24:59 (May 23). doi: 10.1186/s10194-023-01593-2

Key clinical point: Anti-calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAb) are a safe and effective treatment option for patients age > 65 years with migraine and who did not respond to ≥3 prior migraine preventive medications.

Major finding: At 6 months, monthly migraine days, monthly headache days, and monthly acute medication intake days reduced by 10.1 days (P = .0001), 10.5 days (P < .001), and 9.4 days (P < .001), respectively. Nearly 25.3% of the patients experienced adverse effects at some point during follow-up, which were mostly mild in severity.

Study details: The data come from an observational retrospective study including 162 patients age > 65 years with migraine who did not respond to ≥3 migraine preventive medications and were treated with any one of the three anti-CGRP mAb (erenumab, galcanezumab, or fremanezumab).

Disclosures: This study did not receive any specific grant. Several authors, including the lead author, reported receiving honoraria for consulting, speaking, or advisory board participation; research funding; or travel funding from various sources.

Source: Muñoz-Vendrell A et al. Effectiveness and safety of anti-CGRP monoclonal antibodies in patients over 65 years: A real-life multicentre analysis of 162 patients. J Headache Pain. 2023;24:63 (Jun 2). doi: 10.1186/s10194-023-01585-2

Key clinical point: Anti-calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAb) are a safe and effective treatment option for patients age > 65 years with migraine and who did not respond to ≥3 prior migraine preventive medications.

Major finding: At 6 months, monthly migraine days, monthly headache days, and monthly acute medication intake days reduced by 10.1 days (P = .0001), 10.5 days (P < .001), and 9.4 days (P < .001), respectively. Nearly 25.3% of the patients experienced adverse effects at some point during follow-up, which were mostly mild in severity.

Study details: The data come from an observational retrospective study including 162 patients age > 65 years with migraine who did not respond to ≥3 migraine preventive medications and were treated with any one of the three anti-CGRP mAb (erenumab, galcanezumab, or fremanezumab).

Disclosures: This study did not receive any specific grant. Several authors, including the lead author, reported receiving honoraria for consulting, speaking, or advisory board participation; research funding; or travel funding from various sources.

Source: Muñoz-Vendrell A et al. Effectiveness and safety of anti-CGRP monoclonal antibodies in patients over 65 years: A real-life multicentre analysis of 162 patients. J Headache Pain. 2023;24:63 (Jun 2). doi: 10.1186/s10194-023-01585-2

Key clinical point: Anti-calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAb) are a safe and effective treatment option for patients age > 65 years with migraine and who did not respond to ≥3 prior migraine preventive medications.

Major finding: At 6 months, monthly migraine days, monthly headache days, and monthly acute medication intake days reduced by 10.1 days (P = .0001), 10.5 days (P < .001), and 9.4 days (P < .001), respectively. Nearly 25.3% of the patients experienced adverse effects at some point during follow-up, which were mostly mild in severity.

Study details: The data come from an observational retrospective study including 162 patients age > 65 years with migraine who did not respond to ≥3 migraine preventive medications and were treated with any one of the three anti-CGRP mAb (erenumab, galcanezumab, or fremanezumab).

Disclosures: This study did not receive any specific grant. Several authors, including the lead author, reported receiving honoraria for consulting, speaking, or advisory board participation; research funding; or travel funding from various sources.

Source: Muñoz-Vendrell A et al. Effectiveness and safety of anti-CGRP monoclonal antibodies in patients over 65 years: A real-life multicentre analysis of 162 patients. J Headache Pain. 2023;24:63 (Jun 2). doi: 10.1186/s10194-023-01585-2

Key clinical point: The perimenstrual period was associated with an increased susceptibility to migraine without aura exclusively in both women who experienced migraine with and without aura; hence, the study recommended that only attacks without aura should be considered for a perimenstrual migraine diagnosis.

Major finding: A significant interaction was observed between the perimenstrual window and migraine subtype for migraine attack occurrence (P = .022), with the effect of the perimenstrual window being greater among women with migraine without aura (odds ratio [OR] 1.57; 95% CI 1.45-1.69) vs with aura (OR 1.36; 95% CI 1.24-1.49). Women with migraine with vs without aura showed similar increase in migraine attacks without aura during the perimenstrual window (P = .224).

Study details: This longitudinal electronic diary study included 526 premenopausal women diagnosed with migraine with or without aura.

Disclosures: This study was supported by ZonMw and the Dutch Brain Foundation. Five authors, including the lead author, declared receiving independent support from the study funders. Some authors declared receiving consultancy and independent support from various sources.

Source: Verhagen IE et al. Migraine with and without aura in relation to the menstrual cycle and other hormonal milestones: A prospective cohort study. Cephalalgia. 2023;43(6) (May 31). doi: 10.1177/03331024231164322

Key clinical point: The perimenstrual period was associated with an increased susceptibility to migraine without aura exclusively in both women who experienced migraine with and without aura; hence, the study recommended that only attacks without aura should be considered for a perimenstrual migraine diagnosis.

Major finding: A significant interaction was observed between the perimenstrual window and migraine subtype for migraine attack occurrence (P = .022), with the effect of the perimenstrual window being greater among women with migraine without aura (odds ratio [OR] 1.57; 95% CI 1.45-1.69) vs with aura (OR 1.36; 95% CI 1.24-1.49). Women with migraine with vs without aura showed similar increase in migraine attacks without aura during the perimenstrual window (P = .224).

Study details: This longitudinal electronic diary study included 526 premenopausal women diagnosed with migraine with or without aura.

Disclosures: This study was supported by ZonMw and the Dutch Brain Foundation. Five authors, including the lead author, declared receiving independent support from the study funders. Some authors declared receiving consultancy and independent support from various sources.

Source: Verhagen IE et al. Migraine with and without aura in relation to the menstrual cycle and other hormonal milestones: A prospective cohort study. Cephalalgia. 2023;43(6) (May 31). doi: 10.1177/03331024231164322

Key clinical point: The perimenstrual period was associated with an increased susceptibility to migraine without aura exclusively in both women who experienced migraine with and without aura; hence, the study recommended that only attacks without aura should be considered for a perimenstrual migraine diagnosis.

Major finding: A significant interaction was observed between the perimenstrual window and migraine subtype for migraine attack occurrence (P = .022), with the effect of the perimenstrual window being greater among women with migraine without aura (odds ratio [OR] 1.57; 95% CI 1.45-1.69) vs with aura (OR 1.36; 95% CI 1.24-1.49). Women with migraine with vs without aura showed similar increase in migraine attacks without aura during the perimenstrual window (P = .224).

Study details: This longitudinal electronic diary study included 526 premenopausal women diagnosed with migraine with or without aura.

Disclosures: This study was supported by ZonMw and the Dutch Brain Foundation. Five authors, including the lead author, declared receiving independent support from the study funders. Some authors declared receiving consultancy and independent support from various sources.

Source: Verhagen IE et al. Migraine with and without aura in relation to the menstrual cycle and other hormonal milestones: A prospective cohort study. Cephalalgia. 2023;43(6) (May 31). doi: 10.1177/03331024231164322

Key clinical point: Galcanezumab showed significant efficacy after the first week of treatment, and the treatment efficacy after the first week was a significant predictor of the response rate at 3 months.

Major finding: The mean changes in weekly response rates (RR) at 1, 2, 3, and 4 weeks after galcanezumab initiation were 44.6%, 31.4%, 26.0%, and 32.6%, respectively, with the improvement being greatest at 1 week (P < .001) and the RR at 1 week being the only predictive factor for ≥50% RR at 3 months (adjusted odds ratio 1.029; P = .002). Adverse events were mostly mild.

Study details: This retrospective, observational study included 55 patients with high-frequency episodic migraine or chronic migraine who received galcanezumab treatment (an initial loading dose of 240 mg followed by a dose of 120 mg monthly for at least 2 months).

Disclosures: This study did not receive any funding. Four authors declared receiving lecture fees from various sources. No other conflicts of interest were declared.

Source: Suzuki K et al. Could efficacy at 1 week after galcanezumab administration for patients with migraine predict responders at 3 months? A real world study. J Neurol. 2023 (May 23). doi: 10.1007/s00415-023-11788-x

Key clinical point: Galcanezumab showed significant efficacy after the first week of treatment, and the treatment efficacy after the first week was a significant predictor of the response rate at 3 months.

Major finding: The mean changes in weekly response rates (RR) at 1, 2, 3, and 4 weeks after galcanezumab initiation were 44.6%, 31.4%, 26.0%, and 32.6%, respectively, with the improvement being greatest at 1 week (P < .001) and the RR at 1 week being the only predictive factor for ≥50% RR at 3 months (adjusted odds ratio 1.029; P = .002). Adverse events were mostly mild.

Study details: This retrospective, observational study included 55 patients with high-frequency episodic migraine or chronic migraine who received galcanezumab treatment (an initial loading dose of 240 mg followed by a dose of 120 mg monthly for at least 2 months).

Disclosures: This study did not receive any funding. Four authors declared receiving lecture fees from various sources. No other conflicts of interest were declared.

Source: Suzuki K et al. Could efficacy at 1 week after galcanezumab administration for patients with migraine predict responders at 3 months? A real world study. J Neurol. 2023 (May 23). doi: 10.1007/s00415-023-11788-x

Key clinical point: Galcanezumab showed significant efficacy after the first week of treatment, and the treatment efficacy after the first week was a significant predictor of the response rate at 3 months.

Major finding: The mean changes in weekly response rates (RR) at 1, 2, 3, and 4 weeks after galcanezumab initiation were 44.6%, 31.4%, 26.0%, and 32.6%, respectively, with the improvement being greatest at 1 week (P < .001) and the RR at 1 week being the only predictive factor for ≥50% RR at 3 months (adjusted odds ratio 1.029; P = .002). Adverse events were mostly mild.

Study details: This retrospective, observational study included 55 patients with high-frequency episodic migraine or chronic migraine who received galcanezumab treatment (an initial loading dose of 240 mg followed by a dose of 120 mg monthly for at least 2 months).

Disclosures: This study did not receive any funding. Four authors declared receiving lecture fees from various sources. No other conflicts of interest were declared.

Source: Suzuki K et al. Could efficacy at 1 week after galcanezumab administration for patients with migraine predict responders at 3 months? A real world study. J Neurol. 2023 (May 23). doi: 10.1007/s00415-023-11788-x