Use of a mobile health patient engagement technology improves perioperative outcomes in gynecologic oncology patients.

OBJECTIVE: To evaluate the impact of a mobile health patient engagement technology (PET) on postoperative outcomes in gynecologic oncology patients. METHODS: All gynecologic oncology patients undergoing laparotomy on an enhanced recovery program (ERP) were approached from July 2019 to May 2021 to enroll in a PET, which can be accessed by computer, tablet, or smart phone. This platform provides enhanced pre- and postoperative patient education and remote patient monitoring. Patients who elected to participate were provided with targeted education based on their age and comorbidities and were asked to complete daily health checks during the postoperative period. Participants in the PET were compared to patients who opted out as well as to a historical cohort from prior to PET implementation. Patient and procedure-level factors were recorded. The primary outcomes were length of stay (LOS) and 30-day readmission rate. Analysis was performed using SPSS v.26. RESULTS: 682 women met inclusion criteria during the study time; 347 in the PET group and 335 in the control group. Demographic and other factors including race, BMI (kg/m2), Charlson Comorbidity Index (CCI), surgical complexity, and insurance status were not different between the PET and control group; however, patients in the PET cohort were slightly younger (55.0 yo vs. 57.2 yo; p = 0.04). Patients in the PET group had a significantly shorter LOS (2.9 days vs. 3.6 days; p < 0.01) and lower readmission rate (4.3% vs. 8.6%; p < 0.01) when compared with the control group. CONCLUSIONS: Use of a PET in our gynecologic oncology patients decreased LOS by nearly one day despite an absence of differences in other demographic and surgical factors other than age. Furthermore, there was a 50% reduction in readmission rates in the PET group. The use of a PET allows for healthcare professionals to engage, evaluate, and treat patients in a way that improves perioperative care.

Sensitivity and specificity of drug interaction databases to detect interactions with recently approved oral antineoplastics.

RATIONALE: Drug-drug interactions (DDIs) with oral antineoplastics (OAs) are of increasing concern given the rapid increase in OA approvals and use in cancer patients. A small pilot study of 20 DDIs with OAs showed significant variability in commonly used DDI screening databases in sensitivity of detecting potentially clinically relevant DDIs. This study builds upon that work by expanding the number of potential DDIs analyzed and including a specificity analysis. METHODS: Newly approved OAs from 2016 to May 2019 (n = 22) were included in this analysis. Prescribing information for each drug was reviewed. A list of explicit and theoretical drug interactions was created for each OA by the two investigators. A board-certified oncology pharmacist adjudicated all DDI pairs for potential clinical significance. In total, 229 DDI pairs were used to analyze sensitivity of 5 DDI databases (Lexicomp®, Micromedex®, Medscape, Eporactes®, & Drugs.com). Additionally, 64 "dummy" or false DDI pairs were created to analyze specificity. Sensitivity and specific were analyzed using Cochran's Qtest, while accuracy was analyzed using chi-square test. RESULTS: There was significant variability among the databases with regards to sensitivity (p < 0.0001), specificity (p < 0.0001), and accuracy (p < 0.0001). In terms of accuracy (max score = 400), Lexicomp®(355), Epocrates® (344), and Drugs.com (352) scored higher than MicroMedex® (270) and Medscape (280). CONCLUSIONS: Considerable variability exists among DDI screening databases with regards to OAs and potential drug interactions. Clinicians should be vigilant in both screening for DDIs with OAs and describing DDIs encountered in clinical practice.

Trends in the Utilization of Palliative Care in Patients With Gynecologic Cancer Who Subsequently Died During Hospitalization.

OBJECTIVE: To determine factors associated with the utilization of palliative care (PC) in patients with metastatic gynecologic cancer who died while hospitalized. METHODS: Data were abstracted from the National Inpatient Sample database for patients with cervical, uterine, and ovarian cancers from 2005 to 2011. Chi-squared and logistic regression models were used for statistical analyses. RESULTS: Of 4559 women (median age: 65 years; range: 19-102), 1066 (23.4%) utilized PC. Patients were 24.9% low socioeconomic status (SES), 23.9% low-middle, 23.7% middle-high, and 25.1% high SES. Medicare, Medicaid, and private insurance coverage were listed at 46.2%, 37.5%, 11.3% of patients; 36.2%, 21.1%, 18.1%, 24.6% were treated in the South, West, Midwest, and Northeast. Over the 7 year study period, the use of PC increased from 12% to 45%. Older age (odds ratio [OR]: 1.36; 95% CI: 1.11-1.68; P = .003), high SES (OR: 1.41; 95% CI: 1.12-1.78; P = .003), more recent treatment (OR: 9.22; 95% CI: 6.8-12.51; P < .0001), private insurance (OR: 1.81; 95% CI: 1.46-2.25; P < .001), and treatment at large-volume hospitals (OR: 1.36; 95% CI: 1.04-1.77; P = .02), Western (OR: 2.00; 95% CI: 1.61-2.49; P < .001) and Midwestern hospitals (OR: 1.35; 95% CI: 1.08-1.68; P = .001) were associated with higher utilization of PC. CONCLUSIONS: The use of inpatient PC for patients with gynecologic cancer increased over time. The lower utilization of PC for terminal illness was associated with younger age, lower SES, government-issued insurance coverage, and treatment in Southern and smaller volume hospitals, and warrants further attention.

Relationship status and other demographic influences on survival in patients with ovarian cancer.

OBJECTIVE: To evaluate the influence of marital status and other demographic factors on survival of patients with ovarian cancer. STUDY DESIGN: Data were obtained from the Surveillance, Epidemiology, and End Results database from 2010 to 2015. Analyses were performed using Kaplan-Meier and multivariate Cox proportional hazard methods. RESULTS: Of 19 643 patients with ovarian cancer (median age 60 years, range 18-99), 16 278 (83%), 1381 (7%), 1856 (9%), and 128 (1%) were White, Black, Asian, and Native American, respectively. The majority of patients (10 769, 55%) were married while 4155 (21%) were single, 2278 (12%) were divorced, and 2441 (12%) were widowed. Patients were more likely to be married if they were Asian (65%) or White (56%) than if they were Black (31%) or Native American (39%) (p<0.001). Most married patients were insured (n=9760 (91%), non-Medicaid) compared with 3002 (72%) of single, 1777 (78%) divorced, and 2102 (86%) of widowed patients (p<0.001). Married patients were more likely to receive chemotherapy than single, divorced, and widowed patients (8515 (79%) vs 3000 (72%), 1747 (77%), and 1650 (68%), respectively; p<0.001). The 5-year disease-specific survival of the overall group was 58%. Married patients had improved survival of 60% compared with divorced (52%) and widowed (44%) patients (p<0.001). On multivariate analysis, older age (HR 1.02, 95% CI 1.016 to 1.021, p<0.001), Black race (HR 1.24, 95% CI 1.11 to 1.38, p<0.001), and Medicaid (HR 1.19, 95% CI 1.09 to 1.30, p<0.001) or uninsured status (HR 1.23, 95% CI 1.05 to 1.44, p<0.01) carried a worse prognosis. Single (HR 1.17, 95% CI 1.08 to 1.26, p<0.001), divorced (HR 1.14, 95% CI 1.04 to 1.25, p<0.01), and widowed (HR 1.16, 95% CI 1.06 to 1.26, p<0.001) patients had decreased survival. CONCLUSION: Married patients with ovarian cancer were more likely to undergo chemotherapy with better survival rates. Black, uninsured, or patients with Medicaid insurance had poorer outcomes.

Endometrial cancer in the morbidly obese: a review.

PURPOSE OF REVIEW: With a worldwide increase in obesity, there has been an increase in obesity-related diseases. Endometrial cancer is a common cause of cancer for women worldwide. Incidence of endometrial cancer has risen worldwide. Accompanying these patients are risk factors and challenges that may prevent standard of care from being delivered. RECENT FINDINGS: The current article describes recent literature describing surgical approaches to the obese patient and special considerations in this population. This article also reviews bariatric surgery and endometrial cancer as well as new updates in radiation, chemotherapy and hormonal therapy research in the obese population. SUMMARY: The current article reviews therapeutics and surgery in the morbidly obese for the treatment of endometrial cancer.

Ovarian, uterine, and cervical cancer patients with distant metastases at diagnosis: most common locations and outcomes.

To determine the location patterns of distant metastases at initial staging and outcomes of ovarian, uterine, and cervical cancer patients. Data were obtained from the SEER database from 2010 to 2015. Analyses were performed using Kaplan-Meier and multivariate Cox proportional hazard methods. Of 3035 patients (median age: 63, range: 17-95) with stage IV gynecologic cancer, ovarian, uterine, and cervical cancers were present in 42%, 40%, and 18% of the cohort. The proportion of lung, liver, bone and brain metastases were identified in 38%, 57%, 4%, and 1% of ovarian cancer patients, 62%, 22%, 13%, and 3% of uterine cancer patients, and 59%, 16%, 23%, and 2% of cervical cancer patients, respectively. The 5-year disease-specific survival for all patients was 19%. Those with liver metastases had survival rates of 26% compared to 15% for lung, 13% for bone, and 6% for brain (p < 0.0001). Patients with ovarian, uterine, and cervical cancers had survival rates of 28%, 12%, and 12%, respectively (p < 0.0001). On multivariate analysis, brain metastasis (HR = 1.64, 95% CI 1.21-2.22, p < 0.01), uterine (HR = 1.77, 95 CI 1.56-2.02, p < 0.0001) and cervical (HR = 1.35, 95% CI 1.11-1.63, p < 0.01) cancers, and lack of insurance (HR = 1.41, 95% CI 1.16-1.73, p < 0.001) were independent predictors for poorer survival. Age, year, region, and race did not affect prognosis. Stage IV ovarian cancer most frequently metastasizes to the liver, whereas uterine and cervical cancers spread more to the lung. Overall, these patients have poor prognosis, particularly those with uterine or cervical primary disease or brain metastases.

Hearing Screening in the Community.

BACKGROUND: Adults typically wait 7-10 yr after noticing hearing problems before seeking help, possibly because they are unaware of the extent of their impairment. Hearing screenings, frequently conducted at health fairs, community events, and retirement centers can increase this awareness. To our knowledge, there are no published studies in which testing conditions and outcomes have been examined for multiple "typical screening events." PURPOSE: The purpose of this article is to report hearing screening outcomes for pure tones and self-report screening tests and to examine their relationship with ambient noise levels in various screening environments. STUDY SAMPLE: One thousand nine hundred fifty-four individuals who completed a hearing screening at one of 191 community-based screening events that took place in the Portland, OR, and Tampa, FL, metro areas. DATA COLLECTION AND ANALYSIS: The data were collected during the recruitment phase of a large multisite study. All participants received a hearing screening that consisted of otoscopy, pure-tone screening, and completion of the Hearing Handicap Inventory-Screening Version (HHI-S). In addition, ambient sound pressure levels were measured just before pure-tone testing. RESULTS: Many more individuals failed the pure-tone screening (n = 1,238) and then failed the HHI-S (n = 796). The percentage of individuals who failed the pure-tone screening increased linearly with age from <20% for ages <45 yr to almost 100% for individuals aged ≥85 yr. On the other hand, the percentage of individuals who failed the HHI-S remained unchanged at approximately 40% for individuals aged ≥55 yr. Ambient noise levels varied considerably across the hearing screening locations. They impacted the pure-tone screen failure rate but not the HHI-S failure rate. CONCLUSIONS: It is important to select screening locations with a quiet space for pure-tone screening, use headphones with good passive attenuation, measure sound levels regularly during hearing screening events, halt testing if ambient noise levels are high, and/or alert individuals to the possibility of a false-positive screening failure. The data substantiate prior findings that the relationship between pure-tone sensitivity and reported hearing loss changes with age. Although it might be possible to develop age-specific HHI-S failure criteria to adjust for this, such an endeavor is not recommended because perceived difficulties are the best predictor of hearing health behaviors. Instead, it is proposed that a public health focus on education about hearing and hearing loss would be more effective.

Hospital-acquired conditions after surgery for gynecologic cancer - An analysis of 82,304 patients.

OBJECTIVE: To evaluate the hospital-acquired condition (HAC) following oophorectomy and/or hysterectomy for gynecologic cancer patients based on clinical outcomes and costs. MATERIALS AND METHODS: Data were obtained from the Nationwide Inpatient Sample from 2005 to 2011. Chi-squared and Wilcoxon rank sum two-sample tests and multivariate logistic regression model were used for statistical analysis. RESULTS: Of 82,304 women (median age: 60 years, range: 1-101), 49,386 (60.0%) had endometrial, 23,510 (28.6%) had ovarian, and 9408 (11.4%) had cervical cancers. Of 135 HAC events, these involved catheter-associated urinary tract infections (n = 47), vascular catheter-associated infection (n = 41), foreign object retained after surgery (n = 19), pressure ulcers (n = 16), manifestation of poor glycemic control (n = 10), and air embolism (n = 2). Older patients (≥60 years) experienced more HACs relative to younger (0.23% vs. 0.09%; OR = 2.13, 95% CI: 1.30-3.50; p = 0.003), and patients with Medicaid experienced more HACs compared to those with private insurance (0.35% vs. 0.10%; OR = 3.09, 95% CI: 1.70-5.62; p < 0.001). Laparoscopic surgeries were associated with less HACs compared to open surgeries (0.05% vs. 0.19%; OR = 0.41, 95% CI: 0.19-0.90; p = 0.03). Length of hospitalization and hospital charges were greater for those with HACs, (12 days vs. 3 days; p < 0.001; $89,324 vs. $31,107; p < 0.001), respectively. CONCLUSION: The odds of hospital-acquired conditions were higher in older patients, open surgery, Medicaid insured with higher associated hospital charges.

Disparities Associated With Inpatient Palliative Care Utilization by Patients With Metastatic Gynecologic Cancers: A Study of 3337 Women.

OBJECTIVE: To determine the factors associated with inpatient palliative care (PC) use in patients with metastatic gynecologic cancer. METHODS: Data were obtained from the Nationwide Inpatient Sample (NIS) for patients with metastatic cervical, uterine, and ovarian cancers. Chi-square and multivariate models were used for statistical analyses. RESULTS: Of 67 947 inpatients with metastatic gynecologic cancer, 3337 (5%) utilized PC (median age: 63 years, range: 18-102 years). For the entire cohort, the majority was white (59%) and the remainder was black (10%), Hispanic (8%), and Asian (3%). Sixty-one percent had ovarian, 25% uterine, and 14% cervical cancers. Forty-four percent had Medicare, 37% private insurance, 12% Medicaid, and 3% were uninsured. Fifty-three percent of patients were treated at teaching hospitals, while 33% were treated at nonteaching hospitals. In multivariate analysis, the use of PC was associated with older age (≥63, median; odds ratio [OR] = 1.52, 95% confidence interval [CI]: 1.36-1.70; P < .0001) and black race (OR = 1.22, CI: 1.08-1.39; P < .01). Compared to patients with ovarian cancer, patients with uterine (OR = 1.63, CI: 1.46-1.83; P < .0001) and cervical (OR = 1.14, CI: 1.104-1.25; P < .01) cancer had higher rates of PC utilization. The proportion of patients receiving PC increased from 2% in 2005 to 10% in 2011. In a subset analysis of the 4517 patients who died during hospitalization, only 1056 (23%) patients received PC. CONCLUSION: Patients who were older, black, or had uterine and cervical cancers were more likely to use PC. Although the overall use of PC has increased, less than one-quarter of patients who died in the hospital used PC services during their final hospital admission.

The influence of age and other prognostic factors associated with survival of ovarian immature teratoma - A study of 1307 patients.

OBJECTIVE: To determine impact of age and other prognostic factors on the survival of ovarian immature teratoma (IT) patients. METHODS: Data obtained from the SEER database between 1973 and 2012. Kaplan-Meier methods and multivariate Cox regression models were used for statistical analyses. RESULTS: Of 1307 patients (median: 24years; range: 0-93), 78%, 5%, 13%, 4% were stages I, II, III and IV, respectively. 25%, 35%, and 40% had grades 1, 2, and 3. Whites were less likely to be diagnosed, and Asians had a nearly 3-fold higher proportion of IT compared to the proportion of Asians in the U.S. census. The 5-year disease-specific survival (DSS) was 91.2%. Those with stages I, II, III and IV disease had survivals of 99.7%, 95%, 81%, and 71.8% (p<0.001) and grades 1, 2, and 3 had DSS of 98.7%, 95.8%, and 91% (p<0.001), respectively. Of those who underwent fertility-preserving surgery, the DSS was 98.8%. Over time from 1973 to 1986, to 1987-1999, to 2000-2012, the survivals were 76.4%, 92.8%, and 94.7% (p<0.001). Of stage I patients, no patient <18years (n=214, used as adult cutoff) and 2 of 283 patients >18years died of cancer, with corresponding 5years DSS of 100% vs. 99.6% (p>0.05). Older age (by year, HR: 1.05; 95% CI: 1.04-1.06; p<0.0001) and higher stage (HR: 11.52; 95% CI: 4.08-32.48; p<0.0001) were independent factors indicating poorer survival. CONCLUSION: The outcome of patients with stage I disease was excellent at 99.7%, with children and adults having corresponding survivals of 100% and 99.6%.

Robotic versus laparoscopic versus open surgery in morbidly obese endometrial cancer patients - a comparative analysis of total charges and complication rates.

OBJECTIVE: To compare the complications and charges of robotic vs. laparoscopic vs. open surgeries in morbidly obese patients treated for endometrial cancer. METHODS: Data were obtained from the Nationwide Inpatient Sample from 2011. Chi-squared, Wilcoxon rank sum two-sample tests, and multivariate analyses were used for statistical analyses. RESULTS: Of 1087 morbidly obese (BMI ≥40kg/m(2)) endometrial cancer patients (median age: 59years, range: 22 to 89), 567 (52%) had open surgery (OS), 98 (9%) laparoscopic (LS), and 422 (39%) robotic surgery (RS). 23% of OS, 13% of LS, and 8% of RS patients experienced an intraoperative or postoperative complication including: blood transfusions, mechanical ventilation, urinary tract injury, gastrointestinal injury, wound debridement, infection, venous thromboembolism, and lymphedema (p<0.0001). RS and LS patients were less likely to receive blood transfusions compared to OS (5% and 6% vs. 14%, respectively; p<0.0001). The median lengths of hospitalization for OS, LS, and RS patients were 4, 1, and 1days, respectively (p<0.0001). Median total charges associated with OS, LS, and RS were $39,281, $40,997, and $45,030 (p=0.037), respectively. CONCLUSIONS: In morbidly obese endometrial cancer patients, minimally invasive robotic or laparoscopic surgeries were associated with fewer complications and less days of hospitalization relative to open surgery. Compared to laparoscopic approach, robotic surgeries had comparable rates of complications but higher charges.

The centralization of robotic surgery in high-volume centers for endometrial cancer patients--a study of 6560 cases in the U.S.

OBJECTIVE: To evaluate the hospital and patient factors associated with robotic surgery for endometrial cancer in the United States. METHODS: Data was obtained from the Nationwide Inpatient Sample from the year 2010. Chi-squared and multivariate analyses were used for statistical analysis. RESULTS: Of the 6560 endometrial cancer patients who underwent surgery, the median age was 62 (range: 22 to 99). 1647 (25%) underwent robotic surgery, 820 (13%) laparoscopic, and 4093 (62%) had open surgery. The majority was White (65%). Hospitals with 76 or more hysterectomy cases for endometrial cancer patients per year (4% of hospitals in the study) performed 31% of all hysterectomies and 40% of all robotic hysterectomies (p<0.01). 29% of Whites had robotic surgery compared to 15% of Hispanics, 12% of Blacks, and 11% of Asians (p<0.01). Patients with upper-middle and high incomes underwent robotic surgery more than patients with low or middle incomes (p<0.01). 27% of Medicare patients and 26% of patients with private insurance had robotic surgery compared to only 14% of Medicaid patients and 12% of uninsured patients (p<0.01). CONCLUSIONS: The majority of robotic surgeries for endometrial cancer were performed at a small number of high-volume hospitals in the United States. Socioeconomic status, insurance type, and race were also important predictors for the use of RS. Further studies are warranted to better understand the barriers to receiving minimally invasive surgery.

Metabolic engineering of lactate dehydrogenase rescues mice from acidosis.

Acidosis causes millions of deaths each year and strategies for normalizing the blood pH in acidosis patients are greatly needed. The lactate dehydrogenase (LDH) pathway has great potential for treating acidosis due to its ability to convert protons and pyruvate into lactate and thereby raise blood pH, but has been challenging to develop into a therapy because there are no pharmaceutical-based approaches for engineering metabolic pathways in vivo. In this report we demonstrate that the metabolic flux of the LDH pathway can be engineered with the compound 5-amino-2-hydroxymethylphenyl boronic acid (ABA), which binds lactate and accelerates the consumption of protons by converting pyruvate to lactate and increasing the NAD(+)/NADH ratio. We demonstrate here that ABA can rescue mice from metformin induced acidosis, by binding lactate, and increasing the blood pH from 6.7 to 7.2 and the blood NAD(+)/NADH ratio by 5 fold. ABA is the first class of molecule that can metabolically engineer the LDH pathway and has the potential to have a significant impact on medicine, given the large number of patients that suffer from acidosis.

Biomaterials-based modulation of the immune system.

The immune system is traditionally considered from the perspective of defending against bacterial or viral infections. However, foreign materials like implants can also illicit immune responses. These immune responses are mediated by a large number of molecular signals, including cytokines, antibodies and reactive radical species, and cell types, including macrophages, neutrophils, natural killer cells, T-cells, B-cells, and dendritic cells. Most often, these molecular signals lead to the generation of fibrous encapsulation of the biomaterials, thereby shielding the body from these biomaterials. In this review we will focus on two different types of biomaterials: those that actively modulate the immune response, as seen in antigen delivery vehicles for vaccines, and those that illicit relatively small immune response, which are important for implantable materials. The first serves to actively influence the immune response by co-opting certain immune pathways, while the second tries to mimic the properties of the host in an attempt to remain undetected by the immune system. As these are two very different end points, each type of biomaterial has been studied and developed separately and in recent years, many advances have been made in each respective area, which will be highlighted in this review.

A fluorescent peroxidase probe increases the sensitivity of commercial ELISAs by two orders of magnitude.

The low detection sensitivity of enzyme linked immunosorbent assays (ELISAs) is a central problem in science and limits progress in multiple areas of biology and medicine. In this report we demonstrate that the hydrocyanines, a family of fluorescent reactive oxygen species (ROS) probes, can act as turn on fluorescent horseradish peroxidase (HRP) probes and thereby increase the sensitivity of conventional ELISAs by two orders of magnitude.