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1.
J Obstet Gynaecol Can ; 46(5): 102404, 2024 May.
Article in English | MEDLINE | ID: mdl-38336006

ABSTRACT

OBJECTIVES: Examine whether preoperative antibiotics in class I/clean abdominal gynaecologic surgery decrease the incidence of surgical site infections (SSI). METHODS: Retrospective cohort study at academic safety net hospital of patients undergoing class I laparoscopic or open gynaecologic surgery between November 2013 and September 2017. Performance improvement initiative to administer preoperative antibiotics to all surgical patients starting July 2016. RESULTS: In total, 510 patients were included: 283 in the antibiotic group and 227 in the no-antibiotic group. PRIMARY OUTCOME: incidence of SSI. Baseline characteristics were similar between groups once balanced by propensity score method. In unweighted analysis, incidence of SSI decreased from 9.3% (21/227) in the no-antibiotics group to 4.9% (14/283) in antibiotics group, but this was not statistically significant (odds ratio (OR) 0.51 CI 0.25-1.03, P = 0.0598). Following of inverse probability of treatment weighting adjustments in weighted analysis, incidence of SSI was found to be significantly lower in patients who received antibiotics compared to patients who did not receive antibiotics across entry types (4.6% vs. 9.8%, OR 0.45; CI 0.22-0.90, P = 0.023). Weighted analysis demonstrated in the exploratory laparotomy group patients who received antibiotics had a lower incidence of SSI compared to patients who did not receive antibiotics (5.1% vs. 18.7%, OR 0.23; CI 0.08-0.68, P = 0.008). In the laparoscopy group, there was no difference between groups (4.4% vs. 5.4%, OR 0.81; CI 0.3-2.16, P = 0.675). CONCLUSIONS: There is limited literature on SSI prevention/preoperative antibiotic use in class I gynaecologic surgeries. This study demonstrates antibiotics in class I procedures decrease SSI rates, specifically in open procedures. There was a lack of demonstrated benefit in laparoscopy.


Subject(s)
Anti-Bacterial Agents , Antibiotic Prophylaxis , Gynecologic Surgical Procedures , Surgical Wound Infection , Humans , Surgical Wound Infection/prevention & control , Surgical Wound Infection/epidemiology , Female , Retrospective Studies , Gynecologic Surgical Procedures/adverse effects , Middle Aged , Anti-Bacterial Agents/therapeutic use , Anti-Bacterial Agents/administration & dosage , Adult , Incidence , Safety-net Providers , Laparoscopy , Preoperative Care/methods
2.
Gynecol Oncol ; 179: 138-144, 2023 Dec.
Article in English | MEDLINE | ID: mdl-37980768

ABSTRACT

OBJECTIVE: We aimed to identify social needs of gynecologic oncology patients using a self-administered social needs assessment tool (SNAT), compare the SNAT to a formal social work assessment performed by cancer care navigators (CCN), and provide SNAT-informed community resources. METHODS: We analyzed prospectively collected data from a performance improvement initiative in a safety-net gynecologic oncology clinic between October 2021 and July 2022. We screened for eight social needs domains, health literacy, desire for social work, and presence of urgent needs. Clinicodemographic data were abstracted from the electronic medical record. Univariate descriptive statistics were used. Inter-rater reliability for social needs domains was assessed using percent agreement. RESULTS: 1010 unique patients were seen over this study period. 488 (48%) patients completed the SNAT, of which 265 (54%) screened positive for ≥1 social need. 83 (31%) patients were actively receiving cancer treatment, 140 (53%) were in post-treatment surveillance, and 42 (16%) had benign gynecologic diagnoses. Transportation (19% vs 25%), housing insecurity (18% vs 19%), and desire to speak with a social worker (16% vs 27%) were the 3 most common needs in both the entire cohort and among patients actively receiving cancer treatment. 78% patients in active treatment were seen by a CCN and received SNAT informed community resources. The percent agreement between the SNAT and formal CCN assessment ranged from 72%-94%. CONCLUSIONS: The self-administered SNAT identified many unmet social needs among gynecologic oncology patients, corresponded well with the formal social work CCN assessment, and informed the provision of community resources.


Subject(s)
Genital Neoplasms, Female , Health Literacy , Humans , Female , Genital Neoplasms, Female/therapy , Reproducibility of Results , Social Support
3.
Obstet Gynecol ; 142(3): 699-707, 2023 09 01.
Article in English | MEDLINE | ID: mdl-37535963

ABSTRACT

OBJECTIVE: To evaluate the effects of a community health worker-supported hereditary cancer risk-assessment and genetic testing program in a safety-net hospital serving more than 70% medically underserved patients. METHODS: This community health worker pilot program began in January 2020 at women's health clinics by administering original National Comprehensive Cancer Network (NCCN)-based questionnaires. Patients meeting high-risk criteria were offered video-based genetic education and testing, notified of results using telehealth, and offered indicated counseling. We compared the rate of genetic counseling and testing in the first 18 months of the pilot program with that in the prior 18 months. RESULTS: In the first 18 months of the pilot program, 940 patients were screened through the community health worker program: 196 were identified as high-risk, 103 patients were tested, and pathogenic variants were identified in 10 (9.7%), two of whom had a personal cancer history. In addition, 73 patients were tested per usual practice by a certified genetic counselor: pathogenic variants were identified in 16 (21.9%), 11 (68.8%) of whom had a personal cancer history. In the 18 months before the program, 68 patients underwent genetic testing with a certified genetic counselor, pathogenic variants were identified in 16 (23.5%), 13 (81.3%) of whom had a personal cancer history. The community health worker program led to a significant increase in testing among unaffected patients based on family history alone (odds ratio [OR] 7.0; 95% CI 3.7-13.2; P <.001), paralleled by a respective significant increase in the identification of pathogenic variants (OR 4.33; 95% CI 1.0-18.9; P =.051). CONCLUSION: This pilot program demonstrates the feasibility of a community health worker-supported program, using self-administered questionnaires and telehealth-based genetic services in a primarily medically underserved population. This program improved the detection of unaffected high-risk patients based on family history, increasing the volume of tests performed for this indication. Programs of this type may improve family history-based hereditary cancer testing in medically underserved patients, further enabling cancer-prevention strategies.


Subject(s)
Genetic Predisposition to Disease , Neoplasms , Humans , Female , Community Health Workers , Genetic Testing , Genetic Counseling , Neoplasms/genetics , Risk Assessment
4.
J Low Genit Tract Dis ; 27(3): 193-197, 2023 Jul 01.
Article in English | MEDLINE | ID: mdl-37285236

ABSTRACT

OBJECTIVE: To evaluate single-pass loop electrosurgical excision procedure (LEEP-SP) versus LEEP with top hat (LEEP-TH) in terms of treatment failure defined as high-grade squamous intraepithelial lesion (HSIL) cytology within 2 years' follow-up. METHODS: This single-institution cohort study used a prospectively collected cervical dysplasia database including all patients who underwent LEEP-SP or LEEP-TH for biopsy-proven cervical intraepithelial neoplasia between 2005 and 2019. RESULTS: Of 340 patients included, 178 underwent LEEP-SP and 162 LEEP-TH. The LEEP-TH patients were more likely to be older (mean age, 40.4 vs 36.5 years; p < .001) and have a positive preprocedure endocervical sampling (68.5% vs 11.8%; p < .001). Positive margins were found in 23 LEEP-SP (12.9%) and in 25 LEEP-TH (15.4%; p = .507). There was no significant difference in depth of excision between LEEP-SP (13.21 ± 23.19 mm) and LEEP-TH (17.37 ± 28.26 mm; p = .138). At 2 years, there was no difference in the rates of HSIL cytology (5.2% vs 6.3%; p = .698), any positive human papillomavirus test, or HSIL cytology (25% vs 15%; p = .284). The 57 patients undergoing repeat excision were more likely to be older (mean age, 40.95 vs 37.52 years; p = .023), have had a LEEP-TH (26.3% vs 73.7%; p < .001), and have initial cytologic HSIL (64.9% vs 35.0%; p < .001). CONCLUSIONS: In this single-institution study, there is no difference in the rate of recurrent HSIL in patients undergoing LEEP-SP versus LEEP-TH. A LEEP-TH may have limited additional benefit over a LEEP-SP in the treatment of cervical HSIL.


Subject(s)
Carcinoma, Squamous Cell , Squamous Intraepithelial Lesions of the Cervix , Squamous Intraepithelial Lesions , Uterine Cervical Dysplasia , Uterine Cervical Neoplasms , Female , Humans , Adult , Uterine Cervical Neoplasms/surgery , Uterine Cervical Neoplasms/pathology , Squamous Intraepithelial Lesions of the Cervix/surgery , Squamous Intraepithelial Lesions of the Cervix/pathology , Cohort Studies , Electrosurgery/methods , Uterine Cervical Dysplasia/pathology , Squamous Intraepithelial Lesions/surgery , Retrospective Studies , Carcinoma, Squamous Cell/surgery
5.
Lancet Oncol ; 24(5): 468-482, 2023 05.
Article in English | MEDLINE | ID: mdl-37080223

ABSTRACT

BACKGROUND: Standard treatment for locally advanced cervical cancer is chemoradiotherapy, but many patients relapse and die of metastatic disease. We aimed to determine the effects on survival of adjuvant chemotherapy after chemoradiotherapy. METHODS: The OUTBACK trial was a multicentre, open-label, randomised, phase 3 trial done in 157 hospitals in Australia, China, Canada, New Zealand, Saudi Arabia, Singapore, and the USA. Eligible participants were aged 18 year or older with histologically confirmed squamous cell carcinoma, adenosquamous cell carcinoma, or adenocarcinoma of the cervix (FIGO 2008 stage IB1 disease with nodal involvement, or stage IB2, II, IIIB, or IVA disease), Eastern Cooperative Oncology Group performance status 0-2, and adequate bone marrow and organ function. Participants were randomly assigned centrally (1:1) using a minimisation approach and stratified by pelvic or common iliac nodal involvement, requirement for extended-field radiotherapy, FIGO 2008 stage, age, and site to receive standard cisplatin-based chemoradiotherapy (40 mg/m2 cisplatin intravenously once-a-week for 5 weeks, during radiotherapy with 45·0-50·4 Gy external beam radiotherapy delivered in fractions of 1·8 Gy to the whole pelvis plus brachytherapy; chemoradiotherapy only group) or standard cisplatin-based chemoradiotherapy followed by adjuvant chemotherapy with four cycles of carboplatin (area under the receiver operator curve 5) and paclitaxel (155 mg/m2) given intravenously on day 1 of a 21 day cycle (adjuvant chemotherapy group). The primary endpoint was overall survival at 5 years, analysed in the intention-to-treat population (ie, all eligible patients who were randomly assigned). Safety was assessed in all patients in the chemoradiotherapy only group who started chemoradiotherapy and all patients in the adjuvant chemotherapy group who received at least one dose of adjuvant chemotherapy. The OUTBACK trial is registered with ClinicalTrials.gov, NCT01414608, and the Australia New Zealand Clinical Trial Registry, ACTRN12610000732088. FINDINGS: Between April 15, 2011, and June 26, 2017, 926 patients were enrolled and randomly assigned to the chemoradiotherapy only group (n=461) or the adjuvant chemotherapy group (n=465), of whom 919 were eligible (456 in the chemoradiotherapy only group and 463 in the adjuvant chemotherapy group; median age 46 years [IQR 37 to 55]; 663 [72%] were White, 121 [13%] were Black or African American, 53 [6%] were Asian, 24 [3%] were Aboriginal or Pacific islander, and 57 [6%] were other races) and included in the analysis. As of data cutoff (April 12, 2021), median follow-up was 60 months (IQR 45 to 65). 5-year overall survival was 72% (95% CI 67 to 76) in the adjuvant chemotherapy group (105 deaths) and 71% (66 to 75) in the chemoradiotherapy only group (116 deaths; difference 1% [95% CI -6 to 7]; hazard ratio 0·90 [95% CI 0·70 to 1·17]; p=0·81). In the safety population, the most common clinically significant grade 3-4 adverse events were decreased neutrophils (71 [20%] in the adjuvant chemotherapy group vs 34 [8%] in the chemoradiotherapy only group), and anaemia (66 [18%] vs 34 [8%]). Serious adverse events occurred in 107 (30%) in the adjuvant chemotherapy group versus 98 (22%) in the chemoradiotherapy only group, most commonly due to infectious complications. There were no treatment-related deaths. INTERPRETATION: Adjuvant carboplatin and paclitaxel chemotherapy given after standard cisplatin-based chemoradiotherapy for unselected locally advanced cervical cancer increased short-term toxicity and did not improve overall survival; therefore, it should not be given in this setting. FUNDING: National Health and Medical Research Council and National Cancer Institute.


Subject(s)
Cisplatin , Uterine Cervical Neoplasms , Female , Humans , Middle Aged , Carboplatin/adverse effects , Uterine Cervical Neoplasms/therapy , Neoplasm Staging , Antineoplastic Combined Chemotherapy Protocols/adverse effects , Neoplasm Recurrence, Local/therapy , Chemoradiotherapy/adverse effects , Chemotherapy, Adjuvant , Paclitaxel/adverse effects
6.
Cancer ; 127(20): 3809-3816, 2021 10 15.
Article in English | MEDLINE | ID: mdl-34250590

ABSTRACT

BACKGROUND: Social needs are actionable mediators of social determinants of health. Along with distress, they affect quality of life and survival in patients with cancer. The objectives of this study were to identify the most common social needs and distress in a largely immigrant gynecologic oncology patient population at a public safety-net hospital and to evaluate for specific needs associated with distress and poor outcomes. METHODS: This was a prospective, survey-based cohort study of patients who participated in a performance-improvement initiative offering social needs assessment and distress screening. Patients provided sociodemographic information and completed validated surveys adapted from the Health Leads Social Needs Screening Toolkit, the National Comprehensive Cancer Network Distress Thermometer, and the Emotion Thermometers Tool. Associations between social needs, distress, and treatment outcomes were analyzed. RESULTS: In total, 135 women were included. Of these, 65.2% had at least 1 unmet social need, and 36.3% screened positive for distress. Help reading hospital materials (30.4%) was the most frequently reported need. Social isolation (odds ratio [OR], 3.65; 95% CI, 1.35-9.9; P = .01) and lack of safety at home (OR, 4.90; 95% CI, 2.23-10.62; P = .0001) were associated with distress. Perceived lack of finances for medical care (OR, 5.69; 95% CI, 1.12-28.9; P = .036) and lack of transportation (OR, 20.5; 95% CI, 2.69-156.7; P = .004) were associated with nonadherence-related treatment interruption, whereas positive distress scores were associated with interruption because of comorbidities or treatment-related toxicities (OR, 20.5; 95% CI, 1.5-268.6; P = .02). CONCLUSIONS: Systematically identifying social needs and developing interventions aimed at mitigating them may lead to more actionable health care disparities research and affect treatment outcomes. LAY SUMMARY: Social needs are individual-level social conditions that drive health disparities. In this survey-based study, the objective was to identify common social needs and how these relate to distress and poor health outcomes in a largely immigrant and underserved gynecologic oncology patient population. The authors found that greater than one-third of patients screened positive for distress, nearly two-thirds had at least 1 unmet social need, and these factors were associated with emergency room visits, hospital admissions, and treatment interruptions. These findings suggest that screening for universal social needs allows providers to identify unrecognized needs and implement interventions to mitigate distress and improve health outcomes.


Subject(s)
Genital Neoplasms, Female , Quality of Life , Cohort Studies , Female , Genital Neoplasms, Female/diagnosis , Genital Neoplasms, Female/psychology , Genital Neoplasms, Female/therapy , Humans , Needs Assessment , Prospective Studies , Quality of Life/psychology
7.
J Med Syst ; 45(5): 59, 2021 Apr 07.
Article in English | MEDLINE | ID: mdl-33829303

ABSTRACT

Health systems are struggling to manage a fluctuating volume of critically ill patients with COVID-19 while continuing to provide basic surgical services and expand capacity to address operative cases delayed by the pandemic. As we move forward through the next phases of the pandemic, we will need a decision-making system that allows us to remain nimble as clinicians to meet our patient's needs while also working with a new framework of healthcare operations. Here, we present our quality improvement process for the adaptation and application of the Medically Necessary Time-Sensitive (MeNTS) toolto gynecologic surgical services beyond the initial COVID response and into recovery of surgical services; with analysis of the reliability of the modified-MeNTS tool in our multi-site safety net hospital network. This multicenter study evaluated the gynecology surgical case volume at three tertiary acute care safety net institutions within the LA County Department of Health Services: Harbor-UCLA (HUMC), Olive View Medical Center (OVMC), and Los Angeles County + University of Southern California (LAC+USC). We describe our modified-Delphi approach to adapt the MeNTS tool in a structured fashion and its application to gynecologic surgical services. Blinded reviewers engaged in a three-round iterative adaptation and final scoring utilizing the modified tool. The cohort consisted of 392 female consecutive gynecology patients across three Los Angeles County Hospitals awaiting scheduled procedures in the surgical queue.The majority of patients were Latina (74.7%) and premenopausal (67.1%). Over half (52.4%) of the patients had cardiovascular disease, while 13.0% had lung disease, and 13.8% had diabetes. The most common indications for surgery were abnormal uterine bleeding (33.2%), pelvic organ prolapse (19.6%) and presence of an adnexal mass (14.3%). Minimally invasive approaches via laparoscopy, robotic-assisted laparoscopy, or vaginal surgery was the predominant planned surgical route (54.8%). Modified-MeNTS scores assumed a normal distribution across all patients within our cohort (Median 33, Range 18-52). Overall, ICC across all three institutions demonstrated "good" interrater reliability (0.72). ICC within institutions at HUMC and OVMC were categorized as "good" interrater reliability, while LAC-USC interrater reliability was categorized as "excellent" (HUMC 0.73, OVMC 0.65, LAC+USC 0.77). The modified-MeNTS tool performed well across a range of patients and procedures with a normal distribution of scores and high reliability between raters. We propose that the modified-MeNTS framework be considered as it employs quantitative methods for decision-making rather than subjective assessments.


Subject(s)
COVID-19/epidemiology , Gynecologic Surgical Procedures/statistics & numerical data , Quality Improvement/organization & administration , Triage/organization & administration , Adult , Age Factors , Aged , Aged, 80 and over , Body Mass Index , Comorbidity , Delphi Technique , Female , Humans , Los Angeles/epidemiology , Middle Aged , Pandemics , Reproducibility of Results , SARS-CoV-2 , Time Factors , Young Adult
9.
Cancer ; 126(23): 5060-5068, 2020 12 01.
Article in English | MEDLINE | ID: mdl-32888331

ABSTRACT

BACKGROUND: Despite being the standard of care for patients with locoregional cervical cancer, many patients do not complete all components of primary chemoradiotherapy (pCRT): external beam radiotherapy, chemosensitization, and brachytherapy. Incomplete or protracted pCRT is associated with worse survival. The authors implemented a socially determined cervical cancer care navigation program at a public safety-net hospital to improve treatment adherence. METHODS: Patients with International Federation of Gynecology and Obstetrics (FIGO) stage IB1 to IVA cervical cancer who underwent pCRT from 2012 to 2016 were prospectively enrolled into this navigation program spanning the medical, financial, and psychosocial aspects of care. This patient cohort was compared with a similar cohort of consecutive nonnavigated patients who were treated from 1998 to 2008. Patient characteristics, treatment data, and patient outcomes were collected. A database of navigation encounters was maintained prospectively. RESULTS: A total of 46 patients composed the navigated cohort and 85 patients composed the nonnavigated cohort. After implementation of the cervical cancer care navigation program, the percentage of patients receiving ≥5 cycles of weekly cisplatin increased from 74% to 93% (P < .01) and rates of the initiation of brachytherapy during external beam radiotherapy increased from 49% to 78% (P < .01). The median treatment time was reduced from 67 days in the nonnavigated patients to 55 days in the navigated patients (P < .01). Approximately 95% of navigated patients who completed pCRT did so within 63 days, compared with 52% of nonnavigated patients (P < .01). Treatment completion within 63 days was associated with significantly improved overall survival. CONCLUSIONS: Socially informed cervical cancer care navigation can significantly improve the timeliness of guideline-based care, enhance access to resources for underserved minority patients receiving pCRT, and may improve overall patient outcomes.


Subject(s)
Patient Navigation , Uterine Cervical Neoplasms/therapy , Adult , Aged , Brachytherapy , Chemoradiotherapy , Female , Humans , Los Angeles , Middle Aged , Safety-net Providers , Time Factors , Uterine Cervical Neoplasms/mortality
10.
Pract Radiat Oncol ; 10(4): 220-234, 2020.
Article in English | MEDLINE | ID: mdl-32473857

ABSTRACT

PURPOSE: This guideline reviews the evidence and provides recommendations for the indications and appropriate techniques of radiation therapy (RT) in the treatment of nonmetastatic cervical cancer. METHODS: The American Society for Radiation Oncology convened a task force to address 5 key questions focused on the use of RT in definitive and postoperative management of cervical cancer. These questions included the indications for postoperative and definitive RT, the use of chemotherapy in sequence or concurrent with RT, the use of intensity modulated radiation therapy (IMRT), and the indications and techniques of brachytherapy. Recommendations were based on a systematic literature review and created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength. RESULTS: The guideline recommends postoperative RT for those with intermediate risk factors, and chemoradiation for those with high-risk factors. In the definitive setting, chemoradiation is recommended for stages IB3-IVA, and RT or chemoradiation is conditionally recommended for stages IA1-IB2 if medically inoperable. IMRT is recommended for postoperative RT and conditionally recommended for definitive RT, for the purposes of reducing acute and late toxicity. Brachytherapy is strongly recommended for all women receiving definitive RT, and several recommendations are made for target dose and fractionation, the use of intraoperative imaging, volume-based planning, and recommendations for doses limits for organs at risk. CONCLUSIONS: There is strong evidence supporting the use of RT with or without chemotherapy in both definitive and postoperative settings. Brachytherapy is an essential part of definitive management and volumetric planning is recommended. IMRT may be used for the reduction of acute and late toxicity. The use of radiation remains an essential component for women with cervical cancer to achieve cure.


Subject(s)
Radiation Oncology/standards , Uterine Cervical Neoplasms/radiotherapy , Female , Humans
11.
Gynecol Oncol ; 157(3): 563-569, 2020 06.
Article in English | MEDLINE | ID: mdl-32107049

ABSTRACT

Gynecologic oncologists have the unique opportunity of caring for patients in a broad range of surgical and medical settings. With increasing awareness of the opioid epidemic and the various factors that contribute to chronic opioid use, gynecologic oncologists must also better understand how to best address acute postoperative pain without unknowingly placing patients at risk for opioid misuse. This article examines the use of opioids in the acute surgical setting and provides clinical guidelines and various strategies to reduce opioid misuse.


Subject(s)
Analgesics, Opioid/therapeutic use , Genital Neoplasms, Female/epidemiology , Pain, Postoperative/drug therapy , Postoperative Care/methods , Female , Humans
12.
J Community Health ; 45(3): 446-451, 2020 06.
Article in English | MEDLINE | ID: mdl-31659600

ABSTRACT

Human papillomavirus vaccination (HPV) remains low in the United States. The inpatient postpartum setting provides an innovative opportunity to vaccinate eligible patients. This study evaluated two different interventions to improve HPV vaccination rates in hospitalized postpartum patients: a nurse based protocol and an electronic medical record (EMR) postpartum order prompt. This was a comparative intervention study performed in a prospective cohort of postpartum patients at two affiliated County Hospitals. The intervention was conducted over a 6-month period aimed at increasing HPV vaccination rates through a nurse based protocol at one hospital (H-NBP) and an EMR postpartum order prompt at the second hospital (H-EMR). Outcomes measures included vaccine administration, patient refusal, and vaccine wastage. A multiple logistic regression model was used to compare outcomes. At H-NBP, 143 vaccine-eligible patients (74%) were identified of which 44 (32%) received the HPV vaccine, 66 (46%) refused, and 33 (21%) had missed opportunities. At H-EMR, 169 patients (87%) were identified as vaccine-eligible of which 111 (66%) received the HPV4 vaccine, 24 (14%) refused and 34 (20%) had missed opportunities. After adjusting for sociodemographic variables, patients at H-EMR were nearly 6 times more likely than patients at H-NBP to undergo postpartum HPV vaccination (OR 5.865, CI 3.358-10.245, p value < 0.0001). An EMR prompt offers a greater impact on HPV vaccination rates than a nursing protocol. The feasibility and success of inpatient postpartum HPV vaccination interventions as demonstrated in this study provides insights on how to approach vaccination strategies in nontraditional clinical settings.


Subject(s)
Electronic Health Records , Papillomavirus Vaccines/therapeutic use , Vaccination/statistics & numerical data , Adolescent , Cohort Studies , Female , Humans , Male , Papillomavirus Infections/prevention & control , Papillomavirus Vaccines/administration & dosage , Postpartum Period , Prospective Studies , United States , Young Adult
13.
J Surg Oncol ; 120(4): 779-785, 2019 Sep.
Article in English | MEDLINE | ID: mdl-31283034

ABSTRACT

BACKGROUND: We sought to determine if complete pathologic response (cPR) and cytoreductive status at interval debulking surgery (IDS) after neoadjuvant chemotherapy (NACT) are associated with improved clinical outcomes in ovarian cancer. METHODS: We evaluated 91 patients with advanced ovarian cancer who underwent NACT and IDS. Pathologic response, cytoreductive status, and outcomes were determined. Descriptive statistics, bivariate analysis, and Kaplan-Meier survival probabilities were calculated. RESULTS: cPR occurred in 9 (10%), microscopic pathologic response (microPR) in 18 (20%), and macroscopic pathologic response (macroPR) in 64 (70%) patients. Median progression-free survival (PFS) for patients with cPR was significantly improved compared with patients with any pathologic residual disease (microPR/macroPR; undefined vs 10.9 months, P = .01); whereas, microPR was not associated with significantly improved PFS compared with macroPR (16.3 months vs 10 months, P = .08). Cytoreduction to no gross residual disease was associated with improved PFS (undefined vs 7.5 months vs 5.5 months, P < .01) and overall survival (undefined vs 38.7 months vs 12 months, P < .01) compared with visible residual disease less than or equal to 1 cm or suboptimal. CONCLUSIONS: cPR is uncommon (10%) after NACT for advanced ovarian cancer. Better pathologic response and cytoreductive status are associated with improved PFS, emphasizing the importance of both chemotherapy response and surgical effort.


Subject(s)
Cystadenocarcinoma, Serous/pathology , Cytoreduction Surgical Procedures/mortality , Neoplasm Recurrence, Local/pathology , Ovarian Neoplasms/pathology , Adult , Aged , Aged, 80 and over , Antineoplastic Combined Chemotherapy Protocols/therapeutic use , Chemotherapy, Adjuvant , Cohort Studies , Cystadenocarcinoma, Serous/drug therapy , Cystadenocarcinoma, Serous/surgery , Female , Follow-Up Studies , Humans , Male , Middle Aged , Neoadjuvant Therapy , Neoplasm Recurrence, Local/drug therapy , Neoplasm Recurrence, Local/surgery , Ovarian Neoplasms/drug therapy , Ovarian Neoplasms/surgery , Prognosis , Survival Rate
14.
Brachytherapy ; 18(2): 123-132, 2019.
Article in English | MEDLINE | ID: mdl-30665713

ABSTRACT

Brachytherapy is well-established as an integral component in the standard of care for treatment of patients receiving primary radiotherapy for cervical cancer. A decline in brachytherapy has been associated with negative impacts on survival in the era of modern EBRT techniques. Conformal external beam therapies such intensity modulated radiation therapy (IMRT) or stereotactic body radiation therapy (SBRT) should not be used as alternatives to brachytherapy in patients undergoing primary curative-intent radiation therapy for cervical cancer. Computed tomography or magnetic resonance image-guided adaptive brachytherapy is evolving as the preferred brachytherapy method. With careful care coordination EBRT and brachytherapy can be successfully delivered at different treatment centers without compromising treatment time and outcome in areas where access to brachytherapy maybe limited.


Subject(s)
Brachytherapy , Radiosurgery , Radiotherapy, Intensity-Modulated , Uterine Cervical Neoplasms/radiotherapy , Brachytherapy/trends , Female , Humans , Magnetic Resonance Imaging , Radiotherapy, Image-Guided , Survival Rate/trends , Tomography, X-Ray Computed , United States , Uterine Cervical Neoplasms/diagnostic imaging
15.
Gynecol Oncol ; 152(3): 540-547, 2019 03.
Article in English | MEDLINE | ID: mdl-30665615

ABSTRACT

Brachytherapy is well-established as an integral component in the standard of care for treatment of patients receiving primary radiotherapy for cervical cancer. A decline in brachytherapy has been associated with negative impacts on survival in the era of modern EBRT techniques. Conformal external beam therapies such intensity modulated radiation therapy (IMRT) or stereotactic body radiation therapy (SBRT) should not be used as alternatives to brachytherapy in patients undergoing primary curative-intent radiation therapy for cervical cancer. Computed tomography or magnetic resonance image-guided adaptive brachytherapy is evolving as the preferred brachytherapy method. With careful care coordination EBRT and brachytherapy can be successfully delivered at different treatment centers without compromising treatment time and outcome in areas where access to brachytherapy maybe limited.


Subject(s)
Brachytherapy/methods , Uterine Cervical Neoplasms/radiotherapy , Brachytherapy/statistics & numerical data , Female , Humans , Radiosurgery/methods , Radiotherapy, Image-Guided/methods , Radiotherapy, Intensity-Modulated/methods , Uterine Cervical Neoplasms/diagnostic imaging , Uterine Cervical Neoplasms/mortality
16.
Female Pelvic Med Reconstr Surg ; 25(4): 289-293, 2019.
Article in English | MEDLINE | ID: mdl-29300258

ABSTRACT

OBJECTIVES: The aims of this study were to determine the efficacy of phenazopyridine when used intraoperatively to assess ureteral patency and to investigate factors that may influence its efficacy. METHODS: This is a retrospective chart review performed at the Olive View-UCLA Medical Center, a Los Angeles County teaching hospital, from January 2014 through July 2016. Patients undergoing cystoscopy at the time of gynecologic surgery were identified via department case logs. All women receiving preoperative oral phenazopyridine were included. If ureteral flow was unable to be visualized with phenazopyridine alone, the medication was deemed ineffective, and sodium fluorescein was given intraoperatively. Patients were divided into a phenazopyridine effective or phenazopyridine ineffective group. Patient demographics, renal function, intraoperative fluids and urine output, estimated blood loss, timing and dose of medication administration, and complications were gathered from the chart and compared between groups using Fisher exact test, 2-sample t test, Wilcoxon test, and logistic regression for multivariable analysis. P < 0.05 was determined to be significant. RESULTS: Preoperative phenazopyridine was effective in 190 (91.8%) of 207 patients. It was ineffective in 17 patients who then required intraoperative sodium fluorescein. The group in which phenazopyridine was effective was more likely to have been given a 200-mg (vs 100-mg) dose (P = 0.02) and had lower intraoperative urine output (median, 450 vs 800 mL; P = 0.002). CONCLUSIONS: Preoperative oral phenazopyridine is effective in more than 90% of cases to detect during gynecologic surgery. A higher phenazopyridine dose and lower intraoperative urine output were associated with increased efficacy.


Subject(s)
Coloring Agents , Intraoperative Complications/diagnosis , Phenazopyridine , Surgical Wound/diagnosis , Ureter/injuries , Administration, Oral , Adult , Aged , Coloring Agents/administration & dosage , Cystoscopy , Female , Fluorescein , Gynecologic Surgical Procedures/adverse effects , Humans , Intraoperative Complications/etiology , Intraoperative Period , Middle Aged , Phenazopyridine/administration & dosage , Preoperative Period , Retrospective Studies , Surgical Wound/etiology , Urine
18.
Am Surg ; 81(10): 1074-9, 2015 Oct.
Article in English | MEDLINE | ID: mdl-26463311

ABSTRACT

Sepsis remains a significant source of mortality among hospitalized patients. This study examines the usage of a vital sign-based screening protocol in identifying postoperative patients at risk for sepsis at an academic-affiliated medical center. We identified all general surgery inpatients undergoing abdominopelvic surgery from January to June 2014, and compared those with positive screening tests to a sample of screen-negative controls. Multivariate logistic regression was used to identify predictors of positive screening tests and progression to severe sepsis. In total, 478 patients underwent abdominopelvic operations, 59 had positive screening tests, 33 qualified for sepsis, and six progressed to severe sepsis. Predictors of a positive screening test were presence of cancer [odds ratio (OR) 30.7, 95% confidence interval (CI) 2.2-420], emergency operation (OR 6.5, 95% CI 1.7-24), longer operative time (OR 2.2/h, 95% CI 1.2-4.1), and presence of postoperative infection (OR 6.4, 95% CI 1.5-27). The screening protocol had sensitivity 100 per cent and specificity 88 per cent for severe sepsis. We identified no predictors of severe sepsis. In conclusion, vital sign-based screening provides value by drawing early attention to patients with potential to develop sepsis, but escalation of care for these patients should be based on clinical judgment.


Subject(s)
Early Diagnosis , Emergency Service, Hospital , Inpatients , Sepsis/diagnosis , Surgical Wound Infection/diagnosis , Adult , California/epidemiology , Disease Progression , Female , Follow-Up Studies , Hospital Mortality/trends , Humans , Incidence , Male , Middle Aged , Odds Ratio , Retrospective Studies , Risk Factors , Sepsis/epidemiology , Severity of Illness Index , Surgical Wound Infection/epidemiology , Survival Rate/trends
19.
Obstet Gynecol ; 126(4): 811-814, 2015 Oct.
Article in English | MEDLINE | ID: mdl-26132453

ABSTRACT

BACKGROUND: A "hook effect" resulting from saturation of antibodies used in pregnancy tests can occur at human chorionic gonadotropin (hCG) levels above 500,000 milliinternational units/mL, resulting in falsely negative values. CASE: A 34-year-old woman, gravida 5 para 3, presented to the emergency department after heavy bleeding. Ultrasonogram revealed a uterine mass, urine pregnancy test result was negative, and endometrial biopsy inconclusive. The patient was discharged and presented 10 days later with recurrent bleeding. Urine pregnancy test result was again negative, but serum hCG was 581 milliinternational units/mL. Serial dilution revealed an actual hCG higher than 5 million milliinternational units/mL. She was diagnosed with gestational trophoblastic disease. CONCLUSION: Awareness of the risk of a false-negative pregnancy test result when hCG levels are extremely high may prevent delayed diagnosis of gestational trophoblastic disease.


Subject(s)
Chorionic Gonadotropin/blood , Chorionic Gonadotropin/urine , Gestational Trophoblastic Disease/diagnosis , Adult , Delayed Diagnosis , False Negative Reactions , Female , Gestational Trophoblastic Disease/blood , Gestational Trophoblastic Disease/urine , Humans , Pregnancy
20.
Curr Opin Obstet Gynecol ; 26(6): 516-22, 2014 Dec.
Article in English | MEDLINE | ID: mdl-25310529

ABSTRACT

PURPOSE OF REVIEW: Physicians have increasingly given up private practices to become members of, and key stakeholders in, large healthcare systems. These systems are currently transforming to meet the Triple Aim: guaranteeing the equitable provision of high-quality, evidence-based care at a reasonable cost. Participatory leadership is an organizational change theory that engages key stakeholders as architects in the transformation process. This review highlights the utility of this leadership strategy in designing care for women's health. RECENT FINDINGS: Our blueprint describing participatory leadership theory in women's health systems change is discussed in three case studies, highlighting what we call the six Ps of participatory leadership: participants, principles, purpose, process, and power. The 'sixth P', product, can then be substantially influential in changing the paradigm of care. SUMMARY: Obstetrics and gynecology is increasingly practiced in large health systems responsible for the health of populations. Innovations in clinical practice impact care at the level of the individual. In order for advances in clinical practice to reach broad populations of women, they must be integrated into a delivery system. Physician engagement in leadership during this time of system transformation is of critical importance.


Subject(s)
Delivery of Health Care, Integrated , Evidence-Based Medicine , Health Care Reform , Organizational Innovation , Psychological Theory , Quality of Health Care , Women's Health Services/organization & administration , Female , Gynecology/organization & administration , Humans , Leadership , Los Angeles , Obstetrics/organization & administration , Pregnancy , Workforce
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