Low serum creatinine levels are associated with major post-operative complications in patients undergoing surgery with gynecologic oncologists.

OBJECTIVE: Serum creatinine is a byproduct of muscle metabolism, and low creatinine is postulated to be associated with diminished muscle mass. This study examined the association between low pre-operative serum creatinine and post-operative outcomes. METHODS: This retrospective cohort study utilized the 2014-2021 National Surgical Quality Improvement Program to identify patients undergoing surgery with gynecologic oncologists. Patients with missing pre-operative creatinine, end-stage renal disease, sepsis, septic shock, dialysis, or pregnancy were excluded. Pre-operative creatinine was categorized into markedly low (≤0.44 mg/dL), mildly low (0.45-0.64 mg/dL), normal (0.65-0.84 mg/dL), and four categories of elevated levels (0.85-1.04, 1.05-1.24, 1.25-1.44, and ≥1.45 mg/dL). Outcomes included major (≥Grade 3) 30-day complications, categorized into any complications, wound, cardiovascular and pulmonary, renal, infectious, and thromboembolic complications. Also examined were 30-day readmissions, reoperations, and mortality. Logistic regressions assessed the association between creatinine and complications, with stratification by albumin and sensitivity analysis with propensity score matching. RESULTS: Among 84 786 patients, 0.8% had markedly low, 19.6% mildly low, and 50.2% normal creatinine; the remainder had elevated creatinine. As creatinine decreased, the risks of major complications increased in a dose-dependent manner on univariable and multivariable analyses. A total of 9.6% (n=63) markedly low patients experienced major complications, second to creatinine ≥1.45 mg/dL (9.9%, n=141). On multivariable models, both markedly and mildly low creatinine were associated with higher odds of major complications (OR 1.715, 95% CI 1.299 to 2.264 and OR 1.093, 95% CI 1.001 to 1.193) and infections (OR 1.575, 95% CI 1.118 to 2.218 and OR 1.165, 95% CI 1.048 to 1.296) versus normal. Markedly low creatinine had similar ORs to creatinine ≥1.45 mg/dL and was further associated with higher odds of cardiovascular and pulmonary complications (OR 2.301, 95% CI 1.300 to 4.071), readmissions (OR 1.403, 95% CI 1.045 to 1.884), and mortality (OR 2.718, 95% CI 1.050 to 7.031). After albumin stratification, associations persisted for markedly low creatinine. Propensity-weighted analyses demonstrated congruent findings. CONCLUSIONS: Low creatinine levels are associated with major post-operative complications in gynecologic oncology in a dose-dependent manner. Low creatinine can offer useful information for pre-operative risk stratification, surgical counseling, and peri-operative management.

The activity advantage: Objective measurement of preoperative activity is associated with postoperative recovery and outcomes in patients undergoing surgery with gynecologic oncologists.

OBJECTIVE: To examine the association between objectively-measured preoperative physical activity with postoperative outcomes and recovery milestones in patients undergoing gynecologic oncology surgeries. METHODS: Prospective cohort study of patients undergoing surgery with gynecologic oncologists who wore wearable actigraphy rings before and after surgery from 03/2021-11/2023. Exposures encompassed preoperative activity intensity (moderate- and vigorous-intensity metabolic equivalent of task-minutes [MAVI MET-mins] over seven days) and level (average daily steps over seven days). Intensity was categorized as <500, 500-1000, and >1000 MAVI MET-mins; level categorized as <8000 and ≥8000 steps/day. Primary outcome was 30-day complications. Secondary outcomes included reaching postoperative goal (≥70% of recommended preoperative intensity and level thresholds) and return to baseline (≥70% of individual preoperative intensity and level). RESULTS: Among 96 enrolled, 87 met inclusion criteria, which constituted 39% (n = 34) with <500 MET-mins and 56.3% (n = 49) with <8000 steps preoperatively. Those with <500 MET-mins and <8000 steps had higher ECOG scores (p = 0.042 & 0.037) and BMI (p = 0.049 & 0.002) vs those with higher activity; all other perioperative characteristics were similar between groups. Overall, 29.9% experienced a 30-day complication, 29.9% reached postoperative goal, and 64.4% returned to baseline. On multivariable models, higher activity was associated with lower odds of complications: 500-1000 MET-mins (OR = 0.26,95%CI = 0.07-0.92) and >1000 MET-mins (OR = 0.25,95%CI = 0.07-0.94) vs <500 MET-mins; ≥8000 steps (OR = 0.25,95%CI = 0.08-0.73) vs <8000 steps. Higher preoperative activity was associated fewer days to reach postoperative goal. CONCLUSION: Patients with high preoperative activity are associated with fewer postoperative complications and faster attainment of recovery milestones. Physical activity may be considered a modifiable risk factor for adverse postoperative outcomes.

Shifting trends and sicker patients: Reassessing hysterectomy performed for benign indications by gynecologic oncologists.

OBJECTIVE: To assess trends and differences in patient characteristics, complications, and distributions of hysterectomy for benign indications by benign gynecologists (BG) and gynecologic oncologists (GO). METHODS: This retrospective cohort study identified patients undergoing hysterectomy for benign indications using the National Surgical Quality Improvement Program data from 2014 to 2021. Exclusions were made for gynecologic or disseminated cancers, ascites, non-gynecologic surgeons, and cesarean hysterectomies. Primary outcome was major (≥Grade 3) 30-day complications, categorized into any complications, wound, cardiovascular and pulmonary, renal, infectious, andthromboembolic complications. Thirty-day readmissions, reoperations, and mortality were also analyzed. Propensity score matching was performed in a 1:1 match of GO to BG patients and was compared. Linear regressions assessed trends. RESULTS: Among 198,767 patients, 18% (n = 37,707) underwent hysterectomy for benign indications with GO. GO patients exhibited more risk factors for complications and differed significantly from BG patients in comorbidities and perioperative characteristics. Overall, GO patients had higher major complication rates (3.1% vs 2.2%, p < 0.001) and for several other composite complications. After matching, compared to BG, GO-performed hysterectomies had similar rates of major complications (3.0% vs 3.0%, p = 0.55) and no differences in other composite complications, except fewer reoperations (1.2 % vs 1.5%, p < 0.01) and wound complications (0.4% vs 0.5%, p = 0.02) in GO patients. Over the eight years, the percentage of GO-performed hysterectomy (ß = 0.41, R2 = 0.71,p < 0.01) increased significantly whereas BG-performed surgeries decreased by the same magnitude. BG had a significant decrease in frail patients (ß = -0.47, R2 = 0.90, p < 0.01), but GO did not (ß = -0.36, R2 = 0.38, p = 0.10). CONCLUSIONS: GO are performing more hysterectomies for benign indications on higher-risk patients. However, on a matched cohort, risks of major complications were similar between GO and BG.

In the patient's shoes: The impact of hospital proximity and volume on stage I endometrial cancer care patterns and outcomes.

OBJECTIVE: To compare the impact of travel burden and hospital volume on care patterns and outcomes in stage I endometrial cancer. METHODS: This retrospective cohort study identified patients from the National Cancer Database with stage I epithelial endometrial carcinoma who underwent hysterectomy between 2012 and 2020. Patients were categorized into: lowest quartiles of travel distance and hospital surgical volume for endometrial cancer (Local) and highest quartiles of distance and volume (Travel). Primary outcome was overall survival. Secondary outcomes were surgery route, lymph node (LN) assessment method, length of stay (LOS), 30-day readmission, and 30- and 90-day mortality. Results were stratified by tumor recurrence risk. Outcomes were compared using propensity-score matching. Propensity-adjusted survival was evaluated using Kaplan-Meier curves and compared using log-rank tests. Cox models estimated hazard ratios for death. Sensitivity analysis using modified Poisson regressions was performed. RESULTS: Among 36,514 patients, 51.4% were Local and 48.6% Travel. The two cohorts differed significantly in demographics and clinicopathologic characteristics. Upon propensity-score matching (p < 0.05 for all), more Travel patients underwent minimally invasive surgery (88.1%vs79.1%) with fewer conversions to laparotomy (2.0%vs2.6%), more sentinel (20.5%vs11.3%) and fewer traditional LN assessments (58.1vs61.7%) versus Local. Travel patients had longer intervals to surgery (≥30 days:56.7%vs50.1%) but shorter LOS (<2 days:76.9%vs59.8%), fewer readmissions (1.9%vs2.7%%), and comparable 30- and 90-day mortality. OS and HR for death remained comparable between the matched groups. CONCLUSIONS: Compared to surgery in nearby low-volume hospitals, patients with stage I epithelial endometrial cancer who travelled longer distances to high-volume centers experienced more favorable short-term outcomes and care patterns with comparable long-term survival.

Bluer Phototruncation: Retro-Diels-Alder of Heptamethine Cyanine to Trimethine Cyanine through an Allene Hydroperoxide Intermediate.

The photoconversion of heptamethine to pentamethine cyanines and of pentamethine to trimethine cyanines was recently reported. Here, we report mechanistic studies and initial experimental evidence for a previously unexplored 4-carbon truncation reaction that converts the simplest heptamethine cyanine to the corresponding trimethine cyanine. We propose a DFT-supported model describing a singlet oxygen (1O2)-mediated formation of an allene hydroperoxide intermediate and subsequent 4-carbon loss through a retro-Diels-Alder process. Fluorescence and mass spectrometry measurements provide evidence of this direct conversion process. This 4-carbon truncation reaction adds to a growing body of cyanine reactivity and may provide an optical tool leading to a substantial blue-shift (Δλem) of ∼200 nm.

Gynecologic Oncology fellowship recruitment in the virtual era: An evaluation of program websites and survey of applicant preferences.

Objective: Virtual Gynecologic Oncology fellowship recruitment has altered how candidates and programs exchange information. This study analyzes programs' web-based content and the priorities of fellowship candidates. Methods: Web-based materials of Gynecologic Oncology fellowship programs participating in the 2022 match were reviewed. An anonymous survey was emailed to applicants. Questions assessed importance of web-based materials on a Likert scale. Respondents were asked to rank factors from most to least important in their decisions to interview and rank programs. Results: Of the 66 programs participating in the 2022 Gynecologic Oncology fellowship match, 62 (93.9%) had accessible websites. Over one-fourth (25.8%) of program websites did not list application requirements. Most (74.2%) websites contained requests for letters of recommendation, but fewer (48.4%) specified the preferred quantity or authorship. Residency in-service exam score requirement information was present on 61.3% of websites. Of 100 applicants invited to participate, 44 returned surveys (44% response rate). The median number of programs applied to was 60 (IQR 51-65). Web-based materials most important to candidates were application requirements and deadlines, letter of recommendation details, and in-service exam requirements. Interaction with faculty and program information received during interview days were among the most important factors in decisions to rank programs. Conclusions: Gynecologic Oncology fellowship applicants surveyed in this study applied to nearly all participating fellowships. The content of web-based materials varies across program websites, particularly for application requirements, which applicants indicated as the most important electronically available material. Programs should have clear application requirements and provide clinical details on their websites.

Digital cervicography for cervical cancer screening in low-resource settings: A scoping review.

Introduction: Digital cervicography (DC) is a method of capturing images for analysis during visual inspection with acetic acid (VIA) for cervical cancer screening. Cervical cancer is the 3rd leading cause of female cancer in the world with approximately 90 % of deaths due to cervical cancer occurring in low and middle income countries (LMICs). The need for cost-effective and sustainable methods for screening is vital in these settings. This scoping review systematically synthesizes published data illustrating the use of DC in screening programs. We aim to understand how digital cervicography is used, implemented, and impacted on programs. Methods: Search of eight online databases identified 53 studies published between 1993 and 2021. Inclusion of articles were English language, cervical cancer screening program located in an LMIC, and DC as an intervention. Results: All studies were cross-sectional studies (n = 53), with variation in terminology, uses, and device methods. Devices were grouped as either smartphones (n = 14), commercially available digital cameras (n = 17), or other (EVA®, n = 4; Cerviscope, n = 12; custom device, n = 4; or not specified, n = 2). Nineteen studies found acceptability and feasibility for DC in their screening programs. Various programs using DC found benefits such as task sharing, healthcare worker training, patient education and using images for review from a remote specialist or mentor. Conclusion: The use of DC in LMICs is beneficial for support of healthcare workers, enhances quality improvement and demonstrates overall acceptability in screening programs. Advancing technologies for human papillomavirus (HPV) testing and cytology are common methods for cervical cancer screening, although are limited in LMICs. This scoping review demonstrates the different methods, uses, and benefit of digital cervicography in cervical cancer screening programs.

Barriers to surgical menopause counseling in gynecologic cancers: a quantitative and qualitative study of patients and providers.

OBJECTIVE: The objective of this study is to identify factors associated with receiving surgical menopause counseling in gynecologic cancer patients, as well as patient and provider perspectives, regarding surgical menopause counseling and management. METHODS: We conducted a single-institution mixed-method study combining retrospective chart review and patient and provider surveys. Patients younger than 51 years who experienced surgical menopause after gynecologic cancer treatment from January 2017 to December 2019 were surveyed in April 2021 about experiences with menopause counseling, barriers to care, and quality of life. We then reviewed charts of only patients who fully completed surveys. All gynecologic oncology providers were surveyed about surgical menopause practices. Logistic regression identified factors associated with receiving counseling. RESULTS: Sixty-six of 75 identified met inclusion criteria and received survey invitations. Thirty-five (53%) completed surveys. Sixty percent had documented surgical menopause counseling. Patients who were counseled were younger (43 vs 48.5 years, P = 0.005), more likely to have referrals for menopause care (12 vs 9, P = 0.036), more likely to have menopause providers other than oncology providers (14 vs 8, P = 0.001), and had fewer comorbidities. Decreasing age at surgery increased odds of counseling. Most reported continued menopause symptoms and quality of life disturbances. Half were satisfied with menopause care. Majority preferred counseling from oncology providers. Most providers always counseled on surgical menopause but cited lack of time as the primary obstacle for complete counseling. CONCLUSIONS: Younger age at surgery increased odds of receiving surgical menopause counseling. Gynecologic cancer patients experienced significant menopause-related disturbances. Improved understanding of patient and provider preferences and greater emphases on surgical menopause and survivorship will improve care for gynecologic oncology patients.

Adaptive and maladaptive humor styles are closely associated with burnout and professional fulfillment in members of the Society of Gynecologic Oncology.

Differences in individual humor styles (adaptive: affiliative, self-enhancing; maladaptive: aggressive, self-defeating) are associated with various wellness measures. This study examines the association of humor styles with professional fulfillment (PF) and burnout (BO) among Society of Gynecologic Oncology (SGO) members. SGO members were surveyed in 11/2020. The survey included 64 questions (32-item Humor Styles Questionnaire, 16-item Professional Fulfillment Index, and 16-item demographic and practice characteristics). Differences among faculty physicians (FAC), physician trainees (Res/Fel), and advanced practice providers (APP) were compared. Multivariable linear regression adjusted the association of humor styles with BO and PF for possible confounders. Of 1982 members invited to participate, 320 (16.1%) returned completed surveys (69.4% FAC, 23.4% Res/Fel, and 7.2% APP). All provider types scored highest for affiliative and lowest for aggressive humor. Res/Fel were more likely to employ aggressive and self-defeating humor styles than FAC and APP. One-third of respondents met criteria for BO and half experienced PF. FAC were more fulfilled than Res/Fel (p = 0.038). BO was negatively associated with self-enhancing and positively associated with self-defeating humor. Working > 60 h/week was associated with increased BO (p = 0.008) while trainee status (p = 0.010) and age > 55 (p = 0.008) were associated with decreased BO. PF was positively associated with self-enhancing and negatively associated with self-defeating humor. Spending > 10% of work hours on administrative duties led to lower PF (p = 0.008). Beyond advocating for less working hours and administrative duties, humor-based interventions to increase self-enhancing and reducing self-defeating humor use may lead to less BO and greater PF in SGO members, especially among trainees.

Mechanical and oral antibiotic bowel preparation in ovarian cancer debulking: Are we lowering or just trading surgical complications?

OBJECTIVES: To examine postoperative complications associated with preoperative mechanical and oral antibiotic bowel preparation (MOABP) for patients with ovarian cancer who underwent bowel resection at cytoreductive surgery (CRS). METHODS: This was a single-institution retrospective study of patients with ovarian cancer undergoing CRS from 01/2011-12/2020 using ICD-10 diagnoses and procedure codes. Patients were stratified by those who underwent bowel resection versus no resection. Bowel resection patients were further stratified by those who underwent MOABP versus no bowel preparation. Patient demographics, tumor data, and perioperative metrics were collected. Unadjusted and adjusted logistic regression evaluated odds of 30-day postoperative complications in patients with bowel resection versus no resection and those with MOABP versus no bowel preparation. RESULTS: Of 919 patients identified, 215 (23.3%) required bowel resection, which included 81 (37.7%) who received MOABP. Patient characteristics, co-morbidities, and cancer data were similar between MOABP versus no bowel preparation patients. MOABP patients underwent more interval CRS (34.6% versus 9.0%), more optimal surgical resections (96.3% versus 83.8%), fewer diverting ostomies (13.5% versus 33.5%), and shorter hospital stays (7.1 versus 9.4 days) than no bowel preparation patients. On adjusted analyses, MOABP patients experienced significantly lower odds of deep/organ-space surgical infections and 30-day readmissions but higher odds of unplanned intensive care unit (ICU) admissions and grade 3 or higher cardiac and gastrointestinal complications. CONCLUSIONS: Patients who underwent preoperative MOABP prior to ovarian cancer CRS with bowel resection had lower odds or deep/organ-space infections and readmissions, shorter hospital stays, fewer diverting ostomies, and more optimal resections. However, these patients also experienced higher odds of ICU admissions and grade 3 or higher cardiac and gastrointestinal complications. The positive and negative postoperative outcomes in this population should be considered in clinical practice.

When we open and close: Postoperative outcomes after aborted primary cytoreduction for ovarian cancer.

Objective: Little data exists to adequately counsel patients on the postsurgical morbidity and outcomes of an aborted primary debulking (AD) for advance stage epithelial ovarian cancer. Our objectives were to examine the 30-day morbidity of AD, percentage of patients who subsequently undergo neoadjuvant chemotherapy (NACT) and interval cytoreductive surgery (ICS), residual disease at ICS, and predictors for complications after AD. Methods: This was a single-institution retrospective analysis of patients who underwent AD for ovarian cancer from 01/2008 to 12/2020 using ICD-10 diagnoses and procedure codes. Patient demographics, perioperative metrics, and residual disease at ICS were collected. Thirty-day postoperative complications were graded by the Common Terminology Criteria for Adverse Events. Fisher's exact tests compared categorical and Wilcoxon rank-sum tests compared continuous variables. Logistic regression provided unadjusted odds ratios to identify predictors for post-AD complications. Results: Forty-eight patients underwent AD, and 43 were included for analysis. All had at least stage IIIC high grade serous ovarian cancer. All patients subsequently underwent ICS, with 21 (48.8%) achieving no residual macroscopic disease and 21 (48.8%) to ≤ 1 cm of macroscopic disease. After AD, 16 (37.2%) experienced at least one G ≥ 3 event within the first 30 days. The most common complication was gastrointestinal complications. Preoperative albumin was the only significant predictor for G ≥ 3 complication after AD. Conclusions: Approximately one-third of patients will experience at least one G ≥ 3 complications after AD. Complications may be anticipated by low preoperative albumin. Patients can be counseled that, after AD, proceeding to subsequent NACT and ICS and achieving optimal debulking is common.

Grade 4 Pneumonitis in a Patient Treated with a Combination of Gemcitabine and Docetaxel for Recurrent Leiomyosarcoma of the Uterus.

Gemcitabine and docetaxel combination chemotherapy is the standard of care for patients with unresectable recurrent or metastatic leiomyosarcoma of the uterus. Although they are generally well-tolerated agents, they can also cause severe and life-threatening pulmonary toxicities. Here, we describe a case of grade 4 pneumonitis due to gemcitabine and docetaxel in a 74-year-old woman with recurrent, metastatic uterine leiomyosarcoma. Despite early recognition of chemotherapy-induced lung injury and early administration of corticosteroid, she developed noncardiogenic pulmonary edema, diffuse alveolar hemorrhage, and acute respiratory distress syndrome. She required multiple intubations and a tracheostomy. Physicians should not only be aware of gemcitabine and docetaxel's potential to cause life-threatening pulmonary injuries but also recognize the variability in clinical presentations and treatment responses, the radiographic findings of these lung toxicities, and the need for early corticosteroid therapy in these cases.

A Systematic Review of the Use of Google Glass in Graduate Medical Education.

BACKGROUND: Graduate medical education (GME) has emphasized the assessment of trainee competencies and milestones; however, sufficient in-person assessment is often constrained. Using mobile hands-free devices, such as Google Glass (GG) for telemedicine, allows for remote supervision, education, and assessment of residents. OBJECTIVE: We reviewed available literature on the use of GG in GME in the clinical learning environment, its use for resident supervision and education, and its clinical utility and technical limitations. METHODS: We conducted a systematic review in accordance with 2009 PRISMA guidelines. Applicable studies were identified through a review of PubMed, MEDLINE, and Web of Science databases for articles published from January 2013 to August 2018. Two reviewers independently screened titles, abstracts, and full-text articles that reported using GG in GME and assessed the quality of the studies. A systematic review of these studies appraised the literature for descriptions of its utility in GME. RESULTS: Following our search and review process, 37 studies were included. The majority evaluated GG in surgical specialties (n = 23) for the purpose of surgical/procedural skills training or supervision. GG was predominantly used for video teleconferencing, and photo and video capture. Highlighted positive aspects of GG use included point-of-view broadcasting and capacity for 2-way communication. Most studies cited drawbacks that included suboptimal battery life and HIPAA concerns. CONCLUSIONS: GG shows some promise as a device capable of enhancing GME. Studies evaluating GG in GME are limited by small sample sizes and few quantitative data. Overall experience with use of GG in GME is generally positive.

Endovascular Mechanical Thrombectomy for Acute Middle Cerebral Artery M2 Segment Occlusion: A Systematic Review.

INTRODUCTION: The benefit of endovascular mechanical thrombectomy (EMT) for acute distal occlusions of the middle cerebral artery M2 segment is incompletely defined. The aim of this systematic review is to analyze the recent literature regarding EMT for acute M2 occlusions. METHODS: We reviewed the literature to identify all studies of patients with acute M2 occlusions who underwent EMT that were published after January 1, 2015. Excellent and good outcomes were defined as modified Rankin Scale score of 0-1 and 0-2, respectively, at 3 months. Successful reperfusion was defined as modified Thrombolysis In Cerebral Infarction (mTICI) score of 2b-3. RESULTS: Eight studies, comprising 630 EMT-treated patients with acute M2 occlusions, were included in the analysis. The median National Institute of Health Stroke Scale score ranged from 10 to 16, and the median Alberta Stroke Program Computed Tomography Score ranged from 9 to 10. Excellent and good outcomes at 3-month follow-up were observed in 40% and 62%, respectively, of patients with acute M2 occlusion who underwent EMT, with a mortality of 11%. Successful reperfusion was achieved in 78% of cases. Postprocedural intracerebral hemorrhage (ICH) occurred in 14% of patients, including a symptomatic ICH rate of 5%. CONCLUSIONS: EMT for acute M2 occlusion affords functional independence to most patients, with a modest rate of symptomatic ICH. However, compared with the natural history of distal MCA occlusions, the benefit of M2 thrombectomy using stent retriever or direct aspiration techniques remains unclear.