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1.
Int J Gynecol Cancer ; 34(5): 745-750, 2024 May 06.
Artigo em Inglês | MEDLINE | ID: mdl-38642924

RESUMO

BACKGROUND: The potential for the technique of small bite fascial closure in mitigating incisional hernias in gynecologic oncology patients still needs to be investigated. OBJECTIVE: To evaluate the impact of closure of small fascial bites compared with prior standard closure on incisional hernia rates in gynecologic oncology patients. METHODS: This is a retrospective cohort study comparing patient outcomes before and after the intervention at a single institution at a comprehensive cancer center. Patients who underwent laparotomy with a vertical midline incision for a suspected or known gynecologic malignancy with a 1-year follow-up were included. The pre-intervention cohort (large bites) had 'mass' or modified running Smead-Jones closure. In contrast, the post-intervention cohort had fascial bites taken 5-8 mm laterally with no more than 5 mm travel (small bites) closure using a 2-0 polydioxanone suture.The primary outcome was the incisional hernias rate determined by imaging or clinical examination within the first year of follow-up. Patient factors and peri-operative variates of interest were investigated for their association with hernia formation through univariate and multivariate analyses. These included age, body mass index (BMI), smoking history, estimated blood loss, pre-operative albumin, American Society of Anesthesia (ASA) physical status classification, or treatment with chemotherapy post-operatively. RESULTS: Of the 255 patients included, the total hernia rate was 12.5% (32/255 patients). Patient characteristics were similar in both cohorts. Small bite closure led to a significant reduction in hernia rates from 17.2% (22/128 patients) to 7.9% (10/127 patients), p=0.025. According to logistic regression modeling, small bite closure (OR=0.40, 95% CI 0.17 to 0.94, p=0.036) was independently associated with lower odds of hernia formation. Other factors associated with increased hernia rates were chemotherapy (OR=3.22, 95% CI 1.22 to 8.51, p=0.019) and obesity (OR=23.4, 95% CI 3.09 to 177, p=0.002). In obese patients, small bite closures led to maximal hernia rate reduction compared with large bites. CONCLUSIONS: The small bite closure technique effectively reduces hernia rates in gynecologic oncology patients undergoing midline laparotomy.


Assuntos
Neoplasias dos Genitais Femininos , Hérnia Incisional , Humanos , Feminino , Estudos Retrospectivos , Pessoa de Meia-Idade , Hérnia Incisional/prevenção & controle , Hérnia Incisional/epidemiologia , Neoplasias dos Genitais Femininos/cirurgia , Idoso , Adulto , Fasciotomia/métodos , Estudos de Coortes
2.
Gynecol Oncol ; 178: 89-95, 2023 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-37832182

RESUMO

OBJECTIVE: To compare the venous thromboembolism (VTE) rate in patients with ovarian cancer undergoing neoadjuvant chemotherapy before and after implementing routine thromboprophylaxis. METHODS: This is a quasi-experimental pre-post study evaluating the VTE rate in patients with ovarian cancer who received neoadjuvant chemotherapy following a quality improvement initiative of routine thromboprophylaxis within a single healthcare system that started in January 2017. Patients were excluded if VTE was diagnosed before initiating chemotherapy. Patient factors and perioperative variables of interest were investigated for their association with VTE through univariate and multivariate models. RESULTS: Of the 136 patients in the pre-implementation group, 3.7% (n = 5) received thromboprophylaxis. Of the 154 patients in the post-implementation group, 65.6% (n = 101) received thromboprophylaxis. Provider compliance varied from 51% in 2019 to 79.3% in 2021. The overall rate of VTE, from the start of chemotherapy to the end of treatment, was 21.3% (n = 29) pre- and 8.4% (n = 13) in the post-implementation group (p < 0.01). There was no difference in major bleeding events between groups (0% vs. 0.68%, p = 0.63). On univariate analysis, thromboprophylaxis (OR 0.19; 95% CI 0.07-0.52) and post-implementation period (OR 0.34; 95% CI 0.17-0.69) were associated with a decreased risk of any VTE during primary treatment. On multivariate analysis, only thromboprophylaxis remained significantly associated with reduced VTE rates (aOR 0.19; 95% CI 0.07-0.53). CONCLUSION: Routine thromboprophylaxis during neoadjuvant chemotherapy is associated with reduced risk of VTE throughout primary treatment and is not associated with increased bleeding events.


Assuntos
Neoplasias Ovarianas , Tromboembolia Venosa , Humanos , Feminino , Anticoagulantes , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/prevenção & controle , Terapia Neoadjuvante , Hemorragia/induzido quimicamente , Neoplasias Ovarianas/tratamento farmacológico , Neoplasias Ovarianas/induzido quimicamente
3.
Gynecol Oncol Rep ; 48: 101217, 2023 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-37576357

RESUMO

•Factor VIII inhibitor can be acquired in gynecologic and other malignancies.•The disorder can develop along any timeline of malignancy diagnosis.•Common presentation is uncontrolled bleeding not managed by common interventions.•Treatment requires hemostatic control and an immunosuppressive regimen.

4.
Gynecol Oncol ; 170: 229-233, 2023 03.
Artigo em Inglês | MEDLINE | ID: mdl-36716511

RESUMO

OBJECTIVE: To evaluate the impact a tailored opioid prescription calculator has on meeting individual patient opioid needs while avoiding opioid over prescriptions. METHODS: Our group previously developed and published an opioid prescribing calculator incorporating patient risk factors (history of depression, anxiety, chronic opioid use, substance abuse disorder, and/or chronic pain) and type of surgery (laparotomy or laparoscopy). This calculator was implemented on 1/1/2021 and its impact on opioid prescriptions was evaluated until 12/31/21. The primary outcome of the present study is to determine prescriber compliance with the calculator (defined as not overprescribing from the number of pills indicated by the calculator). The secondary outcome is to determine the excess prescription rate (defined as proportion of patients reporting more than 3 pills remaining at 30 days post-surgery). Refill rates and pain related patient phone calls were collected. Descriptive statistics were used to summarize the cohort. RESULTS: Of the 355 patients included, 54.7% (N = 194) underwent laparoscopy and 45.4% (N = 161) underwent laparotomy. One hundred and forty-two patients (40%) had at least one risk factor for opioid usage. The median number of opioid pills prescribed following laparoscopy was 3 (range 0-15) and 6 (0-20) after laparotomy. The prescriber compliance was 88.2% and the excess prescription rate was 25.1% (N = 89 patients). CONCLUSIONS: Our tailored opioid calculator has a high prescriber compliance. Implementation of this calculator led to a standardization of tailored opioid prescribing, while limiting the number of over prescriptions. A free web version of the calculator can be easily accessed at www.opioidcalculator.org.


Assuntos
Analgésicos Opioides , Dor Pós-Operatória , Humanos , Feminino , Analgésicos Opioides/uso terapêutico , Dor Pós-Operatória/tratamento farmacológico , Padrões de Prática Médica , Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Prescrições de Medicamentos
6.
Gynecol Oncol ; 162(3): 756-762, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34226021

RESUMO

OBJECTIVE: To implement a quality-improvement initiative to assess the impact various patient and procedural factors have on postoperative opioid use. To develop a tailored opioid prescribing algorithm for gynecologic oncology patients. METHODS: A retrospective cohort study was performed of patients who underwent a laparoscopy or laparotomy procedure for a suspected or known gynecologic malignancy between 3/2019-9/2020. Patients were assessed preoperatively for the presence of suspected risk factors for opioid misuse (depression, anxiety, chronic pain, current opioid use, or substance abuse). Patients completed a 30-day postoperative questionnaire assessing for total opioid pill use and refills requests. Multivariate models were developed to estimate the independent effect of sociodemographic characteristics, risk factors for opioid misuse and procedural factors on patient reported postoperative opioid use. RESULTS: A total of 390 patients were analyzed. Thirty-nine percent (N = 151/390) of patients reported not using opioids after discharge and 5% (N = 20/390) received an opioid refill. For both minimally invasive procedures and laparotomy procedures, body mass index, comorbidities, intraoperative or postoperative complications and final diagnosis of malignancy were not associated with the amount of opioid consumption. However, younger age and history of risk factors for opioid misuse significantly impacted postoperative opioid use. In multivariate analysis, age (p = 0.038) and risk factors (p < 0.001) remained significant after controlling for other factors. CONCLUSIONS: Two out of every five patients did not use opioids after surgery. Younger patients and those with risk factors for opioid misuse need a tailored approach to prescribing opioids to balance the need for adequate pain control with the risk of misuse.


Assuntos
Analgésicos Opioides/uso terapêutico , Neoplasias dos Genitais Femininos/cirurgia , Dor Pós-Operatória/tratamento farmacológico , Adulto , Feminino , Humanos , Michigan , Pessoa de Meia-Idade , Medidas de Resultados Relatados pelo Paciente , Padrões de Prática Médica/normas , Melhoria de Qualidade , Estudos Retrospectivos , Transtornos Relacionados ao Uso de Substâncias/prevenção & controle
7.
Gynecol Oncol Rep ; 37: 100819, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-34258359

RESUMO

We report a case of extrauterine epithelioid trophoblastic tumor (ETT)-the rarest variant of gestational trophoblastic tumor-that has been stable on nearly two years of pembrolizumab treatment. A 47-year-old gravida 2, para 2 who underwent a prophylactic bilateral salpingo-oophorectomy nine years prior and bilateral mastectomy five years prior in the setting of a strong family history of breast and ovarian cancer with no genetic testing performed, presented to an outside clinic with recurrent respiratory infections without resolution despite antibiotics. Radiology and pathology testing confirmed the ETT diagnosis, including a second opinion from the John I. Brewer Trophoblastic Disease Center of Northwestern University's Feinberg School of Medicine, and the patient was started on a chemotherapy regimen of etoposide, methotrexate, actinomycin-D, etoposide, and cisplatin for seven cycles, with partial improvement in her disease. After PD-L1 testing showed the tumor had > 5% PD-L1 positivity, she initiated pembrolizumab in April 2019. CT imaging after three months revealed decreased lung, abdominal, and pelvic disease and she was continued on pembrolizumab. As of December 2020, she had completed 29 cycles of pembrolizumab, with a plan for her to continue treatment indefinitely given her decreased, but persistent, disease. Our findings suggest pembrolizumab is a reasonable option for treatment of patients with significant PD-L1 positivity on testing of the tumor.

8.
J Surg Educ ; 78(3): 777-784, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-32921585

RESUMO

OBJECTIVE: Administrative chief residents (ACRs) are integral to residency programs, however little research has been done on the experiences, training, and support of ACRs in surgical fields. The objective of this study was to define the challenges and experiences of surgical ACRs and identify support needed to make them successful. DESIGN: A Qualtrics survey was electronically distributed to participants. Response styles included multiple choice questions, yes/no, Likert scales, and short answers. Question topics included demographics, ACR duties, support, and experiences. SETTING: Obstetrics & Gynecology and General Surgery residency programs in the United States. PARTICIPANTS: Current and past administrative chief residents (2019-2020; 2018-2019) and program directors from Obstetrics & Gynecology and General Surgery residency programs. RESULTS: Seventy-nine surveys were completed by 48 (61%) ACRs and 31 (39%) program directors. The majority (52%) were from academic programs with a median of 6 residents and 2 ACRs per year. On a 10-point Likert scale, mean perceived support from faculty, program director, administration, and other residents was 7.0, 8.8, 6.7, and 7.7 respectively; however, mean stress level was also perceived to be high. Regarding preparation for the role, 56% of administrative chief residents do not receive a job description, 41% do not have a formal handoff process, 42% do not have formal leadership training, and only 61% agreed or strongly agreed that the administrative chief role was clear prior to starting. Common challenges reported by ACR's are limited preparation and training, conflict resolution, and workload management. Many ACRs felt they would benefit from formal leadership training and protected time. CONCLUSIONS: These results summarize the experiences of ACRs in surgical residencies. Best practices and formal training in identified challenge areas should be added to residency curriculum and used to develop toolkits to support ACRs nationwide.


Assuntos
Internato e Residência , Currículo , Humanos , Descrição de Cargo , Liderança , Inquéritos e Questionários , Estados Unidos
9.
J Low Genit Tract Dis ; 23(3): 214-219, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31232912

RESUMO

OBJECTIVE: Vulvar lichen sclerosus (LS) is known to occur in families, suggesting a genetic link. Genomic profiling of patients with vulvar LS was investigated to find underlying pathogenetic mechanisms, with the hope that targeted therapies and future clinical research will arise. METHODS: Two unrelated families with vulvar LS were investigated using whole-exome sequencing. Five affected sisters from 1 family were compared with their unaffected paternal aunt (unaffected control). A mother-daughter pair from a second affected family was compared with the first family. The results of the sequencing were compared with population-specific allele frequency databases to prioritize potential variants contributing to vulvar LS development. RESULTS: Recurrent germ-line variants in 4 genes were identified as likely to be deleterious to proper protein function in all of the 7 affected patients, but not in the unaffected control. The genes with variants included CD177 (neutrophil activation), CD200 (inhibitory signal to macrophages), ANKRD18A (ankyrin repeat protein, epigenetic regulation), and LATS2 (co-repressor of androgen signaling). CONCLUSIONS: Although many providers may see a mother and daughter with vulvar LS, this condition is rarely seen in multiple family members who are available for genetic testing. This is the first report to detail genomic profiling related to a familial association of vulvar LS.


Assuntos
Predisposição Genética para Doença , Estudo de Associação Genômica Ampla , Líquen Escleroso Vulvar/genética , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Frequência do Gene , Humanos , Masculino , Pessoa de Meia-Idade
10.
Gynecol Oncol ; 150(1): 106-111, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29778507

RESUMO

OBJECTIVE: To investigate the association of obesity and other comorbidities as well as route of surgery with postoperative outcomes, as well as 30- and 90-day inpatient cost of care after hysterectomy for endometrial cancer. METHODS: From the 2013 National Readmission Database release, patients who underwent hysterectomy for endometrial cancer were included. Obesity was classified as non-obese (body mass index [BMI] < 35 kg/m2); class I/II obesity (BMI ≥ 35 but <40 kg/m2 and without obesity related medical condition qualifying it as morbid obesity), class III obesity (BMI ≥ 40 kg/m2 OR BMI ≥ 35 kg/m2 with an obesity-related medical condition). Incremental cost at 30 and 90 days was calculated using cost-to-charge ratio. RESULTS: A total of 27,658 patients were identified. Compared to non-obese patients those with class III obesity had higher rate of any medical (non-surgical) complication (22.3% vs 17.2%, p = 0.004), and higher rate of 30-day readmission (6% vs 4.4%, p = 0.003), but similar rates of surgical complications. There were no significant differences in perioperative outcomes between non-obese patients and those with class I/II obesity. Non-obese patients had higher rates of traditional laparoscopy (8.4% vs 13.6%, p < 0.001) and lower conversion rates from a minimally invasive to abdominal (5.5% vs. 8.2%, p < 0.001) than those with class III obesity. Based on multivariate regression model compared to non-obese patients, class I/II obesity (OR 1.05, 95% CI 1.02-1.09) and class III obesity (OR 1.1, 95% CI 1.1-1.18) were associated with higher cost of care. Other factors increasing cost of care included: comorbidity score per unit increase (OR 1.08, 95% 1.07-1.08), insurance status and route of surgery. CONCLUSIONS: Class III obesity was associated with higher medical (but not surgical) complication rates as well as increased overall inpatient care cost when compared to the non-obese population. Number of comorbidities significantly impacted the cost and outcomes after hysterectomy. As more healthcare initiatives focus on bundled payments, our results suggest that payment packages should adjust for obesity rates and medical comorbidities stratified by region and hospital type in order to fairly compensate for increased costs of care.


Assuntos
Neoplasias do Endométrio/economia , Obesidade/complicações , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Efeitos Psicossociais da Doença , Neoplasias do Endométrio/patologia , Neoplasias do Endométrio/cirurgia , Feminino , Humanos , Pacientes Internados , Tempo de Internação , Pessoa de Meia-Idade , Resultado do Tratamento
11.
Am J Med Genet C Semin Med Genet ; 175(2): 268-278, 2017 06.
Artigo em Inglês | MEDLINE | ID: mdl-28557237

RESUMO

Following the principles of care recommended in the 2006 Consensus Statement on Disorders of Sex Development (DSD), along with input from representatives of peer support and advocacy groups, this study surveyed DSD clinical management practices at healthcare facilities in the United States. DSD are congenital conditions in which development of chromosomal, gonadal, or anatomic sex is atypical. Facilities providing care for patients with DSD were targeted for participation. Specialty providers completed a survey with questions in six broad categories: Institution Information, Nomenclature and Care Guidelines, Interdisciplinary Services, Staff and Community Education, DSD Management, and Research. Twenty-two of 36 targeted sites (61%) participated. Differences were observed between sites with regard to what conditions were considered to be DSD. All sites reported some degree of involvement of pediatric urology and/or surgery and pediatric endocrinology in the care of DSD patients. Gynecology and neonatology were most frequently not represented. Wide variation was observed across sites in continuing education standards, obtaining informed consent for clinical procedures, and in specific clinical management practices. This survey is the first to assess DSD clinical management practices in the United States. The findings establish a baseline of current practices against which providers delivering care to these patients and their families can benchmark their efforts. Such surveys also provide a practical framework for collaboration in identifying opportunities for change that enhance health and quality of life outcomes for patients and families affected by DSD.


Assuntos
Transtornos do Desenvolvimento Sexual/epidemiologia , Transtornos do Desenvolvimento Sexual/genética , Inquéritos e Questionários , Atenção à Saúde , Transtornos do Desenvolvimento Sexual/fisiopatologia , Feminino , Humanos , Masculino , Qualidade de Vida , Processos de Determinação Sexual , Estados Unidos/epidemiologia
12.
West J Emerg Med ; 17(3): 350-4, 2016 May.
Artigo em Inglês | MEDLINE | ID: mdl-27330670

RESUMO

INTRODUCTION: This study investigates the impact of the Doximity rankings on the rank list choices made by residency applicants in emergency medicine (EM). METHODS: We sent an 11-item survey by email to all students who applied to EM residency programs at four different institutions representing diverse geographical regions. Students were asked questions about their perception of Doximity rankings and how it may have impacted their rank list decisions. RESULTS: Response rate was 58% of 1,372 opened electronic surveys. This study found that a majority of medical students applying to residency in EM were aware of the Doximity rankings prior to submitting rank lists (67%). One-quarter of these applicants changed the number of programs and ranks of those programs when completing their rank list based on the Doximity rankings (26%). Though the absolute number of programs changed on the rank lists was small, the results demonstrate that the EM Doximity rankings impact applicant decision-making in ranking residency programs. CONCLUSION: While applicants do not find the Doximity rankings to be important compared to other factors in the application process, the Doximity rankings result in a small change in residency applicant ranking behavior. This unvalidated ranking, based principally on reputational data rather than objective outcome criteria, thus has the potential to be detrimental to students, programs, and the public. We feel it important for specialties to develop consensus around measurable training outcomes and provide freely accessible metrics for candidate education.


Assuntos
Escolha da Profissão , Medicina de Emergência/educação , Internato e Residência/estatística & dados numéricos , Internato e Residência/normas , Candidatura a Emprego , Estudantes de Medicina , Inquéritos e Questionários , Correio Eletrônico , Medicina de Emergência/normas , Medicina de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Seleção de Pessoal , Estudantes de Medicina/psicologia , Estados Unidos
13.
West J Emerg Med ; 16(6): 889-93, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-26594285

RESUMO

INTRODUCTION: Choosing a residency program is a stressful and important decision. Doximity released residency program rankings by specialty in September 2014. This study sought to investigate the impact of those rankings on residency application choices made by fourth year medical students. METHODS: A 12-item survey was administered in October 2014 to fourth year medical students at three schools. Students indicated their specialty, awareness of and perceived accuracy of the rankings, and the rankings' impact on the programs to which they chose to apply. Descriptive statistics were reported for all students and those applying to Emergency Medicine (EM). RESULTS: A total of 461 (75.8%) students responded, with 425 applying in one of the 20 Doximity ranked specialties. Of the 425, 247 (58%) were aware of the rankings and 177 looked at them. On a 1-100 scale (100=very accurate), students reported a mean ranking accuracy rating of 56.7 (SD 20.3). Forty-five percent of students who looked at the rankings modified the number of programs to which they applied. The majority added programs. Of the 47 students applying to EM, 18 looked at the rankings and 33% changed their application list with most adding programs. CONCLUSION: The Doximity rankings had real effects on students applying to residencies as almost half of students who looked at the rankings modified their program list. Additionally, students found the rankings to be moderately accurate. Graduating students might benefit from emphasis on more objective characterization of programs to assess in light of their own interests and personal/career goals.


Assuntos
Escolha da Profissão , Medicina de Emergência/educação , Internato e Residência/normas , Estudantes de Medicina/psicologia , Adulto , Feminino , Humanos , Masculino , Inquéritos e Questionários , Estados Unidos
14.
Int J Endocrinol ; 2015: 980121, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25918529

RESUMO

Disorders of sex development (DSD) are congenital conditions in which chromosomal, gonadal, or anatomic sex development is atypical. DSD-associated stigma is purported to threaten positive psychosocial adaptation. Parental perceptions of DSD-related stigma were assessed in 154 parents of 107 children (newborn-17 years) questionnaire comprising two scales, child-focused and parent-focused, and three subscales, perceived stigmatization, future worries, and feelings about the child's condition. Medical chart excerpts identified diagnoses and clinical management details. Stigma scale scores were generally low. Parents of children with DSD reported less stigma than parents of children with epilepsy; however, a notable proportion rated individual items in the moderate to high range. Stigma was unrelated to child's age or the number of DSD-related surgeries. Child-focused stigma scores exceeded parent-focused stigma and mothers reported more stigma than fathers, with a moderate level of agreement. Within 46,XY DSD, reported stigma was higher for children reared as girls. In conclusion, in this first quantitative study of ongoing experiences, DSD-related stigma in childhood and adolescence, while limited in the aggregate, is reported at moderate to high levels in specific areas. Because stigma threatens positive psychosocial adaptation, systematic screening for these concerns should be considered and, when reported, targeted for psychoeducational counseling.

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