The Near-Sightedness of Many-Body Interactions in Anharmonic Vibrational Couplings.

Couplings between vibrational motions are driven by electronic interactions, and these couplings carry special significance in vibrational energy transfer, multidimensional spectroscopy experiments, and simulations of vibrational spectra. In this investigation, the many-body contributions to these couplings are analyzed computationally in the context of clathrate-like alkali metal cation hydrates, including Cs+(H2O)20, Rb+(H2O)20, and K+(H2O)20, using both analytic and quantum-chemistry potential energy surfaces. Although the harmonic spectra and one-dimensional anharmonic spectra depend strongly on these many-body interactions, the mode-pair couplings were, perhaps surprisingly, found to be dominated by one-body effects, even in cases of couplings to low-frequency modes that involved the motion of multiple water molecules. The origin of this effect was traced mainly to geometric distortion within water monomers and cancellation of many-body effects in differential couplings, and the effect was also shown to be agnostic to the identity of the ion. These outcomes provide new understanding of vibrational couplings and suggest the possibility of improved computational methods for the simulation of infrared and Raman spectra.

Obstetrics and gynecology applicant perceptions of residency program culture with virtual interviews: a qualitative analysis of social media posts.

BACKGROUND: In the United States, Obstetrics and Gynecology residency interviews are instrumental in assessing the compatibility between medical student applicants and residency programs during the match process. Applicant perceptions of Obstetrics and Gynecology residency culture are a key component in determining how they rank residency programs. In 2020, residency interviews transitioned to a virtual format, and little is known about how applicants evaluated program culture during this first round of universal virtual interviews. Medical students in the United States commonly use Reddit, a popular social media platform, to discuss residency programs and share interview experiences. We explored Obstetrics and Gynecology applicants' considerations regarding residency program culture during the first universal virtual interview season in 2020-2021 by analyzing posts on a Google spreadsheet accessed through Reddit. METHODS: In 2022, we imported 731 posts from the "2020-21 OB GYN Residency Applicant Spreadsheet" Google spreadsheet posted to the 2020-2021 Residency Interview Spreadsheet megathread on the r/medicalschool subreddit to NVivo 12(QSR International, Burlington, MA), a qualitative analysis software program. Three investigators used qualitative inductive techniques to code and identify themes. RESULTS: Applicants used visual, verbal and behavioral cues during virtual Obstetrics and Gynecology residency interviews to understand three components of the workplace culture: prioritization of diversity, equity and inclusion, social environment, and resident workload. CONCLUSIONS: Obstetrics and Gynecology residency programs convey information about their culture during virtual interviews through the behavior, appearances and responses of residents and interviewers to applicant questions. To ensure they accurately represent their culture to applicants, programs should consider educating residents and faculty around the implications of interview-day conduct.

Persistence of a Delocalized Radical in Larger Clusters of Hydrated Copper(II) Hydroxide, CuOH+(H2O)3-7.

The structures, vibrational spectra, and electronic properties of copper hydroxide hydrates CuOH+(H2O)3-7 were investigated with quantum chemistry computations. As a follow-up to a previous analysis of CuOH+(H2O)0-2, this investigation examined the progression as the square-planar metal coordination environment was filled and as solvation shells expanded. Four-, five-, and six-coordinate structures were found to be low-energy isomers. The delocalized radical character, which was discovered in the small clusters, was found to persist upon continued hydration, although the hydrogen-bonded water network in the larger clusters was found to play a more significant role in accommodating this spin. Partial charges indicated that the electronic structure includes more Cu2+···OH- character than was observed in smaller clusters, but this structure remains decidedly mixed with Cu+···OH· configurations and yields roughly half-oxidation of the water network in the absence of any electrochemical potential. Computed vibrational spectra for n = 3 showed congruence with spectra from recent predissociation spectroscopy experiments, provided that the role of the D2 tag was taken into account. Spectra for n = 4-7 were predicted to exhibit features that are reflective of both the mixed electronic character and proton-/hydrogen-shuttling motifs within the hydrogen-bonded water network.

Pitfalls in the n-mode representation of vibrational potentials.

Simulations of anharmonic vibrational motion rely on computationally expedient representations of the governing potential energy surface. The n-mode representation (n-MR)-effectively a many-body expansion in the space of molecular vibrations-is a general and efficient approach that is often used for this purpose in vibrational self-consistent field (VSCF) calculations and correlated analogues thereof. In the present analysis, a lack of convergence in many VSCF calculations is shown to originate from negative and unbound potentials at truncated orders of the n-MR expansion. For cases of strong anharmonic coupling between modes, the n-MR can both dip below the true global minimum of the potential surface and lead to effective single-mode potentials in VSCF that do not correspond to bound vibrational problems, even for bound total potentials. The present analysis serves mainly as a pathology report of this issue. Furthermore, this insight into the origin of VSCF non-convergence provides a simple, albeit ad hoc, route to correct the problem by "painting in" the full representation of groups of modes that exhibit these negative potentials at little additional computational cost. Somewhat surprisingly, this approach also reasonably approximates the results of the next-higher n-MR order and identifies groups of modes with particularly strong coupling. The method is shown to identify and correct problematic triples of modes-and restore SCF convergence-in two-mode representations of challenging test systems, including the water dimer and trimer, as well as protonated tropine.

Accelerating and stabilizing the convergence of vibrational self-consistent field calculations via the direct inversion of the iterative subspace (vDIIS) algorithm.

The vibrational self-consistent field (VSCF) method yields anharmonic states and spectra for molecular vibrations, and it serves as the starting point for more sophisticated correlated-vibration methods. Convergence of the iterative, non-linear optimization in VSCF calculations can be erratic or altogether unsuccessful, particularly for chemical systems involving low-frequency motions. In this work, a vibrational formulation of the Direct Inversion of the Iterative Subspace method of Pulay is presented and investigated. This formulation accounts for distinct attributes of the vibrational and electronic cases, including the expansion of each single-mode vibrational wavefunction in its own basis set. The resulting Direct Inversion of the Iterative Subspace method is shown to substantially accelerate VSCF convergence in all convergent cases as well as rectify many cases where Roothaan-based methods fail. Performance across systems ranging from small, rigid molecules to weakly bound molecular clusters is investigated in this analysis.

Mortality risk and physical activity across the lifespan in endometrial cancer survivors.

PURPOSE: Physical activity (pre- and post-diagnosis) has been studied in prevention and survivorship contexts for endometrial cancer. However, the association of physical activity (PA) across the lifespan on mortality risk among endometrial cancer survivors is understudied. The study's objective was to identify the association of lifetime PA on mortality risk in endometrial cancer survivors. METHODS: Seven hundred forty-five endometrial cancer survivors drawn from a population-based cancer registry (diagnosed between 1991 and 1994) reported the frequency (sessions/week) of moderate- and vigorous intensity physical activity (MVPA) at age 12, age 20, and 5 years pre-interview (post-diagnosis). Cox proportional hazards were used to estimate hazard ratios (HR) and 95% confidence intervals for the association between PA, all-cause, and cardiovascular disease mortality as assessed in 2016. MVPA was modeled using natural cubic splines. RESULTS: Diagnosis age, body mass index, and smoking (pack-years) were each positively associated with increased all-cause mortality risk. Those who did one session of MVPA 5 years pre-interview had a lower mortality risk (HR 0.61; 95% CI 0.41-0.92) compared to those with no MVPA. Those reporting one session of MVPA was similarly observed at age 12 (HR 0.95; 95% CI 0.86-1.06) and at age 20 (HR 0.87; 95% CI 0.65-1.16). CONCLUSION: Those who participated in PA, compared to those who did not, in the 5 years before diagnosis had a lower mortality risk. While PA was not independently protective against mortality risk at ages 12 or 20, PA is still important for endometrial cancer survivors for other non-mortality outcomes.

Improvements in strength and agility measures of functional fitness following a telehealth-delivered home-based exercise intervention in endometrial cancer survivors.

PURPOSE: Endometrial cancer is strongly linked to obesity and inactivity; however, increased physical activity has important benefits even in the absence of weight loss. Resistance (strength) training can deliver these benefits; yet few women participate in resistance exercise. The purpose of this study was to describe both physiological and functional changes following a home-based strength training intervention. METHODS: Forty post-treatment endometrial cancer survivors within 5 years of diagnosis were enrolled in a pilot randomized trial, comparing twice-weekly home-based strength exercise to wait list control. Participants conducted the exercises twice per week for 10 supervised weeks with 5 weeks of follow-up. Measures included DXA-measured lean mass, functional fitness assessments, blood biomarkers, and quality of life outcomes. RESULTS: On average, participants were 60.9 years old (SD = 8.7) with BMI of 39.9 kg/m2 (SD = 15.2). At baseline, participants had 51.2% (SD = 6.0) body fat, which was not different between groups. Improvements were seen in the 30-s chair sit to stand (d = .99), the 30-s arm curl (d = .91), and the 8-ft up-and-go test (d = .63). No changes were measured for HbA1c or C-reactive protein. No changes were observed for flexibility (chair sit and reach, back scratch tests), 6-min walk test, maximum handgrip test, anxiety, depression, fatigue, or self-efficacy for exercise. CONCLUSIONS: Home-based muscle-strengthening exercise led to favorable and clinically relevant improvements in 3 of 7 physical function assessments. Physical function, body composition, blood biomarkers, and patient-reported outcomes were feasible to measure. These fitness improvements were observed over a relatively short time frame of 10 weeks.

Preoperatively predicting non-home discharge after surgery for gynecologic malignancy.

OBJECTIVE: Returning home after surgery is a desirable patient-centered outcome associated with decreased costs compared to non-home discharge. Our objective was to develop a preoperative risk-scoring model predicting non-home discharge after surgery for gynecologic malignancy. METHODS: Women who underwent surgery involving hysterectomy for gynecologic malignancy from 2013 to 2015 were identified from the Michigan Surgical Quality Collaborative database. Patients were divided by discharge destination, and a multivariable logistic regression model was developed to create a nomogram to assign case-specific risk scores. The model was validated using the National Surgical Quality Improvement Program (NSQIP) database. RESULTS: Non-home discharge occurred in 3.1% of 2134 women. The proportion of non-home discharges did not differ by cancer diagnosis (uterine 3.5%, ovarian 2.5%, and cervical 1.6%, p = 0.2). Skilled nursing facilities were the most common non-home destination (68.2%). Among patients with comorbidities (hypertension, diabetes, coronary artery disease, chronic obstructive pulmonary disease /dyspnea, arrhythmia, and history of deep vein thrombosis/pulmonary embolism), non-home discharge was more common in women with 1 (adjusted OR [aOR] 3.4; p = 0.03) or ≥2 of these comorbidities (aOR 5.1; p = 0.003) compared to none. Non-home discharge was more common after laparotomy (aOR 6.7; p < 0.0001) than laparoscopy, and in those aged ≥70 years (aOR 3.4; p < 0.0001) with American Society of Anesthesiologists class ≥ 3 (aOR 4.5; p = 0.0004) and dependent functional status (aOR 8.7; p < 0.0001). The model C-statistic was 0.89. When the model was applied to 4248 eligible patients from the NSQIP dataset, the C-statistic was 0.84 (95% CI: 0.79-0.89). CONCLUSIONS: Non-home discharge after surgery for gynecologic malignancy was predicted with high accuracy in this retrospective analysis.

Disparities in the allocation of research funding to gynecologic cancers by Funding to Lethality scores.

PURPOSE: To analyze National Cancer Institute (NCI) funding distributions to gynecologic cancers compared to other cancers from 2007 to 2014. METHODS: The NCI's Surveillance, Epidemiology and End Results (SEER), Cancer Trends Progress Report, and Funding Statistics were used to analyze 18 cancer sites. Site-specific mortality to incidence ratios (MIR) were normalized per 100 cases and multiplied by person-years of life lost to derive cancer-specific lethality. NCI funding was divided by its lethality to calculate Funding to Lethality scores for gynecologic malignancies and compared to 15 other cancer sites. RESULTS: Ovarian, cervical, and uterine cancers ranked 10th (score 0.097, SD 0.008), 12th (0.087, SD 0.009), and 14th (0.057, SD 0.006) for average Funding to Lethality scores. The highest average score was for prostate cancer (score 1.182, SD 0.364). In U.S. dollars per 100 incident cases, prostate cancer received an average of $1,821,000 per person-years of life lost, while ovarian cancer received $97,000, cervical cancer $87,000, and uterine cancer $57,000. Ovarian and cervical cancers had lower average Funding to Lethality scores compared to nine other cancers, while uterine cancer was lower than 13 other cancers (p < 0.01 for all comparisons). Analyses of eight-, five-, and three-year trends for gynecologic cancers showed nearly universal decreasing Funding to Lethality scores. CONCLUSION: Funding to Lethality scores for gynecologic cancers are significantly lower than other cancer sites, indicating a disparity in funding allocation that persists over the most recent eight years of available data. Prompt correction is required to ensure critical discoveries for women with gynecologic cancers.

Trends and comparative effectiveness of inpatient radical hysterectomy for cervical cancer in the United States (2012-2015).

OBJECTIVE: Report the up-to-date trends in surgical approach for cervical cancer and compare outcomes between open and minimally invasive routes. METHODS: Radical Hysterectomy (RH) cases from the National Inpatient Sample (NIS) dataset between 2012 and 2015 were grouped into abdominal (ARH) and Minimally Invasive Surgery (MIS). The MIS group was subdivided as "Laparoscopic", "Robotic", and "Converted". Univariate and multivariable logistic regression were used to analyze differences in complication rates. The National Surgical Quality Improvement Dataset 2015 was used for validation. RESULTS: A total of 7180 cases from NIS were identified. Overall, there was 44% decline in RH cases from 2012 (n = 2220) to 2015 (n = 1255). A proportionate increase in robotic cases from 31.5% in 2012 to 41.4% in 2015 was noted. By intention to treat analysis, the rate of at least one complication for abdominal cases was 24.8% compared to 10% for MIS (p < 0.001). On multivariate analysis, abdominal cases had higher odd of any one complication (aOR 2.9,95% CI 2.12-4.00), medical complication (aOR 3.25,95% CI 2.15-4.19), infectious complication (aOR 3.76,95% CI 2.1-6.1) but not for surgical complications (aOR 1.7,95% CI 0.5-5.6). AH resulted in longer hospital stay compared to MIS (4.3 vs 1.9 days, p < 0.001). Median cost of AH was $12,624, laparoscopic $12,873, robotic $14,029 and converted cases $17,036. NSQIP analysis supplemented the outcomes to 30-days and showed similar findings. CONCLUSIONS: Perioperative complications are significantly lower for MIS procedures. These data should be used for contemporary cost-effective analysis and comprehensive counseling regarding risks and benefits of the surgical approach for cervical cancer.

Using simple radiologic measurements to anticipate surgical challenge in endometrial cancer: a prospective study.

OBJECTIVES: To determine if linear measurements of adiposity from pre-operative imaging can improve anticipation of surgical difficulty among endometrial cancer patients. METHODS: Eighty patients with newly diagnosed endometrial cancer were enrolled. Routine pre-operative imaging (MRI or CT) was performed. Radiologic linear measurements of the following were obtained: anterior-to-posterior skin distance; anterior skin to anterior edge of L5 distance (total anterior); anterior peritoneum to anterior edge of L5 distance (visceral obesity); and posterior edge of L5 to posterior skin distance (total posterior). Surgeons completed questionnaires quantifying preoperative anticipated operative difficulty and postoperative reported operative difficulty. The primary objective was to assess for a correlation between linear measurements of visceral fat and reported operative difficulty. RESULTS: Seventy-nine patients had questionnaires completed, preoperative imaging obtained, and surgery performed. Univariate analysis showed all four linear measurements, body mass index, weight, and anticipated operative difficulty were associated with increased reported operative difficulty (P< 0.05). Multivariate analysis demonstrated that body mass index and linear measurements visceral obesity and total posterior were independently associated with increased reported operative difficulty (P< 0.05). Compared with body mass index, the visceral obesity measurement was more sensitive and specific for predicting increased reported operative difficulty (visceral obesity; sensitivity 54%, specificity 91 %; body mass index; sensitivity 38%, specificity 89%). A difficulty risk model combining body mass index, visceral obesity, and total posterior demonstrated better predictive performance than any individual preoperative variable. CONCLUSIONS: Simple linear measurements of visceral fat obtained from preoperative imaging are more predictive than body mass index alone in anticipating surgeon-reported operative difficulty. These easily obtained measurements may assist in preoperative decision making in this challenging patient population.

Factors associated with outcomes and inpatient 90-day cost of care in endometrial cancer patients undergoing hysterectomy - implications for bundled care payments.

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.

Preoperative obstructive sleep apnea screening in gynecologic oncology patients.

BACKGROUND: Women with a gynecologic cancer tend to be older, obese, and postmenopausal, characteristics that are associated with an increased risk for obstructive sleep apnea. However, there is limited investigation regarding the condition's prevalence in this population or its impact on postoperative outcomes. In other surgical populations, patients with obstructive sleep apnea have been observed to be at increased risk for adverse postoperative events. OBJECTIVE: We sought to estimate the prevalence of obstructive sleep apnea among gynecologic oncology patients undergoing elective surgery and to investigate for a relationship between obstructive sleep apnea and postoperative outcomes. STUDY DESIGN: Patients referred to an academic gynecologic oncology practice were approached for enrollment in this prospective, observational study. Patients were considered eligible for study enrollment if they were scheduled for a nonemergent inpatient surgery and could provide informed consent. Enrolled patients were evaluated for a preexisting diagnosis of obstructive sleep apnea. Those without a prior diagnosis were screened using the validated, 4-item STOP questionnaire (ie, Snore loudly, daytime Tiredness, Observed apnea, elevated blood Pressure). All patients who screened positive for obstructive sleep apnea were referred for polysomnography. The primary outcome was the prevalence of women with obstructive sleep apnea or those who screened at high risk for the condition. Secondary outcomes examined the correlation between body mass index (kg/m2) with obstructive sleep apnea and assessed for a relationship between obstructive sleep apnea and postoperative outcomes. RESULTS: Over a 22-month accrual period, 383 eligible patients were consecutively approached to participate in the study. A cohort of 260 patients were enrolled. A total of 33/260 patients (13%) were identified as having a previous diagnosis of obstructive sleep apnea. An additional 66/260 (25%) screened at risk for the condition using the STOP questionnaire. Of the patients who screened positive, 8/66 (12%) completed polysomnography, all of whom (8/8 [100%]) were found to have obstructive sleep apnea. The prevalence of previously diagnosed obstructive sleep apnea or screening at risk for the condition increased as body mass index increased (P < .001). Women with untreated obstructive sleep apnea and those who screened at risk for the condition were found to have an increased risk for postoperative hypoxemia (odds ratio, 3.5; 95% confidence interval, 1.8-4.7; P = .011) and delayed return of bowel function (odds ratio, 2.1; 95% confidence interval, 1.3-4.5; P = .009). CONCLUSION: The prevalence of obstructive sleep apnea or screening at risk for the condition is high among women presenting for surgery with a gynecologic oncologist. Providers should consider evaluating a patient's risk for obstructive sleep apnea in the preoperative setting, especially when risk factors for the condition are present.

Trends in hospice discharge, documented inpatient palliative care services and inpatient mortality in ovarian carcinoma.

OBJECTIVE: To investigate the trends in discharge to hospice, documented inpatient palliative care services, and inpatient mortality in metastatic ovarian cancer (mOvCa) patients. METHODS: Patients≥18years with mOvCa and a non-elective admission between January 1, 2006 and December 31, 2011 were identified from the National Inpatient Sample (NIS). The primary outcome of interest was the temporal trend in the annual proportion of hospitalizations for mOvCa where discharge destination was hospice. Secondary outcomes included temporal trend of inpatient mortality and documented palliative care services. Multivariable logistic regression models were used to ascertain independent factors predictive of hospice discharge and documented palliative services across the clusters of hospitals. RESULTS: A total of 106,203 non-elective hospitalizations were identified. The rate of hospice discharge increased from 9.2% in 2004 to 11.1% in 2011 (ptrend<0.001). Similarly, the rate of documented palliative care services increased from 2.7% in 2004 to 10.4% in 2011 (ptrend<0.001). The inpatient mortality decreased from 9.6% in 2004 to 7.4% in 2011 (ptrend<0.001). In a subset of hospitalizations with extreme risk of dying, 22% were discharged to hospice and 11% received documented palliative care services. One fifth of the patients who died in the hospital received documented palliative care services. CONCLUSIONS: The use of hospice as a discharge destination and documented palliative care services is relatively low but appears to be increasing over time for mOvCa patients. Monitoring this data is vital to plan educational programs regarding palliative care approaches in this at-risk population.

The Feasibility and Safety of Adopting Single-Incision Laparoscopic Surgery into Gynecologic Oncology Practice.

STUDY OBJECTIVE: To determine the complications associated with single-incision laparoscopy in gynecologic oncology surgery. DESIGN: A retrospective cohort (Canadian Task Force classification II-3). SETTING: A single academic institution. PATIENTS: One hundred fifteen consecutive patients undergoing single-incision laparoscopy with suspected gynecologic oncology conditions. INTERVENTIONS: Single-incision laparoscopy. MEASUREMENTS AND MAIN RESULTS: One hundred fifteen patients underwent single-incision laparoscopy. The mean age was 55.3 ± 13.1 years. For procedures completed via single-incision laparoscopy (102/115 [88.7%]), the mean operative time was 130.7 ± 55.5 minutes. The average blood loss was 63 ± 111 mL. The conversion to open rate was 13 of 115 (12.17%). The conversion rate of the 55 patients with benign conditions was lower (2/55 [3.64%]) compared with the 60 patients with malignant conditions (11/60 [18.33%]). The hernia rate was 2 of 115 (1.80%), 1 of which was a recurrent hernia. The median time for follow-up was 30 days (range, 5-653 days). CONCLUSION: Single-incision laparoscopy provides a feasible, safe, and promising minimally invasive modality for treating gynecologic oncology patients.

Frailty index predicts severe complications in gynecologic oncology patients.

OBJECTIVE: The purpose of this study was to quantify the predictive value of frailty index on 30-day Clavien class IV (requiring critical care support) and class V (30-day mortality) complications after gynecologic cancer surgery. METHODS: Patients included in the National Surgical Quality Improvement Program (NSQIP) 2008-2011 had a final diagnosis of gynecologic malignancy. Modified frailty index (mFI) was calculated with 11 variables. Higher mFI scores indicated more severe comorbidities. Logistic regression was used to control for known predictors of complications. RESULTS: Of the total 6551 patients, 188 (2.9%) of the patients experienced a Clavien IV/V complication. 2958 patients had a score of 0 (45.2%), 2405 patients had a score of 1 (36.7%), 985 patients had a score of 2 (15%), 162 patients had a score of 3 (2.5%) and 41 patients had a score≥4 (0.6%). The rates of Clavien IV/V complications were 2%, 2.7%, 4.4%, 7.4% and 24.4% for mFI scores of 0, 1, 2, 3 and ≥4, respectively (p<0.001). Variables found to be significant for predicting Clavien IV and V complications on logistic regression modeling were preoperative albumin<3g/dL (OR=6.5), operative time (OR=1.003 per min increase), non-laparoscopic surgery (OR=3.3), and frailty index (OR score 0=reference, score 1=1.26, score 2=1.9, score 3=2.33 and score≥4=12.5). Taking the two preoperative factors of albumin and mFI allowed for greater precision in identifying women who are at higher risk for requiring ICU care (>10% risk). CONCLUSIONS: Modified frailty index (mFI) is predictive of the need for critical care support and 30-day mortality after surgery for gynecologic cancer.

Predictors of 30-day readmission and impact of same-day discharge in laparoscopic hysterectomy.

OBJECTIVE: The objective of the study was to identify the predischarge predictors of 30-day readmission and the impact of same-day discharge after laparoscopic hysterectomy. STUDY DESIGN: Patients undergoing only laparoscopic hysterectomy with or without bilateral salpingo-oophorectomy participated in the study. RESULTS: The 30-day readmission rate was 3.1% (277 of 8890). Factors predictive of higher rates of readmission were diabetes (4.4% vs 3.0%; P = .03), chronic obstructive pulmonary disease (8.5% vs 3.1%; P = .02), disseminated cancer (20% vs 3.1%; P < .001), chronic steroid use (7.1% vs 3.1%; P = .03), daily alcohol use of more than 2 drinks (12.5% vs 2.5%; P = .04), and bleeding disorder (10.8% vs 3%; P = .001). Operative factors included surgical time of 2 hours or greater (3.5% vs 2.7%; P = .014). After surgery, patients had a higher rate of readmission when they experienced any 1 or more complications prior to discharge, (6.9% vs 3.1%; P = .01) as well as any complication after discharge (3.6% vs 1.6%; P = .01). Infections (35.7%) and surgical complications (24.2%) were the most common reasons of readmissions. Of these patients, 20.9% were discharged the same day (n = 1855) and had a similar rate of readmission (2.6% vs 3.2%; P = n.s.). Laparoscopic hysterectomy readmission score (LHRS) can be calculated by assigning 1 point to diabetes, chronic obstructive pulmonary disease, disseminated cancer, chronic steroid use, bleeding disorder, length of surgery of 2 hours or longer, and 2 points to any postoperative complication prior to discharge. Readmission rates for the LHRS score were score 1 (2.4%), score 2 (3.3%), score 3 (5.8%), or score 4 (9.5%). CONCLUSION: The overall readmission rate after laparoscopic hysterectomy is low. Patients discharged the same day have similar rates of readmission. Higher LHRS is indicative of higher rates of readmission and may identify a population not suitable for same-day discharge and in need of higher vigilance to prevent readmissions.

Preoperative hypoalbuminemia is an independent predictor of poor perioperative outcomes in women undergoing open surgery for gynecologic malignancies.

OBJECTIVE: To quantify the impact of preoperative hypoalbuminemia on 30-day mortality and morbidity after gynecologic cancer surgery. METHODS: Patients included in the National Surgical Quality Improvement Program (NSQIP) dataset who underwent any non-emergent surgery for gynecologic malignancy between 1/1/2008 and 12/31/2010 were identified. Analysis was conducted with albumin both as a dichotomous variable (<3.5 g/dl was defined as low albumin) and as a continuous variable to determine a clinically relevant cut-off value. RESULTS: Of the total 3171 patients identified, 2110 had preoperative albumin levels available for analysis. In addition, 279 (13.3%) of these patients had low albumin levels. According to multivariate analysis, the low albumin group had significantly higher odds of developing one or more post-operative complications (OR-2,CI: 1.47-2.73, p<0.0001), three or more complications (OR-4.1,CI: 2.31-7.1, p<0.0001), surgical complications (OR-2.39,CI: 1.59-3.58, p<0.0001), thromboembolic complications (OR-2.59,CI: 1.33-5.06, p<0.0001), pulmonary complications (OR-4.06,CI: 2.05-8.03, p<0.0001), or infectious complications (OR-1.84,CI: 1.26-2.69, p<0.0001) and a higher 30-day mortality (OR-6.52,CI: 2.51-16.95, p<0.0001). Upon subgroup analysis, this difference was not found in patients undergoing laparoscopic surgery. In patients undergoing open surgery, the probability of experiencing one or more post-operative complications increased linearly with the decrease in albumin level; however, the probability of patients experiencing three or more complications and 30-day mortality increased sharply as soon as the albumin level decreased below 3g/dl. CONCLUSION: Preoperative albumin levels <3g/dL identify a population of patients at a very high-risk of experiencing perioperative morbidity and 30-day mortality after open surgery.

The use of humor in patients with recurrent ovarian cancer: a phenomenological study.

OBJECTIVE: Humor has been shown to decrease the use of pain medicine, improve mood, and decrease stress. However, the timing and setting for using humor can be perceived differently depending on the patient and the context. Our objective was to better understand how patients with recurrent ovarian cancer experience humor to gain insight into the feasibility of using humor as a therapeutic adjunct. METHODS: We conducted structured patient interviews with women being treated for recurrent ovarian cancer. The phenomenological method of Colaizzi was used to gain an in-depth understanding of how women with recurrent ovarian cancer use and view humor in relation to their diagnosis. RESULTS: Most patients used humor to cope with cancer and felt that humor alleviated their anxiety. The use of humor by physicians and nurses was perceived as appropriate and positive. A previous relationship with a physician was often felt necessary before the use of humor. Humor was often perceived not only in traditional jokes but was also found in humorous anecdotes from the caregiver's life outside of medicine. CONCLUSIONS: This study revealed that humor is an often used coping mechanism for women with recurrent ovarian cancer and subjectively helps alleviate anxiety. The use of humor by physicians was found to be universally perceived as appropriate and positive. The waiting area seems to be a place where humorous experiences would be welcomed. These findings provide additional insight into the role that humor plays in the lives of patients with recurrent ovarian cancer.