RESUMO
BACKGROUND: Single-use materials and equipment are regularly opened by the surgical team during procedures but left unused, potentially resulting in superfluous costs and excess environmental waste. OBJECTIVE: This study aimed to estimate the excess use of surgical supplies in minimally invasive benign gynecologic surgeries. STUDY DESIGN: This is a prospective observational study conducted at a university-affiliated single tertiary medical center. Designated study personnel were assigned to observe surgical procedures performed during July to September 2022. Surgical teams were observed while performing surgeries for benign indications. The teams were not informed of the purpose of the observation to avoid potential bias. Disposable materials and equipment opened during the procedure were documented. Excess supplies were defined as those opened but left unused before being discarded. Costs per item of the excess supplies were estimated on the basis of material and equipment costs provided by the hospital. RESULTS: A total of 99 surgeries were observed, including laparoscopic (32%), robotic (39%), hysteroscopic (14%), vaginal (11%), and laparotomy procedures (3%). Excess use of surgical supplies was documented in all but one procedure. The total cost across all surgeries reached $6357. The contained tissue extraction bag was the most expensive item not used (Applied Medical, Rancho Santa Margarita, CA; $390 per unit) in 4 procedures, contributing 25.54% to the total cost. Raytec was the most common surgical waste, with a total of n=583 opened but unused (average n=5.95 per surgery). A significant difference was found in the rate of excess supplies across the surgical approaches, with robotic surgery contributing 52.19% of the total cost (P=.01). CONCLUSION: Excess use of disposable materials and equipment is common in minimally invasive benign gynecologic surgeries and contributes to superfluous costs and excess environmental waste. It is predominantly attributed to the opening of inexpensive materials that are left unused during the procedure. Increased awareness of costs and generated waste may reduce excess use of surgical supplies and should be further explored in future research.
Assuntos
Procedimentos Cirúrgicos em Ginecologia , Procedimentos Cirúrgicos Robóticos , Humanos , Feminino , Procedimentos Cirúrgicos em Ginecologia/instrumentação , Procedimentos Cirúrgicos em Ginecologia/economia , Procedimentos Cirúrgicos em Ginecologia/estatística & dados numéricos , Estudos Prospectivos , Procedimentos Cirúrgicos Robóticos/economia , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos , Procedimentos Cirúrgicos Robóticos/instrumentação , Procedimentos Cirúrgicos Minimamente Invasivos/economia , Procedimentos Cirúrgicos Minimamente Invasivos/instrumentação , Laparoscopia/economia , Laparoscopia/estatística & dados numéricos , Laparoscopia/instrumentação , Histeroscopia/economia , Histeroscopia/estatística & dados numéricos , Equipamentos Descartáveis/economia , Equipamentos Descartáveis/provisão & distribuição , Laparotomia/economia , Adulto , Pessoa de Meia-IdadeRESUMO
STUDY OBJECTIVE: To assess the effect of preoperative bilateral ultrasound-guided quadratus lumborum nerve block (QLB) on quality of recovery after minimally invasive hysterectomy, in an enhanced recovery after surgery setting. DESIGN: Randomized, controlled, double-blinded trial (Canadian Task Force level I). SETTING: University-affiliated tertiary medical center. PATIENTS: All women undergoing an elective robotic or laparoscopic hysterectomy. Women with chronic pain, chronic anticoagulation, and body mass index >50 kg/m2 were excluded. INTERVENTION: Patients were randomized with a 1:1 allocation, to one of the following 2 arms, and stratified based on robotic versus laparoscopic approach. 1. QLB: QLB (bupivacaine) + sham local trocar sites infiltration (normal saline) 2. Local infiltration: sham QLB (normal saline) + local infiltration (bupivacaine) MEASUREMENTS AND MAIN RESULTS: The primary outcome was defined as the quality of recovery score based on the validated questionnaire Quality of Recovery, completed 24 hours postoperatively. Secondary outcomes included dynamic pain scores, accumulated opioid consumption up to 24 hours, postoperative nausea and vomiting, surgical complications, length of hospital stay, time to first pain medication administration in the postanesthesia care unit, and adverse events. A total of 76 women were included in the study. Demographic characteristics were similar in both groups. Median age was 44 years (interquartile range 39-50), 47% of the participants were African American, and mean body mass index was 32.8 kg/m2 (standard deviation [SD] 8.1). The mean Quality of Recovery score was 179.1 (SD ± 10.3) in the QLB and 175.6 (SD ± 9.7) for the local anesthesia group (p = .072). All secondary outcomes were comparable between groups. CONCLUSIONS: QLBs do not significantly improve quality of recovery after elective robotic or laparoscopic hysterectomy compared with local anesthetic port site infiltration.
RESUMO
STUDY OBJECTIVE: To investigate the incidence of venous thromboembolism (VTE) in patients undergoing large specimen hysterectomy for benign indications. To evaluate the impact of route of surgery and operative time in the development of VTE in this population. DESIGN: Retrospective cohort study (Canadian Task Force Classification II2) of targeted hysterectomy data prospectively collected from the American College of Surgeons National Surgical Quality Improvement Program involving over 500 hospitals across the United States. SETTING: National Surgical Quality Improvement Program Database. PATIENTS: Women aged 18 years or older undergoing hysterectomy for benign indications between 2014 and 2019. Patients were further classified into 4 groups according to uterine weight: <100 g, 100-249 g, 250 g-499 g, and specimens ≥500 g. INTERVENTIONS: Current Procedural Terminology codes were used to identify cases. Variables including age, ethnicity, body mass index, smoking status, diabetes, hypertension, blood transfusion, and American Society of Anesthesiologists classification system scores were collected. Cases were stratified by route of surgery, operative time, and uterine weight. MEASUREMENTS AND MAIN RESULTS: A total of 122,418 hysterectomies occurring between 2014 and 2019 were included in our study, of which 28,407 (23.2%) patients underwent abdominal, 75,490 (61.7%) laparoscopic, and 18,521 (15.1%) vaginal hysterectomy. The overall rate of VTE in patients with large specimen hysterectomies (≥500 g) was 0.64%. After multivariable adjustment, there was no significant difference in the odds of VTE between uterine weight groups. Only 30% of the surgeries with uterine weight above 500 g were performed with minimally invasive surgical routes. Patients who underwent minimally invasive hysterectomy had lower odds of VTE via laparoscopic (adjusted odds ratio [aOR] 0.62; confidence interval [CI]: 0.48-0.81) and vaginal (aOR 0.46; CI: 0.31-0.69) routes compared to laparotomy. Prolonged operative time (>120 min) was associated with increased odds of VTE (aOR 1.86; CI:1.51-2.29). CONCLUSION: The occurrence of VTE after a benign large specimen hysterectomy is rare. The odds of VTE is higher with longer operative times and lower with minimally invasive approaches, even for markedly enlarged uteri.
Assuntos
Tromboembolia Venosa , Humanos , Feminino , Estados Unidos , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/etiologia , Estudos Retrospectivos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Histerectomia/efeitos adversos , Histerectomia Vaginal/efeitos adversosRESUMO
OBJECTIVE: In an effort to reduce the primary cesarean delivery (CD) rate, the American College of Obstetricians and Gynecologists (ACOG) recommended new labor guidelines in 2014 that allow longer duration of labor times. There are little data on the impact of these guidelines on CD rates and pregnancy outcomes in a predominantly Hispanic population. This study aimed to compare the primary CD rates and maternal and neonatal outcomes in patients undergoing primary CD for arrest of labor before and after implementation of the 2014 guidelines. STUDY DESIGN: This was a retrospective cohort study of term patients who underwent a CD for an arrest disorder between January 2011 and April 2017 at a county teaching hospital. Our primary outcome was the composite maternal and neonatal morbidities (CMM and CNM, respectively). Differences in the demographic and clinical characteristics, CMM, and CNM stratified by time period (pre- vs. postimplementation) were examined. RESULTS: There were 4,976 deliveries in the study period: 525 (11%) underwent primary CD for arrest disorder; 298 (6%) prior to 2014, and 227 (5%) after 2014 (p = 0.62). There was no significant difference in the rate of CD between the two periods (13.4 vs. 13.3%, p = 0.81). In patients undergoing CD for arrest of dilation (n = 389), the CMM and CNM did not significantly change between both groups (63.3 vs. 56%, p = 0.15). In patients who had a CD for arrest of descent (n = 136), the rate of CMM significantly increased from 50 to 75% (p = 0.02) with no significant change in the CNM (13.2 vs. 20%, p = 0.3). CONCLUSION: Despite significant changes in labor management after the publication of the 2014 guidelines, our primary CD rate was not reduced, and we noticed an increase in CMM in patients who had CD for arrest of descent. A randomized controlled trial is needed to further evaluate the effect of these guidelines nationally. KEY POINTS: · The Obstetric Care Consensus statement aims to decrease the rate of cesarean delivery (CD).. · We observed an increase in morbidity in CD if done for arrest of descent (pre/post the consensus).. · A randomized controlled trial is needed to further assess the impact of the guidelines on morbidity..
Assuntos
Cesárea , Trabalho de Parto , Gravidez , Feminino , Recém-Nascido , Humanos , Estudos Retrospectivos , Hospitais de Ensino , Morbidade , Parto ObstétricoRESUMO
STUDY OBJECTIVE: To assess the external validity of a recently published clinical risk score estimating the risk of failed medical treatment in patients with tubo-ovarian abscess (TOA) based on 4 clinical variables on admission. DESIGN: The probability of failed medical treatment predicted from the reference risk score was compared with the observed rates in a retrospective cohort of patients with TOA. Results were assessed using rigorous methods for clinical prediction models. SETTING: Safety-net teaching hospital system in Houston, Texas. PATIENTS: One hundred and sixty nine consecutive patients admitted with TOA between 2011 and 2018 were included. Some were treated conservatively with intravenous antibiotic agents; others required a drainage procedure. INTERVENTION: Electronic health records were reviewed and the 4 clinical predictors of failed conservative treatment were captured (age, white blood cell count on admission, abscess size, and presence of bilateral abscess). A clinical risk score was calculated for each patient. The prediction model was created using the risk score in a multivariate logistic regression. Then the calibration, discrimination, and accuracy of the model were evaluated to perform the external validation analysis. MEASUREMENTS AND MAIN RESULTS: Among 169 eligible patients, 50.2% were successfully treated with intravenous antibiotic agents and 49.8% needed abscess drainage. Patients undergoing drainage were more likely to be older, be diabetic, to present with elevated white blood cell count and fever, and to have a larger abscess size on univariate analysis. Among the 4 known predictors of drainage, abscess size was found to be the strongest. Significant difference in clinical characteristics was noted between our cohort and the reference cohort, and the model needed recalibration to adjust for these differences. The area under the receiver operating characteristic curve was 0.77 (0.71-0.84) indicating good discrimination. The Brier score was favorable (0.19) and the observed and predicted rates were similar ranging across different risk scores. CONCLUSIONS: Our results provide external validation of a simple clinical risk score predicting failed medical treatment in patients with TOA.
Assuntos
Abscesso Abdominal , Doenças das Tubas Uterinas , Doenças Ovarianas , Abscesso/tratamento farmacológico , Abscesso/cirurgia , Antibacterianos/uso terapêutico , Doenças das Tubas Uterinas/tratamento farmacológico , Doenças das Tubas Uterinas/cirurgia , Feminino , Humanos , Doenças Ovarianas/tratamento farmacológico , Doenças Ovarianas/cirurgia , Estudos Retrospectivos , Fatores de RiscoRESUMO
OBJECTIVE: Although locally advanced cervical cancer can be cured, patients with stage IVB disease have poor prognosis with limited treatment options. Our aim was to describe the pattern of care and analyze health disparity variables that may account for differences in treatment modalities and survival in this population. METHODS: The National Cancer Database was queried for patients diagnosed between 2004 and 2013 with metastatic squamous cell carcinoma or adenocarcinoma of the cervix. Codes representing parenchymal and lymphatic metastasis (beyond the para-aortic radiation fields) were used to identify the cohort. Variables included age, race, insurance status, comorbidity, treatment modality, and outcomes. We used Kaplan-Meier methods to compare survival curves and Cox proportional hazards to estimate the association between variables and overall survival (OS). Log-rank method was used to compare Kaplan-Meier curves. RESULTS: There were 4576 patients identified. The majority was white (59.7%); 19.5% were Hispanic, and 9.6% were black. Fifty-one percent had Medicare/Medicaid; 33.7% had private, and 12.5% had no insurance. The majority (56.3%) received chemotherapy (CMT) alone or in combination with radiation therapy (RT) and/or surgery. Median follow-up was 7.3 months (0-124.8 months). Median OS was 11.5 months (10.5-12.5 months). Higher probability of receiving CMT and RT was associated with having private insurance (P < 0.001). Significant prognostic values positively affecting survival on multivariate analysis included black and Asian race, private insurance, comorbidity index of 0, metastatic site at initial presentation (lung), and treatment modality. Patients treated with CMT + RT with or without surgery had significantly better median OS (12 months) compared with those treated with CMT alone (8.3 months), RT alone (4.8 months), or those untreated (2.3 months) (P < 0.001). CONCLUSIONS: Insurance status influences treatment options in patients with distant metastatic cervical cancer. Race, comorbidity index, metastatic site, and suboptimal treatment appear to affect survival outcomes. Regardless of treatment, survival was extremely limited.
Assuntos
Adenocarcinoma/terapia , Carcinoma de Células Escamosas/terapia , Disparidades em Assistência à Saúde , Neoplasias do Colo do Útero/terapia , Adenocarcinoma/mortalidade , Carcinoma de Células Escamosas/mortalidade , Feminino , Humanos , Estudos Retrospectivos , Fatores Socioeconômicos , Estados Unidos/epidemiologia , Neoplasias do Colo do Útero/mortalidadeRESUMO
OBJECTIVE: Mucinous carcinoma of the endometrium (MCE) is a rare histologic type representing less than 5% of all endometrial carcinomas. The aim of the study was to describe our experience with MCE and determine its clinical outcome. METHODS: After institutional review board approval, we performed a comprehensive retrospective review of medical records of patients with uterine adenocarcinoma who underwent surgical staging for MCE in 2 large academic centers between 1990 and 2009. Patients with 2009 International Federation of Gynecology and Obstetrics stages I to III were included. Patients' demographics and tumor characteristics were obtained and analyzed, including data on follow-up and survival. RESULTS: Thirty-one patients with MCE were identified for the study. Median age was 62 years (range, 43-91 years). All patients underwent surgical staging with lymph node evaluation. Patients' distribution by stage was as follows: 83.9% (n = 26) stage IA, 6.5% (n = 2) stage IIIA, and 9.7% (n = 3) stage IIIC1. Median follow-up was 62 months (range, 1-189 months). Only 30 patients received adjuvant platinum-based chemotherapy. No patients received adjuvant radiation treatment after hysterectomy. Only 4 patients had tumor recurrences with a median time to recurrence of 13.5 months (range, 8-30 months). Three patients with stage IIIC1 and one patient with stage IIIA had a diagnosis of pelvic recurrences. On univariate analysis, factors associated with recurrence were advanced stage (P ≤ 0.0001), deep myometrial invasion (P = 0.0199), lower uterine segment involvement (P = 0.0038), and grade II disease (P = 0.0013). Five-year relapse-free survival was 86.3%, and 5-year overall survival was 81.2%. CONCLUSIONS: Based on our study cohort, the outcome of patients with FIGO stage I to stage II MCE is excellent with surgical staging alone. However, patients with advanced stages may potentially benefit from adjuvant therapies. These findings need to be validated with other similar studies.
Assuntos
Adenocarcinoma Mucinoso/terapia , Neoplasias do Endométrio/terapia , Recidiva Local de Neoplasia/diagnóstico , Recidiva Local de Neoplasia/terapia , Neoplasias Uterinas/terapia , Adenocarcinoma Mucinoso/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Quimioterapia Adjuvante , Terapia Combinada , Neoplasias do Endométrio/patologia , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/patologia , Estadiamento de Neoplasias , Prognóstico , Radioterapia Adjuvante , Neoplasias Uterinas/patologiaRESUMO
Background: Caregiver frustration with inconsolable crying is a commonly cited antecedent factor of Abusive head trauma (AHT) in infants. Objective: To assess the effectiveness of an educational intervention to improve patients' knowledge of normal crying patterns in infants and the implications of AHT among women of Hispanic population. Methods: The Period of PURPLE Crying program was piloted as part of Centering Prenatal Care at an outpatient clinic site in the Harris County Health Department system, which cares for a primarily underserved and Spanish speaking population. Educational material and direct counseling were delivered by the clinician. Demographic data was collected and a pre- and post-test survey was administrated to assess participant's knowledge and behavior. Results: Between April 2017 and April 2018, 63 Hispanic women were included in this study. Prior to implementation of the educational tool, most of the survey questions were answered incorrectly. After the intervention, knowledge regarding normal infant crying patterns was significantly improved in all questions. However, knowledge gaps persisted especially in relation to the adequacy of parents' ability to soothe a crying infant and normalcy of excessive crying. Conclusions: The educational curriculum was an effective tool for improving knowledge about normal infant crying patterns in Hispanic mothers.
Assuntos
Traumatismos Craniocerebrais , Síndrome do Bebê Sacudido , Choro/psicologia , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Hispânico ou Latino , Humanos , Lactente , Mães/psicologia , Pais/psicologiaRESUMO
Objective: To study the association between high-sensitivity C-reactive protein (hs-CRP) and infertility among reproductive-age women while controlling for obesity and other metabolic markers. Previous studies found a link between infertility and cardiovascular diseases (CVDs). C-reactive protein is a sensitive marker of CVDs, and its levels are affected by obesity. Design/Setting: We conducted a cross-sectional study using national data from 2015 through 2018. Patients: A total of 940 women aged 20-45 years who self-reported infertility, had hs-CRP values measured, and did not have CRP >10 mg/L, asthma, arthritis, bronchitis, thyroid disease, bilateral oophorectomy, hysterectomy, and who were not breastfeeding or pregnant, premenarchal at the time of study or had menarche after the age of 20. Interventions: N/A. Main outcome measures: Infertility status (ever reporting inability to conceive with 12 months of trying to become pregnant). Results: In comparison to noninfertile women, self-reported infertile women had higher mean of hs-CRP (3.11 mg/L vs. 2.40 mg/L) and higher percentage of moderate/high hs-CRP values (77.0% vs 58.8%). However, after adjusting for metabolic markers, there was a nonsignificant association between moderate/high hs-CRP and self-reported infertility in the multivariable logistic regression analysis. Odds ratio estimates of the association between hs-CRP and infertility increased over 40% after removing obesity measures and/or high-density lipoprotein from regression models. Conclusion: There was no association between hs-CRP and self-reported infertility after controlling for obesity measures and other risk factors for CVDs in a sample of U.S. women aged 20-45 years.
RESUMO
Reproductive health can be affected by obesity through various mechanisms. Obesity-associated inflammatory markers and altered hormones can have direct and indirect impacts on female reproductive health. However, little is known about obesity prevalence and trend among infertile women and obesity association with infertility in reproductive-age women of the U.S. In a cross-sectional study, we sought to conduct a secondary analysis of National Survey of Family Growth (NSFG) data from 2011 to 2019. A total of 6,035 infertile and non-pregnant fecund women aged 20-44 years were included in a nationally representative sample of the U.S. The weighted prevalence of obesity (BMI ≥ 30) among infertile women was 41.63% for the period 2011-2019. Obese women had 62% higher odds of infertility (95% CI 1.24, 2.17) compared to non-obese women of reproductive age (20-44 years). However, there was no specific trend of obesity among infertile and non-pregnant fecund women aged 20-44 years in the U.S. from 2011 to 2019. Given the negative impact of obesity on female reproductive health and in light of our results, it is important to counsel obese infertile reproductive-age women of the U.S. about behavioral changes that include weight management. Future longitudinal studies are needed to evaluate the risk of infertility among obese women.
Assuntos
Infertilidade Feminina , Estudos Transversais , Feminino , Humanos , Infertilidade Feminina/complicações , Infertilidade Feminina/epidemiologia , Obesidade/complicações , Obesidade/epidemiologia , Estados Unidos/epidemiologiaRESUMO
Objective: Platinum-based chemotherapy and bevacizumab is the standard treatment for stage IVB cervical cancer. When metastases resolve, the benefit of radiating the primary tumor is unclear. We investigate the effect of pelvic radiation on PFS following chemotherapy and bevacizumab in stage IVB cervical cancer. Methods: This is a retrospective series of 29 patients with stage IVB cervical cancer treated with platinum-based chemotherapy and bevacizumab. 3 subgroups were evaluated: definitive pelvic radiation, palliative radiation, and no radiation. The primary outcome was the mean PFS. Progression was determined radiographically. Kaplan-Meier method and the log-rank test for equality analyzed OS and PFS. Results: The median OS was 38.4 months. 11 patients (38%) received definitive radiation, 9 (31%) received palliative and 9 (31%) received no radiation. 7/8 in the palliative group, 7/10 who received no radiation and all in the definitive group experienced progression. The median PFS was 7.5 months and not statistically different (p = 0.62). The median OS was not attained in the definitive group, was 23 months [19.6, -] for the palliative group and 19 months [24.9-45.4] for the no radiation group (p = 0.13). OS was higher in patients receiving definitive radiation vs all others (median OS survival not reached vs 6.6 months, p = 0.04). No difference in PFS between those receiving definitive radiation vs others (12 months vs 5.1 months p = 0.32). Conclusion: Definitive radiation is associated with improved survival among in stage IVB cervical cancer treated with chemotherapy and bevacizumab. This association could be due to treatment, patient, or disease factors associated with improved oncologic outcomes. In absence of higher-level data, shared decision-making with consideration for comorbidities and performance status should be employed.
RESUMO
OBJECTIVE: To determine the effect of surgeon experience on intraoperative, postoperative and long-term outcomes among patients undergoing pelvic exenteration for gynecologic cancer. METHODS: This was a retrospective analysis of all women who underwent exenteration for a gynecologic malignancy at MD Anderson Cancer Center, between January 1993 and June 2013. A logistic regression was used to model the relationship between surgeon experience (measured as the number of exenteration cases performed by the surgeon prior to a given exenteration) and operative outcomes and postoperative complications. Cox proportional hazards regression was used to model survival outcomes. RESULTS: A total of 167 exenterations were performed by 19 surgeons for cervix (78, 46.7%), vaginal (43, 25.8%), uterine (24, 14.4%), vulvar (14, 8.4%) and other cancer (8, 4.7%). The most common procedure was total pelvic exenteration (69.4%), incontinent urinary diversion (63.5%) and vertical rectus abdominis musculocutaneous reconstruction (42.5%). Surgical experience was associated with decreased estimated blood loss (p<0.001), intraoperative transfusion (p=0.009) and a shorter length of stay (p=0.03). No difference was noted in the postoperative complication rate (p=0.12-0.95). More surgeon experience was not associated with overall or disease specific survival: OS (hazard ratio [HR]=1.02; 95% confidence interval [CI]=0.97-1.06; p=0.46) and DSS (HR=1.01; 95% CI=0.97-1.04; p=0.66), respectively. CONCLUSION: Patients undergoing exenteration by more experienced surgeons had improvement in intraoperative factors such as estimated blood loss, transfusion rates and length of stay. No difference was seen in postoperative complication rates, overall or disease specific survival.