Hysterectomy Trends and Risk of Vaginal Cuff Dehiscence: An Update by Mode of Surgery.

STUDY OBJECTIVE: To analyze hysterectomy trends and vaginal cuff dehiscence (VCD) rates by mode of surgery at a tertiary care medical center and to describe characteristics of VCD cases. DESIGN: Observational retrospective cohort study. SETTING: Large academic hospital and affiliated community hospital. PATIENTS: 4722 patients who underwent hysterectomy at Columbia University Irving Medical Center between January 2010 and August 2021. INTERVENTIONS: Current Procedural Terminology and International Classification of Diseases codes identified hysterectomies and VCD cases. Hysterectomy trends and VCD rates were calculated by mode of surgery. Relative risks of VCD for each mode were compared with total abdominal hysterectomy (TAH). Clinical characteristics of VCDs were reviewed. MEASUREMENTS AND MAIN RESULTS: There were 4059 total hysterectomies. Laparoscopic hysterectomies, including total laparoscopic hysterectomies (TLHs), laparoscopic-assisted vaginal hysterectomies, and robot-assisted TLHs (RA-TLHs), increased from 41.9% in 2010 to 65.9% in 2021 (p <.001). RA-TLH increased from 5.7% in 2010 to 40.2% in 2021. Supracervical hysterectomies followed similar trends and were excluded from VCD analysis. There were 15 VCDs (overall rate 0.37%). VCD was highest after RA-TLH (0.66%), followed by TLH (0.32%) and TAH (0.27%), with no VCDs after laparoscopic-assisted vaginal hysterectomy or total vaginal hysterectomy. Compared with TAH, the relative risk for VCD after RA-TLH was 2.44 (95% confidence interval 0.66-9.00) and after TLH was 1.18 (95% confidence interval 0.24-5.83), which were not statistically significant. The mean time to dehiscence was 39 days (range 8-145 days). The most common trigger event was coitus (41%). CONCLUSION: VCD rates were low (<1%) for all modes of hysterectomy, and rates after robotic and laparoscopic hysterectomy were much lower than previously reported. Although VCD rates trended higher after robotic and laparoscopic hysterectomy compared with abdominal hysterectomy, the difference was not significant. It is difficult to determine whether this finding represents true lack of difference vs a lack of power to detect a significant difference given the rarity of VCD.

The Predictive Value of Vital Signs for Morbidity in Pregnancy: Evaluating and Optimizing Maternal Early Warning Systems.

OBJECTIVE: Vital sign scoring systems that alert providers of clinical deterioration prior to critical illness have been proposed as a means of reducing maternal risk. This study examined the predictive ability of established maternal early warning systems (MEWS)-as well as their component vital sign thresholds-for different types of maternal morbidity, to discern an optimal early warning system. STUDY DESIGN: This retrospective cohort study analyzed all patients admitted to the obstetric services of a four-hospital urban academic system in 2018. Three sets of published MEWS criteria were evaluated. Maternal morbidity was defined as a composite of hemorrhage, infection, acute cardiac disease, and acute respiratory disease ascertained from the electronic medical record data warehouse and administrative data. The test characteristics of each MEWS, as well as for heart rate, blood pressure, and oxygen saturation were compared. RESULTS: Of 14,597 obstetric admissions, 2,451 patients experienced the composite morbidity outcome (16.8%) including 980 cases of hemorrhage (6.7%), 1,337 of infection (9.2%), 362 of acute cardiac disease (2.5%), and 275 of acute respiratory disease (1.9%) (some patients had multiple types of morbidity). The sensitivities (15.3-64.8%), specificities (56.8-96.1%), and positive predictive values (22.3-44.5%) of the three MEWS criteria ranged widely for overall morbidity, as well as for each morbidity subcategory. Of patients with any morbidity, 28% met criteria for the most liberal vital sign combination, while only 2% met criteria for the most restrictive parameters, compared with 14 and 1% of patients without morbidity, respectively. Sensitivity for all combinations was low (maximum 28.2%), while specificity for all combinations was high, ranging from 86.1 to 99.3%. CONCLUSION: Though all MEWS criteria demonstrated poor sensitivity for maternal morbidity, permutations of the most abnormal vital signs have high specificity, suggesting that MEWS may be better implemented as a trigger tool for morbidity reduction strategies in the highest risk patients, rather than a general screen. KEY POINTS: · MEWS have poor sensitivity for maternal morbidity.. · MEWS can be optimized for high specificity using modified criteria.. · MEWS could be better used as a trigger tool..

Radiofrequency Ablation of Uterine Myomas and Pregnancy Outcomes: An Updated Review of the Literature.

OBJECTIVE: To provide a systematic review of pregnancy outcomes after radiofrequency ablation (RFA) of uterine myomas. DATA SOURCES: A literature search was conducted using PubMed, Cochrane Library, Scopus, Web of Science, and Embase, from database inception to October 2021. METHODS OF STUDY SELECTION: Two reviewers conducted independent literature searches. Studies that met the criteria based on title and abstract underwent full-text review. Publications were included if they reported pregnancies and obstetric outcomes after laparoscopic or transcervical RFA of myomas. TABULATION, INTEGRATION, AND RESULTS: A total of 405 publications were initially identified and screened, 39 underwent full-text review, and 10 publications were ultimately included. There were 50 pregnancies reported among 923 RFA patients: 40 pregnancies after 559 laparoscopic RFAs and 10 pregnancies after 364 transcervical RFAs. The number of patients from these studies actively trying to conceive after RFA is unknown. Among the RFA patients who conceived, the average age at ablation was 37 years old (range, 27-46 years). Most patients had between 1 and 3 myomas ablated, and myomas size ranged from <2 cm to 12.5 cm. There were 6 spontaneous abortions (12%) and 44 full-term pregnancies (88%), of which 24 were vaginal deliveries and 20 were cesarean deliveries. There were only 2 complications among 44 deliveries: one placenta previa that underwent an uncomplicated cesarean delivery and 1 delayed postpartum hemorrhage with expulsion of a degenerated myoma, with no long-term sequelae. There were no cases of uterine rupture, uterine window, or invasive placentation and no fetal complications. The spontaneous abortion rate was comparable with the general obstetric population. CONCLUSION: Almost all pregnancies after RFA of myomas were full-term deliveries with no maternal or neonatal complications. These findings add to the literature that radiofrequency myoma ablation may offer a safe and effective alternative to existing treatments for women who desire future fertility.

Searching for a biochemical correlate of critical illness in obstetrics: a descriptive study of maternal lactate in patients presenting for acute care in pregnancy.

Obstetric physiology may alter lactate metabolism and affect the ability to use lactate as a discriminator of critical illness in pregnancy. This prospective, cross-sectional study describes venous lactate levels in women presenting for acute care during pregnancy as well as characteristics associated with elevated lactate. Obstetric patients >20-week gestation presenting for acute evaluation were included and a venous lactate sample was drawn for each patient. Elevated lactate was defined as ≥2 mmol/L. One hundred two women were enrolled and venous lactate samples were obtained for 100 participants. Median lactate level was 1.22 (IQR 0.95-1.49) and 86% of patients had normal lactate. Six patients presented with infectious complaints, none of whom had sepsis or elevated lactate. Of the 14 patients with elevated lactate, all presented with labor complaints and 10 (71.4%) were admitted in labor. Elevated lactate level was significantly associated with labor complaints and admission in labor (p < .01). Thus, lactate may not be able to discriminate severe infection consistently in pregnancy as it is confounded by labor. Further research is necessary to clarify how lactate may be used more effectively in pregnant patients and to identify alternate strategies for sepsis screening.

Opioid Use Disorder during Antepartum and Postpartum Hospitalizations.

OBJECTIVE: This study aimed to evaluate temporal trends in opioid use disorder (OUD) during antepartum and postpartum hospitalizations. STUDY DESIGN: This repeated cross-sectional analysis analyzed data from the National (Nationwide) Inpatient Sample. Women aged 15 to 54 years admitted antepartum or postpartum were identified. The presence of OUD was determined based on a diagnosis of opioid abuse, opioid dependence, or opioid overdose. Temporal trends in OUD were evaluated using the Rao-Scott chi-square test. Temporal trends in opioid overdose were additionally evaluated. RESULTS: An estimated 7,336,562 antepartum hospitalizations and 1,063,845 postpartum readmissions were included in this analysis. The presence of an OUD diagnosis during antepartum hospitalizations increased from 0.7% of patients in 1998 to 1999 to 2.9% in 2014 (p < 0.01) and during postpartum hospitalizations increased from 0.8% of patients in 1998 to 1999 to 2.1% of patients in 2014 (p < 0.01). Risk of overdose diagnoses increased significantly for both antepartum hospitalizations, from 22.7 per 100,000 hospitalizations in 1998 to 2000 to 70.3 per 100,000 hospitalizations in 2013 to 2014 (p < 0.001), and postpartum hospitalizations, from 18.8 per 100,000 hospitalizations in 1998 to 2000 to 65.2 per 100,000 hospitalizations in 2013 to 2014 (p = 0.02). DISCUSSION: Risk of OUD diagnoses and overdoses increased over the study period for both antepartum and postpartum hospitalizations.

A meta-analysis of lung cancer gene expression identifies PTK7 as a survival gene in lung adenocarcinoma.

Lung cancer remains the most common cause of cancer-related death worldwide and it continues to lack effective treatment. The increasingly large and diverse public databases of lung cancer gene expression constitute a rich source of candidate oncogenic drivers and therapeutic targets. To define novel targets for lung adenocarcinoma, we conducted a large-scale meta-analysis of genes specifically overexpressed in adenocarcinoma. We identified an 11-gene signature that was overexpressed consistently in adenocarcinoma specimens relative to normal lung tissue. Six genes in this signature were specifically overexpressed in adenocarcinoma relative to other subtypes of non-small cell lung cancer (NSCLC). Among these genes was the little studied protein tyrosine kinase PTK7. Immunohistochemical analysis confirmed that PTK7 is highly expressed in primary adenocarcinoma patient samples. RNA interference-mediated attenuation of PTK7 decreased cell viability and increased apoptosis in a subset of adenocarcinoma cell lines. Further, loss of PTK7 activated the MKK7-JNK stress response pathway and impaired tumor growth in xenotransplantation assays. Our work defines PTK7 as a highly and specifically expressed gene in adenocarcinoma and a potential therapeutic target in this subset of NSCLC.