Who will be readmitted? Evaluation of the laparoscopic hysterectomy readmission score in a gynecologic oncology population undergoing robotic-assisted hysterectomy.

OBJECTIVES: The laparoscopic hysterectomy readmission score (LHRS) was created to identify patients for whom same day discharge (SDD) after minimally invasive hysterectomy (MIH) may not be advisable and includes diabetes, chronic obstructive pulmonary disease, disseminated cancer, chronic steroid use, bleeding disorder, length of surgery, and any postoperative complication prior to discharge. We evaluated the performance of the score at predicting readmission in a gynecologic oncology population, and additionally sought to determine if any factors known prior to surgery could replace those that are not known until the time of surgery (operative time and postoperative complication). METHODS: This was a single-institution retrospective cohort study of women undergoing robotic hysterectomy by a gynecologic oncologist in 2018. Associations between pre-operative, operative and post-operative factors and 30-day readmission, SDD and postoperative complications were assessed using logistic regression. RESULTS: The 30-day readmission rate among the 423 women in the cohort was 4.5% and 1.9% in those undergoing SDD. Readmission rates by LHRS were: score 1 (4.9%), score 2 (7.8%), score 3 (13.6%), score 4 (16.7%). Patients with a LHRS of ≥3 had higher odds of readmission compared to those with a lower score (OR 4.20, p = 0.02). Infectious morbidity accounted for the majority of postoperative complications, emergency room visits and readmissions. We did not identify preoperative factors to replace the intra- and post-operative factors used in the score. CONCLUSIONS: The readmission rate following MIH is low, and a LHRS of ≥3 is associated with increased risk of readmission. Our findings support the applicability of the LHRS to a gynecologic oncology population; addressing risk factors for postoperative infection or closer follow up for patients with a LHRS ≥3 could reduce postoperative readmissions.

Determinants of Surgical Approach and Survival Among Women with Endometrial Carcinoma.

STUDY OBJECTIVE: To investigate determinants of surgical approach among women with endometrial carcinoma (EC) and associations between surgical approach and overall survival (OS). DESIGN: Retrospective cohort. SETTING: The National Cancer Database, 2010 to 2015. PATIENTS: A total of 140 470 patients with histologically confirmed EC who underwent hysterectomy. INTERVENTIONS: Patients were grouped according to surgical approach. MEASUREMENTS AND MAIN RESULTS: A total of 140 470 patients with EC were included. Robotic-assisted laparoscopy (RAL) was the most common surgical approach (48.8%), followed by laparotomy (33.6%) and traditional laparoscopy (17.6%). Use of RAL increased over the study period, and the percentages of cases managed by laparotomy decreased. Older women, those with insurance, residing in ZIP codes with lower proportions of individuals who did not graduate from high school, and those treated at noncommunity cancer programs were less likely to undergo laparotomy than RAL, and non-white women, those diagnosed with high-grade histology, and those with advanced-stage EC were more likely to undergo laparotomy than RAL. Compared with RAL, all other surgical approaches were associated with worse OS (laparotomy: hazard ratio 1.21; 95% confidence interval, 1.18-1.25; traditional laparoscopy: hazard ratio 1.06; 95% confidence interval, 1.02-1.09). Significant effect modification of the surgical approach and OS relationship according to age, race, histology, stage, and adjuvant treatment was observed. CONCLUSION: RAL increased in frequency over the study period and was associated with improved OS, supporting the continued use of RAL for EC management.

Recurrence Rates in Patients With Cervical Cancer Treated With Abdominal Versus Minimally Invasive Radical Hysterectomy: A Multi-Institutional Retrospective Review Study.

PURPOSE: To compare the disease-free survival (DFS) between open and minimally invasive radical hysterectomies (RH) performed in academic medical institutions. METHODS: Retrospective multi-institutional review of patients undergoing RH for stage IA1 (with lymphovascular invasion), IA2, and IB1 squamous, adenocarcinoma, or adenosquamous carcinoma between January 1, 2010 and December 31, 2017. RESULTS: Of 815 patients, open RH was performed in 255 cases (29.1%) and minimally invasive RH in 560 cases (70.9%). There were 19 (7.5%) recurrences in the open RH and 51 (9.1%) recurrences in the minimally invasive group (P = .43). Risk-adjusted analysis revealed that minimally invasive RH was independently associated with an increased hazard of recurrence (aHR, 1.88; 95% CI, 1.04 to 3.25). Other factors independently associated with an increased hazard of recurrence included tumor size, grade, and adjuvant radiation. Conization before surgery was associated with lower recurrence risk (aHR, 0.4; 95% CI, 0.23 to 0.71). There was no difference in OS in the unadjusted analysis (HR, 1.14; 95% CI, 0.61 to 2.11) or after risk adjustment (aHR, 1.01; 95% CI, 0.5 to 2.2). Of 264 patients with tumors ≤ 2 cm on final pathology (excluding those with no residual tumor on final pathology), 2/82 (2.4%) recurred in the open RH group and 16/182 (8.8%) in the minimally invasive RH group (P = .058). In propensity score matching analysis, 7/159 (4.4%) recurrences were noted in the open RH group and 18/156 (11.5%) in the minimally invasive RH group (P = .019). Survival analysis revealed an increased risk of recurrence in the minimally invasive group in propensity-matched cohort (HR, 2.83; 95% CI, 1.1 to 7.18). CONCLUSION: In this retrospective series, patients undergoing minimally invasive radical hysterectomy, including those with tumor size ≤ 2 cm on final pathology, had inferior DFS but not overall survival in the entire cohort.

Differences between first and fourth year medical students' interest in pursuing careers in academic medicine.

OBJECTIVE: The purpose of this pilot study was to assess the differences in the attitudes of first and fourth-year medical students regarding careers in academics. We also sought to identify any factors associated with an increased interest in academic medicine. METHODS: A cross-sectional study was conducted during October 2013 at the University of Louisville. All first and fourth year medical students were invited to complete an online survey utilizing a survey instrument developed through literature review. Demographic data and information about background experiences were collected in addition to participants' perceptions regarding careers in academia using a 5-point Likert scale. Participants were also queried about their current interest in a career in academics and the likelihood they would pursue academic medicine. RESULTS: Of the 330 potential participants, 140 (42.4%) agreed to participate. Overall, fourth-years reported a higher likelihood of pursuing an academic career than first-years. Research experience, publications, distinction track interest or involvement, and belief that a career in academics would reduce salary potential were positively correlated with reported likelihood of pursuing academic medicine. CONCLUSIONS: Findings from this pilot study demonstrate differences in interest in academic medicine between junior and senior medical students. Additionally, several factors were associated with a high likelihood of self-reported interest in academic. Based on these findings, efforts to increase medical students' interest in academic medicine careers could be supported by providing more research and teaching opportunities or distinction track options as a structured part of the medical school curriculum.