An Exploratory Study of Physician Decision-Making When Treating Uncontrolled COPD.

Purpose: Current guidelines recommend triple therapy maintenance inhalers for patients with recurrent exacerbations of chronic obstructive pulmonary disease (COPD); however, these maintenance therapies are underutilized. This study aimed to understand how physicians make COPD treatment decisions, and how combination maintenance therapies are utilized in a real-world setting. Patients and Methods: This exploratory, hypothesis-generating, non-interventional study used a cross-sectional online survey that was administered to a sample of practicing physicians in the United States. The survey included five fictitious vignettes detailing common symptoms experienced by patients with COPD. Survey questions included factors physicians consider in their decisions, and perceived barriers to prescribing treatments. Repeated measures multivariable analyses were conducted to evaluate how likely physicians were to switch to triple therapy versus no change to patient's current maintenance therapy or change to another maintenance therapy. Results: In total, 200 physicians completed the survey. Cost of treatment and patient access to treatment were reported as the most common barriers physicians consider in their prescribing decisions. Physicians were more likely to switch a patient's maintenance inhaler to triple therapy versus no change to maintenance inhaler if they considered the patient's history of new symptoms, insurance status, and clinical guidelines in their decision. Physicians with more experience treating patients with COPD, and those who treat more patients with COPD per week, were more likely to switch to triple therapy versus no change to maintenance inhaler. Conclusion: This study demonstrates the complexity of factors that can influence physicians' decisions when prescribing treatments for patients with COPD, including considerations of treatment cost, patient access and adherence, patient comorbidities, efficacy of current treatment, clinical guidelines, and provider's level of experience treating COPD. Further research may help elucidate the relative importance of the factors influencing physicians' decisions and inform what types of decision-support tools would be most beneficial.

Chronic obstructive pulmonary disease (COPD) symptoms can be effectively managed with maintenance therapies, which are treatments that are taken routinely to help improve symptoms. A combination of three different therapies (triple therapy maintenance) has been shown to be more effective than a combination of two different therapies (dual therapy maintenance) in patients with moderate-to-severe COPD. However, maintenance therapies, including triple therapy, are underutilized. This study aimed to explore how physicians make their treatment decisions for patients with COPD, and how combination maintenance therapies are utilized. To do so, we administered a survey to a sample of practicing physicians in the United States. The survey included five clinically based, fictitious profiles, or vignettes, of patients with COPD, with common symptoms and patient characteristics being described. Physicians were then asked to answer questions about what treatment they would prescribe for each patient, and any factors they considered when deciding on a treatment for a patient. We found that cost of treatment and patient access to treatment were the most common barriers that physicians considered when choosing a treatment. Physicians were also more likely to switch a patient's maintenance inhaler to a triple therapy maintenance inhaler if they considered the patient's history of new symptoms, patient's insurance status, and clinical guidelines when making their decisions. Our study shows that there are many complex factors that influence physicians' decisions when deciding on a treatment for patients with COPD.

Credentialing and Patient Safety in Robotic Gynecologic Surgery: Changes over the Last Eight Years.

Background and Objectives: Robotic gynecologic surgery has outpaced data showing risks and benefits related to cost, quality outcomes, and patient safety. We aimed to assess how credentialing standards and perceptions of safe use of robotic gynecologic surgery have changed over time. Methods: An anonymous, online survey was distributed in 2013 and in 2021 to attending surgeons and trainees in accredited obstetrics and gynecology residency programs. Results: There were 367 respondents; 265 in 2013 and 102 in 2021. There was a significant increase in robotic platform use from 2013 to 2021. Percentage of respondents who ever having performed a robotic case increased from 48% to 79% and those who performed > 50 cases increased from 25% to 59%. In 2021, a greater percentage of attending physicians reported having formalized protocol for obtaining robotic credentials (93% vs 70%, p = 0.03) and maintaining credentialing (90% vs 27%, p < 0.01). At both time points, most attendings reported requiring proctoring for 1 - 5 cases before independent use. Opinions on the number of cases needed for surgical independence changed from 2013 to 2021. There was an increase in respondents who believed > 20 cases were required (from 58% to 93% of trainees and 29% to 70% of attendings). In 2021, trainees were less likely to report their attendings lacked the skills to safely perform robotic surgery (25% to 6%, p < 0.01). Discussion: Greater experience with robotic platforms and expansion of credentialing processes over time correlated with improved confidence in surgeon skills. Further work is needed to evaluate if current credentialing procedures are sufficient.

Racial Disparities in Hysterectomy Route for Benign Disease: Examining Trends and Perioperative Complications from 2007 to 2018 Using the NSQIP Database.

STUDY OBJECTIVE: To examine national trends among race and ethnicity and route of benign hysterectomy from 2007 to 2018. DESIGN: This is a retrospective analysis of the prospective National Surgical Quality Improvement Program cohort program. SETTING: This study included data from the National Surgical Quality Improvement Program database including data from the 2014 to 2018 targeted hysterectomy files. PATIENTS: Adult patients undergoing hysterectomy. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: Current Procedural Terminology codes identified women undergoing benign hysterectomy and perioperative data including race and ethnicity were obtained. To determine relative trends in hysterectomy among race and ethnicity cohorts (White, Black, Hispanic), we calculated the proportion of each procedure performed annually within each race and ethnicity group and compared it across groups. From 2007 to 2018, 269 794 hysterectomies were collected (190 154 White, 45 756 Black, and 33 884 Hispanic). From 2007 to 2018, rates of laparoscopic hysterectomy increased in all cohorts (30.2%-71.6% for White, 23.9%-58.5% for Black, 19.9%-64.0% for Hispanic; ptrend <0.01 for all). For each year from 2007 to 2018, the proportion of women undergoing open abdominal hysterectomy remained twice as high in Black Women compared with White women (33.1%-14.4%, p <.01). Data from the 2014 to 2018 targeted files showed Black and Hispanic women undergoing benign hysterectomy were generally younger, had larger uteri, were more likely to be current smokers, have diabetes and/or hypertension, have higher body mass index, and have undergone previous pelvic surgery (p ≤.01 for all). CONCLUSION: Compared with White women, Black and Hispanic women are less likely to undergo benign hysterectomy via a minimally invasive approach. Although larger uteri and comorbid conditions may attribute to higher rates of open abdominal hysterectomy, the higher prevalence of abdominal hysterectomy among younger Black and Hispanic women highlights potential racial disparities in women's health and access to care.

Ergonomic Assessment of Surgeon Characteristics and Laparoscopic Device Strain in Gynecologic Surgery.

STUDY OBJECTIVE: To evaluate whether surgeon characteristics, including sex and hand size, were associated with grip strength decline with laparoscopic advanced energy devices. DESIGN: Prospective cohort study. SETTING: Ergonomic simulation at an academic tertiary care site and the Society of Gynecologic Surgeons 47th Annual Meeting. PATIENTS: Thirty-eight participants (19 women and 19 men) were recruited. INTERVENTIONS: Surgeon anthropometric measurements were collected. Each participant completed a 120-second trial of maximum voluntary effort with 3 laparoscopic advanced energy devices (LigaSure, HALO PKS, and ENSEAL). Grip strength was measured using a handheld dynamometer. Subjects completed the NASA Raw Task Load Index scale after each device trial. Grip strengths and ergonomic workload scores were compared using Student t tests and Wilcoxon rank sum tests where appropriate. Univariate and multivariate models analyzed hand size and ergonomic workload. MEASUREMENTS AND MAIN RESULTS: Women had lower baseline grip strength (288 vs 451 N) than men, as did participants with glove size <7 compared with ≥7 (231 vs 397 N). Normalized grip strength was not associated with surgeon sex (p = .08), whereas it was significantly associated with surgeon glove size (p <.01). Grip strength decline was significantly greater for smaller compared to larger handed surgeons for LigaSure (p = .02) and HALO PKS devices (p <.01). The ergonomic workload of device use was significantly greater for smaller compared to larger handed surgeons (p <.01). Surgeon handspan significantly predicted grip strength decline with device use, even after accounting for potential confounders (R2 = .23, ß = .8, p <.01). CONCLUSION: Surgeons with smaller hand size experienced a greater grip strength decline and greater ergonomic workload during repetitive laparoscopic device use. No relationship was found between surgeon sex and grip strength decline or ergonomic workload. Laparoscopic device type was also identified as a significant main effect contributing to grip strength decline. These findings point toward ergonomic strain stemming from an improper fit between the laparoscopic device and the surgeon's hand during device use.

Survival disparities for childhood cancers exist when defined by race/ethnicity and sex.

BACKGROUND: There are documented racial/ethnic and sex differences in pediatric cancer survival; however, it is unknown whether pediatric cancer survival disparities exist when race/ethnicity and sex are considered jointly. METHODS: Using SEER data (2000-2017), we estimated survival differences by race/ethnicity within sexes and by sex within race/ethnicity (White, Black, Hispanic, and Asian/Pacific Islander [API]) for 17 cancers in children aged (0-19 years). Kaplan-Meier curves (Log-Rank p-values) were assessed. Cox regression was used to estimate hazards ratios (HRs) and 95 % confidence intervals (95 % CIs) between race/ethnicity/sex and cancer. RESULTS: We included 51,759 cases (53.6 % male, 51.9 % White). There were statistically significant differences in 18-year survival by race/ethnicity-sex for 12/17 cancers. Within sexes, minorities had an increased risk of death compared to Whites for various cancers including acute lymphoblastic leukemia (ALL) (females: HispanicHR: 1.78, 95 % CI: 1.52, 2.10; BlackHR: 1.70, 95 % CI: 1.29, 2.24; APIHR: 1.42, 95 % CI: 1.07-1.89; males ALL: HispanicHR: 1.58, 95 % CI: 1.39,1.79; BlackHR: 1.57, 95 % CI: 1.26,1,95; API-HR: 1.39, 95 % CI: 1.11, 1.75) and astrocytoma (females: HispanicHR: 1.49, 95 % CI: 1.19, 1.85; BlackHR: 1.67, 95 % CI: 1.29, 2.17; API-HR: 1.51, 95 % CI: 1.05, 2.15; males: HispanicHR:1.27, 95 % CI: 1.04, 1.56; BlackHR: 1.69, 95 % CI: 1.32, 2.17; API-HR: 1.92, 95 % CI: 1.43, 2.58). Sex differences in survival within racial/ethnic groups were observed for White (ALL, osteosarcoma), Hispanic (medulloblastoma), and API (Primitive Neuro-Ectodermal Tumor [PNET]) children. CONCLUSIONS: There are disparities in survival by both race/ethnicity and sex highlighting the societal and biologic influences these features have on survival in children with cancer.

Patient Characteristics Associated with Access to Minimally Invasive Gynecologic Surgery: Changes during the COVID-19 Pandemic.

STUDY OBJECTIVE: To evaluate patient characteristics that affect access to minimally invasive gynecologic surgery (MIGS) subspecialty care and identify changes during the coronavirus disease 2019 pandemic. DESIGN: Retrospective cohort study of patients referred to MIGS from 2014 to 2016 (historic cohort) compared with those referred to MIGS in 2020 (pandemic cohort). Primary outcome was the interval between referral and first appointment. SETTING: Single-institution academic MIGS division. PATIENTS: Historic cohort (n = 1082) and pandemic cohort (n = 770). INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: Demographics and socioeconomic variables (race, ethnicity, language, insurance, employment, and socioeconomic factors by census tract) and distance from hospital were compared between historic and pandemic cohorts with respect to referral interval using the chi-square, Fisher exact tests, and logistic regression. After adjusting for referral indication, being unemployed and living in an area with less population density, less education, and higher percentage of poverty were associated with a referral interval >30 days in the historic cohort. In the pandemic cohort, only unemployment persisted as a covariate associated with prolonged referral interval and new associated variables were primary language other than English (odds ratio, 3.20; 95% confidence interval [CI], 1.60-6.40) and "other" race (odds ratio, 2.22; 95% CI, 1.34-3.68). The odds of waiting >30 days increased by 6% with the addition of 1 demographic risk factor (95% CI, 1.01-1.10) and by 17% for 3 risk factors (95% CI, 1.03-1.34) in the historic cohort whereas no significant intersectionality was identified in the pandemic cohort. Average referral intervals were significantly shorter during the pandemic (31 vs 50 days, p <.01). Telemedicine appointments had a significantly shorter referral interval than in-person appointments (27 vs 47 days, p <.01). Of patients using telemedicine, a greater proportion were non-Hispanic, English speaking, employed, privately insured, and lived further from the hospital (p <.05). CONCLUSION: Time from referral to first appointment at a tertiary-care MIGS practice during the coronavirus disease 2019 pandemic was shorter than that before the pandemic, likely owing to the adoption of telemedicine. Differences in socioeconomic and demographic factors suggest that telemedicine improved access to care and decreased access disparities for many populations, but not for non-English-speaking patients.

Length of Stay and 30-Day Postoperative Complications Following Minimally Invasive Apical Prolapse Repair.

IMPORTANCE: Data on the correlation between length of stay and postoperative complications following urogynecologic surgery are limited. OBJECTIVES: The objective of this study was to use a nationwide database to examine the correlation between length of stay and 30-day postoperative complications following minimally invasive apical prolapse repair. STUDY DESIGN: This retrospective cohort study included women in the American College of Surgeons National Surgical Quality Improvement Program database from 2008 to 2018 who underwent laparoscopic/robotic sacrocolpopexy or uterosacral/sacrospinous repair and were discharged on postoperative day 0 (POD0) or 1 (POD1). The primary outcome was 30-day postoperative complication rate. RESULTS: Of the 28,269 women discharged home on POD0/1, 12,663 (45%) underwent laparoscopic/robotic sacrocolpopexy, and 15,606 (55%) underwent uterosacral/sacrospinous repair. Women discharged on POD0 were less likely to be White, less likely to have diabetes or hypertension, had lower mean body mass index, and were less likely to have undergone a hysterectomy ( P < 0.05 for all). Within 30 days of surgery, 7% had a postoperative complication, and 3% had a major complication. Women discharged on POD0 had a lower risk of any complication or any major complication. The most common complication, urinary tract infection, was lower in women discharged on POD0 (3% vs 4%, P < 0.01). Women discharged home on the same day had a higher risk of superficial surgical site infection after undergoing laparoscopic/robotic sacrocolpopexy (1.3% vs 0.5%, P < 0.01) and a higher risk of myocardial infarction/cardiac arrest after uterosacral/sacrospinous repair (0.2% vs 0%, P < 0.04). CONCLUSIONS: In women undergoing minimally invasive reconstructive apical repair, discharge on POD0 is correlated with similar or better (lower) 30-day postoperative complication rates compared with women discharged on POD1.

Investigation of the Association between Surgeon Sex and Laparoscopic Device Ergonomic Strain in Gynecologic Surgery.

STUDY OBJECTIVE: To assess whether female compared with male sex is associated with greater ergonomic strain with the use of 4 advanced energy laparoscopic devices (LigaSure, HALO PKS, ENSEAL, and Harmonic scalpel). DESIGN: Online survey distributed by e-mail using the REDCap platform (Vanderbilt University). All responses were anonymous. SETTING: Nationwide survey in the United States. PARTICIPANTS: Gynecologic surgeons were surveyed through the Society of Gynecologic Surgeons listserv and 4 obstetrics and gynecology departmental listservs. INTERVENTIONS: The survey was distributed between May 1, 2020, and November 1, 2020. The primary outcome was the presence of physical complaints owing to laparoscopic devices. Descriptive statistics compared surgeon characteristics and ergonomic symptoms. Logistic regression was performed, adjusted for surgeon characteristics. MEASUREMENTS AND MAIN RESULTS: The response rate was 39%, comprising 149 women (78%) and 41 men (22%). Women compared with men had a significantly younger age (mean, 34 vs 44 years; p <.01), had smaller glove size (mean, 6.5 vs 7.5; p <.01), had shorter height (median, 66 vs 71 inches; p <.01), and were less frequently in practice for >10 years (19% vs 49%; p <.01). Women significantly more often reported physical complaints related to the use of laparoscopic devices (79% vs 41%; p <.01). Women reported that all devices had too large a fit for appropriate use (p <.01). Women were found to have 5.37 times the odds of physical complaints attributed to the use of laparoscopic instruments (crude oods ratio, 5.37; 95% confidence interval, 2.56-11.25); with adjustment for glove size, age, and laparoscopic case volume and duration, this was no longer significant (adjusted odds ratio, 2.02; 95% confidence interval, 0.59-6.93). CONCLUSION: Women significantly more often report physical complaints and inappropriate fit of the LigaSure, HALO PKS, ENSEAL, and Harmonic scalpel. Female sex is associated with 5-fold greater odds of physical complaints with laparoscopic device use. Further investigation of the surgeon factors underlying device-related strain is a critical next step to understanding and reducing surgeon ergonomic injury.

Parental Age and Childhood Lymphoma and Solid Tumor Risk: A Literature Review and Meta-Analysis.

BACKGROUND: Although advanced parental age has been definitively linked to pediatric acute lymphoblastic leukemia, studies of parental age and pediatric solid tumors have not reached firm conclusions. This analysis aimed to elucidate the relationship between parental age and pediatric solid tumors through meta-analysis of existing studies based in population registries. METHODS: We searched Medline (PubMed) and Embase for registry-based studies of parental age and solid tumors through March 2022. We performed random-effects meta-analysis to estimate pooled effects and 95% confidence intervals (CIs). All statistical tests were 2-sided. RESULTS: A total of 15 studies covering 10 childhood solid tumor types (30 323 cases and 3 499 934 controls) were included in this analysis. A 5-year increase in maternal age was associated with an increased risk of combined central nervous system tumors (odds ratio [OR] = 1.07, 95% CI = 1.04 to 1.10), ependymoma (OR = 1.19, 95% CI = 1.09 to 1.31), astrocytoma (OR = 1.10, 95% CI = 1.05 to 1.15), rhabdomyosarcoma (OR = 1.14, 95% CI = 1.03 to 1.25), and germ cell tumors (OR = 1.06, 95% CI = 1.00 to 1.12). A 5-year increase in paternal age was associated with an increased risk of non-Hodgkin lymphoma (OR = 1.06, 95% CI = 1.00 to 1.12). CONCLUSIONS: This meta-analysis of registry-based analyses of parental age and childhood cancer supports the association between older maternal age and certain childhood solid cancers. There is also some evidence that paternal age may be associated with certain cancers such as non-Hodgkin lymphoma. However, as maternal and paternal age are highly correlated, disentangling potential independent causal effects of either factor will require large studies with extensive data on potential confounders.

Global variation in young adult central nervous system tumor incidence by region, age, and sex from 1988 to 2012.

BACKGROUND: Central nervous system (CNS) tumors result in tremendous morbidity and mortality. Incidence of CNS tumors in young adults is less studied. It is unknown how young adult CNS tumor incidence has changed globally in recent decades. METHODS: We used Cancer Incidence in Five Continents (CI5) data (1988-2012) to estimate incidence rates (IR), average annual percent change in incidence (AAPC; 95% confidence intervals [95% CI]), and male-to-female incidence rate ratios (IRR; 95% CI) by six histologies and age at diagnosis (20-29years, 30-39years). Tumors were classified as astrocytic, medulloblastoma, ependymal, oligodendroglial, meninges, and other embryonal. Geographic regions were defined using the United Nations Statistics Division geoscheme. RESULTS: There were 78,240 CNS tumor cases included. 20-29-year-old (yo) rates were lower than 30-39 yo in most regions for astrocytic, oligodendroglial and ependymal tumors. Globally, astrocytic tumor incidence decreased (20-29 yo AAPC: - 0.70; 95% CI: - 1.32, - 0.08) while incidence increased for oligodendroglial (20-29 yo AAPC: 3.03; 95% CI: 1.57-4.51; 30-39 yo AAPC: 2.67; 95% CI: 0.79-4.58), ependymal (20-29 yo AAPC: 1.16; 95% CI: 0.31-2.03; 30-39 yo AAPC: 2.29; 95% CI: 1.14-3.46), medulloblastoma (30-39 yo AAPC: 0.6; 95% CI: 0.04-1.24) and tumors of the meninges (20-29 yo AAPC: 1.55; 95% CI: 0.04-3.07). There was a 20-40% male incidence excess in all histologies except for meninge tumors (30-39 yo IRR: 0.71; 95% CI: 0.61, 0.84). CONCLUSIONS: Incidence of oligodendroglial and ependymal tumors increased globally in 20-39 yo suggesting better diagnoses or changes in risk factors. Males had a higher incidence of CNS tumors for most tumors studied and in most regions.

Minority children experience a higher risk of death from many central nervous system tumor types even after accounting for treatment received: A National Cancer Database analysis.

BACKGROUND: Brain tumors are the leading cause of death from disease in children. Racial/ethnic minority children have poorer outcomes than White children; however, it is not clear whether this association is mediated by treatment received. METHODS: Children (aged 0-19 years) diagnosed with brain tumors in the National Cancer Database (2004-2016) were identified. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) between race/ethnicity (Black, Hispanic, Asian/Pacific Islander, American Indian/Alaska Native, or White [reference]) and death. An inverse odds weighted mediation analysis was performed with treatment received as the mediator. RESULTS: Among 22,469 cases, White children (69% of the sample) had significantly better overall 12.5-year survival (P < .01). Black children (13% of the sample) and Hispanic children (14% of the sample) had an increased risk of death overall and for glioblastoma and oligodendroglioma. Compared with Whites, Asian/Pacific Islander children had a higher risk of death from choroid plexus tumors and a lower risk of death from medulloblastoma. There were no statistically significant meditating effects by treatment received, although the estimate was borderline in Hispanic children (indirect HR, 1.08; 95% CI, 0.99-1.18). A treatment-independent association between race/ethnicity and death remained for Hispanic children (direct HR, 1.18; 95% CI, 1.04-1.33) and Black children (direct HR, 1.28; 95% CI, 1.13-1.45). If deaths in minorities had equaled those in White children, 5% fewer total deaths and 15% fewer minority deaths would have occurred. CONCLUSIONS: Survival disparities exist in pediatric brain tumors and are largely independent of treatment received, but other mechanisms linked to race/ethnicity remain important.

Young adult males have worse survival than females that is largely independent of treatment received for many types of central nervous system tumors: A National Cancer Database analysis.

BACKGROUND: Central nervous system (CNS) tumors rank among the top 5 cancers diagnosed in young adults aged 20 to 39 years at diagnosis and show a clear male excess in incidence. It is unknown whether sex differences in survival persist across histologic types and depend on the treatment received. METHODS: From the National Cancer Database (2004-2016), young adults (aged 20-39 years) who had been diagnosed with CNS tumors were identified. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated as measures of association between sex and death via Cox regression. An inverse odds weighting mediation analysis was performed with treatment received as a mediator. RESULTS: There were 47,560 cases (47% male). Males had worse overall survival than females for 9 of 16 histologic types, including diffuse astrocytoma, glioblastoma, and meningioma (all P < .05). Males had an increased risk of death after a brain tumor diagnosis overall (HR, 1.47; 95% CI, 1.41-1.53) and for 8 histologies. There was a significant association between male sex and death overall that was mediated by treatment received (indirect-effect HR, 1.17; 95% CI, 1.15-1.18), but no single histology had a significant indirect effect. All histologies examined in mediation analyses had significant direct effects for sex. The excess mortality due to sex was 20% for all CNS tumors combined and 34% among males with CNS tumors. CONCLUSIONS: Overall, treatment received may mediate a portion of the association between sex and death after a CNS tumor, but sex itself appears to be a stronger risk factor for death in this study.

Disparities in Complications After Prolapse Repair and Sling Procedures: Trends From 2010-2018.

OBJECTIVE: To compare 30-day complication rates after prolapse repair and sling procedures across racial/ethnic groups, and evaluate trends over time. METHODS: We identified female patients in a national outcomes-based database who underwent prolapse repair and/or sling procedures between January 1, 2010 and December 31, 2018, stratified by race and ethnicity, and compared 30-day postoperative complication rates. Multivariable logistic regression adjusted for confounders. Trends in complication rates over time were evaluated using a test for trend (p-trend). RESULTS: We identified 70,540 prolapse repairs and 23,968 sling procedures. Following prolapse repairs, Black women had the highest complication rates (11%, vs 8% for Hispanic and 9% for both White and Other race/ethnicity women, P <0.01). Following sling procedures, there were few differences in complication rates between groups. After adjustments, Black women still experienced higher odds of any complication (aOR 1.15, 95% CI 1.03-1.29), particularly a vascular complication (venous thromboembolism or transfusion) (aOR 2.50, 95% CI 2.05-3.04) following prolapse repair procedures. Hispanic women had higher odds of vascular complications after prolapse repair (aOR 1.47, 95% CI 1.23-1.76) and slings (aOR 2.40, 95% CI 1.53-3.76). Trends from 2010-2018 showed a decrease in vascular complication rates among non-Black women after prolapse repairs, but rates among Black women did not decrease. CONCLUSION: Black women have higher odds of experiencing postoperative complications after prolapse repair procedures, particularly vascular complications. Vascular complication rates after prolapse repair decreased over time for all racial/ethnic groups except Black women. Hispanic women have higher odds of vascular complications after prolapse repair and slings than other racial/ethnic groups.

Racial/ethnic and sex differences in young adult malignant brain tumor incidence by histologic type.

BACKGROUND: Brain tumors are among the top four cancers in young adults. We assessed important windows of tumor development and examined the interplay of race/ethnicity, age, and sex in young adult brain tumor incidence. METHODS: Using SEER 18 data (2000-2017), incidence rates were estimated by Poisson regression in individuals aged 20-39 years at diagnosis. Incidence rate ratios (IRR) and 95% confidence intervals (95% CI) were estimated by race/ethnicity, sex and age for 12 malignant histologies. RESULTS: White incidence for all histologies was higher (White vs. Black IRR: 2.09, 95% CI: 1.94, 2.24; White vs Asian Pacific Islander IRR: 1.88, 95% CI: 1.75, 2.03; White vs Hispanic IRR: 1.70, 95% CI: 1.62, 1.78; White vs American Indian IRR: 1.40, 95% CI: 1.14, 1.73). Minority groups had higher lymphoma incidence (White vs Black IRR: 0.32, 95% CI: 0.25, 0.40, White vs Hispanic HR: 0.55, 95% CI: 0.44, 0.68). Males had higher incidence than females for all histologies (IRR: 1.36, 95% CI: 1.31, 1.41). Male rates were highest for lymphoma (male-to-female [MF] IRR: 2.00, 95% CI: 1.65, 2.42) and glioblastoma (MF IRR: 1.61, 95% CI: 1.48, 1.75). The male excess in incidence was similar by race/ethnicity and increased with age (20-24-year-old IRR: 1.18, 95% CI: 1.07, 1.29; 35-39-year-old IRR: 1.44, 95% CI: 1.35, 1.54). CONCLUSIONS: A White race and male incidence excess was observed among brain tumors. IMPACT: The male excess was similar by race/ethnicity and increased with age suggesting male sex may be an intrinsic risk factor for brain tumor development.

Association of Preoperative Depression and Anxiety With Long-term Opioid Use After Hysterectomy for Benign Indications.

OBJECTIVE: To assess whether preoperative depression or anxiety is associated with increased risk of long-term, postoperative opioid use after hysterectomy among women who are opioid-naïve. METHODS: We conducted an observational cohort study of 289,233 opioid-naïve adult women (18 years or older) undergoing hysterectomy for benign indications from 2010 to 2017 using IBM MarketScan databases. Opioid use and refills in the 180 days after surgery and preoperative depression and anxiety were assessed. Secondary outcomes included 30-day incidence of emergency department visits, readmission, and 180-day incidence of opioid complications. The association of depression and anxiety were compared using inverse-probability of treatment weighted log-binomial and proportional Cox regression. RESULTS: Twenty-one percent of women had preoperative depression or anxiety, and 82% of the entire cohort had a perioperative opioid fill (16% before surgery, 66% after surgery). Although perioperative opioid fills were relatively similar across the two groups (risk ratio [RR] 1.07, 95% CI 1.06-1.07), women with depression or anxiety were significantly more likely to have a postoperative opioid fill at every studied time period (RRs 1.44-1.50). Differences were greater when restricted to persistent use (RRs 1.49-2.61). Although opioid complications were rare, women with depression were substantially more likely to be diagnosed with opioid dependence (hazard ratio [HR] 5.54, 95% CI 4.12-7.44), and opioid use disorder (HR 4.20, 95% CI 1.97-8.96). CONCLUSION: Perioperative opioid fills are common after hysterectomy. Women with preoperative anxiety and depression are more likely to experience persistent use and opioid-related complications.

Myofascial Pain in Hysterectomy Patients.

STUDY OBJECTIVE: To assess the prevalence of myofascial pain in women undergoing uncomplicated, minimally invasive hysterectomy for chronic pelvic pain, to identify clinical and demographic factors associated with preoperative myofascial pain, and examine the association between myofascial pain and postoperative pain in hysterectomy patients. DESIGN: A retrospective cohort study. SETTING: A tertiary care teaching hospital. PATIENTS: A total of 353 adult women who underwent uncomplicated, minimally invasive hysterectomy between January 2014 and 2016. INTERVENTIONS: All women underwent a preoperative pelvic floor examination. Myofascial pain was diagnosed as tenderness and reproduction of pain symptoms in at least 2 of 6 pelvic floor muscles. Demographics, comorbidities, and intraoperative characteristics were compared between women with and without preoperative myofascial pain. MEASUREMENTS AND MAIN RESULTS: Of the 353 women who underwent hysterectomy, the prevalence of myofascial pain was 42.7% (86.0% in patients with chronic pelvic pain [CPP] compared with 13.7% without CPP). Women with myofascial pain were more likely younger, Caucasian, sexually active, and with comorbid pain conditions. Patients with myofascial pain used a greater number of adjuvant pain medications before surgery including opiates (29.5%) but were only half as likely to use muscle relaxants (12.1%) for preoperative pain control. Contrastingly, in women without myofascial pain before surgery, controlled substances such as opiates (8%, p <.01) and benzodiazepines (3%, p <.01) were used at a three- fold lower frequency. Postoperative pain score was higher in patients with myofascial pain, with 37% reporting a visual analog scale score greater than 5 at the routine postoperative visit compared with only 1% of patients without myofascial pain. CONCLUSION: Myofascial pelvic pain must be considered in the evaluation of CPP, especially in surgical candidates. Women with myofascial pelvic use a greater amount of pain medication preoperatively and have higher pain scores postoperatively. Identification of these high-risk patients before surgery may improve pre and postoperative pain management with a multimodal therapy approach.

Effect of length of surgery on the incidence of venous thromboembolism after benign hysterectomy.

BACKGROUND: Venous thromboembolism is a leading cause of morbidity and mortality postoperatively. The current venous thromboembolism risk assessment tools have not been validated in gynecologic patients. Most patients undergoing hysterectomy for benign indications will receive mechanical or pharmacologic prophylaxis based on preoperative risk assessment. However, current guidelines do not incorporate newer data that indicate additional risk of venous thromboembolism with prolonged surgery times or mode of hysterectomy. OBJECTIVE: This study aimed to determine the effect of length of surgery, or operative time, on the risk of venous thromboembolism within 30 days after hysterectomy and determine whether differences in the effect of operative time exist across age, body mass index, and surgical approach. STUDY DESIGN: We performed a secondary analysis of prospectively collected surgical quality improvement data using the American College of Surgeons National Surgical Quality Improvement Program database, which contains demographic and perioperative information and 30-day postoperative outcomes from >500 hospitals, and targeted data files including procedure-specific risk factors and outcomes for a subset of hospitals. We analyzed patients undergoing abdominal, vaginal, or laparoscopic hysterectomy for benign conditions from 2014 to 2017, identified by the Current Procedural Terminology codes. We excluded patients with cancer, patients whose surgery was not performed by a gynecologist, patients who were not in the targeted files, and patients with missing operative time or with an operative time of <30 minutes. Patients were compared with respect to the incidence of venous thromboembolism and operative time, stratified by age, body mass index, and surgical approach. Multivariable logistic regression was performed; operative time was treated as a continuous, linear variable. RESULTS: A total of 70,606 patients were included. The 30-day venous thromboembolism incidence was 0.4% (n=259). Patients with venous thromboembolism were more likely to be obese, have inpatient procedures, and had, on average, greater uterine weight. Hysterectomy approach was vaginal in 11,641 patients, laparoscopic in 41,557 patients, and abdominal in 17,408 patients. After adjustment, for each 60-minute increase in operative time, there was a 35% increase in the odds of venous thromboembolism (adjusted odds ratio, 1.35; 95% confidence interval, 1.25-1.45). Stratified by surgical approach, the odds of venous thromboembolism per 60-minute increase in operative time was greatest among abdominal hysterectomy (adjusted odds ratio, 1.49; 95% confidence interval, 1.35-1.65) compared with laparoscopic hysterectomy (adjusted odds ratio, 1.20; 95% confidence interval, 1.05-1.38) and vaginal hysterectomy (adjusted odds ratio, 1.27; 95% confidence interval, 0.97-1.66) (P=.01). Increasing body mass index and increasing age did not modify the impact of operative time on venous thromboembolism incidence (P=.66 and P=.58, respectively). CONCLUSION: Every 60-minute increase in operative time was independently associated with a 35% increased odds of venous thromboembolism within 30 days of hysterectomy, and this risk was cumulative. Minimally invasive hysterectomy had lower odds of venous thromboembolism than abdominal hysterectomy across all time points.

Development and validation of a NanoString BASE47 bladder cancer gene classifier.

BACKGROUND: Recent molecular characterization of urothelial cancer (UC) has suggested potential pathways in which to direct treatment, leading to a host of targeted therapies in development for UC. In parallel, gene expression profiling has demonstrated that high-grade UC is a heterogeneous disease. Prognostic basal-like and luminal-like subtypes have been identified and an accurate transcriptome BASE47 classifier has been developed. However, these phenotypes cannot be broadly investigated due to the lack of a clinically viable diagnostic assay. We sought to develop and evaluate a diagnostic classifier of UC subtype with the goal of accurate classification from clinically available specimens. METHODS: Tumor samples from 52 patients with high-grade UC were profiled for BASE47 genes concurrently by RNAseq as well as NanoString. After design and technical validation of a BASE47 NanoString probeset, results from the RNAseq and NanoString were used to translate diagnostic criteria to the Nanostring platform. Evaluation of repeatability and accuracy was performed to derive a final Nanostring based classifier. Diagnostic classification resulting from the NanoString BASE47 classifier was validated on an independent dataset (n = 30). The training and validation datasets accurately classified 87% and 93% of samples, respectively. RESULTS: Here we have derived a NanoString-platform BASE47 classifier that accurately predicts basal-like and luminal-like subtypes in high grade urothelial cancer. We have further validated our new NanoString BASE47 classifier on an independent dataset and confirmed high accuracy when compared with our original Transcriptome BASE47 classifier. CONCLUSIONS: The NanoString BASE47 classifier provides a faster turnaround time, a lower cost per sample to process, and maintains the accuracy of the original subtype classifier for better clinical implementation.

Beyond Diversity: Focusing on and Enhancing Inclusion in the Society for Epidemiologic Research.

Increasing diversity and inclusion among organizational membership has become a focus for many professional societies, including the Society for Epidemiologic Research (SER). In this issue of the Journal, DeVilbiss et al. (Am J Epidemiol. 2020:189(10):998-1010) assessed dimensions of diversity and inclusion within SER to provide baseline data for future evaluations of Society initiatives. In our response, we note that diversity in SER appears strong but there is lag with regard to inclusion. We also highlight some of the major weaknesses of this study that hinder efforts to accurately evaluate inclusion within SER. There is a need to more concretely define inclusion and think broadly about how measures of inclusion should be operationalized in future surveys. Additional limitations of the study include its limited generalizability to the wider SER membership and the lack of questions about barriers to inclusion in SER activities. We conclude with recommendations for SER and other professional societies based on prior literature evaluating successful diversity and inclusion efforts. We also propose a conceptual model to assist with operationalizing and directing future analyses of inclusion measures. It is essential that SER move beyond efforts around diversity to focus on measuring and enhancing inclusion.