Active shooter in emergency departments in Guanajuato State, Mexico.

Mass violence events, especially in healthcare settings, have devastating consequences and long-lasting effects on the victims and the community. The rate of violent events in Mexico, especially in hospital settings, has increased since 2006, but has become more evident in 2018. Guanajuato State, located in central Mexico, is among the states most affected by the wave of violence, especially active shooter events. The year 2019 had the highest number of incidents. Therefore, the Silver Code and the components of Safe Hospitals, in accordance with the Hartford consensus and PAHO guidelines, were implemented in the hospitals of the Institute of Public Health of the State of Guanajuato, with a focus on the actions of healthcare personnel to prevent collateral damage. Although subsequently there were still fatalities and injuries in the events involving active shooters in the hospitals, there were no casualties among healthcare personnel, according to data from the Institute of Public Health, Guanajuato State. This paper presents information from the data from General Directorate of Epidemiology to describe the hospital mass violence situation in the State of Guanajuato, Mexico and recounts the step taken to effectively manage and prevent these situations moving forward. Specific recommendations based on international consensus and our experience provided include increasing the level of security checks for people entering the hospital premises, training healthcare personnel on violence-related preparedness and improving management of active shooter events consistent with published evidence, to reduce the possibility of casualties.

Qualitative Interview Study of Gynecologic Oncologist Utilization of Recommended Same-Day Discharge Following Minimally Invasive Hysterectomy.

Recent investigations have supported the safety and benefits of discharging women on the same day following a minimally invasive hysterectomy (MIH) for both benign and malignant indications. Not all eligible candidates for same-day discharge (SDD) are discharged the same day, and patients undergoing an MIH for malignant indications have decreased the odds of receiving SDD despite established safety. The objective of this study was to use qualitative interviews to explore physician decision making regarding SDD after an MIH for malignant indications. Six qualitative interviews of gynecologic oncologists were analyzed using recurrent theme analysis for distinct themes in physician decision making regarding SDD. Results suggest that physician-perceived barriers to SDD include patient health characteristics, patient social characteristics, and hospital-system factors. Cited factors influencing SDD include patient travel, social support, practice setting (urban vs. rural) and staff comfort with the recommendation. Obstructive sleep apnea and post-surgical oxygenation appear to be a recurring reason for unplanned admission. The utilization of SDD after an MIH in the gynecologic oncology patient population is influenced by patient, physician, and system factors. Addressing the physician's perceived barriers to SDD and catering recommendations to the gynecologic oncology population may increase utilization.

Endometrial cancer risk factors in Singapore Chinese: a prospective cohort study.

PURPOSE: The incidence of Endometrial cancer (EC) has grown substantially in Asia over the past decade. However, few studies have addressed risk factors associated with EC incidence in Asian populations. We explored the association between reproductive and dietary risk factors and EC in the Singapore Chinese Health Study (SCHS), one of the largest prospective cohort studies in Asia. METHODS: Data were collected from 34,028 ethnically Chinese women aged 45-74 residing in Singapore, enrolled between 1993 and 1998. Baseline demographic, dietary, and reproductive factors were collected via structured questionnaires. EC cases were identified from the Singapore Cancer Registry (n = 126) up to 2010. Cox proportional hazard models were used to analyze association between EC and personal, reproductive, and dietary factors. RESULTS: The incidence of EC in this population was 28.8 per 100,000 person-years. Regardless of menopausal status, obesity (BMI ≥ 27) was associated with increased EC risk (HR = 2.22, 95% CI 1.26-3.92), while later age at menarche was associated with decreased EC risk (HR = 0.14, 95% CI 0.04-0.46). In postmenopausal women, later age at menopause was associated with increased EC risk (HR = 2.82, 95% CI 1.24-6.43). Lifestyle and nutritional factors were not associated with risk of EC in this cohort. CONCLUSIONS: This study is one of the largest cohort studies exploring EC risk factors in Asian populations. Our study identified similarities in EC risk factors for European and Asian populations, which potentially suggests that strategies developed for EC prevention in Western populations can be potentially appropriate for the Singapore Chinese population due to risk factor similarities.

Factors Influencing on Pain in Patients Undergoing Pipelle Endometrial Biopsy for Abnormal Uterine Bleeding: Why a Personalized Approach Should Be Applied?

Objectives. Abnormal uterine bleeding (AUB) is a common complaint of women in different age groups, and endometrial biopsy is widely used to investigate the underlying causes. The aim of this observational study was to assess factors influencing pain in patients undergoing endometrial biopsy for AUB. Methods. Pain intensity before, during, and after Pipelle sampling was evaluated using the numerical rating scale (NRS), where "0" represents no pain at all, "10"­the worst pain ever possible. Pain rating was categorized as 1−6­mild to moderate, 7 and above as severe pain. Results. The study included 160 women who underwent Pipelle biopsy. The median age in the cohort was 42 (34−48) years, 18.1% of women were postmenopausal, 56.3% were either overweight or obese, 30% were nulliparous and 80% reported urban residency. The median pain score during the procedure was 2 (0−4). Pain scores of 5 (4−7) were reported with the junior gynecologist and 2 (0−4) in the senior gynecologist (p < 0.0001). Conclusion. The pain was found to have a strong association with the type of provider performing the endometrial sampling procedure. This fact suggests the need for a personalized approach and that psychological or informational interventions should be scheduled before the procedure to decrease pain and increase satisfaction.

Pipelle endometrial biopsy for abnormal uterine bleeding: do patient's pain and anxiety really impact on sampling success rate?

BACKGROUND: Pipelle endometrial biopsy is vital for the early diagnostics of endometrial pathology and is performed in outpatient setting in minimally invasive manner. One of the reported disadvantages of sampling with Pipelle curette is failure to collect enough tissue for histological analysis. The role of psychological factors such as anxiety and pain sensitivity in obtaining adequate samples is not well known. The study's objective was to explore whether there is relationship between severe pain, anxiety, and the rate of Pipelle failure. METHODS: Study included 158 women with median age of 42 who underwent Pipelle endometrial biopsy at Clinical Academic Department of Women's Health of the University Medical Center (UMC), Nur-Sultan City, Kazakhstan with an abnormal uterine bleeding from June 2019 to April 2021. Women were asked to fill survey on pain, anxiety before, during and after the procedure. RESULTS: 3.8%, 15.19% and 4.43% of women reported severe pain and 39.24%, 34.18% and 14.56% of women reported severe anxiety prior, during and after procedure, respectively. Women who experienced severe pain during procedure tend to be more anxious during procedure (p = 0.0001) and have higher number of sampling attempts (p = 0.0040). Pain level was higher among patients sampled by the junior OB/GYN specialist (p < 0.0001). We found no differences in Pipelle biopsy success rates in relationship to baseline, during and postprocedural pain and anxiety scores. CONCLUSION: Anxiety during procedure performance was significantly associated with severe pain during the procedure but did not represent a key element for the success of Pipelle biopsy.

Pipelle Endometrial Biopsy for Abnormal Uterine Bleeding in Daily Clinical Practice: Why the Approach to Patients Should Be Personalized?

BACKGROUND: Abnormal uterine bleeding (AUB) is a common gynecologic condition, and proper management is based on the histological evaluation of an adequate endometrial sample obtained via biopsy. The aims of this study were to evaluate factors influencing the reliability and success rate of Pipelle endometrial sampling for histopathological diagnosis. METHODS: One hundred and eighty patients with AUB underwent endometrial sampling using both Pipelle and dilatation and curettage (D&C) procedures at the Clinical Academic Department of Women's Health, University Medical Center between January 2019 and April 2021. We analyzed the effects of age, menopausal status, ethnicity, body mass index (BMI), provider experience, and procedure indication on the success and reliability of each procedure. RESULTS: Pipelle sampling was successful in 144 (80.56%) women, while D&C was successful in 164 (91.11%) women. Analysis using Fisher's exact test showed that age, menopausal status, and biopsy indication were factors affecting the success rate of both methods, while ethnicity, BMI, and physician experience had no influence. Overall concordance in the histopathological results between Pipelle and D&C was 91.72%. CONCLUSION: Pipelle sampling was found to be reliable for the detection of endometrial carcinoma and endometrial hyperplasia, while its reliability was low in cases of endometrial polyps. The endometrial sampling approach should be personalized in daily clinical practice for women with AUB, and Pipelle sampling is not suitable for all patients. If an endometrial polyp is suspected, the physician should consider other diagnostic tools, bearing in mind all of the factors influencing endometrial sampling success and reliability rates.

Same-day discharge after minimal invasive hysterectomy: Applications for improved value of care.

OBJECTIVE: Hysterectomy is one of the most common surgical procedures. Same-day discharge (SDD) is increasingly utilized for minimally invasive hysterectomies, but its uptake varies across healthcare systems and surgical specialties. An evidence-based initiative was developed to aid in the incorporation of SDD into the practice of minimally invasive hysterectomy (MIH) in the UPMC Health System. The objective of this study was to identify trends of SDD utilization across various gynecologic specialties at UPMC, as well as evaluate the impact of SDD on length of stay (LOS) and complications after the implementation of SDD initiative. STUDY DESIGN: We retrospectively identified 5554 patients who underwent MIH between 2014 and 2017 and were eligible for SDD, as determined by physicians and authorized by patients' insurance plans. Multivariable logistic regression models evaluated the trend of SDD utilization among four specialty types (general gynecologists, urogynecologists, specialized minimally invasive surgeons, and oncologists) and trends in complications. Multivariable logistic and linear regression models were applied to compare complications and LOS between patients with SDD vs. those with overnight admissions. RESULTS: SDD utilization increased from 28.55% to 74.99% during the study period. SDD significantly increased over the study period for all specialty types, with urogynecologists having the highest uptake from 3.9% in 2014 to 95.8% in 2017 (p<.01). After adjusting for year, specialty types, MIH procedure type, and total case time, SDD utilization was associated with shorter mean LOS (p<.01); such that mean LOS was 764.43 min (95% CI: 735.46-793.40) for SDD patients and 2041.84 min (95% CI: 2015.99-2067.70) for patients with overnight admissions. SDD was also associated with 42% lower odds (95% CI: 0.37-0.93, p=.02) of complications compared with patients with overnight admissions. CONCLUSION: Same-day discharge uptake increased over years and was associated with lower odds of complications and decreased length of stay. More studies are needed to explore same-day discharge process to improve patient outcomes, patient satisfaction, and value of care.

Correlation between total air pollutant emissions and incidence of type 1 diabetes in the Russian Federation.

BACKGROUND: Exposure to air pollution (gaseous pollutants and/or particulate matter) has been associated with the incidence, prevalence, and mortality of type 1 diabetes (T1D). PURPOSE: To examine the quantitative relationship between air pollutant emissions and the incidence of T1D. METHODS: We examined the association between the incidence of T1D and type 2 diabetes (T2D) in 2017 as well as that of T1D in patients younger than 15 years in 2016 with "emissions of air-polluting substances from stationary and mobile sources by regions of the Russian Federation in 2016" as reported by the Federal Diabetes Register of Russia downloaded from the Russian government website (http://www.mnr.gov.ru/docs/gosudarstvennye_doklady/o_sostoyanii_i_ob_okhrane_okruzhayushchey_sredy_rossiyskoy_federatsii/). RESULTS: The incidence of T1D across all ages in each region of the Russian Federation correlated with the total air pollutants emitted in the region each year (r=0.278, P=0.013). The incidence of T2D was also correlated with the amount of air pollutants (r=0.234, P=0.037) and the incidence of T1D (r=0.600, P<0.001) in each country. Similarly, the incidence of T1D in patients younger than 15 years correlated with the total air pollutants emitted each year in each region (r=0.300, P=0.011). CONCLUSION: The quantitative relationship between the total air pollutants emitted and the incidence of T1D and T2D in the Russian Federation suggests that air pollution contributes to the development of T1D and T2D.

Lessons Learned From a Gap Analysis of Obstetric Hemorrhage Protocols across a Health System.

INTRODUCTION: The United States has experienced a rising incidence of maternal deaths, including those attributable to obstetric hemorrhage (OBH). In response, the National Partnership for Maternal Safety developed a standardized OBH Consensus Bundle with the goal of universal adoption. In 2016 a large western Pennsylvania health system adopted the OBH Consensus Bundle across its 8 obstetrical units, with the goal to improve maternal outcomes. METHODS: Gap analysis was used to identify differences between existing OBH protocols and the OBH Consensus Bundle from January to June 2016. Identified gaps as well as existing practices of success were used to systematically develop and implement a standardized system-wide OBH improvement initiative. Hospitals were then categorized by annual birth volume as high (> 2000), medium (500-2000), and low (< 500) with analysis performed across these groups to identify potential trends. RESULTS: All hospitals had individual successes as well as gaps that were used to direct the system-wide OBH improvement initiative. In some cases, individual plans were tailored to meet hospital resources. When hospitals were compared by annual birth volume, variation existed in their preparedness for, and management of OBH, with the single low-volume hospital having the most gaps. DISCUSSION: This gap analysis identified areas for improvement among all hospitals in a health system regardless of annual birth volume. This systematic approach of evaluation of current protocols and identification of improvement targets with implementation strategies may improve maternity outcomes. Additionally, these lessons described may provide a useful framework for other hospitals and health systems as they implement their own safety bundles.

Survival and recurrence after intraperitoneal chemotherapy use: Retrospective review of ovarian cancer hospital registry data.

BACKGROUND: Intraperitoneal/intravenous chemotherapy (IP/IV) was associated with improved survival for ovarian cancer (OC) patients in several randomized clinical trials. However, the uptake of IP/IV in clinical practice is varied due to conflicting evidence about its impact on survival and recurrence. The aim of this study was to explore the uptake of IP/IV treatment and to evaluate its impact on survival and recurrence in OC patients. METHODS: Demographic and clinical information on OC patients (N = 2916) who underwent treatment for OC between 2000 and 2017 was obtained from the large healthcare system cancer registry. Duplicate records, grade 1, rare (eg, gelatinous carcinoma), and non-epithelial (eg, granulosa cell carcinoma) tumors were excluded. Kaplan-Meier survival curves were constructed to compare 5- and 10-year survival based on the chemotherapy type, surgery type, and stage. Multivariable Gray's piecewise constant time-varying coefficient models were fitted to evaluate the effect of IP/IV on adjusted hazard ratio (AHR) of OC survival and recurrence adjusting for potential confounders. RESULTS: The final sample consisted of 1846 OC patients, 14% (250/1846) of which received IP/IV chemotherapy. IP/IV was significantly associated with improved 10-year survival (P < .001). Multivariable Gray's model demonstrated that IP/IV therapy significantly reduced the AHR of death (AHR = 0.39-1.07, P < .001) with the beneficial effect gradually declining over time. Use of IP/IV chemotherapy had no impact on OC recurrence. CONCLUSIONS: These findings demonstrated that only a small fraction of eligible patients underwent IP/IV chemotherapy. We report a significant 10-year survival, but not necessarily recurrence benefit is associated with IP/IV chemotherapy compared to IV only, suggesting the need for novel ways of identifying patients who may benefit from IP/IV chemotherapy.

Relationships Between a History of Abuse, Changes in Body Mass Index, Physical Health, and Self-Reported Depression in Female Bariatric Surgery Patients.

Background/Objectives: A history of physical and sexual abuse has been implicated in weight gain. Although bariatric surgery is effective for weight loss in severely obese individuals, we investigated whether bariatric surgery patients who self-report a history of physical and/or sexual abuse have differential outcomes regarding weight loss, body mass index (BMI), quality of life (SF-36), and depressive symptoms (Center for Epidemiologic Studies Depression [CESD]) compared with nonabused patients. Materials and Methods: Standardized assessments at baseline and follow-up visits were performed on 103 obese (BMI >35) female bariatric surgery patients (mean age: 44.11 years, standard deviation: 11.67 years). Results: In total 49.5% of participants reported abuse. Abused group had significantly higher BMI (p < 0.01) and depression scores (p < 0.01). After surgery, the BMI between the two groups was no longer significantly different, although the abused group remained significantly more depressed. Mixed models showed that abuse was associated with CESD scores (p < 0.01) and SF-36 mental composite scores (p = 0.03) after adjusting for smoking history. Conclusion: Bariatric surgery leads to a better weight loss in abused patients. Abuse history might be an additional factor for clinicians to consider when advising bariatric surgery, as our study suggests that women with history of abuse may have a higher weight loss benefit but less mental health improvement from the intervention.

Metabolic Syndrome in Endometrial Cancer Patients: Systematic Review.

Large numbers of previously published studies show the importance of Metabolic syndrome (MetS) in the development of endometrial cancer (EC), the most common gynecologic malignancy in the United States. Defining the association between EC and MetS is complicated by inconsistencies among the MetS definitions used in EC. The aim of this study was to identify the MetS definition that is most practical for EC patients, as well as to estimate the prevalence of MetS using each definition in EC patients. A systematic literature search of PubMed and Embase was conducted to identify studies published between 1988 and 2018 and reporting the components of MetS in EC patients. Relevant studies were selected based on the presence of key MetS components, including central obesity, dyslipidemia, elevated blood pressure, and impaired glucose metabolism. Two independent reviewers extracted information from these articles. Our literature search has identified 400 articles, 8 of which were used for the final analyses. In this systematic review, the prevalence of MetS in EC patients varied based on the definition used, ranging from 6% for International Diabetes Federation (IDF) to 62% for Harmonized. IDF and Harmonized of MetS were the most practical definitions for women with EC. While our review included different approaches to diagnosing MetS and linking it to EC, we argue that there is a need for single and practical MetS definition criteria to improve diagnostics, decrease the inconsistencies across the future EC studies, and foster a cohesive understanding of the evidence regarding the association between MetS and EC.

Inflammatory biomarker in adipose stem cells of women with endometrial cancer.

AIM: To explore inflammatory biomarkers secreted by adipose stem cells (ASCs) in omental, retroperitoneal and subcutaneous adipose tissues of women with endometrial cancer. PATIENTS & METHODS: ASCs were collected from 22 women, aged 35-83 years, undergoing hysterectomy for endometrial cancer. Angiopoietin-2, EGF, IL-8, leptin, VEGFA, VEGFC and VEFGD levels in the ASC-conditioned media were analyzed by Luminex. RESULTS: We found a significant difference between the three depots for IL-8 (p < 0.0001), with the highest levels of IL-8 in the omental depot. VEGFA levels were highest in the retroperitoneal depot. CONCLUSION: This is one of the first studies to explore biomarker expression in ASC-conditioned media in adipose tissue. ASC characteristics may be important to evaluate in relation to cancer risk.

Cost-effectiveness analysis of biopsy strategies for endometrial cancer diagnosis in women with postmenopausal bleeding: Pipelle sampling curette versus dilatation & curettage.

BACKGROUND: Endometrial sampling is widely used for accurate diagnosis of endometrial cancer (EC), which is the most common gynecologic cancer in US women. The objective of this study was to explore the cost-effectiveness of two endometrial sampling procedures for diagnosing EC: (1) Pipelle endometrial sampling (Pipelle), and (2) dilatation & curettage (D&C), while accounting for sampling procedure failure rates and diagnostic accuracy in women with postmenopausal bleeding (PMB). METHOD: The decision analytic model was built to compare the cost-effectiveness of Pipelle and D&C strategies in a hypothetical cohort of PMB women. The analysis was performed from the perspective of a public healthcare payer (Medicare, US). We used 2017 Medicare reimbursement data for cost estimation. The effectiveness of these two diagnostic strategies was measured by analyzing the remaining life expectancy after EC diagnosis and subsequent treatment. RESULTS: The base case analysis suggested that Pipelle was not only equally effective (32.11 vs. 32.11 years of life), but also less costly ($1897.80 vs. $2999.11) based on Medicare reimbursement when compared to D&C. In one-way sensitivity analyses and Monte Carlo probabilistic sensitivity analysis, the Pipelle remained the more cost-effective sampling strategy even after accounting for sampling failure rate associated with each sampling strategy. CONCLUSION: The Pipelle is the more cost-effective sampling strategy compared to D&C for EC diagnosis in women with PMB. From the cost-effectiveness perspective, the higher sampling failure rate of Pipelle should not be regarded as a limitation in its clinical application.

Racial and Socioeconomic Disparities in Hysterectomy Route for Benign Conditions.

BACKGROUND: The aim of this paper was to explore disparities associated with the route of hysterectomy in the University of Pittsburgh Medical Center (UPMC) health system and to evaluate whether the hysterectomy clinical pathway implementation impacted disparities in the utilization of minimally invasive hysterectomy (MIH). METHODS: We performed a retrospective medical record review of all the patients who have undergone hysterectomy for benign indications at UPMC-affiliated hospitals between fiscal years (FY) 2012 and 2014. RESULTS: A total number of 6373 hysterectomy patient cases were included in this study: 88.7% (5653) were European American (EA), 11.02% (702) were African American (AA), and the remaining 0.28% (18) were of other ethnicities. We found that non-EA, women aged 45-60, traditional Medicaid, and traditional Medicare enrollees were more likely to have a total abdominal hysterectomy (TAH). Residence in higher median income zip code (> $61,000) was associated with 60% lower odds of undergoing TAH. Both FY 2013 and 2014 were associated with significantly lower odds of TAH. Logistic regression results from the model for non-EA patients for FY 2012 and FY 2014 demonstrated that FY and zip code income group were not significant predictors of surgery type in this subgroup. Pathway implementation did not reduce racial disparity in MIH utilization. CONCLUSION: This study demonstrated that there is a significant disparity in MIH utilization, where non-EA and Medicaid/Medicare recipients had higher odds of undergoing TAH. Further research is needed to investigate how care standardization may alleviate healthcare disparities.

Integration of Cancer Registry Data into the Text Information Extraction System: Leveraging the Structured Data Import Tool.

INTRODUCTION/BACKGROUND: Cancer registries in the US collect timely and systematic data on new cancer cases, extent of disease, staging, biomarker status, treatment, survival, and mortality of cancer cases. Existing methodologies for accessing local cancer registry data for research are time-consuming and often rely on the manual merging of data by staff registrars. In addition, existing registries do not provide direct access to these data nor do they routinely provide linkage to discrete electronic health record (EHR) data, reports, or imaging data. Automation of such linkage can provide an impressive data resource and make valuable data available for translational cancer research. METHODS: The UPMC Network Cancer Registry collects highly structured, longitudinal data on all reportable cancer patients, from the point of the diagnosis throughout treatment and follow-up/outcomes. Using commercial registry software, we collect data in compliance with standards governed by the North American Association of Central Cancer Registries. This standardization ensures that the data are highly structured with standard coding and collection methods, which support data exchange among central cancer registries and the Centers for Disease Control and Prevention. RESULTS: At the UPMC Hillman Cancer Center and University of Pittsburgh, we explored the feasibility of linking this well-curated, structured cancer registry data with unstructured text (i.e., pathology and radiology reports), using the Text Information Extraction System (TIES). We used the TIES platform to integrate breast cancer cases from the UPMC Network Cancer Registry system and then combine these data with other EHR data as a pilot use case that can be replicated for other cancers. CONCLUSIONS: As a result of this integration, we now have a single searchable repository of information for breast cancer patients from the UPMC registry, combined with their pathology and radiology reports. The system that we developed is easily scalable to other health systems and cancer centers.

Factors influencing malignant mesothelioma survival: a retrospective review of the National Mesothelioma Virtual Bank cohort.

Background: Malignant mesothelioma (MM) is a rare but deadly malignancy with about 3,000 new cases being diagnosed each year in the US.  Very few studies have been performed to analyze factors associated with mesothelioma survival, especially for peritoneal presentation. The overarching aim of this study is to examine survival of the cohort of patients with malignant mesothelioma enrolled in the National Mesothelioma Virtual Bank (NMVB).   Methods:  888 cases of pleural and peritoneal mesothelioma cases were selected from the NMVB database, which houses data and associated biospecimens for over 1400 cases that were diagnosed from 1990 to 2017. Kaplan Meier's method was performed for survival analysis. The association between prognostic factors and survival was estimated using Cox Hazard Regression method and using R software for analysis. Results: The median overall survival (OS) rate of all MM patients, including pleural and peritoneal mesothelioma cases is 15 months (14 months for pleural and 31 months for peritoneal).  Significant prognostic factors associated with improved survival of malignant mesothelioma cases in this NMVB cohort were younger than 45, female gender, epithelioid histological subtype, stage I, peritoneal occurrence, and having combination treatment of surgical therapy with chemotherapy. Combined surgical and chemotherapy treatment was associated with improved survival of 23 months in comparison to single line therapies. Conclusions: There has not been improvement in the overall survival for patients with malignant mesothelioma over many years with current available treatment options. Our findings show that combined surgical and chemotherapy treatment in peritoneal mesothelioma is associated with improved survival compared to local therapy alone.