Feasibility, Safety, and Provider Perspectives of Bipolar Electrosurgical Cautery Device for (Opportunistic or Complete) Salpingectomy at the Time of Cesarean Delivery.

OBJECTIVES: The aim of the study is to evaluate the use of a bipolar electrocautery device for complete salpingectomy at cesarean to improve procedure completion rates, operative time, and surgeon reported satisfaction as compared with standard bilateral tubal ligation (BTL) and suture-cut-tie salpingectomy. STUDY DESIGN: This is a prospective cohort study of women undergoing planned, non-emergent cesarean with desired sterilization with complete salpingectomy utilizing a bipolar electrocautery device. Study patients were compared with historic controls from a randomized controlled trial (RCT) of complete salpingectomy via suture-cut-tie method versus BTL conducted at our institution (SCORE trial, NCT02374827). Outcomes were compared with groups from the original RCT. RESULTS: Thirty-nine women were consecutively enrolled (12/2018-11/2019) into the device arm of the study and compared with the original SCORE cohort (n = 40 BTL, n = 40 salpingectomy without a device). Salpingectomy performance with the bipolar electrocautery device was successfully completed in 100% (39/39) of enrolled women, with one device failure requiring the use of a second device, as compared with 95% (38/40) in the BTL (p = 0.49) and 67.5% (27/40) in salpingectomies without a device (p < 0.001). Mean operative time of sterilization procedure alone demonstrated device use as having the shortest operative time of all (device salpingectomy 5.0 ± 3.6 vs. no device 18.5 ± 8.3 minutes, p < 0.001; and vs. BTL 6.9 ± 5.0, p = 0.032). Mean sterilization procedure endoscopic band ligation (EBL) was demonstrated to be significantly different between each group, least amongst BTL followed by device (6.3 ± 4.8 vs. 8.4 ± 24.8, p < 0.001), and most by suture-cut-tie method (17.7 ± 14.3, p < 0.001 compared with device). Surgeon reported attitudes of complete salpingectomy performance in general practice outside an academic setting was greater with a device than without (79.5 vs. 35.3%; p < 0.001). CONCLUSION: Use of a bipolar electrocautery device improved operative times and surgeon satisfaction for salpingectomy at cesarean over standard suture ligation. Device use improved surgeon reported outcomes and may improve incorporation of complete salpingectomy at cesarean. KEY POINTS: · Electrocautery bipolar device use was safe at the time of salpingectomy during cesarean.. · Greater surgeon satisfaction occurs using a device than without.. · Decreased surgical time with device use is seen making the procedure equal to BTL..

Sociodemographic characteristics and cervical cancer survival in different regions of the United States: a National Cancer Database study.

OBJECTIVE: To determine how sociodemographic factors impact cervical cancer survival in different geographic locations in the USA. METHODS: A retrospective cohort of patients with cervical cancer from January 1, 2004 to December 31, 2015 in the National Cancer Database (NCDB) was identified. Tumor characteristics as well as race, income, insurance type, and treating facility types were compared among nine geographic regions. χ2 tests and Cox regression were used to compare differences between regions; p values <0.05 were considered significant. RESULTS: A total of 48 787 patients were included. Survival was inferior in seven of nine regions for underinsured patients. In six regions survival was inferior for Medicaid and Medicare patients, respectively: Middle Atlantic: hazard ratio (HR) 1.25 and 1.22; South Atlantic: HR 1.41 and HR 1.22; East North Central: HR 1.36 and HR 1.25; East South Central: HR 1.37 and HR 1.25; West North Central: HR 1.67 and HR 1.42; West South Central: HR 1.44 and HR 1.46. In the Pacific region survival was inferior for Medicare patients (HR 1.35) but not inferior for Medicaid patients. Being uninsured was associated with worse survival in the South Atlantic (HR 1.23), East North Central (HR 1.23), East South Central (HR 1.56), and West South Central (HR 1.31) regions. Annual income level under $38 000 was associated with worse survival in the Middle Atlantic (HR 1.24), South Atlantic (HR 1.35), and East North Central (HR 1.49) regions. Lastly, when compared with academic research institutions, comprehensive community cancer centers had significantly worse survival in four of the nine regions. CONCLUSIONS: Cervical cancer mortality is higher for women with a low income, underinsured (Medicaid or Medicare) or uninsured status, and decreased access to academic institutions in most US regions. An increase in cervical cancer mortality was associated with underinsured or uninsured populations in regions mainly located in the South and Midwest.

Bowel Perforation in the Emergency Department Related to Bevacizumab Therapy and Recurrent Ovarian Cancer.

CASE PRESENTATION: We describe the presentation to the emergency department of a patient with recurrent ovarian cancer treated with bevacizumab with the complication of bowel perforation. DISCUSSION: We review the frequency and outcomes of bevacizumab-related bowel perforation. We also report the patient's imaging findings, including the radiologic presentation of free intraperitoneal air and portal venous gas, both indicative of bowel perforation and the need for emergent surgical evaluation. Our case also illustrates the potentially catastrophic side effects of bevacizumab and other targeted oncologic therapies of which emergecny physicians may not be aware.

Reducing emergency department (ED) computed tomography (CT) utilization in women treated for gynecologic cancers.

OBJECTIVES: The objective of this quality improvement (QI) project was to decrease the rate of low-value computed tomography (CT) imaging in established gynecologic oncology patients presenting to the emergency department (ED). METHODS: This was a cohort study with a before and after design that evaluated implementation of a QI project designed to decrease CT utilization in established gynecologic oncology patients in the ED. The pre-intervention cohort included patients admitted through the ED from 4/1/17 to 5/31/18, while the post-intervention cohort was from 6/1/18 to 5/31/19. The intervention included gynecologic oncology consultation before CT on patients who had imaging within the prior 3 weeks. Details regarding CT, ED length of stay (LOS), and oncologic history were abstracted. The value of CT was determined by consensus from 2 reviewers. Prospective data monitoring evaluated for patient safety. RESULTS: Prior to intervention, there were 129 unique ED encounters in gynecologic oncology patients leading to admission. CT scans were performed in 101 (78.3%) encounters, 57.7% of which were deemed to be of low-value. Following implementation, the CT utilization rate decreased significantly from median monthly rate of 75.2% to 49.1% (p < 0.00001), and the ED LOS decreased from 8.1 to 6.9 h (p = 0.0102). The number of CT scans deemed to be low-value in the post-intervention group decreased to 2 (3.8%). CONCLUSIONS: Implementation of an early consultation policy and imaging guidelines led to a significant decrease in unnecessary CT utilization and shorter ED LOS in gynecologic oncology patients presenting to the ED.

Pyridoxine for prevention and treatment of PARP inhibitor induced nausea and vomiting.

Poly-ADP ribose polymerase inhibitors (PARPi) are a promising new treatment option for patients with ovarian cancer and are moderately emetogenic. Tolerance of therapy is paramount, and uncontrolled nausea and vomiting may limit use. Although most patients will experience improvement in nausea and vomiting after one to two months, approximately one in twenty patients will discontinue therapy due to unrelieved symptom burden. Three cases of olaparib-related nausea and vomiting mitigated by primary pyridoxine use are reported. Case 1 demonstrates successful use of pyridoxine in breakthrough nausea. Case 2 details the use of pyridoxine following refractory nausea and vomiting requiring hospitalization. Case 3 describes a prophylactic approach for a patient with significant anticipatory nausea. All three patients tolerated olaparib after starting and continuing pyridoxine. Vitamin B6, or pyridoxine, was successful as both a therapeutic and prophylactic option for significant treatment-related nausea and vomiting with PARPi use.

Impact of individualized target mean arterial pressure for septic shock resuscitation on the incidence of acute kidney injury: a retrospective cohort study.

BACKGROUND: To examine the relationship between delta mean arterial pressure (ΔMAP; MAP change between pre-admission minus post-resuscitation) and acute kidney injury (AKI) among patients with septic shock. In this retrospective, single-center cohort study of adult patients pre-admission MAP is defined as the median MAP recorded from 365 to 7 days before admission. Post-resuscitation MAP was median MAP during the 7th hour after initiating resuscitation. RESULTS: In our cohort (N = 233; 55% male), the median (interquartile range [IQR]) age was 71 (58-81) years and the median (IQR) acute physiology, age, chronic health evaluation (APACHE) III score was 81 (66-97). Although those in the lowest ΔMAP quartile (-24.5 to 3.9 mmHg) had no demographic differences compared with the rest of the cohort, the odds ratio for AKI was 0.26 (95% CI 0.11-0.57) after adjustment for other known AKI risk factors. Among patients with a history of hypertension, the lowest quartile had an odds ratio for AKI of 0.12 (95% CI 0.04-0.37) after adjusting for risk factors for AKI in this cohort. CONCLUSIONS: The incidence of AKI was lowest among those whose post-resuscitation MAP was closest to or higher than their pre-admission MAP. Further study regarding the effect of targeting the pre-admission MAP for post-resuscitation on the incidence of AKI is warranted.

Estimated Blood Loss During Vaginal Hysterectomy and Adnexal Surgery Described With an Intraoperative Pictographic Tool.

OBJECTIVE: We describe a novel way to calculate estimated blood loss (EBL) using an intraoperative pictographic tool in gynecologic surgery. METHODS: A pictographic tool to estimate sponge saturation was developed to calculate EBL during surgery. A prospective cohort of women 18 years or older undergoing benign vaginal hysterectomy with planned adnexal surgery at Mayo Clinic were consented for use of the pictographic tool. Demographic, preoperative, intraoperative, and postoperative data were abstracted. Estimated blood loss was compared among surgeons, anesthesia providers, and the pictographic tool and then correlated with change in hemoglobin. RESULTS: Eighty-one patients met inclusion with mean age of 45.3 ± 8.7 years. Successful vaginal hysterectomy was achieved in all patients with successful completion of planned adnexectomy in 69 (85.2%). Mean EBL among surgeons, anesthesia providers, and pictographic estimates, respectively, was as follows: 199.4 ± 81.9 mL, 195.5 ± 152.2 mL, and 288.5 ± 186.6 mL, with concordance correlation coefficients for surgeons and anesthesia providers versus pictographic tool of 0.40 (95% confidence interval, 0.29-0.51) and 0.68 (95% confidence interval, 0.57-0.79), respectively. The mean postoperative change in hemoglobin was -1.8 g/dL; there were no postoperative transfusions. Change in hemoglobin was more correlated with blood loss estimates from surgeons (r = -0.31, P = 0.008) and anesthesia providers (r = -0.37, P = 0.003) than the pictographic tool (r = -0.19, P = 0.11). CONCLUSIONS: Use of a pictographic tool to objectively estimate blood loss demonstrated significant overestimations compared with both anesthesia providers' and surgeons' estimates because the pictographic tool was less correlated with postoperative change in hemoglobin than anesthesia provider and surgeon estimates.

Competitive Sports Participation in Patients With Catecholaminergic Polymorphic Ventricular Tachycardia: A Single Center's Early Experience.

OBJECTIVES: The study sought to determine the outcomes of continued sports participation in patients with catecholaminergic polymorphic ventricular tachycardia (CPVT). BACKGROUND: Patients with CPVT are at increased risk of sudden death with exertion. Currently, CPVT patients are advised disqualification from nearly all sports in accordance with expert opinion guidelines. However, we have approached this complex issue with a shared decision making model respecting a patient's and their family's right to be a competitive athlete following institution of comprehensive CPVT-directed treatment program. METHODS: A retrospective record review was performed on patients with CPVT who were >6 years of age at the time of initial evaluation to determine their athlete status and frequency/scope of subsequent CPVT-triggered events. RESULTS: Among 63 eligible patients with CPVT (34 females, mean age at diagnosis 16.6 ± 12.9 years), 31 (49%) were athletes at some point in their life. Compared to the nonathletes, these athletes were significantly younger at diagnosis (11.8 ± 6.6 years vs. 21.3 ± 15.6 years; p = 0.003) and more symptomatic (21 [68%] vs. 13 [41%]; p = 0.04). Following diagnosis, 21 of 24 athletes (88%) continued competition. For these 21 athletes, 16 (76%) had experienced 32 CPVT-triggered events prior to diagnosis versus 57 events in 18 nonathletes (43%; p = 0.02). During follow-up, 3 events occurred in 3 of 21 athletes (14%) compared to 7 events in 6 of 42 nonathletes (14%, p = 1.00). No event resulted in death, and all received an adjustment in their CPVT therapy. CONCLUSIONS: Although sports participation is a risk taking behavior in undiagnosed and untreated CPVT, the risk may be acceptable for a well-treated and well-informed athlete following the diagnosis of CPVT.

External validation of the Ottawa subarachnoid hemorrhage clinical decision rule in patients with acute headache.

We aim to externally validate the Ottawa subarachnoid hemorrhage (OSAH) clinical decision rule. This rule identifies patients with acute nontraumatic headache who require further investigation. We conducted a medical record review of all patients presenting to the emergency department (ED) with headache from January 2011 to November 2013. Per the OSAH rule, patients with any of the following predictors require further investigation: age 40 years or older, neck pain, stiffness or limited flexion, loss of consciousness, onset during exertion, or thunderclap. The rule was applied following the OSAH rule criteria. Patients were followed up for repeat visits within 7 days of initial presentation. Data were electronically harvested from the electronic medical record and manually abstracted from individual patient charts using a standardized data abstraction form. Calibration between trained reviewers was performed periodically. A total of 5034 ED visits with acute headache were reviewed for eligibility. There were 1521 visits that met exclusion criteria, and 3059 had headache of gradual onset or time to maximal intensity greater than or equal to 1 hour. The rule was applied to 454 patients (9.0%). There were 9 cases of subarachnoid hemorrhage (SAH), yielding an incidence of 2.0% (95% confidence interval [CI], 1.0%-3.9%) in the eligible cohort. The sensitivity for SAH was 100% (95% CI, 62.9%-100%); specificity, 7.6% (95% CI, 5.4%-10.6%); positive predictive value, 2.1% (95% CI 1.0%-4.2%); and negative predictive value, 100% (95% CI, 87.4%-100%). The OSAH rule was 100% sensitive for SAH in the eligible cohort. However, its low specificity and applicability to only a minority of ED patients with headache (9%) reduce its potential impact on practice.