Complete placenta previa and increta after radical trachelectomy: A case report.

Background: Placenta accreta spectrum (PAS) disorders are increasing in incidence and represent a significant contributor to severe maternal morbidity in the US. Prior uterine surgeries other than cesarean section are important, yet less common, risk factors for PAS. Case: This is a case of a 43-year-old woman with a prior history of cervical cancer necessitating radical trachelectomy. She was subsequently diagnosed with a complete placenta previa with a high degree of suspicion for PAS. Multidisciplinary teams convened to plan for delivery. A cesarean hysterectomy was performed at 32 weeks. Final surgical pathology confirmed the presence of morbidly adherent placenta invading the vaginal cuff. Conclusion: Patients who are diagnosed with early-stage cervical cancers have the option of fertility-preserving surgical management. Serial ultrasound evaluations, specifically looking for PAS, might be warranted in post-trachelectomy pregnancies.

Minimally invasive versus open surgery for women with stage 1A1 and stage 1A2 cervical cancer: A retrospective database cohort study.

Background: Recent studies comparing minimally invasive versus open radical hysterectomy in patients with early-stage cervical cancer have reported a worse overall survival with minimally invasive surgery (MIS). However, in the patients with microscopic disease, there was no survival difference and the optimal surgical approach for microscopic cervical cancer remains unclear. Methods: Using the National Cancer Database, we identified a cohort of women who underwent hysterectomy as the primary treatment for stage IA1/IA2 cervical cancer between January 2010 and December 2016. Using multivariable logistic regression, our primary outcome was to compare overall survival between the open and MIS groups. The data was stratified for simple and radical hysterectomies. Secondary endpoint was comparison of readmission rates and length of stay (LOS). Results: We identified 6230 patients with stage IA1 and IA2 cervical cancer that underwent hysterectomy as primary treatment. 4054 of these women (65%) underwent MIS. There was no difference in age, lympho-vascular invasion, number of lymph nodes retrieved and histology between the two groups. In the overall cohort, there was no difference in survival between the open and the MIS group (Hazard ratio for the open group 1.23; CI 0.92-1.63). Post-operative radiation therapy was more common in the open group (5.24% vs 4.09%, p value < 0.02). The mean LOS (1.35 days vs 3.08 days) was shorter in MIS group (p value < 0.0001). No difference was found in the readmission rates (60% for the MIS group vs 55% for the open group; p value 0.14). Conclusions: Our data suggest that MIS is associated with similar overall survival and shorter length of hospital stay compared to the open hysterectomy in women with stage IA cervical cancer. Based on this large data set, MIS appears to be a safe and effective surgical approach for women with stage IA1/IA2 cervical cancer.

Hospice utilization in advanced cervical malignancies: An analysis of the National Inpatient Sample.

OBJECTIVE: Hospice services improve quality of life and outcomes for patients and caretakers, compared to inpatient mortality. This study identifies factors that exert the strongest influence on end-of-life care modalities in patients with cervical cancer. METHODS: Admissions with a diagnosis of cervical cancer that were discharged to hospice or died in-hospital were identified in the National Inpatient Sample years 2007-2011, excluding admissions coded for hysterectomy. Logistic regression models were used to examine differences in age, race, length of stay, primary payer, hospital region, admission type, hospital bedsize, hospital teaching status, income quartile, and Elixhauser comorbidity index score between the groups. RESULTS: 2073 admissions with a diagnosis of cervical cancer resulting in hospice discharge (n = 1290) or inpatient death (n = 783) were identified. Age (P = 0.01), hospital region (P = 0.01), length of hospitalization (P < 0.01), Elixhauser comorbidity index score (P = 0.03), and urban vs. rural location (P = 0.01) had a significant impact on disposition in univariate analysis. Admissions of patients categorized as Asian/Pacific Islander (OR = 2.24, 95% CI 1.11-4.49), hospitalizations lasting 0-3 days (OR = 1.57, 95% CI 1.21-2.03), and admissions in rural areas (OR = 1.62, 95% CI 1.12-2.36) had higher rates of in-hospital death compared to the reference groups. Patients aged 18-45 years (OR = 0.69, 95% CI 0.52-0.90) and those treated in the South (OR 0.59, 95% CI 0.45-0.77) and West (OR = 0.50, 95% CI 0.30-0.81) had lower odds ratios of inpatient mortality. CONCLUSION: Modalities of care in terminal cervical cancer vary among sociodemographic and clinical factors. This data underscores the continued push for improved end-of-life care among cervical cancer patients and can guide clinicians in appropriate targeted counseling to increase utilization of hospice resources.

Enhancing patient safety in the trauma/surgical intensive care unit.

BACKGROUND: Preventable deaths due to errors in trauma patients with otherwise survivable injuries account for up to 10% of fatalities in Level I trauma centers, 50% of these errors occur in the intensive care unit (ICU). The root cause of 67% of the Joint Commission sentinel events is communication errors. The objective is (1) to study how critical information degrades and how it is lost over 24 hours and (2) to determine whether a structured checklist for ICU handoffs prevents information loss. METHODS: Prospective cohort study of trauma and surgical ICU teams observed with and without use of the checklist. An observational period (control group) was followed by a didactic session on the science and use of a checklist (study group), which was used for patient management and handoffs. Information was tracked for a 24-hour period and all handoffs. Comparisons use chi or Fisher's exact test and a p value <0.05 was defined as significant. RESULTS: Three hundred and thirty-two patient ICU days were observed (119 control, 213 study) and 689 patient care items (303 control, 386 study) were followed. Seventy-five (10.9%) items were lost over 24 hours; 61 of 303 (20.1%) without checklist and 14 of 386 (3.6%) with checklist (p < 0.0001). Critical laboratory values and test results were the most frequent lost items (36.1% control vs. 4.5% study p < 0.0001). Six of 75 (8.1%) items were correctly ordered but not carried out by ICU nursing staff--all caught and corrected with checklist use. CONCLUSION: Critical information is degraded over 24 hours in the ICU. A structured checklist significantly reduces patient errors due to lost information and communication lapses between trauma ICU team members at handoffs of care.