Safety of de-escalation of surgical intervention for atypical ductal hyperplasia on percutaneous biopsy: One size does not fit all.

BACKGROUND: Oncologic safety of active monitoring (AM) for atypical ductal hyperplasia (ADH) on core-needle biopsy (CNB) is not well defined. We sought to define oncologic outcomes for AM to manage ADH meeting institutional predefined low-risk criteria (LOW). METHODS: ADH was diagnosed on CNB from 10/2015-03/2020. LOW (pure ADH, size <1 cm, >50% removed by CNB, <3 foci, and no necrosis) patients were offered AM; all others were recommended for surgical excision. Oncologic outcomes were compared for AM and surgery. RESULTS: 111 were included, 21 (19%) meeting LOW. AM occurred in 18 (86%) while 3 elected for excision (with 0% upgrade). Of the 18 LOW in AM, 2 required additional CNB (none at ADH site): 0% were diagnosed with cancer over median 23 month follow-up. CONCLUSIONS: There were no missed cancers at ADH site during AM for LOW, confirming the oncologic safety of AM in this select group.

Patient Perspectives of Rural Kansas Maternity Care.

INTRODUCTION: Pregnant women in rural areas face a unique set of challenges due to geographic maldistribution of obstetric services. The perspectives of rural Kansas women were sought regarding experience of birth and satisfaction with maternity care. METHODS: Medical student research assistants facilitated discussion groups and structured interviews in rural Kansas communities distributed throughout the state with women who had an uncomplicated delivery in the last 24 months. Participants were recruited via convenience sampling from clinic medical records and appointments over a two-to-three-week period. Guiding questions were used to facilitate discussion. Survey instruments were used to gather information about satisfaction with maternity care. Data for qualitative and quantitative analysis was aggregated using Rural Urban Commuting Area (RUCA) codes. RESULTS: Fourteen groups with 47 total participants completed the survey and discussion. Participants came from large rural, small rural, and isolated areas in Kansas as described by RUCA Code Four Category Classification. Survey results indicated that satisfaction with maternity care in participants' home county was significantly higher in small rural and isolated compared to large Rural RUCAs. Qualitative analysis results showed positive experiences related to doctor characteristics, relationship with doctor, doctor's involvement with care, alternative labor options, and distance convenience. Negative experiences were related to doctor bedside manner, doctor not there until delivery, and staff related complaints. CONCLUSIONS: Kansas women in small rural and isolated RUCA codes appeared to be more satisfied with care.

Kansas maternity deserts: a cross-sectional study of rural obstetric providers.

INTRODUCTION: Kansas is a predominantly rural state that had 9853 rural births in 2018. The Kansas Rural Obstetrical Access Task Force was formed to study and address factors affecting these births. One of these factors is the distance between mothers and the location of maternity services. Poor access leading to increased travel times between mothers and maternity care providers has been associated with a greater rate of pregnancy complications, premature birth, and higher cost of care. In Kansas, the current state of access is not clearly described. Adding to the concern were reports of rural hospital closures and provider cessation of maternity care services. This was likely leading to 'maternity deserts': entire counties that have no maternity care providers. The goal of this project was to identify who currently delivers babies in Kansas, map their location, and determine future plans for maternity care service provision. METHODS: The study began by dividing the state of Kansas into counties by population density and by identifying current practitioners in the state. Once identified, providers were sent a 72-item mixed methods survey with content including demographics, practice location, provision of maternity care, and intents on future practice changes. RESULTS: Analysis of the survey responses led to a clearer picture of the current state of maternity care provider distribution in Kansas. This revealed multiple existing maternity deserts and a projected expansion of these deserts over the next 10 years. CONCLUSION: The current distribution of maternity care services in Kansas reveals numerous maternity deserts, and provider survey projections as far forward as 2030 show expansion of these deserts. This poor access to care may be contributing to unnecessary pregnancy complications. With the extent of this issue identified, targeted efforts toward narrowing the current and expanding maternity deserts are being implemented.

Comparison of the BD MAX MRSA XT to the Cepheid™ Xpert® MRSA assay for the molecular detection of methicillin-resistant Staphylococcus aureus from nasal swabs.

INTRODUCTION: Variation in MRSA genotypes may affect the sensitivity of molecular assays to detect this organism. METHODS: We compared 2 commonly used screening assays, the Cepheid™ Xpert® MRSA and the BD MAX™ MRSA XT on consecutively obtained nasal swabs from 479 subjects. Specimens giving discordant results were subjected to additional microbiologic and molecular testing. RESULTS: Six hundred forty-two (97.6%) of the 658 test results were concordant. Of the 16 discordant results from 12 subjects, additional results suggested that 9 (60%) of the 15 MRSA XT assays were likely correct, and 6 (40%) of the 15 Xpert® assays were likely correct. One discordant result could not be resolved. A mecA dropout and novel mec right-extremity junction (MREJ) sites led to false-positive and negative results by Xpert®. CONCLUSION: While both assays performed well, continued vigilance is needed to monitor for Staphylococcus aureus with novel MREJ sites, mecA dropouts, and mecC, leading to inaccurate results in screening assays.