The prevalence of hyperglycemia and its association with perioperative outcomes in gynecologic surgery: a retrospective cohort study.

BACKGROUND: Preoperative hyperglycemia has been associated with perioperative morbidity in general surgery patients. Additionally, preoperative hyperglycemia may indicate underlying impaired glucose metabolism. Thus, identification of preoperative hyperglycemia may provide an opportunity to mitigate both short-term surgical and long-term health risk. We aimed to study this phenomenon specifically in the gynecologic surgery population. Specifically, we aimed to evaluate the association between preoperative hyperglycemia and perioperative complications in gynecologic surgery patients and to characterize adherence to diabetes screening guidelines. METHODS: This retrospective cohort study included 913 women undergoing major gynecologic surgery on an enhanced recovery pathway from January 2018 to July 2019. The main exposure was day of surgery glucose ≥ 140 g/dL. Multivariate regression identified risk factors for hyperglycemia and composite and wound-specific complications. RESULTS: Sixty-seven (7.3%) patients were hyperglycemic. Diabetes (aOR 24.0, 95% CI 12.3-46.9, P < .001) and malignancy (aOR 2.3, 95% CI 1.2-4.5, P = .01) were associated with hyperglycemia. Hyperglycemia was not associated with increased odds of composite perioperative (aOR 1.3, 95% CI 0.7-2.4, P = 0.49) or wound-specific complications (aOR 1.1, 95% CI 0.7-1.5, P = 0.76). Of nondiabetic patients, 391/779 (50%) met the USPSTF criteria for diabetes screening; 117 (30%) had documented screening in the preceding 3 years. Of the 274 unscreened patients, 94 (34%) had day of surgery glucose levels suggestive of impaired glucose metabolism (glucose ≥ 100 g/dL). CONCLUSION: In our study cohort, the prevalence of hyperglycemia was low and was not associated with higher risk of composite or wound-specific complications. However, adherence to diabetes screening guidelines was poor. Future studies should aim to develop a preoperative blood glucose testing strategy that balances the low utility of universal glucose screening with the benefit of diagnosing impaired glucose metabolism in at-risk individuals.

Robotic-assisted gynecologic surgery associated tympanic membrane perforation: A report of two cases and review of the literature.

Robotic gynecologic surgery is associated with the use of steep Trendelenburg positioning. Steep Trendelenburg is necessary to provide optimal exposure to the pelvis but is associated with an increased risk of non-surgical complications such as suboptimal ventilation, facial and laryngeal edema, increased intraocular and intracranial pressure as well as neurologic injury. Several case reports have described otorrhagia after robotic assisted surgery; however, there are limited reports on the risk of tympanic membrane perforation. To our knowledge, there are no published reports on tympanic membrane perforation in gynecologic nor gynecologic oncology surgery. We report two cases of perioperative tympanic membrane rupture and bloody otorrhagia associated with robot-assisted gynecologic surgery. In both cases otolaryngology/Ear Nose and Throat (ENT) was consulted, and the perforations resolved with conservative management.

Early Femoral Access by Acute Care Surgeons: A Multidisciplinary Approach to Prevent Maternal Exsanguination in Placenta Accreta Spectrum.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) use has expanded to the obstetric condition of placenta accreta spectrum (PAS). Early reports of REBOA for PAS describe prophylactic catheter deployment. We developed a multidisciplinary approach to PAS, with early femoral artery access and selective REBOA deployment. We compared morbidity, mortality, and blood loss before and after implementation of our multidisciplinary protocol for PAS. Prior to, femoral access was obtained only emergently, and maternal death occurred in 2/3 cases (66%). Following protocol implementation, there was one maternal death (6%). There were no access-related complications. We have not yet needed to deploy the REBOA during PAS cases. In contrast to urgent hemorrhage control or prophylactic REBOA deployment, routine early femoral arterial access and selective REBOA deployment as part of a multidisciplinary team approach is a novel strategy for managing PAS. Our experience suggests most PAS cases do not require prophylactic REBOA deployment.

A Letter to Your Care Providers: Implementation and Analysis of a Letter-based Advance Care Planning Initiative for Gynecologic Oncology Patients.

To determine the impact of a letter-based advance care planning (ACP) healthcare improvement (HI) initiative on rates of ACP conversations and documentation among gynecologic oncology (GO) inpatients. An HI initiative was implemented from January to December 2020 to improve ACP documentation among GO inpatients. Patients admitted to the GO service were given ACP packets with a letter-based ACP worksheet. GO inpatients who were interested in learning more about ACP were visited by medical students trained to lead ACP conversations. ACP documentation rates in the EMR (electronic medical record) pre- and post-intervention were evaluated. Descriptive statistics were calculated. Associations between sociodemographic characteristics and ACP documentation were analyzed using logistic regression. There were 172 patients admitted in 2019 (pre-implementation cohort). Of these, 45/172 patients (26%) had an advance directive (AD) documented in their electronic medical record (EMR). Following the implementation of the ACP HI in 2020, 55/168 patients (33%) had an AD documented in their EMR. This was a 7% absolute increase and 27% relative increase from pre-intervention AD documentation rates. Increasing age was associated with an increased likelihood of having an AD in the chart (p = 0.004). Married women were less likely to have an AD in their chart (p = 0.05). An HI utilizing a letter-based ACP packet given to GO inpatients improved AD documentation in the EMR. This HI offers a unique method for introducing ACP to patients. More work is needed to improve the occurrence and documentation of ACP conversations.

Clinical outcomes in patients with COVID-19 and gynecologic cancer: A society of gynecologic oncology COVID-19 and gynecologic cancer registry study.

OBJECTIVES: Patients with gynecologic malignancies may have varied responses to COVID-19 infection. We aimed to describe clinical courses, treatment changes, and short-term clinical outcomes for gynecologic oncology patients with concurrent COVID-19 in the United States. METHODS: The Society of Gynecologic Oncology COVID-19 and Gynecologic Cancer Registry was created to capture clinical courses of gynecologic oncology patients with COVID-19. Logistic regression models were employed to evaluate factors for an association with hospitalization and death, respectively, within 30 days of COVID-19 diagnosis. RESULTS: Data were available for 348 patients across 7 institutions. At COVID-19 diagnosis, 125 patients (36%) had active malignancy. Delay (n = 88) or discontinuation (n = 10) of treatment due to COVID-19 infection occurred in 28% with those on chemotherapy (53/88) or recently receiving surgery (32/88) most frequently delayed. In addition to age, performance status, diabetes, and specific COVID symptoms, both non-White race (adjusted odds ratio (aOR) = 3.93, 95% CI 2.06-7.50) and active malignancy (aOR = 2.34, 95% CI 1.30-4.20) were associated with an increased odds of hospitalization. Eight percent of hospitalized patients (8/101) died of COVID-19 complications and 5% (17/348) of the entire cohort died within 30 days after diagnosis. CONCLUSIONS: Gynecologic oncology patients diagnosed with COVID-19 are at risk for hospitalization, delay of anti-cancer treatments, and death. One in 20 gynecologic oncology patients with COVID-19 died within 30 days after diagnosis. Racial disparities exist in patient hospitalizations for COVID-19, a surrogate of disease severity. Additional studies are needed to determine long-term outcomes and the impact of race.

Stopping the revolving door: An exploratory analysis of health care super-utilization in gynecologic oncology.

The objective of this study was to determine the prevalence of and risk factors for health care super-utilization among gynecologic oncology patients at a single academic hospital. A retrospective cohort study of gynecologic oncology patients with an index unplanned encounter between January and December 2018 was performed. Super-utilizers were defined as patients with 3 or more unplanned hospital encounters during a 12-month period starting at the time of the index unplanned encounter. We identified 553 patients with gynecologic cancer. Of those, 37(7%) met inclusion criteria for super-utilizers accounting for 193/310(62%) of unplanned visits. The median number of unplanned visits was 4 (range 3-24). The most common cancers were uterine (N = 15 (41%)) and ovarian (N = 11 (30%)). Nineteen (51%) super-utilizers had advanced stage disease. Phases of oncologic care at index unplanned encounter included primary diagnosis (N = 24 (65%)), recurrence (N = 10 (27%)), and surveillance (N = 2 (5%)). Twelve super-utilizers (32%) had new diagnoses of cancer without prior therapy, 19(51%) had prior chemotherapy, 17(46%) had prior surgery, and 10(27%) had prior radiation therapy at the time of initial encounter. Fifteen super-utilizers (41%) were in the last year of life. The most common reasons for unplanned encounters were pain (66%) and gastrointestinal symptoms (61%). Multivariable analysis adjusting for key variables demonstrated that Medicaid insurance, ASA classification, and disease status are risk factors for health care super-utilization. The majority of health care utilization occurred during the first year of diagnosis. This exploratory analysis suggests an opportunity to decrease health care utilization, particularly during upfront treatment.

Choosing Wisely: Decreasing the incidence of perioperative blood transfusions in gynecologic oncology.

OBJECTIVE: To evaluate the efficacy and economic impact of a transfusion reduction initiative for patients undergoing gynecologic surgery. METHODS: We conducted a prospective healthcare improvement study to align transfusion practices with the American Society of Hematology's Choosing Wisely® campaign. Baseline transfusion rates were determined retrospectively for all major gynecologic surgical cases from 3/1/14 to 6/30/14. Data for the post-intervention period from 5/15/15 to 5/16/16 were captured prospectively. The primary outcome was transfusion within 72 h of surgery. Secondary outcomes included perioperative morbidity, mortality, number of units ordered per transfusion episode and cost. RESULTS: We identified 1281 surgical cases, 334 in the baseline and 947 in the post-implementation cohort. The baseline cohort was noted to have a higher median estimated blood loss (100 v. 75 mL, P < 0.01). Otherwise, there were no differences in clinical or perioperative characteristics between the two cohorts. The perioperative transfusion rate decreased from 24% to 11% (adjusted OR 0.27, 95% CI 0.16 to 0.45; P < 0.001). The perioperative laparotomy transfusion rate decreased from 48% to 23% (adjusted OR 0.21, 95% CI 0.12, 0.37; P < 0.001). The number of occurrences in which more than one unit of blood was ordered at a time decreased from 65% to 23%, P < 0.001. The incidence of surgical site infections declined in the post-intervention group, otherwise there were no differences in 30-day mortality, cardiac, venous thromboembolism or readmission rates between the groups. The projected cost savings was $161,112 over the 12-month intervention period. CONCLUSIONS: Implementation of an educational based transfusion reduction program was associated with substantial reductions in perioperative transfusions and cost without significant changes in morbidity or mortality.

The earlier the better: the role of palliative care consultation on aggressive end of life care, hospice utilization, and advance care planning documentation among gynecologic oncology patients.

PURPOSE: To evaluate the role of specialty palliative care consultation (PCC) on end of life care outcomes among terminally ill gynecologic oncology patients. METHODS: Retrospective chart review of currently deceased gynecologic oncology patients seen at a single, academic institution between October 2006 and October 2016. Clinical characteristics and outcomes were examined using descriptive statistics and logistic regression. RESULTS: Two hundred and four patients were eligible. Forty-one percent underwent at least one marker of aggressive care at the end of life. Most (53%) had a PCC prior to death, and of these most were inpatient (89%). Patients with a PCC had higher odds of hospice enrollment before death (OR 2.55, p = 0.016) and higher odds of advance care planning documentation before death (OR 6.79, p = < 0.001). Among patients with an inpatient PCC, 44% underwent a marker of aggressive medical care at the end of life and 82% enrolled in hospice before death. Among patients with an outpatient PCC, 25% underwent a marker of aggressive medical care at the end of life and 92% enrolled in hospice before death. Patients with outpatient PCC were engaged in palliative care longer than patients with inpatient PCC (median 106 days vs. 33 days prior to death). CONCLUSIONS: PCC increased hospice enrollment and advance care planning documentation. Patients with outpatient PCC had lower rates of aggressive medical care and higher rates of hospice enrollment when compared to inpatient PCC. Location of initial PCC plays an important role in end of life care outcomes.

Unusual indolent behavior of leiomyosarcoma of the vagina: Is observation a viable option?

•Primary leiomyosarcoma of the vagina is a rare disease.•We identified a case of unanticipated indolent behavior of vaginal leiomyosarcoma.•Observation or hormonal therapy may be viable option for select patients.

How low should we go: A systematic review and meta-analysis of the impact of restrictive red blood cell transfusion strategies in oncology.

BACKGROUND: Most non-oncologic clinical practice guidelines recommend restrictive allogeneic blood transfusion practices; however, there is a lack of consensus regarding the best transfusion practice in oncology. We conducted a systematic review of the literature to compare the efficacy and safety of restrictive versus liberal transfusion strategies in patients with cancer. METHODS: A literature search using MEDLINE, PUBMED and EMBASE identified all controlled studies comparing the use of restrictive with liberal transfusion in adult oncology participants up to August 10, 2015. Two review authors independently assessed studies for inclusion, extracted data and appraised the quality of the included studies. The primary outcomes of interest were blood utilization and all-cause mortality. RESULTS: Out of 4241 citations, six studies (3 randomized and 3 non-randomized) involving a total of 983 patients were included in the final review. The clinical context of the studies varied with 3 chemotherapy and 3 surgical studies. The overall risk of bias in all studies was moderate to high. Restrictive transfusion strategies were associated with a 36% reduced risk of receiving a perioperative transfusion (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.49-0.83). There was no difference in mortality between the strategies (RR 1.00, 95% CI 0.32-3.18). There were no differences in adverse events reported between the restrictive and liberal transfusion strategies. CONCLUSION: Restrictive strategy appears to decrease blood utilization without increasing morbidity or mortality in oncology. This review is limited by a paucity of high quality studies on this topic. Better designed studies are warranted.

Dying well: How equal is end of life care among gynecologic oncology patients?

OBJECTIVE: To identify disparities in utilization of end of life (EoL) resources by gynecologic oncology (GO) patients. METHODS: This retrospective analysis of the medical records of GO patients treated 1/2007-12/2011 and deceased 1/2012-8/2014 evaluated patient demographics, disease characteristics, and utilization of EoL resources. Chi-square, Fisher's exact test, Mann Whitney and Kruskal-Wallis tests were used for statistical analysis. RESULTS: Of 189 patients analyzed, 113 (60%) were white, 38 (20%) Hispanic, 31 (16%) black, and seven (4%) Asian. Ninety-five (48%) had ovarian cancer, 51 (26%) uterine, 47 (23%) cervical, seven (3%) vulvar/vaginal. In the last 30days of life (DoL), 18 (10%) had multiple hospital admissions, 10 (5%) admitted to the Intensive Care Unit (ICU), 30 (16%) multiple Emergency Room (ER) visits, 45 (24%) received aggressive medical care and eight (4%) received chemotherapy in the final 14 DoL. Furthermore, 54 (29%) had no Supportive Care referral and 29 (15%) no hospice referral. Only 46 (24%) had a Medical Power of Attorney (PoA) or Living Will (LW) on file. Non-white race was associated with increased odds of dying without hospice (OR 3.07; 95%CI [1.27, 2.46], p=0.013). However, non-white patients who enrolled in hospice did so earlier than white patients (42 v. 27days before death, p=0.054). Non-white patients were also significantly less likely to have PoA/LW documentation (24% v. 76%, p=0.009) even if enrolled in hospice (12% v. 31%, p=0.007). CONCLUSIONS: Significant racial disparities in hospice enrollment and PoA/LW documentation were seen in GO patients. This warrants further study to identify barriers to use of EoL resources.

Fighting cancer together: Development and implementation of shared medical appointments to standardize and improve chemotherapy education.

OBJECTIVE: Shared medical appointments offer a novel approach to improve efficiency and quality of care consistent with the goals of the Institute of Medicine. Our objective was to develop and implement a shared medical appointment for gynecologic cancer patients initiating chemotherapy. METHODS: We first assessed the level of interest in shared medical appointments among our patients and providers through qualitative interviews. Both patients and providers identified pre-chemotherapy as an optimal area to pilot shared medical appointments. We subsequently created a multidisciplinary team comprised of physicians, advanced practice providers, nurses, pharmacists, administrators, health education specialists and members of the Quality Improvement Department to establish a Shared Medical Appointment and Readiness Teaching (SMART) program for all gynecologic oncology patients initiating chemotherapy with platinum- and/or taxane-based regimens. We developed a standardized chemotherapy education presentation and provided patients with a tool kit that consisted of chemotherapy drug education, a guide to managing side effects, advance directives, and center contact information. RESULTS: From May 9, 2014 to June 26, 2015, 144 patients participated in 51 SMART visits. The majority of patients had ovarian cancer and were treated with carboplatin/paclitaxel. Surveyed patients reported being highly satisfied with the group visit and would recommend shared medical appointments to other patients. CONCLUSIONS: This model of care provides patient education within a framework of social support that empowers patients. Shared medical appointments for oncology patients initiating chemotherapy are both feasible and well accepted.

Perioperative blood transfusion in gynecologic oncology surgery: analysis of the National Surgical Quality Improvement Program Database.

OBJECTIVE: To use a large-scale multi-institutional dataset to quantify the prevalence of packed red blood cell transfusions and examine the associations between transfusion and perioperative outcomes in gynecologic cancer surgery. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) participant use file was queried for all gynecologic cancer cases between 2010 and 2012. Demographic, preoperative and intraoperative variables were compared between transfusion and non-transfusion groups using chi-squared, Fisher's exact and Wilcoxon rank-sum tests. The primary endpoint was 30-day composite morbidity. Secondary endpoints included composite surgical site infections, mortality and length of stay. RESULTS: A total of 8519 patients were analyzed, and 13.8% received a packed red blood cell transfusion. In the multivariate analysis, after adjusting for key clinical and perioperative factors, including preoperative anemia and case magnitude, transfusion was associated with higher composite morbidity (OR = 1.85, 95% CI 1.5-2.24), surgical site infections (OR 1.80, 95% CI 1.39-2.35), mortality (OR 3.38, 95% CI 1.80-6.36) and length of hospital stay (3.02 days v. 7.17 days, P < 0.001). CONCLUSIONS: Blood transfusions are associated with increased surgical wound infections, composite morbidity and mortality. Based on our analysis of the NSQIP database, transfusion practices in gynecologic cancer should be scrutinized. Examination of institutional practices and creation of transfusion guidelines for gynecologic malignancies could potentially result in better utilization of blood bank resources and clinical outcomes among patients.

Improved compliance with venous thromboembolism pharmacologic prophylaxis for patients with gynecologic malignancies hospitalized for nonsurgical indications did not reduce venous thromboembolism incidence.

OBJECTIVE: National guidelines recommend prophylactic anticoagulation for all hospitalized patients with cancer to prevent hospital-acquired venous thromboembolism (VTE). However, adherence to these evidence-based recommended practice patterns remains low. We performed a quality improvement (QI) project to increase VTE pharmacologic prophylaxis rates among patients with gynecologic malignancies hospitalized for nonsurgical indications and evaluated the resulting effect on rates of development of VTE. MATERIALS AND METHODS: In June 2011, departmental VTE practice guidelines were implemented for patients with gynecologic malignancies who were hospitalized for nonsurgical indications. A standardized VTE prophylaxis module was added to the admission electronic order sets. Outcome measures included number of admissions receiving VTE pharmacologic prophylaxis within 24 hours of admission; and number of potentially preventable hospital-acquired VTEs diagnosed within 30 and 90 days of discharge. Outcomes were compared between a preguideline implementation cohort (n = 99), a postguideline implementation cohort (n = 127), and a sustainability cohort assessed 2 years after implementation (n = 109). Patients were excluded if upon admission they had a VTE, were considered low risk for VTE, or had a documented contraindication to pharmacologic prophylaxis. RESULTS: Administration of pharmacologic prophylaxis within 24 hours of admission increased from 20.8% to 88.2% immediately following the implementation of guidelines, but declined to 71.8% in our sustainability cohort (P < 0.001). There was no difference in VTE incidence among the 3 cohorts [n = 2 (4.2%) vs n = 3 (3.9%) vs n = 3 (4.2%), respectively; P = 1.00]. CONCLUSIONS: Our QI project improved pharmacologic VTE prophylaxis rates. A small decrease in prophylaxis during the subsequent 2 years suggests a need for continued surveillance to optimize QI initiatives. Despite increased adherence to guidelines, VTE rates did not decline in this high-risk population.

Missed opportunities: Patterns of medical care and hospice utilization among ovarian cancer patients.

OBJECTIVES: To assess aggressive medical care, hospice utilization, and advance care documentation among ovarian cancer patients in the final thirty days of life. METHODS: Ovarian, fallopian tube, or primary peritoneal cancer patients registered at our institution during 2007-2011 were identified. Statistical analyses included Wilcoxon-Mann-Whitney, Chi-square analysis, and multivariate analysis. RESULTS: 183 patients met inclusion criteria. Median age at diagnosis was 58. Most were white and had advanced ovarian cancer. Fifty percent had experienced at least one form of aggressive care during the last 30days of life. Patients with provider recommendations to enroll in hospice were more likely to do so (OR 27.7, p=<0.001), with a median hospice stay of 18days before death. Seventy-five percent had an in-hospital DNR order and 33% had an out-of-hospital DNR order. These orders were created a median of 15 and 12days prior to death, respectively. Twenty-eight percent had a Medical Power of Attorney and 20% had a Living Will. These documents were created a median of 381 and 378days prior to death, respectively. CONCLUSIONS: Many ovarian cancer patients underwent some form of aggressive medical care in the last 30days of life. The time between hospice enrollment and death was short. Patients created Medical Power of Attorney and Living Will documents far in advance of death. DNR orders were initiated close to death.

Topical treatment of recurrent vaginal melanoma in situ with imiquimod: A case report.

► Vaginal melanoma in situ is a rare neoplasm with a paucity of data regarding the optimal management. ► More conservative approaches are needed to avoid the disfigurement, pain and postoperative complications associated with repeated surgical interventions. ► Imiquimod may prove to be a useful treatment modality for patients with vulvar or vaginal melanoma in situ.