Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 372
Filtrar
Mais filtros










Base de dados
Intervalo de ano de publicação
2.
Am J Obstet Gynecol ; 2020 Feb 25.
Artigo em Inglês | MEDLINE | ID: mdl-32109459

RESUMO

BACKGROUND: Black women experience poorer survival compared to white women across all endometrial cancer stages and histologies. The incidence of endometrial cancer is 30% lower in black women compared to white women, yet mortality is 80% higher in black women. Differences in adherence to evidence-based guidelines have been proposed to be major contributors to this disparity. OBJECTIVES: We examined whether adherence to evidence-based treatment recommendations for endometrial cancer could mitigate survival disparities between black and white women. STUDY DESIGN: The National Cancer Database was used to identify women with endometrial cancer treated from 2004-2016. We established five evidence-based quality metrics based on review of primary literature and accepted guidelines: surgical treatment within 6 weeks of diagnosis (Q1), use of minimally invasive surgery (stage I-IIIC) (Q2), pelvic nodal assessment (high risk tumors) (Q3), adjuvant radiation (high intermediate risk) (Q4), systemic chemotherapy (stage III-IV) (Q5). The rates of 30 and 90-day mortality, and 5-year survival were compared between black and white women. To determine the influence of quality on outcomes, we compared outcomes among perfectly adherent black and white women with stage I and III endometrial cancer. RESULTS: We identified 310,208 women including 35,035 (11.3%) black women and 275,173 (88.3%) white women. Black women were less likely than white women to receive Q1 (65.8 vs. 75.6%), Q2 (58.5 vs. 72.9%), Q3 (71.3 vs.74.2%), and Q5 (72.7 vs.73.2%) (P <0.05 for all). Adherence to each quality metrics was associated with improved survival. Among women with stage I disease, perfect adherence to the relative quality metrics was seen in 53.1% of white and 41.5% of black women. Among perfectly adherent stage I patients, outcomes in black women improved relative to unselected black women, however, they still experienced higher risk of 30-day (aRR=2.25; 95% CI, 1.30-3.90), 90-day (aRR=1.84; 95% CI, 1.23-2.76), and 5-year mortality (aHR=1.42; 95% CI, 1.26-1.59) compared to similar white women. Among women with stage III tumors, perfect adherence to the relative quality metrics was seen in 56.6% of white and 44.1% of black women. Perfectly adherent black women with stage III disease had improved outcomes, but remained at increased risk of 30-day (aRR=1.86; 95% CI, 1.01-3.44) and 5-year mortality (aHR=1.35; 95% CI, 1.22-1.50) compared to white women. CONCLUSIONS: Black women are less likely than white women with endometrial cancer to receive evidence-based care. However, receipt of evidence-based care mitigates but does not eliminate racial disparities in outcomes and black women remain at greater risk of death from endometrial cancer.

3.
Gynecol Oncol ; 2020 Feb 21.
Artigo em Inglês | MEDLINE | ID: mdl-32094021

RESUMO

OBJECTIVE: To examine the risk of nodal metastases in a contemporary cohort of women based on pathologic risk factors including histology, depth of invasion, tumor grade, and lymphovascular space invasion. METHODS: Women with endometrial cancer who underwent hysterectomy from 2004 to 2016 who were registered in the National Cancer Database were analyzed. Patients were stratified by T stage: T1A (<50% myometrial invasion), T1B (>50% myometrial invasion) and T2 (cervical involvement). Lymph node metastases were assessed in relation to tumor T stage and grade, and further stratified by lymphovascular space invasion. RESULTS: We identified 161,960 patients. The rate of nodal metastases within the endometrioid histology cohort was 2.2% for T1A cancers, 12.8% for T1B cancers and 19.9% for T2 cancers. For stage TIA cancers, the percent of patients with positive nodes increased from 1.1% for grade 1 cancers, to 2.9% for grade 2 cancers to 4.8% for grade 3 cancers. The corresponding rates of nodal metastases for stage T1B cancers were 8.6%, 13.7%, and 16.9%, respectively. For T1A cancers without lymphovascular space invasion, nodal metastases ranged from 0.6% in those with grade 1 cancers to 3.0% for grade 3 cancers. The corresponding risk of nodal disease ranged from 11.8% to 13.9% for T1A cancers with lymphovascular space invasion. CONCLUSIONS: There was a sequential increase in the risk of lymph node metastases based on depth of uterine invasion, tumor grade, and the presence of lymphovascular space invasion. The overall rate of nodal metastasis is lower than reported in the original GOG 33.

5.
Am J Obstet Gynecol ; 222(1): 58.e1-58.e10, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31344350

RESUMO

BACKGROUND: Complex oncologic surgeries, including those for endometrial cancer, increasingly have been concentrated to greater-volume centers, owing to previous research that has demonstrated associations between greater surgical volume and improved outcomes. There is a potential for concentration of care to have unwanted consequences, including cost burden, delayed treatment, patient dissatisfaction, and possibly worse clinical outcomes, especially for more vulnerable populations. OBJECTIVE: To describe changes in site of care for patients with endometrial cancer in New York State and to determine whether the distance women traveled for hysterectomy has changed over time. STUDY DESIGN: We used the New York Statewide Planning and Research Cooperative System to identify women with endometrial cancer who underwent hysterectomy from 2000 to 2014. Demographic and clinical data as well as hospital data were collected. Trends in travel distance (straight-line distance) were analyzed within all hospital referral regions and differences in travel distance over times and across sociodemographic characteristics analyzed. RESULTS: We identified 41,179 subjects. The number of hospitals and surgeons performing hysterectomy decreased across all hospital referral regions over time. The decline in the number of hospitals caring for women with endometrial cancer ranged from -16.7% in Syracuse (12 to 10 hospitals) to -76.5% in Rochester (17 to 4 hospitals). Similarly, the percentage of surgeons within a given hospital referral region operating on women declined from -45.2% in Buffalo (84-46 surgeons) to -77.8% in Albany (72 to 16 surgeons). The median distance to the index hospital for patients increased in all Hospital Referral Regions. For residents in Binghamton, median travel distance increased by 46.9 miles (95% confidence interval, 33.8-60.0) whereas distance increased in Elmira by 19.7 miles (95% confidence interval, 7.3-32.1) and by 12.4 miles (95% confidence interval, 6.4-18.4) in Albany. For residents of Binghamton and Albany, there was a greater than 100% increase in distance traveled over the 15-year time period, with increases of 551.8% (46.9 miles; 95% confidence interval, 33.8-60.0 miles) and 102.5% (12.4 miles; 95% confidence interval, 6.4-18.4 miles), respectively. Travel distance increased for all races and regardless of insurance status but was greatest for white patients and those with private insurance (P<.0001 for both). CONCLUSION: The number of surgeons and hospitals caring for women with endometrial cancer in New York State has decreased, whereas the distance that patients travel to receive care has increased over time.

6.
JAMA Netw Open ; 2(12): e1918007, 2019 Dec 02.
Artigo em Inglês | MEDLINE | ID: mdl-31860106

RESUMO

Importance: Citation analysis is a bibliometric method that uses citation rates to evaluate research performance. This type of analysis can identify the articles that have shaped the modern history of obstetrics and gynecology (OBGYN). Objectives: To identify and characterize top-cited OBGYN articles in the Institute for Scientific Information Web of Science's Science Citation Index Expanded and to compare top-cited OBGYN articles published in specialty OBGYN journals with those published in nonspecialty journals. Design, Setting, and Participants: Cross-sectional bibliometric analysis of top-cited articles that were indexed in the Science Citation Index Expanded from 1980 to 2018. The Science Citation Index Expanded was queried using search terms from the American Board of Obstetrics and Gynecology's 2018 certifying examination topics list. The top 100 articles from all journals and the top 100 articles from OBGYN journals were evaluated for specific characteristics. Data were analyzed in March 2019. Main Outcomes and Measures: The articles were characterized by citation number, publication year, topic, study design, and authorship. After excluding articles that featured on both lists, top-cited articles were compared. Results: The query identified 3 767 874 articles, of which 278 846 (7.4%) were published in OBGYN journals. The top-cited article was published by Rossouw and colleagues in JAMA (2002). Top-cited articles published in nonspecialty journals were more frequently cited than those in OBGYN journals (median [interquartile range], 1738 [1490-2077] citations vs 666 [580-843] citations, respectively; P < .001) and were more likely to be randomized trials (25.0% vs 2.2%, respectively; difference, 22.8%; 95% CI, 13.5%-32.2%; P < .001). Whereas articles from nonspecialty journals focused on broad topics like osteoporosis, articles from OBGYN journal focused on topics like preeclampsia and endometriosis. Conclusions and Relevance: This study found substantial differences between top-cited OBGYN articles published in nonspecialty vs OBGYN journals. These differences may reflect the different goals of the journals, which work together to ensure optimal dissemination of impactful articles.

7.
Am J Perinatol ; 2019 Nov 04.
Artigo em Inglês | MEDLINE | ID: mdl-31683325

RESUMO

OBJECTIVE: Severe preeclampsia complicates roughly 1% of all pregnancies. One defining feature of severe preeclampsia is new onset visual disturbance. The accessibility of the choroid to high-resolution, noninvasive imaging makes it a reasonable target of investigation for disease prediction, stratification, or monitoring in preeclampsia. This study aimed to compare subfoveal choroidal thickness between women with severe preeclampsia and those with normotensive pregnancies, and to investigate associations between such findings and other indicators of disease severity, including gestational age and serum angiogenic factors. STUDY DESIGN: We designed a case-control study comprised of 36 women diagnosed with severe preeclampsia (cases) matched to 37 normotensive women (controls) by race/ethnicity and parity, all diagnosed in the postpartum period. All patients underwent enhanced depth imaging spectral-domain optical coherence tomography and serum analysis. RESULTS: Cases showed no difference in subfoveal choroidal thickness compared with controls (p = 0.65). Amongst cases, subfoveal choroidal thickness and gestational age at delivery were inversely related (r = 0.86, p < .001). There was a positive association of placental growth factor with subfoveal choroidal thickness amongst cases (r = 0.54, p = 0.002). CONCLUSION: This study suggests a relationship between the degree of disease severity and the magnitude of choroidal thickening. We also show an association between this index and placental growth factor level in the postpartum period.

8.
JAMA ; 322(19): 1869-1876, 2019 11 19.
Artigo em Inglês | MEDLINE | ID: mdl-31742629

RESUMO

Importance: The American College of Obstetricians and Gynecologists recommends a delay in umbilical cord clamping in term neonates for at least 30 to 60 seconds after birth. Most literature supporting this practice is from low-risk vaginal deliveries. There are no published data specific to cesarean delivery. Objective: To compare maternal blood loss with immediate cord clamping vs delayed cord clamping in scheduled cesarean deliveries at term (≥37 weeks). Design, Setting, and Participants: Randomized clinical trial performed at 2 hospitals within a tertiary academic medical center in New York City from October 2017 to February 2018 (follow-up completed March 15, 2018). A total of 113 women undergoing scheduled cesarean delivery of term singleton gestations were included. Interventions: In the immediate cord clamping group (n = 56), cord clamping was within 15 seconds after birth. In the delayed cord clamping group (n = 57), cord clamping was at 60 seconds after birth. Main Outcomes and Measures: The primary outcome was change in maternal hemoglobin level from preoperative to postoperative day 1, which was used as a proxy for maternal blood loss. Secondary outcomes included neonatal hemoglobin level at 24 to 72 hours of life. Results: All of the 113 women who were randomized (mean [SD] age, 32.6 [5.2] years) completed the trial. The mean preoperative hemoglobin level was 12.0 g/dL in the delayed and 11.6 g/dL in the immediate cord clamping group. The mean postoperative day 1 hemoglobin level was 10.1 g/dL in the delayed group and 9.8 g/dL in the immediate group. There was no significant difference in the primary outcome, with a mean hemoglobin change of -1.90 g/dL (95% CI, -2.14 to -1.66) and -1.78 g/dL (95% CI, -2.03 to -1.54) in the delayed and immediate cord clamping groups, respectively (mean difference, 0.12 g/dL [95% CI, -0.22 to 0.46]; P = .49). Of 19 prespecified secondary outcomes analyzed, 15 showed no significant difference. The mean neonatal hemoglobin level, available for 90 neonates (79.6%), was significantly higher with delayed (18.1 g/dL [95% CI, 17.4 to 18.8]) compared with immediate (16.4 g/dL [95% CI, 15.9 to 17.0]) cord clamping (mean difference, 1.67 g/dL [95% CI, 0.75 to 2.59]; P < .001). There was 1 unplanned hysterectomy in each group. Conclusions and Relevance: Among women undergoing scheduled cesarean delivery of term singleton pregnancies, delayed umbilical cord clamping, compared with immediate cord clamping, resulted in no significant difference in the change in maternal hemoglobin level at postoperative day 1. Trial Registration: ClinicalTrials.gov Identifier: NCT03150641.


Assuntos
Cesárea , Constrição , Hemoglobinas/análise , Hemorragia Pós-Operatória/prevenção & controle , Cordão Umbilical , Adulto , Gasometria , Procedimentos Cirúrgicos Eletivos , Feminino , Sangue Fetal/química , Humanos , Concentração de Íons de Hidrogênio , Recém-Nascido/sangue , Masculino , Hemorragia Pós-Operatória/epidemiologia , Gravidez , Nascimento a Termo , Fatores de Tempo
9.
Obstet Gynecol ; 134(6): 1132-1143, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31764721

RESUMO

OBJECTIVE: To identify use and outcomes of simple hysterectomy compared with radical hysterectomy for women with early-stage cervical cancer. METHODS: The National Cancer Database was used to review the cases of women with stage IA2 and IB1 (2 cm or less) cervical cancer from 2004 to 2015. Patients were classified based on whether they underwent simple or radical hysterectomy. Survival was examined after propensity score weighting. RESULTS: Simple hysterectomy was performed in 44.6% of women with stage IA2 (n=1,530) and 35.3% of those with stage IB1 (n=3,931) tumors. Rates of simple hysterectomy increased from 37.8% to 52.7% from 2004 to 2014 for stage IA2 cancers and from 29.7% to 43.8% between 2004 and 2013 for stage IB1 cancers. For stage IA2 cancers, younger women and those treated at an academic medical center were less likely to undergo simple hysterectomy. For stage IB1 cancers, black women were more likely to undergo simple hysterectomy, and those treated at an academic medical center were less likely to undergo simple hysterectomy. After propensity score weighting, there was no association between route of hysterectomy and survival for stage IA2 cancers (hazard ratio [HR] 0.70, 95% CI 0.41-1.20, 5-year survival 95.1% for radical hysterectomy vs 97.6% for simple hysterectomy). For stage IB1 cancers, patients who underwent simple hysterectomy were at 55% increased risk of death (HR 1.55, 95% CI 1.18-2.03, and 5-year survival was 95.3% for radical hysterectomy vs 92.4% for simple hysterectomy). CONCLUSION: Although there was no association between surgical radicality and survival for women with stage IA2 tumors, there was a 55% increase in mortality for women with stage IB1 neoplasms who underwent simple compared with radical hysterectomy. Radical hysterectomy is the treatment of choice for women with stage IB1 cervical cancer.

10.
J Matern Fetal Neonatal Med ; : 1-7, 2019 Nov 19.
Artigo em Inglês | MEDLINE | ID: mdl-31744356

RESUMO

Background: Placenta accreta spectrum (PAS) is a spectrum of conditions in which the placenta is abnormally adherent and invades the uterine wall. This invasion can cause life-threatening hemorrhage and lead to significant adverse maternal outcomes. Numerous studies have shown an association between treatment of PAS at high volume, specialized centers and improved maternal outcomes; however, little is known about how these data have influenced practice.Objective: The objective of the study was to examine the patterns of care for women with placenta accreta spectrum over time.Study design: Data from New York Statewide Planning and Research Cooperative System (SPARCS) from 2000 to 2017 was used for this analysis. The study cohort comprised of women aged 15-54 years with PAS who underwent a hysterectomy during their delivery hospitalization. Study outcomes included severe maternal morbidity as defined by the Centers for Disease Control and Prevention, surgical complications, and transfusion. Hospitals were stratified into tertiles based on the volume of PAS hysterectomy cases. Patient demographic and clinical characteristics were compared across volume tertiles. Random intercept log-linear regression models with Poisson distributions and log link functions were fit to examine the association between hospital PAS volume and the outcomes of interest.Results: A total of 1958 women with PAS who underwent hysterectomy at 123 hospitals were identified. The number of hospitals providing care ranged from 46 centers in 2000 to 52 hospitals in 2016. The median hospital-level case volume of PAS was 1 (interquartile range [IQR], 1-2) in 2000 and rose slightly to 2 (IQR, 1-4) by 2016. The PAS volume cut-point for the top decile of hospitals was three cases in 2000 and increased to six cases in 2016. There was no significant change in the median travel distance for women with PAS over time. The rate of severe maternal morbidity increased significantly from 14.1% (95% CI: 7.8-24.0%) in 2000 to 19.0% (95% CI: 13.6-25.8%) in 2016. Transfusion occurred in 66.2% (95% CI: 54.6-76.1%) of cases in 2000 compared to 60.1% (95% CI: 52.3-67.4%) in 2016. Surgical complications occurred in 16.9% (95% CI: 9.9-27.3%) of cases in 2000 to 24.7% (95% CI: 18.6-32.0) in 2016. There was no difference in the adjusted rates of transfusion or surgical complications based on hospital volume. Compared to low-volume centers, the risk of severe maternal morbidity was reduced by 33% (aRR = 0.67; 95% CI: 0.50-0.90) at the intermediate volume centers.Conclusion: There has been little change in the patterns of care for women with PAS in New York State. While the volume of patients with PAS has increased at the highest volume centers, a large number of relatively low-volume centers still provide care for a significant number of women with PAS.

11.
Obstet Gynecol ; 2019 Nov 04.
Artigo em Inglês | MEDLINE | ID: mdl-31698372

RESUMO

OBJECTIVE: To identify use and outcomes of simple hysterectomy compared with radical hysterectomy for women with early-stage cervical cancer. METHODS: The National Cancer Database was used to review the cases of women with stage IA2 and IB1 (2 cm or less) cervical cancer from 2004 to 2015. Patients were classified based on whether they underwent simple or radical hysterectomy. Survival was examined after propensity score weighting. RESULTS: Simple hysterectomy was performed in 44.6% of women with stage IA2 (n=1,530) and 35.3% of those with stage IB1 (n=3,931) tumors. Rates of simple hysterectomy increased from 37.8% to 52.7% from 2004 to 2014 for stage IA2 cancers and from 29.7% to 43.8% between 2004 and 2013 for stage IB1 cancers. For stage IA2 cancers, younger women and those treated at an academic medical center were less likely to undergo simple hysterectomy. For stage IB1 cancers, black women were more likely to undergo simple hysterectomy, and those treated at an academic medical center were less likely to undergo simple hysterectomy. After propensity score weighting, there was no association between route of hysterectomy and survival for stage IA2 cancers (hazard ratio [HR] 0.70, 95% CI 0.41-1.20, 5-year survival 95.1% for radical hysterectomy vs 97.6% for simple hysterectomy). For stage IB1 cancers, patients who underwent simple hysterectomy were at 55% increased risk of death (HR 1.55, 95% CI 1.18-2.03, and 5-year survival was 95.3% for radical hysterectomy vs 92.4% for simple hysterectomy). CONCLUSION: Although there was no association between surgical radicality and survival for women with stage IA2 tumors, there was a 55% increase in mortality for women with stage IB1 neoplasms who underwent simple compared with radical hysterectomy. Radical hysterectomy is the treatment of choice for women with stage IB1 cervical cancer.

12.
Paediatr Perinat Epidemiol ; 33(6): 405-411, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31642555

RESUMO

BACKGROUND: Roughly, a fourth of all placental abruption cases have an acute aetiologic underpinning, but the causes of acute abruption are poorly understood. Studies indicate that symptoms of stress, depression, and anxiety during pregnancy may be associated with a higher risk of abruption. OBJECTIVE: We examined the rate of abruption in the 2 hours immediately following outbursts of anger. METHODS: In a multicentre case-crossover study, we interviewed 663 women diagnosed with placental abruption admitted to one of the seven Peruvian hospitals between January 2013 and August 2015. We asked women about outbursts of anger before symptom onset and compared this with their usual frequency of anger during the week before abruption. RESULTS: The rate of abruption was 2.83-fold (95% confidence interval [CI] 1.85, 4.33) higher in the 2 hours following an outburst of anger compared with other times. The rate ratio (RR) was lower for women who completed technical school or university (RR 1.38, 95% CI 0.52, 3.69) compared to women with secondary school education or less (RR 3.73, 95% CI 2.32, 5.99, P-homogeneity = .07). There was no evidence that the association between anger episodes and abruption varied by hypertensive disorders of pregnancy (ie preeclampsia/ eclampsia) or antepartum depressive symptoms. CONCLUSION: There was a higher rate of abruption in the 2 hours following outbursts of anger compared with other times, providing potential clues to the aetiologic mechanisms of abruption of acute onset.

13.
JNCI Cancer Spectr ; 3(3): pkz039, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31535077

RESUMO

Background: Although safety-net hospitals (SNH) provide a valuable role serving vulnerable patients, the quality of gynecologic oncology care at these hospitals remains inadequately documented. We examined the quality of care at SNH for women with gynecologic cancers. Methods: We used the National Cancer Database to identify hospitals that treated patients with uterine, ovarian, or cervical cancer from 2004 to 2015. Hospitals with the greatest proportion of uninsured patients or Medicaid beneficiaries were defined as SNH. Quality metrics were derived from evidence-based recommendations. Thirty-day mortality, readmission rates, and 5-year survival were calculated. Multivariable models were developed to determine the association between treatment at SNH and outcomes. Results: Overall, 594 750 patients diagnosed with gynecologic cancer were treated at 1340 hospitals. Compared with non-SNH, patients at SNH were younger, more frequently racial minorities, low income, and had more aggressive histologies and advanced-stage tumors. SNH had lower rates of minimally invasive surgery for uterine cancer (62.3% vs 75.9%, P < .0001), debulking for ovarian cancer (83.6% vs 86.9%, P < .05), and lymph node assessment for all three cancer types (P < .05). Rates of chemotherapy for uterine and ovarian cancer was greater whereas concurrent chemoradiation for cervical cancer was lower (P < .05 for all). Thirty-day mortality and readmission rates were equivalent. Mortality was moderately worse for patients with stage IV ovarian cancer and stage II-III cervical cancer (P < .05) but were otherwise equivalent. Conclusions: After adjusting for patient and tumor characteristics, women with gynecologic cancers treated at SNH receive lower-quality surgical care and equivalent medical care and a subset of these patients has modest decreases in survival.

14.
Hypertension ; 74(5): 1089-1095, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31495278

RESUMO

We estimated changes in the prevalence of chronic hypertension among pregnant women and evaluated the extent to which changes in obesity and smoking were associated with these trends. We designed a population-based cross-sectional analysis of over 151 million women with delivery-related hospitalizations in the United States, 1970 to 2010. Maternal age, year of delivery (period), and maternal year of birth (birth cohort), as well as race, were examined as risk factors for chronic hypertension. Prevalence rates and rate ratios with 95% CIs of chronic hypertension in relation to age, period, and birth cohort were derived through age-period-cohort models. We also examined how changes in obesity and smoking rates influenced age-period-cohort effects. The overall prevalence of chronic hypertension was 0.63%, with black women (1.24%) having more than a 2-fold higher rate than white women (0.53%; rate ratio, 2.31; 95% CI, 2.30-2.32). In the age-period-cohort analysis, the rate of chronic hypertension increased sharply with advancing age and period from 0.11% in 1970 to 1.52% in 2010 (rate ratio, 13.41; 95% CI, 13.22-13.61). The rate of hypertension increased, on average, by 6% (95% CI, 5-6) per year, with the increase being slightly higher among white (7%; 95% CI, 6%-7%) than black (4%; 95% CI, 3%-4%) women. Adjustments for changes in rates of obesity and smoking were not associated with age and period effects. We observed a substantial increase in chronic hypertension rates by age and period and an over 2-fold race disparity in chronic hypertension rates.


Assuntos
Afro-Americanos/estatística & dados numéricos , Hipertensão Induzida pela Gravidez/diagnóstico , Hipertensão Induzida pela Gravidez/epidemiologia , Idade Materna , Obesidade/complicações , Fumar/efeitos adversos , Adolescente , Adulto , Fatores Etários , Doença Crônica , Estudos Transversais , Bases de Dados Factuais , Progressão da Doença , Feminino , Humanos , Hipertensão Induzida pela Gravidez/tratamento farmacológico , Pessoa de Meia-Idade , Gravidez , Prevalência , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Estados Unidos , Adulto Jovem
15.
Am J Obstet Gynecol ; 221(6): 663-664, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31472108
16.
Gynecol Oncol ; 155(1): 13-20, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31395371

RESUMO

OBJECTIVE: While women with stage III endometrial cancer are often treated with chemotherapy and external beam radiation, the optimal sequence of these modalities is unknown. We examined the association between the sequence of chemotherapy (CT) and external beam radiation therapy (RT) on survival for women with stage IIIC endometrial carcinoma. METHODS: The National Cancer Database was used to identify women with stage IIIC endometrial carcinoma treated with adjuvant CT and RT from 2004 to 2015. Patients were stratified based on the sequence of therapy: RT before CT, CT before RT, or concurrent therapy. The association between treatment sequence and mortality was examined through a weighted propensity score analysis. RESULTS: A total of 6981 patients were identified, including 5116 (73.3%) who received CT before RT, 696 (10.0%) who received RT before CT, and 1169 (16.7%) who received concurrent therapy. The use of CT-RT increased from 39.9% in 2004 to 75.5% in 2015, while use of RT-CT decreased from 34.0% to 4.4% and concurrent therapy decreased from 26.1% to 20.2% over the same period (P < 0.001). Compared to CT-RT, there was no difference in risk of mortality with RT before CT (HR = 1.01; 95% CI, 0.86-1.19) while concurrent therapy was associated with a 47% increased risk of mortality (HR = 1.47; 95% CI, 1.31-1.66). In a sensitivity analysis combining the groups that received RT first (RT before CT or concurrent RT-CT), mortality was 25% higher (HR = 1.25; 95% CI, 1.13-1.39) compared to a strategy of CT followed by RT. CONCLUSION: Among women with stage IIIC endometrial carcinoma treated with combination chemotherapy and external beam radiation, a strategy employing chemotherapy first is associated with improved survival compared to concurrent therapy.


Assuntos
Neoplasias do Endométrio/tratamento farmacológico , Neoplasias do Endométrio/radioterapia , Idoso , Idoso de 80 Anos ou mais , Quimiorradioterapia Adjuvante , Neoplasias do Endométrio/patologia , Neoplasias do Endométrio/cirurgia , Feminino , Humanos , Histerectomia , Pessoa de Meia-Idade , Gradação de Tumores , Estadiamento de Neoplasias
17.
J Matern Fetal Neonatal Med ; : 1-5, 2019 Aug 12.
Artigo em Inglês | MEDLINE | ID: mdl-31370705

RESUMO

Introduction: Shoulder dystocia complicates up to 3% of vaginal births. The clinical ability to predict shoulder dystocia is limited, especially among diabetic women. We sought to evaluate if fetal growth trajectory measured from ultrasonographic (US) estimated fetal weight (EFW) percentiles was associated with increased risk for shoulder dystocia. Methods: We performed a case-control study among women diagnosed with diabetes at a single institution between 2005 and 2015. Two diabetic controls without shoulder dystocia based on the year of delivery were included for each woman with a shoulder dystocia. Women with a single EFW measurement, delivery by cesarean, or multiple gestation were excluded. Demographic and US data were collected. Fetal growth trajectory was calculated from EFW measurements in the last two growth ultrasound scans performed closest to delivery. We compared the odds of EFW percentile change per week above specific thresholds for shoulder dystocia cases versus controls. The following cutoffs were generated: a mean percentile per week increase of > 0%, ≥ 0.5%, ≥ 1%, and ≥ 2%. Among those with EFW percentile changes that decreased (<0%), we evaluated whether odds of an abdominal circumference (AC) > 75th percentile or an EFW > 75th percentile was higher for women with shoulder dystocia. The primary exposure was increased growth trajectory. Secondary outcomes included analysis of the following adverse neonatal outcomes: (i) low 5 minutes Apgar score, (ii) rates of NICU admission, and (iii) neonatal demise. Results: Of 3954 diabetics, we identified 68 cases with shoulder dystocia and 136 controls who did not have shoulder dystocia. Women who experienced a shoulder dystocia were more likely to be of advanced maternal age as compared to those without a shoulder dystocia (41.9% versus 23.5, p = .01); all other demographic characteristics were similar between groups. At growth trajectory cutoffs of > 0%, ≥ 0.5%, ≥ 1%, and ≥ 2% per week, odds ratios were increased among shoulder dystocia cases versus controls (OR = 1.8, 95% confidence interval (CI) = 0.9-3.3; OR = 1.6, 95% CI = 0.8-3.2; OR = 1.7, 95% CI = 0.7-3.9; and OR = 1.8, 95% CI = 0.6-5.3; respectively); however, this was not statistically significant. For women with fetal growth trajectories that decreased (< 0%), shoulder dystocia was associated with increased odds of fetal AC > 75th percentile and overall growth > 75th percentile (OR = 3.3, 95% CI = 1.5-7.1, OR = 4.8, 95% CI = 1.3-17.4, respectively). There was no difference in neonatal outcomes between shoulder dystocia cases and controls. Conclusion: Future research is required to determine if fetal growth velocity proves to be a useful tool in identifying women at increased risk for shoulder dystocia. Larger studies are required for precise estimates of risk, and associated neonatal outcomes.

18.
Neurology ; 93(12): e1148-e1158, 2019 09 17.
Artigo em Inglês | MEDLINE | ID: mdl-31420459

RESUMO

OBJECTIVE: To test whether abruption during pregnancy is associated with long-term cerebrovascular disease by assessing the incidence and mortality from stroke among women with abruption. METHODS: We designed a population-based prospective cohort study of women who delivered in Denmark from 1978 to 2010. We used data from the National Patient Registry, Causes of Death Registry, and Danish Birth Registry to identify women with abruption, cerebrovascular events, and deaths. The outcomes included deaths resulting from stroke and nonfatal ischemic and hemorrhagic strokes. We fit Cox proportional hazards regression models for stroke outcomes, adjusting for the delivery year, parity, education, and smoking. RESULTS: The median (interquartile range) follow-up in the nonabruption and abruption groups was 15.9 (7.8-23.8) and 16.2 (9.6-23.1) years, respectively, among 828,289 women with 13,231,559 person-years of follow-up. Cerebrovascular mortality rates were 0.8 and 0.5 per 10,000 person-years among women with and without abruption, respectively (hazard ratio [HR] 1.6, 95% confidence interval [CI] 0.9-3.0). Abruption was associated with increased rates of nonfatal ischemic stroke (HR 1.4, 95% CI 1.1-1.7) and hemorrhagic stroke (HR 1.4, 95% CI 1.1-1.9). The association of abruption and stroke was increased with delivery at <34 weeks, when accompanied by ischemic placental disease, and among women with ≥2 abruptions. These associations are less likely to have been affected by unmeasured confounding. CONCLUSION: Abruption is associated with increased risk of cerebrovascular morbidity and mortality. Disruption of the hemostatic system manifesting as ischemia and hemorrhage may indicate shared etiologies between abruption and cerebrovascular complications.


Assuntos
Descolamento Prematuro da Placenta/diagnóstico , Descolamento Prematuro da Placenta/epidemiologia , Transtornos Cerebrovasculares/diagnóstico , Transtornos Cerebrovasculares/epidemiologia , Vigilância da População , Adulto , Estudos de Coortes , Dinamarca/epidemiologia , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , Vigilância da População/métodos , Gravidez , Estudos Prospectivos , Sistema de Registros , Fatores de Risco , Adulto Jovem
20.
Obstet Gynecol ; 134(2): 250-260, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31306333

RESUMO

OBJECTIVE: To examine the rate of opioid use for gynecologic surgical procedures and to investigate persistent opioid use among those women who received an initial opioid prescription. METHODS: A retrospective cohort study using the MarketScan database was performed. MarketScan is a claims-based data source that captures claims from more than 50 million privately insured patients and 6 million Medicaid enrollees from 12 states. We identified women who underwent major and minor gynecologic surgery from 2009 to 2016. Among women who received an opioid prescription, new persistent opioid use was defined as receipt of one or more opioid prescriptions from 90 to 180 days after surgery with no intervening additional procedures or anesthesia. Multivariable models were used to examine associations between clinical characteristics and any use and new persistent use of opioids. RESULTS: A total of 729,625 patients were identified. Overall, 60.0% of patients received a perioperative opioid prescription. Receipt of an opioid prescription ranged from 36.7% in those who underwent dilation and curettage to 79.5% of patients who underwent minimally invasive hysterectomy. Among patients who received a perioperative opioid prescription, the rate of new persistent opioid use overall was 6.8%. The rate of new persistent opioid use was 4.8% for myomectomy, 6.6% for minimally invasive hysterectomy, 6.7% for abdominal hysterectomy, 6.3% for endometrial ablation, 7.0% for tubal ligation, and 7.2% for dilation and curettage (P<.001). In a multivariable model, patients who underwent dilation and curettage and endometrial ablation were at highest risk for new persistent opioid use. Younger patients, Medicaid recipients, and patients with depression, anxiety, and substance use disorder more commonly had new persistent opioid use (P<.001 for all). Among women who received an opioid prescription, the rate of new persistent opioid use decreased over time from 7.0% in 2010 to 5.5% in 2016 (P<.001). CONCLUSION: The rate of new persistent opioid use after major and minor gynecologic procedures is substantial.

SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA