Placenta previa percreta with surrounding organ involvement: a proposal for management.

Placenta accreta spectrum encompasses cases where the placenta is morbidly adherent to the myometrium. Placenta percreta, the most severe form of placenta accreta spectrum (grade 3E), occurs when the placenta invades through the myometrium and possibly into surrounding structures next to the uterine corpus. Maternal morbidity of placenta percreta is high, including severe maternal morbidity in 82.1% and mortality in 1.4% in the recent nationwide U.S. statistics. Although cesarean hysterectomy is commonly performed for patients with placenta accreta spectrum, conservative management is becoming more popular because of reduced morbidity in select cases. Treatment of grade 3E disease involving the urinary bladder, uterine cervix, or parametria is surgically complicated due to the location of the invasive placenta deep in the maternal pelvis. Cesarean hysterectomy in this setting has the potential for catastrophic hemorrhage and significant damage to surrounding organs. We propose a step-by-step schema to evaluate cases of grade 3E disease and determine whether immediate hysterectomy or conservative management, including planned delayed hysterectomy, is the most appropriate treatment option. The approach includes evaluation in the antenatal period with ultrasound and magnetic resonance imaging to determine suspicion for placenta previa percreta with surrounding organ involvement, planned cesarean delivery with a multidisciplinary team including experienced pelvic surgeons such as a gynecologic oncologist, intra-operative assessment including gross surgical field exposure and examination, cystoscopy, and consideration of careful intra-operative transvaginal ultrasound to determine the extent of placental invasion into surrounding organs. This evaluation helps decide the safety of primary cesarean hysterectomy. If safely resectable, additional considerations include intra-operative use of uterine artery embolization combined with tranexamic acid injection in cases at high risk for pelvic hemorrhage and ureteral stent placement. Availability of resuscitative endovascular balloon occlusion of the aorta is ideal. If safe resection is concerned, conservative management including planned delayed hysterectomy at around 4 weeks from cesarean delivery in stable patients is recommended.

Trends, characteristics, and outcomes of placenta accreta spectrum: a national study in the United States.

BACKGROUND: Although an infrequent occurrence, the placenta can adhere abnormally to the gravid uterus leading to significantly high maternal morbidity and mortality during cesarean delivery. Contemporary national statistics related to a morbidly adherent placenta, referred to as placenta accreta spectrum, are needed. OBJECTIVE: This study aimed to examine national trends, characteristics, and perioperative outcomes of women who underwent cesarean delivery for placenta accreta spectrum in the United States. STUDY DESIGN: This is a population-based retrospective, observational study querying the National Inpatient Sample. The study cohort included women who underwent cesarean delivery from October 2015 to December 2017 and had a diagnosis of placenta accreta spectrum. The main outcome measures were patient characteristics and surgical outcomes related to placenta accreta spectrum assessed by the generalized estimating equation on multivariable analysis. The temporal trend of placenta accreta spectrum was also assessed by linear segmented regression with log transformation. RESULTS: Of 2,727,477 cases who underwent cesarean delivery during the study period, 8030 (0.29%) had the diagnosis of placenta accreta spectrum. Placenta accreta was the most common diagnosis (n=6205, 0.23%), followed by percreta (n=1060, 0.04%) and increta (n=765, 0.03%). The number of placenta accreta spectrum cases increased by 2.1% every quarter year from 0.27% to 0.32% (P=.004). On multivariable analysis, (1) patient demographics (older age, tobacco use, recent diagnosis, higher comorbidity, and use of assisted reproductive technology), (2) pregnancy characteristics (placenta previa, previous cesarean delivery, breech presentation, and grand multiparity), and (3) hospital factors (urban teaching center and large bed capacity hospital) represented the independent characteristics related to placenta accreta spectrum (all, P<.05). The median gestational age at cesarean delivery was 36 weeks for placenta accreta and 34 weeks for both placenta increta and percreta vs 39 weeks for non-placenta accreta spectrum cases (P<.001). On multivariable analysis, cesarean delivery complicated by placenta accreta spectrum was associated with increased risk of any surgical morbidities (78.3% vs 10.6%), Centers for Disease Control and Prevention-defined severe maternal morbidity (60.3% vs 3.1%), hemorrhage (54.1% vs 3.9%), coagulopathy (5.3% vs 0.3%), shock (5.0% vs 0.1%), urinary tract injury (8.3% vs 0.2%), and death (0.25% vs 0.01%) compared with cesarean delivery without placenta accreta spectrum. When further analyzed by subtype, cesarean delivery for placenta increta and percreta was associated with higher likelihood of hysterectomy (0.4% for non-placenta accreta spectrum, 45.8% for accreta, 82.4% for increta, 78.3% for percreta; P<.001) and urinary tract injury (0.2% for non-placenta accreta spectrum, 5.2% for accreta, 11.8% for increta, 24.5% for percreta; P<.001). Moreover, women in the placenta increta and percreta groups had markedly increased risks of surgical mortality compared with those without placenta accreta spectrum (increta, odds ratio, 19.9; and percreta, odds ratio, 32.1). CONCLUSION: Patient characteristics and outcomes differ across the placenta accreta spectrum subtypes, and women with placenta increta and percreta have considerably high surgical morbidity and mortality risks. Notably, 1 in 313 women undergoing cesarean delivery had a diagnosis of placenta accreta spectrum by the end of 2017, and the incidence seems to be higher than reported in previous studies.

Association of Pre-Operative Full-Body Surgical Preparation with Reduced Incidence of Surgical Site Infection at a Large, Urban Safety-Net Medical Center.

Background: Surgical site infections (SSIs) continue to represent a substantial source of morbidity, mortality, and healthcare costs. The purpose of this study was to determine the effect of implementing a protocol using home pre-operative surgical preparation on the SSI rate at a large, urban safety-net medical center. Patients and Methods: From July through December 2020, Nose-to-Toes® (N2T; Sage Products-Stryker Corporation, Cary, IL) full-body preparation was applied by patients at home on the morning of scheduled surgical procedures. This study was a single-institution, retrospective observational analysis to determine the rates of SSI ≤30 days after an operation. Patients having skin preparation during 2020 (post-N2T) were compared with patients having the same operation during 2019 without having skin preparation (pre-N2T). Results: For gynecology, 10 (7.4%) of 135 pre-N2T and three (2.2%) of 135 post-N2T patients had SSIs. For surgical and gynecologic oncology, 13 (15.1%) of 86 pre-N2T and four (4.7%) of 86 post-N2T patients had SSIs. For orthopedics, four (4.3%) of 94 pre-N2T and zerp of 94 post-N2T patients had SSIs. Overall, 27 (8.6%) of 315 pre-N2T and seven (2.2%) of 315 post-N2T patients had SSIs (p = 0.0004). Conclusions: The implementation of pre-operative full-body preparation was associated with a substantial reduction in the incidence of SSI.

SARS-CoV-2-related outcomes after surgical procedures on SARS-CoV-2-positive patients in a large, urban, safety net medical center.

BACKGROUND: Beginning on March 16, 2020, nonurgent scheduled operations at a large, urban, safety net medical center were canceled. The purpose of this study was to determine complications associated with severe acute respiratory syndrome coronavirus 2 infection for all operations done from March 16 to June 30, 2020. STUDY DESIGN: This study was a single-institution, retrospective observational analysis of data for all surgical procedures and all severe acute respiratory syndrome coronavirus 2 tests done in the medical center from March 16 to June 30, 2020. The charts of all severe acute respiratory syndrome coronavirus 2-positive patients who had a surgical procedure during the study time period were retrospectively reviewed to assess the outcomes. RESULTS: Of 2,208 operations during that time, 29 (1.3%) patients were severe acute respiratory syndrome coronavirus 2-positive and were asymptomatic at the time of their operations. Twenty-four (82.7%) of the 29 required urgent or emergent procedures. The median time between availability of test results and operations for these patients was 0.63 + 1.94 days. With median follow-up of 89 days, none of the 29 patients died from severe acute respiratory syndrome coronavirus 2-related causes, and none developed clinically evident thromboembolism or required reintubation secondary to severe acute respiratory syndrome coronavirus 2-related pneumonia. CONCLUSION: By operating on carefully screened, asymptomatic severe acute respiratory syndrome coronavirus 2-positive patients, it was possible to eliminate major complications and mortality due to severe acute respiratory syndrome coronavirus 2 infection.

Evaluation of an Intervention to Reduce Low-Value Preoperative Care for Patients Undergoing Cataract Surgery at a Safety-Net Health System.

Importance: Preoperative testing for cataract surgery epitomizes low-value care and still occurs frequently, even at one of the nation's largest safety-net health systems. Objective: To evaluate a multipronged intervention to reduce low-value preoperative care for patients undergoing cataract surgery and analyze costs from various fiscal perspectives. Design, Setting, and Participants: This study took place at 2 academic safety-net medical centers, Los Angeles County and University of Southern California (LAC-USC) (intervention, n = 469) and Harbor-UCLA (University of California, Los Angeles) (control, n = 585), from April 13, 2015, through April 12, 2016, with 12 additional months (April 13, 2016, through April 13, 2017) to assess sustainability (intervention, n = 1002; control, n = 511). To compare pre- and postintervention vs control group utilization and cost changes, logistic regression assessing time-by-group interactions was used. Interventions: Using plan-do-study-act cycles, a quality improvement nurse reviewed medical records and engaged the anesthesiology and ophthalmology chiefs with data on overuse; all 3 educated staff and trainees on reducing routine preoperative care. Main Outcomes and Measures: Percentage of patients undergoing cataract surgery with preoperative medical visits, chest x-rays, laboratory tests, and electrocardiograms. Costs were estimated from LAC-USC's financially capitated perspective, and costs were simulated from fee-for-service (FFS) health system and societal perspectives. Results: Of 1054 patients, 546 (51.8%) were female (mean [SD] age, 60.6 [11.1] years). Preoperative visits decreased from 93% to 24% in the intervention group and increased from 89% to 91% in the control group (between-group difference, -71%; 95% CI, -80% to -62%). Chest x-rays decreased from 90% to 24% in the intervention group and increased from 75% to 83% in the control group (between-group difference, -75%; 95% CI, -86% to -65%). Laboratory tests decreased from 92% to 37% in the intervention group and decreased from 98% to 97% in the control group (between-group difference, -56%; 95% CI, -64% to -48%). Electrocardiograms decreased from 95% to 29% in the intervention group and increased from 86% to 94% in the control group (between-group difference, -74%; 95% CI, -83% to -65%). During 12-month follow-up, visits increased in the intervention group to 67%, but chest x-rays (12%), laboratory tests (28%), and electrocardiograms (11%) remained low (P < .001 for all time-group interactions in both periods). At LAC-USC, losses of $42 241 in year 1 were attributable to intervention costs, and 3-year projections estimated $67 241 in savings. In a simulation of a FFS health system at 3 years, $88 151 in losses were estimated, and for societal 3-year perspectives, $217 322 in savings were estimated. Conclusions and Relevance: This intervention was associated with sustained reductions in low-value preoperative testing among patients undergoing cataract surgery and modest cost savings for the health system. The findings suggest that reducing low-value care may be associated with cost savings for financially capitated health systems and society but also with losses for FFS health systems, highlighting a potential barrier to eliminating low-value care.

Lean methods to improve operating room elective first case on-time starts in a large, urban, safety net medical center.

BACKGROUND: Delays in first cases contribute to multiple operating room (OR) inefficiencies and decreases in OR productivity. METHODS: Lean process improvement methods were used to redesign the existing workflow for elective first cases of the day in a large, urban, public hospital. First case start times were prospectively recorded from May 2, 2016 through December 29, 2017. RESULTS: Data from 415 operating days were examined, 86 days prior to, 35 days during, and 294 days after implementation of interventions in the pre-operative holding area. During this time, of 23,891 operations performed, 14,981 were elective procedures, 5963 (39.8%) of which were first cases of the day. The mean rate of elective first case on-time starts per week went from 23.5% before and during to 73.0% after implementation of lean interventions (p < 0.0000001). CONCLUSIONS: Implementation of lean interventions in the pre-operative holding area was associated with significantly improved rates of elective first case on-time starts.

Impact of the Standardized Surgical Checklist on Communication and Teamwork Among Interdisciplinary Surgical Team Members.

Traditional timeouts done ineffectively before surgical procedures can result in late blood product requests, inadequate preparation of needed intraoperative apparatus, improper administration of required antibiotics, and operating room (OR) time delays. This clinical concern is important to address because based on current evidence, implementing a Standardized Surgical Checklist (SSC) during timeout can impact patient safety by reducing complications following surgery and can promote good communication and teamwork among the care team. This quality improvement project is aimed to develop, implement, and evaluate the impact of SSC on communication and teamwork among an interdisciplinary surgical care team at Los Angeles County and University of Southern California Medical Center (LAC + USC). The design of this project was a pre- and postinnovation survey. The participants were the members of the interdisciplinary care team who participated in the surgical timeout before and after the innovation was implemented. The surveys consisted of 219 participants. Results from an independent t test demonstrated that the mean improvement score for both communication (t = -3.704, df = 190, p < .001) and teamwork (t = -3.028, df = 184, p = .003) were significantly higher in the postinnovation group than in the preinnovation group. These results indicate that SSC can improve communication and teamwork among providers inside the OR which can potentially lead to a safer delivery of care.

Enhanced polyhydroxyalkanoate production from organic wastes via process control.

This work explores the use of a model-based control scheme to enhance the productivity of polyhroxyalkanoate (PHA) production in a mixed culture two-stage system fed with synthetic wastewater. The controller supplies pulses of substrate while regulating the dissolved oxygen (DO) concentration and uses the data to fit a dynamic mathematical model, which in turn is used to predict the time until the next pulse addition. Experiments in a bench scale system first determined the optimal DO set-point and initial substrate concentration. Then the proposed feedback control strategy was compared with a simpler empiric algorithm. The results show that a substrate conversion rate of 1.370±0.598mgPHA/mgCOD/d was achieved. The proposed strategy can also indicate when to stop the accumulation of PHA upon saturation, which occurred with a PHA content of 71.0±7.2wt.%.

Vías conductoras a la adicción e intercambio con el medio familiar en adolescentes alcohólicos / Conductive pathways to addiction and exchange with the family environment in alcoholic adolescents

Introducción: Al ser la adolescencia una etapa de transformación biológica, psicológica y social es susceptible a las conductas autodestructibles como el consumo de alcohol y de drogas en general. En este trabajo se describe la relación entre la edad y las vías conductoras a la adicción, los problemas familiares generados por la misma y tácticas de afrontamiento familiar utilizadas. Método: Se estudiaron 250 pacientes diagnosticados de alcoholismo, pertenecientes a un consultorio del estado Falcón, Venezuela. Las variables empleadas fueron: edad, vías conductoras, escolaridad y estado civil de progenitores, funcionamiento familiar, problemas familiares y tácticas de afrontamiento adoptadas por la familia. Los estadísticos fueron, distribuciones de frecuencia con porcentajes y prueba de ji cuadrado. Resultados: La edad predominante fue de 17-20 años (82 por ciento). La vía de conducción más frecuente fue la sociocultural (51 por ciento). Los pacientes consideran su familia funcional en 71 por ciento y el 76 por ciento de los familiares, disfuncional. De los problemas familiares el de mayor relevancia fue las riñas callejeras (88 por ciento) y de las tácticas de afrontamiento familiar: se disgustan (61 por ciento). La escolaridad de los progenitores: en los padres el nivel secundario fue más frecuente (48.4 por ciento) y en las madres el primario (41.2 por ciento). El estado civil unidos prevaleció con el 65.2 por ciento. Conclusiones: Existe dependencia entre las vías de conducción y la edad del paciente. El funcionamiento familiar presenta una tendencia inversa en la apreciación de pacientes y familiares. Los problemas familiares y las tácticas de afrontamiento familiar, así como el nivel escolar primario en las madres y secundario en los padres, fueron manifestaciones de bajo nivel y pocos recursos familiares. El estado civil unido, de los progenitores, en su gran mayoría, se contradice con otros estudios(AU)

Introduction: As a stage of adolescence biological, psychological and social transformation is susceptible to self-destruct behaviors such as alcohol and drugs in general. In this paper the relationship between age and addiction conductive pathways described, family problems generated by the same family coping and tactics used. Methods: 250 patients diagnosed with alcoholism were studied, belonging to the office of Falcon, Venezuela. The variables used were: age, conductive pathways, education and marital status of parents, family functioning, family problems and coping tactics adopted by the family. Statisticians were, frequency distributions with percentages and chi-square test. Results: The predominant age was years 17-20 (82 percent). The most common route of driving was the sociocultural (51 percent). Patients consider their functional family in 71 percent and 76 percent of family, dysfunctional. Family problems was the most important street fights (88 percent) and family coping tactics: get upset (61 percent). Schooling parents: parents at the secondary level was more frequent (48.4 percent) and mothers the primary (41.2 percent). Marital status States prevailed with 65.2 percent. Conclusions: There is dependence between the conduction pathways and patient age. Family functioning has an inverse trend in assessing patients and families. Family problems and family coping tactics, as well as the primary school level and secondary mothers in parents, were manifestations of low and few family resources. United marital status of the parents, the vast majority is contradicted by other studies(AU)

Relación de los efectos nocivos laborales y comunitarios en adictos al alcohol y cocaína / Communitarian and Labor Activities Harmful Relationship on Cocaine and Alcohol Addicts

Introducción: todas las sociedades han consumido y utilizado las drogas con fines muy distintos y también como ayuda en las actividades laborales, buscando mitigar el hambre y el esfuerzo. Conociendo el daño que produce el consumo de estas sustancias en el comportamiento de estos individuos, en el medio donde viven y las actividades que realizan, se realiza este estudio. Objetivo: identificar posibles relaciones entre el consumo de cocaína y alcohol y los efectos nocivos laborales y comunitarios. Métodos: se realizó un estudio descriptivo incluye 172 pacientes masculinos, 37 cocainómanos y 135 alcohólicos ingresados en el Hospital Psiquiátrico de La Habana. Se aplicaron entrevistas estructuradas validadas y en el análisis estadístico la prueba Chi-cuadrado y Odds Ratio con un nivel de significación del 5 por ciento. Las variables seleccionadas fueron: efectos nocivos comunitarios determinados por la toxicomanía: escándalo público, riñas, conducir embriagado y otras; efectos nocivos laborales determinados por la toxicomanía: ausentismo, sanciones, despidos y otras. Resultados: los efectos nocivos comunitarios: hurtos, robos y las sanciones judiciales fueron los de mayor frecuencia en alcohólicos, en cocainómanos hurtos o robos y el parasitismo social; de los efectos nocivos laborales, el desempleo, los consejos de trabajo y el despido fueron más frecuentes en alcohólicos y en los cocainómanos desempleo y ausentismo. Conclusión: los efectos nocivos comunitarios similares en ambas toxicomanías fueron el escándalo público y daño a la propiedad, los demás efectos nocivos se diferenciaron significativamente acorde a la adicción. Los efectos nocivos laborales fueron diferentes en las dos toxicomanías, siendo el principal en ambas el desempleo, pero con riesgo mayor para el alcohólico; los otros, fueron riesgos muy significativos para alcohólicos(AU)

Introduction: all societies have consumed and used drugs with different objectives and also as a support on labor activities with the aid to relieve hunger and effort. This study was carried out based on the knowledge of the damage that these substances provoke on theseindividuals´ behaviors in the environment where they live and work. Objective: to identify the possible harmful relationship between the cocaine and alcohol consumption and the communitarian and labor activities. Methods: a 172 male patients descriptive study was done, (37 cocaine addicts and 135 alcoholics) admitted at the Psychiatry Hospital of Havana. Validated structured interviews and in the statistical analysis of Chi test and Odds Ratio were applied showing a significant level of 5 percent. The selected variable was: communitarian harmful effects by toxic mania, public disturbances, fights, to drive under intoxication among others; while the work harmful effects were related to absence, sanctions, dismiss as well as others. Results: the similar communitarian harmful effects on both toxic manias were public disturbances and property damage, the rest of the harmful effects were no significant according to the addiction. The labor activities harmful effects were different on both toxic manias and the main harmful effect on both was unemployment, but with a major risk for alcoholics and the other harmful effects was very significant for the alcoholics(AU)