Implementing guidelines for risk-stratified thromboprophylaxis among gynecologic oncology patients: A quality improvement initiative.

OBJECTIVE(S): Risk-stratified thromboprophylaxis is recommended for oncology patients with a Khorana risk score (KS) ≥ 2 receiving cancer-directed therapy. We describe a quality improvement (QI) initiative designed to increase adherence to thromboprophylaxis guidelines for patients with gynecologic malignancies initiating outpatient treatment. METHODS: Provider awareness and documentation of venous thromboembolism (VTE) risk assessment and thromboprophylaxis eligibility were identified as key QI drivers. Starting May 2021, a KS calculator and thromboprophylaxis algorithm were incorporated into outpatient documentation templates. Patients with gynecologic malignancies initiating outpatient therapy from January - December 2021 were eligible. The primary process measure was the percentage of patients with KS eligibility documented each month during the baseline (Jan - Apr) versus implementation (May - Dec) periods. Rate of appropriate thromboprophylaxis initiation and incidence of VTE served as outcome measures. Incidence of adverse bleeding events served as the balancing measure. RESULTS: 337 patients accounted for the initiation of 383 treatment regimens, including 128 in the baseline period and 255 in the implementation period. KS documentation increased significantly between the baseline and implementation periods (7% vs 62.4%, p < 0.001). 73 of the 177 eligible patients (46.2%; 166 unique patients) had appropriate documentation; of these, 57 initiated thromboprophylaxis. There was no difference in VTE rates or adverse bleeding events between eligible patients who initiated thromboprophylaxis compared with those who did not (12.3% vs 15.6%; p = 0.65 and 7.0% vs 8.2%; p = 1.0, respectively). CONCLUSION(S): This QI initiative resulted in greater adherence to risk-stratified thromboprophylaxis guidelines. No bleeding signals were identified. Studies addressing cost, medication adherence, and long-term outcomes are necessary.

Opioid-Sparing Multimodal Analgesia Use After Cesarean Delivery Under General Anesthesia: A Retrospective Cohort Study in 729 US Hospitals.

BACKGROUND: Optimizing analgesia after cesarean delivery is essential to quality of patient recovery. The American Society of Anesthesiologists and the Society for Obstetric Anesthesia and Perinatology recommend multimodal analgesia (MMA). However, little is known about clinical implementation of these guidelines after cesarean delivery under general anesthesia (GA). We performed this study to describe the use of MMA after cesarean delivery under GA in the United States and determine factors associated with use of MMA, variation in analgesia practice across hospitals, and trends in MMA use over time. METHODS: A retrospective cohort study of women over 18 years who had a cesarean delivery under GA between 2008 and 2018 was conducted using the Premier Healthcare database (Premier Inc). The primary outcome was utilization of opioid-sparing MMA (osMMA), defined as receipt of nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen with or without opioids and without the use of an opioid-combination drug. Any use of either agent within a combination preparation was not considered osMMA. The secondary outcome was use of optimal opioid-sparing MMA (OosMMA), defined as use of a local anesthetic technique such as truncal block or local anesthetic infiltration in addition to osMMA. Mixed-effects logistic regression models were used to examine factors associated with use of osMMA, as well as variation across hospitals. RESULTS: A total of 130,946 patients were included in analysis. osMMA regimens were used in 11,133 patients (8.5%). Use of osMMA increased from 2.0% in 2008 to 18.8% in 2018. Black race (7.9% vs 9.3%; odds ratio [OR] [95% confidence interval {CI}] 0.87 [0.81-0.94]) and Hispanic ethnicity (8.6% vs 10.0%; OR, 0.86 [0.79-0.950]) were associated with less receipt of osMMA compared to White and non-Hispanic counterparts. Medical comorbidities were generally not associated with receipt of osMMA, although patients with preeclampsia were less likely to receive osMMA (9.0%; OR, 0.91 [0.85-0.98]), while those with a history of drug abuse (12.5%; OR, 1.42 [1.27-1.58]) were more likely to receive osMMA. There was moderate interhospital variability in the use of osMMA (intraclass correlation coefficient = 38%). OosMMA was used in 2122 (1.6%) patients, and utilization increased from 0.8% in 2008 to 4.1% in 2018. CONCLUSIONS: Variation in osMMA utilization was observed after cesarean delivery under GA in this cohort of US hospitals. While increasing trends in utilization of osMMA and OosMMA are encouraging, there is need for increased attention to postoperative analgesia practices after GA for cesarean delivery given low percentage of patients receiving osMMA and OosMMA.

Association between donor gamete use and supernumerary embryo disposition decisions.

PURPOSE: The aim of this study is to determine if donor gamete use is associated with patients' decisions regarding disposition of supernumerary embryos. METHODS: Patients who intended to undergo an IVF cycle at a single academic center signed an embryo disposition consent form to indicate their disposition preferences for any supernumerary embryos. A retrospective chart review was performed to obtain the embryo disposition declarations and demographic information. The primary outcome was the distribution of embryo disposition choices between patients who used donor gametes compared to patients who did not use donor gametes. Fisher's exact test was used to compare groups. Logistic regression models were created to determine the association between donor gamete use and disposition decision after adjusting for patient age, body mass index, and nulliparity. RESULTS: Five hundred six patients were included. Ninety-one (18.0%) patients used donor gametes [46 (9.0%) donor oocytes, 52 (10.3%) donor sperm]. Patients using donor gametes differed from those not using donor gametes when making decisions concerning death of the patient (P < 0.01), simultaneous death (P = 0.04), separation (P < 0.01), discontinuation of ART (P = 0.01), and time-limited storage (P < 0.01). Most patients, regardless of donor or autologous gamete use, awarded embryos to themselves or their partner if given the option. For patients who did not choose this option, excess embryos were generally awarded to research or discarded rather than donating to another couple. Patients using donor gametes were more likely to award embryos to research over discarding. CONCLUSION: Patients using donor gametes made different choices regarding supernumerary embryo disposition compared to patients not using donor gametes.

Comparing magnetic resonance imaging and ultrasound in the clinical evaluation of fibroids prior to uterine artery embolization.

PURPOSE: Uterine artery embolization has become established as a frontline treatment for uterine leiomyomata. In planning embolization, preprocedural imaging can further characterize pathology and anatomy, but it may also reveal coexisting diagnoses that have the potential to change clinical management. The purpose of this study is to compare the diagnostic outcomes of ultrasound and MRI performed for patients prior to undergoing embolization. METHODS: The study cohort consisted of 199 patients who underwent uterine artery embolization at a single academic institution between 2013 and 2018. Prior to embolization, all patients had an MRI confirming a leiomyomata diagnosis. Additionally, 118 patients underwent transvaginal ultrasound within five years prior to MRI. MRI findings were analyzed and, when applicable, compared to prior ultrasound impressions to assess for the incidence of new findings. The diagnoses of interest were adenomyosis, hydrosalpinx, predominantly infarcted leiomyomata, and large intracavitary leiomyomata. Data were collected from retrospective chart review and included demographics, symptomology, and imaging reports. RESULTS: 199 patients ultimately underwent embolization for treatment of MRI-confirmed leiomyomata. Of 118 patients who also had an ultrasound within five years prior to their MRI, 26 (22.0%) received a second gynecologic diagnosis based on MRI findings that was not previously seen on ultrasound. Of 81 patients who only had an MRI before embolization, 19 (23.5%) received a second gynecologic diagnosis not previously documented. The most common coexisting pathology was adenomyosis, presenting in 34 (17.1%) patients with leiomyomata, followed by large intracavitary leiomyomata (8, 4.0%), infarcted leiomyomata (7, 3.5%), and hydrosalpinx (6, 3.0%),. CONCLUSIONS: When considering uterine artery embolization for the treatment of symptomatic leiomyomata, preprocedural MRI is superior to ultrasound in detecting coexisting pathologies, including adenomyosis and hydrosalpinx. It can also better characterize leiomyomata, including identifying lesions as intracavitary or infarcted. These findings have the potential to alter clinical management or contraindicate embolization entirely.

Implementation of a validated post-operative opioid nomogram into clinical gynecologic surgery practice: A quality improvement initiative.

Objectives: The Gynecologic Oncology Postoperative Opioid use Predictive (GO-POP) calculator is a validated tool to provide evidence-based guidance on post-operative opioid prescribing. The objective of this study was to evaluate the impact of the implementation of GO-POP within an academic Gynecologic Oncology division. Methods: Two cohorts of patients (pre-implementation and post-implementation) who underwent surgery were compared with reference to GO-POP calculator implementation. All patients were included in the post-implementation group, regardless of GO-POP calculator use. An additional expanded-implementation cohort was used to compare pain control between GO-POP users and non-GO-POP users prospectively. Wilcoxon rank sum tests or ANOVA for continuous variables and Chi-square or Fisher's exact tests were used to categorical variables. Results: The median number of pills prescribed post-operatively decreased from 15 pills (Q1: 10, Q3: 20) to 10 pills (Q1: 8, Q3: 14.8) after implementation (p < 0.001). In the expanded-implementation cohort (293 patients), 41% patients were prescribed opioids using the GO-POP calculator. An overall median of 10 pills were prescribed with no difference by GO-POP calculator use (p = 0.26). Within the expanded-implementation cohort, refill requests (5% vs 9.2%; p = 0.26), clinician visits (0.8% vs 0.6%, p = 1), ED or urgent care visits (0% vs 2.3%, p = 0.15) and readmissions (0% vs 1.7%, p = 0.27) for pain did not differ between those prescribed opioids with and without the GO-POP calculator. Conclusions: A 33% reduction in post-operative opioid pills prescribed was seen following implementation of the GO-POP calculator into the Gynecologic Oncology division without increasing post-operative pain metrics or encounters for refill requests.

Gender and Language in Letters of Recommendation for Obstetrics and Gynecology Fellowship Applications.

OBJECTIVE: To delineate the use of gender-biased language in letters of recommendation for Obstetrics and Gynecology fellowships and its impact on applicants. DESIGN: Fellowship letters of recommendation from 4 Obstetrics and Gynecology specialties at a single institution in 2020 were included. PRIMARY OUTCOME: frequency of agentic and communal language in letters of recommendation using Linguistics Inquiry Word Count software. SECONDARY OUTCOMES: letter of recommendation length and language utilization by author gender and applicant success measured by interviews and match success. Marginal models were fit to determine if language varied by applicant and writer gender and subspecialty. Modified Poisson regression models were used to determine associations between language and interview receipt. SETTING: Single academic institution (Duke University); 2020 OB/GYN fellowship application cycle. PARTICIPANTS: A total of 1216 letters of recommendation submitted by 326 unique applicants for OB/GYN subspecialty fellowships at our institution. RESULTS: Rates of gender-biased language were low (Agentic:1.3%; communal: 0.8%). Agentic term use did not vary by applicant or author gender (p = 0.78 and 0.16) Male authors utilized 19% fewer communal terms than females (p < 0.001). Each 0.25% increase in agentic language was associated with an 18% reduction in the probability of interview invitation at our institution (p = 0.004). Percentage of agentic or communal language was not associated with successful matching into any subspecialty. CONCLUSIONS: No differences in agentic vs communal language based on applicant gender were found in this cohort, though female letter writers wrote longer letters with more communal terms. Increasing agentic terms negatively impacted interview invitation but did not affect successful matching.

Diagnostic accuracy of clinically reported adenomyosis on pelvic ultrasound and MRI compared to surgical pathology.

BACKGROUND: Adenomyosis is a common gynecologic pathology that relies on diagnostic imaging to guide treatment. Accuracy of both pelvic ultrasound and magnetic resonance imaging (MRI) when specifically evaluating for the presence of adenomyosis is high. However, the accuracy of reported rates in clinical practice is less well understood. PURPOSE: To demonstrate the accuracy in reporting of adenomyosis on pelvic ultrasound and MRI compared to histopathology in common clinical practice. BASIC PROCEDURES: An institutional database was searched for women with a pelvic ultrasound and a pelvic MRI with a subsequent hysterectomy. Findings were extracted from radiology and pathology reports, and the documented presence or absence of adenomyosis was recorded for each modality. Blinded radiologists viewed each imaging pair to directly evaluate for adenomyosis. MAIN FINDINGS: Compared to prior published data, imaging had lower accuracy in clinical practice when adenomyosis was not specifically evaluated for. For the finding of adenomyosis, pelvic ultrasound had a sensitivity of 10.9%, a specificity of 98.3%, positive predictive value (PPV) of 77.8%, negative predictive value (NPV) of 66.7%, an accuracy of 67.2%, and a diagnostic odds ratio (DOR) of 7. Pelvic MRI had a sensitivity of 29.7%, specificity of 85.3%, PPV of 52.8%, NPV of 68.8%, an accuracy of 65.6%, and DOR of 2.5. Overall accuracy of MRI improved when adenomyosis was directly evaluated for (82.4% vs 65.6%). PRINCIPLE CONCLUSIONS: Without direct communication to evaluate for adenomyosis, pelvic ultrasound and MRI may underestimate or misreport adenomyosis. Providers should be aware of these discrepancies when relying on radiology reports to guide treatment and potential interventions when diagnosing and managing adenomyosis.

Fibroids and Fertility: A Comparison of Myomectomy and Uterine Artery Embolization on Fertility and Reproductive Outcomes.

Importance: Leiomyomata, or fibroids, are a common gynecological problem affecting many women of reproductive age. Historically, myomectomy is offered to women with symptomatic fibroids who desire to preserve fertility. More recently, uterine artery embolization (UAE) has been explored as another fertility-sparing option. Objective: This review aims to provide an in-depth summary of the effects on fertility and reproductive outcomes following myomectomy and UAE for the treatment of symptomatic fibroids. Evidence Acquisition: Articles were obtained from PubMed using search terms myomectomy, uterine artery embolization, and fertility, as well as American Society of Reproductive Medicine practice committee reports. References from identified sources were searched to allow for thorough review. Results: While myomectomy and UAE are both fertility-sparing options for women with fibroids, reproductive outcomes following myomectomy are superior to UAE with higher rates of clinical pregnancy and live births and lower rates of spontaneous abortion, abnormal placentation, preterm labor, and malpresentation. Conclusions: Myomectomy should be offered to women with symptomatic submucosal or cavity-distorting fibroids who have a strong desire for a future pregnancy. For women who are not appropriate surgical candidates, UAE can be offered, although detrimental effects on future fertility should be disclosed. Relevance: A thorough understanding of the efficacy of both myomectomy and UAE, as well as their impact on future fertility, allows for improved counseling when deciding the optimal intervention for women with fibroids who desire future fertility.

A Qualitative Assessment of Patient Experience following Systematic Implementation of Goals of Care Conversations in the Ambulatory Gynecologic Oncology Setting.

Objective: Although skilled goals of care (GOC) conversations are known to reduce aggressive futile end-of-life care, they have not been widely implemented nor standardized in the care of gynecologic malignancies. Clinicians express concern regarding patient readiness and willingness to participate in these conversations, which may be a barrier to GOC discussions. Methods: This is a qualitative study, conducted at an academic institution in the United States, of patients with gynecologic malignancies at high risk of death within six months and who had recently completed a GOC discussion with their oncology clinician during an ambulatory visit. Within 10 days of this conversation, patients were approached for potential participation in an hour-long semistructured interview. Patients enrolled in hospice or who were non-English speaking were excluded. Participants were enrolled until thematic saturation was reached. Interviews were transcribed and coded using the five-stage thematic approach. Results: Ten women were consented and participated in semistructured interviews, which occurred a median of 4 (range 1-18) days after the index GOC discussion. The median age was 64 (range 37-78), and the most common diagnosis (50%) was recurrent platinum-resistant ovarian cancer. Four themes were identified: (1) delivery of the GOC conversation, (2) importance of prioritizing individual values, (3) involving family in decision making, and (4) openness to discussing discontinuation of anticancer treatment and hospice. Patients generally felt these GOC conversations were useful, providing a space to express their values and did not compromise the patient-clinician relationship. Conclusions: Patients seemed willing to engage in GOC conversations and were appreciative of their clinicians' communication skills. Often, they used this conversation as an opportunity to convey personal values affecting their care.

Discovery and Characterization of a Nitroreductase Capable of Conferring Bacterial Resistance to Chloramphenicol.

Widespread antibiotic resistance has led to the reappraisal of abandoned antibiotics including chloramphenicol. However, enzyme(s) underlying one form of chloramphenicol resistance, nitroreduction, have eluded identification. Here we demonstrate that expression of the Haemophilus influenzae nitroreductase gene nfsB confers chloramphenicol resistance in Escherichia coli. We characterized the enzymatic product of H. influenzae NfsB acting on chloramphenicol and found it to be amino-chloramphenicol. Kinetic analysis revealed reduction of diverse substrates including the incomplete reduction of 5-nitro antibiotics metronidazole and nitrofurantoin, likely resulting in activation of these antibiotic pro-drugs to their cytotoxic forms. We observed that expression of the H. influenzae nfsB gene in E. coli results in significantly increased susceptibility to metronidazole. Finally, we found that in this strain metronidazole attenuates chloramphenicol resistance synergistically, and in vitro metronidazole weakly inhibits chloramphenicol reduction by NfsB. Our findings reveal the underpinnings of a chloramphenicol resistance mechanism nearly 70 years after its description.