Sharon L. Goughnour

Changes in Hysterectomy Trends After the Implementation of a Clinical Pathway.

OBJECTIVE: To investigate the effect of hysterectomy pathway implementation on the proportion of total abdominal hysterectomy (TAH) procedures performed between fiscal years 2012 and 2014. METHODS: We conducted a retrospective medical record review. All hysterectomy surgeries performed for benign indications at University of Pittsburgh Medical Center hospitals from fiscal year 2012 to fiscal year 2014 were identified through various systems including Medipac and EpicCare. We analyzed the cases by surgical approach (TAH compared with minimally invasive hysterectomy), age, and indication of surgery. Changes over time were analyzed using Cochran-Armitage test for linear trends. RESULTS: A total number of 6,544 patients were included in this study. The mean age of the participants was 48.6 years (standard deviation 11.69). In fiscal year 2012, of 1,934 hysterectomies performed as a result of noncancerous conditions, 538 were TAH procedures (27.8%). However, this number declined in fiscal year 2013 to 22% (485 TAH procedures of 2,186 hysterectomies) and further declined in fiscal year 2014 to 17% (413 TAH surgeries of 2,424 hysterectomies). Overall, there was a significant reduction in the proportion of TAH procedures, from 27.8% in fiscal year 2012 to 17% in fiscal year 2014 (P for trend <.001). After adjusting for surgery indication, the decreasing trend of TAH procedures still persisted (P for trend <.001). CONCLUSION: Implementation of a hysterectomy pathway has been associated with a decrease in the proportion of TAH hysterectomy procedures.

Changes in inflammatory endometrial cancer risk biomarkers in individuals undergoing surgical weight loss

OBJECTIVE Obesity has been strongly linked to endometrial cancer (EC) risk. A number of potential EC risk biomarkers have been proposed, including heightened pro-inflammatory cytokines and adipokines. To evaluate if bariatric surgery can serve as a means for altering levels of such EC risk biomarkers, we investigated changes in these biomarkers after weight loss. METHODS Blood samples were collected pre-operatively and 6months post-operatively in 107 female bariatric surgery patients aged 18-72years. Wilcoxon signed-rank tests were used to compare biomarker levels (measured using xMAP immunoassays) pre- and post-surgery. Normative comparisons were implemented to contrast 6-month post-surgery biomarker levels to levels in a sample of 74 age-matched non-obese women. Linear regression was used to evaluate the relationship between biomarker expression at baseline and 6months post-surgery and the relationship between race and biomarker levels. RESULTS On average, participants lost 30.15kg (SD: 12.26) after the bariatric intervention. Levels of C-peptide, insulin, CRP, leptin, IL-1Rα, and IL-6 significantly decreased, while levels of SHBG, IGFBP1, and adiponectin significantly increased with weight loss. Normative comparisons showed the levels of SHBG, C-peptide, insulin, IGFBP1, adiponectin, CRP, and TNFα after bariatric intervention approached the level of markers in comparison group. Multiple regression analyses revealed significant relationships between changes in BMI and changes in biomarker levels. The changes in IL-1Rα were significantly associated with race. CONCLUSIONS Our findings demonstrate that normalization of EC risk biomarkers can be achieved with bariatric surgery. Improved understanding of biological mechanisms associated with weight loss may inform preventive strategies for EC.

Patient and provider factors associated with endometrial Pipelle sampling failure

OBJECTIVE To explore risk factors associated with sampling failure in women who underwent Pipelle biopsy. METHODS A consecutive sample of 201 patient records was selected from women who underwent Pipelle biopsy procedures for suspected uterine pathology in a large healthcare system over a 6-month period (January 2013 through June 2013). Personal and medical data including age, BMI, gravidity and parity, and previous history of Pipelle biopsy were abstracted from medical records for each patient. Logistic regression analyses were used to determine factors associated with biopsy sampling failure. RESULTS Pipelle biopsy sampling failed in 46 out 201 women (22.89%), where 8 (17.39%) were due to inability to access the endometrium, 37 (80.43%) were inadequate samples, and 1 (2.18%) was due to unknown reasons. Personal and medical factors found to be related to sampling failure included: postmenopausal bleeding as biopsy indication (OR 7.41, 95% CI 2.27-24.14); history of prior biopsy failure (OR 23.87, 95% CI 3.76-151.61); and provider type (physician vs. midlevel provider) (OR 9.152, 95% CI 2.49-33.69). CONCLUSION We identified several risk factors for biopsy failure that suggest the need for particular care with Pipelle sampling procedures among women with certain characteristics, including postmenopausal bleeding and a history of prior failed Pipelle biopsy. Our finding of a significantly higher risk of sampling failure based on personal and clinical data suggests that providers must take into account additional considerations to improve sampling success.

Endometrial cancer associated biomarkers in bariatric surgery candidates: exploration of racial differences

BACKGROUND Obesity is the main risk factor for endometrial cancer (EC), the most common gynecologic malignancy in the United States. A number of potential risk biomarkers have been associated with EC development, including altered proinflammatory cytokines, chemokines, and adipokines. OBJECTIVES The overarching aim of this research is to investigate racial differences in the expression of EC-associated biomarkers among bariatric surgery candidates. SETTING Tertiary academic medical center METHODS: Blood samples were collected from 175 women aged 18 to 72 (mean age: 42.93; standard deviation 11.66), before bariatric surgery. Levels of biomarkers associated with obesity and EC risk were measured using xMAP immunoassays. Wilcoxon rank sum and Fishers exact tests were utilized to compare biomarker and demographic variables between African American and European American women. Linear regression models, adjusted for menopause status and diabetes, were utilized to identify factors associated with biomarker levels. RESULTS When the biomarker levels were compared by race, insulin-like growth factor-binding protein 1 and adiponectin were significantly lower in African American women (P<.05), whereas estradiol was significantly higher in African American women (P<.05). Linear regression models found that race significantly predicted insulin-like growth factor binding protein 1, adiponectin, resistin, and interleukin-1 receptor alpha expression levels, menopause status and diabetes status were significantly associated with adiponectin and leptin levels, whereas body mass index was significantly associated with leptin, adiponectin, interleukin-1 receptor alpha, and interleukin-6 levels. CONCLUSION As one of the first efforts to explore racial differences in EC-associated biomarkers in a cohort of women with severe obesity, this study found several significant differences that should be further explored in large-scale studies.

Development of an evidence-based decision pathway for vestibular schwannoma treatment options ☆ ☆☆

OBJECTIVE To integrate multiple sources of clinical information with patient feedback to build evidence-based decision support model to facilitate treatment selection for patients suffering from vestibular schwannomas (VS). METHODS This was a mixed methods study utilizing focus group and survey methodology to solicit feedback on factors important for making treatment decisions among patients. Two 90-minute focus groups were conducted by an experienced facilitator. Previously diagnosed VS patients were recruited by clinical investigators at the University of Pittsburgh Medical Center (UPMC). Classical content analysis was used for focus group data analysis. Providers were recruited from practices within the UPMC system and were surveyed using Delphi methods. This information can provide a basis for multi-criteria decision analysis (MCDA) framework to develop a treatment decision support system for patients with VS. RESULTS Eight themes were derived from these data (focus group + surveys): doctor/health care system, side effects, effectiveness of treatment, anxiety, mortality, family/other people, quality of life, and post-operative symptoms. These data, as well as feedback from physicians were utilized in building a multi-criteria decision model. DISCUSSION The study illustrated steps involved in the development of a decision support model that integrates evidence-based data and patient values to select treatment alternatives. CONCLUSIONS Studies focusing on the actual development of the decision support technology for this group of patients are needed, as decisions are highly multifactorial. Such tools have the potential to improve decision making for complex medical problems with alternate treatment pathways.

Assessment of hot flushes and vaginal dryness among obese women undergoing bariatric surgery

ABSTRACT Objective Menopausal symptoms are associated with a negative impact on the quality of life, leading women to seek medical treatment. Obesity has been linked to higher levels of menopausal symptoms such as hot flushes. This assessment will explore whether the prevalence and bother of hot flushes and vaginal dryness change from pre- to post-bariatric surgery among obese midlife women. Methods This study is a longitudinal analysis of data from 69 women (ages 35–72 years) undergoing bariatric surgery with reported reproductive histories and menopausal symptoms at preoperative and 6-month postoperative visits. Prevalence of and degree of bother of hot flushes and vaginal dryness at pre- and post-surgery were compared using McNemar’s test and Wilcoxon signed-rank test. Results The reported degree of bother of symptoms associated with hot flushes decreased from pre- to post-surgery (p < 0.01). There was no significant change in the prevalence of hot flushes or vaginal dryness in the overall study sample. Conclusions The degree of bother of symptoms associated with hot flushes among midlife women may decrease after bariatric surgery. These results highlight important secondary gains, including less bothersome menopausal symptoms, for women who choose bariatric surgery for weight loss.

Publication Productivity in Central Asia and Countries of the Former Soviet Union

Introduction Despite the significant number of research institutions and rich scientific heritage, published research from Central Asia (Kazakhstan, Uzbekistan, Kyrgyzstan, Tajikistan, and Turkmenistan) is traditionally underrepresented in international scientific literature. The goal of this paper was to analyze publication patterns in Central Asian countries, and to explore the factors that contributed to the publication productivity in Kazakhstan. Methods Publication productivity was evaluated using data generated by the SCImago Journal & Country Rank over the period of 1996–2014 for all of the 15 former Soviet Union Republics for all subject categories. Country specific data, including total population, gross domestic product (GDP) per capita, research and development (R&D) expenditure (% of GDP), number of reserchers (per million people), was abstracted from World Bank data. ANOVA and ANCOVA analyses compared the mean number of publications among Central Asian countries. Separate analyses was done for publication patterns in the health sciences. Multiple comparisons were performed using Tukey method Results The analysis of publication productivity showed significant discrepancies in the number of published documents among the Central Asian countries. Kazakhstan demonstrated a significant increase in the number of published documents in the period of 1996–2014, mainly in the areas of natural and multidisciplinary sciences. Our analyses also showed that the number of publications are siginicantly associated with GDP and population size. Conclusions We identified large gaps in publication productivity among the Central Asian countries. The association between publication rate with GDP and population size indicates there is a need to adjust for these factors when planning research policy.

Lifestyle Interventions to Reduce the Risk of Obesity-Associated Gynecologic Malignancies: A Focus on Endometrial Cancer

Obesity is an established risk factor for multiple cancer types, with gynecologic cancers gaining more attention in the past decade. While women with obesity may be at increased risk for ovarian and cervical cancer mortality, yet it is endometrial cancer (EC) that appears to be the most sensitive to obesity. Current adiposity, excess weight at the age of 18, metabolic syndrome, and adult weight gain are all associated with substantial increased lifetime risk of EC risk. The incidence of EC has been gradually increasing in recent years, with approximately 60,050 new cases and 10,470 deaths expected in 2016. A recent publication from our group estimates a 55% increase in the incidence of EC by 2030. Reducing the risk of EC by weight loss is an attractive strategy, as weight loss also improves cardiovascular fitness, reduces/treats type-2 diabetes, and reduces the risk of other obesity-related cancers. A variety of behavioral weight loss options are available to patients who would like to reduce their cancer risk, each with their own advantages and disadvantages. Bariatric surgery is emerging as one of the most effective weight loss options for patients for whom other options have failed. Bariatric surgery patients are an excellent group to explore EC risk reduction as these patients experience a very rapid weight loss in a short period of time. Counseling on obesity prevention, diet, and exercise could potentially play a big role in the prevention of EC and other malignancies.

Cost-effectiveness analysis of biopsy strategies for endometrial cancer diagnosis in women with postmenopausal bleeding: Pipelle sampling curette versus dilatation & curettage

BACKGROUND Endometrial sampling is widely used for accurate diagnosis of endometrial cancer (EC), which is the most common gynecologic cancer in US women. The objective of this study was to explore the cost-effectiveness of two endometrial sampling procedures for diagnosing EC: (1) Pipelle endometrial sampling (Pipelle), and (2) dilatation & curettage (D&C), while accounting for sampling procedure failure rates and diagnostic accuracy in women with postmenopausal bleeding (PMB). METHOD The decision analytic model was built to compare the cost-effectiveness of Pipelle and D&C strategies in a hypothetical cohort of PMB women. The analysis was performed from the perspective of a public healthcare payer (Medicare, US). We used 2017 Medicare reimbursement data for cost estimation. The effectiveness of these two diagnostic strategies was measured by analyzing the remaining life expectancy after EC diagnosis and subsequent treatment. RESULTS The base case analysis suggested that Pipelle was not only equally effective (32.11 vs. 32.11 years of life), but also less costly (

Implementation of Hysterectomy Pathway: Impact on Complications

1897.80 vs.