Zainab Siddiq

Patterns of use of hemostatic agents in patients undergoing major surgery.

BACKGROUNDnAlthough a number of prohemostatic agents that are applied intraoperatively have been introduced to minimize bleeding, little is known about the patterns of use and the factors that influence use. We examined the use of hemostatic agents in patients undergoing major surgery.nnnMETHODSnAll patients who underwent major general, gynecologic, urologic, cardiothoracic, or orthopedic surgery from 2000-2010 who were recorded in the Perspective database were analyzed.nnnRESULTSnAmong 3,633,799 patients, hemostatic agents were used in 30.3% (n = 1,102,267). The use of hemostatic agents increased from 28.5% in 2000 to 35.2% in 2010. Over the same period, the rates of transfusion declined for pancreatectomy (-14.4%), liver resection (-15.0%), gastrectomy (-11.7%), prostatectomy (-6.6%), nephrectomy (-4.6%), hip arthroplasty (-10.4%), and knee arthroplasty (-6.6%). Over the same time period, the transfusion rate increased for colectomy (6.0%), hysterectomy (3.7%), coronary artery bypass graft (8.4%), valvuloplasty (4.2%), lung resection (1.9%), and spine surgery (1.6%). Transfusion remained relatively stable for thyroidectomy (0.2%).nnnCONCLUSIONSnThe use of hemostatic agents has increased rapidly even for surgeries associated with a small risk of transfusion and bleeding complications. In addition to patient characteristics, surgeon and hospital factors exerted substantial influence on the allocation of hemostatic agents.

Uptake and outcomes of intensity-modulated radiation therapy for uterine cancer.

OBJECTIVEnWhile intensity-modulated radiation therapy (IMRT) allows more precise radiation planning, the technology is substantially more costly than conformal radiation and, to date, the benefits of IMRT for uterine cancer are not well defined. We examined the use of IMRT and its effect on late toxicity for uterine cancer.nnnMETHODSnWomen with uterine cancer treated from 2001 to 2007 and registered in the SEER-Medicare database were examined. We investigated the extent and predictors of IMRT administration. The incidence of acute and late-radiation toxicities was compared for IMRT and conformal radiation.nnnRESULTSnWe identified a total of 3555 patients including 328 (9.2%) who received IMRT. Use of IMRT increased rapidly and reached 23.2% by 2007. In a multivariable model, residence in the western U.S. and receipt of chemotherapy were associated with receipt of IMRT. Women who received IMRT had a higher rate of bowel obstruction (rate ratio=1.41; 95% CI, 1.03-1.93), but other late gastrointestinal and genitourinary toxicities as well as hip fracture rates were similar between the cohorts. After accounting for other characteristics, the cost of IMRT was

Gastroschisis: epidemiology and mode of delivery, 2005–2013

14,706 (95% CI,

Severe maternal morbidity and comorbid risk in hospitals performing <1000 deliveries per year

12,073 to

Trends in operative vaginal delivery, 2005–2013: a population‐based study

17,339) greater than conformal radiation.nnnCONCLUSIONnThe use of IMRT for uterine cancer is increasing rapidly. IMRT was not associated with a reduction in radiation toxicity, but was more costly.

The role of maternal age in twin pregnancy outcomes

BACKGROUNDnGastroschisis is a severe congenital anomaly the etiology of which is unknown. Research evidence supports attempted vaginal delivery for pregnancies complicated by gastroschisis in the absence of obstetric indications for cesarean delivery.nnnOBJECTIVEnThe objectives of the study evaluating pregnancies complicated by gastroschisis were to determine the proportion of women undergoing planned cesarean vs attempted vaginal delivery and to provide up-to-date epidemiology on the risk factors associated with this anomaly.nnnSTUDY DESIGNnThis population-based study of US natality records from 2005 through 2013 evaluated pregnancies complicated by gastroschisis. Women were classified based on whether they attempted vaginal delivery or underwent a planned cesarean (nxa0= 24,836,777). Obstetrical, medical, and demographic characteristics were evaluated. Multivariable log-linear regression models were developed to determine the factors associated with the mode of delivery. Factors associated with the occurrence of the anomaly were also evaluated in log-linear models.nnnRESULTSnOf 5985 pregnancies with gastroschisis, 63.5% (nxa0= 3800) attempted vaginal delivery and 36.5% (nxa0= 2185) underwent a planned cesarean delivery. The rate of attempted vaginal delivery increased from 59.7% in 2005 to 68.8% in 2013. Earlier gestational age and Hispanic ethnicity were associated with lower rates of attempted vaginal delivery. Factors associated with the occurrence of gastroschisis included young age, smoking, high educational attainment, and being married. Protective factors included chronic hypertension, black race, and obesity. The incidence of gastroschisis was 3.1xa0per 10,000 pregnancies and did not increase during the study period.nnnCONCLUSIONnAttempted vaginal delivery is becoming increasingly prevalent for women with a pregnancy complicated by gastroschisis. Recommendations from the research literature findings may be diffusing into clinical practice. A significant proportion of women with this anomaly still deliver by planned cesarean, suggesting further reduction of surgical delivery for this anomaly is possible.

Population-based risk for peripartum hysterectomy during low- and moderate-risk delivery hospitalizations.

BACKGROUND: While research has demonstrated increasing risk for severe maternal morbidity in the United States, risk at lower volume hospitals remains poorly characterized. More than half of all obstetric units in the United States perform <1000 deliveries per year and improving care at these hospitals may be critical to reducing risk nationwide. OBJECTIVE: We sought to characterize maternal risk profiles and severe maternal morbidity at low‐volume hospitals in the United States. STUDY DESIGN: We used data from the Nationwide Inpatient Sample to evaluate trends in severe maternal morbidity and comorbid risk during delivery hospitalizations in the United States from 1998 through 2011. Comorbid maternal risk was estimated using a comorbidity index validated for obstetric patients. Severe maternal morbidity was defined as the presence of any 1 of 15 diagnoses representative of acute organ injury and critical illness. RESULTS: A total of 2,300,279 deliveries occurred at hospitals with annual delivery volume <1000, representing 20% of delivery hospitalizations overall. There were 7849 cases (0.34%) of severe morbidity in low‐volume hospitals and this risk increased over the course of the study from 0.25% in 1998 through 1999 to 0.49% in 2010 through 2011 (P < .01). The risk in hospitals with ≥1000 deliveries increased from 0.35‐0.62% during the same time periods. The proportion of patients with the lowest comorbidity decreased, while the proportion of patients with highest comorbidity increased the most. The risk of severe morbidity increased across all women including those with low comorbidity scores. Risk for severe morbidity associated with obstetric hemorrhage, infection, hypertensive diseases of pregnancy, and medical conditions all increased during the study period. CONCLUSION: Our findings demonstrate increasing maternal risk at hospitals performing <1000 deliveries per year broadly distributed over the patient population. Rates of morbidity in centers with ≥1000 deliveries have also increased. These findings suggest that maternal safety improvements are necessary at all centers regardless of volume.

Risk for postpartum hemorrhage, transfusion, and hemorrhage-related morbidity at low, moderate, and high volume hospitals

The objectives of this study were to determine temporal trends in forceps and vacuum delivery and factors associated with operative vaginal delivery.

Postpartum hemorrhage outcomes and race

BACKGROUND: There are limited data on how maternal age is related to twin pregnancy outcomes. OBJECTIVE: The purpose of this study was to assess the relationship between maternal age and risk for preterm birth, fetal death, and neonatal death in the setting of twin pregnancy. STUDY DESIGN: This population‐based study of US birth, fetal death, and period‐linked birth‐infant death files from 2007–2013 evaluated neonatal outcomes for twin pregnancies. Maternal age was categorized as 15–17, 18–24, 25–29, 30–34, 35–39, and ≥40 years of age. Twin live births and fetal death delivered at 20–42 weeks were included. Primary outcomes included preterm birth (<34 weeks and <37 weeks), fetal death, and neonatal death at <28 days of life. Analyses of preterm birth at <34 and <37 weeks were adjusted for demographic and medical factors, with maternal age modeled with the use of restricted spline transformations. RESULTS: A total of 955,882 twin live births from 2007–2013 were included in the analysis. Preterm birth rates at <34 and <37 weeks gestation were highest for women 15–17 years of age, decreased across subsequent maternal age categories, nadired for women 35–39 years old, and then increased slightly for women ≥40 years old. Risk for fetal death generally decreased across maternal age categories. Risk for fetal death was 39.9 per 1000 live births for women 15–17 years old, 24.2 for women 18–24 years old, 17.8 for women 25–29 years old, 16.4 for women 30–34 years old, 17.2 for women 35–39 years old, and 15.8 for women ≥40 years old. Risk for neonatal death at <28 days was highest for neonates born to women 15–17 years old (10.0 per 1,000 live births), decreased to 7.3 for women 18–24 years old and 5.5 for women 25–29 years old and ranged from 4.3–4.6 for all subsequent maternal age categories. In adjusted models, risk for preterm birth at <34–<37 weeks gestation was not elevated for women in their mid‐to‐late 30s; however, risk was elevated for women <20 years old and increased progressively with age for women in their 40s. CONCLUSION: Although twin pregnancy is associated with increased risk for most adverse perinatal outcomes, this analysis did not find advanced maternal age to be an additional risk factor for fetal death and infant death. Preterm birth risk was relatively low for women in their late 30s. Risks for adverse outcomes were higher among younger women; further research is indicated to improve outcomes for this demographic group. It may be reasonable to counsel women in their 30s that their age is not a major additional risk factor for adverse obstetric outcomes in the setting of twin pregnancy.

Trends in comorbidity, acuity, and maternal risk associated with preeclampsia across obstetric volume settings

BACKGROUNDnPostpartum hysterectomy is an obstetric procedure that carries significant maternal risk that is not well characterized by hospital volume.nnnOBJECTIVEnThe objective of this study was to determine risk for peripartum hysterectomy for women at low and moderate risk for the procedure.nnnSTUDY DESIGNnThis population-based study used data from the Nationwide Inpatient Sample to characterize risk for peripartum hysterectomy. Women with a diagnosis of placenta accreta or prior cesarean and placenta previa were excluded. Obstetrical risk factors along with demographic and hospital factors were evaluated. Multivariable mixed-effects log-linear regression models were developed to determine adjusted risk. Based on these models receiver operating characteristic curves were plotted, and the area under the curve was determined to assess discrimination.nnnRESULTSnPeripartum hysterectomy occurred in 1 in 1913 deliveries. Risk factors associated with significant risk for hysterectomy included mode of delivery, stillbirth, placental abruption, fibroids, and antepartum hemorrhage. These factors retained their significance in adjusted models: the risk ratio for stillbirth was 3.44 (95% confidence interval, 2.94-4.02), abruption 2.98 (95% confidence interval, 2.52-3.20), fibroids 3.63 (95% confidence interval, 3.22-4.08), and antepartum hemorrhage 7.15 (95% confidence interval, 6.16-8.32). The area under the curve for the model was 0.833.nnnCONCLUSIONnPeripartum hysterectomy is a relatively common event that hospitals providing routine obstetric care should be prepared to manage. That specific risk factors are highly associated with risk for hysterectomy supports routine use of hemorrhage risk-assessment tools. However, given that a significant proportion of hysterectomies will be unpredictable, the availability of rapid transfusion protocols may be necessary for hospitals to safely manage these cases.