The Near-Sightedness of Many-Body Interactions in Anharmonic Vibrational Couplings

Couplings between vibrational motions are driven by electronic interactions, and these couplings carry special significance in vibrational energy transfer, multidimensional spectroscopy experiments, and simulations of vibrational spectra. In this investigation, the many-body contributions to these couplings are analyzed computationally in the context of clathrate-like alkali metal cation hydrates, including Cs+(H2O)20, Rb+(H2O)20, and K+(H2O)20, using both analytic and quantum-chemistry potential energy surfaces. Although the harmonic spectra and one-dimensional anharmonic spectra depend strongly on these many-body interactions, the mode-pair couplings were, perhaps surprisingly, found to be dominated by one-body effects, even in cases of couplings to low-frequency modes that involved the motion of multiple water molecules. The origin of this effect was traced mainly to geometric distortion within water monomers and cancellation of many-body effects in differential couplings, and the effect was also shown to be agnostic to the identity of the ion. These outcomes provide new understanding of vibrational couplings and suggest the possibility of improved computational methods for the simulation of infrared and Raman spectra.

Obstetrics and gynecology applicant perceptions of residency program culture with virtual interviews: a qualitative analysis of social media posts

BACKGROUND

In the United States, Obstetrics and Gynecology residency interviews are instrumental in assessing the compatibility between medical student applicants and residency programs during the match process. Applicant perceptions of Obstetrics and Gynecology residency culture are a key component in determining how they rank residency programs. In 2020, residency interviews transitioned to a virtual format, and little is known about how applicants evaluated program culture during this first round of universal virtual interviews. Medical students in the United States commonly use Reddit, a popular social media platform, to discuss residency programs and share interview experiences. We explored Obstetrics and Gynecology applicants' considerations regarding residency program culture during the first universal virtual interview season in 2020-2021 by analyzing posts on a Google spreadsheet accessed through Reddit.

METHODS

In 2022, we imported 731 posts from the "2020-21 OB GYN Residency Applicant Spreadsheet" Google spreadsheet posted to the 2020-2021 Residency Interview Spreadsheet megathread on the r/medicalschool subreddit to NVivo 12(QSR International, Burlington, MA), a qualitative analysis software program. Three investigators used qualitative inductive techniques to code and identify themes.

RESULTS

Applicants used visual, verbal and behavioral cues during virtual Obstetrics and Gynecology residency interviews to understand three components of the workplace culture: prioritization of diversity, equity and inclusion, social environment, and resident workload.

CONCLUSIONS

Obstetrics and Gynecology residency programs convey information about their culture during virtual interviews through the behavior, appearances and responses of residents and interviewers to applicant questions. To ensure they accurately represent their culture to applicants, programs should consider educating residents and faculty around the implications of interview-day conduct.

Pitfalls in the n-mode representation of vibrational potentials

Simulations of anharmonic vibrational motion rely on computationally expedient representations of the governing potential energy surface. The n-mode representation (n-MR)-effectively a many-body expansion in the space of molecular vibrations-is a general and efficient approach that is often used for this purpose in vibrational self-consistent field (VSCF) calculations and correlated analogues thereof. In the present analysis, a lack of convergence in many VSCF calculations is shown to originate from negative and unbound potentials at truncated orders of the n-MR expansion. For cases of strong anharmonic coupling between modes, the n-MR can both dip below the true global minimum of the potential surface and lead to effective single-mode potentials in VSCF that do not correspond to bound vibrational problems, even for bound total potentials. The present analysis serves mainly as a pathology report of this issue. Furthermore, this insight into the origin of VSCF non-convergence provides a simple, albeit ad hoc, route to correct the problem by "painting in" the full representation of groups of modes that exhibit these negative potentials at little additional computational cost. Somewhat surprisingly, this approach also reasonably approximates the results of the next-higher n-MR order and identifies groups of modes with particularly strong coupling. The method is shown to identify and correct problematic triples of modes-and restore SCF convergence-in two-mode representations of challenging test systems, including the water dimer and trimer, as well as protonated tropine.

Accelerating and stabilizing the convergence of vibrational self-consistent field calculations via the direct inversion of the iterative subspace (vDIIS) algorithm

The vibrational self-consistent field (VSCF) method yields anharmonic states and spectra for molecular vibrations, and it serves as the starting point for more sophisticated correlated-vibration methods. Convergence of the iterative, non-linear optimization in VSCF calculations can be erratic or altogether unsuccessful, particularly for chemical systems involving low-frequency motions. In this work, a vibrational formulation of the Direct Inversion of the Iterative Subspace method of Pulay is presented and investigated. This formulation accounts for distinct attributes of the vibrational and electronic cases, including the expansion of each single-mode vibrational wavefunction in its own basis set. The resulting Direct Inversion of the Iterative Subspace method is shown to substantially accelerate VSCF convergence in all convergent cases as well as rectify many cases where Roothaan-based methods fail. Performance across systems ranging from small, rigid molecules to weakly bound molecular clusters is investigated in this analysis.

Persistence of a Delocalized Radical in Larger Clusters of Hydrated Copper(II) Hydroxide, CuOH+(H2O)3-7

The structures, vibrational spectra, and electronic properties of copper hydroxide hydrates CuOH+(H2O)3-7 were investigated with quantum chemistry computations. As a follow-up to a previous analysis of CuOH+(H2O)0-2, this investigation examined the progression as the square-planar metal coordination environment was filled and as solvation shells expanded. Four-, five-, and six-coordinate structures were found to be low-energy isomers. The delocalized radical character, which was discovered in the small clusters, was found to persist upon continued hydration, although the hydrogen-bonded water network in the larger clusters was found to play a more significant role in accommodating this spin. Partial charges indicated that the electronic structure includes more Cu2+···OH- character than was observed in smaller clusters, but this structure remains decidedly mixed with Cu+···OH· configurations and yields roughly half-oxidation of the water network in the absence of any electrochemical potential. Computed vibrational spectra for n = 3 showed congruence with spectra from recent predissociation spectroscopy experiments, provided that the role of the D2 tag was taken into account. Spectra for n = 4-7 were predicted to exhibit features that are reflective of both the mixed electronic character and proton-/hydrogen-shuttling motifs within the hydrogen-bonded water network.

Gynecologic Oncology fellowship recruitment in the virtual era: An evaluation of program websites and survey of applicant preferences

Objective

Virtual Gynecologic Oncology fellowship recruitment has altered how candidates and programs exchange information. This study analyzes programs' web-based content and the priorities of fellowship candidates.

Methods

Web-based materials of Gynecologic Oncology fellowship programs participating in the 2022 match were reviewed. An anonymous survey was emailed to applicants. Questions assessed importance of web-based materials on a Likert scale. Respondents were asked to rank factors from most to least important in their decisions to interview and rank programs.

Results

Of the 66 programs participating in the 2022 Gynecologic Oncology fellowship match, 62 (93.9%) had accessible websites. Over one-fourth (25.8%) of program websites did not list application requirements. Most (74.2%) websites contained requests for letters of recommendation, but fewer (48.4%) specified the preferred quantity or authorship. Residency in-service exam score requirement information was present on 61.3% of websites. Of 100 applicants invited to participate, 44 returned surveys (44% response rate). The median number of programs applied to was 60 (IQR 51-65). Web-based materials most important to candidates were application requirements and deadlines, letter of recommendation details, and in-service exam requirements. Interaction with faculty and program information received during interview days were among the most important factors in decisions to rank programs.

Conclusions

Gynecologic Oncology fellowship applicants surveyed in this study applied to nearly all participating fellowships. The content of web-based materials varies across program websites, particularly for application requirements, which applicants indicated as the most important electronically available material. Programs should have clear application requirements and provide clinical details on their websites.

Evaluation of a Structured Female Pelvic Medicine and Reconstructive Surgery Resident Rotation Curriculum

IMPORTANCE

Residency education is moving toward competency-based learning, which requires novel educational methods. One solution is structured learning through a formalized curriculum.

OBJECTIVE

The purpose of this study is to evaluate the educational aspects of a novel structured curriculum in female pelvic medicine and reconstructive surgery.

STUDY DESIGN

This was a prospective cohort study of third-year obstetrics and gynecology residents who rotated on the female pelvic medicine and reconstructive surgery service. The curriculum was organized into 7 specific topics with weekly required reading, key specialty articles, and reviewed quizzes on subspecialty topics adapted from the American Board of Obstetrics and Gynecology Guide to Learning. A prerotation and postrotation self-assessment of pelvic anatomy and pelvic floor dysfunction content comprehension was assessed using a Likert scale (0-10) for each domain.

RESULTS

Obstetrics and gynecology residents from 4 academic years resulted in a total of 17 paired assessments for analysis. Each of the 7 domains showed significant improvement among all academic years, with a mean increase of 4.9 ± 0.8 points ( P < 0.001). The 2 domains that showed the greatest improvement were stress urinary incontinence (5.5 ± 1.3, P < 0.001) and pelvic organ prolapse (5.5 ± 1.9, P < 0.001). There was no significant association between score improvement and the number of previous surgical rotations or having the rotation in the first or second half of the academic year.

CONCLUSIONS

This study demonstrated that a structured curriculum in female pelvic medicine and reconstructive surgery was associated with significant improvement in self-assessed perceived resident knowledge during the subspecialty rotation. This approach could be applied to other rotations and direct education curriculum development.

Feasibility and acceptability of home-based strength training in endometrial cancer survivors

PURPOSE

Physical activity is important for healthy cancer survivorship, yet many endometrial cancer survivors do not participate in recommended muscle-strengthening activity. The purpose of this study was to determine the feasibility of home-based muscle strengthening activity in endometrial cancer survivors.

METHODS

Forty post-treatment endometrial cancer survivors were enrolled in a randomized trial, of twice-weekly home-based strength exercise versus wait-list control. The intervention included educational materials, exercise equipment (dumbbells, resistance bands), and support/feedback via video coaching sessions. Participants completed the exercises twice per week for 10 weeks, with a 5-week follow-up period. Feasibility was measured by program adherence, as well as safety of and satisfaction with the study.

RESULTS

On average, participants were 60.9 years old (SD = 8.7), had a BMI of 39.9 kg/m2 (SD = 15.2), and were 2.9 years (SD = 1.2) since diagnosis. The majority (83%) had stage I disease at diagnosis. Seventy-five percent adhered to the exercise prescription of twice/week, with 85% of participants missing fewer than 3 of the workouts. Forty percent of participants continued workouts during the 5-week follow-up. Participants were highly satisfied with intervention. No injuries or adverse everts occurred.

CONCLUSION

This home-based program was feasible in endometrial cancer survivors. While adherence was measured, future research should focus on long-term maintenance of exercise and should explore progressions and modifications of exercises at a distance for various abilities.

IMPLICATIONS FOR CANCER SURVIVORS

Muscle strengthening activities are recommended for all cancer survivors. This study shows that a home-based muscle strengthening exercise is feasible in endometrial cancer survivors.

The long game: Telemedicine patient satisfaction metrics and methods of recurrence detection for gynecologic cancer patients throughout the initial year of the COVID-19 pandemic

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Survey results of demonstrated persistence in high satisfaction with telemedicine over one year into the COVID-19 pandemic.

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Gynecologic oncology patients welcome ongoing use of telemedicine for delivery of cancer care.

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The most common method of gynecologic cancer recurrence detection is patient reported symptoms.

Objective

The primary aim of this study was to evaluate gynecologic cancer patients’ satisfaction with telemedicine visits over a one-year period during the COVID-19 pandemic. The secondary aim was to characterize how gynecologic cancer recurrence was detected with high telemedicine utilization.

Methods

A survey study and a retrospective cohort study of patients participating in telemedicine visits between April 20, 2020 and March 30, 2021 in a gynecologic oncology clinic were undertaken. To assess patient satisfaction with telemedicine visits, the Telemedicine Satisfaction Survey (TeSS) was administered to patients by phone. Retrospective chart review was conducted to gather clinical data regarding diagnosis, treatment, and recurrence.

Results

Three hundred and sixteen patients completed the TeSS for a response rate of 80.2%. Patients rated the following aspects of the telemedicine encounter as good or excellent: quality of technology (97.8%), personal comfort (90.8%), length-of-visit (95.2%), treatment explanation (93.7%), overall experience (92.7%). Moreover, 87.0% of patients would use telemedicine again. Retrospective data was collected for 394 patients, 312 of which had invasive cancer (79.2%). Twenty-nine (7.4%) patients experienced a recurrence during the study period. The most common method of detection was patient-reported symptoms (n = 17, 58.6%). The remaining recurrences were diagnosed by scheduled biomarkers (n = 7, 24.1%), scheduled imaging (n = 4, 13.8%) and asymptomatic exam (n = 1, 3.4%).

Conclusions

After one year of the COVID-19 pandemic and the implementation of routine telehealth visits, gynecologic cancer patients were overwhelmingly satisfied with the use of telemedicine. During this period, recurrences were most often diagnosed by patient-reported symptoms.

Mortality risk and physical activity across the lifespan in endometrial cancer survivors

PURPOSE

Physical activity (pre- and post-diagnosis) has been studied in prevention and survivorship contexts for endometrial cancer. However, the association of physical activity (PA) across the lifespan on mortality risk among endometrial cancer survivors is understudied. The study's objective was to identify the association of lifetime PA on mortality risk in endometrial cancer survivors.

METHODS

Seven hundred forty-five endometrial cancer survivors drawn from a population-based cancer registry (diagnosed between 1991 and 1994) reported the frequency (sessions/week) of moderate- and vigorous intensity physical activity (MVPA) at age 12, age 20, and 5 years pre-interview (post-diagnosis). Cox proportional hazards were used to estimate hazard ratios (HR) and 95% confidence intervals for the association between PA, all-cause, and cardiovascular disease mortality as assessed in 2016. MVPA was modeled using natural cubic splines.

RESULTS

Diagnosis age, body mass index, and smoking (pack-years) were each positively associated with increased all-cause mortality risk. Those who did one session of MVPA 5 years pre-interview had a lower mortality risk (HR 0.61; 95% CI 0.41-0.92) compared to those with no MVPA. Those reporting one session of MVPA was similarly observed at age 12 (HR 0.95; 95% CI 0.86-1.06) and at age 20 (HR 0.87; 95% CI 0.65-1.16).

CONCLUSION

Those who participated in PA, compared to those who did not, in the 5 years before diagnosis had a lower mortality risk. While PA was not independently protective against mortality risk at ages 12 or 20, PA is still important for endometrial cancer survivors for other non-mortality outcomes.

Improvements in strength and agility measures of functional fitness following a telehealth-delivered home-based exercise intervention in endometrial cancer survivors

PURPOSE

Endometrial cancer is strongly linked to obesity and inactivity; however, increased physical activity has important benefits even in the absence of weight loss. Resistance (strength) training can deliver these benefits; yet few women participate in resistance exercise. The purpose of this study was to describe both physiological and functional changes following a home-based strength training intervention.

METHODS

Forty post-treatment endometrial cancer survivors within 5 years of diagnosis were enrolled in a pilot randomized trial, comparing twice-weekly home-based strength exercise to wait list control. Participants conducted the exercises twice per week for 10 supervised weeks with 5 weeks of follow-up. Measures included DXA-measured lean mass, functional fitness assessments, blood biomarkers, and quality of life outcomes.

RESULTS

On average, participants were 60.9 years old (SD = 8.7) with BMI of 39.9 kg/m2 (SD = 15.2). At baseline, participants had 51.2% (SD = 6.0) body fat, which was not different between groups. Improvements were seen in the 30-s chair sit to stand (d = .99), the 30-s arm curl (d = .91), and the 8-ft up-and-go test (d = .63). No changes were measured for HbA1c or C-reactive protein. No changes were observed for flexibility (chair sit and reach, back scratch tests), 6-min walk test, maximum handgrip test, anxiety, depression, fatigue, or self-efficacy for exercise.

CONCLUSIONS

Home-based muscle-strengthening exercise led to favorable and clinically relevant improvements in 3 of 7 physical function assessments. Physical function, body composition, blood biomarkers, and patient-reported outcomes were feasible to measure. These fitness improvements were observed over a relatively short time frame of 10 weeks.

Endoscope-assisted techniques for evacuation of acute subdural haematoma in the elderly: The lesser of two evils? A scoping review of the literature

INTRODUCTION

Surgical evacuation of acute subdural haematoma (ASDH) in the elderly remains a point of contention due to the significant associated mortality. Therefore, there is a dire need for alternative treatment options. Endoscope-assisted techniques (EAT) have been increasingly reported over the last decade with variable outcomes. In this scoping review, we identify studies reporting the use of EAT for ASDH evacuation in elderly patients. Outcomes and patient selection criteria are discussed to identify patients that may benefit from EAT.

METHODS

A multi-database literature search was performed between January 1990 and January 2021. Studies including patients aged 60 years or above who underwent EAT for ASDH evacuation with reported outcomes were included.

RESULTS

A total of 13 studies and 122 patients were eligible for inclusion. Patient age ranged from 65 to 101 years, and average age from 78.6 to 87.4 years. High comorbidity burden, advanced age, absence of adverse imaging features, and pre-operative neurological status were the most common eligibility criteria for EAT. 52% of all procedures were performed under local anaesthetic (LA). Mortality rates ranged between 0% and 40%, whilst favourable outcomes ranged between 26.7% and 96.4%. Re-bleed was the most commonly reported complication, ranging between 0% and 13%.

CONCLUSIONS

EAT pose a viable compromise for elderly patients with ASDH that may be unfit for GA. Heterogeneity of patient selection criteria prevents meaningful comparison between EAT and other approaches, and there is a clear impact of patient selection on outcome among studies reporting EAT. Further studies are required to identify the patient cohort that may benefit from this approach.

BRCA-2 (+) high-grade serous fallopian tube cancer diagnosed as an isolated breast mass by mammography

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High grade serous carcinomas rarely present as oligometastases.

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Oligometastases of Mullerian carcinoma to the breast are very rare.

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PARP inhibitors are an effective maintenance therapy in patients with BRCA mutations.

Ovarian cancer typically presents at advanced stage with intra-abdominal metastases. Rarely, ovarian cancer presents with distant metastases with little to no intra-abdominal disease burden. The patient was a BRCA-2 germline mutation carrier diagnosed with a Stage IVB high-grade carcinoma of the fallopian tube following discovery of a right axillary breast mass on screening mammography. Pre-operative imaging was without evidence of metastatic disease in the abdomen or pelvis. She underwent surgical staging followed by adjuvant chemotherapy and maintenance poly-ADP ribose polymerase (PARP) inhibition. She is without evidence of disease 24 months following her surgical staging procedure. An isolated oligo metastasis in the axilla is a rare presentation of ovarian carcinoma. Extra-abdominal metastases can present a diagnostic challenge in ovarian cancer necessitating thorough pathologic and radiologic work-up, particularly in the absence of intra-abdominal disease.

A retrospective analysis of emergency referrals and admissions to a regional neurosurgical centre 2016-2018

BACKGROUND AND OBJECTIVES

Emergencies account for 60% of UK neurosurgical workload. We analysed the emergency referrals made to the on-call neurosurgical registrar in a regional centre over three years, aiming to identify temporal trends in volume of referrals, admission practices and major diagnostic categories contributing to referrals and admissions.

METHODS

Individual referrals recorded in on-call databases were processed to extract basic demographics, call timing, diagnosis category and whether the patient was admitted under neurosurgery. Linear regression analysis was used to identify temporal trends across the three years.

RESULTS

A total of 18128 calls were made to the on-call registrar between 2016 and 2018, with a significant increase in monthly calls. On average, one call was received every 88 minutes. An increasing proportion of these calls were taken out of office hours. Diagnostic categories accounting for the largest percentage of calls were traumatic brain injury (17.7%) and cauda equina syndrome (13%). Significant increases in referral volume were seen in cauda equina syndrome, traumatic brain injury, spinal trauma and spinal tumours, while no category had a significant decrease. The admission rate was 17.1% - no change was seen in this across the study period, resulting in increasing numbers of admissions, reflecting increasing referrals. Categories most likely to result in admission were hydrocephalus (41.1%), spontaneous subarachnoid haemorrhage (39.4%), intracranial infection (32.6%) and chronic subdural haematoma (CSDH, 32.2%). A change in admission rate was seen only for CSDH, with a significant increase in the percentage of referrals across the study period.

CONCLUSION

Emergency neurosurgical referrals continue to rise in the UK at a rate exceeding population growth. This implies a decreasing referral threshold. However, the constant admission rate suggests either an increasing amount of neurosurgical pathology, the threshold for admission/intervention has decreased, or a combination. Neurosurgical services need to adapt in order to meet increasing demands.

Longitudinal assessment of post-surgical physical activity in endometrial and ovarian cancer patients

OBJECTIVE

Physical activity plays a key role in cancer survivorship. The purpose of this investigation was to (a) describe the post-surgical physical activity trajectories of endometrial (n = 65) and ovarian (n = 31) cancer patients and (b) identify clinical and demographic predictors of physical activity over time.

METHODS

96 participants wore an Actiwatch accelerometer for three days at each of three time points (one week, one month and four months) after surgical intervention for their endometrial or ovarian cancer diagnosis. Analyses were conducted using linear mixed effects regression modeling in SAS 9.4.

RESULTS

For both tumor types, although physical activity levels increased with time after surgery, even at four months patients were performing only a small fraction of the 150 minutes of recommended weekly moderate to vigorous physical activity. At 1 week, subjects were completing on average 14 minutes/week (SD = 4) of moderate-to-vigorous physical activity, compared to 14 minutes/week (SD = 2) of moderate-to-vigorous physical activity at four months post-surgery (p < .05). Better self-rated health was associated with higher physical activity (p = 0.02) in endometrial cancer survivors only. BMI, age, surgery type and use of neoadjuvant chemotherapy were not associated with activity over time.

CONCLUSIONS

Our findings suggest that physical activity levels are different for those with better self-rated health, but those individuals are still insufficiently active. This study adds new information describing the trajectories and variables that influence physical activity in gynecologic cancer survivors after surgery and highlights the need for health promotion interventions in this population.

Variation in the intensity of end-of-life care, hospice enrollment, and the cost of care by cancer site

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Background: To compare end-of-life (EOL) care intensity across multiple cancer sites and its impact on the cost of care during the last 30-days of life. Methods: Cross-sectional retrospective study using Surveillance, Epidemiology, and End Results Program (SEER)-Medicare linked database from 2008-2013. Utilization of the following in the EOL period (last 30 days of life prior to death) was examined: 2 or more visits to the Emergency Department (ED), hospitalizations, receipt of any life-extending procedures, admission to intensive care unit, any hospice use, hospice used ≤3 days, death in hospital, or receipt of chemotherapy (last 14 days). We tallied the claims made during the EOL period for each patient. Median expenditures during the EOL period were tabulated by cancer site and stratified by receipt of hospice care. Results: EOL care utilization varied widely between cancer sites. The rates of any hospice utilization were the highest for breast cancer (48.2%) compared to ovarian (17.4%) (p < 0.001). Chemotherapy during the last two weeks of life was the highest for ovarian cancer (1.7%) and the lowest for colorectal cancer (0.5%). The median cost of care during the EOL period for patients who received hospice care was $7,547.84 (Interquartile range [IQR] $5,422-$17,293) compared to $17,179 (IQR $10,323 - $30,824) for those never received hospice care (p < .0001). There was no significant variation in median cost by cancer site for those who received hospice services (range $7,317 - $9,816). However, the cost of care varied for those who did not receive hospice care. Median costs for this subgroup was the lowest for pancreatic cancer ($14,635) and the highest for colorectal cancer ($24,324) (p < 0.001). Conclusions: Despite increasing acceptance of palliative care services and hospice in cancer care, there continues to be intensive and costly care administered during the EOL period. These costs vary considerably across cancer sites when patients do not receive hospice care, but costs are relatively similar when patient are enrolled in hospice Further research to investigate the causes of this variation should be undertaken to design interventions aimed at improving timely hospice enrollment at the EOL and reducing costly care in the EOL period.

Using simple radiologic measurements to anticipate surgical challenge in endometrial cancer: a prospective study

Objectives

To determine if linear measurements of adiposity from pre-operative imaging can improve anticipation of surgical difficulty among endometrial cancer patients.

Methods

Eighty patients with newly diagnosed endometrial cancer were enrolled. Routine pre-operative imaging (MRI or CT) was performed. Radiologic linear measurements of the following were obtained: anterior-to-posterior skin distance; anterior skin to anterior edge of L5 distance (total anterior); anterior peritoneum to anterior edge of L5 distance (visceral obesity); and posterior edge of L5 to posterior skin distance (total posterior). Surgeons completed questionnaires quantifying preoperative anticipated operative difficulty and postoperative reported operative difficulty. The primary objective was to assess for a correlation between linear measurements of visceral fat and reported operative difficulty.

Results

Seventy-nine patients had questionnaires completed, preoperative imaging obtained, and surgery performed. Univariate analysis showed all four linear measurements, body mass index, weight, and anticipated operative difficulty were associated with increased reported operative difficulty (P< 0.05). Multivariate analysis demonstrated that body mass index and linear measurements visceral obesity and total posterior were independently associated with increased reported operative difficulty (P< 0.05). Compared with body mass index, the visceral obesity measurement was more sensitive and specific for predicting increased reported operative difficulty (visceral obesity; sensitivity 54%, specificity 91 %; body mass index; sensitivity 38%, specificity 89%). A difficulty risk model combining body mass index, visceral obesity, and total posterior demonstrated better predictive performance than any individual preoperative variable.

Conclusions

Simple linear measurements of visceral fat obtained from preoperative imaging are more predictive than body mass index alone in anticipating surgeon-reported operative difficulty. These easily obtained measurements may assist in preoperative decision making in this challenging patient population.

Disparities in the allocation of research funding to gynecologic cancers by Funding to Lethality scores

PURPOSE

To analyze National Cancer Institute (NCI) funding distributions to gynecologic cancers compared to other cancers from 2007 to 2014.

METHODS

The NCI's Surveillance, Epidemiology and End Results (SEER), Cancer Trends Progress Report, and Funding Statistics were used to analyze 18 cancer sites. Site-specific mortality to incidence ratios (MIR) were normalized per 100 cases and multiplied by person-years of life lost to derive cancer-specific lethality. NCI funding was divided by its lethality to calculate Funding to Lethality scores for gynecologic malignancies and compared to 15 other cancer sites.

RESULTS

Ovarian, cervical, and uterine cancers ranked 10th (score 0.097, SD 0.008), 12th (0.087, SD 0.009), and 14th (0.057, SD 0.006) for average Funding to Lethality scores. The highest average score was for prostate cancer (score 1.182, SD 0.364). In U.S. dollars per 100 incident cases, prostate cancer received an average of $1,821,000 per person-years of life lost, while ovarian cancer received $97,000, cervical cancer $87,000, and uterine cancer $57,000. Ovarian and cervical cancers had lower average Funding to Lethality scores compared to nine other cancers, while uterine cancer was lower than 13 other cancers (p < 0.01 for all comparisons). Analyses of eight-, five-, and three-year trends for gynecologic cancers showed nearly universal decreasing Funding to Lethality scores.

CONCLUSION

Funding to Lethality scores for gynecologic cancers are significantly lower than other cancer sites, indicating a disparity in funding allocation that persists over the most recent eight years of available data. Prompt correction is required to ensure critical discoveries for women with gynecologic cancers.

Preoperative obstructive sleep apnea screening in gynecologic oncology patients

BACKGROUND

Women with a gynecologic cancer tend to be older, obese, and postmenopausal, characteristics that are associated with an increased risk for obstructive sleep apnea. However, there is limited investigation regarding the condition's prevalence in this population or its impact on postoperative outcomes. In other surgical populations, patients with obstructive sleep apnea have been observed to be at increased risk for adverse postoperative events.

OBJECTIVE

We sought to estimate the prevalence of obstructive sleep apnea among gynecologic oncology patients undergoing elective surgery and to investigate for a relationship between obstructive sleep apnea and postoperative outcomes.

STUDY DESIGN

Patients referred to an academic gynecologic oncology practice were approached for enrollment in this prospective, observational study. Patients were considered eligible for study enrollment if they were scheduled for a nonemergent inpatient surgery and could provide informed consent. Enrolled patients were evaluated for a preexisting diagnosis of obstructive sleep apnea. Those without a prior diagnosis were screened using the validated, 4-item STOP questionnaire (ie, Snore loudly, daytime Tiredness, Observed apnea, elevated blood Pressure). All patients who screened positive for obstructive sleep apnea were referred for polysomnography. The primary outcome was the prevalence of women with obstructive sleep apnea or those who screened at high risk for the condition. Secondary outcomes examined the correlation between body mass index (kg/m²) with obstructive sleep apnea and assessed for a relationship between obstructive sleep apnea and postoperative outcomes.

RESULTS

Over a 22-month accrual period, 383 eligible patients were consecutively approached to participate in the study. A cohort of 260 patients were enrolled. A total of 33/260 patients (13%) were identified as having a previous diagnosis of obstructive sleep apnea. An additional 66/260 (25%) screened at risk for the condition using the STOP questionnaire. Of the patients who screened positive, 8/66 (12%) completed polysomnography, all of whom (8/8 [100%]) were found to have obstructive sleep apnea. The prevalence of previously diagnosed obstructive sleep apnea or screening at risk for the condition increased as body mass index increased (P < .001). Women with untreated obstructive sleep apnea and those who screened at risk for the condition were found to have an increased risk for postoperative hypoxemia (odds ratio, 3.5; 95% confidence interval, 1.8-4.7; P = .011) and delayed return of bowel function (odds ratio, 2.1; 95% confidence interval, 1.3-4.5; P = .009).

CONCLUSION

The prevalence of obstructive sleep apnea or screening at risk for the condition is high among women presenting for surgery with a gynecologic oncologist. Providers should consider evaluating a patient's risk for obstructive sleep apnea in the preoperative setting, especially when risk factors for the condition are present.

Association of Hospital Volume With Racial and Ethnic Disparities in Locally Advanced Cervical Cancer Treatment

OBJECTIVE

To evaluate racial-ethnic disparities in guideline-based care in locally advanced cervical cancer and their relationship to hospital case volume.

METHODS

Using the National Cancer Database, we performed a retrospective cohort study of women diagnosed between 2004 and 2012 with locally advanced squamous or adenocarcinoma of the cervix undergoing definitive primary radiation therapy. The primary outcome was the race-ethnicity-based rates of adherence to the National Comprehensive Cancer Network guideline-based care. The secondary outcome was the effect of guideline-based care on overall survival. Multivariable models and propensity matching were used to compare the hospital risk-adjusted rates of guideline-based adherence and overall survival based on hospital case volume.

RESULTS

The final cohort consisted of 16,195 patients. The rate of guideline-based care was 58.4% (95% confidence interval [CI] 57.4-59.4%) for non-Hispanic white, 53% (95% CI 51.4-54.9%) for non-Hispanic black, and 51.5% (95% CI 49.4-53.7%) for Hispanic women (P<.001). From 2004 to 2012, the rate of guideline-based care increased from 49.5% (95% CI 47.1-51.9%) to 59.1% (95% CI 56.9-61.2%) (Ptrend<.001). Based on a propensity score-matched analysis, patients receiving guideline-based care had a lower risk of mortality (adjusted hazard ratio 0.65, 95% CI 0.62-0.68). Compared with low-volume hospitals, the increase in adherence to guideline-based care in high-volume hospitals was 48-63% for non-Hispanic white, 47-53% for non-Hispanic black, and 41-54% for Hispanic women.

CONCLUSION

Racial and ethnic disparities in the delivery of guideline-based care are the highest in high-volume hospitals. Guideline-based care in locally advanced cervical cancer is associated with improved survival.

Longitudinal physical activity assessment in post-surgical gynecologic cancer patients

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Background: Physical activity is a key determinant of health, and exercise can be effective for decreasing anxiety and depression and improving quality of life in cancer survivors. The primary aim of this study was to report the trajectory of physical activity over time for post-operative gynecologic cancer patients. The secondary aim was to identify correlates of total physical activity over time. Methods: The study population included patients who underwent surgery for endometrial (n = 80) or ovarian (n = 43) cancer and wore an accelerometer for a 3-day period at 1 week, 1 month and 4 months after surgery. Accelerometer data were captured during all waking hours and were transformed into categories of light, moderate and vigorous intensity physical activity. The outcome of interest was total minutes of moderate to vigorous intensity physical activity (MVPA) collected over the three day period at each time point, analyzed using a linear mixed effect model approach, assessing the correlates of age, body mass index (BMI), self-rated health, laparotomy vs. laparoscopic (endometrial only) and neoadjuvant chemotherapy yes/no (ovarian only). Results: Mean age was 58.8 ± 10.1 years with mean BMI of 35.5±10.3 kg/m2. Over each three-day period, patients performed 7 ± 12 minutes of total accumulated MVPA at 1 week, 20 ± 41 minutes of total MVPA at 1 month, and 25 ± 36 minutes at 4-months post-surgery (p = 0.01). Federal guidelines recommend approximately 70 minutes of moderate intensity activity over a three-day period to collect 150 minutes of moderate activity a week. Better self-rated health at baseline was associated with increased activity over time (p = 0.02). BMI, age, type of surgery or use of neoadjuvant chemotherapy did not predict physical activity in patients of either disease site. Conclusions: Physical activity increased over time for endometrial and ovarian cancer patients. Self-reported health at baseline was also positively associated with increased moderate-vigorous physical activity over time. There is insufficient evidence to show that BMI significantly contributes to changes in moderate-to-vigorous physical activity over time. Future research should address barriers to activity and novel interventions.

Rivaroxaban in the Prevention of Stroke and Systemic Embolism in Patients with Non-Valvular Atrial Fibrillation: Clinical Implications of the ROCKET AF Trial and Its Subanalyses

Atrial fibrillation (AF) is an increasingly common cause of stroke and systemic embolism. While warfarin has been the mainstay of stroke prevention in patients with AF, newer novel oral anticoagulant medications are now available. Rivaroxaban, a direct factor Xa inhibitor with a rapid onset and offset after oral administration, offers potential advantages over warfarin, predominantly due to its predictable pharmacokinetics across wide patient populations. It requires no coagulation monitoring, and only two different doses are needed (20 mg daily for patients with normal renal function and 15 mg daily in those with reduced renal function). A large randomized trial (ROCKET AF) has shown non-inferiority to warfarin for preventing stroke or systemic embolism in the per-protocol population and superiority to warfarin in the on-treatment safety population. Several subanalyses confirm that the treatment effect of rivaroxaban is consistent across different patient subgroups, including those with reduced renal function. The tolerability of rivaroxaban appears similar to that of warfarin, with comparable overall bleeding rates in clinical trials. In ROCKET AF, significantly lower rates of fatal and intracranial bleeding were seen with rivaroxaban, while lower rates of gastrointestinal bleeding were seen with warfarin. Important contraindications to rivaroxaban include valvular AF, the presence of a prosthetic valve (mechanical or bioprosthetic) or valve repair, the need for concurrent dual antiplatelet therapy, and creatinine clearance <30 ml/min. Once-daily dosing and the lack of coagulation monitoring may increase utilization and adherence compared with warfarin, potentially decreasing the large burden of care associated with stroke secondary to AF. Overall, rivaroxaban offers a useful alternative to warfarin for stroke prevention in patients with AF.

The Feasibility and Safety of Adopting Single-Incision Laparoscopic Surgery into Gynecologic Oncology Practice

STUDY OBJECTIVE

To determine the complications associated with single-incision laparoscopy in gynecologic oncology surgery.

DESIGN

A retrospective cohort (Canadian Task Force classification II-3).

SETTING

A single academic institution.

PATIENTS

One hundred fifteen consecutive patients undergoing single-incision laparoscopy with suspected gynecologic oncology conditions.

INTERVENTIONS

Single-incision laparoscopy.

MEASUREMENTS AND MAIN RESULTS

One hundred fifteen patients underwent single-incision laparoscopy. The mean age was 55.3 ± 13.1 years. For procedures completed via single-incision laparoscopy (102/115 [88.7%]), the mean operative time was 130.7 ± 55.5 minutes. The average blood loss was 63 ± 111 mL. The conversion to open rate was 13 of 115 (12.17%). The conversion rate of the 55 patients with benign conditions was lower (2/55 [3.64%]) compared with the 60 patients with malignant conditions (11/60 [18.33%]). The hernia rate was 2 of 115 (1.80%), 1 of which was a recurrent hernia. The median time for follow-up was 30 days (range, 5-653 days).

CONCLUSION

Single-incision laparoscopy provides a feasible, safe, and promising minimally invasive modality for treating gynecologic oncology patients.

Predictors of 30-day readmission and impact of same-day discharge in laparoscopic hysterectomy

OBJECTIVE

The objective of the study was to identify the predischarge predictors of 30-day readmission and the impact of same-day discharge after laparoscopic hysterectomy.

STUDY DESIGN

Patients undergoing only laparoscopic hysterectomy with or without bilateral salpingo-oophorectomy participated in the study.

RESULTS

The 30-day readmission rate was 3.1% (277 of 8890). Factors predictive of higher rates of readmission were diabetes (4.4% vs 3.0%; P = .03), chronic obstructive pulmonary disease (8.5% vs 3.1%; P = .02), disseminated cancer (20% vs 3.1%; P < .001), chronic steroid use (7.1% vs 3.1%; P = .03), daily alcohol use of more than 2 drinks (12.5% vs 2.5%; P = .04), and bleeding disorder (10.8% vs 3%; P = .001). Operative factors included surgical time of 2 hours or greater (3.5% vs 2.7%; P = .014). After surgery, patients had a higher rate of readmission when they experienced any 1 or more complications prior to discharge, (6.9% vs 3.1%; P = .01) as well as any complication after discharge (3.6% vs 1.6%; P = .01). Infections (35.7%) and surgical complications (24.2%) were the most common reasons of readmissions. Of these patients, 20.9% were discharged the same day (n = 1855) and had a similar rate of readmission (2.6% vs 3.2%; P = n.s.). Laparoscopic hysterectomy readmission score (LHRS) can be calculated by assigning 1 point to diabetes, chronic obstructive pulmonary disease, disseminated cancer, chronic steroid use, bleeding disorder, length of surgery of 2 hours or longer, and 2 points to any postoperative complication prior to discharge. Readmission rates for the LHRS score were score 1 (2.4%), score 2 (3.3%), score 3 (5.8%), or score 4 (9.5%).

CONCLUSION

The overall readmission rate after laparoscopic hysterectomy is low. Patients discharged the same day have similar rates of readmission. Higher LHRS is indicative of higher rates of readmission and may identify a population not suitable for same-day discharge and in need of higher vigilance to prevent readmissions.

Elective orthognathic treatment decision making: a survey of patient reasons and experiences

OBJECTIVE

Few studies have explored decisions about orthognathic treatment (OGT) from the patient's perspective. This study describes the factors associated with the patient's decision to have or not have orthognathic treatment, and assesses whether the process can be considered to be informed decision making.

DESIGN

A cross-sectional survey employing both interview and questionnaire methods, conducted in four OGT services in Yorkshire.

SAMPLE

Participants were patients aged over 16 years, either making an OGT decision over a 6-month period or had made their treatment choice 18-42 months prior to the study start date in 2003.

MEASURES

Questionnaires assessed patient demographics, dental history and psychopathology (anxiety, satisfaction with self, body satisfaction, facial appearance); interviews explored patients' reasons for, and experiences of, orthognathic treatment.

RESULTS

Of 138 patients approached, 61 participated (mean age 25 years, 66% female). Psychopathology scores were within the normal range. The thematic content analysis of interview transcripts found: reasons given for having OGT were to improve the 'bite', as well as gaining a more normal facial appearance; most patients reported the service information was satisfactory, but about half made negative comments, with some reporting staff communications made them feel worse; knowledge of OGT risks and benefits was poor; patients had strong emotions about their facial appearance and the orthognathic treatment they received, which did not seem to be addressed by current practice.

CONCLUSIONS

Some OGT patients do not appear to be making informed decisions about their treatment. They seem to have unmet needs in relation to support for their decision making, and managing the emotional effects of undergoing and adjusting to treatment. The implications for information provision, assessment and support during treatment are discussed.

Nature or nurture: the effect of undergraduate rural clinical rotations on pre-existent rural career choice likelihood as measured by the SOMERS Index

OBJECTIVE

Do undergraduate rural clinical rotations increase the likelihood of medical students to choose a rural career once pre-existent likelihood is accounted for?

DESIGN

A prospective, controlled quasi-experiment using self-paired scores on the SOMERS Index of rural career choice likelihood, before and after 3 years of clinical rotations in either mainly rural or mainly urban locations.

SETTING

Monash University medical school, Australia.

PARTICIPANTS

Fifty-eight undergraduate-entry medical students (35% of the 2002 entry class).

MAIN OUTCOME MEASURES

The SOMERS Index of rural career choice likelihood and its component indicators.

RESULTS

There was an overall decline in SOMERS Index score (22%) and in each of its components (12-41%). Graduating students who attended rural rotations were more likely to choose a rural career on graduation (difference in SOMERS score: 24.1 (95% CI, 15.0-33.3) P<0.0001); however, at entry, students choosing rural rotations had an even greater SOMERS score (difference: 27.1 (95% CI, 18.2-36.1) P<0.0001). Self-paired pre-post reductions in likelihood were not affected by attending mainly rural or urban rotations, nor were there differences based on rural background alone or sex.

CONCLUSIONS

While rural rotations are an important component of undergraduate medical training, it is the nature of the students choosing to study in rural locations rather than experiences during the course that is the greater influence on rural career choice. In order to improve the rural medical workforce crisis, medical schools should attract more students with pre-existent likelihood to choose a rural career. The SOMERS Index was found to be a useful tool for this quantitative analysis.

Clinical correlates of suicidal thoughts in patients with advanced cancer

OBJECTIVE

: Cancer patients are at heightened risk of suicide. Clinical correlates of suicidal ideation in advanced cancer patients were examined to identify those at risk and to inform the development of interventions to reduce suicidal ideation in this vulnerable group.

METHODS

: Coping with Cancer (CwC) is an NCI- and NIMH-funded multiinstitutional investigation examining psychosocial influences on the quality of life and care of advanced cancer patients. Baseline face-to-face interviews that assessed mental and physical functioning, coping, spirituality, and use of mental health services were conducted with 700 advanced cancer patients.

RESULTS

: Compared with patients without suicidal ideation, the 8.9% of patients who reported suicidal thoughts were more likely to be white and report no affiliation with an organized religion (p < 0.05). Adjusted analyses revealed that cancer patients who met criteria for current panic disorder (adjusted odds ratio [95% confidence interval] 3.24 [1.01-10.4]) and posttraumatic stress disorder (3.97 [1.13-14.1]), who accessed mental health services (3.70 [2.07-6.67]), particularly psychotherapy (2.62 [1.20-5.71]), who were not feeling well physically, and who lacked a sense of self-efficacy, spirituality, and being supported were more likely than others to report thoughts of suicide (p < 0.05).

CONCLUSIONS

: Advanced cancer patients who report suicidal thoughts are more likely to meet criteria for posttraumatic stress disorder and panic disorder, feel unsupported, lack a religious affiliation, spirituality, and a sense of self-efficacy, and experience more physical distress. Palliative care interventions that promote a sense of self-efficacy, spirituality, and support while minimizing physical distress may offer promise for reducing suicidal thoughts in this at-risk group.

Ovarian dermoid cyst super-infected with methicillin-sensitive Staphylococcus aureus leading to the misdiagnosis of appendicitis in an adolescent

BACKGROUND

Mature cystic teratomas (dermoid cysts) are the most common ovarian tumor in adolescents. Super-infection of a dermoid cyst is a rare event usually associated with a concomitant infection.

CASE

A 14-year-old female was transferred to our institution with five days of fevers and abdominal pain. CT of the abdomen/pelvis was read as acute appendicitis with a 7.6 cm right adnexal dermoid cyst. The patient was treated for appendicitis but later found to have an infected dermoid cyst primarily infected with methicillin-sensitive staphylococcus aureus, which led the misdiagnosis of appendicitis.

SUMMARY AND CONCLUSION

Super-infection of an ovarian dermoid cyst is an extremely rare event. We recommend that previously described evaluation, surgical management, and ovarian conservation be employed in all cases of ovarian dermoid cysts.

Clustering of related individuals in a population of the Australian lizard, Egernia frerei

Stable social aggregations are rarely recorded in lizards, but have now been reported from several species in the Australian scincid genus Egernia. Most of those examples come from species using rock crevice refuges that are relatively easy to observe. But for many other Egernia species that occupy different habitats and are more secretive, it is hard to gather the observational data needed to deduce their social structure. Therefore, we used genotypes at six polymorphic microsatellite DNA loci of 229 individuals of Egernia frerei, trapped in 22 sampling sites over 3500 ha of eucalypt forest on Fraser Island, Australia. Each sampling site contained 15 trap locations in a 100 x 50 m grid. We estimated relatedness among pairs of individuals and found that relatedness was higher within than between sites. Relatedness of females within sites was higher than relatedness of males, and was higher than relatedness between males and females. Within sites we found that juvenile lizards were highly related to other juveniles and to adults trapped at the same location, or at adjacent locations, but relatedness decreased with increasing trap separation. We interpreted the results as suggesting high natal philopatry among juvenile lizards and adult females. This result is consistent with stable family group structure previously reported in rock dwelling Egernia species, and suggests that social behaviour in this genus is not habitat driven.

Protection of the lip from the activator arm of maxillary distractors

The long spring-loaded distractor arms of maxillary distraction devices can cause pain and ulceration of the upper lip. We describe a simple method to relieve the tension and discomfort on the soft tissues using Silastic tubing.

The colonoscope in cecal volvulus: report of three cases

Colonoscopy was employed to attempt detorsion of volvulus of the right colon in four patients considered to be high-risk surgical patients. In one patient detorsion was accomplished, so that emergency laparotomy became unneccesary. The site of torsion was reached in every patient. When detorsion does not occur reasonably soon after the colonoscope enters the right colon, persistent efforts are more likely to be harmful than helpful. Abdominal symptoms in a patient who has been ill or injured for some time should suggest the possibility of volvulus of the right colon. Early diagnosis and earlier employment of colonoscopy would almost surely result in an increased rate of success in accomplishing detorsion. When detorsion is accomplished, subsequent resection of the right colon should be seriously considered as, without it, volvulus is said to recur frequently.

Leiomyosarcoma of the rectum and anus. A series of 22 cases

Twenty-two patients with leiomyosarcoma of the rectum (n = 19) or the anus (n = 3) were treated surgically at the Mayo Clinic from 1950 through 1985. The majority of tumors occurred in men (1.4:1.0) during the sixth and seventh decades of life. Fifty-nine percent of the patients had symptoms including, most commonly, change in bowel habit, bleeding, and pain. Wide local excision was performed in 10 patients, whereas a more radical surgical procedure, including abdominoperineal resection (n = 8), pelvic exenteration (n = 2), and low anterior resection (n = 1), were performed in 11 patients. One tumor was unresectable. The overall survival until death from disease was 90% at 1 year, 74% at 5 years, and 51% at 10 years postoperatively. The percentage of patients free of disease at 1, 5, and 10 years postoperatively was 85, 62, and 40, respectively. Wide local resection was not superior to a more radical surgical approach in preventing tumor recurrence or improving survival. Lesions less than 2.5 cm and confined to the bowel wall can be treated by wide local excision, whereas larger or more extensive tumors should be treated by a more radical surgical approach.

Unusual indelible enamel staining following fixed appliance treatment

Two cases are described of indelible enamel staining following fixed appliance therapy. The acquired pigmentation occurred in patients with an identifiable enamel defect prior to treatment. The interaction of factors to cause the staining is discussed and it's prevention in future cases highlighted. Subsequent restoration of the affected teeth is shown.

The diet and digestive energetics of an Australian short-necked turtle, Emydura macquarii

We described the diet of Emydura macquarii, an omnivorous turtle from south-eastern Australia, compared its digestive performance on diets of fish or plants at two temperatures, and related how both diet and temperature affect its food selection in nature. Filamentous algae constituted 61% of the stomach content of E. macquarii. The turtles rarely fed on motile prey, but selected carrion from the lagoon bottom and terrestrial insects (Diptera, Hymenoptera and Coleoptera) trapped on the surface of the water. Digestive efficiency of E. macquarii was affected little by body temperature, in contrast to consumption rates and rates of passage which were strongly influenced by both temperature and diet. In combination, these responses resulted in a slower rate of digestion at 20 degrees C than at 30 degrees C. Digestive efficiency of E. macquarii on a herbivorous diet at 30 degrees C (49%) was about half that of turtles on a carnivorous diet (91%), but they had longer transit times (118 h on the plant diet versus 70 h). Lower consumption rates and longer mean retention times in turtles fed plants compared those fed fish relate to slower digestive processing of the plant. Rapid processing and higher consumption rates of fish by E. macquarii resulted in higher energy gains compared to turtles consuming plants (almost 100 times more energy at 30 degrees C). The laboratory results suggest that fish carrion and aquatic and terrestrial invertebrates are probably essential dietary items of E. macquarii in the wild, because its metabolic requirements cannot be met from aquatic macrophytes alone.