United States

We present a case of cutaneous scalp metastasis of retroperitoneal leiomyosarcoma. The patient in this case has an initial complaint of left upper quadrant pain, unintentional weight loss, fatigue, and night sweats. On initial physical exam he was found to have two right sided scalp nodules. The patient underwent a series of tests which resulted in a diagnosis of leiomyosarcoma of the retroperitoneum with metastasis to the right sided cutaneous scalp. Leiomyosarcoma is a rare malignancy of smooth muscle cells. It most commonly arises from uterine tissue but other primary locations include other gynecologic tissue, gastrointestinal, somatic soft tissue, and in the case of this patient, retroperitoneal. As with other sarcomas, metastasis likely occurs via hematogenous route. The literature on scalp metastasis of leiomyosarcoma is limited to case reports. To the best of our knowledge, only 4 other reports have been documented of retroperitoneal leiomyosarcoma metastasis to the cutaneous scalp have been identified. In one of these cases, metastasis to many other sites were found as well including lungs, hip, and thigh. Interestingly, in the case we present, no other metastasis besides the cutaneous scalp has been found. Our case serves to highlight the importance of a high index of clinical suspicion when caring for these patients. A full head to toe physical exam should be performed regularly and cutaneous nodules should be biopsied in order to assess for metastasis.

AMA Research Challenge 2022

Metastasis of retroperitoneal leiomyosarcoma to the cutaneous scalp

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Background: Frailty is a spectrum describing a demographic more likely to experience adverse events such as falls, disability, and hospital admission. The Modified Frailty Index (mFI) is a method of quantifying frailty, predicting increased risk of 30-day readmission. Though assessing risk of 30-day readmission is important, 44.7% of posterior lumbar decompression surgery readmissions occurred beyond 30 days. Therefore, a predictive model accounting for readmission within 90 days post-operatively will be more useful for this procedure.
Methods: This is a retrospective study on patient mFI and 90-day readmission for lumbar interbody fusion procedures involving two or more vertebral levels. Patients filled out an 11-point questionnaire derived from mFI prior to XLIF, OLIF, PLIF, TLIF, or ALIF surgery. mFI score and readmission data will be collected between the dates of January 2019 and December 2021. Next, associations will be assessed using Spearman’s rank-order correlation and ROC curves to determine the range of scores associated with readmission within 90 days.
Results: The purpose of this project is to assess whether a patient questionnaire format of the 11-point mFI can be used to predict risk of 90-day readmission for elderly patients undergoing multi-level lumbar interbody fusions. We expect for there to be a positive correlation between mFI and 90-day readmission.
Conclusion: The frailty questionnaire will provide a more time efficient alternative to mFI-11. The ability to calculate risk for 90-day readmission will more accurately assess the patient procedural risk. This will improve pre-operative counseling and may be helpful in reducing hospital length of stay while keeping the emotional interests of patients in mind.

Questionnaire Format of the Modified Frailty Index as a Predictor of 90-Day Readmission in Multi-Level Lumbar Interbody Fusion Patients

Background: Sterilization is an effective form of contraception with approximately 18.6% of women aged 15-49 years relying on this method, however only 39-57% of women who request this procedure prenatally ultimately undergo postpartum sterilization. The implications for incomplete but desired postpartum sterilization procedures negatively impact the health of women. At Penn State Hershey Medical Center (PSHMC), immediate postpartum sterilization after vaginal delivery is not standard practice, so a root cause analysis was done to identify existing barriers to postpartum sterilization after vaginal delivery at PSHMC.
Methods: Voluntary one-on-one qualitative interviews were conducted with a multidisciplinary group of stakeholders involved in performing postpartum sterilization. Stakeholders consisted of women’s health attendings, family and community medicine attendings, ob-gyn residents, anesthesiologists, and nursing leadership with the goal of obtaining a comprehensive understanding of this issue.
Results: Participants were asked standardized questions that were selected according to participant role in the postpartum sterilization process. Barriers identified were found to be either logistic and/or cultural. A root-cause analysis in the form of a fishbone model was performed to identify barriers and create targeted solutions for the future.
Conclusion: Due to the high rates of short-interval pregnancy, dissatisfaction, and associated health consequences, interview participants agreed that postpartum sterilization was an important procedure that patients should be able to obtain. It was also identified that the current model at PSHMC does not adequately provide this service to women who desire it. A sample standard operating procedure was created to begin formulating a framework to help increase the rate of postpartum sterilization to 1 per month at PSHMC, with cyclic re-evaluation.

A Root Cause Analysis of Logistical and Cultural Barriers to Postpartum Sterilization After Vaginal Delivery at a Tertiary Medical Center

Background:
Placenta accreta spectrum (PAS) refers to a disease of morbidly adherent trophoblastic tissue invading into the myometrium of the gravid uterus. The incidence of PAS has been rapidly increasing in recent years. Risk factors include previous uterine surgery, including cesarean delivery, and placenta previa. Patients with antenatally suspected PAS often undergo planned hysterectomy at cesarean delivery. Surgery for PAS is associated with significant maternal morbidity and mortality.
The 2018 joint consensus statement by the American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine (SMFM) recommends the delivery timing for patients with PAS at 34 0/7–35 6/7 weeks of gestation as a Level 1A, strong recommendation based on high-quality evidence (Obstetric Care Consensus No.7, published 12/2018). The objective of this study was to examine the influence of their recommendation on delivery timing for PAS in real-world practice.

Methods:
This retrospective cohort study queried the Healthcare Utilization Cost and Utilization Project’s National Inpatient Sample. The study population was 5,655 patients with a diagnosis of both PAS and placenta previa who underwent cesarean delivery from 1/2016-12/2019. The study period was grouped into pre-consensus period (1/2016-12/2018) and post-consensus period (1/2019-12/2019). A quasi-experimental method with Difference-in-Difference analysis was fitted to examine the change in delivery timing, grouped as early-delivery (<34 weeks), recommended-delivery (34 0/7-35 6/7 weeks), and late-delivery (≥36 weeks).

Results:
At the cohort level, the number of late-delivery decreased by 15.1% and the number of early- delivery increased by 12.8% in the post-consensus period (P=0.001). When stratified by the severity of PAS, more prominent change occurred in severe forms of PAS (increta/percreta) with 37.7% relative-decrease in late-delivery and 13.2% relative-increase in recommended-delivery (P=0.002). When increta/percreta cases were further restricted to the elective admission cases, a marked shift in delivery timing occurred towards recommended-delivery from 32.2% to 51.3% (59.3% relative-increase) whereas late-delivery decreased significantly from 23.5% to <10% (78.3% relative-decrease; P<0.001).

Discussion:
This national-level assessment in the United States suggests that the delivery timing of patients with severe PAS is rapidly shifting to 34 0/7-35 6/7 weeks following the ACOG-SMFM consensus recommendation. Delivery beyond this recommended timing appears to rarely be planned in suspected placenta increta/percreta.
Key limitations of the study included unmeasured bias with a lack of information on exact shared decision-making discussion for the timing of surgery and preoperative diagnosis. Generalizability in different populations was not assessed.

Delivery timing of placenta accreta spectrum in the United States: Influence of a society-based recommendation

Abstract Title: Postpartum Contraception Decision Making Among Adolescent Mothers 

Background 

Adolescent mothers are more likely to experience short-interval repeat pregnancies than their non-adolescent counterparts, placing them at risk for both pregnancy-related morbidity and adverse socioeconomic outcomes. A previous study in our dyadic adolescent-mother baby medical home showed an association between long-acting contraception (LARC) use and decreased repeat pregnancy, but the reasons that adolescent mothers choose their subsequent contraceptive methods is not well elucidated. 

Methods 

We conducted semi-structured, in-depth phone interviews of 6 month postpartum adolescent women regarding contraceptive choice between 6/16/2020 and 11/16/2020. We recruited participants during their 6 week postpartum visit at the Young Mother’s Clinic, a dyadic primary care medical home located at the Children’s Hospital Colorado. All women who presented for their 6 week postpartum visit during the study period were invited to enroll. 

Twenty-one patient interviews were completed. Each interview was independently coded by two reviewers. All interview transcripts were coded to create a matrix outlining common themes related to contraceptive choice. These codes were then looked at further based on subgroup of contraceptive type and race/ethnicity. 

Results 

Multiple themes emerged upon performing rapid qualitative analysis. Most participants cited an inability to remember to take a daily pill as the reason they did not choose OCPs as their birth control method. Those who did not choose an IUD or implant cited invasiveness as reason for refusal. Participants chose methods other than Depo Provera because they felt that frequent appointments were inconvenient. Conversely, participants who chose the IUD/Implant cited its efficacy, convenience, and menses suppression as reasons for their decision. Those who chose Depo Provera favored its ease of use and menses suppression as well. Pregnancy plans were mentioned by several Hispanic/Latino participants as influencing selection of contraceptive methods, but never by non-Hispanic/Latino participants. Perceived efficacy, duration, and positive side effects were mentioned relatively more frequently by non-Hispanic/Latino participants as compared to Hispanic/Latino participants. 

Conclusion 

The data provided by this study highlights factors that influence adolescent mothers’ contraception decisions. This insight can be used to inform patient-centered contraception counseling specific to this population. 



Postpartum Contraception Decision Making Among Adolescent Mothers

Introduction: Multiple studies have demonstrated racial and ethnic disparities in pregnancy-related outcomes in the United States, and disparities in opioid pain management among different races and ethnicities have also been thoroughly documented. However, few studies have evaluated these disparities in the postpartum setting. We evaluated racial and ethnic disparities in postpartum opioid prescription at a high-volume tertiary care center before and after standardized opioid prescription guidelines were implemented. 

Methods: We conducted a retrospective study of all vaginal deliveries between August 14, 2017 and September 17, 2017, before guideline implementation, and between April 9, 2018 and May 4, 2018, after guideline implementation. We categorized patients into: Non-Hispanic Black, Non-Hispanic White, Hispanic, and Non-Hispanic Other. From medical records we collected demographic information, pain score data, inpatient opioid consumption, and oxycodone prescribed (in morphine milligram equivalents [MME]) upon discharge. 

Results: 560 patients were included, 282 pre-intervention and 278 post-intervention. Opioids administered in the first 24 hours of postpartum admission were 12.6 MME pre-intervention and 6.70 MME post-intervention, and the amount of opioids prescribed for home use were 125 MME pre-intervention and 28 MME post-intervention. There were no statistically significant differences in these measures between racial-ethnic groups before or after the intervention, and there were no significant differences between racial-ethnic groups in how often post-intervention guidelines were followed. 

Conclusion: Standardized prescription guidelines successfully decreased both inpatient and outpatient opioid consumption while maintaining equity among racial groups. Future studies may explore disparities in cesarean section patients, as these patients typically require larger amounts of opioids. 


Racial and ethnic disparities in postpartum opioid prescription

Background 

Near-term follow-up after evaluation in the emergency room for minor ophthalmic concerns can impose logistical challenges for patients and ophthalmology practices. While ophthalmic telemedicine has been used for screening and triage, its feasibility and safety for follow-up after presentation to the emergency department (ED) has not been reported. This study describes the initial results of a novel, newly-implemented Virtual Emergency Department Follow-Up (VEDFU) clinic at Mass Eye and Ear (MEE), a tertiary eye care center in Boston, MA. 

Methods

This was a retrospective, cross-sectional study of 145 clinical encounters from December 6, 2021 to July 1, 2022 in the VEDFU. Inclusion criteria included patients discharged from the MEE ED who required near-term follow-up for diagnoses deemed suitable for the virtual clinic, lived within Massachussets, and consented to virtual care. The primary outcome measures included mode of telemedicine encounter (video or phone call), missed appointment rate, documentation of clinical exam findings, clinical diagnoses, time interval between ED encounter and subsequent virtual follow-up, and referrals after initial telemedicine follow-up (stratified by urgency, subspecialty, and reason for follow-up). 

Results

A total of 145 visits scheduled in the EDFU were included. The mean age was 38.1 years (SD 14.2) and 78 (53.8%) were men. The no-show rate was 31.7%. The mean interval time between ED evaluation and virtual follow-up was 8.3 days (SD 3.9). Of the 99 completed visits, 15 were telephone calls and 84 were video visits. The most common diagnoses were conjunctivitis, chalazion, corneal abrasion, and subsequent encounter after removal of corneal foreign body. After virtual follow-up, 23 patients (23.2%) had subsequent referrals, and no patients returned to the ophthalmic ED.

Conclusion

A novel virtual follow-up program for ophthalmic ED patients enabled safe and timely telemedical re-examination for a range of minor indications without any patients necessitating return to the ED. To our knowledge, this is the first program of its kind and may serve as a model for other medical and surgical subspecialties with high rates of ED referrals, limited clinic availability, and diagnoses that can be managed safely through virtual visits. Larger, longitudinal studies are warranted to further validate ophthalmic telemedicine as an alternative avenue for post-acute near-term follow-up care.

A Novel Ophthalmic Telemedicine Program for Follow-Up of Minor Ophthalmic Emergencies

A cross-sectional analysis of harms reporting in systematic reviews evaluating laminectomy

Background
In the field of orthopedic surgery, women have been historically underrepresented. In this analysis, we sought to determine the relative proportion of women amongst active orthopedic surgeons by graduation year and explore related trends.
Methods
Utilizing the Centers for Medicare and Medicaid Services, the investigators were able to acquire the Physician Compare National Downloadable File July 2022 dataset for active physicians who indicated “orthopedic surgery” as their primary specialty. Physicians were queried by graduation year, gender, and state of practice, of which duplicates were removed. Physicians who graduated within the past 7 years (from 2016-2022) were excluded from this analysis to retain only the attending physician population. This query yielded 21,320 orthopedic surgeons. Five-year intervals were used to measure the average proportion of female orthopedic surgeons.
Results
There were 1,477 (6.92%) female and 19,843 male (93.1%) practicing orthopedic surgeons in the United States with medical school graduation dates between 1953-2015. Between graduation years 2011-2015, 12.2% (421/3463) were female. From 2006-2010, 10.7% (346/3224) were
female; 2001-2005, 8.40% (160/2656) were female; 1996-2000, 6.02% (160/2656) were female; 1991-1995, 5.05% (135/2674) were female; 1986-1990, 3.52% (87/2475); 1981-1985, 2.47% (48/1945) were female; 1976-1980, 1.39% (15/1080) were female; 1971-1975, 2.14% (11/515) were female; 1966-1970, 0.93% (2/215) were female; 1961-1965 1.39% (1/72) were female; and before 1961, 0% (0/12) graduates were female. Additionally, geographic trends were recognized by state, with the highest proportions of active female orthopedic surgeons in Hawaii (14.1%, 12/85) and the District of Columbia (13.6%), and the lowest proportions in Nebraska (2.7%, 4/148) and Alaska (0%, 0/72) .
Conclusion
These basic results indicate the proportion of female orthopedic surgery graduates is increasing, yet longstanding gender inequities in orthopedic surgery training remain.

Increasing rates of active female orthopedic surgeons in the United States

In the field of orthopedic surgery, women have been historically underrepresented. In this analysis, we sought to determine the relative proportion of women amongst active orthopedic surgeons by graduation year and explore related trends.
Methods
Utilizing the Centers for Medicare and Medicaid Services, the investigators were able to acquire the Physician Compare National Downloadable File July 2022 dataset for active physicians who indicated “orthopedic surgery” as their primary specialty. Physicians were queried by graduation year, gender, and state of practice, of which duplicates were removed. Physicians who graduated within the past 7 years (from 2016-2022) were excluded from this analysis to retain only the attending physician population. This query yielded 21,320 orthopedic surgeons. Five-year intervals were used to measure the average proportion of female orthopedic surgeons.
Results
There were 1,477 (6.92%) female and 19,843 male (93.1%) practicing orthopedic surgeons in the United States with medical school graduation dates between 1953-2015. Between graduation years 2011-2015, 12.2% (421/3463) were female. From 2006-2010, 10.7% (346/3224) were
© 2022 American Medical Association. All rights reserved.
female; 2001-2005, 8.40% (160/2656) were female; 1996-2000, 6.02% (160/2656) were female; 1991-1995, 5.05% (135/2674) were female; 1986-1990, 3.52% (87/2475); 1981-1985, 2.47% (48/1945) were female; 1976-1980, 1.39% (15/1080) were female; 1971-1975, 2.14% (11/515) were female; 1966-1970, 0.93% (2/215) were female; 1961-1965 1.39% (1/72) were female; and before 1961, 0% (0/12) graduates were female. Additionally, geographic trends were recognized by state, with the highest proportions of active female orthopedic surgeons in Hawaii (14.1%, 12/85) and the District of Columbia (13.6%), and the lowest proportions in Nebraska (2.7%, 4/148) and Alaska (0%, 0/72) .
Conclusion
These basic results indicate the proportion of female orthopedic surgery graduates is increasing, yet longstanding gender inequities in orthopedic surgery training remain.

Proportion of Female Orthopedic Surgeons by Year in the United States 

Background
Acoustic neuromas, also known as vestibular schwannomas, are benign tumors of the vestibulocochlear nerve typically presenting with hearing loss. More common in adults, these are also associated with neurofibromatosis type 2 in children. Once diagnosed via audiogram and MRI, options include conservative management, radiotherapy, or surgical resection. Prior studies have demonstrated disparities such as Black patients tending to be managed conservatively despite larger tumor size at diagnosis and having increased mortality when managed surgically. Given such disparities, this study aims to investigate further socioeconomic factors potentially impacting acoustic neuroma management to facilitate systemic healthcare changes for equitable outcomes.

Methods
Acoustic Neuroma patient data were obtained from the Surveillance, Epidemiology, and End Results (SEER) database and analyzed using binary logistic regression in SPSS 27.0. Demographic variables including sex, age, race, income, and county attributes were analyzed with respect to the dependent variable of initial management with surgery. Demographic groupings were determined using preset SEER coding and United States demographic data.

Results
This was a retrospective analysis of 19,624 patients diagnosed with acoustic neuroma from 2000 to 2019, which consisted of 9,426 males (48.1%) and 10,198 females (51.9%). Factors that predicted whether a patient’s initial treatment was surgery included age between 18 and 64 (p<0.001), race other than Black (p<0.001), income between $60,000 and $75,000 (p<0.001), and living in a county with a population less than one million (p<0.001).

Conclusion
This study indicates that multiple demographic factors predict the course of care for patients with acoustic neuromas. Noticeably, Black patients were treated more conservatively, as they were less likely to be treated with surgery. Other demographic variables in this study indicate that there are likely other factors that play a role in determining a patient’s clinical course, which may include clinical judgment, coexisting comorbidities, and access to non-surgical modalities of care. These findings can inform health system policy on potential shortcomings of care provided to at-risk populations.

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