Publications by authors named "Gregg Nelson"

109 Publications

Maternal and fetal hypothermia: more preventive compliance is required for a mother and her fetus while undergoing cesarean delivery; a quality improvement review.

J Matern Fetal Neonatal Med 2021 Oct 24:1-14. Epub 2021 Oct 24.

Department of Obstetrics and Gynecology, Cumming School of Medicine University of Calgary, Calgary, Canada.

Objective: Cesarean delivery is common, involves two patients, has numerous multi-disciplinary health care providers involved in the delivery management, but has variable levels of anesthesia and health services implementation for decreasing maternal hypothermia and the maternal and neonatal morbidity (and mortality). Limited implementation for either of the ERAS-CD or the ERAC guidelines, for inadvertent or preventive maternal hypothermia, is likely to be occurring on labor delivery floors. This Quality Improvement (QI) review focuses on cesarean delivery and maternal hypothermia.

Methods: This quality and safety initiative used SQUIRE 2.0 methodology and concurrent PubMed searches to identify systematic review, meta-analysis, topic directed studies, additional published cohorts in the topic area not included in SR/MA, limited case reports that had specific clinical outcomes related to maternal hypothermia and fetal effects.

Results: Two quality and safety improvement guidelines have defined the hypothermia activity element differently, with ERAS-CD recommending to while ERAC recommending to . The peer-reviewed literature indicates that the knowledge associated with surgical hypothermia outcome is known but it is not implemented for maternal cesarean delivery care. Increased maternal-effect recognition, surveillance, triage, and evidenced-based protocol management is required for the maternal - neonatal dyad undergoing cesarean delivery for the clinical reduction/prevention of neonatal hypothermia that has proven evidence-based maternal morbidity and neonatal morbidity/mortality.

Conclusion: TEAM-based anesthesia, obstetrical, neonatology-pediatrics and nursing research collaboration is required through quality-safety-ERAS-ERAC directed processes. Healthcare system recognition and financial support is required for maternal-fetal-neonatal hypothermia prevention protocols implementation.
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http://dx.doi.org/10.1080/14767058.2021.1993816DOI Listing
October 2021

Selection of endometrial carcinomas for p53 immunohistochemistry based on nuclear features.

J Pathol Clin Res 2021 Oct 1. Epub 2021 Oct 1.

Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB, Canada.

The World Health Organization endorses molecular subclassification of endometrial endometrioid carcinomas (EECs). Our objectives were to test the sensitivity of tumor morphology in capturing p53 abnormal (p53abn) cases and to model the impact of p53abn on changes to ESGO/ESTRO/ESP (European Society of Gynaecological Oncology/European Society for Radiotherapy and Oncology/European Society of Pathology) risk stratification. A total of 292 consecutive endometrial carcinoma resections received at Foothills Medical Centre, Calgary, Canada (2019-2021) were retrieved and assigned to ESGO risk groups with and without p53 status. Three pathologists reviewed the representative H&E-stained slides, predicted the p53 status, and indicated whether p53 immunohistochemistry (IHC) would be ordered. Population-based survival for endometrial carcinomas diagnosed during 2008-2016 in Alberta was obtained from the Alberta Cancer Registry. The cohort consisted mostly of grade 1/2 endometrioid carcinomas (EEC1/2; N = 218, 74.6%). One hundred and fifty-two EEC1/2 (52.1% overall) were stage IA and 147 (50.3%) were low risk by ESGO. The overall prevalence of p53abn and subclonal p53 was 14.5 and 8.3%, respectively. The average sensitivity of predicting p53abn among observers was 83.6%. Observers requested p53 IHC for 39.4% with 98.5% sensitivity to detect p53abn (99.6% negative predictive value). Nuclear features including smudged chromatin, pleomorphism, atypical mitoses, and tumor giant cells accurately predicted p53abn. In 7/292 (2.4%), p53abn upgraded ESGO risk groups (2 to intermediate risk, 5 to high risk). EEC1/2/stage IA patients had an excellent disease-specific 5-year survival of 98.5%. Pathologists can select cases for p53 testing with high sensitivity and low risk of false negativity. Molecular characterization of endometrial carcinomas has great potential to refine ESGO risk classification for a small subset but offers little value for approximately half of endometrial carcinomas, namely, EEC1/2/stage IA cases.
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http://dx.doi.org/10.1002/cjp2.243DOI Listing
October 2021

Accurate Distinction of Ovarian Clear Cell From Endometrioid Carcinoma Requires Integration of Phenotype, Immunohistochemical Predictions, and Genotype: Implications for Lynch Syndrome Screening.

Am J Surg Pathol 2021 11;45(11):1452-1463

Department of Pathology, University of Calgary.

Ovarian clear cell carcinoma (OCCC) and ovarian endometrioid carcinoma (OEC) are both associated with endometriosis but differ in histologic phenotype, biomarker profile, and survival. Our objectives were to refine immunohistochemical (IHC) panels that help distinguish the histotypes and reassess the prevalence of mismatch repair deficiency (MMRd) in immunohistochemically confirmed OCCC. We selected 8 candidate IHC markers to develop first-line and second-line panels in a training set of 344 OCCC/OEC cases. Interobserver reproducibility of histotype diagnosis was assessed in an independent testing cohort of 100 OCC/OEC initially without and subsequently with IHC. The prevalence of MMRd was evaluated using the testing cohort and an expansion set of 844 ovarian carcinomas. The 2 prototypical combinations (OCCC: Napsin A+/HNF1B diffusely+/PR-; OEC: Napsin A-/HNF1B nondiffuse/PR+) occurred in 75% of cases and were 100% specific. A second-line panel (ELAPOR1, AMACR, CDX2) predicted the remaining cases with 83% accuracy. Integration of IHC improved interobserver reproducibility (κ=0.778 vs. 0.882, P<0.0001). The prevalence of MMRd was highest in OEC (11.5%, 44/383), lower in OCCC (1.7%, 5/297), and high-grade serous carcinomas (0.7%, 5/699), and absent in mucinous (0/126) and low-grade serous carcinomas (0/50). All 5 MMRd OCCC were probable Lynch syndrome cases with prototypical IHC profile but ambiguous morphologic features: 3/5 with microcystic architecture and 2/5 with intratumoral stromal inflammation. Integration of first-line and second-line IHC panels increases diagnostic precision and enhances prognostication and triaging for predisposing/predictive molecular biomarker testing. Our data support universal Lynch syndrome screening in all patients with OEC when the diagnosis of other histotypes has been vigorously excluded.
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http://dx.doi.org/10.1097/PAS.0000000000001798DOI Listing
November 2021

Nicotine Patch Improved Autosomal Dominant Sleep-Related Hypermotor Epilepsy.

Pediatr Neurol 2021 Oct 17;123:41-42. Epub 2021 Jul 17.

Department of Pediatrics, Kaiser Permanente, San Francisco, California.

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http://dx.doi.org/10.1016/j.pediatrneurol.2021.07.006DOI Listing
October 2021

Evaluation of the Implementation of Multiple Enhanced Recovery After Surgery Pathways Across a Provincial Health Care System in Alberta, Canada.

JAMA Netw Open 2021 Aug 2;4(8):e2119769. Epub 2021 Aug 2.

Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.

Importance: Engaging multidisciplinary care teams in surgical practice is important for the improvement of surgical outcomes.

Objective: To evaluate the association of multiple Enhanced Recovery After Surgery (ERAS) pathways with ERAS guideline adherence and outcomes.

Design, Setting, And Participants: This quality improvement study compared a pre-ERAS cohort (2013-2017) with a post-ERAS cohort (2014-2018). All patients were from Alberta Health Services in Alberta, Canada, and had available ERAS and up to 1-year postsurgery administrative data. Data collected included age, sex, body mass index, tobacco and alcohol use, diabetes, comorbidity index, and surgical characteristics. Data analysis was performed from May 7, 2020, to February 1, 2021.

Interventions: Implementation of 5 ERAS pathways (colorectal, liver, pancreas, gynecologic oncology, and radical cystectomy) across 9 sites.

Main Outcomes And Measures: Adherence to ERAS guidelines was measured by the percentage of patients whose care met the common ERAS pathway care element criteria. Surgical procedures were grouped by complexity; complications were classified by severity. Outcome measures for the pre-post-ERAS cohorts included length of stay (LOS), readmission, complications, and mortality.

Results: A total of 7757 patients participated in the study, including 984 in the pre-ERAS cohort (median [interquartile range] age, 62 [53-71] years; 526 [53.5%] female) and 6773 in the post-ERAS cohort (median [interquartile range] age, 62 [53-71] years; 3470 [51.2%] male). In the total cohort, care-element adherence improved from 52% to 76% (P < .001), no significant differences were found in serious complications (from 6.2% to 4.9%; P = .08) or 30-day mortality (from 0.71% to 0.93%; P = .50), 1-year mortality decreased from 7.1% to 4.6% (P < .001), mean (SD) LOS decreased from 9.4 (7.0) to 7.8 (5.0) days (P < .001), and 30-day readmission rates were unchanged (from 13.4% to 11.7%; P = .12). After adjustment for patient characteristics, the LOS mean difference decreased 0.71 days (95% CI, -1.13 to -0.29 days; P < .001), with no significant differences in adjusted 30-day readmission (-3.5%; 95% CI, -22.7% to 20.4%; P = .75), serious complications (1.3%; 95% CI, -26.2% to 39.0%; P = .94), or mortality (30-day mortality: 42% [95% CI, -35.4% to 212.3%]; P = .38; 1-year mortality: 8% [95% CI, -20.5% to 46.8%]; P = .62). The adjusted 1-year readmission rate was -15.6% (95% CI, -27.7% to -1.5%; P = .03) in favor of ERAS, and readmission LOS was shorter by 1.7 days (95% CI, -3.3 to -0.1 days; P = .04).

Conclusions And Relevance: The results of this quality improvement study suggest that implementation of ERAS across multiple pathways may improve health care practitioner adherence to ERAS guidelines, LOS, and readmission rates at a system level.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.19769DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8346943PMC
August 2021

Evaluation of the Fetal Therapy Evidence in Lower Urinary Tract Obstruction: Would an ERAS Guideline Improve Outcomes?

Fetal Diagn Ther 2021 28;48(7):504-516. Epub 2021 Jul 28.

Department of Obstetrics and Gynecology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.

Background: Pregnancies that are prenatally identified to have fetal anomalies are complex and require expert multidisciplinary care. As many conditions can impact the fetus prenatally and require intervention, an enhanced recovery after surgery (ERAS) for lower urinary tract obstruction (LUTO) is being evaluated to determine the level of evidenced-based data available.

Problem: The percutaneous ultrasound-guided fetal surgery procedure for bladder neck obstruction is the focus for elements of preoperative counseling, intraoperative procedure/risk complications, and postoperative management.

Methods: A quality improvement review Squire 2.0 (2000-2020) was undertaken for the percutaneous LUTO fetal surgery shunting (lower urinary tract obstruction), process and procedure which require 2 process pathways, one to evaluate the fetal candidate and a second to treat. This structured review is focused on identifying the process elements to allow the determination of the number of evidenced-based elements that would allow for audit and measurement of the clinical element variance for comparative feedback to the individual surgical provider or surgery center.

Interventions: Titles and abstracts were screened to identify potentially relevant articles with priority given to meta-analyses, systematic reviews, randomized controlled studies, nonrandomized controlled studies, reviews, and case series.

Results: A series of potential clinical elements for the diagnostic fetal evaluation and for the 3 protocol areas of surgical care for the procedures (pre-, intra-, and postoperative care) are identified using an ERAS-like process.

Conclusions: The identified clinical elements have the potential for ERAS-LUTO fetal therapy guideline. Multidisciplinary collaboration (surgeon, anesthesia, nursing, imaging, and laboratory) is required for ERAS quality improvement in the pre-, intra-, and postoperative processes. Process elements in each of the operative areas can be audited, evaluated, compared, and modified/improved.
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http://dx.doi.org/10.1159/000517624DOI Listing
July 2021

Enhanced recovery after surgery in gynecologic oncology: time to address barriers to implementation in low- and middle-income countries.

Int J Gynecol Cancer 2021 08 5;31(8):1195-1196. Epub 2021 Jul 5.

Department of Gynecologic Oncology and Reproductive Medicine, MD Anderson Cancer Center, Houston, Texas, USA.

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http://dx.doi.org/10.1136/ijgc-2021-002841DOI Listing
August 2021

Maternal perceptions of cesarean birth care: A qualitative study to inform ERAS guideline development.

Birth 2021 Jun 16. Epub 2021 Jun 16.

Department of Obstetrics and Gynecology, University of Calgary, Calgary, AB, Canada.

Background: Cesarean birth (CB) is the most common inpatient surgical procedure, and until recently, there were no internationally accepted, standardized clinical guidelines available. The Enhanced Recovery After Surgery (ERAS ) program aims to improve outcomes through the development of international guidelines (IGs). As an ERAS IG for CB was being developed, this qualitative study was conducted to explore and consolidate women's experiences with CB.

Methods: Qualitative methods were used to assess the patient experience with current evidence-based CB protocols across operative phases. Twelve women who experienced CB at a single center in Canada were interviewed using an open-ended, semi-structured interview guide at six weeks postpartum. Two researchers coded the emerging themes separately and compared findings.

Results: Women described feeling informed, but felt they did not have a choice. Presurgery, women wanted more information about the risks of CB. Preoperatively, women expressed confusion with the procedures, but felt informed about local anesthesia and thermoregulation. Post-CB, women felt informed about pain and nausea control; however, urinary catheter removal was delayed when compared to the ERAS recommendations. Information about postpartum infant care was not well communicated, as many women were uninformed about delayed cord clamping and infant thermoregulation.

Conclusions: This qualitative study provides opportunities to improve communication, the patient-practitioner relationship, and the overall satisfaction throughout the CB process. The findings support the implementation of patient decision aids and training with the shared decision model. The improved procedures recommended in the ERAS IG for CB have the potential to deliver significant improvements to patient care and patient satisfaction.
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http://dx.doi.org/10.1111/birt.12561DOI Listing
June 2021

Importance of Enhanced Recovery After Surgery (ERAS) Protocol Compliance for Length of Stay in Ovarian Cancer Surgery.

Ann Surg Oncol 2021 Jun 6. Epub 2021 Jun 6.

Unit of Gynecologic Oncology, Service of Gynecology, Gynecological Oncology Department, Vall d'Hebron Barcelona Hospital Campus, Autonoma University of Barcelona, Barcelona, Spain.

Objectives: Enhanced Recovery After Surgery (ERAS) programs include multiple perioperative care elements, which when implemented together are designed to improve recovery after surgery with subsequent reduction in hospital length of stay (LOS). The aim of this study is to examine the impact of ERAS protocol compliance on LOS in patients undergoing advanced ovarian cancer surgery within the context of a randomized clinical trial.

Methods: Patients were enrolled in a prospective, consecutive, interventional randomized clinical trial between June 2014 and March 2018. Women with either suspected or confirmed advanced ovarian cancer with International Federation of Gynecology and Obstetrics (FIGO) stages IIB-IVA and recurrent ovarian cancer, who underwent cytoreduction surgery, were randomly assigned to either a conventional management (CM) protocol or an ERAS protocol. Demographic items, preoperative clinical data, and surgical characteristics of patients were recorded, as were LOS and ERAS protocol compliance. Negative binomial regression was used to model the relation between length of stay and ERAS protocol compliance.

Results: We included 49 patients in the CM group and 50 patients in the ERAS group. The overall rate of ERAS compliance was 92%. We observed that increasing ERAS protocol compliance was associated with shorter median LOS, and in patients who underwent higher complex surgeries, the length of stay reduction was greater.

Conclusion: This study identifies a correlation between increasing ERAS protocol compliance and decreasing LOS in ovarian cancer surgery. This finding underlines the necessity to implement as many ERAS protocol elements as possible to achieve optimal clinical outcome improvements.
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http://dx.doi.org/10.1245/s10434-021-10228-2DOI Listing
June 2021

Canadian Enhanced Recovery After Surgery (ERAS) Cesarean Delivery Perioperative Management Survey.

J Obstet Gynaecol Can 2021 May 12. Epub 2021 May 12.

Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, Calgary, AB. Electronic address:

Enhanced Recovery After Surgery (ERAS) is a global surgical quality improvement initiative that has spread across numerous surgical disciplines. The uptake of ERAS in cesarean delivery in Canada is presently unknown. This study surveyed the current practices of Society of Obstetricians and Gynaecologists of Canada (SOGC) members with regards to ERAS guidelines for preoperative, intraoperative, and postoperative cesarean delivery care. Survey responses highlight perioperative practice variations across Canada. Active implementation of ERAS cesarean delivery guidelines could potentially lessen variations in perioperative care, improve patient outcomes, and minimize health care costs.
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http://dx.doi.org/10.1016/j.jogc.2021.04.011DOI Listing
May 2021

A case series of aggressive angiomyxoma: Using morphologic type and hormonal modification to tailor treatment.

Gynecol Oncol Rep 2021 May 5;36:100765. Epub 2021 Apr 5.

Tom Baker Cancer Center, Calgary, Alberta, Canada.

Aggressive angiomyxoma is a rare tumour type with a predilection for the female pelvis, high rates of estrogen and progesterone receptor positivity and local recurrence. A retrospective chart review of patients with aggressive angiomyxoma treated at 2 cancer centres is presented. Nine patients were identified with a mean age of 41. Five patients had deeply invasive tumours that were difficult to surgically resect. Four patients had pedunculated tumours with less complex resections. In only two cases was aggressive angiomyxoma considered before resection: one due to classic magnetic resonance imaging findings and one with a preoperative biopsy. Four patients had positive margins after resection, with only one having persistent disease. Two patients were treated with gonadotropin-releasing hormone (GnRH) agonists resulting in tumour regression in one and no recurrence in the other. In this case series, aggressive angiomyxoma presented in deeply invasive and pedunculated forms. Previously reported high rates of recurrence were not observed in this group, perhaps secondary to easier resection in the pedunculated forms. GnRH agonists were successfully used as adjuncts to surgery. Evidence in this case series could be used to provide tailored treatment to patients with aggressive angiomyxoma.
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http://dx.doi.org/10.1016/j.gore.2021.100765DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8066423PMC
May 2021

Opportunities and Challenges for the Next Phase of Enhanced Recovery After Surgery: A Review.

JAMA Surg 2021 08;156(8):775-784

Department of Visceral Surgery, University Hospital Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland.

Importance: Enhanced Recovery After Surgery (ERAS) is a global surgical quality improvement initiative now firmly entrenched within the field of perioperative care. Although ERAS is associated with significant clinical outcome improvements and cost savings in numerous surgical specialties, several opportunities and challenges deserve further discussion.

Observations: Uptake and implementation of ERAS Society guidelines, together with ERAS-related research, have increased exponentially since the inception of the ERAS movement. Opportunities to further improve patient outcomes include addressing frailty, optimizing nutrition, prehabilitation, correcting preoperative anemia, and improving uptake of ERAS worldwide, including in low- and middle-income countries. Challenges facing enhanced recovery today include implementation, carbohydrate loading, reversal of neuromuscular blockade, and bowel preparation. The COVID-19 pandemic poses both a challenge and an opportunity for ERAS.

Conclusions And Relevance: To date, ERAS has achieved significant benefit for patients and health systems; however, improvements are still needed, particularly in the areas of patient optimization and systematic implementation. During this time of global crisis, the ERAS method of delivering care is required to take surgery and anesthesia to the next level and bring improvements in outcomes to both patients and health systems.
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http://dx.doi.org/10.1001/jamasurg.2021.0586DOI Listing
August 2021

Immediate lymphatic reconstruction: the time is right to prevent lymphedema following lymphadenectomy for vulvar cancer.

Int J Gynecol Cancer 2021 06 15;31(6):943. Epub 2021 Apr 15.

Division of Gynecologic Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada

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http://dx.doi.org/10.1136/ijgc-2021-002666DOI Listing
June 2021

Incidence of Pregnancy-Associated Cancer in Two Canadian Provinces: A Population-Based Study.

Int J Environ Res Public Health 2021 03 17;18(6). Epub 2021 Mar 17.

Department of Community Health Sciences, University of Calgary, Calgary, AB T2N 1N4, Canada.

Pregnancy-associated cancer-that is diagnosed in pregnancy or within 365 days after delivery-is increasingly common as cancer therapy evolves and survivorship increases. This study assessed the incidence and temporal trends of pregnancy-associated cancer in Alberta and Ontario-together accounting for 50% of Canada's entire population. Linked data from the two provincial cancer registries and health administrative data were used to ascertain new diagnoses of cancer, livebirths, stillbirths and induced abortions among women aged 18-50 years, from 2003 to 2015. The annual crude incidence rate (IR) was calculated as the number of women with a pregnancy-associated cancer per 100,000 deliveries. A nonparametric test for trend assessed for any temporal trends. In Alberta, the crude IR of pregnancy-associated cancer was 156.2 per 100,000 deliveries (95% CI 145.8-166.7), and in Ontario, the IR was 149.4 per 100,000 deliveries (95% CI 143.3-155.4). While no statistically significant temporal trend in the IR of pregnancy-associated cancer was seen in Alberta, there was a rise in Ontario ( = 0.01). Pregnancy-associated cancer is common enough to warrant more detailed research on maternal, pregnancy and child outcomes, especially as cancer therapies continue to evolve.
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http://dx.doi.org/10.3390/ijerph18063100DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8002657PMC
March 2021

Prognostic and Theranostic Biomarkers in Ovarian Clear Cell Carcinoma.

Int J Gynecol Pathol 2021 Mar 24. Epub 2021 Mar 24.

Department of Pathology and Laboratory Medicine (K.W., L.W., E.Y.K., S.L., Y.O., M.K.) Section of Gynecologic Oncology, Tom Baker Cancer Centre (S.G., P.G., G.S.N.), University of Calgary, Calgary, Alberta Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia (L.F., M.S.A.), Canada Hollings Cancer Center, Medical University of South Carolina, Charleston, South Carolina (L.E.K.).

In this study, we aimed to test whether prognostic biomarkers can achieve a clinically relevant stratification of patients with stage I ovarian clear cell carcinoma (OCCC) and to survey the expression of 10 selected actionable targets (theranostic biomarkers) in stage II to IV cases. From the population-based Alberta Ovarian Tumor Type study, 160 samples of OCCC were evaluated by immunohistochemistry and/or silver-enhanced in situ hybridization for the status of 5 prognostic (p53, p16, IGF2BP3, CCNE1, FOLR1) and 10 theranostic biomarkers (ALK, BRAF V600E, ERBB2, ER, MET, MMR, PR, ROS1, NTRK1-3, VEGFR2). Kaplan-Meier survival analyses were performed. Cases with abnormal p53 or combined p16/IFG2BP3 abnormal expression identified a small subset of patients (6/54 cases) with stage I OCCC with an aggressive course (5-yr ovarian cancer-specific survival of 33.3%, compared with 91.5% in the other stage I cases). Among theranostic targets, ERBB2 amplification was present in 11/158 (7%) of OCCC, while MET was ubiquitously expressed in OCCC similar to a variety of normal control tissues. ER/PR showed a low prevalence of expression. No abnormal expression was detected for any of the other targets. We propose a combination of 3 biomarkers (p53, p16, IGF2BP3) to predict prognosis and the potential need for adjuvant therapy for patients with stage I OCCC. This finding requires replication in larger cohorts. In addition, OCCC could be tested for ERBB2 amplification for inclusion in gynecological basket trials targeting this alteration.
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http://dx.doi.org/10.1097/PGP.0000000000000780DOI Listing
March 2021

Implications for management of ovarian cancer in a transgender man: Impact of androgens and androgen receptor status.

Gynecol Oncol 2021 05 2;161(2):342-346. Epub 2021 Mar 2.

Department of Oncology, Division of Gynecologic Oncology, Tom Baker Cancer Center, University of Calgary, Calgary, Canada. Electronic address:

A 36-year-old transgender man (assigned female at birth) on exogenous testosterone therapy was found to have stage IIA ovarian endometrioid carcinoma, and underwent adjuvant chemotherapy. Diffuse androgen receptor expression in the tumor initiated a multidisciplinary discussion regarding the safety of continuing exogenous testosterone as gender-affirming hormone therapy.
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http://dx.doi.org/10.1016/j.ygyno.2021.02.019DOI Listing
May 2021

Despite barriers, Enhanced Recovery After Surgery for cesarean delivery should be prioritized in developing countries.

Am J Obstet Gynecol 2021 05 21;224(5):554-555. Epub 2021 Jan 21.

Department of Women's Health, Dell Medical School, The University of Texas at Austin, 1501 Red River St., Austin, TX 78712. Electronic address:

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http://dx.doi.org/10.1016/j.ajog.2021.01.011DOI Listing
May 2021

Surgical errors and complications following cesarean delivery in the United States.

Am J Obstet Gynecol MFM 2020 02 16;2(1):100071. Epub 2019 Nov 16.

Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada. Electronic address:

Background: Cesarean delivery is the most common inpatient surgery performed internationally. Although cesarean delivery is typically performed to prevent adverse maternal and fetal outcomes, there is still a risk of surgical errors and complications. This study examined maternal and hospital risk factors associated with errors and complications following cesarean delivery in the United States.

Objective: To determine the prevalence of, and associated individual- and hospital-level risk factors for, surgical errors and complications following cesarean delivery in the United States.

Materials And Methods: Data were obtained from the 2012-2014 National Inpatient Sample. Surgical errors (eg,. foreign body retained during surgery, anesthetic error) can be the result of human error, whereas complications (eg, mortality, postpartum hemorrhage) can be due to external factors such as pre-existing comorbidities. The overall prevalence of surgical errors and complications in cesarean delivery was calculated. Multilevel logistic regression models were used to examine the association between individual and hospital characteristics and surgical errors/complications.

Results: Among 648,584 cesarean delivery hospitalizations, 1.98% (95% confidence interval, 1.95-2.01%) and 8.43% (95% confidence interval, 8.40-8.46%) of women had an error or complication, respectively. The most common errors were anesthetic errors, errors involving blood vessels, and errors involving the bladder. The most common complications were postpartum hemorrhage, infection, and hysterectomy. Both individual- and hospital-level factors were associated with errors and complications. Women with Medicaid insurance had increased odds of errors (odds ratio, 1.40; 95% confidence interval, 1.37-1.43) but lower odds of complications (odds ratio, 0.89; 95% confidence interval, 0.88-0.90) compared to women with private insurance. Compared to non-Hispanic white women, women of all races had lower odds of error, and only non-Hispanic black women had greater odds of complications (odds ratio, 1.14; 95% confidence interval, 1.13-1.16). Similarly, rural hospitals had lower odds of surgical errors (odds ratio, 0.59; 95% confidence interval, 0.56-0.62) and complications (odds ratio, 0.61; 95% confidence interval, 0.59-0.62), whereas hospitals with a large bed number had greater odds of errors and complications than medium-bed size hospitals, at 1.13 (95% confidence interval, 1.09-1.17), and 1.13 (95% confidence interval, 1.11-1.15), respectively.

Conclusion: This study identified specific risk factors for errors and complications that can be further examined through quality improvement frameworks to reduce the prevalence of adverse maternal events during cesarean delivery.
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http://dx.doi.org/10.1016/j.ajogmf.2019.100071DOI Listing
February 2020

Computed-Tomography Body Composition Analysis Complements Pre-Operative Nutrition Screening in Colorectal Cancer Patients on an Enhanced Recovery after Surgery Pathway.

Nutrients 2020 Dec 5;12(12). Epub 2020 Dec 5.

Department of Oncology, University of Alberta, Edmonton, AB T6G2P5, Canada.

Pre-operative nutrition screening is recommended to identify cancer patients at risk of malnutrition, which is associated with poor outcomes. Low muscle mass (sarcopenia) and lipid infiltration to muscle cells (myosteatosis) are similarly associated with poor outcomes but are not routinely screened for. We investigated the prevalence of sarcopenia and myosteatosis across the nutrition screening triage categories of the Patient-Generated Subjective Global Assessment Short Form (PG-SGA) in a pre-operative colorectal cancer (CRC) cohort. Data were prospectively collected from patients scheduled for surgery at two sites in Edmonton, Canada. PG-SGA scores ≥ 4 identified patients at risk for malnutrition; sarcopenia and myosteatosis were identified using computed-tomography (CT) analysis. Patients ( = 176) with a mean age of 63.8 ± 12.0 years, 52.3% male, 90.3% with stage I-III disease were included. Overall, 25.2% had PG-SGA score ≥ 4. Sarcopenia alone, myosteatosis alone or both were identified in 14.0%, 27.3%, and 6.4% of patients, respectively. Sarcopenia and/or myosteatosis were identified in 43.4% of those with PG-SGA score < 4 and in 58.5% of those with score ≥ 4. Overall, 32.9% of the cohort had sarcopenia and/or myosteatosis with PG-SGA score < 4. CT-defined sarcopenia and myosteatosis are prevalent in pre-operative CRC patients, regardless of the presence of traditional nutrition risk factors (weight loss, problems eating); therefore, CT image analysis effectively adds value to nutrition screening by identifying patients with other risk factors for poor outcomes.
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http://dx.doi.org/10.3390/nu12123745DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7762071PMC
December 2020

Return on investment of the Enhanced Recovery After Surgery (ERAS) multiguideline, multisite implementation in Alberta, Canada.

Can J Surg 2020 11 30;63(6):E542-E550. Epub 2020 Nov 30.

From the Strategic Clinical Networks, Alberta Health Services, Edmonton and Calgary, Alta. (Thanh, Wasylak); the Surgery Strategic Clinical Network, Alberta Health Services, Calgary, Alta. (A. Nelson); Analytics, Data Integration, Measurement and Reporting, Alberta Health Services, Edmonton and Calgary, Alta. (Wang, Faris); the Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta. (Gramlich); and the Section of Gynecologic Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alta. (G. Nelson).

Background: Enhanced Recovery After Surgery (ERAS) is a global surgical qualityimprovement initiative. Little is known about the economic effects of implementing multiple ERAS guidelines in both the short and long term.

Methods: We performed a return on investment (ROI) analysis of the implementation of multiple ERAS guidelines (for colorectal, pancreas, cystectomy, liver and gynecologic oncology procedures) across multiple sites (9 hospitals) in Alberta using 30-, 180- and 365-day time horizons. The effects of ERAS on health services utilization (length of stay of the primary admission, number of readmissions, length of stay of the readmissions, number of emergency department visits, number of outpatient clinic visits, number of specialist visits and number of general practitioner visits) were assessed by mixed-effect multilevel multivariate negative binomial regressions. Net benefits and ROI were estimated by a decision analytic modelling analysis. All costs were reported in 2019 Canadian dollars.

Results: The net health system savings per patient ranged from $26.35 to $3606.44 and ROI ranged from 1.05 to 7.31, meaning that every dollar invested in ERAS brought $1.05 to $7.31 in return. Probabilities for ERAS to be cost-saving were from 86.5% to 99.9%. The effects of ERAS were found to be larger in the longer time horizons, indicating that if only the 30-day time horizon had been used, the benefits of ERAS would have been underestimated.

Conclusion: These results demonstrated that ERAS multiguideline implementation was cost-saving in Alberta. To produce a better ROI, it is important to consider a broad range of health service utilizations, long-term impact, economies of scale, productive efficiency and allocative efficiency for sustainability, scale and spread of ERAS implementations.
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http://dx.doi.org/10.1503/cjs.006720DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7747851PMC
November 2020

Improved Outcomes With an Enhanced Recovery Approach to Cesarean Delivery.

Authors:
Gregg Nelson

Obstet Gynecol 2020 12;136(6):1234-1235

Department of Obstetrics and Gynecology, Foothills Medical Centre, Calgary, Alberta, Canada.

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http://dx.doi.org/10.1097/AOG.0000000000004192DOI Listing
December 2020

Efficacy of pre-operative pharmacologic thromboprophylaxis on incidence of venous thromboembolism following major gynecologic and gynecologic oncology surgery: a systematic review and meta-analysis.

Int J Gynecol Cancer 2021 02 19;31(2):257-264. Epub 2020 Nov 19.

Gynecologic Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada.

Introduction: Venous thromboembolism remains a significant complication following major gynecologic surgery. Evidence is lacking on whether it is beneficial to give pharmacologic thromboprophylaxis pre-operatively. The aim of this meta-analysis was to assess the role of pre-operative pharmacologic thromboprophylaxis in preventing post-operative venous thromboembolism.

Methods: PubMed, EMBASE, and the Cochrane Central Register of Clinical Trials were searched to find randomized controlled, cohort, and case-control trials comparing pre-operative pharmacologic thromboprophylaxis to no prophylaxis, mechanical prophylaxis, or only post-operative pharmacologic thromboprophylaxis for open and minimally invasive major gynecologic surgery (benign and malignant conditions). Two authors independently assessed abstracts, full-text articles, and methodological quality. Data were extracted and pooled using ORs for random effects meta-analysis. Heterogeneity was explored using forest plots, Q-statistic, and I statistics. Planned subgroup analysis of use of sequential compression devices, equivalent versus non-equivalent post-operative prophylaxis, cancer diagnosis, and methodological quality were performed.

Results: Some 503 unique studies were found, and 16 studies (28 806 patients) were included in the systematic review. Twelve studies (14 273 patients) were included in the meta-analysis. The OR for incidence of post-operative venous thromboembolism was 0.59 (95% CI 0.39, 0.89), favoring pre-operative pharmacologic thromboembolism prophylaxis compared with no pre-operative pharmacologic prophylaxis (Q=13.80, I=20.30). In studies where post-operative care was equivalent between groups, the OR for venous thromboembolism was 0.56 (95% CI 0.22, 1.40). Pre-operative pharmacologic prophylaxis demonstrated greatest benefit when utilized with both intra-operative and post-operative sequential compression devices (OR 0.43, 95% CI 0.30, 0.64) compared with when no sequential compression devices were utilized (OR 1.27, 95% CI 0.63, 2.56). When looking at only studies determined to be of high quality, the results no longer reached significance (OR 0.73, 95% CI 0.36, 1.46).

Conclusions: Pre-operative pharmacologic thromboprophylaxis decreases the odds of venous thromboembolism in the peri-operative period for major gynecologic oncology surgery by approximately 40%. It remains unclear whether this benefit is present in benign and minor procedures. Adequately powered studies are needed.
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http://dx.doi.org/10.1136/ijgc-2020-001991DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7854514PMC
February 2021

SWI/SNF-deficiency defines highly aggressive undifferentiated endometrial carcinoma.

J Pathol Clin Res 2021 03 30;7(2):144-153. Epub 2020 Oct 30.

Department of Laboratory Medicine and Pathology, Royal Alexandra Hospital and University of Alberta, Edmonton, Canada.

Dedifferentiated/undifferentiated endometrial carcinoma (DDEC/UEC) is an endometrial cancer characterized by the presence of histologically undifferentiated carcinoma. Genomic inactivation of core switch/sucrose nonfermentable (SWI/SNF) complex proteins was recently identified in approximately two-thirds of DDEC/UEC. The aim of this study was to delineate the clinical behavior of SWI/SNF-deficient DDEC/UEC in comparison to SWI/SNF-intact DDEC/UEC. The study cohort consisted of 56 SWI/SNF-deficient DDEC/UEC (2 POLE-mutated), which showed either SMARCA4 (BRG1) loss, ARID1A/1B co-loss, or SMARCB1 (INI1) loss in the undifferentiated tumor, and 26 SWI/SNF-intact DDEC/UEC (4 POLE-mutated). The average age at diagnosis was 61 years for patients with SWI/SNF-deficient tumors and 64 years for SWI/SNF-intact tumors. Mismatch repair (MMR) protein deficiency was seen in 66% of SWI/SNF-deficient and 50% of SWI/SNF-intact tumors. At initial presentation, 55% of patients with SWI/SNF-deficient tumors had extrauterine disease spread in contrast to 38% of patients with SWI/SNF-intact tumors. The 2-year disease specific survival (DSS) for stages I and II disease was 65% for SWI/SNF deficient tumors relative to 100% for SWI/SNF-intact tumors (p = 0.042). For patients with stages III and IV disease, the median survival was 4 months for SWI/SNF-deficient tumors compared to 36 months for SWI/SNF-intact tumors (p = 0.0003). All six patients with POLE-mutated tumors, including one with stage IV SWI/SNF-deficient tumor were alive with no evidence of disease. Among the patients with advanced stage SWI/SNF-deficient tumors, 68% (21 of 31) received adjuvant or neoadjuvant chemotherapy (platinum/taxane-based) and all except the patient with a POLE-mutated tumor (20 of 21) experienced disease progression either during chemotherapy or within 4 months after its completion. These findings show that core SWI/SNF-deficiency defines a highly aggressive group of undifferentiated cancer characterized by rapid disease progression that is refractory to conventional platinum/taxane-based chemotherapy. This underscores the importance of accurate clinical recognition of this aggressive tumor and the need to consider alternative systemic therapy for these tumors.
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http://dx.doi.org/10.1002/cjp2.188DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7869930PMC
March 2021

Randomised controlled trial confirms benefit of enhanced recovery after surgery on length of stay in ovarian cancer: How low can we go?

Eur J Cancer 2020 11 23;139:90-91. Epub 2020 Sep 23.

Division of Gynecologic Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada. Electronic address:

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http://dx.doi.org/10.1016/j.ejca.2020.08.015DOI Listing
November 2020

Level I evidence establishes enhanced recovery after surgery as standard of care in gynecologic surgery: now is the time to implement!

Am J Obstet Gynecol 2020 10;223(4):473-474

Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN.

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http://dx.doi.org/10.1016/j.ajog.2020.07.048DOI Listing
October 2020

Cytology positive pericardial effusion causing tamponade in patients with high grade serous carcinoma of the ovary.

Gynecol Oncol Rep 2020 Aug 7;33:100621. Epub 2020 Aug 7.

Tom Baker Cancer Center, Calgary, Alberta, Canada.

•Three patients with cytology positive pericardial effusions from high grade serous carcinoma.•Patients' conditions amenable to treatment with chemotherapy after effusion symptom improvement.•Patient with pericardial effusion from high grade serous ovarian cancer post a poly ADP ribose polymerase inhibitor.
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http://dx.doi.org/10.1016/j.gore.2020.100621DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7452629PMC
August 2020

Guidelines for Perioperative Care in Cytoreductive Surgery (CRS) with or without hyperthermic IntraPEritoneal chemotherapy (HIPEC): Enhanced recovery after surgery (ERAS®) Society Recommendations - Part I: Preoperative and intraoperative management.

Eur J Surg Oncol 2020 12 25;46(12):2292-2310. Epub 2020 Aug 25.

Division of Gynecologic Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada.

Background: Enhanced recovery after surgery (ERAS) pathways have been shown to considerably reduce complications, length of stay and costs after most of surgical procedures by standardised application of best evidence-based perioperative care. The aim was to elaborate dedicated recommendations for cytoreductive surgery (CRS) ± hyperthermic intraperitoneal chemotherapy (HIPEC) in a two-part series of guidelines based on expert consensus. The present part I of the guidelines highlights preoperative and intraoperative management.

Methods: The core group assembled a multidisciplinary panel of 24 experts involved in peritoneal surface malignancy surgery representing the fields of general surgery (n = 12), gynaecological surgery (n = 6), and anaesthesia (n = 6). Experts systematically reviewed and summarized the available evidence on 72 identified perioperative care items, following the GRADE (grading of recommendations, assessment, development, evaluation) system. Final consensus (defined as ≥50%, or ≥70% of weak/strong recommendations combined) was reached by a standardised 2-round Delphi process, regarding the strength of recommendations.

Results: Response rates were 100% for both Delphi rounds. Quality of evidence was evaluated high, moderate low and very low, for 15 (21%), 26 (36%), 29 (40%) and 2 items, respectively. Consensus was reached for 71/72(98.6%) items. Strong recommendations were defined for 37 items, No consensus could be reached regarding the preemptive use of fresh frozen plasma.

Conclusion: The present ERAS recommendations for CRS±HIPEC are based on a standardised expert consensus process providing clinicians with valuable guidance. There is an urgent need to produce high quality studies for CRS±HIPEC and to prospectively evaluate recommendations in clinical practice.
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http://dx.doi.org/10.1016/j.ejso.2020.07.041DOI Listing
December 2020

Guidelines for Perioperative Care in Cytoreductive Surgery (CRS) with or without hyperthermic IntraPEritoneal chemotherapy (HIPEC): Enhanced Recovery After Surgery (ERAS®) Society Recommendations - Part II: Postoperative management and special considerations.

Eur J Surg Oncol 2020 12 13;46(12):2311-2323. Epub 2020 Aug 13.

Division of Gynecologic Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada.

Background: Enhanced recovery after surgery (ERAS) pathways have been shown to considerably reduce complications, length of stay and costs after most of surgical procedures by standardised application of best evidence-based perioperative care. The aim was to elaborate dedicated recommendations for cytoreductive surgery (CRS) ± hyperthermic intraperitoneal chemotherapy (HIPEC) in a two-part series of guidelines based on expert consensus. The present part II of the guidelines highlights postoperative management and special considerations.

Methods: The core group assembled a multidisciplinary panel of 24 experts involved in peritoneal surface malignancy surgery representing the fields of general surgery (n = 12), gynaecological surgery (n = 6), and anaesthesia (n = 6). Experts systematically reviewed and summarized the available evidence on 72 identified perioperative care items, following the GRADE (grading of recommendations, assessment, development, evaluation) system. Final consensus (defined as ≥50%, or ≥70% of weak/strong recommendations combined) was reached by a standardised 2-round Delphi process, regarding the strength of recommendations.

Results: Response rates were 100% for both Delphi rounds. Quality of evidence was evaluated high, moderate low and very low, for 15 (21%), 26 (36%), 29 (40%) and 2 items, respectively. Consensus was reached for 71/72(98.6%) items. Strong recommendations were defined for 37 items. No consensus could be reached regarding the preemptive use of fresh frozen plasma.

Conclusion: The present ERAS recommendations for CRS ± HIPEC are based on a standardised expert consensus process providing clinicians with valuable guidance. There is an urgent need to produce high quality studies for CRS ± HIPEC and to prospectively evaluate recommendations in clinical practice.
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http://dx.doi.org/10.1016/j.ejso.2020.08.006DOI Listing
December 2020
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