Objective Procedural volume is associated with outcomes for many surgical interventions. Little is known about the association between volume and outcomes of radiation. We examined the association between treatment center and hospital volume and outcomes for women with locally advanced cervical cancer treated with radiation. Methods Women with stage IIB-IVA cervical cancer treated with primary radiation from 1998-2011 and recorded in the National Cancer Database were examined. Hospital volume was estimated as the mean annualized volume, while center-specific effects on care were examined using a hospital-specific random effect. Multivariable regression models adjusted for metrics of treatment quality were used to estimate survival. Results 20,766 patients treated at 1115 hospitals were identified. The median follow-up was 24.2 months while 5-year survival was 36.5% (95% CI, 35.6-37.4%). Higher hospital volume was associated with receipt of brachytherapy (P<0.05), but had no effect on use of chemotherapy. In a multivariable model accounting for clinical and demographic factors as well as quality of care, hospital volume was not associated with survival (P=0.25). The specific hospital in which patients received care was the strongest predictor of survival (P<0.0001) followed by stage, year of diagnosis and treatment quality (P<0.0001 for all). The hospital-specific effect on mortality expressed as a hazard ratio, ranged from 0.66-1.53 across hospitals. Conclusion For locally advanced cervical cancer, hospital volume has a minimal impact on outcome; however, the specific center in which care is delivered is strongly associated with survival.

Introduction: Uncertainty exists regarding the impact of malpresentation on pregnancy outcomes and the optimal mode of delivery in low-and middle-income countries. We sought to compare outcomes between cephalic and non-cephalic pregnancies.Material and methods: Using the NICHD Global Network's prospective, populationbased registry of pregnancy outcomes from 2010 to 2016, we studied outcomes in 436 112 singleton pregnancies. Robust Poisson regressions were used to estimate | 301 DUFFY et al. | INTRODUC TI ONBreech presentation and other less common malpresentations affect up to 3%-4% of pregnancies at term and are even more common at earlier gestation. 1 Risk factors for malpresentation are diverse and include maternal age, parity, uterine anomalies, prematurity, fetal growth restriction, fetal anomalies and amniotic fluid abnormalities. Questions exist regarding the independent impact of malpresentation, especially breech presentation, on fetal and neonatal outcomes, 2,3 and much attention has been given to the best mode of delivery for these pregnancies.Following publication of the multi-country Term Breech Trial, which showed decreased neonatal morbidity and mortality with planned cesarean delivery compared with planned vaginal delivery for term breech presentations, 4 most high-income countries have adopted cesarean as the preferred mode of delivery for breech presentation. 5 Subsequent meta-analyses of additional studies examining mode of delivery have likewise shown an increase in neonatal morbidity and mortality with planned vaginal delivery compared with cesarean for breech presentation, although the absolute risk remains low. 5,6 In low-and middle-income countries (LMIC), there is even more uncertainty as to the significance of malpresentation for pregnancy outcomes, and controversy exists over the optimal management of pregnancies affected by malpresentation. 7,8 Several factors may influence outcomes. For one, the risk of neonatal morbidity and mortality and stillbirth is often greater in LMIC than in high-income countries. Cesarean delivery is also less available in many LMIC settings and may not be uniformly accessible, competently practiced or routinely performed for breech presentations. 9 Furthermore, there is heightened concern over the increased maternal risk associated with operative delivery in these settings. 10Given this knowledge gap, we sought to compare fetal, neonatal and maternal outcomes between cephalic and non-cephalic pregnancies in LMIC, to examine rates of cesarean delivery for malpresentation and to explore the association between mode of delivery and fetal, neonatal and maternal outcomes. | MATERIAL AND ME THODS Using the Global Network for Women's and Children's HealthResearch's prospective, multi-country, population-based maternalnewborn registry of pregnancy outcomes from 2010 to 2016, we analyzed outcomes by presentation and mode of delivery in singleton pregnancies. The Global Network's Maternal and Newborn Health Registry (MNHR) is funded by the Eunice Kennedy Shriver Natio...

BACKGROUND: The COVID-19 pandemic caused by the SARS-CoV-2 has increased the demand for inpatient healthcare resources; however, approximately 80% of patients with COVID-19 have a mild clinical presentation and can be managed at home. OBJECTIVE: This study aimed to describe the feasibility and clinical and process outcomes associated with a multidisciplinary telemedicine surveillance model to triage and manage obstetrical patients with known exposures and symptoms of COVID-19. STUDY DESIGN: We implemented a multidisciplinary telemedicine surveillance model with obstetrical physicians and nurses to standardize ambulatory care for obstetrical patients with confirmed or suspected COVID-19 based on the symptoms or exposures at an urban academic tertiary care center with multiple hospital-affiliated and community-based practices. All pregnant or postpartum patients with COVID-19 symptoms, exposures, or hospitalization were eligible for inclusion in the program. Patients were assessed by means of regular nursing phone calls and were managed according to illness severity. Patient characteristics and clinical and process outcomes were abstracted from the electronic medical record. RESULTS: A total of 135 patients were enrolled in the multidisciplinary telemedicine model from March 17 to April 19, 2020, of whom 130 were pregnant and 5 were recently postpartum. In this study, 116 of 135 patients (86%) were managed solely in the outpatient setting and did not require an in-person evaluation; 9 patients were ultimately admitted after ambulatory or urgent evaluations, and 10 patients were observed after hospital discharge. Although only 50% of the patients were tested secondary to limitations in ambulatory testing, 1 in 3 of those patients received positive results for SARS-CoV-2 (N¼22, 16% of entire cohort). Patients were enrolled in the telemedicine model for a median of 7 days (interquartile range, 4e8) and averaged 1 phone call daily, resulting in 891 nursing calls and 20 physician calls over 1 month. CONCLUSION: A multidisciplinary telemedicine surveillance model for outpatient management of obstetrical patients with COVID-19 symptoms and exposures is feasible and resulted in rates of ambulatory management similar to those seen in nonpregnant patients. A centralized model for telemedicine surveillance of obstetrical patients with COVID-19 symptoms may preserve inpatient resources and prevent avoidable staff and patient exposures, particularly in centers with multiple ambulatory practice settings.