THIS MORNING FROM -- WELCOME,
AGAIN, EVERYONE, I FEEL WE HAD A
GREAT DAY YESTERDAY.
A GREAT DAY OF BRAINSTORMING.
THANK YOU ALL FOR YOUR
PRESENTATION.
SO WE ARE FOR THE PEOPLE
VIRTUAL, WE ARE FROM 8:00 TO
10:00 THIS MORNING, WE MET, WE
HAD A WORKING GROUP REGARDING
EACH OF THE SESSIONS WE
PRESENTED YESTERDAY.
THESE WORKING GROUPS ARE NOW
GOING TO COME AND GIVE US FEW
SLIDES THAT ARE GOING TO GIVE US
SOME OF THE GAP PRIORITY AND
FUTURE FOR EACH OF THESE
SESSIONS, THEN WE WOULD LIKE TO
CONSIDER.
SO, WE'RE STILL WORKING ON A FEW
THINGS.
SO, MAYBE -- I DON'T KNOW IF
DR. FOX IS IN THE ROOM FOR GROUP
WORKING TWO.
IF I CAN GET THE SLIDES FOR
SESSION TWO, WHICH WAS ON TOP,
THAT WOULD BE GOOD.
YEAH, NO, IN THE MAINTAIN.
MAINTIME.
YES?
IT IS GOING TO BE GROUP TWO.
YES, BUT DO WE HAVE THE SLIDES
FROM GROUP TWO?
OKAY.
NEXT ONE IS THE ONE.
I WANT TO BE SURE THIS IS --
HMM.
>> IT IS JUST NOT ADVANCING.
THERE WE GO.
ALL RIGHT.
>> OKAY.
ALL RIGHT.
THANK YOU.
YOU HAVE 10 MINUTES ON THAT.
>> OKAY.
THANK YOU SO MUCH.
WELL, OKAY.
SO, OUR GROUP, OF COURSE, WAS
THE PREOPERATIVE PERIOPERATIVE
CARE GROUP.
WE SHIFTED SOMEWHAT TO
PERIOPERATIVE BECAUSE A LOT OF
WHAT WILL INFORM OUR
PREOPERATIVE PLANNING DEPENDS ON
THE PERIOPERATIVE PERIOD AND
LONG-TERM OUTCOMES.
SO FOR PRIORITIZED WE CAME UP
WITH FIVE GENERAL COMMON GAPS WE
WOULD LIKE TO ADDRESS.
FOR OUR BIG OVERARCHING ONE THAT
WE THINK HAS TOP PRIORITY IS
PLACENTA ACCRETA SPECTRUM PAS
LEVEL CARE BUNDLING, WHICH
INCLUDES WITH THIS MUCH BIGGER,
BROADER PICTURE, QUALITY METRICS
THAT ARE DEFINED AND
STANDARDIZED SO WE CAN REPORT TO
THE TEAM, HOSPITAL, NATIONAL,
AND STATE LEVELS SO WE'RE ALL
SPEAKING THE SAME LANGUAGE.
ONE OF THE KEY DRIVERS TO THIS
GAP NEED IS THE PLEA THAT WE
HEARD FROM REFERRING HOSPITALS
AND FROM PATIENTS SAYING WE
REALLY DO NOT KNOW WHERE TO GO.
WE'RE KIND OF DEFINING THESE
QUALITY METRICS AS WE WORK.
WE'RE TRYING TO DO IT AT OUR
INSTITUTIONAL LEVELS, BUT THERE
IS NO STANDARD LEVEL OF CARE.
WE HAVE WONDERFUL METRIC FOR
SEVERE MATERNAL MORBIDITY, AS WE
HEARD YESTERDAY, 50% OF OUR
PATIENTS WILL HAVE ONE OF THOSE
SUSPEAR MATERNAL MORBIDITY, SMS
IS MORE FOR OVERALL QUALITY.
SO WE NEED THE NEW DEFINITIONS.
AND THE GOAL IS TO HELP
PHYSICIANS AND PATIENT GET TO
THE RIGHT CARE AT THE RIGHT TIME
WITH THE RIGHT TEAM.
THERE ARE BIG BARRIERS WE
IDENTIFIED, SOME, OF COURSE, THE
LACK OF DEFINITIONS.
SO, DEFINITIONS IS A BIG ONE AND
A DIG DRIVER.
THE SECOND ONE IS THE ABILITY
FOR PEOPLE TO REPORT.
WE'VE IDENTIFY AD FEW WAYS WE
CAN DO THIS.
OF COURSE, WE HAVE CENTERS THAT
ARE VOLUNTARILY TRYING TO
COLLECT AND REPORT THEIR DATA.
SOME STATES ARE MANDATING LEVEL
OF CARE DESIGNATION, LIKE IN
TEXAS, WHERE SOME REPORT UP TO
MATERNAL QUALITY MORTALLY
COMMITTEES HAPPENING B. DOUBT WE
HAVE THE RIGHT DATA AND IT IS
STANDARDIZED.
THEN LOOKING AT THE NATIONAL
LEVEL, WE DETERMINE IT WOULD BE
POSSIBLE TO OVERCAME THAT
BARRIER OF REPORTING IF WE WERE
TO PUT A CHECK BOX ON A BIRTH OR
DEATH CERTIFICATE TO SAY
SOMETHING IS RELATED TO PAS.
KNOWING THERE ARE LIMITATIONS
WITH THAT KIND OF DATA.
BUT BETTER THAN PERHAPS USING
ONLY ICD CODING DATA.
VERSUS HAVE A SYSTEM IN PLACE,
WHERE THERE IS AN INFRASTRUCTURE
IN ORDER TO COLLECT DATA LIKE IN
FRANCE OR THE U.K. OBSTRUCTURES
SURVEILLANCE SYSTEM OR USING CDC
PROGRAMS DATA.
WHERE WE ACTUALLY LOOK AT
PLACENTA ACCRETA SPECTRUM AND
THE OUTCOMES AS A MEANINGFUL,
IMPORTANT PREGNANCY OUTCOME THAT
SHOULD BE REPORTED AT A BIGGER
LEVEL.
THIS KIND OF, WE HAVE A MUCH
MORE GRAINULAR SET OF THINGS WE
WOULD LIKE TO ADDRESS WITHIN
THIS GROUP.
BUT AGAIN, A LOT OF IT GOES DOWN
TO LOOKING AT THOSE STANDARDIZED
DEFINITIONS.
AND ESPECIALLY, IMPORTANT, THAT
WE MENTIONED YESTERDAY THAT
WE'RE LACK ARE THOSE LONG-TERM
OUTCOME DATA.
SO HAVING SOME KIND OF
LONGITUDINAL LONG-TERM OUTCOMES
DATA LOOKING AT THE REAL IMPACT
ON LONG CERVICAL MORBIDITY, DO
PATIENTS ACTUALLY NEED TO HAVE
SURGERIES THREE, FOUR, 5 YEARS
DOWN THE LINE THAT TIE BACK TO
THEIR PLACENTA ACCRETA SPECTRUM
SURGERY.
IS THERE IMPACT ON HEART HEALTH,
BONE HEALTH, CANCER HEALTH.
LIKE WE LOOKED AT IN THE TRIALS.
WE DO NOT LOOK THAT IN THE
CONTEXT OF PAS YET.
WE DON'T HAVE THAT DATA.
THIS WILL HELP PREFORM OUR PAIR
OPERATIVE PLANNING.
AND OUR SECONDARY GOAL.
PREOPERATIVE STAGING.
THIS IS A REAL NEED.
WE CANNOT, AGAIN, INFORM OUR
CLINICAL PRACTICES IF WE CAN'T
IDENTIFY WHO IS AT RISK, WHAT
THE RISKS ARE, HOW DO WE GET
PATIENTS TO THE RIGHT CENTER.
AND THEN WHAT, WHAT MANAGE
STRATEGY DO WE NEED.
SO, WE REALLY NEED IMPROVED
IMAGING, REPORTING AND
CONSULTATION STAGING THAT HAS A
POSITIVE IMPACT FOR REFERRAL
TIMING AND LOCATION, THE
REQUIRED RESOURCES NECESSARY OF
THE GOOD LIVERY AND GUIDE
DELIVERY TIMING, WITH OTHER
PERRY OPERATIVE OUTCOME.
WE TALKED ABOUT THE STUDIES THAT
PREDICT BLOOD LOSS.
ONE OF THE KEY DRIVERS, A LOT OF
THE REPORTING OF STUDIES, THE
PROTOCOLS THAT ARE USED FOR
IMAGING ACQUISITION AND IMAGING
REPORTING REMAIN UNCLEAR.
AGAIN, HOW CAN WE HAVE
MEANINGFUL IMAGING DATA IF WE
DON'T KNOW WHAT MUTHENAL IS
DOING USED, HOW THE IMAGE IS
BEING ACQUIRED, WHO IS FOLLOWING
ACCRETA OR WHAT THE SEVERITY IS.
AND CAN THESE PROTOCOLS BE
REPLICATED.
SO AGAIN, HAVING THESE THINGS
DEFINED, ACCEPTED AT THE
STANDARD FOR REPORTING WOULD BE
HELPFUL.
AND HAVING AN INFRASTRUCTURE.
SO THAT AS WE'RE STARTING TO
BRING STUDIES ONLINE, PERHAPS WE
HAVE A CENTER WHERE THEY DON'T
DO THE SAME IMAGING PROTOCOL AT
CENTER X AS DONE IN CENTER Y.
BUT AN EXPERT AT CENTER X THAT
CAN GUIDE, INFORM, AND COUNSEL
THE TEAM AT FOR Y, PERHAPS WE
CAN BRING CENTERS TO A STANDARD.
AN ADDITIONAL PIECE OF
INFORMATION THAT WILL BE
HELPFUL, HOW DO WE STANDARDIZED
OURSELVES FOR THE EXPERT CENTERS
AND COMMUNITY SITES.
CAN WE TEACH PEOPLE THAT YOU CAN
GET CERTAIN IMAGES AND EXPECT WE
ARE GOING TO SEE ALL OF THE
PLACENTA ACCRETA.
AND THEN HOW CAN WE MEANINGFULLY
SHARE THAT DATA WHETHER IT IS
ACROSS INSTITUTIONS, ACROSS
STATE LINES SO THAT WE'RE NOT
REPEATING STUDIES THAT HAVE
ALREADY BEEN DONE, BUT LOOKING
AT THE SAME STUDIES AND HAVING
THAT DATABASE.
WE DISCUSSED YESTERDAY ALSO
BRIEFLY HAVING A BIG IMAGING
DATA WAREHOUSE THAT WILL HOLD
NOT ONLY IMPROVED QUALITY,
IMPROVED EDUCATION, BUT IMPROVED
ADVANCES IN IMAGING RESEARCH,
SUCH AS AI, ACQUISITION IS A KEY
NEED WHEN IT COMES TO
PREOPERATIVE AND PERIOPERATIVE
STAGING.
SOME BEARING IS THAT EXIST, OF
COURSE, WHERE DO WE HOUSE ALL OF
THE DATA?
HOW DO WE GET THE EDUCATION OUT?
AND HOW DO WE GET THE FUNDING
FOR ONGOING MENTORSHIP AND
QUALITY CONTROL?
KNOWLEDGE GAP NUMBER THREE,
REALLY LOOKING AT VOLCOOLKER
OCCLUSION TECHNIQUES.
THIS ONE FELL OUT AS AN OUTLIER
OF ALL OF THE OTHER TECHNIQUES,
SIMPLY BECAUSE THERE ARE A LOT
OF QUESTIONS THAT NEED TO BE
ANSWERED.
WE RELY UPON A LOT OF
SPECIALISTS.
SO, HIGH QUALITY DATA ABOUT
COMPARATIVE USE OF VARIOUS
VASCULAR OCCLUSION TECHNIQUES.
WE HAVE UNCLEAR RESULTS ABOUT
THE TRUE INDICATIONS, WHO NEEDS
WHAT APPROACH, OPTIMAL TIMING,
PROTOCOL AND LOCAL AND MATERIAL
EXPERIENCE.
THIS IS ANOTHER ARRAIGNY WE
THINK HAVING ABSOLUTELY
TRANSPARENCY AND PROTOCOLS,
INFRASTRUCTURE FOR MENTORSHIP
BETWEEN INSTITUTIONS CAN HELP
FACILITATE NOT ONLY QUALITY
OUTCOMES, BUT RESEARCH.
AGAIN, THOSE WHO, IF THERE ARE
CENTERS THAT HAVE EXPERIENCE IN
ONE TECHNIQUE, THEY CAN BE THE
KEY TRAINING CENTER.
TRAINING CAN BE PERFORMED
AMONGST INSTITUTIONS, GET PEOPLE
ON BOARD, MONITOR QUALITY SO WE
CAN ACTUALLY OPTIMIZE OUR
OUTCOMES.
THE BARRIERS, OF COURSE, TO THIS
TYPE OF RESEARCH, WE MENTIONED
BRIEFLY YESTERDAY, TO MEEDING OF
EQUIPOSE, WE THINK THERE IS
ANOTHER IN CENTERS, IF WE DO
HIGH QUALITY PROSPECTIVE
COMPARATIVE TRIALS THIS WILL BE
HELPFUL.
AND MEANINGFUL COMPARATIVE
OUTCOMES.
BECAUSE IF WE HAVE TWO CENTERS,
MAYBE WE HAVE ONE CENTER THAT
DOES ONE TECHNIQUE VERY, VERY
WELL.
IF WE HAVE COMPARABLE OUTCOMES
WE CAN ACTUALLY COMPARE, WE CAN
DO COMPARE SELVE STUDIES, IF
WE'RE NOT RANDOMIZED, NOT
OPTIMAL, BUT HELPS FACILITATE
THE RESEARCH.
WE THEN EXPANDED TO OUR FOURTH
ARENA WHICH IS PARA OPERATIVE
PLANNING IN A BROODER SENSE.
THE NEED TO HAVE PREOPERATIVE
AND INTRAOPERATIVE ADJUNCTS,
INCLUDING NUTRITIONAL,
HEMOGLOBIN OPTIMIZATION, E RAS
PROTOCOLS, AND PREVENTION,
PHYSICAL THERAPY, PELVIC FLOOR
THERAPY, AND CHECKLISTS
PROOPERATIVELY, AND A CHECKLIST
TO GET PATIENTS WHERE THEY NEED
TO GO.
WE DEBATED WHETHER OR NOT THIS
IS ITS OWN REALM, BUT
ANESTHESIA, INCLUDED
CARDIOVASCULAR RISK ASSESSMENT,
AN SETTING APPROACH, AND IMPACTS
ON THE MOTHER AND THE NEONATE,
AND VASCULAR OCCLUSION AND AS
SPECT TIMES.
A CENTRAL LINE, A RIP LINE, AND
PAIN CONTROL.
WHEN IT COMES TO THE SURGERIES.
THESE ARE MAJOR, MAJOR SURGERIES
AND OTHER BIG SURGERIES,
PATIENTS UNDERGOING RELATIVELY
OR SEMI ELECTIVE PROVIDERS HAVE
A CARDIOVASCULAR RISK
ASSESSMENT, BUT WE DON'T DO THAT
WITH OUR ACCRETA PATIENTS WHO
MAY HAVE COMORBIDITIES.
TRANSFUSION PROTOCOLS,
CYSTOSCOPY, ALL OF THE THINGS WE
LISTED, THE WHOLE HOST OF THINGS
THAT ARE LOW-HANGING FRUIT AND
EASY TO COMPARE STUDIES THAT
NEED TO BE DONE WITHIN THE
BIGGER UMBRELLA OF PERIOPERATIVE
PLANNING, AND MORE LEARN TURN
OUTCOME DATA TO BETTER INFORM
OUR PATIENTS AND PROVIDERS.
FINALLY, WE PULLED OUT
ANESTHESIA PLANNING AS OUR FIFTH
PRIORITY.
BECAUSE AGAIN, THIS GOES BACK TO
THE PREOPERATIVE RISK
ASSESSMENT.
BUT ALSO, ALL OF THE THINGS THAT
OUR ANESTHESIOLOGISTS DO, THE
OPTIMAL APPROACH, POSTOPERATIVE
PAIN OPTIMIZATION, INCLUDING
REDUCING THE OPIOID BURNING,
AND, RAS PROTOCOL, SPECIFIC TO
PLACENTA ACCRETA.
AND THE UTILITY OF THINGS LIKE
PAP OR -- BLOCKS VERSUS A
PROLONGED EPIDURAL IN THIS
SETTING.
AGAIN, CLEARLY WE HAVE A LOT OF
POTENTIAL FOR RESEARCH BARRIERS
THAT WE NEED TO ADDRESS.
WE IDENTIFIED KEY STAKEHOLDERS
INCLUDING THE CDC FOR OUR BIG
OVERARCHING FIRST PRIORITY.
LOOKING AT STATE HEALTH AND
HUMAN SERVICES GROUPS.
CLEARLY WHEN WE'RE TALKING ABOUT
ANESTHESIA PLANNING GROUPS FROM
S.O.A.P. WOULD BE HELPFUL TO
PARTNER WITH.
OUR PERIOPERATIVE PLANNING, THIS
IS WHERE WHERE WE NEED TO
REALLY OUT OUR PSYCHOLOGIST,
PSYCHIATRIST, AND PHYSICAL
NURSING STAFF, AND THE CARE TEAM
AND OTHERS.
AND AGAIN, HAVING THAT
INFRASTRUCTURE IN ORDER TO LOOK
AT OUR LONG-TERM OUTCOMES
STARTING WITH THE FIRST PRIORITY
IS THE KEY TO BEING ABLE TO
BUILD ON TO ALL OF THE OTHER
PRIORITIES THAT FOLLOW.
ARE THERE ANY QUESTIONS OR
ANYBODY ELSE FROM GROUP TWO THAT
WANTS TO ADD ANYTHING?
>> DO PEOPLE FROM OTHER GROUPS
HAVE ANY COMMENTS ABOUT THOSE
PRIORITIES?
>> YEAH?
>> JUST FOR THE RECORD, I THINK
ONE OF THE THINGS I DIDN'T
ACTUALLY THINK ABOUT DURING OUR
SESSION WAS THE AMERICAN COLLEGE
OF RADIOLOGY DEVELOPS STANDARDS
OF PRACTICE.
AND SO, AND GUIDELINES.
SO THAT MIGHT BE A GOOD PLACE TO
START WITH THE MRI EVALUATION.
AND MAYBE AFTER AS WELL.
>> YEAH, I THINK THE OTHER THING
THAT CAME UP IN HER
CONVERSATION, THE RECOGNITION
THAT PAS IS THE ONLY DISEASE
ENTITY.
THE OTHER GROUP THAT WE TALK
ABOUT, TOO, THAT WE MENTIONED,
BUT I FORGOT TO MENTION HERE,
PARTNERING WITH THE ELECTRONIC
MEDICAL RECORDS PROVIDERS AND
BIG SERVICES WHERE WE COULD
ACTUALLY, IF WE BUILT A -- THE
DATA ACQUISITION INTO THEIR EMR
SPECIFIC TO PLACENTA ACCRETA
SPECTRUM, WE COULD CERTAINLY
LEVERAGE THINGS LIKE SLICE AND
DICE IN EPIC TO ANSWER THE
RESEARCH QUESTIONS NICELY.
BUT WE NEED TO PARTNER WITH
THOSE FOLKS TO GET THE DATA MORE
EXPEDIENTLY.
OKAY.
KNEE
ANY
ANY OTHER QUESTIONS OR THOUGHTS?
OKAY.
I THINK THAT IS IT.
DO YOU HAVE A QUESTION?
OH.
>> I THINK A LOT OF THE GROUPS
ARE GOING TO HAVE OVERLAP IN
SOME OF THE CONTENT, WHICH I
THINK IT IS IMPORTANT AND GOOD
AND REHIGHLIGHT PRIORITIES.
AND AS SUCH, I THINK, EACH GROUP
SHOULD PREPARE, PRESENT WHAT
THEY PREPARED AND NOT WORRY
ABOUT THAT OVERLAP AND THEN WE
CAN ALSO LEAVE ROOM FOR
QUESTIONS AND ADDITIONAL
PRIORITIES AT THE END ALSO.
>> YEAH.
AND MAYBE DR. SCAD CAN PRESENT
FOR WORKING GROUP THREE.
SORRY, WE'RE GOING A BIT OUT OF
ORDER, BUT SOME LOGISTICS IN
RECEIVING THE PRESENTATIONS.
SO GROUP THREE.
THANK YOU.
>> FIRST OF ALL, I WOULD LIKE TO
THANK THE NICHD AND EVERYBODY
HERE, THE MEMBERS OF EVERY
SESSION, GROUPS, YOU KNOW, THIS
IS A VERY NEEDY WORKSHOP.
AND I THINK THERE'S A LOT, AS
YOU CAN SEE, THERE IS A LOT OF
THINGS THAT WE HAVE TO WORK
FOR -- SUCH AN IMPORTANT
CONDITION THAT IS REALLY CLOSE
TO OUR MINDS AND HEARTS.
SO-- SO I'M GOING TO START WITH
THE KNOWLEDGE THAT WE CURRENTLY
HAVE.
WE NEED TO UNDERSTAND THERE IS A
BIG GAP.
AND KNOWLEDGE, IN KNOWLEDGE OF
THE CURRENT STATUS QUO
CONCERNING THE CONDITION, THE --
SCREENING, EVENTUALLY,
DIAGNOSIS, AND MANAGEMENT.
AS YOU ALL, WE HAVE BEEN
DISCUSSING THIS FOR THE PAST DAY
OR SO.
SO THE PRACTICE THAT WE KNOW ON
THE MANAGEMENT OF PAS IS THE
STANDARD OF CARE.
IN THE UNITED STATES, YOU KNOW,
THE PRETERM C-SECTION IS WHAT IS
THE MOST ACCEPTABLE APPROACH.
AND, AGAIN, IN THE RISK, THERE
IS A RISK FOR MATERNAL
MORBIDITY, AND AGAIN, LOSS FOR
FERTILITY.
AND SO ACUTE AND LONG-TERM
AFFECTS.
THE CURRENT UTERINE SPARING
OPTIONS THAT WE HAVE.
AS THEY HAVE BEEN DISCUSSED IN
THE PAST DATA THAT SHOWS, IS
THAT SOME HIGH VOLUME CENTERS
AND OUT OF EUROPEAN COUNTERPARTS
ARE LEADING ON THAT, AND IN?
CENTERS IN HOUSTON, IS THAT
THERE IS ALSO ALTERNATIVE
STRATEGY THAT INCLUDES
CONSERVATIVE APPROACH AND THEN
EXPECTED APPROACH.
USUALLY CONSERVATIVE APPROACH
MEANS THAT THE AREA EFFECTED IS
RESECTED, TAKEN OUT AND CLOSED
AGAIN.
WHILE THE EXPECTED MANAGEMENT
IS, JUST YOU DELIVER THE BABY,
THE CORD HAS CLOSE TO THE
PLACENTA, AND CLOSE IT OUT.
LIKE WE DO IN ECTOPIC ABDOMINAL
PREGNANCIES.
THESE APPROACHES, OF COURSE,
HAVE TO GO FOR FERTILITY.
AGAIN, REDUCE THE CERVICAL RISKS
AND THE STRESS OF THE PATIENT
AND THE COMORBIDITIES THAT ARE
ASSOCIATED WITH THE, PRETERM
C-SECTION.
AGAIN, IT REQUIRES A CENTER OF
EXPERTISE AND, AGAIN, WHAT KIND
OF CAREFUL, PATIENTS WILL BEACH
FOR TRACK OF CONSERVATIVE OR
EXPECTED MANAGEMENT.
SO, THE GAP TO MANAGE PAS WILL
FOCUS ON MAINLY ON FIVE POINTS.
ONE IS MANY OF YOU HAVE
MENTIONED, IS THE PATIENT
STRATIFICATION.
THERE IS NO REAL CONSENSUS ON
HOW TO CERTIFY PATIENTS, WHAT
ARE THE RISK FACTORS TO
DETERMINE THAT, IN ORDER TO,
OKAY, WHICH ONE IS THE MOST
APPROPRIATE CERVICAL MANAGEMENT?
FACTORS TO THE EXTENSION OF THE
PLACENTA, COMORBIDITIES, PRIOR
OB HISTORY, REALLY NEED TO BE
STANDARDIZED AND COLLECTED.
AGAIN, THE COMPARATIVE OUTCOMES
IS VERY IMPORTANT TO DETERMINE
THERE IS LACK OF ROBUST
COMPARATIVE DATA ON THE
SHORT-TERM AND LONG-TERM
OUTCOMES IN THE DIFFERENT
DISCUSSED SURGICAL APPROACHES.
WHICH INCLUDE IMMEDIATE VERSUS
DELAYED RESECTION VERSUS LEAVING
THE PLACENTA INSIDE, TO LOCAL
RESECTION AND CLOSER.
SO THE GAP IS VERY CLOSURE TO
DEVELOP THIS, TO DEVELOP AND
CHANGE THE PRACTICE THAT WE'RE
DOING, ESPECIALLY IN THE UNITED
STATES.
ALSO, THE EXCLUSION PRACTICE,
THERE IS SIGNIFICANT
VARIABILITY.
AND REALLY THE ONLY THING I SEE
CONSENSUS IN THIS WORKSHOP IS
DEFINING IT AS PLACENTA ACCRETA
SPECTRUM.
AND THE SPECTRUM OF ALL OF THE
DATA THERE.
SO WE HAVE A HUGE SPECTRUM ON
THAT.
I THINK WE NEED TO NARROW THIS.
AND, YOU KNOW, WE HAVE ALSO HIGH
VOLUME CENTERS WITH SPECIALIZED
EXPERTISE, OF COURSE, THEY MAY
HAVE THE BEST OUTCOMES, BUT THE
LOW VOLUME CENTERS MAY FACE SOME
CHALLENGES IN MAINTAINING THE
SKILLS AND RESOURCES.
THE INTRAOPERATIVE TECHNIQUE ARE
ALSO NOT STANDARDIZED
EFFECTIVELY.
AND EXPECTED MANAGEMENT OR
CONSERVATIVE MANAGEMENT AND THE
USE OF THAT THERAPIES ON, ON --
SORRY.
ON-- WHICH ONE TO USE, THE
BALLOON, THE EMBOLIZATION,
STINTS, DEVICES, LIGASURE,
HARMONICS, ALL OF THESE CAN COME
INTO PLAY AND BY CENTERS AND
CERTAIN EXPERTISE, ETC.
THE OTHER THINGS THAT WE TALKED,
WHICH IS ALSO VERY IMPORTANT IS
SOME MEMBERS FROM THE SEA AND
CANADA THAT WE ARE TALKING
ABOUT, IS THE TRAINING AND SKILL
MAINTENANCE REQUIRED FOR THE
SURGICAL TEAMS TO MAINTAIN
PROFICIENCIES, ARE THEY
ADEQUATELY TRAINED TO HANDLE THE
PAS CASES THAT ARE VERY
CHALLENGING.
ESPECIALLY IN THE LOW VOLUME
CENTERS, HOW ARE THESE
MAINTAINED.
IT IS IMPORTANT TO CONTINUE
PROFESSIONAL DEVELOPMENT AND TO
KEEP TEAM TRAINING WHICH IS
EFFECTIVE, WHICH IS CRITICAL AND
CENTER FOR THE PAS MANAGEMENT.
WE, SORRY ABOUT THE FONT BEING
SMALL.
BUT SO MANY POINTS TO PUT.
SO IN SUMMARY, WE IDENTIFIED KEY
GAPS OF KNOWLEDGE AND AREAS FOR
RESEARCH THAT WE INCLUDED FIRST
OF ALL.
IDEALLY, IS -- WHAT WE SHOULD
PURSUE.
THERE'S CHALLENGES, OF COURSE,
EVERYONE, YOU WILL FIND AND
SOMETHING THAT IS GOING TO TELL
YOU DON'T DO IT.
BUT MOST, MAJOR RCTs THAT ARE
DONE BEFORE, THAT CHANGE
PRACTICE, THIS IS THE CHALLENGES
THAT THEY FACE.
AND AT THE END, THEY CHANGE
PRACTICE OVER THE WORLD AND IN
THE UNITED STATES.
ANOTHER IMPORTANT THING THAT WE
TONGED IS DEFINITELY WE'RE GOING
TO COMPARE THE SURGICAL
TECHNIQUES WE TALKED ABOUT THE
STANDARD OF CARE AND PRIMARY,
WHICH IS SIMPLE PRETERM
HYSTERECTOMY.
VERSES THE CONSERVATIVE AND
EXPECTED APPROACHES.
APPROPRIATE-- IT IS VERY
IMPORTANT WHEN YOU DESIGN AN
RCT.
WE DISCUSSED THIS EXTENSIVELY
ABOUT THIS.
FIRST WE TALKED ABOUT THE TIME
FRAMES AND MOST OF OUR OUTCOMES
WILL BE AROUND CLOSE TO SIX
MONTHS PER THE EXPERTISE PANEL
VERSUS ONE YEAR, UP TO ONE YEAR.
AND FOR THE, TO EVALUATE THE
DIFFERENT TECHNIQUES, THERE WAS
A NOVEL APPROACH ABOUT
DESIRABILITY OF OUTCOMES
RANKINGS FROM PATIENTS AND
STAKEHOLDERS IN ORDER TO
DETERMINE THE BEST OUTCOME, THAT
IS USING PRIOR TRIALS.
AND AGAIN, ADDING LONG-TERM
OUTCOMES AND QUALITY OF LIFE
OUTCOMES IN PATIENTS
SATISFACTION AND THE MENTAL
IMPACT ON THESE PATIENTS IS VERY
IMPORTANT.
AGAIN, OBTAINING THE ACCURATE
DATA THROUGH EDUCATION TO REMOVE
BIASES IN STUDY, WHICH CURRENTLY
IN THE PAST KNOWN DATA THAT WE
HAVE THAT EXISTS.
AND ESPECIALLY, THESE CAN BE
DONE THROUGH REGISTRY WHERE A
PROPOSED IS NOT POSSIBLE.
EVALUATING THE CRITERIA FOR
SURGEON TRAINING OR COMPETENCY
IN THESE COMPLEX PROCEDURES
SHOULD BE INCLUDED IN THESE
TRIALS.
AND THE POTENTIAL TRIAL DESIGNS
WITH THESE RCTs, WE DISCUSSED
NONPRIORITY, VERSUS PRIORITY OR
A MIXED MODEL WHERE IF ONE OF
THESE ARE MET, THE OTHER ONE
DOES NEED TO BE FOLLOWED.
BUT THESE DETAILS CAN BE LATER
EXPLORED.
THERE ARE CHALLENGES TO DO AN
RCT.
PATIENT SELECTION, AND
VISIBILITY, THESE WERE ALSO
DISCUSSED.
AND AGAIN, STANDARDIZED THE DATA
COLLECTION ACROSS CENTERS IS
VERY IMPORTANT AND CRUCIAL IN
ORDER TO MAKE IT A VALID TRIAL
AND TO INFORM FUTURE RESEARCH
AND PRACTICES.
SO WE ALSO TALKED EXTENSIVELY
ABOUT SURGEON TRAINING AND
ASSESSING SKILLS.
WE DO THAT, YOU KNOW, IT IS VERY
IMPORTANT TO IDENTIFY,
CATEGORIZED DIAGNOSES OR
SCREENING OF THE ACCRETA IN
ORDER TO DETERMINE APPROPRIATE
CARE AND TRAINING THE SURGEONS.
AND THIS IS -- THIS INCLUDES
ABLE TO PREDICT WHICH CASES ARE
LOW RISK AND HIGH-RISK.
CURRENT DIAGNOSTIC METHODS ARE
LACKING BEHIND.
WE KNOW THAT.
AND THE NEED TO BE VALIDATED AND
FURTHER EVOLUTION IN ORDER TO
CLASSIFY THE SEVERITY AND RISK
CLASSIFICATION.
ENSURING THE SURGEONS TRAINED IN
SCANNING PATIENTS THEMSELVES TO
UNDERSTAND THE ANATOMY AND AID
IN PREDICTING SURGICAL OUTCOMES
WERE ALSO DISCUSSED AND
SUGGESTED DURING OUR DISCUSSION.
AND FOCUSING ON SURGICAL
TRAINING AND EXPERIENCE, A
SELECTED FEW SURGEON SAID FULLY
RATHER THAN SPREADING LIMITED
EXPERIENCE TO BROAD THE RESULTS
WILL USUALLY LEAD TO SAFER AND
MORE COMPETENT CARE.
MAINTAINING SURGICAL SKILLS WITH
A MINIMUM REGULAR CASE VOLUME IS
IMPORTANT.
NOT JUST ONE CASE ANNUALLY.
OTHER SUBSPECIALTIES TO BE ALSO
INVOLVED LIKE ANESTHESIA TO BE
TRAINED ON THIS SPECIFIC
CONDITIONS, TO SAFE WAY HANDLE
COMPLEX CASES.
AGAIN, COORDINATION OF CARE IN
HIGH VOLUME CENTERS IS
EMPIRICAL.
AND AGAIN, CENTRALIZED ACCRETA
CASES AT DESIGNATED HIGH VOLUME
CENTERS WITH TEAMS COULD IMPROVE
OUTCOMES IN LOW VOLUME COMMUNITY
HOSPITALS.
SO THE GAPS IN TRAINING,
TRAINING IN GENERAL, THE
SURGEONS, FELLOW, RESIDENTS IN
PAS SURGERY IS CHALLENGING.
AND THEY ARE UNLIKELY TO REACH
COMPETENCY OR SAFETY EVEN AFTER
MULTIPLE EXPOSURES DUE TO LOW
CASE VOLUME.
AND THIS IS SHOWN BY A LOT OF
DATA PRESENTED YESTERDAY.
IT WAS ALSO ARGUED THAT FOCUSING
TRAINING ON A SELECT FEW PEOPLE
RATHER THAN SPREADING LIMITED
OPPORTUNITIES TOO BROADLY IS
PREFERABLE TO ENSURE THAT THE
ONES INVOLVED IN SURGERY LEADS
TO A SAFE AND COMPETENT OR
ENVIRONMENT.
MAINTAINING SKILLS REQUIRES A
MINIMAL REGULAR CASE VOLUME, SO
RESIDENTS SEEING JUST ONE OR TWO
CASE MAY NOT LEARN SKILLS, SINCE
ACCRETA IS A LOW
COUNTRYDITION -- THAT IS
AVAILABLE DURING RESIDENCY.
AND THE PHYSICIANS HAVE A SMALL
GROUP OF HANDS-ON TRAINING,
BETTER THAN RESIDENTS JUST
OBSERVING, THOUGH GENERAL
RESIDENTS DO NOT NEED TRAINING
ON, IN COMPLEX HYSTERECTOMIES.
THAT WAS OUR SUMMARY.
ANY QUESTIONS?
>> CAN YOU GO BACK TWO SLIDES P?
MAYBE NOT.
>> I THINK IT WAS TURNED OFF.
>> THERE IS A COMMENT ABOUT
SURGEONS SCANNING.
I THINK IF WAS ONE SLIDE
FORWARD.
>> YES, THE SECOND POINT.
>> SO I'M JUST CURIOUS WHAT --
WHAT IS ABOUT THAT?
YOU KNOW, IF THE MAJORITY OF
CENTERS, I MEAN, IN THE UNITED
STATES, IS NOT ABOUT A
TUSTRATION MFM DOING THE CASES,
WHY DOES A G1 ONCOLOGIST, WHAT
IS THE RATIONALE TO COMPLAIN A
SURGEON TO DO ALL OF THE OTHERS?
>> I THINK THIS WAS DR. HOBSON
AND HIS GROUP IN CANADA.
WHERE IT IS DIFFERENT.
I THINK IN THE U.S., THIS WILL
PROBABLY APPLY, IF IT IS
ONCOLOGIST WHO DOESN'T DO
ULTRASOUND.
UNDERSTANDING THE IMPLANTS AND
THE MRI AND HAVING REVIEWED IT.
BUT PROBABLY NOT A REALISTIC
EXPECTATION THERE.
>> YEAH, IT WAS -- AGAIN, IF --
DEFINITELY IF A SURGEON KNOW
EXACTLY WHERE THE PLACENTA, THE
MORE INFORMATION THEY HAVE.
IN OUR CENTERS THEY THERE WERE
TIMES DOING IT, WE REALLY ASSESS
IT RIGHT BEFORE THE SURGERY.
THE ONCOLOGIST USUALLY ASKS FOR
AN ULTRASOUND TO BE DONE WITHIN
THAT WEEK TO DISCUSS IT CASE IF
THEY EVOLVED EARLY OR AN MRI
BEING DONE IN THE PAIRTIVAL,
ESPECIALLY THINKING ABOUT THE
ACCRETA INVADING THE AREAS OR
THE BLADDER.
THAT'S A GREAT POINT.
>> I'M NOT QUESTIONS AT ALL THE
ROLE FOR IMAGING.
BE VERY CLEAR ABOUT THAT.
BUT TO HAVE A STATEMENT THAT
RECOMMENDATION FOR THE SURGEON
ITSELF TO SCAN, THAT MAY BE, IT
MAY BE CREEP THERE IN THE UNITED
STATES.
>> I THINK, THE COMMENT WAS TO
HAVE SOMEBODY IN THE ROOM WHO
KNOWS WHERE THE STRUCTURES ARE
AND WHERE THE PLACENTA IS AND
ALL OF THAT.
NOT TO BE THE SURGEON ONCOLOGIST
OR, BUT TO HAVE SOMEONE IN THE
ROOM WHO KNOWS WHERE -- YOU
KNOW, ALL OF THE DETAILS OF
THE -- ULTRASOUND FINDINGS.
>> I'M GOING TO ADD TO THAT,
JUST REPORTING MECHANISMS, THERE
IS REALLY ROBUST REPORTING
MECHANISMS TO HELP PEOPLE KNOW
EXACTLY WHERE THINGS ARE.
THERE IS THE ONE COMMENT ABOUT
NOT TRAINING YOUR REGULAR OBGYN
ABOUT SOME OF THE SURGERIES, I
DISAGREE WITH THAT
FUNDAMENTALLY, THE MAJORITY OF
RESIDENTS GO OUT INTO THE MIDDLE
OF SMALL TOWN AND COMMUNITY AND
COMMUNITY HOSPITALS, THEY ARE
THE ONES FACED WITH THE DISASTER
CASES THAT DROP IN, IN THE
MIDDLE OF THE NIGHT.
THEY NEED TO AT LEAST LEARN WHAT
THE RECOGNIZE AND THAT WHOLE
ALGORITHM THAT BRETT AND DANNY
WORKED ON, THEY HAVE TO BE
INVOLVED IN THE EDUCATION, NOT
DOING THE STEPS, BUT
RECOGNITION, WHAT YOU CAN DO AND
START AND WHAT TO DO IN AN
EMERGENCY IS CRITICAL FOR THE
RESIDENTS.
>> THIS CAME UP IN THE
DISCUSSION.
I THINK ALL OF US IN THE ROOM
FELT THAT THERE IS MORE HARM IN
TRAINING A RESIDENT WITH ONE OR
TWO CASES FEELING THAT THEY'RE
GOING TO GET ONE CASE THAT WAS
NOT DIAGNOSED EARLY AND ONE OR
TWO CASES FOR THE RESIDENT ARE
NOT GOING TO HELP THEM MANAGE
THE CASE ANYWAY.
VERSUS DILUTING THE TRAINING FOR
ONE PERSON WHO IS GOING BE ABLE
TO TAKE OVER OR STAY AT THAT
CENTER.
WE ALSO FELT THAT THESE CASES
THAT OCCUR IN THE COMMUNITY ARE
REALLY A FAILURE OF THE SYSTEM
OF EARLY DIAGNOSES AND TRANSFER
AND THAT'S WHERE WE SHOULD BE
FOCUSED RATHER IN THE TRAINING
EVERY RESIDENT.
I MEAN, WE HAVE IN OUR PROGRAM
FIVE RESIDENTS, I THINK, IN YOUR
PROGRAM YOU HAVE EIGHT
RESIDENTS, IF THEY ARE LUCKY,
THEY WILL DO TWO CASES DURING
THEIR RESIDENCY, THAT IS NOT
GOING TO TRAIN THEM TO TAKE CARE
OF PATIENTS IN THE COMMUNITY.
>> I THINK THERE IS ALSO A
DIFFERENCE BETWEEN UNDERSTANDING
HOW TO MANAGE A CONDITION AND
BEING A PERSON WHO IS COMPETENT
TO DO THE SURGERY.
I DON'T THINK ANYONE WOULD ARGUE
THAT RESIDENTS NEED TO
UNDERSTAND THE MANAGE OF THIS
CONDITION, MAYBE THEY ARE NOT A
PRIMARY OPERATOR.
>> I THINK THE FOCUS IS, WE WANT
THE TEAM OF THE PAS IN THAT
CENTER TO BE HOMMAL HAVING THOSE
CASE VOLUMES.
IF THEY INVOLVE MORE AND MORE
OTHER PEOPLE, I HEARD A CASE
THAT THERE WERE LIKE FIVE
FACULTY SCRUBBED IN FOR A
RESIDENT PAS, EVERYBODY WANTED
TO LEARN.
WHICH IS GREAT, BUT THE SKILL
GOES DOWN AND DOWN AND DOWN.
RIGHT?
WE WANT FIRST TO GET THE TEAM UP
AND RUNNING AND BE OPTIMIZED,
THEN YOU CAN DONE DO MORE
EDUCATION.
EDUCATION IS -- OUR CENTERS ARE
IMPERATIVE ON THAT.
>> I
>> I THINK THIS IS AN IMPORTANT
AREA WE HAVE TO TALK AT THE
BEGINNING ABOUT THE SPECTRUM.
AND AGREE, RESIDENTS, AND
SOMETIMES RESIDENTS COME TO A
GRADE THREE TEACHES THAT AND
REVIEW THIS, YOU'RE NOT GOING TO
INTENTIONALLY TAKE A GRADE THREE
TO THE OR.
THEY BELIEVE THAT AFTER THEY
HAVE BEEN AT THE CASES.
THEY SHOULD PROBABLY DO A GRADE
ONE, THEY WILL BE IN THE OR WITH
A GRADE ONE PAS.
IT IS GOOD EXPERIENCE TO DO A
HYSTERECTOMY.
IT IS IMPORTANT TO HAVING
SOMEONE AT THE TABLE DOESN'T
MEAN THE PERSON IS COMPETENT IN
THE PROCEDURE, BUT WILL LEARN
FROM ASSISTING AND WATCHING THE
PROCEDURE, BUT THE POINTS HAVE
TO BE SPELLED OUT.
>> YEAH.
THERE'S ALSO THE GAP IN HELPING
THE COMMUNITY PHYSICIAN RIGHT
WHEN DO THINGS EXTERNALLY LOOK
BAD ENOUGH, YOU ARE NOT GOING TO
SEE WHAT HAPPENS, BUT TRANSFER
THAT PATIENT EITHER WITH OR
WITHOUT A BABY DELIVERED.
>> THIS IS VERY IMPORTANT.
I CAN TELL YOU, ONE OF MY CASES
I DO IN MY RESIDENT SAID ABOUT
PAS, I GIVE THEM A SCENARIO
YOU'RE IN A COMMUNITY HOSPITAL
BY YOURSELF AT NIGHT, MIDNIGHT,
AND SOMEBODY CAME BLEEDING, YOU
OPEN UP AND SEE THIS, AND SHOW
THEN THE PICTURE.
WHAT DO YOU DO?
90% OF THEM THE FIRST TIME, THEY
SAY DELIVER THE BABY AND SEE
WHAT IT IS.
THEY DON'T SEE CLOSING THEM AND
TRANSFERRING.
IT IS ONE OF THE PEARLS OF
EDUCATION.
IT SHOULD DEFINITELY BE
EMPHASIZED.
>> I THINK HUMILITY IN THE FACE
OF THE DISEASE COMES WITH
EXPERIENCE FOR SURE.
I ALSO WONDER, SO OUR CURRENT
STRUCTURES ARE BUILT AROUND THE
NOTION OF PERFORM C-SECTION AS
YOU MENTIONED I WONDER IF
ADDITIONAL OB/GYN NEED TO COME
TO THE TABLE.
AND MIXED STURGEONS WHO NOW NEED
TO KNOW HOW TO DO RESECTIONS
LATER.
DANNY IS, SOMEBODY THAT SHE CAN
DO A HYSTERECTOMY OF A RESECTION
OF A PIECE OF SOMETHING LEFT
OVER THAT I CAN'T DO.
SO I WONDER IF WE NEED TO, THIS
HAS BEEN AN INITIAL GREAT
OPPORTUNITY FOR STAKEHOLDERS TO
CONVENE, AS WE EXPAND OUR
TOOLBOX, WE NEED TO EXPAND OUR
FRIENDS IN THE ROOM.
>> I THINK, ADDING TO THAT, YOU
KNOW, I THINK THIS GROUP IS
PROBABLY THE MOST VERSED, WELL
VERSED IN WHAT THE NATURAL
HISTORY OF CONSERVATIVE
MANAGEMENT LOOKS LIKE, BUT MOST
OB/GYNs ARE NOT.
SO IF WE'RE, IF CONSERVATIVE
MANAGEMENT IS IMPLEMENTED MORE
BROADLY, WE NEED TO FURTHER
EDUCATION THE GENERAL OB/GYN
COMMUNITY AND THE RADIOLOGY
COMMUNITY ON WHAT TO EXPECT AND
HOW TO MANAGING COMPLICATIONS.
>> AGAIN, WHAT I HAVE LEARNED BY
STARTING THIS, WHO WILL DO THE
HYSTERECTOMY, BETTER TO DO IT
ROBOTICALLY OR OPEN?
WE STARTED WITH LIMITED INVASIVE
PEOPLE AND THEN OUR ONCOLOGISTS
COMPLAIN THEY WANT TO GET THE
EXPERIENCE WITH DOING THIS.
SO, NOW, WE DECIDED TO LET OUR
ON-CALLS TO IT.
BUT I THINK THERE IS A BIG PLACE
FOR MINIMALLY INVASIVE SURGEON
THERE.
ARE THE BEST PEOPLE WHEN IT
COMES TO DOING THE PROCEDURE.
AND OF COURSE, SOME OF THE
PATIENTS WITH A PLACENTA, YOU GO
IN THERE WITH THE HYSTERECTOMY
TO MOVE IT.
THESE ARE THE SOME OF THE THINGS
YOU'RE GOING TO GET AS YOU DO
MORE OF THESE CASES.
>> THANK YOU.
>> SORRY.
YEAH.
NO.
FROM GROUP ONE.
SORRY, WORLD GOING BACKWARDS.
VERY IMPORTANT.
THANK YOU.
GLOW AS WE STEP BACKWARDS, WE
HAVE BEEN FOCUS ON WHAT TO DO
WITH THE DIAGNOSIS.
WE WERE REALLY CHARGED WITH
THINKING ABOUT UNDERSTANDING THE
EPI, THE SCREENING AND THE
DIAGNOSIS.
WE WROTE IT IN NOTE FORMAT.
THIS IS THE ITERATIVE
DISCUSSION.
SO ANYWAY TO ENLARGE THAT?
I CAN'T CONTROL IT.
AT THE BOTTOM RIGHT THERE.
I CAN'T -- OH.
I CAN'T REALLY CONTROL THE
SCREEN.
OKAY.
SO CAN YOU KEEP INCREASING IT?
I'M TALKING TO SOMEONE
VIRTUALLY.
THANK YOU!
GREAT.
SO, THE INSPIRATION FOR THIS IS
WE'RE CLEARLY MISSING TOO MANY
CASES TO EVEN START HAVING THE
CONSERVATIONS OF WHAT TO DO.
SO WE IDENTIFIED OVER ALL THREE
FAIRLY LARGE AND BROAD, DON'T
FOCUS ON THE LANGUAGE, MOSTLY A
DISCUSSION.
KNOWLEDGE GAP ONE, WHAT IS
ACCRETA, IT COMES UP IN
DIFFERENT FLAVORS AND
DISCUSSION.
WE TALK ABOUT IS THE GOLD
STANDARD HISTOLOGY.
I THINK THAT WE DON'T KNOW.
AND WE HOPE THAT AS WE PUBLISH
AND CREATE PAPERS WE ARE VERY
CLEAR OF HOW WE'RE DEFINING
ACCRETA IN AS MANY, MANY
CLINICAL AND DEMOGRAPHIC
PARAMETERS AS POSSIBLE.
AND THEN THE SECOND KNOWLEDGE
GAP WAS RELATED TO SCREENING.
SO WE ACTUALLY BELIEVE THAT
THERE SHOULD BE UNIVERSAL
SCREENING.
WHEN WE SAY UNIVERSAL SCREENING
THAT IT MEANS CLINICAL RISK
FACTORS.
THAT INCLUDES YOUR CESAREAN,
YOUR INSTRUMENTITATION.
THAT IS PART OF OUR SCREENING.
WE FOLLOW THAT WITH ULTRASOUND.
AND THEN WE MOVE FORWARD FROM
THERE.
THE THIRD KNOWLEDGE GAP IS
CLEARLY, WE ARE MISSING THE HUGE
POPULATION AND WE NEED TO DO A
BETTER JOB FROM LEARNING FROM
THE UNDIAGNOSED CASES.
SO KIND OF FOCUS ON THE THREE
KNOWLEDGE GAP, THE DEFINITION,
THE SCREENING PULLROOMTERS AND
LEARNING FROM THE UNDIAGNOSED
CASES WHICH IS REALLY THE BLACK
BOX AND WE'RE PROBABLY GOING TO
GET A LOT OF DATA.
SO WITH THE EMMY, WE HAVE SUCH A
DIVERSE AND WIDE SPECTRUM FOR
THE PREVALENCE.
SO WE KIND OF HAVE IT IN A
QUESTION FORMAT.
SO WE HOPE THAT THOSE OF US WITH
WHO ARE DOING RESEARCH, AND
THOSE REPORTING ARE REALLY
THOUGHTFUL ABOUT THIS.
WE CAN USE EACH OTHER'S
RESEARCH.
FOR EXAMPLE, YOU KNOW, GROUPS
THAT PUBLISH ON CONSERVATIVE
MANAGEMENT DESCRIBE WHERE THE
PLACENTA IS, DESCRIBE THE
INSTRUMENTATION, THOSE THAT WERE
UNDIAGNOSED, WHO WAS THE ROOM?
WHO WASN'T IN THE ROOM?
WHEN WAS THE DIAGNOSIS MADE IF
AND REALLY, REALLY THE TIME OF
ACCRETA.
HOWEVER WE WANT TO DEFINE IT, AS
MUCH INFORMATION AS POSSIBLE.
BECAUSE AT THE END OUR GOAL IS
WHAT ARE THE DRIVERS OF
MORBIDITY.
AND ON THAT NOTE WITH MORBIDITY,
IT'S, YOU KNOW, WE OBSESS ABOUT
THE CDC'S 21 DEFINITIONS, BUT BY
DEFAULT, HYSTERECTOMY AND BLOOD
TRANSFUSION ARE ALL ACCRETAS
HAVE -- TO SOME DEGREE, SO FOCUS
ON PAS SPECIFIC SMM.
BUT MORBIDITY, SOMETHING
SPECIFIC TO OUR POPULATION.
BECAUSE WE THINK THAT THIS WILL
REALLY OWN THE EPIDEMIOLOGIC
PERSPECTIVE.
THAT KIND OF THE PIECE ON
DEFINITIONS.
THE CAME UP OVER AND OVER.
I KNOW THEY MADE IT VERY CLEAR,
TODAY WE'RE NOT CREATING
DEFINITIONS FOR PAS AND ACCRETA,
BUT ARE WE DOING A CLINICAL
DIAGNOSES, AND ULTRASOUND
DIAGNOSIS AND HISTOLOGICAL
DIAGNOSES.
IF WE'RE DOING THE RESEARCH, BE
VERY CLEAR AND HOW IT IS
DEFINED.
DO YOU MIND GOING DOWN TO
KNOWLEDGE GAP TWO.
FOCUSED ON SCREENING.
OUR GOAL, WE DON'T WANT TO BE
MISSING ACCRETAS, WE ARE CLEARLY
MISSING TOO MANY.
START WITH UNIVERSAL, CLINICAL
SCREENING OF ALL COMERS.
AND THEN TARGET.
SO WE'RE GOING TO MAKE IT, WE
IDEALLY WANT, IF YOU GET A EARLY
ULTRASOUND, SOMEWHERE BETWEEN
SIX AND NINE WEEKS, IT IS IN THE
LOWER UTERUS SEGMENT, SEND TO,
WHAT DO WE CALL IT?
A HIGHER LEVEL OF CARE.
WE STRUGGLED A LOT WOULD DO YOU
SEND IT TO A CENTER THAT IS FOR
ACCRETA DIAGNOSES, MFM, BUT WE
DECIDED A HIGHER LEVEL OF CARE
WE FELT COMFORTABLE WITH.
IF YOU HAVE THAT LOWER SEGMENT
IMPLANTATION REFER OUT.
FOR THE REST OF THE POPULATION,
WHENEVER YOU HAVE ULTRASOUND
MARKERS THAT WE WILL MAKE VERY
CLEAR WHAT THEY ARE, THERE'S
BEEN SOME WHITE PAPERS ON THIS,
YOU NEED TO REFER TO A CENTER OF
EXCELLENCE.
GOING BACK ON THIS THEME, AND
SO, WE WANT TO CREATE A TANGIBLE
AND USABLE COMMUNITY LIKE PIECE
OF RISK FACTORS.
VERY SIMILAR, I THINK THE
EXAMPLE WAS THE ASPIRIN TABLE
THAT WE ALL LOVE AND HATE WITH
THE HIGH RISK CRITERIA, THE
MODERATE AND MIDDLE RISK
CRITERIA, AND THE LOW RISK
CRITERIA, THIS IS FOR REFERRAL
OUT.
WE'RE GOING TOKING GO THROUGH
THE LITERATURE AND CONTINUE TO
ADD THIS OF WHAT ARE YOUR
RELATIVE RISKS FOR ACCRETA?
BASED ON YOUR RISK FACTORS.
SO IF YOU'RE HIGH, THE C-SECTION
I HAD LOWER UTERINE SEGMENT YOU
BETTER REFER OUT.
AND A LOT ARE LOWER DOWN ON THE
LIST WE DON'T UNDERSTAND.
WE WANT A USABLE TABLE WITH THE
FOLKS IN THE COMMUNITY FOR THAT
REGARD.
AND CLEARLY WHAT PIECES, FOUR,
WE WANT TO CONTINUE, THIS IS,
WITH SCREENING.
WE WANT THE DATA FROM THESE
ULTRASOUNDS.
WE WANT TO BE ABLE TO MOVE IN
THE DIRECTION SOMEONE MENTIONED,
YOU KNOW, WE HAD MR SPECIALIST
IN OUR COMMUNITY.
AND SPECTROSOMY.
THE EASE OF MR IS TO ABILITY TO
REMOVE THE OPERATOR OF THE
EQUATION.
SO, WE CAN DO THIS WITH
ULTRASOUND WE CAN STANDARDIZED
THE CLIPS THAT WE WANT, THE
DEFINITIONS WE WANT, AND WE NEED
TO MAINTAIN THAT RICH RESOURCE,
WE CANNOT BE WORKING IN THE
SILOS.
WE WANT TO CREATE A STANDARDIZED
PROTOCOL THAT IS AVAILABLE FOR
PEOPLE AND THEN AREAS TO
MAINTAIN THAT.
SO THIS, DO YOU MIND GOING DOWN,
PLEASE, TO THE -- PERSON,
THAT'S, THANK YOU.
SO THESE ARE KIND OF LIKE OUR
LIST OF DESIRES IN -- THAT TOUCH
THE THEMES.
THE DATA CONSORTIUM, WHATEVER
THAT BECOMES, ALL ACCRETAS AS
SOME OF US HAVE WITH PAS
SQUARED, I UNDERSTAND, IT NEEDS
TO INCLUDE IMAGING.
IT NEEDS TO INCLUDE IMAGING.
AND THESE REGISTRY CAN BE LINKED
TO EMRs, BUT WHATEVER IT IS,
IT NEEDS TO BE LINKED HOW TO
DIAGNOSES WAS OR WAS NOT MADE.
AND THEN SOMETHING I THINK
MISSED WAS WE WANT REVIEW AND
RECOMMENDATION FOR THE STRONG
ACCRETAS.
ANY TIME A ACCRETA WAS DIAGNOSED
INTRAOPERATIVELY OR
POSTOPERATIVELY BASED ON
HISTOLOGY OR CLINICAL OUTCOMES
IT NEEDS TO BE REVIEWED.
WE DEBATED, INTERNALLY REVIEWED
OR NEED TO BE REVIEWED WITH
WHOEVER WE DESIGNATE, LIKE
MATERNAL MORTALITY IS REVIEWED,
EVERY SINGLE CASE, AND FROM THAT
WE LEARN WHAT ARE ADDITIONAL
RISK FACTORS BOTH CLINICALLY, BY
ULTRASOUND, AND THEN, ALONG THAT
MAINTAIN THAT AND CONTINUE TO
IMPROVE IT.
THE OTHER THINGS THAT I THINK WE
DON'T HAVE HIGHLIGHTED HERE, BUT
IT IS PART OF SCREAMING AND
DIAGNOSIS, I KNOW IT IS TOUCHED
IN GROUP FOUR, BUT WE WANT TO
CONTINUE TO BUILD ON FOLKS THAT
ARE DIAGNOSED PRENATALLY.
A WAY TO CONSOLIDATE S.O.A.P.
FOR BIOBANKS AND A HOME HOME
THAT WE CAN SHARE FROM.
WE ARE ALL DOING THE WORK AND
COLLECTING, THINGS SHOULD NOT BE
JUST WAITING FOR A PROJECT.
EVERYONE NEEDS TO KNOW WHAT
EVERYONE IS DOING, BUILD
TOGETHER IN AN OPEN SOURCE
FASHION.
THAT IS PART OF OUR FANTASY.
IT WILL BE CENTRALIZED IN SOME
PLACE, BUT EVERYBODY WILL BE
WORKING AND ABLE TO SHARE
ANYTHING ELSE I MISSED?
FROM URLIVING DOCUMENT.
>> I WANT TO HIGHLIGHT ONE
REALLY IMPORTANT THING WE TALKED
ABOUT THAT CENTERS OF CARE ARE,
CENTERS OF EXCELLENCE ARE
STRATIFIED BASED ON DELIVERY NOT
DIAGNOSIS.
I THINK IS A RESPONSIBLE FOR
CENTERS OF CARE TO ENHANCE THAT
PORTION AND REFERRAL OUT TO
THEIR COMMUNITY, THESE ARE THE
PEOPLE WE WANT TO SEE.
SO I THINK, CENTERS OF
EXCELLENCE SHOULD EXPAND SIMPLY
BEYOND DELIVERY TO INCLUDE
UPSTREAM STAGES, THAT IS A
REALLY IMPORTANT PIECE OF WHAT
WE DISCUSSED.
>> YES.
>> I HAVE A PLEA.
I MENTIONED IT YESTERDAY.
WE NEED TO BE CAREFUL WHEN USING
DIAGNOSIS AND SCREENING.
IN MY OPINION, DIAGNOSES IS AT
SURGERY, AFTER SURGERY, AT
SURGERY, WE CANNOT TALK ABOUT
PRENATAL DIAGNOSIS.
THERE IS NOTE PRENATAL DIAGNOSES
IN THIS AREA.
IT IS PRENATAL SCREENING.
THE REASON I SAY THAT, BECAUSE
I'M AFRAID THAT PEOPLE HAVE
CONFUSED THE SCREENING WITH THE
DIAGNOSIS WHEN THEY ARE SAYING
THAT WE NEED BETTER ULTRASOUND,
WE NEED BETTER TECHNIQUES.
ACTUALLY, THE TECHNIQUES WE HAVE
ARE OUT STANDING FOR A SCREENING
TEST.
I'M AFRAID IF WE START PUSHING
THE SCREENING TEST, ULTRASOUND,
OR WHATEVER IT IS, TO INCREASE
SENSITIVITY, THE, BY DEFINITION
THE SPECIFICITY IS GOING TO GO
DOWN.
WHICH MEANS WE ARE GOING TRADE
THE FALSE-POSITIVE WITH THE
FALSE-NEGATIVE OR VICE-VERSA.
WE NEED TO ACCEPT WE HAVE AN
OUTSTANDING SCREENING TEST, I
BELIEVE ULTRASOUND, AND OTHER
PEOPLE MRI.
BUT MRI IS IN A SERIES WITH
ULTRASOUND, NO ONE DOES MRI
PRIMARILY, WHETHER YOU ADD THE
MRI OR NOT, THAT IS A DIFFERENT
STORY.
WE HAVE AN OUTSTANDING SCREENING
TEST, WE WILL HAVE A TRADE-OFF
BETWEEN SENSITIVITY AND
SPECIFICITY, AND MOVE ON BEYOND
THAT, GETTING THE PEOPLE THE
RIGHT ULTRASOUND RATHER THAN
KEEP FOCUSING ON THE ULTRASOUND.
>> CAN YOU MAKE A CLARIFICATION.
>> I THINK WE DO AGREE WITH
THAT, BUT ALSO IN OUR
DISCUSSIONS CENTERED ON THE FACT
THAT SO MANY WOMEN ARE NOT BEING
DIAGNOSED UNTIL THEY ARE AT
DELIVERY.
I THINK, WE CAN DO BETTER IN
THAT REGARD.
>> BECAUSE THEY ARE NOT GETTING
THE RIGHT ULTRASOUND.
>> WELL, THAT IS KEY.
THEY NEED TO GET THE RIGHT
ULTRASOUND.
>> NOW, IF YOU WANT TO IMPROVE
THE SCREENING BY MARKERS, OTHER
THINGS, THAT'S FINE.
THAT NEEDS TO BE STUDIED.
BUT RIGHT NOW, FOR, AS FAR AS
ULTRASOUND, THEY NEED TO GET THE
RIGHT ULTRASOUND.
>> CORRECT, TO GO BACK ON WHAT
YOU SAID, WE AGREE WITH THAT.
THERE ARE GOOD ULTRASOUND
MARKERS.
WE DO KNOW THIS VERY WELL, BUT
WOMEN ARE NOT GETTING THOSE.
>> I WANT TO COMMENT, SIMILAR TO
GEORGE'S POINT.
IT IS A MAJOR UNDERTAKING TO
IMPLEMENT A POPULATION-BASED
SCREENING PROTOCOL.
SO CERTAINLY, YOU KNOW, THE
PERFORMANCE CHARACTERISTICS OF
ULTRASOUND ARE ONE THING, BUT
YOU'RE GOING TO HAVE TO SCREEN A
LOT OF PEOPLE IF YOU'RE LOOKING
AT ANYONE WHO HAD A PRIOR
C-SECTION AND A PRIOR
UTERINE-TYPE INTERVENTION.
NUMBER ONE THAT COST-EFFECTIVE?
NUMBER TWO, THE PERFORMANCE OF
YOUR SCREENING TEST.
BUT THEN WHAT DO YOU DO WITH THE
RESULTS?
CAN YOU UTILIZE THAT DATA TO
ACTUALLY IMPROVE OUTCOMES?
SO AGAIN, I THINK IT IS
CERTAINLY A LETTABLE GOAL,
THAT'S WHERE WE NEED TO BE.
BUT BEFORE WE MAKE
RECOMMENDATIONS FOR
POPULATION-BASED SCREENING THERE
IS A LOT OF WORK THAT NEEDS TO
BE DONE.
>> SO WHAT WE'RE TALKING ABOUT,
WE ARE DEFINITELY TALKING ABOUT,
WE ALL AGREE THIS IS A SCREENING
TEST.
CLINICAL RISK FACTORS AND
ULTRASOUND ARE SCREENING.
WE WERE PRETTY BLACK AND WHITE
ABOUT OUR GROUP ABOUT THAT.
THE THING WE WERE UNSURE ABILITY
IS THE DIAGNOSIS.
INTEROPERATIVELY OR
HISTOLOGICALLY, WE DON'T KNOW,
THIS IS NOT THE SPACE TO DISCUSS
THAT.
BUT IF WE'RE DOING THE WORK, WE
NEED TO BE CLEAR HOW WE'RE
DEFINING IT.
KAREN IS NEXT.
>> ONE OF THE THINGS THAT CAME
UP IN OUR GROUP THAT OVERLAPS
WHAT YOU'RE SAYING, TOO, EXACTLY
WHAT YOU'RE SAYING, GET PEOPLE
TO THE RIGHT SCREENING AND
TREATMENT, ONE OF THOSE THINGS.
ONE OF THE BIG DRIVERS AND
BARRIERS IS ALSO THE FINANCIAL
INCENTIVE TO INSTITUTIONS TO
ACTUALLY REFER OUT.
THERE ARE A LOT OF HOSPITAL
SYSTEMS THAT WANT TO HOLD INTO
THEIR PATIENTS FOR THE VERY
LAST-MINUTE TO GREEN THERE
FUNDING.
HOW CAN WE AS A PUBLIC HEALTH
SYSTEMS VIEW ACTUALLY GET PEOPLE
TO DO THE RIGHT THING?
I THINK WE DO NEED RESEARCH ON
THAT.
>> BOB?
>> JUST A COUPLE MORE COMMENTS.
AND HOW DO I THINK THIS IS SO
IMPORTANT TO REMEM FUICIZE WHAT
GEORGE SAID, THIS CAME UP IN OUR
GROUP AS WELL.
IT IS REALLY TRICKY TALKING
ABOUT THE FIRST TRIMESTER
ULTRASOUND, BECAUSE DANNY
POINTED THIS OUT, WHAT IF YOU'RE
WRONG, YOU THINK IT IS A
C-SECTION ECTOPIC AND IT IS NOT,
AND SOMEONE TERMINATES THEIR
PREGNANCY.
IT IS SUPER IMPORTANT TO
ACKNOWLEDGE THE IMPERFECTION
THERE.
TO MAKE THE UNEQUIV I IT IS A
SCREENING TEST RATTER THEN A
DIAGNOSTIC TEST.
THE CONSEQUENCES ARE HUGE.
BUT ESPECIALLY HUGE IF WE'RE
WRONG ON A CYSTOSCOPY SCARRING
TOPIC.
AND SECOND, IT IS IDEAL IF
EVERYBODY GOT REFERRED, BUT FOR
THE EARLY ONES, FOR THE
C-SECTION SCAR ECTOPIC, A LOT OF
TIMES THOSE WILL BEHAVE LIKE
MISCARRIAGES.
IT IS IMPOSSIBLE TO REFER EVERY
PATIENT WITH A MISCARRIAGE TO A
TERTIARY CARE CENTER.
SO WHATEVER WE DO IN ADDITION TO
ENCOURAGING REFERRAL, THERE
NEEDS TO BE EDUCATION OF
EVERYBODY DOING ULTRASOUNDS IN
THE WORLD WHO DOES EARLY
ULTRASOUNDS TO BE BETTER AT
DISTINGUISHING BETWEEN A FAILED
ENTRY OR PREGNANCY AND A
C-SECTION SCARED ECTOPIC.
NOT SAYING WE SHOULDN'T REFER
PATIENTS AT HIGH-RISK, BUT
EDUCATE PEOPLE BETTER AT THE
FRONT LINES.
>> I HAVE TO MAKE TWO COMMENTS.
I KEEP HEARING THAT MOST WOMEN
ARE UNDIAGNOSED.
DO WE HAVE DATA?
>> I THINK WE HEARD IT IN THE
FIRST SINCE.
>> BUT I DIDN'T SEE ANY DATA.
THE MAIN REASON, I HAVE BEEN IN
THE BUSINESS FOR 250 ACCRETAS.
AROUND THE -- I SEE THIS --
DIAGNOSIS.
THEY ARE REFERRED.
UNLOSS I SEE COMPLETE ACCRETA.
AND THE SECOND POINT, MY
CONCERN, ANY TIME YOU START
DOING SCREENING, THERE ARE SO
MANY SEQUENCES FOR THIS.
THIS IS THE DANGER ABOUT IT.
SCREENING WILL ALWAYS LEAD TO
MORE INTERVENTION AND MORE
FALSE-POSITIVES.
AND SAYING WE HAVE TO DO -- WE
HAVE TO DO SO MANY THINGS,
BECAUSE SO MANY WOMEN ARE GOING
TO BE DIAGNOSED.
SO WE HAVE TO BE VERY CAREFUL.
I ALWAYS LIKE TO SEE DATA BEFORE
I SEE IT.
SOMEBODY SAID MOST CASES ARE
UNDIAGNOSED.
I HAVE NOT SEEN ANY DATA THAT
THIS IS TRUE.
ARE YOU TALKING ABOUT A FULL
ACCRETA INSTEAD OF TWO
MILLIMETERS?
>> I THINK WE SAW DATA.
>> WHERE.
>> SO THE REFERENCES I PRESENTED
YESTERDAY WERE 2016 AND '17.
YOU ARE CORRECT, THEY ARE NOT
FIVE YEARS.
BUT YOU HAVE TO LOOK FOR IT.
THIS IS, I ENCOURAGE YOU IN YOUR
OWN INSTITUTION, LOOK THAT
PATHOLOGY DATABASE.
I THINK WE ALL THINK WE'RE DOING
A GREAT JOB.
WE'RE DOING A GREAT JOB.
WE SEE THE CASES WHY DIAGNOSE
THOSE, WE ARE RIGHT.
YOU DON'T SEE WHAT HAPPENS AT
3:00 IN THE MORNING I HAD A
PATIENT THAT BLEED CAN WE DID A
HYSTERECTOMY.
I FOUND THREE REFERENCES, A LOT
OF PEOPLE DON'T UTILIZE THAT.
>> I THINK ALSO WHEN YOUR
REFERRAL CENTER, THE NUMBER OF
IDENTIFIED AND REFERRED PATIENTS
STARTS TO OUTWEIGH THE
UNDIAGNOSED ONES AND THEN YOU GO
OUT IN THE COMMUNITY AND EXACTLY
THE OPPOSITE.
YOU HAVE TO CONSIDER AT AN
ENTIRE POPULATION LEVEL, AND NOT
JUST A TERTIARY CENTER.
>> IF I MAY, THIS IS WHAT WE
IDENTIFIED IN OUR GROUP.
IT IS REALLY HARD TO GET DATA
FROM COMMUNITY FACILITIES UNLESS
YOU HAVE A MANDATORY REPORTING
SYSTEM.
JUST TO SHIFT THE DISCUSSION
JUST A LITTLE BIT BRIEFLY, I
WOULD REALLY CONSIDER, I THINK
THE DATABASE AND LOOKING AT THE
IMAGING, THE REPOSITORY IS
GREAT, BUT LET'S ALSO LEVERAGE
TECHNOLOGY, WITH
TELECOMSALITATION TO HELP.
CAN WE CROSS THE STATE LINES IF
SOMEBODY IS IN A PLACE WHERE
THEY DON'T HAVE AN EXPERT CENTER
FOR SCREENING, BUT MAYBE I CAN
REVIEW THE STANDARDIZED IMAGE
ACQUISITION AND GIVE AN OPINION.
>> RIGHT.
GO AHEAD.
GEORGE.
>> I HAVE THE SAME EXPERIENCE AS
DOCTOR IN THE UNDIAGNOSED CASES.
WE RARELY SEE THEM, NOT ONLY WE
DON'T SEE THEM, BUT WE GET, I'M
SURE MANY OF YOU GET CASES TO
REVIEW, MEDICAL LEGALLY, I DON'T
SEE THEM.
SO AGAIN, IT IS NOT A REFERENCE,
MEDICAL LEGALLY, BUT -- I MEAN,
WE SHOULD HAVE SEEN THEM IF THEY
ARE REALLY 50% OF THE CASES ARE
UNDIAGNOSED AS WE HEAR.
WE SHOULD SEE 50 CASES A YEAR AT
PLACES WHERE YOU HAVE HUNDREDS
OF ACCRETAS.
WE DON'T SEE THAT.
SO WHAT MAYBE WE DON'T AGREE ON
THAT.
BUT THAT MEANS THIS IS AN
IMPORTANT AREA THAT WE NEED TO
STUDY.
WE NEED DATA, ACCURATE DATA ON
THAT.
NOT SOMETHING FROM A DISCHARGE
SUMMARY.
EVERY PATIENT WHO BLEEDS IN A
HOSPITAL WILL HAVE ACCRETA ON
THEIR DISCHARGE SUMMARILY
BECAUSE THAT HELPS THEM CODE
BETTER AND MAKE SURE THAT
THEY'RE NOT GOING TO BE BLAMED
FOR SOMETHING.
>> IF WE DO THIS STUDY, WHAT IS
THE DEFINITION OF ACCRETA.
SO WE CAN DO IN THIS ROOM AND
SEE IF WE HAVE A PROBLEM.
SO GO WITH PATHOLOGY AND SEE IF
THEY HAVE ACCRETA.
>> NO, WE DEVELOP THE PROTOCOL,
WITH OBGYN ONCOLOGIST, THEY
DESCRIBE ANYTHING IN THE
OPERATIVE REPORT.
THIS IS HOW WE COMPARE OUR
RESULTS WITH ULTRASOUND AND MRI.
WHAT DID YOUR SURGEON THAT DID
THE PROCEDURE AND THEN DETAILS.
WHAT THEY FOUND, WHEN THEY
STARTED THE DISSECTION, WHAT IS
THE AREA.
THIS IS THE MOST CONCRETE WAY TO
ESTABLISH, NOT PATHOLOGY,
BECAUSE THERE ARE MANY THINGS
THAT HAPPENED DURING THE
SURGERY.
>> BOB?
>> YEAH.
I MEAN, THIS IS -- THIS IS WHY
THIS CONFERENCE IS HAPPENING.
SO I THINK IF YOU REALLY WANTED
TO GET APPROXIMATELY UPSTREAM
FOR KNOWLEDGE GAPS YOU COULD
START WITH WE NEED A
REPRODUCIBLE OBJECTIVE
DEFINITION OF ACCRETA THAT IS
AGREED UPON UNIVERSALLY.
WE DON'T HAVE THAT.
AND I DON'T THINK WE CAN GET
THREE PEOPLE IN THIS ROOM TO
AGREE ON THAT.
WE TRIED TO HAMMER IT OUT OVER
TWO DAYS.
SO, I WOULD PUT THAT AS BEING A
REALLY IMPORTANT KNOWLEDGE GAP
TO FILL IN BEFORE WE CAN EVEN
TAKE ANY OF THE NEXT STEPS.
>> I ALSO WANT TO ADD TO THAT,
SO, DOCTOR?
>> I HAVE -- COMMENTS AND
QUESTION FROM -- CRITICAL
GYNECOLOGY POINT OF VIEW.
ONE IS THE PATIENT REFERRED TO
AS THE VERY LAST MOMENT, LET'S
SAY 32 WEEKS, 33 WEEKS AND THE
CHANCE OF A CASE -- AND MAKE A
HUGE -- NUMBER TWO IS --
DIAGNOSTIC -- AS THEY SAY,
ACCRETA ON THE -- C-SECTION,
PLACENTA SEPARATE AND THEN WE
ARE LOSING -- BECAUSE WE MADE --
ACCRETA CASE IN THE MORNING.
SO WE LOSE THE C-SECTION AND
HYSTERECTOMY, WE ARE LOSING OUR
DAY.
SO THIS IS VERY IMPORTANT.
I THINK.
>> I JUST WANT TO ADD, JUST A
POINT FOR DATA.
SO I THINK THAT 50% NUMBER IS
NOT TOO FAR OFF.
MAYBE IT IS NOT 50, BUT I THINK
IT IS HIGH.
THE MOST RECENT DATA FROM THE
NATIONAL INPATIENT STANDARD.
AND 40% OF IT ACCRETA, WE USE IT
FOR MANY OTHER DISEASE
PROCESSES, 47% AFTER 37 WEEKS,
AND 27% AFTER 37 WEEKS AND 14%
OF PROACCRETAS.
THOSE AFTER 37 WEEKS ARE
MISDIAGNOSED.
WE CAN DISAGREE THERE.
OR VERY LATE DIAGNOSIS.
SO I THINK THAT NUMBER THAT WAS
SHARED WITH US YESTERDAY ISN'T
THAT FAR-OFF, MAYBE THIS IS NOT
THE BEST DATA TO EXTRAPOLATE IT
FROM.
THAT IS, TOO, THAT YOU SHARED,
BUT I THINK IN OUR CENTERS,
YEAH.
IT IS PROBABLY LESS THAN 5%,
10%, BUT THAT IS NOT WHERE MOST
PEOPLE ARE GETTING IT.
THAT'S WHERE WE NEED TO FOCUS
THIS WORK.
>> JUST TO BUILD ON THAT,
THOUGH.
TWO OF THESE STUDIES, ONE IN MY
OWN INSTITUTION AT STANFORD,
50%.
WE DIDN'T DO ALL ULTRASOUND
SOMETIMES THEY COME IN FROM THE
COMMUNITY AND DELIVER.
BUT INPATIENT THAT DELIVES AND
KEEPS BLEEDING.
YOU OVER SEW THE PLACENTA AND
YOU MOVE TO HYSTERECTOMY.
IF PEOPLE LOOKED IN THEIR
PATHOLOGY DATABASES THEY MIGHT
BE SURPRISED, A LOT OF CASES
YOU'RE THINK IT WAS ATTONE, BUT
THEY FOUND ACCRETA THERE.
>> SO KNOWLEDGE GAP ONE THAT WE
HAD SEEMS LIKE TOP OF THE LIST
TO UNDERSTAND OUR DENOMINATOR OF
WHATEVER PERCENT THAT IS, IN
YOUR CASE FROM ZERO TO 50% SEEMS
LIKE THE RANGE, BUT IF WE DON'T
KNOW THE DENOMINATOR WE CAN'T
DEFINE THAT.
WHEN WE HAVE THE DEFINITION, THE
FOCUS ON SCREENING, WE CAN MAKE
RECOMMENDATIONS INCLUDING
EDUCATION AND THEN OUR PIE IN
THE SKY GOALS.
RIGHT?
DO WE FEEL OKAY?
THERE.
>> I JUST HAD A COMMENT ABOUT
THE DEFINITION OF ACCRETA.
THAT IS A REALLY IMPORTANT
THING.
WE THINK OF PATHOLOGY AS A GOLD
[ LOST AUDIO ]
>> MORBIDITY AND AN AFFECT ON
THE PATIENT, AND PATIENT
EXPERIENCE STANDPOINT, THAT IS
FOR PLACENTA ACCRETA SPECTRUM
>> I DO WANT TO LIKE, DISCLOSER
THERE IS NO PATHOLOGIST HERE.
SO WE ARE SPEAKING ON BEHALF OF
PATHOLOGY AS A SUBSPECIALTY, BUT
TO POINT THAT OUT.
>> OKAY.
WORKING GROUP FOUR.
>> HELLO AGAIN.
I WAS VERY HAPPY TO WORK WITH MY
POWER GROUP THIS MORNING.
VERY HAPPY TO WRAP UP THE DAY
ONCE AGAIN.
AND HOPEFULLY, WE HAVE SLIDES TO
TALK ABOUT.
AS A REMINDER, GROUP FOUR WAS A
LITTLE BIT OF A MIX OF TOPICS,
BUT HONESTLY THE DISCUSSIONS
WENT TOGETHER VERY WELL.
SO WE BROKE OUR -- OUR SLIDES
DOWN BASED ON OUR THREE TOPICS.
JUST A SECOND, IF I CAN MOVE
THEM.
LIKE THAT MAYBE.
OKAY.
SO, OUR THREE AREAS, FIRST WAS
BIOMARKERS CAN DIAGNOSIS.
AND FOR EACH OF THESE AREAS WE
BRAINSTORMED ON KNOWLEDGE GAPS.
WE PUT IN A SECTION ON KIND OF
GENERAL PRACTICE RECOMMENDATIONS
THAT WE THE WE COULD MAKE NOW.
AND THEN RESEARCH
RECOMMENDATIONS AND WHAT WE ARE
MISSING AND WHAT WE NEED IN
ORDER TO PURSUE THESE RESEARCH
GOALS.
SO FOR BIOMARKERS THE KNOWLEDGE
GAPS WERE WHAT BIOSPECIMENS
SHOULD BE COLLECTED, YOU KNOW,
AS AN EXAMPLE, SHOULD WE BE
FOCUS ON SERUM, URINE, ALL OF
THESE TO FIND THE PERFECT
SPECIMEN, WHAT PLATFORM IS THE
BEST TO USE IN TERMS OF STANDARD
PROCEDURES FOR COLLECTING AS
WELL AS ANALYZING AND WHAT
MODALITY TO USE.
WHAT POINT OF GESTATION IS
OPTIMAL FOR THE BIOMARKER, THE
BIOMARKER PREDICT DISEASE
SEVERITY, AND SPECIFIC MORBIDITY
AND OUTCOMES, AND CAN BIOMARKERS
HELP TO TAILOR TREATMENT.
I'M SORRY, I KEEP RUNNING THE
SCREEN HERE.
WE DIDN'T HAVE A PRACTICE
RECOMMENDATION RIGHT NOW WITH
REGARD TO BIOMARKER, BECAUSE WE
HAVE NOT VALIDATED A SINGLE
BIOMARKER, THAT WILL BE COMING
IN THE FUTURE.
FOR RESEARCH RECOMMENDATIONS,
OUR STATEMENT WAS FOR PATIENTS
WHO ARE AT RISK FOR PAS AND
THOSE WITH SUSPECTED PAS -- I'M
SORRY, THIS IS IN THE WRONG
PLACE, THIS IS OUR PRACTICE
RECOMMENDATION.
SO PATIENTS AT RISK FOR PAS OR
SUSPECTED WITH PAS, CAN HAVE AN
OPPORTUNITY TO PARTICIPATE IN
TRANSLATIONAL RESEARCH, I THINK
THAT MESSAGE SHOULD GO OUT WHO
TAKE CARE OF THE PATIENTS.
BUT WE DON'T HAVE A PRACTICE
GUIDELINE TO USE THESE.
AND VALIDATE A WIDE BIOMARKER
FOR PAS.
BOTH IN TERMS OF YES/NO OUTCOME
AND TO PREDICT MORBIDITY.
AND THE NEXT STEP AFTER THAT
INCORPORATE THE BIOMARKER TEST
INTO A MORE GLOBAL PREDICTION
MODEL WHICH ALSO INCLUDES
CLINICAL RISK FACTORS AND
ULTRASOUND.
THE MAJOR OBSTACLES IN THE AREA,
CLEARLY TO US, THE BIGGEST ONE
IS FUNDING AND RESOURCES.
THIS IS A VERY EXTENSIVE
UNDERTAKING, WE ARE GETTING INTO
THE VALIDATION STAGE, WE NEED A
LOT OF PATIENTS.
YOU NEED TO START COLLECTING THE
SAMPLES.
NOT JUST ON PATIENTS WITH
SUSPECTED PAS GOING INTO A PAS
CENTER.
BUT ON PREGNANT PATIENTS, A
BROADER GROUP OF PREGNANT
PATIENTS WITH RISK FACTORS YOU
WILL TRY TO APPLY THIS TEST TO.
WE DON'T HAVE STANDARD
PROCEDURES RIGHT NOW.
A LARGE NUMBER OF PATIENTS ARE
NEEDED.
AND JUST THE DIFFICULTY OF
CONDUCTING A MULTICENTER STUDY
LIKE THIS AND KEEPING THINGS
STANDARDIZED.
THE KEY METHODOLOGIES THAT ARE
NEEDED HERE TO DO PERSPECTIVE
RESEARCH AND OBVIOUSLY HAVE THE
VOLUME TO DO IT AS A MULTICENTER
STUDY.
THE NEXT AREA WAS RISK FACTORS
AND PREVENTION.
AND WE HAD A LOT OF KNOWLEDGE
GAPS HERE.
THE FIRST IS JUST WHAT IS THE
OPTIMAL C-SECTION DELIVERY RATE
FOR GOOD MATERNAL AND FETAL
OUTCOMES.
THAT IS A BIG QUESTION THAT GOES
BEYOND PAS.
SOME PEOPLE IN VARIOUS WAYS
TRIED TO ADDRESS THIS, BUT WHAT
WE'RE SAYING THIS SPECIFIC
QUESTION NEEDS TO BE ADDRESSED
WITH PAS AND NOT JUST IMMEDIATE,
LIKE FUTURE PAS AND NOT JUST
IMMEDIATE OUTCOMES IN MIND.
DOES C-SECTION TECHNIQUE
CONTRIBUTE TO THE INCREASES RATE
OF PAS.
IF SO, WHAT IS THE OPTIMAL
C-SECTION TECHNIQUES WITH
SHORT-TERM OUTCOMES AND LONGER
TERM OUTCOMES, AND THINKING
ABOUT FUTURE PAS.
AND SOMETHING WE CAN DO BEYOND
JUST STANDARD C-SECTION CAN HELP
WITH WOUND HEALING AT THE TIME
OF C-SECTION TO IMPROVE FUTURE
OUTCOMES.
AND THE OPTIMAL PREGNANCY
INTERVAL, AND THE OPTIMAL WAY TO
DIAGNOSE PREGNANCY.
THE OPTIMAL TREATMENT FOR
C-SECTION PREGNANCY WITH REGARD
TO SHORT AND LONG-TERM OUTCOMES.
WHAT ARE THE SPECIFICS OF
TECHNIQUE THAT CONTRIBUTE TO
PAS, THIS IS A SMALLER
POPULATION, THEN EVERYBODY WITH
A C-SECTION.
BUT IT MIGHT BE LOW-HANGING
FRUIT TO HAVE SOMETHING
MODIFIABLE TO REDUCE THE RISK.
DOES NONC-SECTION TECHNIQUE
CONTRIGUTE AND THE CONSEQUENCES
OF JUST INCIDENTALLY FOUND
C-SECTION SCAR.
SO AFTER A LOT OF WORK WE
NARROWED DOWN RESEARCH
RECOMMENDATIONS.
AVOIDING UNNECESSARY C-SECTION
DELIVERY AND UTERINE SURGERY.
PROMOTING EARLY DIAGNOSES AND
TREATMENT FOR C-SECTION SCAR
PREGNANCY.
PATIENTS WITH C-SECTION SCAR
PREGNANCY WHO CONTINUE TO
PREGNANCY, SHOULD BE REFERRED TO
PAS CENTERS.
AND PAS NEEDS TO BE INCORPORATED
COUNSELING PATIENTS ON ANY
PROCEDURE.
IT SOUNDS KIND OF OBVIOUS BUT
DISCUSSES RIGHT NOW, THIS IS ON
THE GENECOLOGY AND REPRODUCTIVE
WORLD, WHEN CONVERSATIONS ARE
SOME, SHOULD WE DO THIS, THE
CONCERNS ABOUT FUTURE PREGNANCY
RISK ARE PROBABLY NOT
INCORPORATED IN THE COUNSELING,
BUT THEY SHOULD BE.
FOR RESEARCH RECOMMENDATIONS AND
PRIORITIES, WHAT IS THE OPTIMAL
C-SECTION DELIVERY RATE FOR GOOD
MATERNAL FETAL OUTCOMES.
CAN C-SECTION BE IMPROVED, THE
CONCRETE THINGS WE CAN CHANGE
ABOUT C-SECTION.
THE OPTIMAL METHOD FOR DIAGNOSES
AND TREATING A C-SECTION SCAR
PREGNANCY, AND VALUE FOR
SCREENING AND TREATING NICHES.
OBSTACLES RIGHT NOW, LIKE WE
TALKED ABOUT YESTERDAY, IT IS
VERY HARD TO GO BACK AND GET
DETAILS OF PRIOR SURGERY WHEN WE
ARE SEEING THE PATIENT AT THE
TIME OF THEIR PAS.
SO IT WOULD BE IMPORTANT TO DO
ANY STUDIES LIKE THIS THAT WOULD
COULD CONDUCT PROSPECK POSITIVE
AND LONGITUDINAL RESEARCH AND
LINK FACTORS TO THEIR FUTURE PAS
RISK.
OUR LAST TOPIC AND VERY
IMPORTANT WAS ON PATIENT
EXPERIENCE AND LONG-TERM HEALTH.
KNOWLEDGE GAPS INCLUDED, YOU
KNOW, WHAT INTERVENTIONS WE
SHOULD BE DOING TO IMPROVE THE
MENTAL AND PHYSICAL OUTCOMES FOR
PATIENTS WHO HAVE PAS.
AND THIS IS BOTH IN THE
SHORT-TERM AS WELL AS IN THE
LONG-TERM.
WHAT ARE THE BARRIERS TO
IMPLEMENTING THESE
INTERVENTIONS, WHAT SHOULD
PATIENTS EXCEPT FOR THEIR
LONG-TERM HEALTH FAR INTO THE
FUTURE AFTER THEY HAVE GONE INTO
THE SURGERIES AND LONG-TERM
PSYCHOLOGICAL IMPACTS.
OUR RECOMMENDATIONS NOW ARE THAT
PARTIM MENTAL HEALTH SUPPORT
SHOULD BE AN ESSENTIAL PART OF
PAS CARE.
NOT HERE, EITHER IS A
RECOMMENDATION OR COULD BE A
RESEARCH QUESTION, HOW WE USE
DEDICATED PEOPLE WHO ARE PART OF
THE MULTIDISCIPLINARY TEAM AND
THERE SOLELY TO SUPPORT THE
PATIENT AND FAMILY.
WE NEED A LONG-TERM HEALTHCARE
MODEL TO BE DEVELOPED AND
DISSEMINATED IN PAS CENTERS
AND -- YOU KNOW, IT SHOULD BE BE
PART OF WHAT IS BUILT INTO PAS
CARE AND POSTPARTUM CARE.
RESEARCH RECOMMENDATIONS ARE TO
LOOK AT WHAT ARE EFFECTIVE KAYS
TO IMPROVE THE SHORT-TERM AND
LONG-TERM MENTAL HEALTH.
AND MANY THINGS CAN FALL UNDER
THIS, WE CAN MAKE A PAGE LONG
BULLET LIST IN TERMS OF THE
FACTORS WE CAN STUDY.
THE PRACTICE BARRIERS TO
PROVIDING MENTAL HEALTH AND
EDUCATIONAL SERVICES.
AND WHAT ARE THE LONG-TERM
PHYSICAL OUTCOMES.
AND WE'RE TALKING ABOUT THE
PRACTICE BARRIERS, YOU KNOW, I
THINK THERE IS IMPORTANT TO TALK
TO PAS PROVIDERS.
LIKE JUST FOR US TO UNDERSTAND
WHAT IS HOLDING PEOPLE BACK FROM
INTEGRATING THIS KIND OF CARE
INTO THEIR PAS SERVICE AND
MULTIDISCIPLINARY TEAM RIGHT NOW
TO DO SOMETHING TO IMPROVE THAT.
OBSTACLES THE MOST OBVIOUS ONE
IS, A GENERAL LACK OF MENTAL
HEALTHCARE SERVICES IN THE
UNITED STATES FOR EVERYBODY.
INCLUDING THIS.
I THINK TALKING ABOUT THE
PATIENTS AND PAS CARE, HAVING
PAS INFORMED SERVICES IS REALLY
IMPORTANT.
SO YOU KNOW, I THINK WE NEED TO
DO A BETTER JOB WITH MENTAL
HEALTHCARE PERIOD.
AND THEN HONING ON THIS AREA IS
A CHALLENGE.
AND THEN THE KEY METHODOLOGIES
HERE, ONE TO USE STANDARD
METRICS SO DEFINE AN
INTERVENTION AND MEASURE AN
OUTCOME, IF WE CAN MEASURE IT
THE SAME WAY, USING THE SAME
TOOLS AND TIME POINTS.
AND VERY IMPORTANT TO, AS WE DO
RESEARCH, TO USE A DIVERSE GROUP
OF PATIENTS TO MAKE SURE LIKE
WE'RE INCORPORATING AS MANY
DIFFERENT PERSPECTIVES AND
EXPERIENCES AS POSSIBLE.
WE KNOW FROM TAKING CARE OF THE
PATIENTS, TWO PEOPLE CAN HAVE A
SIMILAR CLINICAL EXPERIENCE AND
HAVE VERY DIFFERENT PERSPECTIVES
ABOUT IT OR EMOTIONAL RESPONSES
TO IT LATER ON.
AND THAT WAS OUR TOPIC.
ANY QUESTIONS?
>> THANKS.
>> DOCTOR?
>> WE CAN START BY SAYING
THIS -- THE PATIENT SHOULD BE
REFERRED TO A PAS CENTER.
WHAT DEFINES A PAS CENTER.
WHO IS GOING TO ENFORCE THIS?
WHERE IN THE UNITED STATES?
YOU HAVE TO ENFORCE IT.
>> YEAH, ABSOLUTELY.
NO, THAT'S COME UP OVER AND OVER
SINCE 2015 WHEN THE STANDARDIZED
PAPER CAME OUT.
THAT'S SOMETHING, AGAIN WE'RE
GOING TO TALK ABOUT STANDARD
METRICS I THINK ANY TIME WE'RE
DOING RESEARCH ON THIS AND WE'RE
TALKING ABOUT BUILDING CARE
MODELS FOR PATIENTS I THINK WE
HAVE TO TALK ABOUT WHAT
ENVIRONMENT ARE WE DISCUSSING?
AT A CENTER FOR WHATEVER, YOU
KNOW, THAT CENTER SAYS THAT IT
IS AND I THINK WE HAVE TO TALK
IN GENERAL WHAT IS AN ACCRETA
CENTER?
OR ARE PEOPLE TAKING CARE OF THE
PATIENTS IN THE COMMUNITY,
ESPECIALLY WITH UNDIAGNOSED
ONES, HOW WHO DO GET THE SAME
KIND RESOURCES TO THOSE PATIENTS
NOT NECESSARILY IN A HIGH VOLUME
CENTER.
>> YOU AND I HAD THIS
CONVERSATION MANY TIMES.
JUST TO HAVE CONTEXT THIS WITH
THAT.
I THINK USING THE TERM CENTER OF
EXCELLENCE IS A DISSERVICE.
BECAUSE I THINK IT PUTS SOME OF
AEROCOLLEAGUES IN A VERY
VULNERABLE POSITION, STUCK
TAKING CARE OF THE PATIENTS IN
THE MIDDLE OF THE NIGHT THERE.
WAS A PUSH BY A PRIVATE
ORGANIZATION YEARS AGO THAT CAME
TO MANY OF US AND SAID WE WANT
YOU TO START ENDURING THIS
PROGRAM.
-- AND COLLECTIVELY, WE SAID
THAT'S PROBABLY NOT THE RIGHT
THING AND FOCUS MORE ON VOLUME
AND OUTCOMES THEN THE TITLE
ITSELF.
SO I HOPE THAT THIS LANGUAGE
DIDN'T IMPLY THAT WE WERE GOING
THERE.
I DON'T THINK THE DID.
>> WELL, I THINK IT IS IMPORTANT
TO THINK ABOUT -- I THINK THE
EASY PART IS, IF YOU ARE CALLING
YOURSELF AN ACCRETA CENTER, I
WON'T SAY CENTER OF EXCELLENCE,
AND SOMEONE PROVIDING ACCRETA
CARE, YOUR TAKING REFERRALS AND
VOLUNTARILY MANAGING THE
PATIENTS, THESE ARE PIECES THAT
NEED TO BE INCORPORATED INTO
THAT PRACTICE.
IT IS ALSO VERY IMPORTANT, MAYBE
EVEN MORE IMPORTANT THAN THE
PATIENTS WHO DIDN'T MAKE IT IN
TO A DEDICATED CENTER WHO HAD AN
UNDIAGNOSED ACCRETA OR DELIVERED
OUT IN THE COMMUNITY GET ACCESS
TO RESOURCES AND A DIFFERENT WAY
OF GETTING THE RESOURCES TO
THOSE PATIENTS.
DOCTOR?
>> YES.
I APPRECIATE THE SENTIMENT AND
THE HOPE THAT WE HAVE CENTERS IN
THE U.S.
WE HAVE EXPERIENCE IN TEXAS, WE
MENTIONED IT DURING OUR MEETING,
SUBGROUP MEETING.
NOW IT IS A MANDATE IN TEXAS TO
DESIGNATE CENTERS AS ACCRETA
CENTERS WITHIN THE LEVEL FOUR
MATERNAL.
AND I DOUBT THIS IS GOING TO
MAKE A BIG DIFFERENCE BECAUSE IT
CANNOT BE IMPLEMENTED.
IT CANNOT BE ENDORSED.
BUT ANYWAY, IF WE ARE GOING TO
PROMOTE THE IDEA OF CENTERS, I
THINK WE NED TO ATTACH TO IT
SOME ADDITIONAL REQUIREMENTS
THAT WILL ENFORCE, MAKE IT MORE
ENFORCEABLE, BUT ALSO MAKE THE
MORE BENEFICIAL.
FOR EXAMPLE, ARE THESE CENTERS
GOING TO TAKE CARE OF PATIENTS
NO MATTER THEIR INSURANCE
STATUS?
THEIR PAYER STATUS?
POSSIBLY, AFTER SIX WEEKS
POSTPARTUM?
ARE THESE CENTERS GOING TO --
SUPER, NOT SUPERVISE, BUT IMPACT
THE CARE IN THE REGION IN ORDER
TO MAKE SURE THAT THESE PATIENTS
ARE EARLY SCREENED OR SENT TO
THEM, HOW, HOW IS THAT GOING TO
WORK OUT?
SO, I -- IF WE'RE GOING TO SAY
CENTERS, IT'S NOT ENOUGH TO JUST
MENTION THE WORD CENTER, IT
REQUIRES A WHOLE BIG PROGRAM
THAT GOES WITH IT.
>> GEORGE, I WANT TO HUG YOU FOR
SAYING THAT.
BECAUSE I THINK THAT IS REALLY
IMPORTANT.
IN THIS AREA OF SYSTEMNESS, WE
OFTEN KNOW WHO OUR REFERS ARE
GOING TO BE.
WE HAVE DEDICATED COMMUNITY.
AND THE POINT ABOUT TELEHEALTH,
IN DESERTS WHERE WE DO NOT HAVE
OPPORTUNITIES FOR PATIENTS TO
DRIVE MANY HOURS TO COME
RELIABLE FOR THE ULTRASOUNDS
THAT THEY NEED, WE CAN HELP.
WE HAVE RESOURCES TO BE ABLE TO
BACK GIVE TO THE COMMUNITY, BUT
WE NEED, WE NEED THAT.
RIGHT?
WE NEED THAT TO BE VALUED AND BE
SOMETHING THAT IS -- KIND OF A
WIDER CATCHMENT THEN JUST THE
IMPLICATION ABOUT DELIVERY
LOCATION.
>> THIS IS -- YEAH?
>> MAY I?
>> YES.
>> SO, THIS IS NICHD WE WANT TO
TALK ABOUT RESEARCH AND
WHATEVER, I JUST WANT TO PUT A
PLUG IN THERE FOR COMPENSATION.
I THINK WE CAN TALK ABOUT THIS
TOPIC FOREVER AND ALL OF THESE
GRANDIOSE IDEAS, BUT UNLESS
THESE CASES ARE IDENTIFIED AS
DIFFERENT THAN JUST A DELIVERY,
I DON'T THINK WE'RE GOING TO
MAKE A BIG IMPACT HERE.
I KNOW THIS IS NICHD.
THIS IS NOT IN THE -- IN THE --
AT PLAY HERE, BUT JUST WANTED TO
PUT THIS PLUG.
>> ONE OPTION FOR THE
PROCEEDINGS OF THIS COMMITTEE
WOULD BE TO TRY TO GIVE AS MANY
RECOMMENDATIONS AND TALK ABOUT
POLICY AND KEY RESEARCH GAPS
INTO A SINGLE DOCUMENT.
ONE OPTION, THOUGH, MIGHT BE
THAT WE DECIDE AT AN
INTERDISCIPLINARY GROUP TO HAVE
A SPECIFIC POLICY STATEMENT OR
REPORT DOCUMENT.
MAYBE WITH OR WITHOUT NICHD TO
SAY THESE ARE THE KEY BARRIERS
THAT ARE KEEPING FOLKS FROM
GETTING CARE THAT THEY NEED.
AND THEN, SO WE SHOULD TALK IN
THE COMING MONTHS ABOUT WHAT
THIS WHITE PAPER BECOMES AND IF
A SECOND PAPER ON POLICY IS
REALLY VALUABLE, I THINK IT
WOULD BE.
THE OTHER THING WITH, I WANT --
US TO KEEP IN MIND A LITTLE BIT
ABOUT REFERRAL AND MAYBE THIS IS
THAT UNIQUE TO UTAH IN THE
MIDDLE OF NOWHERE.
BUT THERE IS A HUGE PATIENT AND
FAMILY BURDEN FOR TRAVEL.
AND I DON'T THINK THAT SHOULD
STOP FOLKS FROM COMING FROM THE
MIDDLE OF EASTERN MONTANA TO GET
CARE IF THEY ARE ACCRETA.
BUT I THINK ABOUT ALL OF OUR
DECISIONS WHO GETS SCREENED, HOW
THEY ARE SCREENED, WHERE THEY
GET SEEN, WHAT IS THE STANDARD,
DOES RESULT IN PATIENTS BEING
SEPARATED FROM THEIR FAMILIES,
LOSING TIME OF THEIR JOBS,
SPENDING AN INCREDIBLE AMOUNT OF
MONEY TO TRAVEL TO ALL OF OUR
CENTERS.
SO I DON'T US TO KEEP THAT IN
OUR HEADS AS ANOTHER PATIENT
EXPERIENCE COMPONENT WE CANNOT
LOSE TRACK OF.
THANKS FOR THE PRIVILEGE.
STEPPING ON MY SOAPBOX.
>> I THINK ANY, AT THE END OF,
ESSENTIALLY, YEARS AND WE DO
TRIALS AND EVERYTHING, THIS
MENTAL COMPONENT AND THE IMPACT
ON OUT PATIENT NEEDS TO BE
EVALUATED IN ANY TRIAL, THIS IS
IMPERATIVE.
AND THE SECOND THING, DID YOU
THINK ABOUT FORMING A STUDY.
WE KNOW THAT, YOU KNOW, THE C
SCAR PREGNANCIES, ONE OF THE
MAJOR RISK FACTORS FOR
EVENTUALLY DEVELOPING ACCRETA.
BUT ALSO AN IMPORTANT FOR STINTS
TO BE ABSTAINED EARLY THERE IS A
LOT OF THE MANAGEMENT OF THE
CASES ARE VARIED.
RIGHT?
SOME DO JUST INJUNCTIONS, SOME
EVEN PROPOSE, OKAY, BECAUSE OF
THE RISK OF ACCRETA FOR NEXT
TIME, TAKE YOUR TOWEL, CLOSE THE
REALLY WELL, AND SEE, SO DID YOU
DISCUSS THE MODALITIES AND THE
EVALUATION, OPPORTUNITY TO HAVE
SPECIMENS?
>> YEAH.
WE, WE -- IT DEFINITELY CAME UP.
WE DIDN'T, SAME KIND OF THINK WE
COULD NOT MAKE LONG LISTS OF ALL
OF THE ELEMENTS THAT GO INTO THE
RESEARCH QUESTIONS, BUT THIS
IDEA OF WHAT IS THE BEST WAY TO
TREAT A C-SECTION SCAR
IMPLANTATION MAY BE DEPENDENT ON
THE WEEKS GESTATION OF THE
PATIENT.
BUT THE NEEDS TO INCORPORATE
FINDINGS AND TREATMENT MODALITY
IN TERMS OF TREATMENT OUTCOMES.
AND THEME FOR THE PREVENTION, WE
HAVE TO BE ABLE TO LINK
PREGNANCIES, AND THAT IS NOT
ALWAYS EASY TO DO.
ESPECIALLY WITH THE MORE
COMPLICATED PREGNANCIES,
PATIENTS MAY BE DELIVERING IN
TWO DIFFERENT LOCATIONS OR MANY
LOCATIONS IN THE U.S., TO GET
THE MEDICAL RECORDS AND GET THEM
TOGETHER AND THE DETAIL IS HARD.
FOR ALL OF THIS COME UP, WE NEED
TO SOMEHOW STANDARDIZED DATA
COLLECTION AND LONGITUDINALLY
FOLLOW THE PATIENTS IN ORDER TO
DO THIS CORRECTLY.
ALL RIGHT.
WELL, THANK YOU VERY MUCH.
>> THANK YOU.
>> WOW.
WHAT A WORKSHOP, HUH?
[ LAUGHTER ]
THANK YOU ALL SO MUCH FOR ALL OF
YOUR WORK IN THE GROUPING
GROUPS.
I THINK, BRETT SORT OF LEANED
OVER TO ME WITH PRESENTATIONS
AND SAID THIS FORMAT IS REALLY
GREAT.
WE ARE HAD ROBUST CONVERSATIONS.
SO MUCH PASSION IN TERMS OF THE
DIFFERENT GAPS IDENTIFIED.
WE ARE GRATEFUL FOR EVERYBODY'S
ENGAGEMENT WITH ALL OF THAT
WORK.
WE KNOW WHO WE ARE.
WE DON'T NEED THAT AGAIN.
JUST TO SORT OF REMIND
EVERYBODY, THE WAY THAT WE
PARSED THIS OUT AND OBVIOUSLY IT
IS A LITTLE ARBITRARY AND THE
WAY WE DID THAT TO THINK ABOUT
EMDODGE, SCREENING AND
DIAGNOSIS, AND STAINING
ANDMAGEMENT, AND OPERATIVE
MANAGEMENT, AND PATIENT-CENTERED
APPROACHES.
THIS IS OUR GOALS, THIS IS WHAT
WE HOPED TO DO DURING THE COURSE
OF THIS WORKSHOP, TO GENERATE
CONCRETE AND INSIGHTS, IDENTIFY
KNOWLEDGE GAPS WHICH I THINK WE
HAVE IDENTIFIED QUITE A FEW,
HIGHLIGHT RESEARCH OPPORTUNITIES
AND THEN ENHANCE OUR
UNDERSTANDING OF PATIENT NEEDS.
THIS IS A LITTLE BIT OF WHAT I
HEARD.
SO OF DISTILLED MOVING FORWARD.
I THINK ONE OF THE THINGS THAT
REALLY CAME OUT IN THE
DISCUSSION I HAD IS THAT THE
REASON THAT THERE WERE SORT OF
INDIVIDUAL ORGANIZATIONS
STAKEHOLDERS BROUGHT WAS SO THAT
WE COULD BRING THIS BACK TO OUR
CONSTITUENCIES, I DO THINK THERE
IS ROOM FOR US TO IMPROVE WHAT
WE MOVE UP STREAM.
BE IT DEVELOPMENT OF A CLINICAL
RISK STRATIFICATION TOOL, BE IT
STANDARDIZATION OF WHO RECOMMEND
HAVE EARLY ULTRASOUND AND WHO IS
REFERRED TO, AGAIN, WHO THE
REFERRAL GOES TO IS IMPORTANT,
BUT IT DOESN'T HAVE TO BE A
SINGULAR ENTITY.
SO FMM.
DO THEY HAVE TO BE THE KEEPER
FOR ACCRETA CAROL. CARE.
THERE ARE OPPORTUNITIES FOR US
TO BRING BACK TO OUR STAKEHOLDER
ORGANIZATIONS FOR US TO
STANDARDIZE THE THINGS WE THINK
ARE IMPORTANT.
SO I DO THINK WE CAN THINK ABOUT
THAT MORE AS WE BRING THAT BACK.
WE ARE ALSO ALL MEMBERS OF THE
DIFFERENT ORGANIZATIONS, SO
THINKING THROUGH IN OUR
ORGANIZATIONAL LEADERSHIP WHO
ARE OUR RIGHT POLICYMAKERS AND
DOCUMENT WRITERS ARE IMPORTANT
TO SORT OF BE OUR -- FUTURE
POLICY.
IDENTIFICATION OF KNOWLEDGE
GAPS, I THINK THERE WERE MANY.
I THINK WE HEARD THE DEFINITIONS
LOUD AND CLEAR.
SOMETHING THAT WE NEED TO SORT
OF STRATIFY AND DO A BETTER JOB
OF BEING REALLY CLEAR ABOUT.
OUTCOMES INCLUDING SEVERE
MATERNAL MORBIDITY.
DIAGNOSIS.
I WILL, AGAIN, SORT OF
DIFFERENTIATE SCREENING AND
DIAGNOSES.
I THINK THAT IS A REALLY
EXCELLENT POINT.
BUT I THINK STAGING IS SOMETHING
THAT REALLY CAME OUT LOUD AND
CLEAR HERE.
HOW DO WE APPROPRIATE USE OUR
SCREENING TOOLS IN ORDER TO GET
THE PATIENTS THE RIGHT CARE IN
THE PLACE THEY NEED.
TECHNIQUE, I THOUGHT GROUP THREE
WAS REALLY CLEAR, THIS IS
SOMETHING THAT IS NOT A
ONE-SIZE-FITS-ALL, AS HAS BECOME
MOSTLY TRUE.
WHERE CAN WE DO A BETTER JOB OF
PROVIDING PATIENTS WITH A MENU
ABOUT TECHNIQUE.
AND LONGER TERM OUTCOMES.
AND THEN THE RESPONSIBILITY BACK
TO OUR COMMUNITY IS REALLY
IMPORTANT.
I THINK THAT IS WHERE -- PEOPLE
NEED OUR HELP.
I THINK OUR REFERRERS ARE
NEEDING OUR HELP.
WE ARE HEARING THAT AND NEED TO
DO A BETTER JOB OF GETTING THAT
BACK OUT TO THEM.
RESEARCH OPPORTUNITIES, MANY.
WE HEARD THE CALL FOR BOTH
ULTRASOUND AND OUTCOMES
REGISTRY, INCLUDING THINKING
THROUGH UNANTICIPATED OUTCOMES.
STAGING, TO DO THAT IN A WAY
THAT IS BETTER THAN WHAT WE'RE
DOING RIGHT NOW.
IN ADDITION TO ULTRASOUND THE
USE OF BIOMARKERS THAT CAN
STRATIFY PATIENTS, USE OF MRI.
I THINK I HEARD, I THINK THE
OLDER PARADIGM OF, YOU KNOW, MRI
IS USEFUL FOR RULING IN A
ACCRETA.
WE KNOW, WE CAN DIAGNOSE A
PROACCRETA, WE DON'T NEED A MRI
FOR THAT, BUT OR THINGS WE CAN
DO.
AND THE OTHER THING OF USING A
REFERRAL, CAN WE USE MRI THERE.
THERE IS A PRIME THERE.
AND THE MANAGEMENT, THINKING
THROUGH WHAT TIMES OF SURGICAL
MANAGEMENT VERSUS CONSERVATIVE
MANAGEMENT, AND THEN AMAZING
OPPORTUNITIES FOR PREVENTION.
I THINK THAT, I'M REALLY PROUD
THIS MEETING TALKED ABOUT
PATIENT NEEDS AND SUPPORT, AND
SHARED DECISIONMAKING TOOLS.
THE CALL HERE TO THINK THROUGH
THE IMPACT ON OUR PATIENTS.
AND THAT DIDN'T ONLY COME
THROUGH IN TERMS OF THINKING
THROUGH MANAGEMENT OUTCOMES AND
SHARED DECISIONMAKING AND ALSO
LONGER TERM OUTCOMES AND MENTAL
HEALTH SUPPORT.
I THINK THESE, TO ME, AS SORT OF
SITTING THERE IN THAT BIT OF THE
ROOM SEEMED LIKE -- WE DID A
GOOD JOB, I THINK WITH
IDENTIFYING KEY GOALS.
DO YOU HAVE ADDITIONAL, WHAT DID
I MISS.
>> NOTHING, I CANNOT ADD
ANYTHING TO THAT.
>> AND IF OTHER PEOPLE DO HAVE
THINGS TO ADD TO THAT, PLEASE, I
ALWAYS WANT TO BE AVAILABLE FOR
MORE CONVERSATION ABOUT THOSE
THINGS.
SO, WHAT HAPPENS NOW?
EACH OF THESE GROUPS, WORKING
GROUP REPORTS WILL BE DISTILLED
FURTHER INTO A ONE TO TWO PAGE
SUMMARY.
WE'RE HOPING THREE MONTHS
FOLLOWING THE WORKSHOP.
THIS MIGHT MEAN THAT THE HEAD OF
YOUR WORKING GROUP WILL WANT TO
RECLARIFY OR RECONVENE, WE ARE
HAPPY TO FACILITATE THAT AND
HAVE A ZOOM MEETING AND THINK
THROUGH DOES THIS DOCUMENT LIKE
WE WANT IT TO BE.
AND REFLECT THE CONVERSATION.
THERE IS A SCIENTIFIC WRITER
PART OF THIS PROCESS.
SO THERE WILL ALSO BE THE
SUMMARY OF THE WRITINGS OF THE
COUNTRY TENT OF -- CONTENT OF
THE WORKSHOP.
THAT IS AVAILABLE TO THE WORKING
GROUPS TO INCORPORATE INTO THE
SUMMARY.
WE ARE HOPING TO HAVE A WHITE
PAPER AVAILABLE FOR OUR
SOCIETIES TO BE ABLE TO TAKE
BACK WARDS AND BE ABLE TO
DEVELOP ONGOING RESEARCH
OPPORTUNITIES.
YEAH.
ANY QUESTIONS, CONCERNS, OR
COMMENTS ABOUT THAT?
AND WANT TO MAKE SURE EVERYBODY
FEELS PRETTY CLEAR.
SO IT IS A LOT TO THINK ABOUT
AND TO CHEW OFF, I REALLY WANT
TO APPRECIATE, AGAIN, SAY THANKS
FOR EVERYBODY FOR ENGAGING SO
INTENSELY.
>> YEAH, WE'RE, I MEAN, WE'RE
HELPFUL THE PROCEEDINGS OF THIS
MEETING WILL INSPIRE PEOPLE TO
DO THE RESEARCH AND MAKE THE
POLICY CHANGES THAT ARE NEEDED
TO MOVE OUR FIELD FORWARD.
IF YOU HAVE INNOVATIVE WAYS THAT
WE CAN DO THAT, BESIDES JUST
WRITING A WHITE PAPER, WE ARE
OPEN TO UP, AND OTHER PAPERS
LIKE THE PALSY PAPER THAT WILL
BE HELPFUL AS AN ADDITIONAL
PIECE TO THIS, LET US KNOW.
OPEN TO YOUR IDEAS.
AND SINCERELY, SINCERELY
APPRECIATE EVERYBODY'S
PRECIPITATION AND NICHD FOR
HOSTING.
>> AND GROUP THREE.
SO TWO DIFFERENT -- OR JUST ONE
BIG ONE AND COME BACK TOGETHER?
OTHERWISE-- MORE -- INTENSE
EFFORT.
>> YEAH.
COMMENTS ON THAT?
>> THERE IS OVERLAP BETWEEN WHAT
GROUP NUMBERS I WAS IN AND YOU
ARE IN, THE SPECIMEN TO COLLECT
AND THE GOAL OF THE SPECIMEN, I
THINK IT IS ONE REGISTRY, COME
UP WITH THE CONSENSUS ON WHAT
YOU CAN GET.
MY CURRENT APPROACH IS GET WHAT
YOU CAN GET.
I MEAN -- WE'LL USE IT.
BUT-- WE NEED TO BE A LITTLE BIT
MORE SYSTEMATIC.
>> YEAH.
I ALSO THINK, RIGHT NOW, I THINK
WE'RE GOING TO GO OUT AND THINK
ABOUT THAT AND TALK TO EACH
OTHER.
I THINK THROUGH WHAT MAKES THE
MOST SENSE.
SO I THINK --
>> WE HAVE AN OPPORTUNITY, AS
NEEDED, TO GROUP, AGAIN, EITHER
WITH THE GROUP WHO SHARED THIS
WORKING GROUP SUMMARY WITH THE
VARIOUS GROUP, I MEAN, WE DON'T
WANT, THERE ARE OVERLAPPING.
IT IS CLEAR THERE WILL BE
OVERLAP.
WE ARE ALL TALKING ABOUT EARLY
DIAGNOSES IN A DIFFERENT WAY, WE
WERE TALKING ABOUT SIMILAR
THINGS THAT MIGHT BE
OVERLAPPING.
SO THAT IS ALSO ABOUT REGISTRY,
SO WE HAVE TO THINK HOW TO BRING
IT UP IN THE BEST WAY FOR ALL OF
US.
IT WILL NOT BE TWO OR THREE OR
ONE.
PROCEDURE.
>> LET ME THROW SOMETHING OUT TO
THE GROUP.
SO GREAT MEETING.
THANKS, EVERYONE.
AND WE WILL HAVE THIS WHITE
PAPER WHICH IS PRETTY MUCH YOU
KNOW, KNOWLEDGE GAPS, SOME BASIC
REPRESENT RECOMMENDATIONS AND
RESEARCH RECOMMENDATIONS IS
THERE A PLACE TO THROW A
PROTEASED DEFINITION.
IF YOU WERE TO CREATE A
DEFINITION, WHAT YOU WOULD DO IS
GET A BUNCH OF EXPERTS TOGETHER
AND HAVE A MEETING FOR TWO DAYS
AND HAMMER OUT A DEFINITION.
>> THE ORGANIZATION THAT YOUR
PRESIDENT OF IS WORKING ON THAT
RIGHT NOW.
[ LAUGHTER ]
YEAH.
YES.
>> SURE.
>> YOU WILL GET AN INVITATION.
>> THE JUST SEEMS LIKE A VERY
BASIC FIRST STEP.
IF YOU WANT TO HAVE A BIOMARKER,
YOU NEED TO HAVE A PHENOTYPE
THAT YOU'RE PREDICTING THAT
EVERYBODY AGREES ON.
IF YOU WANT TO ASSESS A
MANAGEMENT STRATEGY, YOU HAVE TO
HAVE A PHENOTYPE THAT EVERYBODY
AGREES OBJECT.
SO JUST SEEMS LIKE SUCH A
CRITICAL STEP THAT YOU CAN'T DO
ANYTHING ELSE UNTIL YOU HAVE
THAT PART DOWN.
AND IT'S COOL THAT DIFFERENT
ORGANIZATIONS ARE DOING THAT.
BUT YOU SORT OF NEED ONE
DEFINITION THAT EVERYBODY USES
FOR THIS TO ACTUALLY FUNCTION.
>> WE ARE.
LIKE AT LEAST -- PAS -- TO WORK
ON THIS.
>> THAT IS SOMETHING, I THINK IF
YOU ARE THE EXPERT.
SO IN THE GROUP OR WHEN YOU TALK
WITH EACH OTHER AND EXCHANGE
THESE DOCUMENT, THERE IS A NEED
OF THESE NEW DEFINITION, THEN
YOU AGREE WITH EACH OTHER, WITH
THE SOCIETY.
YOU ARE -- THE PAPER YOU'RE
WRITING DOESN'T REQUIRE OUR
PERMISSION.
THERE ARE SOME LIMITATIONS, LIKE
YOU CANNOT HAVE POLICY OR
CLINICAL RECOMMENDATION, THAT IS
NOT OUR GOAL, BUT I THINK THE
DEFINITION COULD BE UNDER THE
UMBRELLA FOR YOU TO RESEARCH BY
IMPROVING YOUR DEFINITION AND
STANDARD EQUATION.
>> PLEASE DO NOT HAVE ANOTHER
PREECLAMPSIA.
>> THAT MEANS BOB CANNOT BE ON
THE COMMITTEE.
>> FOLLOWING THAT DEFINITION,
ACCRETA, ACCRETA WITHOUT SEVERE
FEATURES, ACCRETA WITH SEVERE
FEATURES.
>> ABSOLUTELY NOT.
[ LAUGHTER ]
WHICH ONE IS SUPER IMPORTANT.
[ LAUGHTER ]
>> AND ADD SUPERIMPOSED
ACCRETAS.
>> THINK OF THE CHAT -- IN PART
OF THE GOAL.
WE CAN PROBABLY, WHENEVER WE GET
THIS DRAFT, WE CAN START TO
CIRCULATE SOME OF THE
DEFINITIONS AND TALK TOGETHER.
>> YEAH, I MEAN, I THINK, A CALL
FOR, THE ACTIVITY OF DEFINING
ACCRETA IS THE, IS WHAT'S GOING
TO BE IN THE WHITE PAPER.
AND THEN A SEPARATE PROCESS THAT
SOUNDS LIKE IS ALREADY UNDERWAY,
WHICH IS UNDERWAY.
>> YEAH.
REVIEW FOR PATHOLOGISTS INPUT
FOR THE DEFINITION?
>> YEAH.
BECAUSE WE DON'T HAVE A
PATHOLOGIST IN THIS WORKING
GROUP.
>> THERE IS, DANNY CAN SPEAK TO
THIS BETTER.
BUT PATHOLOGISTS ARE INVOLVED IN
YOUR DEFINITION.
>> YEAH THIS IS THE PERFECT
OPPORTUNITY TO PUT IN A PLUG.
WE WILL BE SENDING OUT EMAIL FOR
FOCUS GROUP PARTICIPATION.
REACHING OUT TO PAS EXPERTS AND
MANY OF YOU WILL BE RECEIVING
THE EMAILS SOON, AND ALSO
INCLUDE PATHOLOGISTS PART OF THE
WORKING GROUP AND TASK FORCE.
>> ( SPEAKER OFF MICROPHONE ).
>> YEAH, I WANTED TO ACKNOWLEDGE
THIS IS SOMETHING TO SHARE -- I
REALLY WANTED TO DO, IT WAS JUST
A LIMITATION WITH THE SECTION OF
PATHOLOGY, THERE WAS SO MUCH WE
COULD ACHIEVE AND TRY TO GET
DONE IN ONE DAY.
AND WE REALLY WANTED TO HAVE
THIS MOMENT OF DISCUSSION AND
NOT JUST HAVING A SERIES OF
PRESENTATION, BUT TO HAVE
ACTIONABLE ITEMS.
SO I'M SORRY THAT WE COULD NOT
GET THE PATHOLOGISTS.
>> I THINK WE'RE TO YOU.
[ LAUGHTER ]
>> OH, THE SAME LIGHTS.
[ LAUGHTER ]
MY PROMISE IS REALLY TWO
MINUTES.
I'M NOT GOING TO HOLD YOU BACK
FROM YOUR LUNCH OR FLIGHT OR
VISIT WASHINGTON, OR FIND COFFEE
SOMEWHERE.
IT'S FINE.
WELL, IT WAS JUST THE NAME OF
THE PANELISTS ON MY SLIDES.
SO I WANTED TO THANK EVERYONE OF
YOU, EVE AND EACH OF YOU, I
WANTED TO THANK THE SOCIETY.
[LISTING SOCIETY MEMBERS] FOR
SENDING AND SUPPORTING THE
WORKSHOP AND HAVING THEIR
REPRESENTATIVES HERE.
AND I REALLY ENCOURAGE TO WORK
WITH EACH OF YOU WITHIN YOUR
GROUP.
BECAUSE, YES, IT'S A PAPER, BUT
HOPEFULLY, THERE IS SOMETHING
THAT WILL COME OUT FROM THE
COMMUNITY, WHAT OUR COMMUNITY
CAN UNDERSTAND AND HAVE A BETTER
GUIDELINE OF WHAT YOU, AS THE
EXPERTS THINK WE SHOULD WORK AS
FAR AS THE SCREENING,
PREVENTION, DIAGNOSIS, AND
MANAGEMENT.
SO THE PRIOR SLIDES WERE ALL OF
YOUR NAMES.
[ LAUGHTER ]
BUT I THINK WE WENT OUT OF
ORDER.
BUT THAT IS FINE.
SO THIS IS JUST LIKE, TO THANK
ALL OF YOU.
AND DEFINITELY THOSE WHO CAME
FROM INTERNATIONAL FLIGHT FOR
48-HOUR TURNAROUND, THANK YOU SO
MUCH.
AND THE SOCIETY AND, AGAIN,
HERE, AND THANK YOU.
AND WE CONCLUDED OUR PLACENTA
ACCRETA SPECTRUM PRESENT AND
FUTURE, WE ARE LOOKING FOR THIS
DRAFT.
SEND YOUR QUESTIONS TO BRETT AND
KRISTINA, WHICH HAS BEEN
FABULOUS.
WORKING ON THIS WORKSHOP.
AND AGAIN, I HAD THE SUPPORT OF
NICHD.
DOCTOR IS WITH US UNTIL THE END.
HOPEFULLY, WE WILL SEE SOME MORE
COMMON MANAGEMENT,
STANDARDIZATION TO DEGREE, TO
REDUCE MORBIDITY AND MORTALITY
RELATED TO THIS TOPIC.
SO THANK YOU VERY MUCH FOR
JOINING US.
[ EVENT CONCLUDED ]