Ovarian Cancer in the Elderly Patient: Are We Doing Enough?

IntroductionOvarian cancer is deadly and frequently affects older patients. In the next 20 years, the number of patients over 65 will double, and cancer, including ovarian cancer, will increase in incidence. We wished to determine whether surgical morbidity, outcomes, and survival rates were worse in the older age group than in younger patients, and whether measuring serum CA 125 could be helpful in triaging patients for surgery.MethodsWe conducted a retrospective chart review of patients undergoing surgery for ovarian cancer in our institution from April 1996 to May 2006. A total of 127 patients met the inclusion criteria and were divided by age into two groups: patients aged under 70 and those aged 70 or older. We used Fisher test, two-tailed Student t test, chi-square test, and Kaplan-Meyer statistical methods to obtain survival curves and to test hypotheses and probabilities.ResultsPatients aged 70 and over were less likely to have stage I disease and to undergo optimal surgery. They also presented with more advanced disease, but this did not translate into a difference in survival rates. Serum CA 125 levels did not enable identification of older patients who would benefit from surgery.ConclusionOlder patients with ovarian cancer did not have reduced survival rates compared to younger patients, but they were more likely to undergo suboptimal surgery and to have more advanced disease. Preoperative serum CA 125 measurements did not identify patients in the older age group for whom surgery would be optimal.     

Pregnancy in early adolescence: Are there obstetric risks?

The purpose of this study was to determine if early adolescence imparts a significant obstetric risk in young primiparas relative to adult primiparas. The records of 239 young primiparas (< 16 years) and 148 older primiparas (18–29 years) were reviewed for demographic information, antepartum complications, mode of delivery, length of labor, episiotomy, lacerations, birthweight, and length of gestation. The young adolescents were shorter, had an earlier age at menarche, a lower pregravid body mass index, and a higher gestational weight gain. The young teens were less likely to smoke cigarettes but were more likely to be Medicaid recipients. The incidence of most antenatal complications (chronic hypertension, pregnancy-induced hypertension, placental abruption, placenta previa, premature rupture of the membranes, urinary tract infections, and anemia) were similar between the two groups. Preterm labor and contracted pelvis were more common among the young adolescent, while gestational diabetes was less common. The young primiparas were significantly (P <. 05) less likely to have a Cesarean delivery and to lacerate with vaginal delivery. The length of labor and its stages were similar, as were overall birthweight and length of gestation. Thus, obstetric concerns regarding pregnancy in early adolescence may be unfounded. With the exception of an increased risk for preterm labor, it appears that pregnancy, labor, and delivery do not pose inordinate obstetric and medical risk to the very young adolescent primipara.     

Antenatal Corticosteroids in the Management of Preterm Birth: Are We Back Where We Started?

Though the preterm birth rate in the United States has finally begun to decline, preterm birth remains a critical public health problem. The administration of antenatal corticosteroids to improve outcomes after preterm birth is one of the most important interventions in obstetrics. This article summarizes the evidence for antenatal corticosteroid efficacy and safety that has accumulated since Graham Liggins and Ross Howie first introduced this therapy. Although antenatal corticosteroids have proven effective for singleton pregnancies at risk for preterm birth between 26 and 34 weeks’ gestation, questions remain about the utility in specific patient populations such as multiple gestations, very early preterm gestations, and pregnancies complicated by IUGR. In addition, there is still uncertainty about the length of corticosteroid effectiveness and the need for repeat or rescue courses. Though a significant amount of data has accumulated on antenatal corticosteroids over the past 40 years, more information is still needed to refine the use of this therapy and improve outcomes for these at-risk patients.     

Are We Getting Closer to Explaining Preeclampsia?

Preeclampsia continues to contribute to major maternal and neonatal morbidity and mortality worldwide. In this article, we review the pathophysiological mechanisms, screening strategies, and novel therapeutic options for preeclampsia.     

Endometrial Biopsy in Low-Risk Women: Are We Over-Investigating?

The appropriate age at which to perform endometrial biopsy for abnormal uterine bleeding (AUB) is controversial. This study aimed to determine the prevalence of malignant and premalignant pathologies in women aged 41–49 years with AUB and without risk factors for endometrial cancer. Records of women who had undergone a biopsy at the gynaecology clinic of the Centre hospitalier de l'Université de Montréal between 2014 and 2018 were reviewed. Of the 209 women included in the study, 2 had atypical hyperplasia, which resolved without treatment, and 3 had hyperplasia without atypia. The remaining women had benign results, showing that the prevalence of malignant and premalignant endometrial pathologies is low in this subgroup of patients.     

Limitations in Correspondence Programs for Cervical Cancer Screening: Who Are the Women We Are Missing?

ObjectiveThis study sought to identify factors associated with gaps in the correspondence program and the characteristics of those women who are not reached with a mailed invitation to screening within an organized cervical cancer screening program.MethodsThis population-based, retrospective observational study examined the factors associated with failed correspondence mailings as part of the Ontario cervical cancer screening program. Administrative databases were used to identify eligible women who were overdue for screening or never screened yet did not receive an invitation to screening as a result of a failed mailing. These women were further characterized on the basis of age, affiliation with a primary care physician, and use of other health services (Canadian Task Force Classification II-2).ResultsA total of 1 350 425 women were eligible, of whom 1 064 637 had a successful mailing (78%). Women who were overdue for screening and who had a failed correspondence were more likely to be younger than 50 (72.5%) and associated with a primary care physician (61.2%), and 66.7% had three or more health care encounters in the preceding 3 years. Underscreened and never-screened women were also more likely to be younger than 50, but only 15% were associated with a primary care physician and only 18.2% had health care encounters in the previous 3 years.ConclusionThis is one of the first studies to evaluate the incidence of failed mailings within correspondence in organized screening programs. Women who are underscreened or never screened are infrequent users of health care services and tend not to have a primary care physician, thus making them less accessible to traditional outreach methods and at further risk of being non-compliant with screening.     

Surgical Simulation: Where Have We Come From? Where Are We Now? Where Are We Going?

It is now clear to most stakeholders that acquisition of surgical psychomotor skills is best achieved outside of the clinical operating room, in the context of a simulated environment. Endoscopic simulation can be accomplished using simple "box" simulators or video trainers, and virtual reality simulation is now possible using microprocessor-controlled systems. Structured surgical training performed outside of the operating room environment is relatively new to health care, a circumstance different from the process of pilot training, in which simulation has been a mainstay for more than 75 years and in which virtual reality simulation is now the norm. Those charged with surgical education are faced with a dilemma as, while attempting to understand the basic goals of simulation, they are simultaneously faced with choice between relatively inexpensive video trainers and the often prohibitively expensive virtual reality systems. This article explores the history of simulation, reports the results of a modified systematic review of currently available systems and performance, and identifies the gaps in current research and development. It is apparent that available video trainers provide the opportunity for skill development that at present is not surpassed by virtual reality systems. In the future, there will likely be an increasing role for virtual reality; however, challenges remain that include determination of the appropriate metrics and system design, and the fiscal resources necessary for the required hardware and related software development.     

Down Syndrome Screening in India: Are We There Yet?

Down syndrome is the most common cause of intellectual disability among live born children and is amenable to prenatal detection. Screening for Down syndrome on a population basis requires a thorough understanding of the principles involved in the screening tests. We discuss the rationale behind the commonly available screening tests and the Indian scenario in this setting.     

Do Receptors Get Pregnant Too? Adrenergic Receptor Alterations in Human Pregnancy

In this review we discuss adrenergic receptor number and function during pregnancy, with emphasis on evidence that pregnancy results in specific receptor alterations from the nonpregnant state. Changes in adrenergic receptor function or distribution in vascular smooth muscle may be in part responsible for the decreased vascular responsiveness seen in human pregnancy, and the lack of the normal alterations may be a part of the syndromes of gestational hypertension, including preeclampsia-eclampsia. The onset of labor may be influenced by adrenergic modulation, and receptor or postreceptor level molecular alterations may trigger or facilitate normal or preterm labor. Human studies are emphasized when possible to assess the role of adrenergic signal transduction regulation in the physiology and pathophysiology of normal and complicated human pregnancy.     

Can We Use the Omron T9P Automated Blood Pressure Monitor in Pregnancy?

Background. Recent events in our hospital, combined with international recommendations, catalyzed the need to move from mercury sphygmomanometry to automated blood pressure (BP) recording in pregnancy. Aim. To test the accuracy of the Omron T9P automated BP recorder in pregnant women, using mercury sphygmomanometry as the gold standard. Setting. Antenatal clinics and obstetric day assessment unit, St George Hospital, Sydney. Participants. Eighty-five pregnant women, 11% of whom were receiving antihypertensives. Methods. Differences in both systolic and diastolic BP between the T9P Omron device and mercury sphygmomanometer were obtained for each woman, using sequential automated and mercury BP recordings, as required by a modified British Hypertension Society (BHS) protocol. The accuracy of the device was graded according to the BHS and the Association for the Advancement of Medical Instrumentation (AAMI) standards. Results. The Omron T9P device received an A/A grade according to this modified BHS and AAMI testing process, though the range of the 255 differences was 1–13 for systolic BP and 1–10 for diastolic BP. Conclusions. The Omron T9P device is an accurate device for use predominantly in an outpatient antenatal clinical setting. Further studies are required solely within hypertensive pregnant women before its use can be recommended with certainty in this group.