Uterine adenosarcomas: A dual-institution update on staging,prognosis and survival

Objective

Uterine adenosarcomas (AS) are rare tumors thought to have a favorable prognosis. The aim of this study was to evaluate clinicopathological characteristics and treatment outcome in women with uterine AS.

Methods

Patients with uterine AS were identified from the institutional databases at two regional cancer centers, Princess Margaret Hospital, Toronto and Vancouver General Hospital. All cases underwent specialist pathological review and were re-staged according to FIGO criteria (2009). Patient demographics, treatment data and outcomes were evaluated.

Results

Between 1984 and 2010, 64 patients with confirmed AS were identified: 30 exhibited sarcomatous overgrowth (AS + SO). 47 patients presented with stage I disease: 27 IA and 18 IB. 57 of the 58 patients with known surgical management underwent hysterectomy: 55 having bilateral salpingo-oophorectomy, 12 having lymph node dissection. 14 patients received adjuvant treatment: 10 radiotherapy, 3 chemotherapy and 1 both. Sixteen of the 45 patients (35.6%) with follow-up recurred; median time to recurrence 21.2 months, range 2.1–87.8 months. Recurrence was associated with myometrial invasion (p = 0.05). Two of the 10 women (20%) with AS + SO receiving adjuvant treatment recurred compared to 9 of the 14 (64%) who did not. One of the 5 women (20%) with stage IB disease who received adjuvant treatment recurred (20%) compared to 6 of the 7 (85.6%) who did not.

Conclusions

Long term surveillance is required given the variable time to recurrence. For those with AS + SO and myometrial invasion adjuvant treatment should be considered and further investigation of adjuvant strategies is warranted.     

Pressure-induced gastric accommodation studied with a new distension paradigm. Abnormally low accommodation rate in patients with functional dyspepsia

OBJECTIVE: A new distension paradigm, by which the gastric volume response to ramp-tonic distension can be analysed in detail, has been developed. The aim of this study was to investigate the applicability of this new paradigm in man, and to compare pressure-induced gastric accommodation in healthy volunteers (HV) and patients with functional dyspepsia (FD). MATERIAL AND METHODS: Ten HV, and 11 FD patients were examined twice; once in the fasting state and once postprandially. Intragastric bag pressure was raised from 1 to 12 mmHg in 4 min (ramp phase) and then kept constant for 5 min (tonic phase). RESULTS: Compared to HV, fasting FD patients had lower gastric accommodation rates (0.9+/-0.2 versus 2.5+/-0.4 ml/s, p=0.002), lower maximum volume (239+/-39 versus 428+/-64 ml, p=0.01) and a longer accommodation time (157+/-26 versus 92+/-15 s, p=0.03). A test meal prior to distension tended to normalize the response in FD patients. CONCLUSIONS: This new barostat paradigm allowed detailed analysis of short-term pressure-induced accommodation in man. Impaired gastric distension-induced accommodation is a novel abnormality in FD.     

Reproductive health services utilization and its associated factors among adolescents in Debre Berhan town,Central Ethiopia: a community-based cross-sectional study

Background

Utilization of reproductive health services is an important component in preventing adolescents from different sexual and reproductive health problems. As a result, the extent of their service utilization should be determined before implementing any kind of interventions. Therefore, this study was aimed at assessing the level of reproductive health services utilization and its associated factors among adolescents who live in Debre Berhan town.

Methods

A community-based cross-sectional method was employed in this study from April 5–May 1, 2016. A multi-stage systematic sampling technique was applied to select a total of 648 adolescents living in 5 randomly selected kebeles of Debre Berhan town. Moreover, a logistic regression was done to identify independent predictors of reproductive health service utilization.

Results

Accordingly, the major findings of this study reveals that about one-third (33.8%) of adolescents utilized at least one of reproductive health services. Adolescents who had discussed sexual and reproductive health issues with their sexual partner and peers were two times more likely to use reproductive health services than their counter parts (AOR?=?2.368, 95% CI: 1.168–4.802 and AOR?=?2.360, 95% CI: 1.155–4.820 respectively). Adolescents who weren’t co-resided with both their parents were also about two times more likely to utilize reproductive health service than those who were living together (AOR?=?2.570, 95% CI?=?1.155–4.820). Positive perception of oneself towards acquisition of Human Immunodeficiency Virus urged the adolescents to use RH services twice than those who didn’t perceive themselves as risky (AOR?=?2.231, 95%CI: 1.001–4.975).

Conclusion

Succinctly speaking, the analysis of the major finding suggests that the utilization of reproductive health services among adolescents in the study area was low. Discussion with sexual partner and peers, risk perception of oneself towards the acquisition of human immune-deficiency virus was among the predictors of reproductive health services usage.

     

A small p-value from an observed data is not evidence of adequate power for future similar-sized studies: A cautionary note

Backgroundp-values are ubiquitous in medical research, but are often misunderstood. In addition to being misused or perhaps even abused at post-statistical analysis stage of making scientific inference and interpretations, p-values can also be a source of confusion at the design stage.MethodsApplication of standard test statistic on observed data may result in a small p-value which in turn may give the impression that a new study that has the same sample size as the observed data, perhaps even smaller, would have adequate power. We used re-sampling method and computed statistical power to illustrate the fallacy of this conclusion. We have also calculated power using analytical formulae.ResultsWe analyzed data consisting of two group comparisons with binary as well as continuous outcome variables. For the binary outcome, the event rates for the outcome of interest in the illustrative data were 15/43 (35%) and 22/34 (65%), respectively (p-value = 0.0093). Using these data, a bootstrap-based empirical power was estimated to be 75.4%. One random sample with only two-third of the original data had a p-value of 0.0066, but only an empirical power of 57.4%. Similar results were observed for a continuous outcome.ConclusionOur results show that the number of zeros after the decimal point in a p-value from an observed sample cannot and should not be used to gauge the adequacy of sample size for a future study that is expected to have sufficient power to detect an effect as big as the observed.     

The Operative Output of District Hospitals in KwaZulu-Natal Province is Heavily Skewed Toward Obstetrical Care

Introduction

District hospitals are key to providing universal coverage of essential surgery and for strengthening surgical care in general. This audit set out to quantify the surgical output of all the district hospitals in KwaZulu-Natal Province (KZN) over a 6-month period to see whether district hospitals were delivering the surgical care they are expected to deliver.

Results

There were a total of 18,871 operations performed at 37 district hospitals in KwaZulu-Natal from July to December 2015. The number of operations per hospital varied widely between 2150 at a single large district hospital and 68 at a small district hospital, respectively. Surgical operations for obstetrical conditions made up by far the majority of operations at 57%, with gynecological operations making up the second highest at 15%. Only 12% of operations were for general surgical conditions. With regards to the bellwether procedures, 96.1% of these were cesarean sections, 2.1% were laparotomies and 1.8% were ORIFs. For almost all the 37 hospitals, the percentage of laparotomies and ORIFs performed was small to negligible, while the percentage of cesarean sections performed was high. The number of bellwether operations performed per 100,000 population was much higher than the number of general surgical or orthopedic operations performed, primarily because of the preponderance of cesarean sections conducted in each hospital. We observed a strong and significant positive correlation (+0.691, 95% CI +0.538 to +0.800, p < 0.001) between increasing distance to nearest regional referral hospital and rate of laparotomies and ORIF procedures performed.

Conclusions

The surgical output of district hospitals in KZN is heavily skewed toward obstetrics and gynecology. Further work is required to understand the reasons for this, but the current data imply that district hospitals are not delivering surgical and orthopedic care at district hospitals in KwaZulu-Natal.

     

Third trimester ultrasound for fetal macrosomia: optimal timing and institutional specific accuracy

Purpose: To determine the performance of third trimester ultrasound in women with suspected fetal macrosomia.

Materials and methods: We performed a retrospective cohort study of fetal ultrasounds from January 2004 to December 2014 with estimated fetal weight (EFW) between 4000 and 5000?g. We determined accuracy of birth weight prediction for ultrasound performed at less than and greater than 38 weeks, accounting for diabetic status and time between ultrasound and delivery.

Results: There were 405 ultrasounds evaluated. One hundred and twelve (27.7%) were performed at less than 38 weeks, 293 (72.3%) at greater than 38 weeks, and 91 (22.5%) were performed in diabetics. Sonographic identification of EFW over 4000?g at less than 38 weeks was associated with higher correlation between EFW and birth weight than ultrasound performed after 38 weeks (71.5 versus 259.4?g, p?Conclusions: Identification of EFW with ultrasound performed less than 38 weeks has greater reliability of predicting fetal macrosomia at birth than measurements performed later in gestation. EFW to birth weight correlation was more accurate than previous reports.     

Addition of Cyclophosphamide “On Demand” to Lenalidomide and Corticosteroids in Patients With Relapsed/Refractory Multiple Myeloma—A Retrospective Review of a Single-center Experience

IntroductionThe combination of lenalidomide and dexamethasone (Len-Dex) is an established regimen for patients with relapsed or refractory myeloma. To prolong the benefit of this effective regimen, the Myeloma Program at Princess Margaret Cancer Centre has routinely added a third agent, oral cyclophosphamide (Cy) given weekly, to Len-Dex at disease progression.Patients and MethodsIn the present report, we describe the cases of 53 patients who had received Len-Dex-Cy for a minimum of 4 weeks from January 2007 to December 2014 after progression with Len-Dex alone. The dose of added Cy ranged from 250 to 500 mg weekly. The median number of previous regimens, including Len-Dex, was 2 (range, 2-4); 80% of patients had undergone previous autologous stem cell transplantation.ResultsThe overall rate of response equal to or greater than a partial response was 34%, and clinical benefit (stable disease or better) was observed in 87% of the patients. The median duration of Len-Dex-Cy therapy was 6.9 months (range, 0.9-55.1 months). The median progression-free survival was 6.1 months (range, 4.2-8.1 months) from the addition of Cy and 24.1 months (range, 15.9-32.0 months) from start of Len-Dex.ConclusionThe addition of Cy for patients with myeloma developing progression with Len-Dex was an inexpensive option with manageable toxicity that resulted in a clinically meaningful extension of disease control.     

The effect of Helicobacter pylori eradication on gastro-oesophageal reflux

BACKGROUND: Increased prevalence of oesophagitis has been reported following eradication of Helicobacter pylori. We hypothesized that H. pylori eradication might increase gastro-oesophageal acid reflux in patients with reflux oesophagitis. METHODS: Twenty-five consecutive patients (13 male, 12 female) with H. pylori infection and reflux oesophagitis grade I (22 patients) or II (three patients) were enrolled; mean age 49.9 (range 33-75) years. Twenty-four hour intra-oesophageal pH recording was performed before and 12 weeks after eradication of H. pylori, which was achieved using bismuth subnitrate suspension 150 mg q.d.s., oxytetracycline 500 mg q.d.s. and metronidazole 400 mg t.d.s. for 10 days. Eradication was confirmed by 14C-urea breath test 12 weeks after completion of treatment. The patients did not receive acid-suppressive medication. RESULTS: All patients had abnormal gastro-oesophageal reflux before anti-H. pylori treatment. After treatment, there was no significant change in the percentage of total time oesophageal pH < 4 (P=0.46) in the 23 patients in whom the infection had been cured. Nine of the cured patients had increased acid exposure, whereas 14 had decreased acid exposure. No significant change in reflux symptom scores was found. There was no relationship between change in acid exposure and symptom improvement. CONCLUSIONS: Twelve weeks after H. pylori eradication there was no consistent change in gastro-oesophageal acid reflux in patients with mild or moderate reflux oesophagitis.     

Gas distribution in intraabdominal and pelvic abscesses on CT is associated with drainability

OBJECTIVE: Intraabdominal and pelvic abscesses are treated by percutaneous image-guided drainage, under sedation or general anesthesia. This study attempts to determine if the CT features of gas distribution are associated with "drainability." Our premise was that gas may be trapped deep in a collection as bubbles, if the material is thick. Gas may rise to the surface if the material is thin, forming either an air-fluid level or superficial bubbles. MATERIALS AND METHODS: Patients with intraabdominal and pelvic abscesses were identified by the interventional radiology database, after research ethics board approval. Patients without prior CT were excluded. The imaging and clinical records were analyzed retrospectively. Intracollection gas distribution was recorded as superficial bubbles, deep bubbles, or air-fluid levels. Collections were classified accordingly: type 1, air-fluid levels; type 2, superficial or deep bubbles and air-fluid levels; type 3, superficial bubbles; type 4, deep bubbles; and type 5, no gas. RESULTS: One hundred five abscesses were examined in 61 patients, ranging in age from 2-17 years. Eight of 8 of type 1, 16 of 16 of type 2, 19 of 21 of type 3, 8 of 13 of type 4, and 43 of 47 of type 5 were drainable. The abscesses of all patients with an air-fluid level were drainable. Of abscesses with deep bubbles, 61.5% were drainable, versus 90.5% of those with superficial bubbles. Of those with superficial gas (superficial bubbles or air-fluid levels), 95.6% were drainable. In comparison with superficial gas, abscesses with deep trapped gas were associated with a longer duration of drainage, longer hospital stay, lower percentage of successful drainage, and higher percentage of residual collections. The difference is significant for drainability (p = 0.0048; p = 0.0331 after statistical adjustment for multiple testing). CONCLUSION: Distribution of gas in an intraabdominal or pelvic abscess is associated with drainability. Abscesses with superficial gas (superficial bubbles or air-fluid levels) have a greater chance of being drained successfully than do abscesses with deep trapped gas.