Fellowship learning curve associated with completing a robotic assisted total laparoscopic hysterectomy

Objective

To describe the learning curve associated with training fellows in completing robotic assisted total laparoscopic hysterectomies.

Methods

All patients scheduled to undergo a robotic procedure at our institution from 5/15/07 to 5/22/12 were identified. Fellow participation per procedure was documented. The learning curve of fellows for the time to complete a hysterectomy (from initiation of developing the retroperitoneal space to the completion of the colpotomy) was analyzed.

Results

Of the 1754 planned robotic cases, 1626 were completed robotically and 128 were converted to laparotomy. Fifty-seven fellows participated in 99.7% of the cases. Eleven gynecologic oncology fellows completed at least 1 robotic assisted total laparoscopic hysterectomy. From 7/7/08 to 5/21/12, 981 hysterectomies were completed robotically, 254 of these (25.9%) by the 11 fellows. Prior to completing a hysterectomy, the median number of hysterectomies in which a fellow participated was 16 (range, 11–40). Median amount of time for a fellow to complete a hysterectomy decreased from 60 min in 2009 (N = 27 cases) to 31 min in 2011 (N = 148 cases). Based on the recorded completion times in which the 11 fellows completed a hysterectomy, it required ~ 33 cases per fellow to be able to perform the hysterectomy and overcome the learning curve.

Conclusions

The learning curve associated with hysterectomy requires completion of ~ 33 cases by the fellow after an initial median experience of 16 cases. Our data suggest that a minimum of 50 total cases is required during fellowship to complete a robotic hysterectomy.     

A comparison of primary intraperitoneal chemotherapy to consolidation intraperitoneal chemotherapy in optimally resected advanced ovarian cancer

Objective

To compare survival outcomes for patients with advanced epithelial ovarian cancer (EOC) who received primary intravenous/intraperitoneal (IV/IP) chemotherapy to those who received IV followed by consolidation (treatment given to patients in remission) IP chemotherapy.

Methods

Data were analyzed and compared for all patients with stage III–IV EOC who underwent optimal primary cytoreduction (residual disease ≤ 1 cm) followed by cisplatin-based consolidation IP chemotherapy (1/2001–12/2005) or primary IV/IP chemotherapy (1/2005–7/2011).

Results

We identified 224 patients; 62 (28%) received IV followed by consolidation IP chemotherapy and 162 (72%) received primary IV/IP chemotherapy. The primary IP group had significantly more patients with serous tumors. The consolidation IP group had a significantly greater median preoperative platelet count, CA-125, and amount of ascites. There were no differences in residual disease at the end of cytoreduction between both groups. The median progression-free survival (PFS) was greater for the primary IP group; however, this did not reach statistical significance (23.7 months vs 19.7 months; HR 0.78; 95% CI, 0.57–1.06; p = 0.11). The median overall survival (OS) was significantly greater for the primary IP group (78.8 months vs 57.5 months; HR 0.56; 95% CI, 0.38–0.83; p = 0.004). On multivariate analysis, after adjusting for confounders, the difference in PFS was not significant (HR 0.78; 95% CI, 0.56–1.11; p = 0.17), while the difference in OS remained significant (HR 0.59; 95% CI, 0.39–0.89; p = 0.01).

Conclusions

In our study, primary IV/IP chemotherapy was associated with improved OS compared to IV followed by consolidation IP chemotherapy in patients with optimally cytoreduced advanced EOC.     

Aberrant crypt foci as precursors of the dysplasia-carcinoma sequence in patients with ulcerative colitis

PURPOSE: Long-standing ulcerative colitis (UC) predisposes patients to the development of colorectal cancer, but surveillance of colitis-associated cancer by detecting the precancerous lesion dysplasia is often difficult because of its rare occurrence and normal-looking appearance. In sporadic colorectal cancer, aberrant crypt foci (ACF) have been reported by many investigators to be precursor lesions of the adenoma-carcinoma sequence. In the present study, we analyzed the genetic background of ACF to determine whether they could be precursors for dysplasia, and we examined the usefulness of endoscopic examination of ACF as a surrogate marker for surveillance of colitis-associated cancer. EXPERIMENTAL DESIGN: ACF were examined in 28 UC patients (19 patients with UC alone and 9 patients with UC and dysplasia; 2 of those patients with dysplasia also had cancer) using magnifying endoscopy. K-ras, APC, and p53 mutations were analyzed by two-step PCR RFLP, in vitro--synthesized protein assay, and single-strand conformation polymorphism, respectively. Methylation of p16 was analyzed by methylation-specific PCR. RESULTS: ACF that appeared distinct endoscopically and histologically were identified in 27 out of 28 UC patients. They were negative for K-ras, APC, and p53 mutations but were frequently positive for p16 methylation (8 of 11; 73%). In dysplasia, K-ras and APC mutations were negative but p53 mutation (3 of 5; 60%) and p16 methylation (3 of 5; 60%) were positive. There was a significant stepwise increase in the number of ACF from patients with UC alone to patients with dysplasia and to patients with cancer. Univariate and multivariate analyses showed significant correlations between ACF and dysplasia. CONCLUSIONS: We have disclosed an ACF-dysplasia-cancer sequence in colitis-associated carcinogenesis similar to the ACF-adenoma-carcinoma sequence in sporadic colon carcinogenesis. This study suggests the use of ACF instead of dysplasia for the surveillance of colitis cancer and warrants further evaluation of ACF as a surveillance marker in large-scale studies.     

Acromesomelic Dysplasia in a Father and Son: Autosomal Dominant Inheritance

A father and son with typical acromesomelic dysplasia are reported, with the father more severely affected than the son. The disease was thus apparently transmitted in an autosomal dominant fashion. This is at variance with the autosomal recessive mode of inheritance assumed from hitherto reported families.     

Interferon production during the course of Mycoplasma pneumoniae infection.

In patients infected with Mycoplasma pneumoniae the development of interferon (IFN) was studied in nasopharyngeal secretions and sera. The production of IFN-gamma by lymphocytes was also investigated in response to M. pneumoniae antigen and mumps virus antigen. IFN-alpha was detected in 25 (61.0%) of 41 nasopharyngeal secretion samples and in 25 (59.5%) of 42 serum samples within 6 days after the onset of illness. IFN-alpha was significantly higher in nasopharyngeal secretions than in sera and a significant correlation was observed between the two. In most of the patients lymphocytes produced a larger amount of IFN-gamma in the convalescent stage than in the acute stage, when lymphocytes were stimulated with M. pneumoniae antigen. In some patients, however, lymphocytes did not produce IFN-gamma during the course of illness. Such lymphocytes, negative for IFN-gamma production in response to M. pneumoniae, produced IFN-gamma after the depletion of macrophages, and readdition of macrophages suppressed the production of IFN-gamma by lymphocytes. When lymphocytes were stimulated with heterogeneous antigen (mumps virus), they produced no IFN or a small amount of IFN in the acute stage of M. pneumoniae infection, and IFN production increased in the convalescent stage. Different mechanisms seem to work for homogeneous and heterogeneous antigens in the suppression of IFN production in M. pneumoniae infection.     

A Maternal Risk Factor for Mother-to-Child HTLV-I Transmission: Viral Antigen-producing Capacities in Culture of Peripheral Blood and Breast Milk Cells

We examined the relationship between productivity of HTLV-I antigen-positive cells in cultured peripheral blood mononuclear cells (PBMC) and breast milk mononuclear cells (BMMC) and the incidence of mother-to-child transmission of HTLV-I. Among 61 cases of HTLV-I carrier mothers, 17 cases were revealed to produce large numbers of HTLV-I antigen-positive cells (high HTLV-I antigen-producing mothers) whose positive rate was 9.6% in PBMC and 10.2% in BMMC, while the remaining 44 cases produced small numbers of HTLV-I antigen-positive cells (low HTLV-I antigen-producing mothers) whose positive rate was 0.3% In PBMC and 0.5% in BMMC. The HTLV-I transmission rate among children born to the high HTLV-I antigen-producing mothers was 37.5% (6/16 children from 11 mothers), while that of the low HTLV-I antigen-producing mothers was 3.2% (1/31 children from 20 mothers). The transmission rate of HTLV-I was significantly different between high and low HTLV-I antigen-producing mothers (P<0.05). However, there was no positive relationship between anti-HTLV-I antibody titers and productivity of HTLV-I antigen-positive cells (P=0.11). These results suggested that mother-to-child transmission of HTLV-I might be influenced by a maternally determined factor to produce HTLV-I antigen-positive cells in PBMC and BMMC of HTLV-I carrier mothers.     

Randomized study with mitomycin C + 5-fluorouracil + cytosine arabinoside (MFC) + 5-fluorouracil,MFC + tegafur and uracil (UFT), and MF + UFT in advanced gastric cancer: Interinstitutional differences in a multicenter study in Japan

In a phase III randomized trial of adjuvant chemotherapy for gastric cancer, interinstitutional differences were analyzed. A trial of three regimens: mitomycin C, 5-fluorouracil(5-FU) and CA (MFC) + continuous oral 5-FU (Group C); MFC + continuous oral UFT(tegafur and uracil) (Group B); and MF + UFT (Group C) after operation was conducted in 466 patients with gastric cancer (stage II and III) at four hospitals in Japan (CIH, CAD, ACC and NCC). Patients were stratified by the institution, stage, and tumor size (8 cm ><). The 5-year survival rates were in the order of Group A (79.0%) > B (70.0%) > C (61.0%) (P = 0.1228) in total, A (95.0%) > B (80.0%) > C (58.0%) (P < 0.05) at CAD (82 patients), A > C> B at CIH (215), C> A > B at ACC (95), and B > A > C at NCC (78). The survival rate of patients with S2(serosal exposure), 8 cm < and NO-1 cancer was higher at CIH than at the other institutions. The interinstitutional differences in patient characteristics and surgical technique were more powerful than the differences among the three groups. © 1995 Wiley-Liss, Inc.     

Incidence and Etiology of Mental Retardation in Patients with Congenital Heart Disease

Of 1,235 patients (609 male; 626 female) with congenital heart disease for whom types, etiology and associated congenital anomalies were determinable, 129 patients (10.4%) had mental retardatin. Patients with congenital heart disease complicated by mental retardation included 70 (54.3%) with chromosome aberrations, three(2.3%) with single gene disorders, two (1.6%) caused by environmental insult, and two (1.6%) with other recognized syndromes. Among the remaining 52 patients, asphyxia at birt was noted in 16, including 12 complicated by multiple malformations, and 4 in whom mental retardedation was presumed to be due to the asphyxia. In the remaining 36 patients, the incidence of the complication of mental retardation in cyanotic congenital heart disese was significantly higher than that in acyanotic congenital heart disease was signicantly higher than that in acyanotic congenital heart disease. Patients with congenital heart disease of unknown etiology associated with mental retardation included those from two families considered to have new pedigree syndromes.     

Clinical and Postmortem Findings of Two Cases With Karyotype: 48, XXX, +18

Clinical and postmortem findings of two cases with karyotype: 48, XXX, +18 are presented. In both patients the usual characteristics of trisomy 18 were found. Case 1 was complicated with congenital esophageal atresia, hypoplastic left auricle with external auditory canal atresia, left congenital dislocation of hip, and left club foot. The patient died on the 9th day after birth. Autopsy revealed mitral atresia, aortic stenosis, ventricular septal defect, patent ductus arteriosus, coarctation of aorta, bicuspid aortic and pulmonary valves, patent foramen ovale, and congenital esophageal atresia (type C). Case 2 died on the 8th day after birth. Postmortem examination revealed ventricular septal defect, but there was no other noteworthy malformation. Dermatoglyphic findings were more prominent on the right hand than the left. The severity of malformations may be biased to either the right or the left side.