Sentinel lymph node mapping with pathologic ultrastaging: A valuable tool for assessing nodal metastasis in low-grade endometrial cancer with superficial myoinvasion

Objective

To report the incidence of nodal metastases in patients presenting with presumed low-grade endometrioid adenocarcinomas using a sentinel lymph node (SLN) mapping protocol including pathologic ultrastaging.

Methods

All patients from 9/2005 to 12/2011 who underwent endometrial cancer staging surgery with attempted SLN mapping for preoperative grade 1 (G1) or grade 2 (G2) tumors with < 50% invasion on final pathology, were included. All lymph nodes were examined with hematoxylin and eosin (H&E). Negative SLNs were further examined using an ultrastaging protocol to detect micrometastases and isolated tumor cells.

Results

Of 425 patients, lymph node metastasis was found in 25 patients (5.9%) on final pathology—13 cases on routine H&E, 12 cases after ultrastaging. Patients whose tumors had a DMI < 50% were more likely to have positive SLNs on routine H&E (p < 0.005) or after ultrastaging (p = 0.01) compared to those without myoinvasion.

Conclusions

Applying a standardized SLN mapping algorithm with ultrastaging allows for the detection of nodal disease in a presumably low-risk group of patients who in some practices may not undergo any nodal evaluation. Ultrastaging of SLNs can likely be eliminated in endometrioid adenocarcinoma with no myoinvasion. The long-term clinical significance of ultrastage-detected nodal disease requires further investigation as recurrences were noted in some of these cases.     

Knowledge, Attitude and Practice of Contraception in Rural Kashmir

Background

Human fertility is determined by many factors such as customs, morals and habits of social groups with regard to marital obligation of life. Acceptance of family planning methods varies within and between societies and there are many factors which are responsible for such variation at community, family and individual level. Socioeconomic environment, culture and education are few of them that play a vital role. Jammu and Kashmir state in general and Kashmir valley in particular is a Muslim-dominated population with traditionally a conservative society. Apart from family customs and influence of the elders, religious background has always been behind the passive resistance, or at the best indifference towards contraception. This study makes an attempt to assess the knowledge, attitude and practice of contraception in rural Kashmir.

Objective

To assess the knowledge, attitude and practice of contraception in rural Kashmir.

Study Design

Community-based Cross-Sectional study.

Study period

December 2006 to May 2008.

Participants

1900 currently married women in the age group of 15–49 years of age.

Setting

Rural households.

Methods

1900 currently married women, aged 15–49 years, selected by multi-stage random sampling technique from three districts of Kashmir valley who were interviewed at home using a pretested oral questionnaire. The assessment of various socioeconomic and other variables made as per the available standard procedures and scales.

Analysis

Percentage, Chi square test and Bivariate analysis.

Results

Knowledge of the contraceptive methods was fairly good especially for terminal methods i.e. female sterilization (97.7 %). Main source of information on contraception was obtained from mass media (60.4 %). Contraceptive practice was significantly related to number of living children, literacy, socioeconomic status and type of family.

Conclusion

What is needed is to promote and stress contraceptive methods and their advantages using mass media approach and to explore more and more participation of private sector.     

A novel murine infection model for Shiga toxin–producing Escherichia coli

Enterohemorrhagic E. coli (EHEC) is an important subset of Shiga toxin–producing (Stx-producing) E. coli (STEC), pathogens that have been implicated in outbreaks of food-borne illness and can cause intestinal and systemic disease, including severe renal damage. Upon attachment to intestinal epithelium, EHEC generates “attaching and effacing” (AE) lesions characterized by intimate attachment and actin rearrangement upon host cell binding. Stx produced in the gut transverses the intestinal epithelium, causing vascular damage that leads to systemic disease. Models of EHEC infection in conventional mice do not manifest key features of disease, such as AE lesions, intestinal damage, and systemic illness. In order to develop an infection model that better reflects the pathogenesis of this subset of STEC, we constructed an Stx-producing strain of Citrobacter rodentium, a murine AE pathogen that otherwise lacks Stx. Mice infected with Stx-producing C. rodentium developed AE lesions on the intestinal epithelium and Stx-dependent intestinal inflammatory damage. Further, the mice experienced lethal infection characterized by histopathological and functional kidney damage. The development of a murine model that encompasses AE lesion formation and Stx-mediated tissue damage will provide a new platform upon which to identify EHEC alterations of host epithelium that contribute to systemic disease.     

Factors associated with the avoidance of red blood cell transfusion after hematopoietic stem cell transplantation

BACKGROUND: Red blood cell (RBC) transfusion is required frequently for most patients after hematopoietic stem cell transplantation (HSCT). RBC transfusion, however, can be associated with adverse events including transfusion reactions, acquiring transmissible disease, and delayed recovery. Factors associated with avoidance of transfusion are not well documented. STUDY DESIGN AND METHODS: Data concerning RBC transfusions between Day 0 and Day +30 were analyzed for patients undergoing HSCT at a single Canadian transplant center between January 2002 and December 2007. RESULTS: Of 555 patients undergoing HSCT with complete RBC transfusion data, 59 patients (10.6%) did not require RBC transfusion in the first 30 days after HSCT. Univariate analysis showed no significant difference in age, graft source, donor type, or conditioning regimen between transfused and nontransfused patients. Factors that were significantly associated with avoidance of transfusion included male sex (p = 0.0013), diagnosis, specifically plasma cell dyscrasias (p < 0.0001), early‐stage disease (p = 0.006), and higher baseline hemoglobin (Hb) at time of transplant (p < 0.0001). In multivariate analysis, higher pretransplant Hb, male sex, and early‐stage disease remained significantly associated with avoidance of RBC transfusion. Pretransplant Hb correlated inversely with the number of RBC transfusions (r = ?0.89). CONCLUSION: Increased pretransplant Hb, male sex, and early‐stage disease are associated with avoidance of RBC transfusion after HSCT. Interventions aimed at improving pretransplant Hb levels require further study.     

Couple functioning and post-traumatic stress symptoms in US Army couples: the role of resilience

The purpose of this study was to investigate combat-related post-traumatic stress symptoms (PTSS) and couple relationships in Army couples. US Army combat veteran couples (N = 66 couples) completed self-report questionnaires on couple functioning, coercion, resilience, and PTSS. In 23% of the couples (n = 15), both members had PTSS above the clinical cut-off for suspected Post-traumatic Stress Disorder (PTSD). Higher levels of PTSS were associated with lower couple functioning and resilience. Individuals with high resilience scores reported higher couple functioning scores, regardless of PTSS (p = .004). Future researchers should focus on the role of resilience in relation to couple functioning, and ways to amplify resilience in military couples.     

Congenital Insensitivity to Pain with Anhidrosis (HSAN Type IV), Extremely Rare Syndrome that Can Be Easily Missed by Bone and Joint Surgeons: A Case Report

Background

Congenital insensitivity to pain with anhidrosis is an extremely rare disorder in which injuries can often be missed by patient, parents and even by orthopedic surgeon. Pain and tenderness, on which a trauma team so much depends to make a clinical diagnosis and to decide whether to go for radiological evaluation can be misleading in this rare syndrome. So complete clinical examination still forms the corner stone to avoid misdiagnosis and pick up the rare disorders.

Case Presentation

We present a 5 year old girl child, who was brought to us as a case of one and a half month old neglected trauma left leg and was diagnosed to be suffering from congenital insensitivity to pain with anhidrosis (HSAN Type IV).

Conclusion

Congenital insensitivity to pain with anhidrosis is extremely rare entity, in which patients are subjected to repeated injuries which are often neglected. There is no specific treatment but patient training and parent education are key to avoid further neglect and damage.     

Detection of sentinel lymph nodes in minimally invasive surgery using indocyanine green and near-infrared fluorescence imaging for uterine and cervical malignancies

Objectives

Our primary objective was to assess the detection rate of sentinel lymph nodes (SLNs) using indocyanine green (ICG) and near-infrared (NIR) fluorescence imaging for uterine and cervical malignancies.

Methods

NIR fluorescence imaging for the robotic platform was obtained at our institution in 12/2011. We identified all cases planned for SLN mapping using fluorescence imaging from 12/2011–4/2013. Intracervical ICG was the fluorophobe in all cases. Four  cc (1.25 mg/mL) of ICG was injected into the cervix alone divided into the 3- and 9-o'clock positions, with 1 cc deep into the stroma and 1 cc submucosally before initiating laparoscopic entry. Blue dye was concurrently injected in some cases.

Results

Two hundred twenty-seven cases were performed. Median age was 60 years (range, 28–90 years). Median BMI was 30.2 kg/m² (range, 18–60 kg/m²). The median SLN count was 3 (range, 1–23 ). An SLN was identified in 216 cases (95%), with bilateral pelvic mapping in 179 (79%). An aortic SLN was identified in 21 (10%) of the 216 mapped cases. When ICG alone was used to map cases, 188/197 patients mapped, for a 95% detection rate compared to 93% (28/30) in cases in which both dyes were used (P = NS). Bilateral mapping was seen in 156/197 (79%) ICG-only cases and 23/30 (77%) ICG and blue dye cases (P = NS).

Conclusions

NIR fluorescence imaging with intracervical ICG injection using the robotic platform has a high bilateral SLN detection rate and appears favorable to using blue dye alone and/or other modalities. Combined use of ICG and blue dye appears unnecessary.     

Quantifying the risk of recurrence and death in stage III (FIGO 2009) endometrial cancer

Objective

Advanced endometrial cancer patients comprise a heterogeneous group. This study assessed the association of clinicopathological factors with relapse and death from endometrial cancer.

Methods

Eligible patients were treated for stage III (FIGO 2009) endometrial adenocarcinoma, had peritoneal cytology performed, and had no gross residual disease post-operatively.

Results

Of 192 patients, 59% were ≥ 60 years old, 48% had ≥ 50% myometrial invasion, 71% lymphovascular invasion, 25% cervical stromal invasion, 37% adnexal involvement, and 23% positive peritoneal cytology. High-grade histology (serous, clear cell, undifferentiated, or grade 3 endometrioid) was present in 45%. Pelvic lymphadenectomy was performed in 93% and para-aortic lymphadenectomy in 73%. Adjuvant chemotherapy and/or radiation therapy was administered to 93%. At a median follow-up of 42 months, the 5-year rate of relapse was 37% and of death from endometrial cancer was 30%. On multivariate analysis, both outcomes were associated with high-grade histology, positive peritoneal cytology, and deep myometrial invasion (p ≤ 0.04). The cohort was divided into subgroups of patients with 0 (n = 46), 1 (n = 83), or ≥ 2 (n = 63) of these high-risk characteristics. The 5-year relapse rate for patients with 0 risk factors was 13%, 1 risk factor was 27%, and ≥ 2 risk factors was 62% (p < 0.001). The corresponding 5-year rates of death from endometrial cancer were 11%, 20%, and 56%, respectively (p < 0.001).

Conclusions

Stratification of stage III endometrial cancer according to high-grade histology, positive peritoneal cytology, and deep myometrial invasion is useful for prognostication and may grant insight into the optimal treatment for specific subgroups of patients.     

Preconception care: delivery strategies and packages for care

The notion of preconception care aims to target the existing risks before pregnancy, whereby resources may be used to improve reproductive health and optimize knowledge before conceiving. The preconception period provides an opportunity to intervene earlier to optimize the health of potential mothers (and fathers) and to prevent harmful exposures from affecting the developing fetus. These interventions include birth spacing and preventing teenage pregnancy, promotion of contraceptive use, optimization of weight and micronutrient status, prevention and management of infectious diseases, and screening for and managing chronic conditions. Given existing interventions and the need to organize services to optimize delivery of care in a logical and effective manner, interventions are frequently co-packaged or bundled together. This paper highlights packages of preconception interventions that can be combined and co-delivered to women through various delivery channels and provides a logical framework for development of such packages in varying contexts.     

Antinociceptive activity of aerial parts of Polygonatum verticillatum: attenuation of both peripheral and central pain mediators

Polygonatum verticillatum All. is used traditionally as an analgesic and plant diuretic. The methanol extract of aerial parts of Polygonatum verticillatum (PA) was assessed in various experimental paradigms. The pain threshold in the form of abdominal constriction induced by acetic acid was significantly (p < 0.01) inhibited by PA at test doses (50, 100 and 200 mg/kg). In the formalin test, PA elicited a significant (p < 0.01) analgesic activity in both phases and strongly attenuated the formalin‐induced flinching behaviour. The hot plate test was used to evaluate central involvement in the analgesic profile of PA. The PA significantly relieved thermal‐induced pain. From a mechanistic point of view, the central antihyperalgesic activity was tested for antagonism with naloxone, but no antagonism was observed. The current investigations suggest that the active constituent(s) in PA has an analgesic profile with predominant peripheral activity which is augmented by an opioid independent central effect. In the diuretic assay, PA (300 and 600 mg/kg) showed mild insignificant diuretic activity. Our study rationalized the traditional use of Polygonatum verticillatum in the treatment of painful conditions. Copyright © 2011 John Wiley & Sons, Ltd.