Benign phyllodes tumour in a transgender woman receiving hormonal therapy.

We present a case of a transwoman taking hormonal feminisation therapy for over 20 years, who underwent surgical excision of a benign phyllodes tumour of the breast. Hormones progesterone and oestrogen act on breast epithelium to increase proliferation. For ciswomen, endogenous and exogenous oestrogen exposure over a lifetime is associated with increased risk for certain benign and malignant breast pathologies. Transwomen taking hormonal therapy may also be at an increased risk of breast disease.

Predictors of Breastfeeding among Women Admitted with Severe Preeclampsia Before 34 Weeks.

OBJECTIVE: Patients with severe preeclampsia (sPREX) face barriers to successful breastfeeding (BF), including an increased risk of maternal and newborn complications, prematurity, and low birth weight. Patients with early-onset sPREX (before 34 weeks' gestation) may be at even greater risk, yet there are little data available on factors associated with BF challenges in this population. We describe rates of BF initiation at hospital discharge and BF continuation at postpartum (PP) visit and identify factors associated with BF noninitiation and BF cessation among patients admitted with early-onset sPREX. STUDY DESIGN: Retrospective cohort study of women with sPREX admitted at less than 34 weeks' gestation to a single tertiary center (2013-2019). Demographic, antepartum, and delivery characteristics were evaluated. Factors associated with BF noninitiation at maternal discharge and with BF cessation at routine PP were assessed. Patients with intrauterine or neonatal demise and those missing BF data were excluded. Bivariate statistics were used to compare characteristics and Poisson regression was used to estimate relative risks (RR). RESULTS: Of 255 patients with early-onset sPREX, 228 (89.4%) had BF initiation at maternal hospital discharge. Initiation of BF occurred less frequently among patients with tobacco use in pregnancy (7.5 vs. 37.0%, χ2 p < 0.001, RR: 0.69 [95% confidence interval, CI: 0.52-0.92]). At 6 weeks' PP, 159 of 199 (79.9%) patients had BF continuation. Maternal age under 20 years (1.9 vs. 17.5%, χ2 p = 0.01, RR: 0.36 [95% CI: 0.14-0.91]) and experiencing maternal morbidity (25.2 vs. 45.0%, χ2 p = 0.01, RR: 0.80 [95% CI: 0.66-0.96]) were associated with BF cessation at the PP visit. CONCLUSION: Among patients with early sPREX, tobacco use in pregnancy was associated with noninitiation of BF at discharge, whereas young maternal age and maternal morbidity were associated with cessation of BF by routine PP visit. Further research is needed on how to support BF in this population, especially among patients with these associated factors. KEY POINTS: · Tobacco use was associated with BF noninitiation in patients with early preeclampsia.. · Maternal age < 20 and maternal morbidity were associated with BF cessation by PP visit.. · BF support for patients with risk factors is important for BF success PP..

Risk Factors for Adverse Maternal Outcomes among Patients with Severe Preeclampsia Before 34 Weeks.

OBJECTIVE: This study aimed to characterize rates of maternal morbidity associated with early (<34 wk) preeclampsia with severe features and to determine factors associated with developing these morbidities. STUDY DESIGN: Retrospective cohort study of patients with early preeclampsia with severe features at a single institution from 2013 to 2019. Inclusion criteria were admission between 23 and 34 weeks and diagnosis of preeclampsia with severe features. Maternal morbidity defined as death, sepsis, intensive care unit (ICU) admission, acute renal insufficiency (acute kidney injury [AKI]), postpartum (PP) dilation and curettage, PP hysterectomy, venous thromboembolism (VTE), PP hemorrhage (PPH), PP wound infection, PP endometritis, pelvic abscess, PP pneumonia, readmission, and/or need for blood transfusion. Death, ICU admission, VTE, AKI, PP hysterectomy, sepsis, and/or transfusion of >2 units were considered severe maternal morbidity (SMM). Simple statistics used to compare characteristics among patients experiencing any morbidity and those not. Poisson regression used to assess relative risks. RESULTS: Of 260 patients included, 77 (29.6%) experienced maternal morbidity and 16 (6.2%) experienced severe morbidity. PPH (n = 46, 17.7%) was the most common morbidity, although 15 (5.8%) patients were readmitted, 16 (6.2%) needed a blood transfusion, and 14 (5.4%) had AKI. Patients who experienced maternal morbidity were more likely to be advanced maternal age, have preexisting diabetes, have multiples, and deliver nonvaginally (all ps < 0.05). Diagnosis of preeclampsia < 28 weeks or longer latency from diagnosis to delivery were not associated with increased maternal morbidity. In regression models, the relative risk of maternal morbidity remained significant for twins (adjusted odds ration [aOR]: 2.57; 95% confidence interval [CI]: 1.67, 3.96) and preexisting diabetes (aOR: 1.64; 95% CI: 1.04, 2.58), whereas attempted vaginal delivery was protective (aOR: 0.53; 95% CI: 0.30, 0.92). CONCLUSION: In this cohort, more than 1 in 4 patients diagnosed with early preeclampsia with severe features experienced maternal morbidity, whereas 1 in 16 patients experienced SMM. Twins and pregestational diabetes were associated with higher risk of morbidity, whereas attempted vaginal delivery was protective. These data may be helpful in promoting risk reduction and counseling patients diagnosed with early preeclampsia with severe features. KEY POINTS: · One in four patients diagnosed with preeclampsia w/ severe features experienced maternal morbidity.. · One in 16 patients with preeclampsia w/ severe features experienced severe maternal morbidity.. · Factors most associated with morbidity/severe morbidity were twins and pregestational diabetes.. · Patients who attempted vaginal delivery appeared to have a lower rate of morbidity..

Arterial-colonic fistula secondary to colonic stent erosion into the left external iliac artery.

Self-expandable metal stent (SEMS) are widely utilized as a bridge to surgical intervention and for palliative treatment of malignant bowel obstructions. The risk of complications associated with SEMS is low in well-selected patients. Stent erosion is a rare but serious adverse event that is associated with high morbidity and mortality. Here, we report the case of a 74-year-old patient with a colonic obstruction secondary to a pelvic mass that was treated with SEMS and radiotherapy, who developed a partial thickness stent erosion and recurrent hematochezia 6 years after placement. Endoscopic retrieval was not technically feasible. During attempted surgical resection, massive hemorrhage occurred from a colonic-arterial fistula to the left external iliac artery resulting in death. While SEMS remain an effective, minimally invasive approach for the management of bowel obstructions, prolonged in-situ lifetime may confer an increased risk of serious adverse events including erosion and fistula formation.

Pregnancy outcomes among women with class III obesity with normal early glucola.

BACKGROUND: Because obese women are at increased risk for insulin resistance and development gestational diabetes (GDM), the American College of Obstetricians and Gynecologists (ACOG) recommends early GDM screening in this population. For obese women with a normal early 1-hour 50 g oral glucose challenge test (eGCT), the risk of developing GDM later in the pregnancy is unknown. Thus, we aimed to assess the risk of developing gestational diabetes based on the value of a normal eGCT. STUDY DESIGN: Retrospective cohort of non-anomalous singleton pregnancies with maternal body mass index (BMI) ≥40 at the time of entry to prenatal care at a single institution from 2013 to 2017. Pregnancies with abnormal early 1-hour 50 g glucose challenge test (eGCT), multiple gestation, late entry to care, type 1 or 2 diabetes, and missing diabetes-screening information are excluded. Primary outcome was development of GDM. Secondary outcomes include fetal growth restriction, macrosomia, gestational age at delivery, large for gestational age, delivery BMI, total weight gain in pregnancy, induction of labor, shoulder dystocia, and cesarean delivery. Bivariate statistics compare demographics, pregnancy complications and delivery characteristics of women who had an eGCT≤ 100 mg/dL (low-normal eGCT) and women who had an eGCT of 101-134 mg/dL (high-normal eGCT). Regression models used to estimate odds of primary outcome. RESULTS: Of 169 women, 66(39%) had a low-normal eGCT, and 103(61%) had a high-normal eGCT. Women in the low-normal eGCT group were more likely to use recreational drugs (p = 0.03), other baseline demographics did not differ. The rate of GDM was low in this population (5.3%), with no difference in the rate of GDM between with a low-normal eGCT (1.5%) and high-normal eGCT (7.7%) (p = 0.09). The median neonatal birthweight was higher in the high-normal GCT group (3405 g) as compared to the low-no GCT (3285 g) (p = 0.03). CONCLUSIONS: Among women with class 3 obesity, the specific value of an early normal GCT was not associated with developing gestational diabetes mellitus later in the pregnancy. Larger studies are needed confirm these findings.

Pregnancy Outcomes among Women with Class III Obesity with Pre-diabetic Early Hemoglobin A1C.

OBJECTIVE: We aimed to assess the risk of developing gestational diabetes mellitus (GDM) in women with a normal A1C (<5.7) compared with those with an A1C in the pre-diabetic range (5.7-6.4). STUDY DESIGN: This study comprises of a retrospective cohort of non-anomalous singleton pregnancies with maternal body mass index (BMI) ≥40 at a single institution from 2013 to 2017. Pregnancies with multiple gestation, late entry to care, type 1 or 2 diabetes, and missing diabetes-screening information were excluded. The primary outcome was development of GDM. Secondary outcomes included fetal growth restriction, macrosomia, gestational age at delivery, large for gestational age, delivery BMI at delivery, total weight gain in pregnancy, induction of labor, shoulder dystocia, and cesarean delivery. Bivariate statistics were used to compare demographics, pregnancy complications, and delivery characteristics of women who had an early A1C < 5.7 and A1C 5.7 to 6.4. Multivariable analyses were used to estimate the odds of the primary outcome. RESULTS: Eighty women (68%) had an early A1C <5.7 and 38 (32%) had a A1C 5.7 to 6.4. Women in the lower A1C group were less likely to be Black (45 vs. 74%, p = 0.01). No differences in other baseline demographics were observed. The median A1C was 5.3 for women with A1C < 5.7 and 5.8 for women with A1C 5.7 to 6.4 (p < 0.001). GDM was significantly more common in women with A1C 5.7 to 6.4 (3.8 vs. 24%, p = 0.002). Women with pre-diabetic range A1C had an odd ratio of 11.1 (95% CI 2.49-48.8) for GDM compared with women with a normal A1C. CONCLUSION: Women with class III obesity and a pre-diabetic range A1C are at an increased risk for gestational diabetes when compared with those with a normal A1C in early pregnancy. KEY POINTS: · One in 3 women with class III obesity had a pre-diabetic range early A1C.. · Class III obese women who have a pre-diabetic A1C have a higher risk of gestational diabetes.. · In this high-risk population, early A1C results in the pre-diabetic range are associated with higher rates of gestational diabetes..

Patterns of cervical cancer screening among Medicaid beneficiaries.

OBJECTIVE: Cervical cancer screening guidelines have evolved over time with the incorporation of human papillomavirus (HPV) testing along with cytology. Current screening guidelines recommend cytological screening every 3 years or HPV testing with or without cytology every 5 years in women age 30-65 years. We examined the use of cervical cancer screening among average-risk Medicaid beneficiaries. DESIGN: Retrospective cohort study. POPULATION: Women age 30-64 years at average risk for cervical cancer who underwent cervical cancer screening with cytology, co-testing or primary HPV testing from 2013 to 2016. METHODS: The IBM Watson Health Multi-State Medicaid MarketScan Database was used. Subsequent screening rates within 3 years of the index test were examined. MAIN OUTCOME MEASURE: The rate of repeat cervical cancer screening was analysed using a cumulative incidence function. RESULTS: A total of 265 083 patients were identified. Overall, 43.1% (n = 114 312) had index co-testing, 55.2% (n = 146 309) had cytology and 1.7% (n = 4462) had primary HPV testing. The cumulative incidence of early, repeat cervical cancer screening was 3.9% at 12 months, 22.7% at 24 months and 33.3% at 36 months. During the period from 12 to 24 months after follow up, 20.9% of women underwent repeat screening while 19.4% underwent repeat screening 24-36 months after the index test. Among women who did not undergo repeat cervical cancer screening, a yearly gynaecological examination was performed in only 16 627 (10.7%) during year 2 and in 11 116 (8.8%) during year 3. CONCLUSION: Among average-risk Medicaid beneficiaries, cervical cancer screening is frequently overused. Women who do not undergo cervical cancer screening are unlikely to undergo routine gynaecological examination. TWEETABLE ABSTRACT: Among average-risk Medicaid beneficiaries, cervical cancer screening is frequently overused.

Incidence and Risk Factors for Postpartum Depression among Women with Preterm Prelabor Rupture of Membranes.

OBJECTIVE: Patients admitted for preterm prelabor rupture of membranes are more likely to have risk factors for postpartum depression, including preterm delivery, low-birthweight infants, and a stressful life event. However, there is a paucity of data characterizing the development of postpartum depression in this population. We aim to evaluate the incidence of and describe risk factors for postpartum depression among patients admitted with preterm prelabor rupture of membranes. STUDY DESIGN: This is a retrospective cohort study of patients admitted for preterm prelabor rupture of membranes in a single health system between 2013 and 2019. Patients who developed depression were compared with patients who did not develop depression. Demographic, antepartum/intrapartum/postpartum, and neonatal characteristics were compared. Bivariate statistics were used to compare outcomes and logistic regression was used to estimate adjusted odds ratios. RESULTS: Of 132 included patients with preterm prelabor rupture of membranes, 25 (18.9%) had postpartum depression. Factors significantly (p < 0.05) associated with postpartum depression included history of depression, anxiety, or any prior mental health condition. Earlier admission gestational age, rupture of membranes < 28 weeks, earlier delivery gestational age, neonatal morbidity, and neonatal necrotizing enterocolitis also were significantly associated with postpartum depression. Latency, maternal postpartum length of stay, and neonatal intensive care unit length of stay were not significantly associated. In regression models, only a history of depression (odds ratio [OR], 11.89; 95% confidence interval [CI], 2.78-50.95) and neonatal morbidity (OR, 5.01; 95% CI, 1.15-21.89) remained associated with postpartum depression. CONCLUSION: Postpartum depression occurred in nearly one in five patients with preterm prelabor rupture of membranes. Pre-existing depression and adverse neonatal outcomes strongly predicted postpartum depression. There is an urgent need to prioritize maternal mental health among patients with preterm prelabor rupture of membranes in the peripartum period. Further research is needed to identify optimal resources for mitigating the risk of postpartum depression in this cohort. KEY POINTS: · After PPROM, postpartum depression is common.. · Maternal depression and neonatal morbidity are risk factors for PPD.. · Hospital admission permits intervention for PPD..

Disparities in Genetic Testing for Heritable Solid-Tumor Malignancies.

Genetic testing offers providers a potentially life saving tool for identifying and intervening in high-risk individuals. However, disparities in receipt of genetic testing have been consistently demonstrated and undoubtedly have significant implications for the populations not receiving the standard of care. If correctly used, there is the potential for genetic testing to play a role in decreasing health disparities among individuals of different races and ethnicities. However, if genetic testing continues to revolutionize cancer care while being disproportionately distributed, it also has the potential to widen the existing mortality gap between various racial and ethnic populations.

Mortality in Older Patients with Breast Cancer Undergoing Breast Surgery: How Low is "Low Risk"?

BACKGROUND: Breast surgery carries a low risk of postoperative mortality. For older patients with multiple comorbidities, even low-risk procedures can confer some increased perioperative risk. We sought to identify factors associated with postoperative mortality in breast cancer patients ≥70 years to create a nomogram for predicting risk of death within 90 days. METHODS: Patients diagnosed with nonmetastatic invasive breast cancer (2010-2016) were selected from the National Cancer Database. Unadjusted OS was estimated using the Kaplan-Meier method. Multivariate logistic regression was used to estimate the association of age and surgery with 90-day mortality and to build a predictive nomogram. RESULTS: Among surgical patients ≥70 years, unadjusted 90-day mortality increased with increasing age (70-74 = 0.4% vs. ≥85 = 1.6%), comorbidity score (0 = 0.5% vs. ≥3 = 2.7%), and disease stage (I = 0.4% vs. III = 2.7%; all p < 0.001). After adjustment, death within 90 days of surgery was associated with higher age (≥85 vs. 70-74: odds ratio [OR] 3.16, 95% confidence interval [CI] 2.74-3.65), comorbidity score (≥3 vs. 0: OR 4.79, 95% CI 3.89-5.89), and disease stage (III vs. I: OR 4.30, 95% CI 3.69-5.00). Based on these findings, seven variables (age, gender, comorbidity score, facility type, facility location, clinical stage, and surgery type) were selected to build a nomogram; estimates of risk of death within 90 days ranged from <1 to >30%. CONCLUSIONS: Breast operations remain relatively low-risk procedures for older patients with breast cancer, but select factors can be used to estimate the risk of postoperative mortality to guide surgical decision-making among older women.