Mortality in Puerto Rico after Hurricane Maria.

BACKGROUND: Quantifying the effect of natural disasters on society is critical for recovery of public health services and infrastructure. The death toll can be difficult to assess in the aftermath of a major disaster. In September 2017, Hurricane Maria caused massive infrastructural damage to Puerto Rico, but its effect on mortality remains contentious. The official death count is 64. METHODS: Using a representative, stratified sample, we surveyed 3299 randomly chosen households across Puerto Rico to produce an independent estimate of all-cause mortality after the hurricane. Respondents were asked about displacement, infrastructure loss, and causes of death. We calculated excess deaths by comparing our estimated post-hurricane mortality rate with official rates for the same period in 2016. RESULTS: From the survey data, we estimated a mortality rate of 14.3 deaths (95% confidence interval [CI], 9.8 to 18.9) per 1000 persons from September 20 through December 31, 2017. This rate yielded a total of 4645 excess deaths during this period (95% CI, 793 to 8498), equivalent to a 62% increase in the mortality rate as compared with the same period in 2016. However, this number is likely to be an underestimate because of survivor bias. The mortality rate remained high through the end of December 2017, and one third of the deaths were attributed to delayed or interrupted health care. Hurricane-related migration was substantial. CONCLUSIONS: This household-based survey suggests that the number of excess deaths related to Hurricane Maria in Puerto Rico is more than 70 times the official estimate. (Funded by the Harvard T.H. Chan School of Public Health and others.).

The Rohingya people of Myanmar: health, human rights, and identity.

The Rohingya people of Myanmar (known as Burma before 1989) were stripped of citizenship in 1982, because they could not meet the requirement of proving their forefathers settled in Burma before 1823, and now account for one in seven of the global population of stateless people. Of the total 1·5 million Rohingya people living in Myanmar and across southeast Asia, only 82 000 have any legal protection obtained through UN-designated refugee status. Since 2012, more than 159 000 people, most of whom are Rohingya, have fled Myanmar in poorly constructed boats for journeys lasting several weeks to neighbouring nations, causing hundreds of deaths. We outline historical events preceding this complex emergency in health and human rights. The Rohingya people face a cycle of poor infant and child health, malnutrition, waterborne illness, and lack of obstetric care. In December, 2014, a UN resolution called for an end to the crisis. We discuss the Myanmar Government's ongoing treatment of Rohingya through the lens of international law, and the steps that the newly elected parliament must pursue for a durable solution.

Adolescents and the right to health: eliminating age-related barriers to HIV/AIDS services in Rwanda.

Under international, regional, and domestic law, adolescents are entitled to measures ensuring the highest attainable standard of health. For HIV/AIDS, this is essential as adolescents lack many social and economic protections and are disproportionately vulnerable to the effects of the disease. In many countries, legal protections do not always ensure access to health care for adolescents, including for HIV/AIDS prevention, treatment, and care. Using Rwanda as an example, this article identifies gaps, policy barriers, and inconsistencies in legal protection that can create age-related barriers to HIV/AIDS services and care. One of the most pressing challenges is defining an age of majority for access to prevention measures, such as condoms, testing and treatment, and social support. Occasionally drawing on examples of existing and proposed laws in other African countries, Rwanda and other countries may strengthen their commitment to adolescents' rights and eliminate barriers to prevention, family planning, testing and disclosure, treatment, and support. Among the improvements, Rwanda and other countries must align its age of consent with the actual behavior of adolescents and ensure privacy to adolescents regarding family planning, HIV testing, disclosure, care, and treatment.

Abdominal radical trachelectomy: Success and pitfalls in a general gynecologic oncology practice.

OBJECTIVE: To report our successes and complications with a series of abdominal radical trachelectomies performed to preserve fertility in young women at the Massachusetts General Hospital (MGH). METHODS: Institutional review board (IRB) permission was obtained for retrospective record review. Data were collected regarding patient age and parity, tumor stage and histology, surgical time and complications, post-operative complications, follow-up, and pregnancy. RESULTS: Ten patients underwent radical abdominal trachelectomy, 9 by the same surgeon (LD). Surgery was essentially identical to that of radical hysterectomy with the exception of re-anastomosis of the uterine fundus to the vagina and placement of cerclage. Pre-operative evaluation and post operative follow-up was for the most part identical for all patients. Two patients achieved pregnancy, with 1 twin delivery and 1 patient had 2 pregnancies. Two patients experienced cervical stenosis with regular menses and the same 2 patients passed their abdominal cerclage vaginally. To date there have been no cancer recurrences. Pap smear follow-up has been complicated by difficulty in reading smears from the lower uterine segment (LUS). CONCLUSION: Radical abdominal trachelectomy can be successfully performed by any gynecologic oncologist who is trained in radical pelvic surgery. Pre-operative counseling is crucial in obtaining informed consent. Patients must be aware of potential post-operative complications, including pre-term delivery. Cytology department needs to be aware of potential pitfalls in reading Pap smears from the LUS.

Surgical management of the subdiaphragmatic mass: a sequential combined approach with laparoscopy followed by posterior thoracotomy.

Recurrent ovarian cancer in the upper abdomen involving the liver parenchyma and diaphragmatic muscle traditionally requires a major abdominal surgical procedure; this involves pubis to xyphoid incision and complete mobilization of the liver. We present a strategy for evaluating 4 cases with apparently isolated recurrence to the diaphragm and liver approached by a sequential 2-phase procedure, involving diagnostic laparoscopy and subsequent posterior lateral thoracotomy. Preliminary diagnostic laparoscopy was performed to distinguish candidates for either definitive laparoscopic treatment or posterior thoracotomy. Two patients with disease confined to the diaphragm were successfully treated by laparoscopy alone, whereas full-thickness diaphragmatic resection and liver metastasis excision with cavitational ultrasonic surgical aspirator was performed in the other 2 patients. Argon beam coagulation was used to control local hemostasis and to fulgurate any possible residual tumor at the margin of resection. This is a multidisciplinary approach that is technically feasible and safe, requiring a short hospital stay.

Utilization of primary health care services among Syrian refugee and Lebanese women targeted by the ICRC program in Lebanon: a cross-sectional study.

BACKGROUND: The Syrian crisis has put tremendous strain on the Lebanese health system, particularly in the historically underserved border region. The ICRC Primary Health Care program has focused on refugee and host communities in these areas. This study objectives were: 1) to determine whether the ICRC program was reaching the most vulnerable populations; 2) to understand the key perceived health needs in the catchment areas of the ICRC supported facilities; and 3) to identify barriers to utilization of health care services. METHODS: Between July and September 2017 we conducted two cross-sectional studies - one randomized household survey and one clinic-based - in the catchment areas of three ICRC-supported facilities, targeting women of reproductive age and caretakers of children under five. Differences between groups were analysed with t-test or chi-squared test. RESULTS: In the household survey, similar socio-demographic profiles were observed between Syrian refugee women and vulnerable Lebanese hosts. With regard to the study objectives:The most vulnerable populations were those seen in the ICRC-supported facilities.For both populations, the most common reasons for seeking care were non-communicable diseases (40.6%) and sexual and reproductive health issues (28.6%). Yet the people reaching the ICRC supported facilities were more likely to seek care for communicable diseases affecting their children (37.8%), rather than for the most common reasons expressed in the household survey.In the catchment areas, reported gaps included low immunization coverage and low levels of antenatal care and family planning both for Syrian and Lebanese. Dental care also emerged as an issue. Out of pocket expenditures was reported as a critical barrier for utilization of primary health care services for both populations, while the most important barrier for utilization of ICRC-supported services was lack of awareness. CONCLUSIONS: Despite the ICRC reaching the most vulnerable Syrian and Lebanese communities, the population-based survey revealed that important gaps exist in terms of utilization of health care services among women of reproductive age and their children. A stronger outreach component is needed to address lack of awareness. Innovative solutions are also needed to address cost barriers at the levels of both facility and individual user.

PET-CT vs. CT alone in ovarian cancer recurrence.

BACKGROUND: To compare fusion, positron emission tomography-computed tomography (PET-CT) with CT alone in detecting ovarian carcinoma recurrence. METHODS: Fifty-one consecutive patients underwent 53 restaging PET-CT scans with a concurrent diagnostic quality CT scan. Two body imaging radiologists independently assessed the CT's; each then teamed with a nuclear medicine specialist to review the PET-CT's. Two teams conferred for consensus on the presence of disease in the chest, abdomen, and body overall with CT alone and with PET-CT, using a six-point reader confidence metric to determine accuracy and receiver operating characteristic (ROC) curves. Reader agreement was compared using kappa. Recurrence was determined by two gynecologic oncologists reviewing clinical records from time of presentation to at least 13 months (mean 22.7) after imaging. RESULTS: Recurrence was based on histopathology in 17% (9/53). Seventy-two percent (38/53) cases had recurrence, with two cases showing isolated chest recurrence. PET-CT accuracy exceeded CT for body 92% (49/53) vs. 83% (44/53), chest 96% (51/53) vs. 89% (47/53), and abdomen 91% (48/53) vs. 79% (42/53). ROC curves for PET-CT dominated that for CT alone; this difference was statistically significant for abdomen and for body overall (P < 0.01). Interobserver agreement was better for PET-CT than for CT alone. CONCLUSIONS: PET-CT demonstrates greater accuracy and less interobserver variability than CT alone.

The Rohingya in Cox's Bazar: When the Stateless Seek Refuge.

The Rohingya people of Myanmar have been subject to human rights violations through government-sponsored discrimination and violence. Since August 2017, an intensified assault by Myanmar authorities has resulted in a rapid increase of Rohingya pouring into Bangladesh, and the expansion of refugee settlements in the district of Cox's Bazar has strained humanitarian and government relief efforts. Assessing Rohingya and host community needs is critical for prioritizing resource allocations and for documenting the rights violations suffered by Rohingya refugees. From March 15 to 18, 2018, we conducted a rapid needs assessment of recently arrived Rohingya and host community households. We collected data on demographics, mortality, education, livelihoods, access to food and water, vaccination, and health care. Among other things, our survey found high levels of mortality among young Rohingya men, alarmingly low levels of vaccination among children, poor literacy, and rising poverty. Denied formal refugee status, the Rohingya cannot access due protections and find themselves in a state of insecurity in which they are unsure of their future and unable to formally seek work or send their children to school. While the government of Bangladesh explores the options of repatriation, relocation, and third-country resettlement for these refugees, it is important to ensure that they are not denied a life of dignity.

Uterine smooth-muscle tumors with unusual growth patterns: imaging with pathologic correlation.

OBJECTIVE: This essay illustrates the salient features of variant smooth-muscle tumors on multiple imaging techniques with correlative pathology. We describe how recognition of these features allows the radiologist to distinguish a uterine leiomyoma variant from the classic fibroid or a leiomyosarcoma. Finally, we highlight the role of the radiologist in triaging these patients to surgical versus medical management and in surgical planning. CONCLUSION: Parasitic leiomyoma, intravenous leiomyomatosis, disseminated peritoneal leiomyomatosis, and benign metastasizing leiomyoma show key features on multiple imaging techniques that correlate with pathology findings. In the appropriate clinical setting, the radiologist should include these unusual lesions in the broader differential diagnosis of smooth-muscle tumors and, in certain cases, aid in surgical planning.

Long-acting octreotide for the treatment and symptomatic relief of bowel obstruction in advanced ovarian cancer.

Symptoms of malignant bowel obstruction in patients with recurrent ovarian cancer lead to a poor quality of life. Sandostatin LAR Depot (LAR) is an intramuscular, monthly administered, long-acting form of octreotide. LAR's safety and utility were evaluated in a pilot study enrolling 15 advanced ovarian cancer patients with bowel dysfunction. Once safety with subcutaneous (SQ) octreotide was assessed, patients were given 30 mg LAR on Day 1 and octreotide SQ for 2 weeks. Of 13 evaluable patients, three patients had a major response to LAR treatment with reduction in bowel obstruction symptoms, two had a minor response, four had no response, and four had progressive symptoms. Three patients remained on LAR for more than 9 months. No significant toxicities were attributable to octreotide or LAR. Because three patients received nine or more monthly injections of LAR, possible direct antitumor effects of LAR or synergy with chemotherapy needs to be explored.

Intraoperative radiation therapy in the management of gynecologic and genitourinary malignancies.

Women with locally advanced primary or recurrent gynecologic malignancies have a poor prognosis. The doses of external radiation necessary to treat gross or microscopic recurrent disease in patients previously irradiated exceed the doses tolerated by normal tissue [1,3-5]. IORT has been added to the treatment armamentarium in this group of patients to maximize local control and minimize the radiation exposure to dose-limiting surrounding structures. In addition, IORT may improve the long-term local control and the overall survival rates in women with pelvic sidewall or para-aortic nodal recurrence [1,4,5]. The most encouraging results are seen in cases of microscopic residual disease following surgical debulking [4,6]. In gynecologic malignancies, IORT has served to reiterate the importance of optimal surgical resection. Higher 5-year disease-free and overall survival rates have been documented in women who have microscopic residual disease, compared with those who have gross residual disease [1,3-6]. IORT in the management of GU malignancies has not been used extensively. In RCC, where surgery alone often results in suboptimal treatment results, IORT seems to be well tolerated and controls local disease [2,27,29,30]. Because of the chemoresistant nature of RCC, IORT may play an important role in the future in the management of locally advanced and recurrent RCC. In bladder cancer, IORT had been used in combination with chemotherapy and EBRT, as part of bladder-sparing protocols. The data suggest that IORT in this patient population is also well tolerated, and may become more widely used as less radical surgical procedures gain clinical importance. IORT in the treatment of prostate and testicular cancers has not been used frequently, given the highly efficacious treatment modalities currently available to treat these malignancies. A review of institutional experiences with IORT may allow the establishment of guidelines for patient selection. These criteria, in turn, may be useful in the design of clinical trials. The construction, execution, and evaluation of clinical trials are mandatory to adequately assess the role of IORT in the treatment of patients with gynecologic and GU malignancies.

Closing the implementation gap in services for children affected by HIV/AIDS: from assisting orphans and vulnerable children (OVC) to providing long-term opportunities for economic growth.

While delivering innovative care for over 17 million children living with and affected by HIV/AIDS is a priority for today's global health community, most of these children's health needs remain unmet. Concerns about funding, implementation, and transparency continue to obstruct quality care for all. This paper discusses why services supported by macro-level funding, local initiatives, innovative financing, and enhanced long-term development strategies, are imperative. Concurrent advocacy and preventive measures, such as universal access to education, can sustain this investment in human capital. Such efforts may enhance economic growth, expand local capacity, and improve the quality of life in communities currently burdened by the HIV epidemic.

Ten-year follow-up of a phase 2 study of dose-intense paclitaxel with cisplatin and cyclophosphamide as initial therapy for poor-prognosis, advanced-stage epithelial ovarian cancer.

BACKGROUND: The objective of this study was to assess activity and toxicity in patients with newly diagnosed, advanced-stage epithelial ovarian cancer (EOC) who were receiving dose-intense paclitaxel, cyclophosphamide, cisplatin, and filgrastim delivered with a flexible dosing schedule. METHODS: Patients with stage III/IV EOC received cyclophosphamide 750 mg/m(2), followed by a 24-hour infusion of paclitaxel 250 mg/m(2) and cisplatin 75 mg/m(2) on Day 2. Filgrastim began on Day 3 at 10 microg/kg daily for 9 days. Patients received 6 cycles of all drugs. Those who achieved a pathologic complete response or had microscopic residual disease at the conclusion of 6 cycles of therapy received an additional 2 to 4 cycles of paclitaxel with cyclophosphamide. Patients who had an objective response continued on cyclophosphamide and paclitaxel. RESULTS: Sixty-two patients were enrolled. Thirty-two of 62 patients had stage IIIC disease, and 26 of 62 patients had stage IV disease. According to an intent-to-treat analysis, 55 patients (89%) experienced a clinical complete remission. At a median potential follow-up of 11.4 years, the median progression-free survival was 18.9 months, and the median survival was 5.4 years. The most serious toxicity was grade 3/4 neutropenic fever (35%). Although all participants developed peripheral neuropathy, improvement in neuropathic symptoms began with the decrease or cessation of paclitaxel. CONCLUSIONS: The studied regimen yielded a high response rate and encouraging overall survival. The current data and those reported by the Japanese Gynecologic Oncology Group suggest that further study is warranted of dose-dense or dose-intense paclitaxel regimens in women with newly diagnosed, advanced-stage EOC.

Epithelioid angiosarcoma of the uterus: a review of management.

BACKGROUND: Uterine epithelioid angiosarcoma is extremely rare. Evidence-based advice regarding optimal management is lacking. METHOD: We report the 22nd case in the world literature and review all the cases reported in English since 1900. An attempt is made to generate information that may help in the management based on the available literature. RESULTS: A 54-year-old woman was found to have an enlarged uterus on routine clinical examination. Although, she had no other symptoms, an endometrial biopsy was performed, which indicated a high-grade sarcoma. She was taken for a total abdominal hysterectomy and bilateral salpingo-oophorectomy and final histology returned a diagnosis of epithelioid angiosarcoma of the uterus. Two months later, she had tumor recurrence and was started on gemcitabine and taxotere later changed to albumin-bound paclitaxel (ABI-007, Abraxane) and bevacizumab. She was still alive with no evidence of disease at the time of this report, 12 months after diagnosis. Literature review suggests that surgical resection followed by chemotherapy is a reasonable management approach. CONCLUSION: Uterine epithelioid angiosarcoma is an uncommon but very aggressive disease. Surgical resection followed by sequential chemotherapy is a reasonable management approach, and modern chemotherapy and anti-angiogenic agents may have merit.

Hope.

Shortly before his death in 1995, Kenneth B. Schwartz, a cancer patient at Massachusetts General Hospital (MGH), founded The Kenneth B. Schwartz Center at MGH. The Schwartz Center is a nonprofit organization dedicated to supporting and advancing compassionate health care delivery that provides hope to the patient, support to caregivers, and encourages the healing process. The Center sponsors the Schwartz Center Rounds, a monthly multidisciplinary forum where caregivers reflect on important psychosocial issues faced by patients, their families, and their caregivers, and gain insight and support from fellow staff members. A patient with recurrent ovarian cancer, now in a 12-year remission after recurrence, and her surgeon, discussed their experiences and feelings around the hopes and fears of cancer and its treatment. Hope sustains many through dark times, and is at the core of the wonderful resilience of many who wrestle with cancer. Concerns about false hope, unrealistic expectations, assumptions, engaging in realistic hopefulness, and the joys and stresses embodied in hope and how they frame the caregiver-patient relationship are discussed. The literature and limited evidence base are reviewed.

A new prognostic model for FIGO stage 1 epithelial ovarian cancer.

BACKGROUND: No consensus exists which patients with surgical stage 1 epithelial ovarian should receive postoperative chemotherapy. The purpose of this study was to evaluate the prognostic impact of preoperative CA-125 and to establish a prognostic index to identify patients in different risk categories. METHODS: Data of 600 surgically staged patients with FIGO stage 1 EOC treated in eleven gynecological cancer centers in Australia, the USA and Europe were analyzed. Eligible patients include those with invasive EOC where a preoperative CA-125 was obtained and standard surgical staging performed. Overall survival (OS) was chosen as study endpoint. Preoperative CA-125 values were compared with other prognostic factors, and univariate and multivariate Cox models were calculated. RESULTS: Two hundred and one patients (33.5%) had preoperative CA-125 < or =30 U/ml and CA-125 levels < or =30 U/ml were associated with lower grade, sub-stage 1A and mucinous histologic cell type. Patients with elevated CA-125 levels were more likely to receive chemotherapy. OS probability was 95% and 85% for patients with pretreatment CA-125 < or =30 U/ml and >30 U/ml, respectively (p 0.003). Multivariate analysis confirmed preoperative serum CA-125 >30 U/ml (OR 2.7) and age at diagnosis >70 years (OR 2.6) as the only independent predictors for overall survival. CONCLUSION: Pretreatment of CA-125 < or =30 U/ml dominates over histologic cell type, sub-stage and grade to identify a subgroup of FIGO stage 1 patients with a genuinely good prognosis with extremely good survival and who could possibly be spared with adjuvant chemotherapy.

Reclassification of a tubal leiomyosarcoma as an eGIST by molecular evaluation of c-KIT.

BACKGROUND: Extragastrointestinal stromal tumors (eGISTs) are rare mesenchymal-derived tumors arising outside of the GI tract. eGISTs are often histologically confused with leiomyosarcoma. Distinction between eGIST and leiomyosarcoma is critical because of the unique responsiveness of eGISTs to the molecularly targeted agent imatinib. CASE: A woman presented with a history of tubal spindle cell tumor that was initially diagnosed and treated as a leiomyosarcoma. Because of minimal response to sarcoma directed chemotherapy, the possibility that the tumor was in fact an eGIST was investigated and supported by immunohistochemical and mutational analyses of the c-Kit receptor tyrosine kinase. The patient currently has stable disease control on imatinib for the last 18 months. CONCLUSIONS: The possibility of eGIST should be considered in the differential diagnosis of tumors with a spindle cell morphology in the gynecologic tract especially when involving the ovary, fallopian tube, or uterine serosa.

The treatment of uterine leiomyosarcoma. Results from a 10-year experience (1990-1999) at the Massachusetts General Hospital.

OBJECTIVE: Uterine leiomyosarcomas (LMS) are rare tumors with a poor prognosis. The purpose of this study is to review the presentation, therapy and outcome of patients with leiomyosarcoma originating from the uterus treated at the Massachusetts General Hospital from 1990 to 1999. METHODS: A retrospective chart review was done to patients treated for uterine leiomyosarcoma during the study period. One author reviewed all available histologic specimens. Statistical analysis was done to determine whether there is an association between histologic criteria or therapy used and overall survival. RESULTS: Forty-seven charts were reviewed to identify 27 patients with leiomyosarcoma arising from the uterus treated in the decade from 1990 to 1999. Most patients received multimodality therapy with surgery followed by chemotherapy and/or radiotherapy. Patients who had no visible disease at the conclusion of primary surgery had a better overall survival than patients who did not achieve surgical remission (P < 0.0003). There is a trend toward improved survival in patients with lower number of mitotic figures per 10 high-power fields (P = 0. 062). Current chemotherapy drugs were minimally effective with 80% of treated patients having progression of disease. Adjuvant therapy after optimal cytoreduction does not decrease the rate of recurrence. CONCLUSION: Uterine leiomyosarcoma continues to be a deadly disease. Aggressive surgical cytoreduction at the time of initial diagnosis offers the possibility of prolonged survival or cure.