Effectiveness of preoperative multimedia educational sessions on the levels of anxiety and satisfaction among women undergoing cesarean: a systematic review and meta-analysis.

This systematic review and meta-analysis aimed to explore the effectiveness of preoperative multimedia educational sessions on the levels of anxiety and satisfaction among women undergoing cesarean section (CS). The Scopus, PubMed, and Cochrane databases were searched without language limitations for eligible randomized controlled trials (RCTs) published from their inception up to October 15, 2023. A random-effect meta-analysis was conducted, and the quality of this meta-analysis was evaluated using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach. Seven RCTs (n = 1006 women) met the inclusion criteria. Preoperative multimedia sessions were found to significantly reduce anxiety levels (n = 6 RCTs, weighted mean difference: -3.10; 95 percent confidence intervals (CI): -4.48, -1.73; I2 = 44.24 percent, moderate certainty of evidence) compared to the control group. However, there was no significant difference between the two groups regarding women's satisfaction after surgery (n = 5 RCTs, risk ratio: 1.37; 95 percent CI: 0.76, 2.50; I2 = 98.26 percent, moderate certainty of evidence). Leave-one-out sensitivity analysis showed robustness of the outcomes. The findings of this meta-analysis suggest that providing multimedia educational programs before surgery could potentially have a beneficial effect on the levels of anxiety experienced by women undergoing CS. However, it is imperative to validate these results through larger samples and multi-centered RCTs.

Association between endometriosis and obstetric complications: Insight from the National Inpatient Sample.

OBJECTIVE: This study aimed to investigate the relationship between endometriosis and adverse obstetric outcomes using data from the National Inpatient Sample (NIS) database. METHODS: The ICD-10 coding system was used to identify codes for endometriosis and obstetric outcomes, and data from the NIS (2016-2019) were analyzed. Descriptive statistics were used to summarize variables, while the chi-square test was used to detect significant differences for categorical variables. Univariate and multivariate regression analyses were conducted to assess the association between endometriosis and obstetric outcomes. On multivariate analysis, adjustment was done for age, race, hospital region, smoking status, and alcohol misuse. Forest plots were used to visualize odds ratios and their 95% confidence intervals. RESULTS: Overall, 2,854,149 women were included in this analysis, of whom 4,006 women had endometriosis. The post-hoc Bonferroni correction was applied to account for multiple comparisons, and our analyses revealed several statistically significant associations (p < 0.004). Specifically, on univariate analysis, significant associations with endometriosis were identified for ruptured uterus, placenta previa, placental abruption, postpartum hemorrhage, preeclampsia, amniotic fluid abnormality, gestational diabetes, preterm labor, and multiple gestation. On multivariate analysis, significant associations with endometriosis were observed for placenta previa, placental abruption, postpartum hemorrhage, preeclampsia, amniotic fluid abnormality, preterm labor, premature rupture of membranes, and multiple gestation. CONCLUSION: The present findings provide important insights into the potential relationship between endometriosis and various adverse obstetric outcomes and may help inform clinical practice and future research. Further studies that use more detailed clinical data and longitudinal designs are needed to solidify the presented conclusions.

Comparison of Letrozole and Clomiphene Citrate in Pregnancy Outcomes in Patients with Polycystic Ovary Syndrome: A Systematic Review and Meta-analysis.

Clomiphene citrate (CC) and letrozole are the predominant medical interventions for the management of infertility in patients with polycystic ovary syndrome (PCOS). To comprehensively summarize the evidence, a systematic review and meta-analysis of randomized clinical trials (RCTs) was carried out to assess the effect of letrozole and CC on pregnancy outcomes in PCOS patients. We searched PubMed/MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials from inception to January 2023. We included RCTs conducted on PCOS women comparing letrozole to CC and assessing endometrial thickness, the number and size of follicles, and ovulation and pregnancy rates. The endpoints were summarized as risk ratio (RR) or standardized mean difference (SMD) with 95% confidence interval (CI) using the random-effects model. Heterogeneity was examined using the I2 statistic. Fifty trials met our inclusion criteria. The mean endometrial thickness was significantly higher in the letrozole group compared to CC group (SMD: 0.89; 95% CI: 0.49, 1.28; I2=97.72%); however, the number of follicles was higher in the CC group (SMD: -0.56; 95% CI: -0.96, -0.17; I2=96.34%). Furthermore, letrozole intake induced higher ovulation rate (RR: 1.20; 95% CI: 1.13, 1.26; I2=54.49%) and pregnancy rate (RR: 1.44; 95% CI: 1.28, 1.62; I2=65.58%) compared to CC. Compared to CC, letrozole has a positive effect on endometrial thickness, monofollicular development, and ovulation and pregnancy rates suggesting that letrozole may be a strong alternative to CC as a first-line medical intervention for chronic anovulation in PCOS women. Larger studies are warranted to further clarify these findings.

Tranexamic acid versus misoprostol for management of postpartum hemorrhage: A systematic review and meta-analysis of randomized controlled trials.

AIM: To conduct the first-ever systematic review and meta-analysis of randomized controlled trials (RCTs) on the antihemorrhagic utility and safety of tranexamic acid (TXA) versus misoprostol for management (prevention and/or treatment) of postpartum hemorrhage (PPH). METHODS: Six databases were screened from inception until May 2023 and updated in September 2023. The RCTs were assessed for quality according to the Cochrane's risk of bias tool. The endpoints were summarized as mean difference (MD) or risk ratio (RR) with 95% confidence interval (CI) in a random-effects model. RESULTS: Ten RCTs with 2121 patients (TXA = 1061 and misoprostol = 1060) were analyzed. There was no significant difference between TXA and misoprostol groups regarding the mean intraoperative blood loss (n = 9 RCTs, MD = 17.32 ml, 95% CI [-40.43, 75.07], p = 0.56), mean change in hemoglobin (n = 6 RCTs, MD = 0.11 mg/dl, 95% CI [-0.1, 0.31], p = 0.30), mean hospital stay (n = 2 RCTs, MD = -0.3 day, 95% CI [-0.61, 0.01], p = 0.06), blood transfusion rate (n = 4 RCTs, RR = 0.49, 95% CI [0.16, 1.47], p = 0.2), and rate of additional uterotonic agents (n = 4 RCTs, RR = 1.05, 95% CI [0.72, 1.53], p = 0.81). Leave-one-out sensitivity analysis showed robustness of the results, and there was no evidence of publication bias. Regarding safety endpoints, there was no significant difference between both groups regarding the rates of minor side effects, such as diarrhea, fever, nausea, and vomiting. No patient developed thromboembolic events in the TXA group. CONCLUSION: There was no significant antihemorrhagic efficacy between adjunct TXA and misoprostol for the management of PPH. The safety profile was comparable between both agents.

Tungsten (VI) oxide reinforced antimony glasses for radiation safety applications: A throughout investigation for determination of radiation shielding properties and transmission factors.

We report the functional assessment of tungsten (VI) oxide on gamma-ray attenuation properties of 60Sb2O3-(40-x)NaPO3-xWO3 antimony glasses. The elemental mass-fractions and glass-densities of each glass sample are specified separately for the MCNPX Monte Carlo code. In addition to fundamental gamma absorption properties, Transmission Factors throughout a broad radioisotope energy range were measured. According to findings, holmium (Ho) incorporation into the glass structure resulted in a net increase of 0.3406 g/cm3, whereas cerium (Ce) addition resulted in a net increase of 0.2047 g/cm3. The 40% WO3 reinforced S7 sample was found to have the greatest LAC value, even though seven glass samples exhibited identical behavior. The S2 sample had the lowest HVL values among the glass groups evaluated in this work, computed in the energy range of 0.015-15 MeV. The lowest EBF and EABF values were reported for 40% WO3 reinforced S7 sample with the highest LAC and density values. According to the findings of this research, WO3 will likely make a significant contribution to the gamma ray absorption properties of antimony glasses, which are employed for optical and structural modification. Therefore, it can be concluded that WO3 may be treated monotonically and can be employed successfully in circumstances where gamma-ray absorption characteristics, optical properties, and structural qualities need to be enhanced.

Transvaginal needle versus laparoscopic ovarian drilling in hormonal profile and pregnancy outcomes of polycystic ovary syndrome: A systematic review and meta-analysis.

BACKGROUND: Polycystic ovary syndrome (PCOS) is a prevalent hormonal disorder distinguished by a persistent absence of ovulation. Ovarian drilling is a recognized therapeutic approach for PCOS patients who are unresponsive to medication and can be performed through invasive laparoscopic access or less-invasive transvaginal access. The aim of this systematic review and meta-analysis was to assess the efficacy of transvaginal ultrasound -guided ovarian needle drilling with conventional laparoscopic ovarian drilling (LOD) in patients with PCOS. METHODS: PUBMED, Scopus, and Cochrane databases were systematically searched for eligible randomized controlled trials (RCTs) from articles published from inception to January 2023. We include RCTs of PCOS that compared transvaginal ovarian drilling and LOD and reported on ovulation and pregnancy rates as the main outcome variable. We evaluated study quality using the Cochrane Risk of bias 2 tool. A random-effects meta-analysis was performed and the certainty of the evidence was assessed according to the GRADE approach. We registered the protocol prospectively in PROSPERO (CRD42023397481). RESULTS: Six RCTs including 899 women with PCOS met the inclusion criteria. LOD was found to significantly reduce anti-Mullerian hormone (AMH) (SMD: -0.22; 95% CI: -0.38, -0.05; I2 = 39.85%) and antral follicle count (AFC) (SMD: -1.22; 95% CI: -2.26, -0.19; I2 = 97.55%) compared to transvaginal ovarian drilling. Our findings also indicated that LOD significantly increased the ovulation rate by 25% compared to transvaginal ovarian drilling (RR: 1.25; 95% CI: 1.02, 1.54; I2 = 64.58%). However, we found no significant difference between the two groups in terms of follicle stimulating hormone (SMD: 0.04; 95% CI: -0.26, 0.33; I2 = 61.53%), luteinizing hormone (SMD: -0.07; 95% CI: -0.90, 0.77; I2 = 94.92%), and pregnancy rate (RR: 1.37; 95% CI: 0.94, 1.98; I2 = 50.49%). CONCLUSION: LOD significantly lowers circulating AMH and AFC and significantly increases ovulation rate in PCOS patients compared to transvaginal ovarian drilling. As transvaginal ovarian drillingremains a less-invasive, more cost-effective, and simpler alternative, further studies are warranted to compare these two techniques in large cohorts, with a particular focus on ovarian reserve and pregnancy outcomes.

Analgesic Efficacy of Intraoperative Superior Hypogastric Plexus (SHP) Block during Abdominal Hysterectomy: A Systematic Review and Meta-Analysis of Controlled Trials.

Background and Objectives: Abdominal hysterectomy is a major surgery that is often associated with pronounced postsurgical pain. The objective of this research is to conduct a systematic review and meta-analysis of all randomized controlled trials (RCTs) and nonrandomized comparative trials (NCTs) that have surveyed the analgesic benefits and morbidity of intraoperative superior hypogastric plexus (SHP) block (intervention) compared with no SHP block (control) during abdominal hysterectomy. Materials and Methods: The Cochrane Central Register of Controlled Trials (CENTRAL), Google Scholar, Web of Science, PubMed, Scopus, and Embase were searched from inception until 8 May 2022. The Cochrane Collaboration tool and Newcastle-Ottawa Scale were used to evaluate the risk of bias of RCTs and NCTs, respectively. In a random effects mode, the data were pooled as risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI). Results: Five studies (four RCTs and one NCT) comprising 210 patients (SHP block = 107 and control = 103) were analyzed. The overall postsurgical pain score (n = 5 studies, MD = -1.08, 95% CI [-1.41, -0.75], p < 0.001), postsurgical opioid consumption (n = 4 studies, MD = -18.90 morphine milligram equivalent, 95% CI, [-22.19, -15.61], p < 0.001), and mean time to mobilization (n = 2 studies, MD = -1.33 h, 95% CI [-1.98, -0.68], p < 0.001) were significantly decreased in the SHP block group contrasted with the control arm. Nevertheless, there was no significant variance between both arms regarding operation time, intraoperative blood loss, postsurgical NSAID consumption, and hospital stay. There were no major side effects or sympathetic block-related aftermaths in both groups. Conclusions: During abdominal hysterectomy and receiving perioperative multimodal analgesia, the administration of intraoperative SHP block is largely safe and exhibits better analgesic effects compared to cases without administration of SHP block.

Prophylactic vasopressin to reduce intraoperative blood loss and associated morbidities during myomectomy: A systematic review and meta-analysis of 11 controlled trials.

OBJECTIVE: To collate evidence from randomized controlled trials (RCTs) and nonrandomized controlled trials (NCTs) on the efficacy and safety of vasopressin versus passive control (placebo/no treatment) during myomectomy. METHODS: Six information sources were screened until 25-June-2022. The Cochrane Collaboration tool and Newcastle-Ottawa Scale were used to evaluate the risk of bias. Data were summarized as mean difference or risk ratio with 95% confidence interval in a random-effects model. RESULTS: Eleven studies, comprising 1067 patients (vasopressin=567 and control=500) were analyzed. For RCTs (n = 8), the overall quality included 'high risk' (n = 4), 'low risk' (n = 2), and 'some concerns' (n = 2). For NCTs (n = 3), the overall quality included 'good' (n = 2) and 'fair' (n = 1). The mean intraoperative blood loss, mean difference in hemoglobin level, mean difference in hematocrit level, rate of perioperative blood transfusion, and mean operative time were significantly reduced in favor of the vasopressin group compared with the control group. However, there was no significant difference between both groups regarding the mean hospital stay. Pertaining to safety endpoints, after omission of an outlier study, the rate of drug-related cardiovascular adverse events did not significantly differ between both groups. There was no quantitative evidence of publication bias for the endpoint of intraoperative blood loss. CONCLUSION: Among patients undergoing myomectomy, prophylactic administration of vasopressin was largely safe and correlated with significant reductions in intraoperative blood loss and associated morbidities compared with a passive control intervention. Nonetheless, the conclusions should be cautiously interpreted owing to the low-evidence quality and the used doses varied greatly between studies.

Superior hypogastric plexus (SHP) block during minimally invasive hysterectomy: A systematic review.

To systematically summarize the efficacy and safety of superior hypogastric plexus (SHP) block versus no SHP block among patients undergoing minimally invasive hysterectomy (MIH). Five information sources were screened from inception until 04.04.2022 and comprised the Cochrane Central Register of Controlled Trials, PubMed, Embase, Scopus, and Web of Science. The inclusion criteria comprised (i) patients: individuals undergoing MIH, (ii) intervention: SHP block, (iii) Comparator: no SHP block, (iv) Outcomes: postoperative pain, postoperative opioid consumption, operation time, estimated intraoperative blood loss, hospital stay, and complications/toxicities, and (v) Study design: randomized controlled trials (RCTs) and non-randomized comparative trials published in peer-reviewed journals. Owing to the insignificant number of available studies, methodologic heterogeneity, and procedural variances, it was impossible to carry out a quantitative meta-analysis. Hence, the results of the included studies were only reported qualitatively (descriptively). Three studies (2 RCTs and 1 cohort study), comprising 210 patients (SHP=107 and non-SHP=103) were included in the qualitative synthesis. Overall, the included studies had a low risk of bias. The results showed that SHP block appeared largely safe and could reduce postoperative pain and opioid consumption. However, SHP block did not offer clinical benefits in terms of reduced operation time, intraoperative blood loss, and hospital stay compared with non-SHP block. Among patients undergoing MIH, this first ever systematic review showed that SHP block was safe and exhibited potential analgesic and opioid-sparing effects postoperatively. Additional RCTs are needed to carry out a powered meta-analysis and validate the findings.

Ovarian Fetiform Teratoma in a 17-Year-Old Adolescent Girl.

Fetiform teratoma, also recognized as a homunculus, is a largely uncommon form of mature cystic teratoma. Here, we present the case of a 17-year-old single female who presented to the emergency department complaining of abdominal distension and pain for four months. Abdominal examination revealed a left-sided mass. Magnetic resonance imaging showed a multi-loculated and multi-septated left cystic ovarian mass, suspicious for a teratoma. The patient underwent laparoscopy and a left cystectomy was performed. The final histopathologic diagnosis was consistent with fetiform teratoma. Although extremely rare, ovarian fetiform teratoma should be considered in the differential diagnosis of women presenting with an abdominopelvic mass. It should be discerned from fetus-in-fetu and ectopic pregnancy. Careful clinical presentation, laboratory testing for beta-human chorionic gonadotropin, histopathologic examination, and cytogenetic analysis can greatly aid in pinpointing the diagnosis. Overall, fetiform teratoma carries a favorable prognosis; however, follow-up surveillance is advised to monitor for uncommon occasions of tumor persistence or relapse.

Preoperative leukocytosis correlates with unfavorable pathological and survival outcomes in endometrial carcinoma: A systematic review and meta-analysis.

AIM: To meta-analytically examine the frequency and prognostic impact of preoperative leukocytosis in endometrial carcinoma (EC). METHODS: Five major databases were searched till 01-February-2021. Studies that evaluated the frequency of preoperative leukocytosis or its correlation with pathological and survival outcomes in EC patients were included. Data were pooled as mean differences (MD), odds ratios (OR), or hazard ratios (HR) with 95% confidence intervals. RESULTS: Nine retrospective studies, with low risk of bias, were included. The pooled prevalence of preoperative leukocytosis was 11.2% (95% CI: 8.2-14.3). There was a significant correlation between preoperative leukocytosis and FIGO stage III-IV (OR = 2.10, 95% CI: 1.60-2.75), ≥50% myometrial invasion (OR = 1.32, 95% CI: 1.02-1.72), lymph node involvement (OR = 1.83, 95% CI: 1.29-2.59), cervical involvement (OR = 2.29, 95% CI: 1.68-3.13), adnexal involvement (OR = 2.17, 95% CI: 1.42-3.31), and tumor size (MD = 1.10 cm, 95% CI: 0.63-1.58). However, preoperative leukocytosis did not significantly correlate with tumor grade II-III, non-endometrioid histology, peritoneal cytology, and lympho-vascular space involvement (p > 0.05). Additionally, preoperative leukocytosis correlated with higher rates of death (OR = 2.85, 95% CI: 2.03-4.00), tumor recurrence (OR = 2.36, 95% CI: 1.21-4.61), and worse overall survival at univariate and multivariate analyses (HR = 2.90, 95% CI: 2.24-3.75 and HR = 2.16, 95% CI: 1.59-2.94, respectively). As for disease-free survival, preoperative leukocytosis emerged as an independent prognostic factor on univariate (HR = 1.27, 95% CI: 1.16-1.39) but not multivariate (HR = 1.08, 95% CI: 1.00-1.18) analyses. CONCLUSIONS: Preoperative leukocytosis is common and correlates with poor pathological and survival outcomes in EC patients.

Intraoperative local injection of uterosacral ligaments with ropivacaine during uterine surgery: A systematic review and meta-analysis of randomized controlled trials.

AIM: To perform a systematic review and meta-analysis of all randomized controlled trials that examined the efficacy of intraoperative local injection of the uterosacral ligaments with ropivacaine on postoperative pain and opioids consumption in patients undergoing uterine surgery for hysterectomy/myomectomy. METHODS: PubMed, Scopus, Web of Science and Cochrane Library databases were screened from inception to September 5th, 2020. We appraised the risk of bias using the Cochrane's risk of bias tool. Resting postoperative pain scores and cumulative consumption of postoperative opioids were regarded as continuous data, analyzed using the inverse variance method and reported as standardized mean difference (SMD) and weighted mean difference (MD), respectively, with 95 % confidence intervals (95 % CIs). RESULTS: Five studies met the inclusion criteria comprising 230 patients (117 and 113 patients received ropivacaine and placebo, respectively). The studies had an overall low risk of bias. Resting postoperative pain scores were not significantly different between both groups at 2 h (SMD = -0.30, 95 % CI [-0.70, 0.11], p = 0.15), 12 h (SMD = 0.04, 95 % CI [-0.26, 0.37], p = 0.81) and 24 h (SMD = -0.06, 95 % CI [-0.32, 0.20], p = 0.68). However, the ropivacaine group had significantly reduced cumulative opioid consumption during the first 24 h postoperatively (MD = -9.07, 95 % CI [-14.47, -3.66], p = 0.001). CONCLUSION: Intraoperative local infiltration of uterosacral ligaments with ropivacaine is technically feasible and significantly reduces postoperative opioid consumption in women undergoing gynecologic surgery of the uterus.

Preoperative anemia predicts poor prognosis in patients with endometrial cancer: A systematic review and meta-analysis.

AIM: To systematically and meta-analytically pool the existing evidence regarding the prognostic impact of preoperative anemia (hemoglobin level <12 mg/dl) in patients with endometrial cancer. METHODS: Four (PubMed, Embase, Scopus and Web of Science) databases were searched from inception to 20-August-2020. We assessed the risk of bias using the Newcastle-Ottawa Scale. We estimated the pooled prevalence of preoperative anemia in the included studies. We pooled odds ratios (ORs) and hazard ratios (HRs) with their 95 % confidence intervals (95 % CIs) to evaluate the correlation between preoperative anemia and its impact on clinicopathologic parameters and survival outcomes. Analyses were performed under random- or fixed-effects meta-analysis models depending on data heterogeneity. RESULTS: Seven studies met the inclusion criteria comprising 1495 patients with endometrial cancer. Nearly all studies had low risk of bias. The pooled prevalence of preoperative anemia was 26.5 % (95 % CI: 18.6%-36.2%). Preoperative anemia significantly correlated with advanced FIGO stage III-IV (OR = 5.14, 95 % CI [3.36, 7.86], p < 0.00001), ≥50 % myometrial invasion (OR = 1.95, 95 % CI [1.36, 2.78], p = 0.0003), lymph node metastasis (OR = 4.46, 95 % CI [2.39, 8.30], p < 0.00001), non-endometrioid histology (OR = 3.25, 95 % CI [1.89, 5.60], p < 0.0001), adnexal involvement (OR = 5.88, 95 % CI [3.05, 10.23], p < 0.001), cervical involvement (OR = 2.91, 95 % CI [1.65, 5.11], p = 0.0002), positive peritoneal cytology (OR = 3.24, 95 % CI [1.41, 7.44], p = 0.006), preoperative thrombocytosis (OR = 6.66, 95 % CI [3.05, 14.52], p < 0.00001) and lymphovascular space invasion (OR = 3.50, 95 % CI [1.82, 6.74], p = 0.0002). High tumor grade II-III was increased in patients with preoperative anemia, yet this effect was not statistically significant (OR = 2.12, 95 % CI [0.97, 4.66], p = 0.06). Consistently, the five-year overall survival (OS) and disease-free survival (DFS) rates were significantly lower in patients with preoperative anemia when compared to those without preoperative anemia. Pooled HR showed that preoperative anemia was significantly associated with reduced DFS at univariate (HR = 3.22, 95 % CI [1.28, 8.11], p = 0.01) and multivariate (HR = 1.02, 95 % CI [1.00, 1.05], p = 0.03) analyses. CONCLUSION: Preoperative anemia predicts poor clinicopathologic and survival outcomes in patients with endometrial cancer.

Preoperative cervical cytology as a prognostic factor in endometrioid-type endometrial cancer: A single-center experience from Saudi Arabia.

OBJECTIVES: The objectives of this study were (1) to estimate the frequency of preoperative abnormal cervical cytology (CC), (2) to explore correlations between preoperative CC and specific clinicopathological prognostic factors (tumor stage, endometrioid grade, myometrial invasion, lymphovascular space involvement, cervical involvement, and recurrence), and (3) to examine the impact of preoperative CC on disease-free survival (DFS) and overall survival (OS) in Saudi patients with endometrioid-type endometrial cancer (EC). MATERIALS AND METHODS: A retrospective cross-sectional study was conducted at a tertiary hospital in Saudi Arabia. The study's inclusion criteria included: (1) patients who underwent staging operation for EC from 2010-2014, (2) patients who had preoperative CC results within 3 months before staging operation, and (3) patients with final histopathological diagnosis of endometrioid-type EC. RESULTS: Hundred and sixteen patients (n = 116) met the study's inclusion criteria. CC results were abnormal in 46 patients (39.7%). Patients with abnormal CC had statistically significant higher rates of unfavorable Grades II-III tumor and cervical involvement than patients with normal CC (P = 0.004, chi-square test). There were no statistically significant differences (log-rank test) between patients with normal and abnormal CC with regard to DFS (P = 0.525) and OS (P = 0.166). Multivariate analyses of DFS and OS (Cox proportional hazards model) failed to show preoperative CC as a significant independent prognostic factor of DFS and OS (P > 0.05). CONCLUSION: The frequency of abnormal preoperative CC in patients with endometrioid-type EC is not uncommon. Abnormal CC correlates with poor prognostic factors, namely high tumor grade and cervical involvement. Preoperative CC is not a significant independent prognostic factor of survival.

Preoperative Leukocytosis as a Prognostic Marker in Endometrioid-Type Endometrial Cancer: A Single-Center Experience from Saudi Arabia.

INTRODUCTION: Only a few studies (n=5) have focused on the importance of preoperative high white blood cell (WBC) count (leukocytosis) as a prognostic marker in patients with endometrial cancer (EC). Nevertheless, more related studies are needed to solidly corroborate these findings. To the best of our knowledge, no such study has been conducted in the Gulf region and Saudi Arabia in particular. METHODS: A retrospective cross-sectional study was conducted at King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia. The medical records of 130 patients with endometrioid-type EC were reviewed for clinico-pathological factors (that is, age, tumor stage, endometrioid grade, myometrial invasion depth, lymphovascular space involvement and recurrence) and survival outcomes. Survival outcomes included disease-free survival (DFS) and overall survival (OS). Leukocytosis was defined as a WBC count level >10 x 103 cells/uL. Chisquare test was used for univariate analysis of categorical data. Survival analyses of DFS and OS were calculated according to the Kaplan-Meier estimates method and compared by using two-tailed log-rank test. Univariate and multivariate analyses of survival were performed using Cox proportional hazards model. Statistical significance was regarded as a p value <0.05. RESULTS: The mean age was 59 ± 10.5 years (range: 36-99). The overall mean preoperative WBC count was 7.7 ± 2.4 x 103 cells/uL (range: 2.7-17 x 103). The frequency of preoperative leukocytosis was 18.5% (n=24). Patients with preoperative leukocytosis have statistically significant higher rates of advanced FIGO stage III-IV disease (p=0.007) and positive tumor recurrence (p=0.009) than patients with normal preoperative WBC count (chisquare test). Patients with preoperative leukocytosis have a higher statistically significant probability of developing recurrence than patients with preoperative normal WBC count (29.4 vs. 11.8%, p=0.008, log-rank test). Patients with preoperative leukocytosis have statistically significant lower mean DFS (58.3 ± 6.9 vs. 67.9 ± 2.3 months, p=0.015) and 5-year DFS rate (66.7 vs. 86.8%, p=0.015) than patients with normal preoperative WBC counts (log-rank test). However, there were no statistically significant differences between patients with preoperative leukocytosis and normal WBC counts in terms of mean OS (73.8 ± 4.5 vs. 79.3 ± 2.1, p=0.581) and 5-year OS rate (87.5 vs. 91.5%, p=0.581), respectively (log-rank test). Multivariate analyses using Cox proportional hazards model failed to significantly demonstrate preoperative WBC count as an independent prognostic factor of DFS and OS (log-rank test, p>0.05). CONCLUSION: Preoperative leukocytosis is not rare in patients with endometrioid-type EC. Besides, preoperative leukocytosis is correlated with poor tumor FIGO stage, higher cumulative incidence of relapse and poor DFS in the univariate analysis. Our study suggests that preoperative leukocytosis may identify high-risk patients who may require more intensified therapy in terms of aggressive debulking and/or perioperative chemotherapy.

Low-risk gestational trophoblastic neoplasia: A single-center experience from Saudi Arabia.

OBJECTIVE: To report our single-center experience in terms of patient clinical characteristics, treatment outcomes, and chemotherapy-related toxicities in patients with low-risk gestational trophoblastic neoplasia (GTN). MATERIALS AND METHODS: A retrospective cross-sectional study (2008-2013) was conducted at a tertiary health-care hospital in Saudi Arabia. Forty-four (n = 44) patients met the inclusion criteria for low-risk GTN. Methotrexate (MTX) was administered in a 5-day regimen: 0.3-0.5mg/kg intravenously (IV) daily for 5 days every 2 weeks (maximum 25mg per dose). Actinomycin D (ActD) was administered 1.25mg/m2 pulsed IV every 2 weeks. RESULTS: The majority of patients had molar pregnancy as the antecedent event (86%), developed GTN within the first 4 months after the initial evacuation (93.2%), had human chorionic gonadotropin levels between 1,000 and 10,000 mIU/dL (36.3%), and had the World Health Organization prognostic scores from 0 to 2 (48.7%). Only 38 patients accepted treatment with chemotherapy. A total of 37 patients received first-line MTX; 34 patients of them achieved complete remission (CR, 92%). The three patients who developed MTX resistance were salvaged with sequential ActD and all achieved CR of 100%. Only one patient received first-line ActD and achieved CR. The overall survival as well as cure rate for all patients with low-risk GTN was 100%. No patient developed MTX-related hepatic toxicity or ActD-related blister formation. No severe adverse effects occurred. CONCLUSION: Our 5-day IV MTX regimen was highly effective in treating patients with low-risk GTN, with CR rate of 92% and no severe toxicity. Primary and sequential ActD therapy appears to be very effective.

An Extremely Giant Ovarian Mucinous Cystadenoma.

Ovarian mucinous cystadenomas are cystic neoplasms lined by mucin-producing epithelial cells. They are mostly benign (80%) and frequently asymptomatic at early stages. The average diameter of ovarian mucinous cystadenomas ranges from 15 to 30 cm. Herein, we report the case of a giant benign ovarian mucinous cystadenoma in a 53-year-old postmenopausal woman. The patient presented with a very huge pelvi-abdominal distention that started ten months ago and was progressively increasing in size. It was associated with on-off abdominal pain, nausea and urinary retention. The case was discussed with a multidisciplinary team. Subsequently, the patient was consented for exploratory laparotomy. The origin of the mass was identified to be the right ovary, and right salpingo-oophorectomy was done. The resected mass measured 73x51x42 cm and weighed 108 kg. The left ovary had a multilocular mass of 15 cm in diameter, and left salpingo-oophorectomy was successively performed. There was no ascites. Histopathological examination confirmed the diagnosis of bilateral benign mucinous cystadenoma. At a postoperative 9-month follow-up in the outpatient clinic, the patient showed up in good condition without evidence of recurrence. To the best of our knowledge, we report the largest benign ovarian cyst in Saudi Arabia, and one of the largest (probably the third) in the English medical literature. It is technically feasible to manage an extremely large-sized benign mass with satisfactorily perioperative outcomes. This should be done through a multidisciplinary approach that demands an orchestrated collaboration between different specialists to yield an optimized perioperative care.

Preoperative Anemia as a Prognostic Factor in Endometrioid-Type Endometrial Carcinoma.

OBJECTIVE: This study sought to determine the frequency of preoperative anemia (hemoglobin level <12 g/dL) and its prognostic significance for clinicopathological factors and survival outcomes in Saudi patients with endometrioid-type endometrial carcinoma (EC). METHODS: A retrospective cross-sectional study was conducted at King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia. A total of 148 patients who underwent staging surgery for primary EC were retrospectively analyzed for perioperative details regarding clinicopathological factors and survival. RESULTS: The frequency of preoperative anemia was 27.7% (n = 41). Patients with advanced FIGO disease (stages III-IV), unfavourable endometrioid tumour grade II-III, ≥50% myometrial invasion, positive lymphovascular space invasion, and tumour recurrence had statistically significant lower mean preoperative hemoglobin levels (two-tailed Mann-Whitney U test; P < 0.05). Patients with preoperative anemia had statistically significant higher rates of advanced FIGO stage III-IV (P = 0.0000), unfavourable grades II-III endometrioid histology (P = 0.0005), ≥50% myometrial invasion (P = 0.0016), positive lymphovascular space invasion (P = 0.0019), and tumour recurrence (P = 0.0064) than patients without preoperative anemia (two-tailed chi-square test). In a univariate analysis, patients with preoperative anemia had statistically lower significant mean 5-year disease-free survival (DFS) and overall survival (OS) rates than patients without preoperative anemia (log-rank test; P < 0.0001 and P < 0.0003, respectively). In a multivariate analysis, preoperative anemia was shown to be an independent prognostic factor for 5-year DFS (P = 0.0303), but not OS (P = 0.2588). CONCLUSION: In patients with endometrioid-type EC, the preoperative anemia is fairly common. Moreover, preoperative anemia is correlated with a number of unfavourable clinicopathological factors, as well as poor survival (in terms of DFS and OS) in the univariate analysis.

Paraneoplastic Teratoma-associated Anti-N-Methyl-D-Aspartate Receptor Encephalitis: The First Published Report from Saudi Arabia.

Paraneoplastic teratoma-associated anti-N-methyl-D-aspartate (anti-NMDA) receptor encephalitis is a lately introduced disease that was first documented in 2007. In a recent systemic review in 2014, only a total of 174 cases of teratoma-associated anti-NMDA receptor encephalitis was reported. Herein, to the best of our knowledge, in Saudi Arabia, we report the first ever case of mature ovarian teratoma-associated anti-NMDA receptor encephalitis in a 21-year-old Saudi woman who presented to clinical attention with a nine-day history of neuropsychiatric symptoms preceded by a two-day flu-like illness. Central nervous system (CNS) examination was remarkable for confusion and an inability to move her lower limbs. Abdominal examination was remarkable for mild right lower quadrant tenderness without palpable organomegaly. Initial laboratory findings were remarkable for high CA-125 level of 205 units/ml (normal: 0 - 35 units/ml) and CA 19-9 level of 121 units/ml (normal: 0 - 37 units/ml). Cerebrospinal fluid (CSF) examination showed lymphocytic pleocytosis and oligoclonal bands. Computed tomography (CT) scan of the abdomen and pelvis showed a 7.2 x 6.3 x 5.5 cm mass of the right ovary that was highly suspicious for a mature teratoma with fat densities and calcified foci. Serum and CSF tested positive for anti-NMDA receptor antibodies. The patient underwent right oophorectomy and the final histopathological diagnosis was confirmed. Postoperatively, the patient had an uneventful postoperative course and did not receive adjuvant secondary immunotherapies. One day following the surgery, her neuropsychiatric symptoms improved dramatically. At a six-month follow-up at the outpatient clinic, the patient was symptom-free.

Preoperative thrombocytosis as a prognostic factor in endometrioid-type endometrial carcinoma.

BACKGROUND: The impact of preoperative thrombocytosis as a prognostic factor in endometrial carcinoma (EC) remains uncertain and has never been examined in Saudi Arabia. OBJECTIVES: To determine the prevalence of preoperative thrombocytosis (platelet count > 400 000/ µL), and its prognostic significance for clinicopathological factors and survival in Saudi patients with endometrioid-type EC. DESIGN: A retrospective cross-sectional study from January 2010 to December 2013. SETTING: A referral tertiary healthcare institute. PATIENTS AND METHODS: Patients who underwent staging surgery for primary endometrioid-type EC were retrospectively analyzed for perioperative details: age, preoperative platelet count, International Federation of Gynecology and Obstetrics (FIGO) stage, endometrioid grade, recurrence, disease-free survival (DFS) and overall survival (OS). Survival analysis was conducted using Kaplan-Meier estimates and a Cox proportional hazards model. MAIN OUTCOME MEASURES: Prevalence of preoperative thrombocytosis, DFS and OS. RESULTS: In 162 patients who met inclusion criteria, the frequency of preoperative thrombocytosis was 8.6% (n=14). Patients with advanced FIGO disease (stages III-IV) and recurrence had significantly higher mean preoperative platelet counts than patients with early FIGO disease (stages I-II) and no recurrence (P=.0080 and P=.0063, respectively). Patients with thrombocytosis had statistically significant higher rates of advanced FIGO stages III-IV disease, unfavorable grades II-III endometrioid histology and recurrence than patients with preoperative platelet counts.