Cost consequence analysis of Apathy in Dementia Methylphenidate Trial 2 (ADMET 2).

BACKGROUND: This paper used data from the Apathy in Dementia Methylphenidate Trial 2 (NCT02346201) to conduct a planned cost consequence analysis to investigate whether treatment of apathy with methylphenidate is economically attractive. METHODS: A total of 167 patients with clinically significant apathy randomized to either methylphenidate or placebo were included. The Resource Utilization in Dementia Lite instrument assessed resource utilization for the past 30 days and the EuroQol five dimension five level questionnaire assessed health utility at baseline, 3 months, and 6 months. Resources were converted to costs using standard sources and reported in 2021 USD. A repeated measures analysis of variance compared change in costs and utility over time between the treatment and placebo groups. A binary logistic regression was used to assess cost predictors. RESULTS: Costs were not significantly different between groups whether the cost of methylphenidate was excluded (F(2,330) = 0.626, ηp2 = 0.004, p = 0.535) or included (F(2,330) = 0.629, ηp2 = 0.004, p = 0.534). Utility improved with methylphenidate treatment as there was a group by time interaction (F(2,330) = 7.525, ηp2 = 0.044, p < 0.001). DISCUSSION: Results from this study indicated that there was no evidence for a difference in resource utilization costs between methylphenidate and placebo treatment. However, utility improved significantly over the 6-month follow-up period. These results can aid in decision-making to improve quality of life in patients with Alzheimer's disease while considering the burden on the healthcare system.

Design and Development of a Community-Based, Interdisciplinary, Collaborative Dementia Care Program.

OBJECTIVE: To describe the design, development, and baseline characteristics of enrollees of a home-based, interdisciplinary, dyadic, pilot dementia care program. DESIGN: Single-arm, dementia care intervention in partnership with primary care providers delivered by Health Coaches to persons with dementia and caregiver "dyads" and supervised by an interdisciplinary team. SETTING: Home- and virtual-based dyad support. PARTICIPANTS: Persons with mild cognitive impairment or dementia diagnosis and/or who were prescribed antidementia medications; had an identified caregiver willing to participate; were under the care of a partner primary care provider; and had health insurance through the affiliated accountable care organization (Banner Health Network). INTERVENTION: Provision of personalized dementia education and support in the home or virtually by Health Coaches supported by an interdisciplinary team. MEASUREMENTS: Cognition, function, mood, and behavior of persons with dementia; caregiver stress and program satisfaction; primary care provider satisfaction. RESULTS: Served dyads from three primary care clinics with a total of 87 dyads enrolled between December 2018 and June 2020. CONCLUSION: A pilot Dementia Care Partners demonstrated feasibility and suggested acceptability, and high satisfaction among primary care providers and caregivers.

Comparison of two diphenyl polyenes as acid-sensitive additives during the biodegradation of a thermoset polyester polyurethane coating.

AIMS: Biochemical hydrolysis and chemical catalysis are involved in the successful biodegradation of polymers. In order to evaluate the potential separation between biochemical and chemical catalysis during the biodegradation process, we report the use of two diphenylpolyenes (DPPs), all trans-1,4-diphenylbutadiene (DPB) and all trans-1,6-diphenylhexatriene (DPH), as potential acid-sensitive indicators in polymers. METHODS AND RESULTS: 1,4-Diphenylbutadiene and DPH (0.1% w/w) were melt-cast successfully with poly(ethylene succinate) hexamethylene (PES-HM) polyurethane (thermoset polyester polyurethane) coatings above 80℃. When these two DPP/PES-HM coatings were exposed to a concentrated supernatant with significant esterase activity resulting from the growth of a recently isolated and identified strain of Tremellomycetes yeast (Naganishia albida 5307AI), the DPB coatings exhibited a measurable and reproducible localized decrease in the blue fluorescence emission in regions below where hydrolytic biodegradation was initiated in contrast with DPH blended coatings. The fluorescence changes observed in the biodegraded DPB coating were similar to exposing them to concentrated acids and not bases. CONCLUSIONS: Our experiments resulted in (1) a method to blend DPP additives into thermoset coatings, (2) the first report of the biodegradation of polyester polyurethane coating by N. albida, and (3) demonstration that hydrolytic supernatants from this strain generate acidic region within degrading polyester coatings using DPB as the indicator. SIGNIFICANCE AND IMPACT OF THE STUDY: Our experiments confirm that N. albida is an active polyester degrader and that DPB is a promising acid sensitive polymer coating additive.

Clinical outcome of multidisciplinary treatment of vulvar necrotising fasciitis.

OBJECTIVE: Vulvar necrotising fasciitis (VNF) is a severe soft tissue infection associated with substantial morbidity and high mortality. At Stony Brook Medicine, US, patients with known or suspected VNF are treated by a structured multidisciplinary team consisting of members of the Departments of Emergency Medicine and Medicine, the Divisions of Gynecologic Oncology, Burn and Surgical Intensive Care Units, Infectious Disease and Plastic Surgery, and the nursing, nutrition, physical/occupational therapy and social work services. METHOD: This is a retrospective review of patients presenting to Stony Brook University Hospital with VNF over an 18-month period. RESULTS: A total of 10 patients were treated for VNF during the study period. All patients were treated by the structured multidisciplinary team, including extensive initial surgical debridement by the gynaecologic oncologists. All patients survived to discharge. CONCLUSION: The results of this review demonstrated that prompt diagnosis, rapid implementation of appropriate antibiotic coverage, surgical debridement of necrotic tissue, and comprehensive care delivered by a structured multidisciplinary team contributed to positive clinical outcomes and decreased the risk of death from VNF.

Endometrial cancer: A society of gynecologic oncology evidence-based review and recommendations, part II.

In 2014, the Society of Gynecologic Oncology's Clinical Practice Committee published a clinical update reviewing the treatment of women with endometrial cancer. At that time, there had been significant advances in the diagnosis, work-up, surgical management, and available treatment options allowing for more optimal care of affected women. This manuscript, Part II in a two-part series, includes specific recommendations on treatment of recurrent disease, post treatment surveillance and survivorship, considerations for younger women, and special situations. Part I covered histopathology and molecular pathology, risk factors, presentation and diagnostic approach, surgical approach and adjuvant therapy.

Endometrial cancer: A society of gynecologic oncology evidence-based review and recommendations.

INTRODUCTION: In 2014, the Society of Gynecologic Oncology's Clinical Practice Committee published a clinical update reviewing the treatment of women with endometrial cancer. At that time, there had been significant advances in the diagnosis, work-up, surgical management, and available treatment options allowing for more optimal care of affected women. Despite these advances, the incidence of endometrial cancer as well as the deaths attributable to the disease have continued to rise; from 1987 to 2014 there has been a 75% increase in cases and almost 300% increase in endometrial cancer deaths. Fortunately, since then, there has been progress in the treatment of patients with endometrial cancer with increased utilization of molecular pathology, greater understanding of genetic predisposition, enhanced methods for lymph node assessment, a broader understanding of the efficacy of radiation and chemotherapy, and a more efficient approach to survivorship and surveillance. The purpose of this document is to present a comprehensive review of this progress. MANUSCRIPT DEVELOPMENT PROCESS: The authors reviewed the available evidence, contributed to the development of this manuscript, provided critical review of the guidelines, and finalized the manuscript recommendations. The review was also presented to and approved by the Society of Gynecologic Oncology (SGO) Clinical Practice Committee, SGO Publications Committee, and the SGO board members prior to submission for publication. The recommendations for this manuscript were developed by a panel of gynecologic oncologists who were members of the SGO Clinical Practice and Education Committees. Panelists reviewed and considered evidence from current uterine cancer literature. The terminology used in these guidelines was adopted from the ASCCP management guidelines [1] using a two-part rating system to grade the strength of recommendation and quality of evidence (Table 1). The rating for each recommendation is given in parentheses.

Measuring Apathy in Alzheimer's Disease in the Apathy in Dementia Methylphenidate Trial 2 (ADMET 2): A Comparison of Instruments.

BACKGROUND: Diagnostic criteria for apathy have been published but have yet to be evaluated in the context of clinical trials. The Apathy in Dementia Methylphenidate Trial 2 (ADMET 2) operationalized the diagnostic criteria for apathy (DCA) into a clinician-rated questionnaire informed by interviews with the patient and caregiver. OBJECTIVE: The goal of the present study was to compare the classification of apathy using the DCA with that using the Neuropsychiatric Inventory-apathy (NPI-apathy) subscale in ADMET 2. Comparisons between NPI-Apathy and Dementia Apathy Interview Rating (DAIR) scale, and DCA and DAIR were also explored. METHODS: ADMET 2 is a randomized, double-blind, placebo-controlled phase III trial examining the effects of 20 mg/day methylphenidate on symptoms of apathy over 6 months in patients with mild to moderate Alzheimer's disease (AD). Participants scoring at least 4 on the NPI-Apathy were recruited. This analysis focuses on cross-sectional correlations between baseline apathy scale scores using cross-tabulation. RESULTS: Of 180 participants, the median age was 76.5 years and they were predominantly white (92.8%) and male (66.1%). The mean (±standard deviation) scores were 7.7 ± 2.4 on the NPI-apathy, and 1.9 ± 0.5 on the DAIR. Of those with NPI-defined apathy, 169 (93.9%, 95% confidence interval [CI] 89.3%-96.9%) met DCA diagnostic criteria. The DCA and DAIR overlapped on apathy diagnosis for 169 participants (93.9%, 95% CI 89.3%-96.9%). CONCLUSION: The measurements used for the assessment of apathy in patients with AD had a high degree of overlap with the DCA. The NPI-apathy cut-off used to determine apathy in ADMET 2 selects those likely to meet DCA criteria.

The risk of female-specific cancer after bariatric surgery in the state of New York.

BACKGROUND: Obesity is a known risk factor for many cancers. Although bariatric surgery has been associated with a decrease in the risk of developing cancer, data on the effect of bariatric surgery on female-specific cancers are limited. This study aimed to assess the impact of bariatric interventions on the development of endometrial, ovarian and breast cancer. METHODS: The New York Statewide Planning and Research Cooperative System database was used to identify all female patients without a pre-existing cancer diagnosis who had a diagnosis of obesity between 2006 and 2012. The risk of having female-specific cancer diagnosis in patients who underwent bariatric surgery were compared with those who had no bariatric interventions using multivariable proportional sub-distribution hazard regression analysis. Subsequent cancer diagnoses were followed up to 2016. RESULTS: We identified 55,781 and 247,102 obese female patients who had and did not have bariatric surgery, respectively. The overall incidence of female-specific cancer was 2.69% and 2.09% for the non-surgery and surgery groups, respectively (p < 0.0001). Surgery patients were less likely to develop female-specific cancers [hazard ratio (HR) 0.78; 95% CI 0.73-0.83; p < 0.0001]. Patients undergoing Roux-en-Y gastric bypass had a lower risk of developing female-specific cancer than laparoscopic sleeve gastrectomy (HR 0.66; 95% CI 0.51-0.87; p = 0.0056) and laparoscopic adjustable gastric banding (HR 0.83; 95% CI 0.69-0.99; p = 0.0056) patients. CONCLUSIONS: Patients undergoing bariatric surgery have a lower incidence of endometrial, female breast and ovarian cancer than non-surgery obese patients. These data suggest that bariatric interventions may reduce the risk of female-specific cancers.

When to Operate, Hesitate and Reintegrate: Society of Gynecologic Oncology Surgical Considerations during the COVID-19 Pandemic.

The COVID-19 pandemic has challenged our ability to provide timely surgical care for our patients. In response, the U.S. Surgeon General, the American College of Srugeons, and other surgical professional societies recommended postponing elective surgical procedures and proceeding cautiously with cancer procedures that may require significant hospital resources and expose vulnerable patients to the virus. These challenges have particularly distressing for women with a gynecologic cancer diagnosis and their providers. Currently, circumstances vary greatly by region and by hospital, depending on COVID-19 prevalence, case mix, hospital type, and available resources. Therefore, COVID-19-related modifications to surgical practice guidelines must be individualized. Special consideration is necessary to evaluate the appropriateness of procedural interventions, recognizing the significant resources and personnel they require. Additionally, the pandemic may occur in waves, with patient demand for surgery ebbing and flowing accordingly. Hospitals, cancer centers and providers must prepare themselves to meet this demand. The purpose of this white paper is to highlight all phases of gynecologic cancer surgical care during the COVID-19 pandemic and to illustrate when it is best to operate, to hestitate, and reintegrate surgery. Triage and prioritization of surgical cases, preoperative COVID-19 testing, peri-operative safety principles, and preparations for the post-COVID-19 peak and surgical reintegration are reviewed.

Phase-Contrast MRI: Physics, Techniques, and Clinical Applications.

With phase-contrast imaging, the MRI signal is used to visualize and quantify velocity. This imaging modality relies on phase data, which are intrinsic to all MRI signals. With use of bipolar gradients, degrees of phase shift are encoded and in turn correlated directly with the velocity of protons. The acquisition of diagnostic-quality images requires selection of the correct imaging plane to ensure accurate measurement and selection of the encoding velocity and thus prevent aliasing and achieve the highest signal-to-noise ratio. Multiple applications of phase-contrast imaging are actively used in clinical practice. One of the most common clinical uses is in cardiac valvular flow imaging, at which the data are used to assess the severity of valvular disease and quantify the shunt fraction. In neurologic imaging, phase-contrast imaging can be used to measure the flow of cerebrospinal fluid. This measurement can aid in the diagnosis and direct management of normal pressure hydrocephalus or be used to evaluate the severity of stenosis, such as that in Chiari I malformations. At vascular analysis, phase-contrast imaging can be used to visualize arterial and venous flow, and this application is used most commonly in the brain. Three-dimensional imaging can yield highly detailed flow data in a technique referred to as four-dimensional flow. A more recently identified application is in MR elastography. Shear waves created by using an impulse device can be velocity encoded, and this velocity is directly proportional to the stiffness of the organ, or the shear modulus. This imaging modality is most commonly used in the liver for evaluation of cirrhosis and steatosis, although research on the assessment of other organs is being performed. Phase-contrast imaging is an important tool in the arsenal of MRI examinations and has many applications. Proper use of phase-contrast imaging requires an understanding of the many practical and technical factors and unique physics principles underlying the technique.©RSNA, 2020.

5-HT does not lower blood pressure in the 5-HT7 knockout rat.

The fall in mean arterial pressure (MAP) after 24 h of 5-HT infusion is associated with a dilation of the portal vein (PV) and abdominal inferior vena cava (Ab IVC); all events were blocked by the selective 5-HT7 receptor antagonist SB269970. Few studies have investigated the contribution of the 5-HT7 receptor in long-term cardiovascular control, and this requires an understanding of the chronic activation of the receptor. Using the newly created 5-HT7 receptor knockout (KO) rat, we presently test the hypothesis that continuous activation of the 5-HT7 receptor by 5-HT is necessary for the chronic (1 wk) depressor response and splanchnic venodilation. We also address if the 5-HT7 receptor contributes to endogenous cardiovascular regulation. Conscious MAP (radiotelemeter), splanchnic vessel diameter (ultrasound), and cardiac function (echocardiogram) were measured in ambulatory rats during multiday 5-HT infusion (25 µg·kg-1·min-1 via minipump) and after pump removal. 5-HT infusion reduced MAP and caused splanchnic venodilation of wild-type (WT) but not KO rats at any time point. The efficacy of 5-HT-induced contraction was elevated in the isolated abdominal inferior vena cava from the KO compared with WT rats, supporting loss of a relaxant receptor. Similarly, the efficacy of 5-HT causing an acute pressor response to higher doses of 5-HT in vivo was also increased in the KO vs. WT rat. Our work supports a novel mechanism for the cardiovascular effects of 5-HT, activation of 5-HT7 receptors mediating venodilation in the splanchnic circulation, which could prove useful in the treatment of cardiovascular disease.

Extent and Predictors of Potentially Inappropriate Antidepressant Use Among Older Adults With Dementia and Major Depressive Disorder.

OBJECTIVE: To quantify the extent and identify predictors of potentially inappropriate antidepressant use among older adults with dementia and newly diagnosed major depressive disorders (MDD). METHODS: This retrospective cohort study included older adults (aged ≥65 years) with dementia and newly diagnosed MDD using Medicare 5% sample claims data (2012-2013). Based on Healthcare Effectiveness Data and Information Set guidelines, intake period for new antidepressant medication use was from May 1, 2012, through April 30, 2013. Index prescription start date was the first date of antidepressant prescription claim during the intake period. Dependent variable of this study was potentially inappropriate antidepressant use as defined by the Beers Criteria and the Screening Tool of Older Persons' potentially inappropriate Prescriptions criteria. The authors conducted multiple logistic regression analysis to identify individual-level predictors of potentially inappropriate antidepressant use. RESULTS: The authors' final study sample consisted of 7,625 older adults with dementia and newly diagnosed MDD, among which 7.59% (N = 579) initiated treatment with a potentially inappropriate antidepressant. Paroxetine (N = 394) was the most commonly initiated potentially inappropriate antidepressant followed by amitriptyline (N = 104), nortriptyline (N = 35), and doxepin (N = 32). Initiation of a potentially inappropriate antidepressant was associated with age and baseline use of anxiolytic medications. CONCLUSION: More than 7% of older adults in the study sample initiated a potentially inappropriate antidepressant, and the authors identified a few individual-level factors significantly associated with it. Appropriately tailored interventions to address modifiable and nonmodifiable factors significantly associated with potentially inappropriate antidepressant prescribing are required to minimize risks in this vulnerable population.

Patterns of care and outcomes for women with uterine cancer and ovarian metastases.

OBJECTIVE: For women with uterine cancer with metastases isolated to the adnexa (stage IIIA) optimal adjuvant therapy is unknown. We performed a population-based analysis to examine the use of chemotherapy, vaginal brachytherapy, and external beam therapy (in women with stage IIIA uterine cancer. METHODS: The National Cancer Database was used to identify women with stage IIIA uterine cancer with ovarian metastasis from 2004 to 2012. We explored the use of chemotherapy, vaginal brachytherapy, and external beam therapy over time. Multivariable models were developed to examine factors associated with survival. RESULTS: We identified 4088 women with uterine cancer and ovarian metastases. Overall, 56.2% of women received chemotherapy. Vaginal brachytherapy was used in 11.1%, while 36.6% received external beam therapy. Five-year survival was 64.7 % (95% CI, 62.9% to 66.5%). In a multivariable model, chemotherapy was associated with a 38% decrease in mortality (HR = 0.62; 95% CI, 0.54 to 0.71). Similarly, both external beam therapy (HR = 0.74; 95% CI, 0.65 to 0.85) and vaginal brachytherapy (HR = 0.67; 95% CI, 0.53 to 0.85) were associated with improved survival. When the cohort was limited to women who received chemotherapy, radiation was associated with improved overall survival (HR 0.74, 95% CI 0.61 to 0.90). There was no difference in survival between the use of external beam therapy and vaginal brachytherapy. CONCLUSIONS: Chemotherapy was associated with a decrease in mortality in women with endometrial cancer and ovarian metastases. The addition of radiation therapy was associated with improved overall survival, although there was no difference between external beam therapy and vaginal brachytherapy.

Understanding fertilizer adoption and effectiveness on maize in Zambia.

Increased fertilizer use will likely be crucial for raising and sustaining farm productivity in Africa, but adoption may be limited by ineffectiveness under certain conditions. This article quantifies the impacts of soil characteristics on maize response to fertilizer in Zambia using a nationally representative sample of 1453 fields, combining economic, farm management and soil analysis data. Depending on soil regimes, average maize yield response estimates range from insignificant (0) to 7 maize kg per fertilizer kg. For the majority of farmers, the estimated average value cost ratio is between 1 and 2, meaning fertilizer use would be fiscally rational, barring uncertainty and transfer costs. Since transfer costs exist and outcomes are uncertain, however, many farmers may sensibly pause before deciding whether to adopt fertilizer. This suggests shifting the emphasis of chronically low fertilizer use in Africa away from explanations of "market failure" toward greater emphasis on improving fertilizer efficacy.

Patient reported outcomes in evaluation of chemotherapy toxicity in women with gynecologic malignancies: A pilot study.

OBJECTIVE: Patient reported outcomes (PRO) relating to treatment toxicities have been demonstrated to reliably evaluate adverse events in clinical trials. We assessed the user satisfaction of implementing a focused PRO questionnaire for patients with gynecologic cancers undergoing chemotherapy. METHODS: Patients with gynecologic cancers undergoing chemotherapy were prospectively identified after IRB approval from April 2017 to August 2017. We administered a 24-symptom questionnaire, adapted from the validated PRO version of the Common Terminology Criteria for Adverse Event, to enrolled participants at the beginning of two outpatient visits. Patient and provider satisfaction with use of PRO was assessed afterwards. Descriptive statistics were performed. RESULTS: A total of 44 patients were enrolled. Patients were racially diverse: 52% Caucasian, 18% African-American, 9% Asian, and 20% other; 27% were of Hispanic origin. The majority of patients had ovarian cancer (54%), followed by uterine (29%) and cervical cancer (15%). Ninety-five percent of patient and 97% of provider satisfaction survey responses indicated the PRO questionnaire addressed important symptoms. Nearly all patient and provider responses indicated the PRO questionnaire was easy to use. Sixty-nine percent of patient and 97% of provider responses indicated the questionnaire positively impacted clinical care; 85% of patients wished to use a similar questionnaire throughout treatment. CONCLUSIONS: We have shown that incorporating a focused patient-reported symptom questionnaire into routine outpatient care of gynecological oncology patients undergoing chemotherapy was met with a high degree of patient and provider satisfaction regarding questionnaire content, feasibility, and perception of care improvement.

Adherence to treatment recommendations and outcomes for women with ovarian cancer at first recurrence.

OBJECTIVE: Treatment selection for recurrent ovarian cancer is typically based on the duration of time between the completion of adjuvant, platinum-based therapy and the time of recurrence, the platinum free interval (PFI). We examined the use of, and outcomes associated with platinum-based chemotherapy based on the PFI in women with recurrent ovarian cancer. METHODS: The Surveillance, Epidemiology, and End Results-Medicare database was used to identify women aged >65years with epithelial ovarian cancer who underwent surgery and platinum-based chemotherapy and who developed a recurrence >3months after the completion of adjuvant therapy. Patients were stratified by PFI into 3 groups: PFI <6months, PFI 7-12months, and PFI >12months. Multivariable models were used to examine predictors of use of platinum-based therapy and survival for each group. RESULTS: A total of 2369 patients were identified. In women with a PFI of ≤6months, treatment consisted of platinum-based combination therapy in 28.2%, single agent platinum in 5.2% and non-platinum therapy in 66.6%. Corresponding rates of these treatments among women with a PFI of 7-12months were 39.7%, 12.4% and 47.9%, respectively; the rates were 57.6%, 13.2% and 29.3% in those with a PFI of >12months, respectively. Median survival was 13, 18, and 27months for patients with a PFI of ≤6months, 7-12months, and >12months, respectively (P<0.0001). For all three groups, platinum combination therapy was associated with decreased risk of death compared to non­platinum based therapy. CONCLUSION: Platinum free interval is a strong predictor of survival in elderly women with recurrent ovarian cancer. There is widespread variation in treatment selection for women with recurrent ovarian cancer with many women receiving non-guideline based regimens.

National Trends in Extended Procedures for Ovarian Cancer Debulking Surgery.

OBJECTIVE: Primary cytoreduction for ovarian cancer often requires extended radical procedures and is associated with significant morbidity. In 2010, neoadjuvant chemotherapy was shown to have similar survival to primary cytoreduction but with less need for radical surgery. We hypothesized that the increased use of neoadjuvant chemotherapy would decrease the use of radical cytoreductive procedures and thus examined trends in the performance of radical cytoreductive procedures. METHODS: We used the Nationwide Inpatient Sample to determine the annual number of extended procedures (colon, small intestine, liver, diaphragm, spleen, and gastric resection, ileostomy, colostomy) performed in women undergoing surgery for ovarian cancer from 1998 to 2013. Estimates were weighted to provide national averages. To account for changes in incidence over time, we used national incidence rates and report procedures performed per 1000 new cases of ovarian cancer. Trends were assessed using Cochrane-Armitage tests. RESULTS: We identified 274,639 ovarian cancer patients who underwent surgery, ranging from 15,720 to 18,714 procedures performed each year. We identified a significant increase in the use of extended procedures over this period. These differences were significant for absolute numbers of procedures, rate per 1000 new ovarian cancer cases, and percent per hysterectomy/bilateral salpingoophorectomy for rectosigmoid resection, diaphragm resection, splenectomy, ileostomy, and liver resection. Specifically, the use of these procedures rose from 1998 to 2010, declined in 2011, and rose again in 2012 and 2013. CONCLUSIONS: Although there was a transient decrease in the use of extended cytoreductive procedures from 2010 to 2011 after the publication of randomized neoadjuvant trial data, use of these procedures again rose in 2012 and 2013.

Management of non-functioning pituitary adenomas: surgery.

Non-functional pituitary adenomas (NFPAs) are benign tumors of the pituitary gland that do not over-secrete hormonal products, therefore, they are generally detected through symptoms of mass effect, including headache, vision loss, or hypopituitarism. There are multiple pathological subtypes of NFPAs, such as null cell adenomas, silent gonadotrophs, silent somatotrophs, silent corticotrophs, and silent subtype 3, all of which can be classified based on immunohistochemical studies and electron microscopy. Despite these numerous pathological subtypes, surgical resection remains the first-line treatment for NFPAs. Diagnosis is best made using high resolution MRI brain with and without gadolinium contrast, which is also helpful in determining the extent of invasion of the tumor and recognizing necessary sinonasal anatomy prior to surgery. Additional pre-operative work-up should include full laboratory endocrine evaluation with replacement of hormone deficiencies, and ideally, full neuro-ophthalmologic exam. Although transcranial surgical approaches to the pituitary gland can be performed, the most common approach used is the transnasal transsphenoidal approach with endoscopic or microscopic visualization. This approach avoids retraction of the brain and cranial nerves during tumor removal. Surgery for symptoms caused by mass effect, including headaches and visual loss, are successfully treated with surgical resection, resulting in improvement in pre-operative symptoms as high as 90% in some reports. Although the risk of complications is low, major and minor events, such as permanent hypopituitarism, persistent CSF leak, and carotid artery injury can occur at rates ranging from zero to about 9%.

A practical method for prevention of readmission for symptomatic hyponatremia following transsphenoidal surgery.

INTRODUCTION: Patients undergoing transsphenoidal pituitary surgery (TSS) are at risk for several serious complications, including the syndrome of inappropriate antidiuretic hormone and subsequent hyponatremia. OBJECTIVE: In this study, we examined the effect of 1 week of post-discharge fluid restriction to 1.0 L daily on rates of post-operative readmission for hyponatremia. METHODS: We retrospectively analyzed all patients undergoing TSS from 2008 to 2014 and prospectively recorded patient data from 2015 to 2017. Patients were divided into a control cohort (2008-2014), who were discharged with instructions to drink to thirst; and an intervention cohort (2015-2017) who were instructed to drink less than 1.0 L daily for 1 week post-operatively. RESULTS: This study included 788 patients; 585 (74.2%) in the control cohort and 203 (25.8%) in the intervention cohort. Overall, 436 (55.3%) were women, the median age was 47 (range 15-89), and average BMI was 29.4 kg/m2 (range 17.7-101.7). Patients were relatively well matched. Of patients in the intervention group, none was readmitted for hyponatremia (0/203), compared to 3.41% (20/585) in the control group (p = 0.003). Patients in the intervention group also had significantly higher post-operative week one sodium levels (140.1 vs 137.5 mEq/L; p = 0.002). No fluid balance complications occurred in patients who followed this protocol. CONCLUSION: Hyponatremia can be a life-threatening complication of TSS, and prevention of readmission for hyponatremia can help improve patient safety and decrease costs. Mandatory post-discharge fluid restriction is a simple and inexpensive intervention associated with decreased rates of readmission for hyponatremia and normal post-operative sodium levels.

Unsuspected Uterine Sarcoma in an Urban Hospital: Does Surgical Approach Matter?

STUDY OBJECTIVE: To compare the incidence of unsuspected uterine sarcoma based on surgical approach, open versus minimally invasive, for myomectomy and hysterectomy. DESIGN: Retrospective chart review of demographic data, preoperative characteristics, operative details, and pathology results from the electronic medical record (Canadian Task Force classification II-3). SETTING: A large, urban, academic medical center. PATIENTS: All women undergoing myomectomy or hysterectomy performed for a benign indication via a benign gynecologic surgical procedure between 2010 and 2014. MEASUREMENTS AND MAIN RESULTS: A total of 1959 myomectomies and hysterectomies were performed, among which 4 unsuspected uterine sarcomas were identified, for an incidence of 2.0 per 1000 cases. The incidence of sarcoma was similar in patients undergoing open abdominal surgery and those undergoing minimally invasive surgery (MIS) (3 in 743 [0.40%] vs. 1 in 1216 [0.08%]; p = .16). The mean age, body mass index, and specimen weights were also similar in the 2 groups. Although more than one-quarter of all cases involved morcellation, the majority via power morcellation, no specimens with sarcoma were morcellated. CONCLUSION: The incidence of unsuspected uterine sarcoma during myomectomy or hysterectomy for benign indications is low at our institution, and is similar for open and MIS cases. Patients should be counseled on the risks and benefits of both open surgery and MIS approaches.