A Cross- Sectional Assessment of Impact of COVID-19 Vaccine on Menstrual Cycle of Pharmacy and Medical Students of Qassim University, Saudi Arabia

Objectives: To determine the relationship between the COVID-19 vaccine and the menstruation and to determine the factors associated with menstrual abnormalities after COVID-19 Vaccine. Method(s): Female students from the Unaizah College of Pharmacy and Medicine at Qassim University who were over the age of menarche, had received the vaccine, were not pregnant or nursing, were not using contraceptives, did not have a history of primary ovarian insufficiency, hypothalamic menopause, or had undergone a hysterectomy were invited to participate. A universal sampling method was used to collect the data using an online method. Consequently, a total of 299 enrolled students participated in the survey. Result(s): Out of 329 registered students, 299 agreed to participate, giving a response rate of 90.88%. The mean age of the participants was 22.1 +/- 1.70, majority were unmarried (n=255;85.3%) and were from PharmD (n=206;69.8%). A total of 70(26.1%) reported to have COVID-19 infection. About 258(86.2 %) reported menstrual symptoms post-vaccination, of which 108(41.8%) reported irregular, 94(36.4 %)length of menstruation changed, for 56(21.7%) mensuration completely stopped. Only 16(6.20%) required a hospital visit to resolve post COVID vaccination menstrual symptoms. Previous COVID 19 infection significantly influenced the incidence of mensural abnormalities (p=0.03). After the second dose of the vaccine, Pfizer-BioNTech (91.3%) followed by Johnson and Johnson (66.7%), there were significant variations in the menstrual abnormalities across different vaccination types (p = 0.014). Conclusion(s): The study showed a possible link between the COVID-19 vaccine and menstrual abnormalities which needs further investigation regarding its impact on their quality of life.Copyright © 2023

Socioeconomic Factors Associated with Delay of Minimally Invasive Benign Gynecologic Surgery and Impact of the COVID-19 Pandemic

Objective: The effects of demographic and socioeconomic characteristics on delay of minimally invasive gynecologic surgery (MIGS) before and during the COVID-19 pandemic were studied. The primary outcome was interval between first MIGS appointment and date of surgery. Materials and Methods: This retrospective cohort study used electronic medical record data of a historical cohort who had benign MIGS in 2014-2016 (n = 370) and a cohort in 2020 during the COVID pandemic (n = 249). Included procedures were laparoscopic hysterectomy, myomectomy, adnexal surgery, or endometriosis excision. Patient demographics (race, ethnicity, age, marital status, language, insurance, and socioeconomic factors) were evaluated for associations with surgery delay (> 90 days from initial consultation to operating room date). Results: Median time to surgery was 21 days faster during the pandemic. In the historical cohort, 61% patients waited >90 days, and in the pandemic cohort, 47% patients waited >90 days. In the pandemic cohort, race and primary language were new factors associated with surgery delays. During the pandemic, a greater proportion of patients having surgery delays were Black or other races, compared to White, and a greater proportion did not speak English. After adjusting for referral indications, in multivariable logistic regression, patients who reported Other race had 3 times the odds of surgery delay, compared to White patients. Black patients had higher odds of surgery delay, although this estimate was less precise. Patients with a non-English primary language had >4 times the odds of surgery delay. Ethnicity, insurance and employment status, median household income, neighborhood segregation, and distance to hospital were not associated with surgery delay. Telemedicine accounted for 71% of visits in the pandemic cohort and was associated with a significant decrease in surgery delays with a median wait time of 87 days for patients seen via telemedicine, compared to 101 days for patients seen in-person. A higher proportion of patients using telemedicine were White and spoke English. Hispanic/Latino ethnicity, non-English primary language, and unemployment were associated with in-person versus telemedicine visits. Visit type was not correlated with insurance status, median household income, neighborhood segregation, and distance from the hospital. A risk score was calculated to summarize the estimated effect of intersectionality of multiple identities;multiple minority characteristics were correlated with surgery delays. Time to benign MIGS decreased from historical baselines during the pandemic, indicating improved access to surgical care. This benefit did not apply equally. Disproportionately, White patients who spoke English had no delays and used telemedicine;racial minority patients who did not speak English had greater odds of surgery delays and in-person appointments. Conclusions: Telemedicine can improve access to both MIGS care and surgical outcomes;additional strategies are needed to ensure that all patients receive care advances equitably. (J GYNECOL SURG 20XX:000)

Barking up the Wrong Hepatobiliary Tree: A Case of Elevated CA19-9

Introduction: Incidental elevations in Carbohydrate Antigen 19-9 (CA19-9) can trigger extensive medical evaluations for malignancy. Though classically associated with pancreatic cancer, CA19-9 is a nonspecific manifestation of multiple benign and malignant disease processes. Case Description/Methods: An asymptomatic, healthy 50-year-old female presented to primary care for an elevated CA19-9 level obtained for pancreatic cancer screening in Asia in 2019. Her evaluation in 2019 included abdominopelvic CT and magnetic retrograde cholangiopancreatography, which were normal. She was offered endoscopic ultrasonography to further evaluate pancreaticobiliary etiologies but was lost to follow-up amid the COVID-19 pandemic. She returned to the US in 2021, and basic laboratory testing and routine cervical cancer screening were performed. She was referred to Gastroenterology (GI) for further evaluation. Cervical cytology revealed atypical endometrial cells, and endometrial biopsy by gynecology was concerning for gastric-type endocervical adenocarcinoma. Transvaginal ultrasound revealed a thickened endometrial stripe, and pan CT revealed duodenal thickening, for which GI performed bidirectional endoscopy without significant abnormalities and no pancreatic or metastatic disease. Repeat CA19- 9 increased. She was referred to gynecologic oncology, where cervical biopsy and pelvic MRI confirmed an endocervical mass. She was diagnosed with Stage IIB gastric-type endocervical adenocarcinoma and underwent hysterectomy and left salpingectomy with adjuvant chemoradiation. Discussion(s): CA19-9 is synthesized in multiple organ systems. Elevations in asymptomatic patients are rarely predictive of pancreatic cancer but may expose patients to unnecessary testing and inadvertent harms without identifying malignancy. Thus, CA19-9 is not recommended for pancreatic cancer screening. Incidental elevations do warrant repeat testing. Benign processes will yield stable or decreasing levels, while rising levels suggest progressive or malignant processes. If concern for pancreatic malignancy is low, a reasonable investigation includes chest X-ray or CT, metabolic studies, hemoglobin A1c, liver and thyroid function panels, abdominopelvic CT or gynecologic cancer evaluation, and any other age-indicated cancer screening. In this case, prior imaging studies suggested low concern for pancreatic cancer. Her subsequent evaluation aligned with this suggested work-up and revealed gynecologic cancer as the ultimate etiology for her elevated CA19-9.

Hysterectomies for endometrial hyperplasia decreased during the first year of the COVID-19 pandemic: where have all the patients gone?

Objectives: To determine change in number of hysterectomies (hyst) and levonorgestrel intrauterine device (IUD) placements as treatment for endometrial hyperplasia (EH), and in the number of diagnostic procedures for abnormal uterine bleeding (AUB) and postmenopausal bleeding (PMB) performed during the first year of the COVID-19 pandemic compared to pre-pandemic levels. Method(s): Hospitals submitting data to the Vizient database for the period 2/1/19 through 2/1/21 provided the study population. We queried Vizient to identify patients undergoing (1) hyst, (2) IUD placement for EH, and (3) endometrial biopsy (EMB) or dilation and curettage (D&C) for AUB or PMB by month (mo.). We defined the pre-pandemic period as 2/1/19 through 1/31/20;2/1/20 began the pandemic period. Mean number/mo of EH hyst, EH IUD placement, and EMB or D&C for AUB or PMB for the pre-pandemic period established a baseline for comparison to mos during the first pandemic year. Result(s): 314 hospitals reported data on 2,374 EH hysts, 2,006 EH IUD placements, and 99,782 diagnostic procedures for AUB and PMB. The mean number of EH hysts was 118/mo pre-pandemic and 79.9/mo during the pandemic;the mean difference was 38.2/mo (95%CI 23.2- 53.1, p=0.00015). Mean EH IUD placements pre-pandemic were 87.6/ mo, and 79.6/mo during the pandemic;mean difference was 8/mo (95%CI -11-27, p=0.37). The mean number of combined EMBs and D&Cs pre-pandemic was 4,547/mo and 3,768/mo during the pandemic;mean difference was 778/mo (95%CI 80-1477, p=0.032).[Formula presented] Conclusion(s): During the first year of the COVID-19 pandemic, the number of EH hysts performed per mo decreased. We found no increase in EH IUD placement. Although Vizient does not report the number of patients prescribed oral progesterone as an alternative treatment, we found that the total number of patients undergoing diagnostic procedures for AUB and PMB decreased significantly during the pandemic period, suggesting that the deficit in hysts performed for EH is due, in part, to fewer patients presenting for workup of abnormal bleeding. Together with our earlier report that 20% fewer hysts for EC were done during the first pandemic year, our findings suggest a meaningful delay in care. More research is needed to determine if this delay will impact stage, treatment and outcome. Data for the 2nd pandemic year will be analyzed in time for the meeting.Copyright © 2022 Elsevier Inc.

Biofeedback Treatment Can Improve Clinical Condition and Quality of Life in Patients with Pelvic Floor Dyssynergy with Irritable Bowel Syndrome: A Prospective Cohort Study

Background: Chronic constipation is a common health concern. Defecatory disorders are considered one of the mechanisms of chronic idiopathic constipation. This study aimed to evaluate the effect of concurrent irritable bowel syndrome (IBS) on the success rate and response to biofeedback therapy in patients with chronic constipation and pelvic floor dyssynergia (PFD). Method(s): This prospective cohort study was performed at the Imam Khomeini Hospital Complex in Tehran from October 2020 to July 2021. Patients aged 18-70 years with chronic constipation and PFD confirmed by clinical examination, anorectal manometry, balloon expulsion test, and/or defecography were included. All patients failed to respond to treatment with lifestyle modifications and laxative use. The diagnosis of IBS was based on the ROME IV criteria. Biofeedback was educated and recommended to all patients. We used three different metrics to assess the patient's response to biofeedback: 1) constipation score (questionnaire), 2) lifestyle score (questionnaire), and 3) manometry findings (gastroenterologist report). Result(s): Forty patients were included in the final analysis, of which 7 men (17.5%) and 21 (52.2%) had IBS. The mean age of the study population was 37.7 +/- 11.4. The average resting pressure decreased in response to treatment;however, this decrease was statistically significant only in non-IBS patients (P = 0.007). Patients with and without IBS showed an increase in the percentage of anal sphincter relaxation in response to treatment, but this difference was not statistically significant. Although the first sensation decreased in both groups, this decrease was not statistically significant. Overall, the clinical response was the same across IBS and non-IBS patients, but constipation and lifestyle scores decreased significantly in both groups of patients with and without IBS (P < 0.001). Conclusion(s): Biofeedback treatment appears to improve the clinical condition and quality of life of patients with PFD. Considering that a better effect of biofeedback in correcting some manometric parameters has been seen in patients with IBS, it seems that paying attention to the association between these two diseases can be helpful in deciding on treatment.Copyright © 2023 The Author(s).

Robotic surgery implementation in an isolated overseas territory - The case of Reunion Island.

INTRODUCTION: In February 2020, robotic surgery was introduced in University Hospital of St Pierre in Reunion Island. The aim of this study was to evaluate the implementation of robotic assisted surgery in the hospital and its impact on operating times and patient outcomes. METHODS: Data was prospectively collected on patients undergoing laparoscopic robotic assisted surgery between February 2020 and February 2022. Information included patient demographics, type of surgery, operating times and length of stay. RESULTS: Over the two-year study period, 137 patients underwent laparoscopic robotic assisted surgery performed by 6 different surgeons. 89 of the surgeries were in gynecology, including 58 hysterectomies, 37 were in digestive surgery, and 11 in urology. The installation and docking times decreased across all specialties and were found to be significantly reduced when comparing the first and last 15 hysterectomies: mean installation time decreased from 18.7 to 14.5 minutes (p=0.048), mean docking time decreased from 11.3 to 7.1 minutes (p = 0.009). CONCLUSIONS: The implementation of robotic assisted surgery in an isolated territory such as Reunion Island was slow due to a lack of trained surgeons, supply difficulties and Covid crisis. Despite these challenges, the use of robotic surgery allowed for technically more challenging surgeries and demonstrated similar learning curves to other centers.

A Case Report of Non-puerperal Uterine Inversion

Objective: Non-puerperal uterine inversion is a rare occurrence. The common etiology for this condition is uterine sarcoma, endometrial carcinoma, and myoma. Case Presentation: This case is a 44-year-old woman with a protruding malodorous vaginal mass, abdominal pain, and urinary retention. Total hysterectomy with bilateral salpingectomy was per-formed. Conclusion: Diagnosis of uterine inversion might be difficult and requires a high index of suspicion. © 2023 Bentham Science Publishers.

Long-term mesh exposure after minimally invasive total hysterectomy and sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: The objective was to evaluate total and incident mesh exposure rates at least 2 years after minimally invasive total hysterectomy and sacrocolpopexy. Secondary aims were to evaluate surgical success and late adverse events. METHODS: This extension study included women previously enrolled in the multicenter randomized trial of permanent vs delayed-absorbable suture with lightweight mesh for > stage II uterovaginal prolapse. Owing to COVID-19, women were given the option of an in-person (questionnaires and examination) or telephone visit (questionnaires only). The primary outcome was total and incident suture or mesh exposure, or symptoms suggestive of mesh exposure in women without an examination. Secondary outcomes were surgical success, which was defined as no subjective bulge, no prolapse beyond the hymen, and no pelvic organ prolapse retreatment, and adverse events. RESULTS: A total of 182 out of 200 previously randomized participants were eligible for inclusion, of whom 106 (58%) women (78 in-person and 28 via questionnaire only) agreed to the extension study. At a mean of 3.9 years post-surgery, the rate of mesh or suture exposure was 7.7% (14 out of 182) of whom only 2 were incident cases reported after 1-year follow-up. None reported vaginal bleeding or discharge, dyspareunia, or penile dyspareunia. Surgical success was 93 out of 106 (87.7%): 13 out of 94 (13.8%) failed by bulge symptoms, 2 out of 78 (2.6%) by prolapse beyond the hymen, 1 out of 85 (1.2%) by retreatment with pessary, and 0 by retreatment with surgery. There were no serious adverse events. CONCLUSIONS: The rate of incident mesh exposure between 1 and 3.9 years post-surgery was low, success rates remained high, and there were no delayed serious adverse events.

Cancer, Covid and Control of Ra - a Toxic Combination?

Case report - Introduction: This case highlights the dilemma of keeping rheumatoid arthritis disease under control in active cancer cases and establishing a consistent multidisciplinary dialogue during a pandemic and staffing crises. During chemotherapy and active cancer treatment, disease-modifying therapies (conventional and biologic) are often stopped. In some cases, the potential benefits versus risks of restarting usual therapies have to be balanced against risks of suppressing disease activity with highdose steroids. Risks of infection (common and atypical) need to be considered. Case report - Case description: A is a 67-year-old female nonsmoker diagnosed with seropositive rheumatoid arthritis (RF, anti - CCP positive) in 2008. Other conditions include type 2 diabetes, atrial fibrillation (on warfarin), hypothyroidism and obstructive sleep apnoea. Due to active disease, despite triple therapy (methotrexate, sulphasalazine and hydroxychloroquine), anti-TNF therapy (etanercept) commenced in 2009 with primary non-response. However, she responded well to B-cell therapy (rituximab) in conjunction with oral methotrexate (25mg weekly) receiving annual infusions from 2010 to 2016. In 2017, an elective sleeve gastrectomy procedure for high BMI was abandoned after peritoneal deposits of concern were noted. Histology and CT imaging were consistent with a primary peritoneal malignancy (Stage 3c low-grade serous adenocarcinoma). Treatment involved debulking surgery (total abdominal hysterectomy, bilateral salpinoophorectomy, omentectomy) and tamoxifen. Treatment for rheumatoid arthritis stalled during this period but as frequent steroids were required for active joint inflammation, in agreement with the oncologists, she had a rituximab cycle in 2018. Unfortunately, in 2019 she had signs of cancer progression (elevated tumour markers, CT imaging) and has subsequently started carboplatin chemotherapy. She has been unable to continue methotrexate or rituximab pending completion of the chemotherapy cycles (ongoing). However, her arthritis is now uncontrolled without increased steroids. Due to recurrent flares, her maintenance dose has been increased from 5mg to 7.5-10mg prednisolone daily until we can establish if it is safe and appropriate to recommence her usual arthritis regime. Even without disease-modifying therapy like methotrexate and rituximab, risk of infection (including atypical ones) is still significant with the combination of chemotherapy and steroids. Risk of progressive joint damage and adverse quality of life with active arthritis also needs to be considered. Staffing crises, exacerbated by COVID pandemic issues, have added to complexity of decision making and coordination of regular multidisciplinary discussions regarding treatment. Case report - Discussion: Cancer is a known association in rheumatoid arthritis patients with a twofold higher risk of lymphoma compared to the general population. Whether condition or treatment affects risk remains unclear as immune dysregulation is relevant in both autoimmunity and cancer. Paraneoplastic, recent onset arthritis, chemotherapy- or immunotherapy-induced arthralgia/arthritis are also well documented. This case had a seropositive rheumatoid arthritis phenotype quite a few years prior to cancer diagnosis. Primary peritoneal cancer is uncommon, often presenting as in this case as an incidental finding. It is usually treated like ovarian cancer Whilst methotrexate has been implicated in lung cancer, melanoma and non-Hodgkin lymphoma, overall safety data suggest any risk is quite low (e.g., EBV-associated lymphoproliferative disorders usually resolve with drug discontinuation). It is also a known chemotherapeutic agent. Anti-TNF treatment algorithms generally exclude patients with recent cancer. Rituximab, originally developed as a cancer drug, is not thought to affect risk of cancer development or progression. Treatment with disease-modifying therapy (conventional and biologics) is often withheld in patients with active malignancy undergoing chemotherapy due to a theo etical risk of potentiated immunosuppression and toxicity, particularly cytopaenias. However, maintaining arthritis control with glucocorticoids also has short- and long-term risks. Combining chemotherapy agents like carboplatin with methotrexate has been used for urothelial carcinoma and can be well tolerated with close monitoring of haematological parameters. Thus, it could be argued this patient is at risk of infections whichever treatment approach is taken and regaining control of arthritis with recommencement of methotrexate and rituximab is much better for her quality of life. Regular multidisciplinary discussions are important to outline risks versus benefits of combined treatment. This may be difficult in practice during staffing crises. Covid risk in patients receiving rituximab and/or chemotherapy, timing and response to COVID vaccination are also important considerations. Case report - Key learning points: . Primary peritoneal cancer is uncommon and can present as an incidental finding . Whilst treatment for progressive cancer is important, withholding rheumatoid arthritis treatment can have a significant adverse impact on quality of life . Morbidity and mortality risks of stopping treatment versus combined treatment (cancer therapy and disease-modifying therapy) ideally needs to be fully discussed and agreed with the patient and all care providers - lack of "named" providers, restructuring, redeployment, multi-specialty care and a global pandemic can make coordination of this difficult.

Facilitating method for removal of the large uterus after laparoscopic hysterectomy: Vaginal vault vertical incision.

BACKGROUND: In patients with a large uterus, an important part of the laparoscopic hysterectomy operation time is the phase of removing the uterus from the abdomen.The development of techniques that will shorten the morcellation time is the key to reducing the total operation time. AIM: To evaluate the effect of vaginal cuff vertical incision in accelerating removal of the large uterus in laparoscopic hysterectomy. METHODS: This study was performed with patients who underwent total laparoscopic hysterectomy. In the study group, a vertical incision was performed in the middle of the posterior vaginal stump before the vaginal removal of the larger uterus (weighing more than 500 g). The control group consisted of patients who underwent vaginal morcellation after conventional colpotomy. Patients in both groups were matched in terms of uterine weights +/-50 g and the same vaginal morcellation technique was applied to all patients. RESULTS: In patients who underwent a vertical incision procedure, the time to remove the uterus from the abdomen (17.55±2.53 min vs 26.62±4.72 min, p<0.001) and the total operation time (130.81±12.83 min vs.143.29±13, 15 min, p = 0.001) was statistically significantly less than the patients without vertical incision. There was no difference between the groups in terms of intraoperative complications, drop in hemoglobin levels, time to flatus, postoperative 6th,24th hour visual analog score and length of hospital stay. CONCLUSIONS: The vertical incision procedure reduces the time to remove the large uterus from the abdomen after laparoscopic hysterectomy and, accordingly, the total operation time. This procedure may be the preferred method before vaginal morcellation, especially in large uterus.

Cancer, Covid and Control of Ra - a Toxic Combination?

Case report - Introduction: This case highlights the dilemma of keeping rheumatoid arthritis disease under control in active cancer cases and establishing a consistent multidisciplinary dialogue during a pandemic and staffing crises. During chemotherapy and active cancer treatment, disease-modifying therapies (conventional and biologic) are often stopped. In some cases, the potential benefits versus risks of restarting usual therapies have to be balanced against risks of suppressing disease activity with highdose steroids. Risks of infection (common and atypical) need to be considered. Case report - Case description: A is a 67-year-old female nonsmoker diagnosed with seropositive rheumatoid arthritis (RF, anti - CCP positive) in 2008. Other conditions include type 2 diabetes, atrial fibrillation (on warfarin), hypothyroidism and obstructive sleep apnoea. Due to active disease, despite triple therapy (methotrexate, sulphasalazine and hydroxychloroquine), anti-TNF therapy (etanercept) commenced in 2009 with primary non-response. However, she responded well to B-cell therapy (rituximab) in conjunction with oral methotrexate (25mg weekly) receiving annual infusions from 2010 to 2016. In 2017, an elective sleeve gastrectomy procedure for high BMI was abandoned after peritoneal deposits of concern were noted. Histology and CT imaging were consistent with a primary peritoneal malignancy (Stage 3c low-grade serous adenocarcinoma). Treatment involved debulking surgery (total abdominal hysterectomy, bilateral salpinoophorectomy, omentectomy) and tamoxifen. Treatment for rheumatoid arthritis stalled during this period but as frequent steroids were required for active joint inflammation, in agreement with the oncologists, she had a rituximab cycle in 2018. Unfortunately, in 2019 she had signs of cancer progression (elevated tumour markers, CT imaging) and has subsequently started carboplatin chemotherapy. She has been unable to continue methotrexate or rituximab pending completion of the chemotherapy cycles (ongoing). However, her arthritis is now uncontrolled without increased steroids. Due to recurrent flares, her maintenance dose has been increased from 5mg to 7.5-10mg prednisolone daily until we can establish if it is safe and appropriate to recommence her usual arthritis regime. Even without disease-modifying therapy like methotrexate and rituximab, risk of infection (including atypical ones) is still significant with the combination of chemotherapy and steroids. Risk of progressive joint damage and adverse quality of life with active arthritis also needs to be considered. Staffing crises, exacerbated by COVID pandemic issues, have added to complexity of decision making and coordination of regular multidisciplinary discussions regarding treatment. Case report - Discussion: Cancer is a known association in rheumatoid arthritis patients with a twofold higher risk of lymphoma compared to the general population. Whether condition or treatment affects risk remains unclear as immune dysregulation is relevant in both autoimmunity and cancer. Paraneoplastic, recent onset arthritis, chemotherapy- or immunotherapy-induced arthralgia/arthritis are also well documented. This case had a seropositive rheumatoid arthritis phenotype quite a few years prior to cancer diagnosis. Primary peritoneal cancer is uncommon, often presenting as in this case as an incidental finding. It is usually treated like ovarian cancer Whilst methotrexate has been implicated in lung cancer, melanoma and non-Hodgkin lymphoma, overall safety data suggest any risk is quite low (e.g., EBV-associated lymphoproliferative disorders usually resolve with drug discontinuation). It is also a known chemotherapeutic agent. Anti-TNF treatment algorithms generally exclude patients with recent cancer. Rituximab, originally developed as a cancer drug, is not thought to affect risk of cancer development or progression. Treatment with disease-modifying therapy (conventional and biologics) is often withheld in patients with active malignancy undergoing chemotherapy due to a theo etical risk of potentiated immunosuppression and toxicity, particularly cytopaenias. However, maintaining arthritis control with glucocorticoids also has short- and long-term risks. Combining chemotherapy agents like carboplatin with methotrexate has been used for urothelial carcinoma and can be well tolerated with close monitoring of haematological parameters. Thus, it could be argued this patient is at risk of infections whichever treatment approach is taken and regaining control of arthritis with recommencement of methotrexate and rituximab is much better for her quality of life. Regular multidisciplinary discussions are important to outline risks versus benefits of combined treatment. This may be difficult in practice during staffing crises. Covid risk in patients receiving rituximab and/or chemotherapy, timing and response to COVID vaccination are also important considerations. Case report - Key learning points: . Primary peritoneal cancer is uncommon and can present as an incidental finding . Whilst treatment for progressive cancer is important, withholding rheumatoid arthritis treatment can have a significant adverse impact on quality of life . Morbidity and mortality risks of stopping treatment versus combined treatment (cancer therapy and disease-modifying therapy) ideally needs to be fully discussed and agreed with the patient and all care providers - lack of "named" providers, restructuring, redeployment, multi-specialty care and a global pandemic can make coordination of this difficult.

A Case Report of Non-puerperal Uterine Inversion

Objective: Non-puerperal uterine inversion is a rare occurrence. The common etiology for this condition is uterine sarcoma, endometrial carcinoma, and myoma. Case Presentation: This case is a 44-year-old woman with a protruding malodorous vaginal mass, abdominal pain, and urinary retention. Total hysterectomy with bilateral salpingectomy was per-formed. Conclusion(s): Diagnosis of uterine inversion might be difficult and requires a high index of suspicion. Copyright © 2023 Bentham Science Publishers.

Maternal race as a risk factor for maternal ICU admission, cesarean delivery, and maternal transfusion

Objective: The study aimed to evaluate maternal race as a risk factor for the following pregnancy outcomes: ICU admission, Cesarean Delivery (CD), and maternal transfusion. Study Design: The study analyzed 15.4 million births in the US from 2016-2019 using natality data provided by the CDC. Data from 2020-2021 was not included in the analysis to eliminate confounding factors caused by the COVID-19 pandemic. Multinomial logistic regression was performed to calculate adjusted odds ratios (aOR) and corresponding 95% confidence intervals using SPSS© for ICU admission, CD, and maternal transfusion across different races. Result(s): When accounting for CD history, the number of previous CDs, gestational and pre-pregnancy hypertension, gestational and pre-pregnancy diabetes, unplanned hysterectomy, and a ruptured uterus, maternal race remained a statistically significant risk factor for ICU admission (p < 0.001) in the multivariate analysis. After normalizing to White race, Asian and Black populations had aORs of 1.478 and 1.501 for ICU admission, respectively. While Native Hawaiian and Pacific Island (NHOPI) and American Indian and Native American (AINA) mothers had the highest aORs of 2.612 and 1.501, they represented a small of births in the US (Table 1, Table 2). Accounting for previous CDs, the number of previous CDs, and BMI, the multivariate analysis of CD and maternal race demonstrated that the Asian population had a higher aOR of 1.304 relative to the White population. In addition, Black race has an aOR of 1.211 for maternal transfusion and AINA and NHOPI have aORs of 2.714 and 1.624, respectively (Table 2). Conclusion(s): The study's findings suggest that maternal race may impact the risk of ICU admission, CD, and maternal transfusion. Notably, Black, Asian, NHOPI, and AINA populations are particularly at increased risk for ICU admission. These results warrant further studies to identify underlying causes of the disparity in pregnancy outcomes across different races. [Formula presented] [Formula presented] Copyright © 2022

Access to treatment for endometrial cancer patients during the COVID-19 pandemic in Ontario, Canada

ObjectivesDuring the first year of the COVID-19 pandemic in Ontario, biopsies for cancer diagnosis decreased by over 40% and surgical cancer treatment decreased by over 25% during the first pandemic wave1. This study aims to assess the impact of the COVID-19 pandemic on endometrial cancer diagnosis and surgical treatment in Ontario, Canada.MethodsCases were identified from January 1, 2017 to December 31, 2022 from endometrial cancer hysterectomy specimens in Ontario Health – Cancer Care Ontario, ePath system. Endometrial biopsy records were matched to surgical specimens by provincial health card number. System performance was compared before (2017–2019) and during (2020–2021) the COVID-19 pandemic.ResultsThere were 10 446 women treated with hysterectomy for endometrial cancer in Ontario from 2017–2021. The majority were low grade (74%) compared to high grade (18%) with 8% unspecified. In April and May 2020 corresponding with the provincial state of emergency, there was a 56% relative reduction in endometrial biopsies. The median time to surgery was 57 days (IQR 41–73) for low grade and 57 days (IQR 42–76) for high grade endometrial cancer. There was no difference in time to surgery and no change in surgical stage at presentation before (2017–2019) or during the pandemic (2020–2021).ConclusionsDespite significant increase in virtual care and decreased operating room time during the COVID-19 pandemic in Ontario, the healthcare system continued to prioritize service delivery to endometrial cancer patients. Importantly, there were no significant surgical delays or upstaging of endometrial cancer, particularly of high-grade histology. 1Walker et al., JAMA Network Open. 2022;5(4):e228855. doi:10.1001/jamanetworkopen.2022.8855

Intra-abdominal actinomycosis-an indolent masquerader of malignancy

Introduction: A 54 years old lady who presented with constitutional symptoms of lethargy, weight loss and asthenia. She had been extensively evaluated for a possible gynaecological malignancy but with no definitive outcome. The symptoms were persistent and a decision had to be made towards Surgery in The present climate of The COVID19 pandemic. Method(s): Following oncology multi disciplinary meeting outcome she was taken up for a total abdominal hysterectomy and bilateral salpingo-oophrectomy. She was noted to have an incidental finding of an extensive tumour infiltrating The liver, colon, anterior abdominal wall and The urinary bladder. A surgical resection with ileostomy was performed on suspicion of an underlying malignancy. Result(s): The histopathological diagnosis revealed a picture of actinomycosis which had evaded us previously. Following this she was treated with prolonged course of antibiotics and has recovered well, thus altering our entire management plan. Conclusion(s): Actinomycosis albeit rare is an interesting mimic of tumours. This case also delves into The on-table decision making when in doubt about cancer.

Safety of Three-Dimensional versus Two-Dimensional Laparoscopic Hysterectomy during the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic has resulted in a significant decrease in the number of surgical procedures performed. Therefore, it is important to use surgical methods that carry the lowest possible risk of virus transmission between the patient and the operating theater staff. AIM: Safety evaluation of three-dimensional (3D) versus two-dimensional (2D) laparoscopic hysterectomy during the COVID-19 pandemic. METHODS: 44 patients were assigned to a prospective case-control study. They were divided either to 3D (n = 22) or 2D laparoscopic hysterectomy (n = 22). Fourteen laparoscopic supracervical hysterectomies (LASH) and eight total laparoscopic hysterectomies (TLH) were performed in every group. The demographic data, operating time, change in patients' hemoglobin level and other surgical outcomes were evaluated. RESULTS: 3D laparoscopy was associated with a significantly shorter operating time than 2D. (3D vs. 2D LASH 70 ± 23 min vs. 90 ± 20 min, p = 0.0086; 3D vs. 2D TLH 72 ± 9 min vs. 85 ± 9 min, p = 0.0089). The 3D and 2D groups were not significantly different in terms of change in serum hemoglobin level and other surgical outcomes. CONCLUSIONS: Due to a shorter operating time, 3D laparoscopic hysterectomy seems to be a safer method both for both the surgeon and the patient. Regarding terms of possible virus transmission, it may be particularly considered the first-choice method during the COVID-19 pandemic.

Misdiagnosis of intramural ectopic pregnancy and invasive gestational trophoblastic disease on ultrasound: A challenging case at Tu Du Hospital in Vietnam in COVID-19 pandemic peak and mini-review of literature.

Differentiation between intramural ectopic pregnancy and molar ectopic pregnancy is very difficult because of their exceptional rarity. Herein, we present a misdiagnosed case of intramural pregnancy and invasive trophoblastic disease on ultrasound. A 45-year-old female patient was admitted to our tertiary referral hospital due to abdominal pain and unusual ultrasonography findings. Initially, a diagnosis of intramural ectopic pregnancy was identified based on transvaginal color Doppler ultrasonography, 3-dimensional ultrasound, and serial serum beta-human chorionic gonadotropin, thus the patient underwent laparotomy with hysterectomy. However, the histopathological endpoint showed an invasive trophoblastic disease. Clinically, this pathology should be included in the differential diagnosis of intramural ectopic pregnancy since an imaging scan remains quite unclear.

Avoidable admissions in gynecology oncology patients undergoing minimally invasive hysterectomy (520)

Objectives: To determine the rate and identify factors associated with potentially avoidable admissions following a minimally invasive hysterectomy. Methods: Patients who underwent a minimally invasive hysterectomy for a suspected or known gynecologic malignancy between January 2019 to July 2021 were identified in our institution's prospectively curated quality improvement surgical database. Preoperatively, patients were assessed for planned same-day discharge versus a planned admission. Reasons for those who were admitted despite a planned same-day discharge were characterized as the following: anesthesia-related, comorbid conditions, intraoperative factors, social factors, system issues, and uncontrolled pain. For planned admissions, reasons for admission were categorized as necessary and potentially unavoidable. Descriptive statistics were used to summarize the cohort. Results: A total of 380 patients were identified, of which 267 (70%) patients had a planned same-day discharge, and 113 (30%) had an anticipated admission. Same-day surgery discharge rates increased over time (Figure 1). Two hundred and thirty-five patients (88%) were successfully discharged the same day. Of these patients, 17 (7%) presented to the emergency department (ED) within 30 days, and the re-admission rate in this group was 12% (n=2). Thirty-two patients did not successfully discharge on the same day, and five patients (15%) presented to the ED for evaluation within 30 days. Most unplanned admissions were anesthesia-related (n=15, 47%), followed by system issues (n=7, 22%), such as failure to recognize comorbid conditions in the preoperative period, intraoperative factors (n=5, 16%), postoperative pain (n=3, 9%), and social factors (n=2, 6%). Among the 113 anticipated admissions, 78 (69%) patients were deemed necessary due to multi-factorial comorbid conditions or surgical complexity. However, 35 (31%) patients could have been optimized for same-day discharge;reasons for which included patients with comorbid conditions that could have been optimized preopera- tively, such as poorly controlled diabetes (n=13, 12%), system issues, (n= 8, 7%), social factors (n= 7, 6%), anesthesia-related (n= 4, 4%), and surgical complexity (n=3, 3%). [Formula presented] Conclusions: Most patients were successfully discharged the same day, and of those who were deemed unsuitable for same-day discharge, nearly half could have been optimized for same-day discharge. Unplanned admissions in the anticipated same-day discharge cohort were primarily due to anesthesia-related concerns in the immediate postoperative period and where patient comorbid conditions could have been better optimized in the preoperative period. Recognizing potential areas for improvement and further optimizing same-day discharge will allow hospital systems to continue providing care for gynecologic oncology patients during COVID-19 surges.

Increasing volume and the role of gynecologic oncologists in peripartum hysterectomies – A single center study of 109 cases over 7 years (008)

Objectives: To evaluate the surgical volume, surgical outcomes, and the evolving role of gynecologic oncologists in peripartum hysterectomies (PPH). Methods: We conducted an IRB-approved retrospective chart review of PPH cases performed at our institution from June 1, 2014, to June 30, 2021. Clinical-pathologic information was ed into a REDCap database. All analyses were conducted using STATA 17. Results: A total of 109 cases were performed over the 7-year period. Gynecologic oncologists (GYO) involvement in the cases increased from 33% in 2014 to 80% in 2021. The mean age was 36 (range: 23-47) years. Most patients were White (81/109, 74.3%), and the median BMI was 30.7 (range: 21-57) kg/m2. Surgical indications included placenta accreta syndrome (PAS) in 84 (77%) cases, uterine atony in ten (9.2%), uterine rupture in three (2.8%), malignancy in five (4.6%), and hemorrhage other than atony in seven cases (6.4%). Intraoperative complications included bladder injury (or intentional dissection) in eight (7.3%), ureter injury in four (3.7%), vascular injury in three (2.8%), and femoral pseudoaneurysm in one (0.9%) of the cases. Postoperative complications included urinary tract infection in 11 (10.1%), nerve injury in one (0.9%), surgical site infection in 13 (11.2%), and venous thromboembolism in five (4.6%) cases. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) usage started in 2019 with one case followed by six cases in 2020 (31.6%) and 3/16 cases in the first half of 2020 (15.8%). A higher REBOA usage in 2020 corresponded with blood products shortages during the COVID crisis.[Formula presented] Conclusions: Overall volume and complexity of peripartum hysterectomy are increasing. This trend is likely driven by an increased incidence of placenta accreta syndrome cases. Gynecologic oncologists are increasingly delegated as primary surgeons in many institutions. Fellowship training programs should strongly consider training in peripartum hysterectomy for trainees.

TRENDS IN HYSTERECTOMY FOR PROLAPSE: AN ANALYSIS OF THE EFFECT OF THE COVID-19 PANDEMIC

Introduction: The COVID-19 pandemic has had a considerable and evolving impact on delivery of surgical care to patients. During the early stages of the pandemic, resource scarcity was experienced by many healthcare systems. This led to the implementation of a surgical moratorium on elective surgeries in New York State between the months of March through June 2020. Certain specialties, specifically those performing elective surgeries, experienced significant strain and transformation. Objective: This study aims to describe perioperative and intraoperative characteristics of patients undergoing hysterectomy for pelvic organ prolapse (POP) with and without concomitant urogynecology procedures between 2019-2021 at a multi-hospital healthcare system that experienced significantly strain and a subsequent moratorium on elective surgery during the first peak of the pandemic. Methods: This is a retrospective cohort analysis of all patients in a multi-hospital healthcare system in New York City who underwent hysterectomy for POP from August 19th, 2019 through August 11th, 2021. Cases were identified using procedural and diagnostic codes for hysterectomy and POP, respectively. Patients were separated into three cohorts based on dates corresponding to phases of the COVID-19 pandemic. The 'early peak' was defined from March through June 2020, coinciding with the New York State moratorium. The primary outcome was the stage of POP for patients undergoing surgery. Secondary outcomes included concomitant urogynecologic procedures, route of surgery, time from indication to procedure, length of inpatient stay, and utilization of pre-operative medical assessment/clearance (POMA). Results: A total of 253 cases were included: 106 (41.90%), 15 (5.93%), and 132 (52.17%) patients in the 'pre-pandemic','early peak pandemic', and 'stable pandemic' groups, respectively. Although not statistically significant, vaginal hysterectomy approach was performed less frequently during the 'early peak pandemic' and 'stable pandemic' cohorts (P = 0.0544). The 'early peak pandemic' cohort had significantly more stage IV POP compared to other cohorts (P = 0.0021). Rates of concomitant urogynecology procedures including slings, anterior or posterior repair, or apical repair did not differ between the cohorts. Further, cystoscopy was utilized intraoperatively more frequently in the 'stable pandemic' cohort (P = 0.0272). Time from surgical indication to operation was also significantly different with patients most frequently waiting at least 3 months in the 'early peak pandemic' group (P = 0.0132). Length of inpatient stay did not demonstrate a significant difference (P = 0.3982). The most frequent postoperative complication was transient voiding dysfunction, and this was observed more commonly in the 'stable pandemic' cohort (P = 0.0236), though overall no cases were complicated by persistent voiding dysfunction or urinary retention requiring surgical intervention in any group. Conclusions: In late spring 2020, when the moratorium was lifted, surgical volume returned to pre-peak numbers. However, time from booking to day of surgery remained significantly longer during and after the 'peak'. There was a statistically significant increase in patients with stage IV POP during the 'early peak' and 'stable' pandemic periods. There was a statistically significant increase in use of precautionary measures peri and intra-operatively during the 'peak' and 'stable pandemic' periods with significant increases in use of POMA performed outpatient by anesthesia and an increased utilization of intraoperative cystoscopy.