National guidelines may reduce socioeconomic disparities in treatment selection for esophageal cancer.

The 2011 National Comprehensive Cancer Network guidelines first incorporated the results of the landmark CROSS trial, establishing induction therapy (chemotherapy ± radiation) and surgery as the treatment standard for locoregional esophageal cancer in the United States. The effect of guideline publication on socioeconomic status (SES) inequalities in cancer treatment selection remains unknown. Patients diagnosed with Stage II/III esophageal cancer between 2004 and 2013 who underwent curative treatment with definitive chemoradiation or multimodality treatment (induction and surgery) were identified from the Surveillance, Epidemiology and End Results (SEER)-Medicare registry. Clinicopathologic characteristics were compared between the two therapies. Multivariable regression analysis was used to adjust for known factors associated with treatment selection. An interaction term with respect to guideline publication and SES was included Of the 2,148 patients included, 1,478 (68.8%) received definitive chemoradiation and 670 (31.2%) induction and surgery. Guideline publication was associated with a 16.1% increase in patients receiving induction and surgery in the low SES group (21.4% preguideline publication vs. 37.5% after). In comparison, a 4.5% increase occurred during the same period in the high SES status group (31.8% vs. 36.3%). After adjusting for factors associated with treatment selection, guideline publication was associated with a 78% increase in likelihood of receiving induction and surgery among lower SES patients (odds ratio 1.78; 95% confidence interval (CI): 1.05,3.03). Following the new guideline publication, patients living in low SES areas were more likely to receive optimal treatment. Increased dissemination of guidelines may lead to increased adherence to evidence-based treatment standards.

Does neoadjuvant therapy for esophageal cancer increase postoperative morbidity or mortality?

Neoadjuvant therapy has proven to be effective in the reduction of locoregional recurrence and mortality for esophageal cancer. However, induction treatment has been reported to be associated with increased risk of postoperative complications. We therefore compared outcomes after esophagectomy for esophageal cancer for patients who underwent neoadjuvant therapy and patients treated with surgery alone. Using the American College of Surgeons National Surgical Quality Improvement Program database (2005-2011), we identified 1939 patients who underwent esophagectomy for esophageal cancer. Seven hundred and eight (36.5%) received neoadjuvant therapy, while 1231 (63.5%) received no neoadjuvant therapy within 90 days prior to surgery. Primary outcome was 30-day mortality, and secondary outcomes included overall and serious morbidity, length of stay, and operative time. Patients who underwent neoadjuvant treatment were younger (62.3 vs. 64.7, P < 0.001), were more likely to have experienced recent weight loss (29.4% vs. 15.9%, P < 0.001), and had worse preoperative hematological cell counts (white blood cells <4.5 or >11 × 10(9) /L: 29.3% vs. 15.0%, P < 0.001; hematocrit <36%: 49.7% vs. 30.0%, P < 0.001). On unadjusted analysis, 30-day mortality, overall, and serious morbidity were comparable between the two groups, with the exception of the individual complications of venous thromboembolic events and bleeding transfusion, which were significantly lower in the surgery-only patients (5.71% vs. 8.27%, P = 0.027; 6.89% vs. 10.57%, P = 0.004; respectively). Multivariable and matched analysis confirmed that 30-day mortality, overall, and serious morbidity, as well as prolonged length of stay, were comparable between the two groups of patients. An increasing trend of preoperative neoadjuvant therapy for esophageal cancer was observed through the study years (from 29.0% in 2005-2006 to 44.0% in 2011, P < 0.001). According to our analysis, preoperative neoadjuvant therapy for esophageal cancer does not increase 30-day mortality or the overall risk of postoperative complications after esophagectomy.

Current practice patterns for initial umbilical hernia repair in the United States.

PURPOSE: The approach to repairing an initial umbilical hernia (IUH) varies substantially, and this likely depends on hernia size, patient age, sex, BMI, comorbidities including diabetes mellitus, and surgeon preference. Of these, only hernia size has been widely studied. This cross-sectional study aims to look at the practice pattern of umbilical hernia repair in the United States. METHODS: A retrospective study was performed using data from the America Hernia Society Quality Collaborative. Patient characteristics included age, sex, hernia width, BMI, smoking status, and diabetes. Outcomes were use of mesh for repair, as well as surgical approach (open vs minimally invasive). Multivariate logistic regression was performed to assess the independent effect of age, sex, hernia width, BMI, smoking status, and diabetes on use of mesh and approach to repair. RESULTS: 3475 patients were included. 74% were men. Mesh use was more common in men (67% vs 60%, P < 0.001). Mesh was used in 33% of repairs ≤ 1 cm, and 82% of repairs > 1 cm (P < 0.001). Younger patients were less likely to receive a mesh repair (54% if age ≤ 35 vs 67% for age > 35, P < 0.001). However, on multivariate analysis, mesh use was associated with increasing hernia width (OR 5.474, 95% CI 4.7-6.3) as well as BMI (OR 1.8, 95% CI 1.5-2.1) but not with age or sex. CONCLUSION: The majority of IUH are performed open. Patient BMI and hernia defect size contribute to choice of surgical technique including use of mesh. The use of mesh in 33% of hernias below 1 cm demonstrates a gap between evidence and practice. Patient factors including patient age and sex had no impact on operative approach or use of mesh.

Laparoscopic antecolic Roux-en-Y gastric bypass with closure of internal defects leads to fewer internal hernias than the retrocolic approach.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass surgery reportedly has a higher rate of postoperative internal hernias than open bypass surgery. Even with closure of mesenteric defects, hernias occur in up to 9% of cases. To minimize this complication, an antecolic antegastric approach to anastomosis of the Roux limb and gastric pouch has been used. Whereas the retrocolic retrogastric technique creates three mesenteric defects, the antecolic approach produces only two: Petersen's defect and the jejunojejunostomy. The rate of internal hernias was compared among patients undergoing laparoscopic Roux-en-Y gastric bypass surgery using the retrocolic and antecolic approaches. METHODS: The experience of a single surgeon from August 2001 to September 2005 was reviewed. Only Roux-en-Y gastric bypass procedures were included. Patients were followed for a minimum of 18 months postoperatively. The retrocolic approach was used for 274 patients and the antecolic approach for 205 patients. All defects were closed at the time of surgery. With the antecolic approach, Petersen's defect was closed from the root of the mesentery of the Roux limb and the transverse colon mesentery up to the transverse colon. RESULTS: Of the 274 patients, 7 (2.6%) experienced a symptomatic internal hernia with the retrocolic retrogastric technique. No internal hernias were reported among the 205 patients treated with the antecolic antegastric method. Chi-square analysis showed that an antecolic approach was associated with a decreased rate of internal hernias (p < 0.025). Of 479 patients, 35 (7%) underwent diagnostic laparoscopy without any internal hernia found. Of these patients, 15 were found to have cholelithiasis and subjected to laparoscopic cholecystectomy. CONCLUSIONS: The antecolic antegastric approach to laparoscopic Roux-en-Y gastric bypass is associated with fewer postoperative hernias than the retrocolic retrogastric approach. The frequency of hernias using either technique is low if meticulous attention is paid to closure of all mesenteric defects.

Pregnancy outcome after early amniotic fluid leakage after transabdominal multifetal reduction.

OBJECTIVE: To assess the importance of amniotic fluid leakage in the early period ( < 14 days) after the fetal reduction procedure. DESIGN: Prospective clinical study. SETTING: Pregnant women who underwent fetal reduction to twins in an academic, tertiary perinatal department. PATIENTS: Sixty triplet and 31 quadruplet pregnancies were identified before the ninth postmenstrual week of gestation. All patients underwent transabdominal multifetal pregnancy reduction was performed within 14 days of the procedure. INTERVENTIONS: Transabdominal multifetal pregnancy reduction from triplets and quadruplets to twins. MAIN OUTCOME MEASURE: Amniotic fluid leakage in the early period after fetal reduction. RESULTS: Early PROM occurred in eight (13.3%) patients from the triplets group and in six (19.3%) patients in the quadruplet group. Three of 60 (5.0%) patients from the triplet group and 1 of 31 (3.2%) patients from the quadruplet group miscarried before 24 weeks gestation. However, none of these patients had had PROM during the early period after the procedure. Early PROM did not influence the incidence of premature contractions of delivery and the reduction procedure, and 59% (99/169) of those who completed 24 gestational weeks delivered between 25 and 37 weeks. CONCLUSION: The presence of amniotic fluid leakage in the period close to the multifetal reduction procedure, although alarming, is not ominous for the remaining fetuses. We see no reason for any intervention in these patients.

Digital road mapping image--a novel fluoroscopic real-time guide for selective transcervical catheterization in the treatment of proximal tubal obstruction.

Ten infertile women 20 to 40 years of age, with a standard HSG diagnosis of unilateral proximal tubal obstruction, underwent a transvaginal catheterization and recanalization of the fallopian tubes. To set a fluoroscopic real-time guidance technique for improving the results of transvaginal catheterization and recanalization of the fallopian tubes and to increase its marginal safety, catheterization was performed under digital road mapping guidance. Transcervical catheterization resulted in an immediate patency of the obstructed tube in all 10 women. Three women conceived 2 to 3 months after the procedure. The improved catheterization technique enables good results in the diagnosis and treatment of proximal tubal obstructions.

Preferred treatment of infertile women older than 37 years of age who demonstrate premature luteinization in the first evaluation cycle.

OBJECTIVE: To evaluate the efficacy of various treatments in abolishing premature luteinization in infertile women over 37 years old who are undergoing ovulation induction. DESIGN: Prospective, nonrandomized study. SETTING: Tertiary care medical clinic. PATIENT(S): Seventeen infertile women >37 years old in whom premature luteinization was detected during their evaluation (pretreatment) cycle. INTERVENTION(S): The patients underwent three consecutive treatment cycles with clomiphene citrate (group A), hMG (group B), and a GnRH agonist plus hMG (group C). MAIN OUTCOME MEASURE(S): Premature luteinization, defined as a progesterone/E2 ratio of >1 on the day of hCG administration. RESULT(S): Fifteen (88%) of the 17 patients in group A and 13 (76%) of the 17 patients in group B demonstrated premature luteinization. In contrast, only 1 (6%) of the 17 patients in group C had a progesterone/E2 ratio of >1 on the day of hCG administration. The mean (+/-SD) E2 level on the day of hCG administration was significantly higher in group C (1.236 +/- 772.7 pg/mL) than in group A (214.02 +/- 104.46 pg/mL) or group B (412.5 +/- 337 pg/mL). CONCLUSION(S): Pituitary desensitization with a GnRH agonist in conjunction with hMG may be of benefit for older infertile women who demonstrate early luteinization in their first evaluation cycle.

Management of women with polycystic ovary syndrome who experienced premature luteinization during clomiphene citrate treatment.

OBJECTIVE: To determine the preferred treatment modality in patients with PCOS who experienced premature luteinization during CC treatment. DESIGN: Prospective randomized study. SETTING: Tertiary medical center. PATIENTS: Twenty-two infertile women with PCOS demonstrating premature luteinization during at least two consecutive CC cycles. INTERVENTIONS: Randomized induction of ovulation either with FSH alone or with GnRH agonist combined with FSH for a single treatment cycle. MAIN OUTCOME MEASURES: Premature luteinization was defined as serum progesterone >1.5 ng/mL before hCG administration. RESULTS: Premature luteinization occurred in eight of the 10 patients (80%) in group A and in two of the 12 patients in group B (16.6%). This result corresponds to the higher mean (+/-SD) progesterone level present in group A patients as compared to those in group B (2.0 +/- 1.2 ng/mL vs. 1.2 +/- 0.6 ng/mL, P=0.03). No pregnancies were achieved in group A, whereas the pregnancy rate per cycle observed in group B was 33.3% (4/12). On the day of hCG administration, the maximum mean (+/-SD) estradiol level was significantly lower (P<0.0001) in group A (210.6 +/- 37.9 pg/mL) than in group B (600.3 +/- 253.8 pg/mL). The treatment duration and the number of FSH ampules used did not differ between the groups. CONCLUSIONS: Pituitary desensitization with GnRH analog in combination with FSH is superior to FSH-only treatment in PCOS patients who demonstrate premature luteinization during CC treatment.

The progestative effect of the levonorgestrel-releasing intrauterine system--when does it manifest?

The objective of the study was to evaluate, clinically and sonographically, the time required for the progestative effect of the levonorgestrel-releasing intrauterine system (IUS, Mirena) to be manifested. Doppler flow of the cervical branch and spiral artery of the uterine artery, as well as the endometrial width (up to day 10 of the cycle), were evaluated in 36 women carrying levonorgestrel-releasing IUS 1-2 months after insertion of the device compared to 4-6 months after insertion. The rate of intermenstrual bleeding was reduced from 44% during the first 2 months, to only 8% of women after 4-6 months of use. Complete cessation of menstrual bleeding occurred in 5% after 2 months and in 66% after 4-6 months following insertion. While there was no change in the Doppler flow in the cervical branch of the uterine artery between both groups, there was a significant reduction in the subendometrial flow in the spiral artery. This observation was reinforced by the demonstration of significant reduction in endometrial thickness in the following 4 months of use. The present study has demonstrated that the local progestative effect of the levonorgestrel-releasing IUS on the endometrium is already manifested within a period of 3 months and over after insertion.

The influence of different copper wires on human sperm penetration into bovine cervical mucus, in vitro.

The influence of four different copper-containing intrauterine devices (IUD) (Nova-T, Multiload, Fincoid 250 and copper-T 250) on the penetration of human sperm into bovine cervical mucus were assessed. Pooled samples of predetermined sperm concentration were suspended in Earl's medium in which a copper IUD was previously incubated for periods between one hour to fourteen days. The mean copper concentration was determined for each of the medium containing IUD and was found to be between 284 +/- 93 micrograms/100 ml to 392 +/- 138 micrograms/100ml. While there was no adverse effect on sperm motility by the copper-containing medium, there was a significant reduction in the number of sperm penetrated into the bovine cervical mucus as compared to the penetration of sperm suspended in pure Earl's medium. It therefore seems that the influence of copper on sperm penetration might be by an effect on the environment or spermatozoal migration rather than by direct effect of copper on sperm motility.

Treatment of minimal and moderate intrauterine adhesions (Asherman's syndrome).

Fifty-one women with only minimal and moderate intrauterine adhesions (Asherman's syndrome) underwent dilatation of the cervix, lysis of adhesions and insertion of intrauterine contraceptive devices (IUDs). A pregnancy rate of 90% was achieved. In 85% of the pregnancies a viable infant was delivered, and 15% terminated in abortions. No complications of pregnancy or of the third stage of labor were noted. The most common procedure preceding the appearance of intrauterine adhesions was curettage for spontaneous abortion and less frequently for missed and induced abortions. It seems that in mild and moderate Asherman's syndrome, lysis of adhesions and IUD insertion without estrogen administration yield satisfactory results.

Intraamniotic prostaglandin F2 alpha for pregnancy termination in the second and early third trimesters of pregnancy.

OBJECTIVE: To examine the effectiveness and safety of intraamniotic prostaglandin F2 alpha (PGF2 alpha) instillation during second- and early third-trimester termination of pregnancy. STUDY DESIGN: The study group consisted of 173 women between 18 and 32 weeks of gestation admitted for termination of pregnancy with a live, singleton fetus. The procedure included intraamniotic instillation of 40 mg PGF2 alpha. In cases of failed induction; after 24 hours an additional procedure (repeated PGF2 alpha injection, oxytocin augmentation or extraovular balloon installation) was performed. RESULTS: The mean induction-to-abortion interval was 27 +/- 17 hours, 26 minutes. The induction-to-abortion interval was not significantly influenced by parity, maternal age, indication for pregnancy termination or gestational age at the time of the procedure. Complications were related to a longer induction-to-abortion interval (35 hours, 41 minutes +/- 26 hours, 15 minutes in complicated cases as compared to 25 hours, 43 minutes +/- 15 hours, 28 minutes, P = .012). However, complications were uncommon. CONCLUSION: Intraamniotic PGF2 alpha instillation was safely used for termination of pregnancy, even at advanced gestational ages. The induction-to-abortion interval is the main factor influencing complications and is important as a catalyst for cases that fail to abort within 24 hours.

The assessment of a cycle with clomiphene as an indicator for further treatment.

A group of 15 anovulatory women was treated during one single cycle with clomiphene citrate (CC) 100 mg daily, starting on day 5 of the cycle for 5 days, (group A). Eleven ovulatory patients represent a control group (group B). Serum levels of follicular stimulating hormone (FSH) and luteinizing hormone (LH) were determined on day 5 and 9 of the cycle. Follicular growth was assessed by ultrasound from day 9 until presumed ovulation. Estradiol levels and cervical mucus characteristics were measured on day 14 and progesterone assessed on day 23 of the cycle. In the clomiphene induced cycles FSH and LH values on day 9 were significantly above pretreatment levels (p less than 0.001 and p less than 0.0001, respectively), and above those of day 9 of the control group (p less than 0.0001). In comparison to the control group under CC treatment, an excessive production of estradiol was observed (p less than 0.0001) corresponding to significant increase in number of follicles (over 15 mm in diameter), p less than 0.04. Inspite this elevated estradiol, the cervical score was significantly lower (p less than 0.004) than in the control group. Three patients out of the 15 were characterized by a discrepancy between elevated estradiol levels and a poor mucus score. The rational of the CC assessment cycle is to identify those patients who may need an alternative treatment such as HMG/HCG or pulsatile GnRH.

Histopathological findings in 226 women with post-menopausal uterine bleeding.

Histopathological findings in 226 post-menopausal bleeding women were reviewed retrospectively. Adenocarcinoma of the endometrium was diagnosed in 7% and hyperplastic endometrium in 15%. The incidence of malignancy showed a definite rise with advancing age, increasing amount and duration of bleeding, prolonged time interval between the menopause and onset of bleeding, and enlarged uterus. Adenocarcinoma of the endometrium was associated in 40% of the patients with either obesity, diabetes mellitus, or hypertension. The most frequent histopathological finding was atrophic endometrium (45%).

Post-cesarean-section necrotizing fasciitis: report of a case and review of the literature.

Necrotizing fasciitis is a rare but potentially lethal, rapidly progressive, soft-tissue infection. Cure is dependent on early diagnosis and prompt surgical intervention. A case of necrotizing fasciitis in a patient after cesarean section is herein reported and the treatment and outcome discussed. An extensive review of the literature revealed a single case report of necrotizing fasciitis after cesarean section.

The local progestational effect of the levonorgestrel-releasing intrauterine system: a sonographic and Doppler flow study.

BACKGROUND: We aimed to evaluate the effect of the levonorgestrel-releasing intrauterine system (LNG-IUS) on the uterine vasculature and the endometrium. METHODS: The study was a prospective controlled study evaluating the local effects of LNG-IUS compared with the copper intrauterine device (IUD). Forty-seven women carrying LNG-IUS (group A) were compared with 35 women carrying copper IUD in a control group (group B). Clinical measures of menstrual bleeding, endometrial thickness and Doppler flow of the cervical branch of the uterine artery and spiral artery were evaluated and compared between the two groups. RESULTS: Doppler flow in the cervical branch of the uterine artery did not reveal any changes between the groups (resistance index = 0.6 +/- 0.01 in both groups). Endometrial width was significantly thinner in group A (4.1 +/- 0.2 mm) compared with group B (7.3 +/- 0.2 mm) (P < 0.0001). Subendometrial flow in the spiral artery was significantly reduced in 35 women of group A (75%) and in none of group B (P < 0.0001). CONCLUSIONS: The present study offers an explanation for the oligomenorrhoea in LNG-IUS users, i.e. a local progestational effect on the endometrium with no change in the blood flow in the uterine artery. This should be presented to the women in the pre-contraceptive counselling in order to lessen the discontinuation rate.

Combined somatostatin analog and follicle-stimulating hormone for women with polycystic ovary syndrome resistant to conventional treatment.

This study was undertaken to determine whether somatostatin analog in combination with human urinary follicle-stimulating hormone (FSH) improves ovulatory performance in patients with polycystic ovarian syndrome (PCOS) who failed to respond to FSH alone. A comparative prospective study was performed in six insulin-resistant, hyperandrogenic, PCOS women treated with somatostatin analog combined with FSH for one cycle. Individual ovulatory performance was compared to the cumulative ovulatory response of three previous cycles. Somatostatin analog was administered subcutaneously by means of an infusion pump, providing a total daily dose of 200 micrograms starting from days 1-3 of the cycle. Induction of ovulation with FSH was initiated on day 5 of the stimulated cycle. Vaginal ultrasonography for follicular surveillance was performed before the pump setting and during the treatment cycle. A significant decrease in insulin, insulin-like growth factor (IGF-I), growth hormone (GH) and luteinizing hormone (LH) was observed during the combined somatostatin analog-FSH treatment cycles. The follicular growth patterns and the incidence of ovarian hyperstimulation syndrome (OHSS) was not affected. These observations suggest that adjuvant therapy with somatostatin analog may have a beneficial effect on the hormonal response of PCOS patients to gonadotropin induction of ovulation.

Effect of washing and suspension on penetration of human sperm into bovine cervical mucus.

The in vitro penetration ability of human sperm into bovine cervical mucus after washing and suspension of the sperm in Earl's medium was compared with that of untreated sperm. The extent of penetration was found to be significantly lower in sperm washed and suspended in Earl's medium than in the unwashed sperm (p less than 0.0001); it increased to some extent on resuspension of the washed sperm in the seminal plasma but still remained significantly lower than that of intact sperm (p less than 0.009). The introduction of caffeine into the Earl's medium resulted in an increased penetration of the washed sperm into bovine cervical mucus, but this was still significantly lower than the penetration of the unwashed sample (p less than 0.02). The data point to the effectiveness of the seminal plasma as a medium facilitating sperm penetration through bovine cervical mucus.