Pheochromocytoma in pregnancy: A case Report.

This is the case of a 38 year-old female patient with an intrauterine pregnancy, in which a previous incidentally identified adrenal mass proved to be a pheochromocytoma during the antenatal period. The patient was started on α-and ß-adrenergic blockade to maintain hemodynamic stability, and surgical removal of the lesion was performed during the second trimester without major complications. In view of the rarity of this disorder in pregnancy, it is imperative to have a high index of suspicion for a prompt and dedicated management, since this tumor, if unrecognized, is associated with high fetal and maternal mortality.

Are the University Hospitals in Puerto Rico following Current Guidelines for Cervical Cancer Screening?

OBJECTIVE: Cervical cancer is the fifth most common cancer among women in Puerto Rico (PR). Information about which obstetricians and gynecologists in PR are following current cervical cytology guidelines is not available. Our two objectives were to determine whether current guidelines for abnormal cervical cytology management were being followed adequately by OB-GYN residents and faculty at 3 university hospitals and, in addition, to evaluate the knowledge of the current guidelines that is possessed by these individuals. METHODS: A retrospective medical record review (records from January 2009 through December 2010) of patients with abnormal cervical cytology results (n=166) to evaluate the management they were given and a cross-sectional survey of OB-GYN residents (n=34) and faculty (n=46) to evaluate their knowledge of cervical cytology guidelines were both performed. RESULTS: One hundred and sixty-six medical records were reviewed. The level of management for 45% of the patients was found to have been optimal."Thirty-three percent were lost to follow-up. Eleven percent of the patients were managed sub optimally and the management of 12% of the patients was considered to have been poor. The survey showed that the faculty were less updated with regard to current guidelines for the management of cervical cytology than were the residents. Study limitations were the lack of electronic medical records in the hospital--which makes access to patient information more difficult--and the low response rate of the faculty. CONCLUSION: OB-GYN physicians and residents were not consistent with their management, according to current guidelines, of cervical cytological abnormalities. The high-risk nature of the patients and their poor adherence to treatment (loss to follow-up) may have been the cause of this inconsistency. Meetings aimed at addressing the lack of compliance by local OB-GYN physicians with the guidelines for cervical cancer screening have been Better screening strategies are also needed if we are to improve patient compliance in our population.

Risk factors for hysterectomy in abnormal placentation at the University District Hospital.

UNLABELLED: The aim of this research was to study the relationship of abnormal placentation and cesarean hysterectomy risk factors at the University District Hospital. METHOD: A retrospective study was conducted using 60 medical records of patients in the University District Hospital from 2001 to 2008 with a diagnosis of abnormal placentation. Descriptive statistics and chi square for associations were used for statistical analysis. RESULTS: The mean age in our population was 29 years and mean BMI was 29.6. 45 % of the patients had a previous history of cesarean, 1.7% of placenta previa and 26.7% of uterine curettage. We found that 33.3% had a cesarean hysterectomy and 41.7% had post-partum hemorrhage. Also 51.7% received blood transfusion. The mean hospital stay was 18.1 days. The probability of cesarean hysterectomy in patients with placenta previa was eleven times higher in patients with history of previous cesarean sections (OR 11, CI: 1.29-97.9, p value=0.01). There was no statistically significant difference in cesarean hysterectomy rate between obese (BMI>30) and nonobese patients (OR 3.8 CI: 0.69-20.5, p value=0.11). CONCLUSION: The probability of cesarean hysterectomy in patients with abnormal placentation was significantly increased in patients with previous cesarean sections. By decreasing the rate of cesarean section we can decrease the incidence of cesarean hysterectomy and its comorbidities.

Human papillomavirus infection in women in Puerto Rico: agreement between physician-collected and self-collected anogenital specimens.

OBJECTIVE: This study aimed to describe the prevalence and concordance between cervical and anal human papillomavirus (HPV) infection and compare cervicovaginal and anal self-collection methods for HPV testing between physician and self-collected specimens in women in Puerto Rico. MATERIALS AND METHODS: Specimens for HPV-DNA testing were obtained from 100 women aged 18 to 34 years attending a general gynecology clinic for a routine Pap smear. Human papillomavirus testing was performed using polymerase chain reaction MY09/MY11 primers. Positive samples were typed for 39 genotypes. Agreement between sampling methods was determined by percent agreement and the κ statistic. RESULTS: For the 39 genotypes evaluated, 38.4% (38/99) of cervicovaginal and 33.7% (30/89) of anal physician-collected samples were HPV+, whereas 35.1% (34/97) of cervicovaginal and 32.0% (31/97) of anal self-collected samples were positive. Human papillomavirus type 16 was the most common type identified in the cervix (8.3%, 8/97) and the anus (5.6%, 5/89) of physician-collected samples, with similar prevalence in self-collected samples. Concordance between cervical and anal HPV infection was high (>90%) for all types evaluated. There was a strong percent agreement between physician- and self-collected cervicovaginal and anal samples (>95% for all HPV types) and good to excellent agreement (κ > 0.60) for most HPV types. CONCLUSIONS: The clinic-based prevalence of anal and cervicovaginal HPV infection was high, with a strong concordance between cervical and anal infection and good to excellent agreement between physician- and self-collected samples. This study supports the feasibility of using cervical and anal self-sampling methods in future population-based studies of HPV infection in Puerto Rico and as an HPV screening method in women.

Cervical human papillomavirus infection in a sample of Hispanic women living in Puerto Rico: comparison with cervical cytology reports.

OBJECTIVE: Persistent infection with high-risk (HR) HPV is a necessary risk factor for the development of cervical cancer. Information on HPV infection is limited in Puerto Rico. This study determined the distribution of HPV types and the association of HR-HPV types with cervical pathology in a clinic-based sample of women in PR. METHODS: Data from 92 female participants aged 18 to 34 years and recruited from the University of Puerto Rico-Gynecology Clinic, were analyzed. Cervical cytology was performed. HPV testing was performed using L1 consensus primer PCR with MY09/ MY11 primers and typed by dot-blot hybridization. Logistic regression modeling was used to determine the crude and covariate adjusted association between HR-HPV and cervical pathology. RESULTS: Twenty percent (n = 18) of the patients had abnormal cytology, 45.7% (n = 42) were HPV positive, and 30.4% (n = 28) were HR HPV-positive. Women infected with HR-risk HPV types were 7.9 (95% CI = 2.5-25.5) times more likely to have abnormal cytology as compared to women without HR infection when adjusted by age and age at first sexual intercourse. CONCLUSION: The burden of HPV infection was high, and, as expected, HR HPVs were strongly associated with dysplasia. A population-based study is needed to estimate HPV prevalence and its association with related malignancies in our population. This will be of great value in determining disease burden and will increase awareness of the HPV vaccination in our population.

Cervical dysplasia and pre-term birth in San Juan city hospital: a cohort retrospective study.

UNLABELLED: Cervical dysplasia alters the release of cytokines and inflammatory mediators in pregnant woman with cervical dysplasia. This study evaluates a cohort of pregnant patients screened for cervical dysplasia to determine the relationship between cervical dysplasia and preterm labor (PTL). METHODS: Retrospective chart review of pregnant patients screened for cervical dysplasia at the San Juan City Hospital between October 2006 and December 2010. Patients with low or high-grade squamous intraepithelial lesions (LGSIL or HGSIL, respectively) were evaluated with colposcopy. Primary outcome was the event of PTL and the risk factor evaluated was presence of cervical dysplasia. RESULTS: A total of 2,059 patients were screened for cervical dysplasia and 59 were evaluated with colposcopy due to LGSIL or HGSIL. From those, 29% were negative for intraepithelial lesions and malignancy (NILM), 54% had cervical intraepithelial neoplasia (CIN)-1, 17% where diagnosed as CIN-2/3 where no invasive cervical cancer was identified. In the group of NILM, 24% had PTL compared to 18% in patients who screened negative on initial cytological evaluation. In cases where CIN-1 was confirmed by colposcopy 28% had PTL compared with 40% in patients with CIN-2/3. Other risk factors associated with PTL were not significantly different among the groups. CONCLUSIONS: Cervical dysplasia in pregnancy may represent an increase risk for premature labor.

A rare case of cutaneous metastasis of postpartum choriocarcinoma.

Gestational trophoblastic disease has been reported to be responsive to chemotherapy, with a 90% cure rate. Several factors place patients at high risk of experiencing treatment failure with single agent chemotherapy. Choriocarcinoma following term pregnancy is very rare and associated with a poor prognosis and a mortality rate of 33-40%. We present a rare case of cutaneous metastasis of choriocarcinoma to the left third digit.

PEARLS randomized lifestyle trial in pregnant Hispanic women with overweight/obesity: gestational weight gain and offspring birthweight.

BACKGROUND: Inappropriate gestational weight gain (GWG) has been associated with adverse perinatal events. High rates of GWG have been reported among Hispanic women. Observational studies indicate that dietary and physical activity interventions during the prenatal period may improve maternal and infant health, but very few randomized trials have been conducted among high-risk overweight/obese Hispanic women. Accordingly, we conducted a lifestyle intervention among high-risk pregnant women and evaluated its impact on achieving appropriate GWG and on improving birthweight. METHODS: Eligible overweight/obese women presenting at the University Hospital in Puerto Rico with a singleton pregnancy before 16 gestational weeks were recruited and randomized to lifestyle intervention (n=15) or control group (n=16). The lifestyle intervention focused on improving physical activity and diet quality and optimizing caloric intake. We evaluated the impact of the lifestyle intervention on achieving appropriate GWG and on infant birthweight. Poisson and linear regression analyses were performed. RESULTS: The primary intent to treat analysis showed no significant effect on achievement of appropriate GWG/week through 36 weeks in the intervention group (4/15 women) when compared with the control group (3/16 women) (adjusted incidence rate ratio =1.14; 95% CI: 0.20, 6.67). Although not statistically significant, women in the intervention group (6/15) were 1.7 times more likely to achieve appropriate weekly GWG until delivery when compared with controls (4/16 women) (adjusted incidence rate ratio = 1.67; 95% CI: 0.40, 6.94). We observed lower adjusted birthweight-for-length z-scores in the intervention compared with the control group among male newborns with z-score difference -1.74 (-3.04, -0.43), but not among females -0.83 (-3.85, 2.19). These analyses were adjusted for age and baseline body mass index. CONCLUSION: Although larger studies are required to determine whether women with obesity may benefit from prenatal lifestyle interventions targeting GWG, our results are suggestive of the intervention improving adherence to established Institute of Medicine guidelines.

Lifestyle modification intervention for overweight and obese Hispanic pregnant women: development, implementation, lessons learned and future applications.

OBJECTIVES: To describe the development, implementation and lessons learned of lifestyle intervention to promote appropriate gestational weight gain among Hispanic pregnant women. DESIGN: The intervention was informed by an empowerment oriented theoretical framework, and targeted women in the Pregnancy and Early Life Improvement Study. METHODS: The nutrition component consisted of recommendations for total calories, food quantity and improving carbohydrate and fat quality. We provided brown rice, omega-3 rich vegetable oil and spread, and water monthly. The physical activity focused on limiting sedentary behavior and promoting regular movement. The intervention was delivered through individual and group sessions and phone calls. Participants set their own goals, which were closely monitored. The intervention was evaluated extracting data from participant's record (attendance, goals, and challenges) and using a questionnaire. RESULTS: Participants were from underserved communities with economic, time, cultural and social barriers for engaging in lifestyle interventions. Modifications were done to facilitate participation, such as coordinating sessions with prenatal appointments and reducing group size and duration of sessions. Weekly text messages were added to reinforce the intervention. The main goal chosen by participants was reduction of sweetened beverages. The greatest challenges were replacing white rice with brown rice and improving physical activity. Participants suggested conducting sessions near their community and using social media as a motivation tool. Main outcomes results will be published elsewhere. CONCLUSION: We identified barriers to delivering the lifestyle intervention, mainly related to group session's participation. Sessions should be conducted in the community, using text messages and social media as reinforcement.

Partial restoration of the microbiota of cesarean-born infants via vaginal microbial transfer.

Exposure of newborns to the maternal vaginal microbiota is interrupted with cesarean birthing. Babies delivered by cesarean section (C-section) acquire a microbiota that differs from that of vaginally delivered infants, and C-section delivery has been associated with increased risk for immune and metabolic disorders. Here we conducted a pilot study in which infants delivered by C-section were exposed to maternal vaginal fluids at birth. Similarly to vaginally delivered babies, the gut, oral and skin bacterial communities of these newborns during the first 30 d of life was enriched in vaginal bacteria--which were underrepresented in unexposed C-section-delivered infants--and the microbiome similarity to those of vaginally delivered infants was greater in oral and skin samples than in anal samples. Although the long-term health consequences of restoring the microbiota of C-section-delivered infants remain unclear, our results demonstrate that vaginal microbes can be partially restored at birth in C-section-delivered babies.

Molecular Triage of Premalignant Lesions in Liquid-Based Cervical Cytology and Circulating Cell-Free DNA from Urine, Using a Panel of Methylated Human Papilloma Virus and Host Genes.

Clinically useful molecular tools to triage women for a biopsy upon referral to colposcopy are not available. We aimed to develop a molecular panel to detect cervical intraepithelial neoplasia (CIN) grade 2 or higher lesions (CIN2+) in women with abnormal cervical cytology and high-risk HPV (HPV+). We tested a biomarker panel in cervical epithelium DNA obtained from 211 women evaluated in a cervical cancer clinic in Chile from 2006 to 2008. Results were verified in a prospective cohort of 107 women evaluated in a high-risk clinic in Puerto Rico from 2013 to 2015. Promoter methylation of ZNF516, FKBP6, and INTS1 discriminated cervical brush samples with CIN2+ lesions from samples with no intraepithelial lesions or malignancy (NILM) with 90% sensitivity, 88.9% specificity, 0.94 area under the curve (AUC), 93.1% positive predictive value (PPV), and 84.2% negative predictive value (NPV). The panel results were verified in liquid-based cervical cytology samples from an independent cohort with 90.9% sensitivity, 60.9% specificity, 0.90 AUC, 52.6% PPV, and 93.3% NPV, after adding HPV16-L1 methylation to the panel. Next-generation sequencing results in HPV+ cultured cells, and urine circulating cell-free DNA (ccfDNA) were used to design assays that show clinical feasibility in a subset (n = 40) of paired plasma (AUC = 0.81) and urine (AUC = 0.86) ccfDNA samples obtained from the prospective cohort. Viral and host DNA methylation panels can be tested in liquid cytology and urine ccfDNA from women referred to colposcopy, to triage CIN2+ lesions for biopsy and inform personalized screening algorithms. Cancer Prev Res; 9(12); 915-24. ©2016 AACR.

The first microbial environment of infants born by C-section: the operating room microbes.

BACKGROUND: Newborns delivered by C-section acquire human skin microbes just after birth, but the sources remain unknown. We hypothesized that the operating room (OR) environment contains human skin bacteria that could be seeding C-section born infants. RESULTS: To test this hypothesis, we sampled 11 sites in four operating rooms from three hospitals in two cities. Following a C-section procedure, we swabbed OR floors, walls, ventilation grids, armrests, and lamps. We sequenced the V4 region of the 16S rRNA gene of 44 samples using Illumina MiSeq platform. Sequences were analyzed using the QIIME pipeline. Only 68 % of the samples (30/44, >1000 sequences per site) yielded sufficient DNA reads to be analyzed. The bacterial content of OR dust corresponded to human skin bacteria, with dominance of Staphylococcus and Corynebacterium. Diversity of bacteria was the highest in the ventilation grids and walls but was also present on top of the surgery lamps. Beta diversity analyses showed OR dust bacterial content clustering first by city and then by hospital (t test using unweighted UniFrac distances, p < 0.05). CONCLUSIONS: We conclude that the dust from ORs, collected right after a C-section procedure, contains deposits of human skin bacteria. The OR microbiota is the first environment for C-section newborns, and OR microbes might be seeding the microbiome in these babies. Further studies are required to identify how this OR microbiome exposure contributes to the seeding of the neonatal microbiome. The results might be relevant to infant health, if the current increase in risk of immune and metabolic diseases in industrialized societies is related to lack of natural exposure to the vaginal microbiome during labor and birth.

Urine-based human papillomavirus DNA testing as a screening tool for cervical cancer in high-risk women.

OBJECTIVE: To test the hypothesis that self-collected urine could be used to detect high-risk human papillomavirus (HPV) DNA with sensitivity and specificity comparable to those of standard cervical testing. METHODS: Women attending a gynecology clinic for evaluation of abnormal cytology were recruited. Fifty-two participants (21-60years of age) collected urine samples, and clinicians collected cervical brush samples. When appropriate, cervical biopsies were obtained during colposcopy. HPV detection and typing were performed on DNA extracts from each sample, using commercial reagents for L1 consensus polymerase chain reaction (PCR) and type-specific hybridization. HPV 16 viral load was determined by quantitative PCR in HPV 16-positive samples. A diagnostic test analysis was conducted for urine samples. RESULTS: Fifty paired samples were analyzed, with 76% agreement between samples. The 12 discrepant pairs were all urine negative/cervix positive. The most common HPV types detected were 16, 51, 53, and 62. The urine test correctly identified 100% of the uninfected and 65% of the infected patients. CONCLUSION: The results indicate that HPV DNA detection using urine is less sensitive than cervical sampling in a population with abnormal cytology. Further exploration is warranted to determine clinical utility when other options are unavailable.

Is there a safe advantage in performing outpatient laparoscopic cholecystectomy in children?

BACKGROUND: Laparoscopic cholecystectomy, the standard procedure for removing the sick gallbladder of children, is generally performed leaving the child overnight in the hospital. PURPOSE: This study aimed to determine if there is a safe advantage in performing laparoscopic cholecystectomy as an outpatient procedure while setting the clinical parameters for those who will benefit from in-hospital stay. METHODS: Thirty-five patients were selected for the study and were divided into group A, if the outpatient procedure was done, and group B, if the child was left overnight in the hospital. Retrospective review of medical charts was performed. Statistical significance was defined as P < .05. RESULTS: Group A consisted of 13 patients and group B of 22 patients. All patients in group A left the hospital the same day of surgery. Distribution by age and sex in the groups was not statistically different. Preoperative symptoms of vomiting were statistically significantly higher in group B. Presence of an associated medical condition was higher in the in-hospital patients. Concomitant procedures, blood loss estimates, and duration of surgery showed no statistical difference. No child was readmitted after release from the hospital. Pre-, intra-, and postoperative pain management were the same in all patients. Mean postoperative stay and medical charges were statistically significant between the groups. CONCLUSIONS: Laparoscopic cholecystectomy can safely be done as an outpatient procedure. Children with a complicated gallbladder disease process or associated medical condition benefit from an overnight stay. Perioperative pain management is crucial in all cases. Reduced hospital stay and medical charges are significant advantages in performing laparoscopic cholecystectomy as an outpatient procedure.