Uterus-Sparing Surgery: Outcomes of Transvaginal Uterosacral Ligament Hysteropexy.

STUDY OBJECTIVE: Recently, there has been a paradigm shift toward uterine conservation during the surgical management of pelvic organ prolapse (POP), specifically uterine prolapse. There are few reports on transvaginal uterosacral ligament hysteropexy (TULH). This study aimed to describe our surgical technique and outcomes. DESIGN: Retrospective review and description of surgical technique. Anatomic outcome has been reported using the POP quantification system. Complications were segregated. A comparison of parametric continuous variables was performed using paired t test. Categoric variables were evaluated using the Pearson χ2 test and the Fisher exact test. A p-value <.05 was considered significant. SETTING: Teaching hospital. PATIENTS: Forty patients who underwent TULH from 2009 to 2017. INTERVENTIONS: TULH. MEASUREMENTS AND MAIN RESULTS: A total of 40 patients met the inclusion criteria. Of these, 56.1% had preoperative stage 3 prolapse. The median operative time was 116 minutes. The mean estimated blood loss was 158.5 mL. Transient ureteral obstruction occurred in 2 patients. The mean follow-up time was 17.2 months, and all patients had significant improvement of prolapse (p <.001). There was also an improvement in urinary incontinence and bladder storage symptoms (p <.001). None of the patients were reoperated on for recurrent POP. CONCLUSION: TULH is an effective uterus-preserving surgical alternative for the treatment of uterovaginal prolapse and provides good apical support. It is also associated with a low short-term recurrence and incidence of reoperation. TULH is a viable option for suitable patients with uterovaginal prolapse who desire uterine conservation.

HIV Screening During Pregnancy in a U.S. HIV Epicenter.

Background: The CDC and ACOG have issued guidelines for HIV screening in pregnancy for patients living in areas with high prevalence of HIV in order to minimize perinatal vertical transmission. There is a lack of data examining providers' compliance with these guidelines in at-risk patient populations in the United States. Objective: To evaluate if HIV screening in pregnant women was performed according to guidelines at a large, urban, tertiary care medical center in South Florida. Study Design. A retrospective review was performed on 1270 prenatal and intrapartum records from women who delivered a live infant in 2015 at a single institution. Demographic and outcome data were chart abstracted and analyzed using arithmetic means and standard deviations. Results: Of the 1270 patients who met inclusion criteria, 1090 patients initiated prenatal care in the first or second trimester and delivered in the third trimester. 1000 (91.7%) patients were screened in the first or second trimester; however, only 822 (82.2%) of these were retested in the third trimester during prenatal care. Among the 178 patients lacking a third trimester test, 159 (89.3%) received rapid HIV testing upon admission for delivery. Of the 1090 patients who initiated prenatal care in the first or second trimester and delivered in the third trimester, 982 (90.1%) were screened in accordance with recommended guidelines. Of the 1270 patients initiating care in any trimester, 24 (1.9%) had no documented prenatal HIV test during prenatal care, however 22 (91.7%) had a rapid HIV test on admission for delivery. Two (0.16%) patients were not tested prenatally or prior to delivery. Conclusion: Despite 99.8% of women having at least one HIV screening test during pregnancy, there is room for improvement in routine prenatal screening in both early pregnancy and third trimester prior to onset of labor in this high-risk population.

Women Living with HIV over Age of 65: Cervical Cancer Screening in a Unique and Growing Population.

OBJECTIVE: Women living with HIV are at increased risk of human papillomavirus (HPV) infection, which can lead to cervical cancer. New guidelines recommend indefinite screening. The objective of this study is to describe cervical cancer screening practices and colposcopy results in a cohort of women living with HIV over age of 65 who were followed before the new guidelines. Comorbidities, sexually transmitted infections (STIs), and other risk factors were evaluated. METHODS: We conducted a retrospective chart review on 75 women aged 65 or older living with HIV with at least one Pap smear. RESULTS: The mean age of the cohort was 66.5 and at HIV diagnosis was 56. The majority of women were immunocompetent. 80% had serial Pap smears. Of these, 86% of 238 were negative or ASCUS. No women progressed to HSIL. 92% of colposcopies had negative or CIN I results. Three women were treated successfully for high-grade dysplasia. More than half of women had other STIs. 72% were screened for HPV; 50% were positive. CONCLUSION: The majority of women had negative and low-grade Pap smears. Questions remain regarding the utility of continued Pap screening and the added value of HPV testing in this unique population of older women living with HIV.

Intensive treatment and survival outcomes in NUT midline carcinoma of the head and neck.

BACKGROUND: NUT midline carcinoma is a rare and aggressive genetically characterized subtype of squamous cell carcinoma frequently arising from the head and neck. The characteristics and optimal management of head and neck NUT midline carcinoma (HNNMC) are unclear. METHODS: A retrospective review of all known cases of HNNMC in the International NUT Midline Carcinoma Registry as of December 31, 2014, was performed. Forty-eight consecutive patients were treated from 1993 to 2014, and clinicopathologic variables and outcomes for 40 patients were available for analyses; they composed the largest HNNMC cohort studied to date. Overall survival (OS) and progression-free survival (PFS) according to patient characteristics and treatment were analyzed. RESULTS: This study identified a 5-fold increase in the diagnosis of HNNMC from 2011 to 2014. The median age was 21.9 years (range, 0.1-81.7 years); the male and female proportions were 40% and 60%, respectively; and 86% had bromodomain containing 4-nuclear protein in testis (BRD4-NUT) fusion. The initial treatment was initial surgery with or without adjuvant chemoradiation or adjuvant radiation (56%), initial radiation with or without chemotherapy (15%), or initial chemotherapy with or without surgery or radiation (28%). The median PFS was 6.6 months (range, 4.7-8.4 months). The median OS was 9.7 months (range, 6.6-15.6 months). The 2-year PFS rate was 26% (95% confidence interval [CI], 13%-40%). The 2-year OS rate was 30% (95% CI, 16%-46%). Initial surgery with or without postoperative chemoradiation or radiation (P = .04) and complete resection with negative margins (P = .01) were significant predictors of improved OS even after adjustments for age, tumor size, and neck lymphadenopathy. Initial radiation or chemotherapy and the NUT translocation type were not associated with outcomes. CONCLUSIONS: HNNMC portends a poor prognosis. Aggressive initial surgical resection with or without postoperative chemoradiation or radiation is associated with significantly enhanced survival. Chemotherapy or radiation alone is often inadequate. Cancer 2016;122:3632-40. © 2016 American Cancer Society.

Knowledge and Acceptability of Anal Cytology Screening Among Women.

OBJECTIVE: Medical providers have initiated anal cytology screening among women to detect anal neoplasia early. Lack of knowledge of the human papillomavirus (HPV) and anticipated screening discomfort may limit patient acceptance. This study investigates attitudes toward anal cytology screening among women. MATERIALS AND METHODS: Women seen for gynecologic care at an urban university medical center were invited to complete an anonymous survey assessing their understanding of HPV and interest in anal cytology screening. Subjects reported the level of pain, discomfort, and embarrassment they expected from screening on a 100-mm visual analog scale. RESULTS: Four hundred four women with mean (SD) age 36 (13) years met criteria for participation. Three hundred thirty-five women reported their race: 52% were white and 36% were African American. Three hundred forty-eight women reported their ethnicities: 76% were Hispanic and 12% were Haitian. Twenty-two percent had never heard of HPV, 57% were not familiar with anal cytology screening, 67% acknowledged that screening was very helpful in detecting anal neoplasia early, and 28% were very interested in undergoing screening. Mean (SD) level of anticipated pain, discomfort, and embarrassment during screening was 62 (32), 68 (30), and 58 (34) mm, respectively. Level of familiarity with anal cytology screening (p < .001), belief in its utility in detecting anal neoplasia (p < .001), and level of anticipated pain (p = .004) were significant predictors of acceptability. CONCLUSIONS: Medical providers should improve counseling about anal cytology screening among at-risk women to familiarize them with the procedure, describe its role in detecting anal neoplasia, and address expectations surrounding pain to increase its acceptability.

Enlargement of the genital hiatus is associated with prolapse recurrence in patients undergoing sacrospinous ligament fixation.

OBJECTIVE: To correlate genital hiatus (GH) size with surgical failures in patients undergoing sacrospinous ligament fixation (SSLF) and compare anatomic outcomes after classification based on GH size. METHODS: A retrospective review of 81 patients who underwent SSLF for apical prolapse from 2010 to 2016 at a teaching hospital. Anatomical outcome is reported using the Pelvic Organ Prolapse Quantifications System. A comparison of parametric continuous variables was performed using unpaired Student t test. Categorical variables were evaluated using Pearson's χ2 test and Fisher's exact test. A P value <0.05 was considered significant. RESULTS: Among the 81 patients, no difference in age, parity, body mass index, preoperative prolapse stage or follow-up time was noted between those whose surgery succeeded and those with failed surgery. Postoperatively, a widened GH was significantly associated with recurrent prolapse (P < 0.001). When the preoperative size of the GH was dichotomized into widened (≥4 cm) or normal (<4 cm), there was a non-significant (P = 0.444) trend of more failures in the widened GH group. A posterior colporrhaphy did not improve success. CONCLUSION: Both preoperative and postoperative widened GH correlated with having more surgical failures following SSLF. Importantly, postoperatively a normal size GH was significantly associated with more surgical success.

Spontaneous sternal fracture during labor in a healthy primigravida with female athlete triad: A case report.

INTRODUCTION: This case raises awareness of the diagnosis of sternal fracture during labor and obviates the need for lengthy, expense-consuming workup. This report identifies a subset of women who may be at higher risk for this pathology. METHODS: Upon diagnosing and treating a patient who spontaneously fractured her sternum during labor, we reviewed previously reported cases and highlight key points of this entity. RESULTS: We report the third case of sternal fracture during labor in a healthy primigravida with female athlete triad. After 12 h of labor, the woman underwent epidural placement. By 16 h, the cervix was fully dilated. During the second push in the chin-to-chest position, a healthy baby was delivered, but the mother experienced acute anterior chest pain. Tenderness persisted for three weeks. Plain radiographs confirmed the presence of the fracture, which healed spontaneously. CONCLUSION: While chest pain during labor often results from serious causes including pulmonary embolism, myocardial infarction, and spontaneous pneumothorax, hyperflexion sternal fracture can occur, particularly in a woman with female athlete triad.

Fertility preservation in an oncology patient who presented with positive human chorionic gonadotropin.

OBJECTIVE: To report the case of a woman who presented for fertility preservation before breast cancer treatment who was found to be pregnant with an undesired pregnancy. DESIGN: Case report. SETTING: Single infertility practice. PATIENT: A 28-year-old woman with a new diagnosis of grade 3 invasive ductal carcinoma of the breast was planning to undergo oocyte cryopreservation and was found to be pregnant with an undesired pregnancy. She underwent a medical termination at a gestational age of 5 weeks 4 days. Neither the patient nor her oncology team wished to delay treatment more than was necessary. The physician and patient decided to initiate controlled ovarian hyperstimulation (COH) before her human chorionic gonadotropin (hCG) returned to normal. INTERVENTIONS: COH in the setting of a positive quantitative hCG. MAIN OUTCOME MEASURES: Number of metaphase II (MII) oocytes cryopreserved; doses of Gonal-F and Menopur; serum E2, follicle-stimulating hormone, luteinizing hormone, hCG levels. RESULTS: COH began 7 days after passing the products of conception. Baseline labs demonstrated hCG at 222 mIU/mL, follicle-stimulating hormone at <0.10 mIU/mL, luteinizing hormone at <1.10 mIU/mL, and E2 at 147 pg/mL. She was started on an antagonist protocol with the use of 150 IU Gonal F and 75 IU Menopur. She was triggered on stimulation day 14 with 5,000 U hCG, and her peak E2 was 5,924 pg/mL. She ultimately had 18 oocytes retrieved, 12 of which were MII, one MI, and five germinal vesicle. All were vitrified. CONCLUSIONS: COH can be achieved in the setting of low positive hCG levels with subsequent successful oocyte maturation. The threshold for hCG trigger to be ineffective in the setting of a positive hCG has yet to be determined.

Fertility preservation before hematopoetic stem cell transplantation: a case series of women with GATA binding protein 2 deficiency, dedicator of cytokinesis 8 deficiency, and sickle cell disease.

OBJECTIVE: To describe fertility characteristics, outcomes of oocyte cryopreservation cycles, and safety of ovarian stimulation in patients with GATA binding protein 2 (GATA2) deficiency, dedicator of cytokinesis 8 (DOCK8) deficiency, and sickle cell disease (SCD) preparing for hematopoetic stem cell transplantation (HSCT). DESIGN: Retrospective case series. SETTING: The National Institutes of Health. PATIENTS: Female patients with GATA2 deficiency, DOCK8 deficiency, and SCD aged between 13 and 38 years. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Demographic and ovarian reserve parameters, stimulation outcomes, and adverse event occurrences were collected through chart review. Descriptive statistics were used to identify trends within disease subcategories. RESULTS: Twenty-one women with GATA2 deficiency, DOCK8 deficiency, and SCD underwent fertility preservation prior to HSCT. Patients with DOCK8 deficiency had the lowest mean age (16.5 years old) and antimüllerian hormone (0.85 ng/mL). Patients with GATA2 deficiency had the highest antral follicle count and antimüllerian hormone (25.77 and 5.07 ng/mL, respectively). Baseline follicle-stimulating hormone, luteinizing hormone, and estradiol were comparable between the cohorts. The duration of stimulation was similar (10.43 to 11.25 days) across all groups. Comparable peak estradiol levels were achieved across the cohorts. Patients with SCD had the highest mature (MII) oocyte yield (10.71). Three patients experienced complications related to stimulation: pain crisis in a patient with SCD, pulmonary embolism, and zero oocytes cryopreserved in a patient with GATA2 deficiency. CONCLUSIONS: This study offers insight into controlled ovarian stimulation in patients with these conditions prior to HSCT. Oocyte cryopreservation can be performed successfully, although adverse events must be considered. Following the outcomes of gamete use in this cohort will serve to further our knowledge of the true reproductive potential of this population.

Prospective Comparison of Nonnarcotic versus Narcotic Outpatient Oral Analgesic Use after Laparoscopic Appendectomy and Early Discharge.

Purpose. To compare narcotic versus nonnarcotic outpatient oral pain management after pediatric laparoscopic appendectomy. Methods. In a prospective study from July 1, 2010, to March 30, 2011, children undergoing laparoscopic appendectomy on a rapid discharge protocol were treated with either nonnarcotic or narcotic postoperative oral analgesia. Two surgeons in a four-person faculty group employed the nonnarcotic regimen, while the other two used narcotics. Days of medication use, time needed for return to normal activity, and satisfaction rate with the pain control method were collected. Student's t-test was used for statistical analysis. Results. A total of 207 consecutive children underwent appendectomy for acute, nonperforated appendicitis or planned interval appendectomy. The age and time to discharge were equivalent between the nonnarcotic (n = 104) and narcotic (n = 103) groups. Both had an equivalent number of medication days and similar times of return to normal activity. Ninety-seven percent of the parents of children in the nonnarcotic group stated that the pain was controlled by the prescribed medication, compared to 90 percent in the narcotic group (P = 0.049). Conclusion. This study indicates that after non-complicated pediatric laparoscopic appendectomy, nonnarcotic is equivalent to narcoticbased therapy for outpatient oral analgesia, with higher parental satisfaction.

MYC, a downstream target of BRD-NUT, is necessary and sufficient for the blockade of differentiation in NUT midline carcinoma.

NUT midline carcinoma (NMC) is an aggressive type of squamous cell carcinoma that is defined by the presence of BRD-NUT fusion oncogenes, which encode chimeric proteins that block differentiation and maintain tumor growth. BRD-NUT oncoproteins contain two bromodomains whose binding to acetylated histones is required for the blockade of differentiation in NMC, but the mechanisms by which BRD-NUT act remain uncertain. Here, we provide evidence that MYC is a key downstream target of BRD4-NUT. Expression profiling of NMCs shows that the set of genes whose expression is maintained by BRD4-NUT is highly enriched for MYC upregulated genes, and MYC and BRD4-NUT protein expression is strongly correlated in primary NMCs. More directly, we find that BRD4-NUT associates with the MYC promoter and is required to maintain MYC expression in NMC cell lines. Moreover, both siRNA knockdown of MYC and a dominant-negative form of MYC, omomyc, induce differentiation of NMC cells. Conversely, differentiation of NMC cells induced by knockdown of BRD4-NUT is abrogated by enforced expression of MYC. Together, these findings suggest that MYC is a downstream target of BRD4-NUT that is required for maintenance of NMC cells in an undifferentiated, proliferative state. Our findings support a model in which dysregulation of MYC by BRD-NUT fusion proteins has a central role in the pathogenesis of NMC.

A prospective study of safety and satisfaction with same-day discharge after laparoscopic appendectomy for acute appendicitis.

BACKGROUND/PURPOSE: This study examines the safety and patient satisfaction in discharging children undergoing laparoscopic appendectomy (LapAppy) for acute appendicitis on the day of surgery. METHODS: After institutional review board approval, data were collected prospectively for 158 consecutive patients undergoing LapAppy for simple appendicitis. Time from operation to discharge and complications were analyzed. At follow-up, parents completed a satisfaction survey. The Student t test was used for statistical analysis. RESULTS: Laparoscopic appendectomy was performed in 158 children ranging from age 2 to 19 years (mean, 12 years) over a 6-month period. Single-port, single-instrument LapAppy was possible in 152 patients (96%). Eighty percent of patients (n = 126) were discharged on the day of surgery, a mean of 4.8 hours postoperatively (range, 1-12 hours). Of the remaining 32, 24 (75%) were admitted because the operation ended too late for postoperative discharge; 3 (9%), for medical reasons; and 5 (16%), when the families declined to leave. One hundred nine parents (87%) whose children went home postoperatively stated that they were happy with the expeditious discharge, whereas 17 (13%) felt nervous. In addition, 116 parents (92%) stated that, in retrospect, same-day discharge was preferable, whereas 10 parents (8%) were not sure that it was the best decision. None, however, would insist on admission if faced with the situation again. There were no major complications and no significant difference in the rate of umbilical wound infections for same-day discharge patients (2%) and admitted patients (3%). CONCLUSION: Routine same-day discharge after pediatric LapAppy for acute appendicitis is safe, with good parent satisfaction.

Routine same-day discharge after acute or interval appendectomy in children: a prospective study.

HYPOTHESIS: The outcomes of and parental satisfaction with same-day discharge in children undergoing laparoscopic appendectomy warrant making it the usual and customary pathway. DESIGN: Prospective cohort study. SETTING: Tertiary care children's hospital. PATIENTS: Between July 1, 2010, and March 30, 2011, a total of 207 children were considered for same-day discharge after acute or interval laparoscopic appendectomy. The all-in-one single-incision single-instrument technique was used in 95.7% of children. INTERVENTIONS: Same-day discharge vs overnight admission. MAIN OUTCOME MEASURES: Operative details, postoperative length of stay, adverse events, and parental satisfaction. RESULTS: Of 207 consecutive children undergoing acute (n = 186) or interval (n = 21) appendectomy, 162 (78.3%) were discharged on the day of surgery. The remaining 45 children were admitted overnight because the hour was too late for discharge in 35 (77.8%), medical indications dictated admission in 5 (11.1%), and social reasons required admission in 5 (11.1%). In all the children, oral medication alone was used for postoperative pain. The complication rates were similar in the same-day discharge group (8.0%) and in the admitted group (6.6%), as were the rates of urgent postoperative visits (7.4% vs 4.4%%) and the readmission rates (2.5% vs 2.2%) (P > .05 for all). The same-day discharge group had a reduced postoperative length of stay compared with the admitted group (mean, 5 vs 16 hours, P < .05). At the time of discharge, most parents (87.0%) stated they were happy with the expeditious discharge, whereas 8.0% indicated they felt nervous but were ultimately satisfied. In retrospect, 8 of 162 parents (4.9%) were not sure early discharge was best, but only 1 parent would insist on admission if faced with the situation again. CONCLUSION: Routine same-day discharge after pediatric appendectomy seems safe, with good parental satisfaction.