Identifying Gaps in Pelvic Pain Education: A Scoping Review and Structured Analysis of Obstetrics and Gynecology Training Milestones.

OBJECTIVE: Several clinical practice guidelines on the evaluation and management (EM) of chronic pelvic pain (CPP) have been published; however, it is not known whether obstetrics and gynecology (OBGYN) educational milestones are aligned with current practice recommendations. Therefore, this scoping review and structured analysis aims to identify gaps between clinical guidelines for the EM of CPP and OBGYN training milestones published by educational authorities like the Accreditation Council for Graduate Medical Education (ACGME) and the AAGL. DATA SOURCES: The literature search was performed in MEDLINE, PubMed Central, and Bookshelf on the PubMed interface from January 2018 to September 2022. Peer-reviewed publications were included if they were a systematic review of recent practice guidelines and focused on female CPP. Publications that focused on a single pelvic pain condition or focused on a specific treatment were excluded. METHODS OF STUDY SELECTION: Two reviewers extracted the data and appraised the study quality following the Critical Appraisal Skills Programme Checklist for systematic reviews. Four articles met inclusion criteria for thematic analysis. A reflexive thematic analysis via the inductive approach was performed to develop clinical themes common to all review articles and presumed important in the EM of CPP. Pelvic pain experts and Delphi methodology was used to assess validity and relevance of each theme in OBGYN training. Validated themes were used in a strengths weaknesses opportunities threats (SWOT) analysis of the ACGME and the AAGL Milestones used for training OBGYN residents and fellows. A SWOT analysis is an organizational tool used to analyze processes in terms of strengths, weaknesses, opportunities for improvement, and threats to implementing a potential change. TABULATION, INTEGRATION, AND RESULTS: Twelve clinical themes were conceptualized and achieved ≥ 90% consensus as being important in the EM of CPP. Clinical themes pertained to pathophysiology, biopsychosocial approach, trauma-informed care, history and physical examination, diagnostic testing, multimodal/multidisciplinary management, pain education, and medical and surgical management. SWOT analysis showed that the ACGME Milestones lacked milestones specific to CPP, while the AAGL Milestones had 6 CPP-focused competencies with multiple milestones. Milestones on trauma-informed care and application of biopsychosocial assessment were notably absent. CONCLUSION: OBGYN educational milestones published by the ACGME and the AAGL are not yet aligned with current clinical guidelines for the EM of CPP.

Reproductive response of crossbred Bos taurus × Bos indicus cows to biostimulation by pre-pubertal and pubertal teasers.

Although the beneficial effect of biostimulation on reproduction has been reported, the influence of selectivity and social factors on the response to biostimulation has not received sufficient research attention in both Bos indicus and Bos indicus influenced cattle. Furthermore, 'green and cheap' strategies to improve cattle reproduction are currently in demand while Bos indicus influenced cattle with inferior reproductive performance, and farmers with economic limitations are common in tropical zones. Hence, to assess the reproductive response of crossbred taurus × indicus cows to biostimulation by pre-pubertal (PPM) or pubertal (PM) teasers males, two trials of 2 years each were conducted. Trial 1 n = 187 cows (Year 1:85 cows exposed to PPM and Year 2:102 cows exposed to PM). Trial 2 n = 196 cows (Year 1:101 cows exposed to PPM and Year 2:95 cows exposed to PM). The effect of exposing cows to PPM and PM on the intervals calving to first service (ICFS), calving to conception (ICC) and economic cost of days open (ECDO) was analysed using Kruskal-Wallis ANOVA and the effect of exposing cows to PPM and to PM on reproductive status at 90 days (RS90) and proportion of cows requiring hormonal protocols (PRH) was compared using χ2 analysis. Both ICFS and ICC were shorter (p < .0001) for PM-exposed females (96.12 ± 4.1 and 110.93 ± 2.9 days; respectively) compared with those PPM-exposed (134.41 ± 3.3 and 135.64 ± 2.4 days; respectively). With RS90, more (p < .0001) PM-exposed cows (50.7%) were pregnant compared with PPM-exposed cows (16.1%). The PRH was greater (p < .0001) in PPM-exposed cows (79.0%) compared with PM-exposed (27.9%). The ECDO was less (p < .0001) in PM-exposed cows (US$ 142.9 ± 3.8) compared with PPM-exposed (US$ 176.3 ± 2.9). In conclusion, cows exposed to PM had shorter ICFS and ICC compared with cows exposed to PPM. More cows exposed to PM were pregnant after 90 days, and PRH was less than cows exposed to PPM. Cows exposed to PM had a reduced ECDO than those exposed to PPM.

A novel cancer preventative botanical mixture, TriCurin, inhibits viral transcripts and the growth of W12 cervical cells harbouring extrachromosomal or integrated HPV16 DNA.

BACKGROUND: The phytochemical mixture TriCurin (curcumin, epigallocatechin gallate (EGCG) and resveratrol) eliminates human papillomavirus (HPV) (+) cancer cells in vitro and in vivo. In this study, we further evaluate TriCurin. METHODS: The activity of TriCurin and its individual compounds was assayed on W12 cells, derived from a cervical precancer containing episomal and integrated HPV16 DNA, using MTT (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) assays, microscopy and reverse transcription-polymerase chain reaction (RT-PCR), and on HeLa cells by gene expression analysis. The stability and toxicity of TriCurin microemulsion were tested in an organotypic cervical tissue model. RESULTS: TriCurin and its individual compounds inhibit the growth of W12 cells, episomal, type 1 and 2 integrants; the relative order of activity is TriCurin, EGCG, curcumin, or resveratrol. RT-PCR shows that TriCurin activates p53 and suppresses HPV16 mRNAs E1, E2, E4, E6 and E7 at 24 h in W12 cells. Gene expression analysis shows that TriCurin activates pro-apoptotic genes and represses anti-apoptotic genes in HeLa cells. TriCurin in a microemulsion is stable and non-toxic to cervical tissue. The combination of TriCurin and tanshinone IIA exhibits additional synergy against HeLa cells. CONCLUSIONS: TriCurin, and the combination of TriCurin with tanshinone IIA, are effective against HPV (+) cells. The phytochemical mixture, in the microemulsion-based cream, is a promising therapeutic for the prevention and treatment of cervical cancer.

Validity of the Favero Assioma Duo Power Pedal System for Measuring Power Output and Cadence.

Cycling power meters enable monitoring external loads and performance changes. We aimed to determine the concurrent validity of the novel Favero Assioma Duo (FAD) pedal power meter compared with the crank-based SRM system (considered as gold standard). Thirty-three well-trained male cyclists were assessed at different power output (PO) levels (100-500 W and all-out 15-s sprints), pedaling cadences (75-100 rpm) and cycling positions (seating and standing) to compare the FAD device vs. SRM. No significant differences were found between devices for cadence nor for PO during all-out efforts (p > 0.05), although significant but small differences were found for efforts at lower PO values (p < 0.05 for 100-500 W, mean bias 3-8 W). A strong agreement was observed between both devices for mean cadence (ICC > 0.87) and PO values (ICC > 0.81) recorded in essentially all conditions and for peak cadence (ICC > 0.98) and peak PO (ICC > 0.99) during all-out efforts. The coefficient of variation for PO values was consistently lower than 3%. In conclusion, the FAD pedal-based power meter can be considered an overall valid system to record PO and cadence during cycling, although it might present a small bias compared with power meters placed on other locations such as SRM.

Evaluating the discordant relationship between Tarlov cysts and symptoms of pudendal neuralgia.

BACKGROUND: Pudendal neuralgia is a painful neuropathic condition involving the pudendal nerve dermatome. Tarlov cysts have been reported in the literature as another potential cause of chronic lumbosacral and pelvic pain. Notably, they are often located in the distribution of the pudendal nerve origin at the S2, S3, and S4 sacral nerve roots and it has been postulated that they may cause similar symptoms to pudendal neuralgia. Literature has been inconsistent on the clinical relevance of the cysts and if they are responsible for symptoms. OBJECTIVE: To evaluate the prevalence of S2-S4 Tarlov cysts at the pudendal nerve origin (S2-S4 sacral nerve roots) in patients specifically diagnosed with pudendal neuralgia, and establish association of patient symptoms with location of Tarlov cyst. STUDY DESIGN: A retrospective study was performed on 242 patients with pudendal neuralgia referred for pelvic magnetic resonance imaging from January 2010 to November 2012. Dedicated magnetic resonance imaging review evaluated for presence, level, site, and size of Tarlov cysts. Among those with demonstrable cysts, subsequent imaging data were collected and correlated with the patients' clinical site of symptoms. Statistical analysis was performed using χ2, Pearson χ2, and Fisher exact tests to assess significance. RESULTS: Thirty-nine (16.1%) patients demonstrated at least 1 sacral Tarlov cyst; and of the 38 patients with complete pain records, 31 (81.6%) had a mismatch in findings. A total of 50 Tarlov cysts were identified in the entire patient cohort. The majority of the Tarlov cysts were found at the S2-S3 level (32/50; 64%). Seventeen patients (44.7%) revealed unilateral discordant findings: unilateral symptoms on the opposite side as the Tarlov cyst. In addition, 14 (36.8%) patients were detected with bilateral discordant findings: 11 (28.9%) had bilateral symptoms with a unilateral Tarlov cyst, and 3 (7.9%) had unilateral symptoms with bilateral cysts. Concordant findings were only demonstrated in 7 patients (18.4%). No significant association was found between cyst size and pain laterality (P = .161), cyst volume and pain location (P = .546), or cyst size and unilateral vs bilateral pain (P = .997). CONCLUSION: The increased prevalence of Tarlov cysts is likely not the etiology of pudendal neuralgia, yet both could be due to similar pathogenesis from part of a focal or generalized condition.

Medicine-Both a Science (Care) and an Art (CARE).

This Viewpoint discusses the concept of CARE (compassion, assistance, respect, and empathy) as a way physicians can practice the art of medicine in the current era of care that increasingly incorporates predictive analytics and artificial intelligence.

When and how to excise vaginal mesh.

PURPOSE OF REVIEW: Since 2011, there has been increasing attention paid to the use of synthetic grafts (mesh) in pelvic reconstructive surgery. Although synthetic grafts are considered permanent implants to improve outcomes, the use of this material has created inadvertent complications such as erosion, chronic pain, and dyspareunia. Patient evaluation is complex and surgical techniques carry risks not yet completely understood. This review summarizes current opinions in synthetic graft excision for the treatment of mesh-related complications. RECENT FINDINGS: Recent studies reveal excisions are being increasingly performed and graft placement is decreasing. Patients of lower-volume surgeons have a higher risk of complication and need for excisional procedures. Pain is becoming the most common indication for vaginal mesh excision and that pain is mostly elicited with palpation of the mesh arms. Explantation is technically challenging and carries significant risks. SUMMARY: Vaginal synthetic graft complications are increasingly being managed by surgical excision. Careful evaluation of patient symptoms and objective findings should help guide management. Surgeons considering operative management should counsel patients regarding the risks of excision including but not limited to hemorrhage, nerve damage, muscular injury, and recurrent symptoms.

Coupling to a glioblastoma-directed antibody potentiates antitumor activity of curcumin.

Current therapies for glioblastoma are largely palliative, involving surgical resection followed by chemotherapy and radiation therapy, which yield serious side effects and very rarely produce complete recovery. Curcumin, a food component, blocked brain tumor formation but failed to eliminate established brain tumors in vivo, probably because of its poor bioavailability. In the glioblastoma GL261 cells, it suppressed the tumor-promoting proteins NF-κB, P-Akt1, vascular endothelial growth factor, cyclin D1 and BClXL and triggered cell death. Expression of exogenous p50 and p65 subunits of NF-κB conferred partial protection on transfected GL261 cells against curcumin insult, indicating that NF-κB played a key role in protecting glioblastoma cells. To enhance delivery, we coupled curcumin to the glioblastoma-specific CD68 antibody in a releasable form. This resulted in a 120-fold increase in its efficacy to eliminate GL261 cells. A very similar dose response was also obtained with human glioblastoma lines T98G and U87MG. GL261-implanted mice receiving intratumor infusions of the curcumin-CD68 adduct followed by tail-vein injections of solubilized curcumin displayed a fourfold to fivefold reduction in brain tumor load, survived longer, and about 10% of them lived beyond 100 days. Hematoxylin-eosin staining of brain sections revealed a small scar tissue mass in the rescued mice, indicating adduct-mediated elimination of glioblastoma tumor. The tumor cells were strongly CD68+ and some cells in the tumor periphery were strongly positive for microglial Iba1, but weakly positive for CD68. This strategy of antibody targeting of curcumin to tumor comes with the promise of yielding a highly effective therapy for glioblastoma brain tumors.

A phase II/III, multicenter, safety, efficacy, and pharmacokinetic study of dexmedetomidine in preterm and term neonates.

OBJECTIVE: To investigate the safety, efficacy, and pharmacokinetic profile of dexmedetomidine in preterm and full-term neonates ≥ 28 to ≤ 44 weeks gestational age. STUDY DESIGN: Forty-two intubated, mechanically ventilated patients (n = 42) were grouped by gestational age into group I (n = 18), ≥ 28 to <36 weeks, and group II (n = 24), ≥ 36 to ≤ 44 weeks. Within each age group, there were 3 escalating dose levels, including a loading dose (LD, µg/kg) followed by a maintenance dose (MD, µg · kg(-1) · h(-1)) for 6-24 hours: level 1, 0.05 LD/MD; level 2, 0.1 LD/MD; and level 3, 0.2 LD/MD. The primary endpoint was the number of patients requiring sedation as determined by the Neonatal Pain, Agitation, Sedation Scale. RESULTS: During dexmedetomidine infusion, 5% of Neonatal Pain, Agitation, Sedation Scale scores were >3, indicating agitation/pain, with 4 patients (10%) requiring more sedation and 17 (40%) requiring more analgesia. Though there was significant variability in pharmacokinetic variables, group I appeared to have lower weight-adjusted plasma clearance (0.3 vs 0.9 L · h(-1) · kg(-1)) and increased elimination half-life (7.6 vs 3.2 hours) compared with group II. Fifty-six adverse events (AEs) were reported in 26 patients (62%); only 3 AEs (5%) were related to dexmedetomidine. There were no serious AEs and no AEs or hemodynamic changes requiring dexmedetomidine discontinuation. CONCLUSION: Dexmedetomidine is effective for sedating preterm and full-term neonates and is well-tolerated without significant AEs. Preterm neonates had decreased plasma clearance and longer elimination half-life.

A novel curcumin-based vaginal cream Vacurin selectively eliminates apposed human cervical cancer cells.

OBJECTIVE: Human papillomavirus (HPV) infections remain a leading cause of mortality worldwide. In the U.S. strategies via screening and vaccination prevent HPV-associated cervical neoplasms, but consume immense healthcare costs. The spice component curcumin has potent anticancer and antiviral properties, which have been difficult to harness as a treatment, due to its poor systemic bioavailability. This project tests the possibility of developing a curcumin-based therapy for cervical cancer. METHODS: Using four HPV(+) cervical cancer cell lines and normal fibroblasts we first tested the selectivity and potency of curcumin in eliminating HPV(+) cells. Subsequently, we developed a curcumin-based cervical cream and tested its efficacy in eliminating apposed HPV(+) cells and also its possible side effects on the vaginal epithelium of healthy mice. RESULTS: Curcumin selectively eliminates a variety of HPV(+) cervical cancer cells (HeLa, ME-180, SiHa, and SW756), suppresses the transforming antigen E6, dramatically inhibits the expression of the pro-cancer protein epidermal growth factor receptor (EGFR), and concomitantly induces p53. Additionally, Vacurin, a uniform colloidal solution of curcumin in a clinically used amphipathic vaginal cream, eliminates apposed HeLa cells while suppressing the expression of EGFR. In mice, daily intravaginal application of Vacurin for three weeks produced no change in body weight and when the mice were sacrificed, the vaginal tract epithelium showed no Vacurin-evoked adverse effects. CONCLUSION: We have developed a curcumin-based vaginal cream, which effectively eradicates HPV(+) cancer cells and does not affect non-cancerous tissue. Our preclinical data support a novel approach for the treatment of cervical HPV infection.

Expression patterns and clinical significance of estrogen receptor in non-small cell lung cancer.

BACKGROUND: Lung cancer death remains the highest among all malignancies. Gender differences show women have an increased cancer incidence while men have worse outcomes. These observations identified that some lung carcinomas express estrogen receptors (ER). This is a promising target as antiestrogen drugs can reduce tumors and improve survival. However, there is a limited understanding of ER distribution and its clinical significance to properly design antiestrogen drug clinical trials. Thus, we comprehensively analyzed ERα and ERß expression patterns by gender, cancer cell type, and receptor location in lung cancer. METHODS: We conducted a systematic review using the PubMed database from all-time through October 2022, using MeSH terms with the keywords "lung cancer," "estrogen receptor," and "immunohistochemistry." We identified 120 studies with 21 reports being evaluated based on our inclusion criteria. RESULTS: We examined 4874 lung cancers from 5011 patients. ERß is the predominant form of ER expressed, mainly found in the nucleus. The ERß positivity rate is 51.5% in males versus 55.5% in females and was not statistically different. In contrast, ERα is predominately extranuclear in location, and ERα expression varies by gender. Males had a positivity rate of 31% versus 26.6% in females, which is statistically different. ERα is associated with a worse prognosis in some studies, while it had no effect in others. Overall, ERß was associated with a better prognosis. CONCLUSION: We characterized ER expression patterns in 4874 lung cancers. Over 50% expressed ERß with equal rates in both sexes and was associated with a better prognosis. ERα expression was slightly higher in males (31%) than females (26.6%) and was associated with a poor prognosis. Our findings suggest estrogen signaling may be a promising drug target in lung cancer.

Time to move beyond surgical classification systems for endometriosis.

Endometriosis is a common condition associated with chronic pelvic pain and infertility. Its pathogenesis is poorly understood, diagnosis relies on laparoscopy, and staging is based on extent of disease. Unfortunately, the current staging systems do not correlate well with pain severity and impact, nor do they predict prognosis, i.e., treatment success and recurrence of disease. In this article, we discuss the strengths and limitations of current staging systems and propose modifications that will enable better classification systems to be developed in the future.

Endonuclease-resistant DNA: a novel histochemical marker for cervical intraepithelial neoplasia and cervical carcinoma.

The diagnosis of cervical intraepithelial neoplasia (CIN) has low interobserver reproducibility. The pathogenesis of human papillomavirus (HPV) from infection to high-grade CIN is well understood. In benign lesions, HPV-DNA is often packaged into virions, whereas malignant transformation disrupts virion assembly. It is conceivable that if cervical lesions were exposed to endonuclease digestion, HPV virions would alter nuclear susceptibility to DNA degradation. We propose that susceptibility to endonuclease digestion can serve as a simple marker to identify CIN grade. From paraffin-embedded tissue blocks, condyloma accuminata, CIN I-III, and cervical carcinoma cases were identified. Sections were placed in a bath containing DNAse I for DNA digestion. Residual DNA was stained by a Feulgen process. Endonuclease-resistant DNA (erDNA) staining was correlated to disease grade. In addition, 10 HPV (+) patients whose infection regressed and 8 whose infection progressed to CIN II or above had their initial HPV lesions stained for erDNA. erDNA was observed in 81% condylomas and 80% CIN I cases. All CIN II, III, and cancer cases were endonuclease sensitive with 100% of lesions showing no staining. Eighty percent of HPV lesions that regressed had erDNA staining, whereas 75% lesions that progressed had no erDNA staining. The spectrum of cervical disease caused by HPV has different susceptibilities to endonuclease digestion, which may aid in the diagnosis of CIN. Furthermore, in our small pilot study, erDNA status was associated with the clinical outcomes. Prospective studies are needed to confirm this observation. erDNA status is a promising novel biomarker.

Repeat operation for treatment of persistent pudendal nerve entrapment after pudendal neurolysis.

STUDY OBJECTIVES: To describe a new approach to transgluteal pudendal neurolysis and transposition and to review the outcome in 10 patients who underwent repeat operation because of persistent pudendal neuralgia after failing to improve after initial surgical decompression. DESIGN: Retrospective analysis (Canadian Task Force classification II-3). SETTING: Academic chronic pelvic pain practice at St. Joseph's Hospital and Medical Center in Phoenix, Arizona. PATIENTS: Women and men with persistent pudendal neuralgia after undergoing transgluteal pudendal neurolysis and transposition. INTERVENTION: Transgluteal decompression of the pudendal nerve was performed in all 10 patients. In brief, a transgluteal incision was made, and the pudendal nerve was identified via a nerve integrity monitoring system. Adhesiolysis was performed from the piriformis muscle to the distal Alcock canal using a Zeiss NC-4 surgical microscope. The nerve was then enclosed in NeuraWrap Nerve Protector and coated with activated platelet-rich plasma. An ON-Q PainBuster catheter was place along the nerve into the Alcock canal, and 0.5% bupivacaine was infused at 2 mL/hr. The sacrotuberous ligament was repaired using an Achilles or gracillis cadaver ligament. The overlying subcutaneous tissue and skin were then closed. MEASUREMENTS AND MAIN RESULTS: From June 2008 to March 2010, 10 consecutive patients (7 women and 3 men; age range, 29-81 years) underwent repeat operation with transgluteal decompression of the pudendal nerve. Neuropathic pain was unilateral (n = 8) or bilateral (n = 2), in the clitoris or penis (30%), vulva or scrotum (70%), perineum (40%), and rectum (50%). Of the 10 patients, 1 patient was lost to follow-up. Mean follow-up was 23 months. Eight of 9 patients reported global improvement, with 2 patients reporting complete resolution of symptoms. One patient reported no change. Pain, as measured using an 11-point numerical scale, improved from a mean of 7.2 to 4.0 (p = .02), with 5 patients reporting clinically significant improvement (change, ≥2). Comfortable sitting or maximum time that the patient was able to sit without exacerbation of pain improved in 8 patients, with a change in median time of 5 to 45 minutes (p = .008). Change in the ability to sit correlated well with patient-reported global improvement (correlation coefficient, 0.86). No patient experienced worsening of symptoms. CONCLUSION: Patients with persistent pudendal neuralgia after surgical decompression may benefit from repeat operation via our novel approach. Ability to sit correlates well with reported improvement due to surgery.

Prospective randomized controlled study comparing low-cost LED and conventional phototherapy for treatment of neonatal hyperbilirubinemia.

Our objective was to carry out a prospective, randomized, single-blind study to evaluate whether light emitting diode (LED) phototherapy using a low-cost set of lights is as effective as conventional phototherapy in treating hyperbilirubinemia in neonates. The study included 45 pre-term neonates requiring phototherapy as per American Academy of Pediatrics guidelines; participants were randomized to receive phototherapy using LED-based lights, conventional fluorescent blue lights or conventional halogen lights. There were no statistically significant differences in the average bilirubin levels at the onset, at the maximum and at the end of treatment, nor in the duration of phototherapy treatment and the rate of decrease in bilirubin levels in the neonates receiving conventional fluorescent blue light, conventional halogen light and LED phototherapy. (Differences were considered significant at p < 0.05). The average rate of decrease of bilirubin levels was 0.047 ± 0.037 mg dl(-1) h(-1), 0.055 ± 0.056 mg dl(-1) h(-1) and 0.057 ± 0.045 mg dl(-1) h(-1) in the groups receiving conventional fluorescent blue light, conventional halogen light and LED phototherapy, respectively. The average duration of phototherapy treatment in the three groups was 108.8 ± 85.9 h, 92.8 ± 38.1 h, 110.4 ± 42.6 h, respectively. In this pilot study, LED phototherapy using a simple, low-cost set of lights was as effective as conventional phototherapy in the treatment of neonatal hyperbilirubinemia. LED phototherapy lights that deliver 30-40 µW cm(-2 )nm(-1) can be assembled in small quantities for

Are Unilateral Devices Valid for Power Output Determination in Cycling? Insights From the Favero Assioma Power Meter.

PURPOSE: Some power meters are available in both bilateral and unilateral versions. However, despite the popularity of the latter, their validity remains unknown. We aimed to analyze the validity of a unilateral pedal power meter for estimating actual ("bilateral") power output (PO). METHODS: Thirty-three male cyclists were assessed at different POs (steady cycling at 100-500 W, as well as all-out sprints), pedaling cadences (70, 85, and 100 repetitions·min-1), and cycling positions (seated and standing). The PO estimated by a left-only power meter (Favero Assioma Uno) was compared with the actual PO computed by a bilateral power meter (Favero Assioma Duo), and the level of bilateral asymmetry (most- vs least-powerful leg) with the latter system was also computed. RESULTS: Nonsignificant differences, high intraclass correlation coefficients (≥.90), and low coefficients of variation (consistently ≤5% except for low PO levels, ie, 5%-7% at 100 W) were found between Favero Assioma Uno and Favero Assioma Duo. However, although a strong intraclass correlation coefficient (.995) was found between both legs, asymmetry values of 4% to 6% were found for all conditions except when pedaling at the lowest PO (100 W), in which asymmetry increased up to 10% to 13%. CONCLUSIONS: Although cyclists tend to present some level of bilateral asymmetry during cycling (particularly at low PO), Favero Assioma Uno provides overall valid estimates of actual PO and is, therefore, an economical alternative to bilateral power meters. Caution is needed, however, when interpreting data at the individual level in cyclists with high levels of asymmetry.

Breast arterial calcifications on mammograms do not predict coronary heart disease at coronary angiography.

PURPOSE: To examine, in women who underwent cardiac catheterization, whether breast arterial calcifications (BACs) seen at screening mammography correlate with coronary heart disease (CHD) seen at coronary angiography. MATERIALS AND METHODS: In an institutional review board-approved, HIPAA-compliant study, 172 women (mean age, 64.29 years +/- 11.97 [standard deviation]) who underwent coronary angiography were recruited, interviewed, and assigned to two groups: those with (CHD+) and those without (CHD-) CHD. The severity and location of the CHD were considered. Their mammograms were reviewed by a breast imaging specialist who was blinded to the CHD status. Student t test, chi(2), and multiple logistic regression tests were performed as appropriate. Presence of BAC was noted and correlated with presence of CHD and presence of cardiac risk factors. RESULTS: There were 104 women with and 68 women without CHD. Thirty-seven (36%) women in the CHD+ group versus 20 (29%) in the CHD-group (P = .40) had BAC. The mean age of the patients with BAC, 72 years +/- 9.8, was significantly older than the mean age of the patients without BAC, 60.4 years +/- 11.1 (P < .001). Therefore, subjects were divided into those younger than 65 years and those 65 years and older. No correlation existed, despite the fact that BAC was associated with some cardiac risk factors. CONCLUSION: The authors did not observe a correlation between BAC and coronary angiography-detected CHD, even when CHD severity was considered. On the basis of these results, caution should be exercised when using screening mammography-detected BAC to identify patients with CHD.

Effects of parathyroid hormone on immune function.

Parathyroid hormone (PTH) function as immunologic mediator has become interesting with the recent usage of PTH analogue (teriparatide) in the management of osteoporosis. Since the early 1980s, PTH receptors were found on most immunologic cells (neutrophils, B and T cells). The in vitro evaluations for a possible role of PTH as immunomodulator have shown inconsistent results mainly due to methodological heterogeneity of these studies: it used different PTH formulations (rat, bovine, and human), at different dosages and different incubating periods. In some of these studies, the lymphocytes were collected from uremic patients or animals, which renders the interpretation of the results problematic due to the effect of uremic toxins. Parathyroidectomy has been found to reverse the immunologic defect in patients with high PTH levels. Nonetheless, the clinical significance of these findings is unclear. Further studies are needed to define if PTH does have immunomodulatory effects.

Age-associated trends of vulvar cancer in the US.

OBJECTIVE: Medical societies have over the years moved away from recommending routine pelvic examinations in older, asymptomatic women above age 65. Consequently, vulvar examination is a largely neglected component of the physical examination, unless sent to a specialist for gynecological evaluation. In recognition of these recommendations, we analyzed US trends in vulvar cancer incidence, age, and stage at diagnosis, survival, and association with human papillomavirus (HPV). METHODS: Cases of vulvar and cervical cancer from 1992 to 2014 were extracted from the National Cancer Institute's Surveillance, Epidemiology, and End Results and Centers for Disease Control's data on age at diagnosis, stage of disease, and HPV-association were analyzed and compared. Incidence and mortality rates were extracted and calculated. RESULTS: From 1992-2014, there was a 14.3% increase in vulvar cancer rates. The absolute average incidence rate was 2.25, with HPV still being seen in vulvar carcinomas in women 65 years and above. Cervical cancer mortality rates declined by 34.2%, while vulvar cancer death rates were unchanged. We show increased intervals for cervical cancer screening is associated with later stage vulvar cancer detection. The proportion of vulvar cancer cases diagnosed in women age <50 steadily decreased, from 42.05% of cases in 1992-1996 to 19.75% of total cases in 2012-2015. Meanwhile, vulvar cancer cases diagnosed in women > 65 yo increased from 36.62% of cases in 1992-1996 to 49.82% of cases in 2012-2015. CONCLUSION: The incidence of vulvar cancer increases with age, with the median age of diagnosis 67 years, with HPV (+) tumors occurring into 70's and 80's. Though medical societies do not routinely recommend an external genital examination in women 65 years and above, we show this is a missed opportunity to improve cancer outcomes in some older females.

Video Summary:http://links.lww.com/MENO/A678.

Prevalence of occult microscopic endometriosis in clinically negative peritoneum during laparoscopy for chronic pelvic pain.

OBJECTIVE:  To determine the prevalence of occult microscopic endometriosis in patients with chronic pelvic pain and negative laparoscopy. METHODS: A retrospective cross-sectional study included women who underwent laparoscopic evaluation for chronic pelvic pain by three fellowship-trained gynecologic surgeons at a community hospital from January 2011 to December 2016. The aim was to evaluate the prevalence of microscopic endometriosis in this population. RESULTS:  In 142 patients with clinically negative peritoneum on laparoscopy, 39% had occult microscopic endometriosis. Cramping pain score during menses was found to be lower in the positive biopsy group (6.9 vs 8.0, P=0.046). No differences were appreciated in age of menarche, pain during various parts of the menstrual cycle, or duration of symptoms. The biopsy-positive group had a younger age at time of evaluation, although not statistically significant (P=0.179). Current use of hormones affected neither biopsy results nor menstrual or pain characteristics. Detection was similar between robotic and laparoscopic cases and operative morbidity was minimal. CONCLUSION: Occult microscopic endometriosis may be present in approximately 39% of patients with clinically negative appearing peritoneum undergoing laparoscopy for chronic pelvic pain. Given this, biopsies should be performed in patients undergoing laparoscopy who do not have visible lesions.