Prediction of Occult Uterine Sarcoma before Hysterectomy for Women with Leiomyoma or Abnormal Bleeding.

STUDY OBJECTIVE: To develop a risk prediction model for occult uterine sarcoma using preoperative clinical characteristics in women undergoing hysterectomy for presumed uterine leiomyomata. DESIGN: Cases of uterine sarcoma were identified from the electronic medical records. Age/race-matched controls were selected at a 2:1 ratio (controls:cases) from a cohort of 45 188 women who underwent hysterectomy for uterine leiomyomata or abnormal bleeding during the same time interval. Unadjusted conditional logistic regression was performed to identify risk factors for occult uterine sarcomas, defined as no preoperative suspicion for malignancy. A risk prediction model was developed using a weighted logistic regression model, and the performance of the model was assessed using the receiver operator characteristic curve and corresponding area under the curve. SETTING: A large integrated health care system in California PATIENTS: Women 18 years of age and older who underwent a hysterectomy and were diagnosed with a uterine sarcoma and matched controls from 2006 to 2013. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 117 cases of occult uterine sarcomas that met inclusion criteria during the study period. The final risk prediction model included age, race/ethnicity, number of myomas, uterine weight, uterine size increase, degree of pelvic pain, and recent history of blood transfusion. The risk prediction model showed high accuracy based on the receiver operating characteristic curve method (area under the curve = 0.83; 95% confidence interval, 0.77-0.90); however, the positive predictive values were low (0.048 or less) at all risk thresholds. CONCLUSION: Multiple clinical features are associated with the presence of a uterine sarcoma, but when incorporated into a prediction model, they fail to provide significantly more information about women who may have an unrecognized sarcoma and only marginally improve the certainty about women who are not likely to have sarcoma.

The Association of Polycystic Ovary Syndrome and Gestational Hypertensive Disorders in a Diverse Community-Based Cohort.

PURPOSE: To examine the association of polycystic ovary syndrome (PCOS) and pregnancy-induced hypertension (PIH) within a large population of pregnant women in an integrated healthcare system. METHODS: This retrospective study utilized a source cohort of 1023 women with PCOS and 1023 women without PCOS who had a delivered pregnancy within Kaiser Permanente Northern California. Preexisting hypertension was defined by hypertension diagnosis, treatment, or elevated blood pressure prior to 20 weeks of gestation. The development of PIH, including gestational hypertension, preeclampsia/eclampsia, or HELLP (hemolysis, elevated liver enzymes, and low platelet count), was ascertained by chart review. Among women without preexisting hypertension who had a singleton pregnancy, the association of PCOS and PIH was examined using multivariable logistic regression. RESULTS: Among 1902 women (910 PCOS) with singleton pregnancy, 101 (11.1%) PCOS and 36 (3.6%) non-PCOS women had preexisting hypertension and were excluded. Of the remaining 1765 women, those with PCOS (compared to non-PCOS) were slightly older (mean age 31.2 versus 30.7), more likely to be obese (39.6% versus 15.1%), nulliparous (63.8% versus 43.4%), and conceive with fertility treatment (54.1% versus 1.9%); they also had a higher incidence of PIH (10.8% versus 6.6%), including gestational hypertension (5.8% versus 3.6%) and preeclampsia or HELLP (4.9% versus 3.0%; all p<0.05). PCOS was associated with increased odds of PIH (odds ratio, OR 1.7, 95% confidence interval, CI 1.2-2.4), remaining significant after adjusting for age, race/ethnicity, nulliparity, and fertility treatment; however, findings were attenuated and no longer significant after adjusting for weight status (OR 1.1, CI 0.7-1.7). Maternal PCOS was also associated with preeclampsia/HELLP in unadjusted but not adjusted (OR 1.0, CI 0.5-1.9) analyses. Nulliparity and higher prepregnancy BMI were associated with PIH in both groups. CONCLUSION: Compared to women without PCOS, women with PCOS are at higher risk for PIH but this association was not independent of weight status.

Minilaparotomy Versus Laparoscopic Myomectomy After Cessation of Power Morcellation: Rate of Wound Complications.

STUDY OBJECTIVE: After the US Food and Drug Administration statement warning against electronic morcellation devices, gynecologic surgeons are performing laparoscopic and robotic myomectomies with minilaparotomy incisions for tissue morcellation and removal. No data exist that focus on the superficial wound complications as a result of these larger incisions. The objective of this study is to compare the rate of wound complications for myomectomy via minilaparotomy versus laparoscopic or robotic myomectomy. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Kaiser Permanente Northern California, a large integrated healthcare delivery system. PATIENTS: Women > 18 years of age who underwent a myomectomy from either complete laparoscopic or robotic approach (LR) were compared with minilaparotomy myomectomy (MM), comprising complete minilaparotomy (ML) and laparoscopic or robotic assisted by a minilaparotomy for morcellation purposes only (LRM) from January 2011 through December 2014. INTERVENTION: Myomectomy via LR, complete ML, and LRM. MEASUREMENTS AND MAIN RESULTS: Medical records were reviewed for outcomes of interest, including superficial wound complications and surgical and demographic data. After exclusion criteria were met, 405 cases were included in the study; 270 cases were classified as MM, which included ML (n = 224), or LRM (n = 46). One hundred thirty-five cases were classified as LR. Parametric and nonparametric analyses were used to compare the 2 groups. There was no significant difference between the groups insofar as patient morbidity, including the primary outcome of wound complications and other postoperative complications; emergency visits; or readmissions. There were 2 (1.5%) wound complications in the LR group and 7 (2.6%) in the MM group (p = .72). Similarly, there were no significant differences in the subcategories of wound complications, including cellulitis, seroma, hematoma, skin separation, wound infection, or postprocedure wound complication. The distribution of estimated blood loss was significantly different between LR and MM groups with an interquartile range of 50 to 150 mL in the LR group versus 50 to 300 mL in the MM group (p < .01). The MM group experienced a shorter procedure time with a median procedure time of 125 minutes compared with 169.5 minutes in LR surgeries (p < .01). The LR group demonstrated a significantly shorter median length of hospital stay (LR 5.0 hours vs MM 23 hours; p < .01). CONCLUSION: Compared with MM, LR is associated with a shorter length of hospital stay and longer operating time but no reduction in wound complication or other patient morbidity.

Same-Day Discharge After Minimally Invasive Myomectomy.

OBJECTIVE: To estimate readmission rates of patients discharged home the same day after a minimally invasive myomectomy. METHODS: This is a retrospective case series of patients who underwent minimally invasive myomectomy and were discharged the same day, which examines the feasibility and safety by rates of readmission within Kaiser Permanente Northern California. Chart review was performed for outcomes of interest including readmission rates, emergency department, and urgent clinic visits within 48 hours, 7 days, and up to 3 months along with surgical and demographic characteristics. RESULTS: Of the 403 minimally invasive myomectomies performed during the study period, 88% (N=356) of patients were discharged home the same day. No readmissions required reoperation or were life-threatening. Two patients (0.6%) were readmitted within 48 hours for postoperative fever. A cumulative total of five patients (1.4%) were readmitted within 3 months. Urgent care and emergency department visits occurred in zero and seven patients (2.0%) within 48 hours of discharge, most commonly for pain and urinary retention. Median leiomyoma weight was 204 g, median body mass index was 26, median blood loss was 75 mL, and median surgical time was 157 minutes. CONCLUSION: Same-day discharge after minimally invasive myomectomy was found to have a low readmission rate and low health care utilization in the immediate postoperative period. Same-day discharge appears to be a safe option for healthy patients after undergoing an uncomplicated minimally invasive myomectomy.

Prevalence of cervical insufficiency in polycystic ovarian syndrome.

BACKGROUND: Pregnant women with polycystic ovarian syndrome (PCOS) experience a greater rate of adverse obstetrical outcomes compared with non-PCOS women. We examined the prevalence and incidence of cervical insufficiency (CI) in a community cohort of pregnant women with and without PCOS. METHODS: A retrospective cohort study was conducted within a large integrated health care delivery system among non-diabetic PCOS women with second or third trimester delivery during 2002-2005 (singleton or twin gestation). PCOS was defined by Rotterdam criteria. A non-PCOS comparison group matched for delivery year and hospital facility was used to estimate the background rate of CI. Women were designated as having new CI diagnosed in the index pregnancy (based on cervical dilation and/or cervical shortening) and prior CI based on prior diagnosis of CI with prophylactic cerclage placed in the subsequent pregnancy. RESULTS: We identified 999 PCOS women, of whom 29 (2.9%) had CI. There were 18 patients with new CI and 11 with prior CI having prophylactic cerclage placement; four CI patients had twin gestation. In contrast, only five (0.5%) non-PCOS women had CI: two with new CI and three with prior CI. The proportion of newly diagnosed incident CI (1.8 versus 0.2%) or prevalent CI (2.9 versus 0.5%) was significantly greater for PCOS compared with non-PCOS pregnant women (both P < 0.01). Among PCOS women, CI prevalence was particularly high among South Asians (7.8%) and Blacks (17.5%) compared with Whites (1%) and significantly associated with gonadotropin use (including in vitro fertilization). Overall, the PCOS status was associated with an increased odds of prevalent CI pregnancy (adjusted odds ratio 4.8, 95% confidence interval 1.5-15.4), even after adjusting for maternal age, nulliparity, race/ethnicity, body mass index and fertility treatment. CONCLUSION: In this large and ethnically diverse PCOS cohort, we found that CI occurred with a higher than expected frequency in PCOS women, particularly among South Asian and Black women. PCOS women with CI were also more likely to have received gonadotropin therapy. Future studies should examine whether natural and hormone-altered PCOS is a risk factor for CI, the role of race/ethnicity, fertility drugs and consideration for heightened mid-trimester surveillance in higher risk subgroups of pregnant women with PCOS.

Laparoscopic 5-mm trocar site herniation and literature review.

OBJECTIVE: To evaluate the evidence for fascial closure of 5-mm laparoscopic trocar sites. METHODS: We conducted electronic database searches of PubMed and the Cochrane Library for articles published between November 2008 and December 2010. We used the keywords trocar hernia, trocar-site hernia, laparoscopic hernia, trocar port-site hernia, laparoscopic port-site hernia. Prospective and retrospective case series, randomized trials, literature reviews, and randomized animal studies of trocar hernias on abdominal wall defects from gynecologic, urologic, and general surgery literature were reviewed. The Cochrane Database was reviewed for pertinent studies. Metaanalysis was not possible due to the significant heterogeneity between studies and lack of randomized trials large enough to assess the incidence of this rare complication. RESULTS: Trocar-site hernias are a rare but known complication of laparoscopic surgery. Trocar size ≥10mm is associated with an increased rate of hernia development. Currently, the accepted gynecologic surgical practice is closure of fascial incisions ≥10mm, while incisions <10mm do not require closure. However, large prospective and retrospective case series reports from general surgery and urology literature support nonclosure of blunt or radially dilating trocars in paramedian sites. Expert opinion and small case reports suggest that in cases of prolonged manipulation of 5-mm trocar sites the surgeon should consider fascial closure, because extension of the initial incision may have occurred. CONCLUSION: There is no evidence to recommend routine closure of 5-mm trocar incisions; the choice should continue to be left to the discretion of the individual surgeon.

Same-day discharge after laparoscopic hysterectomy.

OBJECTIVE: To estimate readmission rates and emergency care use by patients discharged home the same day after laparoscopic hysterectomy. METHODS: This was a retrospective case series of patients discharged home the same-day after total or supracervical laparoscopic hysterectomy in a managed care setting. Chart reviews were performed for outcomes of interest which included readmission rates, emergency visits, and surgical and demographic characteristics. The two hysterectomy groups were compared using χ² tests for categorical variables and t tests or Wilcoxon rank-sum tests for continuously measured variables. RESULTS: One-thousand fifteen laparoscopic hysterectomies were performed during the 3-year study period. Fifty-two percent (n=527) of the patients were discharged home the same-day; of those, 46% (n=240) had total laparoscopic hysterectomies and 54% (n=287) had supracervical. Cumulative readmission rates were 0.6%, 3.6%, and 4.0% at 48 hours, 3 months, and 12 months, respectively. The most common readmission diagnoses included abdominal incision infection, cuff dehiscence, and vaginal bleeding. Less than 4% of patients presented for emergency care within 48 or 72 hours, most commonly for nausea or vomiting, pain, and urinary retention. Median uterine weight was 155 g, median blood loss was 70 mL, and median surgical time was 150 minutes. There was no difference in readmission rates or emergency visits for the total compared with the supracervical laparoscopic hysterectomy group. CONCLUSION: Same-day discharge after laparoscopic hysterectomy is associated with low readmission rates and minimal emergency visits in the immediate postoperative period. Same-day discharge may be a safe option for healthy patients undergoing uncomplicated laparoscopic hysterectomy.

p120 catenin regulates dendritic spine and synapse development through Rho-family GTPases and cadherins.

Both the cadherin-catenin complex and Rho-family GTPases have been shown to regulate dendrite development. We show here a role for p120 catenin (p120ctn) in regulating spine and synapse formation in the developing mouse brain. p120catenin gene deletion in hippocampal pyramidal neurons in vivo resulted in reduced spine and synapse densities along dendrites. In addition, p120 catenin loss resulted in reduced cadherin levels and misregulation of Rho-family GTPases, with decreased Rac1 and increased RhoA activity. Analyses in vitro indicate that the reduced spine density reflects aberrant Rho-family GTPase signaling, whereas the effects on spine maturation appear to result from reduced cadherin levels and possibly aberrant Rho-family GTPase signaling. Thus, p120ctn acts as a signal coordinator between cadherins and Rho-family GTPases to regulate cytoskeletal changes required during spine and synapse development.

Lymphocyte regulation of neuropeptide gene expression after neuronal injury.

The neuropeptides vasoactive intestinal peptide (VIP) and pituitary adenylyl cyclase-activating peptide (PACAP) are induced strongly in neurons after several types of injury, and exhibit neuroprotective actions in vitro and in vivo. It is thought that changes in expression of neuropeptides and other molecules in injured neurons are mediated by new factors produced in Schwann and immune cells at the injury site, a loss of target-derived factors, or a combination of mediators. To begin to determine the role of the inflammatory mediators, we investigated axotomy-induced changes in VIP and PACAP gene expression in the facial motor nucleus in severe combined immunodeficient (SCID) mice, and in mice with targeted mutations in specific cytokine genes. In normal mice, VIP and PACAP mRNA was induced strongly in facial motor neurons 4 days after axotomy. The increase in PACAP mRNA was blocked selectively in SCID mice, indicating that mechanisms responsible for VIP and PACAP gene induction are not identical. The loss of PACAP gene expression in SCID mice after axotomy was fully reversed by an infusion of normal splenocytes, suggesting that PACAP mRNA induction requires inflammatory mediators. PACAP and VIP mRNA inductions, however, were maintained in mice lacking leukemia inhibitory factor (LIF) and interleukin-6 (IL-6), and in mice lacking both receptors for tumor necrosis factor alpha (TNFalpha). The data suggest that an inflammatory response, most likely involving T lymphocytes, is necessary for the axotomy-induced increase in PACAP but not in VIP. LIF, IL-6, and TNFalpha, however, are not required for this response to injury.