Investigating age and ethnicity as novel high-risk phenotypes in mucinous ovarian cancer: retrospective study in a multi-ethnic population.

OBJECTIVES: Primary mucinous ovarian carcinoma represents 3% of ovarian cancers and is typically diagnosed early, yielding favorable outcomes. This study aims to identify risk factors, focussing on the impact of age and ethnicity on survival from primary mucinous ovarian cancer. METHODS: A retrospective observational study of patients treated at Sandwell and West Birmingham Hospitals NHS Trust and University Hospital Coventry and Warwickshire. Patients included were women aged ≥16 years, with primary mucinous ovarian cancer confirmed by specialist gynecological histopathologist and tumor immunohistochemistry, including cytokeratin-7, cytokeratin-20, and CDX2. Statistical analyses were performed using R integrated development environment, with survival assessed by Cox proportional hazards models and Kaplan-Meier plots. RESULTS: A total of 163 patients were analyzed; median age at diagnosis was 58 years (range 16-92), 145 (89%) were International Federation of Gynecology and Obstetrics stage I and 43 (26%) patients had infiltrative invasion. Women aged ≤45 years were more likely to have infiltrative invasion (RR=1.38, 95% CI 0.78 to 2.46), with increased risk of death associated with infiltrative invasion (HR=2.29, 95% CI 1.37 to 5.83). Compared with White counterparts, South Asian women were more likely to undergo fertility-sparing surgery (RR=3.52, 95% CI 1.48 to 8.32), and have infiltrative invasion (RR=1.25, 95% CI 0.60 to 2.58). South Asian women undergoing fertility-sparing surgery had worse prognosis than those undergoing traditional staging surgery (HR=2.20, 95% CI 0.39 to 13.14). In FIGO stage I disease, 59% South Asian and 37% White women received adjuvant chemotherapy (p=0.06). South Asian women exhibited a worse overall prognosis than White women (HR=2.07, 95% CI 0.86 to 4.36), particularly pronounced in those aged ≤45 years (HR=8.75, 95% CI 1.22 to 76.38). CONCLUSION: This study identified young age as a risk factor for diagnosis of infiltrative invasion. Fertility-sparing surgery in South Asian women is a risk factor for poorer prognosis. South Asian women exhibit poorer overall survival than their White counterparts.

Tips and tricks in gynaecological robotic surgery.

It was the dawn of a new era for robotic surgery when the Food and Drug Administration (FDA) approved da Vinci robotic surgical system for general laparoscopic procedures in 2000. The surgical practice saw a transformative breakthrough towards minimally invasive approach with the ever-increasing uptake of advanced robots proven to benefit patients and surgeons in various ways. However, these innovative machines only complement and enhance a surgeon's operating skills, and with such privilege come responsibilities and new challenges. Heavy reliance on such advanced devices while operating on humans necessitates thorough training and supervision to ensure safe and efficient applications. It is the surgeon's responsibility to direct the procedure constantly and lead other team members who assist during the surgery. In this chapter, we provide miscellaneous tips and tricks that can help beginners navigate through robotic surgery with more confidence and enthusiasm.

Haemodynamic stability following adrenaline intracervical block for major haemorrhage during surgical management of late miscarriage: A case report.

The risk of heavy bleeding after a miscarriage is higher in women undergoing medical management compared with surgical. According to the literature, oxytocin receptor mRNA expression in the myometrium is not well formed during early gestation. Adrenaline may be considered in miscarriage which remains refractory to uterotonics and where bleeding from the placental bed may contribute to haemorrhage, before proceeding to surgical intervention. It is used in various settings to control bleeding in gynaecological procedures. A 34-year-old woman in her third pregnancy presented at 15 + 1 weeks of gestation with an open cervical os and bulging membrane. Within three hours of admission, she passed the fetus but failed to deliver the placenta and continued to bleed. She was taken to theatre for surgical management of miscarriage. The bleeding persisted following suction evacuation and despite the standard dose of oxytocin, and misoprostol uterotonics were given. Because the source of bleeding could be the placental bed, potentially low lying at this stage, a 4.4 ml prefix combination of 12.5 µg/ml adrenaline (1:80,000) and lidocaine (20 mg/ml) was administered as an intracervical block equally at four quadrants at the level of the cervical isthmus. This arrested the bleeding immediately and controlled the bleeding until discharge. This technique has not been described previously, which we believe causes vasoconstriction of the placental bed.

Percutaneous Fluoroscopy-guided Retrieval of a Fractured Pelvic Drain after Caesarean Section: A Case Report.

Iatrogenic retention of surgical drains following drain entrapment and breakage is a never event and a preventable complication. The traditional approach for removing a fractured drain from the intra-peritoneal cavity involves exploratory laparotomy. However, over the last few decades, minimal access surgery has been a more popular retrieval method for retained surgical items from peritoneal and extraperitoneal cavities. We report a case of a 32-year-old woman with a fractured pelvic drain post-caesarean section. Postoperatively, the patient developed the signs of infection and features of bowel obstruction. The mechanical obstruction was ruled out by computed tomography scan. Multiple attempts were made to pull the pelvic drain out but the tube snapped, leaving about a quarter of its length. The drain remnant was retrieved using a non-invasive, inexpensive interventional radiology technique. We could not find any such report in the literature describing this innovative approach for retrieving a fractured pelvic drain. Keywords: case report; drain fragment retrieval; fractured pelvic drain; pelvic drain remnant.

The role of preoperative computerized tomography (CT) scan of the pelvis and groin in the management of clinically early staged vulva squamous cell carcinoma.

INTRODUCTION: Vulvar squamous cell carcinoma (VSCC) commonly metastasises through groin lymphatics. However, the use of pre-operative imaging in detecting inguinal nodal metastasis before staging surgery or to triage patients for sentinel node biopsy remains unclear. Here, we investigated if pre-operative CT scan, the imaging choice in our cancer centre, influences the overall course of VSCC management in those patients without clinical evidence of groin lymphadenopathy. METHOD: The study comprised of a prospective cohort of 225 patients with VSCC who underwent staging surgery within a regional tertiary gynaecological cancer centre. Comprehensive information of the cohort's demography, clinicopathological variables and outcome data were collected and analysed. Findings of pre-operative imaging were compared with histological findings of inguinal lymph nodes following groin lymphadenectomy. Statistical analyses were performed using SPSS V24. RESULTS: Pre-operative CT scan was performed on 116 (56.6%) patients. The sensitivity and specificity of cross-sectional imaging in detecting groin lymphatic metastasis were 59.1% and 77.8%, respectively; while the positive (PPV) and negative predictive value (NPV) were 61.9% and 75.7%, respectively. In patients who had sentinel inguinal nodes biopsy, the sensitivity, specificity, PPV and NPV of CT scan in detecting inguinal node metastasis were 30.0%, 85.7%, 33.3% and 83.7%, respectively. There was no difference in disease-free and overall survival in those who received pre-operative imaging when compared to those who did not. CONCLUSION: Pre-operative CT scan may be omitted in early stage VSCC prior to surgical staging as it does not affect overall management and surgical outcomes.

Evaluating the value of intrapartum fetal scalp blood sampling to predict adverse neonatal outcomes: A UK multicentre observational study.

OBJECTIVE: To evaluate the value of fetal scalp blood sampling (FBS) as an adjunct test to cardiotocography, to predict adverse neonatal outcomes. STUDY DESIGN: A multicentre service evaluation observational study in forty-four maternity units in the UK. We collected data retrospectively on pregnant women with singleton pregnancy who received FBS in labour using a standardised data collection tool. The primary outcome was prediction of neonatal acidaemia diagnosed as umbilical cord arterial pH < 7.05, the secondary outcomes were the prediction of Apgar scores<7 at 1st and 5th minutes and admission to the neonatal intensive care unit (NICU). We evaluated the correlation between the last FBS blood gas before birth and the umbilical cord blood and adjusted for time intervals. We constructed 2 × 2 tables to calculate the sensitivity, specificity, positive (PPV) and negative predictive value (NPV) and generated receiver operating curves to report on the Area Under the Curve (AUC). RESULTS: In total, 1422 samples were included in the analysis; pH values showed no correlation (r = 0.001, p = 0.9) in samples obtained within an hour (n = 314), or within half an hour from birth (n = 115) (r=-0.003, p = 0.9). A suboptimal FBS pH value (<7.25) had a poor sensitivity (22%) and PPV (4.9%) to predict neonatal acidaemia with high specificity (87.3%) and NPV (97.4%). Similar performance was noted to predict Apgar scores <7 at 1st (sensitivity 14.5%, specificity 87.5%, PPV 23.4%, NPV 79.6%) and 5th minute (sensitivity 20.3%, specificity 87.4%, PPV 7.6%, NPV 95.6%), and admission to NICU (sensitivity 20.3%, specificity 87.5%, PPV 13.3%, NPV 92.1%). The AUC for FBS pH to predict neonatal acidaemia was 0.59 (95%CI 0.59-0.68, p = 0.3) with similar performance to predict Apgar scores<7 at 1st minute (AUC 0.55, 95%CI 0.51-0.59, p = 0.004), 5th minute (AUC 0.55, 95%CI 0.48-0.62, p = 0.13), and admission to NICU (AUC 0.58, 95%CI 0.52-0.64, p = 0.002). Forty-one neonates had acidaemia (2.8%, 41/1422) at birth. There was no significant correlation in pH values between the FBS and the umbilical cord blood in this subgroup adjusted for sampling time intervals (r = 0.03, p = 0.83). CONCLUSIONS: As an adjunct tool to cardiotocography, FBS offered limited value to predict neonatal acidaemia, low Apgar Scores and admission to NICU.

Histopathological study of endoscopic biopsies.

INTRODUCTION: Diseases of upper gastrointestinal tract are responsible for a great deal of morbidity and mortality. The histopathological study of endoscopic biopsies permits exact diagnosis for further management.The aim of this study is to find out the histopathological pattern of endoscopic biopsy. METHODS: A descriptive study was conducted in consecutive endoscopic gastric biopsies in a Hospital over a period of one year. The patient of all ages and both sexes who underwent gastric biopsy during the study period was included. RESULTS: Endoscopic biopsies were studied on patients of age ranging from 20 years female to 84 years male. The histopathology revealed non-neoplastic lesions 54 (67.5%) and neoplastic lesions 26 (32.5%). Most common non-neoplastic lesion noted was mild chronic gastritis 22(27.5%) followed by chronic active gastritis 15 (18.75%) while H. pylori was present in 13 (16.25%) and absent in 2 (2.5%). CONCLUSIONS: Mild chronic gastritis was the commonest lesion noted in non-neoplastic lesions and adenocarcinoma was the commonest neoplastic lesion in the endoscopic gastric biopsies.

Spinal cord injury rehabilitation in Nepal.

Spinal cord injury is a major trauma, with its short and long term effects and consequences to the patient, his friends and family. Spinal cord injury is addressed in the developed countries with standard trauma care system commencing immediately after injury and continuing to the specialized rehabilitation units. Rehabilitation is important to those with spinal injury for both functional and psychosocial reintegration. It has been an emerging concept in Nepal, which has been evident with the establishment of the various hospitals with rehabilitation units, rehabilitation centres and physical therapy units in different institutions. However, the spinal cord injury rehabilitation setting and scenario is different in Nepal from those in the developed countries since spinal cord injury rehabilitation care has not been adequately incorporated into the health care delivery system nor its importance has been realized within the medical community of Nepal. To name few, lack of human resource for the rehabilitation care, awareness among the medical personnel and general population, adequate scientific research evidence regarding situation of spinal injury and exorbitant health care policy are the important hurdles that has led to the current situation. Hence, it is our responsibility to address these apparent barriers to successful implementation and functioning of rehabilitation so that those with spinal injury would benefit from enhanced quality of life.