Uterine Sarcomas in Patients Undergoing Surgery for Presumed Leiomyomas: 10 Years' Experience.

STUDY OBJECTIVE: To find the incidence of sarcomas in patients undergoing surgery for presumed leiomyomas. DESIGN: Retrospective study (Canadian Task Force classification II-3). SETTING: Paul's Hospital, Centre for Advanced Laparoscopy and Infertility, Kochi, India. PATIENTS: All women who underwent total laparoscopic hysterectomy (TLH), laparoscopic myomectomy (LM), and hysteroscopic myomectomy (HM) at Paul's Hospital for presumed leiomyomas from January 1, 2004 to December 31, 2014 that were then diagnosed as sarcomas on histopathologic examination. INTERVENTIONS: TLH, LM, and HM. MEASUREMENTS AND MAIN RESULTS: A total of 2678 patients underwent TLH, LM, and HM at Paul's Hospital for presumed leiomyomas from January 1, 2004 to December 31, 2014. Five patients were diagnosed as leiomyosarcoma and 3 patients as endometrial stromal sarcoma on histopathologic examination. Women's ages ranged from 12 to 53 years. Histopathologic diagnosis of leiomyosarcoma was made in 3 patients from the TLH group and 2 patients from the myomectomy group. Two patients from the TLH group and 1 patient from the myomectomy group were diagnosed as endometrial stromal sarcoma on histopathologic examination. The incidence of uterine sarcomas (leiomyosarcoma and endometrial stromal sarcoma) in patients undergoing surgery for presumed leiomyomas was found to be .29% (1 in 335 patients) in our study. CONCLUSION: Over a period of 10 years (2004-2014), the incidence of uterine sarcomas in patients undergoing surgery for presumed leiomyomas was found to be .29% in our study.

Contained Morcellation for Laparoscopic Myomectomy Within a Specially Designed Bag.

A technique of contained morcellation of uterine myomas within a bag specially designed for 2-port morcellation during laparoscopic myomectomy is described. Ten patients underwent in-bag morcellation of myomas with a tissue isolation bag (MorSafe) between November 2014 and January 2015. The MorSafe tissue isolation bag is a retort-shaped bag made of medical-grade flexible plastic material with the wider opening of 134 mm in diameter and the tail end measuring 4 mm in diameter, allowing easy accomodation of specimens up to 12 cm in diameter. This technique involves placing the myomas into the isolation bag within the abdomen, exteriorizing the tail end of the bag, insufflating the bag within the peritoneal cavity, and morcellating the myomas under vision. Demographic and perioperative characteristics were studied. The mean operative time was 117 minutes (range, 75-195 minutes), the mean time for specimen introduction into the bag was 12.5 minutes (range, 7-22 minutes), and the mean time for morcellation and bag removal was 24.8 minutes (range, 10-50 minutes). There were no complications related to the in-bag morcellation technique, and there was no visual evidence of damage to the isolation bag. In-bag morcellation using this new bag is a feasible technique for morcellating uterine myomas in a contained manner and may provide an option to minimize the risks of open power morcellation while preserving the benefits of minimally invasive surgery.

A Descriptive Analysis of Factors Leading to a 1-Year Remission in Bipolar Disorder.

BACKGROUND: Bipolar spectrum disorders are associated with symptomatic and functional disability in many patients. Other studies have examined predictors of outcome with variable results. The goal of this retrospective study was to identify medications associated with a minimum of 12 consecutive months of symptomatic, functional, and syndromal remission. METHODS: The charts of 121 patients with confirmed bipolar disorder were reviewed. Data on medical regimen and demographic and adherence factors were gathered using standardized data collection sheets approved by the University of Toledo Institutional Review Board. The criterion for improvement was set at 12 consecutive months of Clinical Global Impressions Improvement ratings of ≤2, which is a far higher standard of syndromal and functional remissions than the usual 8 consecutive weeks used by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. RESULTS: In this sample of 121 patients, 43.8% achieved a minimum of 12 consecutive months of remission, whereas 56.2% did not. When bipolar disorder was divided into its subtypes, 45.5% of our cohort were diagnosed with bipolar I disorder, 27.3% were diagnosed with bipolar II disorder, and 27.3% were diagnosed with bipolar disorder, not otherwise specified. Of the 55 patients with bipolar I disorder, 27 remitted and 28 did not. Of the 33 patients with bipolar II disorder, 12 remitted and 21 did not. Of the 33 patients with bipolar disorder, not otherwise specified, 14 remitted and 19 did not. The treatment regimen that was most closely associated with remission was a combination of atypical antipsychotics (primarily aripiprazole), mood stabilizers (primarily lamotrigine), and an antidepressant. In addition, the patients who achieved remission were more likely to be adherent to medication and with appointments. CONCLUSIONS: The chart review showed that 12 consecutive months of symptomatic remission was achieved in our clinic in 43.8% of patients with bipolar disorder when they were treated with tailored medication regimens. The remainder (56.2%) failed to achieve 12 consecutive months of remission based on real-time Clinical Global Impressions Improvement ratings. The combination of an atypical antipsychotic, a mood stabilizer, and an antidepressant was highly correlated with 1-year remission.

Accessory Cavitated Uterine Mass: A Rare Cause of Severe Dysmenorrhea in Young Women.

We present 3 case reports of a rare Müllerian anomaly called accessory and cavitated uterine mass (ACUM), which is found in young women >30 years of age. They presented with severe dysmenorrhea refractory to medical treatment. The patients were 17, 19, and 25 years old. The patients had the classic Müllerian anomalies. The hysteroscopic examination was normal in all 3 cases, and laparoscopic examination showed a 3- to 4-cm ill-defined mass on the right half of the uterus, without any communication to the uterine cavity. The chocolate-colored material was drained in all of the cases, during excision of the mass. The myometrial defect was sutured laparoscopically. On histological examination, the mass was found to be a cystic cavity, lined by endometrial glands and stroma, which confirmed the diagnosis of ACUM.

Pharmacotherapy Treatment Options for Insomnia: A Primer for Clinicians.

Insomnia is a prevalent disorder with deleterious effects such as decreased quality of life, and a predisposition to a number of psychiatric disorders. Fortunately, numerous approved hypnotic treatments are available. This report reviews the state of the art of pharmacotherapy with a reference to cognitive behavioral therapy for insomnia (CBT-I) as well. It provides the clinician with a guide to all the Food and Drug Administration (FDA) approved hypnotics (benzodiazepines, nonbenzodiazepines, ramelteon, low dose sinequan, and suvorexant) including potential side effects. Frequently, chronic insomnia lasts longer than 2 years. Cognizant of this and as a result of longer-term studies, the FDA has approved all hypnotics since 2005 without restricting the duration of use. Our manuscript also reviews off-label hypnotics (sedating antidepressants, atypical antipsychotics, anticonvulsants and antihistamines) which in reality, are more often prescribed than approved hypnotics. The choice of which hypnotic to choose is discussed partially being based on which segment of sleep is disturbed and whether co-morbid illnesses exist. Lastly, we discuss recent label changes required by the FDA inserting a warning about "sleep-related complex behaviors", e.g., sleep-driving for all hypnotics. In addition, we discuss FDA mandated dose reductions for most zolpidem preparations in women due to high zolpidem levels in the morning hours potentially causing daytime carry-over effects.