Incidence, management, and sequelae of ureteric obstruction in women with cervical cancer.

PURPOSE: Hydronephrosis due to ureteric obstruction (UO) is stage-defining at cervical cancer presentation but may occur after primary staging. We aimed to determine the incidence and review the presentation and management of UO in women with cervical cancer attending our center. Particular attention was paid to the evolving role of interventional radiology (IR) in management. METHODS: Women with a new diagnosis of cervical cancer between January 2012 and December 2016 formed the cohort that was retrospectively reviewed from the oncology database and patient records. RESULTS: There were 310 women diagnosed with cervical cancer; 240 were stages I/II and 70 were stages III/IV. Primary treatments were chemoradiotherapy (n = 168; 54.2%), surgery (n = 121; 39.0%), and palliative care alone (n = 21; 6.8%). UO occurred in 74 (23.9%); present at primary staging in 53 (71.6%) and arising after staging in 21 (28.4%). Primary interventions for hydronephrosis were IR (n = 50; 67.6%), cystoscopic stenting (n = 19; 25.7%), bowel urinary conduit construction (n = 2; 2.7%), and none (n = 3; 4.1%). For those who attended IR, the mean number of IR procedures was 2.2, range 1-7. Maximum serum creatinine was 303 µmol/L for women with UO at primary staging compared with 252 µmol/L for UO after staging (P = 0.267). Thirty-eight women experienced substantial morbidity related to UO. Stage-adjusted mortality risk was 2.3 times higher for UO cases compared with those without UO. CONCLUSIONS: UO is associated with substantial morbidity and survival disadvantage in cervical cancer and may present after primary cancer staging. We recommend renal biochemistry during routine follow-up. A majority of cervical cancer-associated UO cases are managed with IR in our center.

Radial torsion in dogs with medial compartment disease.

OBJECTIVE: To evaluate the magnitude and direction of radial torsion (RT) in dogs with medial compartment disease (MCD). STUDY DESIGN: Case-control study. SAMPLE POPULATION: Twenty-eight healthy dogs and 28 dogs with confirmed MCD. METHODS: Computed tomography images of each dog's antebrachium were evaluated. Radial torsion was measured by using previously described landmarks on the proximal and distal radius. Differences between groups were tested with Student's t tests and Wilcoxon rank-sum tests. RESULTS: Healthy dogs had a mean RT angle of 3.44° (range, 1.28°-5.44°). Dogs with MCD had a mean RT angle of 11.84° (range, 2.31°-26.55°). Both groups included similar proportions of dogs with external (76% vs 77%) and internal (24% vs 23%) torsion. The direction of torsion (P = .21 and P = .69) did not appear to affect the magnitude of the RT angle. CONCLUSION: Dogs with MCD had an increased RT angle compared with healthy controls. The direction of torsion varied similarly between groups regardless of the disease status of dogs in this study. CLINICAL SIGNIFICANCE: The fourfold increase in the RT seen in dogs with MCD may contribute to the rotational overload proposed recently, potentially modifying the orientation of the elliptical radial head and the ligaments crossing the elbow joint.

Trends in maternal obesity in a large university hospital 2009-2013.

INTRODUCTION: Maternal obesity has been identified as an important clinical priority in contemporary obstetrics. This study aimed to determine the incidence of maternal obesity in early pregnancy and track recent trends in body mass index (BMI) categories over 5 years 2009-2013. MATERIAL AND METHODS: This prospective observational study included all women who delivered an infant weighing ≥500 g during the 5 years 2009-2013 in a large university teaching hospital in Ireland. Body mass index was calculated using early pregnancy weight and height measured at first antenatal visits. Sociodemographic and clinical data were gathered prospectively. Trends in maternal obesity were tracked over 5 years and epidemiological associations with obesity were examined using logistic regression, adjusted for confounding variables. RESULTS: Of 42 362 women, 99.0% (n = 41 927) were eligible for analysis with a mean BMI of 25.5 kg/m(2) , mean age of 30.7 years and 40.7% (n = 17054) primigravidas. The absolute number of cases of severe obesity (BMI ≥40.0 kg/m(2) ) increased by 48.5% from 2009 to 2013 (p < 0.001). After multivariate logistic regression analyses, obesity incidence increased with increasing parity, advancing age and socioeconomic disadvantage. The maternal obesity rate among women born in the 13 European Union Accession countries was 8.6%, nearly half that of those born in existing European Union countries (p < 0.001). CONCLUSION: It is concerning that while the overall obesity rate remained stable, the number of cases of severe obesity increased over 5 years. We recommend renewed public health efforts addressing obesity rates before pregnancy and reinforcing attempts to optimize a woman's weight after delivery.

The interplay between maternal obesity and gestational diabetes mellitus.

There is a strong epidemiological association between maternal obesity and gestational diabetes mellitus (GDM). Since the publication of the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study on women with mild hyperglycemia in 2008, new criteria have been introduced in maternity services internationally for the diagnosis of GDM. As a result, the diagnosis of GDM may be made in one-third of obese women (n=68). The aim of this review was to examine the interplay between maternal obesity and GDM in light of the HAPO study and the subsequent revised diagnostic criteria. Obesity and GDM are important obstetric risk factors because they both are potentially modifiable. However, the new international criteria for the diagnosis of GDM have serious resource implications for maternity services provided to the large number of women attending for care in developed countries. Further consideration needs to be given as to whether obese women with mild hyperglycemia need to be referred to a multidisciplinary team antenatally if they do not require insulin treatment.

Extreme macrosomia--obstetric outcomes and complications in birthweights >5000 g.

OBJECTIVE: Management of extremely large birthweight infants presents challenges during the period of labour and delivery. We sought to examine outcomes in infants with extreme macrosomia (birthweight > 5000 g), at an institution where the management of labour is standardised. MATERIALS AND METHODS: This is a retrospective analysis of prospectively gathered data on all infants with a birthweight >5000 g delivered at a tertiary level institution from 2008 to 2012. Details of labour characteristics and outcomes were examined; these were compared according to parity. RESULTS: During the study period, there were 46 128 deliveries at the hospital and 182 infants with a birthweight >5000 g, giving an incidence of 0.4%. The majority of women (133/182) were multiparous. Among nulliparas, 47% (23/49) had a vaginal delivery, while 53% (26/49) had a caesarean delivery. 86% (97/113) of multiparas had a vaginal delivery, and 14% (16/113) had a caesarean delivery. 43% (69/162) required induction of labour. This was more common in nulliparous compared with multiparous women (58% [29/49] vs 30% [40/133], P = 0.005, OR = 3.4, 95% CI = 1.7-6.6). A total of 30% (49/162) of women had their labour accelerated with oxytocin. There were higher rates of oxytocin use in nulliparas than in multiparas (55% [27/49] vs 16.5% [22/133], P < 0.0001, OR = 6.2, 95% CI = 3-12.8). Seventeen of the 120 infants delivered vaginally had a shoulder dystocia (14.2%), with three suffering an Erbs palsy, all of which had resolved before 6 months of age. One baby had a clavicular fracture. CONCLUSION: Extreme macrosomia affects 0.4% of pregnancies in contemporary practice. Multiparas have a low rate of caesarean section. Infants delivered vaginally are at increased risk of shoulder dystocia and associated complications.

Large loop excision of the transformation zone and preterm delivery over a decade in a major women's hospital.

BACKGROUND: The success of cervical screening relies on assessment and treatment of pre-malignant disease. Large loop excision of the transformation zone (LLETZ) has been the mainstay of treatment for cervical intraepithelial neoplasia (CIN). Preterm delivery (PTD) in subsequent pregnancy is a long-term complication of the intervention. AIMS: To describe the characteristics of women who had LLETZ treatment(s) followed by PTD in the Rotunda Hospital over a 10-year period. METHODS: The pathology and the obstetric databases were searched to identify women who had LLETZ followed by PTD from 1 January 2007-31 December 2016. Details including gestation at delivery, depth of LLETZ and grade of CIN were extracted. Exclusion criteria included multiple pregnancy, and deliveries due to current pregnancy indications. RESULTS: There were 97 women eligible for inclusion. Mean gestation at delivery was 33+2 weeks. CIN 1 was diagnosed in 16, CIN 2 in 24, CIN 3 in 53, and four were negative for CIN. No microinvasive or invasive disease was identified. The average depth of excision was 9.9 mm, 11.4 mm and 8.5 mm for CIN 1, 2 and 3, respectively. The difference in depth between excisions with CIN 2 and 3 was significant (p = 0.019). CONCLUSIONS: Despite having a lower mean depth of excision, women with CIN 3 comprised the majority of those who experienced PTD, suggesting that factors other than mechanical weakness are implicated in PTD for these women. This is in keeping with recent suggestions that the common denominator in high grade CIN and PTD is an altered vaginal microbiome.

Radiosurgical Ablation of the Renal Nerve in a Porcine Model: A Minimally Invasive Therapeutic Approach to Treat Refractory Hypertension.

BACKGROUND: Hypertension is strongly associated with cardiovascular diseases such as heart failure, stroke, kidney disease, and has been correlated with an increased risk for heart attack. Current treatment regimens for hypertension are highly inadequate, with reports indicating that only 50.1% of the clinical population with the disease has their blood pressure under control. OBJECTIVE: To study the feasibility of using minimally invasive radiosurgery to ablate the renal nerves as a novel treatment for refractory hypertension, and to assess the safety and efficacy of such an approach. METHODS: A Hanford porcine (miniswine) model (N = 6) was used to investigate the feasibility of using the CyberHeart radiosurgical platform (CyberHeart Inc., Mountain View, CA, USA) to create safe renal nerve ablations. Norepinephrine (NE) levels were measured pre and post treatment. Additionally, renal nerve and arterial histology were studied to examine effect. RESULTS: Plasma norepinephrine levels showed a decrease over the six-month time point. Urea, nitrogen, and creatinine levels showed no changes post procedure. Histology documented no significant arterial injury in targeted areas. Renal nerves documented histologic change consistent with nerve ablation. CONCLUSION: CyberHeart radiosurgery of the renal nerve is feasible and resulted in norepinephrine reduction and renal nerve injury consistent with radiosurgical targeted ablation.

The clinical outcomes of unplanned pregnancy in severely obese women.

OBJECTIVE: The objective of this study was to compare the clinical outcomes of unplanned pregnancies among severely obese women with those of planned pregnancies. METHODS: This prospective cohort study included severely obese women (Body Mass Index [BMI] ≥ 40.0 kg/m(2)) who delivered a baby weighing ≥ 500 g over 5 years 2009-2013 in a large university hospital. Maternal weight and height were measured and BMI was calculated at the first prenatal visit. RESULTS: Of the 650 women, the mean BMI was 43.8 kg/m(2), mean age was 31.6 years, and 30.0% (n = 195) were nulliparous. Prenatal complications including gestational diabetes mellitus (GDM), hypertensive and thromboembolic disorders occurred in 56.6% (n = 368). Compared with planned pregnancies (58.2%, n = 378), those that were unplanned (41.8%, n = 272) were associated with increased prepregnancy risk factors including essential hypertension (4.0% versus 1.6%, p = 0.03) and depression (6.6% versus 3.2%, p = 0.03). Unplanned pregnancy was associated with a higher macrosomia rate (birthweight > 4.5 kg) compared with planned pregnancies (p = 0.03). This was not explained by a higher GDM rate in unplanned pregnancies. Compared with planned pregnancies, unplanned pregnancies were not associated with increased adverse fetomaternal outcomes. CONCLUSION: Despite increased prepregnancy risk factors, in severely obese women, unplanned pregnancies were not associated with increased prenatal complications or adverse pregnancy outcomes compared with planned pregnancies.

Stereotactic Arrhythmia Radioablation (STAR) of Ventricular Tachycardia: A Treatment Planning Study.

PURPOSE: The first stereotactic arrhythmia radioablation (STAR) of ventricular tachycardia (VT) was delivered at Stanford on a robotic radiosurgery system (CyberKnife® G4) in 2012. The results warranted further investigation of this treatment. Here we compare dosimetrically three possible treatment delivery platforms for STAR. METHODS: The anatomy and target volume of the first treated patient were used for this study. A dose of 25 Gy in one fraction was prescribed to the planning target volume (PTV). Treatment plans were created on three treatment platforms: CyberKnife® G4 system with Iris collimator (Multiplan, V. 4.6)(Plan #1), CyberKnife® M6 system with InCise 2(TM) multileaf collimator (Multiplan V. 5.3)(Plan #2) and Varian TrueBeam(TM) STx with HD 120(TM) MLC and 10MV flattening filter free (FFF) beam (Eclipse planning system, V.11) (Plan #3 coplanar and #4 noncoplanar VMAT plans). The four plans were compared by prescription isodose line, plan conformity index, dose gradient, as well as dose to the nearby critical structures. To assess the delivery efficiency, planned monitor units (MU) and estimated treatment time were evaluated. RESULTS: Plans #1-4 delivered 25 Gy to the PTV to the 75.0%, 83.0%, 84.3%, and 84.9% isodose lines and with conformity indices of 1.19, 1.16, 1.05, and 1.05, respectively. The dose gradients for plans #1-4 were 3.62, 3.42, 3.93, and 3.73 with the CyberKnife® MLC plan (Plan #2) the best, and the TrueBeam(TM) STx co-planar plan (Plan #3) the worst. The dose to nearby critical structures (lung, stomach, bowel, and esophagus) were all well within tolerance. The MUs for plans #1-4 were 27671, 16522, 6275, and 6004 for an estimated total-treatment-time/beam-delivery-time of 99/69, 65/35, 37/7, and 56/6 minutes, respectively, under the assumption of 30 minutes pretreatment setup time. For VMAT gated delivery, a 40% duty cycle, 2400MU/minute dose rate, and an extra 10 minutes per extra arc were assumed. CONCLUSION: Clinically acceptable plans were created with all three platforms. Plans with MLC were considerably more efficient in MU. CyberKnife® M6 with InCise 2(TM) collimator provided the most conformal plan (steepest dose drop-off) with significantly reduced MU and treatment time. VMAT plans were most efficient in MU and delivery time. Fluoroscopic image guidance removes the need for additional fiducial marker placement; however, benefits may be moderated by worse dose gradient and more operator-dependent motion management by gated delivery.

Evaluation of the systemic inflammatory response syndrome criteria for the diagnosis of sepsis due to maternal bacteremia.

OBJECTIVE: To examine, in the setting of maternal bacteremia, the implications for the diagnosis of maternal sepsis of customizing the systemic inflammatory response syndrome (SIRS) criteria for physiologic changes of pregnancy. METHODS: Women with maternal bacteremia in a tertiary maternity hospital during 2009-2014 were identified. Records were retrospectively reviewed to determine whether they fulfilled the criteria for diagnosis of sepsis based on either the standard SIRS parameters derived from the Surviving Sepsis Campaign or SIRS parameters customized for pregnancy. Diagnosis of sepsis was based on the presence of two or more SIRS criteria, in conjunction with infection, during the hour before and the 6 hours after phlebotomy for blood culture. RESULTS: Of 93 women with bacteremia, 61 (66%) would have been diagnosed with sepsis based on standard criteria compared with 52 (56%) based on customized criteria (P=0.18). Seventeen women had a diagnosis of sepsis based on the standard but not the customized criteria, while eight women had sepsis based on the customized but not the standard criteria. CONCLUSION: In maternal bacteremia, customized SIRS criteria do not increase the rate of diagnosis of sepsis. Prospective studies should investigate whether the introduction of customized SIRS criteria can improve clinical outcomes.

Evaluation of point-of-care maternal venous lactate testing in normal pregnancy.

OBJECTIVE: There is little information about whether the established non-pregnant adult venous lactate reference range is appropriate for pregnancy. This prospective observational study examined whether the non-pregnant adult reference range is appropriate during pregnancy. METHODS: Women attending for routine prenatal appointments or elective cesarean delivery in a tertiary hospital were recruited. Clinical details were recorded and venous lactate concentration was measured using a point-of-care (POC) device. RESULTS: Of the 246 women, 199 were 6-18 weeks' gestation and 47 were 36-42 weeks' gestation. Mean lactate concentration was within the non-pregnant reference range in early and late pregnancy (0.86 SD ± 0.46 mmol/L and 1.15 SD ± 0.40 mmol/L, respectively). The mean time between phlebotomy and result was 6.1 SD ± 1.7 min. There was no correlation between lactate levels and either maternal age or time interval from tourniquet placement to lactate measurement. In women of 6-18 weeks' gestation positive bivariate relationships were found between lactate and BMI (p = 0.03, r = 0.158), earlier gestational age (p = 0.04, r = -0.145), and smoking (p = 0.01, r = 0.183), but these were not found in late pregnancy. CONCLUSIONS: The venous lactate reference range for the non-pregnant adult may be applied in pregnancy. Further studies should examine lactate dynamics in labor and postpartum.

Maternal C-reactive protein in early pregnancy.

OBJECTIVE: To compare maternal C-reactive protein concentration in the first 18 weeks of pregnancy with the nonpregnant adult reference range. STUDY DESIGN: Serum samples from healthy women with a pregnancy <18 weeks' gestation were retrieved from a Hospital biological resource bank. C-reactive protein was measured using an immunoturbidimetric assay. Clinical and sociodemographic details were retrieved from the Hospital's computerized database. RESULTS: Of the 146 women, 85 (58.2%) were nulliparous, 11 (7.5%) were smokers and 22 (15.1%) were obese. Mean gestational age at phlebotomy was 12.5 (range 8.1-17.4) weeks. Median C-reactive protein was 3.2 (interquartile range 0.3-12.1)mg/L. There were 74 women (50.7%) with C-reactive protein level >3.0mg/L which is above the nonpregnant adult reference range. C-reactive protein levels were positively correlated with increasing Body Mass Index. No relationship was found between C-reactive protein and age, smoking or gestational age. CONCLUSION: C-reactive protein concentration in a well-characterized population in early pregnancy was higher than that cited for the nonpregnant adult, and C-reactive protein was positively associated with Body Mass Index. Therefore, caution is needed in the use and interpretation of C-reactive protein measurements in early pregnancy to avoid unnecessary interventions in women with suspected illness.

Maternal bacteremia and the Irish maternity early warning system.

OBJECTIVE: To assess whether introduction of the Irish maternity early warning system (IMEWS) in 2013 has improved the recording of vital signs among women with proven maternal bacteremia. METHODS: In a mixed retrospective and prospective study at a single center in Dublin, Ireland, the patient records of all cases of maternal bacteremia between January 1, 2009, and March 31, 2014, were reviewed. The IMEWS chart was applied retrospectively to records of vital signs from January 2009 to March 2013, and prospectively from April 2013 to March 2014. RESULTS: For the 61 cases from the period before IMEWS introduction, vital signs were recorded inconsistently on multiple pages. The frequency of recordings was not standardized. Respiratory rate, in particular, was under-recorded. Among the 17 cases between April 2013 and March 2014 that were eligible for IMEWS chart use, 14 women had vital signs recorded on an IMEWS chart. As compared with the period before IMEWS introduction, there was an improvement in respiratory rate recording as part of the first set of observations. CONCLUSION: Among pregnant women with proven bacteremia, introduction of IMEWS has been associated with an improvement in the recording of vital signs, particularly respiratory rate.