A Simulation Study of the Factors Influencing the Risk of Intraoperative Slipping

AbstractBackgroundTo identify the impact of weight, table surface, and table type on slipping in a simulation of minimally invasive gynecologic surgery.MethodsA mannequin was placed into increasing Trendelenburg until a slip was observed; the table angle at the time of the event was measured (slip angle). The influence of mannequin position (supine vs. lithotomy), weight, table surface, and model was evaluated. A linear regression model was used to analyze the data.ResultsMannequin weight, bed surface, and bed type all significantly impacted the slip angles. In general, higher mannequin weights tolerated significantly more Trendelenburg before slipping in the supine position but less in lithotomy compared to lower weights. In lithotomy, the disposable sheet and gelpad performed worse than the bean bag, egg crate foam, and bedsheet. There was no difference in slipping because of bed surface in the supine model. The Skytron operating table performed significantly better than the Steris operating table when tested with the bedsheet.ConclusionOperative position, patient weight, and bed surface together influence the slipping propensity. In lithotomy, heavier patients were more prone to slipping while the inverse was true in supine. The egg crate foam, bean bag, and bedsheet were the best antislip surfaces. Operating room table choice can mitigate slippage

Adverse Impact of a History of Violence for Women with Breast, Cervical, Endometrial, or Overian Cancer

The experience of physical and sexual violence (victimization) is common among U.S. women and is associated with adverse health consequences. The study objectives were to estimate the prevalence of victimization in women with cancer and to examine associations with demographics, cancer screening, and cancer stage. METHODS: From 2004 to 2005, 101 women with breast, cervical, endometrial, or ovarian cancer were interviewed to collect demographics, cancer screening history, health care access/use, and violence history. Chisquare and Fisher exact tests were used test risk-factor associations. A multinomial logistic regression model was used for multivariable analysis. RESULTS: The prevalence of a history of violence was 48.5% (49/101 women), and within that group, 46.9% (23/49) had a positive childhood violence screen, 75.5% (37/49) had a positive adult screen, and 55% (27/49) reported sexual violence at any age. Women with a positive violence screen differed significantly from women with a negative screen in that they were younger (P .031), more often divorced (P.012), more likely to smoke (P.010), more often lacked commercial insurance (P.036), and had more advanced stage of disease (P.013), but they did not differ with regard to race, cancer type, education level, alcohol or drug use, or cancer screening compliance. Multivariable analysis revealed that only stage remained significant; women with a history of violence had a 2.6-fold increased chance of diagnosis in later stages (odds ratio 2.61, 95% confidence interval 1.03– 6.59). CONCLUSION: A history of violence in breast, ovarian, endometrial, and ovarian cancer patients was extremely common and correlated with advanced stage at diagnosis

Serous Tubal Intraepithelial Carcinoma: An Incidental Finding at the Time of Prophylactic Bilateral Salpingo-Oophorectomy

Background. Serous tubal intraepithelial carcinoma (STIC) is a precursor lesion for high-grade pelvic serous carcinoma. The incidence of STIC is estimated to occur in 0.6% to 6% of women who are BRCA positive or have a strong family history of breast or ovarian cancer. Case. A 56-year-old woman underwent robotic-assisted sacrocolpopexy, rectocele repair, and concurrent bilateral salpingo-oophorectomy for recurrent stage 3 pelvic organ prolapse and reported family history of ovarian cancer. Histopathologic examination of her left fallopian tube revealed STIC. Conclusion. We report this rare occurrence of STIC in a patient undergoing surgery primarily for pelvic organ prolapse and having a family history of ovarian cancer. Possible management options include observation with annual physical exam and CA-125, surgical staging, or empiric chemotherapy. However, due to the lack of consensus regarding management options, referral to a gynecologic oncologist is recommended

Condyloma lata mimicking vulvar carcinoma in an immunocompromised patient: A case report

Background: Syphilis is a sexually transmitted infection with increasing incidence in the United States. Presentations of syphilis vary widely and can be easily mistaken for other diagnoses, including cancer, especially in atypical cases. Case description: At her delivery after no prenatal care, a 35-year-old woman was found to have exophytic vulvar and perianal lesions, inguinal lymphadenopathy, and a new diagnosis of HIV, with a strong clinical concern for vulvar and/or anal carcinoma. She was subsequently diagnosed with presumed late latent syphilis and began weekly intramuscular penicillin G benzathine treatment. CT imaging demonstrated a perineal plaque-like area with bilateral inguinal, external iliac and retroperitoneal lymphadenopathy. She was seen in gynecologic oncology clinic one week after her initial presentation with notable improvement in the vulvar lesions, raising suspicion for condyloma lata rather than invasive or preinvasive disease on the vulva, however concern remained for dysplasia in the perianal lesion. Another week later, she underwent an exam under anesthesia with vulvar and perianal biopsies revealing chronic inflammation and granulomatous change without evidence of malignancy or dysplasia. At the four week post operative visit, there was almost complete resolution of the lesions. Conclusion: Syphilis should be considered in the differential diagnosis of atypical vulvar lesions

Endometrial cancer in an increasingly obese population: Exploring alternative options when surgery may not cut it

Objectives: The study objectives were to describe outcomes of obese patients with early endometrial cancer following primary non-surgical treatment, assess predictors of response, and estimate the increased surgical risk for these women. Methods: Retrospective chart review identified women with early stage endometrial cancer at a single institution with BMI ≥ 30 kg/m2 who did not undergo surgery as primary treatment modality due to obesity and medical co-morbidities. Clinicopathologic factors were abstracted, characteristics of responders vs. non-responders compared and the National Surgical Quality Improvement Program (NSQIP) surgical risk calculator utilized to quantify surgical risks. Results: Fifty-one patients were identified, with a mean BMI of 49.0 kg/m2. The NSQIP calculator predicted a significantly higher complication rate for our cohort compared to the expected average risk for hysterectomy (18.8% vs 7.2%, p < .0001). The majority of patients were treated with radiation alone (49%), followed by hormone therapy (45.1%). Response rates were 38.1% for women treated with hormones and 63.6% in the radiation group (p = .063). No significant differences were identified between responders and non-responders with regard to NSQIP scores, BMI, co-morbidities or age. Among those with persistent or progressive disease, 87.5% responded to secondary treatment. Only one death was from cancer progression. Two individuals died following treatment complications (one surgical, one chemotherapy); the remaining twelve deaths were due to pre-existing co-morbidities. Conclusions: Hormone and radiation therapy are both viable options for obese patients deemed to have too significant risk of surgical complications. Pursuing surgical intervention in this population may do more harm than good. Keywords: Obesity, Endometrial cancer, Hormonal therapy, Medically inoperable, NSQI

Post Approval Human Papillomavirus Vaccine Uptake Is Higher in Minorities Compared to Whites in Girls Presenting for Well-Child Care

Since introduction of the human papillomavirus (HPV) vaccine, there remains low uptake compared to other adolescent vaccines. There is limited information postapproval about parental attitudes and barriers when presenting for routine care. This study evaluates HPV vaccine uptake and assesses demographics and attitudes correlating with vaccination for girls aged 11–12 years. A prospective cohort study was performed utilizing the University of Virginia (UVA) Clinical Data Repository (CDR). The CDR was used to identify girls aged 11–12 presenting to any UVA practice for a well-child visit between May 2008 and April 2009. Billing data were searched to determine rates of HPV vaccine uptake. The parents of all identified girls were contacted four to seven months after the visit to complete a telephone questionnaire including insurance information, child’s vaccination status, HPV vaccine attitudes, and demographics. Five hundred and fifty girls were identified, 48.2% of whom received at least one HPV vaccine dose. White race and private insurance were negatively associated with HPV vaccine initiation (RR 0.72, 95% CI 0.61–0.85 and RR 0.85, 95% CI 0.72–1.01, respectively). In the follow-up questionnaire, 242 interviews were conducted and included in the final cohort. In the sample, 183 (75.6%) parents reported white race, 38 (15.7%) black race, and 27 (11.2%) reported other race. Overall 85% of parents understood that the HPV vaccine was recommended and 58.9% of parents believed the HPV vaccine was safe. In multivariate logistic regression, patients of black and other minority races were 4.9 and 4.2 times more likely to receive the HPV vaccine compared to their white counterparts. Safety concerns were the strongest barrier to vaccination. To conclude, HPV vaccine uptake was higher among minority girls and girls with public insurance in this cohort

Evaluation of screening and risk-reducing surgery for women followed in a high-risk breast/ovarian cancer clinic: it is all about the tubes in BRCA mutation carriers

The objectives of this study were to determine both surgical and subsequent cancer outcomes for high-risk women from the University of Virginia's High-Risk Breast/Ovarian Cancer clinic undergoing ovarian cancer risk-reducing surgery. Retrospective review identified high risk women who had ovarian risk reducing surgery over the past decade and surgical outcomes, pathology, pre-operative screening results, and pre-/post-operative cancer diagnoses were evaluated. One hundred and eighty-three high-risk women had risk reducing surgery at a mean age of 50.1 years and with a mean BMI of 28.9 kg/m2 at the time of surgery. Most women (103; 56.3%) had a strong family history of cancer concerning for a hereditary syndrome without an identified mutation, 35.5% of women carried a known deleterious mutation and 7.7% of women had a personal history of breast or ovarian cancer. The most common procedure was a risk-reducing bilateral salpingo-oophorectomy with or without hysterectomy (RRBSO, 89.1%). All women underwent the Sectioning and Extensively Examining the Fimbriated End (SEE-FIM) pathology protocol which found two (1.1%) invasive ovarian cancers (one ovarian/tubal carcinosarcoma, one granulosa cell ovarian cancer), three (1.6%) serous tubal intraepithelial carcinomas (STIC), and one (1.1%) invasive fallopian tube cancer. Subsequent cancer diagnoses included one (0.5%) primary peritoneal cancer, four (2.2%) DCIS, and seven (3.8%) invasive breast cancers. Ultimately, among all high-risk women undergoing RR surgery, about 3.3% were diagnosed with a STIC or an ovarian cancer none of which were identified on screening. All STIC and tubal cancers were diagnosed in women with BRCA mutations (6.6% rate for this group). Keywords: BRCA, Risk-reducing surgery, Serous tubal intraepithelial carcinoma, High-risk cance