Managing Caesarean Scar Pregnancy in low Resource Settings: 2 Case Reports and a Description of Transrectal Ultrasound guided Surgical Approach (TRUGA).

Caesarean scar pregnancy (CSP) occurs when an embryo implants in a previous caesarean section scar. It has a reported incidence of 1 in 1800. Various surgical and medical techniques have been described in case reports for the management of CSP. These techniques are usually undertaken in tertiary level units with significant resource availability. In this paper, we present a new clinical perspective for the management of CSP in low resource settings and describe the steps involved in a transrectal ultrasound guided approach with dilatation of uterine cervix and subsequent evacuation of uterine contents (TRUGA with D&C).Keywords: caesarean scar pregnancy, transrectal ultrasound guided surgical approach.RésuméLa grossesse de la cicatrice césarienne (GCC) se produit lorsqu'un implant d'embryon dans une précédente cicatrice césarienne. Il a une incidence déclarée de 1 à 1800. Les techniques chirurgicales et médicales diverses ont été décrites dans les rapports de cas de la gestion du GCC. Ces techniques sont habituellement effectuées dans les unités de niveau supérieur avec la disponibilité des ressources importantes. Dans cet article, nous présentons un nouveau point de vue clinique pour la gestion du GCC dans les milieux à faibles ressources et nous faisons une description des étapes d'une approche guidée des ultrasons transrectaux avec une dilatation du col de l'utérus et l'évacuation éventuelle du contenu utérin (FARR avec D & C). Mots-clés: grossesse de la cicatrice césarienne, approche chirurgicale guidée de l’échographie transrectale

Exploring global barriers to optimal ovarian cancer care:thematic analysis

Objective: To explore the barriers to ovarian cancer care, as reported in the open ended responses of a global expert opinion survey, highlighting areas for improvement in global ovarian cancer care. Potential solutions to overcome these barriers are proposed. Methods: Data from the expert opinion survey, designed to assess the organization of ovarian cancer care worldwide, were analyzed. The survey was distributed across a global network of physicians. We examined free text, open ended responses concerning the barriers to ovarian cancer care. A qualitative thematic analysis was conducted to identify, analyze, and report meaningful patterns within the data. Results: A total of 1059 physicians from 115 countries completed the survey, with 438 physicians from 93 countries commenting on the barriers to ovarian cancer care. Thematic analysis gave five major themes, regardless of income category or location: societal factors, inadequate resources in hospital, economic barriers, organization of the specialty, and need for early detection. Suggested solutions include accessible resource stratified guidelines, multidisciplinary teamwork, public education, and development of gynecological oncology training pathways internationally. Conclusions: This analysis provides an international perspective on the main barriers to optimal ovarian cancer care. The themes derived from our analysis highlight key target areas to focus efforts to reduce inequalities in global care. Future regional analysis involving local representatives will enable country specific recommendations to improve the quality of care and ultimately to work towards closing the care gap

Exploring international differences in ovarian cancer care: a survey report on global patterns of care, current practices, and barriers

OBJECTIVE: Although global disparities in survival rates for patients with ovarian cancer have been described, variation in care has not been assessed globally. This study aimed to evaluate global ovarian cancer care and barriers to care. METHODS: A survey was developed by international ovarian cancer specialists and was distributed through networks and organizational partners of the International Gynecologic Cancer Society, the Society of Gynecologic Oncology, and the European Society of Gynecological Oncology. Respondents received questions about care organization. Outcomes were stratified by World Bank Income category and analyzed using descriptive statistics and logistic regressions. RESULTS: A total of 1059 responses were received from 115 countries. Respondents were gynecological cancer surgeons (83%, n=887), obstetricians/gynecologists (8%, n=80), and other specialists (9%, n=92). Income category breakdown was as follows: high-income countries (46%), upper-middle-income countries (29%), and lower-middle/low-income countries (25%). Variation in care organization was observed across income categories. Respondents from lower-middle/low-income countries reported significantly less frequently that extensive resections were routinely performed during cytoreductive surgery. Furthermore, these countries had significantly fewer regional networks, cancer registries, quality registries, and patient advocacy groups. However, there is also scope for improvement in these components in upper-middle/high-income countries. The main barriers to optimal care for the entire group were patient co-morbidities, advanced presentation, and social factors (travel distance, support systems). High-income respondents stated that the main barriers were lack of surgical time/staff and patient preferences. Middle/low-income respondents additionally experienced treatment costs and lack of access to radiology/pathology/genetic services as main barriers. Lack of access to systemic agents was reported by one-third of lower-middle/low-income respondents. CONCLUSIONS: The current survey report highlights global disparities in the organization of ovarian cancer care. The main barriers to optimal care are experienced across all income categories, while additional barriers are specific to income levels. Taking action is crucial to improve global care and strive towards diminishing survival disparities and closing the care gap

Exploring global barriers to optimal ovarian cancer care:thematic analysis

Objective: To explore the barriers to ovarian cancer care, as reported in the open ended responses of a global expert opinion survey, highlighting areas for improvement in global ovarian cancer care. Potential solutions to overcome these barriers are proposed. Methods: Data from the expert opinion survey, designed to assess the organization of ovarian cancer care worldwide, were analyzed. The survey was distributed across a global network of physicians. We examined free text, open ended responses concerning the barriers to ovarian cancer care. A qualitative thematic analysis was conducted to identify, analyze, and report meaningful patterns within the data. Results: A total of 1059 physicians from 115 countries completed the survey, with 438 physicians from 93 countries commenting on the barriers to ovarian cancer care. Thematic analysis gave five major themes, regardless of income category or location: societal factors, inadequate resources in hospital, economic barriers, organization of the specialty, and need for early detection. Suggested solutions include accessible resource stratified guidelines, multidisciplinary teamwork, public education, and development of gynecological oncology training pathways internationally. Conclusions: This analysis provides an international perspective on the main barriers to optimal ovarian cancer care. The themes derived from our analysis highlight key target areas to focus efforts to reduce inequalities in global care. Future regional analysis involving local representatives will enable country specific recommendations to improve the quality of care and ultimately to work towards closing the care gap

The genomic landscape of balanced cytogenetic abnormalities associated with human congenital anomalies

Despite the clinical significance of balanced chromosomal abnormalities (BCAs), their characterization has largely been restricted to cytogenetic resolution. We explored the landscape of BCAs at nucleotide resolution in 273 subjects with a spectrum of congenital anomalies. Whole-genome sequencing revised 93% of karyotypes and demonstrated complexity that was cryptic to karyotyping in 21% of BCAs, highlighting the limitations of conventional cytogenetic approaches. At least 33.9% of BCAs resulted in gene disruption that likely contributed to the developmental phenotype, 5.2% were associated with pathogenic genomic imbalances, and 7.3% disrupted topologically associated domains (TADs) encompassing known syndromic loci. Remarkably, BCA breakpoints in eight subjects altered a single TAD encompassing MEF2C, a known driver of 5q14.3 microdeletion syndrome, resulting in decreased MEF2C expression. We propose that sequence-level resolution dramatically improves prediction of clinical outcomes for balanced rearrangements and provides insight into new pathogenic mechanisms, such as altered regulation due to changes in chromosome topology

Intraoperative frozen section of ovarian tumors : a 6-year review of performance and potential pitfalls in an Australian Tertiary Referral Center

Objectives Intraoperative frozen section (IFS) offers a rapid test to guide the extent of surgery, which is essential for optimal treatment of ovarian cancer. This study evaluated the diagnostic performance and influence of IFS in the surgical management of ovarian tumors. Methods A retrospective review was conducted of IFS of adnexal lesions from 2008 to 2013, with diagnoses classified as benign, borderline, or malignant. The diagnostic performance of IFS was calculated, with a focus on primary epithelial tumors. In discordant cases, it was determined whether the results of the IFS influenced the nature of the primary surgery. Results There were 277 consecutive cases over the study period. The overall sensitivity for diagnosing malignant disease was 75.9% and the specificity was 100%. With a benign IFS result, there was a 6.25% (9/144) chance that the final diagnosis would be malignant, and a 7.6% (11/144) chance that the final diagnosis would be borderline, resulting in the potential for understaging. The predictive values for benign, borderline, and malignant IFS results were 86.1%, 66.6%, and 100%, respectively. For a borderline IFS result, there was a 33.3% chance that the final diagnosis would be malignant disease, and this was higher in older patients (53.3%). There were no instances of overdiagnosis in this series. Of 37 cases underdiagnosed, 19 received incomplete primary staging surgery guided by the IFS, and most of these were mucinous tumors. Conclusions Intraoperative frozen section is most valuable for its high specificity in diagnosing malignancy. It should be interpreted with caution in borderline tumors, particularly in older patients and in mucinous tumors. Overdiagnosis did not occur in this series; however, in younger patients, the limitations of IFS must be considered before surgery that would result in loss of fertility

Follow-up after treatment of high-grade cervical dysplasia : the utility of six-month colposcopy and cytology and routine 12-month colposcopy

Background: Australian Cervical Screening Program guidelines no longer recommend colposcopy and cytology at six months following treatment of cervical intraepithelial neoplasia (CIN2/3) and a co-test of cure can be performed at 12 months without colposcopy. Aims: To determine the usefulness of six-month colposcopy and cytology and routine colposcopy with co-testing at 12 months in detecting persistent or recurrent disease in patients treated for CIN2/3. Materials and Methods: We conducted a review of all patients with histologically proven CIN2/3 who underwent a cervical excisional procedure between March 2012 and March 2017 in one specialised centre. Results: We examined 1215 cases and 750 remained after exclusions for analysis. At six months (722 cases, 96.2%) seven of 42 (16.7%) patients with high-grade cytology had a high-grade colposcopy and 24 of 42 (57.1%) had a normal colposcopy. Persistent CIN2/3 was diagnosed in 12 cases (1.7%) and only 1/3 had a high-grade colposcopy. Cytology was more useful than colposcopy in detecting persistent disease. At 12 months (638 cases, 85%) routine colposcopy at the time of co-testing had a high false positive rate with all high-grade changes negative on biopsy and co-test. Recurrent CIN2/3 was diagnosed in five cases, and four had normal colposcopy at co-testing. Conclusions: There may be a delay in detection of persistent/recurrent CIN2/3 in a small number of cases without six-month colposcopy and cytology; however, it is not likely to negatively impact overall clinical outcome. Co-testing at 12 months following treatment of CIN2/3 without colposcopy is safe and routine colposcopy at collection of the co-test can be omitted

The impact of primary human papillomavirus screening on negative loop excision histology following biopsy-proven high-grade cervical intra-epithelial lesions : a review from a large tertiary colposcopy unit

Background: The renewed National Cervical Screening Program incorporating primary human papillomavirus (HPV) screening was implemented in Australia in December 2017. In a previous study conducted in the UK, primary HPV screening was found to be associated with a 25% reduction in the incidence of negative histology following loop electrosurgery excision procedure (LEEP). Aim: To examine the change in incidence and associated risk factors for a negative LEEP with introduction of primary HPV screening. Materials and Methods: A retrospective review of the records of all patients undergoing a LEEP excision for biopsy-proven high-grade cervical intra-epithelial lesions between 1 January 2014 and 30 June 2019 in a specialised centre. Results: There were 1123 patients who underwent a LEEP included in the analysis. The incidence of a negative LEEP specimen was 7.5% (59/784) and 5.3% (18/339) in the pre- and post-HPV screening cohort. More patients in the post-HPV screening group had low-grade cytology on referral (P < 0.001), smaller cervical lesions on colposcopy (P = 0.012) and longer biopsy to treatment interval (P = 0.020). Primary HPV screening was associated with a significant reduction in the incidence of a negative LEEP specimen in a propensity matched cohort (11.2% to 5.1%, P = 0.006) and a 41% (P = 0.045) decreased relative risk of a negative LEEP on multivariate analysis. Conclusions: Primary HPV screening results in a lower incidence of negative LEEP histology, despite a longer biopsy to treatment wait time and higher proportion of low-grade cytology at triage

Cutpoints for screening blood glucose concentrations in healthy senior cats

Objectives The objectives of this study were to determine the reference interval for screening blood glucose in senior cats, to apply this to a population of obese senior cats, to compare screening and fasting blood glucose, to assess whether screening blood glucose is predicted by breed, body weight, body condition score (BCS), behaviour score, fasting blood glucose and/or recent carbohydrate intake and to assess its robustness to changes in methodology. Methods The study included a total of 120 clinically healthy client-owned cats aged 8 years and older of varying breeds and BCSs. Blood glucose was measured at the beginning of the consultation from an ear/paw sample using a portable glucose meter calibrated for cats, and again after physical examination from a jugular sample. Fasting blood glucose was measured after overnight hospitalisation and fasting for 18-24 h. Results The reference interval upper limit for screening blood glucose was 189 mg/dl (10.5 mmol/l). Mean screening blood glucose was greater than mean fasting glucose. Breed, body weight, BCS, behaviour score, fasting blood glucose concentration and amount of carbohydrate consumed 2-24 h before sampling collectively explained only a small proportion of the variability in screening blood glucose. Conclusions and relevance Screening blood glucose measurement represents a simple test, and cats with values from 117-189 mg/dl (6.5-10.5 mmol/l) should be retested several hours later. Cats with initial screening blood glucose >189 mg/dl (10.5 mmol/l), or a second screening blood glucose >116 mg/dl (6.4 mmol/l) several hours after the first, should have fasting glucose and glucose tolerance measured after overnight hospitalisation

Cesarean delivery: Trend in indications over three decades within a major city hospital network

Introduction: The cesarean delivery rate has been increasing globally in recent decades. The reasons for this are complex and subject to ongoing debate. Investigation of the indications for cesarean delivery and how these have changed over an extended period of time could provide insight into the reasons for changing obstetric practice. Our objective was to explore contributing factors to the increasing rate of cesarean delivery by examining the incidence of and indications for cesarean delivery over the past three decades at our institutions. Material and methods: We conducted a retrospective observational study of all cesarean deliveries, from 24 weeks’ gestational age onwards, within an inner-city hospital network in Sydney, Australia, between August 1989 and December 2016. The primary outcome measures were the rates of and indications for emergency and planned cesarean delivery. We also examined our data within the Robson 10-Group Classification system. Results: There were 147 722 births over the study period, with 37 309 cesarean deliveries for an overall rate of 25.3%. The rate of cesarean delivery increased from 18.7% in 1989-1994 (8.7% emergency, 10% planned) to 30.4% in 2010-2016 (11.4% emergency, 19% planned). Emergency cesarean delivery for slow progress increased from 3.4% to 5.5% of all births (a relative increase of 62%) and other emergency cesareans mainly performed for suspected intrapartum fetal compromise increased from 5.2% to 5.6% (a relative increase of 8%). Previous uterine surgery (predominantly cesarean section) was the largest contributor to the increase in planned procedures from 3.8% to 9.0% of all births, and 29% of all cesarean deliveries. Primary cesarean delivery for planned antenatal fetal indications, previous pregnancy problems, multiple gestation and maternal choice all increased substantially in combined rate from 0.7% to 4.9%. Cesarean rates in Robson groups 6, 7 and 8 (term breech and multiple gestations) increased most over time. Conclusions: The increased rate of cesarean delivery is mainly attributable to a greater number of procedures performed for slow progress in labor, breech presentation or repeat cesarean section