Peritoneal Dissemination Complicating Morcellation of Uterine Mesenchymal Neoplasms

Background: Power morcellation has become a common technique for the minimally invasive resection of uterine leiomyomas. This technique is associated with dissemination of cellular material throughout the peritoneum. When morcellated uterine tumors are unexpectedly found to be leiomyosarcomas or tumors with atypical features (atypical leiomyoma, smooth muscle tumor of uncertain malignant potential), there may be significant clinical consequences. This study was undertaken to determine the frequency and clinical consequence of intraperitoneal dissemination of these neoplasms. Methodology/principal findings: From 2005–2010, 1091 instances of uterine morcellation were identified at BWH. Unexpected diagnoses of leiomyoma variants or atypical and malignant smooth muscle tumors occurred in 1.2% of cases using power morcellation for uterine masses clinically presumed to be “fibroids” over this period, including one endometrial stromal sarcoma (ESS), one cellular leiomyoma (CL), six atypical leiomyomas (AL), three smooth muscle tumor of uncertain malignant potential (STUMPs), and one leiomyosarcoma (LMS). The rate of unexpected sarcoma after the laparoscopic morcellation procedure was 0.09%, 9-fold higher than the rate currently quoted to patients during pre-procedure briefing, and this rate may increase over time as diagnostically challenging or under-sampled tumors manifest their biological potential. Furthermore, when examining follow-up laparoscopies, both from in-house and consultation cases, disseminated disease occurred in 64.3% of all tumors (zero of one ESS, one of one CL, zero of one AL, four of four STUMPs, and four of seven LMS). Only disseminated leiomyosarcoma, however, was associated with mortality. Procedures are proposed for pathologic evaluation of morcellation specimens and associated follow-up specimens. Conclusions/significance: While additional study is warranted, these data suggest uterine morcellation carries a risk of disseminating unexpected malignancy with apparent associated increase in mortality much higher than appreciated currently

Poliovirus Protein 3AB Displays Nucleic Acid Chaperone and Helix-Destabilizing Activities

Poliovirus protein 3AB displayed nucleic acid chaperone activity in promoting the hybridization of complementary nucleic acids and destabilizing secondary structure. Hybridization reactions at 30°C between 20- and 40-nucleotide RNA oligonucleotides and 179- or 765-nucleotide RNAs that contained a complementary region were greatly enhanced in the presence of 3AB. The effect was nonspecific as reactions between DNA oligonucleotides and RNA or DNA templates were also enhanced. Reactions were optimal with 1 mM MgCl(2) and 20 mM KCl. Analysis of the reactions with various 3AB and template concentrations indicated that enhancement required a critical amount of 3AB that increased as the concentration of nucleic acid increased. This was consistent with a requirement for 3AB to “coat” the nucleic acids for enhancement. The helix-destabilizing activity of 3AB was tested in an assay with two 42-nucleotide completely complementary DNAs. Each complement formed a strong stem-loop (ΔG = −7.2 kcal/mol) that required unwinding for hybridization to occur. DNAs were modified at the 3′ or 5′ end with fluorescent probes such that hybridization resulted in quenching of the fluorescent signal. Under optimal conditions at 30°C, 3AB stimulated hybridization in a concentration-dependent manner, as did human immunodeficiency virus nucleocapsid protein, an established chaperone. The results are discussed with respect to the role of 3AB in viral replication and recombination

Monitoring the safety of COVID-19 vaccines in pregnancy in the US

Pregnant persons are at increased risk of severe illness from COVID-19. The first COVID-19 vaccines in the U.S. were authorized for emergency use in December 2020 and pregnant persons were eligible and could get vaccinated despite scarce safety data in this population. To monitor the safety of COVID-19 vaccination during pregnancy, four surveillance systems are used by the Centers for Disease Control and Prevention (CDC). The Vaccine Adverse Event Reporting System is a national, passive system that captures reports of potential adverse events. V-safe is a novel, active system that uses text messaging and web-based surveys to provide health check-ins after vaccination; and enrolls eligible v-safe participants in the v-safe pregnancy registry. The Vaccine Safety Datalink is a collaboration between the CDC and nine integrated health care organizations which performs near-real time surveillance and traditional epidemiologic studies on pregnant vaccine recipients. The CDC is committed to timely and comprehensive monitoring of COVID-19 vaccine safety in pregnancy

Dissemination and use of WHO family planning guidance and tools: a qualitative assessment

Abstract Background As countries continue to improve their family planning (FP) programmes, they may draw on WHO’s evidence-based FP guidance and tools (i.e. materials) that support the provision of quality FP services. Methods To better understand the use and perceived impact of the materials and ways to strengthen their use by countries, we conducted qualitative interviews with WHO regional advisors, and with stakeholders in Ethiopia and Senegal who use WHO materials. Results WHO uses a multi-faceted strategy to directly and indirectly disseminate materials to country-level decision-makers. The materials are used to develop national family planning guidelines, protocols and training curricula. Participants reported that they trust the WHO materials because they are evidence based, and that they adapt materials to the country context (e.g. remove content on methods not available in the country). The main barrier to the use of national materials is resource constraints. Conclusions Although the system and processes for dissemination work, improvements might contribute to increased use of the materials. For example, providers may benefit from additional guidance on how to counsel women with characteristics or medical conditions where contraceptive method eligibility criteria do not clearly rule in or rule out a method

Zika Pregnancy Surveillance: Transforming Data into Educational and Clinical Tools

ObjectiveTo describe how Zika virus (Zika) surveillance data informs and improves testing guidance, clinical evaluation and management of pregnant women and infants with possible Zika infectionIntroductionLittle was known about the maternal and fetal/infant effects of Zika infection before the 2015 outbreak in the Americas, which made it challenging for public health practitioners and clinicians to care for pregnant women and infants exposed to Zika. In 2016, CDC implemented a rapid surveillance system, the US Zika Pregnancy and Infant Registry, to collect information about the impact of Zika infection during pregnancy and inform the CDC response and clinical guidance. In partnership with state, tribal, local, and territorial health departments, CDC disseminated information from this surveillance system, which served as the foundation for educational materials and clinical tools for healthcare providers.MethodsThroughout the Zika response, CDC worked closely with health officers, epidemiologists, and clinical partners to seek expert input on the interpretation of emerging data and the evaluation and management of these vulnerable populations. In response to requests from clinical and public health partners, CDC created targeted educational materials and tools to facilitate the implementation of clinical guidance. These materials equipped healthcare providers with the information needed to care for pregnant women and infants with Zika infection. Examples of products developed included: 1) screening tools to identify pregnant women for whom testing is indicated; 2) an interactive web tool to assist with implementation and interpretation of Zika testing guidance (Pregnancy and Zika Testing Widget); 3) patient counseling scripts; and 4) videos to explain critical clinical concepts (e.g., measurement of infant head circumference). These tools were informally pre-tested with the target audiences prior to dissemination, specifically to assess usefulness in clinical settings. CDC disseminated these tools through the CDC website and through comprehensive outreach (e.g., webinars, calls, email alerts) to various audiences. Additionally, several professional organizations incorporated these tools into regular communication with their membership.ResultsThe US Zika Pregnancy and Infant Registry is currently monitoring infants from approximately 7,300 pregnancies in the US states and territories with laboratory evidence of Zika. Surveillance data provided valuable information, including clues toward the pattern of defects and other neurologic disabilities associated with congenital Zika infection, estimates of the risks associated with congenital infection, and timeframes of greatest risk during pregnancy, to help clinicians counsel pregnant patients with potential Zika exposure. CDC used these data to inform their clinical tools, particularly in pretest counseling materials and educational factsheets for healthcare providers to use with pregnant women with potential Zika exposure.After informal testing among healthcare providers, the tools received positive feedback regarding usefulness and applicability in clinical settings. Collectively, CDC’s Zika clinical tools were downloaded more than 300,000 times from CDC’s website. The Pregnancy and Zika Testing Widget was accessed and followed to an endpoint (e.g., Zika testing recommended) more than 17,000 times, with more than 75% of users self-identifying as clinicians.ConclusionsRapid implementation of Zika surveillance captured evolving data about the impact of Zika on pregnant women and their infants. These data informed the development of clinical tools for healthcare providers caring for and counseling patients with Zika exposure. These tools ensured pregnant women and infants were adequately monitored during the Zika outbreak. Health education materials and clinical tools based on surveillance data should be considered in future emergency responses, particularly when knowledge is rapidly evolving.ReferencesCDC Zika Pregnancy Website: https://www.cdc.gov/pregnancy/zika/materials/index.html

Follow-up exploratory laparoscopy in cases of uterine morcellation with unexpected diagnoses.

<p>Follow-up exploratory laparoscopy in cases of uterine morcellation with unexpected diagnoses.</p

Summary of cases of uterine power morcellation with follow-up exploratory laparotomy.

*<p>Intervals are in months.</p>**<p>Proliferation indices are measured by MiB-1/Ki-67 staining on the most recently sampled clinical material.</p>***<p>While no disseminated disease was identified, residual LMS was identified at the site of the prior hysterectomy. This case is not included in the total number of cases with disseminated disease.</p><p>Abbreviations – Dx: diagnosis; ESS: endometrial stromal sarcoma; CL: cellular leiomyoma; AL: atypical (a.k.a. symplastic) leiomyoma; STUMP: smooth muscle tumor of uncertain malignant potential; LMS: leiomyosarcoma; DPL: disseminated peritoneal leiomyomatosis; LG: low grade; arom: aromatase inhibitor therapy; chemo: classic antineoplastic chemotherapy; rads: radiotherapy.</p

A case of STUMP with peritoneal dissemination (case #11) showing implantation into the omentum.

<p>The primary lesion showed scattered marked nuclear atypia and up to 9 mitoses per 10 high power fields; disseminated lesions showed nuclear pleomorphism and atypia as well as increased proliferation indices (40% by MiB-1/Ki-67 staining), but mitoses were not prominent.</p

Intraoperative images of nodules on the peritoneal surface, suspicious for disseminated tumor.

<p>Intraoperative images of nodules on the peritoneal surface, suspicious for disseminated tumor.</p

Unexpected diagnoses following uterine power morcellation for suspected leiomyoma.

<p>Abbreviations – ESS: endometrial stromal sarcoma; CL: cellular leiomyoma; AL: atypical (a.k.a. symplastic) leiomyoma; STUMP: smooth muscle tumor of uncertain malignant potential; LMS: leiomyosarcoma; n/a: not available.</p