Comparison of CA-125, conventional ultrasound and CT imaging in diagnosis and staging of ovarian cancer correlated with surgico-pathological findings

Background: Preoperative evaluation of suspected ovarian malignancy is of paramount importance and a diagnostic tool with high degree of precision helps treating physician in planning appropriate surgery and also neoadjuvant chemo therapy in candidates who are not currently fit for extensive surgical procedure. Though the ultrasound examination of abdomen and pelvis helps one in detection and characterization of adnexal lesion to some extent, its diagnostic ability is further improved by addition of advanced imaging techniques such as computed tomography, magnetic resonance imaging and thus can prove beneficial in choosing patient for right surgery, there by optimising the treatment outcome. Objective of current study was to compare ultrasonography imaging, CT imaging, CA-125 values, RMI 3 score, surgical staging and histopathological findings in carcinoma ovary.Methods: The study is a prospective observational study, carried out between September 2011 and July 2013, in the department of obstetrics and gynaecology, Kasturba hospital, Manipal. All cases of carcinoma ovary who underwent imaging (USG, CT/ MRI) were followed by staging laparotomy during the course of study. All cases of carcinoma ovary who has undergone neoadjuvant chemotherapy were excluded. All patients included in the study underwent CA-125 estimation, conventional ultrasound, CT scan (Sixty four slice with contrast) followed by staging laparotomy and histopathological examination of the specimen. RMI-3 (Risk Malignancy Index Score-3) was calculated in all cases.Results: 54 patients were included in the evaluation. The efficacy of CT (Sensitivity 95.1%, specificity 46.2%) and Ultrasound (Sensitivity 90.2%, specificity 53.8%) were comparable in detection of ovarian malignancy. Combination of CT and USG (Sensitivity 95%, specificity 78.6%) gave the best result in non-invasive investigations whereas combination of CT and surgical staging (Sensitivity 95.1%, specificity 84.6%) gave a better result when invasive modalities were considered. RMI-3 score had sensitivity of 82% and specificity of 64% and did not improve the accuracy.Conclusions: Optimal preoperative evaluation was achieved with combination of USG and CT. Additional of CA-125 further improved the precision. All the three modes had good diagnostic performances, and complimented each other in further refining the characterization of the mass, local spread and distant tumour dissemination

Influence of placental position on obstetric morbidity in placenta previa

Background: In placenta previa, the placenta occupies lower uterine segment and is likely to separate during pregnancy, resulting in significant maternal and perinatal morbidity and mortality. It has been well studied as the degree of placenta previa increases, the risk of bleeding also increases. However, there are few studies regarding configuration of placenta in relation to uterine wall (anterior, posterior or lateral) and associated complications. The primary purpose of this retrospective cohort study is to examine the whether the location of placenta in relation to lower uterine segment during caesarean delivery influences development of bleeding complications necessitating various surgical interventions. The secondary objective was to study various factors such as preterm delivery, fetal growth restriction, perinatal deaths and postpartum haemorrhage in relation to location of placenta.Methods: We conducted a retrospective study of 89 patients with placenta previa with ultrasonographically mapped placenta over a period of 5 years. The subjects were further categorized into anterior, posterior and lateral group depending upon location of placenta in relation to uterine wall. Differences between age, parity, history of previous caesarean delivery, antepartum haemorrhage, preterm deliveries, foetal growth restriction, perinatal deaths, operative complications and surgical interventions, placenta accreta and postpartum haemorrhage were studied and also were compared to traditional classification of placenta previa in relation to internal cervical ostium. The statistical analysis of the data was performed according to Pearson Chi-square test, one way ANOVA test using SPSS Software.Results: The overall incidence of placenta previa was 1.01%. Placental location was anterior in 23 women (25.8%), posterior in 49 women ((55%) and lateral in 17 (19.1%). No significant differences were found in these groups regarding age, gestational age at delivery, parity, previous history of caesarean delivery, incidence of antepartum and postpartum haemorrhage. Need for surgical interventions such as uterine artery ligation, internal iliac artery plication, caesarean hysterectomy was not specific any type of placenta previa. 39.1% of anterior, 40% of posterior and 35.2% of lateral placenta previa received blood component therapy and this variation was not statistically significant. The overall perinatal mortality was 45/1000 live births and mortality rate did not vary significantly in any of the groups.Conclusions: It is difficult to assign a maternal or perinatal morbidity risk to a particular type of placental location. The need for specialized surgical intervention such as uterine / internal iliac artery ligation, peripartum hysterectomy can arise irrespective of placental location, whether underneath the surgical incision (anterior), proximity to main uterine trunks (lateral) or encountered after the delivery of the baby (posterior). Pregnancies complicated by placenta previa must be delivered in the hospitals having expertise of senior and skilled surgeons and well equipped blood bank and good neonatal intensive care unit

Factors influencing pregnancy outcome in women with vaginal bleeding before midpregnancy: a prospective case control study

Background: Pregnancy complications are observed to be higher among women with first trimester bleeding compared to those without bleeding. We intended to compare the obstetric outcome based on details of bleeding episodes, i) in groups with spotting, bleeding and brown discharge; ii) in those with or without subchorionic haemorrhage; and iii) between single versus recurrent episodes of bleeding.Methods: We conducted a prospective case control study involving the women enrolled for antenatal care before 20 weeks of gestation. Information was collected regarding the details of bleeding, the pregnancy complications and the perinatal outcome. The outcome variables were analysed as per the study objectives using SPSS version 16.0.Results: Pregnancies complicated by bleeding before 20 weeks of gestation were associated with the significant increase in preterm premature rupture of the membranes [P 0.045; RR 4.8 (95% CI 1.5-15)], intrauterine growth restriction [P 0.039; RR 2.5(95% CI 1.1-6.3)], oligohydramnios [RR  4.3 (95% CI 2-9)], hypertension [RR 1.8 (95% CI 1.07-3.09)], small for gestational age babies [P 0.047; RR 2.7 (95% CI 1.2-6.1)] and NICU admissions [P 0.016; RR 2.7 (95% CI 1.1-6.5)]. Fresh bleeding/ spotting were associated with increased pregnancy complications (P 0.048) compared to brownish discharge. Presence of subchorionic hemorrhage on ultrasound in women with vaginal bleeding was associated with increased pregnancy complications (P 0.044). No difference in terms of complications, mean gestational age and mean birth weight was noted depending on the number of episodes of bleeding.Conclusions: Fresh bleeding and presence of subchorionic hemorrhage predict a poor pregnancy outcome in women with bleeding before 20 weeks of pregnancy

Antibiogram of Escherichia coli and Staphylococcus aureus Isolated from Milk Sold in Kathmandu District

The emergence of antibiotic resistance in microorganisms and the presence of such isolates in milk pose a great risk to public health. Therefore, this study aims to determine the antibiotic susceptibility pattern of Escherichia coli and Staphylococcus aureus isolated from milk and assess the microbial quality of milk. For this, a total of 70 milk samples were collected and the total bacterial count (TBC) was determined. E. coli and S. aureus were isolated using their respective selective media while antibiotic susceptibility testing was carried out by Kirby Bauer Disc Diffusion method. The TBC showed that the raw milk samples contained two-fold higher microbial load while the pasteurized milk samples contained four-fold higher microbial loads than the standard guidelines. A total of 62 isolates were identified from culture-positive milk samples of which 32 were E. coli and 30 were S. aureus. A significant correlation was observed between microbial load and the organism isolated (r = 0.339, p<0.01). All S. aureus isolates were susceptible to Chloramphenicol while 40% were resistant to Cefoxitin, indicating the presence of Methicillin resistant S. aureus (MRSA). Also, 12 multidrug resistant (MDR) S. aureus were identified. While for E. coli, all were susceptible to Chloramphenicol but resistant to Ampicillin. Also, 9 MDR E. coli were detected. Higher resistance was observed among isolates from the raw milk samples than the pasteurized milk. It can be concluded that the milk produced by small-scale farms and dairy industries of Kathmandu district are of poor quality. Hence, routine microbial quality assessment and antimicrobial resistance monitoring should be followed to safeguard public health

Reference Ranges of Amniotic Fluid Index in Late Third Trimester of Pregnancy: What Should the Optimal Interval between Two Ultrasound Examinations Be?

Background. Amniotic fluid index (AFI) is one of the major and deciding components of fetal biophysical profile and by itself it can predict pregnancy outcome. Very low values are associated with intrauterine growth restriction and renal anomalies of fetus, whereas high values may indicate fetal GI anomalies, maternal diabetes mellitus, and so forth. However, before deciding the cut-off standards for abnormal values for a local population, what constitutes a normal range for specific gestational age and the ideal interval of testing should be defined. Objectives. To establish reference standards for AFI for local population after 34 weeks of pregnancy and to decide an optimal scan interval for AFI estimation in third trimester in low risk antenatal women. Materials and Methods. A prospective estimation of AFI was done in 50 healthy pregnant women from 34 to 40 weeks at weekly intervals. The trend of amniotic fluid volume was studied with advancing gestational age. Only low risk singleton pregnancies with accurately established gestational age who were available for all weekly scan from 34 to 40 weeks were included in the study. Women with gestational or overt diabetes mellitus, hypertensive disorders of the pregnancy, prelabour rupture of membranes, and congenital anomalies in the foetus and those who delivered before 40 completed weeks were excluded from the study. For the purpose of AFI measurement, the uterine cavity was arbitrarily divided into four quadrants by a vertical and horizontal line running through umbilicus. Linear array transabdominal probe was used to measure the largest vertical pocket (in cm) in perpendicular plane to the abdominal skin in each quadrant. Amniotic fluid index was obtained by adding these four measurements. Statistical analysis was done using SPSS software (Version 16, Chicago, IL). Percentile curves (5th, 50th, and 95th centiles) were constructed for comparison with other studies. Cohen’s d coefficient was used to examine the magnitude of change at different time intervals. Results. Starting from 34 weeks till 40 weeks, 50 ultrasound measurements were available at each gestational age. The mean (standard deviation) of AFI values (in cms) were 34 W: 14.59 (1.79), 35 W: 14.25 (1.57), 36 W: 13.17 (1.56), 37 W: 12.48 (1.52), 38 W: 12.2 (1.7), and 39 W: 11.37 (1.71). The 5th percentile cut-off was 8.7 cm at 40 weeks. There was a gradual decline of AFI values as the gestational age approached term. Significant drop in AFI was noted at two-week intervals. AFI curve generated from the study varied significantly when compared with already published data, both from India and abroad. Conclusion. Normative range for AFI values for late third trimester was established. Appreciable changes occurred in AFI values as gestation advanced by two weeks. Hence, it is recommended to follow up low risk antenatal women every two weeks after 34 weeks of pregnancy. The percentile curves of AFI obtained from the present study may be used to detect abnormalities of amniotic fluid for our population

Predictive Value of Middle Cerebral Artery to Uterine Artery Pulsatility Index Ratio in Hypertensive Disorders of Pregnancy

Aims and Objectives. (i) To determine the predictive value of cerebrouterine (CU) ratio (middle cerebral artery to uterine artery pulsatility index, MCA/UT PI) in assessing perinatal outcome among hypertensive disorders of pregnancy. (ii) To compare between CU ratio and CP ratio (MCA/Umbilical artery PI) as a predictor of adverse perinatal outcome. Methods. A prospective observational study was done in a tertiary medical college hospital, from September 2012 to August 2013. One hundred singleton pregnancies complicated by hypertension peculiar to pregnancy were enrolled. Both CU and CP ratios were estimated. The perinatal outcomes were studied. Results. Both cerebrouterine and cerebroplacental ratios had a better negative predictive value in predicting adverse perinatal outcome. However, both CU and CP ratios when applied together were able to predict adverse outcomes better than individual ratios. The sensitivity, specificity, positive predictive value, and the negative predictive values for an adverse neonatal outcome with CU ratio were 61.3%, 70.3%, 56%, and 78.9%, respectively, compared to 42%, 57.5%, 62%, and 76% as with CP ratio. Conclusion. Cerebrouterine ratio and cerebroplacental ratio were complementary to each other in predicting the adverse perinatal outcomes. Individually, both ratios were reassuring for favorable perinatal outcome with high negative predictive value

Modeling the novel SERD elacestrant in cultured fulvestrant-refractory HR-positive breast circulating tumor cells

Purpose: Metastatic hormone receptor-positive (HR+) breast cancer initially responds to serial courses of endocrine therapy, but ultimately becomes refractory. Elacestrant, a new generation FDA-approved oral selective estrogen receptor degrader (SERD) and antagonist, has demonstrated efficacy in a subset of women with advanced HR+breast cancer, but there are few patient-derived models to characterize its effect in advanced cancers with diverse treatment histories and acquired mutations. Methods: We analyzed clinical outcomes with elacestrant, compared with endocrine therapy, among women who had previously been treated with a fulvestrant-containing regimen from the recent phase 3 EMERALD Study. We further modeled sensitivity to elacestrant, compared with the currently approved SERD, fulvestrant in patient-derived xenograft (PDX) models and cultured circulating tumor cells (CTCs). Results: Analysis of the subset of breast cancer patients enrolled in the EMERALD study who had previously received a fulvestrant-containing regimen indicates that they had better progression-free survival with elacestrant than with standard-of-care endocrine therapy, a finding that was independent estrogen receptor (ESR1) gene mutations. We modeled elacestrant responsiveness using patient-derived xenograft (PDX) models and in ex vivo cultured CTCs derived from patients with HR+breast cancer extensively treated with multiple endocrine therapies, including fulvestrant. Both CTCs and PDX models are refractory to fulvestrant but sensitive to elacestrant, independent of mutations in ESR1 and Phosphatidylinositol-4,5-Bisphosphate 3-Kinase Catalytic Subunit Alpha (PIK3CA) genes. Conclusion: Elacestrant retains efficacy in breast cancer cells that have acquired resistance to currently available ER targeting therapies. Elacestrant may be an option for patients with HR+/HER2- breast cancer whose disease progressed on fulvestrant in the metastatic setting. Translational Relevance. Serial endocrine therapy is the mainstay of management for metastatic HR+breast cancer, but acquisition of drug resistance highlights the need for better therapies. Elacestrant is a recently FDA-approved novel oral selective estrogen receptor degrader (SERD), with demonstrated efficacy in the EMERALD phase 3 clinical trial of refractory HR+breast cancer. Subgroup analysis of the EMERALD clinical trial identifies clinical benefit with elacestrant in patients who had received prior fulvestrant independent of the mutational status of the ESR1 gene, supporting its potential utility in treating refractory HR+breast cancer. Here, we use pre-clinical models, including ex vivo cultures of circulating tumor cells and patient-derived xenografts, to demonstrate the efficacy of elacestrant in breast cancer cells with acquired resistance to fulvestrant.SCOPUS: ar.jinfo:eu-repo/semantics/publishe