Iron deficiency and symptoms in women aged 20–49 years and relation to upper gastrointestinal and colon cancers

Objective Iron deficiency anaemia (IDA) in women aged 20–49 years may be caused by menses or gastrointestinal cancer. Data are sparse on the yield of endoscopy/colonoscopy in this population. Our aim was to determine the association of IDA and symptoms with cancers.Design Retrospective cohort study within Kaiser Permanente Northern California. Participants were women aged 20–49 years tested for iron stores and anaemia during 1998, 2004 and 2010 and followed for 5 years for outcomes of oesophageal, gastric and colon cancers. Symptoms from the three prior years were grouped into dysphagia, upper gastrointestinal (UGI), lower gastrointestinal (LGI), rectal bleeding and weight loss.Results Among 9783 anaemic women aged 20–49 years, there were no oesophageal, 6 gastric and 26 colon cancers. Incidences per 1000 for gastric cancer with and without iron deficiency (ID) were 0.60 (95% CI 0.23 to 1.55) and 0.63 (95% CI 0.17 to 2.31), and for colon cancer, 2.72 (95% CI 1.72 to 4.29) and 2.53 (95% CI 1.29 to 4.99). Endoscopies for UGI or dysphagia symptoms rather than bidirectional endoscopy for ID yielded more gastric cancers (n=5 and n=4, respectively) with fewer procedures (3793 instead of 6627). Colonoscopies for LGI or rectal bleed instead of for ID would detect more colon cancers (n=19 and n=18) with about 40% of the procedures (=2793/6627).Conclusions UGI and colon cancers were rare in women of menstruating age and when controlled for anaemia were as common without as with ID. Using symptoms rather than IDA as an indication for endoscopy found equal numbers of cancers with fewer procedures

Using Tumor Registry and Electronic Medical Record Databases to Determine Incidence of Uterine Sarcoma and Occult Malignancy Within an Integrated Health Care System

Background/Aims: There are currently no reliable estimates of uterine sarcoma incidence and occult malignancy at hysterectomy to aid decision-making about surgical route and policy formulation. Methods: We identified women 18 years or older who underwent a hysterectomy and had a new diagnosis of uterine sarcoma in 2006–2013 in a large integrated health care system. Clinical presentation including when the diagnosis was not suspected or known preoperatively was assessed. Age- and race-specific total and annual incidence of uterine sarcoma and leiomyosarcoma and occult malignancy were calculated and evaluated for trends over time. Results: From 2006 to 2013, there were 93,153 hysterectomies, of which 49,314 (52.9%) were for leiomyoma or abnormal bleeding. There were 298 new cases of uterine sarcoma, more than half (58%) of which were suspected or known preoperatively. The incidence of occult uterine sarcoma and leiomyosarcoma among women having hysterectomies for presumed benign leiomyoma and abnormal bleeding was 2.51 and 1.66 per 1,000 hysterectomies, respectively. The incidence was significantly higher for women over age 50; however, there was no significant difference in incidence by race/ethnicity. The annual incidence of uterine sarcoma did not increase over the 8-year period. Discussion: Data from a large, diverse, community-based U.S. population confirms that uterine sarcomas are rare. The risk of occult malignancy must be weighed against the known benefits of minimally invasive hysterectomy. Our estimates of the risk of occult malignancy add important information for discussions between patients and clinicians when considering minimally invasive surgery and power morcellation and providing informed consent

Labor Induction Outcomes with Outpatient Misoprostol for Cervical Ripening among Low-Risk Women

OBJECTIVE: In 2012, two Kaiser Permanente Northern California (KPNC) hospitals began offering outpatient cervical ripening with oral misoprostol under a study protocol. We evaluated inpatient time from admission to delivery and adverse maternal and neonatal outcomes associated with outpatient use of misoprostol for cervical ripening among low-risk women with term pregnancies. STUDY DESIGN: We conducted a retrospective cohort study comparing three groups: women who received misoprostol (1) outpatient, under a study protocol; (2) inpatient, at the study sites; and (3) inpatient, at all KPNC hospitals. Data were obtained from between 2012 and 2017. The primary outcome was time from inpatient admission to delivery. Secondarily, we evaluated maternal and neonatal outcomes, including the duration and maximum rate of oxytocin administered, rate of cesarean delivery, incidence of chorioamnionitis and blood transfusion, Apgar scores, and neonatal intensive care unit admissions. Demographic and clinical characteristics and outcomes of the outpatient group were compared with both inpatient misoprostol groups using the appropriate statistical test. Variables included in the regression analysis were either statistically significant in the bivariate analyses or have been reported in the literature to be potential confounders: maternal age at admission, race/ethnicity, body mass index, cervical dilation at initial misoprostol, and parity. RESULTS: We analyzed data from 10,253 patients: (1) 345 outpatients, under a study protocol; (2) 1,374 inpatients, at the study sites; and (3) 9,908 inpatients, at all the Kaiser hospitals. Women in the outpatient group were more likely to be white than both inpatient groups (63.3 vs. 56.3% at study sites and 47.1% in all hospitals,  0.002 and \u3c0.001, respectively); other demographics were clinically comparable. Most women undergoing labor induction were nulliparous; however, a greater proportion in the outpatient group were nulliparous compared with inpatient groups (70.8 vs. 61.8% and 64.3%,  = 0.002 and 0.01). On inpatient admission for delivery, women who received outpatient misoprostol were more likely to have a cervical dilation of ≥3 cm (39.8 vs. 12.5% at study sites and 9.7% at all KPNC hospitals,  \u3c 0.001 for both). The outpatient group had a shorter mean time between admission and delivery (23.6 vs. 29.4 at study sites and 29.8 hours at all KPNC,  \u3c 0.001 for both). The adjusted estimated mean difference between the outpatient and inpatient group at all the Kaiser hospitals in time from admission to delivery was -6.48 hours ( \u3c 0.001), and the adjusted estimated mean difference in cervical dilation on admission was +1.02 cm ( \u3c 0.001). There was no difference in cesarean delivery rates between groups. The rate of chorioamnionitis in the outpatient group was higher compared with inpatients at all hospitals (17.7 vs. 10.6%,  0001), but similar when compared with the inpatients at the study sites (17.7 vs. 15.4%,  = 0.29). CONCLUSION: Outpatient use of misoprostol for cervical ripening under the study protocol was associated with reduced inpatient time from admission to delivery compared with inpatient misoprostol. Although there was a higher rate of chorioamnionitis among outpatients under the study protocol compared with inpatients at all hospitals, there was no difference when compared with inpatients at the study sites. There was no difference in rates of cesarean delivery or maternal or neonatal complications with outpatient misoprostol. KEY POINTS: · Outpatient misoprostol patients had 6.46 fewer hours from admission to delivery compared with inpatients at all hospitals.. · There was no difference in the rate of cesareans between the outpatient versus inpatient misoprostol groups.. · Other maternal and neonatal complications were low and comparable among outpatients and inpatients who received misoprostol; this study was not large enough to assess rare safety outcomes.