Cost-Utility of Routine Endometrial Evaluation Prior to Le Fort Colpocleisis

Objective: Endometrial evaluation is routinely performed in elderly women undergoing Le Fort colpocleisis. There is little evidence to support this practice. We sought to investigate the cost-utility of routine evaluation of the uterine cavity prior to performing a Le Fort colpocleisis. Study Design: A decision analysis model was created to compare uterine evaluation, by either endometrial biopsy or transvaginal ultrasound, to no evaluation for a cohort of women \u3e 80 years old undergoing Le Fort colpocleisis. Baseline assumptions for our model were made to reflect women who did not carry significant risk for the development of endometrial cancer, such as history of postmenopausal bleeding, abnormal uterine pathology, obesity, diabetes, and tamoxifen use. Decision paths included no screening, ultrasound evaluation, and biopsy. The horizon was five years until the endpoint of survival, death, or the development of cancer. Those pathways in which cancer was diagnosed were carried out to the endpoint of either five-year survival or death. Treatment arms for endometrial cancer were based on management methods used at our institution. Probabilities and utilities for health outcomes were estimated through literature review or, when unavailable, by expert opinion. Costs were obtained from US Medicare charges for the appropriate CPT and DRG codes and are reported in 2012 US Dollars. Cost-utility analysis was performed using US recommendations from a societal perspective. Sensitivity analysis using Monte Carlo simulation was performed to test the validity of our model. Results: Analysis of our decision tree demonstrates that a strategy of no evaluation is superior to that of either biopsy or ultrasound. Univariate sensitivity analysis demonstrates that at a 0.55 probability of cancer, biopsy surpasses both no evaluation and ultrasound as the dominant strategy. Using Monte Carlo simulation, at willingness-to-pay thresholds of $50,000 and$100,000, no evaluation was superior to both biopsy and ultrasound from the patient, health-plan, and societal perspectives. Biopsy appears to be a more effective strategy than ultrasound when uterine evaluation is needed. Conclusions: Our model shows that a practice of not evaluating the endometrial cavity prior to performing Le Fort colpocleisis is superior to either biopsy or ultrasound. These results are likely being driven by the low incidence of endometrial cancer in this population. It may not be necessary to perform uterine evaluation prior to Le Fort colpocleisis in a low-risk population. If uterine evaluation is needed, biopsy appears to be the preferred strategy over ultrasound. More studies are needed to determine utility values for health states experienced by women with pelvic organ prolapse and with endometrial cancer. This will enhance our ability to develop more accurate cost-utility models for treating these women

Temsirolimus with or without megestrol acetate and tamoxifen for endometrial cancer: A gynecologic oncology group study

Preclinical evidence suggested that blockade of the PI3K/AKT/mTOR pathway might overcome resistance to hormonal therapy

Search for eccentric black hole coalescences during the third observing run of LIGO and Virgo

Despite the growing number of confident binary black hole coalescences observed through gravitational waves so far, the astrophysical origin of these binaries remains uncertain. Orbital eccentricity is one of the clearest tracers of binary formation channels. Identifying binary eccentricity, however, remains challenging due to the limited availability of gravitational waveforms that include effects of eccentricity. Here, we present observational results for a waveform-independent search sensitive to eccentric black hole coalescences, covering the third observing run (O3) of the LIGO and Virgo detectors. We identified no new high-significance candidates beyond those that were already identified with searches focusing on quasi-circular binaries. We determine the sensitivity of our search to high-mass (total mass M>70 M⊙) binaries covering eccentricities up to 0.3 at 15 Hz orbital frequency, and use this to compare model predictions to search results. Assuming all detections are indeed quasi-circular, for our fiducial population model, we place an upper limit for the merger rate density of high-mass binaries with eccentricities 0<e≤0.3 at 0.33 Gpc−3 yr−1 at 90\% confidence level

Ultralight vector dark matter search using data from the KAGRA O3GK run

Among the various candidates for dark matter (DM), ultralight vector DM can be probed by laser interferometric gravitational wave detectors through the measurement of oscillating length changes in the arm cavities. In this context, KAGRA has a unique feature due to differing compositions of its mirrors, enhancing the signal of vector DM in the length change in the auxiliary channels. Here we present the result of a search for U(1)B−L gauge boson DM using the KAGRA data from auxiliary length channels during the first joint observation run together with GEO600. By applying our search pipeline, which takes into account the stochastic nature of ultralight DM, upper bounds on the coupling strength between the U(1)B−L gauge boson and ordinary matter are obtained for a range of DM masses. While our constraints are less stringent than those derived from previous experiments, this study demonstrates the applicability of our method to the lower-mass vector DM search, which is made difficult in this measurement by the short observation time compared to the auto-correlation time scale of DM

Cancer of the kidney

Kidney cancers are relatively rare and account for only 3% of adult malignancies. Although these tumors are more common in men than in women, with a male:female ratio of 1.5:1, the kidney is a significant source of cancer diagnoses and death in women. In the United States in 2002, it is estimated that 12,700 women will be diagnosed with kidney cancer and 4,400 women will die of the disease. Approximately two thirds of renal carcinomas are now discovered incidentally while patients are being scanned for abdominal or pelvic conditions, making knowledge of this disease even more important for the practicing obstetrician-gynecologist

Key concepts in management of vulvar cancer

Vulvar carcinoma is an uncommon tumor that is seen most often in older women. Subtle symptoms such as pruritus should prompt examination and targeted biopsy in all women as this disease can be successfully treated even in elderly, frail individuals. Vulvar cancer has a bimodal age distribution and is seen in both young and older women with risk factors including human papillomavirus (HPV) infection, smoking, and vulvar skin diseases (i.e., lichen sclerosus). This cancer is staged surgically, with an update in 2009 incorporating prognostic factors. The treatment of vulvar carcinoma has evolved to include more conservative surgical techniques that provide improved cure rates with emphasis on minimizing morbidity. Advanced and metastatic lesions are now treated with chemoradiation which produces substantial cure rates with decreased morbidity. Promising areas of research in vulvar cancer include refinement of sentinel lymph node biopsy, prevention of lymphedema, and preservation of sexual function following treatment

Cost-utility of routine endometrial evaluation before le fort colpocleisis

INTRODUCTION: Routine preoperative evaluation of the endometrium before Le Fort colpocleisis is often recommended. There are no data, however, to support this practice. In select patients, it may not be a necessary addition to the preoperative evaluation of Le Fort colpocleisis. METHODS: A decision analysis model was created to compare uterine evaluation, by either endometrial (EM) biopsy or transvaginal ultrasound, to no evaluation for a hypothetical cohort of women undergoing Le Fort colpocleisis. We assumed the absence of risk factors for EM cancer. Probabilities and health outcome utilities were obtained from literature review. Medicare charges were used to estimate cost in 2012 US dollars. Cost-utility analysis was performed using US recommendations from a health plan perspective. RESULTS: At willingness-to-pay thresholds of $50,000 and$100,000, no evaluation is superior to both biopsy and ultrasound. At a 64% probability of cancer, biopsy is more cost-effective than no evaluation and ultrasound. CONCLUSIONS: Compared to biopsy and ultrasound, in low-risk women, no EM evaluation before Le Fort colpocleisis demonstrates superior cost-utility

Neuropathic uterine pain after hysterectomy. A case report

BACKGROUND: Neuropathic pain arises when there is damage to or dysfunction of the nervous system. Diabetic neuropathy, postherpetic neuralgia and phantom limb pain are common types of neuropathic pain. It is not commonly recognized in gynecologic practice. CASE: A patient underwent a hysterectomy for a tuboovarian abscess and underlying endometriosis. Despite maximal dosing with conventional pain medications, she continued to have significant pain that had not been present following prior surgeries. Use of low-dose amitriptyline successfully treated the pain, with no sequelae. CONCLUSION: Persistent pain following gynecologic surgery that does not respond to conventional therapy may have a neuropathic origin. Attention to appropriate history and physical examination may lead to an increase in the diagnosis of neuropathic pain in gynecology patients. This may have implications for persistent pain in other gynecologic diseases

Surgery in elderly people: Preoperative, operative and postoperative care to assist healing

Surgery for elderly women is likely to increase steadily as the population of elderly people increases globally. Although increasing age increases perioperative morbidity and mortality, the functional age and physiologic reserve rather than chronological age is more important in preventing complications. Preparation for surgery, with special attention to functional capacity and activity, mental status, and existing comorbid conditions, can improve outcomes. Perioperative management must be tailored to physiologic changes of ageing, which affect respiratory, cardiac and renal function, as well as guidelines for preventing infection and thrombotic events. Of particular note is the enhanced effect of narcotic medications in elderly people, which affects intraoperative and postoperative management of pain. Prevention of postoperative delirium is accomplished through preoperative and postoperative planning. Discharge planning, particularly for frail elderly people, must start before surgery