Preserved anatomical bypasses predict variance in language functions after stroke.

The severity of post-stroke aphasia is related to damage to white matter connections. However, neural signaling can route not only through direct connections, but also along multi-step network paths. When brain networks are damaged by stroke, paths can bypass around the damage to restore communication. The shortest network paths between regions could be the most efficient routes for mediating bypasses. We examined how shortest-path bypasses after left hemisphere strokes were related to language performance. Regions within and outside of the canonical language network could be important in aphasia recovery. Therefore, we innovated methods to measure the influence of bypasses in the whole brain. Distinguishing bypasses from all residual shortest paths is difficult without pre-stroke imaging. We identified bypasses by finding shortest paths in subjects with stroke that were longer than the most reliably observed connections in age-matched control networks. We tested whether features of those bypasses predicted scores in four orthogonal dimensions of language performance derived from a principal components analysis of a battery of language tasks. The features were the length of each bypass in steps, and how many bypasses overlapped on each individual direct connection. We related these bypass features to language factors using support vector regression, a technique that extracts robust relationships in high-dimensional data analysis. The support vector regression parameters were tuned using grid-search cross-validation. We discovered that the length of bypasses reliably predicted variance in lexical production (R2 = .576) and auditory comprehension scores (R2 = .164). Bypass overlaps reliably predicted variance in Lexical Production scores (R2 = .247). The predictive elongation features revealed that bypass efficiency along the dorsal stream and ventral stream were most related to Lexical Production and Auditory Comprehension, respectively. Among the predictive bypass overlaps, increased bypass routing through the right hemisphere putamen was negatively related to lexical production ability.

Multi-institutional Outcomes and Associations After Excision and Primary Anastomosis for Radiotherapy-associated Bulbomembranous Urethral Stenoses Following Prostate Cancer Treatment.

OBJECTIVE: To evaluate the outcomes of excision and primary anastomosis (EPA) for radiation-associated bulbomembranous stenoses using a multi-institutional analysis. The treatment of radiation-associated urethral stenosis is typically complex owing to the adverse impact of radiation on adjacent tissue. METHODS: An IRB-approved multi-institutional retrospective review was performed on patients who underwent EPA for bulbomembranous urethral stenosis following prostate radiotherapy. Preoperative patient demographics, operative technique, and postoperative outcomes were abstracted from 1/2007-6/2018. Success was defined as voiding per urethra without the need for endoscopic treatment and a minimum follow-up of 12 months. RESULTS: One hundred and thirty-seven patients from 10 centers met study criteria with a mean age of 69.3 years (50-86), stenosis length of 2.3 cm (1-5) and an 86.9% (119/137) success rate at a mean follow-up 32.3 months (12-118). Univariate Cox regression analysis identified increasing patient age (P = .02), stricture length (P <.0001) and combined modality radiotherapy (P = .004) as factors associated with stricture recurrence while body mass index (P = .79), diabetes (P = .93), smoking (P = .62), failed endoscopic treatment (P = .08) and gracilis muscle use (P = .25) were not. On multivariate analysis, increasing patient age (H.R.1.09, 95%CI 1.01-1.16; P = .02) and stenosis length (H.R.2.62, 95%CI 1.49-4.60; P = .001) remained associated with recurrence. Subsequent artificial urinary sphincter was performed in 30 men (21.9%), of which 25 required a transcorporal cuff and 5 developed cuff erosion. CONCLUSIONS: EPA for radiation-associated urethral stenosis effectively provides unobstructed instrumentation-free voiding. However, increasing stenosis length and age are independently associated with surgical failure. Patients should be counseled that further surgery for incontinence may be necessary.

Recommendations for MRI-based contouring of gross tumor volume and organs at risk for radiation therapy of pancreatic cancer.

PURPOSE: Local recurrence is a common and morbid event in patients with unresectable pancreatic adenocarcinoma. A more conformal and targeted radiation dose to the macroscopic tumor in nonmetastatic pancreatic cancer is likely to reduce acute toxicity and improve local control. Optimal soft tissue contrast is required to facilitate delineation of a target and creation of a planning target volume with margin reduction and motion management. Magnetic resonance imaging (MRI) offers considerable advantages in optimizing soft tissue delineation and is an ideal modality for imaging and delineating a gross tumor volume (GTV) within the pancreas, particularly as it relates to conformal radiation planning. Currently, no guidelines have been defined for the delineation of pancreatic tumors for radiation therapy treatment planning. Moreover, abdominal MRI sequences are complex and the anatomy relevant to the radiation oncologist can be challenging. The purpose of this study is to provide recommendations for delineation of GTV and organs at risk (OARs) using MRI and incorporating multiple MRI sequences. METHODS AND MATERIALS: Five patients with pancreatic cancer and 1 healthy subject were imaged with MRI scans either on 1.5T or on 3T magnets in 2 separate institutes. The GTV and OARs were contoured for all patients in a consensus meeting. RESULTS: An overview of MRI-based anatomy of the GTV and OARs is provided. Practical contouring instructions for the GTV and the OARs with the aid of MRI were developed and included in these recommendations. In addition, practical suggestions for implementation of MRI in pancreatic radiation treatment planning are provided. CONCLUSIONS: With this report, we attempt to provide recommendations for MRI-based contouring of pancreatic tumors and OARs. This could lead to better uniformity in defining the GTV and OARs for clinical trials and in radiation therapy treatment planning, with the ultimate goal of improving local control while minimizing morbidity.

Poor Glycemic Control Is Associated with Failure to Complete Neoadjuvant Therapy and Surgery in Patients with Localized Pancreatic Cancer.

BACKGROUND: The impact of glycemic control in patients with pancreatic cancer treated with neoadjuvant therapy is unclear. METHODS: Glycated hemoglobin (HbA1c) values were measured in patients with localized pancreatic cancer prior to any therapy (pretreatment) and after neoadjuvant therapy prior to surgery (preoperative). HbA1c levels greater than 6.5% were classified as abnormal. Patients were categorized based on the change in HbA1c levels from pretreatment to preoperative: GrpA, always normal; Gr B, worsened; GrpC, improved; and GrpD, always abnormal. RESULTS: Pretreatment HbA1c levels were evaluable in 123 patients; there were 67 (55%) patients in GrpA, 8 (6%) in GrpB, 22 (18%) in GrpC, and 26 (21%) in GrpD. Of the 123 patients, 92 (75%) completed all intended therapy to include surgery; 57 (85%) patients in GrpA, 4 (50%) patients in GrpB, 16 (72%) patients in GrpC, and 15 (58%) patients in GrpD (p = 0.01). Elevated preoperative carbohydrate antigen 19-9 (CA19-9) (OR 0.22;[0.07-0.66]), borderline resectable (BLR) disease stage (OR 0.20;[0.01-0.45]) and abnormal preoperative HbA1c (OR 0.30;[0.11-0.90]) were negatively associated with completion of all intended therapy. Abnormal preoperative HbA1c was associated with a 2.74-fold increased odds of metastatic progression during neoadjuvant therapy (p = 0.08). CONCLUSIONS: Elevated preoperative HbA1c is associated with failure to complete neoadjuvant therapy and surgery and a trend for increased risk of metastatic progression.

Management of Delayed Onset Postoperative Hemorrhage after Anastomotic Urethroplasty.

Excision with primary anastomosis (EPA) urethroplasty is generally the preferred method for short strictures in the bulbar urethra, given its high success rate and low complication rate compared to other surgical interventions. Bleeding is a presumed risk factor for any surgical procedure but perioperative hemorrhage after an EPA requiring hospitalization and/or reintervention is unreported with no known consensus on the best course for management. Through our experience with three separate cases of significant postoperative urethral hemorrhage after EPA, we developed an algorithm for treatment beginning with conservative management and progressing through endoscopic and open techniques, as well as consideration of embolization by interventional radiology. All the three of these cases were managed successfully though they did require multiple interventions. We theorize that younger patients with more robust corpus spongiosum and more vigorous spontaneous erections, patients that have undergone fewer prior urethral procedures and therefore have more prominent vasculature, and those patients managed with a two-layer closure of the ventral urethra without ligation of the transected bulbar arteries are at a higher risk for this complication.

Patency rates of portal vein/superior mesenteric vein reconstruction after pancreatectomy for pancreatic cancer.

BACKGROUND: Pancreatectomy with venous reconstruction (VR) for pancreatic cancer (PC) is occurring more commonly. Few studies have examined the long-term patency of the superior mesenteric-portal vein confluence following reconstruction. METHODS: From 2007 to 2013, patients who underwent pancreatic resection with VR for PC were classified by type of reconstruction. Patency of VR was assessed using surveillance computed tomographic imaging obtained from date of surgery to last follow-up. RESULTS: VR was performed in 43 patients and included the following: tangential resection with primary repair (7, 16%) or saphenous vein patch (9, 21%); segmental resection with splenic vein division and either primary anastomosis (10, 23%) or internal jugular vein interposition (8, 19%); or segmental resection with splenic vein preservation and either primary anastomosis (3, 7%) or interposition grafting (6, 14%). All patients were instructed to take aspirin after surgery; low molecular weight heparin was not routinely used. An occluded VR was found in four (9%) of the 43 patients at a median follow-up of 13 months; median time to detection of thrombosis in the four patients was 72 days (range 16-238). CONCLUSIONS: Pancreatectomy with VR can be performed with high patency rates. The optimal postoperative pharmacologic therapy to prevent thrombosis requires further investigation.

In vivo proton (H1) magnetic resonance spectroscopy for cervical carcinoma.

Proton magnetic resonance spectroscopy (MRS) may be a useful tool in both the initial diagnosis of cervical carcinoma and the subsequent surveillance after radiation therapy, particularly when other standard diagnostic methods are inconclusive. Single voxel magnetic resonance (MR) spectral data were acquired from 8 normal volunteers, 16 patients with cervical cancer before radiation therapy, and 18 patients with cervical cancer after radiation therapy using an external pelvic coil at a 1.5-T on a Signa system. The presence or absence of various resonances within each spectrum was evaluated for similarities within each patient group and for spectral differences between groups. Resonances corresponding to lipid and creatine dominated the spectrum for the eight normal volunteers without detection of a choline resonance. Spectra from 16 pretreatment patients with biopsy-proven cervical cancer revealed strong resonances at a chemical shift of 3.25 ppm corresponding to choline. Data acquired from the 18 posttreatment setting studies was variable, but often correlated well with the clinical findings. Biopsy confirmation was obtained in seven patients. H1 MRS of the cervix using a noninvasive pelvic coil consistently demonstrates reproducible spectral differences between normal and neoplastic cervical tissue in vivo. However, signal is still poor for minimal disease recurrence. Further study is needed at intervals before, during, and after definitive irradiation with biopsy confirmation to validate the accuracy of MRS in distinguishing persistence or recurrence of disease from necrosis and fibrosis.

p21WAF1 expression is associated with improved survival after adjuvant chemoradiation for pancreatic cancer.

BACKGROUND: Cell cycle arrest after DNA damage is partly mediated through the transcriptional activation of p21(WAF1) by the p53 tumor suppressor gene. p21(WAF1) and p53 are both critical in maintaining cell cycle control in response to DNA damage from radiation or chemotherapy. Therefore, we examined the role of p21(WAF1) and p53 in the determination of outcome for patients who receive radiation and/or chemotherapy for pancreatic cancer. METHODS: p21(WAF1) and p53 protein expression were determined (with the use of immunohistochemistry) in specimens from 90 patients with pancreatic cancer. Forty-four patients underwent surgical resection, and 46 patients had either locally unresectable tumors (n = 9 patients) or distant metastases (n = 37 patients). Seventy-three percent of the patients who underwent resection and 63% of the patients who did not undergo resection received radiation and/or chemotherapy. RESULTS: p21(WAF1) expression was present in 48 of 86 tumors (56%) and was significantly (P<.05) associated with advanced tumor stage. Median survival among patients with resected pancreatic cancer who received adjuvant chemoradiation with p21(WAF1)-positive tumors was significantly longer than in patients with no p21(WAF1) staining (25 vs. 11 months; P = .01). Fifty of 89 tumors (56%) stained positive for p53 protein. p53 overexpression was associated with decreased survival in patients who did not undergo resection. CONCLUSIONS: Normal p21(WAF1) expression may be necessary for a beneficial response to current adjuvant chemoradiation protocols for pancreatic cancer. Alternate strategies for adjuvant therapy should be explored for patients with pancreatic cancer who lack functional p21(WAF1).

Analysis of three decision-making methods: a breast cancer patient as a model.

PURPOSE: To compare three decision making techniques using a common clinical problem. METHODS: Two recently developed methods, the analytic hierarchy process (AHP) and the analytic network process (ANP), were compared with a Markov process in the evaluation of the optimal post-lumpectomy treatment strategy for an elderly woman with a mammographically detected, nonpalpable early-stage breast cancer. The following treatment alternatives were considered: observation, radiation, tamoxifen, combination radiation and tamoxifen, and simple mastectomy. All three decision methods incorporated patient preferences. RESULTS: The models agreed on the ranking of the preferred treatment, radiation and tamoxifen, but there were variations in the rankings of the other treatment choices. Individual differences between the three models were uncovered. The Markov process provided estimates of quality-adjusted life expectancy and distribution of health events. Both AHP and ANP required less development time than the Markov process. CONCLUSION: All three methods may be useful tools to the clinician in analyzing complex medical problems. The Markov is the most labor-intensive method but provides detailed results, whereas the AHP and the ANP give only rank orders of the alternatives. The most important considerations in choosing between these methods are time to project completion and the detail of information sought.

The effect of selective cyclooxygenase inhibitors on intestinal epithelial cell mitogenesis.

INTRODUCTION: Previous research has demonstrated that nonsteroidal anti-inflammatory agents alter the incidence of colorectal cancer. It has been postulated that the response may be due to the effect of these agents on the activities of the cyclooxygenase (COX) enzymes. The COX enzymes catalyze the conversion of arachidonic acid to biologically active prostanoids. Two forms of COX have been identified. COX-1 is a constitutive enzyme, generally involved in cell functions, while COX-2 is commonly an enzyme which is inducible in response to various stimuli, including mitogens. Recently, specific inhibitors of COX-1 and COX-2 enzymes have been developed. PURPOSE: The present study was undertaken to determine the effects of specific COX-1 and COX-2 inhibitors on the proliferation and the induction of apoptosis of intestinal epithelial cells. METHODS: A continuously proliferating rat small intestinal cell line (IEC-18) and a mouse colon cancer cell line (WB-2054) were utilized for these experiments. The cells were placed in microwells with serum-free or serum-supplemented media. The effects of serum on proliferation were then evaluated in the presence of the COX-1 inhibitor, valerylsalicyclic acid (VSA), the COX-2 inhibitor, SC-58125, or indomethacin. The presence of COX-1 and COX-2 protein was evaluated by Western blotting. Proliferation of intestinal cells was quantitated by incorporation of [3H]thymidine into DNA and cell counting, and apoptosis was determined by evaluating cell attachment. COX activity was evaluated by prostaglandin E2 production measured by enzyme-linked immunoabsorbent assay (ELISA). RESULTS: Western blotting of IEC-18 and WB-2054 cell protein demonstrated COX-1 enzyme in cells incubated in serum-free media with increased COX-1 expression produced by incubation in media supplemented with 10% serum. COX-2 enzyme was not demonstrated in serum-free media; however, it was present in cells maintained in 10% serum-supplemented media. Spontaneous DNA synthesis was present in both cell lines and serum increased proliferation. In both cell lines [3H]thymidine incorporation stimulated by serum was inhibited by the COX-2 inhibitor SC-58125, but not by the COX-1 inhibitor VSA. Both indomethacin and SC-58125 produced a dose-dependent increase in apoptotic ratios in both cell lines. PGE2 formation, stimulated by serum, was inhibited by SC-58125, VSA, and indomethacin. CONCLUSION: A differential effect on intestinal cell mitogenesis was seen with different COX inhibitors. The COX-2 inhibitor, but not the COX-1 inhibitor, significantly inhibited [3H]thymidine incorporation in both cell types, suggesting COX-2 inhibitors may be specific inhibitors of normal epithelial cell proliferation and growth of malignant cells. SC-58125, a selective inhibitor of COX-2, has a potent apoptosis inducing effect. The inhibition of PGE2 production did not correlate with the inhibition of proliferation, suggesting the two processes are unrelated.

Urea reduction ratio and urea kinetic modeling: a mathematical analysis of changing dialysis parameters.

Based mainly on the simplicity of its calculation, the urea reduction ratio (URR) has been suggested as an alternative to urea kinetic modeling (Kt/V) as a measure of hemodialysis adequacy. However, recent studies have raised questions concerning the accuracy of URR, particularly in the presence of residual kidney function (KrU). This study was initiated to evaluate the relationship between URR and Kt/V under a variety of dialysis conditions. Equations based on the variable-volume, single-pool model described by Gotch were used to construct a model incorporating the variables used in the estimation of URR and Kt/V. The model's prediction of URR correlated closely with measured URR in 30 patients (r = 0.9987, p < 0.000001). This analytic approach showed that changes in each of several dialysis parameters caused divergence in the values of URR and Kt/V. The model showed that URR could be less than 0.65, while total Kt/V was greater than 1.2, whether or not KrU was present. In fact, when KrU was greater than 1. 0, URR could be less than 0.65, while Kt/V might be 2.0 or higher. On the other hand, the model showed instances where URR could be greater than 0.65, when Kt/V was less than 1.2. This occurred only when KrU was less than 1.0. To determine the prevalence of these anomalies in clinical practice, 767 kinetic modeling determinations were evaluated in 207 patients. One of the above discrepancies was observed at least once in 30.9% of the patients, representing 12.1% of all determinations. In addition, it was found that omitting KrU from the calculation of Kt/V generally leads to a Kt/V <1.2. This, when associated with a URR <0.65, could erroneously imply inadequate dialysis. The patient data are consistent with the view that URR and Kt/V are the net result of several variables that may act together or even in opposing directions. Based on this mathematical model and the observed clinical data, the use of URR alone to assess dialysis adequacy, or neglecting the contribution of KrU to Kt/V, may lead to changes in the dialysis prescription that are neither correct nor necessary.

Molecular metastases in stage I pancreatic cancer: improved survival with adjuvant chemoradiation.

BACKGROUND: Reports of improved survival rates for patients with resected adenocarcinoma of the pancreas coincide with the adoption of adjuvant chemoradiation protocols. The impact of nodal micrometastases demonstrated by molecular assays and adjuvant therapy on survival of patients with stage I pancreatic cancer has not been adequately assessed. METHODS: A retrospective analysis of postoperative chemoradiation on survival in 61 patients undergoing resection of pancreatic adenocarcinomas from 1984 to 1997 was performed. Archival tumors and regional nodes from 25 patients with stage I cancers were tested for a Kiras oncogene mutation using polymerase chain reaction and analysis for restriction fragment length polymorphisms (PCR/RFLP). RESULTS: Adjuvant chemoradiation was associated with improved survival for stage I (P < .01), but not stage III, disease. Seventeen (68%) of 25 patients with stage I disease tested had evidence of mutant Kiras in one or more regional nodes. Survival did not differ for patients with molecular micrometastases. Six of 17 (35%) patients with micrometastases received adjuvant chemoradiation and had improved survival (P < .05). CONCLUSIONS: The majority of patients with stage I pancreatic cancer have PCR/RFLP evidence of lymph node micrometastases. Adjuvant chemoradiation improves survival in these patients by treating micrometastases not detected by histology. Adjuvant chemoradiation should be used for patients with stage I pancreatic cancers.

Treatment of early-stage breast cancer in the elderly: a health-outcome-based approach.

PURPOSE: To evaluate the post-lumpectomy treatment of a nonpalpable, stage I, T1b tumor, mammographically detected, in a 74-year-old woman without comorbidities. METHODS: A Markov process, through 120 monthly cycles, was used to model patient progression through a treatment program, employing literature data and a health-outcome utility. Treatments considered were: observation; radiation totaling 5,000 cGy over six weeks; tamoxifen, 20 mg/day, for five years; simple mastectomy; and radiation therapy plus tamoxifen. Health states included absence of disease (NED), loco-regional recurrence, distant metastasis, age-sex-race (ASR)-adjusted death, cancer mortality, treatment complications, and post-mastectomy death. Transition probabilities were established from the literature. Health-state utilities were determined from the responses of health care professionals to a basic reference gamble. RESULTS: Quality-adjusted life years (QALYs) were determined to be 8.19 for radiation plus tamoxifen, decreasing to 8.04 for mastectomy, a difference of only a 0.15 years (1.8 months). Sensitivity analysis, however, showed relative stability in the ranking among treatment options. CONCLUSION: Although the model showed little difference between QALYs with the treatments, the combination of radiation and tamoxifen provides the optimal therapy for this case.

Biliary tree malignancies.

Radiation therapy is used as definitive treatment for unresectable bile duct tumors, or as adjuvant therapy after resection. External beam irradiation of 45-50 Gy is generally given whenever feasible. Intraluminal brachy-therapy is a useful technique to deliver higher doses of radiation to the tumor while respecting the tolerance of the surrounding normal tissues. Brachytherapy can be given at a high dose rate or low dose rate via an in-dwelling biliary drainage catheter to boost external beam doses. Brachytherapy alone is reserved for palliative therapy. Techniques should be implemented with care to make them not only effective but safe. The long-term efficacy and morbidity of this mode of radiation should be studied further. Only large prospective trials can lead to resolution of some of the questions yet unsolved in treatment of these challenging malignancies.

Lipophorin levels in the yellow fever mosquito, Aedes aegypti, and the effect of feeding.

High density lipophorin (HDLp) is the major lipid transport vehicle in insect hemolymph. Using an indirect ELISA, levels of HDLp were measured in the yellow fever mosquito, Aedes aegypti. The level of lipophorin, when normalized to the total weight of the insect, was similar in the different developmental stages. Starvation (access to water only) of adult females did not affect the level of HDLp nor its density when compared to sugar-fed females. On the other hand, blood feeding (of normally sugar-fed females) resulted in a three-fold increase of the HDLp level at 40 h after feeding. This increase was accompanied by a slight but significant increase in the density of HDLp at 24 h after feeding. Ingestion of a lipid-free protein meal or a lipid-supplemented protein meal induced changes in HDLp level and density that were comparable to those induced by ingestion of a blood meal. Ingestion of a blood meal, following starvation (access to water only) from the moment of adult emergence, did not induce an increase in HDLp level. The results presented indicate that, in contrast to other insect species, A. aegypti responds to an increased need for lipid transport in the hemolymph by increasing the amount of HDLp. Arch. Insect Biochem.

Quality assurance in anatomic pathology: automated SNOMED coding.

This case study details the set-up and implementation of the PathNet autocoder (Cerner Corporation) in a busy anatomic pathology laboratory. After initial start-up, procedures were developed to improve the system's performance. Four classes of software coding errors were identified, and an index was developed to measure the number of cases between errors (CBE). Through modifications in the program, the CBE increased sharply by the end of the six-month study period. During the last three months of the study, the efficiency of case retrieval was tested by comparing manual and electronic methods on the same reference cases. This demonstrated significant time saving and removed the variability of manual coding. The technique employed in this study may assist other institutions seeking to implement such a coding system within their respective environments.

Sequential test selection in the analysis of abdominal pain.

Numerous decision-making tools exist to assist physicians in diagnosis management. However, the accuracy of available clinical information is often ambiguous or unknown and current analytical models do not explicitly incorporate judgementally defined information. A model encompassing both physician judgment and probability analysis was developed to accommodate such data. A problem requiring sequential diagnostic testing was structured utilizing the analytic hierarchy process (AHP). The case presented involved a patient complaining of upper abdominal pain who, after initial evaluation, did not need immediate surgery. Physicians were faced with identifying the optimal sequence of diagnostic testing. The criteria used for test selection included minimizing risk, patient discomfort, and cost of testing and maximizing diagnostic capability. Although at the onset the "best" test choice was unknown, the clinical picture indicated four test alternatives: upper gastrointestinal series (GI), abdominal ultrasonography (US), abdominal computed tomography (CT), and upper gastrointestinal endoscopy (END). Based upon the relative preferences of the criteria utilized, the AHP analysis indicated that upper GI series was the optimal first test. Given a negative test, posterior probabilities were calculated using Bayes' theorem, resulting in a new estimate of diagnostic capability. The AHP analysis was reiterated, identifying abdominal ultrasonography as the optimal second test. This analysis may be repeated as many times as necessary. Sensitivity analysis demonstrated that changing criteria preferences may alter the choice of tests and/or their sequence.

Chronic gynecological conditions reported by US women: findings from the National Health Interview Survey, 1984 to 1992.

OBJECTIVES: This study sought to describe prevalence rates of chronic gynecological conditions and correlates of these conditions in a representative sample of US women. METHODS: National Health Interview Survey data from 1984 through 1992 for women aged 18 to 50 were used. RESULTS: The estimated annual prevalence rate for the reported presence of one or more gynecological conditions was 97.1 per 1,000 women. Menstrual disorders were most common, with an annual prevalence rate of 53.0 per 1,000 women. Adnexal conditions and fibroids were the next most common conditions, with rates per 1,000 women of 16.6 and 9.2, respectively. Prolapse, endometriosis, and fibroids were the conditions most likely to lead to hysterectomy within the year prior to the interview. More than three quarters (77.1%) of women with gynecological conditions had talked with a doctor in the previous year concerning their condition, and 28.8% reported spending 1 or more days in bed in the previous year because of their condition. CONCLUSIONS: Nearly a tenth of American women aged 18 to 50 report having one or more chronic gynecological conditions annually, the most common being disorders of menstruation.

Optimal interval for triple-lumen catheter changes: a decision analysis.

A survey of 53 university and community hospitals revealed that 73% of the institutions had no standard policy for the replacement of triple-lumen catheters (TLCs). Since the maintenance of a TLC in place for a prolonged period may lead to infectious complications, it appeared warranted that standards of management be developed. A decision-tree model was constructed for evaluating the optimal time for changing a TLC that would minimize infection. Cost estimates and health effects at three-, five-, and ten-day change intervals were considered for catheter insertion and complications resulting from such insertion. The results suggested that prophylactic catheter changes should occur no later than every five days, provided that there are no signs of infection. However, sensitivity analysis of several variables suggested that individual institutions should establish policy timing changes based upon careful interpretation of their own data. A model was developed to assist in determining the optimal time to change a TLC based upon such data.