Impact of perioperative chemotherapy on survival in patients with advanced primary urethral cancer: results of the international collaboration on primary urethral carcinoma.

BACKGROUND: To investigate the impact of perioperative chemo(radio)therapy in advanced primary urethral carcinoma (PUC). PATIENTS AND METHODS: A series of 124 patients (86 men, 38 women) were diagnosed with and underwent surgery for PUC in 10 referral centers between 1993 and 2012. Kaplan-Meier analysis with log-rank testing was used to investigate the impact of perioperative chemo(radio)therapy on overall survival (OS). The median follow-up was 21 months (mean: 32 months; interquartile range: 5-48). RESULTS: Neoadjuvant chemotherapy (NAC), neoadjuvant chemoradiotherapy (N-CRT) plus adjuvant chemotherapy (ACH), and ACH was delivered in 12 (31%), 6 (15%) and 21 (54%) of these patients, respectively. Receipt of NAC/N-CRT was associated with clinically node-positive disease (cN+; P = 0.033) and lower utilization of cystectomy at surgery (P = 0.015). The objective response rate to NAC and N-CRT was 25% and 33%, respectively. The 3-year OS for patients with objective response to neoadjuvant treatment (complete/partial response) was 100% and 58.3% for those with stable or progressive disease (P = 0.30). Of the 26 patients staged ≥cT3 and/or cN+ disease, 16 (62%) received perioperative chemo(radio)therapy and 10 upfront surgery without perioperative chemotherapy (38%). The 3-year OS for this locally advanced subset of patients (≥cT3 and/or cN+) who received NAC (N = 5), N-CRT (N = 3), surgery-only (N = 10) and surgery plus ACH (N = 8) was 100%, 100%, 50% and 20%, respectively (P = 0.016). Among these 26 patients, receipt of neoadjuvant treatment was significantly associated with improved 3-year relapse-free survival (RFS) (P = 0.022) and OS (P = 0.022). Proximal tumor location correlated with inferior 3-year RFS and OS (P = 0.056/0.005). CONCLUSION: In this series, patients who received NAC/N-CRT for cT3 and/or cN+ PUC appeared to demonstrate improved survival compared with those who underwent upfront surgery with or without ACH.

Complications of pelvic lymph node dissection for prostate cancer.

Pelvic lymph node dissection (PLND) represents the standard for detection of occult pelvic nodal metastases from prostate cancer, and may be performed separately from or at the time of radical prostatectomy. In addition to its potential for diagnostic staging, a PLND may be therapeutic in some patients. However, considerable debate centers on the appropriate candidates for the procedure, the extent and proper boundaries of dissection, optimal surgical approach, and absolute oncologic benefit. Several series suggest that there likely is limited benefit of PLND in low-risk patients and that PLND can be safely omitted in a high percentage of men undergoing contemporary radical prostatectomy. Furthermore, the value of PLND in patients with intermediate- and high-risk disease must be balanced against the potential morbidity of the procedure. In the setting of this debate, concern over morbidity directly attributable to this procedure is of paramount importance. This review focuses on the complications associated with PLND, including lymphocele, thromboembolic events, ureteral injury, nerve injury, vascular injury, and lymphedema.

The "dangerous multipara": fact or fiction?

OBJECTIVE: Our purpose was to compare the intrapartum complication incidence among grand multiparous women with that of age-matched control multiparous women. STUDY DESIGN: A total of 382 grand multiparous women (para > or = 5) were compared with 382 age-matched control subjects (para 2 to 4), all delivering between July 1989 and September 1991. Intrapartum complications classically associated with grand multiparity (abruptio placentae, dysfunctional labor, fetal malpresentation, postpartum hemorrhage, and shoulder dystocia) were compared. RESULT: Both groups had comparable antepartum complications and gestational ages at delivery. The overall intrapartum complication incidence for grand multiparous women was 33% (127/382 patients), not significantly different from that of the control multiparous women, 27% (103/382). Grand multiparity was associated with an increased incidence of macrosomia (16% vs 11%) and a decreased incidence of operative delivery (14% vs 21%). Macrosomia increased the incidence of intrapartum complications from 31% to 46% (p < 0.03) in the grand multiparous patients, and a trend was observed in the multiparous patients, from 26% to 37%. However, when properly controlled, this was noted to be a confounding variable and was not related to parity. CONCLUSIONS: In a largely Hispanic population grand multiparous patients do not have an increased incidence of intrapartum complications.

Effects of rotation discipline on medical student grades in obstetrics and gynecology throughout the academic year.

OBJECTIVES: Our purpose was to determine whether the sequence of rotation disciplines taken can effect medical student examination scores on the National Board of Medical Examiners Subject Exam score for obstetrics and gynecology. STUDY DESIGN: A retrospective study was conducted of 439 student files for the academic years 1987 through 1991. The final clerkship grades and subject examination scores for internal medicine, pediatrics, psychiatry, surgery, and obstetrics and gynecology were reviewed. RESULTS: It was determined that completion of internal medicine or surgery before obstetrics and gynecology yielded higher scores in obstetrics and gynecology (p < 0.00001), with the largest improvement (from 533 to 586) observed when obstetrics and gynecology followed the internal medicine rotation. CONCLUSION: The sequence of rotation can affect scores on the National Board of Medical Examiners subject examination in obstetrics and gynecology. The largest improvement in student scores was observed when obstetrics and gynecology followed the internal medicine or surgery clerkships.

Fetal choroid plexus cysts: an independent risk factor for chromosomal anomalies.

As a result of numerous conflicting reports, we designed a prospective controlled study to determine the inherent risk of aneuploidy with second-trimester fetal choroid plexus cysts. Our controls were patients who had ultrasonography and genetic amniocentesis, between 15 weeks and 22 weeks, menstrual age, by the same sonologist on the same day as a study subject with a choroid plexus cyst. Sixty-three cases of fetal choroid plexus cysts were detected in 3247 second-trimester examinations (1.9%). Six chromosomally abnormal fetuses [Trisomy 18 (3), Down syndrome (2), Klinefelter syndrome] were found in the cyst group (9.5%) with only one Trisomy 21 among the controls (0.5%) (p < .002). Of note, 5 of 21 (23.8%) fetuses with cysts greater than 5 mm in diameter had aneuploidy, as compared with only 1 of 42 (2.4%) chromosomal anomalies with smaller cysts (p < .02). We conclude that fetal choroid plexus cysts are an independent risk factor for chromosomal anomalies; genetic counseling and prenatal chromosomal analysis are indicated.

Hyperstimulation contraction stress tests: an evaluation of outcome by test pattern.

Contraction stress tests (CSTs) interpreted as equivocal, with hyperstimulated contractions accompanied by late decelerations (hyperstimulation CSTs), were analyzed by test pattern and outcome and compared to a control group with negative CSTs. Outcome was evaluated for subsequent abnormal CST, low Apgar score, the presence of meconium, and cesarean section for fetal distress. Patients with hyperstimulation CSTs and solitary late decelerations, and the remainder of the test interpretable as a negative CST, had the least morbidity. In both the presence and absence of 10-minute negative windows, patients with more than one late deceleration were at significantly higher risk for cesarean section for fetal distress than controls. It would seem warranted in the presence of hyperstimulation CSTs, therefore, to repeat the CST within 24 hours regardless of the presence of a negative window.

Quantitation of uterine activity preceding preterm, term, and postterm labor.

To assess uterine activity before labor in patients delivering preterm, at term, and postterm, the maximum spontaneous contraction frequency per 10-minute window during the initial portion of antepartum fetal heart rate monitoring was analyzed. Patients with multiple gestation, third trimester bleeding, polyhydramnios, or premature rupture of membranes and those already diagnosed with preterm labor were eliminated from the study. Of the 2446 remaining patients (7247 antepartum fetal heart rate tests) who went into spontaneous labor, 237 did so before 37 completed weeks of gestation, 1077 entered labor at term (38 to 42 completed weeks), and 1132 did so after 42 weeks. There was a significant increase in maximum uterine activity per 10-minute window from 30 to 44 weeks of gestation (average 4.7% per week; r = 0.97, p less than 0.0001). When compared with patients delivering spontaneously at term, average maximum uterine activity per 10-minute window was greatest in the preterm labor group (p less than 0.05) and least in the postterm labor group (p less than 0.05). These differences were present for several weeks preceding the onset of spontaneous labor. All three groups showed a surge of uterine activity during the 3 days before the onset of spontaneous labor.

The breast-stimulated contraction stress test.

A method was developed for using breast stimulation to induce uterine contractions for a contraction stress test (BSCST). Six hundred fifty-seven patients made 1,484 attempts with the BSCST and were successful in 1,072 trials (72.2%). A lower success rate was observed only in gestations less than or equal to 34 weeks. The distribution of test results (positive, negative, equivocal) by BSCST was unchanged from that of contraction stress tests performed with exogenous oxytocin (oxytocin challenge test [OCT]). The incidence of false-positive tests was similar to that in previous reports. The corrected perinatal mortality rate for the study population was 1.5 per 1,000 births. The time required for an adequate uterine response was 23.8 +/- 15.2 minutes, with 87.5% of patients responding in less than 30 minutes. The BSCST appears to be a reasonable alternative to the OCT, with elimination of the intravenous line and oxytocin administration and with a shorter testing time.

The nonstress test.

The NST has been used extensively in the management of high-risk pregnancies and has been a useful preliminary screening test. However, lack of standardization and multiple testing protocols have made comparisons of reports difficult. The high false-positive rate for protocols not extended for long periods have required back-up testing with other biophysical means whenever there is nonreactivity. Continued research is required to define "normal" reactivity. Meanwhile, ongoing investigations in the area of fetal stimulation may be helpful in arousing the non-reactive sleeping fetus. The benefit of the NST is in its simplicity. Busy practitioners can use it in the office, and large testing centers can screen greater numbers of patients in an effective manner. Given a reactive test, a high expectation of normal outcome is warranted. The false-negative rate, however, for diabetes, postdates, and IUGR, warrant twice-weekly testing. Attention to other baseline characteristics, such as bradycardia and minivariables, coupled with sequential NST evaluation should improve NPV by potentially diagnosing compromise earlier.

Effects of norepinephrine on lung fluid flow rate in the chronically catheterized fetal lamb.

The influence of norepinephrine on lung fluid flow rate was studied in seven chronically catheterized fetal lambs. Lung fluid was collected through a catheter inserted into the fetal trachea. In six experiments, continuous saline solution infusion for 1 hour followed by equivolumnar norepinephrine (3.0 micrograms/min) for 1 hour via the fetal jugular vein was carried out. In three additional experiments (two fetuses), a 3.0 mg intravenous bolus of propranolol was administered before norepinephrine infusion. Saline solution infusion did not influence the lung fluid flow rate or fetal biophysical and biochemical parameters. Norepinephrine increased fetal blood pressure by 22% and decreased lung fluid flow by 45% from control values. Lung fluid flow rate recovered within 2 hours after the end of the norepinephrine infusion. Pretreatment with propranolol did not alter the results. In addition to previous reports that demonstrated beta-sympathomimetic agonist-enhanced reabsorption of lung fluid from fetal alveolar epithelial cells, our present results suggest that a reduction in fetal lung fluid secretion may be implemented as well through stimulation of alpha-sympathomimetic receptor sites in the pulmonary vasculature.

A randomized trial of ritodrine tocolysis versus expectant management in patients with premature rupture of membranes at 25 to 30 weeks of gestation.

Expectant management was compared with similar management plus ritodrine tocolysis in a randomized controlled trial in patients with premature rupture of membranes at 25 to 30 weeks of gestation. In the tocolysis group intravenously administered ritodrine was instituted at the onset of labor and then changed to the oral form if successful. Tocolysis was discontinued or not instituted after 31 weeks of gestation. Seventy-nine patients were randomized over a 4-year period, 39 in the tocolysis group and 40 in the expectant group. Twenty-three patients in the tocolysis group actually received ritodrine. No difference between the two groups was demonstrated in the interval between premature rupture of membranes and delivery or in reaching 32 weeks of gestation. No statistical difference was seen in maternal morbidity. Birth weights and gestational ages at delivery were similar between the two groups as were the incidences of neonatal morbidities caused by prematurity and infection and in the duration of neonatal hospital stays. Despite being conducted in those gestational ages in which prolongation of pregnancy might be expected to be of most benefit, no difference could be demonstrated with the addition of tocolytic therapy over expectant management alone.

A prospective evaluation of nipple stimulation techniques for contraction stress testing.

Nipple stimulation techniques for achieving a contraction stress test were evaluated prospectively in 1271 nipple stimulation contraction stress tests in 753 patients. Success was unrelated to parity, gestational age, or warm, moist towels but was related to the presence of spontaneous prestimulation contractions. Various stimulation techniques were equally successful in achieving a completed test in the presence of prestimulation contractions; however, continuous stimulation was more successful when contractions were absent. Hyperstimulation test results occurred in 21.5% of attempts and increased to 28.8% when bilateral, continuous stimulation was performed.

Effect of arginine vasopressin on arterial oxygen partial pressure in the chronically catheterized fetal lamb.

Fetal plasma 2,3-Diphosphoglycerate (2,3-DPG) and glucose levels were observed during infusion of arginine vasopressin into 6 chronically catheterized fetal lambs. Low dose infusion of arginine vasopressin (5-10 mIU/min.) did not change fetal arterial blood gases significantly. At a high concentration of vasopressin (20-40 mIU/min.), infusion for 60 minutes increased fetal arterial pO2 by approximately 5 mmHg (p less than 0.005 by paired t-test), and decreased pCO2 by approximately 2 mmHg (p less than 0.005 by paired t-test) without significant changes in pH. Neither low nor high dose infusion of arginine vasopressin was accompanied by significant changes in 2,3-DPG or the glucose level.

Abnormal fetal heart rate pattern associated with severe intrapartum maternal ethanol intoxication. A case report.

Acute intrapartum ethanol intoxication occurred in a chronic ethanol abuser. Continuous fetal heart rate monitoring revealed a pattern of fetal tachycardia, decreased variability and late and variable decelerations in association with a maternal serum ethanol level of 300 mg/dL. This case gives evidence of an association between very high maternal serum ethanol levels and acute fetal distress.

Obstetric characteristics and fetal heart rate patterns of infants who convulse during the newborn period.

Seizure activity in the immediate neonatal period has been shown to correlate with long-term neurological handicap. The perinatal course of 34 term and 32 preterm infants who developed seizure activity in the neonatal period was compared to that of 66 matched control infants without neonatal seizure activity. The incidence of antenatal complications and abnormal fetal heart rate patterns and the percentages of abnormal labor, operative delivery, and low Apgar scores were significantly greater in the study infants than in the control infants. Earlier onset of seizure activity was seen in term versus preterm infants and term infants with abnormal versus normal fetal heart rate patterns. Management decisions regarding intervention or nonintervention based on fetal heart rate patterns were deemed appropriate in 31 of 34 term infants, yet short- and long-term neurological sequelae were significant.

Use of fetal scalp hematocrit in the diagnosis of severe hemorrhage from vasa previa.

Described in a case in which a timely diagnosis of severe fetal anemia from bleeding vasa previa was made with the aid of a fetal scalp hematocrit. This technique can be used in patients in labor when bleeding vasa previa is suspected, and scalp sampling is feasible.