Sexual function status after adjuvant radiation including vaginal cuff brachytherapy in survivors of cancer cervix.

CONTEXT: Adjuvant radiation therapy plays an important role in the management of high-risk cervical cancer after radical hysterectomy or inadvertent hysterectomy. The prime concern with the use of dual modality is steep decline in sexual well-being in cervical cancer survivors. Intravaginal brachytherapy (IVBT) delivered by vaginal cylinder or ovoids is essential for local control but at the cost of impairment of sexual function. AIM: The purpose of this study was to assess the sexual well-being of cervical cancer survivors, who underwent surgery followed by adjuvant radiation and compare the subgroups of ovoids with sorbo brachytherapy. SETTINGS AND DESIGN: This was an observational, cross-sectional, and analytical study, whereby we evaluated sexual function of cervical cancer survivors by the Female Sexual Function Index (FSFI) instrument. SUBJECTS AND METHODS: Seventy-five women, identified as cervical cancer survivors who had received adjuvant radiation and IVBT, were administered FSFI questionnaire in face-to-face interviews. RESULTS: The mean age of 75 interviewed women was 48.64 years. Fifty survivors had received IVBT with a sorbo applicator and twenty-five with ovoids. FSFI full score ranged from 4.4 to 32.40. The mean full score for the whole group was 11.3. The mean FSFI full score was 24.91 (± standard deviation [SD] 5.71) in the ovoid group versus 4.49 (± SD 0.35) in the sorbo group. On Pearson's correlation analysis, age and type of brachytherapy were significantly correlated with FSFI full score (P = 0.006) with correlation coefficient of - 0.312 and - 0.948, respectively. CONCLUSIONS: Sexual dysfunction was found prevalent in 83% of cervical cancer survivors. The patients treated with IVBT with sorbo had worse sexual functioning than those treated with ovoids.

A Case of Acute Colonic Pseudo-Obstruction (Ogilvie's Syndrome) in a Nonsurgical Patient with Plasma Cell Leukemia.

Ogilvie's syndrome, also known as acute colonic pseudo-obstruction (ACPO), is a rare, nonobstructive dilation of the colon of unclear etiology. We present the case of a patient who presented with Ogilvie's syndrome and significant hypokalemia due to colonic loss despite repletion. This case report demonstrates the difficulty in diagnosis, treatment, and outcome.

Post-implementation Review of the Himalaya Home Care Project for Home Isolated COVID-19 Patients in Nepal.

Background: The emergence of coronavirus disease 2019 (COVID-19) has resulted in a pandemic that has significantly impacted healthcare systems at a global level. Health care facilities in Nepal, as in other low- and middle-income countries, have limited resources for the treatment and management of COVID-19 patients. Only critical cases are admitted to the hospital resulting in most patients in home isolation. Methods: Himalaya Home Care (HHC) was initiated to monitor and provide counseling to home isolated COVID-19 patients for disease prevention, control, and treatment. Counselors included one physician and four nurses. Lists of patients were obtained from district and municipal health facilities. HHC counselors called patients to provide basic counseling services. A follow-up check-in phone call was conducted 10 days later. During this second call, patients were asked about their perceptions of the HHC program. Project objects were: (1) To support treatment of home isolated persons with mild to moderate COVID-19, decrease burden of hospitalizations, and decrease risks for disease transmission; and, (2) To improve the health status of marginalized, remote, and vulnerable populations in Nepal during the COVID-19 pandemic. Results: Data from 5823 and 3988 patients from May 2021-February 2022 were entered in initial and follow-up forms on a REDCap database. The majority of patients who received counseling were satisfied. At follow-up, 98.4% of respondents reported that HHC prevented hospitalization, 76.5% reported they could manage their symptoms at home, and 69.5% reported that counseling helped to limit the spread of COVID-19 in their household. Conclusions: Telehealth can be an essential strategy for providing services while keeping patients and health providers safe during the COVID-19 pandemic.

Novel methods of predicting ionized calcium status from routine data in critical care: External validation in MIMIC-III.

BACKGROUND: Low ionized calcium (ICa) is prevalent and prognostic in critical care, but poorly detected by either total calcium (TCa) or albumin-corrected TCa (cTCa). We recently derived models of ICa (Pred-ICa) and low ICa (ProbHYPO) in critical care that adjust TCa for binding to albumin and small anions-represented by the anion gap's components. On internal validation, they outperformed cTCa in diagnosing low ICa. Two other new anion gap-based models of ICa, derived in renal patients, have not been validated. This study tested the external validity of these 4 new models in the Medical Information Mart for Intensive Care III (MIMIC-III) database. METHODS: We identified 4105 patients in MIMIC-III with ICa measured on an arterial blood gas panel within 20 min of chemistry panel measurements of TCa, albumin, sodium, chloride, and total carbon dioxide. The 4 models and cTCa were assessed by their diagnostic discrimination for low ICa (<1.10 mmol/l) and high ICa (>1.32 mmol/l), and by the agreement between predicted and observed values. RESULTS: Pred-ICa and ProbHYPO had the best discrimination and agreement. CONCLUSIONS: Pred-ICa and ProbHYPO were externally validated in MIMIC-III. They can help clinicians efficiently decide when to order direct ICa testing in critical care.

Evaluation of metastatic neck nodes search for primary and subsequent management.

Background: Cancers in the head-and-neck region are the sixth most common cancers worldwide with an increasing incidence in developing countries. Methods: This study was carried out in the department of ENT and head-and-neck surgery in collaboration with the department of radiotherapy for a period of 1 year extending from May 01, 2014, to April 30, 2015. A total of 48 cases of metastatic secondary nodes were included in the study. Results: The male-to-female ratio in the present study was 4.33:1. Maximum number of patients were seen in the seventh decade. The youngest patient was a female 30 years old and the oldest was a male of 80 years. About 95.84% of primary tumors were squamous cell carcinomas and 40.47% of the patients of head-and-neck cancer with metastatic lymph nodes had well-differentiated squamous cell carcinomas. Majority of cases presented with N2 nodes, while N1 nodes were highest in cases of carcinomas larynx. Conclusions: Metastatic neck disease is a major problem in patients with head-and-neck cancer. The therapeutic goal includes not only known disease but also the elimination of possible subclinical disease. The judicious use of moderate doses of irradiation and modified surgical procedures should be used in specific clinical situations to significantly decrease neck recurrences while eliminating morbidity.

Predicting ionized hypocalcemia: External validation of an ionized calcium prediction model in patients with COVID-19 and renal failure.

BACKGROUND: Ionized hypocalcemia is common in critically ill patients with COVID-19 and is associated with adverse outcomes. We previously developed a linear model that estimates ionized calcium (ICa) by adjusting total calcium (TCa) for the three components of the anion gap and albumin. On internal validation, it outperformed the popular method that corrects TCa for albumin alone (cTCa) in diagnosing low ICa. In this study, we sought to externally validate our ICa model in hospitalized COVID-19 positive patients. METHODS: We retrospectively studied all 200 patients with COVID-19 who were admitted to the State University of New York Downstate Medical Center between March 11th and April 30th 2020 and referred to the nephrology service for renal failure, and who had ICa measured on a venous blood gas within 25 min of a comprehensive metabolic panel. We compared the performance of the ICa model and cTCa in diagnosing low ICa by ROC analysis, and also examined the accuracy of the absolute values predicted by the two methods relative to measured ICa. RESULTS: On ROC analysis, the ICa model was better than cTCa (area under ROC curve: 0.872 [0.025] vs. 0.835 [0.028]; p = 0.045). The ICa model estimated ICa accurately, but the cTCa method seemed to overcorrect TCa, as a substantial number of patients with clearly normal cTCa values had low ICa. CONCLUSIONS: In an external validation cohort, the ICa model estimated ICa accurately and was better than cTCa in the diagnosis of low ICa. This finding can be useful in guiding direct ICa testing.

The Implication of Dropping Race from the MDRD Equation to Estimate GFR in an African American-Only Cohort.

The widely used Modification of Diet in Renal Disease (MDRD) formula adapts a 1.212 multiplier for individuals who are identified as African Americans (AAs) or Blacks, which leads to a higher GFR estimation. As it stands, AAs have a lower prevalence of chronic kidney disease (CKD) but higher incidence of end-stage renal disease (ESRD) compared with Whites. Many hypotheses have been postulated to explain this paradox, but the imprecision of the GFR estimation with race-adaptation could be contributory. We performed a single-center, longitudinal, retrospective study on a cohort of outpatient AA patients using the MDRD and MDRDrace removed and CKD-EPI and CKD-EPIrace removed and their progression to CKD G5 (eGFR <15 ml/min/1.73 m2). 327 patients were analyzed. Median follow-up was 88.1 months (interquartile range, 34.4-129.1). When race was removed from MDRD, 39.9% of patients in CKD G1/2 were reclassified to CKD G3a, 72.6% of patients in CKD G3a would be reclassified to CKD G3b, and 54.1% and 36.4% of patients would be reclassified from CKD 3b to CKD G4 and CKD G4 to CKD G5, respectively (p < 0.0001). Comparing the CKD-EPI formula against the MDRD in our cohort, we found that 8.2%, 18.8%, and 11.4% of patients were reclassified from CKD G1/2 to CKD G3a, CKD G3a to G3b, and CKD G3b to CKD G4 respectively. Overall median time to progression to CKD G5 was 137.4 (131.9-142.8) months in patients who were not reclassified and 133.6 (127.6-139.6) months for patients who were reclassified by MDRDrace removed(p < 0.288). Concerns of inequitable access to healthcare have elicited calls to review race-corrected eGFR equations. A substantial number of individuals would have their CKD stage reclassified should have the MDRDrace removed equation be adopted en masse on an AA-only population. The discrepancy is highest at the 45-59 and >60 ml/min/1.72 min2 ranges. This will have tremendous impact on our center's approach to pharmacological dosing, referral system, best practices, and outcome surveillance. Comprehensive review of the current "race-corrected" eGFR will require a multifaceted approach and adjunctive use of noncreatinine-based approach.

Diagnosis and management of tumor lysis syndrome.

Tumor lysis syndrome (TLS) is an oncological emergency characterized by a classic tetrad of hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia. Risk assessment and prophylactic therapy is critical in preventing this oncological emergency. Treatment of established TLS involves aggressive hydration, electrolyte management, and the use of hypouricemic agents.

Intestinal dialysis for conservative management of Uremia.

PURPOSE OF REVIEW: Renal replacement therapies, such as hemodialysis are invasive and impose significant financial burden as well as burden on quality of life. Conservative and 'gentler' forms of renal replacement therapy for the frail and palliative care patient is an unmet medical need. RECENT FINDINGS: The treatment of uremia using the gut as a substitute for the kidney has been proposed but is not practiced widely because of proven lack of long-term mortality benefit coupled with complications like edema and hyperchloremia. Mounting evidence showed that endotoxins from gastrointestinal tract are a major source of chronic inflammation in chronic kidney disease (CKD). The high load of nitrogenous waste elimination through the bowel could potentially serve as an alternative modality to remove uremic wastes especially in people who opt for conservative management for end-stage renal disease with some recent studies in Iran and China showing promising benefits in uremia. SUMMARY: In this review, we will discuss the history, recent evidence and potential of these therapies and their implications in CKD for conservative and easy management of uremia.

A System for Accurate Tracking and Video Recordings of Rodent Eye Movements using Convolutional Neural Networks for Biomedical Image Segmentation.

Research in neuroscience and vision science relies heavily on careful measurements of animal subject's gaze direction. Rodents are the most widely studied animal subjects for such research because of their economic advantage and hardiness. Recently, video based eye trackers that use image processing techniques have become a popular option for gaze tracking because they are easy to use and are completely noninvasive. Although significant progress has been made in improving the accuracy and robustness of eye tracking algorithms, unfortunately, almost all of the techniques have focused on human eyes, which does not account for the unique characteristics of the rodent eye images, e.g., variability in eye parameters, abundance of surrounding hair, and their small size. To overcome these unique challenges, this work presents a flexible, robust, and highly accurate model for pupil and corneal reflection identification in rodent gaze determination that can be incrementally trained to account for variability in eye parameters encountered in the field. To the best of our knowledge, this is the first paper that demonstrates a highly accurate and practical biomedical image segmentation based convolutional neural network architecture for pupil and corneal reflection identification in eye images. This new method, in conjunction with our automated infrared videobased eye recording system, offers the state of the art technology in eye tracking for neuroscience and vision science research for rodents.

Cytoreductive surgery for advanced or recurrent endometrial cancer: a meta-analysis.

OBJECTIVE: To determine the relative effect and quantify the impact of multiple prognostic variables on median overall survival time among cohorts of patients with advanced or recurrent endometrial cancer undergoing cytoreductive surgery. METHODS: Fourteen retrospective cohorts with advanced or recurrent endometrial cancer (672 patients) meeting study inclusion criteria were identified. Univariate analysis was used to assess the effect on median overall survival time of multiple variables. The limited number of studies available made multivariate analysis impractical. RESULTS: Statistically significant clinical variables associated with median overall survival time were the proportion of patients undergoing complete surgical cytoreduction, adjuvant radiation, or receiving adjuvant chemotherapy. Cohort median overall survival time was positively associated with increasing proportion of patients undergoing complete surgical cytoreduction (each 10% increase improving survival by 9.3 months, p=0.04) and receiving post-operative radiation therapy (each 10% increase improving survival by 11.0 months, p=0.004), while an increasing proportion of patients receiving chemotherapy was negatively associated with survival (each 10% increase decreasing survival by 10.4 months, p=0.007). CONCLUSIONS: The current analysis suggests that among patients with advanced or recurrent endometrial cancer, complete cytoreduction to no gross residual disease is associated with superior overall survival outcome. The unexpected correlation between treatment modality and survival may be a surrogate marker for more precise factors such as location of disease, performance status, or cytoreductive status post-operatively, which may have influenced the decision to administer adjuvant radiation versus chemotherapy and were not able to be controlled for given the limitations of the extracted data.

Analysis of contemporary trends in access to high-volume ovarian cancer surgical care.

BACKGROUND: Positive volume-outcome relationships exist for cancers treated with technically complex surgery, including ovarian cancer. However, contemporary patterns of primary surgical care for ovarian cancer according to hospital and surgeon case volume remain poorly defined. METHODS: The Maryland Health Service Cost Review Commission database was accessed for annual hospital and surgeon primary ovarian cancer surgical case volume for 2001-2008 and evaluated for statistically significant trends in access to high-volume surgical care compared with the earlier period for 1990-2000. chi(2) and logistic regression analyses were used to evaluate for significant trends in case volume distribution over time as well as factors associated with access to high-volume care. RESULTS: Overall, 2,475 primary ovarian cancer operations were performed by 472 surgeons at 43 hospitals. There was a statistically significant increase in the proportion of cases performed at high-volume centers from 22.8% in 1990-2000 to 61.1% in 2001-2008 (odds ratio = 5.30, 95% confidence interval = 4.68-6.00, P < .0001), while low-volume hospital case distribution decreased from 49.6 to 31.3%. Access to high-volume surgeons increased from 34.5% in 1990-2000 to 64.5% in 2001-2008 (odds ratio = 3.44, 95% confidence interval = 3.06-3.87, P < .0001), while the proportion of cases performed by low-volume surgeons decreased from 56.3 to 28.9%. After controlling for other variables, high-volume surgeons were significantly more likely to perform ovarian cancer surgery that included hysterectomy and staging/cytoreductive surgical procedures. CONCLUSIONS: The proportions of ovarian cancer patients undergoing primary surgery at high volume centers and by high-volume surgeons increased statistically significantly from 1990-2000 to 2001-2008. Further investigation is necessary to determine factors contributing to this favorable trend.

Characteristics of obstetric intensive care unit admissions in New Jersey.

OBJECTIVE: To assess the demographic characteristics, risk factors and perinatal outcomes among maternal intensive care unit (ICU) admissions in New Jersey from 1997 to 2005. METHODS: Data were obtained from a perinatal linked database from MCH epidemiology programme in New Jersey. Chi-square test was used for bivariate analysis and stepwise logistic regression was used to assess the influence of the potential risk factors and pregnancy complications. RESULTS: There were 15,447 (1.54%) ICU admissions and 23 maternal deaths (0.15%) among the 1,004,116 pregnancies. Analysis of demographic factors revealed that maternal age, race and smoking were significantly associated with ICU admission. Regression analysis adjusting for maternal age, parity, gravida, race, smoking status, maternal education and place of delivery found the following predictors for ICU admission, preeclampsia (odds ratio (OR): 2.8, 95% confidence interval (CI): 2.6-3.0), eclampsia (OR: 6.8, 95% CI: 5.4-8.6), placenta previa (OR: 3.0, 95% CI: 2.7-3.4), abruption (OR: 8.9, 95% CI: 8.3-9.6), multifetal pregnancy (OR: 4.2, 95% CI: 4.1-4.4), diabetes (OR: 3.1, 95% CI: 2.7-3.5), acute renal failure (OR: 22.1, 95% CI: 13.3-36.6) and cesarean delivery (OR: 1.9, 95% CI: 1.5-2.4). Infants born to ICU admitted mothers had higher rates of NICU admission, neonatal intubations and lower Apgar scores compared with infants born to non-ICU admitted mothers. CONCLUSION: Pregnancy complications are predictive of ICU admission amongst pregnant patients after adjusting for demographic factors.

Amniotic fluid embolism-risk factors, maternal and neonatal outcomes.

OBJECTIVE: To investigate demographic characteristics, risk factors, maternal and neonatal outcomes of all cases of amniotic fluid embolism that occurred in New Jersey during 1997-2005. METHODS: Information was derived from a perinatal linked dataset provided by the MCH-Epidemiology Program in the New Jersey Department of Health. Bivariate analysis for dichotomous variables used the Chi-square test. Stepwise logistic regression models were created to assess the influence of potential risk factors and p value < 0.05 considered statistically significant. RESULTS: Forty-five cases of amniotic fluid embolism were identified among 1,004,116 deliveries, for a prevalence rate of 1 in 22,313 pregnancies. Statistically, significant association was found with multifetal pregnancy, caesarean section, placenta previa, placental abruption, eclampsia and cervical laceration. The rate of maternal complications such as coagulopathy, seizures, neurological damage, shock and cardiac arrest were significantly greater in the cases as compared with the overall study population. Neonatal morbidity was significant as demonstrated by higher NICU admissions and neonatal intubation rates and lower 5-min Apgar scores. CONCLUSIONS: Significant correlation was identified between historically reported risk factors and amniotic fluid embolism. The fetal and maternal mortality rates were lower compared with previous studies, attributed both to improvements in perinatal healthcare and reporting of 'milder' cases.

Adenocarcinoma in situ of the uterine cervix: a metaanalysis of 1278 patients evaluating the predictive value of conization margin status.

OBJECTIVE: We sought to determine the value of conization margin status in predicting residual and recurrent adenocarcinoma in situ (ACIS) of the cervix. STUDY DESIGN: In all, 33 studies (1278 patients) were identified. Metaanalysis with pooled Mantel-Haenszel odds ratio (OR) was used to compare the risk of residual and recurrent disease according to margin status. RESULTS: A repeated excisional procedure was performed in 607 patients; a positive conization margin was associated with a significant increase in the risk of residual disease (OR, 4.01; 95% confidence interval [CI], 2.62-6.33; P < .001). Of the 671 patients followed up with surveillance only, 2.6% with negative margins and 19.4% with positive margins developed a recurrence (OR, 2.48; 95% CI, 1.05-6.22; P < .001). Invasive adenocarcinoma was more commonly associated with positive margins (5.2%) compared with negative margins (0.1%). CONCLUSION: After conization for ACIS, patients with positive margins are significantly more likely to have residual or recurrent disease, whereas those with negative margins may be treated conservatively.

Cytoreductive surgery for recurrent ovarian cancer: a meta-analysis.

OBJECTIVE: To determine the relative effect of multiple prognostic variables on overall post-recurrence survival time among cohorts of patients with recurrent ovarian cancer undergoing cytoreductive surgery. METHODS: Forty cohorts of patients with recurrent ovarian cancer (2019 patients) meeting study inclusion criteria were identified from the MEDLINE database (1983-2007). Simple and multiple linear regression analyses, with weighted correlation calculations, were used to assess the effect on median post-recurrence survival time of the following variables: year of publication, age, disease-free interval, localized disease, tumor grade and histology, the proportion of patients undergoing complete cytoreductive surgery, requirement for bowel resection, and the sequence of cytoreductive surgery and salvage chemotherapy. RESULTS: The mean weighted median disease-free interval prior to cytoreductive surgery was 20.2 months, and the mean weighted median overall post-recurrence survival time was 30.3 months. The weighted mean proportion of patients in each cohort undergoing complete cytoreductive surgery was 52.2%. Median survival improved with increasing year of publication (p=0.009); however, the only statistically significant clinical variable independently associated with post-recurrence survival time was the proportion of patients undergoing complete cytoreductive surgery (p=0.019). After controlling for all other factors, each 10% increase in the proportion of patients undergoing complete cytoreductive surgery was associated with a 3.0 month increase in median cohort survival time. CONCLUSIONS: Among patients undergoing operative intervention for recurrent ovarian cancer, the proportion of patients undergoing complete cytoreductive surgery is independently associated with overall post-recurrence survival time. For this select group of patients, the surgical objective should be resection of all macroscopic disease.