The impact of expanding gynecologic oncology care to ovarian cancer patients in small cities and rural communities.

OBJECTIVE: Patients with ovarian cancer from smaller cities and rural communities face unique challenges in accessing comprehensive care. This study compares management strategies, outcomes, and access to care for patients in a small city and surrounding rural communities before and after establishing a full-time gynecologic oncology (GO) office. METHODS: A local tumor registry was used to identify patients diagnosed with ovarian cancer before and after a full-time GO office was established. Quantitative analyses were used to compare disease characteristics, management strategies, overall survival, and distance traveled for care between cohorts. RESULTS: Out of 381 patients, 171 women were diagnosed prior to establishing a full-time GO office (pre-GO) and 210 after (post-GO). Post-GO patients were more likely to undergo surgery by a GO specialist (97.1% versus 53.2%, p < 0.01), receive surgery locally (79.0% versus 43.3%, p < 0.01), and undergo complete lymph node dissection (63.3% versus 38.6%, p < 0.01). Patients treated with chemotherapy by GO increased from 10.3% pre-GO to 76.9% post-GO. 5-year survival rates were 33.8% versus 49.5% in the pre-GO and post-GO groups, respectively (p < 0.01). Median survival time increased from 30.8 months to 52.5 months from pre-GO to post-GO time periods. Distance patients traveled for surgery decreased from a mean of 47.9 miles pre-GO to 26.8 miles post-GO. CONCLUSION: After establishing a full-time GO office within a small city, local patients had significantly improved overall survival and access to care. These results highlight the benefit of expanding GO care into small cities with surrounding rural communities and may be used to address public health discrepancies for women across the country.

Cervical cancer recurrence presenting as abdominal wall mass and accompanying cellulitis.

BACKGROUND: Most recurrences of early stage cervical cancer occur in the pelvis or lymphatic system. Distant metastases occur in a minority of patients. Large abdominal wall recurrence presenting as cellulitis and intra-abdominal mass is unusual and presents diagnostic as well as treatment challenges. CASE: A 46-year-old woman with a history of stage 1B1 poorly differentiated squamous cell carcinoma of the cervix 2 years earlier presented with infraumbilical abdominal wall erythema, tenderness and warmth to the touch. She had a subcutaneous mass in that area with associated abdominopelvic pain. Imaging showed a 9.5 × 11 cm lobulated mass in the anterior lower abdominal wall, encompassing the width of the lower rectus muscles also invading the small bowel and the bladder. Superimposed cellulitis led to the symptoms with which she presented. She was treated with intravenous antibiotics, and biopsy of the mass revealed squamous cell carcinoma consistent with her prior cervical cancer. She was treated with neoadjuvant chemotherapy followed by surgical debulking with negative margins and adjuvant chemotherapy. Three months after completing treatment she recurred in the inguinal lymph nodes and restarted multimodality treatment. She was without evidence of disease for the entire 18 months of follow up following treatment to the lymph nodes. CONCLUSION: Cervical cancer recurrence patterns can be unique. Surveillance for recurrence may also include consideration of these unusual patterns of recurrence.

Loperamide Abuse and Its Sequelae.

INTRODUCTION: Loperamide is an opioid available over the counter and in prescription form. Loperamide functions as a µ-agonist within the enteric nervous system to slow intestinal motility. Its antidiarrheal properties and primarily peripheral activity make loperamide an important tool in the management of inflammatory bowel disease. CASE REPORT: A 42-year-old man was found unconscious in cardiac arrest, and emergency medical personnel restored normal sinus rhythm. Family reported complaints of abdominal pain and that he "went through a lot" of loperamide. In the emergency department, the patient exhibited symptoms consistent with an opioid overdose. Mental status improved after administration of naloxone, an opioid antagonist. An electrocardiogram revealed a prolonged QTc interval, which progressed into Torsades de Pointes rhythm during admission. The patient succumbed from hypoxic brain injury, and there was evidence of acute pancreatitis at autopsy. Loperamide and desmethylloperamide (loperamide metabolite) were detected in blood samples. Cause of death was ruled loperamide toxicity. DISCUSSION: Because of reduced central nervous system activity and associated euphoria at therapeutic doses, loperamide abuse is rarely reported. This case demonstrates that an overdose on loperamide can occur in patients seeking symptom alleviation, and may mimic the presentation of opioid overdose.