Postoperative spinal cord infarction on a gravid woman with suspected IV drug use: a case report.

BACKGROUND: Back pain is common in the gravid population and spinal cord infarction (SCI) or chronic osteomyelitis are exceptionally rare underlying causes of back pain in this population. No case report to date has described this unexpected adverse event in a gravid woman with suspected history of IV drug use (IVDU). This diagnosis could potentially become more common with increasing rates of IVDU, and increased education could result in sooner recognition. CASE: A 38 year old G9P0171 at 24 weeks gestation with a complex past medical history, and a suspected history of IVDU, presented repeatedly with back pain. Following cesarean delivery at 36w2d, she developed signs and symptoms of an anterior spinal artery syndrome (ASAS) and had evidence of chronic osteomyelitis at T9-T10 on imaging. This required emergent decompressive laminectomy and ultimately resulted in paraplegia. CONCLUSION: This case highlights the difficulties in recognizing all SCI risk factors pre-operatively and the importance of investigating back pain in pregnant patients with a suspected history of IVDU. We believe this patient's chronic infection put her at an increased risk for SCI that was possibly compounded by the anatomical changes from its chronicity, possibly occurring in combination with several other precipitating causes of hypoperfusion. We hope this case report highlights the modern necessity to include a history, or suspected history, of IVDU as a red flag to initiate imaging in pregnant patients with acute, persistent, or unresolved back pain.

Contemporary Incidence of Medical Inoperability in Clinical Stage I Endometrial Cancer.

BACKGROUND: Minimally invasive surgical (MIS) staging is the standard treatment approach for clinical stage I endometrial cancer. Historical rates of inoperability in endometrial cancer are approximately 10%. Given surgical and medical advancements against increasing population obesity, we aimed to describe a contemporary incidence of medical inoperability in clinical stage I endometrial cancer. PATIENTS AND METHODS: Patients diagnosed with clinical stage I endometrial cancer of any histology from April 2014 to December 2018 were included in this retrospective cohort study. The primary outcome, medical inoperability, was defined as (1) patients deemed inoperable by a gynecologic oncologist at initial consultation, (2) patients deemed inoperable during preoperative clearance, or (3) an aborted hysterectomy. Fisher's exact or χ2, and Student's t-test or Wilcoxon rank sum test were used, as appropriate, for data analysis. Multivariable logistic regression was also employed. RESULTS: Overall, 767 patients were included, of which 4.6% (35/767) were determined to be inoperable. The inoperable group had a higher body mass index (52.7 vs. 33.9, p < 0.001), and increased rates of diabetes (62.8%, 22/35 vs. 27.1%, 199/732, p < 0.001), coronary artery disease (31.4%, 11/35 vs. 7.1%, 52/732, p < 0.001), and hypertension (94.3%, 33/35 vs. 70.2%, 514/732, p < 0.001). Of those with attempted surgical staging, hysterectomy was aborted intraoperatively in 0.68% (5/737). The overall complication rate was 11.6% (86/737). CONCLUSIONS: With maximal surgical effort and MIS, hysterectomy is possible in > 95% of patients with newly diagnosed endometrial cancer treated at a high-volume center. Complication rates were comparable to other trials evaluating the safety of MIS staging for endometrial cancer.

Clinical Perspective Concerning Abdominal Entry Techniques.

OBJECTIVE: Entry into the abdomen during operative laparoscopy is a source of some controversy regarding the safest and most useful method. The objective of this review is to describe, compare, and contrast the most popular entry techniques. DATA SOURCES: Data were collected from the historical starting point until present day from English language journal articles and book chapters. METHODS OF STUDY SELECTION: Descriptive accounts dating back to the start of laparoscopy in the 1970s and spanning to present day well-designed randomized controlled trials and Cochrane reviews were compiled to evaluate the evidence for the effectiveness and safety of abdominal entry techniques. TABULATION, INTEGRATION, AND RESULTS: The most common sites of entry are the umbilicus and the left upper quadrant. Between the Veress needle, direct trocar insertion, and open entry there is no high-quality evidence to suggest that any of these offers a universal safety advantage. The Veress needle is still the most used among gynecologists and facilitates primary trocar placement. Direct trocar entry under laparoscopic visualization may be underused, is faster, and may result in fewer failed entries. Open (Hasson) entry can be more technically challenging, but may be best for patients with suspected intra-abdominal adhesions. CONCLUSION: Surgeon comfort is critical in choosing the entry site, method, and equipment. Surgeon familiarity with entry-failure troubleshooting, possible complications, and management is essential because major entry complications are rare in modern laparoscopy but critical because the essential steps of recognition and management can be lifesaving.

Prognostic significance of MTOR expression in HPV positive and negative head and neck cancers treated by chemoradiation.

BACKGROUND: The mechanistic target of rapamycin (MTOR) plays a key role in regulating cell growth and metabolism and is commonly overexpressed in head and neck cancer (HNSCC). This study investigated the association of MTOR with clinical outcome in human papilloma virus (HPV) positive and negative HNSCC patients treated by chemoradiation. METHODS: A tissue microarray (TMA) consisting of cores from 109 HNSCC patients treated by definitive chemoradiation was constructed and stained with antibodies against p16 and MTOR and expression correlated with clinicopathological features and clinical outcome. RESULTS: MTOR varied widely between tumor cores and was not associated with HPV status or clinicopathological features. There was a positive correlation with pre-treatment FDG uptake. (P = .01). In HPV negative patients, MTOR predicted for shorter locoregional control (P = .02), diseases free survival (P = .02), and overall survival (P = .04). MTOR expression was not associated with outcome in HPV positive patients. CONCLUSIONS: Prognostic significance of MTOR expression depends on HPV status.