To meet the challenges of providing affordable, efficient ultrasound training, a low-cost, portable personal ultrasound training simulator with structured curriculums and integrated assessment methods has been developed. By using extended image volumes for training, the realistic experience of scanning over a larger body surface is emulated.
Temsirolimus with or without megestrol acetate and tamoxifen for endometrial cancer: a gynecologic oncology group study
OBJECTIVES: To determine the response, toxicities, and progression free survival of a regimen of temsirolimus with or without hormonal therapy in the treatment of advanced, or recurrent endometrial carcinoma.
BACKGROUND: Preclinical evidence suggested that blockade of the PI3K/AKT/mTOR pathway might overcome resistance to hormonal therapy.
METHODS: We performed a randomized phase II trial of intravenous temsirolimus 25mg weekly versus the combination of weekly temsirolimus with a regimen of megestrol acetate 80 mg bid for three weeks alternating with tamoxifen 20mg bid for three weeks in women with recurrent or metastatic endometrial carcinoma.
RESULTS: There were 71 eligible patients who received at least one dose of therapy with 21 of these treated on the combination arm which was closed early because of an excess of venous thrombosis, with 5 episodes of deep venous thrombosis (DVT) and 2 pulmonary emboli. There were three responses observed in that arm (14%). A total of 50 eligible patients were treated on the single agent arm with 3 episodes of DVT and 11 responses (22%). Response rates were similar in patients with prior chemotherapy (7 of 29; 24%) and those with no prior chemotherapy (4 of 21; 19%). Two of four patients with clear cell carcinoma responded.
CONCLUSIONS: Adding the combination of megestrol acetate and tamoxifen to temsirolimus therapy did not enhance activity and the combination was associated with an excess of venous thrombosis. Temsirolimus activity was preserved in patients with prior adjuvant chemotherapy.
OBJECTIVES: Unplanned pregnancy is a public health problem in the United States, including in rural areas. Primary care physicians are the main providers of health care to women in rural areas and are uniquely positioned to help reduce unplanned pregnancy in rural women. This study documents provision of contraception by rural primary care physicians, focusing on the most effective, long acting methods, intrauterine devices (IUDs) and contraceptive implants.
METHODS: We surveyed all primary care physicians practicing in rural areas of Illinois and Wisconsin. Bivariate analysis was performed using chi squared and Fisher's exact test, and multivariable analysis was performed with logistic regression to determine factors associated with provision.
RESULTS: The response rate was 862 out of 2312 physicians (37%). Nine percent of respondents place implants and 35% place IUDs. Eighty-seven percent of physicians had not had training in implant placement, and 41% had not had training in IUD placement. In multivariable analysis, factors associated with placement of long acting contraception include provision of maternity care, and female gender of the physician. The most common reasons for not providing the methods were lack of training and perceived low demand from patients.
CONCLUSIONS: Many rural primary care providers do not place long acting contraceptive devices due to lack of training. Female physicians and those providing maternity care are the most likely to place these devices. Increased training for primary care physicians both during and after residency would help increase access to these options for women in rural areas.
Vulvar carcinoma is an uncommon tumor that is seen most often in older women. Subtle symptoms such as pruritus should prompt examination and targeted biopsy in all women as this disease can be successfully treated even in elderly, frail individuals. Vulvar cancer has a bimodal age distribution and is seen in both young and older women with risk factors including human papillomavirus (HPV) infection, smoking, and vulvar skin diseases (i.e., lichen sclerosus). This cancer is staged surgically, with an update in 2009 incorporating prognostic factors. The treatment of vulvar carcinoma has evolved to include more conservative surgical techniques that provide improved cure rates with emphasis on minimizing morbidity. Advanced and metastatic lesions are now treated with chemoradiation which produces substantial cure rates with decreased morbidity. Promising areas of research in vulvar cancer include refinement of sentinel lymph node biopsy, prevention of lymphedema, and preservation of sexual function following treatment.
BACKGROUND: Hypothetical choice studies suggest that physicians often take more risk for themselves than on their patient's behalf.
OBJECTIVE: To examine if physicians recommend more screening tests than they personally undergo in the real-world context of breast cancer screening.
DESIGN: Within-subjects survey.
PARTICIPANTS: A national sample of female obstetricians and gynecologists (N = 135, response rate 54%) from the United States. In total, they provided breast care to approximately 2,800 patients per week.
MEASURES: Personal usage history and patient recommendations regarding mammography screening and breast self-examination, a measure of defensive medicine practices.
RESULTS: Across age groups, female physicians were more likely to recommend mammography screening than to have performed the procedure in the past 5 years (86% vs. 81%, p = .10). In respondents aged 40-49 this difference was significant (91% vs. 82%, p < .05), whereas no differences were detected for younger or older physicians. Among respondents in their 40s, 18% had undergone annual screenings in the past 5 years, compared to 48% of their colleagues above 50. Respondents were as likely to practice breast self-examination (98%) as to recommend it (93%), a pattern that was consistent across age groups. A logistic regression model of personal use of mammography significantly predicted recommending the procedure to patients (OR = 15.29, p = .001). Similarly, number of breast self-examinations performed over the past 2 years positively predicted patient recommendations of the procedure (OR = 1.31, p < .001).
CONCLUSIONS: Obstetricians and gynecologists tended to recommend early mammography screening to their patients, though their personal practices indicated later start than their own recommendations and lower frequency of screening than peers in recent studies have recommended.
Patient-focused websites related to stress urinary incontinence and pelvic organ prolapse: a DISCERN quality analysis
INTRODUCTION AND HYPOTHESIS: The quality of information related to pelvic floor disorders is varied and understudied. Using a validated instrument we evaluated the quality of selected websites addressing treatment options for pelvic organ prolapse (POP) and stress urinary incontinence (SUI).
METHODS: English-language, patient-focused professional, governmental, and consumer websites related to POP and SUI were identified using the International Urogynecology Association (IUGA) list of continence societies worldwide, search terms, and provider nomination. Websites were evaluated by 10 providers at an academic medical center, representing urogynecology (6), urology (3), and general gynecology (1). Quality assessment utilized the DISCERN instrument, a validated instrument consisting of 16 questions addressing the quality of consumer health information.
RESULTS: Websites of 13 organizations met inclusion criteria and were assessed, 12 relating to SUI and 8 to POP. The websites with the highest mean total DISCERN score for POP were those of the IUGA, the American Society of Colon and Rectal Surgeons, and the American Urogynecologic Association, and for SUI, the National Association For Continence, the American Urological Association, and the IUGA. High correlations were obtained for the total DISCERN score and the overall quality scores for POP (0.76) and SUI (0.82). The most commonly omitted components of the DISCERN instrument were a clear statement of the content objectives, references or sources of the content, and a discussion of what patients could expect if they opted for no intervention.
CONCLUSIONS: Available English-language professional websites written to inform patients about management choices for SUI and POP miss key components of quality patient information.
Circulating Levels of sFlt1 Splice Variants as Predictive Markers for the Development of Preeclampsia
Angiogenic biomarkers, including soluble fms-like tyrosine kinase 1 (sFlt1), are thought to be predictors of preeclampsia onset; however, improvement is needed before a widespread diagnostic test can be utilized. Here we describe the development and use of diagnostic monoclonal antibodies specific to the two main splice variants of sFlt1, sFlt1-1 and sFlt1-14. These antibodies were selected for their sensitivity and specificity to their respective sFlt1 isoform in a capture ELISA format. Data from this pilot study suggest that sFlt1-1 may be more predictive of preeclampsia than total sFlt1. It may be possible to improve current diagnostic platforms if more specific antibodies are utilized.
On a day-to-day basis, doctors must decide which treatments are most beneficial for their patients, and which make the most sense in terms of costs. In medical decision making, factors such as efficiency and cost-effectiveness can be particularly challenging to navigate because many of the most expensive procedures encountered in medical practice are also high-stake treatments for patients. One-hundred-six obstetricians-gynecologists (Obs/Gyns) completed a survey asking them to allocate the following resources in scenarios in which they are scarce: human papilloma virus (HPV) vaccinations, mammograms, and in vitro fertilization (IVF) treatments. Additional questions focused on how fairness and cost-effectiveness factored into the allocation decisions of each group. Results indicated that Obs/Gyns were more efficient in their distribution of HPV vaccinations and mammograms than in their distribution of IVF treatments. More efficient responding was associated with placing less emphasis on fairness in decision making. This study demonstrates the differences that exist in the emphasis that physicians place on medical evidence, cost, outcomes, and perceptions of fair (equal) allocation when faced with different costs and health impacts.
The increasing use of point-of-care (POC) ultrasound presents a challenge in providing efficient training to POC ultrasound users for whom formal training is not readily available. In response to this need, we developed an affordable compact laptop-based obstetric ultrasound training simulator. It offers a realistic scanning experience, task-based training, and performance assessment. The position and orientation of the sham transducer are tracked with 5 DoF on an abdomen-sized scan surface with the shape of a cylindrical segment. On the simulator, user interface is rendered a virtual torso whose body surface models the abdomen of the pregnant scan subject. A virtual transducer scans the virtual torso by following the sham transducer movements on the scan surface. A given 3-D training image volume is generated by combining several overlapping 3-D ultrasound sweeps acquired from the pregnant scan subject using a Markov random field-based approach. Obstetric ultrasound training is completed through a series of tasks, guided by the simulator and focused on three aspects: basic medical ultrasound, orientation to obstetric space, and fetal biometry. The scanning performance is automatically evaluated by comparing user-identified anatomical landmarks with reference landmarks preinserted by sonographers. The simulator renders 2-D ultrasound images in real time with 30 frames/s or higher with good image quality; the training procedure follows standard obstetric ultrasound protocol. Thus, for learners without access to formal sonography programs, the simulator is intended to provide structured training in basic obstetrics ultrasound.
Absence or Presence of High-Grade Squamous Intraepithelial Lesion in Cervical Conization Specimens: A Clinicopathologic Study of 540 Cases
OBJECTIVES: To explore the implications of cervical conization specimens lacking the targeted high-grade squamous intraepithelial lesions (negative cone).
METHODS: We studied 540 conization procedures: 400 positive cones and 140 negative cones. Clinicopathologic features and 2-year follow-up results were reported.
RESULTS: Negative cones comprised 22% of procedures triggered by CIN2 or higher biopsies. Procedures triggered by cytology produced much higher percentages of negative cones (37% high-grade squamous intraepithelial lesion [HSIL], 46% atypical squamous cells-cannot exclude high-grade squamous intraepithelial lesion [ASC-H], and 76% low-grade squamous intraepithelial lesion-cannot exclude high-grade squamous intraepithelial lesion [LSIL-H]). Upon reviewing negative excision-triggering biopsy and cytology, we downgraded 24 (24%) CIN2 biopsies, three (14%) HSIL, five (83%) ASC-H, and 12 (92%) LSIL-H. One-third of our negative cones can be attributed to overdiagnosis either on biopsy or cytology. Patients with negative cones were older and had smaller excisions, negative colposcopic findings, and negative/equivocal high-risk human papillomavirus (HR-HPV). Within 2 years, 35 (25%) women with negative cones experienced ASCUS or LSIL. Only one (0.7%) recurred as CIN3, a significantly lower percentage than women with positive cones (13%).
CONCLUSIONS: We advocate careful review of all excision-triggering biopsy and cytology, especially in cases of LSIL-H. Patients with negative cones should be surveyed with cytology and HR-HPV testing.