Treatment of mild-to-moderate facial cutaneous aging using a combination peel containing 6% trichloroacetic acid and 12% lactic acid

Chemical peeling treats facial cutaneous aging and may avoid risks in patients with sensitive skin, darker skin types, limited finances, or concern for side effects of other resurfacing techniques. Tolerability and improvement of photoaging using a combination peel containing 6% trichloroacetic acid and 12% lactic acid for treatment of mild-to-moderate signs of facial photoaging were assessed. This is a prospective, single-center, single-arm, study of 32 female subjects with mild-to-moderate signs of facial aging and Fitzpatrick Skin Types I-V treated with three monthly treatments of a combination peel containing 6% trichloroacetic acid and 12% lactic acid. After 3 treatments, there were statistically significant improvements in clarity, brightness, redness, pigmentation, fine lines, tactile and visual roughness, and overall appearance scores. Subjective improvements in photoaging parameters varied from 53% (fine lines) to 91% (clarity/brightness). Three treatments with a combination peel containing 6% trichloroacetic acid and 12% lactic acid achieved improvements in signs of facial photoaging. This procedure is safe and effective at treating cutaneous aging for all skin types and a viable option for patients who wish to avoid other resurfacing techniques such as laser resurfacing, microneedling among others.

SARS-CoV-2 hijacks host cell genome instability pathways

The repertoire of coronavirus disease 2019 (COVID-19)-mediated adverse health outcomes has continued to expand in infected patients, including the susceptibility to developing long-COVID; however, the molecular underpinnings at the cellular level are poorly defined. In this study, we report that SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) infection triggers host cell genome instability by modulating the expression of molecules of DNA repair and mutagenic translesion synthesis. Further, SARS-CoV-2 infection causes genetic alterations, such as increased mutagenesis, telomere dysregulation, and elevated microsatellite instability (MSI). The MSI phenotype was coupled to reduced MLH1, MSH6, and MSH2 in infected cells. Strikingly, pre-treatment of cells with the REV1-targeting translesion DNA synthesis inhibitor, JH-RE-06, suppresses SARS-CoV-2 proliferation and dramatically represses the SARS-CoV-2-dependent genome instability. Mechanistically, JH-RE-06 treatment induces autophagy, which we hypothesize limits SARS-CoV-2 proliferation and, therefore, the hijacking of host-cell genome instability pathways. These results have implications for understanding the pathobiological consequences of COVID-19.

The Effects of a Pain Management-Focused Mobile Health Behavior Intervention on Older Adults' Self-efficacy, Satisfaction with Functioning, and Quality of Life: a Randomized Pilot Trial

BACKGROUND

This report investigates the impact of a remote physical activity intervention on self-efficacy, satisfaction with functioning, and health-related quality of life (HRQOL) as assessed by the SF-36 in obese older adults with chronic pain. The intervention was group-mediated in nature and based in social cognitive theory and mindfulness-based relapse prevention.

METHODS

Participants (N = 28; 70.21 ± 5.22 years) were randomly assigned to receive either the active intervention, which focused on reducing caloric intake and increasing steps across the day or to a waitlist control condition.

RESULTS

Over 12 weeks, intervention participants reported a moderate, positive improvement in self-efficacy for walking relative to control. They also reported large magnitude improvements in satisfaction for physical functioning as well as improvements on pain and the physical functioning subscales of the SF-36.

CONCLUSIONS

These findings expand on previous research showing similar effects in response to structured exercise, this time via a protocol that is likely to be scalable and sustainable for many older adults. Additional work on larger and more diverse samples is warranted.

Relationships between respiratory sinus arrhythmia and stress in college students

The purpose of this study was to examine the relationships between university students' respiratory sinus arrhythmia (RSA) profiles and both retrospective and momentary ratings of stress. Participants were undergraduate students enrolled in an introductory health science course (N = 64). Participants provided RSA data at rest (tonic) and following an orthostatic challenge (phasic), completed the 10-item Perceived Stress Scale (PSS), and completed 6 daily ecological momentary assessments (EMA) of stress for 1 week. Higher tonic RSA was associated with lower perceived stress assessed via PSS and average EMA responses. Those with higher tonic RSA did not differ in their experience of stress across the week, whereas those with lower tonic RSA experienced increased stress across the week, and these trajectories varied as a function of phasic responses. These findings suggest a need for greater emphasis on behavioral strategies for maintaining and enhancing autonomic nervous system health among college students.

Empowered with Movement to Prevent Obesity & Weight Regain (EMPOWER): Design and methods

Promoting lasting weight loss among older adults is an important public health challenge. Participation in physical activity aids in weight loss and is important for the maintenance of physical function and quality of life. However, traditional intensive lifestyle interventions place a focus on discrete bouts of structured activity, leaving much of the remainder of the day for sedentary behavior. Structured exercise and weight loss programs often produce short-term weight loss that is typically followed by weight regain, and older adults are more likely to regain weight as fat mass rather than lean mass. Preliminary evidence suggests a focus on day-long movement intended to minimize time spent sitting produces better short-term weight loss and weight maintenance. Herein we describe the design and methods for a three-arm randomized controlled trial comparing mHealth-supported weight loss (WL) + structured exercise (EX); WL + a novel daily movement intervention (SitLess); and WL + EX + SitLess. Older adults (N = 180) will be randomly assigned to one of the three interventions, each comprised of a 6-month intensive phase; a 3-month transition phase; and a 9-month maintenance phase. The primary aim of the study is to determine whether the addition of SitLess to a traditional intensive lifestyle intervention comprised of dietary weight loss and structured exercise produces a larger 18-month reduction in body weight relative to WL + EX and WL + SitLess.

Evaluation of Association Between Gynecologic Oncology Fellowship Length and a Career in Academic Medicine

The purpose of this study is to determine the association between gynecologic oncology fellowship training factors, including fellowship length, and a career in academic medicine. A survey was sent to all 980 gynecologic oncologists identified via the SGO membership directory. The survey questions focused on demographics, fellowship training, practice- type, and research involvement. Demographics of the study population and survey responses were reported using frequencies and percentages. Chi-squared tests were used to test for associations between selected survey responses and length of fellowship. The authors received 410 (42 %) responses. Most respondents (60 %) graduated from a 3-year fellowship, while 27 and 13 % attended 2- and 4-year fellowships, respectively. Practice descriptions included academic/university (52 %), community/private practice (21 %), private practice with academic appointment (20 %), and other (7 %). A majority (64 %) reported current involvement in research as a principal investigator (PI); however, 54 % reported spending 10 % or less of their time in research-related activities. Approximately half reported that their fellowship research experience contributed to their current practice. Graduates of 3- and 4-year fellowships had similar rates of employment in academic/university settings (58 and 52 %, respectively). Graduates of 4-year fellowships were more likely to hold an advanced degree and 11 or more publications at completion of fellowship. A majority of graduates of a gynecologic oncology fellowship practice in an academic/university setting and are involved in research. Fellowship length does not correlate with a current academic medicine appointment. Graduates of 4-year fellowships are more likely to hold additional advanced degrees and more publications.

Replacing sedentary time with sleep, light, or moderate-to-vigorous physical activity: effects on self-regulation and executive functioning

Recent attention has highlighted the importance of reducing sedentary time for maintaining health and quality of life. However, it is unclear how changing sedentary behavior may influence executive functions and self-regulatory strategy use, which are vital for the long-term maintenance of a health behavior regimen. The purpose of this cross-sectional study is to examine the estimated self-regulatory and executive functioning effects of substituting 30 min of sedentary behavior with 30 min of light activity, moderate-to-vigorous physical activity (MVPA), or sleep in a sample of older adults. This study reports baseline data collected from low-active healthy older adults (N = 247, mean age 65.4 ± 4.6 years) recruited to participate in a 6 month randomized controlled exercise trial examining the effects of various modes of exercise on brain health and function. Each participant completed assessments of physical activity self-regulatory strategy use (i.e., self-monitoring, goal-setting, social support, reinforcement, time management, and relapse prevention) and executive functioning. Physical activity and sedentary behaviors were measured using accelerometers during waking hours for seven consecutive days at each time point. Isotemporal substitution analyses were conducted to examine the effect on self-regulation and executive functioning should an individual substitute sedentary time with light activity, MVPA, or sleep. The substitution of sedentary time with both sleep and MVPA influenced both self-regulatory strategy use and executive functioning. Sleep was associated with greater self-monitoring (B = .23, p = .02), goal-setting (B = .32, p < .01), and social support (B = .18, p = .01) behaviors. Substitution of sedentary time with MVPA was associated with higher accuracy on 2-item (B = .03, p = .01) and 3-item (B = .02, p = .04) spatial working memory tasks, and with faster reaction times on single (B = -23.12, p = .03) and mixed-repeated task-switching blocks (B = -27.06, p = .04). Substitution of sedentary time with sleep was associated with marginally faster reaction time on mixed-repeated task-switching blocks (B = -12.20, p = .07) and faster reaction time on mixed-switch blocks (B = 17.21, p = .05), as well as reduced global reaction time switch cost (B = -16.86, p = .01). Substitution for light intensity physical activity did not produce significant effects. By replacing sedentary time with sleep and MVPA, individuals may bolster several important domains of self-regulatory behavior and executive functioning. This has important implications for the design of long-lasting health behavior interventions. Trial Registration clinicaltrials.gov identifier NCT00438347.

Effects of a DVD-delivered exercise program on patterns of sedentary behavior in older adults: a randomized controlled trial

INTRODUCTION

In the present study, we examined the influence of a home-based, DVD-delivered exercise intervention on daily sedentary time and breaks in sedentary time in older adults.

METHODS

Between 2010 and 2012, older adults (i.e., aged 65 or older) residing in Illinois (N = 307) were randomized into a 6-month home-based, DVD-delivered exercise program (i.e., FlexToBa; FTB) or a waitlist control. Participants completed measurements prior to the first week (baseline), following the intervention period (month 6), and after a 6 month no-contact follow-up (month 12). Sedentary behavior was measured objectively using accelerometers for 7 consecutive days at each time point. Differences in daily sedentary time and breaks between groups and across the three time points were examined using mixed-factor analysis of variance (mixed ANOVA) and analysis of covariance (ANCOVA).

RESULTS

Mixed ANOVA models revealed that daily minutes of sedentary time did not differ by group or time. The FTB condition, however, demonstrated a greater number of daily breaks in sedentary time relative to the control condition (p = .02). ANCOVA models revealed a non-significant effect favoring FTB at month 6, and a significant difference between groups at month 12 (p = .02).

CONCLUSIONS

While overall sedentary time did not differ between groups, the DVD-delivered exercise intervention was effective for maintaining a greater number of breaks when compared with the control condition. Given the accumulating evidence emphasizing the importance of breaking up sedentary time, these findings have important implications for the design of future health behavior interventions.

Minimally invasive hysterectomy at a university teaching hospital

BACKGROUND AND OBJECTIVES

To evaluate the feasibility of a minimally invasive approach for hysterectomy for benign disease at a university teaching hospital.

METHODS

Five hundred thirty-seven consecutive patients underwent hysterectomy for benign disease at Penn State Milton S. Hershey Medical Center in 2010. No cases were excluded. Minimally invasive approaches included total vaginal hysterectomy, laparoscopy-assisted vaginal hysterectomy, total laparoscopic hysterectomy, and laparoscopic supracervical hysterectomy. All surgeries were completed with the resident as the primary surgeon or first assistant.

RESULTS

The median age was 45 years, the median body mass index was 30 kg/m2, the median estimated uterine size was 11 cm, and 22% of patients had a prior cesarean section. Of the 537 hysterectomies, 526 (98%) were started with a minimally invasive approach and 517 (96%) were completed in that fashion; thus only 9 conversions (2%) were required. Of the cases in which a minimally invasive approach was used, 16% were vaginal and 84% were laparoscopic. The median operative time was 86 minutes, the median blood loss was 95 mL, the median hospital stay was 1 day, and the median uterine weight was 199 g. For the minimally invasive hysterectomies, there was a 5% major complication rate.

CONCLUSION

Our residency training institution completed 96% of 537 hysterectomies using a minimally invasive approach while maintaining an acceptable operative time, amount of blood loss, hospital stay, and complication rate. Thus our study supports that a minimally invasive approach for hysterectomy for benign disease at an academic resident teaching facility is feasible.

Laparoscopy-assisted supracervical hysterectomy for ovarian cancer: cervical recurrence

Background and Objectives:

The purpose of our study is to evaluate the incidence of cervical recurrence after laparoscopic supracervical hysterectomy for ovarian cancer debulking or staging.

Methods:

From a prospective surgical database, we identified 51 cases of laparoscopic supracervical hysterectomy for ovarian cancer debulking or staging. No cases were excluded.

Results:

From 2009 to 2012, 51 patients were identified. The median age was 62 years (range, 32–83 years), and the median body mass index was 29 kg/m² (range, 16–41 kg/m²). Medical comorbidities were present in 40 patients (78%), and 53% had prior abdominal surgery. The median operative time was 2 hours (range, 1–3.5 hours), and the median blood loss was 200 mL (range, 50–900 mL). The median length of stay was 1 day (range, 0–12 days). The stage was I in 12 patients, II in 6, and III/IV in 33. At a median follow-up time of 1.7 years (range, 0.3–2.6 years), 20 patients (39%) had recurrence of cancer, with a median time of recurrence of 1.1 years (range, 0.3–2.3 years). All recurrences were in the abdomen or pelvis except for 1 axillary node recurrence and 1 recurrence in the distal vagina. There were no recurrences in the remaining cervical stump. No patient had a postoperative vaginal cuff infection. Among the 104 cycles of intraperitoneal chemotherapy, there was no vaginal leakage of intraperitoneal chemotherapy.

Conclusion:

Laparoscopic supracervical hysterectomy for ovarian cancer debulking or staging does not result in cervical recurrence.

Effects of electrosurgery and vaginal closure technique on postoperative vaginal cuff dehiscence

BACKGROUND AND OBJECTIVES

The aim of our study is to evaluate the role of electrosurgery and vaginal closure technique in the development of postoperative vaginal cuff dehiscence.

METHODS

From prospective surgical databases, we identified 463 patients who underwent total laparoscopic hysterectomy (TLH) for benign disease and 147 patients who underwent laparoscopic-assisted vaginal hysterectomy (LAVH) for cancer. All TLHs and LAVHs were performed entirely by use of electrosurgery, including colpotomy. Colpotomy in the TLH group was performed with Harmonic Ace Curved Shears (Ethicon Endo-Surgery, Cincinnati, OH, USA), and in the LAVH group, it was performed with a monopolar electrosurgical pencil. The main surgical difference was vaginal cuff closure--laparoscopically in the TLH group and vaginally in the LAVH group.

RESULTS

Although patients in the LAVH group were at increased risk for poor healing (significantly older, higher body mass index, more medical comorbidities, higher blood loss, and longer operative time), there were no vaginal cuff dehiscences in the LAVH group compared with 17 vaginal cuff dehiscences (4%) in the TLH group (P = .02).

CONCLUSION

It does not appear that the increased vaginal cuff dehiscence rate associated with TLH is due to electrosurgery; rather, it is due to the vaginal closure technique.

Ribonucleotide reductase inhibition restores platinum-sensitivity in platinum-resistant ovarian cancer: a Gynecologic Oncology Group Study

Background

The potent ribonucleotide reductase (RNR) inhibitor 3-aminopyridine-2-carboxyaldehyde-thiosemicarbazone (3-AP) was tested as a chemosensitizer for restored cisplatin-mediated cytotoxicity in platinum-resistant ovarian cancer.

Methods

Preclinical in vitro platinum-resistant ovarian cancer cell survival, RNR activity, and DNA damage assays were done after cisplatin or cisplatin plus 3-AP treatments. Six women with platinum-resistant ovarian cancer underwent four-day 3-AP (96 mg/m², day one to four) and cisplatin (25 mg/m², day two and three) infusions every 21 days until disease progression or adverse effects prohibited further therapy. Pre-therapy ovarian cancer tissues were analyzed by immunohistochemistry for RNR subunit expression as an indicator of cisplatin plus 3-AP treatment response.

Results

3-AP preceding cisplatin exposure in platinum-resistant ovarian cancer cells was not as effective as sequencing cisplatin plus 3-AP together in cell survival assays. Platinum-mediated DNA damage (i.e., γH2AX foci) resolved quickly after cisplatin-alone or 3-AP preceding cisplatin exposure, but persisted after a cisplatin plus 3-AP sequence. On trial, 25 four-day overlapping 3-AP and cisplatin cycles were administered to six women (median 4.2 cycles per patient). 3-AP-related methemoglobinemia (range seven to 10%) occurred in two (33%) of six women, halting trial accrual.

Conclusions

When sequenced cisplatin plus 3-AP, RNR inhibition restored platinum-sensitivity in platinum-resistant ovarian cancers. 3-AP (96 mg/m²) infusions produced modest methemoglobinemia, the expected consequence of ribonucleotide reductase inhibitors disrupting collateral proteins containing iron.

Trial registry

ClinicalTrials.gov NCT00081276

Fertility-sparing treatment of endometrial cancer: options, outcomes and pitfalls

Endometrial cancer is the most common gynecologic malignancy in the United States, with over 40,000 cases diagnosed each year. While a majority of cases are diagnosed in post-menopausal women, up to 14% of cases will be in pre-menopausal women, including 4% diagnosed in women less than 40 years of age. While hysterectomy with bilateral salpingo-oophorectomy with assessment of the retroperitoneal lymph nodes is standard initial treatment for endometrial cancer, younger women may desire fertility sparing options. The decision to proceed with conservative management in this younger patient population is associated with multiple complexities, including the inherent oncologic risks of an inadequately staged and treated endometrial cancer, the risk of a synchronous or meta-synchronous cancer, the increased risk of an inherited genetic predisposition to malignancy and the lack of uniformity in the medical management and surveillance. In this review we will discuss the conservative management of endometrial cancer, specifically the role of progestin hormonal therapy, including the risks associated with non-standard care, appropriate candidate selection and work up, expected outcomes, various progestin agents and recommended follow-up.

Cost analysis of prophylactic intraoperative cystoscopic ureteral stents in gynecologic surgery

CONTEXT

Prophylactic intraoperative ureteral stent placement is performed to decrease operative ureteric injury, though few data are available on the effectiveness of this procedure, and no data are available on its cost.

OBJECTIVE

To analyze the cost of prophylactic intraoperative cystoscopic ureteral stents in gynecologic surgery.

METHODS

All cases of prophylactic ureteral stent placement performed in gynecologic surgery during a 1-year period were identified and retrospectively reviewed through the electronic medical records database of Summa Health System. Costs were obtained through the Healthcare Cost Accounting System. The principles of cost-effective analysis were used (ie, explicit and detailed descriptions of costs and cost-effectiveness statistics). Importantly, we evaluated cost and not charges or financial model estimates. In addition, we obtained the contribution margins (ie, the hospital's net profit or loss) for prophylactic ureteral stent placement. Other gynecologic procedures were also analyzed.

RESULTS

Among 792 major inpatient gynecologic procedures, 18 cases of prophylactic intraoperative ureteral stents were identified. Median costs were as follows: additional cost of prophylactic intraoperative ureteral stenting, $1580; additional cost of surgical resources, $770; cost of ureteral catheters, $427; cost of surgeons, $383. The contribution margins per case for various gynecologic surgical procedures were as follows: oophorectomy, $2804 profit; abdominal hysterectomy, $2649 profit; laparoscopically assisted vaginal hysterectomy (LAVH), $1760 profit. When intraoperative ureteral stenting was added, the contribution margins changed to the following: oophorectomy, $782 profit; abdominal hysterectomy, $627 profit; LAVH, $262 loss. Overall, the contribution margin profit was decreased by about 85%, from $2400 to $380.

CONCLUSION

Prophylactic intraoperative ureteral stenting in gynecologic surgery decreases a hospital's contribution margin. Because of the expense of this procedure, as well as scientific data suggesting a lack of effectiveness, the authors argue that prophylactic intraoperative ureteral stenting should not be used in gynecologic surgery to decrease operative ureteric injury.

Laparoscopic major gynecologic surgery in patients with prior laparotomy bowel resection

BACKGROUND AND OBJECTIVES

To review the success and morbidity of laparoscopic major gynecologic surgery in patients with prior laparotomy bowel resection.

METHODS

Review of a prospective surgical database of all cases of laparoscopic major gynecologic surgery in patients with prior laparotomy bowel resection. No cases were excluded. Bowel diagnoses and procedures were total colectomy for inflammatory bowel disease (4), partial colectomy for colon cancer (6), partial small bowel resection for obstruction (1), and Whipple for pancreatic cancer (2). Two patients had 3 prior laparotomies, 8 patients had 2 prior laparotomies, and 3 patients had 1 prior laparotomy. All prior abdominal incisions were midline. Gynecologic diagnoses and procedures were laparoscopic cytoreduction for ovarian cancer (1), lsh/bso/staging for ovarian cancer (1), lavh/bso/lymphadenectomy for endometrial cancer (4), and lavh/bso, lsh/bso, or bso for large ovarian mass (7). Median patient age was 57 years, median BMI was 31kg/m(2), and all patients had medical comorbidities.

RESULTS

All 13 laparoscopic gynecologic surgeries were successful without trocar insertion injury, conversion to laparotomy, and without enterotomy. Abdominal adhesions were present in all cases. Median operative time was 2 hours, median blood loss was 100cc, and median hospital stay was 1 day. There were no postoperative complications.

CONCLUSION

Laparoscopic major gynecologic surgery in patients with prior laparotomy bowel resection is feasible for experienced laparoscopic surgeons.

Safety and Efficacy of Immediate Postoperative Feeding and Bowel Stimulation to Prevent Ileus After Major Gynecologic Surgical Procedures

Context: Postoperative ileus is a major complication of abdominal surgical procedures

Objective: To evaluate the incidence of ileus and gastrointestinal morbidity in patients who received immediate postoperative feeding and bowel stimulation after undergoing major gynecologic surgical procedures.

Methods: During a 5-year period, the authors tracked demographic, surgical outcome, and follow-up information for 707 patients who underwent major gynecologic operations. All patients received the same postoperative orders, including immediate feeding of a diet of choice and bowel stimulation with 30 mL of magnesium hydroxide (milk of magnesia) twice daily until bowel movements occurred.

Results: Of 707 patients, 6 (<1%) had postoperative ileus. No patients experienced postoperative bowel obstruction and 2 patients (0.3%) had postoperative intestinal leak. No serious adverse effects associated with bowel stimulation were reported.

Conclusion: Immediate postoperative feeding and bowel stimulation is a safe and effective approach to preventing ileus in patients who undergo major gynecologic surgical procedures.

Laparoscopic-assisted cytoreduction for primary advanced ovarian cancer: success, morbidity and survival

OBJECTIVE

The purpose of this paper is to evaluate laparoscopic-assisted cytoreduction for primary advanced ovarian cancer: feasibility, morbidity, response to chemotherapy and survival.

METHODS

All patients with presumed stage 3/4 primary ovarian cancer underwent attempted laparoscopic cytoreduction. All patients had CT evidence of omental metastasis and ascites. A five port (5-mm) transperitoneal approach was used. A bilateral salpingo-oophorectomy, supracervical hysterectomy and omentectomy were performed with the PlasmaKinetic (PK) cutting forceps. A laparoscopic 5-mm Argon-Beam Coagulator was used to coagulate tumor in the pelvis, abdominal peritoneum, intestinal mesentery, and diaphragm.

RESULTS

Twenty-three cases (92%) were successfully cytoreduced laparoscopically without conversion to laparotomy. Median operative time was 2.3h and median blood loss was 340 cc. All tumors were debulked to less than 2 cm and 36% had no residual disease. Median length of stay was 1 day. Median VAS pain score was 4-discomforting. Six patients (24%) had post-operative complications, none grades 3-4. Median overall survival is 3.5 years.

CONCLUSION

Laparoscopic-assisted cytoreduction for primary advanced ovarian cancer was successful, resulting in minimal morbidity, and acceptable survival.

Reduced-force closed trocar entry technique: analysis of trocar insertion force using a mechanical force gauge

BACKGROUND AND OBJECTIVES

Trocar insertion injury has a high morbidity, mortality, and cost. The purpose of this study was to compare standard trocar entry with our reduced-force closed trocar entry technique by measuring trocar insertion force using a mechanical force gauge.

METHODS

In the operating room, the force gauge was inserted into a sterile glove and connected to the proximal portion of the trocar to measure insertion force. Through one incision, we used a standard closed trocar entry, while through the other incision, we used our reduced-force closed trocar entry technique. After making the skin incision and before trocar entry, we spread and dilated the skin, subcutaneous tissue, fascia, and muscle with a hemostat.

RESULTS

Twenty-five patients entered the trial and none were excluded. Median trocar insertion force was 3.3lb (range, 1.6 to 5.4) with our reduced-force trocar entry technique versus 6.5lb (range, 2.0 to 14.0) with the standard trocar entry (P=.001). No complications occurred with the reduced-force trocar entry technique.

CONCLUSION

Our reduced-force trocar entry technique decreases trocar insertion force by 50%, requires no additional instruments or cost and is fast and safe. Reduced-entry force pressure may decrease the risk of trocar insertion injury.

Laparoscopic cytoreduction for primary advanced ovarian cancer

Laparoscopic-assisted cytoreduction for primary advanced ovarian cancer was found to be a feasible intervention technique with minimal morbidity.

Introduction:

We evaluated the feasibility of laparoscopic cytoreduction for primary advanced ovarian cancer.

Methods:

All patients with presumed stage 3/4 primary ovarian cancer underwent attempted laparoscopic cytoreduction. All patients had CT evidence of omental metastasis and ascites. A 5-port (5-mm) transperitoneal approach was used. A bilateral salpingo-oophorectomy, supracervical hysterectomy, and omentectomy were performed with PlasmaKinetic (PK) cutting forceps. A laparoscopic 5-mm Argon-Beam Coagulator was used to coagulate tumor in the pelvis, abdominal peritoneum, intestinal mesentery, and diaphragm.

Results:

Nine of 11 cases (82%) were successfully de-bulked laparoscopically without conversion to laparotomy. Median operative time was 2.5 hours, and median blood loss was 275 mL. All tumors were debulked to <2 cm and 45% had no residual disease. Stages were 1–3B, 7–3C, and 1–4. Median length of stay was one day. Median VAS pain score was 4 (discomforting). Two of 11 patients (18%) had postoperative complications.

Conclusion:

Laparoscopic cytoreduction was successful and resulted in minimal morbidity. Because of our small sample size, additional studies are needed.

Transvaginal application of a laparoscopic bipolar cutting forceps to assist vaginal hysterectomy in extremely obese endometrial cancer patients

INTRODUCTION

The purpose of this report is to evaluate our experience with transvaginal application of a laparoscopic bipolar cutting forceps to assist vaginal hysterectomy in extremely obese women with endometrial cancer in whom obesity precluded LAVH/BSO and lymphadenectomy and vaginal obesity limited visualization and exposure.

MATERIALS AND METHODS

We performed a retrospective review and identified 6 consecutive cases. No cases were excluded. A laparoscopic 33-cm Plasma Kinctic (PK) cutting forceps with a 5-mm diameter was applied transvaginally to coagulate and cut the uterosacral and cardinal ligaments, uterine vasculature, and ovarian ligaments. The uterus was delivered vaginally. Staging lymphadenectomy was not performed.

RESULTS

Median age was 51 years, median weight was 405 lbs, and median BMI was 66 kg/m². Five of 6 cases were successfully performed vaginally (83%). Median operative time was 1 hour 10 minutes, median blood loss was 500 mL, and pain was only discomforting. All patients were discharged the day after surgery. There were no complications. At median follow-up of 1 year, all patients were alive with no evidence of disease.

CONCLUSION

It is our opinion that the transvaginal application of a laparoscopic bipolar cutting forceps can successfully assist vaginal hysterectomy in extremely obese endometrial cancer patients who cannot tolerate LAVH/BSO and lymphadenectomy and vaginal obesity limits visualization and exposure.

A preliminary study of transcranial direct current stimulation for the treatment of refractory chronic pelvic pain

BACKGROUND

The modulatory effects of transcranial direct current stimulation (tDCS) appear beneficial for different chronic pain syndromes; however, it is unclear whether this method can be used to treat refractory chronic pelvic pain.

OBJECTIVE

The objective of this preliminary study was to determine the efficacy and safety of tDCS for the management of refractory chronic pelvic pain.

METHODS

Seven patients with chronic pelvic pain having failed standard medical or surgical therapy underwent a crossover, double-blind sham controlled tDCS treatment protocol consisting of 1 mA applied for 20 minutes on two consecutive days with 2 weeks of follow-up symptom recording. Symptoms were recorded using multiple scoring systems, including visual analog scales for different pains, as well as organ-specific symptom scales. Comparison between active and sham treatment was performed by using paired t tests.

RESULTS

Overall and pelvic pain scores were significantly lower after active compared with sham treatment, as were disability and traumatic stress scores. No patient discontinued the study because of side effects, which were infrequent.

CONCLUSIONS

Active tDCS treatment induces a modest pain reduction in refractory chronic pelvic pain patients as compared with sham tDCS treatment. These results can guide the design and implementation of further studies investigating this method of neuromodulation for the treatment of refractory chronic pelvic pain.

A method for the consistent creation and quantitative testing of postoperative pelvic adhesions in a porcine model

INTRODUCTION

The assessment of methods for the prevention of postoperative pelvic adhesions is hampered by the lack of a quantifiable adhesion measurement technique. Currently available methods for adhesion model assessment rely on qualitative grading scales; a quantitative method would have many attendant benefits, including standardized reporting.

METHODS

A technique was developed to generate consistent and significant adhesions in a swine model that are suitable for quantitative assessment using a Material Testing System (MTS) machine platform. In this method, the uterine horns are cannulated and then attached to the pelvic sidewall using loose silk sutures. The underlying sidewall and adjacent uterine serosa are injured with electrocautery. Following a two-week survival the entire complex of uterine horn and sidewall are excised en bloc and prepared for MTS testing.

RESULTS

Extrication of the adhesion, as measured by the MTS platform, generates a quantitative assessment of adhesion strength that can be scaled and analyzed to produce several continuous variable descriptions.

DISCUSSION

This technique represents a novel quantitative method for adhesion assessment in an animal model. This quantitative technique may then be applied to accurately assess a range of adhesion prevention techniques, producing results which can be standardized for comparison.

Robotic radical hysterectomy

Robotic radical hysterectomy is increasingly being utilized in the treatment of cervical cancer and initial studies are promising. Compared to open radical hysterectomy, robotic radical hysterectomy is expected to result in decreased pain, infection, length of stay, and adhesions and quicker return to activity. Prospective randomized controlled trials are needed to compare robotic, laparoscopic and open radical hysterectomy for the treatment of cervical cancer.

Laparoscopic-assisted vaginal hysterectomy for uteri weighing 1000 grams or more

INTRODUCTION

Prospective randomized trials have proven the benefits of laparoscopic-assisted vaginal hysterectomy (LAVH) compared with abdominal hysterectomy. The purpose of this study was to evaluate the safety and efficacy of LAVH performed for uteri weighing > or =1000 grams.

METHODS

Fifteen patients underwent attempted LAVH for uteri >1000g. Median age was 45 years old (range, 31 to 57), and median weight was 170 pounds (range, 130 to 236); 64% had medical comorbidities, and 43% had prior pelvic surgery. Five ports (5 mm) were used to allow maximum uterine manipulation. Uterine vessels were doubly coagulated.

RESULTS

Fourteen of 15 cases (93%) were successfully completed laparoscopically. Median uterine weight was 1090 grams (range, 1000 to 1650). Median operative time was 3.5 hours (range, 2 to 4.6), and median blood loss was 400 mL (range, 100 to 1200). All patients were discharged on postoperative day one, and no patients developed a postoperative complication.

CONCLUSION

We believe that LAVH is a safe and effective approach for uteri larger than 1000 g. It is our opinion that 3 surgical techniques are required; maximum Trendelenburg position, adequate number of ports, and double coagulations of the uterine vessels.

Robotic radical hysterectomy

OBJECTIVE

Advanced laparoscopic procedures are increasing being used in gynecologic surgery. The da Vinci robotic system (Intuitive Surgical Corporation, Sunnyvale, CA) can further augment laparoscopic surgery. We describe our initial experience using the da Vinci robotic system to perform radical hysterectomy.

STUDY DESIGN

Twenty consecutive patients with primary stage IB-IIA cervical carcinoma underwent class 3 radical hysterectomy with the use of the da Vinci robotic system. Median age was 44 years, median weight was 69.9 kg, 65% of patients had medical comorbidity, and 40% had prior abdominal surgery.

RESULTS

All 20 patients successfully underwent robotic radical hysterectomy. Median operative time was 6.5 hours (3.5-8.5 hours) and median blood loss was 300 mL. All patients were discharged on the first day after surgery. At median follow-up of 2 years (0.6-3 years), 90% of patients are alive and disease free.

CONCLUSION

We report the first series of robotic radical hysterectomy for early stage cervical cancer. All cases were successfully performed robotically with minimal complications and all patients were discharged on postoperative day 1.

Phase I/II prospective trial of autologous platelet tissue graft in gynecologic surgery

STUDY OBJECTIVE

To perform the original phase I/II trial of autologous platelet tissue graft in gynecologic surgery to evaluate toxicity and efficacy on decreasing pain.

DESIGN

Prospective nonrandomized trial (Canadian Task Force classification II-A).

SETTING

Teaching hospital.

PATIENTS

Fifty-five consecutive patients undergoing major gynecologic surgery were entered into this prospective phase I/II trial and were matched with 55 patients from the previous 6 months.

INTERVENTION

After anesthesia was induced, peripheral venous blood (55 mL) was obtained from the patient producing, autologous platelet tissue graft (20 mL). At completion of surgery, autologous platelet tissue graft was directly applied to the surgical site.

MEASUREMENTS AND MAIN RESULTS

Median pain on the day of surgery was 2.7 (mild) in the autologous platelet tissue graft group vs 6.7 (severe) in the control group, p <.001. Likewise, pain on postoperative day 1 was 2.1 (mild) in the autologous platelet tissue graft group vs 5.5 (moderate) in the control group, p < or =.001. Median of morphine per hospital stay for the autologous platelet tissue graft group was 17 mg (range 1-98 mg) vs 26 mg (range 3-90 mg) in the control group, which was statistically significant at p = .02. There were no adverse effects associated with autologous platelet tissue graft.

CONCLUSIONS

In the original phase I/II prospective trial of autologous platelet tissue graft in gynecologic surgery, there were no apparent adverse effects, and pain was significantly reduced.

Findings from a 10-year follow-up of bone mineral density in competitive perimenopausal runners

OBJECTIVE

To evaluate bone mineral density (BMD) in perimenopausal competitive runners with long-term follow-up.

STUDY DESIGN

Fifteen master female runners between 40 and 50 years old who ran at least 20 miles per week were evaluated. BMD was measured by dual-energy x-ray absorptiometry (DEXA) at baseline and at the 10-year follow-up.

RESULTS

The median age was 46 and median miles run per week, 25. At baseline, after a median of 11 years of competitive running, hip BMD was above peak bone mass (T-score = 0.8) and that of age-matched controls (Z-score = 1.6), while lumbar spine BMD was below peak bone mass (T-score = -0.8) and equal to that of age-matched controls (Z-score = -0.1). At the 10-year follow-up, hip BMD fell below peak bone mass (T-score = -0.2, p = 0.0004) but was still above that of age-matched controls (Z-score = 0.5, p = 0.002), while there was little change in lumbar spine BMD.

CONCLUSION

Competitive running prior to the perimenopausal period seems to be associated with improved hip BMD. However, continued competitive running during the perimenopausal period is not associated with prevention of a perimenopausal hip BMD decline. In contrast, competitive running had little effect on peri-menopausal lumbar spine BMD.

Feasibility of the Maylard transverse incision for ovarian cancer cytoreductive surgery

The vast majority of abdominal incisions used in gynecologic surgery are either transverse or vertical midline. The advantages of a vertical midline incision are considered to be rapid abdominal entry and increased exposure to the abdomen and pelvis. The advantages of transverse incisions are purported to be cosmesis, decreased postoperative pain, decreased hernia rate, decreased abdominal adhesions, and fewer postoperative pulmonary complications. The Maylard incision is a transverse incision that combines the advantages of a transverse incision with improved pelvic and abdominal exposure. We wanted to evaluate the feasibility of the Maylard incision to provide adequate abdominal and pelvic exposure in women with advanced ovarian cancer undergoing cytoreductive surgery and to evaluate the extent of anterior abdominal wall adhesions at secondary cytoreductive surgery. In our experience, it appears that the Maylard incision provides adequate exposure to perform ovarian cytoreductive surgery. It appears that there are minimal anterior abdominal adhesions after cytoreductive surgery through a Maylard incision.

Cost-effectiveness analysis of the treatment of large leiomyomas: laparoscopic assisted vaginal hysterectomy versus abdominal hysterectomy

OBJECTIVE

The purpose of this study was to perform a cost-effectiveness analysis comparing the treatment of large leiomyomas by laparoscopic assisted vaginal hysterectomy (LAVH) versus abdominal hysterectomy (AH).

STUDY DESIGN

Twenty consecutive LAVH were compared to 20 consecutive AH for leiomyoma > or = 250 g. Hospital costs were obtained through Healthcare cost accounting system. The 6 principles of cost-effectiveness analysis were used.

RESULTS

The groups were similar in respect to age, weight, race, medical comorbidities, blood loss, and operative time. Median uterine weight (513 g) was approximately 20% > for LAVH. Length of stay and pain was significantly less for LAVH. Total hospital cost for AH was approximately 12% less expensive ($4394 vs $5023, P = .18).

CONCLUSION

Because of multiple benefits of LAVH versus AH and no significant difference in cost, we believe LAVH is an acceptable treatment for large leiomyoma.

Postoperative femoral motor neuropathy: diagnosis and treatment without neurologic consultation or testing

OBJECTIVE

To review the diagnosis and treatment of postoperative femoral motor neuropathy without neurologic consultation or testing.

STUDY DESIGN

A retrospective review of 6 consecutive patients with postoperative femoral motor neuropathy following gynecologic surgery. Diagnosis was made on clinical evaluation: history of falling during postoperative ambulation, quadriceps weakness, straight leg raise weakness, diminished knee jerk response, and no evidence of psoas hematoma or abscess. Neurologic consultation, electromyography, nerve conduction study and radiologic imaging, such as computed tomography, were not obtained. Instead, a physical therapy consultation was obtained for a knee orthotic and rehabilitation.

RESULTS

Four postoperative femoral motor neuropathies developed following 3,014 cases of major gynecologic surgery (0.1%). Two additional cases were seen in consultation. The median age was 57 years. All patients fell while attempting ambulation on postoperative day 1. Recovery occurred at a median of 3 months (1-4). At a median follow-up of 4 years, no patient had developed additional neurologic sequelae. A history of prior postoperative femoral motor neuropathy was noted in 2 of 6 patients (33%).

CONCLUSION

This was the first study of diagnosis and treatment of postoperative femoral motor neuropathy following gynecologic surgery without neurologic consultation or testing. Because of the significant expense of neurologic consultation and testing, patients with postoperative femoral motor neuropathy can have the condition diagnosed by the gynecologist and be referred directly to physical therapy without adversely affecting outcome. This also was the first study to elicit a prior history offemoral neuropathy in 33% of patients. Thus, a prior history may be a risk factor for recurrence.

A laparoscopic simulator tool for objective measurement of residents' laparoscopic ability

OBJECTIVE

We sought to develop an objective measurement of residents' laparoscopic ability by using a laparoscopic simulator assessment tool.

METHODS

An inexpensive laparoscopic simulator was developed. Three laparoscopic assessment procedures were created: 1) bead/pom-pom drop, 2) checkerboard drill, and 3) bead manipulation. Two minimally invasive surgeons and 8 PGY 3/4 and 15 PGY 1 residents were timed performing the 3 procedures. Ten of the PGY 1 residents were retested at the end of their PGY 1 year.

RESULTS

The minimally invasive surgeons completed the laparoscopic drills in approximately half the time of the PGY 3/4 (P=0.02), and PGY 3/4 were 60% faster than PGY 1 (P=0.01). PGY 1 completed the drills in half the time at the end of the PGY 1 year (P=0.005). As an objective measurement of residents' laparoscopic surgery competency, by the completion of the academic year, all PGY 1 residents must be able to complete the drills as fast as or faster than the original PGY 3/4 times.

CONCLUSION

We developed an inexpensive, objective, simple laparoscopic simulator assessment tool for measurement of residents' laparoscopic ability.

A laparoscopic bipolar cutting forceps can assist in a case of difficult vaginal hysterectomy

A vaginal approach to hysterectomy can become challenging when visualization is limited by poor or absent uterine descent, obesity, or other factors that make an approach to the uterine pedicles difficult. When factors occur that make application or visualization of conventional vaginal instruments difficult, using an instrument designed for laparoscopic application, with its thin, elongated shape, may permit continuation of a vaginal approach. In such a case, a Gyrus bipolar laparoscopic cutting forceps was used for coagulation and transection of the uterine pedicles during a vaginal hysterectomy. This represents a way to expand on traditional techniques for completion of difficult vaginal hysterectomy, which may be used concurrently. Surgical techniques that more easily and safely permit completion of hysterectomy by the vaginal approach can improve outcomes for all.

Examining interactions between biomeds and caregivers

Quality healthcare delivery is a team effort requiring trust, mutual respect and a little professional courtesy when stress levels are high and equipment problems arise. Trust and professional respect are best established through other means like committees or special projects done together rather than the heat of a crisis, yet bonds created during difficulties are some of the strongest. Biomedical technicians equipped with an attitude of patience and humility can contribute to a positive learning experience when the problem lies with the equipment operator.