Deepa Maheswari Narasimhulu

Radical surgery in ovarian cancer.

While there is an ongoing debate regarding the timing of the maximal surgical effort in epithelial ovarian cancer, it is well established that patients with suboptimal tumor debulking derive no benefit from the surgical procedure. The amount of residual disease after cytoreductive surgery has been repeatedly identified as a strong predictor of survival, and accordingly, the surgical effort to achieve the goal of complete gross tumor resection has been constantly evolving. Centers that have adopted the concept of radical surgery in patients with advanced ovarian cancer have reported improvements in their patients’ survival. In addition to the expected improvements in the pharmacologic treatment of this disease, some of the next challenges in the surgical management of ovarian cancer include the preoperative prediction of suboptimal debulking, improving the drug delivery to the tumor, and increasing access to centers of excellence in ovarian cancer regardless of geographical, financial, or other social barriers. This review will discuss an update on the role of surgery in the treatment of primary epithelial ovarian cancer as it has evolved since the emergence of the concept of surgical cytoreduction.

Healthcare Workers' Attitudes Toward Patients With Ebola Virus Disease in The United States

Healthcare workers willingness to care for Ebola patients did not precisely mirror their beliefs about the ethics of refusing to provide care, they were strongly influenced by concerns about potentially exposing families and friends to Ebola virus disease.

Use of 50% Dextrose as the Distension Medium During Cystoscopy for Visualization of Ureteric Jets.

BACKGROUND: Indigotindisulfonate sodium has been used to color the urine and thereby improve the visualization of ureteric jets during intraoperative cystoscopy. After indigotindisulfonate sodium became unavailable, there has been an ongoing search for an alternate agent to improve visualization of the jets. METHOD: We used 50% dextrose, which is more viscous than urine, as the distension medium during cystoscopy so that the ureteric efflux is seen as a jet of contrasting viscosity. We instilled 100 mL of 50% dextrose into the bladder through an indwelling catheter, which is then removed and cystoscopy is performed as usual. EXPERIENCE: We observed jets of contrasting viscosity in every patient in whom 50% dextrose was used as compared with coloring agents in which the jet is not always colored at the time of cystoscopy. Visualization of the other structures in the bladder and the bladder wall itself is not altered by 50% dextrose, although the volume of 50% dextrose that we typically use may not provide adequate distension for a complete assessment of the bladder. If additional distension is necessary, normal saline may be used in addition to the 50% dextrose once the ureteric jets have been assessed. CONCLUSION: Fifty percent dextrose is an effective alternative to indigotindisulfonate sodium for visualization of ureteric jets during cystoscopy.

50% dextrose versus normal saline as distension media during cystoscopy for assessment of ureteric patency

OBJECTIVE To compare the visualization of ureteric jets when using 50% dextrose (D50) as opposed to normal saline (NS) as distension media during cystoscopy. STUDY DESIGN Cross sectional study. METHODS Two patients each had two cystoscopy videos recorded at the time of a ureteric jet; one using NS and the other using D50 resulting in two sets of paired videos (four videos). A fifth cystoscopy video was recorded, as a control, at a time when there was no ureteric-jet. Fifty participants including attending physicians, residents and medical students were recruited at an academic-affiliated community hospital. Participants were blinded to the medium used and viewed each of the five videos. Participants assessed each video for presence of a ureteric-jet, ease of interpretation, and compared the paired D50 and NS videos for clarity of ureteric-jets. MAIN OUTCOME MEASURES Participants assessment of clarity of the ureteric jets when D50 was used as compared to when NS was used in the paired videos. RESULTS All 100 observations of the two D50 videos with jets identified the presence of a jet; for the NS videos, 96/100 observations identified a jet, 2/100 did not identify a jet and 2/100 were unsure. 48/50 observations of the video with no jet were correct, while 2/50 were unsure. Participants rated the ureteric-jets to be clearer in videos with D50 (86% vs 14%, P<0.001); and had difficulty interpreting cystoscopy videos with NS (62% vs 2%, OR: 80, 95% CI: 10.2-627.6). CONCLUSION Participants preferred the clarity of the ureteric-jet when 50% dextrose was used as the distension medium during cystoscopy as compared to normal saline.

Endometrial osseous metaplasia: an unusual cause of infertility

Osseous metaplasia of the endometrium is a rare disorder associated with the presence of bone in the uterine endometrium. Most patients with this condition presenting with infertility do so owing to the presence of a foreign body in the endometrium. We report a case of a 38-year-old woman who presented with secondary infertility due to osseous metaplasia in the endometrial cavity. She conceived spontaneously after hysteroscopic removal of the bony fragments from the uterus. Uterine osseous metaplasia is a rare cause of infertility that can be easily managed by hysteroscopic removal of the bony fragments, which results in return of fertility.

Delayed presentation of uterine rupture postpartum

FIGURE 2 Computed tomography scan of pelvis: transverse view Case notes A 32-year-old G2P1 with a history of cesarean delivery had an uncomplicated vaginal delivery at term. Two days after giving birth, she developed high-grade fever, tachycardia, hypotension, lower abdominal pain, and right flank pain. Computed tomography (CT) scan at that time revealed bladder wall thickening and a small amount of pelvic free fluid. She was started on broad-spectrum antibiotics for suspected pyelonephritis and sepsis. However, urine cultures were

The expanding repertoire of targets for immune checkpoint inhibition in bladder cancer: What lies beneath the tip of the iceberg, PD-L1

Over the last decade, a new understanding of tumor-immune system interplay has been ushered in, lead in large part by the discovery of immune checkpoints mediated through B7-CD28 family interactions. Therapeutic blockade of the PD-L1 immune checkpoint pathway has already shown great success as a cancer immunotherapy for advanced urothelial carcinoma, leading to durable clinical remissions in an otherwise incurable disease. There are newly described members of the B7-CD28 family including B7-H3, B7x, and HHLA2. These ligands are thought to play an essential role in suppressing T-cell response, leading to immune tolerance of tumors. This feature makes them attractive targets for novel immunotherapy treatment paradigms. Here, we review the literature of current strategies and future directions of immune checkpoint blockade therapy for bladder cancer.

Torsion of an iatrogenic parasitic fibroid related to power morcellation for specimen retrieval

Parasitic fibroids are generally diagnosed incidentally at the time of surgery performed for symptomatic uterine fibroids. Torsion of a parasitic fibroid causing severe acute onset pain is extremely rare. We report a torsed parasitic fibroid in a patient who underwent hysterectomy using power morcellation for specimen retrieval. A 40-year-old patient with a history of laparoscopic supracervical hysterectomy 8 years prior presented with severe abdominal pain. She was diagnosed with degenerating parasitic fibroids on magnetic resonance imaging and was managed conservatively. Surgery was performed 3 days later for persistent pain, and the parasitic fibroid was found to have undergone torsion. Torsed ischemic fibroids can undergo necrosis and gangrene and can potentially cause life-threatening coagulopathy and peritonitis. Awareness of this potential complication will reduce errors in diagnosis and facilitate timely management.

Resolution of superimposed pre-eclampsia, and improvement in umbilical artery flow in a surviving twin after intrauterine demise of its co-twin

Pre‐eclampsia has a progressive clinical course, and is only cured by delivery of the placenta. We report a 30‐year‐old G1P0 with dichorionic twins, discordant growth and chronic hypertension who developed superimposed pre‐eclampsia in her 21st week of gestation. After intrauterine demise of the severely growth‐restricted twin, the superimposed pre‐eclampsia resolved. The surviving twin initially had absent end diastolic flow, which resolved after the demise. A healthy 1935‐g neonate with Apgar 9/9 was delivered at 34 weeks. Antenatal resolution of pre‐eclampsia is extremely rare and resolution of superimposed pre‐eclampsia has not, to our knowledge, been reported.

A randomized trial comparing surgeon-administered intraoperative transversus abdominis plane block with anesthesiologist-administered transcutaneous block

BACKGROUND Injection of local anesthetic into the transversus abdominis plane (TAP block) decreases systemic morphine requirements after abdominal surgery. We compared intraoperative surgeon-administered TAP block (surgical TAP) to anesthesiologist-administered transcutaneous ultrasound-guided TAP block (conventional TAP) for post-cesarean analgesia. We hypothesized that surgical TAP blocks would take less time to perform than conventional TAP blocks. METHODS We performed a randomized trial, recruiting 41 women undergoing cesarean delivery under neuraxial anesthesia, assigning them to either surgical TAP block (n=20) or conventional TAP block (n=21). Time taken to perform the block was the primary outcome, while postoperative pain scores and 24-hour opioid requirements were secondary outcomes. Students t-test was used to compare block time and Kruskal-Wallis test opioid consumption and pain-scores. RESULTS Time taken to perform the block (2.4 vs 12.1 min, P <0.001), and time spent in the operating room after delivery (55.3 vs 77.9 min, P <0.001) were significantly less for surgical TAP. The 24 h morphine consumption (P=0.17) and postoperative pain scores at 4, 8, 24 and 48 h were not significantly different between the groups. CONCLUSION Surgical TAP blocks are feasible and less time consuming than conventional TAP blocks, while providing comparable analgesia after cesarean delivery.