Joseph T. Santoso

Postpartum regression rates of antepartum cervical intraepithelial neoplasia II and III lesions.

OBJECTIVEnTo study the histologic regression and progression rates of cervical intraepithelial neoplasia (CIN) II and III after delivery and the effect the route of delivery has on the regression rates of CIN.nnnMETHODSnPregnant patients with satisfactory colposcopic examinations and biopsy-proven CIN II and III were identified. Delivery information and postpartum biopsy results were obtained by chart review.nnnRESULTSnTwo hundred seventy-nine patients had antepartum biopsies of CIN II or CIN III. Of these, 126 women were excluded for the following reasons: lost to follow-up (75), human immunodeficiency virus positive (two), cesarean hysterectomy (four), and inadequate postpartum follow-up (45). This yielded a study group of 153 patients consisting of 82 with CIN II and 71 with CIN III. The regression rates were 68% and 70% among CIN II and CIN III patients (P = .78), respectively. Seven percent of patients with CIN II progressed to CIN III on postpartum evaluation. Twenty-five percent of those patients with CIN II and 30% of those with CIN III remained the same postpartum. No CIN lesions progressed to invasive carcinoma. There were no differences in regression rates or progression rates among the women who had vaginal deliveries (130), women who labored and then underwent cesarean (17), or women who proceeded to a cesarean without laboring (six).nnnCONCLUSIONnWe found similar high postpartum regression rates despite the route of delivery. We recommend conservative antepartum management with postpartum colposcopic evaluation regardless of route of delivery because we are unable to predict which of these lesions are more likely to regress.

Pathology slide review in gynecologic oncology.

Objective To analyze the diagnostic accuracy and alteration in treatment planning from interinstitution (different institution) pathologic consultation. Methods We reviewed pathologic reports from 720 referred patients. The diagnosis rendered from a gynecologic pathologist was compared with the original diagnosis. Discrepancies were coded as none, minor, or major. A discrepancy was major if it led to treatment alteration. A discrepancy was minor if it did not lead to treatment alteration. The judgment to declare a discrepancy was made by a gynecologic pathologist, a gynecologist, and three gynecologic oncologists. The review cost was

Massive blood loss and transfusion in obstetrics and gynecology

150 per case. The Cochran Mantel-Haenszel test evaluated any systematic pattern in discrepancies. Results Seven hundred twenty specimens consisted of 113 vulvar, 170 uterine, 289 cervical, 105 ovarian, and 43 vaginal tissues. Six hundred one (84%) pathologic diagnoses showed no discrepancy. There were 104 (14%) minor and 15 (2%) major discrepancies. After reviewing 15 major discrepancies, six surgeries were canceled, two surgeries were modified, one adjuvant radiation treatment was added, one chemotherapy treatment was modified, and five adjuvant chemotherapy treatments were cancelled. No systematic error was identified with regard to the sources (tissue origin) or methods of obtaining the specimen (P = .675). The cost of reviewing 720 specimens was

Primary malignant melanoma of the uterine cervix: Two case reports and a century’s review

108,000. The cost of identifying each major discrepancy was

Transfusion medicine in obstetrics and gynecology

7200. Conclusion Reviewing pathology slides before definitive treatment reveals notable discrepancies in diagnoses. The cost of pathology review is globally expensive but has consequential impact on proper treatment planning for the individual patient.

Risk factors for anal intraepithelial neoplasia in women with genital dysplasia.

Massive perioperative or periparturitional bleeding occasionally occurs in obstetric and gynecologic patients. Placenta previa, uterine atony, and ectopic pregnancy are just a few examples of many conditions that could predispose patients to significant blood loss. Therefore, it is important for physicians specializing in obstetrics and gynecology to be proficient in managing episodes of massive hemorrhage and the practice of the most commonly used blood components. We review and update the management of massive hemorrhage for obstetrics and gynecologic patients. In addition, we explore blood component therapy, its risks and benefits. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to explain the necessity of being proficient in managing episodes of massive hemorrhage, list the indications for use of various blood components, and summarize the risks and benefits of blood component therapy.

Comparison of gastric mucosal pH and clinical judgement in critically ill patients

Primary malignant cervical melanoma is diagnosed by the presence of junctional melanocytic abnormality and the absence of distant metastasis. Amelanotic and poorly differentiated tumors can often be diagnosed with the HMB-45 immunoperoxidase stain which is very specific for melanoma. Early reported cases were treated with simple excision followed many times by radiation therapy. Radical hysterectomy, pelvic lymphadenectomy, and partial vaginectomy have been advocated by some contemporary investigators. Radiation can be used as adjuvant or palliative treatment; its efficacy is not well established. Few patients have been treated with modern chemotherapy. No patient has been treated with immunotherapy. Primary malignant cervical melanoma carries a very poor prognosis. Most patients succumb from their disease within 2 years. One patient has survived 14 years. The small number of reported cases makes it difficult to evaluate the efficacy of any treatment modality.

Optimal pain management in total abdominal hysterectomy.

Obstetricians and Gynecologists care for many patients with conditions potentially requiring blood transfusions. Cesarean section and hysterectomy are the two surgeries performed most frequently and both have the potential for blood loss requiring transfusion. Other examples include postpartum hemorrhage, placenta previa, and ruptured ectopic pregnancy. Obstetricians and gynecologists need to become knowledgeable about the ever-changing aspects of blood transfusion and apply it in their clinical practice. This review intends to update obstetricians and gynecologists and other health care professionals about the basic as well as the latest technologies of blood transfusion. The different types of blood components are discussed including their preparation, indications, risks, and benefits. The complications of blood transfusion and their management are reviewed, including infections, noninfectious, and immunological etiologies. HIV and hepatitis are explored, these being the most serious infectious risks of transfusion. Autologous blood transfusion, an underutilized option, is examined. Hemodilution and intraoperative blood salvage, other techniques for using the patients own blood, are discussed. Finally, synthetic agents such as erythropoietin, granulocyte colony-stimulating factors, factors, desmopressin acetate, gonadotropin-releasing hormone agonists, and new products are introduced as potential replacements to blood transfusion in the future.

Colposcopic acetowhitening of vulvar lesion: a validity study

OBJECTIVE: To identify risk factors associated with anal intraepithelial neoplasia and develop a model for predicting the likelihood of anal intraepithelial neoplasia in heterosexual women. METHODS: A prospective cohort of 327 patients from 2006 to 2011 with a biopsy-confirmed diagnosis of genital intraepithelial neoplasia (vulvar, vaginal, or cervical) underwent both anal cytology and anoscopy. Variables significant between those with and without anal intraepithelial neoplasia were identified using logistic regression. A forward stepwise regression analysis was carried out to identify a combination of variables that effectively predicted anal intraepithelial neoplasia. RESULTS: In the cohort of analyzed patients, 64 (46.7%) women with anal intraepithelial neoplasia were identified, yielding a prevalence of 19.6%. Immunosuppression, vulvar dysplasia, multiple sexual partners (more than four), smoking history, and history of anal sex were positively associated with anal intraepithelial neoplasia (P<.05). These variables were analyzed using forward stepwise logistic regression. The final model used the presence of any two of three risk factors (vulvar intraepithelial neoplasia [VIN], immunosuppression, and history of anal sex) to predict 38.8% of anal intraepithelial neoplasia in our population. Area under the receiver operating characteristic curve for two of three of the factors was 0.708 (P<.05). This model has a negative predictive value of 88.2% (95% confidence interval [CI] 0.83–0.92) and positive predictive value of 43.1% (95% CI 0.31–0.56). CONCLUSION: A simple predictive model based on the presence or absence of two of three risk factors (VIN, immunosuppression, and history of anal sex) can be used by the clinician to quantify anal intraepithelial neoplasia risk in women with genital dysplasia. LEVEL OF EVIDENCE: II

p53 Adenovirus as Gene Therapy for Ovarian Cancer.

OBJECTIVESnTo compare gastric tonometry (pHi) with estimates of pHi in ill injured patients, and to correlate pHi with haemodynamic variables.nnnDESIGNnProspective, non-interventional study.nnnSETTINGnICU of Level I trauma centre, USA.nnnMAIN OUTCOME MEASURESn154 gastric tonometry measurements were compared with physicians estimates of adequacy of resuscitation. Resuscitation was categorised as inadequate (pHi < 7.35) or adequate (pHi> or = 7.35). Measured and estimated pHi were also compared with oxygen delivery, oxygen consumption, cardiac index, mixed venous O2 saturation, and critical illness scores.nnnRESULTSnEstimated pHi was often higher than measured pHi in the judgement of all four surgical intensive care physicians. Measured pHi correlated positively with mixed venous O2 tension (r = 0.21). There were significant negative correlations between measured pHi and both oxygen delivery (r = -0.25) and oxygen consumption (r = 0.28). Estimated pHi correlated positively with mean arterial pressure (r = 0.21) and hospital day (r = 0.26); it correlated negatively with pulmonary arterial elastance (r = -0.35).nnnCONCLUSIONnExperienced intensive care physicians tended to overestimate visceral perfusion, which suggests that gastric tonometry adds useful information over and above routine haemodynamic indices. Arterial blood pressure and mixed venous oxygen saturation correlated better with measured pHi than with other indices of perfusion.