Mark Carey

Characteristics of women undergoing repeat induced abortion

Background: Although repeat induced abortion is common, data concerning characteristics of women undergoing this procedure are lacking. We conducted this study to identify the characteristics, including history of physical abuse by a male partner and history of sexual abuse, of women who present for repeat induced abortion. Methods: We surveyed a consecutive series of women presenting for initial or repeat pregnancy termination to a regional provider of abortion services for a wide geographic area in southwestern Ontario between August 1998 and May 1999. Self-reported demographic characteristics, attitudes and practices regarding contraception, history of relationship violence, history of sexual abuse or coercion, and related variables were assessed as potential correlates of repeat induced abortion. We used χ2 tests for linear trend to examine characteristics of women undergoing a first, second, or third or subsequent abortion. We analyzed significant correlates of repeat abortion using stepwise multivariate multinomial logistic regression to identify factors uniquely associated with repeat abortion. Results: Of the 1221 women approached, 1145 (93.8%) consented to participate. Data regarding first versus repeat abortion were available for 1127 women. A total of 68.2%, 23.1% and 8.7% of the women were seeking a first, second, or third or subsequent abortion respectively. Adjusted odds ratios for undergoing repeat versus a first abortion increased significantly with increased age (second abortion: 1.08, 95% confidence interval [CI] 1.04–1.09; third or subsequent abortion: 1.11, 95% CI 1.07–1.15), oral contraceptive use at the time of conception (second abortion: 2.17, 95% CI 1.52–3.09; third or subsequent abortion: 2.60, 95% CI 1.51–4.46), history of physical abuse by a male partner (second abortion: 2.04, 95% CI 1.39–3.01; third or subsequent abortion: 2.78, 95% CI 1.62–4.79), history of sexual abuse or violence (second abortion: 1.58, 95% CI 1.11–2.25; third or subsequent abortion: 2.53, 95% CI 1.50–4.28), history of sexually transmitted disease (second abortion: 1.50, 95% CI 0.98–2.29; third or subsequent abortion: 2.26, 95% CI 1.28–4.02) and being born outside Canada (second abortion: 1.83, 95% CI 1.19–2.79; third or subsequent abortion: 1.75, 95% CI 0.90–3.41). Interpretation: Among other factors, a history of physical or sexual abuse was associated with repeat induced abortion. Presentation for repeat abortion may be an important indication to screen for a current or past history of relationship violence and sexual abuse.

General health and psychological symptom status in pregnancy and the puerperium: what is normal?

OBJECTIVEnTo identify normative changes in psychological and physiologic health status associated with pregnancy and the puerperium.nnnMETHODSnSelf-administered surveys containing Wares Short Form-36 and Derogatiss Brief Symptom Inventory were completed by 393 pregnant women during their third trimester. Of those, 253 completed the same survey during the puerperium. Results were compared between periods and with those of samples of women from standardized community samples.nnnRESULTSnOn the Short Form-36, pregnant women in the third trimester had significantly poorer levels of functioning (P<.01) than community controls with regard to bodily pain (51.86 versus 79.61), physical functioning (62.91 versus 89.12), social functioning (74.0 versus 84.06), vitality (47.24 versus 58.04), and functional limitations resulting from physical health problems (45.0 versus 86.73) subscales. Those differences persisted into the puerperium. Compared with pregnancy, scores on social functioning and functional limitations caused by emotional problems decreased during the puerperium. Women reported improved perceptions of their general health in the puerperium compared with community controls (80.22 versus 74.80). On the Brief Symptom Inventory, pregnant women reported significantly higher levels of emotional distress on the three global measures and on the somatization (0.75 versus 0.35), obsessive-compulsive (0.70 versus 0.48), and hostility (0.59 versus 0.36) subscales than controls; those changes normalized in the puerperium.nnnCONCLUSIONnPregnancy and the puerperium are associated with significant changes in psychological and physiologic health status. Documentation of those changes is important if the Short Form-36 and Brief Symptom Inventory are to be used in health outcomes research with this population.

Are Uterine Risk Factors More Important Than Nodal Status in Predicting Survival in Endometrial Cancer

OBJECTIVE: To evaluate factors associated with survival after lymphadenectomy for endometrial cancer and to address their effect relating to systemic therapy. METHODS: This was a retrospective, population-based cohort study of 316 women with endometrial cancer who underwent surgery including lymphadenectomy in Ontario, Canada, from 1996–2000. Data obtained from administrative databases included comorbidities, socioeconomic status, grade, myometrial invasion, cervical involvement, lymphovascular-space invasion, nodal status, and adjuvant pelvic radiotherapy. Primary outcome was 5-year overall survival. Factors associated with survival were identified in a multivariable Cox proportional hazards model. RESULTS: Mean age was 62.2 years (±11.6 years). Thirty-eight women (12%) had positive pelvic nodes. Seventy-five (23.7%) received adjuvant pelvic radiotherapy. Age older than 60, grade 3 tumor, deep myometrial invasion (greater than 50%), and cervical stromal involvement were associated with a higher risk of death compared with reference categories. There were no survival differences according to comorbidities, socioeconomic status, or lymphovascular-space invasion. Five-year overall survival was 53.1% for node-negative patients with two or three uterine risk factors and 75.0% for node-positive patients with none or only one uterine risk factor. Pelvic-node status was not an independent determinant of survival (positive nodes: hazard ratio 1.39, 95% confidence interval 0.89–2.18). CONCLUSION: High-risk uterine factors including grade 3 tumor, deep myometrial invasion, and cervical stromal involvement are more significant determinants of survival in endometrial cancer than pelvic-node status. Uterine risk factors should be considered, regardless of nodal status, when offering systemic therapy to maximize survival outcomes. LEVEL OF EVIDENCE: II

Systematic review of adjuvant care for women with Stage I ovarian carcinoma

Several adjuvant care interventions to treat women with Stage I ovarian carcinoma have been studied. The aim of the current systematic review was to determine the optimal strategy for adjuvant care for women with Stage I ovarian carcinoma.

Patterns of practice and outcomes in intermediate‐ and high‐risk stage I and II endometrial cancer: a population‐based study

To evaluate patterns of practice and outcomes in intermediate- and high-risk stage I and II endometrial cancer in the province of Ontario, Canada. This was a retrospective population-based study of women diagnosed with stage I and II endometrial cancer in Ontario from 1996 to 2000. After excluding low-risk (stages IA and IB, grades 1 and 2) and nonendometrioid histologies, the population was stratified into two risk groups: intermediate risk (stages IA and IB, grade 3; stages IC and IIA, grades 1 and 2; stage IIA, grade 3 if <50% myometrial invasion) and high risk (stage IC, grade 3; stage IIA, grade 3 if >50% myometrial invasion, and all stage IIB). Patterns of practice were assessed in each risk group, including use of surgical staging and adjuvant pelvic radiotherapy (APRT). Cox proportional hazards models determined effects of prognostic factors on 5-year overall survival (OS), including age, income, comorbidities, lymphvascular space invasion (LVSI), surgical staging, and APRT. There were 995 women in this study: 748 intermediate risk (75.2%) and 247 high risk (24.8%). Only 69 (9.2%) and 40 (16.2%) women underwent surgical staging in the intermediate- and high-risk groups, respectively. Surgical staging did not reduce rates of APRT. Determinants of survival included age >60 and comorbidities in the intermediate-risk group, and age >60, income, and LVSI in the high-risk group. In this population-based study, there were variable patterns of practice for intermediate- and high-risk stage I and II endometrial cancer. Surgical staging and APRT did not affect OS

Infertility surgery for pelvic inflammatory disease: Success rates after salpingolysis and salpingostomy

Abstract Eighty-seven patients with infertility due to pelvic inflammatory disease were retrospectively studied to determine pregnancy rates after infertility surgery. Patients were divided into two groups on the basis of the type of surgical procedure: group 1, lysis of adhesions only (22 patients); group 2, terminal salpingostomy with lysis of adhesions (65 patients). A significantly greater number of patients in group 1 (nine of 22, 41%) than in group 2 (12 of 65, 18%) (p

Factors That Influence Length of Stay for In-Patient Gynaecology Surgery: Is The Case Mix Group (CMG) or Type of Procedure More Important?

OBJECTIVESnTo compare the association between the Case Mix Group (CMG) code and length of stay (LOS) with the association between the type of procedure and LOS in patients admitted for gynaecology surgery.nnnMETHODSnWe examined the records of women admitted for surgery in CMG 579 (major uterine/adnexal procedure, no malignancy) or 577 (major surgery ovary/adnexa with malignancy) between April 1997 and March 1999. Factors thought to influence LOS included age, weight, American Society of Anesthesiologists (ASA) score, physician, day of the week on which surgery was performed, and procedure type. Procedures were divided into six categories, four for CMG 579 and two for CMG 577. Data were abstracted from the hospital information costing system (T2 system) and by retrospective chart review. Multivariable analysis was performed using linear regression with backwards elimination.nnnRESULTSnThere were 606 patients in CMG 579 and 101 patients in CMG 577, and the corresponding median LOS was four days (range 1-19) for CMG 579 and nine days (range 3-30) for CMG 577. Combined analysis of both CMGs 577 and 579 revealed the following factors as highly significant determinants of LOS: procedure, age, physician, and ASA score. Although confounded by procedure type, the CMG did not significantly account for differences in LOS in the model if procedure was considered. Pairwise comparisons of procedure categories were all found to be statistically significant, even when controlled for other important variables.nnnCONCLUSIONnThe type of procedure better accounts for differences in LOS by describing six statistically distinct procedure groups rather than the traditional two CMGs. It is reasonable therefore to consider changing the current CMG codes for gynaecology to a classification based on the type of procedure.

Cost-Effectiveness Analysis of Treatment Strategies for Stage I and II Endometrial Cancer

OBJECTIVEnPractice patterns vary across Canada with respect to indications for surgical staging and adjuvant radiotherapy in early endometrial cancer. We evaluated the cost-effectiveness of two common strategies for managing early endometrial cancer as part of an Ontario population-based study.nnnMETHODSnA decision-analytic model (DATA 4.5) was developed for Stage I and II endometrioid-type cancer using empiric data from Ontario. On the basis of preoperative biopsy grade, one of two surgical procedures was selected: (1) hysterectomy and bilateral salpingo-oophorectomy (HBSO) or (2) surgical staging (HBSO and pelvic +/- para-aortic lymphadenectomy). Adjuvant radiotherapy (RT) was administered according to final grade and stage. After HBSO, pelvic RT was indicated for Grades 1 and 2 if Stage IC, IIA with > 50% myometrial invasion (MI), or IIB, and for Grade 3 if Stage IB, IC, IIA, or IIB. After staging, pelvic RT was indicated for Grades 1 and 2 if Stage IIB, and for Grade 3 if Stage IC, IIA with > 50% MI, or IIB. Main outcome measures were quality-adjusted life-years (QALY) and incremental cost-effectiveness ratios (ICER). Sensitivity analyses were used to evaluate uncertainty around various parameters.nnnRESULTSnThe most cost-effective (dominant) strategies were determined for each preoperative grade. For Grade 1, HBSO strongly dominated surgical staging. For Grade 2, neither strategy was dominant; surgical staging had an ICER of

Endometrial adenocarcinoma encountered at the time of hysteroscopic endometrial ablation.

5216 per QALY. For Grade 3, surgical staging strongly dominated HBSO. These results were stable over a wide range of estimates for costs and utilities (i.e., patient preferences for a particular health state).nnnCONCLUSIONnThe most cost-effective treatment strategies for early endometrial cancer in Ontario differ according to preoperative grade.

Minimal-Deviation Adenocarcinoma of the Cervix Encountered during Hysteroscopic Endometrial Ablation

STUDY OBJECTIVEnTo determine the diagnostic accuracy and possible role of treatment of hysteroscopic endometrial resection in women with abnormal uterine bleeding (AUB) diagnosed with endometrial adenocarcinoma.nnnDESIGNnRetrospective analysis (Canadian Task Force classification II-2).nnnSETTINGnUniversity-affiliated center.nnnPATIENTSnThirteen women with AUB and eight with postmenopausal bleeding.nnnINTERVENTIONnPreablation endometrial office biopsy and hysteroscopic evaluation.nnnMEASUREMENTS AND MAIN RESULTSnPreablation endometrial biopsy was inadequate, inconclusive, or difficult to obtain in these women, and endometrial cancer was found at the time of resectoscopic surgery. Total endomyometrial resection including the tubal ostia was completed in eight women (group 1) and partial resection in five (group 2). Endometrial adenocarcinoma was confirmed histologically in all patients. A small focus of cancer was found in only two women in group 1 after total resection; in one the procedure was performed 9 years earlier and in the other it was completed hastily after absorption of 800 ml of 1.5% glycine irrigation solution. In women in group 2 malignancy was highly suspected and total resection was considered unwise.nnnCONCLUSIONnAll patients were alive and well 0.5 to 9 years after hysterectomy, with no evidence of recurrent cancer.