Michael M. Aziz

Incidental power morcellation of malignancy: A retrospective cohort study

OBJECTIVE Uterine fibroids often require hysterectomy via a laparotomy or utilizing minimally invasive surgical (MIS) approach. Morcellation is a fragmentation of the uterus into smaller pieces. The objective of this study is to determine the incidence of malignancies found in morcellated specimens at our institution. METHODS Women who had a minimally invasive hysterectomy, for presumptive benign uterine conditions were identified, included and reviewed. Patients were divided into two groups being either benign disease or malignancies. The continuous variables uterine weight and patient age were tested for normalcy with the Shapiro-Wilk test. The exposure of subspecialist vs general gynecology was interrogated via a Chi-Squared analysis. RESULTS 10 cases of malignancies were identified including endometrioid endometrial carcinomas (3), uterine serous carcinoma (1), endometrial stromal sarcomas (ESS) (3), and leiomyosarcomas (LMS) (3). An overall risk of occult cancer on a morcellated specimen was .73%; leiomyosarcoma was 0.22%, endometrial stromal sarcoma 0.22%, and endometrial cancer 0.29%. The median uterine weight for the 10 morcellated malignancies was 293.5g whereas the median weight for the benign uteri was only 117.5g giving a theta of -106 (95% CI -261,20). There was no difference in patient age or surgeon type between the groups (See Table 1). CONCLUSIONS Morcellation was associated with substantially higher risk of abdominopelvic recurrence and lower disease-free survival. Morcellated uterine malignancies were significantly heavier than benign uteri. Further research on uterine morcellation should focus on decision and cost-benefit analyses to determine the ideal candidate in whom uterine morcellation during minimally invasive hysterectomy would facilitate more good than harm.

Association Between 6-Minute Walk Test and All-Cause Mortality, Coronary Heart Disease–Specific Mortality, and Incident Coronary Heart Disease

Objective: To examine the association between 6-min walk test (6 MWT) performance and all-cause mortality, coronary heart disease mortality, and incident coronary heart disease in older adults. Method: We conducted a time-to-event analysis of 1,665 Cardiovascular Health Study participants without prevalent cardiovascular disease with a 6 MWT. Results: During a mean follow-up of 8 years, there were 305 incident coronary heart disease events, and 504 deaths of which 100 were coronary heart disease–related deaths. The 6 MWT performance in the shortest two distance quintiles was associated with increased risk of all-cause mortality (290-338 m: hazard ratio [HR] = 1.7; 95% confidence interval [CI] = [1.2, 2.5]; <290 m: HR = 2.1; 95% CI = [1.4, 3.0]). The adjusted risk of coronary heart disease mortality incident events among those with a 6 MWT < 290 m was not significant. Discussion: Performance on the 6 MWT is independently associated with all-cause mortality and is of prognostic utility in community-dwelling older adults.

Is preeclampsia an independent predictor of diastolic dysfunction? A retrospective cohort study.

OBJECTIVE To determine if preeclampsia is an independent predictor of diastolic dysfunction and what factors among patients with preeclampsia are associated with diastolic dysfunction. METHODS This is a retrospective cohort study of patients who delivered between 2008 and 2013 at a single institution who had a maternal echocardiogram during their pregnancy or within 5months of delivery. Patients with structural heart disease, ejection fraction less than 45%, pulmonary embolus, or age over 45years were excluded. Medical records were reviewed for medical and obstetric complications and echocardiogram findings. Demographic characteristics and rate of diastolic dysfunction were compared between patients with preeclampsia and without preeclampsia. Multivariate logistic regression was performed controlling for age, ethnicity, gestational age at delivery, diabetes, preeclampsia, intrauterine growth restriction (IUGR), antihypertensive use and magnesium sulfate administration. RESULTS Sixty-six patients were identified, of which 39 (59%) had preeclampsia. Past history of preeclampsia, IUGR in the current pregnancy, antihypertensive use and magnesium sulfate use were higher in the preeclampsia group. Fifteen patients (39%) in the preeclampsia group were African-American compared to 2 (3%) in the control group (p<0.01). Seventeen (44%) of the patients with preeclampsia were found to have diastolic dysfunction compared to 3 (11%) controls (OR=6.18, 95% CI 1.59,24.02; p=0.006). Logistic regression analysis did not reveal other independent predictors of diastolic dysfunction. In the patients with preeclampsia, history of preeclampsia with severe features and IUGR were not associated with diastolic dysfunction. CONCLUSIONS Our study supports previous findings that preeclampsia is associated with diastolic dysfunction.

Vasa Previa: Prenatal Diagnosis and Outcomes: Thirty‐five Cases From a Single Maternal‐Fetal Medicine Practice

To assess the accuracy and effectiveness of routine screening for vasa previa, to describe our experience, and to assess factors that contribute to missed cases of vasa previa.

Physiologic proteinuria in labor and postpartum: The results of the Postpartum Proteinuria Trial (PoPPy)

The urine protein to creatinine ratio (PC) is a sensitive and specific means of diagnosing preeclampsia in the antepartum period, but the 0.3 g protein per gram of creatinine threshold may be non-specific postpartum due to physiologic proteinuria after delivery. The objective of this study was to examine the reliability of PC in labor and postpartum and to determine if PC is affected by mode of delivery. This is the first study of its kind to examine physiologic proteinuria by catheterized PC in individual patients before and after delivery. This single-center prospective cohort study included two groups: term uncomplicated nulliparous patients in labor with epidural analgesia and patients for scheduled repeat cesarean deliveries. Patients with hypertension, antepartum proteinuria, renal disease, gross hematuria, or evidence of infection were excluded. Catheterized pre- and post-delivery urine PC were compared using paired t-tests. 27 and 40 patients were included in the vaginal and cesarean delivery groups, respectively. 52% of the vaginal delivery and 58% of the cesarean delivery groups were positive for proteinuria at the 0.3 g protein per g creatinine threshold. Pre- and post-delivery specimens were significantly different in the vaginal (mean difference 0.28, p = 0.05) and cesarean (mean difference 0.25, p < 0.01) delivery groups. The conclusions reached included the finding that PC measurements are unreliable in the immediate postpartum period regardless of mode of delivery, and utilizing the 0.3 threshold to diagnose preeclampsia in close proximity to delivery would contribute to increased false positive tests.

Are Women With Threatened Preterm Labor More Dehydrated Than Women Without It

Objective To determine if women who present to the labor and delivery unit at 23 0/7 to 36 6/7 weeks gestation with threatened preterm labor (TPTL) are more likely to be dehydrated than women who present at the same gestational age for other reasons. Design Retrospective cohort study. Setting An academic medical center in the northeastern United States. Participants All women at preterm gestational ages 23 0/7 to 36 6/7 weeks who presented to the labor and delivery unit for care in 2014. Methods We compared hydration status by urine specific gravity of women with TPTL to that of women with other chief complaints. Women for whom data were missing and those with hypertension, diabetes, renal disease, vaginal bleeding, ruptured membranes, advanced dilation (>3 cm), multiple gestation, or fetal demise were excluded. Chi‐square statistic and a receiver operating characteristic (ROC) curve were used for data analysis. Results A total of 840 women at 23 0/7 to 36 6/7 weeks gestation presented during the study period; 188 of these had TPTL, 261 had other chief complaints, and 391 were excluded. The proportion of women diagnosed with dehydration was similar between those with TPTL (39%) and those with other complaints (46%, p = .12). An ROC curve showed no association between TPTL and hydration status (area under the curve = 0.57, 95% confidence interval [0.46, 0.67]). Conclusion At 23 0/7 to 36 6/7 weeks gestation, the hydration status of women with TPTL was not different from those without TPTL. Because there is no relationship, it is unlikely that hydration is a worthwhile therapy for women with TPTL, although additional prospective study is warranted.

Is Preeclampsia an Independent Predictor of Diastolic Dysfunction?: A Retrospective Cohort Study [167].

INTRODUCTION: To determine whether preeclampsia is an independent predictor of diastolic dysfunction and what factors among patients with preeclampsia are associated with diastolic dysfunction. METHODS: This is a retrospective cohort study of patients who delivered between 2008 and 2013 at a single institution who had a maternal echocardiogram during their pregnancy or within 5 months of delivery. Patients with structural heart disease, ejection fraction less than 45%, pulmonary embolus, or age older than 45 years were excluded. Medical records were reviewed for medical and obstetric complications and echocardiogram findings. Demographic characteristics and rate of diastolic dysfunction were compared between patients with preeclampsia and without preeclampsia. Multivariate logistic regression was performed controlling for age, ethnicity, gestational age at delivery, diabetes, preeclampsia, intrauterine growth restriction (IUGR), antihypertensive use, and magnesium sulfate administration. RESULTS: Sixty-six patients were identified; 39 (59%) had preeclampsia. A history of preeclampsia, IUGR in the current pregnancy, antihypertensive use, and magnesium sulfate use was higher in the preeclampsia group. Fifteen (38.5%) in the preeclampsia group were African American compared with two (3%) in the control group (P<.01). Seventeen (44%) of the patients with preeclampsia were found to have diastolic dysfunction compared with three (11%) patients in a control group (odds ratio 6.18, 95% confidence interval 1.59–24.02; P=.006). Logistic regression analysis did not reveal other independent predictors of diastolic dysfunction. In the patients with preeclampsia, a history of preeclampsia, severe disease, and IUGR were not associated with diastolic dysfunction. CONCLUSION: Our study supports previous findings that preeclampsia is associated with diastolic dysfunction.