Neoadjuvant chemotherapy and cytoreductive surgery in epithelial ovarian cancer

Ovarian cancer is one of the leading causes of death among gynecological cancers. This is because the majority of patients present with advanced stage disease. Primary debulking surgery(PDS) followed by adjuvant chemotherapy is still a mainstay of treatment. An optimal surgery, which is currently defined by leaving no gross residual tumor, is the goal of PDS. The extent of disease as well as the operative setting, including the surgeon's skill, infl uences the likelihood of successful debulking. With extensive disease and a poor chance of optimal surgery or high morbidity anticipated, neoadjuvant chemotherapy(NACT) prior to primary surgery is an option. Secondary surgery after induction chemotherapy is termed interval debulking surgery(IDS). Delayed PDS or IDS is offered to patients who show some clinical response and are without progressive disease. NACT or IDS has become more established in clinical practice and there are numerous publications regarding its advantages and disadvantages. However, data on survival are limited and inconsistent. Only one large randomized trial could demonstrate that NACT was not inferior to PDS while the few randomized trials on IDS had inconsistent results. Without a defi nite benefi t of NACT prior to surgery over PDS, one must carefully weigh the chances of safe and successful PDS against the morbidity and risks of suboptimal surgery. Appropriate selection of a patient to undergo PDS followed by chemotherapy or, preferably, to have NACT prior to surgery is very important. Some clinical characteristics from physical examination, serum tumor markers and/or fi ndings from imaging studies may be predictive of resectability. However, no specific features have been consistently identifi ed in the literature. This article will address the clinical data on prediction of surgical outcomes, the role of NACT, and the role of IDS.

Should Propofol and Alfentanil Be Combined in Patient-Controlled Sedation? A Randomised Controlled Trial Using Pharmacokinetic Simulation

Background: Patient-controlled sedation (PCS) is increasingly used for moderate sedation. Detailed understanding is essential for maintaining safety and giving the most benefit. We wanted to explore the associations between patients’ characteristics, perioperative pain and anxiety, the procedure, and the calculated concentrations at the effect site (Ce) of propofol. We also wanted to analyse the pharmacokinetic profiles of propofol and alfentanil during PCS, and their association with respiratory complications. Methods: 155 patients were double-blinded and randomised to have propofol or propofol and alfentanil for PCS during gynaecological surgery. Pharmacokinetic simulation of Ce and multiple regressions aided the search for correlations between explanatory variables and concentrations of drugs. Results: In group propofol, treatment for incontinence, anterior repair, and the patient’s weight correlated the best (B-coef = 0.20, 0.20 and 0.01;r = 0.69;r&#178 = 0.48). When alfentanil was added, alfentanil and the patient’s weight were associated with Ce of propofol (B-coef = &#450.40 and 0.01;r = 0.70;r&#178 = 0.43). Logistic regression indicated that age and Ce of drugs were related to ten cases of respiratory complications. Conclusions: Patients’ weights and the type of surgery performed were associated with the Ce of propofol;this knowledge could be used for refinement of the doses given during PCS. Because the pharmacokinetic profiles of propofol and alfentanil are different, the alfentanil effect becomes predominant during the time course of sedation. In order to reduce the risk of early and late respiratory depression, alfentanil should not be added to propofol in the same syringe.

糖筛查试验异常但口服葡萄糖耐量试验正常患者的特点:与正常及妊娠期糖尿病患者的比较

Objective: The purpose of this study was to evaluate the characteristics and outcomes of patients who had abnormal glucose challenge test results and subsequent normal oral glucose tolerance test results and to assess whether such patients are at agreater risk than normal pregnant patients for adverse perinatal outcome. Study design: In this retrospective cohort study that was conducted between June and December 2003, 101 pregnant women (group A) had an abnormal glucose challenge test result and a normal oral glucose tolerance test result. Data were also collected on 2 control groups: 100 pregnant women with normal glucose challenge test results (group B) and all 76 pregnant women who were diagnosed with gestational diabetes mellitus during this period of time (group C). Patients with multiple pregnancies, chronic hypertension, pregestational diabetes mellitus, or any other maternal or fetal problems that were diagnosed before 24 weeks (when the glucose challenge test was performed) were excluded from the study groups. The following data were collected and analyzed: maternal age, maternal weight and height, parity and gravidity, diabetes mellitus in first-degree relatives, medical and obstetric history, ethnicity,complications during the third trimester of pregnancy, birth- weight, gestational age at delivery, mode of delivery, Apgar scores, cord blood gas results, maternal complications of labor and during the postpartum period, and infant admission to then eonatal intensive care unit. For comparison between groups,we used the Student t test, 1-way analysis of variance, the chis-quaretest, and stepwise logistic regression. Results: Patients in groups A and C were significantly older compared with group B (29.2 ± 5.6 years and 30.4 ± 5.5 years, respectively, vs 24.8± 5.5 years; P < .01), had a lesser rate of primiparity (48% and 31% , respectively, vs 24% ; P < .05), had greater body mass index (30.8 ± 5 kg/m2 and 31.3 ± 6 kg/m2, respectively,vs 29.2 ± 4.4 kg/m2; P < .01), had a greater rate of previous gestational diabetes mellitus (6% and 20% , respectively, vs 0% ; P < .05), and had a greater rate of first-degree family members with diabetes mellitus (21% and 21% , respectively,vs 3% ; P < .01). None of the outcome parameters was statistically significant when group A was compared with group B. Conclusion: Patients with an abnormal glucose challenge test result and a subsequent normal oral glucose tolerance test result have different maternal characteristics and backgrounds compared with patients in whom both test results are normal,yet both groups have normal outcomes. We should continue to consider patients who have an abnormal glucose challenge test result and subsequent normal oral glucose tolerance test result as low-risk; however, these findings may represent an indication of an increased likelihood for the development of overt diabetes mellitus later in life.

Efficacy and safety of transvaginal mesh repair in a cohort with a minimum of 10-year follow-up

Although transvaginal mesh(TVM)repair is no longer used in some countries,long-term outcomes after TVM surgery are of great importance globally.However,reports with follow-up>10 years are limited.Thus,this study aimed to report outcomes in a prospective cohort with at least 10 years of follow-up.Women with stageⅢ–Ⅳsymptomatic prolapse were approached consecutively from 2008 to 2013 at one tertiary hospital.The main outcome measure was symptomatic failure.Secondary outcomes included anatomic failure,recurrence,patient satisfaction,complications,and reoperation.The Kaplan-Meier curve was used to estimate the cumulative failure rate.Of the 121 patients enrolled in the study,103(85.1%)completed a median follow-up of 11 years.The estimated probability rates of symptomatic and anatomic failure were 17.6%and 8.8%in 11 years,respectively.The estimated incidence of symptomatic failure increased by 8.2%between 5 and 11 years;however,the corresponding rate for anatomic failure was 3.7%.The most common complication was vaginal mesh exposure,and its estimated probability increased from 19.3%to 28.4%from 5 to 11 years,respectively.Office trimming resolved 80.0%of vaginal exposures.These patients did not report decreased overall satisfaction.Patients with vaginal mesh exposure requiring>3 office procedures or mesh removal in the operating room(5.8%by 11 years)had lower satisfaction rates(P<0.01)and were defined as having severe mesh exposure.The rates of postoperative pain,reoperation,and Patient Global Impression of Improvement≥2 were 2.5%,3.3%,and 94.2%,respectively.The results of this study implied that TVM treatment gradually increased the symptomatic failure rate but provided durable anatomical support of the vaginal wall.Vaginal mesh exposure was common in women who were largely not sexually active;however,80%of the cases could be managed in the outpatient clinic,which did not affect patient satisfaction.

经腹骶骨阴道固定术伴与不伴子宫切除术的网眼侵蚀

Objective: The purpose of this study was to examine risk factors for mesh erosion, including concomitant hysterectomy,in abdominal sacral colpopexies. Study design: Weconducted a retrospective cohort study of 313 women who underwent an abdominal sacral colpopexy. Data regarding patient demographics, operative techniques, length of follow-up,postoperative complications, and mesh erosion were collected.Results: Of 313 subjects, 101 (32.3% ) had concomitant hysterectomies and 212 (67.7% ) had had previous hysterectomies.The overall rate of mesh erosion was 5.4% . In bivariate analysis,concomitant hysterectomy was not associated with erosion(6.9% vs 4.7% previous hysterectomy, P = .42); however, estrogen therapy was an effect modifier. In women on estrogen,hysterectomy (OR 4.9, CI 1.2- 19.7) and anterior imbrication(OR 5.6, CI 1.1- 28.6) were associated with mesh erosion. No risk factors were identified in women not on estrogen. Conclusion:In women on estrogen therapy, hysterectomy was associated with mesh erosion in abdominal sacral colpopexy.

Updates in Long-term Maternal and Fetal Adverse Effects of Gestational Diabetes Mellitus

Gestational diabetes mellitus(GDM)is associated with long-term maternal and fetal adverse outcomes.Recent evidences suggest GDM increases long-term maternal cardiovascular disease,chronic kidney disease,and cancer risks.Maternal hyperglycemia is associated with offspring obesity,overweight,insulin resistance,and neurocognitive development.It remains unclear whether treating mild GDM would reduce long-term maternal and fetal adverse effects.