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The prognosis of patients presenting with stage IVB uterine serous carcinoma (USC) remains extremely poor, with a reported 5-year survival of20%. Here were evaluate the survival impact of cytoreductive surgery and identify other prognostic factors in stage IVB USC.A multicenter retrospective analysis of patients with stage IVB USC was conducted from 2000 to 2018. Inclusion criteria were patients who had undergone comprehensive surgical staging/tumor debulking; followed by adjuvant chemotherapy+/-external beam radiation therapy (EBRT). Optimal cytoreduction (R1) was defined as residual disease ≤1 cm at completion of surgery, and suboptimal cytoreduction (R2) was defined as1 cm. Progression free survival (PFS) and overall survival (OS) analysis was performed using Kaplan-Meier estimates. Multivariate analysis (MVA) was performed using Cox proportional hazards model.Final analysis included 68 patients. There was no difference in the frequency of treatment delays between regimens (p = 0.832). 96% of patients received platinum-based chemotherapy. There was no difference in the age (p = 0.227), race (p = 0.936), type of radiotherapy (p = 0.852) or chemotherapy regimen received (p = 0.996) between R1 and R2 cohorts. The median PFS for all patients was 8 months and the median OS was 13 months. Cytoreduction to R1 was associated with a median PFS of 9 months, compared to R2 with a median PFS of 4 months (p 0.001, HR 0.32, 95% CI 7.4-14.1). Median OS was also improved with R1 vs. R2 cytoreduction (17 months vs. 7 months, respectively) (p 0.001, HR 0.21, 95% CI 13.7-26.4). Compared to R1, cytoreduction to R0 was not associated with a survival benefit. The R0 median OS was 17 months versus 18 months in R1 (p = 0.67). The combination of adjuvant chemoradiation was associated with improved PFS (11 months vs. 7 months) (p = 0.024, HR 0.41, 95% CI 6.5-9.4) and OS (22 months vs 13 months) (p = 0.65, HR 0.25, 95% CI 10.5-15.4) compared to chemotherapy-alone, respectively. On MVA, only the amount of residual disease (p = 0.003, HR 0.39, 95% CI 0.2-0.7) and receipt of adjuvant chemoradiation (p = 0.010, HR 0.09, 95% CI 0.01-0.58) were independent predictors of survival.In stage IVB USC, optimal cytoreduction should be the goal at the time of primary surgery. The combination of chemoradiation was associated with superior survival compared to chemotherapy alone and should be further investigated in this patient population.

Objectives: The cornerstone of the management of cervical cancer (CC) traditionally relies on clinical examination (CE) of tumor size (TS) and local extension of disease. The goal of this study is to determine the accuracy of CE in comparison to final pathology (FP) in early operable CC. Methods: This is a multi-center retrospective review of patients with early CC (FIGO 2009 Stage IB1, IIA1). CE of TS, parametrial invasion (PI), and vaginal involvement (VI) were compared to FP. Results: The final analysis included 135 patients. Overall, there was a significant difference between CE of TS compared to FP; mean error of 1.22 cm (p

Background. Coronavirus Disease 2019 (COVID-19) is responsible for a global pandemic that has significantly affected New York City. There is limited data about COVID-19 infection in pregnancy, especially in critically ill patients. Case. A 30-year-old female who presented at 26 weeks gestation with acute severe respiratory distress that required intubation and intensive care unit (ICU) admission. We had a high suspicion of COVID-19 disease despite repeated negative SARS-CoV-2 PCR testing, with eventual positive COVID IgG antibody testing. Through an integration of obstetrical knowledge, critical care, and comparing outcomes from similar cases in the literature, we decided to expectantly manage her pregnancy and did not recommend administration of antenatal steroids. She was extubated after 23 days of mechanical ventilation and recovered from her respiratory illness. She had a full-term spontaneous vaginal delivery of a baby boy at 39 weeks gestation with excellent maternal and fetal outcomes at delivery. Conclusion. In the face of COVID-19, a new disease with unclear maternal and fetal outcomes to date, a collaboration of care teams is essential to navigate through the challenging decisions made, including timing of delivery, treatment options, and administration of steroids. Our paper is unique as there is no other published case report of a critically ill pregnant patient with COVID-19 in which delivery was deferred, and a full recovery was observed, with a vaginal delivery at term.

Highlights • Ovarian cancer (OC) metastasizes cutaneous in up to 6% of cases. • Cutaneous metastasis to the vulva is rare; with only one prior report in the literature. • Resection of cutaneous metastasis offers symptom relief as well as a potential survival benefit. • Molecular tumor profiling should be employed to expand therapy options.

Highlights • Metastasis of endometrial cancer (EC) to bone is rare, occurring in, Metastasis to bone (BM) is an uncommon manifestation of advanced endometrial cancer (EC). The present study will review the clinicopathologic features of a cohort of patients with EC and BM. We conducted a multi-center retrospective review of patients with EC and BM. Demographic and clinical information was extracted from the medical records. Survival outcomes were determined using Kaplan-Meier Curves. Final analysis included 10 patients. The median age was 65 years (range 31–71). 80% had FIGO stage III/IV disease. The most common site of BM was the spine (66%). All patients presented with extraosseous dissemination at the time of diagnosis of BM and 70% were found to have multiple sites of BM. 80% of patients were diagnosed with BM in the recurrent setting. The median time to diagnosis of bone recurrence was 14 months (range: 0–44). Median survival after diagnosis of BM was 11 months (range: 1–22 months). Patients with endometrioid histology and single site of bone metastasis experienced improved survival (p = 0.04 and p = 0.05, respectively). Eight patients had immunohistochemistry or molecular tumor profiles available for review. Seven of these patients (87.5%) were found to have microsatellite instability (MSI). The most common mutation was hypermethylation of MLH-1 (43%). To our knowledge, this is the first report demonstrating a correlation between MSI and metastasis to bone. The identification of BM in EC is uncommon, but will alter treatment strategies and dramatically impact prognosis. Molecular tumor profiling should be performed to identify targeted therapy options and optimize adjuvant treatment strategies.

Objectives: Despite recent advances in adjuvant therapy for various gynecologic malignancies, the prognosis of patients presenting with stage IVB uterine serous carcinoma (USC) remains extremely poor, with a reported 5-year survival of Methods: A multicenter retrospective analysis of patients with stage IVB USC was conducted from 2000 - 2018. Inclusion criteria were patients who had undergone comprehensive surgical staging/tumor debulking; followed by adjuvant chemotherapy±external beam radiation therapy (EBRT). Optimal cytoreduction (R1) was defined as residual disease =1cm. Patients receiving neoadjuvant chemotherapy were excluded from analysis. Progression free survival (PFS) and overall survival (OS) analysis was performed using Kaplan-Meier estimates. Multivariate analysis (MVA) was performed using Cox proportional hazards model. Results: Final analysis included 68 patients. 50 (74%) patients were cytoreduced to R1 and 18 (26%) to R2. Additionally, 11 (16%) R1 patients were cytoreduced to no gross residual disease (R0). The mean age was 66 years (range 44-89) and 96% of patients were African American. The majority of patients, 56 (82%), received systemic chemotherapy alone and 12 (18%) received a combination of chemotherapy and EBRT±vaginal brachytherapy (chemoradiation). Adjuvant therapy regimens were well-balanced between R1 and R2 patients (p=0.992). There was no difference in the frequency of treatment delays between regimens (p=0.832). 96% of patients received platinum-based chemotherapy. There was no difference in the age (p=0.227), race (p=0.936), type of radiotherapy (p=0.852) or chemotherapy regimen received (p=0.996) between R1 and R2 cohorts. The median PFS for all patients was 8 months and the median OS was 13 months. Cytoreduction to R1 was associated with a median PFS of 9 months, compared to R2 with a median PFS of 4 months (p Conclusions: In stage IVB USC, the amount of residual disease follow cytoreductive surgery is an important determinant of survival. Optimal cytoreduction should be the goal at the time of primary surgery. The combination of chemoradiation was associated with superior survival compared to chemotherapy alone and should be further investigated in this patient population.

Patient: Male, 51 Final Diagnosis: ST-segment elevation myocardial infarction with acute stent thrombosis Symptoms: Chest pain • hiccups Medication: — Clinical Procedure: — Specialty: Cardiology Objective: Unusual clinical course Background: Acute coronary syndrome (ACS) can present with atypical chest pain or symptoms not attributed to heart disease, such as indigestion. Hiccups, a benign and self-limited condition, can become persistent or intractable with overlooked underlying etiology. There are various causes of protracted hiccups, including metabolic abnormalities, psychogenic disorders, malignancy, central nervous system pathology, medications, pulmonary disorders, or gastrointestinal etiologies. It is rarely attributed to cardiac disease. Case Report: We report a case of intractable hiccups in a 51-year-old male with cocaine related myocardial infarction (MI) before and after stent placement. Coronary angiogram showed in-stent thrombosis of the initial intervention. Following thrombectomy, balloon angioplasty, and stent, the patient recovered well without additional episodes of hiccups. Although hiccups are not known to present with a predilection for a particular cause of myocardial ischemia, this case may additionally be explained by the sympathomimetic effects of cocaine, which lead to vasoconstriction of coronary arteries. Conclusions: Hiccups associated with cardiac enzyme elevation and EKG ST-segment elevation before and after percutaneous coronary intervention (PCI) maybe a manifestation of acute MI with or without stent. The fact that this patient was a cocaine user may have contributed to the unique presentation.

Context: Pain is one of the most common postpartum complaints by women in the United States, and the pain varies in its location. Research on intervention strategies for postpartum pain has focused primarily on the lower back, but pain management for other types of postpartum pain remains unclear. Objective: To investigate the effects of osteopathic manipulative treatment (OMT) on postpartum pain; the location, quality, and timing of pain; and the difference in pain between vaginal and cesarean delivery. Methods: Postpartum patients who reported having pain were recruited at St Barnabas Hospital in Bronx, New York. The short-form McGill Pain Questionnaire was administered along with a screening questionnaire. Second- or third-year residents in neuromusculoskeletal medicine and osteopathic manipulative medicine examined patients and then diagnosed and managed somatic dysfunction with OMT for approximately 25 minutes. The short-form McGill Pain Questionnaire was again administered after OMT. Paired t tests and McNemar tests were used to analyze changes before and after OMT for continuous and categorical variables, respectively. Differences in visual analog scale (VAS) pain scores between patients who had vaginal vs cesarean delivery were tested using analysis of variance, and group differences in pain location were tested using a Pearson χ2 test. Results: A total of 59 patients were included in the study. The mean VAS score for pain was 5.0 before OMT and 2.9 after OMT (PPP Conclusion: Preliminary results demonstrate that OMT is efficacious for postpartum pain management. The lack of a control group precludes the ability to make causal claims. Future studies are needed to solidify OMT efficacy and generalizability.

The family Giraffidae is represented by two extant taxa (Giraffa camelopardalis and Okapia johnstoni), both of which are committed browsers. During the late Miocene, however, the Pikermian Biome included more than 15 giraffid species with a wider range of dietary ecologies. To examine the diet of these taxa, we apply a novel combined approach using four variables from two methods of dental mesowear. We score the traditional outer mesowear, which evaluates the sharpness and relief of the labial-most paracone enamel band. We also apply inner mesowear, which evaluates the surface morphology of the lingual band of paracone enamel on the mesial and distal ends, as well as the junction point between the two. Using a database of 8 extant species (N = 98) of browsing, grazing, and mixed feeding ruminants, we predict the diets 190 extinct giraffid specimens. The discriminant function analysis (DFA) of the extant taxa using all four mesowear variables predicted diet with greater accuracy than any single mesowear variable. We compare the dietary profiles of species found in four Pikermian Biome regions: Samos, Pikermi, North China, and Linxia Basin. We find differences in the giraffid diet throughout the Pikermian Biome: in the localities from Greece, a larger number of giraffids were predicted as browsers, whereas both Chinese regions included a larger number of mixed feeding individuals. Our inner and outer mesowear dietary predictions agree with previously studied ecomorphological paleodietary proxies. Our data supports the hypothesis that the late Miocene giraffids comprised a wider range of dietary habits than the living giraffe and okapi.

5526 Background: The cornerstone of the management of cervical cancer (CC) traditionally relies on clinical examination assessment (CE) of tumor size (TS) and local extension of disease. Previous reports demonstrate poor accuracy of CE, with the most common discrepancy being failure to identify parametrial involvement (PI). The goal of this study is to determine the accuracy of CE in comparison to final pathology (FP) in early operable CC. Methods: This is a multi-center retrospective review of patients with early CC (FIGO stage IB1, IIA1). Data on age, race, histology, stage, CE findings, FP report and receipt of adjuvant radiation therapy (RT) were collected. CE findings included TS, PI and vaginal involvement (VI). CE of TS, PI, and VI were compared to FP. Subanalysis was also conducted based on TS ( < or ≥ 2cm) and location of tumor (exophytic vs endophytic). Analysis was performed using paired-T and Cohen’s Kappa tests. Results: Final analysis included 135 patients. Mean age was 52.6 years. The majority of patients had squamous cell carcinoma (72.6%). Overall, there was a significant difference between CE of TS compared to FP; mean error of 1.22 cm (p < 0.0001). In those with tumors ≥ 2cm the mean error was 1.28 cm (p < 0.0001). No significant discrepancy was observed in tumors < 2 cm (mean error: 1.10cm; p = 0.5). CE of TS of endophytic tumors was poor (mean error 1.68cm; p = 0.004) compared to exophytic tumors (mean error: 1.12 cm; p = 0.693). There was no significant difference in the identification of VI between CE and FP (3.7% vs 8.89%; p = 0.067). No patients with PI on CE were included in this analysis. However, 14.07% of patients were found to have PI on FP (p < 0.0001). There was no difference in the accuracy CE of TS between non-obese ( < 30 kg/m2) and obese patients (≥30 kg/m2), mean error 1.13 and 1.3, respectively (p = 0.061). As a results of FP, 55 patients (40.7%) received adjuvant RT and 38 patients (28.14%) were upstaged from IB1 to IB2. Of these 38 patients, 36 (94.7%) went on to receive adjuvant RT. Conclusions: CE of TS and PI is inaccurate, especially in tumors ≥ 2cm and endophytic tumors. This suggests imaging should be strongly encouraged, particularly in the setting of the updated FIGO 2018 staging system and recent debate over surgical approach.