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Since its description in 2016, the erector spinae plane block (ESPB) has become a widely employed regional anesthetic technique and kindled interest in a range of related techniques, collectively termed intertransverse process blocks. There has been ongoing controversy over mechanism of action of the ESPB, mainly due to incongruities between results of cutaneous sensory testing, clinical efficacy studies, and investigations into the neural structures that are reached by injected local anesthetic (LA). This paper reviews the spread of LA to the paravertebral and epidural space and the cutaneous anesthesia in ESPB, with specific emphasis on the dorsal root ganglion (DRG). We hypothesize that the DRG, due to its unique and complex microarchitecture, represents a key therapeutic target for modulation of nociceptive signaling in regional anesthesia. This paper discusses how the anatomical and physiological characteristics of the DRG may be one of the factors underpinning the clinical analgesia observed in ESPB and other intertransverse process blocks. [ABSTRACT FROM AUTHOR]

Background/importance Infant spinal anesthesia has many potential benefits. However, the delivery of infant spinal anesthesia is technically challenging. The landmark-based technique has not changed for over a century. Advancements in ultrasound technology may provide an opportunity to improve infant spinal procedures. Objective Our primary objective is to conduct a comprehensive review of the current literature on ultrasonography for spinal anesthesia in infants. Given the narrow scope of this topic, our secondary objective is to review the current literature on ultrasonography for lumbar puncture in infants. Evidence review We reviewed all papers related to the use of ultrasound for infant spinal anesthesia. Two large databases were searched with key terms. Eligibility criteria were full-text articles in English. For our secondary objective, we searched one large database for key terms relating to ultrasonography and infant lumbar puncture. Eligibility criteria were the same. Findings Our primary search retrieved six articles. These consisted of four review articles, one case report, and one retrospective observational study. Our secondary search retrieved fourteen articles. These consisted of five randomized control trials, four prospective studies, three retrospective studies, and two review papers. Conclusions Ultrasound yields high-quality images of the infant spine. Most literature regarding ultrasound for infant spinal procedures arises from emergency medicine or interventional radiology specialties. The literature on ultrasound for infant spinal anesthesia is extremely limited, but shows promise. Future studies are needed in order to determine whether ultrasound can improve the success rate for delivery of infant spinal anesthesia. [ABSTRACT FROM AUTHOR]

Introduction Low back pain is a significant burden to society and the lack of reliable outcome measures, combined with a prevailing inability to quantify the biopsychosocial elements implicated in the disease, impedes clinical decision- making and distorts treatment efficacy. This paper aims to validate the utility of a biopsychosocial spine platform to provide standardized wearable sensor- derived functional motion assessments to assess spine function and differentiate between healthy controls and patients. Secondarily, we explored the correlation between these motion features and subjective biopsychosocial measures. Methods An observational study was conducted on healthy controls (n=50) and patients with low back pain (n=50) to validate platform utility. The platform was used to conduct functional assessments along with patient- reported outcome assessments to holistically document cohort differences. Our primary outcomes were motion features; and our secondary outcomes were biopsychosocial measures (pain, function, etc). Results Our results demonstrated statistically significant differences in motion features between healthy and patient cohorts across anatomical planes. Importantly, we found velocity and acceleration in the axial plane showed the largest difference, with healthy controls having 49.7% and 55.7% higher values, respectively, than patients. In addition, we found significant correlations between motion features and biopsychosocial measures for pain, physical function and social role only. Conclusions Our study validated the use of wearable sensor- derived functional motion metrics in differentiating healthy controls and patients. Collectively, this technology has the potential to facilitate holistic biopsychosocial evaluations to enhance spine care and improve patient outcomes. [ABSTRACT FROM AUTHOR]

Background/importance Anesthesiologists frequently use truncal catheters for postoperative pain control but with limited characterization of dosing and toxicity. Objective We reviewed the published literature to characterize local anesthetic dosing and toxicity of paravertebral and transversus abdominis plane catheters in adults. Evidence review We searched the literature for bupivacaine or ropivacaine infusions in the paravertebral or transversus abdominis space in humans dosed for 24 hours. We evaluated bolus dosing, infusion dosing and cumulative 24-hour dosing in adults. We also identified cases of local anesthetic systemic toxicity and toxic blood levels. Findings Following screening, we extracted data from 121 and 108 papers for ropivacaine and bupivacaine respectively with a total of 6802 patients. For ropivacaine and bupivacaine, respectively, bolus dose was 1.4 mg/ kg (95% CI 0.4 to 3.0, n=2978) and 1.0 mg/kg (95% CI 0.18 to 2.1, n=2724); infusion dose was 0.26 mg/kg/hour (95% CI 0.06 to 0.63, n=3579) and 0.2 mg/kg/ hour (95% CI 0.06 to 0.5, n=3199); 24-hour dose was 7.75 mg/kg (95% CI 2.1 to 15.7, n=3579) and 6.0 mg/kg (95% CI 2.1 to 13.6, n=3223). Twenty-four hour doses exceeded the package insert recommended upper limit in 28% (range: 17%-40% based on maximum and minimum patient weights) of ropivacaine infusions and 51% (range: 45%-71%) of bupivacaine infusions. Toxicity occurred in 30 patients and was associated with high 24-hour dose, bilateral catheters, cardiac surgery, cytochrome P-450 inhibitors and hypoalbuminemia. Conclusion Practitioners frequently administer ropivacaine and bupivacaine above the package insert limits, at doses associated with toxicity. Patient safety would benefit from more specific recommendations to limit excessive dose and risk of toxicity. [ABSTRACT FROM AUTHOR]

Background/importance: Despite over 30 years of use by pediatric anesthesiologists, standardized dosing rates, dosing characteristics, and cases of toxicity of truncal nerve catheters are poorly described. Objective: We reviewed the literature to characterize dosing and toxicity of paravertebral and transversus abdominis plane catheters in children (less than 18 years). Evidence review We searched for reports of ropivacaine or bupivacaine infusions in the paravertebral and transversus abdominis space intended for 24 hours or more of use in pediatric patients. We evaluated bolus dosing, infusion dosing, and cumulative 24-hour dosing in patients over and under 6 months. We also identified cases of local anesthetic systemic toxicity and toxic blood levels. Findings: Following screening, we extracted data from 46 papers with 945 patients. Bolus dosing was 2.5 mg/kg (median, range 0.6-5.0; n=466) and 1.25 mg/kg (median, range 0.5-2.5; n=294) for ropivacaine and bupivacaine, respectively. Infusion dosing was 0.5 mg/kg/hour (median, range 0.2-0.68; n=521) and 0.33 mg/kg/hour (median, range 0.1-1.0; n=423) for ropivacaine and bupivacaine, respectively, consistent with a dose equivalence of 1.5:1.0. A single case of toxicity was reported, and pharmacokinetic studies reported at least five cases with serum levels above the toxic threshold. Conclusions: Bolus doses of bupivacaine and ropivacaine frequently comport with expert recommendations. Infusions in patients under 6 months used doses associated with toxicity and toxicity occurred at a rate consistent with single-shot blocks. Pediatric patients would benefit from specific recommendations about ropivacaine and bupivacaine dosing, including age-based dosing, breakthrough dosing, and intermittent bolus dosing. [ABSTRACT FROM AUTHOR]

Background/importance: Delayed cerebral ischemia (DCI) is the second-leading cause of death and disability in patients with aneurysmal subarachnoid hemorrhage (aSAH), and is associated with cerebral arterial vasospasm (CAV). Current treatments for CAV are expensive, invasive, and have limited efficacy. Cervical sympathetic block (CSB) is an underappreciated, but potentially highly effective therapy for CAV.Objective: To provide a comprehensive review of the preclinical and human literature pertinent to CSB in the context of CAV.Evidence Review: This study followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. We conducted a literature search using Embase, PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Scopus and Web of Science until February 2022, to identify abstracts, conference proceedings, and full-text papers pertinent to cervical sympathectomy and CAV in animal/adult patients.Findings: We included six human and six experimental studies. Human studies were mostly prospective observational, except one retrospective and one randomized clinical trial, and used various imaging modalities to measure changes in arterial diameter after the block. Studies that used digital subtraction angiography showed an improvement in cerebral perfusion without change in vessel diameter. Transcranial Doppler studies found an approximately 15% statistically significant decrease in velocities consistent with arterial vasodilatation. Overall, the results suggest an increase in cerebral arterial diameter and neurological improvement in patients receiving a CSB. Animal studies demonstrate that sympathetic system ablation vasodilates cerebral vasculature and decreases the incidence of symptomatic vasospasm.Conclusions: This scoping review suggests that CSB may be a viable option for treatment and prevention of CAV/DCI in patients with aSAH, although the included studies were heterogeneous, mostly observational, and with a small sample size. Further research is needed to standardize the technique and prove its effectiveness to treat patients suffering of CAV/DCI after aSAH. [ABSTRACT FROM AUTHOR]

Background/importance There is heterogeneity among the outcomes used in regional anesthesia research. Objective We aimed to produce a core outcome set for regional anesthesia research. Methods We conducted a systematic review and Delphi study to develop this core outcome set. A systematic review of the literature from January 2015 to December 2019 was undertaken to generate a long list of potential outcomes to be included in the core outcome set. For each outcome found, the parameters such as the measurement scale, timing and definitions, were compiled. Regional anesthesia experts were then recruited to participate in a three-round electronic modified Delphi process with incremental thresholds to generate a core outcome set. Once the core outcomes were decided, a final Delphi survey and video conference vote was used to reach a consensus on the outcome parameters. Results Two hundred and six papers were generated following the systematic review, producing a long list of 224 unique outcomes. Twenty-one international regional anesthesia experts participated in the study. Ten core outcomes were selected after three Delphi survey rounds with 13 outcome parameters reaching consensus after a final Delphi survey and video conference. Conclusions We present the first core outcome set for regional anesthesia derived by international expert consensus. These are proposed not to limit the outcomes examined in future studies, but rather to serve as a minimum core set. If adopted, this may increase the relevance of outcomes being studied, reduce selective reporting bias and increase the availability and suitability of data for meta-analysis in this area. [ABSTRACT FROM AUTHOR]

Introduction Inappropriate citation of retracted literature is a common problem in the general medical literature. In 2020, more than 2300 articles were retracted, a dramatic increase from 38 in 2000. By exploring a contemporary series of retractions by one research group, we aimed to evaluate if citations of retracted articles is occurring in the area of regional anesthesiology. Methods Using the Scopus database, we examined the full text of all the articles citing research articles coauthored by an anesthesiologist who had multiple articles retracted in 2022. After excluding the research articles citing non-retracted articles authored by the above mentioned anesthesiologist, we included in our analysis all the articles containing a retracted citation and published after the retraction notice. Results The search was performed on October 30, 2022, retrieving a total of 121 articles citing the researcher's work. Among the retrieved articles, 53 correctly cited non-retracted research and 37 were published before the retraction notice. Among the 31 remaining articles, 42 retracted research papers were cited. Twenty-five of the retracted articles were cited in the Discussion section of the manuscripts, 15 in the Introduction section, 1 in the Methods section (description of a technique), and one was cited in a review. No manuscript used the flawed data to calculate the sample size. Discussion In this contemporary example from the regional anesthesia literature, we identified that citation of retracted work remains a common phenomenon. [ABSTRACT FROM AUTHOR]

Ensuring proper placement of epidural catheters is critical to improving their reliability for pain control and maintaining confidence in their continued use. This article will seek to address the role of objective confirmation of successful epidural placement via either single view or continuous epidural contrast studies, each creating an 'epidurogram.' Furthermore, the pertinent anatomical corollaries of continuous fluoroscopy used frequently in chronic pain medicine, from which these techniques emerged, will be addressed. Technical radiographic information needed to better understand and troubleshoot these studies is also included. Image examples which highlight the patterns key for successful interpretation of epidurograms will be provided. The aim of this paper was to provide an anesthesiologist unfamiliar with fluoroscopic evaluation of epidural catheters with the tools necessary to successfully conduct and interpret such an examination. [ABSTRACT FROM AUTHOR]

Misalignment of measures, measurement and analysis with the goals and methods of quality improvement efforts in healthcare may create confusion and decrease effectiveness. In healthcare, measurement is used for accountability, research, and quality improvement, so distinguishing between these is an important first step. Using a case vignette, this paper focuses on using measurement for improvement to gain insight into the dynamic nature of healthcare systems and to assess the impact of interventions. This involves an understanding of the variation in the data over time. Statistical process control (SPC) charting is an effective and powerful analysis tool for this. SPC provides ongoing assessment of system functioning and enables an improvement team to assess the impact of its own interventions and external forces on the system. Once improvement work is completed, the Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines is a valuable tool to describe the rationale, context, and study of the interventions. SQUIRE can be used to plan improvement work as well as structure a manuscript for publication in peer-reviewed journals. [ABSTRACT FROM AUTHOR]

This is a report from the European Society of Gynaecological Oncology State-of-the-Art Virtual Meeting held December 14-16, 2020. The unique 3-day conference offered comprehensive state-of-the-art summaries on the major advances in the treatment of different types of gynecological cancers. Sessions opened with a case presentation followed by a keynote lecture and interactive debates with opinion leaders in the field. The speakers also presented scientific reviews on the clinical trial landscape in collaboration with the European Network of Gynecological Oncological Trial (ENGOT) groups. In addition, the new ESGO-ESRTO-ESP endometrial cancer guidelines were officially presented in public. This paper describes the key information and latest studies that were presented for the first time at the conference. [ABSTRACT FROM AUTHOR]

Increasing numbers of women are surviving for longer with epithelial ovarian cancer. Consequently, there is increased focus on long-term quality of life in national guidance. Psychosexual morbidity including vaginal dryness, pain during intercourse (dyspareunia), reduced libido, and negative perceived body image exacerbate stress and anxiety and impact intimate relationships. Although a priority for women with epithelial ovarian cancer, clinicians seldom discuss sexual problems. Therefore, psychosexual morbidity and the associated distress remain unaddressed. We synthesize evidence from primary qualitative and quantitative research studies exploring psychosexual morbidity in women with epithelial ovarian cancer to identify potential risk factors and common symptoms, to facilitate the identification and management of sexual problems in clinic. Literature (2008--19) from 10 databases identified 29 suitable publications (4116 patients). The papers were assessed to answer the question: "What are the key potential risk factors and presentations of psychosexual morbidity in women with epithelial ovarian cancer?" Current literature lacks consensus in defining clinically significant psychosexual morbidity in women with epithelial ovarian cancer. Discrepancies in measurement tools, questionnaires, and primary outcome measures confound result interpretation, limiting wider application. Key potential risk factors identified included: younger age (<53 years); pre-menopausal status at diagnosis; aim of treatment; extent of surgery; more courses of chemotherapy; cardiovascular co-morbidities; and anxiety and depression. Up to 75% of women with epithelial ovarian cancer reported adverse changes in their sex lives following diagnosis and, of the sexually active, vaginal dryness affected 81--87% and pain 77%. Other prevalent symptoms included: reduced sexual desire and activity, impaired orgasm, diminished perceived body image, and reduced partner intimacy. Psychosexual morbidity represents a significant unmet need for women with epithelial ovarian cancer. Effective treatment necessitates a multimodal approach encompassing medical, psychoeducational, and physiotherapy-based strategies. Future studies need agreement in their questionnaires, definitions, thresholds, and primary outcome measures for meaningful interstudy comparisons to be drawn. [ABSTRACT FROM AUTHOR]

Introduction: Studies involving Twitter and chronic pain can provide highly valuable patient-generated information. The aim of this paper was to examine pain-related tweets in Ireland over a 2-week period from 22 June 2017 to 5 July 2017 using pain-related keywords. We wished to identify Twitter user gender profile; most common discussion topics; sentiment analysis; and dissemination of tweets.Methods: A third-party data analytics company conducted a Twitter social media analysis over a randomly chosen 14-day period between the dates 22 June and 5 July 2017. All relevant keywords were included in the search. Author group consensus yielded 24 terms. Geographical location was restricted to Ireland. A computational sentiment dictionary was used to provide a rating of the emotional properties of the text on a 9-point scale from -5 to +4 of negative to positive sentiment. Dissemination was calculated by the number of times the tweet was displayed ('impressions').Results: There were 941 tweets identified during the study from 715 contributors. These generated 2.88 million impressions. The most frequently occurring keywords were headache (n=321); migraine (n=147); back pain (n=123); cannabis (n=114); and chronic pain (n=85). There were 1.94 times as many tweets from females as males. The highest proportion of tweets from female users was in the fibromyalgia (83%) and migraine (60%) categories; and from males in the sciatica (35%), chronic pain (34%) and back pain (32%) categories. Cannabis-related tweets reflected mostly non-personal content (90%), with a highly positive sentiment, and the highest number of impressions per tweet. The largest amount of advice was offered in the back pain category. Reposting of other users' content ('retweets') was more likely to contain a positive sentiment.Conclusion: A substantial discussion of pain-related topics took place on Twitter during our study period. This provided real-time, dynamic information from individuals on discussion topics in pain medicine. This can be used to gain a greater understanding of the pain experience. As patients are increasingly acquiring healthcare information through online sources, high-quality information from approved sources should be promoted on such platforms. [ABSTRACT FROM AUTHOR]

Objective Recurrence of low-risk endometrioid endometrial cancer is rare, and traditional hospital follow-up has a cost to both the patient and the healthcare system, without evidence of benefit. We examined the uptake of patient-initiated follow-up, pattern of recurrences, and survival for women following surgical treatment of low-risk endometrial cancer and compared estimated costs with hospital follow-up. Methods This study was a prospective audit of outcomes following implementation of a patient-initiated follow-up policy in a UK-based gynecological cancer center for women with low-risk endometrial cancer treated surgically (International Federation of Gynecology and Obstetrics (FIGO) stage 1A, G1-2) from January 2010 to December 2015. Women were identified following multidisciplinary team meetings and data were collected from the electronic cancer register, paper, and electronic clinical records. Health service costs were calculated based on standard tariffs for follow-up appointments; patient costs were estimated from mileage traveled from home postcode and parking charges. Progression-free survival and overall survival were assessed. Estimated financial costs to the health service and patients of hospital follow-up were compared with actual patient-initiated follow-up costs. Results A total of 129 women were offered patient-initiated follow-up (declined by four; accepted by another 11 after hospital follow-up for 6 months to 3.5 years) with median follow-up of 60.7 months (range 1.4-109.1 months). Ten women recurred: four vaginal vault recurrences (all salvaged), three pelvic recurrences (all salvaged), and three distant metastatic disease (all died). Five-year disease-specific survival was 97.3%. Ten women in the cohort died: three from endometrial cancer and seven from unrelated causes. The cost saving to the health service of patient-initiated follow-up compared with a traditional hospital follow-up regimen was £116 403 (median £988.60 per patient,range £0-£1071). Patients saved an estimated £7122 in transport and parking costs (median £57.22 per patient,range £4.98-£147.70). Conclusion Patient-initiated follow-up for low risk endometrial cancer has cost benefits to both health service and patients. Those with pelvic or vault recurrence had salvageable disease, despite patient-initiated follow-up. [ABSTRACT FROM AUTHOR]

Background and Objectives: Blockade of the trigeminal nerve and its branches is an effective diagnostic tool and potential treatment of facial pain. Ultrasound-guided injections in the pterygopalatine fossa (PPF) to block the trigeminal nerve divisions and sphenopalatine ganglion have been described but a consensus has yet to be reached over the ideal approach. We sought to delineate and compare the various approaches to the ultrasound-guided trigeminal divisions blockade via the PPF.Methods: The literature search was performed by searching the National Library of Medicine's PubMed database, the Cochrane Database of Systematic Reviews and Google Scholar within the date range of January 2009-March 2019 for keywords targeted toward "trigeminal nerve," "maxillary nerve," or "pterygopalatine fossa," "ultrasound," and "nerve block," using an English language restriction. Six papers were included in the final review: one prospective double-blinded randomized controlled trial, one prospective descriptive study, one case series, two case reports, and one cadaveric study.Results: There are three main approaches to the ultrasound-guided trigeminal nerve branches blockade via the PPF: anterior infrazygomatic in-plane, posterior infrazygomatic in-plane, and suprazygomatic out-of-plane approaches. Each showed injectate spread to the PPF in cadaver, adult and pediatric patients, respectively.1-5 Injectate used varied from 3 to 5 mL to 0.15 mL/kg.Conclusions: These studies demonstrated that the PPF is a readily accessible target for the ultrasound-guided maxillary nerve block via three main approaches.2 The ideal approach is yet to be determined and must be further explored. [ABSTRACT FROM AUTHOR]

Background Maintenance therapy induces remission and prolongs disease free interval in primary and recurrent ovarian disease. For the treatment decision making process, aspects of quality of life and patients' preferences are crucial, despite the fact that scientific data are lacking. Therefore, we conducted this European-wide study in patients with ovarian cancer. Methods A 25 item questionnaire was provided to ovarian cancer patients via the internet or as a paper version in 10 European countries (Austria, Belgium, France, Germany, Italy, Romania, Slovenia, Finland, Turkey, and Spain). Data recorded were demographics, tumor stage, therapy after firstline and recurrent disease, preferences for administration, and expectations concerning maintenance therapy. Results Overall, 1954 patients participated from September 2013 to March 2016; 42% had recurrent disease. Most patients (98%) with primary epithelial ovarian cancer underwent surgery followed by chemotherapy (91%). Almost one-third of participants (29%) were receiving maintenance therapy whereas 45% had only heard of it. For 70% of patients with primary epithelial ovarian cancer, they heard about maintenance therapy from their doctor, 10% heard about maintenance therapy from other patients, and 8% from the internet. The main source of information about maintenance therapy in patients with epithelial ovarian cancer relapse was from the treating physician (72%), from other patients (8%), and from the internet (7%). For patients undergoing maintenance therapy, the four most disturbing adverse effects were polyneuropathy (37%), nausea (36%), hair loss (34%), and vomiting (34%). The main objective of maintenance treatment, as perceived by patients, was to increase the chances of cure (73%), improvement in quality of life (47%), and delay in tumor growth (37%). Many patients were willing to undergo maintenance therapy until tumor progression (38%) and 39% would prefer oral administration. No significant differences were detected in the cross country subanalysis regarding expectations of maintenance therapy and patients with primary or relapsed ovarian cancer. Conclusion Patients with ovarian cancer were willing to accept maintenance therapy of prolonged duration and preferred oral administration. There is still a gap between the efficacy of maintenance therapy and patient expectations. Patients need more information on the adverse effects and treatment goals of maintenance therapy to avoid misunderstandings. [ABSTRACT FROM AUTHOR]

Background The Michigan Body Map (MBM) was developed to assess pain location in a reliable and valid manner; however, electronic formats have not been validated. This study had two aims: (1) initial validation of the electronic form of the MBM (eMBM) and (2) preliminary test of assessing pain severity within body zones. Methods For the first aim, 68 participants with chronic pain completed paper and electronic forms of the MBM, then underwent scripted interviews to assess preferences among body maps and verbal confirmation of pain locations. For the second aim, a subset of the participants (n=40) completed the Brief Pain Inventory (BPI) pain severity subscale, as well as the eMBM again and endorsed pain severity using additional screens showing body zones that contained areas in which pain was endorsed. Results There were few discrepancies between MBM, eMBM and verbal report (1.9% and 1.6%, respectively), and no difference between forms in perceived ability to indicate areas of pain or ease of completion. Patients accurately indicated their bodily pain on both maps, with 84% and 87% reporting one or no errors on MBM and eMBM, respectively. Participants also reported no preference for which version best-depicted areas of pain or best distinguished left from right. Lastly, the most preferred measure was eMBM with pain severity zones, followed by eMBM without zones, followed by the BPI pain severity subscale. Conclusions These data support the validity of the eMBM for patients with chronic pain. Further, an expanded form of the eMBM that assesses pain severity was preferred by most participants. [ABSTRACT FROM AUTHOR]

Objectives: To review the published literature on vulvar Paget's disease (VPD) molecular bases, aiming to support the need for tailored treatment in women affected by this 'orphan' tumor. Methods: MEDLINE-PubMed and Scopus were interrogated using the following algorithm: (extramammary OR extra mammary OR vulvar) AND (paget OR pagets OR paget's) AND (molecular OR biological OR marker OR protein OR target OR expression). The inclusion criteria for papers were: peer-reviewed English-language journals, articles published in the last 30 years, studies focused on fixed research questions, quality assessment on the basis of the relevance and contribution to the selected topics. Results: A total of 42 studies were selected, providing the following results. Molecular markers implicated in cell cycle transitions seem to be related to prognosis and could help to tailor conventional treatments. Fragmented but consistent preliminary data exist on hormonal receptor expression, ERBB2 amplification/overexpression and abnormal vascular proliferation, offering a concrete possibility for target therapy trials. Conversely, other fields linked to the possible use of immunotherapy are currently relatively unexplored, such as the tumor 'immune contexture', programmed death ligand-1 (PD-L1) expression and defects in the mismatch repair system, which is involved in genomic instability and potentially promotes a consistent response to treatment. Conclusions: Additional effort is needed to further characterize these aspects. Centralization of patients in dedicated units would be beneficial for concentrating patient numbers, collecting valuable clinical data and conducting clinical trials. Interdisciplinary study platforms should be developed and integrated into wider multicentric networks. [ABSTRACT FROM AUTHOR]

Background: Lymph node status is one of the most important prognostic factors in endometrial cancer and crucial for deciding adjuvant therapy. Objective: The aim of the study was to assess the different models used to predict lymphatic nodal disease. Search Strategy: A literature search was conducted to detect the relevant studies. Inclusion Criteria: Relevant papers comparing the preoperative modality with the final histopathological results including randomized clinical trials, case-control studies, and any publications with a minimum of 50 patients in the report. Results: Molecular-based predictors are still far from a practical application. Preoperative radiological scans (positron emission tomography, computed tomography, magnetic resonance imaging, and ultrasound) have shown the best predictor of lymphatic dissemination. However, there is currently no ideal model available, which can be used within standard clinical care. Conclusions: Surgical staging still remains the criterion standard in the determination of lymph node status in endometrial cancer. [ABSTRACT FROM AUTHOR]

Cervical cancer is one of the most common cancers among women worldwide, and more than 85%of the disease occurs in low- and middle-income countries. Although it ranks as the most common cancer in Ghanaian women, there are no data available on cervical cancer survival. Methods: Information on women with a diagnosis of cervical cancer from 2010 to 2013 was collected from the Komfo Anokye and Korle-Bu Teaching Hospitals through review of paper-based and electronic medical records (including pathology records) at the oncology units and the departments of obstetrics and gynecology. Telephone interviews were conducted with patients and relatives to gather further information. Data were recorded using a standardized questionnaire and analyzed using summary statistics. Results: Information for 821 women was available for the survival analysis. Of these, 497 (60.5%) died during follow-up. At 3 years after diagnosis, survival was 39%. Survival was lowest in women with stage IV disease. Women with squamous cell carcinoma had a survival advantage over those with adenocarcinoma. Furthermore, women who received surgery, radiotherapy, and chemotherapy had better survival than did women with other forms of treatment. Conclusions: In conclusion, cervical cancer survival is low in Ghana and is likely to be improved if a greater proportion of the disease is detected early. Improving knowledge of the disease for early diagnosis, reducing financial barriers, and greater organization of health care delivery are likely to improve survival from cervical cancer in Ghana. [ABSTRACT FROM AUTHOR]

Objective: Studies have confirmed that patients with circulating tumor cells (CTCs) in their peripheral blood (PB) or disseminated tumor cells (DTCs) in bone marrow (BM) might have bad prognosis. In this paper, we discuss whether CTCs/DTCs would be an appropriate biomarker to predict the prognosis of ovarian cancer. Methods: We systematically searched PubMed, EMBASE, Cochrane library, and Chinese National Knowledge Infrastructure to collect relevant studies published from the time the database were created to February 2014. Studies quality was assessed by Newcastle-Ottawa Scale. The effect size was estimated by hazard ratio (HR) and corresponding 95% confidence interval (95% CI). Meta-analysis was conducted with STATA Version 12.0. Results: Eight studies of 1184 patients were included in the final analysis. In the PB group, it showed that patients with positive CTCs had significantly shorter overall survival and disease-free survival than patients with negative CTCs (HR, 2.09; CI, 1.13-3.88 and HR, 1.72; CI, 1.32-2.25, respectively). The same result was shown with DTCs in the BM group (HR, 1.61; CI, 1.27-2.04 and HR, 1.44; CI, 1.15-1.80, respectively). We also discussed the influence of CTCs/DTCs on International Federation of Gynecology and Obstetrics stage, pathological grade with odds ratio and 95% CI. However, it did not show any statistical significance. Conclusions: The CTCs/DTCs might be a new biomarker to predict the prognosis of ovarian cancer. Future studies are needed to confirm this consequence. [ABSTRACT FROM AUTHOR]

Supplemental digital content is available in the text. Synopsis: Our paper concludes that G3 EAC has a slightly more favorable survival than UPSC and CC but predictably does poorer than G1-2 EAC. Objectives: High-risk histology including UPSC, CC, and high-grade (G3) endometrioid adenocarcinoma (EAC) have a worse prognosis compared to G1-2 EAC. It is unknown whether G3EAC outcomes are more similar to UPSC/CC or to G1-2 EAC. The purpose of this study was to compare overall survival (OS) among UPSC, CC, and G1-3 EAC, for International Federation of Gynecology and Obstetrics stages I to III. Methods: The National Cancer Data Base was queried for patients diagnosed with International Federation of Gynecology and Obstetrics (1988 classification) Stage I-III UPSC, CC, and EAC from 1998 to 2012 who underwent surgery as definitive treatment. Patients with unknown grade/stage, nonsurgical primary therapy, other histologies, and less than 30-day follow-up were excluded. Overall survival was calculated using the Kaplan-Meier product-limit method and compared using log-rank tests. Results: 219,934 patients met our inclusion criteria. For patients with stage I disease (n = 174,361), 5-year OS was for 92.4% for G1EAC, 87.8% for G2EAC, 77.5% for G3EAC, 74.9% for CC, and 74.6% for UPSC. For stage II patients (n = 17,361), 5-year OS was 86.7% for G1EAC, 80.2% for G2EAC, 62.7% for G3EAC, 64.3% for CC, and 56.7% for UPSC. For stage III patients (n = 28,212), 5-year OS was 79.7% for G1EAC, 68.9% for G2EAC, 49.6% for G3EAC, 40.2% for CC, and 35.7% for UPSC (P <0.0001). On multivariate analysis, black race, age 60 years and older, higher stage, higher grade, high-risk histologies, receiving chemotherapy, and higher comorbidity scores were all significantly (P < 0.0001) predictive of death while receiving radiation therapy was protective (hazards ratio, 0.7; 95% confidence interval, 2.6–2.9). Conclusions: The results suggest that G3 EAC has a slightly more favorable survival than UPSC and CC but predictably does poorer than G1-2 EAC. Further research is warranted to determine if G3 EAC should be reclassified as a type II cancer. [ABSTRACT FROM AUTHOR]

Objective: Cervical cancer is the most common gynecological cancer occurring in pregnancy, creating a complex situation both for patient and physician. Neoadjuvant chemotherapy is an innovative way of managing cervical cancer in pregnancy. Methods: In our paper, we report a retrospective case series of 4 women treated with chemotherapy for invasive cervical cancer during pregnancy in our center over the last 5 years, and we summarize the available literature and guidelines. Results: All the cases were locally advanced cervical cancers that received chemotherapy with platinum and/or taxanes. All patients showed a good response to chemotherapy and a radical surgery was performed with no additional morbidities at the cesarean delivery time in 3 of 4 cases. Three of 4 patients are alive and have a good outcome with no recurrence of disease up to date. One patient died because of recurrent disease 2 years after the first-line treatment during pregnancy. All babies are alive and well up to date (maximum follow-up, 63 months). Conclusions: Even if there are no standardized practices in the treatment of cervical cancer in pregnancy, in our opinion, neoadjuvant chemotherapy can be a very useful strategy for patients and physicians facing the challenge. [ABSTRACT FROM AUTHOR]

Mechanism of action of Ht X-011: a novel, extended- release, dual- acting local anesthetic formulation for postoperative pain. 1030 Reg Anesth Pain Med December 2020 Vol 45 No 12 PostScript Mechanism of action of HTX011: a novel, extended- release, dual- acting local anesthetic formulation for postoperative pain To the Editor We read with great interest the paper on the mechanism of action of HTX-011. [Extracted from the article]

Introduction Endometriosis is a benign gynecological condition that affects approximately 5-10% of reproductive aged women all over the world. The oncogenic role of endometriosis has first been described first in 1952 by Sampson, that proposed a theory of malignant progression. Endometriosis-related ovarian cancer (ERONs) represent a group of tumors including clear cell carcinoma, endometrioid carcinoma and seromucinous borderline tumors that supports the hypothesis that endometriosis is a cancer precursor. The aim of this study was to review the mechanisms whereby genetic and molecular factors can be involved in the neoplastic progression of this pathology. Methods A comprehensive research of the literature was performed using PubMed, Scopus, Google scholar and Science Direct databases, up to 31 March 2018. The research had the purpose to identify the original and review papers that mentioned the genetic and molecular factors that are potentially involved in the oncogenic role of endometriosis. Results A total of 35 articles met the inclusion criteria and were included in our review. ERONs have different prevalence: 30%-60% are endometrioid carcinomas, 20%-35% clear cell carcinomas, 5%-10% serous carcinomas and 4%-10% mucinous carcinomas. Molecular analyses of the ERONs have identified a series of alterations that involves: the aberrant activation or inactivation of pathways such as PTEN, KRAS, TP53, PIK3 CA, β-catenin and rarely, P53. The loss of heterozygosity (LOH) at the PTEN locus is proved to be present in 10%-20% of endometriosis cases and the patterns of LOH in ERONs are similar. LOH in the Xq region is about 38% of ERONs but it is infrequent in endometriosis. In atypical endometriosis, which is a high risk factor for ovarian cancer, LOH of 10q23 is found in 40% of cases, while in ERONs, LOH of 10q23 is higher than 45%. K-Ras mutation is frequently found in endometriosis-associated carcinoma (10-20% of cases) and in more than 50% of cases of mucinous ovarian carcinoma. Β-catenin is encoded by CTNNB1 and the Wnt/β-catenin signaling pathway dysregulation is occurring in 16-38% of ovarian endometrioid carcinoma, for which this mutation seems to be characteristic. PTENPIK3CA- mTOR pathway has also been implicated in the tumor progression process, identifying PIK3CA mutation in approximately 46% of clear cell ovarian cancers. The loss of ARID1A, a tumor suppressor gene that encodes BAF250a protein, is the most common molecular change in ERONs and seems also to be an early mechanism. In ovarian cancers, it have been proved that ARID1A mutations are found in 50% of endometrioid cancers and in 73% of clear-cell cancers, compared to approximately 10% of non-ERONs. Conclusion Endometriosis is a multi-factorial disease with a strong oncogenic potential. The molecular and genetic mechanisms remain still unclear and there are required future studies that will be the key-point for the early detection and for improved treatment strategies for ERONs. [ABSTRACT FROM AUTHOR]

Introduction Sarcomas of the uterus are rare gynecological tumors as they constitute only 3% of uterine malignancies. Among these, leiomyosarcoma of uterus represents one of the most aggressive histologic types. Very few papers have assessed the role of secondary cytoreduction in the treatment of recurrent uterine leiomyosarcoma. The aim of this study is to evaluate the surgical and oncological outcomes of patients with recurrent uterine leiomyosarcoma treated with secondary cytoreductive surgery in a tertiary referral center. Materials and methods All consecutive patients operated for recurrent uterine leiomyosarcoma between 01/2010 and 01/2018 at our Institution with confirmation of leiomyosarcoma at secondary cytoreductive surgery histology were included. All patients operated for recurrent endometrial stromal sarcoma or carcinosarcoma, have been excluded. Demographic, surgical and pathologic data was retrieved from medical and surgical records. Intraoperative complications were graded according to CTCAE 4.03 system and post-operative complications according to Clavien-Dindo classification. Follow-up data were collected. Progression-free survival and overall survival were calculated from the time in months from the date of the cytoreductive surgery to the date of first progression, last follow-up or death and from the date of the cytoreductive surgery to the date of the last follow-up or death related to the uterine leiomyosarcoma, respectively. Results 40 patients underwent secondary cytoreductive surgery for uterine leiomyosarcoma in the study period (in the same period 85 were women newly diagnosed with uterine leiomyosarcoma). Most of the patients underwent complete cytoreduction to no residual macroscopic disease and received adjuvant chemotherapy after the surgery. Majority of the women recurred with large pelvic masses requiring bowel and/or urinary tract surgery and high complexity procedures to achieve complete cytoreduction. Surprisingly, in some cases (approximately 20%) the recurrence was localized in pelvic lymph nodes only. Major intra- and post-operative complications were not common findings in this group of women despite the radicality of the surgery required. Survival outcomes in relation to cytoreduction result and progression-free interval are also presented. Conclusion Secondary cytoreduction to no residual disease is one of the most important prognostic factors in recurrent uterine leiomyosarcoma but it requires radical surgical procedures and referral to tertiary centers. The low incidence of major intra- and post-operative complications emphasizes the feasibility of the surgical treatment in patients with a poor prognosis. [ABSTRACT FROM AUTHOR]

Positive serum beta-human chorionic gonadotropin (beta-hCG) in reproductive-age women generally indicates a pregnancy. In the absence of pregnancy, an elevated betahCG is highly suspicious of an underlying malignancy. Most cases maybe due to gestational trophoblastic disease and rarely involve trophoblastic differentiation in nongestational neoplasm including germ cell and epithelial tumours. We report a case of extremely high human chorionic gonadotropin levels associated with an advanced stage of ovarian dysgerminoma in young girl and perform the review of literature. A 13-year-old girl was referred to the Department of Obstetrics and Gynecology at Kyung Hee University Hospital at Gangdong in April 2018 because of an abdominal pain and huge pelvic mass. Preoperatively, the level of the β-subunit of human chorionic gonadotropin was 3,790 IU/liter and AFP was within normal range. Pelvic MRI revealed the presence of a 16 x 14 x 11 cm sized huge pelvic mass with central necrosis. Pelvic and chest CT revealed no significant lymph node enlargement. Abdominal exploration revealed a stage III dysgerminoma; Unilateral salpingooophorectomy, Partial Omentectomy, small bowel resection, multiple peritoneal biopsy, and pelvic/para-aortic lymphadenectomy were performed. Pathologic result revealed Ovarian dysgerminoma (18.5 x 17 x 11cm) with microscopic omental involvement and no lymph node metastasis. HCG level dropped in the next 10 days after surgery to 33 and remained stable. Diagnosis of stage III dysgerminoma was made and the patient received 3 cycles of BEP chemotherapy. Malignant ovarian germ cell tumors with advanced stage are rare and knowledge about prognostic parameters is limited. A number of papers have documented increased serum beta-hCG levels in patients with ovarian dysgerminoma and elevation of serum markers beta-human chorionic gonadotropin and alpha-fetoprotein were also found to be significant predictors of overall survival in malignant ovarian germ cell tumors. Therefore, beta HCG testing as a tumor marker should be considered for ovarian dysgerminoma. [ABSTRACT FROM AUTHOR]