Outcome of a multimodal therapy of a recurrent adenocarcinoma arising from Caesarean section scar endometriosis—A case report

Background

Endometriosis occurring in surgical scars is a well-described entity. Malignant transformation of endometriosis is a rare event, with most cases belonging to adenocarcinoma. The initial surgical treatment is a method of choice. Due to lack of therapeutic recommendations, adjuvant therapy and recurrence management are a great challenge for oncologists.

Aim

The aim of this paper was to present a long-term survival as the outcome of multimodal therapy in the patient with recurrent adenocarcinoma arising from Caesarean section scar endometriosis.

Case

We present the case of a woman with recurrent adenocarcinoma arising from Caesarean section scar endometriosis. The disease was first diagnosed in September 1997 at age 43. The patient underwent abdominal hysterectomy with tumour excision. Due to a local recurrence after 4 years, tumour excision with abdominal wall repair using a plastic mesh, regional lymphadenectomy, bilateral salpingo-ovariectomy and adjuvant radiotherapy for the pelvic region with local boost were performed; in addition hormontherapy with medroxyprogesterone was started. Because of a recurrent pelvic tumour, chemotherapy, further local palliative radiotherapy and brachytherapy were administered. Subsequently distant metastases in bilateral axillary lymph nodes were diagnosed and palliative radiotherapy was performed. The patient died of morbus neoplasmaticus generalisatus in September 2008. The follow-up period had been 132 months.

Conclusion

This paper is, to our knowledge, the only report in literature that presents a long-term survival as the outcome of multimodal therapy in the patient with this rare diagnosis. Further reports of new cases can help establish optimal treatment guidelines.     

At What Price? A Cost-Effectiveness Analysis Comparing Trial of Labour after Previous Caesarean versus Elective Repeat Caesarean Delivery

Background

Elective repeat caesarean delivery (ERCD) rates have been increasing worldwide, thus prompting obstetric discourse on the risks and benefits for the mother and infant. Yet, these increasing rates also have major economic implications for the health care system. Given the dearth of information on the cost-effectiveness related to mode of delivery, the aim of this paper was to perform an economic evaluation on the costs and short-term maternal health consequences associated with a trial of labour after one previous caesarean delivery compared with ERCD for low risk women in Ireland.

Methods

Using a decision analytic model, a cost-effectiveness analysis (CEA) was performed where the measure of health gain was quality-adjusted life years (QALYs) over a six-week time horizon. A review of international literature was conducted to derive representative estimates of adverse maternal health outcomes following a trial of labour after caesarean (TOLAC) and ERCD. Delivery/procedure costs derived from primary data collection and combined both “bottom-up” and “top-down” costing estimations.

Results

Maternal morbidities emerged in twice as many cases in the TOLAC group than the ERCD group. However, a TOLAC was found to be the most-effective method of delivery because it was substantially less expensive than ERCD (€1,835.06 versus €4,039.87 per women, respectively), and QALYs were modestly higher (0.84 versus 0.70). Our findings were supported by probabilistic sensitivity analysis.

Conclusions

Clinicians need to be well informed of the benefits and risks of TOLAC among low risk women. Ideally, clinician-patient discourse would address differences in length of hospital stay and postpartum recovery time. While it is premature advocate a policy of TOLAC across maternity units, the results of the study prompt further analysis and repeat iterations, encouraging future studies to synthesis previous research and new and relevant evidence under a single comprehensive decision model.     

Is there a double pathway for the secretion of thyroglobulin: a "short circuit" weakly glycosyl-iodinated and a "long circuit" strongly glycosyl-iodinated?

Intact rat thyroid lobes incubated in vitro release recently synthesized thyroglobulin (Tg) into the media at a faster rate than they release thyroglobulin stored in follicular structures. Differential release of this Tg fraction cannot be explained by morphological alterations in thyroid architecture during incubation. This rapidly excreted fraction exhibits a low density on rubidium chloride gradients characteristic of poorly sialylated and poorly iodinated thyroglobulin, comigrating on rubidium chloride gradients with thyroglobulin isolated from tunicamycin treated glands. This poorly sialylated and poorly iodinated thyroglobulin is itself unaffected in its density or release into the media by tunicamycin treatment. Tg isolated from the media of tunicamycin treated glands has nearly the same low iodine and low sialic acid content as rat serum thyroglobulin and does not incorporate radiolabelled glucosamine. This fraction thus appear to duplicate properties of low glycosylated-low iodinated thyroglobulin released from thyroid cells in organisms that have no follicular structures and no follicular storage process as well as from thyroid tissue in patients with thyroid disease states, particularly thyroid tumors. Thus it is proposed a "short loop" pathway of low-glycosylated low-iodinated thyroglobulin directly into circulation, that bypasses and is not stored in the follicular lumen, the "long loop".     

Obstetricians’ Opinions of the Optimal Caesarean Rate: A Global Survey

Background

The debate surrounding the optimal caesarean rate has been ongoing for several decades, with the WHO recommending an “acceptable” rate of 5–15% since 1997, despite a weak evidence base. Global expert opinion from obstetric care providers on the optimal caesarean rate has not been documented. The objective of this study was to examine providers’ opinions of the optimal caesarean rate worldwide, among all deliveries and within specific sub-groups of deliveries.

Methods

A global online survey of medical doctors who had performed at least one caesarean in the last five years was conducted between August 2013 and January 2014. Respondents were asked to report their opinion of the optimal caesarean rate—defined as the caesarean rate that would minimise poor maternal and perinatal outcomes—at the population level and within specific sub-groups of deliveries (including women with demographic and clinical risk factors for caesareans). Median reported optimal rates and corresponding inter-quartile ranges (IQRs) were calculated for the sample, and stratified according to national caesarean rate, institutional caesarean rate, facility level, and respondent characteristics.

Results

Responses were collected from 1,057 medical doctors from 96 countries. The median reported optimal caesarean rate was 20% (IQR: 15–30%) for all deliveries. Providers in private for-profit facilities and in facilities with high institutional rates reported optimal rates of 30% or above, while those in Europe, in public facilities and in facilities with low institutional rates reported rates of 15% or less. Reported optimal rates were lowest among low-risk deliveries and highest for Absolute Maternal Indications (AMIs), with wide IQRs observed for most categories other than AMIs.

Conclusions

Three-quarters of respondents reported an optimal caesarean rate above the WHO 15% upper threshold. There was substantial variation in responses, highlighting a lack of consensus around which women are in need of a caesarean among obstetric care providers worldwide.     

Is a closing "GA pair" a rule for stable loop-loop RNA complexes?

RNA hairpin aptamers specific for the trans-activation-responsive (TAR) RNA element of human immunodeficiency virus type 1 were identified by in vitro selection (Ducongé, F., and Toulmé, J. J. (1999) RNA 5, 1605-1614). The high affinity sequences selected at physiological magnesium concentration (3 mm) were shown to form a loop-loop complex with the targeted TAR RNA. The stability of this complex depends on the aptamer loop closing "GA pair" as characterized by preliminary electrophoretic mobility shift assays. Thermal denaturation monitored by UV-absorption spectroscopy and binding kinetics determined by surface plasmon resonance show that the GA pair is crucial for the formation of the TAR-RNA aptamer complex. Both thermal denaturation and surface plasmon resonance experiments show that any other "pairs" leads to complexes whose stability decreases in the order AG > GG > GU > AA > GC > UA > CA, CU. The binding kinetics indicate that stability is controlled by the off-rate rather than by the on-rate. Comparison with the complex formed with the TAR* hairpin, a rationally designed TAR RNA ligand (Chang, K. Y., and Tinoco, I. (1994) Proc. Natl. Acad. Sci. U. S. A. 91, 8705-8709), demonstrates that the GA pair is a key determinant which accounts for the 50-fold increased stability of the TAR-aptamer complex (K(d) = 2.0 nm) over the TAR-TAR* one (K(d) = 92. 5 nm) at physiological concentration of magnesium. Replacement of the wild-type GC pair next to the loop of RNA I' by a GA pair stabilizes the RNA I'-RNA II' loop-loop complex derived from the one involved in the control of the ColE1 plasmid replication. Thus, the GA pair might be the preferred one for stable loop-loop interactions.     

Rosehip -- a "new" source of lycopene?

Lycopene, an efficient antioxidant and singlet oxygen quencher, is mainly delivered within the human diet out of tomatoes and tomato products. Processing liberates this carotenoid from complexes with proteins and thus makes it more bioavailable. Rosehip, a wild fruit which is used more often recently to produce mark, jams and juices, showed remarkable contents of lycopene (12.9–35.2 mg/100 g) with an unexpected isomer pattern.     

Can there be a "cultural epidemiology"?

A brief excursion through the history of social medicine suggests that, at least in principle, epidemiology and anthropology are natural allies in the study of disease in human populations. In practice, however, this alliance has been limited and remains problematic. This article examines the possibilities for interdisciplinary research, taking cancer epidemiology as a case in point. I argue, on the basis of participant-observation over a period of nearly two years in the epidemiology department of a medical research institute in Catalonia (Spain), that bioscientific uses of the concept of culture have led, disappointingly, to its reification as "beliefs" and its incorporation into the naturalist epistemology of Western institutional medicine. The unfortunate consequence is the medicalization of culture understood as "difference," which often stands in for social class.     

Is the doubly deleted alpha-thalassemia gene a "fugitive" allele?

The alpha-thalassemias (particularly in Asia) can be considered as a three-allele system, with one "normal" allele (N) consisting of a pair of closely linked alpha-chain loci, a second "single" allele (S) in which one of the loci has been lost by deletion, and a third "double" allele (D) in which both have been lost. Representatives of all the sets of fitnesses leading to the maintenance of this condition by selection for malaria resistance have been explored, and after the discarding of unlikely sets of fitnesses, it is found that there will be three outcomes: (1) the S chromosome is fixed, (2) the S and N chromosomes form a stable polymorphism, and (3) the N and D chromosomes form a stable polymorphism, but this can be lost and the population forced to fixation by the introduction of sufficiently large number of S chromosomes. Some Melanesian populations appear to have reached outcome (1), while frequencies in African, Mediterranean, and Middle Eastern populations are not incompatible with outcome (2). Southeast Asian populations, however, which carry S and D chromosomes in high frequency, may be in a state of flux. The D chromosome may form a polymorphism with N locally, but it can be driven from the local population by the introduction of large numbers of S chromosomes. The D chromosome would thus be somewhat analogous to a fugitive species, which can only exist in certain transient environments and is displaced as the environment changes. The possibility that N, S, and D are coexisting as a stable polymorphism can almost certainly be ruled out by a consideration of fitness sets required.     

Is the osteoclast calcium "receptor" a receptor-operated calcium channel?

Elevated extracellular calcium levels ([Ca2+]e) inhibit osteoclast function by elevating cytosolic free calcium levels ([Ca2+]i), presumably via the activation of a surface Ca2+ "receptor". It is unclear whether or not Ca(2+)-induced [Ca2+]i elevation involves the direct gating, by the putative "receptor", of a divalent cation channel. The results show that [Ca2+]i elevation in response to elevated [Ca2+]e comprises a distinct component of Ca2+ influx, the magnitude of which can be decreased and increased, respectively, by depolarising (100 mM-[K+]) and hyperpolarising (1 microM-[valinomycin]) the osteoclast membrane. In addition, activation of the putative Ca2+ "receptor" by elevated [Ca2+]e causes influx of the related divalent cation, magnesium (Mg2+). We suggest that Ca2+ influx induced by Ca2+ "receptor" activation is a major component of the observed [Ca2+]i response.