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Wiesenfeld H.C.,Magee Womens Hospital of UPMC
New England Journal of Medicine | Year: 2017

chlamydia screening because she is younger than 25 years of age and sexually active. Assessment of the risks of sexually transmitted diseases and counseling on safer sex, including the use of condoms, are recommended. I would recommend screening with either a vaginal swab (collected by the woman herself or by a clinician) or an endocervical swab obtained by means of pelvic examination, because these specimens have similar sensitivity and specificity for the diagnosis of chlamydial infection when nucleic acid amplification assays are used. Alternatively, testing can be performed by means of a first-catch urine sample, although testing of a urine sample has slightly lower sensitivity than testing of a vaginal or endocervical sample. If the patient tests positive, oral treatment with either 1 g of azithromycin as a single dose or 100 mg of doxycycline twice daily for 7 days is recommended, and a repeat screening test should be performed in 3 months. All sexual partners of this woman should be tested and treated empirically for chlamydia if the sexual contact occurred within 60 days before she received the diagnosis of chlamydial infection or before the symptoms developed. ©2017 Massachusetts Medical Society. All rights reserved.


Estrogen receptor (ER) status is a strong predictor of response to hormonal therapy in breast cancer patients. Presence of ER and level of expression have been shown to correlate with time to recurrence in patients undergoing therapy with tamoxifen or aromatase inhibitors. Risk reduction is also known to occur in ER-negative, progesterone receptor (PR)-positive patients treated with hormonal therapy. Since the 1990s, immunohistochemistry has been the primary method for assessing hormone receptor status. Recently, as a component of its oncotype DX® assay, Genomic Health began reporting quantitative estrogen and PR results determined by quantitative reverse transcription polymerase chain reaction (qRT-PCR). As part of an ongoing quality assurance program at our institution, we reviewed 464 breast cancer cases evaluated by both immunohistochemistry and oncotype DX® assay for estrogen and PR. We found good correlation for ER status between both assays (98.9% concordance), with immunohistochemistry being slightly more sensitive. Concordance for PR was 94.2% between immunohistochemistry and qRT-PCR with immunohistochemistry again more sensitive than RT-PCR. The results also showed linear correlation between immunohistochemistry H-scores and qRT-PCR expression values for ER (correlation coefficient of 0.579), and PR (correlation coefficient of 0.685). Due to the higher sensitivity of hormone receptor immunohistochemistry and additional advantages (ie preservation of morphology, less expensive, faster, more convenient), we conclude immunohistochemistry is preferable to qRT-PCR for determination of estrogen and PR expression. © 2012 USCAP, Inc. All rights reserved.


Mission J.F.,Magee Womens Hospital of UPMC | Marshall N.E.,Oregon Health And Science University | Caughey A.B.,Oregon Health And Science University
Obstetrics and Gynecology Clinics of North America | Year: 2015

Obesity has increased dramatically in the United States over the last several decades, with approximately 40% of pregnant women now considered overweight or obese. Obesity has been shown to be associated with numerous poor pregnancy outcomes, including increased rates of preeclampsia, gestational diabetes, fetal macrosomia, stillbirth, postterm pregnancy, and increased rates of cesarean delivery. Many of these complications have been found to increase even further with increasing body mass index in a dose-response fashion. In this review, the association of obesity with maternal, fetal, and pregnancy outcomes is discussed as are the recommendations for caring for the obese gravida. © 2015 Elsevier Inc.


Lesnock J.L.,Mon General Hospital | Farris C.,RAND Corporation | Beriwal S.,Magee Womens Hospital of UPMC | Krivak T.C.,Magee Womens Hospital of UPMC
Gynecologic Oncology | Year: 2013

Objective Radiation can be delivered via four-field box (BOX-RT) or intensity modulated radiation therapy (IMRT). We sought to evaluate the cost-effectiveness (C/E) of IMRT relative to BOX-RT for the treatment of locally advanced cervical cancer. Methods A three-year Markov model with eight-week cycles was developed to compare IMRT to BOX-RT. A proportion (25%) received extended-field radiation therapy (EFRT) to include para-aortic nodes. The model assumed equal overall survival (OS). The model captured costs and utility estimates for BOX-RT, IMRT, and each complication. Modeled complications included acute and chronic toxicities. Baseline model assumptions were obtained by literature review and supplemented by expert opinion. Costs were based on Medicare reimbursement rates and the Agency for Healthcare Research and Quality Database. Treatment strategies were compared using an incremental cost-effectiveness ratio (ICER). One-way, probabilistic and structural sensitivity analyses were performed to account for uncertainty in assumptions. The C/E of each strategy was evaluated from the perspective of the health care system. Results C/E analysis revealed an ICER for IMRT of $182,777/ quality adjusted life year (QALY) gained. Although this value was higher than the willingness to pay threshold of $100,000/QALY, sensitivity analysis revealed several modifications that would make IMRT a C/E option relative to BOX-RT. For patients requiring EFRT, IMRT was C/E with an ICER of $91,580/QALY. Conclusions Although IMRT was not C/E at the $100,000 willingness-to-pay threshold, in those requiring EFRT, IMRT was C/E relative to BOX-RT. A randomized trial comparing IMRT to BOX-RT for the treatment of locally advanced cervical cancer is warranted. © 2013 Elsevier Inc.


McGuire M.M.,University of Pittsburgh | Yatsenko A.,University of Pittsburgh | Hoffner L.,University of Pittsburgh | Jones M.,Magee Womens Hospital of UPMC | And 2 more authors.
PLoS ONE | Year: 2012

Uterine leiomyomas (uterine fibroids) arise from smooth muscle tissue in the majority of women by age 45. It is common for these clonal tumors to develop from multiple locations within the uterus, leading to a variety of symptoms such as pelvic pain, abnormal uterine bleeding, and infertility. We performed whole exome sequencing on genomic DNA from five pairs of leiomyomas and corresponding normal myometrium to determine genetic variations unique to leiomyomas. Whole exome sequencing revealed that the gene encoding transcription factor MED12 (Mediator complex subunit 12) harbored heterozygous missense mutations caused by single nucleotide variants in highly conserved codon 44 of exon 2 in two of five leiomyomas. Sanger re-sequencing of MED12 among these five leiomyomas confirmed the two single nucleotide variants and detected a 42 base-pair deletion within exon 2 of MED12 in a third leiomyoma. MED12 was sequenced in an additional 143 leiomyomas and 73 normal myometrial tissues. Overall, MED12 was mutated in 100/148 (67%) of the genotyped leiomyomas: 79/148 (53%) leiomyomas exhibited heterozygous missense single nucleotide variants, 17/148 (11%) leiomyomas exhibited heterozygous in-frame deletions/insertion-deletions, 2/148 (1%) leiomyomas exhibited intronic heterozygous single nucleotide variants affecting splicing, and 2/148 (1%) leiomyomas exhibited heterozygous deletions/insertion-deletions spanning the intron 1-exon 2 boundary which affected the splice acceptor site. Mutations were not detected in MED12 in normal myometrial tissue. MED12 mutations were equally distributed among karyotypically normal and abnormal uterine leiomyomas and were identified in leiomyomas from both black and white American women. Our studies show an association between MED12 mutations and leiomyomas in ethnically and racially diverse American women. © 2012 McGuire et al.


Zorn K.K.,Magee Womens Hospital of UPMC
Oncology | Year: 2012

The treatment strategy of poly(ADP-ribose) polymerase (PARP) inhibition capitalizes on the inherent defect in homologous recombination that occurs in BRCA-deficient tumors by inhibiting the alternative DNA repair pathway involving base excision repair. Although PARP inhibitors were initially considered a potential treatment specifically for tumors with germline BRCA mutations, evidence of frequent somatic deficiency in the BRCA pathway has caused reconsideration of that approach. PARP inhibitors have been shown to have activity in epithelial ovarian, fallopian tube, and primary peritoneal cancer in phase I and II clinical trials. Responses have been seen in both BRCA-deficient and sporadic tumors, and they do not appear to require platinum sensitivity. Although PARP inhibitors are well tolerated as monotherapy, additional study is required to determine their efficacy and toxicity in combination with chemotherapy and other targeted agents. Many hurdles remain along the pathway to drug registration, but the motivation of the community of ovarian cancer patients, researchers, and clinicians to find new treatments may speed the process.


Ecker A.M.,Magee Womens Hospital of UPMC | Donnellan N.M.,Magee Womens Hospital of UPMC | Shepherd J.P.,Magee Womens Hospital of UPMC | Lee T.T.M.,Magee Womens Hospital of UPMC
American Journal of Obstetrics and Gynecology | Year: 2014

Objective The objective of the study was to review patient characteristics and intraoperative findings for excised cases of abdominal wall endometriosis (AWE). Study Design A 12 year medical record search was performed for cases of excised AWE, and the diagnosis was confirmed on pathological specimen. Descriptive data were collected and analyzed.Results Of 65 patients included, the primary clinical presentation was abdominal pain and/or a mass/lump (73.8% and 63.1%, respectively). Most patients had a history of cesarean section (81.5%) but 6 patients (9.2%) had no prior surgery. Time from the initial surgery to presentation ranged from 1 to 32 years (median, 7.0 years), and time from the most recent relevant surgery ranged from 1 to 32 years (median, 4.0 years). Five patients (7.7%) required mesh for fascial closure following the resection of the AWE. We were unable to demonstrate a correlation between the increasing numbers of open abdominal surgeries and the time to presentation or depth of involvement. Age, body mass index, and parity also were not predictive of depth of involvement. There were increased rates of umbilical lesions (75% vs 5.6%, P <.001) in nulliparous compared with multiparous women as well as in women without a history of cesarean section (66.7% vs 1.9%, P <.001).Conclusion In women with a mass or pain at a prior incision, the differential diagnosis should include AWE. Although we were unable to demonstrate specific characteristics predictive for AWE, a large portion of our population had a prior cesarean section, suggesting a correlation. © 2014 Elsevier Inc. All rights reserved.


Zuley M.L.,Magee Womens Hospital of UPMC
Radiologic Clinics of North America | Year: 2010

Current day digital mammography acquisition units have already been shown to be equal or better than screen film systems for the detection and classification of breast lesions. The optimal multimodality breast imaging diagnostic workstations and connectivity to existing picture and archiving communication systems and information systems is still a work in progress, but with more and more facilities transitioning to digital imaging it is only a matter of time until these hurdles are overcome. © 2010 Elsevier Inc.


Vallejo M.C.,Magee Womens Hospital of UPMC
Journal of healthcare risk management : the journal of the American Society for Healthcare Risk Management | Year: 2012

Among all complications of airway management, dental injury is the most common cause of patient complaints with medicolegal consequences. Over an 8-year period, data on dental injury were collected within a large university hospital system that included community, tertiary, and quaternary care centers. Patient characteristics were compared among all patients receiving anesthesia care using billing data collected from the same period. Of the 816,690 patients who received anesthesia care, there were 360 dental injuries, giving an overall incidence of 1:2,269 (0.044%). Patients receiving general anesthesia were at an increased risk for dental injuries, with an incidence of 1:1,754 (0.057%) compared with patients receiving monitored anesthesia care in whom the incidence was 1:12,500 (0.008%). Patients in the age group 18 to 65 years had a higher incidence of dental injuries of 1:1,818 (0.055%) compared with pediatric patients, who had an incidence of 1:7,692 (0.013%). Emergency procedures were not associated with an increased risk of dental injury in the 816,690 cases. However, of the 360 patients who sustained a dental injury, emergency procedures were associated with a higher incidence of injuring multiple teeth. © 2012 American Society for Healthcare Risk Management of the American Hospital Association.


Soran A.,Magee Womens Hospital of UPMC | Kamali Polat A.,Magee Womens Hospital of UPMC | Johnson R.,Magee Womens Hospital of UPMC | McGuire K.P.,Magee Womens Hospital of UPMC
Surgeon | Year: 2014

Introduction: Numerous studies have shown a trend towards increasing rates of contralateral prophylactic mastectomy (CPM) in the US. In this review, we will explore the trend, possible causative factors and outcomes from CPM. Methods: We performed a literature review of all relevant retrospective reviews, clinical trials and review articles regarding contralateral prophylactic mastectomy. Results: Several studies have noted a four to fivefold increase in CPM in recent years; an increase most notable in younger patients. When surveyed, patients report that the most important factors affecting their choice of CPM include fear of cancer recurrence, genetic counseling/testing, family history or additional high risk factors, stress surrounding close follow up, the availability of reconstructive surgery and information provided about contralateral breast cancer (CBC) risk and risk for local recurrence. Women who have undergone CPM do report high satisfaction with the procedure and some studies suggest risk reduction. Conclusion: CPM rates have increased across the US and numerous factors have been reported to increase the likelihood of choosing CPM. Despite that bilateral mastectomy is associated with an increased risk of wound and overall postoperative complications for certain populations, this surgery appears to have psychological, cosmetic and possibly oncologic benefit. © 2014 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland.

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