Faculty Bibliography

OBJECTIVE:Preterm induction of labor can be necessary for maternal and fetal wellbeing. Duration of cervical ripening balloon (CRB) use has been studied in only term inductions. Our study investigated duration of time in hours for CRB expulsion and vaginal delivery in preterm inductions of labor. METHODS:This was a single-institution retrospective cohort study of preterm (< 37 weeks) and term (≥ 37 weeks) inductions with CRB between 2010 and 2021. Cesarean deliveries were excluded. Primary outcome was insertion to expulsion time of CRB. Secondary outcomes included induction to delivery time, cervical dilation after expulsion, misoprostol, and Pitocin use. Institutional review board (IRB) approval was obtained prior to the study. RESULTS:Ninety-eight patients with vaginal delivery after preterm CRB use were identified and matched 1:1 on baseline characteristics (p > 0.05) to term patients with vaginal delivery after CRB use. Mean insertion to expulsion time was significantly shorter for term than preterm inductions (mean 7.2 ± 3.09 h versus 8.5 ± 3.38 h; p < 0.01). Mean induction to delivery time was significantly shorter for term than preterm inductions (18.4 ± 7.6 h versus 22.5 ± 9.01 h; p < 0.01). Increased use of misoprostol, Pitocin, and second CRB were noted among the preterm cohort. Among term patients, more CRB placement at start of induction and greater cervical dilation post-balloon were found in comparison to preterm patients. CONCLUSION/CONCLUSIONS:Among patients undergoing preterm induction, longer insertion to expulsion time of CRB, longer induction to delivery time, and increased interventions should be expected. Different standards for labor management should be considered for achieving vaginal delivery in preterm inductions.

INTRODUCTION: Preterm induction of labor can be necessary for maternal and fetal wellbeing. Duration of cervical ripening balloon (CRB) use has been studied only in term inductions. Our study investigated duration of time for CRB expulsion and vaginal delivery in preterm inductions of labor.
METHOD(S): This was a single-institution retrospective cohort study of preterm (<37 weeks) and term (>=37 weeks) inductions with CRB between 2010 and 2021. Cesarean deliveries were excluded. Primary outcome was insertion to expulsion time (IET) of CRB. Secondary outcomes included induction to delivery time (IDT), cervical dilation after expulsion, and misoprostol and Pitocin use. Institutional review board approval was obtained prior to the study.
RESULT(S): A total of 98 patients with vaginal delivery after preterm CRB use were identified and matched 1:1 on baseline characteristics to patients with vaginal delivery after term CRB use. Mean IET was significantly shorter for term CRB than for preterm induction (mean 7.2+/-3.09 hours versus 8.5+/-3.38 hours; P=.004). Mean IDT was significantly shorter for term CRB than preterm CRB induction (18.4+/-7.6 hours versus 22.5+/-9.01 hours; P<.001). Increased use of misoprostol, Pitocin, and second CRB were noted among the preterm cohort compared to the term cohort. Among term patients, more CRB placement at start of induction and greater cervical dilation postballoon were found in comparison to preterm patients.
CONCLUSION(S): Among patients undergoing preterm induction, longer IET, longer IDT, and increased interventions should be expected. Different standards for labor management should be considered for achieving vaginal delivery in preterm inductions

OBJECTIVE:The optimal sequence of adjuvant chemoradiation in the treatment of advanced endometrial carcinoma (EC) remains unclear. We sought to evaluate the outcomes of patients treated with chemoradiation in sandwich fashion (chemotherapy-radiotherapy-chemotherapy; CRC), versus those treated sequentially (chemotherapy-radiotherapy; CR) (radiotherapy-chemotherapy; RC), to determine if there is a survival advantaged associated with a particular treatment sequence. METHODS:A multicenter retrospective analysis of patients with stage III and IV EC from 2000-2018 was conducted. Inclusion criteria were patients who had undergone comprehensive surgical staging/tumor debulking; followed by adjuvant chemoradiation. Differences in the frequencies of adverse events were evaluated using Pearson's χ² test. Progression free survival (PFS) and overall survival (OS) rates were calculated using Kaplan-Meier estimates. RESULTS:Final analysis included 152 patients; 36.8% (n=56) CRC, 28.9% (n=44) CR, and 34.2% (n=52) RC. Histology included 44.0% endometrioid, 47.5% serous and 8.5% clear cell tumors. There was no difference in the frequency of histology (p=0.973), stage (p=0.143), cytoreduction status (p=0.932), or treatment delays (p=0.571) between adjuvant therapy sequences. The most frequent location of disease recurrence was abdomen. The median PFS favored CRC versus CR or RC (36-months vs. 22-months and 24-months, respectively) (p=0.038), as did the median OS (48-months vs. 28-months and 34-months, respectively) (p=0.003). CRC demonstrated superiority over CR and RC sequencing in terms 3-year PFS (55% vs. 34% and 37%, respectively) and 3-year OS (71% vs. 50% and 52%, respectively). CONCLUSIONS:Adjuvant chemoradiation delivered in CRC sequence was associated with improvements in both PFS and OS compared to alternant therapy sequencing.

OBJECTIVES/OBJECTIVE:Uterine carcinosarcoma is a rare, aggressive form of uterine cancer with a high recurrence rate and poor survival at all stages. We sought to evaluate the outcomes of patients treated with chemotherapy versus a combination of chemotherapy and radiation (chemoradiation) to determine survival. METHODS:test. Progression-free and overall survival rates were calculated using Kaplan-Meier estimates. RESULTS:Final analysis included 148 patients; 40.5% (n=60) chemotherapy and 59.5% (n=88) chemoradiation. The mean age was 67 years (range 39-89). Stage distribution included 24.3% stage I, 12.2% stage II, 37.2% stage III, and 26.3% stage IV. There was no difference in the frequency of stage (p=0.81), cytoreduction status (p=0.61), treatment delays (p=0.57), or location of recurrence (p=0.97) between cohorts. The most frequent location of recurrence was the abdomen (50.0%). The median progression-free survival favored chemoradiation over chemotherapy (15 vs 11 months, respectively), as did the median overall survival (26 vs 20 months, respectively). Chemoradiation was associated with a statistically significant improvement in 2 year progression-free survival (22.5% vs 13.6%; p=0.006) and 2 year overall survival (50.0% vs 35.6%; p=0.018) compared with chemotherapy alone. On subanalysis of patients receiving chemoradiation, 'sandwich sequencing' (chemotherapy-radiation-chemotherapy) was associated with superior overall survival compared with alternate therapy sequences (chemotherapy-radiation and radiation-chemotherapy) (34 months vs 14 months and 14 months, respectively) (p=0.038). CONCLUSIONS:Chemoradiation was associated with improvement in both progression-free and overall survival for all stages of carcinosarcoma compared with chemotherapy alone.

Isaacs syndrome is a rare neuromuscular disorder characterized by chronic muscle stiffness, cramping, fasciculations, myokymia, and hyperhidrosis. Pathogenesis includes autoimmunity, paraneoplastic disorders, genetic predisposition, or toxin exposure. There is no known cure for Isaacs syndrome. This case report describes a patient who had been given the diagnosis of Isaacs syndrome and received osteopathic manipulative treatment to manage fascial and cranial dysfunctions and reduce nervous system hyperexcitability. Long-term decrease of myokymia and reduction of severity and frequency of exacerbations resulted.