Uterine Pathology in Women Undergoing Minimally Invasive Hysterectomy Using Morcellation.

Even though minimally invasive surgery has improved outcomes for hysterectomy, the procedure requires removal of the uterus through small incisions. Morcellation, or fragmentation of the uterus into smaller pieces, is one method to remove the uterus. Recently, concern has been raised that morcellation may result in the spread of undetected malignancies.1

Despite the commercial availability of electric power morcellators for 2 decades, accurate estimates of the prevalence of malignancy at the time of electric power morcellation (herein referred to as morcellation) are lacking,1,2 with single-center studies reporting prevalences from 9 to 100 in 10 000.3,4 We used a large insurance database to investigate the prevalence of underlying cancer in women who underwent uterine morcellation.

The Perspective database was used to identify women who underwent a minimally invasive hysterectomy from 2006-2012. Perspective is an all-payer database including more than 500 hospitals capturing 15% of hospitalizations. Hospitals within this database are more frequently urban teaching centers and located in the southern United States. Data undergo a rigorous quality control process. Use of commercially available morcellators was captured by identification of charge codes.5 The analysis was deemed exempt by the Columbia University institutional review board.

The primary outcome was identification of uterine corpus cancer (all histologies) based onInternational Classification of Diseases, Ninth Revision, coding at surgery. We also examined the occurrence of uterine neoplasms of uncertain malignant potential; malignancies of other parts of the uterus, including cervical cancer, and surrounding adnexal structures (other gynecologic cancer); and endometrial hyperplasia.

Multivariable mixed-effects log-linear models, including clinical and demographic covariates and a random-intercept for the procedural hospital, were developed for uterine cancer and endometrial hyperplasia. The other outcomes were rare and the models did not converge.

All statistical analyses were 2-sided and performed with SAS version 9.4 (SAS Institute Inc). A Pvalue of <.05 was considered statistically significant.

Within the cohort of 232 882 women who underwent minimally invasive hysterectomy from 2006-2012, morcellation was performed in 36 470 (15.7%). Women who underwent morcellation differed in clinical and demographic characteristics from women who did not (eTable in the Supplement). Among those who underwent morcellation, 99 cases of uterine cancer were identified, a prevalence of 27/10 000 (95% CI, 22-32/10 000). Twenty-six cases of other gynecologic malignancies were found (a prevalence of 7/10 000 [95% CI, 4-10/10 000]), 39 uterine neoplasms of uncertain malignant potential (11/10 000 [95% CI, 7-14/10 000]), and 368 cases of endometrial hyperplasia (101/10 000 [95% CI, 91-111 per 10 000]).

Among women who underwent morcellation, advanced age was associated with underlying cancer and endometrial hyperplasia (Table). Compared with women younger than 40 years, the prevalence ratio for a uterine malignancy increased with increasing age from 4.97 (95% CI, 1.91-12.93) in women aged 50 to 54 years, to 19.37 (95% CI, 7.66-48.95) in those aged 55 to 59 years, to 21.36 (95% CI, 7.22-63.21) in those aged 60 to 64 years, and to 35.97 (95% CI, 14.14-91.53) for women aged 65 years or older.
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Table.  Multivariable Models Among Women Who Underwent Morcellation

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Our data demonstrate that uterine cancers occurred in 27 per 10 000 women undergoing morcellation. Other malignancies and precancerous abnormalities were also detected. Although morcellators have been in use since 1993, few studies have described the prevalence of unexpected pathology at the time of hysterectomy.2– 4 Prevalence information is the first step in determining the risk of spreading cancer with morcellation. Although data are limited, women with apparent uterine-confined neoplasms at the time of morcellation have been found to have intraperitoneal tumor dissemination at the time of reexploration.3,6

We recognize a number of limitations including the inability to verify pathological findings, possible misclassification of pathology, potential undercapture of morcellation, and the fact that our findings may not be generalizable to all hospitals. Last, we lack data on long-term follow-up, and the outcome of women with pathological abnormalities who underwent morcellation requires further study. Patients considering morcellation should be adequately counseled about the prevalence of cancerous and precancerous conditions prior to undergoing the procedure.

 Patient safety must be a priority in all aspects of care. Lancet Oncol. 2014;15(2):123.
PubMed   |  Link to Article
Kho  KA, Nezhat  CH.  Evaluating the risks of electric uterine morcellation. JAMA. 2014;311(9):905-906.
PubMed   |  Link to Article
Seidman  MA, Oduyebo  T, Muto  MG, Crum  CP, Nucci  MR, Quade  BJ.  Peritoneal dissemination complicating morcellation of uterine mesenchymal neoplasms. PLoS One. 2012;7(11):e50058.
PubMed   |  Link to Article
Hagemann  IS, Hagemann  AR, LiVolsi  VA, Montone  KT, Chu  CS.  Risk of occult malignancy in morcellated hysterectomy: a case series. Int J Gynecol Pathol. 2011;30(5):476-483.
PubMed   |  Link to Article
Wright  JD, Ananth  CV, Lewin  SN,  et al.  Robotically assisted vs laparoscopic hysterectomy among women with benign gynecologic disease. JAMA. 2013;309(7):689-698.
PubMed   |  Link to Article
Oduyebo  T, Rauh-Hain  AJ, Meserve  EE,  et al.  The value of re-exploration in patients with inadvertently morcellated uterine sarcoma. Gynecol Oncol. 2014;132(2):360-365.
PubMed   |  Link to Article

Diabetes prevalence continues to climb in China.

Data from a survey of over 98,000 Chinese adults indicate that the prevalence of diabetes affects approximately 50% of the Chinese population, and only 25.8% of diagnosed patients are being treated.

“These data suggest that diabetes may have reached an alert level in the Chinese general population with the potential for a major epidemic of diabetes-related complications, including cardiovascular disease, stroke and chronic kidney disease in China in the near future without an effective national intervention,” the researchers wrote.

Researchers from the 2010 China Noncommunicable Disease Surveillance Group collected data from 162 study sites in the Chinese Center for Disease Control and Prevention’s (CDC’s) National Disease Surveillance Point System. According to researchers, measurements of HbA1c, fasting plasma glucose and 2-hour plasma glucose were collected from a nationally representative sample of 98,658 adults aged 18 years or older in 2010.

They found that the overall prevalence of diabetes was about 11.6% (95% CI, 11.3% to 11.8%) among the adult Chinese population (12.1% in men vs. 11% in women).

Further data indicate the prevalence of previously diagnosed diabetes was estimated to be 3.5% (95% CI, 3.4% to 3.6%) in the Chinese population (3.6% in men vs. 3.4% in women). Undiagnosed diabetes was estimated at 8.1% (95% CI, 7.9% to 8.3%) in the overall population (8.5% in men vs. 7.7% in women), according to data.

Moreover, the prevalence of prediabetes was estimated to be 50.1% (95% CI, 49.7% to 50.6%) in Chinese adults (52.1% in men vs. 48.1% in women).

The prevalence for prediabetes was greater among patients in older age groups (P<.001), urban residents, patients living in economically-developed regions and those who were overweight or obese, researchers wrote.

Data also demonstrate only 25.8% of patients with diabetes received treatment. Of those treated, only 39.7% had HbA1c levels less than 7% (40.7% in men vs. 38.6% in women), researchers wrote.

In an accompanying editorial, Juliana C. N. Chan, MD, FRCP, from the department of medicine and therapeutics at the Hong Kong Institute of Diabetes and Obesity, the Chinese University of Hong Kong Prince of Wales Hospital International Diabetes Federation Centre of Education, Shatin, Hong Kong, SAR, China, wrote that diabetes is a societal and health care challenge.

“To this end, government leaderships, partnerships, and community empowerment will be needed to create a health-promoting environment, encourage self-management, and strengthen the health care system to make health a reality,” Chan wrote.

Source: Endocrine Today.



Use of Oral Fluconazole during Pregnancy and the Risk of Birth Defects.


Case reports suggest that long-term, high-dose fluconazole treatment for severe fungal infections during pregnancy causes a pattern of birth defects. It is unclear whether commonly used lower doses increase the risk of specific birth defects.


In a registry-based cohort of liveborn infants in Denmark, we evaluated first-trimester oral fluconazole exposure and the risk of birth defects overall and of birth defects previously linked to azole antifungal agents.


The majority of fluconazole-exposed pregnancies were in women who received common therapeutic doses of 150 mg (56% of pregnancies) or 300 mg (31%). Oral fluconazole exposure was not associated with an increased risk of birth defects overall (210 birth defects among 7352 fluconazole-exposed pregnancies [prevalence, 2.86%] and 25,159 birth defects among 968,236 unexposed pregnancies [prevalence, 2.60%]; adjusted prevalence odds ratio, 1.06; 95% confidence interval [CI], 0.92 to 1.21). In addition, oral fluconazole exposure was not associated with a significantly increased risk of 14 of 15 types of birth defects previously linked to azole antifungal agents: craniosynostosis, other craniofacial defects, middle-ear defects, cleft palate, cleft lip, limb defects, limb-reduction defects, polydactyly, syndactyly, diaphragmatic hernia, heart defects overall, pulmonary-artery hypoplasia, ventricular septal defects, and hypoplastic left heart. A significantly increased risk of tetralogy of Fallot was observed (7 cases in fluconazole-exposed pregnancies [prevalence, 0.10%] as compared with 287 cases in unexposed pregnancies [prevalence, 0.03%]; adjusted prevalence odds ratio, 3.16; 95% CI, 1.49 to 6.71).


Oral fluconazole was not associated with a significantly increased risk of birth defects overall or of 14 of the 15 specific birth defects of previous concern. Fluconazole exposure may confer an increased risk of tetralogy of Fallot.

Source: NEJM






Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis.


Lower extremity peripheral artery disease is the third leading cause of atherosclerotic cardiovascular morbidity, following coronary artery disease and stroke. This study provides the first comparison of the prevalence of peripheral artery disease between high-income countries (HIC) and low-income or middle-income countries (LMIC), establishes the primary risk factors for peripheral artery disease in these settings, and estimates the number of people living with peripheral artery disease regionally and globally.


We did a systematic review of the literature on the prevalence of peripheral artery disease in which we searched for community-based studies since 1997 that defined peripheral artery disease as an ankle brachial index (ABI) lower than or equal to 0·90. We used epidemiological modelling to define age-specific and sex-specific prevalence rates in HIC and in LMIC and combined them with UN population numbers for 2000 and 2010 to estimate the global prevalence of peripheral artery disease. Within a subset of studies, we did meta-analyses of odds ratios (ORs) associated with 15 putative risk factors for peripheral artery disease to estimate their effect size in HIC and LMIC. We then used the risk factors to predict peripheral artery disease numbers in eight WHO regions (three HIC and five LMIC).


34 studies satisfied the inclusion criteria, 22 from HIC and 12 from LMIC, including 112 027 participants, of which 9347 had peripheral artery disease. Sex-specific prevalence rates increased with age and were broadly similar in HIC and LMIC and in men and women. The prevalence in HIC at age 45—49 years was 5·28% (95% CI 3·38—8·17%) in women and 5·41% (3·41—8·49%) in men, and at age 85—89 years, it was 18·38% (11·16—28·76%) in women and 18·83% (12·03—28·25%) in men. Prevalence in men was lower in LMIC than in HIC (2·89% [2·04—4·07%] at 45—49 years and 14·94% [9·58—22·56%] at 85—89 years). In LMIC, rates were higher in women than in men, especially at younger ages (6·31% [4·86—8·15%] of women aged 45—49 years). Smoking was an important risk factor in both HIC and LMIC, with meta-OR for current smoking of 2·72 (95% CI 2·39—3·09) in HIC and 1·42 (1·25—1·62) in LMIC, followed by diabetes (1·88 [1·66—2·14] vs 1·47 [1·29—1·68]), hypertension (1·55 [1·42—1·71] vs 1·36 [1·24—1·50]), and hypercholesterolaemia (1·19 [1·07—1·33] vs 1·14 [1·03—1·25]). Globally, 202 million people were living with peripheral artery disease in 2010, 69·7% of them in LMIC, including 54·8 million in southeast Asia and 45·9 million in the western Pacific Region. During the preceding decade the number of individuals with peripheral artery disease increased by 28·7% in LMIC and 13·1% in HIC.


In the 21st century, peripheral artery disease has become a global problem. Governments, non-governmental organisations, and the private sector in LMIC need to address the social and economic consequences, and assess the best strategies for optimum treatment and prevention of this disease.

Source: Lancet.


Is the Prevalence of Dementia Changing?



In England, the prevalence fell from 8.3% to 6.5% during the past 20 years.

Dementia in the growing elder population is an important driver of healthcare costs and a matter of societal concern. Some trends might increase dementia prevalence (e.g., longer lifespan, increasing obesity and diabetes, survival after stroke), whereas others might reduce it (e.g., more-effective prevention of cardiovascular disease, improved early-life education). Between 1989 and 1994, researchers estimated dementia prevalence in three geographic areas in England by interviewing a population-based sample of more than 7500 older adults (age, ≥65). Now, investigators report results of an identical survey in a similar sample from the same areas between 2008 and 2011.

The overall prevalence of dementia fell significantly, from 8.3% to 6.5%. In care facilities, dementia prevalence rose from 58% to 73%; however, the proportion of elders living in such facilities declined from 5% to 3%. In both surveys, dementia prevalence was higher in women than in men in care and community settings.


This rigorous study is a persuasive piece of evidence that, at least in some settings, the prevalence of dementia in elders is declining and might be sensitive to societal efforts to improve education, primary prevention, and healthcare delivery.

Source: NEJM

Peripheral Artery Disease Increased Dramatically Over the Past Decade Worldwide.

Lower-limb peripheral artery disease (PAD) has become a worldwide problem, and its prevalence over the past decade increased twice as fast in lower- and middle-income countries (by 29%) as it did in high-income countries (by 13%), according to Lancet estimates.

Researchers examined data from community-based studies in which PAD was defined by an ankle-brachial index of 0.90 or lower. The 34 studies encompassed over 100,000 participants.

In high-income countries, PAD prevalence did not differ between men and women, but in other countries it was higher among women. Prevalence rose with age worldwide, reaching 10% by age 70 and 17% after age 80. The most important modifiable risk factor was smoking, followed by diabetes, hypertension, and hypercholesterolemia.

The authors call the dramatic increase in prevalence — to about 200 million cases — “a major public health challenge,” given PAD’s association with loss of mobility, functional decline, and cardiovascular risk.


Association of seasonal variation in the prevalence of metabolic syndrome with insulin resistance.

The aim of this study was to examine the hypothesis that seasonal variation in the prevalence of metabolic syndrome (MetS) is associated with increased insulin resistance. Among 840 Japanese male workers who were evaluated using the homeostasis model assessment of insulin resistance (HOMA-IR) in June (summer) 2010, we prospectively studied a total of 758 subjects (40–65 years of age) who underwent an assessment in December (winter) 2010. MetS was defined according to the criteria proposed by the International Diabetes Federation (IDF) and the Japanese Society of Internal Medicine (JSIM). The median level of HOMA-IR in the study subjects was 0.84 (interquartile range: 0.60–1.19). The prevalence rates of IDF- and JSIM-MetS significantly increased from 12.4 and 9.6% in the summer to 16.6 and 13.3% in the winter, respectively (each P<0.05). Our data suggest that these increases are mainly due to increases in blood pressure (BP) and glucose during the winter assessment. The prevalence rates of IDF-MetS in the first, second, third and fourth quartiles of HOMA-IR were 1.1, 5.8, 14.3 and 29.1% in the summer and 3.1, 10.6, 21.9, and 31.3%in the winter, respectively. Similar results were obtained when using the JSIM criteria. In the third quartile, the frequency of elevated BP increased from 42.4% in the summer to 61.2% in the winter (P<0.05), and these values were mainly correlated with significant variations in IDF- and JSIM-MetS prevalence rates. This study demonstrates that seasonal variation in MetS prevalence is associated with mildly to moderately increased insulin resistance in middle-aged Japanese men.


Source: Nature

Prevalence, Distribution, and Impact of Mild Cognitive Impairment in Latin America, China, and India: A 10/66 Population-Based Study.

Rapid demographic ageing is a growing public health issue in many low- and middle-income countries (LAMICs). Mild cognitive impairment (MCI) is a construct frequently used to define groups of people who may be at risk of developing dementia, crucial for targeting preventative interventions. However, little is known about the prevalence or impact of MCI in LAMIC settings.

Methods and Findings

Data were analysed from cross-sectional surveys established by the 10/66 Dementia Research Group and carried out in Cuba, Dominican Republic, Peru, Mexico, Venezuela, Puerto Rico, China, and India on 15,376 individuals aged 65+ without dementia. Standardised assessments of mental and physical health, and cognitive function were carried out including informant interviews. An algorithm was developed to define Mayo Clinic amnestic MCI (aMCI). Disability (12-item World Health Organization disability assessment schedule [WHODAS]) and informant-reported neuropsychiatric symptoms (neuropsychiatric inventory [NPI-Q]) were measured. After adjustment, aMCI was associated with disability, anxiety, apathy, and irritability (but not depression); between-country heterogeneity in these associations was only significant for disability. The crude prevalence of aMCI ranged from 0.8% in China to 4.3% in India. Country differences changed little (range 0.6%–4.6%) after standardization for age, gender, and education level. In pooled estimates, aMCI was modestly associated with male gender and fewer assets but was not associated with age or education. There was no significant between-country variation in these demographic associations.


An algorithm-derived diagnosis of aMCI showed few sociodemographic associations but was consistently associated with higher disability and neuropsychiatric symptoms in addition to showing substantial variation in prevalence across LAMIC populations. Longitudinal data are needed to confirm findings—in particular, to investigate the predictive validity of aMCI in these settings and risk/protective factors for progression to dementia; however, the large number affected has important implications in these rapidly ageing settings.


Incidence, prevalence, and survival of chronic pancreatitis: a population-based study.

Population-based data on chronic pancreatitis (CP) in the United States are scarce. We determined incidence, prevalence, and survival of CP in Olmsted County, MN.
METHODS: Using Mayo Clinic Rochester`s Medical Diagnostic Index followed by a detailed chart review, we identified 106 incident CP cases from 1977 to 2006 (89 clinical cases, 17 diagnosed only at autopsy); CP was defined by previously published Mayo Clinic criteria. We calculated age- and sex-adjusted incidence (for each decade) and prevalence rate (1 January 2006) per 100,000 population (adjusted to 2000 US White population). We compared the observed survival rate for patients with expected survival for age- and sex-matched Minnesota White population.
RESULTS: Median age at diagnosis of CP was 58 years, 56% were male, and 51% had alcoholic CP. The overall (clinical cases or diagnosed only at autopsy) age- and sex-adjusted incidence was 4.05/100,000 person-years (95% confidence interval (CI) 3.27-4.83). The incidence rate for clinical cases increased significantly from 2.94/100,000 during 1977-1986 to 4.35/100,000 person-years during 1997-2006 (P<0.05) because of an increase in the incidence of alcoholic CP. There were 51 prevalent CP cases on 1 January 2006 (57% male, 53% alcoholic). The age- and sex-adjusted prevalence rate per 100,000 population was 41.76 (95% CI 30.21-53.32). At last follow-up, 50 patients were alive. Survival among CP patients was significantly lower than age- and sex-specific expected survival in Minnesota White population (P<0.001).
CONCLUSIONS: Incidence and prevalence of CP are low, and approximately 50% are alcohol related. The incidence of CP cases diagnosed during life is increasing. Survival of CP patients is lower than in the Minnesota White population.




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