Presenting Residents Characteristics of adolescents with CIN 3 :

Presenting Residents Characteristics of adolescents with CIN 3: findings from a tertiary care colposcopy database Author: Aine Clements, MD Preceptor: Lori A. Boardman, MD, ScM Other authors: Christina Raker, ScD; Amy C. Cooper, CRNP Objective: To identify demographic characteristics of adolescents with high grade histology Methods: Our review of the literature identified several risk factors for high grade lesions including number of lifetime sexual partners, history of sexually transmitted infections, parity, HIV status, smoking, ethnicity and low socio-economic status. At our hospital, demographic characteristics, medical history, cytologic diagnosis and histologic diagnosis of women referred to our colposcopy clinic have been collected in a database. Using our institutional colposcopy database, we identified 841 adolescents (defined as ≤20 years of age) seen for the evaluation of an abnormal Papanicolaou smear between January 1, 1999 and September 30, 2007. For the purposes of this analysis, we excluded 197 young women without available histologic results and 30 who did not have number of partners recorded. Our hypothesis was that teens with 4 or more lifetime sexual partners are twice as likely to have CIN3 or higher as compared to teens with 3 or fewer partners. Our secondary outcomes were to investigate the other aforementioned demographics. Unconditional multivariable logistic regression was used to calculate odds ratios and 95% confidence intervals for patient characteristics and the detection of CIN3+. Characteristics associated with CIN3+ with p<=0.1 in the crude analysis were added to a multivariable regression model. Data analysis was performed with SAS version 9.1. Results: Of the 614 eligible adolescents, the median age was 19, with a range of 13-20. The population was largely nulliparous, single (579 or 95%), not privately insured (455 or 82%), and racially/ethnically diverse (198 or 33% Hispanic, 246 or 42% non-Hispanic white and 108 or 18% non-Hispanic black). Only one was HIV positive. The mean age at first intercourse of the cohort was 15.3 years (SD 1.7), and the median number of lifetime male sexual partners was 4 (range 1-50). Mild cytologic abnormalities predominated, with 329 adolescents (53%) referred to colposcopy for LSIL and 184 (30%) for ASC-US. HSIL was documented in 64 (10%) of the population. Clinically significant histologic disease (CIN 3+) was found in 54 (8.8%). No cases of invasive disease or AIS were found. In our univariate analysis, gravidity, parity, marital status, insurance status, race/ethnicity, smoking, age at first coitus, lifetime male sexual partners and pregnancy were not associated with increased odds of CIN3. History of sexually transmitted infections and indication for colposcopy did have increased odds of CIN3. Our multivariate analysis confirmed these findings, both including and excluding the variable of number of partners. Conclusion: In this study population of over 600 young women with an initial cytologic abnormality, the prevalence of CIN 3 was 8.8%. Risk factors in the adult population for dysplasia such as number of sexual partners, parity, smoking, ethnicity and low socio-economic status (as measured by insurance status) were not risk factors in this adolescent population for CIN3. History of sexually transmitted infections and indication for colposcopy, as expected, were. Intrapartum group B streptococcus prophylaxis in patients who report a penicillin allergy: Has there been an improvement in adherence to the 2002 CDC guidelines? Author: Agatha Critchfield, MD Preceptor: Kristen A. Matteson, MD, MPH Other authors: Stacey P. Lievense, MD; Christina Raker, ScD Objective: To compare adherence to the 2002 CDC guidelines for the prevention of perinatal group B streptococci (GBS) disease in penicillin allergic patients between 2004-2006 and 2008. Methods: In 2007, we conducted a retrospective cohort study of all GBS-positive, penicillin-allergic women who delivered at Women and Infants Hospital (WIH) between 2004 and 2006 (n=233). Because this study demonstrated suboptimal adherence to the 2002 CDC guidelines, WIH conducted a series of hospital based interventions to improve adherence. To determine whether or not adherence improved, we repeated this study with a retrospective cohort of GBS positive, penicillin allergic patients who delivered at WIH between April 2008 and January 2009 (n=74). Medical records were analyzed. Main outcome measures were (#1) the proportion of penicillin-allergic, GBS positive patients who had antimicrobial sensitivity testing performed and (#2) the proportion of penicillin-allergic, GBS positive patients who received the appropriate antibiotic based on 2002 CDC guidelines. Women with either a scheduled cesarean delivery or a preterm delivery were excluded from analyses. We compared main outcomes between this 2008 dataset and the 2004-2006 dataset. Based on number of eligible cases identified for analyses and assuming α=0.05, we had approximately 95% power to detect a 25% difference in both proportion with antimicrobial sensitivity and proportion with appropriate antibiotic received. Data were analyzed using STATA 9.0. Results: In 2008, 94.2% (95% confidence interval [CI]= 87-97%) of GBS-positive, penicillin-allergic women received antibiotic prophylaxis (n=98) and 76.2% (95% CI 66-84%) of GBS pos, penicillinallergic women received appropriate antibiotics (compared to 16.2% in 2004-2006, p<0.001). Antimicrobial sensitivity testing was performed in 79.4% of cases (95% CI 68-87%), compared to 11.4% in 2004-2006 (p<0.001). Among patients who did not have antimicrobial sensitivity testing, 50% received clindamycin (n=7) and 42% received vancomycin (n=6). Among cases where an appropriate antibiotic was not administered 80% received clindamycin (n=11). Conclusion: Adherence to the 2002 CDC guidelines for GBS prophylaxis in penicillin-allergic women has increased dramatically since the 2004-2006 data collection period. However, there is continued room for improvement and efforts aimed to optimize adherence should be implemented and maintained. Long-term use of pegylated liposomal doxorubicin in recurrent ovarian carcinoma Author: Beth Cronin, MD Preceptors: Don S. Dizon, MD & Katina Robison, MD Objective: Ovarian cancer is the fifth leading cause of death in women, with an estimated five-year survival of thirty percent. For women who relapse, pegylated liposomal doxorubicin (PLD) is a FDAapproved agent for the treatment of recurrent disease, with response rates ranging from 16 to 20. However, there is no consensus on whether treatment should be to progression or to best response, and very little is known about the outcomes of women receiving PLD beyond six cycles. The aim of this project is to determine progression free survival of this highly selected population, as compared to women who received only six cycles. Methods: A retrospective chart review was performed of women receiving 6 or more cycles of pegylated liposomal doxorubicin between 1998 and 2007. All patients with recurrent ovarian, fallopian tube, primary peritoneal, or uterine papillary serous carcinoma were included. Those who received only 6 cycles were our control group. Evaluation for progression was based on CA-125, physical examination, and imaging studies. Results: Forty eight patients were included in our analysis: 36 (75%) received a median of 9 cycles of PLD (range 7 to 28) and 12 (25%) received 6 cycles who made up the control group. The median PFS were 11 (range 6-29) and 8.5 months (range 6-15). The difference between these two groups was not statistically significant (p=0.065). Of the 36 patients receiving over 6 months of treatment, 25 (69%) were treated less than one year and the remaining 11 (31%) received 12 months or more of treatment. Comparing these two groups, the median PFS was 8 (range 6-29) and 16 months (range 14-28 months), which was a statistically significant difference (p<0.001). Conclusion: In this highly selected population, no difference in PFS was seen in women treated with PLD by duration of therapy. However, for the group able to remain on therapy for 12 months or longer, PFS was significantly longer than those women who received it for less time. This suggests that PLD may be used to treat until progression and for those able to stay on it, may prove effective in prolonging PFS. Increased interpersonal partner violence inquiry with standardized health prevention screening Author: Jennifer Kang, MD Preceptor: Lori A. Boardman, MD, ScM Other authors: Amy S. Gottlieb, MD; Sonia S. Aneja, BS; Christina A. Raker, ScD Objective: To evaluate the impact of patient and provider variables on rates of intimate partner violence screening in an ambulatory gynecology practice. Methods: A cross-sectional study of 300 patients chosen randomly from annual healthcare visits during 2007 at a university-affiliated ambulatory gynecology clinic. All encounters were recorded on a standardized health history form which included questions about abuse history. Data on patient and provider characteristics were collected. The association of provider screening with selected patient variables was assessed using multivariable logistic regression. Results: The median age of the study population was 29 (range 15-73). In general, the cohort was racially/ethnically diverse and the majority was on government assistance. Sixty-seven percent (194/291) had children living at home, and 57% (164/286) were single. Of the 300 patients, 243 (81%) had documentation of abuse screening in their medical records. Variables previously found to be associated with higher rates of partner abuse, such as younger age, increased parity, or substance abuse, did not influence whether patients were screened. Similarly, differences in screening by provider type (NP/resident) or gender did not emerge. Patients were, however, significantly more likely to be questioned about partner violence when they received other preventive screening (adjusted OR 2.50 (1.26-4.99)) or presented with a somatic pain complaint (adjusted OR 2.55 (1.12-5.83). Conclusion: Ambulatory gynecology patients were more likely to be screened for intimate partner violence when providers performed other preventive health screening utilizing a standardized health history form. Effect of routine pelvic floor exercise counseling and pelvic floor physical therapy on symptoms and life impact for female pelvic floor disorders Author: Nicole Korbly, MD Preceptor: Vivian W. Sung, MD, MPH Objective: Our primary objective was to evaluate the effect of pelvic floor physical therapy (PFPT) compared to routine pelvic floor education on symptoms and life impact in women with pelvic floor disorders (PFD). Our secondary objective was to evaluate the combined effect of both PFPT and routine education on improving symptoms and life impact of PFDs. Methods: This is a prospective cohort study of women with PFDs who opted for treatment with PFPT. All women received routine education on pelvic floor exercises from physicians, then enrolled and completed a course of PFPT. Patients completed PFD-specific questionnaires for symptom bother [Pelvic Floor Distress Inventory-20 (PFDI-20)] and life impact [Pelvic Floor Impact Questionnaire-7 (PFIQ-7)] at the following time points: 1) prior to any intervention; 2) after routine education and performing independent pelvic floor exercises; and 3) after completing PFPT. Women also completed the Sexual Function Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) and Body Image Scale (BIS) before and after completing PFPT. Paired t-tests and a one sample binomial test were performed to measure improvement in scores. Results: Thirty four participants have been enrolled and recruitment is ongoing. Twenty-three participants have completed the study and are included in this analysis. The mean age of study participants was 57.8 years. The majority of the women are Caucasian (95.7%), menopausal (73.9%), nonsmokers (95.7%), with a median parity of 2. Thirty percent reported prolapse symptoms, 34.8% reported defecatory symptoms, and 72% reported urinary incontinence symptoms at baseline. The median number of PFPT sessions was 4, with a mean duration of 6 weeks. For our primary objective comparing routine education vs PFPT, there were no differences in symptom bother, life impact, sexual function, or body image between groups in this preliminary analysis. For our secondary objective, women reported significant improvement in PFD symptom bother (mean PFDI score 101 + 54 vs 62 +38, p=.04 for baseline versus post PFPT, respectively) and life impact (mean PFIQ score 50 + 44 vs 23 + 27, p=.0002 for baseline versus post PFPT, respectively) after both routine education and PFPT. Participants demonstrated significant improvements in symptom bother for the colorectal-anal and urinary distress domains as well as life impact for the prolapse, colorectal-anal and urinary domains (P<.05 for all). Conclusion: Women with pelvic floor disorders have significant improvements in symptom bother and life impact after routine pelvic floor education and PFPT. Continuing enrollment and collection of data may reveal differences in routine education compared to PFPT. Repeat teen birth: does mode of delivery make a difference? Author: Laura Ricchio, MD Preceptor: Maureen G. Phipps MD, MPH Other authors: Christina A. Raker, ScD Objective: To evaluate the association between repeat teen births and mode of delivery (cesarean vs. vaginal) in adolescent mothers. Methods: Vital statistics data from the Rhode Island Department of Health for the years 2004-2006 were used to conduct this retrospective cohort study. The 2004 vital statistics records were searched for all singleton first births to mothers 19 years old and younger. Birth files for the years 2005 and 2006 were searched to match those adolescents having a subsequent live birth within 24 months of the index birth. Maternal baseline characteristics and infant birth record data for each birth were collected. Repeat birth rates were calculated and compared between adolescents delivering their first baby via cesarean vs. vaginally. Fisher’s exact test, Wilcoxon rank sum test, and survival analysis methods were utilized. Results: 899 adolescents delivered their first child in 2004. 18.6% (n=167) delivered via cesarean and 81.4% (n=732) delivered vaginally. Overall, the repeat birth rate within two years was 15.9% (n=143) with 17.4% for cesarean delivery and 15.6% for vaginal delivery. Median time to repeat birth in the cesarean cohort was 20 months and in the vaginal cohort was 17.6 months. The cohorts differed statistically (p-value <0.01) with regard to pregnancy complications (72.5% for cesarean vs. 17.8% for vaginal) and birth weight (3347g for cesarean vs. 3197g for vaginal). A time-to-event analysis (time-tonext-delivery) showed differences in the rates of repeat pregnancy over time. 15-20 months after the first birth, the vaginal cohort had a higher rate of repeat births; and 21-24 months after the first birth, the cesarean cohort had a higher rate. Conclusion: We observed a slightly higher rate of repeat birth within two years of an index birth for teen mothers whose first birth was by c-section compared with vaginal delivery; this difference was not statistically significant. The trend in time-to-next-delivery may give the most information about when to direct interventions, reinforce contraceptive messages and provide education around pregnancy prevention and planning for parenting teens. Comparison of a novel multiple biomarker assay to the risk of malignancy index for the prediction of epithelial ovarian cancer in patients with a pelvic mass Author: Moune Jabre Raughley, MD Preceptor: Richard Moore, MD Other authors: Amy K. Brown, MD; Katina Robison, MD; Craig C. Miller; MD; Jeffery Allard, MD; Robert Kurman, MD; C. O. Granai, MD. Objective: Patients with epithelial ovarian cancer (EOC) have decreased morbidity and increased survival when initially cared for by gynecologic oncologist at centers experienced in the management of EOC. Therefore, it is important to be able to triage patients at increased risk for EOC to the appropriate centers. The objective of this trial is to compare the risk of malignancy index (RMI) to the Risk of Ovarian Malignancy Algorithm (ROMA), a novel multiple marker assay for the prediction of EOC in patients with a pelvic mass. Methods: Multicenter prospective trial. All patients had a documented pelvic mass on imaging and had preoperatively determined serum values for HE4 and CA125. Surgical pathology results were confirmed through a central review. An RMI and ROMA were determined for each patient. Sensitivity and specificity were calculated for each method and compared. Results: 566 patient enrolled into the trial with 456 evaluable patients. There were 123 EOC (17 stage I, 17 stage II, 80 stage III, 6 stage IV and 3 unstaged), 22 LMP, and 311 benign tumors. There were 175 premenopausal patients and 281 postmenopausal patients. Examination of all patients and stages at a set specificity of 75% revealed ROMA had a sensitivity of 95% (95% CI: 90-98) and the RMI had a sensitivity of 84% (95% CI: 76-90) for determining benign from EOC. In patients with stage I and II disease, the ROMA achieved a sensitivity of 88% (95% CI: 73-97) compared with the RMI sensitivity of 62% (95% CI: 44-78). For patients with stage I, II, IIIA/B and node positive only IIIC, the ROMA had a sensitivity of 91% (95% CI: 50-80) and the RMI had a sensitivity of 66% (95% CI: 44-78). The sensitivity for stage III and IV patients with bulky disease was 99% (95% CI: 93-100) for ROMA and 95% (95% CI: 87-99) for RMI. Conclusion: The dual marker algorithm utilizing HE4 and CA125 to calculate a risk of malignancy achieves a greater sensitivity for the detection of EOC. The ROMA accurately stratified patients with early stage I & II, stage IIIA and IIIB disease into the high risk group.