Morcellation risk outweighed by risks of laparotomy

A new study that modeled outcomes for treatment of fibroids with laparoscopic plus morcellation versus an abdominal procedure indicates that risks of an open procedure outweigh those associated with potentially morcellating a leiomyosarcoma. The findings, for a hypothetical cohort of 100,000 premenopausal women with a 5-year time horizon, could help better inform decision-making about morcellation.

Published in the American Journal of Obstetrics & Gynecology, the decision-tree analysis predicted fewer overall deaths with laparoscopic hysterectomy than with an abdominal procedure (98 vs 103 per 100,000). Risk of leiomyosarcoma-related deaths was higher with laparoscopy (86 vs 71 per 100,000) but risk of hysterectomy-related death was higher with an abdominal procedure (32 vs 12 per 100,000). The authors chose the study design because of the challenge inherent in doing a prospective study in this area but noted that data are lacking on the incidence of occult leiomyosarcoma associated with uterine procedures for “benign” fibroids and on how morcellation impacts those masses.

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For the study, researchers from the University of North Carolina School of Medicine focused on a cohort of 100,000 because an estimated 200,000 hysterectomies are performed annually in the United States. Existing published data-largely from high-quality studies and more recent publications-were analyzed and morbidity and mortality outcomes were evaluated extending out 5 years. In arriving at the conclusion about risks, the model took into account the reality that women can experience multiple adverse events simultaneously.    

Transfusion, abdominal wound infection, vaginal cuff dehiscence, venous thromboembolism (VTE), incisional hernia, leiomyosarcoma and death from leiomyosarcoma or hysterectomy were the surgical outcomes assessed. For laparoscopic surgery, rates of transfusion, VTE, and incisional hernia were lower for laparoscopic surgery than for abdominal hysterectomy (2400 vs 4700, 1500 vs 6300, and 710 vs 8800, respectively, all per 100,000), whereas rates of vaginal cuff dehiscence were higher (640 vs 290 per 100,000).

Estimates of death from leiomyosarcoma were based on data from Surveillance, Epidemiology and End Results reports and incidence of leiomysarcoma in women undergoing hysterectomy for presumed fibroids was based on data from 10 studies.

“On average,” the authors stated, “women who undergo laparoscopic hysterectomy experience an additional 0.85 quality-adjusted life years over 5 years (1.02 months), compared with women who undergo abdominal hysterectomy.” In concluding, they acknowledged a need for further researcher on morcellation, calling for “new diagnostics to preoperatively distinguish benign from malignant myomata” and “enhanced methods of tissue extraction.” 

Are bisphosphonates too costly for routine post-fracture prevention?

Routine bisphosphonate treatment for women over 65 who sustain distal radius fractures could significantly reduce risk of additional fractures-but the annual cost may be prohibitively high, according to an economic analysis by researchers from the Rothman Institute in Philadelphia, Pa. Presented at the 2015 Annual Meeting of the American Academy of Orthopaedic Surgeons, their findings point to a need to optimize the cost and efficiency of use of the bone-building drugs.

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In what may be the first such analysis of its kind, the authors looked at the economic impact of routine use of bisphosphonates to prevent subsequent hip fracture in women aged 65 and older who had suffered a distal radius fracture. Using existing literature, they determined incidence of distal radius fracture and rates of age-specific hip fracture after distal radius fracture with and without bisphosphonate treatment. They then created a model to determine future fracture rates with and without treatment, and related costs, using reimbursement information from Medicare.

Simulation of a cohort of women aged 65 and older, based on US population estimates from 2012, showed that with use of bisphosphonates in the target group, 94,888 lifetime hip fractures could be avoided but an estimated 19,464 patients would suffer atypical femur fractures. That translated to a cost of $205,534 per hip fracture avoided and a breakeven price point of $70 per year for use of bisphosphonates after distal radius fracture to prevent hip fractures.

“Routine treatment of all women over 65 suffering distal radius fracture with bisphosphonates would result in a significant reduction in the overall hip fracture burden,” said the authors, “however at a substantial cost of over $2 billion dollars annually. To optimize cost and efficiency of treatment, either patients may be selectively treated or the cost of annual bisphosphonate treatment should be reduced to cost-effective margins.”  

Prenatal air pollution may impact brain development

A small study on prenatal exposure to polycyclic aromatic hydrocarbons (PAH) seems to indicate that such exposure may impact brain development. PAH are byproducts of vehicle emissions, coal burning, and smoking and can also be generated indoors by cooking and space heaters.

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Researchers performed a cross-sectional imaging study in a representative community-based cohort which was followed up prospectively from the fetal period to ages 7 to 9 years. The sample contained 40 minority urban youth who were born to either Latina (Dominican) or African-American mothers and were recruited between February 2, 1998 and March 17, 2006. The settings were an academic imaging center or urban community residences.

The researchers found a dose-response relationship between increased PAH exposure prenatally, which was measured in the third trimester and considered to be the index exposure for the entirety of the pregnancy, and a reduction in white matter brain surface in later childhood. The reduction affected almost the entire surface of the left hemisphere. The reduced left hemisphere white matter is linked to severe externalizing behavioral problems and slower information processing during intelligence testing. The amount of left hemisphere white matter disturbances mediated the significant tie between PAH exposure and slower processing.

They concluded that exposure to the PAH pollutants prenatally was linked to disruption in the development of white matter on the left hemisphere, which can contribute to slower information processing and behavioral problems with attention deficit hyperactivity disorder.