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  • February 17, 2017 9:03 AM | Deleted user

    By Janelle Bludorn, MS, PA-C

    Posted on: February 15, 2017

    Olivia is a 37-year-old healthy female who presented to the emergency department (ED) with pelvic pain and vaginal spotting. She has had a hormonal intrauterine device (IUD) in place for four years, yet continues to have regular menses. Her last regular menses was 3 weeks ago, and she has had light spotting and midline pelvic cramping ever since. The night prior to Olivia's presentation in the ED, the pain acutely worsened (but had since waned). Acetaminophen provided her moderate relief; she was pain-free at time of evaluation. She denied experiencing other symptoms, notably fever, vomiting, dysuria, vaginal discharge, and flank pain. Olivia voiced concern that there could be something wrong with her IUD.

    Medical History Olivia reported being monogamous with a male partner. Her medical history revealed that Olivia was G4P2Ab2 (meaning, pregnant 4 times, having birthed 2 children and lost 2 pregnancies).

    Physical Examination At triage, Olivia's vital signs were as follows: BP 109/58 mm Hg; P 61 beats/min; RR 16; T 97.8 F; and SpO2 99% on room air. She appeared well and said she felt comfortable. Her physical examination was unremarkable, other than a report of mild midline suprapubic tenderness. A pelvic examination revealed a small amount of dark blood in Olivia's vaginal vault, IUD strings at the cervical os, and mild bilateral adnexal tenderness without masses or fullness.

    Initial diagnostic studies performed included complete blood cell count, urinalysis, urine hCG, chlamydia/gonorrhea swabs, and pelvic ultrasound.

    The CBC and urinalysis were unremarkable. The urine hGC, however, was positive and the pelvic ultrasound revealed a 2.7 cm x 3.4 cm x 2.5 cm mixed echogenicity adnexal structure adjacent to the right ovary. The IUD was visualized in the uterus and there were no findings consistent with an intrauterine pregnancy.

    Upon these findings, gynecology was consulted and additional diagnostics were obtained. The tests ordered included quantitative hCG, Rh, basic metabolic panel (BMP), and liver function tests (LFTs).

    Pregnancy of Unknown Location Often, after an initial workup in the ED, providers are left with a diagnosis of pregnancy of unknown location (PUL). This is defined as the absence of pregnancy localization (either intra- or extra-uterine) by pelvic ultrasonography in patients who have a serum beta hCG less than 1,000 IU/L to 1,500 IU/L, a range known as the discriminatory zone (the hCG level at or above one would expect to visualize pregnancy on ultrasonography).1

    Any woman classified as having a PUL must be followed closely until a final outcome can be determined. Outcomes include intrauterine pregnancy (IUP), pregnancy failure, or ectopic pregnancy. Current guidelines recommend following the patient's serial beta hGC levels at 48-hour intervals on an outpatient basis.

    A 50% to 66% rise in hCG levels in a 48-hours period is consistent with likely IUP, while a 21% to 35% decline is more consistent with pregnancy failure.3 A static or irregularly rising or falling hCG level raises concerns for an ectopic location of the pregnancy. Serial ultrasonography and examinations are also indicated based on clinical status and hCG laboratory values.

    Ruling Out Ectopic Pregnancy Ectopic pregnancy (EP) occurs in approximately 1% of all pregnancies.1 An ectopic pregnancy is defined as a pregnancy that is located anywhere outside of the endometrial cavity of the uterus. The most common location is one of the fallopian tubes, but an EP can also occur at an ovary, or in the cervix or abdominal cavity.2 Since none of these sites are able to support a growing embryo, there is always a chance of rupture and associated hemorrhage.

    A ruptured ectopic pregnancy is one of the leading causes of pregnancy-related mortality in the U.S., accounting for between 10% to 15% of all maternal deaths. It is, therefore, a true medical emergency and a very important differential diagnosis for emergency medicine providers. 

    Making a definite diagnosis of EP in a stable patient can become a prolonged process, but it begins with clinical suspicion. Higher suspicion should occur among women with risk factors.

    Risk factors that provide strong evidence for association with EP include:2

    ·  Pelvic inflammatory disease;

    ·  Previous ectopic pregnancy;

    ·  Endometriosis;

    ·  Previous tubal surgery;

    ·  Previous pelvic surgery;

    ·  Infertility treatments;

    ·  Uterotubal anomalies;

    ·  History of in utero exposure to diethylstilbestrol; and

    ·  Cigarette smoking.

    Risk factors that offer weaker evidence for association with EP include:2

    ·  Multiple sexual partners;

    ·  Early age at first intercourse; and

    ·  Vaginal douching.

    The patient in this case was not high-risk for ectopic pregnancy based on the risk factors listed above, so the initial workup aimed at ruling out common causes of irregular vaginal bleeding and pelvic pain in a patient with an IUD, such as pregnancy, ovarian pathology, hormonal IUD side effects or expulsion, dysfunctional uterine bleeding, or mittelschmerz.

    Managing Ectopic Pregnancy Management options for EP depend on many factors and can include surgical, medical, or expectant modalities.

    For patients that are hemodynamically unstable, emergent surgical management is indicated. Other indications for surgical management include: ectopic masses >3.5cm, fetal cardiac motion, higher beta hCG levels, known or suspected rupture, or patient preference. Surgical procedures generally include salpingectomy or salpingostomy, either via laparoscopy or laparotomy.2

    Medical management of EP offers the advantages of lower cost, preservation of tubal function, and avoidance of surgery. Many chemical agents have been studied for the medical treatment of ectopic pregnancy. To date, the mainstay of medical treatment is the folic acid antagonist, methotrexate, in either one or two dose regimens.2

    Patients with EP whose blood type is Rh negative should be treated with Rho(D) immune globulin in order to prevent Rh incompatibility, which can cause complications for future pregnancies. These complicating conditions range from mild-to-moderate infantile anemia and/or hyperbilirubinemia to severe conditions such as kernicterus, hydrops fetalis, or even death in utero from massive antibody-induced hemolytic anemia.4

    Several studies have found that approximately 68% to 77% of ectopic pregnancies resolve without any surgical or medical interventions, making expectant management a potential option. This management modality should be reserved for stable patients with small ectopic pregnancies and falling beta hCG levels who can be trusted to closely follow up with outpatient providers.2

    Regardless of which approach is utilized to manage ectopic pregnancy, the patient should have serial beta hCG levels followed until undetectable, out of concern for potential heterotopic pregnancy or treatment failure [2]. 

    Olivia's Diagnosis Olivia's quantitative hCG result was 830 and Rh was negative, while the BMP and LFTs were unremarkable. These findings are consistent with pregnancy of unknown location. Once it had been determined that Olivia was pregnant, an ultrasound raised the concern of implantation in the adnexa and the diagnosis of likely ectopic pregnancy was determined.

    The gynecology consult service was called into the ED, and members of that team administered Methotrexate to Olivia before performing a Karmen biopsy-for both diagnostic and potentially therapeutic purposes.

    Additionally, members of the gynecology consult team removed Olivia's IUD. Rho(D) immune globulin was administered intramuscularly. After a period of observation with stable vital signs, Olivia was discharged to her home with strict warnings to return to the ED if symptoms returned and to follow up with the gynecology clinic within 2 days.  

    Olivia soon followed up with the gynecology clinic to have her serial quantitative hCG levels tested. At that visit, Olivia learned that her Karmen biopsy revealed endometrial cells without chorionic villi, consistent with ectopic pregnancy, and the swab that had been taken to test for both chlamydia and gonorrhea were negative.

    Olivia's quantitative hCG levels required approximately one month from administration of methotrexate to reach zero. At this time, she elected to resume the hormonal IUD as her method of contraception.

    Analysis of This Case Intrauterine devices are often mistakenly associated with ectopic pregnancy, although there is no evidence to suggest that modern-day IUDs increase the risk of this condition.2 In fact, because the IUD is such a reliable and reversible contraception method, they decrease the overall risk of pregnancy, including the risk of ectopic pregnancy. Consider, for example, the hormonal IUDs that are currently available, which boast low failure rates of 0.1 to 0.6 per 100 woman-years (WY), and even lower rates of ectopic pregnancy (0.02 to 0.2 per 100 WY).5In fact, the hormonal IUD boasts one of the lowest rates of ectopic pregnancy among other birth control methods (other than complete abstinence). 

    It is important to note that despite these reassuring statistics and the fact that IUD use does not increase the absolute risk of ectopic pregnancy, if an IUD should fail and result in pregnancy, the implantation is slightly more likely to occur in an ectopic location.2,6

    Although we considered EP as an initial differential diagnosis for a woman with a hormonal IUD who had reported weeks of cramping and spotting with a sudden, acute worsening of pain, our initial clinical suspicion for this was not as high as other possible diagnoses. The leading differential diagnoses for Olivia's case were ovarian cyst rupture, ovarian torsion, mittelschmerz, IUD expulsion, IUD-related side effects, or dysfunctional uterine bleeding. Pregnancy (including intrauterine, ectopic, and spontaneous abortion), tubo-ovarian abscess, and sexually transmitted infection were also considered as possible differential diagnoses.

    Janelle Bludorn is a physician assistant in the emergency department at UNC Health Care and an assistant professor at the University of North Carolina at Chapel Hill School of Medicine. This is a case she encountered in her previous practice at Massachusetts General Hospital emergency department in Boston. 

    References

    1. Varma R, Gupta J. Tubal ectopic pregnancy. BMJ Clinical Evidence. 2012:1406.

    2. Tenore JL. Ectopic pregnancy. Am Fam Physician. 2000;61(4):1080-1088. 

    3. Kirk E, Bottomley C, Bourne T. Diagnosing ectopic pregnancy and current concepts in the management of pregnancy of unknown location. Hum. Reprod. Update. 2014;20(2):250-261.

    4. Fung K, Eason E, Crane J, Armson A, De La Ronde S, Farine D, et al. Prevention of Rh alloimmunization. J Obstet Gynaecol Can. 2003;25(9):765-773.

    5. Heinemann K, Reed S, Moehner S, Do Minh T. Comparative contraceptive effectiveness of levonorgestrel-releasing and copper intrauterine devices: the European Active Surveillance Study for Intrauterine Devices. Contraception. 2015;91(4):280-283.

    6. Li C, Zhao WH, Meng CX, Ping H, Qin GJ, Cao SJ, et al. Contraceptive use and the risk of ectopic pregnancy: a multi-center case-control study. PLoS ONE. 2014;9(12).


  • February 17, 2017 9:02 AM | Deleted user

    Adverse outcomes are more likely to occur in babies born to mothers with gestational diabetes compared with those born to non-diabetic mothers.

    A study in Diabetologia examined the 796,346 deliveries that took place in France after 22 weeks of gestation in 2012, using data from hospital discharges and the national health insurance system.

    "Complications of gestational diabetes are well known, such as preterm birth, macrosomia, preeclampsia, and Caesarean section, for example, but large-scale study is rare," one of the co-authors, Sophie Jacqueminet, MD, of Assistance Publique Hôpitaux de Paris, the city's public hospital system, told MedPage Today. "Our study, by limiting the analyses after 28 weeks of gestation, avoided immortal time bias and highlighted the real level of risk of gestational diabetes ... Furthermore, we observed a higher risk of respiratory distress, which had not been clearly established before."

    Of the original cohort, 57,629 mothers (7.24%) had gestational diabetes. Investigators then further filtered the analysis to include only deliveries after 28 weeks, the point at which gestational diabetes usually begins to appear, and 37 weeks, to determine the risk of adverse outcomes in term deliveries.

    Mothers with gestational diabetes were identified based on their use of glucose-lowering agents, hospital diagnosis at delivery, and overall medical history. Gestational diabetes was classified as "insulin-treated" when insulin was dispensed at least once during pregnancy. Further, as a way of filtering out mothers with undiagnosed pregestational diabetes, Jacqueminet and colleagues excluded those who received insulin or oral glucose-lowering agents at least once during the year after pregnancy.

    After the analysis was limited to deliveries after 28 weeks to reduce immortal time bias, the risks of preterm birth (OR 1.3 [95% CI 1.3-1.4]), Caesarean section (OR 1.4 [95% CI 1.4-1.4]), pre-eclampsia/eclampsia (OR 1.7 [95% CI 1.6-1.7]), macrosomia (OR 1.8 [95% CI 1.7-1.8]), respiratory distress (OR 1.1 [95% CI 1.0-1.3]), birth trauma (OR 1.3 [95% CI 1.1-1.5]), and cardiac malformations (OR 1.3 [95% CI 1.1-1.4]) all increased in women with gestational diabetes compared with those without diabetes.

    For deliveries after 37 weeks, the odds ratio initially rose by 30% for perinatal death in the gestational group compared with the non-diabetes group. No significant differences were observed for the other outcomes in deliveries after 28 weeks.

    After this unexpected finding, the investigators then excluded women with gestational diabetes who received glucose-lowering agents at least once during the year after pregnancy. This analysis excluded 1,376 women in the group of deliveries after 28 weeks (6.8% in the insulin-treated group and 0.7% in the non-insulin-treated group) and 1,171 women in the group of deliveries after 37 weeks (7.3% in the insulin-treated group and 0.64% in the non-insulin-treated group).

    In this more restricted group, the risk of respiratory distress among deliveries after 28 weeks and of perinatal death among deliveries after 37 weeks in the insulin-treated group were no longer significantly increased (OR 1.0 [95% CI 0.9-1.1] and OR 0.9 [95% CI 0.6-1.5], respectively), the team reported.

    However, the risk of perinatal death among deliveries after 37 weeks remained moderately increased in the non-insulin-treated group (OR 1.3 [95% CI 1.0-1.6]).

    "The risk of perinatal death is controversial during gestational diabetes in different studies," Jacqueminet noted. "Most of the time this risk is not increased, but after limiting the analysis after 37 weeks, the risk of perinatal death was slightly increased."

    The findings underscore the importance of vigilance when treating those with gestational diabetes, she continued: "For physicians and other providers, it is important to consider gestational diabetes with caution even when women are not treated by insulin. Careful monitoring at the end of pregnancy should be implemented to decide the better time to give birth."

    Jacqueminet said that moving forward, researchers "need to better know these women," including more about factors like age and body mass index, time of diagnosis, and glucose level at diagnosis.

    The authors note that the study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

    The researchers reported having no relationships with industry.


  • February 16, 2017 10:42 AM | Deleted user

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  • February 14, 2017 9:39 AM | Deleted user

    Feb. 13 (UPI) -- Researchers at the University of Texas at San Antonio, or UTSA, have found that a drug previously used to prevent infections in cancer patients could also prevent infertility.

    Infertility is a common problem for cancer patients, especially in males because cancer treatments often stop sperm production.

    The research team discovered a link between the drug G-CSF or granulocyte colony-stimulating factor, and the regeneration of sperm production in men who had cancer as children and were infertile.

    "We were using G-CSF to prevent infections in our research experiments," Brian Hermann, assistant professor of biology at UTSA and study author, said in a press release. "It turned out that the drug also had the unexpected impact of guarding against male infertility."

    G-CSF stimulates the bone marrow to make neutrophils, which are white blood cells used to fight infections.

    Hermann and his team determined that by promoting cell growth, G-CSF was able to regenerate sperm production.

    "Male infertility is an intuitive disease and we need creative solutions," Hermann said. "But we need to understand how things work before we can fix them."

    The study was published in Reproductive Biology and Endocrinology.


  • February 09, 2017 9:45 AM | Deleted user

    Postmenopausal women with obesity who intentionally lost weight had a lower risk for endometrial cancer, according to results of the Women’s Health Initiative observational study.

    “Many older adults think it’s too late to benefit from weight loss, or think that because they are overweight or obese, the damage has already been done, but our findings show that’s not true,” Juhua Luo, PhD, associate professor of epidemiology and biostatistics at Indiana University School of Public Health, said in a press release.

    Luo and colleagues evaluated 36,794 postmenopausal women aged 50 to 79 years recruited from 40 clinical centers between September 1993 and December 1998. Weight was measured at enrollment and again at 3 years.

    Weight change was categorized as stable (within ± 5%) or a loss or gain (more than 5% change). All incidences of endometrial cancer diagnosed after the 3-year visit served as the primary outcome of the study.

    Over a mean follow-up of 11.4 years, 566 women were diagnosed with endometrial cancer.

    Multivariate analyses adjusted for baseline BMI, age and menopausal hormone therapy showed that women who had lost more than 5% of weight had a 29% lower risk for endometrial cancer compared with women who had stable weight (HR = 0.71; 95% CI, 0.54-0.95).

    When analyzed by baseline BMI, weight loss was associated with significantly lower endometrial cancer risk among women who had been obese (HR = 0.47; 95% CI, 0.29-0.77), but not among women who were overweight (HR = 1.16; 95% CI, 0.74-1.83) or normal weight (HR = 0.8; 95% CI, 0.47-1.35).

    Women obese at baseline who intentionally lost weight had a greater risk reduction than women who unintentionally lost weight (intentional, HR = 0.44; 95% CI, 0.25-0.78; unintentional, HR = 0.57; 95% CI, 0.25-1.3). When measured in pounds rather than a percentage, the association persisted among obese women who intentionally lost weight (HR = 0.52; 95% CI, 0.3-0.9).

    In a sensitivity analysis of weight loss and endometrial cancer subtypes, researchers observed a stronger association between intentional weight loss and risk for type I endometrial cancer compared with overall results (all women, HR = 0.48; 95% CI, 0.3-0.76; obese women, HR = 0.26; 95% CI, 0.12-0.57).

    This study shows that weight loss even later in life is beneficial, according to Jennifer A. Ligibel, MD, ASCO expert in cancer prevention and director of the Leonard P. Zakim Center for Integrative Therapies at Dana-Farber Cancer Institute, who was not involved in the study.

    “There have been more than a thousand studies linking obesity to an increased risk for endometrial and other cancers, but almost none that look at the relationship between weight loss and cancer risk,” Ligibel said in the press release. “This study tells us that weight loss, even later in life, is linked to a lower risk of endometrial cancer.”

    The researchers would like to further examine the role of weight loss in other populations, according to the release.

    “We’re interested to see whether weight loss plays a role in the prevention of other cancers that are linked to obesity, Luo said. “We already know that avoiding obesity is associated with many health benefits, but we do not know enough about the benefits of weight loss for adults who are already obese.” – by Melinda Stevens

    Disclosures: Luo reports no relevant financial disclosures. Please see the full study for a list of all other researchers’ relevant financial disclosures.

    Luo J, et al. J Clin Oncol. 2017;doi:10.1200/JCO.2016.70.5822.


  • February 09, 2017 9:44 AM | Deleted user

    For many years, cytology has been the established method used for cervical cancer screening. Commonly known as the Pap test, cytology and its regular use in yearly exams has been credited with significantly reducing the number of deaths from cervical cancer. Evidence now shows that sexually transmitted human papillomavirus (HPV) infection is almost always responsible for cases of cervical cancer with two HPV types responsible for 70% of all cases. Many members of the health care community are now calling for a shift in screening procedures to reflect our improved understanding of cervical cancer development. In a special issue of Preventive Medicine, experts look at the emerging evidence that HPV screening may be a better way than Pap tests for doctors to screen for cervical cancer. They also address the difficulty of implementing such a change in different parts of the world based on available resources or public health priorities.

    "Whether in conventional or automated forms, Pap cytology has been a core technology in medicine and public health; that is until it was firmly established that cervical cancer was the long-term consequence of persistent infection with a specific sexually transmitted infection. It has since become clear that testing for the causal agent, HPV, can bring substantial improvements and efficiency to cervical cancer screening," remarked Preventive Medicine Deputy Editor Gayle A. Shinder, PhD, Department of Oncology at McGill University. "The above transition in technologies serves at the backdrop for this special series of articles and commentaries."

    The issue presents in-depth coverage of the scientific evidence supporting the transition from cytology to HPV testing, along with reasons why policy around cervical cancer screening is so context specific. The contributors to this issue endorse that HPV testing offers a better way to screen for cervical cancer, but also acknowledge that changes to screening paradigms cannot be made in a vacuum, based only on scientific findings.

    As Guest Editor for the special issue, Mark Schiffman, MD, MPH, Senior Investigator in the Clinical Genetics Branch of the National Cancer Institute, NIH, Bethesda, MD, wrote, "HPV testing is coming and the role of cytology will be reduced; however, this collection of evidence summaries, guidelines, and editorials aims to illustrate the variety of ways the changeover will occur globally. More broadly, this special issue illustrates the importance and limits of epidemiology as the 'basic science of public health.' The conclusion is that given an established epidemiologic set of scientific facts and validated prevention tools, real-life concerns that vary by region will determine which public health strategies are used."

    Dr. Schiffman's straightforward editorial touches on the potentially controversial elements of HPV testing as a primary screening method for cervical cancer. "It turns out that detailed implementation of HPV primary screening to replace cytology reveals many choices reliant on value judgments and not risk assessment, particularly when resources are limited," said Dr. Schiffman. "Controversial areas include acceptable costs and effort, choices of safety and action thresholds, and the role of the clinician in the integration of test data vs apps and guidelines."

    This special issue highlights the evidence for supporting the switch from cytology to HPV testing, contrasted with regional responses. Two reviews address the efficacy and specificity of HPV testing, along with providing possible triage methods to help clinicians identify the highest risk patients. Another study uses HPV vaccine data to make the case for phasing out first-line cytology and replacing it with HPV testing.

    In addition to the studies, the special issue also features five commentaries focusing on how different approaches to health care and levels of available resources around the world are set to influence this change in screening protocols. They address how these changes would affect various parts of the world based on their existing health care systems, the values of those systems, and the available medical resources in different areas.

    The special issue is designed to help facilitate a meaningful conversation about evidence-based best practices for cervical cancer screening in many different parts of the world and to begin to look at the challenges associated with implementing such a shift. "I believe that, among experts, there is an emerging consensus that HPV testing is theoretically the optimal available primary screening testing, but that optimal implementation is far from settled," concluded Dr. Schiffman. "As different strategies are applied worldwide, the hope is that they will be translatable and represent different societal conclusions sharing a jointly-understood scientific base."

    Articles: Changes on the horizon for cervical cancer screening, Sandra D Isidean and Gayle A. Shinder, Preventive Medicine, published online 27 December 2016.

    Cervical cancer screening: Epidemiology as the necessary but not sufficient basis of public health practice, Mark Schiffman, Preventive Medicine, published 7 February 2017.

    Introduction of molecular HPV testing as the primary technology in cervical cancer screening: Acting on evidence to change the current Paradigm, Joseph Tota; James Bentley; Jennifer Blake; Francois Coutlee; Maire Duggan; Alex Ferenczy; Eduardo Franco; Michael Fung-Kee-Fung; Walter Gotlieb; Marie-Helene Mayrand; Meg McLachlin; Joan Murphy; Gina Ogilvie; and Sam Ratnam, Preventive Medicine, published 7 February 2017.

    Approaches for triaging women who test positive for human papillomavirus in cervical cancer screening, Joseph Tota; James Bentley; Jennifer Blake; Francois Coutlee; Maire Duggan; Alex Ferenczy; Eduardo Franco; Michael Fung-Kee-Fung; Walter Gotlieb; Marie-Helene Mayrand; Meg McLachlin; Joan Murphy; Gina Ogilvie; and Sam Ratnam, Preventive Medicine, published 7 February 2017.



  • February 09, 2017 8:29 AM | Deleted user

    TUESDAY, Feb. 7, 2017 (HealthDay News) -- Women can reduce their risk of cervical cancer through vaccination and screening, the U.S. Food and Drug Administration says.

    In 2016, an estimated 13,000 women in the United States were diagnosed with cervical cancer and more than 4,100 died from the disease, according to the U.S. National Cancer Institute.

    The FDA wants to make women aware of how to protect themselves from cervical cancer, which is caused by the human papillomavirus (HPV).

    An FDA-approved vaccine called Gardasil 9 protects against 9 HPV types and can prevent about 90 percent of cervical, vulvar, vaginal and anal cancer cancers, and also protects against genital warts. The vaccine is approved for use in females and males aged 9 to 26.

    Gardasil 9 is not a treatment for HPV disease or cervical cancer, noted Marion Gruber, director of the FDA's Office of Vaccines Research and Review.

    "Women, including those who have been vaccinated, should continue to get Pap tests because they are essential to detect cervical cancer and precancerous changes," she said in an FDA news release.

    A Pap test (or smear) and HPV test are two ways to spot cervical cancer. If abnormalities are detected on a Pap smear, follow-up testing may include another Pap smear, a HPV test and testing tissue via biopsy from the cervix.

    Cervical cancer often causes no pain, which means a woman can have cervical cancer and not know it. That makes testing for the disease that much more important. The earlier the cancer is detected, the easier it is to treat, the FDA said.

    More information

    The U.S. National Cancer Institute has more on cervical cancer.

    SOURCE: U.S. Food and Drug Administration, news release

    -- Robert Preidt

    Last Updated: Feb 8, 2017

    Copyright © 2017 HealthDay. All rights reserved.


  • February 09, 2017 8:28 AM | Deleted user

    Approximately 500 million people around the world are infected with the genital herpes virus known as herpes simplex virus 2 (HSV2). A vaccine that could bring an end to this global pandemic is needed desperately, yet no candidate vaccine has ever performed well in clinical trials. Now scientists in the Perelman School of Medicine at the University of Pennsylvania have shown that a new type of vaccine provides powerful protection in standard guinea pig and monkey models of HSV2 infection.
    The new "trivalent" vaccine induces antibodies against three different parts of the virus, including two components that normally help HSV2 evade immune attack.

    "It's a novel strategy, and it works beautifully," said senior investigator Harvey M. Friedman, MD, a professor of Infectious Diseases at Penn. "I know of no other HSV2 vaccine candidate with published results that are as promising as this study."

    The findings, reported today in PLOS Pathogens, are likely to lead to human clinical trials of the vaccine.

    The public health burden from HSV2 is enormous. In the United States alone, researchers estimate that approximately one in six people age 15 to 49 have HSV2 infection. In some parts of Africa, more than half the adult population is thought to be infected. Aside from the direct burden on adults, HSV2 can cause devastating and often lethal infections of infants born to infected mothers. HSV2 infection also greatly increases the likelihood of HIV transmission and thus accounts for much of the HIV public health burden as well.

    Candidate HSV2 vaccines developed in recent years have largely targeted gD2, a glycoprotein (a protein coated with sugar-like molecules) that is mounted on the virus's outer envelope and helps it break into host cells. However, vaccines targeting gD2 alone have not shown very robust protection in animal and human trials.
    Friedman and his team, therefore, designed their new vaccine to induce an immune response against not only gD2 but also two other viral glycoproteins, gC2 and gE2. The latter are known to block elements of the immune response, helping HSV2 to survive long-term in its hosts.

    "In essence, we're stimulating the immune system to attack the virus and at the same time preventing the virus from using some of the tools it has to thwart that immune attack," Friedman said.

    Working with the Tulane National Primate Center in Louisiana, Friedman and his group showed that the trivalent vaccine—given three times at monthly intervals—induced a strong immune response in macaque monkeys, whose immune system closely resembles the human version. The response included antibodies against gC2, gD2, and gE2 in both blood and vaginal secretions. In the lab dish, these antibodies potently neutralized HSV's ability to spread from cell to cell. The vaccine also induced a sharp rise in CD4 T-cells, whose job is to mobilize the antibody response and other immune elements against viral infections.

    The researchers also showed that the antibodies induced by the trivalent vaccine potently neutralized four isolates of HSV2 from sub-Saharan Africa, where infection prevalence is very high.

    Macaques do not usually develop genital lesions when infected with HSV2, but in this case, the unvaccinated monkeys showed signs of mild vaginal inflammation soon after exposure to the virus, whereas the vaccinated monkeys showed none.

    In a second set of experiments, guinea pigs, which normally develop a more severe genital infection when infected with HSV2, were almost completely protected from genital lesions by the vaccine. The scientists were still able to detect a small amount of viral DNA in the genital secretions of the animals, but only a tiny fraction of this viral DNA was capable of replicating in cells.

    "We are pleased to have demonstrated such a potent and durable immune response to the vaccine," said the study's lead author, Sita Awasthi, PhD, a research associate professor of Infectious Diseases at Penn. "If found effective in clinical trials, the vaccine will have a huge impact on reducing the overall prevalence of genital herpes infections and could reduce new HIV infections as well, especially in high-burden regions of sub-Saharan Africa."

    "If the vaccine behaves like this in people, it would limit lesions to appearing only about one day in 100, and the virus would be potentially contagious only about two in every 1,000 days," Friedman said.

    In principle, he added, that would virtually shut down HSV2's ability to spread in the population.

    Friedman and colleagues are now in discussions with pharmaceutical companies to move the vaccine, or an optimized version of it, into initial clinical trials.
    If the vaccine does emerge successfully from clinical trials, it would probably be given on a schedule of three inoculations, at 0, 1 and 6 months.

    Source:

    https://www.pennmedicine.org/news/news-releases/2017/january/new-genital-herpes-vaccine-candidate-provides-powerful-protection-in-preclinical-tests


  • February 09, 2017 8:26 AM | Deleted user

    Understanding how to utilize nonphysician providers can maximize the efficiency and profitability of your organization. This report is the most recent addition to MGMA’s Research & Analysis series, and includes the latest tips, guidelines, rules and regulations for utilizing nonphysician providers.

    Read report here.

  • February 06, 2017 9:10 AM | Deleted user


    Wednesday, May 17, 2017, 9-10am
    SPARK Student Session - PAs in OBGYN

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    This year, hear from practicing PAs and subject matter experts on surviving clinical rotations, preparing for PANCE, choosing a specialty and acing your interview and contract negotiation. Prepare yourself for life after graduation with sessions on financial advice, volunteering opportunities, global PA developments and professional advocacy.


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    APAOG Meet and Greet ~ no RSVP required

    Come meet the board and members of the Association of PAs in OBGYN (APAOG) to find out all about what APAOG has to offer! APAOG is a constituent organization of AAPA and focuses on PAs practicing in women's health in a variety of specialties including family medicine, internal medicine, GYN, OB, MFM, REI, pediatrics, geriatrics, GYN oncology, and many more! All are welcome!


    Thursday, May 18 2017 6-8 pm
    APAOG Banquet and Annual Meeting - RSVP today!

    Join APAOG in Las Vegas! APAOG is hosting a free event for APAOG members and non members to meet at AAPA in Las Vegas. Light horderves and drinks will be served.

    The event will feature award winners and provide an update to the group from the APAOG board.


    AAPA Conference Sessions Related to Women's Health

    2017's AAPA Conference will feature a number of women's health related presentations and topics. A few APAOG members have also been accepted to present their information at the national conference. 

    • Female Pelvic and Vulvar Pain (Aleece Fosnight, APAOG President)
    • Basic Obstetrics Review (Melinda Blazar, APAOG Director at Large)
    • Preconception Counseling (Heather Adams, APAOG Publications Committee Chair)
    • Genital Ulcer STIs
    • Female Urology Update
    • Zika and Pregnancy
    • Women's Health Issues
    • Breast Cancer Patient Options
    • HPV Vaccination
    • Contraception Update
    • Menopause Management
    • Drug and Alcohol and Sexual Assault

    For more information and to register for the AAPA conference, click here. 


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