An extremely rare case of superfetation in a surrogate mother leading to legal custody issues

Jessica Allen with her family, Malachi is on the left side of screen. 

A California woman got pregnant when she was already pregnant under a surrogacy contract that resulted in ‘Twin Pregnancy’ with two different set of parents.

Jessica Allen, 31- year old agreed to be a surrogate for a Chinese couple, through a surrogacy agency in Southern California.  Surrogacy is legal in some states in US, including California, but it is illegal in China. 

In April 2016, Jessica underwent a single embryo transfer with the Chinese couple’s embryo after a successful IVF.

At six weeks of pregnancy, she was told that she is carrying twins. She was a bit scared, but the Chinese couple was thrilled. She and her partner thought that the embryo must have split into two after implantation. Her $30,000 payment, including expenses —was increased by $5,000 for the second child.

She denies that throughout her prenatal period, none of the staff and physician at the hospital told her that the babies were in separate sacs.

In December 2016, she gave births to both babies by C-section at a hospital in Riverside, California. As per her legal contract with the surrogate agency, she was not allowed to see the babies. She did briefly see a cell-phone picture and did notice that they looked different.

On January 2017, she received a message from the Chinese couple that the twins look different, along with a picture.

“They are not the same, right?” the message read, according to the New York Post. “Have you thought about why they are different?”

A DNA test soon followed and revealed that one of the twin was indeed Allen and Jasper’s biological son. Despite using condoms, she has become pregnant with her own son, after being already pregnant with the Chinese couple baby.

Courtesy: Victoria Roberts

What followed was a lengthy, expensive legal battle, but she finally won the case and got her son back in February 2017. She and Jasper renamed their newest family member Malachi, and he is now 10 months old.

Superfetation is common among mammals, but in order for superfetation to occur in humans, three seemingly impossible things need to happen at the same time: ovulation must take place during an ongoing pregnancy, sperms must somehow penetrate the blocked cervical canal with thick mucus plug and travel all the way into the fallopian tube and finally, the embryo should  successfully implant itself in an already-occupied uterus. The odds of all three of them happening together are very rare, making it an extremely rare occurrence.

A 2008 paper in the European Journal of Obstetrics and Gynaecology, mention that this phenomenon is so rare that only 10 documented cases are mentioned in literature so far.

A review of literature showed that superfetation is mentioned in some case of ARTs.

In the meantime, this case should be a "reason for pause and thoughtfulness" among physicians and surrogacy organization to check for superfetation in unexpected twins in a surrogate mother said Dr. Saima Aftab, medical director of the Fetal Care Center at Nicklaus Children's Hospital, who was not involved in Allen's case.

News from ASRM 2017: Uterine Artery Embolization is preferable over focused ultrasound for Uterine Fibroids

Women undergoing MR-guided focused ultrasound (MRgFUS) for symptomatic fibroids are twice as likely to undergo a second procedure as compared to women treated by Uterine Artery Embolization(UAE) reports results of study presented at ASRM 2017.

The study is also published in Fertility and Sterility September supplement.

The FIRSTT study (NCT00995878) enrolled 83 premenopausal women with symptomatic uterine fibroids and have completed their families, with an aim to compare the safety and effectiveness of two standard fibroid treatments approved by FDA: MRI guided ultrasound surgery (MRgFUS) and uterine artery embolization (UAE).

It also focused on better understanding of fibroid symptoms that bothered the women most, and how it affects the quality of life.

The study randomized the women to one of the treatment arms as well as observed the outcome for women who refused randomization but met the study criteria.

The average age of the study participant was 45 years with nearly 2/3 being obese (BMI > 25 kg/m²) and Caucasian. Nearly twice the number of women who underwent MRgFUS, required a second procedure at the end of two years as compared to women undergoing embolization (HR 2.8, 95% CI: 1.1, 7.8).

A significantly more number of women attained menopause in embolization arm (9%) vs MRgFUS(0%). Disease specific quality of life was also much better in women who had embolization, perhaps early menopause alleviated the symptoms of fibroid.

The authors concluded that, “Women undergoing MRgFUS were more likely to have a second procedure for fibroids compared with those undergoing UAE.”

More News from ASRM 2017

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In case you missed it: Here are the top 5 posts this month

Finally, an oral drug found effective in treatment of Uterine Fibroids following successful phase-3 trial

Relugolix successfully reduced heavy menstrual blood loss among Japanese women in a Multicenter, Randomized, Double-Blind, Parallel-Group, Phase 3 Study to Evaluate the Efficacy and Safety of Oral relugolix 40 mg as compared with injectable leuprolide  in the Treatment of Uterine Fibroids.

Relugolix is an oral, once-daily, small molecule GnRH receptor antagonist that has been evaluated in almost 1,600 study participants in Phase 1, Phase 2 and Phase 3 clinical trials. In these trials, it has shown to suppress estrogen and progesterone levels in women and testosterone levels in men. (It is also being evaluated in advanced prostate cancer via ongoing phase-3 HERO study).

https://obgynupdated.blogspot.com/2017/10/finally-oral-drug-found-effective-in.html

Now ‘Switch’ the way you suture: Reinventing suturing technique with the new device

Mellon Medical, a Dutch MedTech developer has reinvented suturing by developing a device which enables the surgeon to suture with only one hand, the other hand remaining free to use as needed. The product is named Switch®, a single use precision instrument that allows the surgeon to suture tubular structures or skin with twice the speed of conventional suturing.

https://obgynupdated.blogspot.com/2017/10/now-switch-way-you-suture-reinventing.html

ACOG updates its guidelines on LARC

The American College of Obstetricians and Gynecologists (ACOG) today updated its guidelines on Long-Acting Reversible Contraception(LARC): Implants and Intrauterine Devices. These updated guidelines were published online October 24 in Obstetrics & Gynecology and replaces the old practice bulletin published in July 2011.

https://obgynupdated.blogspot.com/2017/10/acog-updates-its-guidelines-on-larc.html

ACOG updates guidance on postpartum hemorrhage- calls for standard, coordinated, protocol based intervention

The American College of Obstetricians and Gynecologists (ACOG) recently released expanded guidelines for management of postpartum hemorrhage (PPH)—the leading cause of maternal mortality worldwide.

PPH is defined as total blood loss of 1000 ml or more along with signs or symptoms of hypovolemia within 24 hours after the labor, but can occur up to 12 weeks postpartum. Although Maternal Mortality Rates(MMR) have decreased worldwide in last 4 decades, it still accounts for 10% of all pregnancy related mortality.

https://obgynupdated.blogspot.com/2017/10/acog-updates-guidance-on-postpartum.html

Endometriosis fertility index can accurately predict a women’s chances of conception after laparoscopy

The Endometriosis fertility index can accurately predict the possibility of non-ART conception or the need of ART for achieving pregnancy after surgical resection of moderate-severe (Stage III–IV) endometriosis reports the results of study published in Human Reproduction. The study confirmed that adnexal function is deciding factor in evaluation of fertility prognosis after the surgery.

There is no evidence based guidelines about post-surgery fertility management of women who have undergone surgery for severe endometriosis. Physicians differ in their approach about the length of conservative treatment and that sometimes add years and causes unnecessary delays.

https://obgynupdated.blogspot.com/2017/10/endometriosis-fertility-index-can.html

News from ASRM 2017: Subfertility May be Harbinger of Disease Later in Life

The American Society for Reproductive Medicine (ASRM) 2017 Scientific Congress kicked of today morning by an opening keynote address from President Richard J. Paulson, M.D. at San Antonio, TX. The agenda ranges from the latest molecular and genetic technologies to advocacy for the patients with a focus on access to care.

Researchers from the University of Pennsylvania today presented research showing that women seeking infertility treatment have a shorter life span as compared to their parous counterparts. They have a higher risk of dying from endocrine related disorders such as diabetes and breast cancer than other women.

This retrospective cohort study examined  records of nearly 80,000 women and followed them for nearly 13 years, with an aim to determine the association of a history of infertility with all-cause mortality.

These women were enrolled in the Prostate Lung, Colorectal, and Ovarian (PLCO) Cancer screening trial from 1992-2001. Nearly 76,000 women had data on infertility.

It was seen that 14.5% (n=11,006) of women did not have any children. The average age at death for each cohort was similar (74 years) but women in infertile cohort had 10% greater chances of dying as compared to fertile cohort.  (HR1.10, 95%CI 1.03, 1.17, p=0.005).

Infertile women also face 69% increased chances of dying due to diabetes, 49% more chances of death due to breast cancer.

Ovarian cancer and Endometrial cancer did not increase the risk of death, although infertile women had marginally high risk of ovarian cancer.

This large retrospective study does show an association between endocrine related diseases and infertility but does not prove causation.It stresses the need of prospective studies and more research  in this area.

But, infertility can present an early opportunity to screen these women for chronic diseases and interventions.

Richard J. Paulson, MD, President of ASRM said in a News Release, “This is an intriguing and potentially very important study. More work is clearly needed to help us understand if, in some patients, there might be an underlying medical problem that presents as infertility during the reproductive years and then contributes to endocrine-related disease later in life. We also need to investigate if infertility treatments can counter some of this increased risk.”

The study is also published in Fertility and Sterility September supplement.

North American Menopause Society (NAMS) video series about important midlife health topics: Contraception in Perimenopause

The North American Menopause Society (NAMS) has started comprehensive video series for clinicians about important midlife health topics. All the interviews in the series are hosted by NAMS Board of Trustees Member and President Dr. Marla Shapiro, a Canadian physician, who led this exciting initiative.

In this latest video, Contraception in Perimenopause, Dr. Shapiro interviews Dr. Andrew Kaunitz, University of Florida Research Foundation Professor and Associate Chairman in the Department of Obstetrics and Gynecology at the University of Florida College of Medicine at Jacksonville. Dr Kaunitz discusses IUDs and oral contraceptives and the appropriate type for your patients.

Almost always a treatment option exists for women with urinary incontinence

Almost one in five women in general population, and nearly 3 out of 4 women living in nursing homes suffer from urinary incontinence, but only 1 in 4 women seek treatment for this issue which has profound effect on quality of life.

Wide range of therapies are available and almost there is some treatment option for all women suffering from this issue says a review of therapies published online in JAMA.

Stress urinary incontinence is the commonest problem in women and often caused by weak pelvic muscles because of physical changes from pregnancy, childbirth, and menopause. 

Urge incontinence does not have a specific cause, it is often termed as ‘overactive bladder’ and the leakage follows a strong urge to urinated. It is associated with other medical disorders like diabetes, Alzheimer’s disease, Parkinson’s disease, multiple sclerosis, or stroke.

The two types of incontinence sometimes coexist.

Women are mostly shy of discussing this problem with the healthcare provider and continue coping with the problem instead of seeking treatment and cure.

The physician should initiate the treatment with understanding the women’s goal for seeking the consultation, how it’s affecting her quality of life, and any previous treatment. A concomitant physical examination should follow to rule out pelvic organ prolapse, cancer or neurological disease.

Urinary Tract Infection and hematuria should also be ruled out.

The therapy should begin with advising about pelvic muscle exercise and life style modifications. If the patient is obese she should be advised to reduce weight, adequate hydration, limiting the caffeine intake and timed voiding at regular intervals to reduce the urgency of episodes.

For stress urinary incontinence, options include estrogen vaginal cream, transurethral and periurethral injection techniques bulking procedures. Common agents used for bulking are autologous fat, glutaraldehyde cross-linked bovine collagen, calcium hydroxylapatite, pyrolytic carbon-coated beads, polydimethylsiloxane, and ethylene vinyl alcohol copolymer.

Botox and stem cell therapy may be useful in some cases.

Urethral inserts are also in use, along with pessary or stiff vaginal ring to support prolapsed bladder or vagina.

Other surgical options include bladder neck suspension, mid-urethral sling, and Transobturator vaginal tape (TVT-O) is widely used for stress incontinence in women.

For treating the urge incontinence, medications are prescribed to relax the bladder and that includes Antimuscarinics, Tricyclic antidepressants and Beta-3 agonists.

Botox (onabotulinumtoxinA) and electric nerve stimulation are the other options.

Non-ablative vaginal Er:YAG laser (VEL) has been reported to improve SUI in small pilot studies. Large randomized studies are needed to compare its efficacy with other treatments and evaluate the duration of therapeutic effects.

Urinary incontinence is a common problem of aging, and physicians should initiate the conversation about it, as women are too embarrassed to talk about it. Treatment should be initiated by life style modification, medicines and surgery if conservative measures fails.

Abstract

‘All or none’ does not apply to walking, anything is better than nothing

Walking below recommended levels is also associated with lower all-cause mortality, even if the recommended goal is not met says the results of large prospective cohort study published online in in the American Journal of Preventive Medicine.

The current public health guidelines recommend >150 minutes of moderate-intensity or 75 minutes of vigorous-intensity physical activity per week; a goal met by only 50% of US adults.

Walking is the most common form of moderate- or vigorous-intensity physical activity (MVPA), and is known to be associated with lower incidence of cardiovascular disease, type 2 diabetes, and breast and colon cancers. But, its association with all-cause mortality has not been examined so far.

The study looked at data from 62,178 men (mean age 70.7 years) and 77,077 women (mean age 68.9 years), who were followed up for a period of 13 years from 1999–2012. The researchers studied the effect of moderate- or vigorous-intensity physical activity (MVPA) on all-cause mortality.

During the study period, 24,688 men and 18,933 women died.

The mean age of men was 71 years and 69 years for women, about 5.8% of men and 6.6% of women reported no MVPA when the study started. These ‘inactive’ individuals were 26% (HR=1.26) likely to die prematurely as compared to subjects who were active but not to the recommended level (only for <2 hours/week).

Meeting the minimum recommendation of walking one or two times per week was associated with 20% lower risk of mortality (HR=.77) which was at par with any MVPA.

Walking that extra mile than what was recommended did not add any extra benefit and the benefits were equivalent to meeting the requirements.

Walking one or two times per week as per the minimum recommendation also reduced the CVD and cancer mortality by 20% and 9% respectively.

All these results were adjusted by sex, baseline age, BMI, prevalent disease status, and leisure-time sitting.

Alpa Patel, PhD, the lead author and researcher at the American Cancer Society opines, “walking has been described as the “perfect exercise” because it is a simple action that is free, convenient, does not require any special equipment or training, and can be done at any age.”

The walking intensity in this study was not ‘power walk’ or ‘strolling in the garden’ but average walking that may make you slight breathless and you cover about a mile in 20 minutes. This constitutes moderate intensity activity.

In absolute figures not corrected for the confounders, it was seen that there was 4293 per 100,000 deaths for inactive participants vs  2851 for walking less than the recommended amount. That is 1442 fewer deaths per 100,000 than inactive participants.

And the number of deaths were further reduced to 2088 per 100,000 for those who met the walking guidelines.

A lot of people are now a day do a walking meeting instead of sitting meeting in the office. 

The authors conclude, “This study shows that engaging in walking is associated with increased longevity and has the potential to improve the public’s health significantly.”

Media: wisegeek. 

Abstract

Full Text

Laparoscopic hysterectomies for leiomyomas on decline after FDA communication discouraging the use of power morcellator.

The US FDA communication discouraging the use of power morcellator was issued on April 17, 2014 and have resulted in 4% decline in rate of laparoscopic hysterectomies, says the results of cross sectional study published in forthcoming issue of Journal Obstetrics and Gynecology.

FDA issued the statement because of advocacy and anti-morcellator campaign by Amy Reed, MD, PhD, an anesthesiologist who died because of uterine leiomyosarcoma on Wednesday, May 24 at age of 44.

She underwent a laparoscopic hysterectomy in October 2013 for fibroid, but her undiagnosed, occult uterine leiomyosarcoma was upstaged because of dispersion in abdominal cavity by the use of power morcellator. Since then, the power morcellator is the focal point of a four-year debate that has divided the surgical field.

The researchers examined data from 4 states inpatient and ambulatory surgery database for year 2013 to 2014, and compared the rates of laparoscopic hysterectomy 15 months before and 9 months after the FDA announcement.

Women with a diagnosis of leiomyomas who underwent hysterectomy or myomectomy were included in the analysis.

Total 77,637 hysterectomies and myomectomies were performed during that period. The rate of laparoscopic hysterectomies declined from 62% of all hysterectomies before to 58% afterward with an accompanying increase in abdominal hysterectomies of 8% from 71% to 79%.

The rate of myomectomies in women with leiomyoma remained the same as compared to hysterectomies.

On April 7, 2016 The U.S. Food and Drug Administration today permitted the marketing of the first tissue containment system for use with certain laparoscopic power morcellators to isolate uterine tissue that is not suspected to contain cancer.

"PneumoLiner is intended to contain morcellated tissue in the very limited patient population for whom power morcellation may be an appropriate therapeutic option - and only if patients have been appropriately informed of the risks," FDA deputy director William Maisel said in a news release.

"This new device does not change our position on the risks associated with power morcellation. We are continuing to warn against the use of power morcellators for the vast majority of women undergoing removal of the uterus or uterine fibroids," Dr Maisel added.

Based on an analysis of currently available data, the FDA has estimated that approximately 1 in 350 women who undergo hysterectomy or myomectomy for fibroids is found to have an unsuspected uterine sarcoma. 

ACOG statement on power morcellator 

Abstract

ACOG updates its guidelines on LARC

Courtesy:http://northlandfamilyplanning.com

The American College of Obstetricians and Gynecologists (ACOG) today updated its guidelines on Long-Acting Reversible Contraception(LARC): Implants and Intrauterine Devices. These updated guidelines were published online October 24 in Obstetrics & Gynecology and replaces the old practice bulletin published in July 2011.

The recent recommendations were jointly developed by Committee on Practice Bulletins—Gynecology and the Long-Acting Reversible Contraception Work Group in collaboration with Eve Espey, MD, MPH; and Lisa Hofler, MD, MPH, MBA.

Two types of LARC are currently available in US: 1) intrauterine devices (IUDs) and 2) the etonogestrel single-rod contraceptive implant. The IUDs available are copper containing IUD and 4 levonorgestrel-releasing intrauterine devices (LNG-IUDs).

The guidelines seek to increase LARC acceptance among patients, at the same time assuring them on the safety and efficacy of the five different intrauterine devices (IUDs) and implant currently available for use.

ACOG-LARC initiative 

DR. ESPEY, author of the Practice Bulletin and Associate Professor of Obstetrics and Gynecology and Director, Section of Reproductive Health, University of New Mexico, Albuquerque, N.M. said in a news release “We have many more contraception options for women of all ages and life stages, especially in the realm of LARC. Many patients may not know they’re a good fit for an IUD or implant, or that IUDs now come in varying sizes and hormone levels.  Counseling will help women to align their contraceptive choice with other health care priorities, whether that’s preventing pregnancy during adolescence or making a plan for contraceptive use following pregnancy.”

Summary of Recommendations based on levels of evidence:

Level A recommendations:

Insertion of IUD immediately after first trimester uterine aspiration is safe and effective option and should be offered routinely to patients.

Similarly, patient can be safely offered contraceptive implant on the same day as first-trimester or second-trimester induced or spontaneous abortion.

Routine antibiotic prophylaxis is not advised before IUD insertion.

Level B recommendations:

IUDs and contraceptive implants are not contraindicated in nulliparous women and adolescents, and carry the same safety and efficacy as in multiparous women. US MEC Category 2, (advantages outweigh the risks).

IUDs and contraceptive implants can be offered anytime during the menstrual cycle as long as pregnancy is ruled out.

IUD insertion is safe immediately after medically induced first trimester abortion.

Immediate postpartum insertion (within 10 minutes of delivery of placenta in vaginal and cesarean birth) is a safe and effective means of post-partum contraception.

Women with history of ectopic pregnancy can safely be offered IUD insertion.

Those women who have not been screened for Sexually Transmitted Infections (STI) or who are at high risk of contracting such infections can be offered screening and IUD insertion at the same visit, while awaiting the screening test results. If the tests are positive, the patient can receive the treatment without removing the IUD.

Level C recommendations

LARCs are suitable, safe and effective, have few contraindications and should be routinely recommended to most women.

The copper containing IUD is the preferred choice for emergency contraception in women who are eligible for IUD insertion.

All patients receiving LARC should undergo adequate counselling and reassurance about irregular bleeding pattern and be assured that it is harmless.

Endometrial biopsy, endocervical sampling, colposcopy, and cervical ablation or excision may all be performed with an IUD in place.

In case of accidental pregnancy with the device in place, it can be safely removed if the strings are visible.

If a woman attains menopause while IUD or implant in place, it is not required to be removed before its expiration date.

Actinomyces detected on cell cytology is an incidental finding, and does not warrant the removal of IUD or antimicrobial treatment in absence of symptoms.

A revolutionary personal fertility sensor that sends you a message- “You are about to ovulate”

A Medical Device Premier Innovation summit was held recently at Minneapolis, MN by MedTech Strategist in association with The Medical Alley Association. About more than 40 start-up and emerging medical companies presented their technologies and devices at the summit.

Among the display was “Priya”, a vaginal temperature sensor that is being developed to wirelessly capture your continuous core temperature to detect the subtle changes that occur PRIOR to ovulation. 

Priya is developed by Prima-Temp, a medical device and technology  company situated in Boulder, CO, USA.

Priya is currently undergoing clinical trials, the intravaginal ring directly sends the temperature data to Priya App on the patients’ smartphone. When the subtle fall in temperature before ovulation is detected, the smartphone alerts the women.

Priya is an intravaginal ring made from medical-grade silicone form-factor and have a wireless continuous temperature sensor inserted within it. It’s dimensions and flexibility are similar to Estring®. Women are using these contraceptive vaginal rings or estrogen containing rings since may years. Prima-Temp just replaced the medications with a very sensitive sensor that measures core body temperature. Currently an algorithm is being tested to detect the DIP in temperature prior to ovulation.

This device has no extra monitor, urine strips or other extra parts that needs to be attached or monitored. The patient only needs to pair the ring with the app on the smartphone and insert the ring in the vagina.

Unlike the Basal Body Temperature (BBT), Priya monitors the internal core temperature continuously, which has been shown to more precise than oral or skin temperature. Based on this continuous core monitoring, the algorithms developed for Priya have been shown to achieve a 99% sensitivity for detection of ovulation, with a 99% percent accuracy in clinical trials.

Women’s body shows a striking diurnal variation and exhibit a pattern that is has been established as highly reliable marker for circadian rhythm. This pattern shows a distinct dip in body temperature 48- hours period prior to ovulation which is detected by the continuous monitoring by the ring sensors.

Now ‘Switch’ the way you suture: Reinventing suturing technique with the new device

Mellon Medical, a Dutch MedTech developer has reinvented suturing by developing a device which enables the surgeon to suture with only one hand, the other hand remaining free to use as needed. The product is named Switch®, a single use precision instrument that allows the surgeon to suture tubular structures or skin with twice the speed of conventional suturing.

The company recently secured € 6 million, to advance its ground breaking patented technology on the path to completion of CE certification in 2019 and market launch (Netherlands and Germany) in late 2019/early 2020 according to a press release.

The annual worldwide sutures and suturing devices market size is expected to reach at $3 billon by 2020.

Although the market introduction is focused on vascular surgery, it has its application in suturing all tubular and layered structures, giving access to multiple disciplines and indications. In gynecology, it can be used fallopian tube reanastomosis, cesareans and hysterectomies.

Single handed Switch® technology allows for high precision suturing of tubular (e.g. arteries) and layered structures (e.g. skin). The technique requires just the use of thumb and index finger to apply a suture as oppose to multiple orchestrated movements of both hands in classical suturing.

In this method, the surgeons are no longer required to transfer the needle from one hand to other as the needle remains secured in one of the two jaws of the device. There are two double action buttons and a single pinch of thumb transfers the needle from one hand to other.

It can easily be maneuvered because of its ergonomic design like a pencil, that has a 30° jaw-angle, that allows the surgeon to suture in all possible radial direction. The device is for single patient use, saving the cost of sterilization.

The combination of suture and needle can be changed according to surgeon’s preference. At present it is available in 8 cm long jaws, but soon 11 cm long jaws model will be there for suturing procedures in deep cavities.

Beside open surgery, the technology can also be applied to  a laparoscopic and robotic setting. The full product portfolio will include devices with various geometries, needles and sutures. Also, will be added a microsurgical model, laparoscopic and robotic variant to complete the armamentarium. 

The technology is expected to save time and reduce many complications. It is estimated that on an average 30% of surgical time is spent on suturing. Mellon has received several international innovation awards for this new invention, including one from the vascular surgeon community during last years’ Charing Cross International Symposium for Vascular Surgery in London.

Here is  the video, to fully understand the scope of suturing with Switch. 

Mellon Medical 3D Animation Switch from Mellon Medical B.V. on Vimeo.

Media courtesy: Mellon Medical 

Consuming the right amount of Calcium is key to prevent postmenopausal osteoporosis: EMAS guidelines

Courtesy: Washington post 

Intake of right amount of Calcium, preferably from dietary source is the key to manage bone health in postmenopausal women and anything in excessive may not help, and can be harmful, says the new European Menopause and Andropause Society (EMAS) clinical guidelines published in forthcoming issue of Maturitas.

Postmenopausal osteoporosis is rife throughout the world and despite recommendations about diet and lifestyle changes from societies and governmental bodies, many issues remain unresolved. Calcium is drug which is often consumed as either single supplement or in combination with Vitamin D3 and self-dosing is very common.

Different societies have recommended different doses ranging from 700 and 1200 mg/daily and uncertainties prevail about the most appropriate dose.

Excessive intake of calcium beyond 2000mg/day is linked to increases risk cardiovascular events, dementia, urolithiasis and even fractures, but the issue remains unresolved.

To develop the current EMAS guidelines the authors looked at systematic reviews, meta-analyses, and randomized controlled trials from 2007 till present.

The key recommendations by EMAS are:

The guidelines reiterate the role of adequate intake of calcium in preventing postmenopausal osteoporosis and fracture risk.

The recommended calcium intake should be between 700 and 1200 mg per day after menopause.

Diet should be the preferred method for sourcing the daily requirements, as the intake is uniformly distributed throughout day and avoids the calcium peaks in blood.

Higher than recommended amount is not useful, on the contrary it may do possible harm.

If women are not able to take supplements and the diet also does not supply the recommended amount of calcium, they should have regular physical exercise and take Vitamin D to maintain healthy bones.

The EMAS recommendation of 700 to 1200 mg per day differ from US guidelines in terms of daily dosage. The National Osteoporosis Foundation (NOF) and the American Society for Preventive Cardiology (ASPC) the US Institute of Medicine (IOM) Food and Nutrition Board, and the North American Menopause Society(NAMS) recommends 1200 mg of elemental calcium per day.

The National Institutes of Health (NIH) recommended 1500 mg of elemental calcium per day.

But, the study authors opined that the 300-mg difference between European and US guidelines does not matter much as the real problem starts if the daily intake exceeds 2000 mg or more.

The EMAS recommendations does not apply to women receiving antiosteoporotic drugs, which require concomitant supplementation with calcium and vitamin D. 

Abstract

Does all ovarian cancer originate in fallopian tube? Increasing evidence suggests so!

John Hopkins Medicine

Most-and possibly all ovarian cancer originates not in ovaries, but instead in the distal end of fallopian tubes attached to them, reports the findings of multi-center ovarian cancer genetics study published October 17, 2017 in Journal Nature Communications.

Douglas A. Levine, MD, director of the Division of Gynecologic Oncology at Perlmutter and professor of Obstetrics and Gynecology at NYU School of Medicine said in a news release, "Based on a better understanding of its origins, our study suggests new strategies for the prevention and early detection of ovarian cancer."

Serous tubal intra-epithelial carcinoma (STIC) are identified as precursors in ~50% cases of advanced high-grade serous carcinomas (HGSCs) of the pelvis. STIC have helped us a lot in understanding the origin of ovarian malignancies. It was originally diagnosed in fimbrial part fallopian tube when researchers examined the serial sections of this area in tube samples in cases of women who underwent prophylactic bilateral salpingo-oophorectomy(BSO).

This discovery led researchers to identify many cases of presumed ovarian cancer to be of tubal origin because of presence of a STIC.

The researchers in this study identified a total of 96 bio specimens’ samples, with or without STIC. 

The median age of the women was 59 years, with majority being Caucasians, with nearly 50% of women in FIGO stage IIIC and all women had HGSCs. Presence or absence of STIC did not change the clinical features or median survival.

In depth a morphologic, immunohistochemical, and molecular analysis of the samples failed to identify any difference in genetic profile of cells from HGSCs vs those from STIC in fallopian tube.

"We found no differences in the 20,000 genes that we can identify," says Levine. "This leads us to believe that that these ovarian cancers all originate in the fallopian tubes."

In fact, HGSCs had molecular profiles more similar to normal fallopian tube epithelium than to ovarian surface epithelium or peritoneum.

This study findings have several implications for early diagnosis of ovarian malignancy. If biomarkers can be identified on these tubal cells, then one day we may be able to diagnose ovarian malignancy by blood test. Since the tube is connected to the uterus, direct tissue sampling can also be carried out in future.

If the study finding is confirmed, then only removing the tubes may reduce the women’s risk of ovarian malignancy in patients with BRCA1 and 2 mutations. In fact, the NYU Langone Health center is  currently participating in a study Women Choosing Surgical Prevention or WISP trial, which is comparing the quality of life in women who have undergo only  salpingectomy as compared to salpingo-oophorectomy.

The researchers believe that it may take years before the study findings are confirmed and translate into actual clinical practice. But, at this stage the study holds a lot of meaning for gynecological oncologists and the evidence is sufficient to support incidental salpingectomy in average-risk women.

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Esaote releases MyLab9 Ultrasound Systems, setting new standards in image clarity and performance

Esaote, the Italian ultrasound manufacturer, today unveiled its brand-new flagship MyLab9 ultrasound system at JFR 2017 (Journées Françaises de la Radiologie - French Imaging Congress) in Paris.

It is designed to provide services at hospitals, clinics and private offices as it can be easily carried from one room to other because of easy to unplug and quick boot-up and stand-by mode.   

It is uniquely designed incorporating non-composite single crystal probe technology for generating images that have a stunning display quality, are clear, have better color contrast, thereby, assisting physicians in wide range of diagnostic procedure.

Its ultra-ergonomics design offers a floating keyboard tablet-like touchscreen and full HD wide format screen. The system hardware has a solid-state hard disk (SSD), latest Intel® Core™ i7 processor, and Windows® 10 that offers unparalleled data security and ease of processing.

Designed according to needs of busy radiology practitioner it’s easyMode, inbuilt software offers ‘one touch’ image optimization technology through intelligent real-time algorithm that adjusts to the illumination of the room. This results in superior image quality along with reducing the use of number of controls by the operator. This increases productivity at the same time reducing the musculoskeletal fatigues experienced often by ultrasound operators.

Massimo Rosa, Esaote Chief Global Marketing Officer said in a news release “Today economic constraints, and the increase in average life expectancy, are opposing forces. The MyLabTM9 eXP provides advanced diagnostic capabilities and clinical efficacy to respond effectively to the most demanding healthcare needs expanding the access to innovative technologies for more customers.”

MyLab™9, Uncompromised Ease-of-Use