Annual Resident Research Day 2012

Lani Burkman, PhD
Associate Professor, Emerita, Gynecology and Obstetrics, and Urology, University at Buffalo
Founder and CTO LifeCell Dx, e-fertility diagnostics, Buffalo, New York

Sarah Crimmins, DO
Mentor: Stephanie E. Mann, MD

Group Beta Streptococcus (GBS) causes early onset neonatal sepsis. The only effective strategy for reducing the incidence of neonatal GBS infection is the use of intrapartum antibiotic prophylaxis. Our goal is to determine if patients who are delivering at WCHOB have been screened and treated for GBS as recommended by the CDC guidelines.

We performed a prospective study of all births at WCHOB (March 2011-March 2012). Outcomes that were measured include GBS prevalence, percentage of patients with a penicillin allergy, and frequency of sensitivity testing among all penicillin allergic patients. Chi square was used to determine significant relationships between GBS status and ethnicity. After January 2012, all GBS positive cultures from WCHOB were tested for antibiotic sensitivity to penicillin, vancomycin, erythromycin, and clindamycin. Chi square was used. P < 0.05 was significant.

1699 cultures were collected. Carrier prevalence was 25.8%. There were no differences in prevalence based on race or gestational age at delivery. Penicillin allergy was documented in 13.2% of thepopulation. 52 patients with a positive GBS culture were penicillin allergic. Of these 52 patients, 3 had screening for antibiotic resistance. This finding prompted the initiation of reflex antibiotic sensitivities by the laboratory. We found that 42.3% of GBS cultures were resistant to clindamycin, 55.4% were resistant to erythromycin, and 41% were resistant to both. There was 100% sensitivity to vancomycin.

Adherence to GBS screening guidelines is less than expected. In view of the higher than anticipated rates of GBS resistance to clindamycin and erythromycin, susceptibility testing is necessary prior to use of these antibiotics. When delivery is imminent, vancomycin is the optimal antibiotic for prophylaxis in penicillin allergic GBS positive women. With high resistance rates, improvements are necessary to ensure that antibiotic susceptibility screening is requested for penicillin allergic patients.

Alexander Eswar, MD
Mentor: Pankaj Singhal, MD

To estimate the impact of patient’s age on surgical outcomes in patients undergoing robotic hysterectomy.

A retrospective cohort data analysis of a consecutive series of patients undergoing gynecologic robotic surgery. Patient’s age was abstracted from the medical charts of all patients undergoing robotic hysterectomy. Data on perioperative variables was collected.

293 patients underwent robotic surgery for Gynecologic disease. 274 patients who were under age 70 were compared with 19 patients who were over age 70. When comparing patients under age 70 with patients over age 70, the mean age was 47.6 and 76.4 (P<0.05), mean BMI was 33.9 and 27.6 kg/m2 (P<0.05), mean procedure time was 179 and 219 mins (P<0.05), mean console time 122 and 164 mins (P<0.05), mean EBL was 75.7 and 44.7 ml (P<0.05), Hb drop 1.6 and 1.3 (P=0.29), uterine weight was 206 and 94.9 gms (P=0.98), and length of stay was 1.49 and 1.25 days(P=0.08). The patients over age 70 had a statistically significant lower mean BMI, higher blood loss, longer procedure time, and console time. No statistically significant difference was noted between the 2 groups and Hb drop, LOS, or complications. There were no operative deaths. Morbidity occurred in 11 patients (3%), and were all in the under 70 age group.

Advanced age does not appear to be associated with an increased risk of morbidity in patients undergoing robotic hysterectomy.

Bethany L. Hart, DO
Mentors: Dennis M. Mauricio, MD & Stephanie E. Mann, MD

Trans-abdominal ultrasound is routinely used to diagnose retained products of conception and guide curettage in patients with acute post-partum hemorrhage; however, no studies have evaluated the utility or efficacy of this modality compared to blind curettage. The purpose of this study was to evaluate the use of trans-abdominal ultrasound in the diagnosis and treatment of retained products of conception. We hypothesized that ultrasound guided curettage would have better diagnostic prediction, efficiency and fewer complications than blind curettage.

A single center retrospective chart review from January 1, 2000 to June 30, 2011 was performed for all women delivering between 24-41 weeks gestation who underwent curettage for primary post-partum hemorrhage. Data collected included: maternal age, gravidity/parity, gestational age, type of curettage performed, pre-op and post-op hemoglobin, blood transfusions, complications (infection, uterine perforations, need for repeat procedures or hysterectomy), operating room time, length of hospital stay and curettage pathology reports. Data was analyzed using Fishers Exact and two-tailed t-tests. P < 0.05 was considered significant.

55 patients were analyzed. There was no statistically significant difference in maternal age, gravidity, parity, OR time, EBL, post-operative Hgb, length of hospital stay or diagnosis of retained products of conception between the patients in the ultrasound vs. non-ultrasound guided curettage groups. Even though there was no difference in blood loss between the two groups, patients in the ultrasound group were more likely to be transfused (p<0.004). Although more patients required repeat procedures in the ultrasound-guided group, the only reported uterine perforation occurred during a blind procedure.

While underpowered, our study suggests there is no difference in diagnosis or outcomes in patients who underwent blind verses ultra-sound guided curettage, however more conclusive evidence may be found in a larger prospective study.

Patrice Paolucci, DO
Mentor: Mandeep Brar, MD

Depo-provera is a commonly used method of birth control, especially at Women and Children’s Hospital of Buffalo. It was approved for contraceptive use in the United States in 1992. It is a suspension of 150 mg of depot medroxyprogesterone acetate injected intramuscularly into the deltoid or gluteus maximus muscles every 13 weeks. The pregnancy rate at one year is 0.1%. Advantages of using depo-provera include: decreased menstrual blood loss and amenorrhea (in 50% of users after 1 year of use and 80% after 5 years). Disadvantages of depo-provera include: irregular menses for the first several months of use (unpredictable spotting/bleeding), hypoestrogenemia, headaches, and an average weight gain of 5.4 lbs during the first year of use. It may also exacerbate the symptoms of depression, anxiety, PMS, and fatigue. There is also a slow return to baseline fertility after the last depo-provera injection. The discontinuation rate for depo-provera at one year can be very high in the absence of structured counseling. Some of the common reasons for discontinuation are irregular menses and weight gain. With proper counseling, women would be more prepared for the adverse affects associated with depo-provera and perhaps less likely to discontinue its use and potentially have an unplanned pregnancy. Obviously, this is a highly effective, low compliance form of contraception and therefore this project set out to see just how popular it is.

Depo-provera is a commonly used method of birth control, especially at Women and Children’s Hospital of Buffalo. It was approved for contraceptive use in the United States in 1992. It is a suspension of 150 mg of depot medroxyprogesterone acetate injected intramuscularly into the deltoid or gluteus maximus muscles every 13 weeks. The pregnancy rate at one year is 0.1%. Advantages of using depo-provera include: decreased menstrual blood loss and amenorrhea (in 50% of users after 1 year of use and 80% after 5 years). Disadvantages of depo-provera include: irregular menses for the first several months of use (unpredictable spotting/bleeding), hypoestrogenemia, headaches, and an average weight gain of 5.4 lbs during the first year of use. It may also exacerbate the symptoms of depression, anxiety, PMS, and fatigue. There is also a slow return to baseline fertility after the last depo-provera injection. The discontinuation rate for depo-provera at one year can be very high in the absence of structured counseling. Some of the common reasons for discontinuation are irregular menses and weight gain. With proper counseling, women would be more prepared for the adverse affects associated with depo-provera and perhaps less likely to discontinue its use and potentially have an unplanned pregnancy. Obviously, this is a highly effective, low compliance form of contraception and therefore this project set out to see just how popular it is.

All patients who have received depo-provera will be identified by chart review. Information to be collected will include: age, gravity and parity, current contraception used. A retrospective analysis will then be performed on charts collected between 2006 and 2009. The study endpoints are: 1) how many women continued with depo-provera, 2) Why patients stopped using depo-provera, 3) A comparison of women by age and parity.

This project originally began with 107 charts. This number dropped down to 50 after accounting for chart availability. From this set of 50 charts, it was found that about 44% of patients continued to use depo-provera. Further data analysis was conducted comparing patient’s ages, gravidity and parity, and reasons for discontinuation.

Laura Rayner, MD
Mentor: Shailini Singh, MD

Fetal loss is a painful experience. The advent of the cervical cerclage has allowed patients with presumed cervical insufficiency to carry a pregnancy successfully. There is a body of evidence suggesting that ascending infection may act synergistically with cervical weakness leading to fetal loss or preterm morbidity. The cervical mucus plug acts as a barrier between the vagina and uterus protecting the feto-maternal unit from ascending infection. It is thought that the occlusion of the cervical canal protects the cervical plug and its inherent immunologic role. Recently, there has been a trend towards total cervical occlusion, placing a second stitch at the level of the external cervical os below the McDonald suture, in hopes of increasing the effectiveness of the cervical cerclage.

To determine if a double cervical cerclage procedure is more effective than traditional cerclage.

A review of the literature is currently being undertaken. Additionally, several residency programs are being contacted to determine if this practice is routinely implemented.

Preliminary review reveals that double cerclage may be more effective than traditional cerclage in preventing extreme preterm labor or fetal loss and its devastating consequences.

Suruchi Thakore, MD
Mentor: Armando Arroyo, MD

Marshall and Tanner’s classic 1969 study defined the age at menarche as 13.5 years; however the National Health and Nutrition Examination Survey (NHANES) completed from 199 to 2004 showed average menarche in America to be 12.34 years. Though a similar decline is seen, the age at menarche based on racial groups in America drastically differs from their international counterparts. We hoped to elucidate the age at menarche in Western New York (WNY) and menarche of local racial groups and compare this to international averages.

Self-reported data was collected via physician directed questionnaires of patients born and raised in WNY. These questionnaires gathered participant’s age at menarche, height, weight, and medical conditions. The average age was determined and subdivided by their racial groups. The standard deviation and confidence intervals were calculated.

We expect a total of 300 surveys. The average age at menarche currently is 12.38 ± 1.71 in whites, 11.6 ± 1.54 in blacks, 12.5 ± 1.97 in hispanics, and 12.0 ± 1.31 in Asians. We have noted a difference in menarche for the Hispanic and Asian populations when compared to national means from Mexico/Puerto Rico and India/China.

By understanding the age of menarche, we can further define precocious and delayed puberty for individual racial groups in WNY, allowing personalized treatment for these conditions. We also hope to develop insight into factors influencing the onset of menses in a controlled geographic and ethnically diverse location.

Prethi Vaddadi, MD
Mentor: Kunle Odunsi, MD, PhD

Cancer-testis (CT) antigens are protein antigens that are expressed in a variety of human cancers, but not in normal adult tissues, with the exception of germ cells of testis. Some CT antigens have elicited humoral and cell-mediated immune responses in cancer patients, which raise the possibility of whether or not these antigens could be potential targets for cancer vaccines. CT antigen expression is variable among different tumor types and has been generally more often expressed in high-grade late-stage cancer cases.

The purpose of this study was to evaluate XAGE-1 and SLC06A1 as potential targets for immunotherapy in Epithelial Ovarian Cancer (EOC) by examining the expression and clinico-pathologic correlation to these antigens.

Seventy-five EOC tissues were used to extract RNA and determine mRNA expression by reverse transcription-PCR (rt-PCR) and protein expression by Immunohistochemistry (IHC). Clinical data for these patients was extracted including age at diagnosis, histologic subtype, tumor grade, stage, surgical debulking status, baseline CA125, recurrence status, and platinum sensitivity. The extent and prognostic significance of XAGE 1, XAGE 1 Transcript Variant a (TVa), XAGE 1 Transcript Variant d (TVd), and SLC06A1 expression in EOC will be analyzed with respect to survival and other clinical outcomes.

75 patients met inclusion criteria and were available for analysis. Expression of XAGE 1 in EOC tissues was 69% (52/75), XAGE 1 TVa was 13% (10/75), XAGE 1 TVd was 27% (20/75), and SLC06A1 was 4% (3/75). Co-expression of XAGE 1, XAGE 1 TVa, and XAGE 1TVd was 11% (8/75) while co-expression of XAGE 1 and XAGE 1 TVa was 1.3% (1/75), and XAGE 1 and XAGE 1TVd was 15% (11/75). Statistical analysis of XAGE 1, XAGE 1 TVa, XAGE 1 TVd, and SLC06A1 with respect to expression in EOC and clinical outcomes is currently in progress.